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Suppose that you're a senior citizen with one or more chronic diseases, along with all the other nuisances of advancing age, and that you visit your physician two or more times a month—getting lots of attendant lab tests, x-rays, and other support services.

Visit: Now suppose that instead of a frantic 12- to 15- minute appointment, you were offered a one- to two-hour visit every month (or even twice a month), and not only with your doctor but also with a pharmacist to answer questions about your medications, a nurse to show you how to better manage your care, a physical therapist to help you get proper exercise, and a dietician to teach you some better eating habits. All of that in a leisurely time frame so you don't fry your neurons trying to remember everything you're told while also formulating questions about the parts you don't understand. They might even throw in some coffee and donuts.

There is one catch—there will be half a dozen to a dozen other patients in the same room. Oops, there goes doctor-patient confidentiality! "Not necessarily," says Marjorie Godfrey, M.S., R.N., director of clinical practice improvement at DHMC.

Patients participating in what are called "group visits" are asked to sign consent forms and confi- dentiality statements, and only first names are used. Although there is no way to enforce confidentiality, Godfrey is not aware of any blatant violations among the practices that are pioneering this new way of delivering medical care.

The concept of group therapy— a group visit with a psychologist or psychiatrist—has a long and productive history, despite the fun poked it in the 1970s on TV's Bob Newhart Show. Because of confidentiality concerns, only a few psychotherapists used groups before World War II, though at least one such group, Alcoholics Anonymous, evolved into a free-standing movement. After the war, the large number of soldiers requiring care compelled psychiatrists to treat them in groups. The method proved so effective that it spread rapidly into civilian psychotherapy.

Principle: The same principle is now being applied in many medical specialties. Group techniques are as varied as those of individual therapies, but one central theme is to create a mutually supportive atmosphere.

Kaiser Permanente has been experimenting with groups since 1991 and has enumerated many advantages for the concept: (1) Patients and providers get to know each other personally, and participants feel they are known as an individual and not just as "the gall bladder case." (2) Patients realize that they are not the only ones with a given problem. (3) Most feel that they learn more, and many benefit from questions asked by more assertive members of the group. (4) Ample time is available for detailed answers to questions. (5) And the major advantage, one not anticipated by the organizers, turns out to be social. A group quickly evolves into a tight-knit "family" that often holds social gatherings outside the therapeutic setting.

The Kaiser group was not organized around any particular theme or illness. Members were invited to join because of their age and their frequent use of the health-care system. Even so, the number of individual physician visits among the patients decreased, there was greater job satisfaction among the caregivers, and there was a shift from physician to nonphysician care-giving, which increased physician efficiency. The fact that patients' emotional needs were being dealt with more effectively led to a drop in physical complaints. And there was also a decrease in lab and x-ray orders.

Counsel: Godfrey says DHMC-affiliated clinics in southern New Hampshire, in the seacoast and Nashua areas, began to use group visits in 1999. They started a variation on a concept called DIGMA, for Drop-in Group Medical Appointment. An hour every Friday afternoon is reserved for any patients who would like to avail themselves of the counsel of a physician and his or her assistants. DIGMA participants are, therefore, a selfselected group—you come if you want to participate.

At DHMC's Lebanon campus, group visits are now used for a range of conditions, including patients about to have joint-replacement or stomach-reduction surgery, patients with diabetes or hepatitis C, and prenatal patients. Plans are in place to start a group for women interested in breast reduction surgery.

Condition-specific group visits usually include patients of various ages and in various stages of a specific disease. There are thus important lessons to be learned from those in more advanced stages of a disease by those more recently diagnosed. But such groups need to be carefully managed. A trained facilitator must be available to handle problems, such as the inevitable group member who tries to share misinformation.

Patients are usually invited to participate in a group by their caregiver. Of course, group visits are not a substitute for one-onone care, which, at the least, must still be provided for those who do not wish to participate in groups.

Payers: In addition to patient preference, the biggest obstacle to instituting group visits is the reimbursement system. Thirdparty payers are not very amenable to innovative methods of delivering care, though Godfrey is quick to note that "Anthem Blue Cross-Blue Shield of New Hampshire has been extremely supportive of group visits, and negotiations about payment are currently ongoing."

Yet DHMC plans to continue developing groups even if the reimbursement issue is not resolved. Godfrey and her colleagues are convinced that it's the right thing to do, since the groups' major advantage, as she emphatically states, is "patient satisfaction."

Roger P. Smith, Ph.D.

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