Interdisciplinary Education Comes to Medicine — What About Law?

A recent NYT blog highlights how medical education trains its varied professionals, doctors, nurses, physicians assistants, in totally isolated silos, even though today they almost always actually practice in integrated teams.

But, there are now some changes described in the article extract pasted below:

The push toward more collaborative care has been underway for years. In 2001, the Institute of Medicine issued a report recommending that all health professionals receive training in interdisciplinary teams. .  .

.  .   . [t]he Robert Wood Johnson Foundation and three other leading foundations recently helped start the National Center for Interprofessional Practice and Education to improve teamwork and break down siloed training approaches. Another initiative, Retooling for Quality and Safety, led by the Josiah Macy Jr. Foundation and Institute for Healthcare Improvement, awarded grants to six universities to support interprofessional activities aimed at integrating patient safety into medical and nursing school curricula. Participating schools designed a variety of creative learning models to bring students together, such as interprofessional Grand Rounds conferences and web-based learning modules; small-group exercises to develop care plans or break bad news; quality improvement projects to improve hand hygiene or prevent falls; and clinical simulations with debriefing sessions during which all team members had the opportunity to describe what went well and what could have been improved.

Data evaluating whether interprofessional training improves teamwork, communication and leadership is still preliminary, but promising. A study of over 600 medical, nursing, physiotherapy and occupational therapy students enrolled in an interprofessional training course found that all student groups gained knowledge of other professions’ work, but also developed a deeper understanding of their own professional role. Other research suggests that joint clinical simulation and facilitated debriefing sessions can improve confidence by providing collaborative care for a rapidly deteriorating patient and enhance communication by increasing providers’ ability to identify various professional roles, “close the loop on patient care,” and correct others in a constructive manner. Similar results have been found for medical and nurse anesthetist students in operating room simulations. At the resident level, the use of multidisciplinary rounds — in which doctors-in-training discuss diagnoses and patient care issues with case managers, nursing coordinators and others — has been shown to improve hospital performance on quality metrics for heart failure and pneumonia and decrease how long patients stay in the hospital.

While it is certainly true that the range of other professionals who are thought to work regularly with lawyers is smaller than those who work with physicians, surely that is a restatement of the problem, rather than an excuse for our failure to consider equivalent approaches.

More and more lawyers are working regularly and closely with social workers, yet how many law school clinical programs are teaching this skill?  In the defense world, investigators are critically important, but how many have the experience of learning with lawyers?  Similarly, I doubt that many incubators are yet including the integration of other professionals into the curriculum.

Indeed, what about the idea of co-training for lawyers and doctors?  Given the spread of medical legal partnerships, how many law schools include a class on working with doctors and other medical professionals, and how many medical schools expose their students to partnering with (rather than fearing) lawyers.

Similarly, I would hope that the trend to exploring expansion of “beyond lawyers” roles will speed and be sped by approaches such as these.  Indeed, one of the strengths of the Washington State Limited License Legal Technician model is the participation of the state’s law schools in the educational component.


Posted in Law Schools, Medical System Comparision, Public Defender, Systematic Change

While Study On Greater Happiness of Nonprofit Lawyers Raises Methodological Questions, It Still Has Useful Lessons

Its hard for some of us not to feel smug and self-satisfied when we see the following blog headline in the New York Times: Lawyers With Lowest Pay Report More Happiness.

And its hard not to come to the conclusion that the article implies that making the choice to be a nonprofit lawyer will lead to greater happiness.

Of the many rewards associated with becoming a lawyer — wealth, status, stimulating work — day-to-day happiness has never been high on the list. Perhaps, a new study suggests, that is because lawyers and law students are focusing on the wrong rewards.

Researchers who surveyed 6,200 lawyers about their jobs and health found that the factors most frequently associated with success in the legal field, such as high income or a partner-track job at a prestigious firm, had almost zero correlation with happiness and well-being. However, lawyers in public-service jobs who made the least money, like public defenders or Legal Aid attorneys, were most likely to report being happy.

Lawyers in public-service jobs also drank less alcohol than their higher-income peers. And, despite the large gap in affluence, the two groups reported about equal overall satisfaction with their lives.

Making partner, the ultimate gold ring at many firms, does not appear to pay off in greater happiness, either. Junior partners reported well-being that was identical to that of senior associates, who were paid 62 percent less, according to the study, which was published this week in the George Washington Law Review.

There are numerous theories to explain the phenomenon, like the kind of work people have to do, the hours, the fear, etc.  This is a new one for me:

And then there is the public hostility. “People just seem to hate lawyers,” Ms. Spataro said. “There are thousands of prominent websites for lawyer jokes. That’s just horrific.” Case in point: Many of the more than 3,000 comments on the CNN article about lawyer suicides applauded the trend. The comments are no longer visible in the link to the online article.

I assume that the final line of that paste is meant to discourage NYT readers from adding to the comments!

I think it is important to point out the methodological issue.  It may be that happier people go into lower income legal jobs because they have less to prove.– and they stay happier  Indeed, it would be interesting to do a happiness assessement before law school, during law school, and during career, although even that has methodological weaknesses.

More valid might be a randomized study in which students at a law school were offered counseling on how to align personal goals and values with career direction, and then do the follow up for all who were offered it (it is invalid to compare those who accepted the offer with those who rejected it.)  Even with the offer comparison study, you still run the risk of “contamination,” if the law students talk to each other.  To avoid this, I think, you would have to compare some schools at which all were offered the help, with similar others at which none were.

In the end, however, I think the study can be of help with career direction choice.  If the lower income lawyers are happier, you are more likely to be happy if you join them, if only because the main choice you make is life is who to be with.  You might as well choose happy people to make you happy.

So there are sometimes solutions without randomized studies.


Posted in Law Schools, Legal Aid, Research and Evalation, Vocation

DOJ ATJ Initiative Director Lisa Foster Keynotes at Equal Justice Conference

As Department of Justice Access to to Justice Director Foster pointed out at her keynote at the Equal Justice Conference, yesterday (see below for full text), there have been sixteen of these Conferences.  What she did not point out was that this is the first time that the Conference has been addressed by someone in her position.  So this alone represents an important step, and she rose to the challenge of saying something very different and helpful that lays the groundwork for different access world.

Frankly, we have become used to many such speeches at these kind of conferences, they start with a statement about how terrible things are, they recite the numbers, they tell us what wonderful work we do what heroes we are.

But this was a fundamentally different speech.  The pivot point was these words:

One could argue, based on those statistics that the movement for equal justice in America has not made much progress.  But those statistics are only half the story.

And then she went on to highlight the achievements — the Commissions, and,

In 1999, the internet was new, self-help centers were rare, and we still used Latin to refer to self-represented litigants.  Today, we have HotDocs, ProBono Net, Stateside Legal, the Self-Represented Litigants Network, Limited License Legal Technicians in Washington, Navigators in New York, and the Justice Corps in California.
And in 1999, although there was a Department of Justice, there was no sign on the door anywhere in the building that said this.

And she showed the office door sign slide.

She also spoke about the trends that we creating opportunities for change, starting specifically about the new and critical focus on inequality:

What’s different today is that everyone – and I mean everyone – is talking about it.  The President has called income inequality, “the defining challenge of our time.” In January, at a forum sponsored by Freedom Partners, an organization that describes itself as a chamber of commerce that promotes the benefits of free markets and a free society, Ted Cruz, Rand Paul and Marco Rubio all spoke about the problem of income inequality. Jeb Bush said that Americans are frustrated because they see only a few people riding “the economy’s up escalator.”
It’s not just the chattering classes that are worried about income inequality and the collateral damage it can cause.  Last year, the Pew Research Center conducted a survey in 54 countries about which of five dangers people considered to be the “greatest threat to the world.”  Many of the countries polled listed religious and ethnic hatred first.  Americans chose income inequality.

She is right that is a critical change, and while it presents many challenges to our community, they can be overcome.  Our polling data, and our political experience, particularly in Washington, tell us that an inequality message risks fragmenting the very carefully built up bi-partisan consensus about access to justice funding.  Yet, when the discussion about surely we can find a way to leverage this to greater rather then lesser bi-partisan support for this funding.  The key, at least initially, I suspect is in the next poin Lisa Foster made:

The second dynamic can be summarized in a word — and in pictures: Ferguson.  Ferguson – a city whose fiscal and judicial policies have trapped too many of its largely African-American residents in a cycle of poverty and despair.
The light that was shined on Ferguson – a light made a little brighter by the Report issued by the Justice Department’s Civil Rights Division – that light has illuminated many other dark corners of our country where the practice of incarcerating people simply because they can’t pay geometrically mounting fines and fees is rampant.  In California, and in many other states, the Legislature has permitted and in many instances required judges to suspend or revoke a person’s driver’s license if they have not paid fees, fines or child support, leading – because one has to drive to get to work to earn the money to pay off those fines and fees – to additional citations and ultimately arrest.

I think our message has to be — being poor is not a crime, and neither is being middle income.  Its not so much about lessening inequality, but about lessening both the causes of, and consequences of inequality — and it turns out that the legal system — even the accessibility of the legal system, are contributors to inequality, and exacerbators of the consequences.  Maybe that is a broader message that can drive change.  Indeed, Lisa’s third major point, the importance of criminal justice reform, highlighted this, with its implications for exclusion from the job market, and thus permanent exclusion from the main legal path out of poverty:

At a speech at the National Press Club last week, Senate Judiciary Committee Chairman Grassley said: “We’re seeing studies that show 32 percent of American adults have criminal records if arrest records are included.  If an employer uses the database for hiring purposes, the records can be inaccurate and old.  It’s unfair that an arrest – not resulting in a conviction – is included in a criminal background check.  And while there is a process by which people can contest their records being in the database, there are flaws in that process that need to be looked at and changed.”  In the same speech, Senator Grassley also called for counsel to be provided in civil asset forfeiture proceedings, the need to ensure that the states are truly meeting their constitutional obligations under Gideon, and the need to reform the juvenile justice system.  Bipartisanship can happen.

Indeed, a national expungement strategy should be a key part of our new law and anti-inequality agenda.

The speech also included detailed and inspiring examples of partnerships, and just as important, a very strong message about the importance of overcoming fragmentation with strategy at the national and local levels.

To make progress, we need a coordinated strategy.  The movement for equal justice is larger than our individual offices or programs.  We need to be aware of and work in concert with all of the many organizations that try to secure justice for, and improve the lives of our clients, including the courts, community health centers, social service agencies, and state and local government.
And that’s hard, because we are, truly by definition, fragmented.  We are often geographically fragmented – we are legal aid of mid-Florida and Western Michigan, and southeast Louisiana.
We are fragmented by issues – protection and advocacy services, housing, domestic violence and immigration.  We are fragmented by affiliation – we are LSC and non-LSC programs, we are law school clinics, pro bono programs, and court self-help centers.  It’s also hard because, let’s face it, we are for the most part overworked  – we have too much to do without trying to figure out what everyone else is doing and try to work together.
But we must.  An effective strategy can’t just be at the national level – although rest assured, we at ATJ, together with national organizations like NLADA, the ABA, Voices for Civil Justice and many others, are working on it.  Coordination – and critical thinking – has to start at the local and state level. We need to assess our community’s strengths and weaknesses and then coordinate and integrate services.  We can’t afford to be duplicative or competitive.

That is a very major challenge, and a critical one, building on the research work, in which DOJ has played such a critical role.  Hopefully the LAIR work, in which DOJ helps get other federal agencies interested in the access community, and integrating them into grant eligibility, and which Lisa also highlighted, can be a critical lever for this.

Equally important was the highlighting of the importance of research and evaluation, with frankly, Lisa issuing an implied warning:

This year, the White House Office of Management and Budget – or OMB – launched the budgeting process by telling every department that their budgets should advance “evidence-based policymaking by increasing access to administrative data, utilizing low-cost randomized trials, embedding evidence and evaluation into grant programs, and strengthening agencies’ capacity to build and use evidence.”

She followed up with examples of research into successful projects, and examples of how DOJ embeds the approach into its work.  This is unavoidable, and it is only a matter of time before we will be help accountable if we do not get with this program.

So, far more than most keynotes, this was a speech of optimism and challenge — optimism about how much we have done, and why this is such a moment of great opportunity, but also challenge because she implicitly reminded us of how much we have to stretch and change in order to take advantage of the moment and fulfill our obligations to our clients and the future.

When a speech covers so much, it takes time to fully sink in.  Hopefully by the end of the Conference we will have a sense of what more might need to be done to ensure that the lessons that Director Foster sought to teach are fully internalized into our work and our movement.

What more can I say, but “Congratulations on a true keynote.”

Well, I can paste in the photo of the summary written up in front of us during the speech.


Click below for full text.

Continue reading

Posted in Court Fees and Costs, Criminal Law, Dept. of Justice, Funding, Research and Evalation, Self-Help Services, Systematic Change

Ohio Supreme Court Task Force Recommends “Access to Justice Impact Statement” Requirement

The Ohio Supreme Court Task Force on Access to Justice has included among other great proposals, a new and exciting idea in its Recommendations, which would be to require an “Access to Justice Impact Statement” before any changes in the Ohio Rules of Court.


The Task Force recommends that the Supreme Court require that an “access to justice impact statement” be filed with any proposed amendment to the Ohio Rules of Court.


Ohio law currently provides that a fiscal analysis be submitted to the General Assembly for every proposed bill or resolution.34 This is because fiscal impact statements are critical to ensure that any legislator voting on a particular bill has sufficient information to evaluate the bill’s full impact; for example, whether adopting a bill might require defunding a competing program. Similarly, the Revised Code provides that the Ohio Judicial Conference may prepare a “judicial impact statement” for the General Assembly when a bill or resolution “appears to affect the revenues or expenditures of the courts of Ohio, to increase or decrease the workload or caseload of judges or members of their staffs, or to affect case disposition.” R.C. 105.911. Through these measures, the General Assembly ensures that its members have the fullest information available on the full impact of a bill before they vote on its passage.

Similarly, the Supreme Court should require that the Access to Justice Director prepare an “access to justice” impact statement for any proposed change to the Ohio Rules of Courts. In the same manner that the legislative budget office may seek information from any department, institution, board, commission, authority or other instrumentality or officer of the state, county or other governmental entity,so too may the Access to Justice Director request information from any state or local governmental entity, court, nonprofit entity, for-profit entity or any proponent of a change to the Ohio Rules of Courts. The “access to justice” impact statement shall address the likely number of Ohioans impacted by the proposed change; whether the change will increase or decrease access to Ohio’s courts for low-income Ohioans; what impact, if any, the proposed change will have on Ohio’s minority populations’ access to the courts; and, what impact, if any, the proposed change will have on the ability of Ohioans with limited English proficiency to access justice. In this way, the Court and its boards and commissions will have the fullest information possible as to the effect of a proposed rule change prior to adopting or rejecting it.
(Bold added)

This is truely an excellent idea.  Every state should do this.

I would add the suggestion that all Court Committees should have a member assigned to carry the access perspective into the deliberations of the Committee.

I would also hope that Ohio would develop, and other states would adopt, a template for such an impact statement and for the process that would guide the preparation of the statement. I would offer that national folks would be very happy to help with the brainstorming of that template.

Many of us wold love to see the Federal government adopt a similar process for changes in Federal agency processes, and for changes in state agency processes funded by the Feds. This has been suggested in a prior blog about the power of the phone and the pen.

There have been prior similar suggestions in Canada (at p 28), and Australia (at p. 6).






Posted in Access to Justice Boards, Court Management, LEP

Univ of DC Law School Encourages Student Engagement with Baltimore Protests and “Legal Observer and Other Assistance” / “Legal Support”

Here, as reported by the Washington Post, is the letter from the Dean to the student body.  For those who worry about how this is organized, I bold the relevant paragraph and some other text, which includes the carefully limited description of the role.

Dear Students,

We have been watching the news from Baltimore and know that it is having a profound effect on many in the Law School community.   As John Lewis said earlier this week, community/police relations is the civil rights issue of this time.  Across this Nation, for nearly a year, the concerns of communities of color about persistent and long standing police abuse, have been reflected in demonstrations and public debate.   The energy and commitment of those involved in the movement is inspiring and we want the Law School to be part of it.

The situation in Baltimore is of particular concern.  Not only is Baltimore just 30 miles up the road, but many members of our community have roots in the City.  It is important that we not ignore what is happening to our neighbors.   Several students have come to the Deans with a request that they be permitted to defer an exam so that they can provide legal observer and other assistance to those who have taken to the streets to exercise their First Amendment rights and to address these serious issues.

We would like to support this activism.   To that end, if any student wishes to participate in legal support for the demonstrations, we will defer one exam until May 11.   To do so, you need to connect with one of the legal assistance organizations, develop a plan for the assistance you intend to provide and get this information to Dean Steward before your exam.   If you are having difficulty in identifying a group to work with, please let me know and we can assist you.  In addition, because these issues affect everyone at the Law School, we would be pleased to support a student organized teach-in.   A community event that brings us together around these issues and promotes mutual support is important during these challenging times.

The police accountability movement needs and will continue to need the best lawyers that we can train.   It is our aspiration that you become the future of the legal support for the most important cases of the next generation.  It is critical that, while we pay attention to what is going on today, that we not lose sight of the essential role you will play once you pass the bar.  We need to invest in you to be prepared to play that role.   That is our shared commitment.


Posted in Criminal Law, Law Schools

Broader Lessons From NYT Highlighted Brennan Center Book Featuring Presidential Candidates (and others) on Criminal Justice Reform

The Times rightly highlights the astonishing fact of how many of the presidential candidates, regardless of party, agree on the need for often similar reforms of the criminal justice system, in this new book released today by the Brennan Center.  As the Times puts it:

 The last time a Clinton and a Bush ran for president, the country was awash in crime and the two parties were competing to show who could be tougher on murderers, rapists and drug dealers. Sentences were lengthened and new prisons sprouted up across the country.

But more than two decades later, declared and presumed candidates for president are competing over how to reverse what they see as the policy excesses of the 1990s and the mass incarceration that has followed. Democrats and Republicans alike are putting forth ideas to reduce the prison population and rethink a system that has locked up a generation of young men, particularly African-Americans.

Former Secretary of State Hillary Rodham Clinton, Senator Ted Cruz and Senator Rand Paul want to ease mandatory minimum sentences. Gov. Chris Christie wants to release nonviolent offenders pending trial without bail. Gov. Scott Walker, former Gov. Rick Perry and former Senator James Webb want to expand drug treatment as an alternative to prison. Senator Marco Rubio wants to make it harder to convict federal defendants without proving intent.

Online, here, the Times also summarizes the policy suggestions.

Some thoughts.  First, this really is an astonishing transformation.  Since the Watts riots, fear of crime has been a driving political force, particularly exploited by one party.  Until very recently, the response to Ferguson, others, and now Baltimore, would be to subtly suggest that all who fail to support “our” police are themselves a threat.  While there are many reasons, from the fall in crime, to the massive cost of incarceration, to the use of video cameras, to having a black President, to right wing donors interest in change (thank you Citizens United!), the old songs do just not play anymore.

Secondly, I found it hard not to feel that the news is not in the suggestions, but rather in who is making them. For those involved in the justice system, there are unlikely to be many new ideas in the book (and why, please, do politicians spend all their time bragging about what they have achieved, rather than trying to make suggestions for the future?)

Thirdly, that there is almost general consensus about general approaches means that this might be a time for broader debate about a new generation of changes that go beyond the tried but not fully replicated ones.  Could we find better ways to support neighborhoods and neighborhood networks that try to help when kids get into trouble?  What can we do to make the justice system (all of it) less of an enemy?

Fourthly, why do we not have any book like this on the civil justice system.  If anything is sure, it is the chasm that often divides communities and the legal system is not just about cops and criminal courts, but also about all the quasi-criminal civil enforcement systems, about which most citizens do not make complex jurisdictional distinctions.  Obviously, we do not yet have the attention from politicians to the civil justice system, but to say that is just to restate the problem.  It may be that we have been reluctant to engage the political class for fear of politicizing the issue.  But what has happened in the criminal justice area would suggest that engagement does not necessarily lead to politicization, rather it may transcend it.




Posted in Access to Justice Generally, Criminal Law, Funding

Illinois “Safe Habor” Policy for SRL assistance Moves the Ball Foward

There has long been debate about whether listing what self-represented litigant assistance policies are permitted when performed by court staff is useful or harmful.  The argument for listing them is that it makes it much easier for staff to perform them without worry.  The argument against is that a listing may be interpreted as exclusive, and be used as an excuse to turn down experimentation and innovation.

I think  the argument in favor of the full listing approach is enhanced by the just released Illinois Supreme Court Order ( Letter here, Illinois Order here) which attempts a comprehensive approach including such a list, as well as one of prohibited activities and a discussion of confidentiality and ethical obligations.  Congratulations to the Court and the ATJ Commission.

The listing of Illinois permitted activities is here:

(d) Permitted Services. To assist court patrons, circuit clerks, court staff, law librarians, and court volunteers—acting in a non-lawyer capacity on behalf of the court—may, as resources and expertise permit:

(1)  Provide legal information about court rules, court terminology andcourt procedures, but not limited to providing information regarding; requirements for service, filing, scheduling hearings and compliance with local procedure;

(2)  Inform court patrons of legal resources and referrals if available,, including but not limited to:

Pro bono legal services;

Low-cost legal services;

Limited scope legal services;

Legal aid programs and hotlines;

Law and public libraries;

Non-profit alternative dispute resolution services;

Lawyer referral services;

Internet-based resources;

Court-sponsored or -affiliated educational classes, including, but not

limited to, parenting education and traffic safety classes and alternative

dispute resolution services;

Units or departments of government; or

Domestic violence resources.

(3)  Encourage self-represented litigants to obtain legal advice from a lawyer;

(4)  Provide information about security protocols at the courthouse and directions

around the courthouse, including, but not limited to, photocopier and telephone

locations, children’s waiting room locations and other courthouse offices;

(5)  Offer educational classes and informational materials;

(6)  Assist court patrons in identifying approved forms and related instructions based

on the court patron’s description of what he or she wants to request from the court, including but not limited to, providing approved forms for the waiver of filing fees. When necessary, explain the nature of the information required to fill out the approved forms. Where no approved form exists to accomplish the court patron’s request, inform the litigant of that fact and direct him or her to other legal resources;

(7)  Record verbatim information provided by the self-represented litigant on approved forms if that person is unable to complete the forms due to disability or literacy barriers;

(8)  Review finished forms to determine whether forms are complete, including checking for signature, notarization, correct county name and case number;

(9)  Provide assistance to litigants pursuing self-guided research;

(10)  Provide docket information, including but not limited to:

Stating whether an order has been issued

Explaining how to get a copy if one was not provided

Reading the order to the individual if requested

Providing instructions about how to access such information;

(11)  Inform court patrons of the process for requesting a foreign language or sign language interpreter;

(12)  At the direction of the court, review documents for completeness prior to hearing;

(13)  Provide a court patron with access to a case file that has not been restricted by statute, rule or order, or instructions about how to obtain such access;

(14)  Provide the same services and information to all parties to an action, as requested;

(15)  Provide services based on the assumption that the information provided by the court patron is accurate and complete;

(16)  Provide other services consistent with the intent of this policy.

While I suspect that I would expand this list, to include, for example, assisting to litigant to obtain information about related cases from other courts, and reviewing the completeness of the form even without “direction of the court,” and providing information and explanation about how to comply with, an obtain compliance with, a court’s order, overall I like it.  I think  I would also like an expanded list of how people can provide additional assistance in explaining what information a form actually seeks, without taking over from the litigant.  Often instructions are inadequate, and an explanation could be completely neutral.

It is reassuring that items 14, and 15 underline how to make sure that information is neutrally provided, and that item 16 includes a broad expansion of the “safe harbor” to “other services consistent with the intent of this policy,” which I would interpret as to provide as much assistance with access, provided that it is neither non-neutral, or runs the risk of being perceived as non neutral.  Indeed, the purposes section of the order says that:

The purpose of this policy is to provide guidance to circuit clerks, court staff, law librarians, and court volunteers acting in a non-lawyer capacity as to what services may and may not be offered to assist court patrons to achieve fair and efficient resolution of their cases. (Bold added.)

I would love for anyone to use the comments section to add more suggestions for additions to the permitted list.

I would conclude that the one thing we know for sure is that with experience we are learning more and more about how broader assistance can be given in a neutral manner, and that often services are initially perceived as non-neutral only because they have not previously been provided.  Perhaps the way to test whether a service is neutral is not to ask if it is, but rather to ask how it might be provided in a neutral manner, and then see if that is practical.

Posted in Court Management, Self-Help Services | 1 Comment