how do clinicians learn to request permission for autopsies?

231 MEDICAL EDUCATION 1995, 29, 231-234

How do clinicians learn to request permission for autopsies?

S J Shemood', R D Stad, K S Bird?, D W K Cotton' G, D Bunce' 'MRC/ESRC Social and Applied Psychology Unit, Department of Psychology and 'Department of PathologyUniversity of Sheffield, UK

SUMMARY by which clinicians learn to request autopsies and to assess the preferred techniques and timing of appropriate communication skills training. A postal survey of 434 clinicians at four local hospitals

was undertaken in order to identify the methods by which clinicians learn how to request permission for hospital autopsies and to assess the preferred techniques and timing of relevant communication skills training. The majority of 128 responding clinicians had learnt through personal experience with some assistance from senior colleagues and peers. Few clinicians appeared to have learnt through formal training. The preferred methods for the provision of communication skills training were training in small groups (such as seminars or tutorials) and observation of clinicians at work. The most desirable time for the provision of this training was considered to be between the beginning of the final undergraduate year and the end of the pre-registration house officer year. The communication skills training provided within medical education is in need of improvement. More emphasis should be given to clinical-task- or situation- specific applications such as requesting permission for autopsies.

METHODS

The study was conducted in four local hospitals in which permission for autopsy is requested by clinicians of all grades. Information obtained from a review of the litera- ture and preliminary semi-structured interviews with clinicians was used to construct a postal questionnaire. The clinicians were asked to indicate the level of their personal exposure to seven methods of learning how to make an autopsy request. The clinicians were then asked to indicate the desirability of various teaching methods for communication skills relevant to requesting autopsies and the preferred timing of such training. Responses were measured using 7-point Likert scales. A within-subjects analysis of variance was used to detect differences between the mean response scores for each item. Post-hoc comparisons of the mean response scores were performed using the Tukey HSD test.

Keywords

clinical medicine/*educ; *education, medical, under- RESULTS graduate; *autopsy; *informed consent; persuasive communication; England A total of 134 clinicians (50 consultants, 19 senior regis-

trars, 20 registrars, 26 senior house officers, 10 house

INTRODUCTION

Clinicians have a central role in determining clinical autopsy rates (Peacock et al. 1988). Some clinicians are reluctant to request autopsies because of the personal discomfort experienced when approaching bereaved relatives for consent (Lundberg 1984; Sherwood 1993). Those clinicians who do seek permission for autopsies often cannot provide adequate reassurance regarding the fears and reservations expressed by relatives.

Many studies have highlighted the problems of obtain- ing permissions for autopsies but these have generally not appreciated the importance of how clinicians learn to request autopsies (Chana et al. 1990; Champ et al. 1992). This study was conducted in order to identify the methods

officers and 9 other clinicians) completed the questionnaire after a single reminder. This represented a response rate of 31%. Six incomplete questionnaires were excluded from the study. The number of clinicians marking each item response is indicated in Tables 1-3.

Many respondents reported that they had learnt to request autopsies through personal experience with some assistance from senior colleagues (Table 1 : items 1-3). The mean response score for personal experience was significantly higher than the scores for all other methods (HSD (7,630) = 0.568, P < 0.05). Few clinicians appeared to have learnt through formal training (Table 1: item 7) and the mean response score for this item was significantly lower than for all other methods (HSD (11,1090) = 0.642, P < 0.05).

The preferred methods of providing communication

Correspondence: R D Start, Department of Pathology, University of Sheffield Medical School, PO Box 596, Beech Hill Road, Sheffield S10 ZUL, UK


Table 1 Extent to which clinicians had learnt to request autopsies via different methods

Aggregated responses*

Item Learning methods Insignificant extent Equivocal Significant extent Mean** (ratings 1-3) (rating 4) (ratings 5-7) score

1 Personal experience 3 2 Advice offered by senior clinicians 67 3 Advice requested from senior clinicians 66 4 Observation of senior clinicians at work 79 5 Advice requested from peer group 79 6 Observation of peer group at work 83 7 Formal training 113

8 113 21 30 25 24 14 25 12 22 6 26 0 2

6.1 5 3.14 2.94 2.86 2.74 2.63 1.24

Likert scale ratings ranged from 1 = not at all to 7 = to a large extent. **A within-subjects analysis of variance indicated that there were significant differences between the extent to which clinicians had learnt via the different methods (F(6,630) = 12053; P < 0.001).

Table 2 Desirability of various teaching methods for communication skills training


Item Teaching methods Undesirable Equivocal Desirable Mean** (ratings 1-3) (rating 4) (ratings 5-7) score

1 2 3 4 5 6 7 8 9

10 11

Small groups Accompany a clinician Group discussion Video demonstration Use of video feedback Role-playing Demonstrations by mo Use of group feedback Written guidelines Use of audio feedback Lectures

'dels

7 17 17 17 32 35 33 29 48 45 72

14 14 21 23 30 21 27 34 31 31 24

100 90 81 79 56 64 54 53 41 40 23

5.56 5.30 4.98 4.87 4.45 4.43 4.28 4.2 7 3.86 3.78 3.06

* Likert scale ratings ranged from 1 = highly undesirable to 7 = highly desirable. **A within-subjects analysis of variance indicated that there were significant differences between the desirability of the various methods (F(lOJ090) = 24.71;P < 0.001).

skills training were training in small groups (e.g. seminars or tutorials) and observation of clinicians at work on an individual basis (Table 2: items 1 and 2). More active methods, such as demonstration video sessions, video feedback sessions based on the performance of partici- pants and role-play techniques, were found to be more desirable than the more passive training methods such as written guidelines and lectures. The mean response score for the lecture method was significantly lower than for all other methods (HSD (11,1090) = 0.642, P < 0-05).

The provision of formal training was thought to be most appropriate in the period between the beginning of the final undergraduate year and the end of the pre-registration house officer year (Table 3: items 5-7). Training

within this period was significantly more desirable than at the other suggested times (HSD (8,742) = 0-675, P < 0-05).

DISCUSSION

Most of the clinicians in this study reported no personal experience of formal training in how to obtain permission for autopsies. This observation is supported by other studies and is a clear indication of the failure of medical education to provide the necessary communication skills training required for clinical practice (jolly & MacDonald 1989; Chana et al. 1990; Birdi 1992). The few detailed assessments of formal communication skills

Requesting permission for autopsies Sy Sherwood et al.


Table 3 Desirability of communication skills training at various stages within medical education

Item Stage

~~


Undesirable Equivocal Desirable Mean** (ratings 1-3) (rating 4) (ratings 5-7) score

First undergraduate year Second undergraduate year Third undergraduate year Fourth undergraduate year Fifth undergraduate year Induction session prior to pre-registration year During pre-registration house officer year After pre-registration year

92 85 68 49 12 18 16 44

1s 16 16 23

8 7

13 20

4 10 31 46

101 93 91 51

1.89 2.20 3.03 3.80 5.65 5.49 5.51 4.04

~~

* Likert scale ratings ranged from 1 = highly undesirable 7 = highly desirable. ** A within-subjects analysis of variance indicated that there were significant differences between cEicians’ preferences regarding the timing of communication skills training (F(7,742) = 92.17; P c 0.001).

training in this country have mainly concentrated on undergraduate education and have not reviewed the attitudes or needs of clinicians at more advanced career stages (Whitehouse 1991; Frederikson & Bull 1992). Such information is essential both to evaluate the current provision of communication skills training and to enable a detailed review of the communication skill require- ments of future clinicians.

The effectiveness of communication skills training is dependent on the method of provision and the complex- ity of the required skill (Maguire 1990). Autopsy requests are complex procedures and the preferred methods in this study were training in small groups (e.g. seminars or tutorials) and observing clinicians at work on an individual basis. These methods are already employed in some medical schools but with no formal commitment to provide situation-specific training for procedures such as autopsy requests (Jolly & MacDonald 1989; Whitehouse 1991; Frederikson & Bull 1992). Training in how to undertake autopsy requests should begin at the appropriate stage of the undergraduate curriculum when medical students are introduced to the autopsy and should include information relating to the continuing importance of autopsies to modern medicine (Start et al. 1992). The provision of relevant communication skills training throughout the subsequent years would be ideal but our observations indicate that specific training in relation to autopsy consent should be concentrated in the period from the final undergraduate year to the end of the pre- registration house year. The identification of this partic- ular period may be a consequence of the unacceptable but very common practice of routinely delegating autopsy requests to junior clinicians. These doctors may not have gained sufficient practical experience to manage situations like the autopsy request and the provision of

appropriate postgraduate communication skills training would be of considerable benefit (Jolly & MacDonald 1989). Senior clinicians also have a responsibility to provide additional practical training for their junior colleagues. Many clinicians adopt a fixed style of communication early in their medical careers and the development of an effective style through accepted forms of specific training must be preferable to an unsatisfactory style which requires modification later (Byrne & Long 1976). Additional training in relation to autopsy requests at this time would also remind junior clinicians of the importance of autopsies and may serve to increase interest in autopsies.

While many clinicians, particularly those in junior grades, appear to want more instruction in how to approach relatives for autopsy consent (Wilkes et al. 1990; Hinchliffe et al. 1994), others do not consider the provision of specific training for autopsy requests to be a priority within the limited time available for communication skills education. Many respondents in this study indicated that training in autopsy requests would be less desirable than instruction in other areas of bereavement such as how to talk to patients and relatives about death, how to break bad news and how to cope with angry or distressed relatives and their complaints about patient management. Training in autopsy request procedures must form part of a comprehensive programme designed to provide a range of communication skills appropriate to dealing with death and the dying (Field 1984; Tolle et al. 1984; Black et al. 1989). Our observations indicate that more emphasis may have to be given to clinical-task- or situation-specific applications such as requesting permission for autopsies. These skills are essential if clinicians are to be capable of approaching the difficult situations that arise in relation to bereavement with the necessary confidence and competence (Maguire 1990).

Requesting permission for autopsies SJSherwood et al.


Some communication skills, such as the breaking of bad news, are transferable between different areas of clinical practice (Buckman 1984). Autopsy requests repre- sent a clinical-taskhituation-specific application for communication skills training that is probably not directly transferable to other areas and which therefore requires specific attention. The focused nature of clinical- taskhituation-specific communication skills training may serve to facilitate the application of acquired know- ledge and skills to the relevant real-life situations (Jolly & MacDonald 1989). Provision of training in how to request permission for autopsies has been shown to con- tribute to the improvement of autopsy rates (Clayton & Sivak 1992). Clinicians with little or no interest in autopsies may still have to inform relatives of the requirement for a medico-legal autopsy and all clinicians must therefore be equally capable of providing adequate reassurance regarding the autopsy to bereaved relatives.

The process of requesting an autopsy from recently bereaved relatives is stressful and any sense of personal discomfort will decrease the motivation of clinicians to request autopsies (Birdi 1992; Sherwood 1993). Those clinicians who have received appropriate training may have more confidence and consequently may be more willing to take the time to educate relatives in the nature and the importance of the autopsy. The manner in which permission for autopsy is sought is important and can influence the decision of the family in approximately one- third of cases (Gardner et al. 1973). Any significant improvement in autopsy requesting techniques should stimulate more autopsy requests of a higher standard. Increasing the number of autopsy requests is probably the only basis upon which autopsy rates will be improved.

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Received 13 May 1994; editorial comments to authors 26 Augusr 1994; accepted for publication 27January 1995

Requesting permission for autopsies SJSherwood et al.

how do clinicians learn to request permission for autopsies?

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