Monday, December 1, 2008

Shared Medical Appointments - a Clinical and Ethical Innovation

Yesterday's Boston Globe had a fascinating article about shared medical appointments at Harvard Vanguard Medical Associates (HVMA), the group I practiced with for 32 years before retiring from clinical practice last year.

As implemented at HVMA and the Cleveland Clinic, shared medical appointments are 90 minute visits with one's own physician along with perhaps 8 - 10 other patients (see here for HVMA and here for the Cleveland Clinic). In shared appointments physicians do what they would do in a typical 15 minute visit - listen to the patient's story, ask questions, do the necessary physical examination, order tests and prescribe medications. (The intimate components of the physical exam are done outside of the group.)

The literature about shared appointments emphasizes productivity gains, improvement in access, and patient and physician satisfaction with the format. But from historical research I did on an earlier version of the shared appointment and my own experience with a related format in psychiatry, I believe there is an ethical or even spiritual dimension as well.

In 1905 Dr. Joseph Hersey Pratt, then at the Massachusetts General Hospital and later at the New England Medical Center, began to hold what he called the "tuberculosis class" at the Emmanuel Church in Boston. Pratt thought of the class as an efficient way of encouraging patients to follow a rigidly defined regimen of out-of-doors rest, the only treatment for TB at the time. Patients were directed to spend day and night in tents erected on the roofs and balconies of Boston tenements. A "friendly visitor," the prototype of the medical social worker - made regular visits to the home to provide supervision and support, and to assist the family in making the needed practical arrangements. A subsidy provided by Dr. Elwood Worcester, rector of the Emmanuel Church, paid the salary of the friendly visitor and aided in purchasing tents, blankets and other necessities. Pratt ran the class for 18 years. His results with poor patients from Boston appeared to be similar to the results achieved at the best sanataria.

In 1975 I had the privilige of starting an outpatient program for patients with chronic mental illness at the Harvard Community Health Plan (which later became Harvard Vanguard Medical Associates). The medical literature suggested that group-based programs were as effective as individual appointments (see here), so with the same productivity rationale we established a "continuing care group." The group, staffed by a psychiatrist and a psychiatric nurse met weekly, with 5 - 20 patients attending. We met for 90 minutes and discussed medications, managing symptoms, and life.

The group format was indeed efficient. But over time I observed that for many of the patients, as well as for myself, it was more than that. A closeness and sense of shared humanity gradually emerged. It helped patients see themselves as people with illnesses, not as "schizophrenics" and "manic depressives." People were able to help and support each other. Although I had to work hard at the meetings I found the rich human exchange exhilarating and deeply rewarding. It was a thoroughly secular exchange, but I believe a cultural anthropologist would have seen the group as having many elements in common with religious settings.

When I went to the Harvard Vanguard website I saw that my own primary care physician is among those who are offering shared medical appointments. I'm happiest when I have no need to see a health professional, but when I do I look forward to experiencing the format from the patient's perspective!

(The Boston Globe article gives access to a short video clip of a shared medical appointment, with background comments by Dr. Gene Lindsey, who'se leading the shared appointment. I encourage readers to make a two minute investment to watch the video - it's very informative.)


Anonymous said...

Hi Jim,
I agree completely with your perspective that there is another dimension to group patient visits that has not been discussed much in that specific literature nor researched. There is, however, a diverse literature documenting the benefits of group-based or community-based activity, or what might be termed social capital, to borrow a social science term. Our own experience with Shared Medical Appointments over the past year is similar to your known.
First of all - there are concrete informational benefits that derive from having other patients in the visit. Other patients often ask questions or raise issues that one might have forgotten or not think to ask. Patients also have access to knowledge that the physician might not have - issues like local community-based resources that patients can take advantage of, etc... But, on another level, there is an almost intangible quality to the group patient visit that is difficult to describe. Patients often come away from these group visits energized. There is clearly the aspect of empathy and listening - having other people listen and pay attention to us (without criticizing or critiquing)- a rare luxury in these fast-paced times. And then there's the issue of simply having the opportunity to share with others who are in a similar situation. There is a commonality to being a patient, no matter what illness, concern or disease one is coping with. And yet, the experience of being a patient is typically a lonely, isolating and frustrating one - often a disempowering one. The group visit and the group process during that visit afford patients the ability to transcend the isolation and any sense of disenfranchisement. Far from being an imposition on one's privacy, the group visit format is a an unusual opportunity in our technocratic health care environment to discover comfort, hope and healing; and to create a little oasis - a community of caring with one's doctor and one's patient colleagues.

Jim Sabin said...

Hi Zeev -

Thank you for these very thoughtful and illuminating comments. I especially like the end of your last sentence - " create a little oasis - a community of caring with one's doctor and one's patient colleagues."

I have been priviliged to have been the physician leader of group visits in psychiatry in the past, but as I said in the post - I'm looking forward to being a patient in a group visit with my own primary care physician in the future!

Best to all at Harvard Vanguard Medical Associates!


Anonymous said...

I was interested in reading the linked articles, but they appear to be non-functioning. Could you re-link, or alternatively provide the full citations?


Jim Sabin said...

Dear Anonymous -

I'm glad you are interested in this fascinating topic.

I checked the links - they appear to be OK except for the link to the article I wrote. I need some help from the web guru in my academic department to reestablish the link, and I'll try to do that later this week, but the reference is: Sabin JE. Research findings on chronic mental illness: a model for continuing care in the health maintenance organization. Comprehensive Psychiatry 1978; 19:83-95.

I redid the link to the video and it seems to be working, but if it crumps for you you can access the video via the Boston Globe article mentioned in the first sentence.

I'll be interested in your further thoughts on shared medical appointments!