'Doctors have traditionally seen their patients using a one-to-one, closed door model that is designed to get patients in and out quickly and efficiently. However, the rise in chronic disease has changed the kind of treatment many patients need. Dr Garry Egger suggests that shared medical appointments could improve chronic disease management in Australia.
It’s perhaps ironic that while health services have changed dramatically over the years, the delivery of these services—at least at the primary care level—has remained largely the same.
If you have a health problem—or even if you just need a check-up—you visit your doctor. You’re usually in a closed room, with just him or her, for a hurried discussion about your problem.
By necessity of demand, this is designed to get you in and out as quickly and efficiently as possible, everyone else can get their equal share of care.
You’ll probably leave thinking ‘I forgot to ask about such and such’, or ‘I really didn’t get a chance to talk, because she was so busy typing my notes into the computer’, or ‘I didn’t really understand what was said—it was so quick’.
Still, that’s the system that’s been with us for centuries. Since the shaman and witch doctors of tribal societies, it’s usually been one-on-one consulting—one expert advising you on what to do to improve your health, and little old you, sitting back and lapping it up as the passive recipient.
While this model of healthcare delivery has served us well in the past, the time has come to re-evaluate the approach; to maybe visit the doctor in a different way; where things are more laid back and more of your questions get answered.
The Americans, with all the deficiencies of their health care system, came up with a strategy in the 1990s called ‘group visits’ or ‘shared medical appointments’. This was developed by an American clinician, Dr Ed Noffsinger who, when very sick himself in the 1980s, decided that he wanted three things from his healthcare system:
1. Immediate accessibility to the doctor of his choice;
2. Having more time to discuss his problem with that doctor; and
3. Getting support and information from others with similar health problems.
Noffsinger trialled sequential consultations with up to 15 people at a time seeing the doctor over the course of an hour, and with two to three other health professionals in the room doing their thing for up to 20 minutes before and after the doctor entered the room. This then became an individual consultation but with others listening, observing, and where appropriate, participating, in the consultation.
Both patients and doctors seemed to benefit. In the following years he tested it with the most extreme groups—homeless native Indians in British Columbia, mental health cases in San Francisco, cancer survivors in Ohio. It worked well and was extremely popular under all conditions, and hence expanded to Canada and parts of Europe.
With a grant from the RACGP, the Australian Lifestyle Medicine Association in Sydney and the Baker International Diabetes Institute in Melbourne trialled a number of shared medical appointments over six months in different parts of the country
While the trial didn’t run long enough to measure the health outcomes from this, patient and provider satisfaction with the process was found to be overwhelming.
More than 90 per cent of patients from around 220 shared visits claimed they would probably or definitely continue to use shared medical appointments if they were available at their medical centre. Ninety-five per cent rated them as a good or great form of medical care, and most thought they would be good for anyone.
Of particular interest was the popularity amongst one group of Indigenous men with whom the process was tested three times. All found it much more valuable and less threatening than the often ‘scary’ experience for them, of seeing a doctor alone in a closed office. They saw it more like a traditional ‘yarn-up’ that’s part of the Aboriginal culture.
Importantly, more than 60 per cent claimed one shared medical appointment would reduce the number of other one-to-one visits they would need with their doctor. If every type 2 diabetic patient in Australia went to the doctor one less time in a year, this would save the health system more than $100 million. Factor in heart disease, respiratory problems, and all the other chronic disease ailments and you’ve got huge potential cost savings though such a simple change in process.
On the provider side, all of the doctors involved enjoyed the group visits approach, and want to continue being involved in these. They benefited mostly from not having to repeat the same advice over and over to patients, not having to type in medical records—these are inputted by a facilitator—being able to relax and hear patients share experiences more, and getting other patients to contribute practical advice.
The key to a good shared medical appointment is the facilitator, who runs the show for the doctor, keeps him or her on time, manages any complex group dynamics, and can also contribute to the consultation in some cases. Currently, there’s no such creature in the Australian health care system. However, practice nurses, who make up one of the fastest growing professions in the country, are ideally suited to take on the role with minimal extra training.
Naturally the first obstacle that crops up when shared medical appointments are mentioned, is confidentiality: ‘How can I talk to my doctor about personal matters without somebody in the group going off and telling the rest of the world about this?' Participants sign a confidentiality agreement to protect against this, but we were shocked at the level of intimacy patients shared with each other in a group situation, once they got started—from sexual function and erectile dysfunction, to bowel habits.
While shared medical appointments are not for every patient or every provider, the only real restriction to their expansion into Australian medical centres, apart from Medicare compensation, (which is currently being worked out), is the reluctance of doctors to change a system which they’ve never been taught to question
However, with chronic disease now making up around 70 per cent of all presentations to primary care, with costs rising rapidly and with no apparent end to the chronic disease epidemic in sight, all options need to be put on the table.
The idea of SMAs is not to replace standard medical consultations, but to provide an adjunct to these in specific cases where they are likely to be most helpful.
Improvements in the science of medicine mean we know so much about the content of diseases—what causes them, what prevents them, and the medical interventions that may help to treat them—albeit at ever increasing cost.
What we need more of is a conscientious look at processes: how do we manage chronically ill patients and help them manage themselves in an era of chronic disease with drastically changed causality. Shared medical appointments may be just one-way of doing this—if we get it right.' http://www.abc.net.au/radionational/programs/ockhamsrazor/5951658
Is the option of group consultations something worth considering in your country? For your profession? In your specific place of work? As a patient would you see this process has having merit? Would you be happy to join a group consultation?
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It is proposed that health professionals should offer group consultations in our country