Medical Law and Medical School Curricula: A Systematic Review

Health law plays a crucial role in the field of medicine, as it dictates appropriate practices, regulations, and rights and responsibilities for healthcare professionals and patients. Despite this undeniable relationship, there is a lack of focus on health law, and an outdated hidden curriculum in medical education has perpetuated long-standing negative perceptions of the legal system. PubMed was searched for articles related to medicolegal education that were published from January 1950 to December 2022. The following search terms were utilized: “(medical student) AND (law OR legal OR medico-legal) AND (education)”. Literature that directly or indirectly discussed the relationship between law and medicine as well as the role of medical student education within the medicolegal nexus were reviewed. Additional literature was identified from reference lists of systematic and literature reviews. The authors manually reviewed each included publication to determine key details, study populations, and conclusions. The PubMed search revealed 3,592 papers that were sorted for relevance. Forty-four articles published between 1971 and 2022 were reviewed and analyzed. Three main themes consistently emerged from the discussions in these articles. The first theme concerns the sentiment among medical students that they were ill-prepared to manage the legal aspects of healthcare. The second theme concerns the negative perception of health law by medical students. The third theme details the benefits of including medicolegal courses in medical school curricula. This study sheds light on the notion that medical students feel ill-prepared to handle the legal aspects of healthcare due to limited medicolegal education. Furthermore, negative perceptions of the legal field continue to exist amongst medical students due to a plethora of factors, including an outdated hidden curriculum. Incorporating medicolegal courses into medical school curricula can foster positive attitudes toward the field of law and lead to enhanced professional ethics, increased patient advocacy, and potentially improved patient outcomes.


Introduction And Background
Medical law plays a crucial role in the field of medicine because it dictates appropriate practices, regulations, and rights and responsibilities for health care professionals and patients.Despite the undeniable connection between the medical and legal systems, there is a long-standing perception that the fields of medicine and law are at odds.Although there has been a notable shift in attitudes and perspectives in recent years, medical students commonly learn about health law from a hidden curriculum that tends to reinforce this outdated belief [1][2][3][4][5][6].This hidden curriculum is composed of the implicit or unspoken messages, attitudes, and norms that shape student perception.
As the intricate relationship between medicine and law continues to evolve, the need to educate and prepare medical students for future encounters with legal medicine, including medical ethics, becomes increasingly important.In the United States, medical education is often divided into one to two years of didactic training and two to three years of clinical training.In contrast, internationally, the structure and duration of medical education differs and may span five to six years.
A comprehensive understanding of the interplay between law and medicine can help medical students advocate for health policy reform, identify medical practices that fail to meet standards of care, navigate ethical dilemmas, and inform patients of their rights and legal matters pertaining to the social determinants of health, such as housing issues, income maintenance, health care access, and social service care [7][8][9].This systematic review highlights the importance of incorporating medical-legal education into medical school curricula.

Review Methods
PubMed was searched for articles published from January 1952 to December 2022 related to medicolegal education.The following search terms were used: (medical student) AND (law OR legal OR medico-legal) AND (education).These terms yielded 3,592 publications, of which 51 duplicates and 116 papers of ineligible study types, such as clinical trials were excluded.The remaining 3,425 publications were then manually sorted by the authors.Of these, 3,381 were excluded for irrelevance or being written in a non-English language.Literature that discussed the relationship between law and medicine as well as the role of medical student education within the medicolegal nexus were reviewed.No limitation was placed on the inclusion of articles based on medical students' year of study, age or gender of students, or questionnaire pattern.This resulted in a final collection of 44 publications.A flowchart depicting the selection process for this review can be found in Figure 1.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart template was utilized in the creation of Figure 1.

Results
A total of 3,592 papers were identified and sorted for relevance.Forty-three articles published between 1971 and 2022 in the United States, United Kingdom, Arab Gulf Cooperation Council, France, Australia, South Korea, Canada, Poland, and Germany were included and reviewed .The authors then reviewed each included publication to determine key details, study populations, and conclusions.The data from the final pool of included publications were used to fill in Table 1 as an organized platform to compare the literature.Three main themes emerged from the articles.The first theme concerns the negative perception of health law by medical students.The second theme dictates the sentiment among medical students that they were ill-prepared to manage the legal aspects of health care.The third theme details the benefits of including medicolegal courses in medical school curricula.The reviewed literature is summarized in Table

Theme 1: Medical Students Have Negative Perceptions of the Legal Field
Historically, medical students and resident physicians have harbored negative attitudes and perceptions toward the legal field.O'Leary et al. found that few experienced healthcare professionals try to alter negative perceptions among medical students and many even encourage avoidance rather than interdisciplinary collaboration during their education [2].Additionally, the authors noted that a significant portion of surveyed medical students and residents reported being explicitly taught by attending physicians to consider liability when making clinical decisions [2].Thus, while healthcare professionals typically take malpractice liability into consideration when making clinical decisions, the guidance of medical students to embrace defensive medical practices is not always the appropriate solution and can perpetuate the poor relations between the fields of medicine and law.A survey conducted at Brown Medical School in 2006 by Kelly and Miller revealed drastically negative perceptions of the legal field and the medical malpractice system, especially in students intending to specialize in high-risk areas [3].These negative perceptions included the notion that the current United States medical malpractice system is functioning poorly, needs major changes, and includes many lawsuits that are brought when no physician negligence or incompetence has occurred.These perceptions were not significantly different between students' first and fourth years, further emphasizing the need for curricula that portray the realm of legal medicine as a tool rather than an obstacle.

Theme 2: Medical Students Feel Ill-Prepared to Handle the Legal Aspects of Healthcare
The notion that medical students feel ill-prepared to handle the legal aspects of health care is not surprising considering that many medical schools in the United States do not require medicolegal education beyond lectures addressing ethical dilemmas and medical malpractice.In 1979, medical schools that included medicolegal education in their curriculum required approximately 13 hours of instruction [21].Although discussion of ethics is now required in medical curricula, the limited medicolegal education in medical school can translate to a lack of fundamental clinical skills.These skills include discussing informed consent, collaborating with medical-legal partnerships, understanding confidentiality, and applying relevant laws in the clinical setting regarding child abuse, abortion, and involuntary hospitalization [1,13,27].
Although a medicolegal curriculum is important, it must be accompanied by proper assessment in order to evaluate student proficiency and ensure future application of knowledge.As of 2023, only Texas, Maine, and Kansas require separate medical jurisprudence examinations for physicians to become licensed in the state [15].Although it may not be necessary for physicians to pass a separate examination for licensing purposes, an adequate understanding and assessments at the medical school level, such as including medicolegal assessment in board examinations, are needed to thoroughly prepare students.

Theme 3: Incorporation of Medicolegal Courses in Medical School Curricula Benefits Students
Despite the prevalence of negative perceptions, we must acknowledge that a sound understanding of the law is essential for resolving medical issues and being an ethical physician.Thankfully, there is evidence that medicolegal education can improve the perceptions medical students have of the field of law.Preston-Shoot et al. reported increased positive perceptions of law among medical students after formal legal teaching had taken place [38].Additionally, LeBlang et al. found that medical students' attitudes toward the law improved after they completed a specialized educational program [27].Comparisons of pretest and posttest responses revealed that attitudes toward the legal system, interprofessional cooperation, and medical malpractice crises improved favorably after medicolegal instruction.Thus, these studies demonstrate that medical curricula have the potential to address preformed biases from the start of medical school.
The noted benefits of including medicolegal coursework range from lessening liability risks to improving interdisciplinary collaboration and professional ethics.Additionally, medicolegal education enables physicians to advocate for patients, lobby for policy changes, and bridge the gap between legislation and clinical medicine in a way that improves patient outcomes [12].
Strategies to improve medical students' understanding of legal medicine include individualized medicinelaw electives, mock trials, and simulations [7][8][9]13,22,28,30,33,[35][36][37]40,42].If possible, collaborations between local law and medical school faculty can optimize the use of institutional resources while providing students the opportunity to interact and mitigate negative perceptions and biases.Medicolegal education can be incorporated in each phase of medical school: preclinical years of training can focus on understanding medical law, and clinical years of training can focus on exploring and applying this knowledge.Information surrounding medicolegal topics can be incorporated into ongoing patient-care courses and clerkships by identifying potential legal barriers to care during a standardized patient encounter or by discussing the use of medical-legal partnerships during a workshop on social determinants of health.

Conclusions
Preparing future physicians to navigate complex legal discussions, recognize and address legal issues, advocate for patient rights, manage risks, and contribute to policy is crucial.Thus, the authors encourage the creative expansion of medical school curricula to include simple yet impactful approaches to teaching and assessing medical students' knowledge in this area throughout all years of medical school.In doing so, we will ensure that physicians are prepared to foster a positive relationship with the field of law and improve interdisciplinary collaboration and patient outcomes.

FIGURE 1 :
FIGURE 1: Literature selection PRISMA flowchart Literature selection visualization.PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses 1.

TABLE 1 : Thematic categorization of reviewed publications
Theme 1, medical students have negative perceptions of the legal field; Theme 2, medical students feel ill-prepared to handle legal aspects of health care; Theme 3, incorporation of medicolegal courses in medical school curricula benefits students.
[5]andale et al. 1996[5]United KingdomUnderstand medical students' knowledge of malpractice, attitudes toward litigation, and the significance of litigation in their future practice Survey 3 Al-Azri NH 2020 [10] Arab Gulf Cooperation Council Address the need for a medical law curriculum in medical schools Review 3 Andrews MD 1991 [11] Oklahoma City, OK, USA Describe an approach to teaching about ethical and legal issues 2024 Arbel et al.Cureus 16(2): e54377.DOI 10.7759/cureus.543773 of 7 a