What's wrong with the dead body?

Many anatomists are adamant that dissection is the best way to learn anatomy,14 although there is little hard evidence for this. In fact, many studies have suggested that medical students who learn human anatomy by prosections and audiovisuals perform just as well in anatomy examinations as those who learn by dissection.19-21 Newer tools, such as plastinated models and computerised images, should also help compensate for a lack of "hands-on" dissecting experience.

Nevertheless, it is arguable that experience with dissection gives students a better appreciation of the three-dimensionality of the human body22,23 and better understanding of normal variation in human anatomy.24 These are important lessons that should not be overlooked.

The autopsy has been used extensively for teaching pathological concepts, clinicopathological correlation and gross and microscopic anatomy, as well as for enhancing understanding of disease entities.25 However, if autopsies are to be the primary means of teaching pathology, then students must witness many cases. As no Australian medical school requires students to attend more than six autopsies (Box), it seems obvious that other methods of teaching pathology have become widely accepted. The medical literature reports much sorrow about the decreasing hospital autopsy rate and the limited exposure of medical undergraduates to the autopsy,11 and a significant number of Australian pathology academics believe this has adversely affected pathology learning (Box). However, I was unable to find any studies investigating the relationship between student experience with autopsies and understanding of pathology.

Arguably, anatomy and pathology can be taught effectively without student contact with the dissected human body. However, this does not mean that the human cadaver has nothing to teach medical students. Autopsies often uncover difficulties with clinical, radiological and in-vivo pathological diagnoses, and unsuspected major clinical conditions are still found with astounding regularity.11 The autopsy therefore teaches the student about medical fallibility and uncertainty,12,13,25,26 vital lessons for future doctors.

In addition, attending an autopsy gives first-hand understanding of the procedure — what it entails, how the body is likely to appear afterwards, and the benefits and limitations of the examination. Students also gain an understanding of the role of the autopsy in quality control13,27 and research, and learn how and why to request permission for autopsy13,16,28 and to discuss the procedure knowledgeably with relatives. These lessons are so important that it has been argued that lack of understanding of the autopsy by recent medical graduates, who have never attended one, has contributed to the decreasing autopsy rate.13

Finally, what of education about death? Medical students need to learn to deal with patients facing death, with grieving relatives, and with their own feelings of inadequacy, guilt and helplessness when confronted with dying patients. Few will have had close personal contact with death. Not all medical schools have formal teaching on death and dying (Box), and students report little experience with death during their medical school years.29 In Australia, students in four medical schools can conceivably progress through their entire training without seeing a dead body (Box).

Is this important? Fox argues that the experience of viewing the dead body is an important tool in teaching medical students the trait of "detached concern",26 an attitude that enables them to practise medicine efficiently and empathically, despite constant exposure to disease, suffering and death.18 Others agree that the dissected body is a significant influence on student attitudes to death,30 but are less enthusiastic than Fox about the lessons learnt. As mentioned earlier, contact with the cadaver can be highly stressful for some students,8,14,16-18,31,32 and may result in their becoming "dehumanised"33 — more "detached" than "concerned". However, this should not be used as an argument for withdrawing exposure to the dead body from the medical curriculum, but rather should encourage schools to introduce formal courses on death and dying.16,18,29,31,34 The anatomical dissection or the autopsy are ideal focal points for discussion of these topics.18,35

Perhaps the fundamental question is whether exposure to the dissected body, in anatomy, pathology or another course, contributes to the making of better doctors. In general, academics are unable to produce hard facts about the value of the dissected body in medical education. It has proved difficult to measure the success or otherwise of problem-based learning in producing "better" doctors,36,37 and measuring the importance of one component of a medical course, such as student experience with anatomical dissection and autopsy, is similarly unrealistic. Cahill admits: "We [would] be more persuasive in convincing sceptics [of the value of anatomical dissection] if we [had] hard data that demonstrate[d] whether or not knowledge obtained by dissection is key to proper patient care . . . Who would fund a study to compare the clinical skills of physicians who dissected, versus those who did not?".14

I believe that students who have experience with the dead body will be better equipped to deal with issues surrounding death and more aware of medical uncertainty. This will make them better clinicians.