An 8-year-old Hispanic male came to clinic for his well child care. His mother had no concerns except that he was not doing as well in second grade as she had wanted. He had received English-language learner (ELL) services during kindergarten and first grade, but they were stopped when he entered 2nd grade. He had always struggled with reading she said. The teacher said that he didn’t qualify for ELL services anymore and there were no other additional services for him. She recommended going to the library and having him read to his mother at home. His mother had tried this but had limited availability because of her work schedule and she felt that there was more to this problem than just not being able to read as well. The past medical history showed him to be a full-term infant with normal growth and development. Vision and hearing screening at school were reportedly normal. The family history was positive for relatives on both sides of the family who had some school problems but the mother was not sure what they were. Her sister and brother got some “special help” at school, and some paternal relatives struggled to finish school.
The pertinent physical exam showed a well-appearing male with normal vital signs. Growth parameters were 50-75%. The diagnosis of a healthy male with a possible learning disability was made. The mother was told to contact the school and ask for him to be formally evaluated. In addition, the physician also arranged formal vision and hearing evaluations that eventually were normal. The mother returned with another child for an acute care appointment 2 weeks later. She said that she had gone to the school and they again told her there was nothing more they could do for her son. The pediatrician told the mother that he would draft a letter that the mother could re-write and send to the school. “Sometimes you need to have to ask them in writing,” the pediatrician said. About 1 month later, the pediatrician saw the mother in a clinic hallway and she reported that the educational evaluation was underway because of the letter. The pediatrician was glad to learn this because he was not sure how he could intervene if the letter hadn’t worked. He now realized the next hurdle was to make sure the child actually got educational services if they were needed.
Health does not exist in the vacuum of the office or hospital visit. Therefore the social needs of the patient and family must also be addressed to promote the health of the individual, family and the community also.
“Legal needs are adverse social conditions with legal remedies that reside in laws, regulations or policies.” Benefit denial is a common example. The patient such as the one above who was denied educational assistance initially had a social need that would have becomes a legal need because access to the system is prescribed by law.
The first medical-legal partnership in the U.S. was established in Boston, Massachusetts in 1993 serving pediatric families, and since then the programs have expanded to serve more than 200 institutions around the United States. In a recent review of a pediatric medical-legal partnership, the most common legal needs were because of benefits, housing issues and educational rights issues. Many of the reasons families sought help were to ask questions about the legal system such as how to escrow rent or ask for a school evaluation.
Medical-legal partnerships may also be formed to help alleviate public policy and system burdens – benefit claims, gun control, child safety, benefit claims, etc.
Legal issues that affect health include:
- Income and Insurance
- Insurance access and benefits
- Disability benefits
- Food programs
- Social security benefits
- Access to shelter
- Access to shelter subsidies such as Section 8 program
- Foreclosure prevention
- Safe/sanitary housing conditions such as lead or mold abatement
- Utility access
- Compliance with regulations including Federal, State and local laws and ordinances – Americans with Disability Act
- Education and Employment
- Compliance with regulations including Federal, State and local laws and ordinances – Americans with Disability Act, Individuals with Disability with Education Act
- Discipline issues
- Legal status
- Criminal record and juvenile justice system issues
- Immigration – asylum, Violence Against Education Act
- Personal and Family Stability
- Custody, guardianship, divorce foster care, paternity
- Capacity/competency including mental health and minors
- Child and elder abuse and neglect
- Domestic violence
- Advance directives and end of life care
- Estate planning
- Powers of attorney
Other legal issues for health care providers
- Professional liability/malpractice – civil, criminal and ethical
- Personal liability
- Research – patent, trademark, compliance
- Running a business – legal compliance and taxation
- Reportable obligations – whistle blowing, knowledge of laws being broken, criminal investigation
Questions for Further Discussion
1. What legal services do you have available to you where you practice?
2. How are legal services for needy families financed?
- Disease: Legal Issues | Advance Directives | Caregivers | School Health
- Symptom/Presentation: Health Maintenance and Disease Prevention | Developmental Delay
- Specialty: General Pediatrics | School
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Caregivers, Advance Directives, and School Health.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Zuckerman B, Sandel M, Smith L, Lawton E. Why pediatricians need lawyers to keep children healthy. Pediatrics. 2004 Jul;114(1):224-8.
Zuckerman B, Sandel M, Lawton E, Morton S. Medical-legal partnerships: transforming health care. Lancet. 2008 Nov 8;372(9650):1615-7.
Sandel M, Hansen M, Kahn R, Lawton E, Paul E, Parker V, Morton S, Zuckerman B. Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations. Health Aff (Millwood). 2010 Sep;29(9):1697-705.
Klein MD, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children–outcomes from a successful partnership between professions. J Health Care Poor Underserved. 2013 Aug;24(3):1063-73.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital