N.C. Doctors Schedule 'Group Medical Appointments'

N.C. Doctors Schedule 'Group Medical Appointments'

News Feb 03, 2013

Most of the patients were strangers.

But they had this in common: They wanted more time with their rheumatologist, Dr. Henry Chow.

So, instead of scheduling appointments for 15 or 20 minutes each, they shared one appointment for 90 minutes.

It's a concept that's becoming popular with a growing number of doctors and patients in the Charlotte area and across the country. A small movement, it promises to get more attention as doctors have less time to spend with patients who need more information to deal with chronic conditions such as diabetes.

One afternoon last week, nine patients, all with some form of arthritis, sat in a semi-circle in a large, sunny room at Carolinas Medical Center-NorthEast in Concord.

One by one, Chow spoke to each patient about symptoms, pain levels and medicines. He scooted toward each on his rolling stool so he could touch their hands, knees and ankles, where arthritis pain concentrates.

Frequently, he addressed the whole group about a shared concern, such as how different drugs work. Sometimes, he just let them teach each other.

When one woman mentioned that her fingers are cold and stiff, another patient suggested "paraffin wax."

"Tell her about it," Chow said.

Adelta Comer, 60, of China Grove, explained how she dips her hands in warm paraffin, a treatment offered at nail salons. "The heat goes all the way to the joints," she said.

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Since October, when Chow started group visits for arthritis patients, about a half-dozen other doctors in Carolinas HealthCare System have done the same for patients with diabetes, heart failure and asthma. Other groups are planned for people with sleep disorders and pulmonary hypertension.

For years, family doctors at UNC Chapel Hill have offered group appointments for patients with diabetes, for expectant mothers and for healthy newborns.

"Patients really appreciate the mutual support they get from one another ... and they appreciate having more time with the provider," said Dr. Cristy Page, director of the residency program at UNC Family Medicine.

Chow said group appointments allow him to see twice as many patients as he normally would in the same time. Group visits are not only efficient, they're rewarding and effective, Chow said.

"I like the interaction of the patients," he said. "In some ways, they help me help them."

Born out of frustration

Edward Noffsinger is one of the pioneers behind shared medical appointments. The California psychologist became frustrated with traditional doctor visits when he became seriously ill with pulmonary hypertension in the late 1980s and early 1990s.

It often took him months to get an appointment. There were long waits for short visits with harried practitioners. And in the rush, he often forgot to ask questions he had planned to ask.

Thinking there must be a better way, Noffsinger designed a new kind of office visit in which patients could be seen on shorter notice, get more time with the doctor, and benefit from the experience, support and questions of other patients.

He introduced the idea to Kaiser Permanente, the large health care organization where he worked for many years, and doctors there began offering group visits in 1996. Noffsinger said the concept initially drew criticism from doctors who already felt overwhelmed by the pace of change in medicine.

"What I hear now is, 'We know we have to change. Just show us how to do it successfully,'?" he said. In recent years, Noffsinger has helped establish group medical appointments around the world.

"There's hardly a medical institution that you could mention that hasn't done something with group medical visits," he said. "The fact that they have prompt access and 90 minutes of care is almost unheard of these days.

"If you have cancer or heart disease or kidney disease or any chronic illness, you enjoy being with other patients who are dealing with similar issues. ... It's not like going to the Internet where you don't know where on earth this advice is coming from."

Dr. Brent Jaster, a Colorado consultant who helps other doctors set up shared medical appointments, said the concept has been around for 100 years, but was popularized by Noffsinger and two others, Colorado physician John Scott and Connecticut nurse-midwife Sharon Schindler Rising.

Two U.S. studies found patients have fewer preterm births and fewer hospitalizations and emergency room visits if they have taken part in group appointments, Jaster said. A five-year study in Italy found diabetes patients in group appointments had better control of their disease and took less medicine than those who had private appointments.

Jaster said he's heard criticism of the concept, but it usually comes from "people who have false expectations or have a really strong preference for privacy, or they weren't really told what to expect in advance."

Group medical appointments don't save money for patients and could mean more income for doctors who see more patients without expanding hours. Patients are charged as if they've had a private visit, and insurance typically reimburses as it would for private visits.

Doctors say the goal is not making more money, but providing better access and care. They say patients get more time with a physician for the same fee and may save money overall if they better manage their conditions, need fewer visits and avoid complications.

Charlotte groups take off

The first group medical appointments in Charlotte were started a couple of years ago after some Carolinas HealthCare doctors heard Noffsinger speak at a conference. But the program really took off last year after the hospital system hired Dr. Zeev Neuwirth to help redesign delivery of primary health care.

Neuwirth previously worked for Harvard Vanguard Medical Associates in Boston, where Noffsinger helped establish one of the largest programs of group medical appointments in the country, with about 60 groups in more than a dozen specialties.

Group medical appointments don't work for everyone, and they're always offered on a volunteer basis, Neuwirth said.

Patients who volunteer can generally get group appointments sooner and without as much notice. They can still get one-on-one time with the doctor for private matters.

"Our research shows that patient satisfaction was as good as, if not better than, if patients are seen individually. And the outcomes are the same," said Neuwirth, who wrote the foreword to Noffsinger's 2009 book, "Running Group Visits in Your Practice."

Neuwirth recalled one Harvard patient, a middle-aged contractor who was the last to be examined by a surgeon in a 90-minute visit for back pain. When Neuwirth asked if it was worth the wait, the man said yes. It had given him a chance to watch the surgeon's interaction with other patients, get a sense of the physiology of the spine and figure out if this was the doctor he wanted to operate on his back.

Doctors also find value in the visits. They work with a team, including nurses who take vital signs and keep records, and social workers or therapists who address psychological concerns. Doctors save time by educating multiple patients at once about similar issues.

"Why should a doctor say the same thing over 15 times a day," Neuwirth asked, "when he could be spending that extra time answering questions?"

Practices vary

Group appointments work for all types of visits, from primary care to surgical consultations, Noffsinger said. They differ from support groups or classes because everyone in the room gets direct medical care. Under Noffsinger's concept, patients come to group appointments only when they have a medical need.

That's different from the prenatal and well-baby groups offered at UNC. Based on Centering Pregnancy, the model developed by nurse-midwife Rising, the UNC visits include individual medical care, but patients in the group meet on the same schedule for a defined period instead of making appointments as needed.

Dr. Sheila Kilbane, a Charlotte pediatrician, recently began offering a variation on group appointments, without individual medical care. These groups don't meet Noffsinger's definition of group medical appointments, but Kilbane created them with similar frustrations and goals in mind.

During a normal day of office visits, "I'm saying the same thing all day long," Kilbane said. "So I thought, 'Wouldn't it be good if we could have a group of parents come together for a longer period of time? Most people have very similar questions, so they all benefit from hearing the discussion."

Kilbane recently led two two-hour sessions for 20 parents with shared concerns about their children with food allergies, attention deficit disorder, sensory integration disorder and autism. In addition to hearing from Kilbane and occupational therapist Kristen Oliver, parents had plenty of time to ask questions and offer their own suggestions.

"Thank you. I'm inspired," said Carmen Cawley, a north Charlotte mother of 3-year-old twins, one with autism. After hearing the discussion at the first meeting, she switched her son from dairy to almond milk.

"We definitely think he does better off dairy," Cawley said. "It was nice to meet other moms of children with similar issues and to hear some alternative things that can help."

'Learn from each other'

Last week at CMC-NorthEast, Chow's group appointment for arthritis patients started with Susan Yaguda, a clinical nurse specialist, asking each patient to sign a form agreeing to keep others' health information confidential.

She explained how the appointment would flow and encouraged them to "learn from each other."

When several patients said they have trouble sleeping, Jennifer Hagler, 36, of Concord described the rituals that help her calm down before bedtime -- washing dishes, straightening the house, taking a bath.

Hagler has been to several group appointments and is pleased with the experience.

"I like the ability to hear how he explains things to other people," she said. "And it helps to see that other people are going through the same thing."

Copyright 2013 - The Charlotte Observer

McClatchy-Tribune News Service

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