Some doctors turning patient visits into group experience

Model allows patients to get appointments faster, but privacy concerns being raised

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Gunny Alford, a 63-year-old with advanced liver disease, took a seat as his doctor listened to his heart as part of a regular checkup.

As the UC San Diego physician explained lab results and asked about Alford's recent symptoms, several other patients and their family members looked on, paying close attention.

A liver transplant specialist, Alexander Kuo, explained to the group that Alford had cirrhosis of the liver from years of drinking but was doing well and would be an excellent candidate for a transplant.

"Your blood work looks good," Kuo told Alford. "This is beautiful."

A growing number of physicians around the nation are turning the traditional medical visit inside out, making what were once one-on-one, private appointments a group experience.

Shared medical appointments are becoming more widespread as physicians look for more efficient and effective ways to treat increasing numbers of patients with chronic diseases. The visits could increase significantly under the nation's healthcare overhaul when millions more Americans gain insurance coverage and need to access doctors. Multi-patient appointments are especially valuable in areas with physician shortages, proponents say.

Group appointments are being offered through UC San Diego to patients with diabetes, HIV and liver disease. Obesity and diabetes patients at the L.A. County-run Martin Luther King outpatient and specialty health clinic also have the option of attending group visits, and similar programs are being rolled out in Massachusetts, North Carolina and Ohio.

Proponents say the model allows patients to get appointments faster and spend more time with doctors. Physicians like not having to repeat themselves several times a day to people with the same ailments. Research shows that for certain patients, group visits can reinforce healthy behaviors and reduce emergency room visits.

"I can tell them until I am blue in the face what they have to do," Kuo said. "The peer pressure of the group does the trick."

But the practice is raising concerns about privacy, as doctors share patients' confidential and intimate medical details with group members. "It is a recipe for disaster," said attorney Rabeh M.A. Soofi, who handles privacy cases. "It is just a matter of time before there is going to be an increase in litigation involving group physician visits."

At most shared appointments, patients and their family members are required to sign confidentiality agreements, promising not to talk about other patients outside the room.

Edward Noffsinger, a Northern California psychologist who helped pioneer group appointments, said they won't work for everyone. But with a growing physician shortage, they offer an alternative for doctors and clinics facing patient backlogs and busy schedules.

At the Martin Luther King clinic, endocrinologist Theodore Friedman leads a two-hour group appointment for obese patients. The sessions are a mix of a social gathering, support group, health education class and personal medical discussion.

During a recent appointment, Friedman asked two dozen patients seated in a conference room why they were there. Several wanted to lose weight. Friedman, speaking with the help of a Spanish translator, stressed the dangers of being overweight, including heart disease, diabetes and high blood pressure.

Then he shed his lab coat and started an exercise video. "Everyone who can, stand up," he said. "And don't watch me. I have no rhythm." Following Friedman's lead, other clinic staff joined patients in several minutes of stretching, bouncing side to side and breaking a sweat.

The patients also watched a demonstration on cooking a healthy stew and listened to a presentation about the harmful effects of too much fast food. Meanwhile, Friedman made his way around the room to chat with each patient, checking their lab work and evaluating their medications.

"We've got to get you better," he told one woman with diabetes after reviewing her chart. He asked her to schedule a personal appointment and assured her that they could get her disease under control with medication, diet and exercise.

Several of the same patients were back for a group session the next month. One reported eating more vegetables; another started walking more. A third cut out fast food.

The group applauded when Maricela Guajardo said she lost 15 pounds by giving up soda and tortillas. "It helps making a commitment to others," Guajardo said afterward.

That's one key advantage of group appointments, Friedman said. In addition to seeing the doctor, patients regularly interact with dietitians, orthopedists, social workers and one another. And they learn from questions others raise and how others are managing their disease.

"If you walk into a room and see other people who face the same challenges and struggles, that can be very empowering," said Ellen Rothman, the Los Angeles clinic's interim medical director.

The American Academy of Family Physicians supports the appointments because they improve results for patients, said President Jeff Cain.

Wells Shoemaker, medical director of the California Association of Physician Groups, said the visits can be a great model for patients with chronic disease, but some doctors worry about privacy and cultural differences among patients. The unconventional nature of the appointments also can create billing issues with insurance companies, he said.

At Kuo's group session in a San Diego medical office building, several patients and family members signed confidentiality agreements as nurse Nina Krishun reminded them, "You are entering a safe zone."

Kuo arrived a short time later and invited individual patients to step forward for their exams. Kuo said they were similar to regular doctor visits, with one difference: "They just happen to have an audience." Between patients, Krishun led discussions on diet and liver disease symptoms, with patients eagerly volunteering experiences and suggestions.

The discussions can be chatty, eclectic and frank, passing quickly from bowel movements to staying sober and complications of transplant surgery. As he prepared to examine patient Rory Baker, a 51-year-old hair stylist, Kuo explained to the group that Baker had liver disease that was causing fluid to build up in his abdomen. "His liver function has started to go south," Kuo said.

Kuo checked swelling in Baker's stomach and ankles, listened to his breathing and asked whether he had any recent confusion, a common symptom of advanced liver disease. Kuo said he would adjust Baker's medication to reduce fluid retention. But overall, he said, "You are status quo."

Mark Terry, a candidate for a transplant, said that hearing what other patients have to say about the experience is nearly as valuable as talking to the doctor.

"It helps me be prepared for what can happen," he said. "As long as the group exists, I'll keep coming."

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