Forensic medicine is often seen as a glamorous yet morbid field of work, a myth perpetuated by television stars like the notorious Quincy, ME. But it's not all solving crimes and post mortems. Richard Jones and Roy Palmer describe the different career opportunities that bring the law and medicine together

If you are interested in the law, or the legal aspects of practising medicine, there are a number of highly satisfying medicolegal careers. You may have to do a lot of casework and use a variety of skills that you would not use in clinical medicine.

Forensic medicine combines knowledge of the law with that of various branches of medicine. You may have seen Dr Sam Ryan or Dr Quincy, ME, on television, working in that "most fascinating sphere of police work," single handedly solving murders. The reality is somewhat different.

A forensic practitioner is someone who provides evidence for court proceedings (the word "forensic" is from the Latin "forensis," a court or forum). Practising clinicians working mainly in clinical medicine may occasionally find themselves giving professional evidence of fact, or expert opinion reports, in personal injury (including medical negligence) claims, other civil cases (for example, family law cases), in criminal courts, or for the coroner. Some careers, however, allow a practitioner to spend more of their time dealing with medicolegal matters.

Forensic pathology

Perhaps the most instantly recognisable forensic medical practitioner is the forensic pathologist. Forensic pathology is a subspecialty of histopathology and morbid anatomy. The modern forensic pathologist spends much of his or her time carrying out "routine" autopsies for the coroner, to determine the cause in cases of sudden, violent, or unexpected death. Most of these deaths are due to natural causes--for example, severe coronary artery disease, intracranial haemorrhages, or ruptured abdominal aortic aneurysms.

The forensic pathologist comes into his or her own with cases that are suspicious, or where criminal actions are evident. In large cities, there are several full time practitioners; in the regions there may be those who work primarily as clinicians, on a retainer with the local constabulary to be available at the scene of a suspicious death at any time.

A growing number of forensic pathologists are leaving academic medicine (where they were traditionally attached to an academic forensic medicine department) and entering private practice. In the United States, many states have introduced a medical examiner system, which is staffed by full time forensic pathologists, with a defined career path for trainees. In the United Kingdom there is no comparable system.

Budding forensic pathologists must gain a senior house officer post in histopathology and, after a minimum of nine months, must satisfy the Royal College of Pathologists that they have the aptitude for a career in general pathology. If successful, they have to get a registrar post, and this is where the real fun begins.

You can take a "slanted part 1" membership exam in histopathology and forensic pathology, if you can find a training place in a unit that is able to provide the required standard of training in both aspects of pathology. Following this route is restrictive to a career in forensic pathology, and the subsequent part 2 examination can only be taken in forensic pathology. Due to the lack of training posts for registrars in forensic pathology, better advice is to take the part 1 examination in histopathology and specialise at a later stage. This takes 5-6 years.

By training in general histopathology, and specialising at a later stage, further qualifications can be attained in order to satisfy the Home Office's policy advisory board registration requirements for practising forensic pathologists. These are the diploma in medical jurisprudence (of the Worshipful Society of Apothecaries of London) and the diploma in forensic pathology (of the Royal College of Pathologists). Both of these qualifications have their champions, and each tends to concentrate on slightly different aspects of the subject.

Practising forensic pathologists will tell you that the variety of work is wide. A word of caution though: there is an awful lot of legal report writing and numerous court appearances. The budding forensic pathologist should, therefore, enjoy the details of each case and explaining these details and their implications to a varied audience: the public, barristers, families, judges, and the investigating police officers will all be listening. Further details about the training path towards forensic pathology can be obtained from the Royal College of Pathologists (www.rcpath.org). Potential changes to the coroner's system may open up further career opportunities in forensic pathology.

Clinical forensic medicine

Dangerfield was, until recently, the most widely known police surgeon. Like his television pathologist counterparts, he managed to solve a crime within a 45 minute episode. In real life, police surgeons (now often known as forensic medical examiners or forensic physicians) spend much time examining people who have been arrested. Detainees either ask to see a doctor, or need to be examined to see if they are fit for interview or fit to be detained.

An understanding of the effect of drink and drugs on detained people is an important part in the work of the forensic medical examiner. Has the drunk person with a head injury passed out because of the drink, or the bang on the head? Do they need to go to hospital now or can they be left in the cell, to be monitored every half hour by the custody sergeant?

In addition to this routine work, examiners look at victims of assault (and sometimes those who are suspected of carrying out assaults), and they must be experts in examining wounds and other evidential matters. Medicolegal work with the living generates reports and paperwork, in addition to the variable amount of court work: the examiner must be able to concentrate on the detail and be a good public speaker.

There is no defined career path for forensic medical examiners, and most come from a general practice background, working part time as a local forensic doctor. In larger cities, some practitioners work as examiners on a full time basis. As with forensic pathology, there are increasing opportunities to provide forensic medicine services on a contract basis. Vacancies are advertised in BMJ Careers and other more specialised journals. You may also hear of future openings on a regional basis at general practice meetings, etc.

The Worshipful Society of Apothecaries of London run the diploma in medical jurisprudence and this probably provides the examiner with the best means of attaining specialist qualifications in clinical forensic medicine. This course can be studied at a growing number of regional centres around the country. More details can be obtained from the Association of Police Surgeons (www.apsweb.org.uk).

Coroners

The role of the coroner in England and Wales is currently under review and is unlikely to come out entirely unscathed. It is a position of much history and tradition, however, and has many positive attributes. Scotland has evolved an entirely different legal system and, not surprisingly, the process of investigating deaths is also different.

The coroner in England and Wales is an independent judicial officer responsible for inquiring into violent, sudden and unexpected, unnatural, or suspicious deaths. The procurator fiscal in Scotland holds a similar function. Most coroners are lawyers and perform their functions on a part time basis. In larger cities, many are full time. Few are doctors, but a small number of coroners, usually full time coroners in large cities, have qualifications in both medicine and law.

If you are interested in becoming a
coroner, contact the coroner for your district and discuss career options with them.
The section of clinical forensic and legal medicine of the Royal Society of Medicine (www.rsm.ac.uk) is a useful source of advice.

Other careers in legal medicine

Careers in the legal system that benefit from a medical background have been covered before by studentBMJ and will be updated again soon. ¹ These include working as a lawyer specialising in medical negligence claims, or for a medical defence organisation advising doctors on medicolegal aspects of their clinical practice. Academic positions that combine medical knowledge with the law, or with the legal and ethical issues of medical practice, are also available.

In order to practice law in England or Wales, you must become a solicitor or barrister and obtain a basic legal qualification--for example, a law degree. To qualify as a solicitor you must comply with the regulations of the Law Society (www.lawsociety.org.uk). Barristers must meet the criteria of the
Bar Council of England and Wales (www.barcouncil.org.uk).