The Doctor Will See You and You and You and You and You Now…
More than 100 million patients in the United States suffer from chronic conditions, such as diabetes, cirrhosis or HIV. Even though these diseases demand constant management by patients, access to doctors, such as endocrinologists and hepatologists, can be hampered by long waits for appointments.
To create a better patient experience, UC San Diego Health System has launched a pilot program to increase access to medical experts and comprehensive patient education through shared medical appointments. With a shared appointment, patients can see their doctors for up to 90 minutes in the company of other patients with the same condition.
“I love my shared medical appointment and think the sessions are beneficial to doctors and nurses too,” said patient Christy Dickson. “Getting any disease diagnosis is scary. One minute you feel fine, and then you’re suddenly thrown into the ‘unhealthy’ category. But in a group medical appointment, you feel like you’re not alone. You learn from your doctor and directly from the mouths of other patients.”
Inside a group medical appointment, five to 10 patients gather in a conference room for their medical visit. Their doctor attends the session accompanied by a nurse and a documentation expert who will record all medical observations and prescription changes. All patients are required to sign a legal form to protect each others privacy and confidentiality so that personal information is not shared outside the appointment.
“When I started with shared medical appointments, I really wanted to focus on patients with advanced liver disease. These are patients with cirrhosis who are either on the waiting list for transplant or are considering being placed on the list,” said Alexander Kuo, MD, chief of hepatology at UC San Diego Health System.
“What I found is that these patients had a lack of information on the complexities of transplantation. The standard 20-minute, one-on-one doctor visit with me just wasn’t enough. The patients needed more time with me and I needed more time with them.”
Kuo’s shared medical appointments bring together both men and women, typically in their mid-50s or 60s. While the cause of the patients’ liver disease ranges from genetic disorders to cancer and alcohol abuse, all share the need to better care for their livers and overall health. Some are newly diagnosed with liver disease, others have already undergone transplantation. Caregivers are welcome to attend and contribute to the information shared.
“One misconception that patients have is that they may need to wear a patient gown. Not true,” said Kuo. “Patients are fully clothed. Limited physical exams are performed in the group setting, this might include listening to breathing, palpating the abdomen and examining the legs for swelling. If the patients need a more extensive exam, one can be done afterwards in a regular exam room.”
The patients sit in a group with Kuo at the front of the room. One at a time, each patient has a face-to-face session with the doctor, who performs a brief exam, reviews all current blood work and tests and asks questions. After the exam, the group may ask questions as well.
“In a regular doctor appointment, your mind works so hard to absorb everything the doctor is saying, and then on the drive home you remember, ‘Oh, I should have asked that!,” said Christy, who has liver disease. “But in a group appointment, nothing is rushed. You have time to ask all your questions and to learn from others questions and answers.”
When appropriate, Kuo takes each person’s medical history as an opportunity to educate the group on various aspects of liver disease. If one person is scheduled for a liver biopsy, for example, he describes the steps of the test and the average wait for results. If another patient enters a clinical trial, he explains why they are eligible. The environment feels like a mini-medical school.
“For me, I have had issues with my weight and feeling cold,” said Christy. “Dr. Kuo asked the group if anyone else had the same issue. Sure enough they did and shared how they addressed it. People offer information about low-sodium diets, high-protein intake and other dietary issues.”
Because some patients with liver disease experience neurologic symptoms caused by a back-up of ammonia in the blood, these patients are prescribed lactulose. Lactulose works by preventing the ammonia produced in the colon from getting absorbed into the bloodstream. The medication causes patients to have frequent bowl movements – a subject which comes up in the sessions.
“Everything is discussed and no one is embarrassed or inhibited. It’s like talking to a friend who really understands you. Your honesty helps others. Your true progress can then be charted. It creates a bond among everyone. Applause, hugs and words of encouragement are not uncommon,” said Christy.
Kuo estimates that 80 to 90 percent of patients in his current medical practice are eligible for shared medical appointments.
“It’s not for everyone,” he said. “If you are extremely bashful, or somewhat of a wallflower, it might not be your cup of tea. If you are domineering, shared medical appointments may not work either. These are the two extremes. But if you fall somewhere in-between, this could be a very helpful and educational experience.”
“The feedback that I get from patients is that they feel like they are part of a community, that they don’t feel alone. By bringing patients with similar problems together, they really feel empowered. This sense of community aids healing.”
Steven Edelman, MD, leads shared medical appointments for patients with diabetes, which requires around-the-clock monitoring.
“Diabetes is 24/7. It is not a urinary tract infection or a cold,” Edelman said. “You have to regulate what you eat, how much you exercise, medication, stress and a number of other variables. With shared medical appointments, you can educate and motivate patients to take a more active role in managing their disease.”
Edelman organizes his patients in groups of ten by Type 1 and Type 2 separately, as well as by gender, male and female.
“For our patients with Type 1 diabetes, technology is often a topic of discussion. The patients compare and contrast devices for insulin pumps and continuous glucose monitoring. Some patients in the room should actually be using a monitoring device. Even though I have diabetes myself and use a device, I often cannot talk patients into using one. But when they hear advice from their peers, many change their minds.”
Edelman puts the patients’ vitals and glucose monitoring data on screen so that the group can analyze the data together.
“We don’t do a comparison to browbeat people. It is a really good strategy for people who have poor glucose control. Instead of a doctor nagging them, they just see themselves among their peers. That seems to be to more powerful in turning these people around,” Edelman said.
“Patients are inherently afraid to do new things. I could talk all day, but not get through to each patient one-to-one. With peers, patients see how well others are doing. People have good suggestions for others about the influencers for diabetes control and give each other suggestions on techniques, skills, phone apps and restaurants that have diabetic-friendly foods. I learn too.”
A Medical Home
Amy Sitapati, MD, interim medical director of the UC San Diego Owen Clinic says that in treating patients with HIV or AIDS, the shared medical appointment is a model that helps give patients a medical home – a requirement of the California HIV/AIDS Research Program.
A medical home is not just a place, but a model for how a hospital delivers primary health care services. Attributes of a medical home include comprehensive, patient-centered care that is coordinated, offers superb access and provides a system-based approach to quality and safety.
“Patient-centered medical homes are being adopted as a care delivery model. With shared medical appointments, we have found something that is effective, especially in light of the Affordable Care Act,” said Sitapati.
“Why adopt shared medical appointments? As a clinician, the best reason to do it is always for the patient. In the first month of implementing shared medical appointments, patients were improving the ability to care for themselves. I was immediately sold.”
Sitapati said that depression is an issue among her patients, as it often is for many patients with chronic disease.
“Our patients take a written self-survey to identify being depressed. Even if they score high, they may not be open to discussion about their mental state. There is a sense of resistance,” she said.
Sitapati is amazed, however, at how rapidly patients can change their minds about receiving mental health services when they hear their peers discuss it.
“In just five seconds, a person in the group can say to another, ‘Wow, it sounds like you’re feeling depressed and having a tough time. I had the same thing and got these services by calling this phone number.’
“If it was just me, as their doctor, asking for them to get the help, they would not have done it. But when a peer says it, it’s easier to accept, almost instantly.”
Sitapati added that shared medical appointments have the ability to help normalize health conditions.
“What my patients learn is that they are part of a larger group. You are HIV-positive and you may feel depressed — but so are lots of others. You are not alone”
Endocrinology, Diabetes and Metabolic Disease