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Monday, August 03, 2009

Medical Versus Legal Education

I'm going to sneak in here one last time (before Dan cuts off my access) to record some reactions to the WhiteCoatUniversity of Michigan Medical School White Coat Ceremony, which, as a commenter to my earlier post noted, was indeed quite moving.  (If you hadn't guessed, that's Matthew the student-doctor in the middle, and Alene, on his left, is where he gets his good looks.)  I couldn't help but compare legal and medical training, as well as the structure of the two academies.  When I was in business, one of the modern manufacturing methods was "benchmarking," and it wasn't always completely apples to apples, at least on the surface.  For example,  one of our businesses made brake pads, which involved mixing a bunch of powdery stuff with liquid, shaping in a pan, and then heating it until it hardened.  One source of best practices had nothing to do with the automotive business; the setting was commercial bakeries.  Do we benchmark?  I suspect not.

The day involved three parts:  (a) an introduction to students and families together; (b) an overview of the curriculum for families while the students exited to prepare for the white coating hooding ceremony; and (c) the ceremony itself.  For what it's worth, I'll have some legal educator's thoughts about it below the fold.

The overview of the curriculum gave me pause for what we do in law school.  The first two years are mostly hard sciences, but there are additional programs in which students are matched up in small groups and with real and hypothetical patients to begin the process of clinical training, "longitudinal clinics,"  (i.e. where students work through a hypothetical case of breast cancer over the time period such a case would normally evolve), communication skills, and professionalism.  As to the latter two, for example, I was floored by the fact that students go through a unit on delivering bad news in the patient and family setting within the first year. 

The sciences are lectures and labs, and EVERY lecture is available via the internet, and there is simply no penalty for "attending" class on line or by way of a download (the director of the M1 and M2 curriculum, a clinical associate professor, referred to it as attending class "on your couch in your jammies and bunny slippers").  I think the idea is that there is so much pressure on the students anyway that the school does anything it can do to facilitate learning.  The director made a fleeting reference to how the professors feel about the system, and I didn't get a chance to ask about it, but obviously they've adapted.  I decided, sitting there, that I couldn't see any reason not to have all of my classes recorded, at least for our MP3 ITunes capability at Suffolk, and that whether students showed up for class really ought to have to do with how much value I add to the experience.  More on students as professional colleagues in a minute, because I think that has something to do with it.

As most people know, med students take the first of their US Medical Licensing Examinations after the second year, and passage is a condition to moving on to the clinical rotations which make up the bulk of the third and fourth years.  Again, what struck me was the emphasis on the science and art of being a physician.  Is that the medical profession has enough confidence in its scientific bona fides that it can easily focus on the art?  Let's say that the first two years of med school are 80% hard science, and 20% social, clinical, and communications skills, and 100% of the last two years are clinical.  That means that about 40% of the training is "doctrinal," if the analogy between law school and medical school holds, whereas it's fair to say that most legal education now is more like 80-90% doctrinal.  I have a hard time believing that there's so much more hard stuff to be learned in law versus medicine!  And why does the bar exam have to take place at the end of the entire three years?  Why not give the multi-state portions relating to the first year after the first year?  (Note, by the way, that the med boards test on hard sciences that may or may not have much to do with the actual practice of medicine, something that bar exam critics focus on as well.) 

I was curious about the fact that the director of the M1/M2 education program was a clinical associate professor.  Indeed, the faculty structure is similar to most law faculties:  the clinical professors are only obliged to the teaching and service elements of the usual triad - they are not on a tenure track, and do not have to produce research.  I asked one of the deans if there was a pecking order of tenure-track and clinical, or a academy-practice issue as between the tenured research faculty and the practice, and the reply was something like "not as much as there used to be."  So some of those analogies to the legal academy hold as well.

Throughout, including the White Coat Ceremony, there was an emphasis on the fact that they are not just students, but student-doctors, and part of the health care system.  The keynote speaker, a member of the pediatric oncology faculty, talked about her first experience, while a student, scrubbing up (not knowing what to do and having to repeat it nine times), assisting the primary surgeon and surgical team in a quadruple bypass, holding clamps and retractors, helping the surgeon close, and, at one point, holding the heart in her hand so that the surgeon-professor could see it better.  The speaker was choking up a little bit as she talked about how she began visiting the patient and meeting with his family every day until his discharge - "I actually held his heart in my hand; how could I not follow up with him?"  Again, what struck me was the extent to which the student-doctors are professional colleagues of the professor-doctors from the first day.   (Note:  at the end of the program, there was a recitation of the Hippocratic Oath, but by the physicians in the audience, not by the students, who were not eligible.)  Can we say the same thing in law school?  Do we emphasize to entering law students that they are now student-lawyers, not just students?  Why do we trust medical students to learn what they have to learn, even if in jammies and bunny slippers, but, as to law students, we are all hung up on taking attendance and cutting off the Internet access?  Why are students not professional colleagues-in-training?

The hooding ceremony itself involved each of the 170 students walking onto the stage of the Power Center (one of the large performing arts centers at Michigan) with the white coat he or she had received just before the processional, stepping to the microphone to state the student's name, hometown, and undergraduate school, then having the dean of the med school assist in putting on the white coat, then receiving a stethoscope from one of the associate deans, shaking hands across the stage, and getting photographed.  This particular ceremony started at Columbia in 1992, and Michigan adopted it in 1994, and I understand that it has critics who think of it as somehow guild-ish or elitist.  I suppose that would be possible if there were an arrogance about the program, but everything was about caring, compassion, patients, commitment, and other virtues.  So I thought without reservation that it was a moving and visible commitment to being a professional.  Again, in a trivial way, the fact that the student doctors (not lawyers!) spoke to the multitude in the auditorium made me wonder about the patterns into which I've fallen in my classroom.  I collect index cards with exactly the same information, but they come to me.  Even though I'm teaching a second year class, many (most?) of the students don't know each other because they were in different first year sections.   Why not take fifteen minutes and go around the room and hear their voices in addition to their data?

I have no doubt that (a) I've idealized and sentimentalized, and (b) the grass is greener over there, but, as I said, it did give me pause to ask some questions of myself.

Posted by Jeff Lipshaw on August 3, 2009 at 12:30 PM in Teaching Law | Permalink


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This is a great post, Jeff. Congrats to you and your family on this experience. I think you did us a great service by pausing to question how your experience there might enhance legal education, and I think you identified some good takeaways, especially regarding professionalism.

One quick thought: the lecture + lab model for teaching substantive law is one that I have been slowing inching towards over the past couple of years, and I think it has great promise. I don't call it that, but I might start. Anyway, I talk more about it at The Conglomerate.

Posted by: Gordon Smith | Aug 4, 2009 1:22:34 AM

At FIU, we end orientation week (which is heavily focused on ethics and professionalism) by having students take a mock oath, designed to welcome them into the profession as student-lawyers and to emphasize the professionalism that now is expected of them. Not sure how well it takes, but the sentiment is there and, I think, can be built upon. The colleagues-in-training point is a bit tougher, because it sounds like there is a greater student-professor hierarchy in law school.

As a law student, I always liked seeing the med students walk around in lab coats and carrying stethoscopes (the law and med schools shared a campus), identified as a group. I always thought it was too bad there was not something similar we could do for law students. Having just now learned about White Coat Ceremonies (the inaugural class of FIU's Medical School had its ceremony last weekend), there is even more meaning to these identifying objects.

So what could we do for law students--Wigs? Black robes? Copies of Black's Law Dictionary or Blackstone? Briefcases?

Posted by: Howard Wasserman | Aug 3, 2009 11:10:44 PM

Interestingly, neither devote any significant amount of time to business management, yet both legal and professional medical ethics impose severe restrictions on practice that is not owned and actively managed by members of the same profession. Most doctors and lawyers will spend a fair share of their professional careers engaged in business management and marketing.

What distinguishes the best medicine from the merely mediocre is mostly good systems. Similarly, the most profitable law firms are also those with many lawyers that pose an imposing management challenge. The original Hippocratic Oath was as much concerned about guild rules that went to the business management of enterprises, and the care of retired masters, as it was about doing no harm.

The medical profession certainly provides a lot of positive models for law to emulate. But, are both flawed in terms of preparing people for practice?

Posted by: ohwilleke | Aug 3, 2009 3:33:22 PM

Great post. I attended my son's White Coat ceremony at NYU Medical school four years ago - now he's a physician and an orthopedic surgery resident at NYU Hospital for Joint Diseases. Many times during the four years I told him that I took my oath seriously and was there to help him in many ways. I still feel the same way. Congrats and best of luck.

Posted by: John Hochfelder, Esq. | Aug 3, 2009 1:16:01 PM

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