Compared to medical services generally, medicolegal services in the UK are to this day plagued by outdated ideas and practice.
It is clear for example that educational practice in the medicolegal system is still based largely on classroom work, a practice which is unsuitable for the clinical settings (De Cossart and Fish ,2005) and indeed a practice that was abandoned elsewhere in medicine a very long time ago. Yet this view underpins much of the education available in the medicolegal system and is the prevailing view to this day.
The underlying principle from the point of view of teaching and learning is that knowledge can be “transmitted" to the learner .GS Medical Group aims to challenge this view which according to the standards of good medical practice is positively antediluvian (Box 2).
(Box 2) The view that knowledge is transmitted from the teacher to the learner as it were by passive osmosis rather than being constructed by the learner is no longer accepted in postgraduate medical education, the prevailing view now being that knowledge is always constructed.
The idea that Knowledge is constructed by the learner rather than being “transmitted “was first introduced by the Constructivist School whose challenge to the Orthodoxy was very successful (Vygotsky, 1978)
In medicine the view of the infant as a “tabula rasa “is also now completely discredited and has lost any traction
Other outdated views however also abound in the medicolegal system which are prejudicial to teaching and learning. The experience of Junior Doctors is for example believed to be very limited, further affecting medicolegal education detrimentally.
Such views are deep and almost intractable.
Doctors in training are thus thought to be lacking the required experience to be able to undertake any medicolegal work or take instructions and therefore unsuitable to act as an Expert Witness.
Accordingly, and from an educational point of view, they are also deemed not to require any training. This view certainly in the field of Psychiatry is manifestly false for at least two reasons:
First, unlike the MRCP, an “entry” exam taken by physicians to enter specialist medical training, the MRCPsch, an “ exit “ exam taken at the end of core training, certifies the standards required of a Psychiatrist have been met , the GMC’s Specialist Register being a much later invention.
[1] A distinction of course ought tobe made between experience and expertise , which is acquired over time. Thedistinction is of vital importance in medicolegal education and has been mosteloquently made with regard to the Registration of experts (Rix, Eastman, Haycroft and Adshead 2017)
Psychiatrists unlike Psychologists are of course medically qualified and like any other doctors are expected to complete their medical training when they are deemed by definition to be qualified for independent practice.
Secondly, Psychiatrists whose ability “to diagnose and treat Mental Disorder” is capable of being certified by the Secretary of State, do need of course to be able to show that they have the relevant experience to do this , regardless of their being on the Specialist Register. Indeed, they demonstrate this on a regular basis as part of their being “on call “or for example in the case of doing a Mental Health Act Assessment. The process of certification which is enshrined in the Mental Health Act 1983 is known as Section 12 Approval [2]
A Section 12 Approved Doctor of course provided he or she has the required experience, need not even be a Psychiatrist and the role is discharged regardless of status. The provision to approve doctors as having the required experience to diagnose and treat Mental Disorders is well established and regulated.
(Box 3) Reflective practice in the medicolegal system is unknown and Experts are largely self-taught , Medicolegal Curricula being entirely non-existent under the current system .Indeed on many occasions experts will admit privately to have learned their skills in the Coroner’s Court.
Standards of practice in the medicolegal system are also very inconsistent causing Experts to often display very idiosyncratic practices, Joint Expert Statements ordered by the Courts being but one example.
Despite the formal training available there are also no current agreed standards for the delivery of expert evidence to the Courts, and different templates have been suggested by different training organisation.
However, the subject of Supervision has appeared recently in case law (Pinkus vs Direct Line, 2018) where it seems to be undermined. The Judgement in this case is known colloquially as the Pinkus Trap.
[2] The role of a Section 12 Approved Doctor is a quasi-Judicial role. The role allows a doctor to detainpatients in hospital, thereby depriving a subject of their liberty. Psychiatrists may become Sect 12 Approved subjectto certain criteria at a very early stage.
( Box 4 ) The concept of Supervision meaning literally “a view from above “is not antipathetic to the legal principle of Independence, on the contrary it is plain that it positively reinforces it.
The Pinkus case has however been misconstrued elsewhere as a legal muzzle restricting rather than expanding the scope of medicolegal Education. In practice it is generally perceived as antieducational.
In this case, an extremely complex case of Personal Injury, eventually thrown out on the grounds of Fundamental Dishonesty, the claimant’s Expert, a Neuropsychologist sought help from a senior colleague in the form of Supervision.
The Defendant in this matter applied successfully for disclosure of the supervisory material before the case went to trial. The Expert was in any event severely reprimanded for lacking “independence “ ( Box 4 .)
Medicolegal Case based Discussions (CbD’s) otherwise have been advocated in Medicolegal Education for some time (Rix and Powers, 2021) but its place in practice is to this day poorly understood (Box 5 ).
( Box 5 ) CbD’s are a vital part of Appraisal and evidence of engagement is normally provided in the Appraisal Document under Quality Improvement .The use of Medicolegal CbD’s however to this day is unknown , the requirement to engage in Whole Practice Appraisal again notwithstanding
Indeed, the use of medicolegal CbD’s during Appraisal is to this day believed to be very low possibly due to the fact that Medicolegal practice is a part time activity for Consultants and certainly compared to the GMC requirement to engage in 360 Degree feed back
Tools for 360 Medicolegal Feedback as it applies to the medicolegal system have now been developed and are commonly in use although still very experimental. Medicolegal CbD’s however lack any tools to undertake them although a dedicated Form designed especially for this purpose has been suggested (Rix and Powers 2021).
Spiralling costs of litigation delays in the provision of medical evidence to the Courts and the poor quality of evidence available to the Courts are seriously poor outcomes and in the opinion of GS Medical Group the direct consequences of an outdated system which needs to change and in the opinion of the Group is ripe for reforming.
The shrinking of the pool of experts is of course a further adverse outcome noted in medical indemnity settings amongst others (Hendry 2019).
GS Medical Group challenges outdated practice in Medicolegal Education and Services (Box 6 ) and is determined to update them.
(Box 6) There are several potential reasons why outdated practice is still prevalent in the medicolegal system such as the following:
- vested interests
- fee paying structure
- contractual constraints
- conflicting educational objectives equating for example Forensic and Medicolegal practice
- social isolation
- fragmentation due to the many training organisations providing medicolegal training in the UK
- the role and function of Reporting Agencies in the medicolegal system including administration and marketing of expert services exceedingly legalistic as opposed to clinical views and priorities in medicolegal education
Unlike training available under other organisation where principles and values are rarely stated, training under GS Medical Group is value-based and based on the following principles.
A ) medicolegal training should within the law be practice based and based on real cases
B ) trainees make excellent Expert Witnesses provided they are adequately trained and suitably supervised.
