Article Published by University of Minnesota Libraries Publishing Promoting Physician/Attorney Collaboration on Behalf of Older Individuals: The Contribution of Medical School Regional Campuses Gregory Turner, Ed.D., M.B.A., M.P.H., Marshall B. Kapp DOI: https://doi.org/10.24926/jrmc.v1i1.1000 Journal of Regional Medical Campuses, Vol. 1, Issue 1 (2018) z.umn.edu/JRMC All work in JRMC is licensed under CC BY-NC https://doi.org/10.24926/jrmc.v1i1.1000 https://pubs.lib.umn.edu/index.php/jrmc/index Gregory Turner, Ed.D., M.B.A., M.P.H. Associate Professor and Associate Dean for Faculty Development, Florida State University College of Medicine Marshall B. Kapp, J.D., M.P.H. Professor and Director, Center for Innovative Collaboration in Medicine and Law Florida State University College of Medicine and College of Law All work in JRMC is licensed under CC BY-NC Volume 1, Issue 1 (2018) Journal of Regional Medical Campuses Original Report Promoting Physician/Attorney Collaboration on Behalf of Older Individuals: The Contribution of Medical School Regional Campuses Gregory Turner, Ed.D., M.B.A., M.P.H. Marshall B. Kapp, J.D., M.P.H. Abstract There are many situations in which an older person needs the services of both an attorney and a physician and communication and collaboration between members of those two professions would be highly advantageous to the older patient/client’s well-being. Unfortunately, the record of physician/attorney interprofessional collaboration on behalf of the shared older patient/client in such circumstances too often is deficient and needs to be improved. This article reports on a project designed to maximize the synergistic value of physicians as patient advocates and attorneys as problem solvers when the two professions work together. The project consisted of several components, culminating in the availability of a continuing education toolkit for these two helping professions that identifies and aims to overcome an array of potential impediments inhibiting effective physician/attorney collaboration in the aging arena. One project component featured here focuses on the contribution of the Florida State University College of Medicine’s Regional Campuses in carrying out the described project. Financial support: This project was supported by Retirement Research Foundation Grant #2015-121 to the Florida State University Research Foundation, Inc. Human Subjects: This project was approved and reapproved by the Florida State University Human Subjects Committee, HSC No. 2017.20466. Keywords: Interprofessional Collaboration; Older Persons; Attorneys; Faculty Development; Continuing Medical Education Introduction There are many situations in which an older person needs the services of both an attorney and a physician and communication and collaboration between members of those two professions would be highly advantageous to the older patient/client’s well- being. Physicians and medical records they generate may be sought by attorneys in various legal contexts as sources of evidence regarding the physician’s first- hand observations of the older patient/client’s symptoms and behaviors, clinical diagnoses, and treatments offered and dispensed. In addition to the fact-provider role, the physician also may be solicited to provide an expert opinion about some facet of an older person’s health or health care that is being or might become disputed in a legal proceeding or other context. Conversely, a physician, in the course of evaluating or treating an older patient, may identify particular needs and issues for which the advice or representation of a legal professional might be beneficial or even essential to the patient. Unfortunately, the record of physician/attorney interprofessional collaboration on behalf of the shared older patient/client in such circumstances too https://creativecommons.org/licenses/by-nc/4.0/legalcode DOI: https://doi.org/10.24926/jrmc.v1i1.1000 Journal of Regional Medical Campuses, Vol. 1, Issue 1 Article often is deficient and needs to be improved. The chasm between the ideal and the actual is lamentable, but not surprising. While there are many benefits to the increased collaboration between lawyers and physicians, it is important to acknowledge that there are differences in the professions, which pose challenges for these collaborations to occur and thrive. These differences, which are deep-seated and emanate from many sources, include education, training, and socialization. There are also differences in the language, customs, values and definitions of roles that can impact effective interactions. The variations in role are very broad, including views of role in society and roles in relation to clients/patients.1 (p. 214) This project was designed to maximize the synergistic value of physicians as patient advocates and attorneys as problem solvers when the two professions work together.2 The project consisted of several components, culminating in the availability of a continuing education toolkit3 for these two helping professions that identifies and aims to overcome an array of potential impediments inhibiting effective physician/attorney collaboration in the aging arena. One of the most important components of this project significantly involved the contribution of Florida State University College of Medicine’s Regional Campuses. Robust Faculty Development for Community Faculty Among the resources available for the FSU College of Medicine’s multi-campus educational program, the most important are the more than 2,000 local physicians across Florida who provide both their time and their patients. Figure 1. Regional Campus Sites of Florida State College of Medicine Core faculty play important educational leadership roles within their own departments and units, and they also play important institutional roles as the experts and leaders of the educational mission. Within their own disciplines, they serve as important role models, mentors, and resources for educational practice, both formally and informally. Indeed, the success or failure of the program will depend largely on the level and quality of community faculty cooperation. It is essential that a comprehensive program of faculty development is established. The overwhelming majority of FSU COM Community- based clinical teachers are practicing clinicians, mostly physicians, who receive limited financial remuneration for their clinical teaching role. Our clinician educators are a widely diverse group of practitioners. Theoretical Frameworks Informing the Project The concept of knowledge translation4 offers an important framework for designing effective continuing medical and legal education. Knowledge translation recognizes that successful practice change requires more than just learning something new to improve care or services. Educational interventions that are responsive to point-of-service concerns (e.g., https://doi.org/10.24926/jrmc.v1i1.1000 DOI: https://doi.org/10.24926/jrmc.v1i1.1000 Journal of Regional Medical Campuses, Vol. 1, Issue 1 Article time constraints and office processes) increase the likelihood of practice change. The second theory which informed this project is the Normalization Process Theory (NPT).5 This theory focuses on explicating the legitimacy of an intervention and the role of opinion leaders. NPT is concerned with understanding trust and interpersonal relationships within social networks as they impact innovations. Describing the organization and action of work performed, it proposes that for a complex intervention to become part of everyday practice, the following mechanisms need to be considered: (1) coherence (‘What is the work?’); (2) cognitive participation (‘Who does the work?’); (3) collective action (‘How does the work get done?’); and (4) reflexive monitoring (‘How is the work understood and enacted?’). Identifying Areas of Potential Interprofessional Collaboration and Competencies A Project Advisory Board composed of Florida legal and medical experts with significant practical and academic experience and expertise in geriatrics and gerontology was assembled, with several members representing relevant state organizations. Through an in-person meeting, supplemented by subsequent conference calls and several electronic exchanges of written materials, as well as informal consultation by Advisory Board organizational representatives with some of their key organizational members, the Advisory Board and project staff compiled and prioritized a list of key factual situations meeting two criteria. First, situations identified were those that arise frequently within professional relationships between older individuals and their physicians and attorneys. Second, enumerated situations involve problems or issues that require, or at least ought to have, the involvement of both medical and legal professionals for the older patient/client to attain an optimum outcome.6 The most important situations believed by project participants to merit potential physician/attorney collaboration on behalf of older patients/clients are those raising issues about the following: decisional capacity, elder mistreatment, self-neglect, medical payment, family relationships, and confidentiality. Connected to the issue identification exercise, project staff and the Advisory Board also discussed specific interprofessional competencies that physicians and attorneys should possess and be able to practice in providing their services to older persons. This discussion was consistent with the general modern movement in professional education to emphasize the development of actual, demonstrable practice abilities on the part of learners, and the cultivation of legal competencies for physicians ought to be an important part of that movement.7 In addition to the Advisory Board consultation process, a review of the quite limited literature regarding physician/attorney collaboration in practice was conducted. Two forms of interprofessional collaboration appear to be in place presently. First, several formal written agreements have been negotiated between bar associations and medical associations at the state or local level. These agreements almost invariably focus on the respective rights, interests, and responsibilities of attorneys and physicians when they have worked together on a particular case.8 The current project sought to move beyond these self-interested, professional-focused agreements toward an enhanced consumer-centered direction, concentrating less on concerns of professional courtesy and decorum and more on fostering and improving interprofessional collaboration in ways that mainly benefit the mutual patient/client of the physician and attorney. The other, more recently-evolved extant collaborative development revolves around the proliferation of Medical-Legal Partnership (MLP) programs throughout the United States. This service delivery model integrates legal assistance into a medical care delivery setting or system.9 In early 2017, the National Center for Medical-Legal Partnership reported programs in its network at 294 health centers in 41 states, as well as dozens in various legal entities.10 Some of these programs target their provision of interprofessional services specifically on older persons.11 The current project aimed to expand on these formal programs based in organizations or https://doi.org/10.24926/jrmc.v1i1.1000 DOI: https://doi.org/10.24926/jrmc.v1i1.1000 Journal of Regional Medical Campuses, Vol. 1, Issue 1 Article institutions to encourage consumer-centered interprofessional collaboration and cooperation at the level of individual, independent physicians and attorneys, as well as those who work in organizations or institutions that might participate in a formal Medical-Legal Partnership. Educational Toolkit The project produced an educational module for physicians and attorneys. This module could be presented by a physician or attorney facilitator to live audiences, in a (flexible) two-hour block, of physicians, attorneys, or—ideally—a mixture of the two professions. Live presentation builds in opportunities for robust audience interaction. Additionally, the module has been posted on the website of the Florida State University College of Medicine Office of Faculty Development and access is available to individual physicians and attorneys who wish to use it in a self- directed manner, deriving their own responses to questions posed in the module. Substantively, the module beings with a brief introduction explaining the rationale for an educational module encouraging physician-attorney collaboration on behalf of older individuals and setting out overall learning objectives. The introduction is followed by seven case scenarios, each raising several of the different issues identified earlier as important by the Project Advisory Board. After each case, the module presents the key issues or challenges facing the older person and the actors responsible for the older person’s well-being, opportunities for interprofessional collaboration in addressing the key issues or challenges, potential impediments inhibiting physicians and attorneys from taking advantage of the interprofessional opportunities, and organizational and written resources to assist medical and legal professionals in their own practices when similar issues are presented. For each case study, after the learner has had the chance to review the key issues, opportunities, and impediments, the learner is asked two overarching  Regional Campuses are located in Daytona Beach, Fort Pierce, Orlando, Pensacola, Sarasota, and Tallahassee. questions. First, “How you would address the impediments in order to maximize the interprofessional collaborative opportunities if you were the older person’s attorney or physician?” Then, “How would interprofessional collaboration potentially improve the older person’s medical or legal experience or outcome?” Additionally, a Facilitator’s Guide was created for this project. This Guide fleshes out in detail, for each of the seven cases created for the educational module, the main opportunities for, obstacles to, and resources to aid in interprofessional physician- attorney collaboration on behalf of older individuals. Regional Campus Field Testing and Feedback One of the Project Co-Directors and co-authors (MBK) field tested the educational module developed by utilizing it as the centerpiece of a Faculty Development Workshop conducted live at four regional campuses of the Florida State University College of Medicine. Faculty development plays a particularly important role at the Florida State University College of Medicine, given its model of clinical education in which third and fourth-year medical students are distributed among six regional campuses across the state and are educated primarily by clinical educators who are actively engaged in patient care within their respective communities.12 Marketing and Outreach to Participants – Early Planning and Wide Dissemination Key to the successful implementation of the program was the cooperation and assistance of the College’s regional campuses. Planning and marketing activities were coordinated through each of the regional campus sites. Wide dissemination of information about the program began 6 – 8 weeks prior to each workshop. Announcements and reminders were sent clinician educators on a bi-weekly schedule (Appendix 1). Publicizing this Faculty Development workshop to local Elder Law attorneys was unique and required special attention. A spreadsheet was created with https://doi.org/10.24926/jrmc.v1i1.1000 DOI: https://doi.org/10.24926/jrmc.v1i1.1000 Journal of Regional Medical Campuses, Vol. 1, Issue 1 Article names and email addresses of members of the Florida Bar Elder Law Section who practice in each of the campus vicinities. The four Faculty Development workshops, conducted during 2017, were attended by 45 members of the College of Medicine’s community- based faculty. Consistent with the interprofessional collaboration theme of this project, attorneys identified as Elder Law practitioners in the respective regional campus communities were invited; a total of 24 attorneys attended the four workshops. Discussions emanating from the case studies in the educational module at each of the workshops were honest and lively, but collegial. Specific points of emphasis differed among participants somewhat from one workshop to another, but common themes that were discussed at each of the workshops included, among others: pervasive presumptive distrust between physicians and attorneys; communication barriers; medical and legal private practitioner time constraints impinging on collaboration; confidentiality obstacles to sharing patient/client information between professionals; the sometimes disruptive role of family members; lack of good knowledge among physicians and attorneys about available assistive community resources; and financial constraints of older individuals, which especially deter them from retaining and involving legal counsel on their own behalf. Workshop participants provided feedback to the authors both informally afterwards and formally through pre- and post-workshop survey and evaluation instruments. Based on this feedback, minor revisions were made to the educational module. A copy of the Facilitator’s Guide was sent to each Workshop participant. Conclusion To “solve complex issues effectively …, it is imperative for our professions [medicine and law] not just to cooperate, but also to collaborate.”13(p. 319) Benefits of interprofessional collaboration are likely to include enhanced health and well-being for the patient/client and increased satisfaction for the professionals. Nonetheless, as has been noted, serious barriers to physicians and attorneys working as trusted colleagues with a mutual interest (in the patient/client good), rather than as adversaries, exist. The project described here sought to identify and help to address some of the most vexing of these impediments, with particular emphasis on maximizing resultant benefit to older individuals whose optimal well-being is jeopardized when legal and medical practitioners fail to work together on behalf of their shared patient/client. The involvement of the College of Medicine’s Regional Campuses in providing opportunities to meaningfully field test the educational module developed was essential to the success of this project. The formal and informal feedback of clinical faculty who actually care for older patients regularly in situations that could benefit from interprofessional collaboration helped to practically ground and refine the educational module. Moreover, the Regional Campus’ cooperation in this project provided an excellent chance for the College of Medicine to initiate or enhance ties with the legal communities surrounding their respective locations, thus laying or strengthening the foundation for future productive interactions. References 1.Trubek LG, Zabawa B, Galowitz. Transformations in health law practice: The intersections of changes in health care and legal workplaces. Ind Health Law Rev 2015;12:183-226. 2. Scott C. Doctors as advocates, lawyers as healers. J Pub Law & Pol’y 2008;29:331-399. 3.Toolkit is available at http://mediaproduction.med.fsu.edu/mdjd/playmodul e/story_html5.html. 4. Estabrooks CA, Thompson DS, Lovely J & Hofmeyer A. A guide to knowledge translation theory. J Continuing Educ in the Health Professions 2006; 26:25–36. 5. Murray A, Treweek S, Pope C, MacFarlane A. Ballini L, Dowrick C, Finch T, Kennedy A, Mair F, O’Donnell C, Ong BN, Rapley T, Rogers A, & May C. Normalization process theory: a framework for developing, https://doi.org/10.24926/jrmc.v1i1.1000 http://mediaproduction.med.fsu.edu/mdjd/playmodule/story_html5.html http://mediaproduction.med.fsu.edu/mdjd/playmodule/story_html5.html DOI: https://doi.org/10.24926/jrmc.v1i1.1000 Journal of Regional Medical Campuses, Vol. 1, Issue 1 Article evaluating and implementing complex interventions. BMC Med 2010; 8:63. 6. Kapp MB, Taite SM, Turner G. Medical-Legal partnerships: Six situations in which elder law attorneys and physicians caring for older patients need each other. Bifocal: J Amer Bar Assn Commission on L & Aging 2016 (July-Aug.);37:115-118. 7. Kapp MB, Campbell A. Interprofessional education for future physicians: Including legal competencies. Med Sci Educator 2013;23:566-569. 8. North Carolina Bar Association Medico-Legal Liaison Committee. Medico-Legal Guidelines. Sept. 2014. Available at http://www.ncmedsoc.org/wp- content/uploads/2013/06/Medico-Legal-Guidelines- 2014.pdf. 9. Lawton E, Sandel M. Investing in legal prevention: Connecting access to civil justice and healthcare through Medical-Legal Partnerships. J Legal Med 2014;35:29-39. 10. National Center for Medical-Legal Partnership. http://medical-legalpartnership.org/ (last accessed Sept. 26, 2017). 11. Newman J. Miami’s medical-legal partnership: Preparing lawyers and physicians for holistic practice. Ind Health L Rev 2012;9:471-483. 12.http://med.fsu.edu/index.cfm?page=comAboutUs. educationalProgram. 13. Morton L, Taras H, Reznik V. Encouraging physician-attorney collaboration through more explicit professional standards. J Pub Law & Pol’y 2008;29:317-330. https://doi.org/10.24926/jrmc.v1i1.1000 http://www.ncmedsoc.org/wp-content/uploads/2013/06/Medico-Legal-Guidelines-2014.pdf http://www.ncmedsoc.org/wp-content/uploads/2013/06/Medico-Legal-Guidelines-2014.pdf http://www.ncmedsoc.org/wp-content/uploads/2013/06/Medico-Legal-Guidelines-2014.pdf http://medical-legalpartnership.org/ http://med.fsu.edu/index.cfm?page=comAboutUs.educationalProgram http://med.fsu.edu/index.cfm?page=comAboutUs.educationalProgram DOI: https://doi.org/10.24926/jrmc.v1i1.1000 Journal of Regional Medical Campuses, Vol. 1, Issue 1 Article Appendix 1: Promoting Physician/Attorney Collaboration on Behalf of Older Individuals Flyer https://doi.org/10.24926/jrmc.v1i1.1000