Whatever the power—even the necessity—of the disciplines. . . in the end, questions never stop at the boundaries of a discipline. Efforts to develop decisive and personal ideas of the true, the beautiful, and the good necessarily take us beyond specific disciplines and invite synthesis.1
While I apparently announced somewhere around the auspicious age of six that I wanted to become a medical lawyer when I “grew up,” it was probably during my second year of law school, when I participated in an interdisciplinary child advocacy clinic advocating for children in the dependency system in Philadelphia that I truly came to understand the value of interdisciplinary work and education.2 As a child advocate and guardian ad litem for dependent children, I worked alongside social work and medical students, under the supervision of an attorney, social worker and child abuse pediatrician. I attended home visits, school visits, hearings, and therapy sessions. I participated in individualized education plan drafting, wrote letters to landlords, utility companies, and schools advocating for the rights of my clients. I reviewed and drafted court documents to support legal remedies when necessary. I saw and learned more about the social determinants of health in that experience than I had experienced in the three years of medical school which preceded it.
Though I had not anticipated it when I began in the clinic, it taught me the crucial value of having individuals from different disciplines utilizing their different skill sets to address the complex social needs of our shared clients. Realizing that there was not a set curriculum in my preclinical coursework which taught medical students about the social determinants of health or how to address them, I co-organized an elective course called Practical Introduction to Social Services for Medical Students (PRISSMS). The goal of the course was to broaden the lens of others to view health problems in the setting of larger social structures. These combined experiences have driven a passion for acknowledging and responding to social determinants of health throughout my career, as well as for thinking about how to best integrate education across the necessarily interdisciplinary team needed to address them.
In the decade and a half since I started my journey learning about the social determinants of health through my work in a medical-legal partnership (MLP), we are still learning about the best practices both for implementing and optimizing client services, and for educating the future generations of leaders who will move the field forward. From a patient and medical provider standpoint, MLP models that emphasize client services which are often supported outside of academic institutions through legal services organizations offer the best opportunity to address the greatest number of patient needs. This is because they have established practices and staff, rather than many academic models which have both an educational and service focus, need to work within the limitations of learners performing new skills, and have the challenge of the natural turnover of students over the course of their education. While these two models have different capacity for management of client loads, they are both critically important to optimizing the impact of MLPs.
As we move forward, then, we need to focus on evaluating outcomes of different MLP models and also consider new models, such as potential partnerships between academic and community based models as well as integration of other disciplines that address non-legal social determinants alongside legal services. Recognizing that there are potential impacts not only to individual patients, but also at institutional and community levels, we need to continue to build relationships in all of these domains. We need continued training in structural competency and health equity in both undergraduate medical education and legal education, coupled with training in population health research methods to evaluate the impact of the work that is done.3,4
Balancing meeting the needs of existing patients with a need to build a future cohort of lawyers and doctors who will partner in this work mandates ongoing opportunities for engagement of students. Most agree that this is best accomplished through experiential learning in actual MLP settings. Experts in the field have suggested that while we need continued experiential opportunities, the way forward also requires a culture shift in legal education to graduate lawyers who understand the social determinants of health and work to build systems and policies that prevent individuals from experiencing them. Having experienced what it is like to be both a medical student ill equipped to change the social structures impacting my patients and a law student who learned about antitrust law and managed care in health law rather than the impact of poverty on health and potential legal remedies to address poverty, I too agree that a culture shift is needed. This culture shift must happen not only in medical and legal education but across the disciplines that can partner to address the social determinants from a proactive rather than reactive perspective. This is the synthesis I hope for.
Erin Paquette, MD, JD
Erin Paquette is a pediatric intensivist at Lurie Children’s Hospital and Assistant Professor of Pediatrics at Northwestern University Feinberg School of Medicine. She is a Pediatric Critical Care and Trauma Scientist Scholar studying disparities in research engagement by diverse populations and a Public Voices Fellow through the Op-Ed Project. Her academic interests include studying and advocating for practices and policies to address the social determinants of health and reduce barriers to health equity at the individual, institutional and societal levels.
- Gardner, H. (1999). The disciplined mind: What all students should understand. New York: Simon & Schuster.
- Lerner, A. & Talati, E. (2006). Teaching Law and Educating Lawyers: Closing the Gap Through Multidisciplinary Experiential Learning. Journal of Clinical Legal Education, 96-133.
- Teitelbaum, J. & Lawton, E. (2017). The Roots and Branches of the Medical-Legal Partnership Approach to Health: From Collegiality to Civil Rights to Health Equity. Yale Journal of Health Law, Policy and Ethics, Vol 17(2). Article 5.
- Doobay-Persaud A (Producer). (2018) Teaching and Learning about Social Medicine and Structural Competency in Undergraduate Medical Education. Retrieved from NCEAS websitehttps://sdoheducation.org/community-hub/category/webinars/