North Shore Medical Center
North Shore Medical Center's Associate Chief of Neurosurgery, Dr. Terence Doorly, conducts a shared medical appointment.
Under the Affordable Care Act, a surge of people will need healthcare, but how will medical professionals be able to accommodate everyone? The Annals of Family Medicine projects that an additional 34 million people will receive health insurance and will need over 51,000 more primary care physicians by 2025 to meet that need. When Massachusetts law mandated health care coverage for its estimated half a million uninsured, wait times for primary care physicians increased.
To solve this problem, some physicians in Massachusetts started practicing “shared medical appointments” (SMA), also known as group visits. In this model, five to 13 patients see the doctor at once for a session that can last up to two hours. For example, patients with diabetes who have similar difficulties share an appointment. After each patient signs a confidentiality agreement, the doctor and perhaps a team of various medical personnel examine each patient one-by-one. Then the doctor leads a discussion with the entire group about questions and symptoms.
Seeing the doctor in a group isn’t a totally new idea. The pioneer of SMAs, Dr. Edward Noffsinger, started practicing group visits in 1996. By 2010, 12.7 percent of family physicians have tried group visits, according to the American Academy of Family Physicians. But for most of these physicians, they tried it out of curiosity. Now groups like the North Shore Medical Center in Massachusetts have been using group visits regularly for a few years and are starting to see the results.
On AirTalk today, Evelina Sands, the Administrative Director at North Shore Physicians Group said she has been instituting SMAs for three years to deal with the increasing number of people who need health care. At North Shore Medical Center, a typical follow-up visit is 15 minutes, so in 90 minutes, a physician can see six patients. In a shared appointment, an internal medicine physician can see 8-10 patients in the same amount of time. Sands said somewhere between 25-30 percent of their patients have tried a shared appointment.
In this model, the benefits are that the patients get more time with a physician, they’re able to ask more questions and they learn from one another’s medical experiences. For doctors, they are able to see more patients in a day and do not need to repeat general information over and over. Also, instead of waiting for months for an individual appointment, patients would not have to wait as long for a group visit.
There are plenty of concerns about shared medical appointments. Many patients are reluctant to discuss private information with other people, and some doctors also find the group setting to be awkward and prefer the confidentiality of individual appointments.
“All our patients must sign a confidentiality agreement, which states that they will not disclose any confidential information about others after the visit. It also allows the physician to discuss the patient’s medical history in front of the group. Our hope is that this provides the patient peace of mind so that they can speak freely and openly in this group setting,” said Sands.
Kyle from Burbank, an AirTalk listener, called to ask about doctor-patient confidentiality. He wondered if the other patients in the group are legally under the same protection as the physician. Sands responded that she has not yet come across that scenario.
Dr. Wells Shoemaker, Medical Director of the California Association of Physician Groups and co-leading Governor Brown’s Health System Redesign for California, said that he was a pediatrician who tried group visits in the 1980s. He discussed on AirTalk why group visits work very well for some illnesses like diabetes but are not practical for other issues because of the lack of intimacy and confidentiality.
Shoemaker said concerning issues like child abuse or a husband who’s drunk, “if I fail to recognize that threat, then I let that family down.”
Sands explained that the patients often attend group appointments out of respect for the physician.
“The physician says to a patient, ‘I think it would be great for you to attend this. I’m going to be running this. We can talk about you.’ That in itself is gold to them. The physician is the expert, and if the patient has that trust in the physician, they’re easily swayed,” she said on AirTalk.
Sands and Shoemaker both spoke on how the comfort of the physician is important. While some physicians do well in group settings, others shy away.
“You have to be really comfortable ‘in your skin,’ so to speak, because they’re really in a fishbowl,” said Sands.
Shoemaker also mentioned other difficulties related to shared medical appointments, namely scheduling and billing. He found group visits to be most effective with an “almost homogenous ethnic group,” but it was difficult to coordinate everyone’s schedules and fill an appointment. If the groups are too small, then this model would be financially unsustainable for physicians. Also, because of different insurance plans with different rules, SMAs are difficult to bill.
“The practicality of administering this in a cottage-based office is a challenge. I eventually had to abandon mine despite my enthusiasm for the idea and despite seeing how well it worked,” said Wells. “But beyond thinking in terms of the usual visit, which is the way a lot of people think about doctors, we’re really looking at new ways of communicating with our patients in a modern world.”
Have you ever participated in a shared medical appointment? Is this new model a plausible solution to health care needs? If group visits gain popularity, would those unwilling to be in a group visit wait longer for individual visits? Are group visits a step forward in health care reform or an attempt to stretch resources?
Evelina Sands, Administrative Director at North Shore Physicians Group in Massachusetts; she has been instituting shared medical appointments for three years.
Wells Shoemaker, M.D., Medical Director of the California Association of Physician Groups, practiced primary care pediatrics for 25 years on the Central Coast and has conducted shared medical appointments. He currently works with medical groups across the state for quality improvement, health disparities, and primary care revitalization. He co-leads Governor Brown’s current task force on Health System Redesign for California.