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The doctor will see all of you now

Amid physician shortage, shared visits get a tryout

By Liz Kowalczyk
Globe Staff / November 30, 2008
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WELLESLEY - When Dr. Gene Lindsey arrived to see his 4 p.m. appointment on a recent Thursday, his nine patients already were seated on folding chairs arranged in a semicircle around a table of snacks. Lindsey, a cardiologist, shook each patient's hand, rolled up his sleeves, and, for the next 90 minutes, examined them, one by one.

As he listened to lungs and hearts, he discussed their personal medical details out loud.

Since July, Lindsey has been seeing his Harvard Vanguard Medical Associates patients only in groups, formally called shared medical appointments. It's part of an ambitious plan by Harvard Vanguard to ease physician shortages, and reduce patient and doctor dissatisfaction over constantly feeling rushed during appointments.

Many patients, it turns out, are willing to sacrifice privacy and modesty for improved access to doctors. Patients willing to see their doctor in a group visit generally can get appointments far sooner. And many pa tients have similar problems and questions, and can learn from one another in the group visits. If a particular examination requires that a patient disrobe, the doctor and patient move into a private room for that portion of the checkup.

Doctors don't have to repeat the same information to patients individually throughout the day. And if the groups - offered in many specialties - are full, doctors make out better financially. Many insurers generally pay what they would if the doctor were seeing those patients individually. A doctor normally would see four to six patients in 90 minutes if he or she were seeing them one-on-one.

"It was fabulous," said Nicholas Poly, an 80-year-old retired engineer who saw Lindsey during the Thursday group visit. "I have problems similar to what other people have. I get to hear their questions too, and that's good."

While many patients seem to like group appointments, they are clearly not for everyone.

Walter Kelly, 89, began seeing Lindsey five years ago after he got a pacemaker for his heart murmur. "I was mostly curious," he said. "I am not an intensely private person so I don't mind sharing these sorts of things." But after attending two group visits, Kelly said he would rather see Lindsey individually if that were an option.

Harvard Vanguard found in a survey this year that 77 percent of patients who had attended one said they would do so again, 15 percent said they weren't sure, and 5 percent said they would not schedule another group visit.

"The 15-to-20-minute medical appointment is a failure," Lindsey, Harvard Vanguard's chief executive, declared in a recent interview. "For doctors, it's too much to do in a short period of time. For patients, it's not enough time with the doctor to get their needs met."

By the end of next year, Harvard Vanguard plans to offer shared medical appointments with at least 50 doctors and nurse practitioners, which would make it the largest such practice in the country, doctors there said. Earlier this year, Harvard Vanguard hired Ed Noffsinger, who developed group visits at California-based Kaiser Permanente more than a decade ago and is considered the national expert on the topic, to run its program.

Partners HealthCare, the parent organization of Massachusetts General and Brigham and Women's hospitals, is exploring shared appointments again. The network experimented with the idea a decade ago, but not enough patients enrolled because the groups were for too narrow a patient population.

"We think a lot of patients for whom access is a real problem will be ready to try this," said Dr. Thomas Lee, chief executive of Partners' physicians network.

For the group appointment to work, physicians must bring in additional staff and develop strict privacy policies. When patients arrived for their appointment with Lindsey last week, medical assistant Sally Gaudaitis took their vital signs and gave vaccines in a small exam room next to the conference room where the patients sat. Supervisor Jennah Bergin required them to sign a confidentiality form, promising not to discuss other patients after the visit and allowing the doctor to discuss their own medical histories in front of the group.

Nurse Deb Apone wrote patients' first names on two large white boards in the conference room, listing their vital signs on one and patients' questions for Lindsey on the other. Lindsey moved seamlessly between talking with individual patients about their test results to group education.

When one patient said she wanted to cut back on a medication, Lindsey addressed the entire group. "Who else takes diuretics?" he asked. Three patients raised their hands. He launched into a several-minute explanation of when it's OK to skip their medicine.

"People came to me with similar complaints and I had these canned speeches," Lindsey said later, explaining one way group appointments save him time.

Lindsey said patients can talk to him afterward if they have questions they don't want to discuss in front of the group, and many will approach him privately about sexual problems or difficult bosses. But, he said, he is often amazed at how comfortable people are revealing depression or family struggles during shared visits.

And patients feel they are spending more time with their doctor in a group visit because the pace is relaxed and they are in the room with their doctor far longer, he said.

At the Cleveland Clinic, which has offered group appointments since 2002, 59 percent of patients rate their doctors as excellent after individual appointments, while 74 percent of patients rate the same doctors as excellent after group visits, said Dr. Richard Maxwell, director of the clinic's shared medical appointment project.

Doctors like group visits, Noffsinger said, because they can dramatically increase their productivity without working more hours.

Harvard Vanguard is just starting to study the impact on access. But, in one example, a waiting list of 400 to 500 patients for the group's gynecology clinic in Burlington was eliminated in several weeks when the practice started offering group visits this summer, said Dr. Zeev Neuwirth, vice president for clinical effectiveness and innovation at Harvard Vanguard.

"It takes 10 hours a day for a doctor to deliver preventive care. It takes another eight hours a day to deliver chronic disease management. The job of the physician has become literally un-doable," Neuwirth said. "This is not a novelty; it's really a necessity for saving primary care."

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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