Amanda Brower

William Steers, MD, wanted to put shared medical appointments (SMAs) to the test in his busy urology department at the University of Virginia Health System, Charlottesville, VA, where he serves as chair. A shortage of urologists and a growing number of patients kept a heavy backlog of patients from being seen in a timely fashion. After hearing an interview on National Public Radio about SMAs as a way to provide prompt access to care, improve patient satisfaction, increase productivity, produce more comprehensive care, and cut costs, Dr. Steers thought SMAs might be a solution.

Although SMAs are a radical departure from the traditional doctor-patient visit, they are being conducted by a handful of urologists, including Dr. Steers.

An SMA is a physician-to-patient visit in the presence of other patients awaiting their turn. During a typical 90-minute SMA, patients discuss their health concerns in front of other patients and listen to strangers talk about theirs. Virtually everything-diagnoses, prescriptions, medical histories, treatment-is discussed in the group setting. These are not, however, support groups, patient education programs, or group counseling sessions.

"It is not a lecture and not a health talk," said J. Stephen Jones, MD, vice chairman of the Glickman Urological and Kidney Institute at Cleveland Clinic, who has been successfully conducting SMAs for the past 8 years.

The idea for SMAs was borne out of one health care professional’s unhappy experiences while battling a life-threatening disease. After he recovered in 1996, Edward Noffsinger, PhD, then director of clinical access improvement at Palo Alto Medical Foundation for the Kaiser Permanente Medical Centers in California, wanted to fix what he considered broken.

"I wanted prompt access to care, I wanted 90 minutes with my doctor, and I wanted the help and support of my fellow patients," he said.

As an adviser, Dr. Noffsinger has helped implement SMAs for more than 400 physicians and medical centers around the world, resulting in more than 20,000 patient visits. He is currently the vice president of Shared Medical Appointments and Group-Based Disease Management at Harvard Vanguard Medical Associates in the Boston area.

After hearing Dr. Noffsinger on NPR, Dr. Steers asked him to help start an SMA. His expertise has been essential in eliminating potential pitfalls, Dr. Steers said.

Dr. Steers found that he enjoyed the group format, and that his patients were much more satisfied in a group setting because of the additional time they had to ask questions and discuss their care. He also found patient care improved.

"The big surprise in the group appointment was how many drug side effects and interactions were happening, which in an individual appointment were not really coming out," said Dr. Steers. "One person would say something and another would chime in about cognitive impairment associated with antimuscarinic drugs or patients getting a little more confused while taking a drug. I saw a trend."

When Cleveland Clinic opened its new urology and kidney building in 2008, the design included dedicated space to accommodate urology SMAs. Dr. Noffsinger also advised Cleveland Clinic on how to successfully run shared appointments.

"We continue to be big believers in shared medical appointments," Dr. Jones said.

Cleveland Clinic conducts SMAs for wide range of urologic conditions, including prostate cancer, interstitial cystitis, incontinence, bladder cancer, and erectile dysfunction.

"There are several advantages that we found from the group appointment and probably the biggest one is patient satisfaction and care," said Dr. Jones.

The opportunity for patients to learn from each other’s conditions is one reason Zeev Neuwirth, MD, is a proponent of SMAs. Dr. Neuwirth, chief of clinical effectiveness and innovation at Harvard Vanguard Medical Associates in Boston, has spearheaded the launch of SMAs across a wide range of medical specialties over the past 2 years, including pediatrics, dermatology, neurology, and cardiology. Vanguard will soon implement SMAs in nephrology and plans to add pain management, rheumatology, and urology, with a goal of more than 50 by the end of the year.

SMAs improve access for patients and reduce workloads for health care professionals, he said.

"It is difficult to measure, but there is some soft data that suggests patients with a number of conditions might actually have better physical outcomes," said Dr. Jones. "Just as diabetics are better controlled, people with prostate cancer risk may have a higher likelihood of having their cancer detected early because they are getting more intense and productive medical interaction."

Dr. Jones regularly holds group appointments for men at risk of prostate cancer. These patients have had negative biopsy results, but are at risk for prostate cancer because of an elevated PSA level. He finds the group setting allows him to more quickly cover common issues, such as risk and counseling.

"In your standard, in-and-out appointment in a busy medical practice, it can be difficult to discuss all of the issues patients are concerned about," Dr. Jones said. "When you can discuss with the first patient (patient A) most of the issues, by the time you get to patient B, you do not have to go back and reiterate but build upon it or elaborate."

For patients with chronic conditions such as interstitial cystitis, SMAs can be very therapeutic.

"Patients with incontinence may find that their condition is not as severe after attending a group appointment because it is very helpful to hear from others," said Dr. Jones.

Often, patients are more comfortable talking about personal issues in a group setting than they are one-on-one with their physician, Dr. Noffsinger said. He attributes this to the relaxed nature of the SMA. Patients who are nervous asking personal questions alone with their physician feel encouraged to do so when they see others sharing personal issues in a group.

Patient satisfaction with SMAs at Cleveland Clinic is well over 90%, with most patients returning for follow-up appointments, according to Dr. Jones.

SMAs shift patient care toward prevention and wellness. For example, time is available in the group appointment to emphasize the importance of kidney stone preventive strategies, taking medications, weight loss, and how to better control incontinence, said Dr. Steers.

Peer pressure from others in the group also keeps patients on track.

"I think there are very few ways to effectively accomplish some of our goals," Dr. Steers said. "It does get us back to basic principles of medicine-patient contact, interaction, dialogue, listening to their history-and it gets away from doing a test, image, or lab."

Dr. Jones agreed: "We have found group appointments as one way to get more in-depth as a opposed to pilling on procedures and instead emphasizing wellness."

SMAs bring back the team approach to medicine, Dr. Neuwirth said.

"We learned in a group format, not in a room alone with a patient. We learned in rounds, which are about learning," he said. "Essentially, this is taking the origins of our development and bringing it into practice, which is incredibly liberating for a clinician."

"If you triple your productivity, which is usually my goal with physicians, that means that they are doing 4.5 hours of work in 1.5 hours," Dr. Noffsinger said. "That is a net gain of 3 hours of physician time; in other words, for every 12 groups that are SMAs, the result is 36 hours of physician time saved, without adding an additional physician."

Essentially, the equivalent of a full-time physician is created from efficient use of physicians’ time without an increase in overhead expenditure, he says.

The savings can be substantial. "If you launched 18 of these a year, the savings is more than $6 million within 7 years," Dr. Noffsinger said. "The physician is able to see three times as many patients in a 90-minute period because they are delegating non-medical tasks."

Harvard Vanguard is studying how much group visits save.

"If you add up the number of hours a day it takes for a primary care physician to practice medicine, it takes 18 hours a day and it is just not doable," said Dr. Neuwirth. "We have some physicians that you cannot get a general appointment with for several months, at least you couldn’t until they started doing shared medical appointments."

Dr. Jones calls it the "doorknob phenomenon."

"Physicians so often feel like they need to have their hand on the doorknob to see the next patient," he explained. "In a group appointment, you are committed to caring for a group in an hour and half, which is why I think patients are happy with it because they feel like they get more from the physician than they would one on one, which is a little counterintuitive."

Dr. Steers agrees. "It is not intuitively obvious and we were really surprised how well they worked," he said. "Urologists may not think that it would fit well with urology, but it amazingly does work."

Dr. Steers said physicians, not patients, are most opposed to SMAs. He often finds other urologists concerned that SMAs destroy the sanctity of medicine. Physicians do not like being questioned in public and challenged in a group setting, he said. In addition, many urologists just cannot make the switch.

"Just because you are taught since 1900 that one-on-one interaction is the way to provide care, it doesn’t necessarily mean that in the 21st century it is correct," said Dr. Steers.

Sometimes, though, it’s patients who need to be convinced to try an SMA, which can require strong leadership on the part of physicians and staff.

"In an era of limited resources, an era of a shortage of urologists, this is one solution," Dr. Steers said. "It may not be the best solution and probably not the only solution, but it works."

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Although shared medical appointments are a radical departure from the traditional doctor-patient visit, they are being conducted by a handful of urologists.

Author | Amanda Brower

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Shared appointments improve patient satisfaction, access