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ORIGINAL ARTICLE
Year : 2023 | Volume
: 11
| Issue : 1 | Page : 60-66
Emergency physicians' awareness of medico-legal case management: A cross-sectional study from Saudi Arabia
Shahad Alabdulqader1, Rana Alabdulqader1, Mohammed Madadin1, Haider Kashif2, Mohammed A Al Jumaan3, Abdullah Abdulsalam Yousef4, Ritesh G Menezes1
1 Department of Pathology, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2 Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
3 Department of Emergency Medicine, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
4 Department of Pediatrics, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
Correspondence Address:
Mohammed Madadin
Department of Pathology, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/sjmms.sjmms_267_22
Background: Emergency department physicians often encounter medico-legal cases when patients initially present to the hospital, and thus there is a strong need for them to have robust medico-legal management and reporting knowledge.
Objective: To assess the awareness of emergency department physicians of two major hospitals in the Eastern Province of Saudi Arabia in managing medico-legal cases.
Methods: This descriptive cross-sectional survey-based study included all adult and pediatric emergency physicians working at King Fahd Hospital of the University and King Fahd Specialist Hospital, two major government hospitals in the Eastern Province of Saudi Arabia. The questionnaire included questions about demographic information, the workload in the emergency department, previous medico-legal training, and information about physicians' perspectives regarding medico-legal situations.
Results: A total of 85 physicians completed the questionnaire, with most being Saudis (78.8%) and consultants (44.7%). Most participants (84.7%) immediately notified the police authority through the official procedure on suspicion of a case being criminal. However, only 28.2% of the participants were aware of how to complete the medico-legal report, and the majority (82.4%) had not received any specific training or attended specific courses in writing medico-legal reports. Most participants (91.8%) expressed the need for additional medico-legal case training programs, with continuous education (29.4%) being the preferred mode. In addition, 60% of the consultants were dissatisfied with the current medico-legal reporting and management workflow in their hospital. About half of the participants did not obtain photographs in medico-legal cases and did not know if their workplace provided a protocol for collecting evidentiary material such as clothes, swabs, bullets, remnants of foreign bodies, etc.
Conclusions: The results of the present study indicate the necessity to consider periodical continuing medical education programs and workshops for emergency department physicians in the Eastern Province of Saudi Arabia to help them in appropriately handling medico-legal cases.
Keywords: Awareness, continuing education, emergency medicine, medico-legal report, physicians; medicolegal, Saudi Arabia
Medical cases are diverse in type, nature, and approach. While some cases are managed by a single department, others require a multidisciplinary team. This diversity brings to light the need for certain knowledge and skills to be acquired by physicians when managing everyday medico-legal issues. The emergency department (emergency room/ER), as the first line of contact when patients seek medical help, carries an important role in patients' initial evaluation and management. Besides, it is important to be aware of cases with potential medico-legal implications. The management of such cases is significantly crucial and certain protocols are adopted to establish a proper approach to the reporting of medico-legal cases such as road traffic accidents, burns, physical assault or battery, poisoning, drowning, alleged suicide, homicide, etc.
A medico-legal case can be defined as “a case of injury or illness that requires investigation by law-enforcing agencies to fix the responsibility regarding the causation of the injury or illness”.[1],[2],[3] Obtaining forensic evidence is a common issue faced by emergency department physicians who provide the first line of management. Emergency department physicians may fail to recognize such cases. This can be partly attributed to the incomplete or obscure history provided when patients are frightened or ashamed of narrating the truth behind their injury.[4]
A Turkish study has reported traffic accidents to be the most common type of traumatic medico-legal cases. Incomplete recording of patients' cooperation status and ill-defining of the external lesions in the majority of cases were the common errors found in medico-legal reporting of cases.[1] Another cause preventing physicians from organizing medico-legal reports was the fact that they lacked experience and knowledge and were unwilling to take responsibility in this regard.[5],[6] This issue highlights the need of managing every trauma patient in the emergency department as a medico-legal case until proven otherwise. If not applied and if the healthcare providers are unable to identify medico-legal cases or fail to collect forensic evidence, the patient's right to justice will be violated.[7]
In the present study conducted in the Eastern Province of Saudi Arabia, we aimed to assess the awareness of emergency department physicians in managing medico-legal cases encountered by them in the emergency department.
MethodsStudy design, setting, and participants
This descriptive cross-sectional survey-based study was conducted in two major government hospitals (King Fahd Hospital of the University and King Fahd Specialist Hospital) located in the urban areas of the Eastern Province of Saudi Arabia between May and June 2021. King Fahd Hospital of the University is a teaching hospital affiliated to Imam Abdulrahman Bin Faisal University in Dammam. King Fahd Specialist Hospital is a specialized hospital under the Ministry of Health in Dammam. The study participants included all adult and pediatric emergency physicians working in these two hospitals, while all non-physicians working in the emergency department were excluded from the study. The study was conducted after obtaining approval from the Institutional Review Board (IRB) of Imam Abdulrahman Bin Faisal University. In addition, permission to obtain data was obtained from the chairperson of the emergency medicine department at both hospitals.
Survey content and administration
A structured questionnaire was drafted in English, hosted on Google Forms, and distributed electronically by email to the emergency department physicians; Web-based data entry was allowed. The initial contact point was the chairperson of the emergency medicine department at the two hospitals, who in turn distributed the questionnaire to their respective staff through email. Three reminder emails were sent 2 weeks apart. The electronic technical functionality of the questionnaire was tested before distributing it to the participants.
An electronic informed consent was obtained from all the participants prior to completing the questionnaire. The participants were provided with the objectives of the study. It was mandatory to complete all responses to be able to successfully submit the completed questionnaire. The approximate time required to complete the questionnaire was not mentioned. Participation was voluntary and participants were assured of anonymity and data confidentiality. Personally identifiable information of the participants was not collected, and no incentives were offered to the participants for completing the questionnaire.
The questionnaire included questions about demographic information, the workload in the emergency department, previous medico-legal training, and information about physicians' perspectives regarding medico-legal situations. The questionnaire was drafted based on a literature review and the knowledge and experience of the investigators. Two academicians in emergency medicine and two academicians in forensic medicine reviewed the questionnaire for content validity.
Data analysis
Responses collected from the completed questionnaires were manually coded and tabulated within Microsoft Excel. The statistical analysis and creation of figures and tables were carried out using IBM SPSS statistics version 26 for Windows. Descriptive statistics were expressed as frequency and percentage.
ResultsA total of 90 physicians were eligible for participation, of which 85 (94.4%) completed the questionnaire, with an almost equal gender distribution. Most of the participants were Saudis (78.8%) and consultants (44.7%) [Table 1].
Current reporting practices, awareness, and sources of knowledge
Regarding the appropriate notification of medico-legal cases, the majority of the participants (72; 84.7%) immediately notified the police authority through the official procedure on suspicion of the case being criminal [Table 2]. [Table 3] provides the responders' awareness regarding the documentation of medico-legal cases in the ER. Only 28.2% (n = 24) of the participants were aware of the standards related to completing the medico-legal report. More than half of the participants (51; 60%) did not know if their workplace provided a unified protocol on how to deal with medico-legal cases. Nearly half of the participants (39; 45.9%) did not obtain photographs in medico-legal cases. Nearly half of the participants (40; 47.1%) did not know if their workplace provided a protocol for collecting evidentiary material such as clothes, swabs, bullets, remnants of foreign bodies, etc. In terms of sources, most (39; 45.9%) acquired their knowledge for handling the medico-legal cases from the senior staff [Figure 1].
Table 2: Physician's responses to items assessing the appropriate notification of medico-legal cases
Table 3: Physician's responses to items assessing the awareness of documentation of medico-legal cases in the emergency room
Figure 1: Participants' sources of knowledge related to handling medico-legal casesTraining levels and needs
The majority of the participants (82.4%) had not received any specific training/attended particular course in writing medico-legal reports [Table 1]. In terms of segregation based on nationality, a higher proportion of non-Saudis had received prior training in handling medico-legal cases compared with Saudis [Figure 2]. There was no difference in terms of previous medico-legal/forensic medicine training according to gender [Figure 3].
Figure 2: Nationality-wise percentage of physicians who received previous medico-legal/forensic medicine training
Figure 3: Gender-wise percentage of physicians who received previous medico-legal/forensic medicine trainingIn terms of training, most of the physicians expressed the need for additional medico-legal training (n = 78, 91.8%). The most preferred reported stage at which medico-legal training should be provided was continuous education alone (25; 29.4%), followed by undergraduate + residency + continuous education (24; 28.2%) and residency + continuous education (20; 23.5%) [Table 4]. For medico-legal training purposes, consultants most commonly preferred continuous education alone (14; 36.8%) followed by the combination of the three stages (13; 34.2%); specialists most commonly preferred the combination of residency and continuous education (8; 33.3%); and residents most commonly preferred residency (9; 39.1%) [Table 4].
Table 4: Physician's responses to items regarding the current handling of medico-legal cases and related information pertaining to training programs stratified by work designationAdequacy of current reporting workflow
Most of the consultants (33; 86.8%) regarded the current approach to the handling of medico-legal cases as inappropriate. Overall, 64.7% (n = 55) of the physicians considered the current workflow for reporting medico-legal cases as inappropriate [Table 4].
DiscussionER is usually the first station in the hospital to encounter medico-legal cases.[1],[8] This raises the importance of emergency department physicians being knowledgeable and skillful in detecting medico-legal cases and not merely treating and saving lives.[9],[10] In the present study, most of the physicians (84.7%) were aware of the importance of immediately notifying the police authority through the official procedure when suspecting a medico-legal case, which is concordant with the results of a similar study conducted in Jeddah, Saudi Arabia.[11] On the other hand, a study from Turkey reported that 75.9% of child abuse cases were discharged without being reported as judicial cases,[12] which may have been due to minimal exposure or lack of training in handling medico-legal cases.
In the present study, 42.4% of the emergency department physicians did not know about the standards on how to complete medico-legal reports, which is unsurprising given that 82.4% had not received formal training in writing medico-legal reports. This highlights the need for policymakers within these hospitals and in the country to lay emphasis on training/courses for writing medico-legal reports. In the Arab world, our findings are similar to a study from Cairo, Egypt, where writing the medico-legal report was reported as the most difficult aspect of medico-legal cases.[2] However, these findings are in contrast to those of a study from Hong Kong, where most of the emergency department physicians had experience in writing medico-legal reports.[8]
In the present study, the majority of the participants (60%) did not know if their workplace provided a unified protocol on how to deal with medico-legal cases. On the contrary, the study from Jeddah found that 76.6% of the emergency department physicians were aware of their workplace protocol.[11] Our study found that around half of the participants did not obtain photographs in medico-legal cases and did not know if their workplace provided a protocol for collecting evidentiary material such as clothes, swabs, bullets, remnants of foreign bodies, etc. Similarly, the Jeddah study from Saudi Arabia showed that >75% of emergency department physicians did not practice obtaining photographs during the documentation of any medico-legal case.[11] The findings of the two studies conducted in Saudi Arabia demonstrate the need for standardization of reporting protocols and adequate training regarding the same.
In the present study, over half of emergency medicine physicians (64.7%) were not satisfied with the approach to medico-legal cases. The majority of the consultants (86.8%) thought that the current approach to medico-legal cases was not appropriate. Therefore, we further emphasize the requirement to conduct workshops and consultations to standardize reporting protocols. In terms of training needs, most respondents (91.8%) expressed a need for additional training in the management of medico-legal cases. Similarly, the need for additional training was highlighted in the study from Jeddah.[11] Further, our study found that non-Saudi respondents had received more education/training programs than Saudis. In Saudi Arabia, forensic medicine is included in the undergraduate medical curriculum, but in some universities, it is taught without practical training,[13] similarly to education in some European countries.[14],[15] However, the collective evidence from our study and that from Jeddah indicates that training in medico-legal management is inadequate and there is a need for rectifying the same.
Training can certainly result in closing gaps in knowledge, as was highlighted in a study from Sri Lanka, where the undergraduates received practical forensic training. The students had role-play sessions and participated in history taking, examining the victim, and completing medico-legal documents, which were corrected and returned to them. These measures positively impacted students' inference and opinion, reporting, and documentation.[16] Similarly, a study conducted in Australia, assessed the skills of emergency department physicians who undertook 6 months of rotation in forensic medicine and found that trainees were able to examine physical and sexual assault cases, prepare medico-legal reports, deal with the police, and provide evidence to courts.[17]
In our study, most participants preferred the continuous education mode for receiving training. This is understandable given that beyond the degree-level and specialization education, continuous education programs serve to reiterate and advance knowledge among medical professions over short durations. In contrast to our findings, respondents of the study from Jeddah considered undergraduate and residency to be best stages for obtaining medico-legal training.[11] However, there is a need for a comprehensive country-wide survey of emergency physicians to determine the best mode and stage of training to help policymakers in determining the next actionable points for rectification of the existing gaps.
Limitations
Our study is not without limitations. The inherent limitations of the study design include response and recall bias. The component of social-desirability response bias and/or unthoughtful completion of the questionnaire cannot be ruled out. Further, the study is limited to two government hospitals of one region; therefore, the sampled population may not be representative of emergency department physicians nationally as well as of those working in the private hospitals/rural areas regionally. Finally, although we assume that the questionnaire was not completed more than once by the participants, checks were not in place to ensure the same.
ConclusionsThis study highlights the self-reported deficiencies and training needs among emergency department physicians in the Eastern Province of Saudi Arabia, and thus the need for actionable steps to ensure standardization and training to improve the reporting and management of medico-legal cases.
Ethical considerations
This study was approved by the IRB of Imam Abdulrahman Bin Faisal University (Reference number: IRB-2021-01-183; date: April 28, 2021). All participants provided informed consent before participation. The study adhered to the principles of Declaration of Helsinki, 2013.
Data availability statement
The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
Peer review
This article was peer-reviewed by five independent and anonymous reviewers.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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