Teaching forensic pathology to undergraduates at Zhongshan School of Medicine

Abstract

Producing qualified forensic pathological practitioners is a common difficulty around the world. In China, forensic pathology is one of the required major subspecialties for undergraduates majoring in forensic medicine, in contrast to forensic education in Western countries where forensic pathology is often optional. The enduring predicament is that the professional qualities and abilities of forensic students from different institutions vary due to the lack of an efficient forensic pedagogical model. The purpose of this article is to describe the new pedagogical model of forensic pathology at Zhongshan School of Medicine, Sun Yat-sen University, which is characterised by: (a) imparting a broad view of forensic pathology and basic knowledge of duties and tasks in future careers to students; (b) educating students in primary skills on legal and medical issues, as well as advanced forensic pathological techniques; (c) providing students with resources to broaden their professional minds, and opportunities to improve their professional qualities and abilities; and (d) mentoring students on occupational preparation and further forensic education. In the past few years, this model has resulted in numerous notable forensic students accomplishing achievements in forensic practice and forensic scientific research. We therefore expect this pedagogical model to establish the foundation for forensic pathological education and other subspecialties of forensic medicine in China and abroad.

Keywords

Forensic pathology forensic education undergraduate education pedagogical model

Background

Forensic medicine, an essential specialty for the presentation of medical evidence in court, encompasses various subspecialties that involve resolving legal issues using diverse techniques. Currently, five main branches comprise the disciplinary structure of forensic medicine: forensic pathology, forensic biology, forensic clinical medicine, forensic psychiatry and forensic toxicology. Additionally, subspecialties such as forensic dentistry, forensic anthropology and forensic entomology play increasingly important roles.

Forensic pathology is a key subspecialty of forensic medicine as well as medico-legal practice, which mainly deals with the deceased.¹ The model for producing forensic pathology practitioners varies from different districts, education systems and justice systems. In terms of forensic education based on British models, medical undergraduates are supposed to receive lectures and tutorials in forensic pathology and then take an examination during their third or fourth years,¹ where the forensic pathology curriculum is most likely elective for those students interested in forensic practice. Contrarily, the Chinese medical education system offers forensic medicine as a major subject, specifically educating undergraduates for five years, including forensic pathology, forensic psychiatry, forensic serology and other related subspecialties. However, imbalanced development and unequal allocation of resources, manpower and funds among institutions has led to variance in students’ professional qualities and abilities.

Zhongshan School of Medicine at Sun Yat-sen University was one of the earliest medical schools to initiate the forensic medicine specialty in China. However, educational globalisation, allowing communication and cooperation among the top medical schools, revealed limitations and drawbacks of didactic Chinese forensic pedagogy. Lack of available books, lab manuals and teaching materials² and insufficient emphasis on practice had critically hindered the development of Chinese forensic students. From 2001 to 2002, widespread reform of medical pedagogy was carried out among the top Chinese medical schools,³ with Zhongshan School of Medicine at Sun Yat-sen University significantly contributing to this reform.⁴ This included a revitalisation project by the Department of Forensic Pathology.

Herein, we introduce the pedagogical model initiated by the Department of Forensic Pathology at Zhongshan School of Medicine, Sun Yat-sen University, on the forensic pathology curriculum in order to provide a Chinese forensic pedagogical model for other forensic medical schools in China and abroad.

Course design

Zhongshan School of Medicine annually enrols approximately 30 students majoring in forensic medicine through the College Entrance Examination. After five years of systematic study in the field of forensic medicine, these students receive the diploma of Bachelor of Medicine.

The forensic pathology curriculum is designed for undergraduates studying in their fourth year. Before that, all students are expected to complete a three-year course in basic medicine, such as anatomy, histology and pathology, so that it will be easier for them to learn from a forensic perspective. Subsequently, all students are sent to local public securities for their internship, where they have the opportunity to learn and to solve actual forensic issues. The course was originally taught during their fifth year, following the completion of students’ internship, but feedback from both students and teachers was negative, since students had little forensic awareness and few forensic skills. Thereafter, this course is now taught during the fourth year, before their internship, which helps students to build up a framework of forensic practice and then to consolidate forensic knowledge in practice.

Course content

Currently, the course textbook is the fourth version of Forensic Pathology.⁵ Twenty-two chapters are taught to students. After reassignment, we arrange 11 lectures (Table 1) and nine practical courses (Table 2), and at the end of this curriculum, students take both theoretical and practical examinations.

Table 1.

Course design of lectures.

Lectures	Topics	Contents and demands
1	Introduction	Being familiar with the basic concept of forensic pathology and primary knowledge of forensic tasks, skills and techniques. Learning to deal with medico-legal issues.
2	Death and posthumous changes	Knowing the following concepts and points: the classification and diagnostic standards of death, brain death and apparent death, posthumous changes in the early or late phase.
3–4	Mechanical injurya	Being familiar with concepts of various injuries caused by sharp instruments, blunt force, firearms and traffic accidents. Knowing the techniques to identify causal instruments, to judge ante-mortem injuries and to estimate survival period after wounding.
5–6	Mechanical asphyxiab	Knowing the general mechanism and posthumous features of mechanical asphyxia, such as hanging, strangulation and drowning, etc., paying particular attention to distinguishing suicide from homicide.
7	Physical injury	Focusing on burning and burning to death, frostbite and death from cold, electric death and death from lightning.
8–9	Sudden unexpected deathc	Knowing the diagnostic points of sudden unexpected death due to different systematic anomalies. Being familiar with exceptional types such as SUNDS and SINDS.
10	Medical tangle	Being aware of the cause of medical tangle and how to deal with it in terms of forensic pathology.
11	Forensic anatomy	Being skilled in forensic autopsy, microscopy and reservation of biological samples, especially being familiar with autopsy procedure of exceptional death.

^aAs for mechanical injury, part 1 is to familiarise student with the concepts and features of various mechanical injuries, while part 2 is for student to master techniques in identifying causal instruments, judging ante-mortem injuries and estimating the survival period after wounding.

^bIn the topic of mechanical asphyxia, part 1 is about hanging, strangulation and other types of asphyxia, while drowning is separate as a single part.

^cSudden unexpected death is divided according to the causal system: cardiovascular system, respiratory system, nervous system, alimentary system, endocrine system and urogenital system. In particular, exceptional types such as SUNDS and SINDS are also included.

Table 2.

Course design of practical courses.

Courses	Topics	Contents	Tasks
1–3	Reviews	Anatomy	Reviewing anatomy by observing specimens.
		Histology	Reviewing histology by observing normal tissues under a microscope.
		Pathology	Reviewing pathology by observing abnormal specimens and tissues.
4	Posthumous phenomena		Sacrificing animals, then observing and recording posthumous changes that have happened to their bodies – temperature, cornea, rigor mortis, etc. – at different time points.
5–6	Mechanical injury	Falling	Designing and implementing an animal model of falling from high altitude. Generalising common features of death due to falling from height.
5–6	Mechanical injury	Aeroembolism	Designing and implementing an animal model of aeroembolism. Mastering the special procedure of dissecting the deceased in cases resulting from aeroembolism.
7–8	Mechanical asphyxia	Diatom examination	Mastering the method of morphological diatom examination.
7–8	Mechanical asphyxia	Positional asphyxia	Keeping animals in a peculiar position until death, and observing their physiological changes before dying and posthumous changes on viscera.
9	Physical injury	Electric shock	Observing animals’ behaviour and physiological changes when receiving an electric shock. When dissecting, paying attention to morphological changes of the electrified area.

Lectures

The purpose of lectures is to ensure students acquire and manage forensic knowledge and are qualified to be forensic practitioners. In terms of the content, lectures comprise three main parts. The first part is an introductory lecture where teachers introduce the history, concept and tasks of forensic pathology. In the second part, students acquire the primary knowledge of all aspects of forensic pathology. In order to standardise and facilitate teaching and learning, a ‘three-step’ format is adopted in lectures. First, the concept of a certain kind of injury or death is introduced and explained in detail, as well as the causal mechanism. Students are then taught explicitly about the characteristics of injuries or death, which is the most important part for students. Furthermore, microscopy is necessary on account of minor anomalies being undetectable to the naked eye, so that features of changes among tissues and cells are not be ignored. In the third part, students are taught about three key areas: (a) how to perform forensic autopsy and reserve biological materials correctly; (b) how to write medico-legal reports correctly; and (c) how to deal with medical tangle correctly. These three points have a close relationship with forensic practice, and help students become familiar with medico-legal cases.

Practical courses

Current practical courses are aimed to help students consolidate knowledge learned in the classroom by conducting experiments on animals. Through these confirmatory animal experiments, students’ abilities to generalise knowledge, analyse problems and self-direct their learning are promoted. Practical courses consist of two parts: reviewing and practicing. Students are initially assigned to review anatomy, histology and pathology, which provide fundamental knowledge for performing forensic examinations. Six subjects are then selected based on their relevance to forensics: posthumous phenomena, falling from high altitude, diatom examination, electric shock, aeroembolism and positional asphyxia. Following predesigned experimental guidance, students implement experiments in groups and complete experimental reports. Since sacrificing laboratory animals is a precondition for implementing forensic animal experiments, animal ethics and animal welfare are of the utmost importance. The procedures for animal preparation and experimentation strictly follow and adhere to the Standard of Procedures of Laboratory Animal Experiments at Sun Yat-Sen University. Furthermore, all students are required to complete a laboratory animal experimental courses in their second year, increasing their awareness of animal ethics and welfare.

Practical experience

The educational tenet of forensic medicine is to produce forensic practitioners with a high level of professional qualities and skills, requiring that students hone their forensic capabilities before the start of their careers. A qualified forensic pathological practitioner should be skilled in four key areas: (a) investigating the scene, (b) collecting and reserving biological samples, (c) performing a systematic forensic autopsy and histological examination, and (d) completing forensic reports. However, forensic practices, such as scene investigations and medico-legal autopsies, are extremely limited by campus conditions. Hence, a forensic internship for undergraduates is arranged in public securities. During their internship in public securities, students acquire many chances to investigate scenes and conduct medico-legal autopsies and forensic clinical examinations. Training undergraduates in forensic clinical examinations is beneficial for recognising injuries on living individuals and this then helps them to analyse injuries on the deceased. After their internship, students should have a full understanding of the forensic aspects of criminal and civil cases, helping them to prepare for their future careers. Moreover, in cooperation with the Law School at Sun Yat-sen University, we set up mock trials, providing a place for advanced forensic practice training. In these mock trials, students experience acting as expert witnesses in a court setting, which is of particular value, in addition to the value of learning to use professional terms to present evidence and keeping calm and composed under pressure.⁶

Supportive designs

When forensic pathology is an elective course, which it commonly is in Western countries, students’ prior knowledge of sensitive forensic topics is predominantly acquired from informal sources, which results in myths and stereotypes being frequently highly endorsed.⁷ However, for undergraduates majoring in forensic medicine, if a textbook is the only available teaching material, this fosters an disinterested and inefficient classroom environment. It is therefore imperative that a new forensic pedagogical model be provided with appropriate, evidence-based information.⁸

In order to enrich teaching methods and contents, we carried out a long-term pedagogical project to create a database of forensic pathology cases. Various forensic cases were collected, mainly from the Centre of Medico-Legal Expertise at Sun Yat-sen University as well as case reports from forensic journals. Original case files are stored in this database, including medico-legal autopsy documents and photographs of gross and histopathological slices. We believe this aids teachers in facilitating lectures and benefits students’ understanding. More importantly, by directing students to actual forensic cases, the new model has crucially trained forensic undergraduates with regard to their legal duties.⁹

Scientific research

The ultimate goals of forensic pathology undergraduate education are not only to produce first-class forensic practitioners but also to foster excellent forensic scientific researchers. In order to trigger students’ interests in forensic science research, a project entitled the Forensic Undergraduates’ Exploratory Experiment, designed for senior forensic students, was introduced in 2009. This project is supported by the faculties of Zhongshan School of Medicine, including financial support, supplying labs and materials for implementing experiments, as well as professional advice and guidance from forensic teachers. In their fifth year, students independently determine a subject, design and conduct experiments, and develop theses under the guidance of forensic pathology teachers. This project has trained students in the elementary abilities of implementing scientific research, and this invaluable experience has inspired and impacted their subsequent research.

Discussion

Producing specialists in forensic pathology has become a widespread problem worldwide.¹⁰ Hence, teaching forensic medicine to undergraduates is not only important but necessary.⁹ In many Western countries, forensic medicine is traditionally taught to medical undergraduates,^11,12 but in Sri Lanka, like China, forensic medicine is taught as a major subject.¹³

In the Chinese medical education system, forensic pathology is one of the most important and major subspecialties for medical undergraduates majoring in forensic medicine. This is noticeably different from other countries, where forensic courses would be offered as elective courses for senior medical students.¹⁴ Accordingly, it is necessary to standardise the model of undergraduate forensic education.

The new model of forensic pathological education described herein is characterised by: (a) giving students a broad overview of forensic pathology and basic knowledge of the duties and tasks of their future career; (b) educating students in the primary skills of legal and medical issues, as well as advanced forensic pathological techniques; (c) providing students with resources to broaden their professional minds, and opportunities to improve their professional qualities and abilities; and (d) mentoring students in preparing for their future occupations and further forensic education.

Currently, there is a high demand for forensic practitioners. As previous studies on forensic education have stated, attending autopsies promotes learning and is helpful in organising information for self-directed learning, covering cognitive, emotional and societal issues.¹⁵ Thus, the forensic medicine curriculum must include instruction on autopsies, from both theoretical and practical perspectives.¹⁶ Additionally, reporting the results of forensic examinations in a logically correct and scientifically rigorous way is a daily challenge for any forensic practitioner.¹⁷ This is because the accuracy, fluency and relevance of the medico-legal report lay the foundations for success in forensic practice.¹⁸ Furthermore, there is also a need in China for skilful handling of medical tangles by forensic practitioners, since medical tangles have increasingly become a prominent social topic. Therefore, the content of the lectures and practical courses described here are designed to teach students important and practical knowledge of forensic pathology, cultivating their awareness of forensic tasks, as well as duties. Meanwhile, the practical courses provide undergraduates with opportunities to practice and, more importantly, help students develop a scientific learning style that consolidates knowledge by independently testing and practising.

Significantly, we have built up a forensic pathology database of cases for use in lectures. In this database, various actual forensic cases have been collected, including key details and pictures. The traditional pedagogical model easily led students into passive learning and thinking, and they gained limited knowledge from tedious speeches and book descriptions. When real-case analysis is integrated into lectures, students are more engaged, and the pictures help to visualise the descriptions and consequently facilitate students’ comprehension.

The last year of undergraduate study is intended to be the year of self-promotion. First, students complete a half-year forensic internship at public securities. During their internship, they have opportunities to practice and gain practical experience that cannot be acquired through textbooks. In addition, an exploratory practical project promotes students’ qualities in other ways, by stimulating personal enthusiasm for forensic science research and helping them to develop a scientific mind and learning style. In the past five years, our undergraduates have published 10 papers, including seven SCI articles, which is considerable growth compared to our past efforts and to our counterpart faculties. Thus, we believe that the new pedagogical model of forensic pathology described above has substantially promoted the qualities and capabilities of our forensic undergraduates.

Conclusion

We herein introduce a new pedagogical model of forensic pathology carried out at Zhongshan School of Medicine at Sun Yat-sen University. In this new model, students gain an overview of forensic pathology and basic knowledge of forensic skills and techniques. More importantly, they have greater access to forensic pathology practices and forensic pathology research, allowing them to prepare for their future occupations and further forensic education. Currently, the outcomes of this course are promising. Although there might be some limitations, it still provides a positive direction for the development of forensic pathology education in China.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by grant of National high quality resource sharing course Forensic Pathology (2016-1463) from Ministry of Education of the People’s Republic of China.

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