albert, Re:" a fortune to be made in Shorty Inc Psychoanalysis sessions ".
I agree.
As you know I always try and help and so I will consider offering
group sessions at a lower rate.Many shorts wil not be able
to afford the regular rate after " 'T H E' SQUEEZE "
TA
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August 21, 2000
Marketplace
Doctors Save Time by Seeing
Patients in Groups of Twelve
By BARBARA MARTINEZ
Staff Reporter of THE WALL STREET JOURNAL
SUITLAND, MD. -- Ethiopia Abebe, a physician at Kaiser Permanente's Marlow Heights Medical Center here, likes to see many of her elderly patients regularly. So she schedules them all to come in once a month. On the same day. At the same time.
It's called a group visit, and it's the latest twist on the most fundamental encounter in medicine: the doctor-patient relationship. Health clinics across the country, from a Mayo Clinic affiliate in Wisconsin to Stanford University School of Medicine in California, have recently introduced programs in which as many as two dozen patients attend one monthly two-hour group session rather than rely on a traditional individual appointment.
Some doctors set up their group visits around patients with specific chronic ailments -- such as diabetes, arthritis or hypertension, or for routine pediatric or geriatric complaints. Fallon Clinic Inc., Worcester, Mass,, has such visits, and its medical director, Jonathan Harding, praises their efficiency. Rather than saying the same thing 20 different times to 20 different patients, he says, the doctor only has to say it once.
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At a clinic operated by Kaiser Permanente in
Springfield, Va., a doctor addresses his patients in a setting resembling a college seminar
Though it seems paradoxical, both doctors and patients maintain the arrangement reclaims the closeness of the doctor-patient relationship that many argue has been eroded in the era of managed care. Dr. Abebe says she gets to know her group-session patients at a level that wasn't achieved during traditional visits. Besides divulging their medical complaints, "they've talked about their dating, their marriages," she says. "It makes you feel like you're part of their family."
One of Dr. Abebe's patients reciprocates her enthusiasm. "At our age, you don't always get people to talk about what's going on in your life," says 73-year-old Styna Richardson, who attends her monthly group visit with her husband. "We've become so much more aware of our bodies" by sharing medical appointments with other patients, she says.
Mass visits often include some private conversation between the doctor and an individual patient as others in the group talk among themselves. For exams that require disrobing, the patient and doctor meet privately before or after the group session. But while many patients say they get whatever private attention they would need, Melody Matthews Lowman, a San Francisco psychotherapist, worries that some of the more reticent among them may have trouble asking for additional time. "A group visit fails to take care of the whole person," she says.
For patients, group programs are always voluntary, and doctors say private appointments are always available for personal or urgent medical problems. Even enthusiasts acknowledge that group visits don't provide for all their doctor needs. Wilma Rattner says she looks forward to her monthly group appointment at a Kaiser clinic in Springfield, Va., but doesn't consider it a substitute for a private visit. "I don't necessarily choose to" talk about what ails her in front of other people, says the 66-year-old from Fairfax, Va.
Other patients want nothing to do with groups. One woman says she was astonished when her pediatrician recently suggested that she and her son start coming to pediatric visits with other children and parents. Don't worry, she was told, they will be same-sex groups so that the little boys won't be embarrassed about taking off their clothes in front of little girls. She found another pediatrician.
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A patient can confer with a doctor even in the middle of a group visit, as seen at the Kaiser Permanente clinic in Springfield, Va.
Some managed-care companies aren't too thrilled about the idea, either. "We philosophically believe that the patient-physician relationship is a one-on-one relationship, not a 12-on-one relationship," says Mark Di Giorgio, a Cigna Corp. spokesman. So far, health-insurance companies have balked at developing billing codes for such appointments. Consequently, even though doctors say the group visit can cut a clinic's costs, the patient pays the same as a regular visit.
At Kaiser Permanente clinics, among others, doctors are paid a salary, not by the visit, so reimbursement isn't an issue for them. But however a doctor is compensated, the emergence of group visits reflects the toll taken by economic pressures on the doctor-patient encounter. Doctors complain that reduced reimbursement and managed-care demands for increased productivity have led to shorter individual appointments. At many practices, patients have to wait weeks to schedule a visit for routine complaints.
Proponents of group visits say they go a long way toward addressing such problems. "They solve access problems without increasing staffing," says Edward B. Noffsinger, who works for the Palo Alto Medical Foundation setting up group programs in California. Patients who want to see their doctor right away can just drop in to the next group visit rather than having to wait weeks or months for an individual appointment.
John Scott, a Colorado internist and a pioneer of group appointments, says that 10 years ago, he would schedule visits every 20 minutes. Today, he sometimes "double-books" patients in 15-minute slots, and shuttles between exam rooms so that he may actually get less than 10 minutes of face time with many patients. "That's just not enough time," he says. It's a major reason why he began experimenting with group visits in the early 1990s. With such gatherings, he says, "you walk out of there after 2 1/2 hours, and you feel like you've accomplished something, rather than just being on a treadmill."
A visit to Dr. Abebe's clinic suggests that the group appointment is part regular medicine, part medical education and part support group. A nurse takes the blood pressure of each patient before the session begins. Then Dr. Abebe makes her way around the room, talking individually to each of the 14 patients in attendance. She feels swollen ankles, listens to details of recent troubles and asks about pressing concerns.
The approach makes it possible for patients to bring up sensitive issues directly to the doctor without broadcasting them to the entire group. When Dr. Abebe asks Jane Talbert how she had responded to a new drug, her patient doesn't hesitate. "I get a lot of gas, especially in mornings and it's painful," she replies. "It's quite embarrassing." Dr. Abebe tells her the reaction should subside after a few more days on the medication.
As the doctor does her one-on-ones, the rest of her patients help themselves to a table filled with fruit and low-calorie cakes that the patients themselves have brought in. Then, as Dr. Abebe makes notations in the patients' thick files, another doctor arrives to give a slide presentation about the dangers of diabetes, how being overweight and having hypertension can lead to the disease, and how exercise can help fend it off -- medical education that often gets left out in a private appointment.
When the doctor making the presentation proclaims that at the current rate, 100% of all Americans will be overweight or obese by the year 2233, one woman cries out, "Have mercy!" When he talks about the link between waist size and diabetes, Leon Roberts, 75 years old, takes a deep, loud breath, pulls in his stomach and juts out his chest. "I shall be slim one day," he proclaims. They all laugh, including the young physician.
After nearly two hours, the group visit is over, but several of the patients stay behind to catch up and to talk to the nurses. "You're not just a number to them," says Hannah Burke, 80, who lives 30 miles away but hasn't missed one group visit since they started in 1998. "They really know you," she says. For her part, Dr. Abebe thinks her group patients are much more likely to follow her orders and thus much less likely to come back with the same problems. "It sort of makes you feel like you've done a miracle," she says.
Little evidence exists so far to gauge whether group care is better care. But a two-year study of Kaiser group-visit programs involving 790 patients provides support for the approach. The report found that while the number of hospital visits among group- and private-appointment patients was about the same, those participating in groups spent fewer days in the hospital. They also rated their quality of life higher than patients seeing the doctor privately.
Some of that well-being may stem from the realization that others in a group have more serious complaints. "You recognize that things could be a lot worse," says Dr. Noffsinger. "That's a reality check for people."
Write to Barbara Martinez at barbara.martinez@wsj.com1
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