A Combined Hospital

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A Combined Hospital Forensic Autopsy SuiteAn
Opportunity for Education

• GRIPE June 2003
• Dr. E. Tweedie

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an old problemDecline of the hospital autopsy

• despite important role in
• quality assurance
• research
• education.medical teaching

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• steadily decreasing autopsy ratesthe trend, I
  fear, is irreversible
• teaching of autopsy pathology and autopsy
  techniques during most residencies is
  insufficient.
• Jurgen Ludwig
• Handbook of Autopsy Practice 2002

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Solutions

• revive the hospital autopsy
• (good luck!)

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Solutions

• find other autopsies make use of medicolegal
  cases
• (ie. rob banks because thats where the money
  is)

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• few pathologists still specialize in autopsy
  practice and, as a consequence, expertise in
  autopsy technology and autopsy pathology has
  declined. Our colleagues in the forensic field
  have remained the only large group of autopsy
  practitioners.
• Jurgen Ludwig
• Handbook of Autopsy Practice 2002

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objectives

• Show how hospital and forensic autopsy services
  can be combined
• Recognize special issues when integrating
  forensic cases into a teaching institution
• Explain differences in hospital and forensic
  cases in terms of education
• Propose ways of delivering autopsy teaching

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Checklist for effective education using autopsies

• Cases
• Teachers
• Delivery

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Checklist for effective education using autopsies

• Cases
• Teachers
• Delivery

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Where we were...
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where we are
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Death investigation in Ontario
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Southwest Region
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Caseload 2002
Total 570
1/3 hospital

• 2/3
• medicolegal

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comparison of case types

• Hospital
• disease /- treatment effects
• clinico-pathological correlation
• communication with clinicians, housestaff

• Forensic
• disease (unaltered), trauma
• cause /- manner of death
• communication with coroners, law enforcement, etc

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Manner of death (2001)

• Natural 134
• Accident 81
• Suicide 47
• Homicide 12
• Undetermined 35

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Sudden cardiac death
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special considerations in forensic
autopsiesConfidentiality

• Who can attend?
• Factors considered
• educational program with relevance to forensic
  death investigation
• recognized member of the forensic death
  investigation team
• professional relevance (ie. health care providers
  whose clinical care and documentation are of
  particular significance to coroners
  investigations)

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special considerations in forensic autopsies
Confidentiality

• Discussion at rounds
• Reporting/ archiving
• separate from laboratory information system
• may limit availability for education

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Special considerations in forensic
autopsiesOrgan retention/ research

• Organs kept only for investigative purposes
• Consent different from hospital cases
• British experience
• (so take pictures instead!)

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Checklist for effective education using autopsies

• Cases
• Teachers
• Delivery

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Teachers

• 25 pathologists
• 9 on autopsy service
• 4 forensic pathologists
• 3 neuropathologists

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Checklist for effective education using autopsies

• Cases
• Teachers
• Delivery

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Students

• medical undergrad
• dental undergrad
• pathology residents
• other residents
• nursing, allied health professions
• bachelor of medical sciences students
• police, paramedics, fire marshalls, etc

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• Training
• hands on
• pathology residents
• other residents
• bachelor of medical sciences
• police, etc

• Teaching
• hands off
• medical students
• dental students
• nursing, etc

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Pathology residency training in Canada

• fellowship certification requirement- to be
  capable of undertaking a complete forensic
  autopsy in all common situations excluding
  homicides
• application submitted for a forensic subspecialty
  certification

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Pathology residency autopsy training at U.W.O.

• hands on
• exposure to hospital and forensic cases
  throughout 4 years
• graded responsibility of performance and
  reporting
• senior resident forensic rotation
• hands off
• weekly forensic autopsy case conference
• forensic lecture series

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Teaching outside of the morgue

• Hospital rounds
• ICU
• cardiovascular pathology
• medicine CPC
• (often involve forensic cases)

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Undergraduate medical education

• Current
• no stand alone pathology course, integrated
  into systems curriculum
• no formal autopsy lecture
• pathology small group discussions
• occasional autopsy participation, no requirement
• 4th year optional forensic course

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Undergraduate medical education

• Future ideas
• integrate more CPCs into curriculum
• create library of computer-based cases for
  self-study or make available as a teaching
  resource
• digital technology lots of possibilities

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Summary

• Educational advantages of a combined
  forensic/hospital autopsy service
• more cases
• greater variety of pathology
• different approach/objectives/reporting
• Multiple ways of teaching delivery customized to
  the type of student

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the end