Evaluation of occupational factors influencing the experience of an autopsy demonstration

The performance of autopsy demonstrations is a traditional component of the practical training of medical students in the compulsory curriculum of forensic medicine [11, 12, 21]. Such courses are also offered or even mandatory for other students (exempli gratia, medicine-ethics-law or law studies) and professional groups (e.g., police recruits and officers, nurses, paramedics) [16, 24, 25].

In social discussion and the medical literature, it is repeatedly emphasized that autopsies are an important instrument in medical teaching and quality assurance as well as for ensuring legal certainty [2, 10, 17, 30]. In recent years, a number of modern didactic methods have been integrated into teaching of legal medicine. These include teaching, learning and examination methods, such as e‑learning modules, skills lab stations, OSCE examinations, mostly accompanied by corresponding evaluations [1, 6, 13, 14, 26, 27].

When conducting and planning such autopsy demonstrations, several factors have to be taken into account, such as the prior level of knowledge, motivation, learning objectives and possible vulnerable aspects of the corresponding target group; however, the available resources must also be taken into account, such as the availability of suitable cases and the valences of time and personnel. To continuously enhance the quality of such courses, their systematic evaluation is helpful.

Although autopsy demonstrations as part of this process have been an important tool to ensure practical relevance and sustainable learning success for decades, there are currently only isolated accounts in the pathology and forensic medicine literature of participants’ reflections on such courses, whereas several studies are available on emotional and ethical aspects of the cadaver dissection course in anatomy among medical students [3, 5, 22, 23, 29]; however, systematic studies on this topic are largely lacking so far.

Evaluations of 54 forensic autopsy demonstrations were performed at the Institute of Legal Medicine of the University Hospital Halle (Saale) and the branch office in Magdeburg for the period 2017–2020. Evaluation items and parameters were selected and compiled based on the authors’ previous experience with such courses and the limited information in the literature. Exclusion criteria for the autopsy demonstrations were autopsies of children, severe polytrauma, and cadaveric decomposition. Immediately after each autopsy demonstration, the performing physicians were requested to provide baseline information and all participants were asked to complete an anonymized evaluation. Thereafter, the case documentation of the autopsy physicians was merged with the evaluations in each case.

The participants were explicitly reminded of the obligation to maintain confidentiality, also with respect to ongoing investigative proceedings.

The following information was requested from the physicians:

The following data were collected from participants during the evaluation:

The questionnaire was structured in 9 items in the section “Motivation to participate” and 11 items in the section “Evaluation of the autopsy”, as well as 6 additional items in the section “Reasons for discontinuation”. These 6 items were to be filled in explicitly only in the case of an unambiguous dropout from the autopsy on the part of the participants. Participants could answer a maximum of 26 items (20 items when excluding dropout-related questions) on a Likert scale (5: fully agree, 4: mostly agree, 3: neither agree nor disagree, 2: mostly disagree, 1: disagree). Further feedback could be entered in a free-text field.

The proportion of complete and predominant agreement (Likert scale 5 and 4) was summarized for the evaluation.

The total cohort was first described and analyzed statistically using the IBM SPSS v24.0 (IBM, Armonk, NY, USA) program for Windows 10. For the recording of differences between the professional groups and study courses, several selected items were combined into complexes which most closely reflected the motivation and reflection of the participants: “personal motivation” (Questions 3–6), “comprehensibility of the autopsy” (Questions 10–14) “positive expectations” (Questions 15, 16, 18 and 19), “reasons for dropping out” (Questions 21–26). The scores of the respective Likert scales were summed and tested for significance using the Kruskall-Wallis test. Finally, the significance was corrected by means of Bonferroni correction, by comparing the results of the occupational groups and study programs. The tendency was described by the mean values of the sums from the maximum score. Significance testing of the relative dropout rates in the different occupational groups and programs was performed using the χ²-test. Of further interest was a comparison between participants in the medical sector (medical students and medical assistants) and the nonmedical sector. The corresponding significance test was performed using the Mann-Whitney U‑test. The significance level was set at p < 0.05.

In the present study, for the first time a comprehensive systematic investigation was carried out on the evaluation of autopsy demonstrations in forensic medicine in various professional groups or courses of study.

In terms of motivation to participate, the overall cohort showed a high rate of approval based on personal interest. The majority of the participants also estimated that they had been sufficiently prepared professionally and emotionally. High personal motivation was shown by the medical assistant group, where participation was rarely (11.7%) mandatory. In this group, an autopsy demonstration is by no means regularly offered in the training or professional activity and mostly only once [9]. Thus, a favorable opportunity for clarification of comprehension issues and presentation of real anatomical conditions arises for the medical assistant professions compared to other forms of teaching and learning, such as atlases, textbooks, and computer programs [2, 8, 18, 20]. In contrast, personal motivation was lower among lawyers, law clerks and law students, with participation being mandatory in only about one third (34.1%). Consistent with this, only the motivation of “coping” was more pronounced in the nonmedical groups compared to the medical groups. The observed differences can most likely be explained by the fact that in the medical group knowledge of human anatomy and pathophysiological mechanisms are more important for training and professional activities [28].

Assessments by the medical assistant professions showed the highest approval rates. One of the possible reasons could be that forensic physicians are more accustomed than other medical specialties to the presentation of medical findings in a simple, clear, comprehensible form [15]. With the group of police recruits and officers, this advantage could not be exploited to the same extent, so that within the framework of future courses, more attention needs to be paid to these specific characteristics of the group (including medical laypersons, criminological orientation). Likewise, the corresponding wishes of medical students in the 3rd semester (e.g.,more detailed presentation of anatomical structures) should be considered more precisely, which were also listed in the open answer entries. Furthermore, the difference between an anatomical dissection and a goal-oriented forensic autopsy should be explained in more detail to medical students in the 3rd semester at the beginning of the learning event in the future. Another reason for the somewhat lower ratings in the two groups may have been the significantly higher numbers of participants in the police recruits and officers (47.1% of dissections with more than 20 participants) and 3rd semester medical students (85.7% of dissections with more than 20 participants). In the open answer entries data, poor visibility and hearing conditions were also mentioned in this context. A strict limit of no more than 20 participants could be helpful in addressing this issue.

In terms of positive expectations, the overall cohort still showed a clear preponderance of approving assessments; however, these did not reach the level of the assessments on the comprehensibility of the dissection. For example, potential for improvement was still evident in the handling of the corpse. Significant differences were also evident in this category, both between the individual occupational groups and study courses. It was found that positive expectations were met more frequently in the medical groups, as were negative expectations in the nonmedical groups. The most critical evaluation was found among lawyers, law clerks and law students. According to Martyn et al., participation in an autopsy demonstration involves confrontation with one’s own mortality and the inevitability of death [19]. It is possible that this group was confronted with the problem for the first time to such an extent, while medical groups have previous experience, such as the anatomy course or even their own experience of patients dying.

Among the 66 autopsy discontinuations in the total cohort, the perception of a circulatory derailment and consternation about the measures taken to open the body were the most prominent, and unpleasant odors were also more frequently reported in the free-text statements.There were significant differences in the dropout rates between medical and nonmedical groups as well as between the individual occupational groups or courses of study. The lowest dropout rates were found among students of human medicine, consistent with the findings of Prayson [23]. Overall, participants from the nonmedical groups showed higher dropout rates than the medical professional groups, although differences were also evident among nonmedical professionals. In this respect, a relatively high rate of 15.4% was seen among participants from the postgraduate medicine-ethics-law program, which is mainly composed of lawyers. The dropout rates of lawyers, law clerks and law students were even more than twice as high as the average dropout rates of the other participating groups. So far, there are no systematic studies in the literature on the reflections of these professional groups on medicolegal autopsy demonstrations. It is possible that this is due to the fact that they often largely avoid the subject in their daily work. In contrast, depending on the area of deployment, this avoidance strategy was less common among police recruits and officers, which could have contributed to the significantly lower dropout rates.

Medicolegal autopsy demonstrations represent an important tool in the education, training, and further education of a wide variety of professional groups; however, autopsies should be carefully and sensitively integrated into the training programs [7]. For future physicians, these teaching sessions are an important preparation for the communication that will later be required between postmortem examiners, clinically active physicians, and the relatives of the deceased [30]. Medical assistants also benefit from a better understanding of anatomy, as well as learning medical and surgical nursing concepts [9]. Despite increased dropout rates and lower motivation, it was an important event for participants with a legal background, as it represents an insight into medicolegal practice and how it works [25].

The predominantly positive and very positive evaluations indicate that the basic concept of autopsy demonstrations in legal medicine can be maintained or, where not yet in place, introduced. This is in line with the results of Bamber et al., according to which autopsy demonstrations are highly appreciated by students and the knowledge gained there can be applied to many different medical specialties and skills [4]; however, this requires careful preparation and organization of autopsy demonstrations to maximize potential educational benefits and reduce negative emotional impacts. From the differences found between medical and nonmedical participants as well as between the individual professional groups and courses of study, it is evident that, depending on the structure of the participant group, there is still room for improvement.

For example, the highly developed personal motivation of medical students in early semesters can be further enhanced in the introduction by more detailed explanations of the difference between anatomical dissection and forensic autopsy and in the execution by going into more detail about anatomical structures. For medical students from higher semesters, there should be a stronger focus on forensic aspects, emphasizing the distinction from anatomical and pathological postmortem examinations. Furthermore, it could be helpful if the courses were to focus more on the communication between postmortem examiners, clinically active physicians and relatives that is required in later professional life. The markedly high personal motivation of the medical assistant professions is most likely to be maintained by optimizing a readily understandable form of the autopsy demonstration and addressing aspects specific to the profession. In the case of police recruits and officers, future autopsy demonstrations should emphasize a presentation that is understandable to medical lay personnel and emphasize criminological aspects. Autopsy demonstrations for participants with a legal background pose a particular challenge. With this group, it could prove beneficial if the motivation of testing physical and mental limits is placed more in the background. This can be made possible, for example, by a specifically designed introduction, in which a sensitive introduction to the topic of mortality is made, among other things, with suitable visual material. In addition, it could be helpful to avoid cases with traumatological causes of death in this group, if possible. Furthermore, the present study showed that, in principle, a manageable number of participants should be aimed for (e.g., a maximum of 20) and that the potential for improvement in the sensitive handling of the corpse is exhausted. Of course, these recommendations can only ever be implemented in consideration of the availability of suitable cases as well as time and personnel resources. As the scientific examination of this sensitive topic to date has been more marginal, further studies are needed [23]. For this purpose, longitudinal observations of the same cohort in different semesters or a comparison of several sites, for example, could provide further insights.