Appraisal by Year Six French medical students of the teaching of forensic medicine and health law

Introduction

The quality of the training received by medical students is a major preoccupation of lecturers at the faculty of medicine, and this quality affects the students' behaviour, satisfaction and success. ¹ The teaching of forensic medicine carries specific characteristics that are inherent to the scope of this specialty, at the interface of medicine and law. It is a cross-sectional specialty, often intertwined with other disciplines, whether in the fields of forensic pathology and diagnosis of causes of death, forensic medicine and examination of victims of assault or sexual assault, or in the field of medical ethics, bringing together medical responsibility and the deontological rules that govern medical practice. Teaching of medical law during Years Two to Six is necessary so that future physicians may master the implications of their decisions and of their acts in daily practice. Teaching of medical law is similar to that of health law, which is taught in law faculties, but for physicians it differs by the numerous legal ramifications which intervene in the provision of health care. ² All physicians, whether specialists or general practitioners, will meet in the course of practice clinical situations that will call on their theoretical knowledge of forensic medicine and health law. Medical students’ perceptions of their own learning during Years Two to Six are varied and are influenced by the educational environment, the opportunities for gaining practical clinical experience and the quality of the teaching. ³ Legal medicine is taught during the second year of the second cycle of medical studies (Year 4), as lectures given in the lecture hall. Several kinds of support material are available for the preparation of the legal medicine module, in the form of duplicated lecture notes produced by the faculty, standard textbooks available in specialist bookshops and also online course material. The main goal of medical students is to acquire the theoretical knowledge necessary to succeed in the national ranking examination which marks the end of the second cycle of study and which is mandatory for entrance to the third cycle of medical studies and to become a resident. This examination has led to a new orientation in the training of students, towards more cross-sectional topics which link the different specialties. The teaching of legal medicine and medical law has had to adapt to this new mode of assessing students’ knowledge, leading to changes in the way it is delivered. As far as we are aware, the teaching of legal medicine has never been appraised by medical students themselves.

Methods

The second cycle of medical studies extends from Year Three to Year Six. Teaching is given in the form of modules from Year Four to Year Six (Table 1), and the aim of these modules is to decompartmentalize the teaching of the various disciplines and to allow more cross-sectional training, with an approach to global management of the sick person. The cross-sectional modules emphasize study of the major disease processes, collaboration between medical specialties and acquisition by the students of a spirit of analysis and synthesis. The educational objectives correspond to the requirements of the students’ future national ranking examination for entrance to the third cycle. Fourteen hours of lectures are devoted to the forensic sciences and medical law in Year Four as part of Module 1, ‘Learning medical practice’, which comprises 57 hours of lectures. This module consists of several items, whose main educational objective is centred on the physician–patient relationship and on adherence to the rules of professional practice not only in the field of medical ethics but also in patient rights and medical deontology.

During mandatory training in management of cardiac arrest organized by the faculty of medicine and covering 10 half days, during which the students worked together in small groups, 132 sixth-year students were included in our study. Year Six marks the end of the second cycle of medical studies. A questionnaire (Table 2) was developed by two physicians from the legal medicine department who taught at the faculty. The questions were designed to cover the topics included in the national ranking examination. The questionnaire explored students’ knowledge in the specialty of legal medicine, the medico-legal situations which the students could have encountered during clinical rotation in hospital clerkship, the educational support material used, the students’ satisfaction with teaching received and their opinion of their own competence before starting the third cycle of medical studies. After reading the questionnaire, the students who participated gave their consent. The replies to the questionnaires were treated anonymously. The statistical tests used were Pearson's χ ² test and Fisher's test after checking the conditions of application (STATA software, version 8). Ethical approval was not required for this study.

Results

Our study population consisted of 132 students of mean age 25 years (95% CI 22; 31), of whom 86 were women (65.1%). All were enrolled at the medical faculty of Toulouse. In our sample, four students (3%) were considering a career as a legal physician. A small number of students (n = 6) chose to do a rotation in the medico-legal unit. The principal activities of the forensic physician, according to the students, were autopsy (87.9%), the writing of death certificates (75.8%) and consultations for victims of violence (60.6%). The other activities cited were acting as a medico-legal expert witness (45.4%), intervening in amiable or legal proceedings during conflictual situations with patients (12.9%) and lastly prison medicine (11.4%). The students stated that complementary teaching on themes encountered in our specialty of legal medicine was found in the teaching of other medical disciplines. The two themes most often mentioned were the writing of certificates and their medico-legal implications (n = 86, 65.1%), and the risk of medical liability (n = 13, 9.9%). We evaluated the medico-legal situations which the students could have encountered in Years Two to Six of their studies. Seventy-one students (53.8%) had never been confronted with suspect or violent death, 65 (49.2%) had never examined or been present at the examination of a victim of assault or sexual assault, and 76 students (57.6%) had never participated in the writing of a death certificate. We also evaluated assiduity of attendance at lectures (Table 3). The support material available to the students (Table 4) consisted of duplicated lecture notes written by the specialist lecturers and provided by the faculty of medicine, medical textbooks obtainable in specialized bookshops and the Internet. Standard textbooks available in specialized bookshops were the support material most frequently used. Lecturers in legal medicine published online material on the medical faculty website, but this support material was not used by 70.4% of the students (n = 93, 70.4%), and 27 (20.5%) declared that they did not know it existed. Replies concerning satisfaction with the teaching received are shown in Table 5 (one student did not reply to these questions). We observed a significant difference in satisfaction in this group, regarding questions of thanatology (P < 0.004), medical responsibility (P < 0.003), regulations on transfer of medical records (P < 0.004) and medico-legal rules on confidentiality (P < 0.016). The 132 students expressed their opinion of their own competence before starting the third cycle of medical studies (Table 6). At the end of the second cycle, they did not feel ready to examine a corpse (95.6%) or to examine victims of assault (92.4%). They felt that they had inadequate knowledge of the law and of the risks of medical practice (60.5%), as well as of the writing of a medical certificate (56.8%).

Discussion

Years Two to Six of medical study are still an essential stage in pre-doctoral training, one which emphasizes the development of professional competencies and essentially aims to train undifferentiated doctors suitably qualified to become general practitioners or specialists. ⁴ Following the clerkship, the third cycle begins, enabling the resident to acquire the identity of doctor of medicine. The transition from student to resident is an important phase, which must be successfully negotiated in order to facilitate integration of the future physician into her or his professional activity. ⁵ The main goal of medical students is to acquire the necessary theoretical knowledge to succeed in passing the national ranking examination which marks the end of Year Six and is a necessary hurdle before entering the third cycle of medical studies and becoming an intern. The particular feature of this examination, which was set up in 2003, is that it is a single, national examination with a similar marking system to the competitive entrance examinations to the major business and management schools. ⁶ Since this examination was set up, training has been oriented towards more cross-sectional subject matter, with the ultimate aim of creating a dialogue between the different specialties. Legal medicine and medical law are consistent with this cross-sectional character, as many of the themes taught find an application in the other medical disciplines. This is why in our study students reported that the medico-legal implications of writing medical certificates and medical liability risk were subjects which had been dealt with in teaching modules of other specialties.

Legal medicine appears to be little known to students, except for activities related to thanatology and death certificates with medico-legal implications. The diverse medico-legal implications in the other specialties are not mastered at the end of Year Six, even though this immediately precedes entrance to the third cycle. During this period, the future intern will have personal medical responsibility and will have to face clinical situations which may be complex and which will require the intern to refer to what he or she has learnt. Acknowledgement of this fact should lead those who teach legal medicine to react to improve learning. Legal medicine differs from other medical specialties in that it lies at the interface of medicine and law. It also differs in that the physician's practice involves being in contact with living patients in acute distress, during examination of victims of assault or sexual assault, or with corpses during work related to thanatology. Our discipline calls for a specific approach to patients and is particularly difficult to appreciate in view of the small number of students who choose a rotation in a medico-legal unit, and also of the turnover which is imposed by the short duration of rotations. The latter point is regrettable, as early exposure of students to clinical practice increases their motivation and stimulates their curiosity to learn. ⁷ These difficulties are also encountered in other clinical specialties such as urology ⁸ and may account for the lack of knowledge of our discipline and its conditions of exercise that is revealed in our study.

Regarding the educational support material available to students, we observed that the duplicated lecture notes written by the lecturers and provided by the faculty were not the reference document for students. These duplicated notes are free and contain the material of all the courses included in Module 1, ‘Learning medical practice’. Students primarily chose the series of medical textbooks available in specialized bookshops. This choice is easily explained by the uniformity of the goals set in these books and the fact that the content is identical for all faculties and for all students, their ultimate aim being to succeed in the national ranking examination. In our specialty, and for the whole of Module 1, ‘Learning medical practice’, the infrequent use made of the duplicated notes given out by the lecturers teaching the specialty differs from what has been observed in other disciplines, notably in urology where teaching staff produced lecture notes written by the College of Urology for nationwide use. In this case, the students stressed the importance of the availability, in a course organized into modules, of educational material that deals with all the questions of a specialty, and the importance of providing an overall, homogeneous view of each of the disciplines. ⁹ Rating by students is useful to identify the strengths and weaknesses of the teaching and remains a source of important information in order to establish priorities for improvement within the faculty. ¹⁰ Retrospective rating by students is important for teachers, especially as this method has been found to be valid and reproducible. ^11–13 Students at Harvard University were the first to assess lecturers and to publish the results. ¹⁴ Bias may of course be introduced by retrospective rating which is based only on the student's subjective opinion, but this confounding factor is lessened by the nature of the population questioned, consisting of students who are sufficiently mature to assess the teaching they receive at the end of the second cycle of medical study. ¹³

Certain aspects of our specialty remain difficult to teach, in particular medical law and medical malpractice liability rules, which are very theoretical and may seem boring to students who are not yet aware of their clinical application. Like other specialties, especially radiology, ¹⁴ our specialty is only a small part of the medical curriculum. However, the time allocated to theoretical teaching is short and out of proportion in view of the educational goals to be attained, as has been observed in other studies. ¹⁵ The clinical environment influences the students' behaviour, predicts their satisfaction and gives better compliance with the theoretical teaching programme, but in this case the duration of rotations in our specialty should be increased. ¹⁶ Attendance at theoretical lectures in a lecture hall setting may be improved by changing their content. Indeed, while offering courses in the form of cross-sectional modules is already an advance in education, students attach importance to the characteristics of lectures in the lecture hall. Students react negatively when lectures become merely a recitation of facts and they value context and clear explanations. They are more attentive to new information that is linked to the educational material they possess, whether this is textbooks or the faculty's duplicated lecture notes, and they prefer problem-solving which allows them to apply their theoretical knowledge. ¹⁷ This is one of the possible explanations for low lecture attendance. Increasing attendance at lectures is one of the objectives that lecturers in our specialty must attain, in view of the close link between attendance and satisfaction (Table 6). Our lecturers have decided not to give theoretical lectures any longer, and the educational material must have been read the day before the teaching session. This lecture-free approach is undergoing assessment in our specialty. Teaching is given in the form of case reports, thus making students less passive.

Regarding students’ appraisal of their own competencies, our findings show that they feel little or no competency in carrying out clinical examinations of assault victims or of corpses, and that they know little of law and of the risks of medical practice. This feeling of incompetence is less marked regarding the writing of medical certificates. However, it may appear surprising that during their different rotations in the various departments, whatever the medical or surgical specialty, these students have not been faced with such situations. This observation shows that clinical rotations should aim to consolidate theoretical knowledge by illustrating it through clinical situations. ⁷

The writing of medical certificates is an almost daily activity in medical practice and some time is devoted to this subject in the teaching of other disciplines. This being so, rigorous teaching is necessary which could be linked with clinical work during hospital rotations.

This study revealed shortcomings concerning support material and the knowledge acquired at the end of the course when compared with the prerequisite objectives set by the lecturers, and above all those set by the content of the national ranking examination. Solutions are needed to incorporate the theoretical aspects of the questions in the medical law curriculum into clinical practice. This can be done during rotations in medical departments, with the aim of doing away with the abstraction that is difficult for the students to assimilate when the subject is taught only from a theoretical viewpoint. It is incumbent on lecturers to improve the quality of the teaching given and to pursue their mission as a dynamic process of education.

This study has certain limitations. The cohort studied came from a single faculty of medicine and may not be representative of students as a whole. This preliminary work must be continued with each new student intake in order to eliminate single cohort bias. The questionnaire method satisfactorily meets the aims the authors had set. As the replies were anonymous and the findings confidential, the influence of the lecturer on the replies to certain questions was avoided. The method we chose for our study was one that has frequently been used in the literature. ¹⁸ However, the results relate only to the items included in the questionnaire, which was designed to appraise current teaching of legal medicine and medical law in France and may not be totally applicable to other specialties. Certain observations are noteworthy and deserve to be underlined, because they are relevant to appraisal by Year Six medical students. However, this subjective evaluation limits exploitation of the results and complementary work is needed, as the student's appreciation of their own competence may be attenuated by their perception of that of the teacher, a factor that we did not seek in our study. ¹⁹ Specific knowledge acquisition was not assessed, other than by the examination at the end of the year. This study highlights the fact that students finishing the second cycle of medical studies have little training in the clinical aspects of legal medicine. Medical law and legislation is undoubtedly difficult to teach, because the clinical applications are less concrete than those of physical diseases in other medical and surgical disciplines. This study reveals that the duplicated notes as currently distributed do not correspond to the expectations of medical students in our specialty. Other medical specialties, such as urology, have proposed national duplicated notes which are a reference for the theoretical knowledge needed for the national ranking examination. ⁹ Our specialty is incorporated in the module ‘Learning medical practice’, which brings together several specialties, increasing the time needed to produce the national duplicated notes which are to be the reference for teaching. This work is in preparation. Our specialty comes up against the problem of short rotations in the medico-legal unit, and yet an early encounter in the medical pathway influences the choice of career. Here again, other specialties such as radiology ¹⁴ and psychiatry ²⁰ are faced with similar problems, which can be countered by clinical exposure during the preclinical years.

Appraisal of the teaching of our discipline by collecting and analysing the students’ own perceptions is a first step towards achieving the quality that the faculty has to provide. It increases our understanding of what medical students expect, even if this concept is qualified by the need to teach the basic principles of our specialty.