Medical–Legal Partnership Builds a Culture of Upstream Advocacy

Originally posted on March 13, 2014

By Elizabeth Tobin Tyler, JD and Edward Paul, MD

Sometimes the screening questions a doctor most needs to ask her patients are not the ones she has traditionally been taught to use.

During a recent visit, Dr. Jordan, a family physician, asked Maria if she had any concerns about her housing or her family’s safety. Maria, a married, young mother of three, burst into tears. She told Dr. Jordan that the utility company was threatening to shut off the electricity and gas in their home because they were behind in their payments. Maria’s husband was disabled on the job several months earlier and had been unable to work. His application for disability insurance was denied, leaving the family with limited income.

For the past several months, the family had made the difficult choice to buy food instead of paying the utility bills. Dr. Jordan was also treating one of Maria’s children for severe asthma and knew that losing their electricity would jeopardize the use of his nebulizer and that living in a house without heat could seriously exacerbate his symptoms. It was the beginning of winter and temperatures were already in the low 20s.

Many physicians might have hesitated to ask Maria questions about her income, housing, or safety. Doctors know that patients, particularly low-income and vulnerable patients like Maria, often have multiple unmet social and legal issues that impact their health. In fact, studies indicate that low-income families have two to three unmet legal needs that directly harm health and family stability (threat of eviction or homelessness, domestic violence, erroneous denial of public and disability benefits, unsafe housing conditions). However, doctors often don’t ask patients about these issues because they do not feel adequately prepared to provide answers.

Dr. Jordan had an ally at the clinic who could help when these types of unmet legal needs were detected. At the end of Maria’s visit, Dr. Jordan walked Maria down the hall to meet a lawyer who works as part of a medical–legal partnership (MLP), one of more than 230 programs across the country where legal aid agencies, law schools, and health care institutions integrate expertise and services to improve patient and population health. The attorney’s sole purpose at the hospital is protecting the health of patients.

Together with Dr. Jordan, he went to work for Maria. Dr. Jordan wrote a letter indicating that the threatened utility shut-off jeopardized a family member’s health; the lawyer used the letter to seek protected status for the family under regulations that protect people from utility shutoffs. The attorney also appealed the disability insurance denial for Maria’s husband, using detailed health information provided by Dr. Jordan. Neither Dr. Jordan nor the attorney could have helped Maria alone.

Team-oriented, patient-centered care that includes a variety of disciplines is rapidly becoming the standard for primary care medicine in the United States through the growth of the “patient-centered medical home” (PCMH). Being accessible to patients when they most need care, having a long-term patient–provider relationship, and understanding the broader scope of the individual’s health are central themes to the patient-centered revolution, which recognizes that health care has historically prioritized the demands and conveniences of systems, institutions, and providers over those of patients. Increasingly, teams include social workers, case managers, psychologists, nutritionists, certified chronic disease educators, pharmacists, nurses, and medical assistants. Lawyers are an important extension of the PCMH model.

As a lawyer and a physician who have been advocates of MLP for many years, we believe in its power not only to address social determinants of health within the clinical setting, but also to improve the delivery of health care to be more sensitive and responsive to patient needs. We have witnessed the powerful combination of health care providers and lawyers working together to advocate for systemic and policy changes that benefit vulnerable patient populations and address the upstream determinants of poor health.

As medical educators, we also see enormous promise for MLP to train the next generation of physicians in the practice of interprofessional, patient-centered care as they embark in a complex, ever-changing health care system. Educating undergraduate medical students in the MLP model is synergistic with many of the important innovations occurring in medical education. These include the expansion of curricula on health disparities, social and behavioral health, health policy and systems, the integration of public health and clinical care, and an emphasis on interprofessional education.

Currently, 27 medical schools are affiliated with a medical–legal partnership. Increasingly, medical schools are also offering joint medical–legal elective courses in which law, medical, public health, and nursing students learn together about the role of law and policy in the social determinants of health and health disparities, and practice team-based collaborative problem-solving. Some medical schools also offer clerkships or clinical rotations where medical students work with lawyers and law students on-site at MLPs.

Similarly, residency programs are using MLP as a forum to explore patient-centered, team-based care and the importance of social determinants. Many programs use residents’ participation in MLP to meet ACGME competencies and the primary care milestones. MLP education is helping to shape a culture of patient advocacy in medicine and creating a cadre of new health care providers and lawyers committed to upstream prevention. A recent study showed that when lawyers were part of the health care team, residents were more likely to screen patients for social and legal needs.

Maria’s power stayed on and the disability application was approved, which meant that her son’s asthma stayed under control. This would not have happened without a doctor who thought differently about health care or without an attorney who had an understanding of the health care system. Fifty million low-income and vulnerable patients in the United States like Maria need physicians willing to ask different types of questions and to forge partnerships with new groups of professionals to treat the problems they uncover.

Elizabeth Tobin Tyler, JD, is Clinical Assistant Professor of Family Medicine and Co-Director of the Scholarly Concentration in Advocacy and Activism at the Warren Alpert Medical School of Brown University. She is the senior editor of Poverty, Health and Law: Readings and Cases for Medical–Legal Partnership.

Edward Paul, MD, is a board certified family physician and currently the Director of Medical Education at Yuma Regional Medical Center. He is a Clinical Associate Professor in the Department of Family & Community Medicine at The University of Arizona College of Medicine in Tucson where he helped develop Arizona’s first medical–legal partnership in the Family Medicine residency clinic.