Our study shows that a brief intervention can improve the accuracy of death certificate completion by medical students. These findings are consistent with other studies involving interventions with resident and non-resident physicians.3
To our knowledge, only two studies have evaluated an intervention with medical students,8
both conducted in Europe and more than ten years ago.
The two previous studies conducted on medical students were performed in Spain and the United Kingdom. Miron Canelo et al. used an informative seminar for 175 medical students at the University of Salamanca, Spain.8
This study showed that the seminar improved the quality of death certificates after the seminar in sixth-year medical students. Pain et al. involved 175 first-year medical students with little clinical experience and included the use of a training video in addition to the usual lecture.9
The video added little statistical improvement on a test measuring knowledge and skill in death certification (p = 0.046) but raised participants’ knowledge that inaccurate death certificates can cause distress to relatives.
Previous studies have used varying methods to assess their interventions’ success. Many studies have used error rates, both major and minor, as criteria.3
Our study used a modified version of the MAHI Death Certificate Scoring System previously used by Lakkireddy D et al.1
This scoring system was established by the College of American Pathologists, the National Association of Medical Examiners and the National Center for Health Statistics.
In previous studies, cardiac causes are generally overstated as a cause of death. In one study, cardiac cause of death was inaccurately reported 45% of the time.1
Cardiac pathology is generally the MTE and not the COD. In our study, cardiac causes were inaccurately listed as COD 65% of the time pre-intervention versus only 2.4% post-intervention. Post-tutorial, 112 (91.06%) students correctly identified an infectious primary COD (). In the United States, cardiovascular disease and disease of the heart have been recorded as the most common causes of death for the past several years.11
Based upon our data and previous studies, the inaccurate recording of cardiac pathology could be an underlying reason for the increased incidence of cardiovascular death in the United States.
Distribution of Primary Cause of Death Pathologies
The subjective survey data also showed a surprising change in attitude with respect to death certificates. Despite every student's having some limited exposure to death certificates as second-year medical students during a community health class, less than one third mentioned or acknowledged this experience. Before the tutorial, 14% of the students indicated comfort with completing a death certificate, whereas post-tutorial that number increased to 93%.
Our intervention also produced a clear change in the medical students’ understanding of the importance of the death certificate (). When asked about the significance of death certificates before the intervention, legal importance was listed 36% of the time and statistical purposes only 23%. Post-tutorial, when asked the same question, legal importance fell to 19% and statistical purposes rose to 44%. Of all the reasons given, only legal and insurance significance fell post-tutorial.
Distribution of Death Certificate Importance
Unfortunately, our study did not evaluate participants’ ability to maintain the knowledge that they gained through the tutorial. Ideally, students should be re-evaluated in yearly increments, even into post-graduate clinical training. One would assume that practicing physicians and senior residents with advanced experience and medical knowledge would complete more accurate death certificates. However, one study showed that this experience did not appear to improve death certificate completion.12
Several other studies have shown that interventions improve performance in post-graduate physicians.3
Generally, these interventions have been of longer duration or on a voluntary basis. The question arises as to whether such a brief tutorial as ours would be as effective in physicians. Secondary to the self-study and web-based nature of the tutorial, we believe that this intervention would be fruitful, but further studies would need to be performed to confirm this.
Our greatest concern is that when medical students become residents they are often required to complete death certificates without any formal training. Third-year clinical rotations could include death certificate training; training could also be offered during residency orientation similar to Advance Cardiac Life Support or computer training. Similar to dictations and other chart work, death certificates should be reviewed by attending-physicians and proper completion discussed with residents. Completion of the death certificate should also routinely be included in Morbidity and Mortality conferences and could be used as a teaching tool during rounds.