Teaching, learning and assessment of law in medical education

Teaching, learning and assessment of law in medical education Outcomes of a literature review and practice survey

Background
Funded by MEDEV & UKCLE HEA subject centres
Systematic literature review
National survey of law curricula in all medical schools: 31 undergraduate programmes
Builds on similar study of law in social work education (Braye & Preston-Shoot et al 2005)
Alongside National Teaching Fellowship project on outcomes of student learning in medical and social work education

Research questions
what enables students to acquire and to retain knowledge of the legal rules relating to medical practice, and skills in using law in medicine;
how to engage student interest and effort in a subject about which students are often anxious or doubtful of its relevance;
the effectiveness of different ways of organising the academic curriculum, in particular the question of discrete law modules versus integrated curricula which include law teaching within other areas of learning;
the effectiveness of different ways of organising practice learning, in particular the impact on student learning of service and agency procedures, targets and attitudes, and the question of specific law competencies versus integration of law in broader statements of competence for practice;
student reactions to different methods of teaching, learning and assessment of law;
how students ‘position’ themselves towards the law and how this relates to their future professional practice;
how different professional disciplines configure the relationship between law and practice.

Literature review - summary
Law seen as core component of medical curricula but little known about influence and impact of law teaching on subsequent practice
Majority of papers refer to law teaching at postgraduate level, either:
clinical specialties (surgery, older persons’ care)
issues for different client groups relating to new legislation or landmark cases (children, mental health)
Undergraduate level:
Law tends to be reported alongside ethics teaching
Little research on effectiveness of methods of ‘learning’ or assessing law

Literature Review – Evidence Base
42 papers included from 177 retrieved, of which 31 reporting empirical studies
Variable response rates, mainly single institutions, reliance on self-reporting, limited follow up and control/comparison groups
Focus on attitude change and knowledge gain
Limited evidence of impact of training across time or of change to practice

Literature Review – Detailed Findings
Law and ethics: under-theorised relationship, with law learning often implicit/tacit and any tensions or complexities minimised
Why law: main emphasis on individual patients rather than inter-professional practice
What law: acquisition rather than application or critical engagement, with specific law often implicit and breadth/depth debate not teased out

More Findings
Structure: vertical (integrated) and horizontal (specific module), large and small groups, case based but limited effectiveness evidence
Time: variability and acknowledged insufficiency; continuing professional development of legal knowledge and skills inadequate
Assessment: limited consideration but some support for a know – can – do journey (but does assessment predict actual field performance?)
When: non-clinical inputs too far removed from actual practice so learning decays

Further Findings
Practice curriculum: neglected; clinical and non-clinical teaching often unrelated; academic learning “trained out” in practice; hidden curriculum and poor practice reported by students
Outcomes: evidence base not extensive; where clinical rotations foreground law and link learning to academic curriculum, knowledge sticks
More research needed on effectiveness of different methods of teaching and assessment, including at post-registration level and for clinical tutors

Practice survey - overview
Responses received from 25 of 33 schools
Law tends to be:
Taught alongside medical ethics within an integrated curriculum, reflecting the IME ‘Core curriculum on medical ethics and law’ (1998) and GMC curriculum guidance
Two schools teach a discrete core law module
Some schools offer specialist degrees in law/ethics
More recently a shift to learning and assessing law as part of the development of ‘professionalism’:
Legal responsibilities and duties, rights of patients, medical decision-making, NHS complaints procedures, professional practice, human rights

Practice survey - teaching
Mainly through case studies, seminars, PBL and ethical dilemmas, though some lectures and other methods
Some ‘classroom’ teaching in 1 st and 2 nd years: primarily knowledge of legal powers, duties and case law (plus ethical issues)
Little learned about the legal system and rules relating to broader issues and community care
Learning not close to clinical placements and usually no specific outcomes for placement law learning
Teachers tend to be a team of ‘clinical enthusiasts’, academic ethicists or lawyers
Though many facilitate PBL or case based scenarios and are not law specialists
2 schools have only one person responsible for law
Five schools provide training/guidance in law for clinical teachers
Little involvement of service users/carers

Practice survey – clinical learning
Much of the ‘law learning’ is acquired during specific clinical attachments:
“ ethics and law are part of clinical practice” (R21)
Typically law is learned around:
Paediatrics/child health
Mental health
Women’s health
However, in clinical attachments only five schools specify law learning outcomes and identify discrete law teaching; most schools do not formally assess law learning on placement and do not support clinical tutors in their learning of law

Practice survey - assessment
One school assesses law separately from ethics in written assessments (moot court)
Two schools assess law formally on clinical placement
Majority integrated written and practical assessments
Some ‘good practice’ examples:
Wide teaching team; staff training; law specialists; applying law to clinical cases and practice; mock inquiries, trials and courts
Range of views relating to whether students are well prepared for Foundation training: one third of respondents are ‘a little dissatisfied’ with the current approach to teaching law; one quarter think that students are less than adequately prepared
No systematic approach, large numbers of students, too few specialist staff

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, Cull, L-A, Johns, R and Roche, J. 2005 Teaching, learning and assessment of law in social work education . London: Social Care Institute of Excellence.
5 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
6 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

Contact details
Michael Preston-Shoot
Faculty for Health and Social Sciences, University of Bedfordshire
[email_address]
Judy McKimm
[email_address]

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Teaching, learning and assessment of law in medical education

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