Undergraduate medicines legal wrangle

Teaching in forensic medicine is woefully lacking at undergraduate level and this has serious implications for us all, says Richard Jones

Forensic medicine is the medical specialty that links medicine with the law, incorporating forensic pathology (a subspecialty of histopathology) and clinical forensic medicine. Over the past 50 years forensic medicine as an academic subject has been in slow (some would say terminal) decline. In fact, newly qualified doctors probably start practising without having received even a basic grounding in medicolegal matters. In today's increasingly litigious society, this is a serious matter.

The late professor of forensic medicine at Guy's Hospital, London, Keith Mant, was often outspoken about this decline. He was frustrated that forensic medicine was losing out to other subjects in the “overcrowded curriculum” that were of no practical use to students once they qualified. Medicolegal problems, however, will be encountered by junior doctors, whatever branch of medicine they choose to specialise in.²

Examining a homicide victim

Medicolegal procedures include examination of assault victims (including sexual assault), certification of death, reporting a death to a coroner, writing medicolegal reports, and giving evidence in coroners' and other courts. Unfortunately, concerns have been raised on several occasions about doctors' ability to complete death certificates correctly (see studentBMJ 2002;10:54-7), and deal with medicolegal matters in general: the Harold Shipman inquiry and the recent Home Office review of the death certification process highlight societal concern about the recording and certifying of death. Embarrassingly, we cannot even describe wounds correctly.⁸

A forensic pathologist gives evidence t the Louise Woodward trial

Many experts link the decline in the teaching of forensic medicine at undergraduate level to the removal of the subject from final qualifying examinations at medical school and the loss of status that this produced.^{3 11} Other subjects mushroomed and the “service requirements” of forensic pathology departments caused universities to question funding arrangements, causing further contractions of academic staff. A recommendation by the report of the working party on forensic pathology,¹² finding that the service need not be provided within the NHS framework, caused further changes to the way in which forensic pathology services were delivered: now there are no longer any academic departments left in London.

The late Professor Keith Simpson and Professor Keith Mant set out the medicolegal knowledge that they considered medical undergraduates should be familiar with (see box).^{2 13}

The modern medical undergraduate curriculum does attempt to cover medical ethics thoroughly, and most students receive at least some instruction in the completion of a death certificate. “Practising within a legal framework,” however, and the role of the coroner and the giving of evidence, are not well covered. Despite all students undertaking rotations within accident and emergency departments and trauma medicine, the curriculum gives scant attention to wound identification and interpretation.

Interested students may pursue special study modules in forensic medicine (assuming their medical school still has teachers in this area) or even, if they go to Dundee Medical School, an intercalated degree. Final year electives can also be spent in forensic medicine units worldwide, but most students feel that a clinical attachment offers the best chance to practise clinical skills before finals.

A forensic pathologist runs DNA tests

Most students are, therefore, at a disadvantage when they start their junior hospital posts because of the deficiencies in medicolegal training at medical school. For those who are suited to self directed learning, there are several clinically oriented textbooks on forensic medicine available, but without formal teaching in this subject area the principles of forensic medicine will not be adequately reinforced.

If the decline of forensic medicine at undergraduate level is allowed to become complete the medical profession is bound to come under more intense public scrutiny. The knock-on effect on justice of our inability to deal with medicolegal issues should not be underestimated. If we do nothing, our failings will surely be added to that increasing list of things that the media “bash” us with.

Richard Jones is the creator of www.forensicmed.co.uk which provides medical students with educational materials about forensic medicine. He was also an organiser of the EMSA forensic medicine conference held at Guy's Hospital on 16 March 2002.

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