Medical-legal partnership in medical education: Pathways and opportunities

Journal of Legal Medicine

Volumn 35, Issue 1, 2014, Pages 149-177

  Tyler, Elizabeth Tobin ^a   Anderson, Lauren Taylor ^b   Rappaport, Leah ^a   Shah, Anuj Kumar ^c   Edberg, Deborah L ^c   Paul, Edward G ^d  

^a BROWN UNIVERSITY   (United States)

^b NORTHWESTERN UNIVERSITY   (United States)

^c Erie Family Health Center   (United States)

^d Yuma Regional Medical Center   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL COMPETENCE; CLINICAL EDUCATION; COOPERATION; CURRICULUM; HEALTH CARE DELIVERY; HEALTH CARE DISPARITY; HEALTH CARE POLICY; HUMAN; INTEGRATED HEALTH CARE SYSTEM; INTERDISCIPLINARY COMMUNICATION; LEGISLATION AND JURISPRUDENCE; MEDICAL EDUCATION; PATIENT CARE; SOCIAL DETERMINANTS OF HEALTH; TEACHER; UNITED STATES;

CLINICAL CLERKSHIP; CLINICAL COMPETENCE; COOPERATIVE BEHAVIOR; CURRICULUM; DELIVERY OF HEALTH CARE; DELIVERY OF HEALTH CARE, INTEGRATED; EDUCATION, MEDICAL; HEALTHCARE DISPARITIES; HUMANS; INTERDISCIPLINARY COMMUNICATION; INTERNSHIP AND RESIDENCY; MENTORS; PATIENT CARE TEAM; PATIENT PROTECTION AND AFFORDABLE CARE ACT; SOCIAL DETERMINANTS OF HEALTH; UNITED STATES;

EID: 84897403640     PISSN: 01947648     EISSN: 1521057X     Source Type: Journal    
DOI: 10.1080/01947648.2014.885317     Document Type: Article

References (141)

1. Victoria S. Kaprielian et al.
2. Teaching Population Health: A Competency Map Approach to Education, 88 ACAD. MED. 626, 626 (2013).
3. Sir William Osler & His Inspirational Words, THE OSLER SYMPOSIA, http://www.oslersymposia.org/about-Sir-William-Osler.html. (last visited Sept. 30, 2013);
4. see S. W. OSLER, Aequanimitas, With Other Addresses To Medical Students, Nurses And Practitioners Of Medicine (1932).
5. See Medical Education in the United States and Canada Bulletin Number Four, CARNEGIE FOUND.
6. FOR THE ADVANCEMENT OF TEACHING 1 (1910), http://www.carnegiefoundation. org/sites/default/files/elibrary/Carnegie Flexner Report.pdf.
7. Ronald A. Arky, Abstract, Abe Flexner, Where Are You? We Need You!, 118 TRANS. AM. CLIN. CLIMATOLOGICAL ASS'N 89 (2007).
8. See generally Molly Cooke et al., Educating Physicians: A Call For Reform Of Medical School And Residency (2010).
9. Molly Cooke et al., Summary of Educating Physicians: A Call for Reform of Medical School and Residency, CARNEGIE FOUND.
10. FOR THE ADVANCEMENT OF TEACHING (June 7, 2010), http://www.carnegie foundation.org/elibrary/summary-educating-physicians.
11. See generally Julio Frenk et al., Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World, 376 LANCET 1923 (2010).
12. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat.
13. codified as amended in scattered sections of 42 U.S.C.);
14. Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (codified as amended in scattered sections of 42 U.S.C.).
15. These two statutes are collectively known as PPACA.
16. Medical-legal partnership is a health care delivery model that improves the health andwell-being of lowincome and other vulnerable populations by addressing unmet legal needs and removing legal barriers that impede health.
17. The Model, NAT'L CTR. FOR MEDICAL-LEGAL PARTNERSHIP, http://www. medicallegalpartnership. org/model (last visited Sept. 30, 2013).
18. Legal professionals are integrated into the healthcare team to: "(1) provide direct legal assistance to patients; (2) develop/align strategies to improve health and legal institutions and practices; and (3) change policies, all in service to ensuring vulnerable people get and stay healthy." Id.
19. See Revisiting the Medical School Educational Mission at a Time of Expansion, JOSIAH MACY FOUND. (2009), http://macyfoundation.org/docs/macy pubs/Macy MedSchoolMission proceedings 06-09.pdf.
20. This report posits that: 16 See, e.g., Nancy E. Adler & Judith Stewart, Health Disparities Across the Lifespan: Meaning, Methods, and Mechanisms, 1186 ANNALS N.Y. ACAD. SCI. 5 (Feb. 2010).
21. See, e.g., Paula A. Braveman et al., Broadening the Focus: The Need to Address the Social Determinants of Health, 40 AM. J. PREVENTIVE MED. S4 (2011).
22. Some examples illustrate the diversity of approaches to teaching health disparities in United States medical schools.
23. The University of California San Francisco (UCSF) has taken a longitudinal approach to the teaching of social and behavioral sciences (SBS), which cover health disparities curriculum, by integrating SBS learning objectives into every block that is taught.
24. UCSF has found points of intersection and ideal locations for SBS curriculum (i.e., lectures, small groups, and clinical teaching points).
25. Through an extensive review process that has enabled educators to integrate it through all four years of the medical educational program.
26. Duke University currently offers a population health curriculum that teaches medical students how to address the role of socio-economic, environmental, cultural
27. other population-level determinants of health on the health status and healthcare of individuals and populations.
28. Kaprielian et al., supra note 1, at 628.
29. Duke's curriculum not only encompasses health disparity content but also requires students to expand their understanding of health disparities to community health and health policy through clerkships and electives.
30. From a review of the literature, Duke and UCSF appear to be two of the few medical schools that integrate disparities.
31. Uurriculum longitudinally; most medical schools offer health disparity curricula through small blocks or day workshops.
32. Eduardo Pena Dolhum et al., Cross-Cultural Education in U.S. Medical Schools: Development of an Assessment Tool, 78 ACAD. MED. 615, 617 (2003).
33. Ingrid M. Allard&Wilma E.Waithe, Preparing Future Physicians: A Reexamination of Communication and the Physician-Patient Relationship Through the Lens of Culturally Sensitive Teaching and Learning Methodologies, 2. 1 OPEN MED. EDUC. J. 44, 45 (2009).
34. Wally R. Smith et al., Abstract, Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care, 147 ANNALS INTERNAL MED. 654, 655 (2007).
35. Nisha Dogra et al., Twelve Tips for Teaching Diversity and Embedding It in the Medical Curriculum, 31 MED. TEACHER 990 (2009).
36. See Dolhum et al., supra note 19.
37. See Andrew F. Beck et al., Identifying and Treating a Substandard Housing Cluster Using a Medical-Legal Partnership, 130 PEDIATRICS 831 (2012).
38. This study suggests the power of MLP to be as follows: "The multidisciplinary approach we describe, the partnership of clinicians and attorneys, made identification and treatment of home environmental risks possible.
39. This, in turn, may prove to alleviate triggers and stressors that make chronic disease worse for our patients." Id.
40. See, e.g., Gail R.Wilensky & David Satcher, Don't Forget About the Social Determinants of Health, 28 HEALTH AFF. W-194 (2009).
41. Behavioral and Social Science Foundations for Future Physicians, ASSOC. AM. MED. COLLS. 1, 5 (2011), https://www.aamc.org/download/271020/data/ behavioralandsocialsciencefoundationsforfuturephysicians. pdf.
42. See id. at 4.
43. See Jason M. Satterfield et al., Integrating the Social and Behavioral Sciences in an Undergraduate Medical Curriculum: The UCSF Essential Core, 79.1 ACAD. MED. 6 (2004).
44. Behavioral and Social Science Foundations, supra note 28, at 17.
45. SeeHEALTHBEGINS, http://healthbegins.ning.com/(last visited Sept. 30, 2013).
46. Manchanda's recent book, The Upstream Doctors, argues that "the future of our health care depends on growing a new generation of health care practitioners.
47. We need doctors who look upstream for the sources of our problems, rather than simply go for quick-hit symptomatic relief."
48. The TED Book: The Upstream Doctors: Medical Innovators Track Sickness to Its Source, THE UPSTREAMISTS, http://www.upstreamists.org/TED%20Book (last visited Sept. 30, 2013).
49. These "upstreamists," as he calls them, are doctors and nurses on the frontlines of medicine who.
50. see that health, like sickness, is more than a chemical equation that can be balanced with pills and procedures administered within clinic walls. Id.
51. They see that health begins in our everyday lives, in the places where we live, work, eat, and play. Id.
52. Rika Maeshiro et al., Integration of Public Health into Medical Education: An Introduction to the Supplement, 41AM. J. PREV. MED. S145 (2011)
53. Medical Education for a Healthier Population: On the Flexner Report from a Public Health Perspective, 85 ACAD. MED. 211 (2010).
54. Primary Care and Public Health: Exploring Integration to Improve Population Health, INST. OF MED. OF THE NAT'L ACADS. 1 (Mar. 2012), http://www.iom.edu/-;/media/Files/Report%20Files/2012/Primary-Care-And-Public- Health/Primary%20Care%20and%20Public%20Health Revised%20RB FINAL.pdf.
55. For further discussion of the importance of integrating clinical care with public health
56. see F. Douglas Scutchfield et al., Are We There Yet? Seizing the Moment to Integrate Medicine and Public Health, 42 AM. J. PREVENTATIVE MED. S97 (2012).
57. Primary Care and Public Health, supra note 35, at 147.
58. Kaprielian et al., supra note 1, at 629.
59. Accelerating Change in Medical Education, AM. MED. ASS'N (2013), http://www.ama-Assn.org/resources/doc/about-Ama/accelerating-change-in-medical- education.pdf.
60. Accelerating Change in Medical Education: Grant Projects, AM. MED. ASS'N, http://www.ama-Assn. org/sub/accelerating-change/grant-projects.shtml (last visited Sept. 30, 2013).
61. For discussion of the role ofMLP in addressing the issue of "heat or eat,"
62. see Elizabeth Tobin Tyler et al., Housing: The Intersection of Affordability, Safety and Health, in POVERTY, HEALTH AND LAW: READINGS AND CASES FOR MEDICAL-LEGAL PARTNERSHIP 260 (Elizabeth Tobin Tyler et al. eds., 2011).
63. See Medical School Graduation Questionnaire, 2012 All Schools Summary Report, ASS'N OF AM. MED. COLLS. (July 2012), https://www.aamc.org/download/ 300448/data.
64. Govind C. Persad et al., The Current State of Medical School Education in Bioethics, Health Law and Health Economics, 36 J.L. MED. & ETHICS 89, 89-94 (2008).
65. See Amy T. Campbell, Teaching Law in Medical Schools: First Reflect, 40 J.L. MED. & ETHICS 301 (2012).
66. See id.
67. Ashish Premkumar et al., ACall fromBelow: WhyDeeper Education inHealth and Human Rights IsCrucial for Medical Students, J. HEALTH&HUMAN RTS., http://www.hhrjournal.org/2013/04/05/a-call-frombelow-why-deeper-education-in- health-And-human-rights-is-crucial-for-medical-students/(last visited Sept. 30, 2013).
68. Campbell, supra note 45, at 305;
69. see also Elizabeth Tobin Tyler, Allies Not Adversaries: Teaching Collaboration to the Next Generation of Doctors and Lawyers to Address Social Inequality, 11 J. HEALTH CARE L. & POL'Y 249 (2008).
70. See Wendy E. Parmet et al., Social Determinants, Health Disparities and the Role of Law, in POVERTY, HEALTH AND LAW, supra note 42, at 3, 3-36.
71. See generally Tobin Tyler, supra note 50.
72. Framework for Action on Interprofessional Education & Collaborative Practice, WORLD HEALTH ORG. (2010), http://whqlibdoc.who.int/hq/2010/WHO HRH HPN 10.3 eng.pdf.
73. Sharon M. Mickan, Evaluating the Effectiveness of Health Care Teams, 29 AUSTL. HEALTH REV. 211, 211-17 (2005).
74. Interprofessional Education Collaborative Expert Panel, Core Competencies for Interprofessional Practice: Report of an Expert Panel, INTERPROFESSIONAL EDUCATION COLLABORATIVE 1, 4 (May 2011), http://www.aacn.nche.edu/education- resources/ipecreport.pdf.
75. See, e.g., Robert A. Berenson, Health Policy Brief: Next Steps for ACOs: Will This New Approach to Health Care Delivery Live Up to the Dual Promises of Reducing Costs and Improving Quality of Care?, HEALTH AFF. (Jan. 31, 2012), http://healthaffairs.org/healthpolicybriefs/brief pdfs/healthpolicybrief 61. pdf.
76. Revisiting the Medical School, supra note 15, at 18.
77. Lowell T. Coggeshall, Planning for Medical Progress Through Education, 197 JAMA 909, 910 (1965).
78. Amy V. Blue et al., Interprofessional Education in US Medical Schools, 24.2 J. INTERPROF. CARE 204 (2010);
79. Dawn M. Schocken et al., Approaching Interprofessional Education in Medical School, 15 JAMA 504, 505 (2013).
80. The report notes that "clear development of core competencies for interprofessional collaborative practice requires a unifying concept." Interprofessional Education, supra note 55, at 8.
81. The report authors apply D'Amour and Oandasan's definition of interprofessionality as the process by which professionals.
82. Reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population....
83. It involves continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patient's participation....
84. Interprofessionality requires a paradigm shift, since interprofessional practice has unique characteristics in terms of values, codes of conduct, and ways of working.
85. These characteristics must be elucidated.
86. citing Danielle D'Amour & Ivy Oandasan, Interprofessionality as the Field of Interprofessional Practice and Interprofessional Education: An Emerging Concept, 19 J. INTERPROF. CARE 8, 9 (2005)).
87. New Coordinating Center Will Promote Interprofessional Education and Collaborative Practice in Health Care, HEALTH RES. & SERVS. ADMIN., http://www.hrsa.gov/about/news/pressreleases/120914interprofessional.html (last visited Sept. 30, 2013).
88. Lisa Bliss et al., A Model for Interdisciplinary Clinical Education: Medical and Legal Professionals Learning and Working Together to Promote Health, 18 INT'L J. CLINICAL LEGAL EDUC. 149, 150 (2012);
89. see Tobin Tyler, supra note 50.
90. Medical Schools, NATIONAL CENTER FOR MEDICAL LEGAL PARTNERSHIP, http://www.medicallegalpartnership. org/movement/medical-schools (last visited Sept. 24, 2013).
91. Medical Schools with joint medical-legal courses include: Boston University School of Medicine and Boston University School of Law;
92. Morehouse School of Medicine and Georgia State College of Law; Stanford University School of Medicine and Stanford Law School;
93. University of California, San Francisco School of Medicine; and Warren Alpert Medical School of Brown University and Roger WilliamsUniversity School of Law.
94. Medical schoolswith electives include: BostonUniversity School of Medicine; Medical College ofWisconsin;Morehouse School of Medicine; University of Kentucky College of Medicine;
95. Vanderbilt University School of Medicine; and Virginia Commonwealth University School of Medicine. Id.
96. Elizabeth Tobin Tyler, Introduction, in POVERTY, HEALTH AND LAW, supra note 42, at xxxi, xxxiv.
97. For example, the joint course at Stanford Medical School and Law School focuses on child health.
98. Randee Fenner, Beyond Health: The Interplay of Law and Medicine, STANFORD LAWYER (June 7, 2013), http://stanfordlawyer.law.stanford.edu/2013/06/beyond- health-%E2%80%A8the-interplayof-law-And-medicine/.
99. See Tobin Tyler, supra note 50;
100. Elizabeth Tobin Tyler, Teaching Social Justice and Health: Professionalism, Ethics and Problem-Solving in the Medical-Legal Classroom, 38 J.L. MED. & ETHICS 701 (2010).
101. Tobin Tyler, supra note 68.
102. For a longer discussion of specific joint medical-legal courses, see Elizabeth Tobin Tyler et al.
103. Bridging the Health and Legal Professions Through Education and Training, in POVERTY, HEALTH AND LAW, supra note 42, at 110-12.
104. For example, Morehouse School of Medicine students participate in joint classes with law students from the Help Law Clinic at Georgia State University College of Law.
105. See Lisa Bliss et al.
106. A Model for Interdisciplinary Clinical Education: Medical and Legal Professionals Learning and Working Together to Promote Public Health, 18 INT'L J. CLINICAL LEGAL EDUC. 149, 160-61 (2012).
107. The stated objectives for the rotation are: By the end of the rotation medical students will: 1. be able to elicit information from families that may indicate they have a potential legal problem; 2.
108. know how to provide families with a referral to the Medical-Legal Alliance for Children; [and] 3.
109. recognize common legal issues that may affect a family's ability to care for their children, including, but certainly not limited to: guardianships, access to health care, special education, immigration status and consent for health care.
110. Description of the Phase III CAC Rotation with the Medical-Legal Alliance (on file with the authors).
111. See generally Medical-Legal Alliance for Children, U. NEW MEX. SCH. OF LAW, http://lawschool.unm. edu/news/archives/2009/june/medalliance.php (last visited Sept. 24, 2013).
112. Medical-Legal Partnership, MDR 966 Course Description, (on file with the authors).
113. The stated goals for this clinical rotation are as follows: 1.
114. Establish a foundation inmedicine and law in health care for subsequent clinical experiences.
115. Build on basic issues in medicine and lawthat studentswill encounter in their future endeavors as practitioners of medicine and law.
116. Teach students about the collaborative relationship between medical ethics and law and professional identity formation. Id. The objectives include: 1.
117. Students will develop interdisciplinary strategies for medical and legal decision-making to approach clinical problems and issues.
118. Identify appropriate resources (books, relevant journal articles and case law that deal[] with the topic).
119. Experience opportunities for collaboration of medicine and law. Id.;
120. see generally Health Rights Clinic, U. MIAMI SCH. OF LAW, http://www.law.miami.edu/clinics/health-rights/(last visited Sept. 30, 2013).
121. For example, fourth-year medical students at the Alpert Medical School of Brown University have completed project-based work with the Rhode IslandMedical-Legal Partnership through the community health clerkship program.
122. Information on file with the authors.
123. Donald M. Berwick & Jonathon A. Finkelstein, Preparing Medical Students for the Continual Improvement of Health and Health Care: Abraham Flexner and the New "Public Interest," 85 ACAD. MED. s56, s56-57 (2010).
124. Joel Teitelbaum, Presentation at Southern Illinois Healthcare/Southern Illinois University Health Policy Institute (May 2013).
125. Gary Ahlquist et al., Bundled Care State of Play, Lessons Learned and Future Prospects, BOOZ & CO. 1, 6 (2013), http://www.booz.com/media/file/ BoozCo Bundled-Care State-of-Play-Lessons-Learned-And-Future-Prospects.pdf.
126. Recent Studies and Reports on Physician Shortages in the US, CTR. FOR WORKFORCE STUDIES ASS'N AM. MED. COLLS. 1, 8 (Oct. 2012), https://www.aamc.org/ download/100598/data/.
127. Eric Barnes, JACR: Proposed Medicare Cuts Threaten Radiology Training, AUNTMINNIE.COM (June 14, 2013), http://www.auntminnie.com/index.aspx?sec= ser&sub=def&pag=dis&ItemID=103666.
128. About ACGME, ACCREDITATION COUNCIL FOR GRADUATE MED. EDUC., http://www.acgme.org/acgmeweb/tabid/116/About.aspx (last visited Sept. 24, 2013).
129. ACGME Mission, Vision and Values, ACCREDITATION COUNCIL FOR GRADUATE MED. EDUC., http://www. acgme.org/acgmeweb/tabid/121/About/Misson,VisionandValues. aspx (last visited Sept. 24, 2013).
130. About ACGME, supra note 81.
131. ACGME History, ACCREDITATION COUNCIL FOR GRADUATEMED. EDUC., http://www.acgme.org/acgmeweb/tabid/122/About/ACGMEHistory.aspx (last visited Sept. 24, 2013).
132. Categorizing of Common Program Requirements, ACCREDITATION COUNCIL FOR GRADUATE MED. EDUC., http://www.acgme-nas.org/ccpr.html (last visited Sept. 24, 2013).
133. See Common Program Requirement, ACCREDITATION COUNCIL FOR GRADUATE MED. EDUC., http://www.acgme.org/acgmeweb/Portals/0/PDFs/commonguide/IVA5f EducationalProgram ACGMECo-mpetencies SBP Explanation.pdf (last visited Sept. 24, 2013).
134. ACGME Program Requirements for Graduate Medical Education in Family Medicine, ACCREDITATION COUNCIL FOR GRADUATE MED. EDUC. (2007), available at http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/ 120pr07012007.pdf.
135. Edward Paul et al., Medical-Legal Partnerships: Addressing Competency Needs Through Lawyers 1 J. GRAD. MED. EDUC. 304, 304-09 (2009).
136. Milestones, ACCREDITATION COUNCIL FOR GRADUATE MED. EDUC., http://www.acgme-nas.org/milestones. html (last visited Sept. 25, 2013).
137. Molly Cooke et al., American Medical Education 100 Years After the Flexner Report, 355 NEW ENG. J. MED. 1339, 1339-44 (2006).
138. See generally Family Medicine Residency Program, NW. U., http://www.familymedicine.northwestern. edu/residency/(last visited Sept. 30, 2013).
139. See generally Clinical Partners in Advocacy: How Can I-HELP?, MEDICAL-LEGAL PARTNERSHIP BOSTON (Oct. 2009), http://www.medical- legalpartnership.org/sites/default/files/news story file/I-HELP%20Guide.pdf.
140. Paul, supra note 89.
141. Megan Sandel et al., Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations, 29 HEALTH AFF. 1697 (2010).