LEVEL OF KNOWLEDGE, INTEREST, AND PERCEPTION OF CLINICAL ROTATION STUDENTS REGARDING FORENSIC MEDICINE AND MEDICOLEGAL SCIENCE

Background: Forensic medicine and medicolegal science (FMMS) as mandatory competences that clinical rotation students must possess. However, the number of forensic medicine and medicolegal specialists is still significantly less. Currently, there are 271 people recorded and spread across Indonesia, including two people in Aceh Province with three medical faculties to be managed. For this reason, it is necessary to think about how to increase the number of forensic medicine and medicolegal specialists in Aceh. This study describes the level of knowledge, interest, and perceptions of clinical rotation students regarding FMMS. Methods: The type of study was observational analytic with a cross-sectional design. The instrument used was an online questionnaire with a Content Validity Ratio of 0.750. The samples of this study were clinical rotation students who had passed the forensic medicine and medicolegal sciences stages. The samples were collected using the purposive sampling method. Results: A total of 102 respondents were involved in this study. The majority of respondents had good knowledge (97.1%). As many as 63.7% of respondents were interested in studying forensic medicine and medicolegal and 59.8% of respondents positively perceived these studies. Based on the Spearman’s statistical test showed a significant correlation between the interest and perception under the Sig.(2-tailed) 0.002 (Sig.(2-tailed) ≤0.05). Conclusion: Clinical rotation students of the Faculty of Medicine, Syiah Kuala University have good knowledge, high interest, and positive perceptions. This is a new opportunity and challenges for the development of FMMS in Indonesia.


INTRODUCTION
Forensic medicine and medicolegal science (FMMS) applies the principles and practice of medical science to assist the administration of justice. 1 Forensic medicine is a branch of medical science that uses medical science and technology to benefit law enforcement and justice. Meanwhile, medicolegal is a branch of medical science that studies the legal aspects of medical action to help health services. Cases handled by forensic medicine are legal cases from outside health services such as murder, assault, and rape. Investigators handle these cases and ask doctors for help to make clear a criminal case. Meanwhile, cases handled by medicolegal services are events, problems, medical or non-medical cases that could potentially become legal problems in the form of criminal or civil cases. 2,3 The investigators task is in line with article 133 of the Criminal Procedure Code, paragraph 1, in the case that an investigator for the sake of justice handles victims whether they are injured, poisoned or died due to a criminal act, he or she has the authority to submit expert testimony to an expert in forensic medicine or a doctor or other expert. 4 Aceh Province in 2018 ranks the 12 th highest total number of crime cases in Indonesia, based on reports from the Indonesian National Police, Regional of Aceh, with 22 murder cases, 1,475 physical abuse cases, and crimes against decency (sexual immorality and rape) 262 cases. 5 Increasing cases of lawlessness relating to human bodies and lives, so the assistance of forensic medicine and medicolegal scientists is needed who can assist related parties in disclosing cases in the justice system. 6 Based on data from the Indonesian Association of Forensic Medicine and Medicolegal in 2020, the number of forensic medicine and medicolegal specialists in Indonesia is 271, spread across 34 provinces and 514 districts or cities. 7 Aceh Province itself only has two forensic medicine and mengetahui gambaran tingkat pengetahuan, minat, dan persepsi mahasiswa rotasi klinik terhadap IKFM.
Candidates for forensic medicine and medicolegal specialists are also scarse. Specialist education centres are limited to 7 universities such as the University of Indonesia, Sumatera Utara University, Padjadjaran University, Gadjah Mada University, Diponegoro University, Airlangga University and Hasanuddin University. The Higher Education Data Base of the Ministry of Research, Technology and Higher Education reports that the Specialist Doctor Education Programme of Forensic Medicine and Medicolegal (SDEP-FMMS) of the University of Indonesia, only has 12 students during the odd semester in 2019. It is different from other study programs, such as the SDEP of Internal Medicine, which was also established in the same year with 202 odd semester students in 2019. Likewise, SDEP-FMMS of Gadjah Mada University, established in 1980, only had 2 students in even semester 2018. 10 Recapitulation of applicants' interest and capacity for admission to SDEP-FMMS of Diponegoro University reported that the number of applicants for the SDEP-FMMS was only 6 people from a capacity of 8 people. While the number of registrants for other specialties, such as the SDEP in Internal Medicine, total 70 people of a capacity of 10. 11 A study conducted on 90 medical college students in Uttar Pradesh India, showed that most students (77.85%) did not want to choose forensic medicine as a career. Most of the students argued that they did not want to deal with the court. The majority of male students answered that it was related to death. In contrast, most female students said they were more interested in other specialities and did not want to be associated with the corpse. 12 Research conducted on 117 co-assistants in the Sumatra region showed an interest in FMMS at 4.27%. The few interested in studying FMMS get the most answers: they are less attractive in terms of income or finances (27.32%) and because it is difficult to open a medical practice (20.51%). 13 FMMS are relatively rarely chosen professions. Many medical students found them dire, outside the clinical setting, with long and unpredictable working hours and insufficient appreciation of jobs especially financial compared to other specialities. The study was conducted on 135 students at the Faculty of Medicine Toulouse, France showed that 60.5% of students did not have sufficient knowledge of forensics medicine and medicolegal. As many as 96% of students felt that they were not ready to examine a corpse, and 92.4% of students thought that they were not prepared to examine victims of criminal cases. 14 The results of another study conducted on 143 medical students at Damman University, Saudi Arabia stated that students had inadequate knowledge, poor attitudes, and limited awareness of the importance of forensic medicine courses among medical students. As many as 91.6% of students still know that forensic medicine only deals with people who have died. Only 23.1% of these students believed that forensic medicine courses would help in their future careers. 15 Another study conducted on 100 medical students in third year at Rai Medical College Sargodha Pakistan, as many as 36% of students agreed and 9% of students strongly agreed that they feel anxious when observing an autopsy. Students have the perception that autopsy is a skill that is less friendly to corpses. 16 The importance of knowledge about FMMS, and the lack of interest in medical students and various negative perceptions of FMMS encourages researchers to conduct research related to the level of knowledge, interest, and perception of FMMS. This research also will be helpful as a preliminary survey for the opening plan of the SDEP-FMMS at the Faculty of Medicine, Syiah Kuala University, Banda Aceh. Researchers took respondents, the final stage of clinical rotation students because they had passed the exposure of all specialities and made decisions for their careers.

METHODS Instruments
The instrument used is an online questionnaire (Google form) that was made by the researcher tested for validity with a Content Validity Ratio/CVR by experts. The CVR validity test was conducted from 29 June to 6 July 2020. The assessment of each question item involved 8 panellists consisting of 4 FMMS experts and 4 non FMMS experts such as pathology anatomy, biomedical science, tropical medicine and public health. The average result of the CVR value was 0.750. From this CVR value, it can be stated that the instrument content validity is at a high level.

Design and research subjects
The research type is an observational analytic with a cross-sectional design. This study involved 102 students who met the inclusion criteria. Respondents who participated in this study were medical students from academic year 2011-2015 who entered the clinical rotation at forensic medicine in 2015-2020. The study aims to get information about the level of knowledge, interests and perceptions of clinical rotation students at the Faculty of Medicine, University of Syiah Kuala, forensic medicine and medicolegal science. The respondents of this study were students of the Faculty of Medicine at Syiah Kuala University who had passed the clinical rotation in the forensic medicine and medicolegal department.

Population and samples
The population in this study were all clinical rotation students of the Syiah Kuala University Medical Faculty in the 2019/2020 academic year total of 378 people. The sample in this study were clinical rotation students of the Faculty of Medicine, Syiah Kuala University who met the requirements based on the inclusion criteria. The minimum sample size used in the study can be calculated using the Slovin formula, which is obtained at least 79 respondents.

Research procedure
The data collection technique in this study uses primary data using an online questionnaire (Google form) which researchers have prepared to respondents, which are distributed via social media by enumerators to help gather students in filling out the questionnaire. The time for data collection began on 19 August to 19 September 2020. All respondents filled out the questionnaire independently consisting of student knowledge (19 questions), interests (6 statements), and perceptions related to FMMS (33 questions).
Knowledge is everything that clinical rotation students know about FMMS. The measurement of knowledge uses the Guttman scale which consists of correct and wrong answer choices. Each correct answer is given a value of 1 and each wrong answer is given a value of 0. 17 Criteria for assessing the respondent's knowledge: 18 (1) Good knowledge: 76-100%, (2) Good enough knowledge: 56-76%, and (3) Poor knowledge: < 56%.
Interest is a feeling of preference or interest in the FMMS without any coercion felt by the clinical rotation student. The measurement of interest uses a Likert scale which consists of 5 answer choices, namely strongly agree, agree, neutral, disagree and strongly disagree. To answer positive questions, strongly agree is given a value of 5, agree is given a value of 4, doubt is given a value of 3, disagrees with a value of 2, and strongly disagrees is given a value of 1. As for answers to negative questions, it is returned with positive questions. respondents' interest 18 : (1) High interest: 76-100%, (2) Medium interest: 56-76%, and (3) Low interest: <56%.
Perception is the response or assessment of clinical rotation students on FMMS. Perception measurement uses a Likert scale which consists of 5 answer choices, namely strongly agree, agree, neutral, disagree and strongly disagree. To answer positive questions, strongly agree is given a value of 5, agree is given a value of 4, doubt is given a value of 3, disagrees with a value of 2, and strongly disagrees is given a value of 1. As for answers to negative questions, it is returned with positive questions. 19 Respondents' perceptions: 20 Positive perceptions if the total score obtained by the respondent from the questionnaire> mean. Negative perception if the total score obtained by the respondent from the questionnaire is ≤ mean.

Data analysis
This study uses univariate and bivariate data analysis to describe each variable. Descriptive statistics are used to explain the characteristics of respondents, the knowledge, interests and perceptions of students regarding the FMMS. To investigate the correlation between knowledge, interests, and perceptions was determined by the Spearman's test at 90% confidence intervals, it was taken significant when found Sig.

Ethical clearance
The Health research ethics committee at the Medical Faculty of Syiah Kuala University / Zainoel Abidin Regional Public Hospital approved this study No. 144/ EA/FK-RSUDZA/2020. The researcher explained the purpose and benefit of the research, also how to fill out the questionnaire before data collection. Respondents participated in the study voluntarily. All respondents agreed to participate in the study by signing the consent sheet in Google form before answering the questionnaire.

Characteristics of subjects
This study was conducted in the Faculty of Medicine, Syiah Kuala University with a data collection time span of one month, namely 19 August 2020 to 19 September 2020. Data were collected using primary data, namely online questionnaires (google form). The characteristics of the respondents in this study were grouped by gender, age, and year in the medical profession education, which shows that the largest number of respondents based on gender were female with 67 students (65.7%), while male amounted to 35 students (34.3%). Based on the age, many respondents were 24 years old, namely 39 students (38.2%). Based on the year of class in attending the clinical rotation, many respondents came from the 2014 class, namely 59 students (57.8%).
Measurement of knowledge, interest and perceptions regarding FMMS in clinical rotation students of the Faculty of Medicine, Syiah Kuala University was assessed using a questionnaire that had been compiled by researchers and validated by experts. In table 1, it is found that the majority of respondents  (1) states that "In case the investigator deems necessary, he/ she can ask the opinion of an expert or person with special expertise". 4 In many cases, CSI is more important than the autopsy. Through a complete CSI will lead to a correct diagnosis of the cause and manner of death. By looking at the victim's body in its context in the environment, forensic medicine and medicolegal experts are better able to interpret certain findings before the autopsy is performed, such as the pattern of neck marks in hanging cases and advising investigators about the nature of death, determining homicide in some way, natural death, as well as due to certain diseases. 28 CSI contains elements between the victim, the perpetrator, and evidence in accordance with the theory of "triangle evidence".
The qualification of the forensic medical examiner cannot be separated from the prevailing laws and regulations.

Description of subject knowledge
Questions 1-8 relate to the respondent's knowledge of the definition and scope of FMMS. FMMS are medical practice terms related to medical and legal sciences. 6 In other words, it can be interpreted as applying medical knowledge to solve findings and opinions in assisting legal proceedings. 1,6 The term forensics comes from the Latin "forensis" which means forum. A forum in a public place to resolve disputes over the cause of death and the level of injury and determine who caused the injury in ancient Roman times. 6,21 Medicolegal services are services provided by medical personnel in the application of medical science for the benefit of laws in force in a country and law in medical ethics. 22 The results of medical evidence that can be used in a court of law are called medicolegal evidence. 23 Comprehensive medicolegal management is needed to ensure that forensic medical examinations relate to living or dead victims, and contain ethical responsibilities and human interests for victims and victims' families. 24 Medicolegal has greater relevance to civil law and prosecutions, which affect patient care. In contrast, forensics deals with criminal law and damage to or by patients. 25 Detailed information about respondents' knowledge about FMMS can be seen in table 2.
In this study, the knowledge about FMMS is divided into three, namely knowledge about definition, role, and scope. In the following three aspects, it is found that the majority of respondents have good knowledge. This study found that the majority of respondents have good knowledge of forensic medicine and medicolegal. It was found that there were 99 people (97.1%) who had good knowledge (see Table.1). Knowledge within the scope of forensic toxicology, ethics, medicolegal, and products from forensic medicine is the component of knowledge most mastered by respondents. These results are in line with a study conducted by Taufan.
The study with a cross-sectional design involving Medicolegal relating to aspects of medical services and practices regulated in law. Forensic medicine and medicolegal science is also called "state medicine" 78 (76,47%) 24 (23,53%) doctor the "primary" authority, but also gives the "doctor" (general or any specialist) the opportunity to act as an examiner. This shows that doctors other than forensic doctors only obtain authority if certain requirements are met, such as "unavailability" of forensic doctors. At the same time, outside these circumstances the referral system commonly applied in the medical world or it means that the forensic doctor is authorized. Because of its interests for the state, forensic medicine is also called state medicine. 29,30

Description of subject interests
Interest is a condition in which individuals are interested in something accompanied by curiosity to learn and prove further. The definition of interest is a feeling of liking and a tendency to something or an activity without orders from others. The basis of interest is a form of acceptance of bonds between individuals and things outside the individual. Interest is a psychological aspect of a person that can form feelings of liking and being attracted to a particular object and can change an individual's behavior. The sense of interest causes the individual to have a happy feeling when involved in the thing he is interested in so that he will show more attention to the object. 31 Interest indicators are divided into four parts, namely: (1) Feeling happy. A person who likes something, then he will continue to learn what he likes. A person will do what he likes voluntarily, without coercion. (2) Interesting. Interest is related to the constant urge that makes someone always feel attracted to do activities that they are interested in.
(3) Attention. Someone's interest in something causes that person to continuously make observations on the object he is interested in, without realizing it. (4) Involvement. Individuals who have an interest in and enjoy a certain thing tend to take part and be involved in carrying out activities that they are interested in. 32 The results of this study found that the majority of respondents have a high category of interest in FMMS. It was found that there were 65 people (63.7%) who had a high level category (see Table.1) . Statement 1 relates to indicators of attention, with 90 people stating "I think the forensic medicine and Based on the answers to the questionnaire, it is known that the components that increase respondents' interest the most are information or news in the media related to forensic medicine and medicolegal. Other components such as the nature of the job, job challenges, and personal reasons are also components that increase respondents' interest. However, there were 8 respondents (7.84%) who were not very interested and 14 (13.72%) respondents who were not interested in continuing their education in the fields of forensic medicine and medicolegal. This research is in line with research conducted by Madadin at the University of Damman, Saudi Arabia. The study with a cross sectional design involving 143 medical students showed 115 students (80.4%) considered forensics an area where they wanted to specialize and only 6 students (4.2%) did not consider forensics as a specialization in the future and 22 students (15.4%) answered that they did not know. 15 The unique thing about this research is the number of respondents who are interested in continuing their careers in this field are 61.75% (39.21% strongly agree, and 22.54% agree) with statements "I am interested in continuing my career in the fields of forensic medicine and medicolegal science (statement 5)". This result is relatively different from a study conducted by Alawad et al, at the Faculty of Medicine, University of Medical Science and Technology, Khartoum, Sudan. This research involving 604 medical students with a cross sectional design aims to determine the specialization preferences chosen by medical students. The study found that very few medical students chose forensics medicine as one of their chosen specialities. Only 5 (1.1%) medical students were interested in becoming forensic and medicolegal specialists. 33 A person's interest can be influenced by several factors, including internal, social, and emotional factors. Although the respondent's interest in FMMS is high, this interest can change over time with many factors that can affect respondents when they become general practitioners later. 31

Description of subject perception
This study found that the majority of respondents had a positive category of perception regarding FMMS. It found that 61 people (59.8%) had positive perceptions. Respondents of this study perceived that FMMS is indispensable in various legal practices, clinical practices, and higher education. Respondents also perceived that it is necessary to add education and training programs on FMMS in higher education. In addition, respondents also considered that forensic and medicolegal specialists  have good career prospects and are on par with other specialties. All respondents believed that autopsy was a vital examination to be carried out in various criminal cases and accidents. Detailed information about perceptions can be seen in table 4.
Respondents who agreed that FMMS were indispensable in medical and legal practice were 84 respondents (82.35%) strongly agreed, and 18 respondents (17.65%) agreed. An assessment of the urgency of FMMS is critical given the increasing number of criminal cases in Indonesia and cases of reporting of suspected medical negligence, which require an expert who can to understand medical and legal sciences to assist investigators in disclosing a case so that it does not cause harm to other parties. 6,29,30 Research on medical students' perceptions of FMMS has been researched several times before, especially regarding perceptions of autopsy, one of which is a study conducted by Jadeep at BJ Medical College, India. With a cross-sectional design involving 200 medical students, the study aims to determine the attitudes and perceptions of medical students regarding demonstrations of various medicolegal actions, including autopsy, as part of forensic science training. This study found that the majority of respondents thought that the autopsy was one of the actions needed in the medicolegal process and the majority of respondents also felt uncomfortable when they first went through the autopsy training process. 34 The result which is also in line with this study is a study conducted by Ravi at the All India Institute of Medical Sciences, India. The study with a cross-sectional design involving 166 medical students aimed to determine medical students' attitudes towards autopsy. This study found that most respondents agreed with the existence of an autopsy and felt that autopsy was an essential step in the medicolegal process. 35 Similar results were also shown by a study conducted by Chawla at the Government Medical College of Southern Haryana, India. With a cross-sectional design involving 249 medical students, this study aimed to determine the knowledge and perceptions of medical students towards autopsy. This study found that most respondents had a good level of expertise and positive perceptions about the autopsy procedure. 36 Factors affecting perception: 1) Experience or knowledge. The factors are most important in interpreting an object, namely the experience or knowledge possessed by each individual. 2) Expectations. Everyone has different expectations so that it will impact the perceptions that each person has. 3) Needs. A person's needs will affect the person's perception of something. 4) Motivation. Motivation in a person affects his perception. 5) Emotions. The stimulus that appears in an individual who feels scared or sad will be different if he is brave or happy. 6) Culture. Individuals who have different backgrounds will interpret things in different ways. 37 This study aims to get information about perceptions of clinical rotation students regarding FMMS and as a preliminary survey for the opening plan of the SDEP-FMMS at the Faculty of Medicine, Syiah Kuala University. The most important thing is to look at the three factors that influence perceptions, namely expectations, needs and motivation. Statements 26, 27, 28 deals with expectations, statements 20, 21, 24, 25 deals with needs, and statements 29, 31, 32, 33 deals with motivation. The number of respondents who have expectations for the scientific development of FMMS were 96.7%, meanwhile 98.8% of respondents also need this programme, and 95.8% of respondents are motivated.
A total of 78 respondents (76.47%) strongly agreed, and 24 respondents (23.53%) agreed regarding the statement that there is a need for additional forensic and medicolegal specialists in Indonesia. This assessment is critical due to the lack of FMMS specialists in small cities in Indonesia. 9 Some provinces do not have FMMS specialists such as North Kalimantan, Gorontalo, West Sulawesi, North Maluku, and West Papua. 38 The role of FMMS is needed in the process of medical education by higher education institutions. Respondents also perceive that it is necessary to add education and training programs on FMMS in higher education. This is in line with the research conducted by Fouche, et al. 39 that there is a need for additional exposure to integrate the theory and practice of forensic medicine at the undergraduate level. The exposure increases the medical graduates' knowledge, given many cases involved will be faced when they become a doctor later. 39 In addition, respondents also considered that forensic medicine and medicolegal specialists have good career prospects and are on par with other specialities.
A total of 60 respondents (58.82%) strongly agree, and 34 respondents (33.33%) agree with the statement. FMMS specialists themselves can work in teaching hospitals, regional hospitals and police hospitals. The demand for FMMS in the police department is also increasing. At present, the availability of FMMS specialists in every city is needed to facilitate and speed up the investigation process, thereby reducing the various losses that can arise due to the referral process to regional hospitals with forensic experts which can be time consuming and costly. 9 Table 5 describes the correlation between knowledge and interest, knowledge with perception, and interest with perception. The Spearman's statistical test showed a positive correlation between knowledge and perception but with a deficient level of correlation. A positive correlation between knowledge and perception can be understood because one of the factors that influence perception is knowledge. In this study, the correlation is very low because other factors predominantly influence perception. Perception can also be inadequate and subjective because various situations and variables affect it. The results of this study at least provide an overview of students' perceptions if they are related to the forensic and medicolegal professions that they will do as careers. 40 This study found that the Spearman's statistical test showed a positive correlation between interest with perception, but with a low level of correlation. If the significance of the correlation is assessed, there is a significant correlation between interest and perception with a Sig.(2-tailed) 0.002 (Sig.(2-tailed) ≤0.05). Respondents have positive perceptions about FMMS because they are influenced by expectations, needs, motivation and emotion. This correlation shows that the higher the interest in a career will be increasing to positive the perception about the career, so it can also be interpreted that the more positive the perception of a profession will increase interest in studying or pursuing that career.

Statistical analysis
The advantage of this research is that it uses a questionnaire that the researcher made and the content validity has been tested by experts who assess the relevance of the contents of the questionnaire. This study also measures the level of knowledge, interest and perception in detail with valid questions. Another advantage is that respondents are given a time limit in filling out the questionnaire to ensure the answers given are as objective as possible. So much information was generated from this research that it can be re-explored into several studies, both quantitative and qualitative approach.
A limitation of this study is that the data collection was limited to respondents from the Faculty of Medicine at the Syiah Kuala University at the time of the study, so the study results may not reflect all respondents who had undergone clinical rotation in previous years. It may also be irrelevant to the knowledge, interests and perceptions of students from other institutions. Another limitation is that the research results obtained only describe knowledge, interests and perceptions quantitatively, have not measured the quality of respondents' answers, and further research is needed, which is more focused on career choice interests for final stage clinical rotation students. However, in general, this research is very useful for the development of FMMS in Indonesia in the future.

CONCLUSION
The level of knowledge of the clinical rotation students of the Faculty of Medicine, Syiah Kuala University towards FMMS is very high, while the level of interest and perception is moderate. This is an important asset for the Faculty of Medicine, University of Syiah Kuala in its plan to develop this science in the future given the lack of teaching staff in the forensic medicine and medicolegal sciences.

RECOMMENDATION
Given the importance of adding medical specialists in forensic medicine and medicolegal in Indonesia both for educational activities and medical services, it takes innovation from all medical institutions, especially the Faculty of Medicine, University of Syiah Kuala to continuously socialize in order to continue to foster student interest and motivation. Further research is needed on how much interest and motivation doctors have in choosing a career as a forensic medicine and medicolegal specialist.