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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 3  |  Page : 61-67

Measuring the awareness of emergency department physicians toward the management of medicolegal cases in Jeddah, Kingdom of Saudi Arabia


1 Consultant of Forensic Medicine, Department of Forensic Medicine, Jeddah Forensic Medicine Center, Ministry of Health, Jeddah, Saudi Arabia
2 Associate Professor of Forensic Medicine, Department of Pathology, Faculty of Medicine, King Abdul Aziz University, Jeddah, Saudi Arabia; Assistant Professor of Forensic Medicine, Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Cairo University, Egypt
3 Medical Researcher, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission18-Sep-2018
Date of Decision02-Nov-2018
Date of Acceptance18-Dec-2018
Date of Web Publication19-Dec-2019

Correspondence Address:
Dr. Mamdouh Kamal Zaki
2502-Al-Faisaleyah District, Zip Code 23442, Additional Number 8859, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjfms.sjfms_13_18

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  Abstract 


Background: Worldwide, there is a great discrepancy between the hospital and forensic reporting. The medical team priority is saving the lives of victims especially in case of fatal or dangerous wounding. Hence, minimal documentation will be expected under these conditions. Objective: The aim of this study was to measure the awareness of emergency department (ED) physicians toward the legal and ethical aspects of the management of medicolegal cases, assessment of physical and sexual abuse, photo-documentation, and management of forensic evidence in emergency circumstances. This is the first study to investigate this critical topic in Jeddah City, Kingdom of Saudi Arabia. Methodology: The authors accomplished a cross-sectional study in EDs in major Jeddah hospitals during April–May 2017. The authors used a self-administrated questionnaire and used the Survey-Monkey engine and SPSS Statistics for data gathering and statistical analysis, respectively. Results: A total of 137 ED physicians from the main four general hospitals in Jeddah participated in the study. Most of the physicians were males. Most of the participants did not receive any training program in writing medicolegal reports in ED. About two-thirds of the respondents were certain that their workplace provided a specified protocol about collecting evidence from a medicolegal case until referral to forensic medical centers. On the other hand, 86.1% did not have any training program in evidence collection in EDs. Most of the participants believed that they needed more training programs concerning management of medicolegal cases at ED. Conclusion: Although the level of awareness is significantly high, more than half of the physicians considered that the current approach of medicolegal cases was inappropriate. Medical students and residents need more training programs in medicolegal reporting and chain of custody as well as for specialists and consultants.

Keywords: Emergency, evidence collection, forensic, medicolegal, reports


How to cite this article:
Zaki MK, Bayoumi KA, Rawas MI, Alshutayri ZN, Kensarah EA, Jamal AM, Zughbi MA. Measuring the awareness of emergency department physicians toward the management of medicolegal cases in Jeddah, Kingdom of Saudi Arabia. Saudi J Forensic Med Sci 2018;1:61-7

How to cite this URL:
Zaki MK, Bayoumi KA, Rawas MI, Alshutayri ZN, Kensarah EA, Jamal AM, Zughbi MA. Measuring the awareness of emergency department physicians toward the management of medicolegal cases in Jeddah, Kingdom of Saudi Arabia. Saudi J Forensic Med Sci [serial online] 2018 [cited 2020 Jan 28];1:61-7. Available from: http://www.sjfms.org/text.asp?2018/1/3/61/273581




  Introduction Top


Medicine is a risky profession. Some medical specialties, such as emergency medicine, carry a greater risk than other fields. Patients often present to the emergency department (ED) with diverse complaints and with varying levels of urgency, for which grading and prioritization are done according to different systems of triage. Therefore, patients with minor, less urgent complaints who do not represent a priority, become usually frustrated due to long waiting time.[1],[2],[3]

Health professionals in the ED are responsible for both patient management and preparation of medicolegal reports. However, most of the emergency medicine physicians, even those with enough experience, do not properly recognize their medicolegal reporting role.[4]

Most clinical forensic examinations are only requested days after the initial management in the ED, and hence, the need of the medicolegal physician to report on wounds or injuries that were treated several days earlier. The condition could even be worse if they have to base their reports only on clinical and if available, radiological data gathered from medical files. Both situations explicitly reveal the importance of medicolegal reporting and documentation carried out by the emergency medicine physicians who are the first to deal with the patient.[5],[6]

Furthermore, some universities teach forensic medicine only to medical students and do not teach it to students in other colleges such as dentistry and nursing.[7]

Worldwide, there is a great discrepancy between the hospitals and forensic reporting. This discrepancy is attributed mainly to the fact that the medical team's priority is saving the lives of victims, especially in case of fatal or dangerous wounding. Therefore, minimal documentation is expected under the stressful conditions of the ED. As it is impossible to provide forensic doctors in every hospital, ED physicians should be aware of the proper management of medicolegal cases that present to the ED, including documentation of all injuries as well as collection and preservation of evidence.[8]

Hence, the aim of the present study was to measure the awareness of physicians in ED toward the legal and ethical aspects during the management of medicolegal cases, assessment of physical and sexual abuse, photo-documentation of wounds, and management of forensic evidence in emergency circumstances. The study will help to determine whether ED physicians need more learning in medicolegal management, for example, adding a course of medicolegal management in residency years. This study is the first of its kind to investigate this critical topic in the Makkah Region, Kingdom of Saudi Arabia.


  Methodology Top


Ethical considerations

Ethical approval for the current study was obtained from the Institutional Review Board of King Abdulaziz University, Jeddah, Saudi Arabia. All patients' information was kept confidential, and an informed written consent was obtained from each participant, before completing and submitting the questionnaire.

Study design

This was a cross-sectional study.

Participant's eligibility criteria

The target: ED physicians in the major hospitals in Jeddah City, Kingdom of Saudi Arabia. Participants with incomplete data were excluded from the study.

Setting and dates

The study was conducted in ED in major hospitals in Jeddah including (1) King Abdul Aziz University Hospital; (2) King Abdul Aziz Hospital; (3) King Fahd Hospital; and (4) King Khalid National Guard Hospital. Data collection was done during April–May 2017.

Data collection instrument

A self-administrated questionnaire was divided into the following three sections: (1) demographic information including participants' age, gender, nationality, professional degree, hospital, specialty, and experience; (2) information about the workload in ED and previous medicolegal training; and (3) information concerning perspectives of physicians about medicolegal situations. The Survey-Monkey survey was used for data gathering.

Data entry and statistical analysis

Data analysis was carried out using statistical package for the social sciences (IBM SPSS®, IBM Corporation., USA). All numerical variables were checked for normality using Shapiro–Wilk test. Normally distributed variables were expressed as means ± standard deviation; while abnormally distributed variables were expressed as median and interquartile range (IQR) (25th–75th percentile). Categorical variables were summarized as frequencies and percentages.


  Results Top


Most of the ED physicians from the main four general hospitals in Jeddah participated in the study (n = 137) and responded to the questionnaire. The demographic and occupational data of the respondents revealed that 90 physicians (65.7%) were male and 47 (34.3%) were female, and the mean age was 29 ± 6 years. Most of the participants were Saudi physicians (n = 126; 92%). Residents accounted for 44.5% (n = 61), followed by interns (n = 34.5%), then specialists (n = 23, 16.8%), and finally consultants (n = 6, 4.4%). The highest frequency of respondents worked in King Abdul Aziz University Hospital (n = 52, 38%), followed by King Fahd Hospital (n = 42, 30.7%). Approximately 70% of the participants were emergency physicians, followed by the pediatricians (20.4%), gynecologists (6.6%), and surgery (2.9%). The respondents had experience ranged from one to 4 years (IQR = 2), and their weekly number of duty shifts ranged from two to three (IQR = 2) [Table 1].
Table 1: Demographic and occupational data of the respondents (n=137)

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Regarding the previous experiences and medicolegal duties practiced by the respondents – The majority of physicians admitted that they received forensic education (mostly as undergraduates; 86.9%). However, most of the respondents stated that they neither received forensic training (89.1%) nor training in writing medicolegal reports in the ED (86.9%). About half of the respondents (56.9%) were used to manage 5–9 living cases per shift; while the majority (94.9%) were used to manage four or fewer dead cases per shift. Most of the physicians (84.7%) encountered <2 cases of medicolegal importance [Table 2].
Table 2: Previous experiences and medicolegal duties practiced by the respondents (n=137)


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As regards the beliefs and practices of the respondents in the notification of medicolegal cases encountered in the ED, and case of criminal suspicion – 90.5% stated that they notified the police immediately; and 96.4% thought that “notification to the police authority is an essential legal procedure and represents a legal responsibility.” Half of the respondents stated that they notified the relatives about their suspicions (before police notification); while 26.3% believed that “notification of relatives depends on the circumstances.” Only 7.3% (n = 10) from all respondents experienced stress from relatives, preventing them from disclosure to the police [Table 3].
Table 3: Beliefs and practices of the participants as regards notification of medicolegal encountered in the emergency room (emergency departments) (n=137)


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[Table 4] shows the beliefs and practices of the respondents toward the documentation of medicolegal cases in ED. About 76.6% of physicians were aware of the presence of a unified protocol for the management of medicolegal cases in their workplace. Most of the respondents (88.3%) agreed to the importance of photography in the documentation. Furthermore, 83.9% thought that this could protect the ED medical staff from remote legal consequences. However, only 38.7% of respondents admitted that their workplace provided instruments for photography. Most of the participating physicians neither practiced photographic documentation for any medicolegal cases (79.56%) nor had any training for photographic documentation (88.3%). About two-thirds of the respondents were certain that their workplace provided a specified protocol about collecting evidence from a medicolegal case and Sexual Assault Kits for evidence collection until referral to forensic medical centers. Only 48.9% were certain that their workplace provided a well-organized chain of custody for evidence collection until delivery to police authority. On the other hand, most respondents (86.1%) did not have any training program in evidence collection in EDs. Overall, 68.6% of the participating physicians thought that they provided proper documentation for each medicolegal case.
Table 4: Beliefs and practices of the respondents about documentation of medicolegal cases encountered in the emergency department (n=137)


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[Table 5] demonstrates the expectations and needs of the participants. Only 45 physicians (32.8%) thought that “incomplete medico-legal reports issued from the ED at their workplace are legally valuable.” In the same context, 42.3% were always expecting major legal consequences or penalties of medicolegal reports in courts. More than half of the studied persons (n = 74; 54%) believed that “current overall medical approach of medico-legal cases is inappropriate.” Most of the participants (89.09%) believed that they needed more training programs concerning the management of medicolegal cases at ED. More than half of all participants (55.5%) thought that undergraduate time and residency programs are the best stages for training programs of medicolegal cases.
Table 5: Expectations and needs of the participants (n=137)


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  Discussion Top


In the current study, the ED physicians participated in the study and responded to the questionnaire (n = 137) were from the main four general hospitals in Jeddah with mean age 29 ± 6 years. The highest frequency of respondents worked in King Abdulaziz University Hospital (n = 52, 38%), followed by King Fahd Hospital (n = 42, 30.7%).

Most participants (92%) were Saudi physicians and males (65.69%). Approximately 70% of the participants were emergency physicians, followed by pediatricians (20.4%), Residents accounted for 44.5%, followed by interns (34.5%). The respondents had experience ranged from for one to 4 years (IQR = 2). Unfortunately, there is no previous study investigated our critical topic in the Kingdom of Saudi Arabia.

Regarding the previous experiences and medicolegal duties practiced by the respondents, the majority of physicians received forensic education (mostly as undergraduates; 86.9%). However, most of them did not have any training in forensic medicine (89.1%), or in writing medicolegal reports in ED (86.9%).

Medical records and official reports at the ED are of paramount importance in medicolegal cases. Forensic reports written by the ED physicians represent crucial evidence for investigating authorities. Inaccurate reports result in delays in judicial proceedings and formation of misleading conclusions that may lead to the loss of victims' rights. Teaching forensic medicine to undergraduates differs across the countries, depending on the duties that the graduates are required to perform in each country. Germany, Portugal, and most European countries teach forensic medicine to undergraduate students.[9],[10] In Asia, forensic medicine is taught as a major subject in countries such as India and Sri Lanka.[11] More than half of the Saudi medical colleges include forensic medicine into the undergraduate curriculum of medical students, but clinical training seems – from our results – to be lacking. This can be explained by the fact that the principal role of forensic medicine is teaching only in Saudi universities. Field casework and autopsy are carried out by forensic medicine centers at the Ministry of Health. To improve the current situation of lack of clinical forensic training, medical colleges should establish their forensic medicine departments to participate in casework and provide training courses for their students.[7],[12]

In the present study, about half of the respondents (56.9%) were used to manage 5–9 living cases per shift; while the majority (94.9%) were used to manage four or fewer dead cases per shift. Most of the physicians (84.7%) encountered <2 cases of medicolegal importance.

Previous studies showed that medicolegal cases constituted variable percentages of patients seen in the ED; ranging from 0.43% to 7%.[13],[14]

In the current study, physicians thought that notification to the police authority was an essential legal procedure and represents a legal responsibility (96.4%) and notified the police immediately in cases of criminal suspicion (90.5%).

However, this satisfactory rate of police notification could be influenced by recall bias; as the method used in the present study depended on a questionnaire.

A previous study found that cases of child abuse are under-reported by emergency physicians.[15] This could indicate that emergency physicians may not be aware of all cases that should be notified to the authorities or may lack the ability to detect early cases of abuse. There is a medical and legal obligation on the physicians to serve the patients' rights, the public health, and the state needs. Physicians must be aware of public health and legal obligations.[16]

Half of our respondents stated that they disclosed their suspicions to the relatives (before police notification); while 26.3% believed that notification of relatives depends on the circumstances. A small percentage (7.3% from all respondents) experienced stress from relatives, to prevent them from disclosure to the police.

Disclosure of the patients' medical information is ethically and legally forbidden; and the act of disclosure may subject the physician to the legal penalty on the basis of breach of confidentiality. However, the disclosure of confidential data is permitted in specific situations, to prevent harm of the patient or others, or to obey legal obligations. Physicians should be aware of whom disclosure and notification are allowed. Many health-care practitioners are not aware that the patient's own family is not routinely allowed to know or access the patient's information.[16]

In the current study, about 76.6% of physicians were aware of the presence of a unified protocol for the management of medicolegal cases in their workplace. However, a considerable proportion (about one-third of the respondents) were not sure or denied the provision of necessary equipment that is required for effective documentation and evidence collection, such as photography equipment and sexual abuse kit.

This indicates that there is a defect in the workplace strategy to manage medicolegal cases and the protocols to the health-care providers do not include enough information for the junior physicians concerning the availability of certain equipment in ER Department.

In this study, most of the respondents valued the importance of photographic documentation to both the victims (88.3%) and the ED medical staff (83.9%). However, only one-third of respondents were certain that their workplace provided instruments for photography. Most of the participating physicians neither practiced photographic documentation for any medicolegal cases (79.56%) nor had any training for photographic documentation (88.3%). Digital cameras are economic, fast, and allow simple production of good quality photographs. Although some mobile phones offer reasonable picture quality, it is verbally prohibited by the seniors, either for diagnostic or academic purposes, this is not written in the policy or procedures of these hospitals. However, mobile phones should not be used for the documentation of injuries because the quality might be limited, there might be problems with data protection, and it might create the impression of a lack of professionalism.

Digital photography allows the immediate check of the picture on the camera or the computer screen, and can easily be shared and printed.[6],[17] The common mistakes that affect the quality of forensic photographs include poorly focused images, blurred images (due to camera shake), over-or under-exposed images, poor color reproduction, and image noise. To avoid these mistakes, some technical aspects of photography should be learned by the practitioners. Therefore, training in forensic photography should be included as a part of a clinical forensic medicine training course for emergency residents. A noteworthy result of our study was the concept of a high proportion of the respondents that they need not take the patients' consent before photography. Taking of photographs is similar to all diagnostic procedures in that a patient's consent is required. If a patient declines to have photographs taken, despite the physician's recommendation, then this should be documented in their records.[6]

As regards the expectations and needs of the participants in this study, 32.8% thought that incomplete medicolegal reports issued from the ED at their workplace are legally valuable. In the same context, 42.3% were always expecting major legal consequences or penalties of medicolegal reports in courts.

Insufficient knowledge of the forensic medical issues causes problems in the judicial process; patients may face legal difficulties, and physicians can be prone to legal penalties.[14] Previous studies have found that forensic reports written by nonforensic specialists may be incomplete and inaccurate.[18],[19],[20] External traumatic lesions were not documented in 30.5%–62% of forensic reports written by ED physicians; and about half cases with external lesions were not described in detail as required for forensic reports.[14],[19] Other important information that was absent from many records included patient consciousness status, orientation, and cooperative status.[14],[20]

Parker et al. discussed the beneficial effect of structured forms of reports. They concluded that a possible reason for this inaccuracy was the concept held by some physicians that reports written in the ED are insignificant and will be later modified by forensic experts. These defects in report writing and documentation can be improved by providing training programs for emergency physicians that focus on report writing for medicolegal cases, and collection and preservation of evidence; also, providing official forms for the reports in the ED that the physicians will fill in can eliminate many of the difficulties that physicians experience on writing the report from their memories.[21]

In the current study, more than half of our respondents recognized that current overall medical approach of medicolegal cases is inappropriate. Most of the participants (89.09%) believed that they needed more training programs concerning the management of medicolegal cases at ED. Undergraduate and residency stages were thought by nearly half of the participants to be the best for training programs.

Many studies have discussed the necessity and importance of including clinical forensic medicine training into the residency programs of emergency medicine.[14],[22],[23],[24] The formal training in clinical forensic medicine is lacking in many countries.[25]


  Conclusion and Recommendations Top


Most of the ED physicians in the current work, predominantly the residents, did not receive any training program in writing medicolegal reports. Although the level of awareness is very significantly high, more than half of the physicians consider that the current approach of medicolegal cases is inappropriate. Medical students and residents in different specialties need appropriate forensic training programs before graduation and certification. Forensic units at universities in Saudi Arabia should collaborate with forensic medicine centers at the Ministry of Health to complete the practical gaps and enhance research activities of undergraduates and postgraduate students. The authors recommended that it is a necessity to have continuous medical education and specialized training programs in forensic medicine, medicolegal reporting, and chain of custody for specialists and consultants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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