257699B_IJCLE_July_09 A Medical/Legal Teaching and Assessment Collaboration on Domestic Violence 61 A Medical/Legal Teaching and Assessment Collaboration on Domestic Violence: Assessment Using Standardized Patients/Standardized Clients Antoinette Sedillo López, J.D.1, Cameron Crandall, M.D.2, Gabriel Campos J.D., Diane Rimple, M.D., Mary Neidhart B.S.N, Teresita McCarty, M.D., Lou Clark MFA, Steve McLaughlin M.D., Carrie Martell M.A. 1 J.D. UCLA, Professor of Law and Associate Dean for Clinical Affairs, University of New Mexico School of Law. The authors would like to thank the University of New Mexico School of Medicine, Scholarship in Education Allocations Committee for a grant to fund the use of the standardized patients/clients for the pre- test and the post test. The support is very much appreciated. P. Maclean Zehler, BA assisted in training the standardized patients and clients. Law Professor April Land assisted with the role development of the standardized client. Nancy Sinclair, RN, MBA assisted with the planning and development of the project. We also thank the law students and emergency room residents who participated in this project. 2 Associate Professor and Vice Chair for Research, Emergency Medicine, University of New Mexico School of Medicine. 62 International Journal of Clinical Legal Education July 2009 Introduction Assessment of skills is an important, emerging topic in law school education. Two recent and influential books, Educating Lawyers3 published by the Carnegie Foundation and Best Practices in Legal Education,4 published by the Clinical Legal Education Association have both suggested dramatic reform of legal education. Among other reforms, these studies urge law schools to use “outcome-based” assessments, i.e., using learning objectives 5 and assessing knowledge and skills in standardized situations based on specific criteria, rather than simply comparing students’ performances to each other. 6 According to Best Practices, England, Wales, Scotland and Australia are transitioning to outcome based legal education.7 The American Bar Association (ABA) Council on Legal Education has formed a special committee to study law school outcome measures in connection with its role as the accrediting agency in the United States.8 The Committee report specifically mentions the outcome based accreditation standards used in medical education that include objective structured clinical examinations (OSCE).9 The OSCEs use standardized patients (SPs) to simulate medical problems in order to teach and to assess learners’ clinical skills in simulated, “real world” situations. Since the 1970’s medical schools in the United States have used standardized patients to teach and assess patient evaluation skills. These assessments provide feedback to both learners and educational programs. Learners use feedback to focus their learning efforts and programs use feedback to guide curricular changes.10 In 2004, the National Board of Medical Examiners incorporated standardized patient assessments into physician licensing requirements.11 The use of standardized clients in law schools has been much more limited.12 3 William M. Sullivan, Anne Colby, Judith Welch Wegner, Lloyd Bond & Lee S. Shulman, Educating Lawyers: Preparation for the Profession of Law (2007) (hereinafter Educating Lawyers or the Carnegie Report). 4 Roy Stuckey and others, Best Practices for Legal Education: A Vision and a Road Map (2007) (hereinafter Best Practices). Mary Lynch and Albany Law School have created a blog: “1) to create a useful web-based source of information on current reforms in legal education arising from the publication of Roy Stuckey’s Best Practices for Legal Education and the Carnegie Foundation’s Educating Lawyers; and 2) to create a place where those interested in the future of legal education can freely exchange ideas, concerns, and opinions.” http://bestpracticeslegaled .albanylawblogs. org/ (visited 9/14/08). 5 Roy Stuckey, Teaching with Purpose: Defining and Achieving Outcomes in Clinical Courses, 13 Clinical L. Rev. 807 (2007). 6 Antoinette Sedillo Lopez, Leading Change In Legal Education – Educating Lawyers and Best Practices: Good News for Diversity, 31 Seattle L. Rev. (forthcoming). Greg S. Munro, How Do We Know if We are Achieving Our Goals?: Strategies for Assessing the Outcome of Curricular Innovation, 1 J. Ass’n L. Writing Directors 229 (2002). 7 Best Practices, op. cit at 45. See also, Roy Stuckey, The Evolution of Legal Education in the United States and the United Kingdom: How one system became more faculty-oriented while the other became more consumer- oriented, (2004) IJCLE 101. 8 The committee is chaired by Randy Hertz. A copy of the committee report is posted on the ABA web site. American Bar Association, Section of Legal Education and Admissions to the Bar, Report of the Outcome Measures Committee, http://www.abanet.org/legaled/ committees/subcomm/Outcome%20Measures%20Fin al%20Report.pdf 9 Id. 10 Greg S. Munro, How Do We Know if We are Achieving Our Goals?: Strategies for Assessing the Outcome of Curricular Innovation, 1 J. Ass’n L. Writing Directors 229 (2002). 11 Howard S. Barrows, An Overview of the Uses of Standardizd Patients for Teaching and Evaluating Clinical Skills, 68 Acad. Med. 443 (1993). 12 Professor Grosberg developed a pilot project to evaluate their effectiveness at New York Law School. See Lawrence M. Grosberg, Medical Education Again Provides a Model for Law Schools: The Standardized Patient Becomes the Standardized Client, 51 J. Legal Educ. 212 (2001). (noting the uniqueness of the model A Medical/Legal Teaching and Assessment Collaboration on Domestic Violence 63 The social problem of domestic violence (DV) has created a need for increased professional awareness and expertise.13 Two of the key systems that identify and offer assistance to victims of DV include the legal system (e.g., judges, law enforcement, family law lawyers, legal aid) and the medical system (e.g., first responders, physicians and nurses, particularly in emergency departments and primary care clinics, dentists). As in most professional schools, the DV curricula in our law and medical schools are underdeveloped and they were not integrated. In the summer, 2007 a public interest lawyer (GC) and a faculty member (CC) from the Department of Emergency Medicine at the University of New Mexico approached the Law School about collaborating on a joint DV training program. Professor Sedillo Lopez teaches family law, and she was very interested in leveraging resources and in new approaches to addressing DV.14 Thus, the DV Medical/Legal Collaboration was born. Educational Foundation Learning theory indicates students learn best when they are engaged, when they have an immediate “need to know”; when learning is active; 15 and, when they receive timely, constructive feedback.16 Problem based learning can help teachers identify students’ misconceptions and can help students build on their prior knowledge.17 A goal was to use best practices in education to boost knowledge about DV and interviewing and counseling skills in DV among law students and medical 16 (12 cont) for legal education); Karen Barton, Clark Cunningham, Gregory Todd Jones & Paul Maharg, Valuing What Clients Think: Standardized Clients and the Assessment of Communicative Competence, 13 Clinical L. Rev. 1 (2006) (measuring effectiveness of use of standardized client in a Scottish law school); Paul Maharg, Transforming Legal Education: Learning and Teaching the Law in the Early 21st Century (2007) (describing vision for reform of legal education in Scotland, including the unique use of standardized client). 13 Lenora Olson, Carolyn L. Anctil, Fullerton, Judith Brillman, Justin Arbuckle, David Sklar. Increasing emergency physician recognition of domestic violence. 27(6): Ann Emerg. Med. 741 (1996) Justin Arbuckle, Lenora Olson, Mike Howard, Judith Brillman, Carolyn Anctil, David Sklar, Safe at Home? Domestic Violence and other homicides about women in New Mexico. Ann. Emerg. Med. 1996 Feb.27;(2): 210–5. Jennifer Brokaw, Lynne Fullerton-Gleason Lenora Olson L, Cameron Crandall, Steven McLaughlin S, David Sklar D. Health status and intimate partner violence: a cross-sectional study. 31 Ann Emerg Med. 8 (2002). 14 Although Family Law is taught at the University of New Mexico (UNM) School of Law as a substantive course and not a clinical course, this project was an example of using clinical methodology in a traditional substantive course. The University of New Mexico requires all law students to complete a six credit required client-service clinical course. See Michael Norwood, Requiring a Live Client, In-House Clinical Course: A Report on the University of New Mexico Law School Experience, 19 N.M. L. Rev. 265 (1989) (analyzing the structure and history of the UNM clinical program); Antoinette Sedillo Lopez, Learning Through Service in a Clinical Setting: The Effect of Specialization on Social Justice and Skills Training, 7 Clinical L. Rev. 307 (2001) (describing UNM’s required clinical law program). 15 Julie Macfarlane and John Manwaring, Using Problem- Based Learning to Teach First Year Contracts, 16 J. Professional L. Educ. 271 (1998); Susan Bryant & Elliot Millstein, Rounds: Signature Pedagogy for Clinical Legal Education? 14 Clinical L. Rev. 195(2007); Myron Moskovitz, Beyond the Case Method, It’s Time to Teach with Problems, 42 J. L. Educ. 241 (1992). 16 Frank S. Bloch, The Andragogical Basis of Clinical Legal Education, 35 Vand. L. Rev. 321 (1982); Amy Zielgler, Developing a System of Evaluation in Clinical Legal Teaching, 42 J. Legal Educ. 575 (1992). 17 Antoinette Sedillo Lopez, Making and Breaking Habits: Teaching (and Learning) Cultural Context, Self Awareness and Intercultural Communication in a Client Service Clinic, 28 Wash. U. J. L. & Pol’y (forthcoming); Peter Toll Hoffman, The Stages of the Clinical Supervisory Relationship, 4 Antioch L. J. 301 (1986); Beryl Blaustone, Teaching Law Students to Self- Critique and to Develop Critical Clinical Self Awareness in Performance, 13 Clinical L. Rev. 1213 (2006) (describing how to use feedback sessions to teach students to self-critique and emphasizing the value of feedback); Ann Shalleck, Clinical Contexts: Theory and Practice in Law and Supervision, 21 N.Y. 21 N.Y.U. Rev. L.& Soc. Change 109, 146–49 (1993–94); Richard K. Neumann, A Preliminary Inquiry into the Art of Critique, 40 Hastings L.J. 725 (1989) (discussing methods of critiquing simulation). residents.18 Best Practices includes the use of formative assessment, which is ungraded feedback about students’ performance.19 It is a valuable way to help students learn, because it gives students interim feedback so that they can improve their skills. Students can reflect on the formative assessment to enhance their learning. Particularly in the area of domestic violence, students presented with situations to address can become more aware of their attitudes toward the issues and the clients. 20 Focusing on effective communication skills can help students develop the ability to establish rapport and demonstrate empathy.21 Giving students feedback on their performance in a realistic environment can help them improve their performance.22 The problems were used in a pre-test and a post-test to evaluate the effectiveness of our training sessions. 23 The paper will discuss the law-medicine collaboration process in the development and use of a standardized patient/ client as part of training and assessment about domestic violence. Method The Collaboration In order to implement the educational principles described above, a collaborative team was formed. Team members included emergency medicine professors from the medical school, formative assessment specialists, SP training specialists, a community attorney who specializes in domestic violence, professors and a teaching assistant from the law school. The team members met to design the teaching (curricular intervention) and assessment plan (pre- and post-test). Selected participant learners were 18 emergency medicine residents in their second and third post graduate year and 26 second and third year law students enrolled in a family law course. Once the learning objectives were identified for each group (Table 1), four simulated cases were created with focus on health issues and legal concerns related to DV. SPs (trained actors or community members) portrayed the case, first as a medical patient and then as a legal client. Learners interviewed the patient/client in order to evaluate the presenting problem(s) and make recommendations consistent with best professional practice. Learners interacted with two cases prior to the curricular interventions and another two cases afterward. Each of the four cases had two dimensions. Each case began with the SP presenting to the emergency department with a medical issue related to domestic violence. In half of the cases, the relationship of the medical complaint to domestic violence was overt24; in the other half, the relationship was 18 Susan M. Williams, Putting Case-Based Instruction Into Context: Examples from Legal and Medical Education, 2 (4) J. Learning Sciences 367 (1992) . 19 Best Practices at 191. 20 Emma Williamson, Domestic Violence and Health (2000). 21 Antoinette Sedillo Lopez, Making and Breaking Habits: Teaching (and Learning) Cultural Context, Self Awareness and Intercultural Communication in a Client Service Clinic, 28 Wash. U. J. L. & Pol’y (forthcoming). 22 Beryl Blaustone, Teaching Law Students to Self- Critique and to Develop Critical Clinical Self Awareness in Performance, 13 Clinical L. Rev. 1213 (2006) (describing how to use feedback sessions to teach students to self-critique). 23 An abstract summarizing the results was published. Cameron Crandall, Antoinette Sedillo Lopez, Steve McLaughlin, Diane Rimple, Gabriel Campos, Teresita McCarty, Assessment of a Cross-Disciplinary Domestic Violence Training for Emergency Medicine Residents and Law Students, 15 Academic Emergency Medicine Issue S1 p S225-S225 Published Online: May 1 2008 12:00AM DOI: 10.1111/j.1553-2712.2008.00130_4.x. 24 An overt relationship involved injury that was caused by the domestic violence. 64 International Journal of Clinical Legal Education July 2009 A Medical/Legal Teaching and Assessment Collaboration on Domestic Violence 65 more covert25. Following the medical assessment, the patient was then “referred” to a family law student for legal counseling.26 The individuals who portrayed the patients/clients had ten hours of training per case led by training specialists and case content experts. Although there was more than one SP who portrayed a role in the case, the training methodology helped assure a higher level of consistency and standardization within and across portrayals. The SPs were also trained to score the learner’s interview skills in a consistent and reliable manner using team developed, case specific checklists.27 The learners’ communication skills were assessed on a behaviorally anchored global rating scale developed at the UNM School of Medicine. The medical interview lasted 15 minutes and the law student interview lasted 30 minutes. Interviews were videotaped so the learners could watch and learn from observing themselves in action. Learners documented their interview as they would for the medical record or the client intake memo respectively. Finally, learners completed surveys that elicited information about their attitudes toward DV, the learning methods used in this intervention, and perceived preparedness and competence for working with DV victims. The interview and communication skills scores were calculated and provided to the learners, as was access to a video recording of their interview. The Curricular Intervention The learners received lectures from DV experts including a legal aid attorney, emergency medicine physicians, a tribal attorney, and a domestic violence hearing commissioner. Academic and community resource materials were distributed, a first person account was shared, and there was a session for interdisciplinary case discussion between the residents and the law students. Case Scenarios The following are brief synopses of the case scenarios prepared by the team. Case 1 Medical: Gabriela, a 30 year old woman, presents to the Emergency Department because of cramping and vaginal bleeding. Her live in boyfriend kicked her in the abdomen yesterday. The cramping and bleeding began after the assault. Legal: Gabriela and John have been together for about 1 year and for the past 6 months they have had an increasingly violent relationship. Gabriela was born in Mexico and she is not a US citizen. John has become more controlling and often threatens to “deport” her while keeping their child. Case 2 Medical: Maggie, 35 years old, presents to the Emergency Department because of a headache. She is worried about her blood pressure. Maggie is recently homeless and cannot afford her blood pressure medication. She and her two children are living in her car in a parking lot. 25 A covert relationship involved a tenuous relationship between the reason for the emergency room visit and the incidence of domestic violence. 26 This is similar to what would happen as a part of the Clinical Law Program’s Med/Law Alliance started by Professor Mike Norwood. http://bestpracticeslegaled .albanylawblogs.org/2008/02/19/learning-from- medical-school%E2%80%94resident-and-law-student- interaction/ See also, J. Michael Norwood and Alan Paterson, Problem Solving in a Multidisciplinary Environment: Must Ethics get in the Way of Holistic Service, 9 Clinical L. Rev. 337 (2002). 27 A sample from the checklists is in the appendix. Legal: Maggie divorced her husband, about 6 months ago. There was a history of physical and emotional abuse. He is supposed to pay $550 per month in child support but has not paid for several months. They have joint custody. Maggie is concerned about finances, housing, John’s behavior and is worried about losing the kids. While she has not wanted to go to a shelter in previous encounters, with professionals, at this time, she is ready. Case 3 Medical: Lucinda, 30 years old, presents to the Emergency Department complaining of a sore throat. She wears a scarf around her neck to hide strangulation impression marks sustained during an argument with her fiancé (Glen). She was encouraged to go to the ED by her sister. Legal: Lucinda and Glen have been together for about 2 years. For the past 6 months, they have had an increasingly violent relationship. She works as an accountant. She is referred to the legal clinic to explore her legal options. She is resistant to an order of protection. She talks about the planning that has gone into her upcoming wedding. Case 4 Medical: Charlene, a 40 year old American Indian woman, presents to the Emergency Department because her blood sugar has been high. The insulin she uses to control her diabetes went “bad” when her electricity was turned off because she could not afford to pay her utility bill. She is living in her apartment her two teenage children. She has mild thirst and frequent urination and no other symptoms of her elevated blood sugar. Legal: Charlene legally separated from her husband, Mike about 6 months ago. Because there was physical and emotional abuse, she obtained a legal tribal order of protection. Charlene wants to know if the protection order is good off the tribal reservation. Although Charlene has custody of the two kids, Mike is not paying the mandated child support. Mike has been harassing Charlene for several weeks and she is concerned about money, housing, and safety. Results Eighteen (78%) emergency medicine residents and 26 (93%) family law students completed both the pre- and post-test portions of the study. Pre-intervention, emergency medicine residents scored 63% (8% standard deviation (SD)) on communication skills and gathered 71% (13%) of the pre- specified critical historical elements. Law students scored 62% (8%) on communication skills and gathered 66% (8%) of critical historical elements. Emergency medicine residents (64% (6%)) and family law students (63% (6%)) showed similar post-intervention communication skills scores. Both residents (77% (10%), improvement 6%, p = 0.13) and law students (71% (14%), improvement 8%, p = .15) showed modest but non-significant improvement in critical historical element gathering. While there were no statistically significant changes in communication skills or critical history gathering by either the residents or the law students, post assessment surveys indicated the experience provided opportunities to learn new information and skills and review prior knowledge; learners indicated they felt more confident, most indicated an interest in learning more about DV. Law students indicated that they would have liked to have general interviewing skills training prior to the pre-test, the first two SP cases, so that they would have been more prepared 66 International Journal of Clinical Legal Education July 2009 A Medical/Legal Teaching and Assessment Collaboration on Domestic Violence 67 to interact with clients. In contrast, the emergency medicine residents have had substantial practice with general interviewing skills in their training program and in medical school. In addition, OSCE/SP interviews are relatively frequently used amongst medical trainees. The law students were unfamiliar with the concept of a formative pre-test and did not trust that the pretest was really formative (not graded). Despite having an orientation to the SP interview and viewing a videotape of an example interview, law students did not like feeling “un-prepared” for the pre-test. Following the pre-test for the law students, the assessment truly demonstrated the powerful effect of formative techniques, as their level of interest in the material and their engagement of the material after the pre-test was very high. Additionally, it was the law professor’s impression on reviewing of a sample of the video-tapes that the law students demonstrated more confidence and empathy in the post test. Family law student comments about the experience were generally quite positive in the course evaluations. Finally, performance on the traditional law school exam was very good. All but one student identified the domestic violence issue on the exam and the discussion of the issue was quite comprehensive. Following the intervention, the emergency medicine faculty noted an increased awareness of legal issues among the emergency medicine residents in their clinical assessments of patients in the emergency department. One emergency medicine resident stated that he had recognized important legal issues in several patients with a history of domestic violence in the first week after the intervention. An unanticipated result of this collaborative project was the critical review of assessment practices occasioned by the impact of the criterion-referenced assessment culture of the medical school on the norm referenced law school assessment culture. Performance assessment, interview simulation, formative assessment, and scores that do not result in grades were new concepts to most of the law students.28 The collaborative group produced a synergy that has resulted in a number of related projects that are impacting the community (Table 3) and the curricula of both the law and medical school. Conclusion A brief cross-disciplinary training between medical and legal learners demonstrated low baseline scores in domestic violence assessment for both learning groups with modest, but non-significant improvements in gathering of critical historical elements following intervention. Longer didactic training or more focused skill building might improve skills. Results from this project were instrumental in promoting a critical evaluation of domestic violence training at both the law and medical schools at our university. The team recently received a second grant from the Scholarship in Education Allocations Committee of the School of Medicine. The School of Law also contributed to the funding of the second phase of this project. We will use the grant to redesign the training to include skills training and role play exercises to enhance the law students’ and residents’ communication skills. We will be able to compare the effectiveness of the skills training to the didactic training we provided in 2007. 28 Best Practices for Legal Education blog: http://bestpracticeslegaled.albanylawblogs.org/2008/02/06/learning-from- medical-school-about-assessment/ Appendices Table 1: Student Learning and Performance Objectives Medical residents will: • obtain appropriate and focused medical history • recognize Domestic Violence as contributing factor to medical and social problems • perform assessment and appropriate referral • document patient findings in the medical record in a manner that is useful for legal follow-up • develop evidence informed attitudes about how and why people end up in DV situations Law students will: • conduct an interview and establish rapport with a client who has experienced domestic violence • work with the client to identify legal options and resources; • provide information to client about legal options including civil and criminal remedies; • provide information and counseling regarding safety planning; • write an intake memo about the encounter that includes relevant case facts, identification of legal and social resources as well as client’s desired outcomes. Table 2: Sample critical action checklists for legal and medical legal learners for case 2, “Maggie” Legal checklist for case 2 Law Students 1. Did student establish that interview is confidential? 2. Did student elicit/do a safe way to contact the client? 3. Did student elicit/do complete contact information for the perpetrator? 4. Did student elicit/do the current safety of the client? 5. Did student elicit/do safety planning with the client? 6. Did student discover if client is ready file order of protection? 7. Did the student explain legal options available to client pertaining to restraining orders? 8. Did the student elicit information from client regarding custody? 9. Did the student elicit information from client regarding child support? 10. Did student provide information for social service assistance (e.g. shelters, food banks)? 11. Did student elicit pattern of Domestic Violence including the number of incidents or the dates of incidents? 12. Did student elicit severity of abuse? 13. Did student elicit if there were any witnesses to the incidences of abuse? 68 International Journal of Clinical Legal Education July 2009 A Medical/Legal Teaching and Assessment Collaboration on Domestic Violence 69 Emergency medicine checklist 1. Did student discover when the headache started? 2. Did student elicit how bad the headache was? 3. Did the student elicit the associated symptom of dizziness? 4. Did student obtain medical history? 5. Did student elicit and address domestic violence as a contributing factor to the patient’s presenting complaint? 6. Did student provide patient with information to contact at least 1 of the 4 following methods for people with low incomes to receive financial assistance for medication needs: Healthcare for the Homeless, UNM Care Program (for residents of Bernallio County), applying for public assistance or low cost drugs ($4) available through Wal-Mart? 7. Did student elicit current safety of the patient and her children? 8. Did student make a legal referral for patient? 9. Did student provide a medical follow up plan for patient? Table 3 Med-Law Clinical Education Collaboration Interim Outcomes: 1. Best Practices for Legal Education blog entries: http://bestpracticeslegaled .albanylawblogs.org/2008/02/06/learning-from-medical-school-about-assessment/ 2. Project presentation made to the New Mexico Domestic Violence Leadership Commission, Sharon Pino, New Mexico Domestic Violence Czar, Office of the Governor, Barbara Richardson, honorary chair. May 8, 2008. 3. Peer reviewed abstract accepted and poster presented at the Society for Academic Emergency Medicine. Washington, DC, May 31–June, 2008: Crandall C., Sedillo-Lopez A., McLaughlin S., Rimple D., Campos G., McCarty T., Assessment of a cross-disciplinary domestic violence training for emergency medicine residents and law students. Academic Emergency Medicine. 2008;15(1);S225-S225. 4. Peer reviewed abstract accepted and poster presented at Association of Standardized Patient Educators (ASPE) 2008 Conference: Scholarship and Simulation: Progress & Promise. San Antonio, Texas, June 29–July 2, 2008 5. Problem-based teaching case with DV related clinical content developed for SOM Phase I Human Structure Function & Development (HSF&D) Course. Block leader, Paul McGuire PhD. 6. Peer reviewed abstract accepted and oral presentation given at the 6th International Journal of Clinical Legal Education Conference, Cork, Ireland, July 14–15, 2008. 7. Peer reviewed abstract accepted and oral presentation planned for the Mid-West Clinical Education Conference, Bloomington, IN, November 13–15, 2008. 8. Anticipate submitting standardized patient cases for publication in AAMC’s Med-Ed Portal.