Undergraduate teaching of forensic medicine in Saudi Arabia

Introduction

Medicine and law are inextricably linked. Lawyers need medical knowledge, and health professionals need some knowledge of the law. For example, health professionals require ethics to practice their profession, and they need to know what to do and what not to. There are also cases where doctors act as expert witnesses in medico-legal cases. Those who work in forensic medicine must complete more training to perform their work as experts. ¹

Although the activity of forensic work is not exclusive to forensic medical experts, any physician may encounter medico-legal issues. The practice of medicine therefore needs robust education in legal issues. ¹ In Saudi Arabia, there is an increase in medico-legal issues as a result of the increasing population and changes in social structure. There are not enough Saudi doctors in the field of forensic medicine.^2,3 Forensic medicine needs are now more important than ever for the country. Such needs must be addressed to prepare graduates for the future. This should be undertaken by institutions at the undergraduate level.^1,4

A total of 30 universities – 25 governmental and five private – have medical colleges accredited by the Ministry of Higher Education in Saudi Arabia. ⁵ However, we do not know how effective they are in teaching undergraduate forensic medicine and medico-legal issues. No data are available, and previous research has not been undertaken in this area.

The aim of this study was to research undergraduate training courses in forensic medicine in Saudi universities.

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Table 1.

The questionnaire.

1. How do you teach the forensic medicine course?

2. In which year is the course being taught?

3. Is there a department of forensic medicine?

4. If the answer to Q3 is no, under which department does forensic medicine belong?

5. How long is the forensic medicine course?

6. How many credit hours are there for the forensic medicine course?

7. How many lectures are there per week?

8. Is there a practical part to the course (autopsy and morgue visits)?

9. Is the course taught in other colleges (e.g. dentistry or nursing)?

10. How many teachers are there for the course?

11. Are the teachers employed full time?

12. What are the teachers’ qualifications for the forensic medicine course?

13. What are the teachers’ nationalities?

Methodology

We conducted a cross-sectional study in September 2013. This study included all colleges of medicine in Saudi Arabia. A total of 30 universities with medical colleges – 25 governmental and five private – were invited to participate. A structured self-administered questionnaire containing 13 items relating to the undergraduate forensic medicine course was used (Table 1). The questionnaire contained mainly closed questions as well as some open-answer queries.

Deans of the medical colleges were asked to complete the questionnaire by e-mail. An eight-week period was given to respond and return the questionnaire. Wherever possible, university websites were checked for information. All data were analysed using SPSS Statistics for Windows v.16.0 (SPSS, Inc., Chicago, IL).

The study was approved by the university authority and Institutional Review Board. We offered all medical colleges the opportunity to participate and benefit from the results. Management of the information was confidential, and did not identify the name of the academic institution. Finally, to maximise the benefits of the research and allow for qualitative changes to society, a report will be sent to each medical college that participated in the study.

Results

Out of a total of 30 universities, 27 responded. All questionnaires were completed fully, with no missing or unanswered questions. Of the 27 universities that responded, 16 (59.26%) teach forensic medicine to undergraduate medical students, and 11 (40.74%) do not teach forensic medicine in their undergraduate curriculum.

None of the 27 universities that responded has a department of forensic medicine. The universities that do not teach forensic medicine have no forensic medicine unit/division or faculty at all. Of the other 16 universities, forensic medicine belongs to the pathology department in 11 universities, to the pharmacology department in two universities, and, for the remaining three, to the internal medicine department, family and community medicine department, and biomedical sciences department.

Of the 16 universities that teach forensic medicine at the undergraduate level, 11 (68.8%) teach forensic medicine as an independent course, while five (31.3%) teach it either within the pathology curriculum or within modules.

The course is mainly taught in the fourth year by 11 (68.8%) universities, while it is taught in the third year in two (12.5%) universities; two (12.5%) also teach it in the fifth year. Only one university teaches forensic medicine in different years within a module in the second, third, and fourth years.

With regard to the length of forensic medicine course, seven (43.8%) universities teach it for one semester, five (31.3%) teach the course within modules (weeks), while four (25%) teach it for a full academic year. The number of lectures per week varied from university to university.

Regarding credit hours for the course, we only considered the 11 universities that teach forensic medicine as an independent course because for those that teach forensic medicine in modules, the credit hours are given for the whole module. So, out of these 11 universities, seven valued the forensic medicine course at two credit hours, two universities at one credit hour and two universities at three credit hours.

For the practical part and morgue visit, 7/16 (43.8%) universities have practical sessions. The remaining nine (56.3%) universities only teach the theoretical part of forensic medicine.

All 16 universities teach forensic medicine only to medical students and not to other colleges such as dentistry and nursing.

Regarding the number of faculty members who teach forensic medicine, nine universities have two faculty members, six have one faculty member, and one has three faculty members. Thirteen (81.3%) universities have full-time faculty members, whereas three have part-time faculty. Only two universities have Saudi faculty members, one at each university; all others have non-Saudi faculty members. All the faculty members are qualified medical doctors with a postgraduate degree in the specialty of forensic medicine.

Discussion

More than half of the medical colleges teach forensic medicine to undergraduate medical students in Saudi Arabia, although forensic medicine is traditionally considered a low-priority subject in medical college. ⁶ Major academic countries such as the USA and the UK have standards for the medical curriculum and objectives to achieve. This is true in Saudi Arabia where the universities and medical colleges should follow the National Commission for Academic Accreditation and Assessment (NCAAA) standards. However, variation in subjects taught may occur. ⁷

Different countries vary in how they teach forensic medicine to undergraduates. In Germany, forensic medicine is traditionally taught to medical students, although the content has been reduced recently. ⁸ Portugal and most European countries teach forensic medicine to undergraduate students. ⁹ In Asia, forensic medicine is taught as a major subject in countries such as India and Sri Lanka.^10,11

Depending on the law and judicial system, the teaching of forensic medicine may vary from one country to another. In some countries, any medical practitioner can be called for medico-legal work. In such cases, previous exposure to forensic medicine during undergraduate studies plays a crucial role, as such exposure will be necessary to acquire the required skills. A study in Turkey regarding self-perceived competence levels of junior medical doctors reported poor competence in skills and conducting forensic post-mortem examinations. The study concluded that increasing skills training in undergraduate medical education may increase the competency level of medical students. ¹²

Due to the fact that in medical practice the physician must be in contact with the law, it is crucial that medical students have training concerning their legal duties. The forensic medicine curriculum should provide proper orientation to medico-legal cases.^9,13

There is no department of forensic medicine in Saudi universities. The main role of forensic medicine in Saudi universities is purely teaching, while autopsy and field casework is the duty of forensic medicine centres at the Ministry of Health. ² This is why there is no forensic medicine department at Saudi universities. There is a long-standing belief that there is no need for forensic medicine in the academic discipline, although this idea has changed recently worldwide. ¹⁴ We believe that universities should participate in casework and play a major part in research in addition to activating branches of forensic medicine (e.g. toxicology, clinical forensic medicine) and not limit it to forensic pathology. All of these are reasons to call for establishing forensic medicine departments and activating their roles.

Despite different studies showing the role of autopsy in medical education, fewer than half of the universities in Saudi Arabia that teach forensic medicine comprise a practical part and morgue visit. Medical students appreciate autopsy as a learning objective. However, little research has assessed the definite impact of autopsies on current medical practice. ¹⁵

None of the universities teach forensic medicine in nursing or dental colleges. With the recognition of the legal implications on health issues, different health specialties have started to include basic forensic knowledge in their educational programmes. This was perceived as a crucial factor that aids in delivering justice. Forensic nursing education has started after much research that indicated the need for such a specialty. In North America, colleges and universities offer formal and informal educational programmes. Online educational courses were developed, and universities have started to offer doctorate-level courses in forensic nursing. The role of a forensic nurse mainly includes evidence collection, documentation, interviewing skills, and testifying in court.^16,17

A previous study in Saudi Arabia surveyed Saudi nurses who were working in the emergency department in the area of Dammam and Qatif, Eastern province of Saudi Arabia, about their attitude towards forensic nursing. The majority of participants had not received any forensic lectures, and 77% thought that forensic nursing should be included in the nursing curriculum. The study recommended including lectures on forensic nursing in the nursing curriculum, and stressed the positive effect of this initiative on the advancement of forensic practice in Saudi Arabia. ¹⁸

With the worldwide spread of natural and man-made disasters, the need for forensic training of dental students was perceived as fundamental. Courses stressing on fatality identification, disaster preparedness, and bite-mark analysis are conducted. ¹⁹ Standardising forensic teaching is needed for better forensic dental practice in post-disasters. ²⁰ As no community is exempt from disasters, colleges of dentistry in Saudi Arabia should take part in the globalisation of forensic dentistry education and consider including forensic dentistry courses in the curriculum.

Conclusion

Teaching forensic medicine to undergraduates is not only important, it is necessary in many countries. By law, any medical graduate may face medico-legal work. More research is needed about the method and curriculum design in forensic medicine, as well as standardising forensic medical education. In addition, more research about the current role of autopsy in medical education is needed.

Saudi universities should make more effort to enhance education on medico-legal issues and conduct more research to discover the quality of these courses. Forensic units at universities in Saudi Arabia should collaborate with forensic medicine centres at the Ministry of Health so that practical, research and education aspects are met.

The implementation of forensic courses in dental and nursing colleges in Saudi Arabia should be started, and more studies should be conducted to discover if Saudi doctors avoid forensic medicine as a specialty and, if so, why this might be.