In shared appointments the interaction with one participant can stimulate questions from others. The information that emerges during these additional exchanges can be useful for everyone – even the doctor.
Kamalini Ramdas, Professor of Management Science and Operations at London Business School, has done a lot of research into shared medical appointments in the USA where organisations such as the Cleveland Clinic in Ohio and the University of Virginia Health System in the USA are long term users. Based on this research, the Aravind Eye Care System in India has become a recent adopter.
She explains why they seem to work so well: “Many patients feel anxious and pressured in consultations. They often want to know more about their condition and prognosis than a physician has time to give. Moreover, patients are able to see a doctor more often simply by joining scheduled shared consulting sessions and they provide a ready-made support group for patients with similar conditions.”
Joining the club
The University of Virginia Health System has pioneered shared medical appointments for cardiology patients with its Club Red initiative. Traditionally, cardiology patients at UVA are allotted half an hour with the doctor. At Club Red, they can choose between that personal appointment and a 90 minute appointment in which the consultant meets the patients in a group with 6 to 12 others.
Those participating in Club Red go straight to the meeting room where they complete any paperwork and get to know to each other. They each see the physician for a few physical tests. The rest of the consultation is run as group. The physician gives individual advice, reviews therapies, prescribes further diagnostics and discusses progress and set-backs and future plans while others listen in. Everyone shares with and learns from everyone else while at the same time maintaining confidentiality within the group.
UVA has documented several benefits. Productivity has soared. In a 90 minute session a physician can see a dozen patients rather than the usual three to five. Outcomes have improved and patient satisfaction runs at about 98%. Professor Ramdas says: “Surprisingly, those who attend Club Red shared appointments seem to develop a stronger connection with the doctor, perhaps as a result of seeing first-hand the way in which he or she interacts and sympathises with many patients. The outcomes are beneficial too – overweight patients in Club Red lose more weight than those who attend the more usual one-on-one consultations.
At the Cleveland Clinic the introduction of shared appointments has reduced waiting lists by almost a third and delivered increased patient satisfaction. The power of the group enables patients to share information about prescriptions, tests, progress and challenges.
In both instances, shared medical appointments have added value for patients, clinicians and the system. But while shared medical appointments might work well for groups of people with long-term conditions whose ongoing needs are similar, they will not necessarily always be the answer for health systems seeking to increase value.
In a Harvard Business Review article , Professor Ramdas gives an example where individual appointments are preferred: “The West German Headache Center in Essen, Germany, uses group appointments for treatment but not for diagnosis. This migraine clinic found that although patients get significant amounts of similar information on their first visit, suggesting a potential for shared appointments, the value of the interaction depends critically on the accuracy of the individual diagnosis, which is better in private meetings.”
Changing the culture
Doctors who have pioneered the shared appointment approach report that there are significant challenges involved. Dr Marianne Sumego, director of shared medical appointments, Cleveland Clinic, tells the story of introducing shared medical appointments in diabetes care at the Cleveland Clinic back in 1999. She says: “I didn't realise how innovative it was, because it just seemed natural to me that I wanted to spend more time and be able to convey more to my patients. The patient response was tremendous, and so, five years ago, we really looked at taking that to the next level and organisationally committing to offering shared medical appointments.”
She identifies culture change as the most significant challenge. “When you're changing a care model that has been around for a long time, there are a lot of unknowns. The challenge is how do you implement and get buy-in for a care model that folks haven't done before, may not be familiar with, and don't know how to implement?”
Physicians and nurses are trained in a model of personal service and privacy; the shared medical appointment is a fundamental challenge to that mind-set. They need shared goals and a way of testing the innovation against agreed standards. Dr Sumego says: “Your team is part of that challenge. They have to know what you're trying to accomplish. They have to know how to help you. The physicians are worried about what's the patient going to think. Is this the same quality of care? Am I going to be able to get the efficiencies that are marketed, or am I going to just have chaos because I really don't know how to manage a group of ten? And then patients. You have to make them understand what their appointment is, what the expectation is.
“So, if an organisation was looking to start shared medical appointments, I would advise them to start small. Get the buy-in from a few champion physicians, develop the workflow and develop some experience. Put an infrastructure behind what that best practice should look like. Create some standards so that, as the concept spreads, you can leverage that experience to start the next shared medical appointments and the next.”
Dr Rengaraj Ventakesh, chief medical officer at Aravind Eye Hospital, Pondicherry, has taken this advice as he starts to develop shared medical appointments at Aravind Eye Care System in India. He says: “We had a lot of meetings with our medical team to find out how we can implement this safely, and I think, the biggest challenge is to make them understand the concept and how it would benefit our patients. Once we could take it across to our team, we wanted to try it safely and practise it on a very safe period of time.”
Aravind piloted shared medical appointments at the weekends – when patient volumes at this high-throughput centre are smaller – and has gradually rolled that out to one weekday. They started with 20 patients per group but found that too large and too noisy and scaled it back to five. Patient satisfaction is now high as is feedback from the medical teams involved.
“I'm sure it's got a very bright future,” says Dr Ventakesh. “My advice to healthcare systems wanting to try shared medical appointments would be to see those practices and discuss with them, read material on this, and then start practising it.”
Just as patients learn from the experience of others, innovating systems is sometimes best achieved by observing what works for others and copying it.
Redesigning the process
Professor Ramdas says her work has shown that there is more to shared medical appointments than simply pooling patients. Which cohorts of patients will see added value? What is the optimal group size? Who does what in a new system? Where should shared medical appointments take place? How long should they last? What are the shared goals and outcomes? A lot of research is needed to answer these questions.
Often making the change requires an overhaul of the whole process that may challenge some preconceived notions. Take, for example, note-taking. In the usual (non-group) model, the doctor, who is responsible for creating the medical record, takes notes. In a group appointment a nurse takes notes electronically. Patients see a copy before they leave, confirming their veracity and printing off a paper copy that records prescriptions and suggested changes to regimen. Healthcare professionals may fear that patients will complain at the lack of personal care. In fact, the opposite happens. Patients like the fact that doctors look them in the eye and have time for dialogue rather than having their faces buried in notepads for half the consultation.
Dr Steven Kaufman, medical director, Urban Health Institute, Cooper Health System, pioneered shared medical appointments in diabetes care in a disadvantaged area where access to healthcare is poor. He says the benefits of shared medical appointments are so overwhelming that he expects to see more take up of the model: “We get constant feedback from patients, which is just so rewarding because there is nothing like being a physician, or the team I work with - the nurses, pharmacists - just to hear from patients about the experience and how much they've gained from learning from others.”