Comparison of Learning Outcomes Among Medical Students in Thailand to Determine the Right Time to Teach Forensic Medicine: Retrospective Study

Introduction

Forensic medicine is a crucial field that intersects with the legal system. It involves the collection, analysis, interpretation, and presentation of evidence in legal cases [Shepherd R. Simpson’s Forensic Medicine. 12th ed. Arnold; 2003. ISBN: 03408105991]. Forensic medicine plays an essential role in assisting courts with making correct decisions by providing reliable and timely information. It also plays a critical role in protecting peoples’ rights by ensuring that their legal, civil, and human rights are upheld throughout the legal process [Payne-James J. History and development of clinical forensic medicine. In: Clinical Forensic Medicine: A Physician’s Guide. Humana Press; 2005:1-36. [CrossRef]2]. Furthermore, studying forensic medicine is important for medical students in different countries, as they are equipped with the necessary knowledge and skills to accurately assess and document injuries and provide expert opinions on causes of death and other relevant medical information that may have legal implications [Tóth D, Petrus K, Heckmann V, Simon G, Poór VS. Application of photogrammetry in forensic pathology education of medical students in response to COVID-19. J Forensic Sci. Jul 2021;66(4):1533-1537. [CrossRef] [Medline]3-Fayed MM, Abdo SA, Sharif AF. Preclinical and clinical medical students’ perception of the learning environment: a reference to the Forensic Medicine and Clinical Toxicology course. Adv Med Educ Pract. Apr 23, 2022;13:369-406. [CrossRef] [Medline]6].

This subject is included among the professional subjects that every Thai medical student must study to comply with the Criminal Procedure Code of Thailand, which requires physicians working in public hospitals to be able to perform postmortem inquests with police in cases where no forensic physician is available [Thailand Criminal Procedure Code sections 148-156. Thai Law Forum. Jul 3, 2024. URL: http://www.thailawforum.com/thailand-criminal-procedure-code-sections-148-156/ [Accessed 2025-01-28] 7]. The Medical Council of Thailand has included forensic medicine as a mandatory subject in every doctor of medicine program.

The doctor of medicine programs in Thailand are 6-year programs conducted after graduating from high school. They are generally divided into 3 years at the preclinical level (first through third year) and another 3 years at the clinical level (fourth through sixth year). The teaching of each university’s curriculum differs in detail depending on various factors, such as the number of students, number of teachers, location, and service characteristics. Forensic medicine is subject to these differences.

Studying forensic medicine involves dealing with dead bodies, crime scenes, and traumatic injuries that can be emotionally and mentally stressful for some students [Papadodima SA, Sergentanis TN, Iliakis RG, Sotiropoulos KC, Spiliopoulou CA. Students who wish to specialize in forensic medicine vs. their fellow students: motivations, attitudes and reactions during autopsy practice. Adv Health Sci Educ Theory Pract. Nov 2008;13(4):535-546. [CrossRef] [Medline]8]. A study from Saudi Arabia revealed that medical students have poor attitudes toward and awareness of the importance of forensic medicine [Madadin MS. Assessment of knowledge about, attitudes toward, and awareness of a forensic medicine course among medical students at the University of Dammam. J Forensic Leg Med. Nov 2013;20(8):1108-1111. [CrossRef] [Medline]9]. Additionally, forensic medicine courses cover a wide range of topics, such as anatomy, physiology, pathology, toxicology, psychology, and jurisprudence, which can be difficult to master and integrate [Wyatt JP, Squires T, Norfolk G, Payne-James J. Oxford Handbook of Forensic Medicine. Oxford University Press; 2011. URL: https://academic.oup.com/book/29998 [Accessed 2026-01-17] [CrossRef] ISBN: 019922994510,Levinson SA, Muehlberger CW. An introductory course in legal medicine for medical students. Acad Med. Sep 1934;9(5):293-301. [CrossRef]11].

Students with different levels of medical knowledge may experience different forensic medicine course outcomes. In Thailand, most medical curricula are currently designed to teach forensic medicine to medical students at the clinical level (fifth year) [Faculty of Medicine Ramathibodi Hospital, Mahidol University. Doctor of Medicine Program, Revised Curriculum 2020 [Article in Thai]. Mahidol University. 2020. URL: https:/​/www.​rama.mahidol.ac.th/​meded/​sites/​default/​files/​public/​img2024/​course/​%E0%B8%A1%E0%B8%84%E0%B8%AD.​2%20%E0%B8%AB%E0%B8%A5%E0%B8%B1%E0%B8%81%E0%B8%AA%E0%B8%B9%E0%B8%95%E0%B8%A3%20%E0%B8%9E%E0%B8%9A.​-63-pdf%20%E0%B8%A3%E0%B8%A7%E0%B8%A1-110863.​pdf [Accessed 2024-08-24] 12-Chulalongkorn University. Doctor of Medicine Program (Revised Curriculum 2017) [Article in Thai]. Chulalongkorn University. 2017. URL: https://bhumibol-med.com/Media/media-2017-11-19-04-35-32.pdf [Accessed 2024-08-12] 14]. However, some curricula have been designed to teach forensic medicine to medical students at the preclinical or early clinical level (third or fourth year) [Clinical Medical Education Center, Sawanpracharak Hospital. Course Specification: Forensic Medicine 1 (NVEF411). Revised January 13, 2014. [Article in Thai]. Mahidol University. 2014. URL: https://www.rama.mahidol.ac.th/patho/sites/default/files/public/file/NVEF411.pdf [Accessed 2024-08-12] 15]. There are no clear guidelines regarding the level of students who should be taught forensic medicine.

This study aims to compare the learning outcomes of medical students in a curriculum that teaches forensic medicine at the clinical level and those of medical students in a curriculum that teaches forensic medicine at the preclinical level.

Methods

Study Design

This retrospective study was conducted to compare multiple-choice question (MCQ) scores of fifth- and third-year medical students from two medical curricula that teach forensic medicine. Both groups of students studied forensic medicine with the same instructors, used similar content, and were assessed via MCQ examinations with similar difficulty levels. The scores indicated the participants’ learning outcomes.

Setting and Participants

Samples

Our samples included (1) medical students in a curriculum that teaches forensic medicine at the clinical level (fifth year) through the Doctor of Medicine Program at Ramathibodi Hospital, Mahidol University (782 students), and (2) medical students in a curriculum that teaches forensic medicine as the last subject at the preclinical level (third year) through the Joint Program for Producing More Doctors for Rural Areas, Mahidol University (281 students).

Sample Size Calculation

The sample size was designed to compare 2-sided differences in the MCQ percentage scores between third- and fifth-year medical students studying forensic medicine. The null hypothesis (H₀) was that the MCQ percentage scores between third- and fifth-year medical students would not be significantly different. The alternative hypothesis (H₁) was that the MCQ percentage scores between third- and fifth-year medical students would be significantly different.

We calculated the sample size according to a 5% type 1 error (α) and an 80% study power (1 – β). The significant difference (µ1 – µ2) and SD (σ) were set at 10 and 11, respectively, based on MCQ score data for medical students who studied forensic medicine from 2010 to 2014. The required sample size was 38 (19 participants in each group;

Multimedia Appendix 1

Sample size calculation.

Intervention

Teaching Method

Both groups of medical students received on-site theoretical lectures before completing the MCQs. The content included basic knowledge of forensic pathology (including postmortem inquest, identification, time of death estimation, crime scene investigation, unnatural death, and sudden unexpected death), clinical forensic medicine (including patients who are wounded, child abuse, sexual assault, and forensic psychiatry), forensic evidence, forensic genetics, forensic toxicology, and medical law and ethics. Third-year medical students studied for 30 hours. Fifth-year medical students studied for 15 hours, using similar content that was more concise, and had the opportunity to visit a court for 3 hours. Neither group had the opportunity to attend crime scene investigations or autopsies (which they would attend later). This teaching method was performed regularly, and the authors did not intervene with any of the participants.

MCQ Examinations

For examinations, all teaching staff (4 staff members) created 5-option MCQs with a single best answer according to the topics they taught, including basic knowledge of forensic pathology (40% of questions), clinical forensic medicine (30% of questions), forensic evidence (5% of questions), forensic genetics (5% of questions), forensic toxicology (5% of questions), and medical law and ethics (15% of questions). The tests were designed to ensure that medical students are able to perform basic postmortem inquests, examine various types of forensic patients, produce accurate medicolegal reports, have basic knowledge of law and ethics, and understand the process of testifying in court. The MCQ examinations were structured via a balanced approach for cognitive function, allocating approximately 25% of the examination to knowledge, 30% to comprehension, 25% to application, and 20% to analysis level, according to the Bloom taxonomy. This distribution is maintained consistently from year to year. The examination was intended to have a moderate level of difficulty. Third-year medical students completed a 100-question examination in 2 hours, and fifth-year medical students completed an 80-question examination in 1.5 hours. Based on an analysis of the examination, most of the items had a difficulty level (p) in the range of 0.4 to 0.7 and a discriminatory power (r) in the range of 0.1 to 0.5. Internal consistency reliability (Kuder-Richardson Formula 20) was in the range of 0.6 to 0.7.

Data Collection

In this study, the data were collected retrospectively for 5 years, from academic years 2010 through 2014.

Statistical Analysis

For the comparison between the two groups, we used the means and SDs of the MCQ scores to test this study’s hypothesis that the learning outcome is different between third- and fifth-year students. Kruskal-Wallis and Mann-Whitney U tests were used for continuous variables with normal and nonnormal distributions, respectively [De Muth JE. Overview of biostatistics used in clinical research. Am J Health Syst Pharm. Jan 1, 2009;66(1):70-81. [CrossRef] [Medline]17]. The significance level was set at 5% (P<.05). The program used for data analysis was SPSS software (version 26; IBM Corp).

Ethical Considerations

This study was approved by the Ethical Clearance Committee on Human Rights Related to Research Involving Human Subjects, Faculty of Medicine Ramathibodi Hospital, Mahidol University (MURA 2015/213). The need for informed consent was waived by the Ethical Clearance Committee on Human Rights Related to Research Involving Human Subjects, Faculty of Medicine Ramathibodi Hospital, Mahidol University. Data were collected by using an anonymous method—assigning numbers to all participants instead of names. No compensation was provided to participants.

Results

From the collection of MCQ scores of medical students from academic years 2010 to 2014 who were taught forensic medicine, the scores of 1063 students were used in this study. The scores were divided into scores of third-year medical students (n=281) and scores of fifth-year medical students (n=728), as shown in Table 1.

When comparing students’ scores, it was found that fifth-year medical students had an average score of 76.09% (SD 6.75%), which was higher than that of third-year medical students (mean 62.94%, SD 8.33%). The difference was statistically significant (Kruskal-Wallis test: P<.001). In addition, when comparing the average scores in each academic year, it was found that the average score of fifth-year medical students was significantly higher than that of third-year students in every academic year (Mann-Whitney U test: all P values were <.001), as shown in Figure 1.

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Discussion

Principal Findings

According to this study’s findings, fifth-year medical students achieved significantly higher marks on MCQs than those achieved by third-year medical students, despite the latter having more opportunities to prepare and take examinations due to their longer duration of study. The fact that the two groups of medical students had different scores may be due to their different levels of basic knowledge of medicine. Fifth-year medical students study basic clinical subjects. Therefore, they may have more comprehensive and complete basic medical knowledge and may be able to apply it to prove facts about legal cases better than third-year medical students who have not completed their basic clinical subjects. These results are consistent with a study in Italy, which showed that students’ awareness of forensic medicine improved in the fifth or sixth year of a forensic medicine course [Aulino G, Beccia F, Siodambro C, et al. An evaluation of Italian medical students attitudes and knowledge regarding forensic medicine. J Forensic Leg Med. Feb 2023;94:102484. [CrossRef] [Medline]18].

When analyzing the data by academic year, fifth-year medical students still had higher MCQ scores than those of third-year medical students, with statistical significance for each academic year. These data show that the difference in MCQ scores was unlikely due to different medical students from year to year.

In forensic medicine, students should have the opportunity to learn about real cases, including examinations of legal patients, autopsies, and crime scene examinations. This would improve students’ understanding of applying and ability to apply medical knowledge to legal applications. A study in India revealed that a court visit in a real scenario was the method that generated the most interest, and student-led objective tutorials comprised the method that best facilitated enhanced learning; the “model answer” method was also found to be an effective method for teaching forensic medicine [Gupta S, Parekh UN, Ganjiwale JD. Student’s perception about innovative teaching learning practices in forensic medicine. J Forensic Leg Med. Nov 2017;52:137-142. [CrossRef] [Medline]19]. Furthermore, a study in Mexico showed that crime scene investigation laboratory visits are an innovative method of learning that may help broaden medical students’ perspectives on forensic sciences and help them understand the multidisciplinary processes of crime investigation [Eraña-Rojas IE, López Cabrera MV, Ríos Barrientos E, Membrillo-Hernández J. A challenge based learning experience in forensic medicine. J Forensic Leg Med. Nov 2019;68:101873. [CrossRef] [Medline]20].

By integrating forensic medicine into the medical curriculum, students also gain a deeper awareness of the complexities surrounding child abuse. Training on this topic not only enhances students’ diagnostic skills but also instills a sense of responsibility to act in the best interests of the child, ensuring that they are better prepared to contribute to the early detection, intervention, and prevention of child abuse in their future careers [Aulino G, Beccia F, Rega M, et al. Child maltreatment and management of pediatric patients during COVID-19 pandemic: knowledge, awareness, and attitudes among students of medicine and surgery. A survey-based analysis. Front Public Health. Sep 20, 2022;10:968286. [CrossRef] [Medline]21].

This study used only MCQ scores from theoretical teaching, which may not measure all of the knowledge and skills of students. Although MCQs can test higher-order thinking, they are typically limited to the “application” and “analysis” levels of the Bloom taxonomy [Ehsan SB. Effectiveness of MCQs in assessing higher order cognition. Biomedica. 2017;33(4):269-272. URL: http://thebiomedicapk.com/articles/554.pdf [Accessed 2025-01-17] 22]. The use of MCQs is often driven by practical concerns, such as large class sizes, rather than pedagogical reasons. Although MCQs have their place, they may restrict the scope of teaching and require careful consideration to align with higher-order learning objectives [Liu Q, Wald N, Daskon C, Harland T. Multiple-choice questions (MCQs) for higher-order cognition: perspectives of university teachers. Innovations in Education and Teaching International. Jun 8, 2023;61(4):802-814. [CrossRef]23]. Thus, a combination of test methods can be used. A study from Nepal found that objective structured practical examination is an acceptable and well-received method for medical students [Menezes RG, Nayak VC, Binu VS, et al. Objective structured practical examination (OSPE) in forensic medicine: students’ point of view. J Forensic Leg Med. Nov 2011;18(8):347-349. [CrossRef] [Medline]24].

Integrating some content of clinical subjects via vertical integration for preclinical medical students may help to enhance their knowledge and understanding of forensic medicine. A previous study on learning environments found that undergraduate medical students from Egypt who received integrated curriculum teaching experienced a more positive learning environment [Fayed MM, Abdo SA, Sharif AF. Preclinical and clinical medical students’ perception of the learning environment: a reference to the Forensic Medicine and Clinical Toxicology course. Adv Med Educ Pract. Apr 23, 2022;13:369-406. [CrossRef] [Medline]6]. Further, a similar study from Malaysia showed that integrated teaching positively affects medical students’ learning environment [Yusoff MSB, Jaa’far R, Arzuman H, Arifin WN, Pa MNM. Perceptions of medical students regarding educational climate at different phases of medical training in a Malaysian medical school. Education in Medicine Journal. Sep 1, 2013;5(3):e30-e41. [CrossRef]25]. These studies are also consistent with guidelines from the Medical Council of Thailand for developing medical curricula in Thailand, which support horizontal and vertical integration teaching [Medical Council Announcement No. 76/2023 on the criteria for requesting to open/improve the Doctor of Medicine program and certify medical school institutions in 2023 [Article in Thai]. The Medical Council of Thailand. 2023. URL: https://tmc.or.th/index.php/News/Announcement/1089 [Accessed 2024-08-12] 26]; that is, clinical teachers should teach about clinical experiences from the beginning and integrate basic medical science knowledge into the clinical years.

Limitations

A limitation of this study was its retrospective design; that is, past MCQ scores were analyzed to evaluate the medical curricula at the time of writing. No systematic interventions were conducted to test the hypothesis. In addition, this study used only MCQ scores; therefore, it may not include every learning outcome of the forensic medicine course.

Recommendations

Students’ basic medical knowledge should be considered when teaching and learning subjects that require clinical application, especially in forensic medicine, which applies medical knowledge to law. Teaching such subjects to preclinical-level students, whose medical knowledge remains incomplete, may be too ambitious. It may be appropriate to integrate introductory content from clinical subjects to increase knowledge and understanding. In comparison, clinical-level students with complete basic knowledge may be more suitable for such clinical subjects.

Conclusion

Forensic medicine requires basic medical knowledge and the ability to apply this knowledge in legal cases. Students’ basic medical knowledge should be considered when planning the teaching and learning of this subject. Teaching forensic medicine in the preclinical years may be too early, and doing so may result in students being unable to sufficiently understand the clinical content.