Galowitz, P --- "The opportunities and challenges of an interdisciplinary clinic" [2013] LegEdDig 34; (2013) 21(3) Legal Education Digest 8

---

The opportunities and challenges of an interdisciplinary clinic

P Galowitz

International Journal of Clinical Legal Education, Vol 17-18, 2012, pp 165-180

Law school clinics in many countries increasingly provide the major opportunities that law students have to engage in interdisciplinary collaborations with other professionals. These clinics teach students to represent clients effectively and offer the possibility to advance social justice.

Typically, an interdisciplinary clinic is collaboration between or among law students and other students in professional schools, or other professionals, to help address the multidimensional problems faced by clients. It is a ‘multidisciplinary model [that] can respond to the myriad needs of those who are poor or marginalised by their social, medical or psychological circumstances.’

Professionals are increasingly aware that working together with other professions can better serve clients and improve outcomes.

Certain attributes typify interdisciplinary clinics in which there are integrated interdisciplinary teams. One is a shared expertise, so that it is not legally focused and lawyer-directed. In this model it is not just the other professions assisting the lawyer, but rather the lawyer and other professional undertake a joint approach. In addition, the collaboration uses and relies on the knowledge of all of the participating disciplines. It is important that the various professionals understand that there are many ways that the law can be part of a comprehensive approach to meet the needs of the clients: litigation is not the only way. An additional component of interdisciplinary service is a team commitment to the importance of developing creative approaches to assist clients. Moreover, there should be a structure that formalises the relationship between the professionals and anticipates the possible problem areas in joint service provision.

The opportunities and challenges of an interdisciplinary clinic for students, clients and faculty teaching the clinic are discussed, using the model of and through the lens of a medical-legal interdisciplinary clinic that I co-teach. The Medical-Legal Advocacy Clinic at New York University School of Law (hereinafter MLAC) is a medical and legal collaboration.

The MLAC employs a multidisciplinary and holistic approach to provide legal advocacy in a medical setting for clients referred by medical professionals. Many legally-related issues can affect the health of low-income families and many of the problems that affect the health of the children and families have legal remedies. This clinic is a medical-legal collaboration to improve health outcomes for patients/clients by providing on-site legal advocacy and training to medical providers.

In the first few years that the MLAC was taught, law students, who were in their second or third (last) year of law school, and paediatric medical residents (in the second and third year of a three year residency program after completing four years of medical school) collaborated to address more effectively the health issues of their clients/patients. The medical residents were in the Residency Program in Social Pediatrics at Montefiore Medical Center in New York City. These residents intend to practise in clinical practice, community health and advocacy; they spend a significant part of their clinical time in their second and third years of residency in a federally- funded community health centre serving primarily low-income African-Americans and Latinos. The patients of the community health centre present a multitude of psychosocial issues, including family disruption (due to illness, incarceration, violent injury, child abuse and/ or neglect), poor housing, unemployment and poverty, domestic violence, lack of access to health care, and immigration problems. Many legally-related issues can affect the health of the patients of the community health centre, such as: asthma triggered by mould from leaky ceilings or rodent infestation; lead poisoning from paint not removed; burns caused by families heating apartments with stoves; and children who suffer due to insufficient nourishment. The patients of this community health centre were referred by the medical residents to the law students for assistance.

The law students and the medical residents were trained together to practice an interdisciplinary and holistic approach to their patients/clients. The program was planned jointly by me and Iman Sharif, M.D., M.P.H., who was then Associate Director of Residency Training in Social Pediatrics and Associate Professor of Clinical Pediatrics at the Albert Einstein College of Medicine/ Children’s Hospital at Montefiore Hospital. As part of developing the program, Dr. Sharif and I had to learn to collaborate, including understanding each other’s language, culture, ethics, professional values, and approaches to our clients/patients.

In the clinic seminar, the law students and medical residents learned together. They met for eight two-hour joint seminars over the course of the law school semester, covering such topics as: collaboration and interdisciplinary work; ethics and confidentiality; asthma and environmental triggers; substantive law training on advocacy; early childhood education advocacy; lobbying training; holistic advocacy; and health law. The joint seminars were co-taught with Dr. Sharif. For each joint seminar, the law students and medical residents were given readings and learning objectives. Seminar speakers included practicing doctors, ethicists, lawyers, social workers, and leaders from child advocacy and legal advocacy.

The fieldwork had a three-fold approach: (1) direct client representation; (2) education of the medical residents and other health professionals about how to identify legal issues and incorporate advocacy into their treatment plans, as well as education of the clients/patients about their legal rights; and (3) identifying and exploring health care issues and presenting interdisciplinary strategies to address the issues. For the direct client representation, procedures were implemented to enable the medical residents and faculty at the outpatient community health centre to refer patients to the law students for legal advocacy. Each week, law students provided a free legal clinic for clients referred by the medical residents. A joint electronic account was created to allow the doctors to schedule the legal appointments for their patients, after obtaining the consent of their patients. Legal assistance was provided on such areas as housing, government benefits, education and other issues that had an impact on the family’s health.

In addition to the joint seminar and the referral of cases, there were other parts of the collaboration. The law students developed policy projects by identifying and exploring health care issues and presenting interdisciplinary strategies to address those issues; students presented those policy projects at a joint seminar of the law students and medical residents. The law students and medical residents, after receiving joint training on how to lobby legislators, participated in an all-day lobbying effort of state legislators at the New York State capital in Albany, New York on an issue affecting their patients/clients. At the beginning of the semester, the law students and medical residents together observed proceedings in Housing Court. In addition, there were a few informal gatherings outside of class to help build rapport and relationships.

While there are many advantages for students in interdisciplinary clinics, there are six categories that I think are the most important. The first, and in some ways the most important, is the broadening of perspectives. The law students and medical residents learned from each other and appreciated the differing professional cultures and skills as well as the problem-solving approaches of the other profession.

The law students and medical residents began to understand what they had in common and not just what separated them. They learned about the roles, boundaries and limits of each member of the collaboration, as well as a familiarity with the knowledge base of the other profession. We specifically discussed some of the similarities in the two professions, including the shared set of core social and ethical values (including shared respect for the individual, the commitment to reason, and using experience as a basis for decision-making); valuing of professional autonomy and decision-making; the primacy of serving their patient’s/client’s interests; the fiduciary obligation each owes to their patient/client; and the aspiration of each profession to provide services to the poor.

This broadening of perspective can lead to what is described as a higher level of cognitive processing, what some psychologists define as ‘wisdom’. Particularly for the law students, they learned the skills and values to function in a variety of forums (i.e. not just litigation) and learned skills and approaches from the other disciplines. It helped the law students and medical residents to move away from the narrow approach of seeing the patient’s/client’s issues as only medical or legal ones; it helped remove the ‘blinders’ and minimise the ‘silo’ effect.

The second benefit is that it helps to build trust, understanding and respect amongst the members. The third is that it teaches the importance of collaboration. The law students and medical residents in our joint seminars were taught skills to help them collaborate successfully. In the joint seminar, we first discussed their own experiences in collaboration, including what they had found to be helpful in successful collaborations and what had been problematic. We also highlighted, based on assigned readings and their comments in the class discussion, some things that can be done to improve collaboration, including the value of listening and effective communication; understanding and appreciating the ‘other’, including the competencies of each profession; clearly stated role expectations; attitudes of respect and openness; learning skills for shared decision-making; and the importance of setting boundaries at the outset of the collaboration. (For our collaboration, one particular boundary issue was differing approaches to confidentiality and how it could limit what client/patient information could be shared between the doctor and lawyer).

The fourth advantage of an interdisciplinary clinic is what I call a ‘window’. It is a window in two very different ways. One is that it can help students prepare for the ‘real world’ by modelling the experience of practising law, which increasingly uses interdisciplinary collaborations.

The fifth point is that the collaboration can be a more satisfying and fulfilling professional and personal experience for all. The sharing of experiences and approaches to assist clients/patients can result in increased satisfaction. It can also result in increased comfort in being able to learn from and rely on the other professionals. Collaboration can help reduce the stress that lawyers can experience. From their comments in class as well as their written reflections, it was apparent that it was a more fulfilling model for each of the professions involved.

The complementary skills of the other professions can help the lawyer serve the client, as can the legal information assist the doctor to be a better medical provider and advocate for his or her patients. For example, the medical residents became more familiar with laws affecting their clients (such as educational services for children with special health care needs and eligibility for disability programs) and developed practical skills for advocating for their patients to receive the services to which they were entitled. For the law students, they understood the medical conditions that could impact on their clients’ disabilities and were able to use that information to argue more persuasively for the benefits for which their clients were eligible.

Teaching in an interdisciplinary structure also has unique additional advantages for the faculty. One is that it helps emphasise the importance of teaching creative problem-solving and collaboration. In the seminar and in the fieldwork, the students can be helped to see the issues that the client faces in the broader context of the client’s life and the students can be helped ‘to think about prevention of future problems, not just solving current ones’.

While there are many challenges in interdisciplinary clinics, there are five categories that I think are the most significant. The first (and an especially pervasive) one was the differences in the language, customs, and norms of the collaborating professions. Each needed to learn and appreciate the other.

The second category is that of ethical obligations and professional values. There are differences in ethical obligations such as confidentiality, conflicts of interest and the professional independence of the lawyer that must be addressed. While dealing with them can be challenging, they are not barriers, particularly if the anticipated issues are discussed and addressed amongst the various professionals when forming the collaboration. Guidelines and protocols for the anticipated ethical issues (such as what information received from the client can be shared with the other professionals) should be drafted together as part of the development plan.

The third area is student discomfort and anxiety. Any discomfort and possible anxiety can be compounded by working with other professions when the students may be unsure of their own professional roles and values.

Fourth, the nature of the professional norms in law school can create challenges. Law students tend to be more competitive (which would also make it more difficult for them to collaborate) and that they have less experience in collaboration than other professions (such as students in business school). Collaboration as an important skill and value for professionals needs to be directly addressed.

Finally, there are many logistical and situational challenges in an interdisciplinary clinic. For example, the law school schedule and the definition of a semester differ substantially from medical schools and residency training programs.

For the clients, there can be confusion about the roles and approaches of the various professions. The client may not be sure which issues should be addressed with which professional. In addition, there may not be consistent information or opinions conveyed to the client by the various professionals who are interacting with the client. The client may also have unclear expectations. The ethical requirements of each of the professions need to be addressed, particularly the varying definitions of who is the ‘client’, confidentiality, conflicts and capacity of the person to make decisions. As with many other challenges, ethical and professional value issues can be anticipated and dealt with in the design and planning of the curriculum, including developing protocols to address them.

There may also be different pedagogical goals for the students and different learning experiences in the relevant professional schools. One example is that law school emphasises getting law students to think like a lawyer compared with a business school focus on problem solving.

An issue that I found particularly difficult was getting the law students ready to be ‘lawyers’ in many different kinds of subjects, approaches and practice. While getting students comfortable in a variety of subject areas can be a challenge in any clinic that practices holistic advocacy, it can be more difficult in an interdisciplinary clinic since the students need some knowledge about the other profession or professions with whom they will be collaborating. There were two things that Dr. Sharif and I did in the MLAC to help address these challenges. The first was to front-load the clinic to spend the first few weeks discussing the substantive law areas and professional skills, including a simulation of a client interview for which the law students reflected and received feedback to prepare them before seeing their first clients. I was also at each of the fieldwork clinics when the law students interviewed their clients so that they could check-in with me before the interview was completed. This ensured that critical issues, such as deadlines and statute of limitations, weren’t missed.

An interdisciplinary clinic has many different advantages for the students, faculty, professionals, clients and the professional schools. While there are challenges for all involved, they are far outweighed by the multiple benefits. I have found that all, including myself, were enriched by the interaction with our medical colleagues. The clinic also helped model for the law students and medical residents the value of interdisciplinary approaches to help meet the needs of our clients/ patients. Interdisciplinary clinics can ‘help develop a cadre of future lawyers with the sensitivity and expertise to play a leading role in addressing complex health and human rights issues’.