By Ranit Mishori
Special to The Washington Post
Tuesday, March 9, 2010; HE01
On a recent weekday morning, 15 expectant mothers are gathered in a circle in a large room at a Washington hospital for a collective third trimester checkup.
A midwife is off to one side taking measurements of Marilis Quijada's abdomen and using a Doppler monitor to listen to her baby's heartbeat. She notes the results in Quijada's chart, and as another patient steps forward to be measured -- they each get a turn, and each has an individual chart -- Quijada returns to the circle, where a nurse is leading a conversation on how to recognize the onset of labor.
The women have been booking shared appointments since early pregnancy and are happy, they say, to give up the privacy of a one-on-one visit for the benefits of a group session: more face time collectively with the doctor or midwife and the learning experience of sharing time with other pregnant women.
Caring for multiple patients simultaneously has gotten a new boost as the nation urgently searches for sustainable models of health care. The group visit was cited as one of 10 trends to take seriously by the Future of Family Medicine Project, a national effort headed by the American Academy of Family Physicians looking for ways to improve the delivery of health care for both patients and their doctors.
The important question, of course, is how group appointments measure up. The answer seems to be: surprisingly well.
Colleen Kivlahan of Herndon, a family physician who has been conducting group visits for years, points to research carried out in Chicago, where she practiced earlier. Two groups of patients were compared: One received traditional care, and one attended group appointments. It was no contest, she says. "The 'group visit' folk . . . blew them away in terms of self-management, knowledge, behavior change, dietary and exercise change," as well as in improvements in blood sugar control and cholesterol levels, she said. (These findings were presented at a chronic disease conference but have not yet been published.)
Kivlahan is adamant that group appointments should not be mistaken for some sort of support group or hygiene class. "They're getting comprehensive care in that setting," she said, which includes thorough medical examinations and referrals for lab tests and follow-up with specialists. It's full-fledged medical care.
But, of course, it does require some sacrifice of privacy, which some people handle more easily than others, Kivlahan says. "Patients know that they're going to have their heart and lungs listened to in that setting" -- that is, in front of everybody else in the group, whose members all have the same diagnosis. "Patients actually get used to taking their socks off and having everyone's feet checked simultaneously," she said, referring to a common check for people with diabetes. Patients who need a little more privacy with the doctor are offered a few minutes away from the group.
Providence Hospital in Northeast Washington, where Quijada goes for her group visits, also reports good results. Debra Keith, a nurse-midwife and director of the hospital's Center for Life OB-GYN clinic, says that since group appointments for pregnant women were initiated, the clinic has seen the rate of premature births drop and breast-feeding rates go up.
Quijada, 22, who already has one child, says she prefers the group model to the traditional path she followed for that first birth. Beyond the shorter wait times, she says, she loves the connection she is forming with the other women and feels more on top of what's going on during this pregnancy.
Before the program started in 2007, patients "were facing wait times of two to three hours," Keith recalls. "The physicians and midwives were totally stressed out with the backup because it was like a factory of going in and out of rooms and seeing patients and trying to hurry up."
Now, says Keith, "you can see 10 or 12 women in two hours and give them such good care that they walk away saying, 'I just got the best of it.' "'This is about empowerment'
In the group setting, the women have access not just to doctors, nurses and midwives, but also to each other. They are taught how to take their own and others' blood pressure and weigh themselves. Further, over two hours, they can go much further into depth on topics of pregnancy -- working off each other's questions and experiences -- than would be possible during a 15-minute visit. In fact, the chat about knowing the signs of labor evolved into a discussion -- complete with role-playing -- about how to tell your husband it is time to leave for the hospital.
To Keith, that's the essence of it: "Truly, this is about empowerment." The patients at the clinic are mostly low-income Latinas; some are treated for free and others receive discounts. Before the clinic began group appointments for such women, she points out, "they did not really have the opportunity to participate in their own care. . . . They don't even know what blood pressure is, let alone taking it and figuring out their numbers, using a scale and following their weight. It is really exciting for me, as a provider, to see and hear these women, some of them with a third-grade education, really taking charge of their own health."
By sharing in the group setting, Keith says, "they realize how smart they are and how much they already know. And that's a really powerful thing."
It can also look like a powerful thing from the doctor's point of view. "I've been a family doctor for 26 years, and it generally takes four or five visits with me for people to reveal their whole story," Kivlahan says of the patients coming to the clinic. But "in group settings it is much quicker."
She thinks there's something to the fact that in a group appointment, the doctor is outnumbered. "There isn't that power differential there as with a single physician and a single patient," she says. Often it's embarrassing for patients to be candid one-on-one with a doctor about bad health habits such as smoking or drinking. But in a group, she finds, patients surprisingly "are much more ready to talk." She says this is true of "even very hesitant patients."
Kivlahan said group visits generally haven't "been recognized from the health-care-financing standpoint as an optimal strategy. And that's probably why it is being used primarily on the uninsured."Research shows benefits
Positive results are showing in several studies. One found that women enrolled in group prenatal care used the emergency department less during the third trimester. A recent review of multiple studies that appeared in the Journal of Family Practice found that group prenatal care may reduce the rate of preterm births, especially among minority or low-income women. Some studies have further shown that group care can boost breast-feeding rates and increase general knowledge about what to expect during pregnancy.
And a 2009 study in the Journal of Midwifery and Women's Health showed that participants in the group model chalked up "significantly more prenatal visits, increased weight gain, increased breast-feeding rates and higher overall satisfaction."
A 2006 review of nearly 20 studies published in the Journal of the American Board of Family Medicine called group appointments "a promising approach" to chronic-care management for the motivated patient. It concluded that "there is sufficient data to support the effectiveness of group visits in improving patient and physician satisfaction, quality of care, quality of life and in decreasing emergency department and specialist visits."
While there are sufficient data to support all of these findings, what seems to be missing is definitive proof that patients in group settings are actually healthier -- and have fewer medical issues over time -- than they would if they received usual care with their doctors.
Kivlahan believes that although more research is needed, this is a good model from the patient's perspective: "Patients are able to talk with other people who share their same condition and get and give advice, understand symptoms and adapt to their chronic conditions in a manner that fits their learning style." This is better, she says, than "talking only to their doctor about what it is like to live daily with chronic disease."
Mishori is a family physician and faculty member in the Department of Family Medicine at Georgetown University School of Medicine.