الفهرس 
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Abstract
In our modern day, physicians often find themselves indulged in cases that have medicolegal depths. Unless handled properly, these cases could lead to dire effects that would cause harm to fall upon the physician or the patient.
This study is aimed at probing the existing way that medicolegal cases are handled and matching the results to current international guidelines as a first step towards proposing a unified set of guidelines on how to deal with these cases in order to preserve both patient rights and physicians’ rights.
In order to formulate an idea about how these cases are handled, this cross sectional study was conducted on physicians working in Ain Shams University Hospitals in different departments.
A Self-administered structured questionnaire was created. It was filled by the physicians working within ASUH during the period between November 2021 and June 2022 to assess physicians’ way of handling cases that had medicolegal depths
The questionnaire has three sections;
• The first section assesses the socio-demographic characteristics of the participants;
• The second section questions the participant’s self-perception of the aspects of proper healthcare criteria and/or medicolegal hazards that the physician might encounter
• The last section assesses the current procedure that the participant and his/her department follows when encountering a case with medicolegal depths including medical documentation procedures.
Procedure of the study:
The questionnaire was prepared using English language. Then; it was revised by a group of two experts in the Forensic Medicine and Toxicology Department, Faculty of medicine, Ain Shams University.
Based on the opinion of a panel of expertise; vague and confusing questions were excluded some modifications were done; and then the final form was developed.
The questionnaire format was filled by the respondents anonymously. The questionnaire was distributed electronically to physicians working at Ain Shams University Hospitals in different departments. The questionnaire was made relatively short to minimize the time it needed to be completed and encourage physicians that have a high workload at ASUH to participate. Electronic online dissemination was used using different department certified staff messaging app groups and official university emails. Participation in this questionnaire was not mandatory. Implied consent was obtained from each physician via email by participating in the study after clarifying the aim and procedure of the study and that their participation is not mandatory and counts as consent. Participants were informed about their right to withdraw at any time without any consequences. Confidentiality of data was ensured.
Matching the questionnaire results to international guidelines of handling MLCs:
• International guidelines of handling medicolegal cases (MLCs) were gathered from different resources. Common areas were sorted and those acted as a base upon which a list of proposed guidelines was built.
As regards the characteristics of the responding physicians that work in ASU hospitals, the majority of them were younger physicians whether residents, 36.7%, or teaching assistants (demonstrators) 17.4%, 21% were assistant lecturers, while only around 7.3% professors and 4.5% assistant professors, as for the work experience, 66% had less than 5 years of experience, 14.7% had 5-10 years of experience which also constitutes the majority of responders.
The results of the inquiry about the responders’ department showed that the responders were predominantly from Anesthesiology and ICU with 18.3%, 15.6% from Internal Medicine, 9.2% from the General Surgery Department, 5.5% from the Plastic Surgery Department, 4.5% from Orthopedic surgery, 8.2% from Cardiology, 8.2% from the Forensic Medicine and Clinical Toxicology department from anesthesiology and ICU, 4.5% from Pediatrics, 6.4% from Obstetrics and Gynecology, 7.4% from Geriatrics and 11% responded with other departments.
The results of this study showed that nearly half of the responders in fact did not think that they have sufficiently studied medical ethics. As for the percentage that did, they stated that they mainly got the knowledge only from undergraduate lectures (16.5%) and by only experience at work (18.3%), while 7.3% answered during training, indicating either the internship year or the first years of residency, and another 7.3% from lectures and seminars, 1.8% answered from their own readings.
This also goes in synchrony with the responders’ answer to whether they knew the main contents of the Hippocratic oath with 78% answering that they in fact did while nearly quarter of the responders 22% didn’t.
Findings of this study however were consistent with having proper knowledge when the majority (67%) of responders stated that it would be acceptable to withhold full information when informing the patient about their condition if the patient had unstable personality disorder.
The majority (80%) of responders of this study agree in fact that the patient should always be told if something went wrong during the course of treatment, including bad prognosis and malpractice, while the majority disagreed with that the close relatives of the patient have to always be told about the patient’s condition even without the patient permission.
The majority of the responders (63.3%) disagreed with refusing to treat patients who behave violently, although up to 17.5% were neutral about the concept, and 19.5% agreed.
On the other hand, most responders were able to recognize behaviors that would be considered incompatible with proper medical ethics of practice, although nearly half (45%) considered reallocating scarce resources towards more needing patients to be incompatible with proper medical ethics while this in fact is the definition of equity in medical ethics practice.
Most responders disagreed to writing a death certificate for their deceased patient during handling a medicolegal case, although around 30% agreed.
As for the responders’ knowledge about the Egyptian law governing healthcare practice, 26.6% only stated that they have knowledge about the law and the majority didn’t with 72.4%.
The frequency of facing ethical or legal problems in the course of the responders work has been taken into consideration, as well as the ability to identify these cases as Medicolegal ones, where 3.66% only mentioned that they never encountered any MLCs, which raises the question whether they actually work in a subspecialty or environment where they never encounter any cases bearing medicolegal weight or their inability to identify them when they pass by them, while on a more expected side, 53.2% encountered Medicolegal problems on daily basis, 20.2% on weekly basis, 18.3% on monthly basis, and 4.6% on yearly basis.
When a list of common medicolegal cases were asked about, not all responders were able to recognize that all choices were MLCs, although the majority of responders did, such that all choices had above average scores.
On the other hand, the vast majority of them erroneously recognized instances of spontaneous abortion, cases of trauma regardless of the etiology of the trauma, and all cases of poisoning, including unintentional cases, as MLCs.
84.4% of participants answered correctly that providing healthcare for the patient was the number 1 priority, while 8.25% answered wrong where they would prioritize reporting to the authorities before caring for the patient, and 3.6% prioritized reporting the case to hospital management, and, 2.75% would rather ask for consultation.
When asked about the doctor’s first action when reporting a suspected medicolegal case (MLC) 45.8% answered that they would prefer reporting to the authorities, 27.5% answered they would prefer reporting to their senior supervising doctor, 20.2% would choose to report to the hospital management, 3.66% to the forensic medicine department and 2.75% would choose to ask for consultation.
Most of responders in this study (84.4%) answered correctly where it was a priority to acquire a consent form especially in cases that are considered medicolegal, 1.8% answered that they don’t have to acquire a consent, 13.7% said that verbal consent was enough.
To further prove the need for hands on forensic training and systematic teaching of ethics to young doctors, responders were asked about who they preferred to consult or discuss an ethical or legal problem arising at the workplace, where the majority chose to ask their supervisor (61.5%).
The same goes for consulting or discussing a legal problem arising at the workplace, 4.5% answered they would rather consult a colleague, 59.6% would prefer their supervisor, 13.6% would prefer to go to the head of the department, 12% would go to a lawyer, 2.7% would go to the hospital administration, where 7.3% would rather go to the forensic medicine department.
When the responders of this study were asked about the existence of a designated ethics committee in Ain Shams University hospitals, 40% answered yes thinking that the clinical ethical committee at the hospitals was the same concept as the research ethics committee, 13% answered no, while 47% weren’t sure.
As for the inquiry about the knowledge of the importance of sample collection in MLCs, the majority (89%) of participants agreed that sample collection is important, while there was still a number of participants that were neutral or disagreed, although this number was less than expected.
In the current study it was also important to find out the actual situation by which departments start preparing their young doctors to deal with MLCs, most responders (36%) stated that they were not sure if their department does have a clear guideline by which they were supposed to handle MLCs, while only 19% stated there were.
Discrepancies were also noted by asking who actually decides next steps in dealing with medicolegal cases, where 42% stated that they were by the head of department, 29% by their direct supervisor, 15% answered by an internal council inside the department, 7.3 by themselves and 6% answered by the forensic medicine department.
Most of the responders (66%) mentioned that their department does not provide them with knowledge on how to identify a medicolegal case, 18% were not sure while 21% mentioned that their department did.
Most of the responders also denied having been properly prepared to collect evidence and samples while handling MLCs.
The majority of responders also stated that their department does not provide them with systematic advice on how to behave as an expert witness if they were asked by law enforcement to testify.
When asked about attending courses to refresh their knowledge regarding forensic medicine and to prepare them to write proper medicolegal reports, half of the responders were not interested in attending courses to refresh their forensic knowledge, while nearly third of the responders were.
When investigating the difference between the junior, intermediate and senior physicians the current study proved there was a statistically significant difference between the three groups regarding general knowledge about medical ethics and the laws governing healthcare practice, where assistant lecturers and lecturers appeared to have more knowledge about medical ethics and professors and assistant professors have more knowledge regarding laws governing healthcare practice.
The findings of the current study, shows that there was a statistically significant difference between the three groups of physicians regarding knowledge of the first action when reporting a suspected MLC, where junior faculty appeared to tend to report to their supervisors more than middle and senior faculty. There was no statistical significant difference between the three physician groups regarding knowledge about informed consent.
The present study shows that there was a statistically significant difference between the three groups of departments sectors — the surgical, medical, and academic sectors — with regard to the frequency of encountering medicolegal cases, with surgical departments encountering the cases more frequently than academic departments, which had the least frequency of encountering cases overall.
The findings of the current study indicate that there was a statistically significant difference between the three main department groups — the surgical, medical, and academic sectors — with regard to the knowledge provided by the department to the responding physicians.
This study demonstrates that the international guidelines and the results of the questionnaire are consistent with one another with regard to handling of MLCs.
This study recommends the establishment of a set of unified guidelines, provided that these guidelines stipulate how to accurately identify forensic medical cases, deal with the patient when it is suspected that it is a forensic medical case, record the case and collect samples to be evidence. It should also stipulate how doctors should act as expert witnesses in court.