Thursday, December 4, 2008

Our Presentation in Cuba

I couldn't post this when we were down there, as the bandwidth was not sufficient to load the 13 pictures.   Valerie Zolezzie-Wyndham and I presented this talk to an audience of about 50, and got positive feedback from several folks, including one Pediatrician from Cuba.  My work on the Medical-Legal Partnerships has been very exciting, and you can read more about it here.
Thank you. Medical-legal partnerships are collaborative programs that have been established in more than 100 hospitals and clinics throughout the United States since the founding of the first program at Boston Medical Center in 1993. They provide direct advocacy services to families who lack access to social systems that can offset the social factors that affect health. Many of these Partnerships also serve as sites for community-engaged education, allowing health care students in a variety of professional education programs the opportunity to 
understand the impact of poverty on the health of children and families, and the potential for health professionals to intervene on behalf of children. After I briefly outline the model and common structures of these programs, my colleague will highlight the ways in which 3 of these Partnerships have integrated undergraduate and graduate medical education training into the structure of their Partnerships, to the benefit of the programs, the patients and the students.

The American Academy of Pediatrics “recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces act favorably or unfavorably, but always significantly, on the health and functioning of children.” Housing, utilities, food, employment, income, health care, to name a few , are of paramount concerns to families. Unmet basic needs can profoundly affect the stability of a family and the health of a child.

-   With insufficient money for food, a child who is already failing academically goes to school hungry.
-   A landlord’s failure to fix leaky pipes and eliminate vermin can have dire effects on the health of children.
-   Children who live under threat of deportation lay awake at night, anxious that a parent or caregiver will be sent away to their home country leaving them alone.

In the United States, there is a complex “safety net” to buffer families and in particular young children against the impact of the social determinants of health, regrettably the safety net is often difficult for those most in need to access. The social programs that make up the “safety net “ have complicated and intimidating rules which impede access and can interrupt the continuity of services.  Negative social determinants that can be remedied with legal advocacy often manifest themselves in a scheduled appointment or sick visit. The problem is that providers are not trained to identify a solution. So, can we teach medical students, residents and other health care workers that:
- Housing codes, when enforced, ensure safe conditions for children’s growth and development
- Utility protections can prevent power shutoff, allowing light and heat for families during the winter
- Maintaining health insurance in the context of ongoing documentation requirements is challenging for low income families and can interrupt care. 

Medical-legal partnerships allow physicians and lawyers together, to address the social factors that affect child health by ensuring a coordinated advocacy plan that tackles legal and medical issues likely to affect child health outcomes Medical-legal partnerships typically include three programmatic components: 
1) provider training on how to identify legal issues and how they affect health, 
2) legal advice and counsel for patients and families in need, and 
3) systemic advocacy to improve child health.

Today, we are focusing on the use of Medical-Legal Partnerships as vehicles for training in medical education. In 2007, medical-legal partnerships around the county conducted over 950 training sessions by both medical and legal staff. These trainings reached approximately 17,000 people. The majority of trainings conducted were for frontline health care staff, and the primary audience was medical faculty, residents, social workers and case managers. The trainings extended to staff in pediatrics, family medicine, internal medicine and other clinical settings.

The training process is central to the development of the partnership. Physicians need to learn how they can identify legal problems that can affect child health during their medical assessment. Attorneys need to learn how physicians approach clinical problems and what sorts of things they are likely to learn about their patients. Attorneys and physicians involved in medical legal partnerships often work together to create curriculum and to lead trainings that teach health care workers about the social determinants of health. Models of training vary, depending on the nature of the partnership and local educational resources. My partner will highlight the models of training used in three partnerships in New England: the Medical-Legal Partnership for Children of Rhode Island, a partnership of Hasbro  Children’s Hospital and Rhode Island Legal Services in Providence, RI; Family Advocates of Central Massachusetts, a partnership of UMass Medical  School and Legal Assistance Corporation of Central Massachusetts in Worcester  MA, and the Medical-Legal Partnership/Boston a partnership housed at Boston Medical Center in MA. We hope that by examining these collaborative teaching experiences other educators will develop an interest in developing similar inter- disciplinary educational programs that attack the negative social determinants of health.

The Rhode Island Medical Legal Partnership for Children is a collaboration among five medical and legal partners. The Partnership offers a joint course in Poverty, Health and Law, which brings together medical students at Warren Alpert Medical School at  Brown University and law students at Roger Williams University School of Law in a joint seminar program. The training is focused on three areas: professionalism, interdisciplinary skills, and the social determinants of health. The students examine several case studies, including the relationship between childhood asthma and safe and affordable housing, child development and lead paint and the domestic violence and family function as issues that demonstrate the need for a multidisciplinary approach.

A recent publication examined the self-reflections written by students for the course, and found evidence that course participation led to positive understanding of the values of diverse professional viewpoints and a positive understanding of their own role in the profession. “By taking away professional labels, one is able to focus solely on the client herself, her problems, and her concerns.” one student wrote, “Once this is achieved, then the labels of the professional can come back into play.” This kind of insight can only occur in the context of cross-disciplinary discussion. Some challenges in the logistics of the course were also noted. Medical school and law school calendars don’t match, the medical school is 30 miles distant from the law school and the styles of learning are quite different. With appropriate effort, however, collaborative teaching can open an interdisciplinary discussion about the social determinants of health.

Family Advocates of Central Massachusetts is a partnership of the Legal Assistance Corporation of Central Massachusetts and several primary care practices affiliated with the University of Massachusetts Medical School. For the last five years, it has been one of the sites used by students from the Medical School and Graduate School of Nursing on their Community Clerkship, a two to three week block rotation lets students learn about social issues affecting patients from different perspectives. In our rotation, the students shadow doctors in our partner practices, and participate in court proceedings involving families served by the M-L partnership. They also investigate a public health problem within our catchment area, and document the problem on a “public Health grid”. Finally, the students journal reflectively, and prepare posters to share their reflections with the other groups.

Feedback on FACM’s participation in the Clerkship has been overwhelmingly positive. As one student said ““I am gaining more background and insight into the where these kids come from … I have never had first hand experience in this type of context … Every court case I sit through or patient I shadow has real, immediate needs and their lives do not stop while I reflect on what it may mean to walk in their shoes. …These days have empowered me to make a difference moving forward but have also overwhelmed me as I face the vastness of our responsibility to patients...” This insight, achieved early in the first year, may help this student and others like him or her achieve much going forward into their clinical work.

The Boston Medical-Legal Partnership for Children is the founding program in our Network, and is well integrated with the Boston Combined Residency Program, which brings together Boston Medical Center, a “city hospital model program”, and Children’s Hospital Boston, a national leader in pediatric research and training. The Partnership runs several programs within the Residency: a poverty simulation during resident orientation to raise awareness of the social factors influencing patient health, a two-week block of didactic, observational and clinical activities in the primary care track that provides foundation for future work, and pre-clinic and noon conferences for all residents working in a primary care clinic at BMC. Beginning in spring 2009, MLPC will partner with physicians in internal medicine to pilot a four-week course for all primary care interns, moving out of pediatrics into the other specialty areas.

At each of our programs, medical students have become involved in ongoing research, assessing our educational modules and assuring the quality of what we have done. One project, involving the development of a brief screening tool to identify those most likely to need services, was extremely successful, and was published in a peer-reviewed journal. Others have been presented at national and regional meetings. These projects all demonstrate a depth of commitment that should be cultivated in the learners who will be the next generation of leadership within community health.

At our programs, and at many of the programs throughout the United States, participation in Medical-Legal partnerships by clinical faculty has led to the integration of heath equity into the clinical teaching of our institutions. The Partnerships serve as a model for presenting diverse views of the complex problems associated with living in poverty. As more Partnerships develop, we expect that participation in a medical-legal partnership will enable medical faculty to address the social determinants of health while addressing the critical needs of low income families throughout the United States.   Thank you for your attention.
It's amazing how fast ten minutes goes.

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