INTRODUCTION
Since ancient times, the knowledge obtained from undertaking autopsies has aided in advancing scientific knowledge. The practice evolved from conducting a mere examination of the cadaver to understand anatomy to identify the pathologies of clinical events before the patient’s death.[1,2] Moreover, the events before death may imply legal investigations, wherein issues may be encountered by not only pathological experts but also any physician. Hence, educating and training medical students in the procedure and practice of autopsy hold significance. Accordingly, the present study was undertaken to understand the level of awareness, education, and motivations toward the practice of autopsy among undergraduate medical students at King Saud University. The insights obtained from the study aim to improve and advance the cause of postmortem education among medical students in Saudi Arabia.
Several studies worldwide have evaluated the role of medicolegal autopsy demonstrations in the education curricula and the perceptions of both students and teachers regarding the issue. McNamee et al.[3] used the phenomenological study design to conclude that the perceived importance of autopsies among students is useful in self-directed learning. Learning about anatomy and traumatology was perceived as a primary cognitive benefit. The students also experienced emotional development in their ability to detach clinically from the case and display improved handling of death issues. However, error rates on death certificates are universally high, mandating certifier education to expand beyond local and state efforts. Simplifying and standardizing underlying literal text for the cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.[4]
At present, the importance of teaching autopsies during undergraduate medicine to allow holistic professional development and ensure ethical and informed behaviors remains unserved.[5] At the same time, support for the evolving needs of Saudi Arabia for postmortem medicine experts is needed.[6] Thus, while testing the existing knowledge, the current study also identified the areas of improvement that could support future frameworks.
METHODS
Study design
This study followed a cross-sectional study design undertaken in 2021 at King Saud University, Saudi Arabia. Students enrolled in undergraduate medical courses were administered a structured, self-administered questionnaire comprising 19 items to assess their knowledge, attitude, and awareness toward autopsy practice as taught in the college. Figure 1 presents the different variables of this study.
;)
Figure 1: Conceptual model
As indicated, this study aimed to investigate medical students’ theoretical and practical knowledge of autopsy as well as their attitude and ideology toward it. Moreover, it examined the different connections between students’ training (academic and practical) and their interest in autopsy.
Study population
The students were able to complete the questionnaire within an hour, during the lecture, and submit it back to the lecturer. The responses included those from both the male and female colleges, as they remain segregated in the university.
Instrument and procedure
To take part in the study, each participant filled in a consent form where they were informed of the confidentiality of their data. They were offered the possibility to have access to the study results in case they provided their contact details. Each respondent consented to participate in the study, providing their verbal consent. Postcollection, the data were coded and analyzed using SmartPLS. The analysis involved descriptive and frequency statistics. The confidentiality of the students was maintained. All procedures were conducted in line with STROBE recommendations.
The following hypotheses were formulated:
- H1a: Ideology positively affects course evaluation
- H1b: Ideology positively influences students’ attitude toward performing autopsy
- H2a: Course evaluation positively affects medical investigations
- H2b: Course evaluation positively influences students’ attitude toward performing autopsy
- H3: Knowledge about autopsy procedures positively influences students’ attitude toward performing autopsy.
RESULTS
The total number of students who took part in this study is 199 (n = 199). As indicated in Table 1, 50.80% of the total informants were males and 49.20% were females. In addition, 71.40% of them were 4th-year students in medical school and 21.60% were in their 3rd year. Some participants did not fully answer the questionnaire.
Table 1: Participant demographics (n=119)
In measuring students’ general knowledge of autopsy, most of the participants recorded correct answers on the items dealing with postmortem and causes of death. Interestingly, when responding to questions presenting causes of death such as “single-car accidents, aircraft crash, natural disease, and unwitnessed accidents,” the informants did not have a correct answer. This knowledge gap for these students emanates from a plethora of reasons, which include their limited access to observe autopsies, with only 6.5% of the participants able to attend just one to three autopsies. Moreover, the number of observed/attended autopsies is not enough to foster the students’ theoretical knowledge with some experimental background.
To assess the awareness toward the importance of autopsy education, the study informants were also asked about the need to observe the autopsy. Most of the students indicated that it is central for them to attend autopsies. This translated to 88% of the population expressing their willingness to watch an autopsy. However, this practice is still limited given that only 35.80% have had access to that.
The students’ opinion on autopsy was also investigated, as it is important to consider their own views about postmortem practice. A total of 67.40% of the participants believe that it does not result in a disfigurement of the body, and 85.80% believe that it is not disrespectful to the body. To assess students’ attitudes toward autopsy, the students confirmed more interest in other specialties that do not involve any autopsy practice.
We distributed 213 questionnaires and obtained 199 responses. We then applied structural equation modeling to study the cause-and-effect relationships between the defined constructs. Tables 2 and 3 display the reliability and validity measures, while Table 4 demonstrates the outer loadings and variance inflation factor values.
Table 2: Reliability measures
Table 3: Fornell’s matrix (validity)
Table 4: Outer loading and variance inflation factor
The first studied construct examined how the attitude toward performing autopsy was shaped by the ideology of the medical students, which included determinist, fundamentalist, liberalist, materialist, positivist, pro-scientism, religionist, and secularist. The most influencing indicators were being a religionist or positivist, whereas being an advocate of scientism or a secularist were the least governing factors. The subordinate hypotheses concerned how positively these indicators influenced the autopsy course evaluation (H1a) and students’ attitude toward performing autopsy (H1b). Ideology positively affects autopsy course evaluation (β = 0.277, P < 0.001) and students’ attitude toward performing autopsy (β = 0. 571, P < 0.001). Therefore, H1a and H1b were supported. The collected responses demonstrated that the Saudi medical students who studied the autopsy course find a student’s ideology to be a determinant variable governing the perception of autopsy performance. Therefore, H1 was supported.
The second studied hypothesis was the positive influence of course evaluation on demonstrating knowledge about autopsy (H2a) and students’ attitudes toward performing autopsy (H2b). Students’ self-reported course evaluation positively affects their demonstration of adequacy of knowledge about autopsy (β = 0.740, P < 0.001) but not their attitude toward performing autopsy (β = 0.646, P = 0.875). Therefore, H2a was supported but not H2b. The collected responses demonstrated that Saudi medical students find knowing about autopsy crucial for perceiving the importance of performing an autopsy, regardless of their evaluation of the college course.
The third studied hypothesis was the positive influence of knowledge about autopsy on students’ attitudes toward performing autopsy (H3). Students’ self-reported awareness positively affects their attitude toward performing autopsy (β = 0.015, P < 0.001). Therefore, H3 was supported. The path analysis corresponding to the cause-and-effect relationship between the training and ideology of students as well as the attitude toward performing autopsy is shown in Figure 2. The validation of the studied hypothesis is shown in Table 5. The Standardized Root Mean Square Residual value was 0.138 and root mean square (RMS) theta was 0.191. Therefore, the measurement model is accepted. Accordingly, it is worthwhile to note that students’ attitude determines their acceptance of autopsy and their assessment of their respective medical programs.
Figure 2: Measurement model
Table 5: Validation of the postulated hypotheses
DISCUSSION
This cross-sectional study aimed to gain a deeper understanding of the knowledge, awareness, and attitudes toward autopsy of medical students. With almost equal representations of male (50.80%) and female (49.20%) participants, the obtained results demonstrate a better understanding of autopsy practices among the students. In terms of the general theoretical background on autopsy, the results showed that the medical students did have a good understanding of this medical specialty. However, regarding the practical side, the study results revealed that these students did not have the opportunity to attend autopsies. Previous studies that tackled the same matter showed that the acquisition of fundamental theoretical knowledge of autopsy during coursework[7,8] is a proviso along with practical know-how and experience.[9] However, the results reveal that while academic knowledge is available to students, a clear gap is detected on the practical side. Concerning students’ awareness of the practical importance of observing autopsy, they showed a consistent view accentuating the need to attend and observe autopsies to develop their academic intake.[10] Although it is commonly known that students would generally report some discomfort during autopsies, based on these results, the medical students likewise agreed that postmortem practices do not involve any disfigurement and/or disrespect to the body.[11] The study results did not report any signs that emotional development needed to be assessed or considered among the examined population.
In attempting to cross-check the obtained results against other findings, another study conducted in Hamburg, Germany, indicated that medical students underscored the significance of postmortem learning and practices, which are devoid of any disrespect to the body. The study findings revealed that thanks to these practices, 70% of the students managed to perform an external examination and fill in a death certificate. The researchers then highlighted the need to establish the learning goals and course standardization (formal curriculum) along with the tutor’s conduct (informal curriculum) in autopsy education.[12]
In another study, the participants were supposed to fill in a death certificate after being exposed to a real case scenario, and then a lecture was delivered on the same matter followed by a different real case scenario.[13] The generated results showed a high error rate of 63.75% in the certificates, with the error of sequencing causal events reaching a high frequency (60%). Such an outcome indicates that the participants were not fully aware of the importance of death certificates, a shortcoming that was compounded by the negligent conduct of the attending doctors.
The general attitude toward autopsy, however, presented a contrasting stance because of the limited practice that medical students face. Given the limited access to postmortem practices, the current study observed that a lower percentage of the students (14.7%) showed interest in this specialty. In another context from AlBaha University in Saudi Arabia, of 95 male students, 34% were willing to uptake a medical specialty involving postmortem analysis,[14] even though the students indicated that they did not have access to autopsy observations and performance. They agreed that more medical students should perform an autopsy and should even be allowed to conduct postmortem examination on relatives. In another study, Seyoum etal.[4] postsurveyed 161 medical students from Ethiopia based on their access to postmortem examination and outlined their inspiration, experience during clinical practice, financial reward, dedication to the field, competencies possessed, and teacher influence as plausible reasons influencing their choice of specialty.[4] Hence, it is worthwhile to note that a lack of practical and hands-on training in autopsy could influence the choices of medical students in their specialty.
In another study, Schröder etal. also detected a theory–practice gap that could result in a misdiagnosis of nonnatural causes of deaths and homicides based on postmortem external examination.[15] Based on the findings of the aforementioned studies, it is necessary to establish a convenient curriculum in pre- and postgraduate education and foster academic training along with practical training in the different educational programs to enhance the experimental knowledge of students, restrict any misdiagnosis and raise their awareness of the importance of death certificates.[16,17]
Pedagogical implications
From the obtained results, this study has many pedagogical implications that can be invested to improve the current educational program of autopsy courses. This study has proved that students’ attitudes toward autopsy are central toward accepting it and can have an impact on their evaluation of their educational programs. In fact, as this study has shown, the practical training in autopsy constitutes the main gap in the current programs and represents a serious knowledge gap for medical students, leading many of them to avoid it as a specialty. Hence, it is critical that pre- and postgraduate programs integrate a training phase where these students can observe, attend, and perform autopsies. Having access to this training part is relevant in not only allowing students to better understand their own attitudes toward autopsy but also to accept it.
Another consideration that must be stressed in the current programs is raising students’ awareness of the importance and relevance of autopsy to other medical specialties, particularly forensic medicine. To ensure that learners can observe and perform autopsies, it is crucial to establish clear learning outcomes and formal curricula, coupled with acute doctors who pay special attention to the essential training that students need to acquire. Providing this sort of training is crucial to ensuring that not only is the theory–practice gap bridged but also that the choices of medical students are not influenced by any lack of autopsy practice.
CONCLUSIONS
Controversially, while students, in general, do not think about the informative significance of an autopsy course, they do believe that students should perform autopsy and that autopsy can be performed on relatives. These views can be noted in the responses of the current study’s informants.
This study concludes that there is a dire need to improve autopsy education at King Saud University, with the induction of more practical and hands-on teaching and training. The medical students possess knowledge about theoretical principles but fail to assess the importance of attending and performing autopsies for professional development. The students’ responses indicate their acceptance of postmortem practice and the belief that it neither disfigures nor disrespects the cadaver. Nevertheless, the inclusion of a more hands-on approach could help include the “hidden curriculum,” i.e., the crucial aspects that escape formal teaching and arise from watching teachers, their attitudes, techniques, and interests. Furthermore, we suggest embedding teaching an autopsy course in longitudinal curricula on death and dying.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The author would like to extend his appreciation to the Researchers Supporting Project number (RSP2023R480) at King Saud University, Riyadh, Saudi Arabia.
REFERENCES
1. Herdson PB. Autopsies, medicine, and the public. Ann Saudi Med 1988;8:317–9.
2. Aljerian K, BaHammam AS. COVID-19:Lessons in laboratory medicine, pathology, and autopsy. Ann Thorac Med 2020;15:138–45.
3. McNamee LS, O'Brien FY, Botha JH. Student perceptions of medico-legal autopsy demonstrations in a student-centred curriculum. Med Educ 2009;43:66–73.
4. Seyoum N, Biluts H, Bekele A, Seme A. Medical students'choice of specialty and factors determining their choice:A cross-sectional survey at the Addis Ababa University, School of Medicine, Ethiopia. Ethiop Med J 2014;52:129–35.
5. Aljerian K. The final consultation:The autopsy. Forensic Leg Investig Sci 2017;3:017.
6. Al-Waheeb S, Al-Kandary N, Aljerian K. Forensic autopsy practice in the Middle East:Comparisons with the west. J Forensic Leg Med 2015;32:4–9.
7. Bamber AR, Quince TA, Barclay SI, Clark JD, Siklos PW, Wood DF. Medical student attitudes to the autopsy and its utility in medical education:A brief qualitative study at one UK medical school. Anat Sci Educ 2014;7:87–96.
8. Tandon A, Kanchan T, Atreya A, Tandon A. Perceptions of medical students towards autopsy teaching and its significance. Med Sci Law 2019;59:143–8.
9. Aljerian K. Saudi physicians'perceptions of the validity of autopsy and its implications –Structural equation modeling. J Forensic Leg Med 2022;86:102320.
10. Aljerian K. SIDS in Saudi Arabia:Reality or myth?. Fetal Pediatr Pathol 2023;42:167–70.
11. Ali AM, AbdulKareem H, Al Anazi M, Reddy Parine N, Shaik JP, Alamri A, et al. Polymorphisms in DNA repair gene XRCC3 and susceptibility to breast cancer in Saudi Females. Biomed Res Int 2016;2016:8721052.
12. Anders S, Fischer-Bruegge D, Fabian M, Raupach T, Petersen-Ewert C, Harendza S. Teaching post-mortem external examination in undergraduate medical education –The formal and the informal curriculum. Forensic Sci Int 2011;210:87–90.
13. Sudharson T, Karthikeyan KJ, Mahender G, Shashidhar CM, Balaji Singh M. Assessment of standards in issuing cause of death certificate before and after educational intervention. Indian J Forensic Med Toxicol 2019;13 3.
14. Madadin M, M Alkhattaf I, H Abutaki F, A Almarzooq M, A Alzahrani F, Al-Saif DM, et al. Workplace hazards in forensic mortuaries in Saudi Arabia:A survey of forensic mortuary personnel. Med Sci Law 2022;62:24–30.
15. Schröder AS, Wilmes S, Sehner S, Ehrhardt M, Kaduszkiewicz H, Anders S. Post-mortem external examination:Competence, education and accuracy of general practitioners in a metropolitan area. Int J Legal Med 2017;131:1701–6.
16. Binsaeed AA, Al-Saadi MM, Aljerian KA, Al-Saleh SA, Al-Hussein MA, Al-Majid KS, et al. Assessment of the accuracy of death certification at two referral hospitals. J Family Community Med 2008;15:43–50.
17. Aljerian K, Almohammed RA, Alghaith TM, Al-Saffer Q, Alazmi NM, BaHammam AS. Unifying the death notification form:Recommendations by the Saudi health council task force. J Taibah Univ Med Sci 2021;16:672–82.
