Medical-Legal Partnerships to Enhance Residency Training in Advance Care Planning

Abstract

Background and Objectives: Only about one-third of adult Americans have completed advance directives for end-of-life care, and primary care physicians report that they are not always comfortable discussing advance care planning (ACP) with patients. Current approaches to teaching clinicians about ACP have limited evidence of effectiveness. With the objective of improving residents’ comfort and skill discussing ACP with patients, we developed a curriculum that involved clinicians and attorneys working together to teach first-year family medicine residents (R1) about leading ACP discussions with patients. Methods: Our curriculum consisted of a 1-hour multimedia training session on ACP followed by a series of direct in-exam room observations. Attorney and/or physician faculty observed residents holding ACP discussions with patients and provided structured feedback to residents about their performance. The initial R1 cohort observed had a series of three direct observations; the subsequent R1 cohort had two direct observations. We developed an evaluation tool with a 5-point developmental scale (beginner, novice, developing, near mastery, mastery) corresponding to the Accreditation Council for Graduate Medical Education’s milestone system to score residents’ performance. Results: R1 performance improved from the beginner/novice level during the first observed ACP discussion to the novice/developing level during the second or third discussion, representing an increase in competence to that expected of a second- or early third-year resident. Conclusion: Based on our initial experience, using medical-legal partnerships to teach residents about ACP may be more effective than previously reported approaches. Validation of our results with a larger sample is needed.

Advance Care Planning in Healthcare Systems: A Literature Review and Call to Action

“…This is an area full of research potential. [55] As previously reported, Palliative Medicine and ACP are lacking in clinical care pathway development. [56] A definition of a care pathway is "a methodology for mutual decision making of care for a well-defined group of patients during a well-defined period."…”

Teaching the Social Determinants of Health Through Medical Legal Partnerships: A Systematic Review

“…Participants included medical students [16], internal medicine interns [13], and residents [13], family medicine interns [17], combined medicinepediatrics residents [15], as well as pediatric interns [12,13] and residents [14,15]. Medical Legal Partnerships in all but one of the studies included a legal aid organization partnering with an academic medical center; In the MLP program that did not have a partnering legal aid organization, lawyers were integrated into the healthcare organization directly [17]. One MLP program also included a law school partnership [16].…”

“…control group) [12,14]. Three studies were pre/post intervention measuring the impact of the intervention on the same group of residents over time [13,16,17]. One study was a cross sectional study that compared residents at different clinical sites with varying levels of social work and legal aid support, ranging from having a colocated MLP with multiple social workers and lawyers on site, to a clinical site without co-located MLP services (but remote access) [15].…”

“…One study incorporated direct observations of residents' patient care interactions to gauge the effectiveness of the skills learned in MLP didactic sessions. [17] Outcomes Each study used different measures of determining the effectiveness of their interventions. However, each study demonstrated improvements in some aspects of knowledge, attitudes or practice regarding participants' understanding, comfort, con dence and abilities in identifying and intervening on the social determinants of heath in their patients.…”

“…In the MLP program that targeted intern performance in discussing advanced care planning with their patients, the intervention was successful in improving ACGME rated levels of competence in these discussions. [17]…”