Year : 2021 Month : July Volume : 8 Issue : 30 Page : 2811-2816.
Azfar Mateen1, Pradeep Yadav2, Berendra Yadav3, Ajay Kumar Singh4
1 Department of Forensic Medicine, Mahamaya Rajkiya Allopathic Medical College, Ambedkar Nagar, Uttar Pradesh, India.
2 Department of Forensic Medicine, Baba Raghav Das Medical College, Gorakhpur, Uttar Pradesh, India.
3 Department of Physiology, Mahamaya Rajkiya Allopathic Medical College, Ambedkar Nagar, Uttar Pradesh, India.
4 Department of Biochemistry, Mahamaya Rajkiya Allopathic Medical College, Ambedkar Nagar, Uttar Pradesh, India.
Dr. Ajay Kumar Singh,
Department of Biochemistry,
M.R.A Medical College, Ambedkar Nagar,
Uttar Pradesh, India.
Email : email@example.com
Forensic medicine is an important subject in the medical curriculum as it teaches the doctor about the legal intricacies related to healthcare and also provide aid to law abiding agencies. Apart from dealing with medico-legal autopsies and forensic pathology, Forensic medicine also comprises of applied medical sciences and clinical forensic medicine dealing with conditions like domestic violence and rape.1 Post-mortem examination which means examination of body after death is also taught in forensic medicine. Autopsy or postmortem examination can be either clinical autopsy which helps in reaching the diagnosis of the deceased or autopsy can be medico legal. Medico-legal postmortem is conducted to know the time since death and cause of death and sometimes to know the identity of the deceased along with many other medical science related opinions in relation to death.
Historically physicians like Osler and Virchow conducted autopsy to understand the pathology of certain diseases like pulmonary embolism and endocarditis.2 Post mortem examination has always been central to medical education it helps the student to understand the gross anatomy, clinic-pathological correlations, death certification and death statistics.3 Autopsy rate has been declining worldwide,2 possible reasons for the decline may be advancement in diagnostic techniques, inadequate training of the staff and reluctant relatives.4
In India, the quality of medico-legal work has been substandard5 as it is not surprising for a doctor to undergo training without observing autopsy6 as most of the private colleges and in Uttar Pradesh most of the government colleges too, don’t have the authority or permission to undertake autopsies.7 In India, a medical graduate can conduct autopsy, so if he did not undergo proper training of postmortem then there is a possibility that the report prepared by such doctors might be incomplete as stated by various court orders/strictures, which has expressed concern over the poor quality of the autopsy report and the need of improving the same.8,9 Also, as the forensic medicine is taught in the second year and in third year part-1, the undergraduate students needed to refresh the subject on regular basis as they tend to forget theoretical aspects of the subject in due course of time.10
The present systematic review was carried out in order to ascertain the knowledge, attitude, and perception of undergraduate medical students towards autopsy in India. Both electronic as well as manual search was carried out for the literature. Electronically, the relevant literature search was carried on PubMed, MEDLINE databases and manual search irrespective of date of publication using both medical subject heading (MeSH) terms like “Autopsy”, “Students”, “India” and keywords like knowledge, attitude, perception, post-mortem, undergraduate, India, medical curriculum. Different combinations of key words were made using “And” and “Or” as Boolean operators.
The present study was conducted according to the guidelines set forth by preferred reporting items for systematic reviews and without meta-analyses (PRISMA).11
Initial search, after removal of duplicates, yielded 163 articles (Fig.1). 146 articles were excluded after screening of title and abstract. 4 articles out of the remaining 17 articles were excluded because either the article focused on superfluous topics or provided insufficient information to assess or repeated attempt to contact the author for additional information failed, resulting in 13 articles that were used for the analysis of the present study. All articles were cross-sectional studies where data was collected by using a self-administered questionnaire. Indian journal of forensic medicine and toxicology (n=3) is most common journal for publication while journal of indian academy of forensic medicine (n=2) is the second most common journal for publication on student competency towards autopsy in India. Summaries of the relevant articles are listed in Table 1.12-24
Location and Year of Study
All the studies in the present review were conducted in the last decade, from 2013 to 2019. All the studies were conducted in the 9 states, two studies were conducted in the states of Gujarat, Haryana, Telangana, Uttar Pradesh respectively and one study in the states of Bihar, Karnataka, Kerala, Madhya Pradesh, and Maharashtra.
Analysis of the Included Studies
Most of the participants in almost all the studies were aware of the necessity of the autopsy in case of unnatural deaths. Preservation of viscera for either histo-pathological analysis or toxicological analysis or for both is required when the cause of death cannot be ascertained after autopsy. Except for the three studies, all of them had asked their participants regarding the utility of viscera preservation and majority of the participants responded positively regarding the knowledge of utility of viscera preservation.
On the first exposure to postmortem, not more than ¼th of the participants (10.6 %16 to 36.6 %12) were comfortable in most of the studies except in the study of Najan23in which 88.2 % of the participants were comfortable on their first exposure. According to study by Rautji21, 47.7 % of the participants were of the opinion that student should watch more post-mortem examination while in rest of the studies in which this question was asked, more than 50 % of the participants were of the opinion that students should watch more post-mortem. Also, when asked about whether student should actively participate in autopsy, except for the two studies conducted by Rao12 and by Patel14 where only 14 % and 25.4 % of the participants respectively, more than 50 % in rest of the studies were of the opinion that students should actively participate in autopsy.
Out of the 8 studies which asked about whether conducting postmortem causes disfiguration of the body, opinion of the subjects were divided, where about ¼th of the participants of the four studies 27 %,13 24.9 %,14 26.2 %,18 22 %20 respectively agreed for the same, in the remaining four studies more than 50 % of the participants 57 %,12 62.9 %,15 80.8 %,19 56.8 %23 respectively agreed that the post mortem causes disfiguration of the body.
Only 6 studies gathered opinion regarding the scrapping of autopsy from medical curriculum and barring one study13 where 97.6 % of the subjects agreed for the removal of autopsy, in rest of the study 74.6 %,12 90.5 %,19 94 %,22 83.3 %,23 93.5 %24 of the participants respectively were of the opinion that autopsy should not be scrapped from the medical curriculum.
When asked about the suggestions regarding the improvement of autopsy procedure, majority of the subject of the 5 studies 68.3 %,12 55.3 %,13 79.7 %,17 74.1 %,22 57.4 %24 respectively, suggested that replacing the primitive instrument with the modern instrument will help in improving the autopsy procedure. Also, most of the participants agreed that there is a need for the improvement of hygiene level of the mortuary.
Only 3 studies, conducted by Rao, Ahmad13 and Kumar17 gathered the information about the need of specific casualty posting in forensic medicine and 76.6 %, 84 % and 90.4 % of the participants respectively, were of the opinion of having specific casualty posting in forensic medicine.
Out of 13 studies considered for the study, 5 studies conducted by Patel14, MN15, Kumar17, Jadav18 and Chawla20 collected the data for the main source of knowledge about autopsy, and the percentage of the participants that credited medical curriculum as the main source for their knowledge regarding autopsy were 94.9 %, 89.5 %, 95.7 %, 89 % and 83 % respectively. Also, in the study conducted by Patel14 and Kakkeri,19 61.5 % and 92 % of the participants respectively, suggested replacing traditional autopsy with virtual autopsy.
Two studies which gathered information regarding capability of the students to conduct independently, the answer is contrasting that while in the study by Kakkeri,19 60.9 % of the participants were confident in conducting the autopsy independently, only 2 % of the participants in the study of Chawla20 feel the same regarding conducting the autopsy independently. Majority of the participants in most of the studies were not interested in specializing in forensic medicine and the reason given by them was that they are interested in some other specialties except in the two studies conducted by Bharathi16 and Bagga,21 where 68.3 % and 65 % of the participants respectively, where not interested in the forensic medicine because they do not want to go to the court for giving evidence.
As forensic medicine has become essential part of medical curriculum, so teaching them is mandatory at medical college,25 and thus teaching it effectively to the MBBS students will improve their knowledge and attitudes toward forensic medicine.26 The focus of this systematic review is to assess the knowledge, attitude, and awareness of an undergraduate medical students toward autopsy in India. All the studies in the review used self-administered questionnaire for gathering relevant information from the subjects regarding medico-legal autopsies in India. All the studies in consideration used only close-ended questionnaire in their studies which reduces the recall bias and is also easier to compare and analyze the data but the disadvantage of closed ended question is that it did not give proper insight of the participants.
As evident from the result that, in most of the studies only about one-fourth of the subjects were comfortable on their first exposure to autopsy except for one study.23 Though no study in the present review asked their participants specifically what they felt after the exposure to autopsy. It has been reported by some authors that the feeling can be from nausea, anxiety to having nightmares27,28 and post-traumatic stress29,30 as postmortem is considered by many as strong emotional event for the undergraduate students. These traumatic experiences can be minimized by doing proper psychological counselling of the students.31
It can be seen from the result that, most of the subjects were of the opinion that students should watch more autopsies which is consistent with those of other studies.31,32 But, in the present review, 8 out of 13 studies14-21 had not asked their participants about the number of autopsies they have witnessed and in the remaining 5 studies,12,13,22-24 they had just mentioned that their participants have witnessed minimum 10 autopsies each.
According to the previous medical curriculum, all the undergraduates were required to watch at least 10 autopsies. As per the current NMC based guidelines, undergraduate students are required to conduct and prepare post-mortem examination report of at least 15 autopsies in a simulated/ supervised environment.33
Medical curriculum was cited as the main source of knowledge, regarding the postmortem examination, by majority of the subject in the studies in which question regarding the same was asked.14,15,17,18,20 which is in contrast to the study conducted by Madadin34 in which 73.4 % of the participants credited TV and media as their main source of information.
When asked about the specialization in forensic medicine, most of the participants were not interested in considering forensic medicine as future career which compares favorably with the study of Ekanem32 and of Papadodima35 but in contrast to the study conducted by Madadin34 in which 80.4 % of the participants wanted to pursue forensic medicine as future career.
The medical curriculum of undergraduate pertaining to autopsy has significant educational benefit because students can learn about anatomy, pathology and correlate pathological findings with clinical presentations. The analysis of present review revealed that though the undergraduate students have knowledge and awareness of the subject, they do not have the confidence of performing the autopsy independently. Most of the students were uncomfortable during their first experience of autopsy. On the basis of present study, the authors recommend the following points:
There are certain limitations in the present study that should be considered. First of all, the search strategy including the choice of MeSh terms and keywords might not have covered all the relevant published article related to present study. Also, as the present study is not funded, so although some article which passed the inclusion criteria could not be included as they were available only on payment and repeated request for the waiver of the same to the author/journal availed no response. Only those aspects were compared and discussed in the present review regarding autopsy that were common in all of the studies as to discuss the different features of each and every study is insuperable and beyond the scope of present study.
Financial or other competing interests: None.
Disclosure forms provided by the authors are available with the full text of this article at jebmh.com.
Disclosure forms provided by the authors are available with the full text of this article at jebmh.com
Financial or other competing interests: None.
Copyright © 2021 Azfar Mateen et al. This is an open access article distributed under Creative Commons Attribution License [Attribution 4.0 International (CC BY 4.0)]
Mateen A, Yadav P, Yadav B, et al. Assessing medical student’s competency toward post-mortem in India - a systematic review. J Evid Based Med Healthc 2021;8(30):2811-2816. DOI: 10.18410/jebmh/2021/515