Education that occurs among patients in a group
SUZANNE KOVEN, MD | PHYSICIAN | JULY 2, 2013
Several years ago I cut my hand badly on a broken glass and required surgery to reattach a tendon. For a few weeks after the operation, I attended regular sessions in a physical therapy department devoted to people with hand injuries. There were no closed curtains in the large therapy room — we bared only our hands, after all. As I had my fingers warmed, splinted, or stretched, I observed other patients receiving similar treatments. Some had far worse injuries than mine. Some had similar injuries, but were farther down the road to recovery than I was. Camaraderie arose among the wounded. We shared tips, along with words of encouragement and commiseration.
Without realizing it, I had participated in an informal version of a new trend in medicine: the group visit.
Prompted mostly by a shortage in primary care doctors, anticipated to worsen when more people have access to insurance under the Affordable Care Act, group medical visits now account for up to 10 percent of visits in some practices. In the most common type of group visit, each patient sees a practitioner briefly one-on-one to discuss personal matters and for a physical exam. Then, up to 90 minutes may be spent with other patients learning about a shared condition such as joint replacement, menopause, or hypertension. Though many initially resist the loss of individual attention by a physician, patient satisfaction with these visits is quite high. Clinical outcomes, such as diabetes control, seem to be improved by group visits as well.
Many clinicians who conduct group visits do so because the increased duration of such visits allows the kind of patient education that simply can’t be crammed into an individual encounter. If, for example, you’re going to teach people with diabetes to read nutrition labels, why not teach 15 at a time?
But there’s a more subtle form of education — and therapy as well — that occurs among patients in a group. Illness, especially chronic illness, can be very isolating, and group visits can help counteract this isolation.
I’ve seen it over and over in a group I lead, along with dietician Suzanne Russell-Curtis, for patients with multiple risk factors for cardiovascular disease. Suzanne and I are perfectly capable of teaching the patients about triglycerides and saturated fat, but when it comes to dealing with the complex feelings involved in trying to pass up birthday cake at a family party, our patients are often more credible experts than we are.
A unique group in Lynn, sponsored by the Harvard Program in Refugee Trauma, offers diabetes treatment and counseling to Cambodian survivors of torture. Though the connection between these patients’ trauma and their diabetes may not be immediately obvious, their shared history and mutual support enhances their medical progress. The group is co-led by a medical professional and a trained fellow-survivor who acts as both health coach and interpreter.
Group visits aren’t the only ways patients are enlisted to help heal other patients. Part of the routine preparation for weight loss surgery, for example, is attendance at a seminar at which a patient who has already had the surgery offers insights about his or her experience.
Sometimes, clinicians arrange for patients to meet one-on-one with people who have had a similar condition. This occurred recently, after the Marathon bombings, where people who’d lost limbs years earlier counseled new amputees. In one remarkable video, a US Marine who lost both legs in combat visited the hospital bedside of a middle-aged woman who lost both legs in the Marathon bombings. “I can’t do anything!” she cries at the beginning of the video. By the end, she’s smiling as she talks about taking up running. The video is barely three minutes long.
Not long ago, I had the opportunity to witness how patients can help other patients in subtle and unexpected ways.
I’d seen a patient of mine, a woman in her 40s who has two disabled sons. Both boys were born with a metabolic disorder which makes them unable to communicate fully or to care for themselves. During a visit a couple of years ago, my patient mentioned that her older son would soon turn 18, and that the issues involved in arranging and financing care for severely disabled adults were different from those involved in caring for children. She was in the process of researching her family’s options.
This isn’t an issue I know much about, but I know someone who does: a patient of mine in her 70s, who also has two disabled sons, who are now middle-aged. She’d come up with a way of keeping her sons at home and securing good care for them. After getting permission from both patients, I gave the younger woman the older woman’s contact information. They had a long conversation by phone, after which the younger woman concluded that the other woman’s strategy wasn’t specifically applicable to her family.
I’d chalked up the episode as a well-intentioned but not particularly successful effort on my part. But, just recently, I asked my patient whether, even though that conversation hadn’t been useful in a practical way, it had been worthwhile. I was surprised at how emphatic her response was. Though the older woman’s circumstances weren’t exactly analogous, she’d provided my patient with a model of how to think out of the box in planning her sons’ care.
“She came up with her own rules,” said my patient, “Which made me realize that I need to be creative, too.”
And there was something more:
“It wasn’t so helpful in the step-by-step,” she said. “But it was tremendously helpful to speak to another mother of two disabled kids. It helped me emotionally. There’s just no one in the world who could really understand my situation, other than someone like her.”
Suzanne Koven is an internal medicine physician and a Boston Globe columnist.