Learning the law : an exploration of how undergraduate medical students acquire understanding of law in relation to professional medical practice Judy McKimm and Michael Preston-Shoot, University of Bedfordshire Susan Tomlinson, University of Auckland ‘ Quality Counts’ conference – 18 November 2008

Background and context NTFS funded two year ‘snapshot’ study in 2007/8 and 2008/9 for medical students Evaluates outcomes for practice of different curricular approaches to learning, understanding and applying the law in practice between social work and medical students Explores: medical students’ ‘position’ towards the law perceptions and understanding of law as it relates to professional practice, values, ethics their role as a future medical practitioner

NTFS funded two year ‘snapshot’ study in 2007/8 and 2008/9 for medical students

Evaluates outcomes for practice of different curricular approaches to learning, understanding and applying the law in practice between social work and medical students

Explores:

medical students’ ‘position’ towards the law

perceptions and understanding of law as it relates to professional practice, values, ethics

their role as a future medical practitioner

Study participants and methods Over 2000 1st, 2nd and final year medical students from six programmes at four medical schools. Methods: Literature review Documentary analysis of curriculum documents Self audit questionnaire survey and mind mapping (students) Focus groups (students and staff) Interviews (students and staff) From 2008/9 – practice survey of all UK law curricula in undergraduate medicine and systematic literature review (MEDEV & UKCLE funded)

Over 2000 1st, 2nd and final year medical students from six programmes at four medical schools.

Methods:

Literature review

Documentary analysis of curriculum documents

Self audit questionnaire survey and mind mapping (students)

Focus groups (students and staff)

Interviews (students and staff)

From 2008/9 – practice survey of all UK law curricula in undergraduate medicine and systematic literature review (MEDEV & UKCLE funded)

Results - Literature review and curriculum analysis Literature review – preliminary review indicates little research on effectiveness of methods of ‘learning’ law in medicine Curriculum analysis: undergraduate medicine, law tends to be: considered alongside medical ethics introduced as part of the development of ‘professionalism’ acquired during clinical attachments relating to different client groups teachers tend to be medical ‘enthusiasts’ or lawyers Preliminary results confirm reported studies in the literature Professional codes of practice are enshrined in a legal framework, but no consistent approach to teaching, learning and assessment of law Law learned alongside ethics or opportunistically in clinical placements The literature indicates that much of ‘the law’ is assumed to be learned at postgraduate level as applied to clinical specialties (surgery, older persons care) or different client groups (ie children, mental health)

Literature review – preliminary review indicates little research on effectiveness of methods of ‘learning’ law in medicine

Curriculum analysis: undergraduate medicine, law tends to be:

considered alongside medical ethics

introduced as part of the development of ‘professionalism’

acquired during clinical attachments relating to different client groups

teachers tend to be medical ‘enthusiasts’ or lawyers

Preliminary results confirm reported studies in the literature

Professional codes of practice are enshrined in a legal framework, but no consistent approach to teaching, learning and assessment of law

Law learned alongside ethics or opportunistically in clinical placements

The literature indicates that much of ‘the law’ is assumed to be learned at postgraduate level as applied to clinical specialties (surgery, older persons care) or different client groups (ie children, mental health)

Preliminary results (1) 2007/8- questionnaire survey 677 1 st & 2 nd year students from 3 medical schools Varying perceptions and understanding of the law and how it is used in practice Emerging themes: Students identify ‘confident knowledge’ (75% or above) in only: ethical issues (consent and confidentiality) Abortion Act Data Protection Act Overall knowledge of legal powers, duties and case law is perceived as very low Over 70% of students identify ‘little or no confidence’ in skills for practising law in relation to medicine

Varying perceptions and understanding of the law and how it is used in practice

Emerging themes:

Students identify ‘confident knowledge’ (75% or above) in only:

ethical issues (consent and confidentiality)

Abortion Act

Data Protection Act

Overall knowledge of legal powers, duties and case law is perceived as very low

Over 70% of students identify ‘little or no confidence’ in skills for practising law in relation to medicine

Preliminary results (2) 2007/8- questionnaire survey Students’ overall perception of the law is positive. They believe that: a sound understanding of the law is essential to being a good doctor law promotes accountability of doctors for their practice law can be used by doctors to achieve health improvements law protects vulnerable people and meets their needs law generally endorses and supports medical value. However, students express some anxiety: keeping up to date with knowledge of legal rules having to consider legal requirements increases anxiety Also, the law encourages defensive practices in medicine

Students’ overall perception of the law is positive. They believe that:

a sound understanding of the law is essential to being a good doctor

law promotes accountability of doctors for their practice

law can be used by doctors to achieve health improvements

law protects vulnerable people and meets their needs

law generally endorses and supports medical value.

However, students express some anxiety:

keeping up to date with knowledge of legal rules

having to consider legal requirements increases anxiety

Also, the law encourages defensive practices in medicine

‘ Mind map’ results 2007/8 (Med + SW) Themes 1. Political structures or politics 2. Authorities, organisations and agencies 3. Legal terms – general 4. Ethico - legal matters relating to social work or medicine 5. Legal terms applied to social work or medicine 6. Role of social worker or doctor and professional identity 7. Perceptions of what law means in practice 8. Personal emotions and feelings about the law 9. Client or patient populations 10. Problems encountered by social workers or doctors 11. Professional groups 12. Criminal matters 13. Financial matters 14. Education, knowledge and skills 15. Problems encountered by clients or patients 16. Miscellaneous

1. Political structures or politics

2. Authorities, organisations and agencies

3. Legal terms – general

4. Ethico - legal matters relating to social work or medicine

5. Legal terms applied to social work or medicine

6. Role of social worker or doctor and professional identity

7. Perceptions of what law means in practice

8. Personal emotions and feelings about the law

9. Client or patient populations

10. Problems encountered by social workers or doctors

11. Professional groups

12. Criminal matters

13. Financial matters

14. Education, knowledge and skills

15. Problems encountered by clients or patients

16. Miscellaneous

Statistically significant differences between medical and SW students More social work students associate the following themes with ‘the law’ than do medical students: Political structures and politics Role of social worker (or doctor) and professional identity, Perceptions of what law means in practice Personal emotions and feelings about the law Client populations Problems encountered by social workers Problems encountered by clients or patients Criminal matters More medical students associate the following themes with ‘the law’ than do social workers: Legal terms – general Ethico - legal matters relating to (social work or) medicine Legal terms applied to (social work or) medicine Professional groups Financial matters All Z scores are significant at the 99% level. Chi square statistic is not calculated as the Z test scores are significant at the .0001 level .

More social work students associate the following themes with ‘the law’ than do medical students:

Political structures and politics

Role of social worker (or doctor) and professional identity,

Perceptions of what law means in practice

Personal emotions and feelings about the law

Client populations

Problems encountered by social workers

Problems encountered by clients or patients

Criminal matters

More medical students associate the following themes with ‘the law’ than do social workers:

Legal terms – general

Ethico - legal matters relating to (social work or) medicine

Legal terms applied to (social work or) medicine

Professional groups

Financial matters

All Z scores are significant at the 99% level. Chi square statistic is not calculated as the Z test scores are significant at the .0001 level .

Mind maps – key words/main themes (medical students) Ethico - legal matters relating to social work or medicine (25%) Ethics, 28% (229) Euthanasia, 21% (174) Confidentiality, 18% (152) Legal terms applied to social work or medicine (19%) Patient consent, 24% (154) GMC guidelines, 16% (105) Rights of patient, 11% (69) Legal terms - general (18%) Suing/being sued, 18% (113) Litigation, 11% (69) Lawsuits, 8% (51)

Ethico - legal matters relating to social work or medicine (25%)

Ethics, 28% (229)

Euthanasia, 21% (174)

Confidentiality, 18% (152)

Legal terms applied to social work or medicine (19%)

Patient consent, 24% (154)

GMC guidelines, 16% (105)

Rights of patient, 11% (69)

Legal terms - general (18%)

Suing/being sued, 18% (113)

Litigation, 11% (69)

Lawsuits, 8% (51)

Differences between SW and medical students Social work students , the 3 themes related most to ‘the law’ with the highest responses are (% responses in brackets): Role of social worker (or doctor) and professional identity (25%) Legal terms – general (15%) Personal emotions and feelings about the law (11%) Medical students , the 3 themes related most to ‘the law’ with the highest responses are (% responses in brackets): Ethico - legal matters relating to social work or medicine (25%) Legal terms applied to social work or medicine (19%) Legal terms - general (18%)

Social work students , the 3 themes related most to ‘the law’ with the highest responses are (% responses in brackets):

Role of social worker (or doctor) and professional identity (25%)

Legal terms – general (15%)

Personal emotions and feelings about the law (11%)

Medical students , the 3 themes related most to ‘the law’ with the highest responses are (% responses in brackets):

Ethico - legal matters relating to social work or medicine (25%)

Legal terms applied to social work or medicine (19%)

Legal terms - general (18%)

Links with professionalism and professional identity We suggest that the development of ‘professionalism’ and ‘professional identity’ needs to consider a student/doctor’s understanding and position towards the law, this should be included in curriculum interventions and we should not simply assume that all students see the law in the same way

We suggest that the development of ‘professionalism’ and ‘professional identity’ needs to consider a student/doctor’s understanding and position towards the law, this should be included in curriculum interventions and we should not simply assume that all students see the law in the same way

A model of professional identity formation PROFESSIONAL IDENTITY Professional Identity Law Professional ethics and codes of practice Personal values, attitudes, morals and beliefs Professional Identity Law Professional ethics and codes of practice Personal values, attitudes, morals and beliefs Professional Identity Law Professional ethics and codes of practice Personal values, attitudes, morals and beliefs Professional Identity Law Professional ethics and codes of practice Personal values, attitudes, morals and beliefs Personal values, attitudes, morals and beliefs Law Professional ethics and codes of practice

Discussion points Should the consensus statement on law and ethics be reviewed to include a specific list of legal principles, rules, statutory obligations and case law? How can we ensure that graduates are equipped with relevant understanding of ‘the law’, how can we best teach and assess this? What lessons can we learn from other professions in the way that they equip students with understanding and skills to work with the law in practice? How is ‘law’ perceived by teachers and curriculum developers? Is it seen as static/fixed? What assumptions are made about how knowledge, skills and attitudes about law is learned? What are the implications for patients and clients when health and social care professionals have different positions vis a vis the law in terms of advocacy, rights and professional role?

Should the consensus statement on law and ethics be reviewed to include a specific list of legal principles, rules, statutory obligations and case law?

How can we ensure that graduates are equipped with relevant understanding of ‘the law’, how can we best teach and assess this?

What lessons can we learn from other professions in the way that they equip students with understanding and skills to work with the law in practice?

How is ‘law’ perceived by teachers and curriculum developers? Is it seen as static/fixed? What assumptions are made about how knowledge, skills and attitudes about law is learned?

What are the implications for patients and clients when health and social care professionals have different positions vis a vis the law in terms of advocacy, rights and professional role?

Next steps Curriculum mapping to identify where and how students acquire and retain knowledge of the legal rules relating to medicine and develop skills in practising law relating to medicine Interviews and focus groups with staff and students to explore perceptions of law relating to medical practice and the impact of curricular interventions A second questionnaire survey of all participating medical programmes in 2008/9 Further development and testing of the model of ‘professional identity’ A survey of all UK medical schools’ law/ethics curricula, funded by the HEA Subject Centres for Legal Education (UKCLE) and MEDEV Comparative research between medical, nursing, pharmacy and social work students and curricula in the UK and New Zealand

Curriculum mapping to identify where and how students acquire and retain knowledge of the legal rules relating to medicine and develop skills in practising law relating to medicine

Interviews and focus groups with staff and students to explore perceptions of law relating to medical practice and the impact of curricular interventions

A second questionnaire survey of all participating medical programmes in 2008/9

Further development and testing of the model of ‘professional identity’

A survey of all UK medical schools’ law/ethics curricula, funded by the HEA Subject Centres for Legal Education (UKCLE) and MEDEV

Comparative research between medical, nursing, pharmacy and social work students and curricula in the UK and New Zealand

Contact details Judy McKimm Centre for Medical and Health Sciences Education, University of Auckland & University of Bedfordshire [email_address] or j.mckimm1@btinternet.com Research partners in medical education: Dr Jon Fuller - Barts and The London Medical School, Queen Mary London Dr Wing May Kong and Dr Sue Smith – Imperial College, London Professor Stewart Petersen – Leicester Medical School Dr Aidan Byrne and Dr Peter Matthews – Swansea Medical School

Judy McKimm

Centre for Medical and Health Sciences Education, University of Auckland & University of Bedfordshire

[email_address] or j.mckimm1@btinternet.com

Research partners in medical education:

Dr Jon Fuller - Barts and The London Medical School, Queen Mary London

Dr Wing May Kong and Dr Sue Smith – Imperial College, London

Professor Stewart Petersen – Leicester Medical School

Dr Aidan Byrne and Dr Peter Matthews – Swansea Medical School

References 1 Consensus Group of Teachers of Medical Ethics and Law in UK Medical Schools. Teaching medical ethics and law within medical education: a model for the UK core curriculum. J Med Ethics 1998; 24: 188-192 2 Goldie, J, Dowie, A, Cotton, P and Morrison, J. 2007. teaching professionalism in the early years of a medical curriculum: a qualitative study. Medical Education, 41:6, 610-617 3 Jha, V, Bekker, H, Duffy, SRG and Roberts, TE. 2007. A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine. Medical Education 41:8, 822-829 4 Braye, S, Preston-Shoot, M and Johns, R. 2006. Lost in translation? Teaching law to non-lawyers, reviewing the evidence from social work. The Law Teacher . 40 (2) 131-150 5 Braye, S, Preston-Shoot, M and Thorpe, A. 2007. Beyond the classroom: learning social work law in practice. Journal of Social Work 7 (43) 322-340

1 Consensus Group of Teachers of Medical Ethics and Law in UK Medical Schools. Teaching medical ethics and law within medical education: a model for the UK core curriculum. J Med Ethics 1998; 24: 188-192

2 Goldie, J, Dowie, A, Cotton, P and Morrison, J. 2007. teaching professionalism in the early years of a medical curriculum: a qualitative study. Medical Education, 41:6, 610-617

3 Jha, V, Bekker, H, Duffy, SRG and Roberts, TE. 2007. A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine. Medical Education 41:8, 822-829

4 Braye, S, Preston-Shoot, M and Johns, R. 2006. Lost in translation? Teaching law to non-lawyers, reviewing the evidence from social work. The Law Teacher . 40 (2) 131-150

5 Braye, S, Preston-Shoot, M and Thorpe, A. 2007. Beyond the classroom: learning social work law in practice. Journal of Social Work 7 (43) 322-340