A major milestone and rite of passage for thousands of medical students is eminent or has recently come to pass. For the last 3 ½ years, they have successfully cleared many major educational hurdles. They have waited anxiously for the day to find out where the next chapter of life will unfold.
That day…is Match Day. After graduation, they will begin a rigorous period of training as residents, and continue the journey on to becoming our future physicians.
Our health and therefore quality of life depends upon competent medical care. How ready will our future doctors really be to care for us, during life and at death? This will depend on the strength of resident training programs, particularly in the primary specialties like internal medicine, family medicine, pediatrics, obstetrics/gynecology geriatrics, and emergency medicine. This will also depend on their educators, their trainers, who carry out the educational goals of the training program for that medical specialty. Trainers will expend enormous time and effort to teach the medical resident about patient care and how to diagnose and treat disease and injury with the goals of prolonging life, increasing the quality of life, and preventing death. Unfortunately, this leaves little opportunity to give in-depth instruction on an important end-of-life patient care duty: proper death reporting and certification. Death is a daily reality and an eventuality, even after the best of clinical efforts. But what we learn from death importantly can and does aid the living.
With the ever-dwindling rate of hospital autopsies created by the veil of better diagnostic tools (better scans, better tests, better and quicker results etc.), the enthusiasm of physicians to become educated on proper death certification also continues to decline, a sentiment that “rubs off” on impressionable trainees 1,2. Despite this, the autopsy remains the gold standard and the quality assurance tool for understanding disease processes and identifying the actual cause of the patient’s death 2.
But just how trained are the trainers? Are they prepared to educate doctors-in-training on how to:
- educate families about the benefits of the autopsy and obtain consent for one 3 ?
- utilize the expertise of the hospital pathologist and forensic pathologist to gain understanding of the lethal potential of disease as demonstrated by the autopsy 3 ?
- locate and apply the legal statutes that mandate reporting certain deaths to the Medical Examiner or Coroner (ME/C) 3 ?
- locate and apply the legal statutes that mandate the physician-of-record to certify deaths that do not fall under the jurisdiction of the ME/C 3 ?
- access resources on death reporting and death certification provided by ME/Cs and local and state Vital Statistics agencies?
- compose an acceptable and defensible cause-death-statement on the death certificate 3 ?
- execute role as stewards of public health?
As part of a comprehensive curriculum, resident training programs must begin or continue to make routine efforts to increase proficiency in death reporting and death certification and include this as a core competency milestone requirement of graduate medical education in the primary care specialties 4. This is necessary in order to increase the accuracy of the information derived from death certificates such as the leading causes of death, disease patterns, and outcomes of the many types of medical intervention. It cannot be overstated that the cause of death information provided on death certificates directly influences mortality data, disease surveillance and fund allocation for health programs. Traditional lectures, morbidity and mortality conferences, and online courses and tutorials can be used as platforms of instruction throughout the years of clinical training and beyond. Demonstration of competency in death reporting and certification, just like for any medical procedure, should be required, not voluntary.
- Wexelman BA, Eden E, and Rose KM. Survey of New York City resident physicians on cause-of-death reporting, 2010. Prev Chronic Dis. 2013;10:E76. Available at: https://dx.doi.org/10.5888%2Fpcd10.120288 .
- Burton EC. The autopsy: a professional responsibility in assuring quality of care. Am J Med Qual. 2002. Mar-Apr; 17(2):56-60.
- Armstrong EJ. Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner Chapters 3, 5, 7 and 8. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
- Accreditation Council for Graduate Medical Education (ACGME) Milestones Guidebook. Available at: https://www.acgme.org/Portals/0/MilestonesGuidebook.pdf .
A valuable resource! Follow the link and get your copy: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408