Download Should Doctors see patients in group sessions

Should Doctors see patients in group sessions?
By Ken Terry
Senior Editor
Internist Jonathan Walker is standing in front of 15 elderly patients at a Kaiser
Permanente clinic in Denver, asking them to think of discussion topics for their
group's next monthly meeting. He adds that they can get free flu shots there.
Then the doctor proposes a change in the meeting format. He wants to limit
guest speakers, such as dieticians and pharmacists, to 30 or 40 minutes. That
way, he says, he'll have more time to talk with patients individually at the end of
each 90-minute session. "A lot of you have two or three medical problems I'd like
to keep on top of," he says.
The seniors, who all have at least one chronic condition, agree this is a good
idea. But one woman raises her hand and asks plaintively, "Does that mean you
won't spend as much time here?"
"Of course not," replies Walter. Then he changes the subject, explaining why it's
best to get shots just a month or two before the flu season begins.
After a physical therapist's presentation on exercise, Walter and two nurses work
the room. The nurses give needed injections, take blood pressures, and review
charts with patients. Meanwhile, the doctor is busy answering some patients'
questions and buttonholing others who need follow-up or reminders on
preventive care.
Although these encounters are somewhat rushed. Walter says the group
program is "extremely valuable. The group setting is beneficial because people
are relaxed. They're willing to joke and ask some open questions they might not
ask otherwise. They also get a lot of very good, helpful information."
IN the 18 months since he held his first group appointment, he adds. His
relationships with these patients have greatly improved (see page 82). "They
smile, they say hello, they talk personably to me. Now they're good-humored
instead of just grousing about their problems.
"The group has also helped them develop a better perspective on their disease
processes and situations. For one thing, they see other people with similar or
worse problems. And they learn how those people are coping with their
difficulties."
All the patients in the group were invited to join because they were "high
utilizers"--they saw their primary-care doctor or another Kaiser provider at least
once a month. Now, the patients can still visit their doctor in his office whenever
they need to, but Walter says they tend to see him less than in the past.
That raises the quest5in of whether Walter can stay on top of their medical
problems as well as he could before. "It's different from seeing them individually
in the office," he admits. "Sometime the patients feel that, too. They see me in
the group, but they haven't always gotten the chance to talk to me one on one.
I've heard that form some of them, and I'm learning how to adjust my behavior
and the time spent in group sessions so we can get that done."
The group-appointment idea is spreading
Walter is one of about 30 primary-care doctors at Kaiser Colorado who run group
sessions for about 400 seniors. The HMO plans to double that number and
expand the 5-year-old program to more sites. While only a small portion of
Kaiser Colorado's 33,000 Medicare patients will be involved, group appointments
for chronic-disease patients of all ages are in the planning stages. (The seniors
aren't divided into disease-specific groups because they tend to have multiple
health problems.)
Meanwhile, other Kaiser divisions are experimenting with group appointments,
too. The HMO's Hawaii region has senior groups, and the northern California
and Southwest divisions have groups organized around various chronic
diseases. Kaiser's Northwest and Ohio subsidiaries, have both types of groups.
There's also rising interest in the concept outside Kaiser. According to Arne
Beck, Kaiser Colorado's research and development director, Harvard Pilgrim
Health Care, Cigna, and some Blue Cross and Blue Shield plans have inquired
about Kaiser's program. Boston-based Harvard Pilgrim recently launched pilot
groups for chronically ill seniors at two of its staff-model health clinics.
And Chicago's Advocate Health Partners, a large integrated delivery system, is
studying the feasibility of group appointments for its Medicare HMO patients.
"Groups seem to cut down on utilization, improve patient education, and made
physicians more efficient," says FP Lee Sacks, Advocate's president.
Indeed, Kaiser has data showing that senior group appointments have reduced
ER use, hospital admissions, and primary-care office visits, while increasing
patient satisfaction. These favorable findings have emboldened the HMO to go
further. Starting next year, says Beck, Kaiser Colorado would like the patients in
the program to use groups for all primary care except urgent needs; Kaiser's
Northwest division is already doing this with some senior patients.
Critics fear group sessions slight individual needs
That idea alarms internist Sheldon Greenfield, a senior scientist at the New
England Medical Center Health Institute and an authority on doctor-patient
communication. "Even patients who like to be in groups have personal problems
they want to discuss privately with the doctor," he notes. "They have colds,
diarrhea, arthritis, and prostatism--all kinds of complaints. How do they discuss
their back pains in a group?"
Chronic-disease groups, he says, are find for education. "But our work on the
doctor-patient relationship suggests that it's the individual questions that are
important to patients. And almost all of the elderly have multiple problems, which
can't be adequately handled in a group."
While Walter and other Kaiser doctors say they're able to address nearly all
patient concerns in group appointments, Greenfield feels that providing most
primary care in these meetings is going too far. Even if all of a group's patients
have the same chronic disease, he notes, they'll display a range of symptoms
that require different treatments. "Group sessions don't take care of their
individual medical problems," he insists.
Richard Frankel, another communication expert who directs the Primary-Care
Institute at the Highland Health System in Rochester, N.Y., agrees that many
health problems can't be resolved in a group setting. He also opposes the idea
of transferring all non-urgent primary care to group appointments. "Some
concerns are best taken care of in the privacy of a one-to-one relationship," he
says.
But Frankel things it's worthwhile pursuing experiments like Kaiser's to find out
which medical treatments and discussions can be handled most effectively in
groups. At least some care for most of the top 10 diagnoses--including diabetes,
hypertension, and hyperlipidemia--might be properly performed in groups, he
estimates.
What brings patients to group appointments?
Some observers point out that non-attendance has plagued many patient-care
groups. That was true for Healthtrac/Preferred Health Systems, a healthpromotion and demand-management company based in Bethesda, Md., and
Menlo Park, Calif., which tried group appointments in the early '80's. "The
problem was that the seniors who came were just a handful of those who signed
up," recalls Harry Harrington, the firm's executive vice president. "Low
attendance was a huge problem, and it would invariably cause group sessions to
be canceled."
At Kaiser Colorado, some group members attend only one or two meetings or
never show up. But many are regular attendees who come to an average of
eight out of 12 annual sessions, says Beck. Most group members can get to the
meetings without help, although Kaiser has aided some patients with
transportation.
The mail difference between the Healthtrac and Kaiser programs is that the
patient's own doctors lead the Kaiser groups. "The drawing card is that you're
seeing your individual physician," notes GP David Sobel, regional director of
education and health promotion for Kaiser's northern California region.
Observers agree that group appointments provide older patients with muchneeded social support. Frankel notes that getting together with peers has been
shown to improve seniors' functional ability. And group appointments may also
offer some relief to physicians who find it difficult to deal with the "worried well."
"My colleagues are often frustrated with seniors because of the perception that
they're making unnecessary visits," observes Lee Sacks. "Plus, they may have
all day to spend at the doctor's office, and you want to get done in 10 minutes."
The group interaction soaks up some of this need for social support, he
observes.
Walter says that overall, he enjoys dealing with elderly patients more than he
used to. And, in a study comparing physicians involved in group appointments
with ones who weren't, Kaiser found that the physicians who led group sessions
for seniors were more satisfied with their patient encounters. ON the other hand,
doctors who didn't lead groups cited a number of significant problems: insufficient
time allotted for care, redundancy of care, inadequate patient education,
excessive callbacks, and inab9ility to meet all of each patient's needs.
It was because of these frustrating aspects of senior care that internist John
Scott helped establish group appointments at Kaiser Colorado five years ago.
One morning, he recalls, eh saw eight or 10 patients in their 80s. Most had half a
dozen chronic conditions and were taking an array of medications. In a typical
15-minute visit, he notes, "I hadn't really met their needs. And I said to myself,
'There's got to be a better way to do this.'"
Since then, Scott has led several senior groups. "It's a much more enjoyable
way of seeing patients, " he says. "You have the time to discuss the things that
need to be discussed. You don't feel rushed. You feel like you're doing the job
for these people, and they feel that, too. If I can serve 25 of these patients in a
morning, and I can see another group in the afternoon, I've seen 50 patients, and
I can go home on time. To me, that's efficiency on a very personal basis."
Do group sessions cut overutilization?
Kaiser didn't originate the concept of group appointments. Many organizations
have run educational sessions for chronic-disease patients, and a Salt Lake City
pediatrician named Lucy Osborn pioneered group well-child appointments in the
late '70's (see page 90). But Kaiser's physicians may have been the first to do
hands-on primary care in groups of senior patients. Moreover, Kaiser has
measured the impact of its experiment in randomized, controlled trials.
According to the first study, which was conducted for one year, seniors who
attended groups made one and a half fewer visits to their primary-care doctors
than the control patients did. There were also fewer hospitalizations, nursinghome admissions, and ER visits.
Also, "there were significantly fewer callbacks per patient because the nursed
managed that better," says Kaiser Col………
……….
Jonathan Walter has had similar experiences. "Once the patients get
comfortable, it's pretty surprising what they'll ask. I've had men ask me about
impotence in a side discussion. People have been very open about other
medical problems."
Patients also help each other deal with their chronic diseases, says Scott. "Once
when I was talking about arthritis, a little voice in the back of the room said, 'You
mean I'm going to have to live with this? How am I going to do it?" And the lady
next to her had this terrible rheumatoid arthritis, and she held up her hands and
said, 'Honey, see this? At the break, I'll tell you how to live with this.' There isn't
a doctor in the world who could do a better job of education."
Has patient education improved compliance?
Among the core topics that the group appointments must cover are medications,
advance directives, exercise, use of the ER and out-of-area care, home health
care, nursing homes, and durable medical equipment. Beyond that, physicians
and patients are free to discuss anything. The group address most of the
common chronic diseases, sometimes devoting an entire session to one
condition, such as arthritis.
Despite this patient education, Beck admits that there's no hard evidence that
group members manage their conditions better than other patients do. "The
newest data we have suggest that they're function better at one year than the
controls are," he says. "They're less likely to show declines in activities of daily
living. They rate their own health status higher, and they're less likely to report
that they often feel sad or depressed. But whether that's a result of managing
their conditions better or the group support is an open question."
Walter feels that his group patients are more compliant with prescriptions, partly
because group sessions give them contacts with an HMO pharmacist. "They
know a little more about how to take their medications, why they're on the
medicines, and whether there are any potential interactions," he says.
Wouldn't a doctor normally discuss this in the office? "Yes, it's something you
should do. But in the middle of a busy schedule, seeing a lot of people every
day, you can't always go over every little thing."
Aside from the functional data, there's no proof that group patients have better
outcomes. But anecdotal evidence indicates that group appointments do help
patients deal with psychosocial problems. So even if the program doesn't lessen
their physical symptoms, it could enhance their quality of life.
Beck tells about a man who was "the jokester in his group and would tease the
physician. After he had a CABG, he became depressed and seemed to lose his
sense of humor. Then, after several group sessions, he bounced back. And his
wife felt that the group setting 'brought my husband back.'"
The group experience may also help chronic-disease patients by giving them
more confidence, suggests GP David Sobel of Kaiser's northern California
division. He cites a Stanford University study showing that group sessions of
arthritis patients produced significant decreases in pain and office visits. The
study found no direct association, he notes, between health-behavior changes
and improved outcomes. "People got better because they felt more confident
and in control," he says.
John Scott has seen many of his group patients gain in self-confidence. As a
result, he says, they're "more independent and less anxious" than other seniors.
"The group is an opportunity to get their anxieties reduce and their questions
answered," he observes. "The patients are probably using information better and
are less worried about things they shouldn't be worried about."
Can small practices do group appointments?
Some observers believe that group appointments are mainly suited to HMOs,
large group practices, and integrated delivery systems. While the approach
could also be helpful to small practices, it's hard to see how group sessions
would be reimbursed in an "unmanaged world," says FP Lee Sacks, president of
Chicago's Advocate Health Partners, a large integrated system. He also doesn't
think there'd be enough of the right kind of patients in a small practice to make it
economically feasible.
Few physicians in small practices have tried group appointments. But one who
has, pediatrician Lucy Osborn of Salt Lake City, feels that they were a big asset.
"Group
………………….