Legal and Forensic Medicine Specialty in Spain: the consolidation by the medical residency system

The specialty of Legal and Forensic Medicine (Medicina Legal y Forense [MLF]) emerged through the need for doctors to serve the Justice Administration as advisors to the Courts and Tribunals in the resolution of medical/biological issues arising in the field of law enforcement, establishing a bridge between medicine and law. MLF started in 1843 when Pere Mata's plan to reform the teaching of Medicine at Spanish universities included MLF as an individual discipline in the studies of Medicine and Surgery, and the first MLF chair was created at the Universidad Central of Madrid. Later, in 1855, the role of the forensic doctor was established with the enactment of the Health Law, which led to the creation of the Corps of Forensic Doctors (Cuerpo de Médicos Forenses [CMF]) in 1862.¹ Since then, academic legal medicine and the professional legal medicine practiced by the forensic doctors of the Justice Administration have become somewhat separated. On the one hand, academic MLF, under the university faculty, has been primarily concerned with the provision of undergraduate teaching, as well as MLF research and knowledge transfer. On the other hand, the practical aspects involved in assisting the Justice Administration has fallen in the main to professional MLF.

The enactment of Judiciary Organic Law 6/1985, of 1 July ² was a fundamental milestone in the reform of Spanish forensic medicine, as it shaped the Institutes of Legal Medicine, currently the Institutes of Legal Medicine and Forensic Sciences (IMLCF), as the pillars of its organization.^3,4 The consolidation in our country of the IMLCFs, regionally structured and organised by services, has demonstrated their effectiveness, preserving the advantages of the system and establishing a new organisational model of effective and efficient management and integration with the academic world.

The speciality of MLF has a long history in Spain. In addition to that described in 1855, Legal and Forensic Medicine was among the 33 medical specialties included in the Law of 30 July 1955 on the teaching, qualification and practice of medical specialities.⁵ Traditionally it was linked to the University as one of the student specialities. However, the fourth transitory provision of Law 44/2003, of 21 November, on the organisation of health professions, established the modification, suppression or adaptation of health specialities whose training system was not that of residency.⁶ Royal Decree 183/2008⁷ of 8 February, maintained the validity of this transitory provision, but Royal Decree 639/2014⁸ of 25 July, on core medical training, left the specialty of MLF, and the other student specialties, out of the list of Health Science specialisation through the residency system. It expressly mentioned in the Seventh Additional Provision that from the 2015 call for selective tests for access in 2016 no places would be offered in student training.

In parallel, Organic Law 7/2015,⁹ of 21 July, amending Judiciary Organic Law 6/1985, of 1 July, redrafted its article 475, establishing the requirement of holding not only the official qualifications of Bachelor or Degree in Medicine, but also that of MLF specialist, for access to the CMF.

This situation was of concern to MLF professionals and a solution to the issue had to be found.^9–12 Eventually, last July, the Council of Ministers enacted Royal Decree 704/2020 of 28 July, ¹³ establishing access to the qualification of MLF specialist physician through the residency system. The Royal Decree has at last been drafted, driven by the Ministry of Justice and the valuable collaboration of the Ministry of Health. On 17 June 2011, a Conference on the Health Importance of MLF was organised in Barcelona to mark Dr Pere Mata celebrating one year at Barcelona's Official College of Physicians. The Conference brought together for the first time the Ministries of Justice and Health and began to study the possibility of converting the specialty of MLF into one that could be accessed through the residency system like the other health specialities. The Spanish Journal of Legal Medicine had advocated the adaptation of the MLF specialty to the MIR system more than a decade ago.¹⁴

The regulation enacted in July 2020 consolidates the MLF speciality by regulating access to the qualification of medical specialist in MLF through the residency system (MIR), putting it on a par with the rest of the training of health science specialists. It also aims to improve technical advice on MLF, which will be provided by specialists in this discipline, who have been comprehensively trained in the acquisition of the necessary competencies to meet the demands of society in general, and in particular those of especially vulnerable and sensitive groups such as victims of gender-based violence, minors and people with disabilities, among others. The current regulation extends the scope of action of this speciality to cover both the Justice Administration and the bodies of management and direction of hospitals, as well as the public and private institutions.

The residency system for access to this degree includes theoretical and practical training over a four-year period in the accredited teaching units of the IMLCFs under the Ministry of Justice or the autonomous communities with transferred competencies in the area of justice administration. This training programme, which has been developed and updated by the National Commission of the Specialty of MLF after its renewal in March 2020, is a mixed programme that is innovative with respect to programmes in other specialities, as it establishes a training itinerary of 2 years in health teaching centres and a further 2 years in the various services of the IMLCFs.

The Directorate General for Professional Organisation of the Ministry of Health will be responsible for resolving applications for accreditation of IMLCFs as teaching units to provide specialist training. In addition, the residency training system for obtaining the specialist MLF degree will be accessed through the annual national public call for applications.

Thus, the new regulation of the MLF specialty complies with European harmonization criteria and the recommendations made by the European Council of Legal Medicine (ECLM) and the European Union of Medical Specialists (UEMS).¹⁵ On this basis, it is recommended that MLF specialist training should be a minimum of 4 years, that the project of the National Commission on Legal and Forensic Medicine sets as the duration full-time to acquire the necessary knowledge and sufficient training on completing the specialty.

In accordance with the seventh transitory provision of Organic Law 7/2015,⁹ the enacted text provides for a transitional regime that guarantees the stability of staff that has or will have access to the CMF before the specialty is a requirement. For the sake of legal certainty, the aforementioned MLF specialist qualification will not be a compulsory requirement until the Ministry of Justice so determines, once at least the first cohort of these specialists have completed their training through the residency system.

We can conclude that, following the publication of this Royal Decree, access to the MLF specialty through the MIR system meets the following objectives:

• a)

  It incorporates specialised health training (MIR) into the scope of the MLF, which provides an essential social service in Spain, especially through the administration of justice. In this way, the anachronistic nature of the previous situation is overcome, and these doctors are put on an equal footing with other doctors in terms of the form and quality of their training.

• b)

  It complies with the provision established in Article 475 of Judiciary Organic Law 6/1985, of 1 July, as drafted in 2015, which required holding the official degree of Bachelor in Medicine and specialist in MLF for access to the CMF, a qualification that was formerly accessed through the professional education system.

• c)

  Technical advice on MLF is improved with medical specialists whose entire training has been devoted to acquiring the competencies needed to care for especially protected population groups such as victims of gender-based violence, minors and people with disabilities, among others.

• d)

  It provides professionals with the necessary technical competencies in MLF to meet the demand in this area, both from Justice Administration and from the management and direction bodies of health centres, as well as public and private institutions.

• e)

  It enables the presence in the hospital environment of doctors specialised in the knowledge of the many and varied medical-legal issues that arise in daily clinical practice (Hospital Legal Medicine Services).

• f)

  It promotes research and knowledge transfer in the field of MLF.

• g)

  It adapts Spanish regulations to European regulations in the field of specialist health training, in accordance with the recommendations of the ECLM and the UEMS.

In Spain, MLF has a history of over 175 years. However, its situation has become critical in recent years. The publication of Royal Decree 704/2020, is, in our opinion, not only great news, but also a historical advance for the consolidation of the speciality of MLF, reinforcing all its areas and putting it on a par with the rest of the health science specialities.

Once the specialisation stage has been passed through the residency system, new paths will be opened in the near future, such as training in specific areas, the possibility of linking IMLCF places to university teaching units or other forms of linkage in the field of general administration, such as in public health.