Feb 06, 2008

Have You Tried Group Medicine?

David Spero

How do you like your medical appointments? If you’re like many of us, you find that doctors are rushed and focused mostly on clinical goals. It’s all about the numbers and the drugs. They’re in charge, and our job is mostly to listen.

Many people are not satisfied with the quality of their one-on-one doctor visits. Many physicians are frustrated, too. Donald Berwick, M.D., director of the Institute for Healthcare Improvement, says, "One-to-one, face-to-face appointments are the dinosaurs of the medical system."

Medical appointments are very different when groups of people see the doctor at the same time. It may sound a little strange or scary at first, but many people find that the support of others makes communicating with doctors easier. You don't have to remember everything or ask everything, because other people will have similar questions.

Started in Italy
As I describe in my book, Diabetes: Sugar-coated Crisis, a group of Italian researchers in the 1990s were looking to find a better way to meet the needs of people with diabetes. As in the U.S., doctors were overwhelmed keeping up with cholesterol, blood glucose, blood pressure, and all the other numbers. They had little time for their patients as people.

Most of their patients were low-income and had little education. As here, their difficult lives and unhealthy environments made diabetes control very difficult. The research clinics started having people come for their routine appointments in groups of 6 to 20. The appointments included individual and group time with the doctor, group education, sharing, and support.

The Italians and many others have shown that patients with group appointments do better in all clinical outcomes studied. They also enjoy the appointments more, have better relationships with their doctors, and even report improved quality of life!

Types of group appointments
Now group appointments are spreading through American medicine because they are cost-effective and popular with both patients and physicians who try them. Some are called Cooperative Health-Care Clinics, where a group of people will meet with a whole health-care team at the same time. A medical assistant or nurse aide may take vital signs, while a dietitian answers questions about food, while the doctor talks with patients one or two at a time. The same group of people will usually meet together regularly, becoming something of a support group.

In Drop-In Group Medical Appointments (DIGMAs), a clinic may set up several group times, and people can come to whichever they choose. Sometimes even the discussions between patients and the doctor are held in the group. Planners originally thought that patients would be embarrassed to bring up hard issues in front of other patients, but the reverse is often true. It's the doctors who tend to intimidate us; having other patients there makes it easier to speak out.

There are many other types of group appointments as well. Some are led by dietitians, psychologists, social workers, or nurses. Some are even led by other patients!

Are groups for you?
Groups aren't for everybody. Studies seem to show they work for about two-thirds of patients. Some people are just not comfortable in groups. Some may be shy, or may have trouble getting along with others in groups. Group appointments take longer than one-on-one, and some people may not have time for them.

More often, though, the problems come from the provider's side. Clinics have to get used to different ways of doing things; there may be logistical problems (like finding space); and health-care providers may not be comfortable facing so many patients at once.

If you're interested in groups, you may have to ask for them. You can click on any of the links above or download how-to's on groups here and show them to your doctor.

I'm working with a group called New Health Partnerships that helps health-care systems and patients work together better. We'd like to know what you think about groups. Have you thought about group appointments? What have been your experiences with them? What did you like and dislike about them? Let us know by commenting here.

And thanks to everyone who sent messages of support last week. I think I'm doing better now.

Finally, a couple of follow-up notes on my blog entries on sleep apnea: Lyla asked about CPAP treatments and atrial fibrillation. In a 2003 article in the journal Circulation, patients with a-fib who were on CPAP had less fibrillation than the group with sleep apnea who weren't on CPAP, and also less than those who didn't have known sleep apnea at all! So it sounds like a good idea.

Janet described having all the symptoms of sleep apnea—I hope you're getting checked out, Janet.

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