To our knowledge this is the first systematic review of medical education curricular interventions that center on Medical Legal Partnerships targeting social determinants of health. In this review of eight MLP programs, all interventions were effective at improving participants’ knowledge, attitudes and/or practice regarding issues related to the SDoH and health disparities. These improvements were wide in scope and included benefits in participants’ understanding, comfort, confidence, and abilities in identifying and intervening on the social determinants of heath in their patients. Participants from multiple disciplines including family medicine, pediatrics and internal medicine residencies, as well as undergraduate medical students each demonstrated benefit from the MLP-centered interventions. Students and residents engaged with MLPs through varied activities built into an SDoH curriculum including didactics, advocacy training, and interactive programs such as a poverty simulation. Multiple MLP programs highlighted in this review brought learners out of the ivory towers of academia and into the community to learn about, and collaborate with, community based resources. In doing so, MLP’s help bring learners closer to the context where risks emerge, and foster collaboration with key change agents[18].
Even with a targeted curriculum, effective training on SDoH that impacts health disparities is no easy task; this study highlights the important role that MLPs may provide in addressing this difficult topic in medical education. As teaching the SDoH to impact health disparities is relatively new in medical education, there is a limited evidence base to guide and assess effective curricular development. Thus, it is important to consider teaching the SDoH through MLP in the context of known effective medical education approaches that target other health topics with the goals of better health outcomes.
First, understanding causal pathways is critical for learners to comprehend, retain, apply and advance most topics in medicine[19]. Causal pathways in the SDoH and health disparities are no exception. An understanding of the systems, laws and policies that are in part responsible for ongoing disparities in environmental, behavioral or medical determinants is important to integrate into medical education curriculums. As highlighted in each of the studies within this review, lawyers focused on caring for vulnerable populations through legal advocacy are well-equipped to provide this education within the context of a MLP.[12, 14, 16, 17, 20, 21]
Second, to impact health disparities through education, it is critical to teach students actionable and practical skills to help address SDoH[7]. In traditional medical education, learners gain these skills by practicing medicine in closely supervised environments alongside of supervisory clinicians (e.g. clinical rotations in medical school or residency training). Similarly, MLP’s provide a unique opportunity for which learners can foster advocacy skills by working alongside a lawyer with experience and expertise in advocacy. In many of the above-described MLP programs, learners work one-on-one with lawyers, and gain confidence in ameliorating unmet social needs in their patients through real patient encounters.
Third, simulation training is a widely established tool in medical education that can help learners experience a virtual reality through which they gain situational awareness, enhance communication skills and learn through a cycle of feedback and debriefing[22]. Simulation trainings, such as the poverty simulator which was incorporated in the Boston Medical Center MLP program described in this review[13], can be an effective experiential learning tool within SDoH training[23]. For learners who might not have previously experienced poverty, a simulator, which includes an interactive immersion experience, can sensitize participants to the ways in which their patients are constrained and shaped by economic and political forces[24]. An improved understanding of these structural challenges is an important aspect of training physicians to become advocates for the needs of their most vulnerable patients.[24, 25]
As educators consider how they will incorporate SDoH into their curriculums, the opportunity to partner with MLP’s is timely as MLP’s are increasingly becoming an important component of multidisciplinary clinical care teams around the country. Over 400 health care organizations have developed MLPs in 48 states in the US and most have formed in the past decade[26]. Many MLPs, including all of the presented programs in this review, operate in partnership or within an academic medical center which facilitates the engagement of medical trainees into multidisciplinary programs.
This systematic review has several limitations. First, we included all MLP studies that focused on medical education outcomes. These studies are heterogeneous in their intervention, design and evaluation. This heterogeneity limited our capacity to conduct a quantitative meta-analysis. Second, while we employed a comprehensive search strategy with the help of an experienced medical librarian, it is possible that we did not capture all relevant articles. Third, there were no studies that compared the MLP intervention directly with other forms of social determinants of health training. However, the qualitative study results presented above highlight the importance of the multi-disciplinary perspective in SDoH curricula: Having a legal expert on the team positively impacted measured outcomes including participants’ perceived ability make a difference as a physician. Lastly, most MLP’s around the country have been formed in the last decade and research into the impact of MLP on patient care outcomes is nascent. Several of the included studies analyzed the impact on student or resident behavior, such as demonstrating improvement in documentation surrounding SDoH in the electronic record[12] or increased likelihood of referrals to community organizations including legal aid[13]. However, more rigorous, quantitative analysis exploring the impact of MLP educational programs on participants’ future practice is warranted. Studying the impact of MLP programs on patient outcomes outside of a medical educational program was beyond the scope of this review.