Amy Price on shared medical appointments—just say no

It is premature to identify this strategy as medically helpful without clear outcomes and clinical trials, says Amy Price

amy_price2The BMJ recently published an editorial about shared medical appointments (SMAs). These are clinical encounters in which patients receive healthcare, from one or more health professionals, in a group setting with other patients.

As a patient, I am concerned that group appointments will fracture care, and limit individual long-term access to physicians and consultants. It may be practical to integrate social and medical care to redesign shared appointments with patients. [1] However this is unlikely to resolve the dangers of caring for many sick patients simultaneously. [2] Patients are already shuffled to group diabetes, asthma, cardiac, physiotherapy and mental healthcare where their medical interventions may be decided with examination of the patient records, but not personal contact with the patient themselves. In some cases, information sharing is so inadequate that the patients have to look up further information.

SMAs can be driven by guidelines which are written without patient input or preferences. And they often result from a need to meet targets. Patients with serious conditions will still have to self-manage their care and may not be able to express individual preferences within the context of a group appointment. SMAs may not be conducive to fine tuning interventions or observing subtle but critical patterns, this takes individual observation. SMAs may need to be managed, led, and conducted by experienced practitioners who can navigate the complex and even dangerous complications that might be presented in a group environment. There will also need to be consideration about how witnessing these complications as a group may affect other patients.

SMAs set on reducing costs and meeting targets might relegate individual care to a luxury or an add-on. Patients needing individual care may be stigmatized. There is great value in incremental medical care where the physician and patient work together through complex conditions to find the right care. [3] Patient involvement is a prerequisite for redesigning the medical appointment. [4]

The authors of the editorial reflect on video conferencing as a way of providing SMAs for patients living in rural areas or those with mobility difficulties. An interesting example of integration and patient involvement can be explored through User Driven Health Care in India. [5] Resources are scarce and patient to doctor ratios are high in rural India with medical care being so under-resourced that a family may live their entire lives without seeing a doctor. In this group, care plans and interventions are discussed and critically appraised by local doctors, consultants, evidence synthesis experts, medical students, social care professionals, healthcare IT staff and patients. Local doctors, social workers or patients and families can submit protected healthcare data and request help. This network makes recommendations, locates resources, and provides support. [6] The patients have access to their medical records. Local doctors and patients choose the best course of action together. The learning points and results have been written up for BMJ Case Reports. [7] This shows a person friendly strategy where patients, family members, health providers and students can work together to improve care, health literacy, and patient autonomy.

As a patient, I may not have the stamina for a ninety-minute appointment with everyone but my doctor. Unidentified critical needs may be identified at this appointment and necessitate that I discuss options with my specialist so that I can leave this appointment having made an informed shared decision. It is not my remit to support other patients at a cost to myself. If I want to talk to other patients I can join a support group or talk to them in the waiting room for free. As a clinician, I may prefer to see my patients as individuals, rather than through group interaction.

It is premature to consider “medical” appointment redesign without the patient’s involvement or to identify this strategy as medically helpful without clear outcomes and clinical trials. [8] SMAs endorsed as a cost cutting measure without long-term data about fewer complications, relapse ratios, or reduced mortality could increase patient risk.

Amy Price worked as a neurocognitive rehabilitation consultant and in international missions before sustaining serious injury and undergoing years of rehabilitation. She is a BMJ research fellow, serves on the BMJ Patient Panel, and is reading for a DPhil in evidence based healthcare at the University of Oxford.

Patient involvement and acknowledgement: I would like to thank Jo Kirkpatrick, Niall Moran, and Ryan Price as patients, Dr SchMiyah Smith a medical resident, and Professor Kevin Clausen for reading this response and for their edits.

Competing interests: See http://www.bmj.com/about-bmj/advisory-panels/patient-panel-members/amy-price

References:

1         The Health Foundation. Evaluation: what to consider. Commonly asked questions about how to approach evaluation of quality improvement in health care. 2015.

2         McCartney M. Margaret McCartney: Why GPs are always running late. BMJ 2017;358.

3         Gawande A. The Heroism of Incremental Care | The New Yorker. Annals of Medicine  The NEW YORKER. 2017.http://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care (accessed 2 Sep2017).

4         Richards T, Snow R, Schroter S. Logging The BMJ ’s ‘patient journey’. BMJ 2015;348:h4396. doi:10.1136/bmj.h4396

5         Chatterjee P, Bera K, Seth B, et al. Thematic Analysis of a Collaborative, Patient-Centered Model of Care Bringing Personalized Medicine to Resource Restricted Settings. Indian Journal of Medical Informatics 2014;8:85–90.

6         Purkayastha S, Price A, Biswas R, et al. From Dyadic Ties to Information Infrastructures: Care-Coordination between Patients, Providers, Students and Researchers. Contribution of the Health Informatics Education Working Group. Yearbook of medical informatics 2015;10:68–74. doi:10.15265/iy-2015-008

7         Shah BS, Yarbrough C, Price A, et al. An unfortunate injection. BMJ Case Reports 2016;:bcr2015211127. doi:10.1136/bcr-2015-211127

8         Kings Fund. A new settlement for health and social care. 2014;:1–86. doi:10.1136/bmj.g4818

 

  • Caroline Struthers

    What a terrible idea. The author of the editorial seems to have jumped to the conclusion that “promising” is enough. “Further research is needed to define the most effective model of SMAs—and how and where they may be most usefully implemented in practice”. They say after this “..and to evaluate their effectiveness in improving quality of care and reducing healthcare costs”. Shouldn’t the evaluation come before developing the most effective model? Test an existing model first – and properly – with patient input into the design of the trial and choice of outcomes. And make sure the research is not led by an invested and already convinced academic. Conflict of interest is never just financial.

  • Rajib Sengupta

    I think , shared medical appointment or group medical appointment is not the answer – the answer is going back to the earlier days – Family Medicine/General Practitioner (whatever you call it) based treatment .. But this should be real treatment as was provided in the earlier days. The GP should not be just a referral point, referring the patient to a specialist without trying to do any type of treatment. That means, the medical education also need to be overhauled so that medical students after completing their first level of study (3 yr/4yr/5yr/6yr -whatever the timeframe is) should be confident enough to treat. And for that should use evidence based practice as well as be ready to collaborate with other doctors and medical researchers – technology should play big role in that collaboration..

  • e-Patient Dave deBronkart

    Applause to Amy for this perspective. I have never experienced an SMA, and I don’t know details, but I’ve heard of good experiences with them in the US. Benefits included not just efficiency but improved sharing of information – cross-pollination between consultants (specialists), who hear from others outside their specialty, and exchange of information between patients, all of which is overheard by the professionals.

    Note that the benefit here is not just efficiency, but expanded utility of the appointment time: an increase in total knowledge among all participants. THAT is a transformative benefit, not just an efficiency benefit. But I have no idea whether the programme described in the article is structured to achieve that benefit.

    My primary concern about the article – and it’s a big one – is that this “patient-centred” programme seems to have been designed without including the ultimate stakeholder (the patient – the one who has the most at stake about whether healthcare is succeeding). We must stop designing practice change without involving the most affected party!

    After hundreds of engagements in 17 countries, speaking to or working with governments and providers and companies in this space, I have hungered for a good model of how to understand what real engagement is, and I found it, in the domain of “citizen participation.” It’s explained in a five minute mini-speech at http://dave.pt/empoweredengaged, and draws on both the World Bank and Arnstein’s Ladder of Citizen Participation.

    In my experience the professionals who make this mistake aren’t (usually) intentional about it; they just don’t think about it. That’s the point. Think!

    Nothing can be said to be patient-centred if the most-affected person, the patient, is not actively involved.

  • Amy Price

    I have compiled more responses here and used these with permissions:

    On Twitter some practitioners have found these to be useful and have invited me to attend and I hope to do this. It is interesting that they are doing this in the context of social care rather than as a medical appointment so can bring all these important elements in and yet leave the patient clinician time targeted and protected.

    More feedback below:

    [MGT]I think the question is why is it being done:

    – to cut costs – risks breaching confidentiality, personal care and nuance

    – to share experiences – then should be led by patients either doing it themselves or telling professionals what they want in group settings – this used to happen locally with various diabetes groups who decided themselves what they wanted info and discussion on and then ask for whatever support was needed. It worked very well and people could share whatever information they wanted – or not, if they didn’t.

    A sense of some kind of control is so important in healthcare, when due to illness much can be taken from us; we should be very careful of taking away even more as Amy says.

    [MJ]Just preparing the Huxley Brave New World

    Personal communication is a the heart of our vision of medicine. Family consultation are usual. Group health education could be useful. Public consultation are allowed in some African cultures. But patient are not cows. For cutting cost, better to have a look at drug market

    Vient de paraître : http://www.publier-un-livre.com/fr/le-livre-en-papier/481-ethique-d-un-medecin-de-famille

    [JG] Even in the most promising field, diabetes, we need more science before adopting this group-care
    http://bmjopen.bmj.com/content/7/6/e017363

    Having control of our own”disease” is key in clinical care. Shared medical appointments is another initiative that transforms suffering persons in numbers and favours the depersonalization of the patient and the loss of compassion.

    It is implicit in shared medical appointments that it is more important the disease than the people who have the disease. There are many initiatives to transform personal care in industrial care, and this is another one

    “-of course, this industrial care is more “appropriate” for
    poor people; the rich one will have a “personal” doctor (a general
    practitioner”

    See the opinion of patients/families about “tumor board review” when
    decisions are taken without patients’ involvementTumor board review from the
    patients’/families perspective. Lack of involvement, representation,
    communication,…
    https://www.dovepress.com/articles.php?article_id=34762