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

The 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