In 2015, Wally Gardner was struggling with obesity and diabetes, and juggling 14 different medications to manage his deteriorating health. At 55, Gardner feared he wouldn’t live to see 60 without gastric bypass surgery.
During check-ins with his doctor, he’d wait 30 minutes or more to get five minutes of face-time. He just wasn’t getting the attentive care he needed.
That’s when Gardner, who lives in Mentor, Ohio, first heard about shared medical appointments, or SMAs. An SMA is a series of group medical appointments typically designed around a common condition or health goal like diabetes, asthma, cancer, weight loss or stress reduction. The Cleveland Clinic was looking for people who needed to lose weight to participate in an SMA at its Obesity and Medical Weight Loss Center. Gardner figured he didn’t have anything to lose, so he signed up, committing himself to one 75-minute doctor’s appointment each month for a year alongside nine other patients, all strangers to him.
Led by a multidisciplinary team of doctors and other kinds of clinicians, the appointments were designed to help patients lose weight and improve health conditions linked to obesity, like type 2 diabetes. At first, Gardner was wary of talking about his health in front of a group. But four years later, he’s still a part of the program. Thanks to exercise and diet tips he’s learned during appointments, and support from the program leader and other patients, Gardner has lost more than 100 pounds and taken 14 inches off his waist. And he’s down to one medication, for high blood pressure.
Gardner credits shared medical appointments for his health transformation, and he doesn’t plan to start going to the doctor alone anytime soon. “We’re all here to get the same results,” he says. “Group visits keep you accountable, and you really get to where you’re looking forward to that appointment, to make sure you’re staying on track.”
Shared medical appointments have been around since the 1990s, when a California-based psychologist named Ed Noffsinger became frustrated with his own healthcare and sought out a way to improve the patient experience. The concept didn’t take off right away. In fact, group appointments are still rare, but in recent years, more and more physicians and healthcare systems have started to experiment with them. Between 2005 and 2015, instances of shared appointments nearly doubled, according to the American Academy of Family Physicians.
Proponents say they give patients more quality time with doctors, promote positive lifestyle changes, result in higher satisfaction for both patients and physicians, and shorten wait times. Some view them as one solution to help stem the rising incidence of chronic diseases like diabetes, which alone costs Americans $327 billion a year.
“Shared appointments increase efficiency, improve access and help the bottom line,” says Noffsinger. “They’re changing healthcare for the better.”
How do shared medical appointments work?
Patients agree to attend a set number of sessions — usually once a month for one year — at a healthcare facility or doctor’s office. Sessions are led by a team of practitioners that might include some combination of a physician, nutritionist, dietician and therapist, depending on the group’s theme. Appointments can last anywhere from one to two hours — versus the 15- to 20-minute norm for one-on-one visits. Each appointment is covered by insurance and billed as an office visit.
When a patient arrives at a shared medical appointment, they check in at the front desk, before a nurse takes their blood pressure and collects any other relevant health information, like their weight or blood sugar level. These assessments are either done privately or in the same room with other group members, depending on how the sessions are organized.
Often, a patient’s family member or caregiver can attend the appointments as well. All participants have to sign a confidentiality agreement at the start of the program that prohibits them from divulging any information about other participants and their health conditions outside of the group.
Most shared appointments start off with a five- to seven-minute discussion of each patient, their current health status and their progress toward health goals. The group leader goes over their data and any other pertinent information that’s been written on a white board for all to see. Group appointments also usually include a short educational talk given by the group’s regular physician or another provider who’s been invited to speak.
“Everyone feeds off of each other, and there’s no judgment,” Gardner says. In his experience, patients often find that other group members ask worthwhile questions they hadn’t thought of themselves. Everyone in the group goes home armed with information they might not have if they’d done a traditional one-on-one visit.
Some facilities pair up with community partners to design their SMA. At the University of Wisconsin School of Medicine and Public Health, family medicine doctor Magnolia Larson partners with local health insurance companies on her weight management group appointments. Patients covered by those companies receive a $100 insurance benefit after attending at least five of six sessions.
Program participants also receive discounts at a local gym and grocery store. And at the grocery store, they do a walk-through with a dietician to go over food labels. Sessions start off with light stretching. Patients then eat a meal together prepared by the dietician, before breaking into small groups to be individually assessed by Larson.
“I was feeling disappointed with how little impact I could have in quick visits,” Larson says. “Group visits make me feel like I can make a bigger impact. Some patients specifically said, ‘It was so nice to get to know you as a provider.’”
Growing interest in SMAs
The renowned Cleveland Clinic introduced group visits more than a decade ago. In recent years, it’s added more varieties of shared appointments, including SMAs for chronic heart failure, dizziness, Parkinson’s disease and multiple sclerosis.
More than 200 of the clinic’s doctors now run shared appointments, and by the end of 2019, Cleveland Clinic will have run a total of 160,000 shared visits, says Marianne Sumego, an internist, pediatrician and director of the clinic’s shared medical appointments program.
“The feedback is tremendous,” Sumego says. “Patient satisfaction is higher for SMAs than for one-on-one appointments.”
When Sumego got involved in SMAs early in her career, it was under the eye of Noffsinger, the psychologist behind the whole concept. Noffsinger thought of it in the late ‘80s, after being diagnosed with a rare lung disorder and told he had seven years to live. Laid up in bed, he began thinking about how he would redesign healthcare to better meet the needs of chronically ill patients like himself and those he’d spent years counseling. He called his innovative solution “drop-in group medical appointments.” The name didn’t last, but the model of care did. After making an unexpected recovery, Noffsinger began piloting group visits. He’s written two dozen articles on SMAs and trained countless physicians around the world on how to run group appointments.
At the clinic, Sumego runs a 90-minute SMA focused on diabetes, lipids and hypertension alongside a certified diabetes educator who facilitates the appointments. When one patient lowered his average blood sugar level from 13 percent to 9 percent, group members applauded him, and he gave them advice to replicate his success. Topics for educational talks during Sumego’s appointments might include safe over-the-counter medications for diabetics during flu season, or healthy meal planning.
She also trains physicians how to lead SMAs, and she says interest is up. Five years ago, she stopped recruiting doctors into the clinic’s SMA program. “They were coming to me,” she says. “They become champions of SMAs and they direct patients to them.
A complementary approach
The research on shared appointments has shown mostly positive but still mixed results.
In a 2016 study comparing SMAs to traditional visits for teenagers with type 1 diabetes, Sumego and colleagues found that in one year, group-visit patients showed less improvement lowering their blood sugar levels. But researchers still concluded that SMAs increase access to care and provide valuable peer support, and a different 2016 study found notable reductions in blood sugar levels among members of small SMA groups. Also, one study on patients with chronic neuromuscular disorder found greater health-related quality of life improvements among those who’d done SMAs versus traditional one-on-one visits.
Noffsinger says SMAs aren’t for everyone: They’re not appropriate for initial evaluations, one-time consultations, medical procedures or treating acute or infectious illnesses. Patients who take part in SMAs still have individual appointments with providers, including wellness visits and appointments for issues that fall outside the scope of the group appointments.
What SMAs are is an additional healthcare option, Noffsinger says, complementary to traditional visits. “There will always be a role for individual office visits,” he says. “But there’s also a role for group visits, and it may be a much bigger one than anyone ever expected, especially with the growing problem of chronic disease.”