Walter Gardner knew his life was at risk: Nearly 100 pounds overweight, he had developed Type 2 diabetes and needed several prescriptions. Traditional medical appointments had little effect on the 55-year-old’s health. Then he was offered a way to spend more time with his doctor. Gardner seized the opportunity.
“I needed to do something or I probably wasn’t going to make it to 60,” he said.
Instead of rushed, one-on-one huddles in an exam room, Gardner joined eight to 10 peers in shared appointments with a physician to work on health challenges, nutrition and exercise for an hour or more each month.
Group medical appointments, which can last as long as 2½ hours, aim to offer patients expanded information, access and control over their health. They also help providers see more patients more efficiently.
Gardner joined sessions at Cleveland Clinic, which offers more than 200 types of shared appointments, including ones for diabetes or heart disease, male and female wellness, osteoporosis, prenatal and postpartum issues, chronic pain and cancer survivorship.
After more than 800 days, Gardner has dropped 103 pounds, trimmed 14½ inches off his waist and overcome his diagnosis as a diabetic. He has reported to his group as he catalogued his food intake, switched to a Mediterranean-style diet and revved up his exercise. He continues to tally the days since he changed his lifestyle and the hours he has exercised.
Introduced in the 1990s, the shared appointment has proved promising in areas such as managing diabetes and reducing emergency room visits. The large-scale impact of the approach is hard to quantify, however, because they can differ based on staffing and organization.
“When we think of advances in health care, they’re always technology or medication or vaccines, and it’s really time to look at the health-care model,” said Marianne Sumego, an internist and pediatrician who is the director of shared medical appointments at Cleveland Clinic.
Shared appointments allow providers to see more patients than their usual schedules allow, which may prove useful if a national shortage of tens of thousands of physicians develops by 2030, as data from the Association of American Medical Colleges projects.
Ten percent of family physicians offered group appointments in 2015, up from 5.7 percent in 2005, the American Academy of Family Physicians reports.
Group medical appointments were developed by Ed Noffsinger in his work as a psychologist at Kaiser Permanente in California. Sumego, one of the original providers, brought them to Cleveland Clinic in 1999. They are now considered an important, standardized option in the range of care offered there.
Increasing numbers of Cleveland Clinic patients participate in shared appointments each year, and internal surveys suggest a high level of patient satisfaction, particularly in access to care.
Sumego fields calls every week about shared appointments. “I think it’s gaining traction,” she said. “Our success indicates that it’s very sustainable, viable, and that it’s well received.”
Most insurance plans cover the appointments, which are billed as medical visits, similar to usual care. As with all change, there is a development and learning curve in implementing shared appointments, but ultimately shared appointments lower costs of care, Sumego said.
The power of a group can be palpable: Sumego recalls a diabetic who told his fellow patients he was having trouble because he worked a third shift and was not getting lunch. Two others in the group also worked third shifts. They told him that he needed to talk to his boss and then explained what they do and how they take their medications. Sumego said all three benefited from the interaction.
Cleveland Clinic addresses privacy concerns by requiring patients to sign confidentiality paperwork and by having its staff remind patients “how we really want to respect [all participants] and keep the information within the room,” Sumego said.
Several years ago, Joanna Stark, an obstetrician with Kaiser Permanente Santa Clara Medical Center in California, saw two women in back-to-back appointments. Each was 28 weeks pregnant. Each was alone. Each asked similar questions. Stark thought there had to be a way to get these women together. “I’d have more time to answer their questions, and they’d also maybe make a friend,” she explained.
Stark researched shared medical appointments, a concept Kaiser Permanente offers throughout the country. She came across Centering, a licensed group-appointment model developed for prenatal care in the 1990s.
Centering sessions begin and end at promised times. They include one-on-one time with providers along with group time, when patients and providers sit in a circle for informal discussions, with snacks and a range of activities.
Stark and colleagues offer Centering-based pregnancy groups in a comfortable space decorated with plants and pictures on the walls and equipped with a futon with throw pillows in lieu of an exam table. “Patients call us by our first names. We don’t wear our white lab coats. We dress more casually. We’re all at same level,” she said.
Robin Washington, 33, from Campbell, Calif., was hesitant when offered a “CenteringPregnancy” appointment. She was very excited and very scared about being a first-time mom, she said. “I was embarrassed that I had a million questions,” she said. But after she and her husband attended one session and heard from the 11 other couples at roughly the same spot in their pregnancies, she realized that everyone had a million questions.
“There will be somebody who says, ‘What do I do about my hemorrhoids?’ and you feel like, ‘Oh, I’m not alone, I’m not the only one.’ And it just normalizes it. And that is just such a reassuring thing for people,” Stark said.
Because all of the women started to show their pregnancies around the time the group formed, Washington decided to take group baby-bump photos. To share them, she, like moms-to-be in some other groups, created a private Facebook page. While not organized by Kaiser Permanente staff, the Facebook group allowed the women to stay in touch between appointments and after the Centering group ended, even at 2 a.m. nursing time.
Eva Miller’s younger sister died of breast cancer at age 36. The Raleigh, N.C., resident remembers her sister’s long waits for appointments and rushed sessions with busy providers in another city.
So Miller was open to a different kind of medical appointment: a visit with several women who, like her, needed to assess their risk of developing breast cancer. Kathryn Trotter, senior nurse practitioner at Duke University Cancer Center and a Centering group leader and consultant, offered Miller a chance for group medical care, discussion, education and a healthy serving of community and time.
“What I usually say to people is ‘Think of it as an opportunity to kind of delve into some of your questions and concerns that we don’t have time for in an individual visit,’ ” said Trotter.
Miller had no idea what to expect. “Every time I go to the cancer center, it’s extremely emotional, and it’s really hard for me to show up,” she said. But the shared experience was a positive one, in which women voiced a variety of concerns, learned techniques of self-examination and ate healthy snacks before undergoing tests and meeting individually with their provider.
“I definitely felt super supported and that I wasn’t alone on this journey,” Miller said. “It did give me some time and space to think about how am I moving forward with some of my medical decisions.”
Shared medical appointments might not be right for everyone. People who have hearing problems, do not speak a shared language or have complex medical concerns might be better served in a more traditional setting, Sumego said. Some may prefer not to share provider time.
They may not be a perfect fit for every doctor. “There are certainly people who aren’t as comfortable working in front of a group,” said Stark.
Back in Cleveland, Walter Gardner occasionally shares his enthusiasm with medical students and experts.
“You’ve got to go in with an open mind. You realize that you’re going into something where the other patients in the group are facing the same struggles that you’re facing,” he said. And when group members stumble, it’s not “shame on you,” but “what can we do to help you get to your goal?”