“The Doctor Will See All 8 of You Now” — But What About the Lawyer?

A recent fascinating New York Times article and blog discusses experiments in which doctors provide group rather than individual consultations to pregnant women. The goal, other than efficiency, is to help create supportive communities.

Group visits are useful for any condition in which the patient’s participation matters. That’s nearly every condition, but it’s especially important for chronic diseases such as diabetes. In a two-hour meeting, a doctor can see (and bill for) the same eight patients she would see individually. But instead of a rushed 15-minute consultation, patients get two hours to ask the doctor questions. And most important, they get the benefits of regular meetings with other patients going through the same thing.

The concept, which includes extensive restructuring the prenatal check-up process,  is supported by randomized study.

 A randomized controlled trial of more than 1,000 mothers found that participants were 33 percent less likely to have a premature birth than women in traditional prenatal care. The effect was even greater for black women – a 41 percent drop. This is important as more than 17 percent of births to African-American mothers are pre-term — a rate 50 percent higher than that of white women. And African-American women are four times more likely than white women to delivery extremely prematurely — at 20 to 28 weeks. (Some of the reason is demographics, but much of it is a mystery; a married, college-educated black woman is more likely to have a preterm delivery than a white, unmarried high-school dropout, and no one knows why.) Women in the Centering program also had fewer C-sections and breast-fed more. They had more knowledge about their pregnancies, were more satisfied with their care and felt better prepared.

So, should we, and could we try the same thing in law?  It would seem to make sense that  building a support group and sharing knowledge would be a good thing, and there is a long history of legal aid clinics and now court clinics in which training is done in a group context, but is limited to informational assistance.

Up till now, whenever I have wondered about the possibility of testing group consultations, I have come to a dead end because I felt that there were would be no privilege when several people were given a group consultation.

But, maybe I have been cutting off the thought too fast.  Maybe even under existing law, a group consultation process could be designed to provide the protection of the privilege.  If all the participants agreed to keep all communications secret, and if all agreed that the participation of the group was necessary for the mode of consultation wanted and needed, then perhaps communications might be protected.

In any event, perhaps an appropriate regulatory body could be persuaded issue a document providing a safe harbor for a pilot experiment for such an understanding of the privilege.

People who had been in the same group would be able to support themselves, and perhaps even find a role in the courtroom.

It is surely worth a try.

P.S.  Bonnie Hough adds:

Interestingly, this is exactly what court based self help centers do in workshops.  They provide group settings, answer questions, diagnose problems, etc.  The Los Angeles court self help centers have found that people are much more apt to follow up and finish their divorce if they have participated in a workshop setting.  I was really impressed by the camaraderie of the group that I observed earlier this year – they were very supportive of each other, gave each other legal tips and were all going to go out to lunch to celebrate.  They wanted the Justicecorps student who was their teacher to be their club president.  The self-help center at the central courthouse in Los Angeles runs over 100 workshops per month and serves more than 200 people per day with very high quality services using workshops where much of the paperwork is completed using Hotdocs programs so that the time in the workshop is focused on addressing legal issues rather than “put your name here, address there …)   The SHARP program serves Butte, Glenn and now Lake Counties – all rural counties in California.  Many of their services are provided by videoconferenced workshops with an attorney in one location and litigants at different self-help centers where they had a paralegal making sure that they were following along and asking any questions.  The Bet Tzedek program in Los Angeles is offering workshops to help parents of developmentally disabled persons get limited conservatorships when their children turn 18.  They have found that it is a really efficient way to provide services, that they are able to answer many questions and that the parents share all kinds of resources with each other.  It helps to normalize the experience so that people don’t feel as if they are in it by themselves.  Obviously, there will be some people that need other levels of service depending on their legal issue or ability to follow along.  But the proliferation of workshops in languages in addition to English suggests that language capacity should not be a barrier.  This can be a really efficient way to provide services in other languages.


About richardzorza

I am deeply involved in access to justice and the patient voice movement.
This entry was posted in Attorney-Client, Medical System Comparision, Systematic Change. Bookmark the permalink.

4 Responses to “The Doctor Will See All 8 of You Now” — But What About the Lawyer?

  1. Jim Greiner says:

    Richard, this is an idea that is long, long overdue in law. My view is that the privilege issues can be managed, much as you discuss. But as is ordinarily the case, we cannot adapt this idea without thinking and testing. The RCT that supports the medical intervention was for pregnant mothers. I speculate that there are at least five features of this setting that allowed the group treatment to work so well: (1) all participants shared the same fundamental medical condition (pregnancy); (2) most participants were at roughly the same stage in their condition (less than 24 weeks); (3) participants were close in age (they were all 18-24), making it easy for them to relate to one another; (4) most (over 80%) were African-American; and (5) participants were identical in gender (I’ll let you guess which one). Were we to try this in law, the best way to go might be to group participants by type and stage of legal problem, stage of that legal problem’s development, age, race, and gender. That might be a tad hard to do in some locations (perhaps Allison Paul can weigh in on whether this could work in Montana) and for certain kinds of legal issues (child custody) could be tough. But just think if the potential power of this kind of arrangement. in a big city. I’m thinking about New York Housing Court’s 300,000 summary eviction actions per year. Or simple divorces in most large MSAs. Even putting aside the potential for legal aid for those who can afford to pay nothing, surely this is a profit center for a small law firm or a sole practitioner that could increase access to civil justice for low income clients?

    And now, a big question: would we in law be willing to cluster our clients by race, gender, and age? Would it be legal to do so? Ethical? And wouldn’t the legal and ethical question be informed by knowledge about whether this idea worked? Hmm. Imagine that. The medical intervention was tested via a randomized trial. Hmm.

    • Zoe Cronin says:

      This model for women in pregnancy is being used all over Boston, at least. To clarify how it’s being used by medical clinics, the participants (at least at Harvard Vanguard in Massachusetts) are not all the same age or ethnic background. They are just women who are within a few weeks of each other in terms of due date for their pregnancy. One of the benefits of the group is meeting future moms who are of every background — some who are 1st time moms, some who aren’t, some who are older, some from other countries, etc.

      I think it would be a mistake to ask our clients to group by age/ethnicity, as that would limit the type of support and mutual assistance we are trying to encourage. I think if we tried to deliver legal assistance in this way, we would see not only support/encouragement but would also find that people began to try to create political change and start to take action on the underlying factors that led to their current situation. If people come from a variety of life experiences and backgrounds, they will have more to draw upon in problem solving.

      I think these groups would/do work well in an eviction context.

  2. Ainsile Embree says:

    Very interesting. But it seems to me one wants an answer to one particular question from a lawyer and not likely to feel that one is sharing a common experience, indeed a universal one, as is the
    case with a pregnancy. A good subject for a discussion group.

  3. Zoe Cronin says:

    Thank you for writing this post! I have been thinking about the same thing, being a legal aid lawyer for a dozen years and having recently had a baby and been offered this type of group prenatal support. I think the best community lawyering follows this model, for instance, the outstanding work of City Life/Vida Urbana and its sibling organizations across New England, where organizers and lawyers help people in a group context with their individual cases and members gain strength from each other.

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