Risks and Rewards of Externships: Exploring Goals and Methods

This article explored the risks and rewards of designing and teaching in an externship program, the goals one might have, and the methods one might use. We have argued that it is important to pay attention to the principles of intentional design when developing an externship program. In particular, we have identified and challenged the assumption that skills development must be the predominant goal for externships. This is a common assumption on the part of legal education regulators in our respective home countries, the USA and Australia, as well as in England and Wales. Skills development can, but does not have to, be a focus for every externship. If it is to be a focus, the targeted skills should be articulated as clearly and specifically as possible. Students must learn the theory and methods behind the skills to be used in the placement, either through appropriate pre-requisites, a skills-focused classroom component, or a clear understanding that the placement supervisor will be able to impart both the relevant theory and methods. Then the reflection component also must be designed to enhance students’ acquisition of the identified skills. We have explored how this can be done with either the “tailor-made” or the “retail” externship structure. However, we believe the regulatory focus on skills has obscured the important values that can be acquired through a well-designed and well-taught externship

Risks and Rewards of Externships: Exploring Goals and Methods

This article grew from a presentation relating externship clinical programs to the theme of the July 2016 International Journal of Clinical Legal Education and Association of Canadian Legal Education conference: The Risks and Rewards of Clinical Legal Education Programmes. Externships or field placement programs involve students placed away from the law school and supervised by a person who is not employed by the law school. Externships offer many potential rewards for students as well as other stakeholders, including especially community institutions. But there are also risks—risks that the externship will be expected to accomplish too much with too few resources or that the externship program will be held back in the potential for contribution due to inadequate imagination or planning. This article seeks to encourage externship teachers to put aside assumptions that are sometimes made about how externship programs “should be” and consider some alternative approaches to course design and possible goals for externship courses

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Risks and Rewards of Externships: Exploring Goals and Methods

This article explored the risks and rewards of designing and teaching in an externship program, the goals one might have, and the methods one might use. We have argued that it is important to pay attention to the principles of intentional design when developing an externship program. In particular, we have identified and challenged the assumption that skills development must be the predominant goal for externships. This is a common assumption on the part of legal education regulators in our respective home countries, the USA and Australia, as well as in England and Wales. Skills development can, but does not have to, be a focus for every externship. If it is to be a focus, the targeted skills should be articulated as clearly and specifically as possible. Students must learn the theory and methods behind the skills to be used in the placement, either through appropriate pre-requisites, a skills-focused classroom component, or a clear understanding that the placement supervisor will be able to impart both the relevant theory and methods. Then the reflection component also must be designed to enhance students’ acquisition of the identified skills. We have explored how this can be done with either the “tailor-made” or the “retail” externship structure. However, we believe the regulatory focus on skills has obscured the important values that can be acquired through a well-designed and well-taught externship

Risks and Rewards of Externships: Exploring Goals and Methods

This article grew from a presentation relating externship clinical programs to the theme of the July 2016 International Journal of Clinical Legal Education and Association of Canadian Legal Education conference: The Risks and Rewards of Clinical Legal Education Programmes. Externships or field placement programs involve students placed away from the law school and supervised by a person who is not employed by the law school. Externships offer many potential rewards for students as well as other stakeholders, including especially community institutions. But there are also risks—risks that the externship will be expected to accomplish too much with too few resources or that the externship program will be held back in the potential for contribution due to inadequate imagination or planning. This article seeks to encourage externship teachers to put aside assumptions that are sometimes made about how externship programs “should be” and consider some alternative approaches to course design and possible goals for externship courses