Structure

Only two programmes reported teaching law as a separate topic, the remainder integrating it alongside ethics, professionalism or clinical topics. Both these programmes offered law teaching as a student selected component, either in year 1 or year 3, in addition to core law teaching integrated with ethics. The main reason for teaching law as a separate topic was cited as a lack of curricular time for teaching law in the core curriculum. Four other schools reported offering an student selected component in medical ethics and law.

Only 14 of the remaining 23 schools gave details of where teaching law as an integrated topic was included in the curriculum. The number of taught hours varies markedly, with most teaching located early in programmes (see table 1). As clinical placements were described as covering general and community medicine from year 1, with more specialist learning opportunities, such as in mental health or paediatrics, following from year 3 onwards, some law teaching will be quite distant from its practical application.

The dominant reason cited for integrating the teaching of law within other modules and not as a separate topic was to encourage students to connect the legal rules with all programme areas, including clinical practice, and to promote student engagement with law alongside ethical situations and clinical cases or settings. Many schools incorporated law and ethics teaching as a vertical theme throughout the programme as part of a spiral curriculum. Some used problem-based learning or structured the curriculum around ‘learning weeks’ or ‘cases of the week’, often led by clinicians, when no topics are taught separately. However, it is noteworthy that many schools did not have specific law learning outcomes for clinical placements except for specific legal rules that underpin specialist settings, such as the Mental Health Act 1983 and the Mental Capacity Act 2005 within psychiatry attachments. Many respondents found it difficult to identify specific law-related learning outcomes, given the integration with ethics and clinical cases, while in the relationship between law and ethics the main teaching focus appeared to fall on the latter.

Content

Respondents were asked to confirm which topics were covered in university-based teaching and on clinical attachments (see table 2). The results can be compared with subject benchmark7 and curriculum consensus statements.1 2 It is noteworthy that no single topic is covered by more than three-quarters of responding schools, and that mental health and capacity, consent to treatment, and confidentiality, data protection and negligence are prominent in non-clinical teaching. In clinical attachments, mental health and capacity are again emphasised but here by less than half the responding schools. Some schools identified other taught topic areas including euthanasia and end-of-life decisions and fitness to practice. The selection of topics appeared to be determined partly by clinical relevance but partly by the availability of curriculum space and staff expertise and interest in law, challenges noted in previous research8–11 and the consensus statements.1 2

Teaching and learning

Among responding schools, 88% of law teaching is the responsibility of more than one person, as recommended,2 with most programmes having between two and four curriculum law leads. This responsibility is usually combined with teaching ethics. These teachers tend to be medical ethicists, philosophers or lawyers. Curriculum leads may be supported by academic lawyers or doctors, NHS managers or clinicians, especially when programmes use problem-based, small group teaching, or case-based scenarios, and for law teaching in clinical attachments (see table 3). Clinicians are viewed as invaluable for putting the law into a clinical context. They play a variety of roles. Some are specialists in law or ethics, but the majority provide input on law relating to their clinical speciality, most commonly paediatrics, mental health, obstetrics and gynaecology, palliative care and general practice. Not all these contributors will have formal ethicolegal training or qualifications, which raises questions about professional development to teach law effectively.

There is limited outcome focused research on what combination of teachers best facilitates medical law learning.12 As with social work law13 no common pattern emerges. A multiprofessional teaching team demonstrates to students an openness to interdisciplinarity, offers breadth of experience and knowledge, and potentially can illuminate legal discourses and processes. The challenge is to ensure that teaching is relevant to professional practice and to secure time for preparation so that the team can blend their different orientations and approaches to the subject.

Examples were given of contributions from patients and carers, but their involvement appears underdeveloped, as is true elsewhere in professional education (such as social work).13

A wide range of teaching and learning methods is used (see table 4), the choice of which related closely to overall curriculum structure and approach, such as problem-based learning with an emphasis on medical professionalism, or a spiral integrated curriculum wherein students return to blocks at different levels and with additional new material. Most schools used a combination of methods but with a developing programmatic emphasis on application to clinical situations in order to embed learning. Clinical contextualisation is overwhelmingly seen as central. Case scenarios, tutor-led seminars, clinical placement teaching and lectures are the most common methods used. E-learning and simulation exercises are little used. Three respondents noted that small group learning is probably one of the most effective ways of teaching and learning law, but that their approach was constrained by curriculum space, resources and budgets.

A range of materials and sources of law is used to foster and embed law learning (see table 5). The most common sources of law cited were codes of practice (64%), guidance (60%) and case law (56%). However, given that the law evolves rapidly in response to social concerns, and comprises a body that begins with statute and is developed through regulations, guidance and case law, the coverage of sources and materials may be insufficient to enable students to appreciate the full extent and complexity of the legal rules. For example, evidence14 suggests that students benefit from reading case law because it illuminates legal and ethical practice issues such as those surrounding assisted suicide, consent to treatment and vulnerable adults who self-neglect. However, this source of learning appears underutilised.

Clinical placements

Schools reported law teaching and learning as occurring across the range of clinical attachments, predominantly in later years of the programme. Seventy-six per cent of schools, however, did not have specific learning objectives for clinical placement teaching of law. Only 16% of schools included law overtly in clinical placement learning agreements. Eighty per cent did not provide any guidance or continuing professional development to clinical teachers to support their teaching of law. Programme respondents were increasingly aware that this curriculum component had not been formally planned, coordinated or adequately monitored. If the practice curriculum for law learning in medical education is underdeveloped, there are parallels elsewhere in professional education.13

Assessment

Choice of assessment methods was linked to overall course structure and approach, with 92% of schools reporting that assessment of law was integrated with assessment of other topics, such as ethics, and with a strong applied practical focus in addition to testing accurate knowledge. Ninety-two per cent of schools assess law using written assessments. A range of coursework and written summative assessments was used, including presentations (20%), case studies (24%), multiple choice (44%) or short answer papers (36%) and essays (28%). Forty-four per cent of programmes tested practical application using objective structured clinical examination, with smaller numbers employing work-based clinical assessment, objective structured long examination records or a moot court. Seventy-two per cent of respondents cited that the purpose of assessment was to assess students' application of ethical principles to professional medical practice, with 68% looking for students to apply the law to professional medical practice. Specific aspects of law that were assessed included human rights (48%), content of legal frameworks (32%) and sources of law (28%). Only 20% noted that they required students to demonstrate a critical analysis of legal frameworks, an area that the revised core curriculum2 emphasises.

Eighty-four per cent of responding schools did not assess law formally on clinical placements, raising questions about how to ensure that student knowledge has been embedded in practice. Reasons cited were that it was not practical, that students had enough assessments already and that assessment of law has never been part of the clinical curriculum.

Respondent evaluations

Nineteen schools responded to a question about how prepared they believed students were in relation to law for their next stage of training. Twenty-six per cent stated that students were well prepared and 47% adequately prepared. Sixteen per cent thought that students were insufficiently prepared while 11% said that their teaching would shortly change. A majority (56%) of respondents were very or reasonably satisfied with their current approach to teaching, learning and assessment of law in medical education. This appeared, however, to be primarily based on student, teacher and external examiner feedback and personal reflection. Eighty-four per cent of schools have not undertaken any systematic outcome study of law learning. The principal reasons for dissatisfaction related to a lack of curriculum time and the absence of specific law-related learning outcomes.