Shared medical appointmentsBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4034 (Published 30 August 2017) Cite this as: BMJ 2017;358:j4034
All rapid responses
Further to your editorial September 23rd 2017, regarding shared medical appointments (BMJ 2017;358:j4043), we have experience of a number of differing models of shared medical appointments within a rheumatology setting, in our hospital.
Longitudinal Regional data has confirmed that the Rheumatology outpatient follow up burden doubles every 5 years. NICE guidelines require that patients with a new diagnosis of an inflammatory arthritis start their Disease Modifying therapies (DMARDs) within 3 weeks of diagnosis. DMARDs and Biologics require regular monitoring and review for safety and efficacy.
Finances in the NHS are tight, thus additional staffing cannot be provided to manage this increase in work, demanding a novel approach be instituted to initiate DMARD and Biologic therapies quickly.
For nearly ten years, our department has extensive experience developed a range of shared medical appointments (SMAs) or group clinics.
Group DMARD clinics
Initially, we began starting patients on DMARDs using SMAs. We run 3 clinics per week to start medications such as Methotrexate, Sulphasalazine and Leflunomide, in groups of 6 patients; the clinic room determining the size of the group. The decision to start a drug is discussed with the patient by the consultant in a standard one-one clinic, written information is given and safety investigations were requested. Once these results are through, the patient is invited to the group DMARD clinic.
Patients are provided with the first six weeks’ supply of their DMARDs from the hospital pharmacy. A shared care agreement is sent to the GP and a follow up letter sent to the patients reminding them that both monitoring and further prescribing is undertaken by their GP.
We audited our practice in 2015. Of 607 patients starting DMARDs, 60% started in a group clinic, 27% were started via a telephone consultation. Only 8% requested an individual face-face consultation with the specialist nurses. Time saved, over one year, was equivalent of 1664 rheumatology nurse appointments (of 30 minutes each), allowing the nurses to see more patients with urgent problems.
Patients were equally satisfied with this new arrangement as they were with a traditional one-one consultations with a specialist nurses in the initiation of their drug therapy. This level of patient satisfaction has continued at the same high level (4.7/5) since 2008.
Average time to starting DMARDs on the above regime was 10 days. Prior to this change in protocol, the average time to start a DMARD in our clinic was > 8 weeks.
Group Biologic Clinics
Recently, we have undertaken a similar approach, to prescribe and monitor patients starting Biologic therapies, such as anti-TNF therapies. We have undertaken this to establish patients onto their Biologic therapy as quickly as possible, given the severity of their disease. These patients cannot afford any delays.
Group Education MDT Clinic
Since January 2017, the department has run group education for patients with newly diagnosed Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA), involving the whole rheumatology multi-disciplinary team (MDT). Previously, these patients were invited to see the rheumatology podiatrist, physiotherapist and occupational therapist on a one-one basis, but unfortunately this was time intensive and there were high DNA rates.
Now, up to 18 people with a new diagnosis of RA or PsA, are invited for a monthly group education session. This comprises 5 x 30 minute talks with question and answer sessions, lead by a rheumatology consultant, specialist nurse, podiatrist, physiotherapist and OT. Tea and coffee are available with time for patients to interact with each other, encouraging peer-peer support.
Average attendance per clinic was 12 patients with the addition of some relatives and carers. This regime elicited a Patient satisfaction score averaging 4.8/5 over the 6 clinics audited. As a consequence of this approach, 11 clinics per month have been released for other work for the physiotherapists, OTs and podiatrists. Anecdotal reports suggest, patients have been better educated about their treatment plans and their underlying disease, when seen in follow up clinics.
Group Rheumatology Follow up Clinics
From November 2016, we have run a monthly group clinic to follow up for those with RA and PsA . These clinics are held at 5.15pm, thus everyone can park and avoid missing time from work. Those attending this clinic have consented to be seen in a group environment. Suitable patients for these clinics have either stable disease, often taking a Biologic therapy, and those with early disease, who are starting their treatment plan, requiring frequent follow up.
Before attending, a questionnaire is sent to each patient, enquiring about new medications, new diagnoses, recent illnesses, and a CDAI score and their recent blood test results are to hand. Specialist Rheumatology nurses review the patients, performing a DAS score. I review the questionnaire, investigations, and DAS score following which a treatment plan is made. The group, meanwhile, invariably talk amongst themselves and discuss their rheumatological conditions and medications. Following this there is a group question and answer discussion, talking about important points such as vaccinations, infection risk, new medications, dose reduction etc. The group discussion is led by the patients. Time for peer-peer discussion is strongly encouraged and very valuable.
We have been impressed with the advantage of group medical appointments, particularly from the perspective of peer-peer support. Patient satisfaction has been universally supportive. It has allowed us to continue to provide a responsive service, despite a doubling in workload.
Competing interests: No competing interests
Shared medical appointments have their shortcoming but could be useful for some. Digital health + coaching is another alternative: http://blogs.bmj.com/bmj/2016/05/18/shared-appointments-medical-utopia-o...
Competing interests: No competing interests
In a linked BMJ Opinion piece, Amy Price, who is a BMJ research fellow and part of the BMJ Patient Panel, has written a patient perspective on why she thinks it is premature to identify shared medical appointments as medically helpful without clear outcomes and clinical trials. The piece has been widely read and commented on. You can read the article and comments here: http://blogs.bmj.com/bmj/2017/09/18/amy-price-on-shared-medical-appointm...
Competing interests: No competing interests
“One million thanks”, a patient spontaneously stood up and announced, towards the end of the second Shared Medical Appointments pilot for glaucoma held on a Sunday at the Aravind Eye Hospital in Pondicherry, India in 2015. Aravind glaucoma specialist Dr. Venkatesh had just delivered one-on-one glaucoma care to each patient in a group of eight. Aravind achieves eye surgery outcomes comparable in quality to those of the best US and UK hospitals at a small fraction of the cost (1). Yet Aravind’s primary aim in experimenting with SMAs was not to reduce costs. Instead, they conjectured that SMAs might improve the chances that glaucoma patients would comply with medications and return for their follow up appointments – necessary to defer irreversible vision loss.
Patient and doctor feedback from Aravind’s first Sunday pilot SMA had been less glowing. “It felt like a wedding”, said ophthalmologist Dr. Kavitha who had led it. If you have been to an Indian wedding, you know that is not self-praise. Patient and medical-team feedback gathered after the first pilot (also held on a Sunday to avoid disrupting weekday workflow), had led to refinements – to the size of the patient group, how they would be seated and the content and format of the glaucoma SMA. Before these full-fledged pilots, Aravind had first soft-trialled the SMA idea – with a counsellor instead of a physician leading the patient group. The counsellor had collected a group of patients who were waiting in between stages of a regular glaucoma appointment and talked to them one at a time in a group setting.
I observed these SMA experiments not as a medical practitioner or a patient, but rather as a researcher of innovation. In any service – be it healthcare, education, financial services or hospitality – radical innovations in delivery are notoriously slow to spread (2). SMAs, introduced by Dr. Ed Noffsinger in the US in the 1990s (3), are a radical innovation in care delivery. SMAs challenge a fundamental assumption in the classic doctor-patient interaction – the notion that care needs to be delivered one-on-one and in private. By offering one-on-one care to each patient in a group of patients with similar conditions, SMAs also change the “boundary” of the service a doctor provides (4). The support group is now within the doctor’s office. SMAs have the potential to improve value in healthcare delivery by simultaneously improving outcomes and reducing cost.
I agree with Dr. Amy Price that the patient must be the centrepiece in the design of any method of care delivery. However, patient feedback – be it positive or negative – must be balanced against the reality that in many services – education, legal services and healthcare come easily to mind – the client is not always best placed to know what is in their best interest. Equally importantly, patient feedback must be scientifically gathered and analysed, with care taken to not put undue weight on dismissive or jubilant voices at either end of the feedback spectrum. The spontaneous positive feedback during the second SMA pilot at Aravind was only the start of an arduous journey in experimentation. My research colleagues Ryan Buell at Harvard Business School , Nazli Sonmez at London Business School and I are collaborating with Dr. Venkatesh and Dr. Kavitha at Aravind, to conduct a randomized controlled trial with 1,000 glaucoma patients, half undergoing SMAs and the other half traditional one-on-one care over four consecutive appointments. Early results suggest that SMA patients show significantly higher patient satisfaction and knowledge of glaucoma.
Evidence on SMAs is starting to amass across a variety of SMA settings, as has been pointed out in earlier letters by Dr. Fraser Birrell at Newcastle University, Dr. Abi Morbi at Imperial College London, Dr. Marianne Sumego at the Cleveland Clinic, Dr. Garry Egger from Australia and others. If a body of clear scientific evidence of benefits to patients is established, I would go so far as to recommend that SMAs are made the standard mode of care for conditions where their value is proven, with one-on-one care always possible if the physician sees it as necessary for particular patients. Any potential “stigma” (as mentioned by Dr. Amy Price) of being singled out for one-on-one care needs to be balanced against the benefits of SMAs. After all, we do not question that children should be taught in classrooms with a mix of lecture and one-on-one attention, with the option for one-on-one sessions instead of or in addition to classroom sessions, for those who need them.
I first learned about shared medical appointments in 2006 when my research colleague Elizabeth Teisberg introduced me to a cardiac preventive care clinic in the University of Virginia Medical System that was considering SMAs. Since then, I have interacted with SMAs practitioners in hospitals and clinics on three continents. These include the Cleveland Clinic, the Cooper University Hospital in Camden New Jersey – one of the poorest cities in the US – hospitals and GP surgeries in the UK and the Aravind Eye Care System in India. In every case, the patients have been very different. Yet whether for drug addiction management in Camden, arthritic pain management in Newcastle or the care of chronic eye conditions in India, I’ve seen medical practitioners experiment with and evolve SMAs to suit their patients’ specific needs.
The medical profession is unique in the magnitude of its impact on humankind. Quick and cheap early experimentation combined with systematic randomized controlled trials to build the evidence base are the way forward for potentially transformative innovations in care delivery.
Competing interests: No competing interests
We read responses by Amy Price PhD, Garry Egger, Marianne Sumego & Abi Morbi to this editorial with great interest. We welcome this debate and note Shared Medical Appointments (SMA) was the focus of these, but group clinics/consults is the generic term, including SMAs and similar models.
Dr Price does not appear to have ever experienced a group clinic and makes a number of assumptions & speculations, which are not apparently evidence-based.
We don't agree 'medical interventions may be decided with examination of patients records, but not personal contact'. The assumption is there is no opportunity for patients to discuss their problems & be examined: not true, as Dr Morbi has clarified.
Dr Price speculates that guidelines used may not include patients, but the current NHS standard is 'no decision about you without you', so NICE and other guideline bodies include patient representatives, with very real influence (e.g. CG79  & CG177  ). These and other peer-reviewed evidence    inform our group clinic.
We wanted to share our perspective - informed by UK experience of co-designed models since 2008. Major positives from a patient perspective are that our inflammatory arthritis group clinic is especially good for new patients and active disease - offering monthly review, easy access for flares, intensive treatment and education (both important for tight control), treatment to an explicit target of low disease activity/remission, more time with the consultant/team and excellent continuity.
Many of Dr Price's negative opinions were shared and freely expressed by the patient representative working with the Northumbria Healthcare Rheumatology team when piloted. However, this was something that delivered high quality care in the USA, so the team agreed to pilot and see whether UK inflammatory arthritis patients could benefit. The pilots were positive - enjoyable and successful for patients and staff for satisfaction and outcomes. Patients were fully involved in determining exactly how the group clinic would run. After winning the British Society of Rheumatology Innovation in Development Award, the service was commissioned by Northumberland CCG in 2010: monthly at two community hospitals, with a dedicated early arthritis clinic initiated at a third in 2016. When that patient representative attended a group clinic her experience was very positive: 'I was rather sceptical of the idea of group clinics but after attending my opinion changed as the clinic was excellent and covered everyone’s needs'. Another patient shared, ‘as a first time member… I can say that I came away feeling much more empowered, knowledgeable and certainly less lonely regarding my RA’.
Patients have suggested all major developments implemented since: agreeing to celebrate remission by ringing a bell; having intramuscular steroid injections with the clinic nurse during rather than after the session; involving multidisciplinary team members in integrated education. This is democratic healthcare, as everything important is discussed & agreed.
As patients and a consultant with experience of group clinics, let us highlight:
1) Patients always have a choice of attending a group session or a normal clinic with the consultant or specialist nurse
2) Group clinics improve access to the consultant & the rest of the team: allowing monthly review of those with early & active disease and patients with flare-ups know they can ring up and be seen within a month
3) Group clinics give patients choices and are empowering
Dr Price seems concerned this will be ‘the thin end of the wedge’ and group clinics will necessarily evolve into patient support groups, lose medical & clinical input and reduce quality of care, as their focus is efficiency. Actually, our experience is the opposite: by operating efficiently and giving more time with an expanded healthcare team (rotating educational input from Pharmacist, Physiotherapist, Occupational Therapist, Podiatrist, Specialist Nurse); by having more patients ask searching questions; and by having the expertise & time to answer them, group clinics facilitate better care. We recognise no clinical contact is perfect, but with group clinics information sharing is actually better. For example a new drug can be suggested by the consultant during microconsultation, patient leaflet given & read, experience of it shared by other patients and questions asked & answered. A constant theme of feedback is really helpful questions are asked by others and much more information gained. This is reinforced by a personalised letter to each patient & GP, summarising key educational points, disease activity and individual care plan.
As they take pressure off the normal clinics, even those patients who don't opt to use the group clinic benefit. The main barrier is lack of experience/understanding of the group clinic model (we feel this includes Dr Price) and once patients have tried a group clinic, >90% see benefits and will recommend to others.
We don't think usual care will disappear, as Dr Price worries. But as a mature service, one group clinic a month delivers 40% of the follow-up workload and is a really enjoyable way of both giving and receiving care: we give each other permission to make jokes in clinic (laughter being the best medicine sometimes): a positive experience for all.
Others have summarised there is more evidence than many recognise. We agree more evidence is desirable and outcomes must be collected. However, clinical trials are not always the answer - to paraphrase feedback from NIHR on a proposed multicentre trial of our model - 'you have already shown this works, so a trial is not needed'. However, publishing data in an area that is not topical and not directly supported by randomised controlled trial evidence can be challenging, so we are delighted to see such great interest. Our long term data & qualitative research will be submitted for publication shortly.
Finally, we ask Dr Price: experience this for yourself. Seeing the shared decision making and empowerment of self-management in action is inspirational: available in Primary Care SMAs across the UK now as well as other countries. We unanimously invite Dr Price to attend our group clinic at Alnwick Infirmary or Berwick Infirmary to experience this model of care first-hand. Please contact the clinic secretaries (01665 626756 or 01289 356633) to accept.
Dr Fraser Birrell
1 NICE Clinical Guideline 79. Rheumatoid arthritis: the management of rheumatoid arthritis in adults. https://www.nice.org.uk/guidance/cg79/ifp/chapter/About-this-information; accessed 29/7/17
2 NICE Clinical Guideline 177. Osteoarthritis: care and management. https://www.nice.org.uk/guidance/cg177/ifp/chapter/About-this-information
3 Grigor C, Capell H, Stirling A, McMahon AD, Lock P, Vallance R, Kincaid W, Porter D. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial. Lancet. 2004 Jul 17-23;364(9430):263-9
4 Coates LC, Moverley AR, McParland L, Brown S, Navarro-Coy N, O'Dwyer JL, Meads DM, Emery P, Conaghan PG, Helliwell PS. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomised controlled trial. Lancet. 2015;386(10012):2489-98
5 Scott DL, Ibrahim F, Farewell V, O'Keeffe AG, Walker D, Kelly C, Birrell F, Chakravarty K, Maddison P, Heslin M, Patel A, Kingsley GH. Tumour necrosis factor inhibitors versus combination intensive therapy with conventional disease modifying anti-rheumatic drugs in established rheumatoid arthritis: TACIT non-inferiority randomised controlled trial. BMJ. 2015;350:h1046.
Competing interests: No competing interests
I read with interest the letter by Amy Price and would like to respond to a number of points that she raised regarding shared medical appointments (SMAs).
Firstly, Dr Price suggests there is a need for clinical trials and evidence for the clinical benefit of SMAs. There is an increasingly wide body of literature, demonstrating the benefits of SMAs, as demonstrated by the systematic review by Booth et al (1). There is evidence of clinical benefit, with improvement in specific markers, such as HbA1c and systolic blood pressure (2,3,4) and evidence of improved quality of life (5). Patient (6) and clinician satisfaction has been shown to be high (5) and there is evidence for better resource utilisation, through a reduction in the number of emergency admissions to hospital (5,7).
Dr Price suggests that the SMAs may limit individual long-term access to clinicians and that SMAs would be a replacement for individual care. It needs to be stressed that SMAs do not eliminate the one-to-one consultation. Rather, patients are still seen in turn, but in the presence of a group of patients, who can all benefit from the shared information and education (8). Additionally, providing SMAs does not prevent clinicians from also providing traditional one-to-one clinic appointments.
She questions whether patients who want one-to-one care would be stigmatized. Of course, one size does not fit all and there will be some patients who prefer the traditional model of care, just as some clinicians may prefer to deliver care in a one-to-one setting. As such, SMAs should be seen as one model of care, not as a replacement for one-to-one appointments.
However, that does not mean SMAs are not of value. I recently met Professor Noffsinger and Dr Sumego, two pioneers of SMAs with a wealth of experience in designing, implementing and running them in clinical practice; it is clear from their experience that SMAs have a key role in the management of patients with chronic disease. Not only do they allow patients to spend increased time with their doctor, typically having a 90 minute appointment, but they allow patients to interact with others who are managing the same condition, enabling them to learn from each other and providing them with additional emotional and practical support from peers who have experience of living with that diagnosis.
Dr. Price raises a concern that in the group setting, medical decisions may be made on the basis of patient records rather than through talking to the patient. This, with respect, suggests a key misunderstanding regarding how SMAs are run. SMAs provide patient-centered care, with the focus being on consulting with each patient in turn, establishing their symptoms and concerns, involving them in their care and establishing a management plan that is acceptable to the patient, just as in one-to-one care. Additionally, the group setting allows the patient to benefit from ‘extra’ information, from the lived experiences of other patients in the group, as well as allowing patients to benefit from the shared learning from the clinician, as the information provided to one patient will be relevant to others in the group.
I strongly agree that patient involvement is key when redesigning models of care. We need to ensure that models of care are acceptable to patients, clinicians, non-clinical healthcare teams and the healthcare system that we are working in. To this end, it is important to understand the barriers and enabling factors to using SMAs and elicit patient experience of SMAs, which is the current focus of our work at Imperial College, in collaboration with the Cleveland Clinic.
I have been fortunate enough to spend time at Cleveland Clinic, where there has been a drive to adopt and spread SMAs, as a means of providing better patient experience and care. I have seen SMAs in a number of different specialties, and spoken with clinicians, managers and patients who have been involved in the SMAs. It is too early to provide detailed analysis, but the observations alone show that patients can benefit from the group setting, sharing stories and lifestyle advice with each other, supporting one another and showing them that they are not alone. The clinicians have more time to deliver education and discuss lifestyle management as well as medical management, compared to one-to-one care, enabling more comprehensive delivery and experience of care.
In the current climate, with an increased prevalence of chronic disease but limited resources, we need to look at ways to improve care, providing patients with the education and tools to be able to manage in the community and finding ways of utilising healthcare resources more effectively. There may of course be cultural differences in our patient populations that mean the existing evidence may not be generalisable for all cohorts and healthcare systems and so further studies should be undertaken in different healthcare settings, to further establish the role of SMAs.
SMAs may not be the answer for every clinician and every patient, but we should certainly consider the evidence for them. Rather than ‘just saying no’, we should work with our colleagues in other healthcare systems, to learn from their experiences, and be open to adopting innovative models of care, to ensure we are providing the best possible care for our patients in the UK.
Dr Abigail Morbi is a junior doctor, currently undertaking a PhD at Imperial College, London. Her research focus is on SMAs.
I would like to acknowledge my PhD supervisors, Professor the Lord Ara Darzi, Professor Kamalini Ramdas, Dr Stephanie Archer and Mr Colin Bicknell, as well as Dr Marianne Sumego and Anne Maggiore and the wider teams at Cleveland Clinic who have allowed me to observe their SMAs and shared their experiences with me.
1. Booth A, Cantrell A, Preston L, Chambers D, Goyder E. What is the evidence for the Effectiveness, Appropriateness, and Feasibility of group clinics for patients with chronic conditions? A systematic review. Accepted by Health Services and Delivery Research journal. Currently unpublished. Available at http://www.nets.nihr.ac.uk/projects/hsdr/130512
2. Edelman D, Fredrickson SK, Melnyk SD, Coffman CJ, Jeffreys AS, Datta S, Jackson GL, Harris AC, Hamilton NS, Stewart H, Stein J, Weinberger M. Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial. Annals of Internal Medicine 2010;152(11):689-96.
3. Edelman D, McDuffie JR, Oddone E, Gierisch JM, Nagi A, Williams JW Jr. Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review. VA Evidence-based Synthesis Program Reports.Washington (DC), Department of Veterans Affairs (US), 2012.
4. Burke RE, Ferrara SA, Fuller AM, Kelderhouse JM, Ferrara LR. The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: a systematic review. JBI Library of Systematic Reviews 2011;9(23):833-35.
5. Jaber R, Braksmajer A, Trilling JS. Group visits: a qualitative review of current research. Journal of the American Board of Family Medicine 2006;19(3):276-290.
6. Ramdas K, Teisberg E, Tucker AL. Four Ways to Reinvent Service Delivery. How to create more value for your customers and you. Harvard Business Review 2012.
7. Scott JC, Conner DA, Venohr I, Gade G, McKenzie M, Kramer AM, Bryant L, Beck A. Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic. Journal of the American Geriatrics Society 2004;52(9):1463-70.
8. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Systematic Review 2005;18;(2):CD003417.
Competing interests: Dr Abigail Morbi is currently undertaking a PhD, investigating the role of shared medical appointments for the management of chronic disease.
I would like to share our experience in the United States. Our current healthcare delivery systems are not equipped to accommodate the needs of care in the future and will require innovation. We share common challenges regarding access and quality of care especially surrounding chronic condition management and we should not be satisfied with our existing state of healthcare delivery. Indeed, change is difficult and takes time, but it also requires having a vision of the innovation’s potential. When I began conducting Shared Medical Appointments under the enthusiastic eye of Dr. Ed Noffsinger in 1999, we did not have experience or an understanding of what we were trying to create. The benefits were intuitive: that seeing multiple patients at the same time with a similar condition over a longer appointment duration would promote more information to be gained and shared. Intuition alone does not stimulate or propagate change, experience and results are necessary. We needed to socialize the concept addressing the misunderstandings and concerns expressed by our providers. By starting with a small pilot group of physicians and collecting feedback we were able to understand and meet the challenges, allowing us to create best practices. We then shared these processes with additional providers, many of whom are seen as early adopters.
Having conducted close to 100,000 shared visits at our institution over the past decade, we can support the tremendous potential of the SMA model. Patient satisfaction is rated consistently higher for the “appointment given” and higher when compared to our 1:1 provider care. We embedded a process addressing privacy and have not had such concerns surface routinely. To the contrary, our patient verbatims regularly quote the ability to share and learn as a benefit, siting the value of education and having extended time with the provider. Our visits are standard, full appointments that address the medical needs of each patient. In addition, they tackle traditional hurdles such as time constraints, resources and complexity of care.
We are showing that the financial margins are positive for a well done, efficient SMA. Through our preliminary data we also demonstrate improved metrics in several areas such as anxiety, obesity and appropriate use of recommended medications in diabetes. During our growth we encountered many hurdles especially surrounding workflow and efficiency. The sharing of success amongst our providers created enthusiasm, the “possible” and support.
The uniqueness of the SMA model is its greatest benefit and also the largest barrier to adoption. I hope this response illustrates that we have a common bond in the need to impact patient care and access. By sharing a piece of our SMA experience, I aspire to encourage the continued development and adoption of SMAs. We need to lead the way in changing healthcare .There will be challenges, hesitation and skepticism, but we need to meet them head on with creative solutions, passion and patient commitment. I applaud my UK colleagues for taking on health care and SMAs. Patient care is a continuum and this model does not address all of the healthcare needs, but allows us additional ways to positively affect patient experience, access and quality of care. It may be time to add one more idea to our armamentarium as providers!!!
Marianne Sumego MD
Staff physician Internal Medicine/Pediatrics
Director, Shared Medical Appointments:
Clinical Assistant Professor of Medicine CCLCM of CWRU
Competing interests: No competing interests
Your editorial by Hayhoe et al on Shared Medical Appointments (BMJ 2017;358:j4034) and response by Amy Price (BMJ Opinion, 2017 Sept 18) should not go unremarked. We have been running and researching SMAs in Australia, modified from the model by Noffsinger1 for over 5 years and have shown over 95% patient and 100% provider approval of the process.2-4 In our experience, SMAs are badly misunderstood by those who have not experienced them, either as patient or provider. As your editorial points out, these are not an alternative to standard care, but a useful adjunct for managing chronic diseases.
SMAs are defined as: “…consecutive individual medical visits carried out in a supportive group setting of similar patients where all can listen, interact, and learn.” 2 They involve a doctor (GP or specialist) consulting patients sequentially amongst a group of peers, with similar problems who can interact throughout the consultation, under the guidance and direction of a trained facilitator (usually a practice nurse or other allied health professional).
The letter by Amy Price, with respect, demonstrates some basic misunderstandings of the process. At the outset, it’s worth asking if Ms Price, who asks for evaluative evidence for SMAs, has any evidence supporting the superiority of the conventional 1:1 consulting model over any other form of medical consult? (It doesn’t exist). If not, how can this process be advocated so confidently over any other model, particularly in the case of chronic diseases and ailments, which are relatively new to modern societies. Chronic, unlike acute diseases, require significant clinician’s time (which is not available in the 1:1 situation), peer support (which is one of the classical models for learning from peers with a similar problem), self-management skills, and support from other Allied Health professionals.
Details such as confidentiality (to date, there has not been any issue relating to this, even in litigious-voracious USA where these have been running for 25 years), lack of personal contact with the clinician (these are the same as personal consultations – just with others watching and contributing), complications affecting patients (this is the whole point of the process – to discuss and get feedback from others who have similar problems) are easily overcome in Ms Price’ critique.
Finally, in contradiction to Ms Price’ assertion, SMAs are not ‘a cost-cutting measure’. Nor are they a financial boon for doctors working in a private health care model (such as the US), semi-private (such as Australia) or capitation model (such as New Zealand and the UK). They are roughly cost equivalent to 1:1 care, but a much more efficient use of medical resources, clinicians’ time, educational input (clinicians are not repeating the same advice over and over) and patient waiting lists. The wheels of health care innovation turn slowly. But we would encourage Ms Price to at least experience an SMA to understand the value and popularity of these in the modern health mix, before throwing the patient out with the holy water.
(Prof) Garry Egger AM MPH PhD FASLM
Australasian Society of Lifestyle Medicine.
1. Noffsinger E. The ABCs of Group Visits. Springer NY, 2013
2. Egger G, Binns A, Cole M-A et al. Shared Medical Appointments: An adjunct for chronic disease management in Australia? Aus fam Phys 2014;43(3):151-154
3. Stevens J, Egger G, Cole M-A, Binns A, Dixon J. A user assessment of the potential for Shared Medical Appointments in Australia. Aust Fam Phys 2014;43(11):904-7.
4. Egger G, Dixon J, Meldrum H, Binns A, Cole M-A, Ewald D, Stevens J. Patient and Provider Satisfaction with Shared Medical Appointments. Aust Fam Phys (2015; in press)
Competing interests: No competing interests
The editorial by Hayhoe et al successfully highlights the potential and challenges of the shared medical appointment (SMA) as a solution to capacity issues in contemporary practice. We would like to take this opportunity to share our real life experience of employing this approach in the management of gestational diabetes (GDM), in south west Essex.
Over the years, the palpable despair and sense of isolation displayed by many pregnant women following a diagnosis of GDM, captured our attention. However, things only really came to a head in February 2015 when NICE updated its’ pregnancy guidance to stipulate a new requirement for specialist clinic review within 7 days of a new diagnosis of GDM. At a time of unprecedented increases in the prevalence of gestational diabetes and limited NHS resources, meeting this obligation was predictably challenging. Our rate of achieving this standard gradually deteriorated and rather disappointingly, by February 2016 this standard was being achieved in only 31% of our GDM patients.
In March 2016 this led to a transformation of our weekly conventional first contact clinic to a multidisciplinary group clinic called EGGS (Educating Gestational diabetics Group Sessions), resulting in a four-fold increase in our weekly capacity, at no additional cost. The outcomes have been quite stark and indeed we too soon realised the additional virtue of enabling the professions, patients and partners to learn with, from and about each other. By optimising exchange of experience and expertise, this interactive partnership with service users results in simultaneous co-reflection, with all participants comparing perceptions, values, roles and responsibilities while pulling in the same direction. We now see this as the most critical component of our progression and 16 months after implementation, 94% (Monthly range: 88- 100%) of new GDM patients are being seen within 7 days. Furthermore, over 97% of 338 service user respondents acknowledged that all educational objectives, including adequate psychological adjustment to the new diagnosis, were achieved.
For us this has been a truly exciting development, recently culminating in our winning of the 2017 Health Enterprise East NHS Innovation Award (Diabetes category).
Whilst we recognize the stated challenges and concerns about shared medical appointments, our service journey proves these barriers are not unsurmountable, understandably influencing our perceptions and motivating our full endorsement of SMAs in this domain of care.
Competing interests: No competing interests
Implementing SMA is a complex issue. Given the right platform, it has the potential for a more egalitarian practice, better suited for some patients' wants and needs. The question remains as to how the managerial class will wield this double-bladed sword. A hint lays in the articles' text; "while substantially reducing clinical time commitment". SME might be used as a tool to further infringe on one-on-one clinical encounters.
Competing interests: No competing interests