Group or Shared Medical Appointments

Group (GMA) or shared medical appointments (SMA) seem to have taken on a life of their own in the last few years. I have been involved with two doctors that have asked me about SMAs and they both were surprised that a lay person (patient) would be promoting them. I have put both in contact with the doctors that have trained their own peer mentors to help them and received their thanks.

Now I am beginning to see some research on group medical appointments. I see little difference between them and they can vary by how a doctor wants to call them.

Medical management delivered via group medical appointments appears to be effective for glycemic control in patients with type 2 diabetes, according to research published in Diabetes Spectrum. It is a shame that this research has to be behind a pay wall, but at least I can use this to give to doctors that ask questions.

Cora A. Caballero, NP, from Loma Linda Healthcare System in California, and colleagues conducted an electronic chart review comparing group medical appointments care for 52 male patients with usual primary care for 52 male patients, all with type 2 diabetes. Demographic and health-related variables were analyzed.

The researchers found that the target HbA1c goals were reached by a greater proportion of group medical appointment patients (50%) than usual primary care patients (19.2%). The rate of decline of HbA1c over time was significantly faster for group medical appointment participants vs usual primary care participants.

"This study demonstrated that the concept of medical management delivered in a group approach had a positive effect on glycemic control in patients with type 2 diabetes," the researchers wrote. "GMAs were found to be an effective approach to achieving patient-centered goals for improving the glycemic control of patients with type 2 diabetes."

No mention is made about secrecy and any problems encountered. I think this is great and hopefully opens the door to more GMAs or SMAs.

Format of Shared Medical Appointments Important

This blog by Dr. Fisher really had me scratching my head and then I needed to read the link he provided. Dr. Richard Kratche, a family physician at Cleveland Clinic who conducts group visits for physicals seems quite happy with the results. Now I admit this would not make me happy and even if waivers of confidentiality were signed, who is to say that people won't talk about what they heard. Gossip is common and people like to embellish when they can.


Some people are comfortable with this arrangement, while others shudder at the thought. Now granted, I am familiar with a different type of shared medical appointments (SMAs). A couple of doctors in two western rural states have peer mentors for diabetes education. One doctor has four peer mentors and the second has two peer mentors. The doctor with four peer mentors has two for type 1 diabetes and two for type 2 diabetes. Both doctors have patients that travel up to 100 miles one way and they want to make the best use of their time. Both doctors are family physicians and have patients on oral medications and insulin. The second doctor does refer the more complicated patients to the first doctor and they make things work between them.


In their SMAs, they use the peer mentors for gathering information and meter readings and then the doctor first takes any combination patients (husband/wife, parent/child), covers the lab results with them, and covers their meter printouts. Then each moves to single patients (not that they are single), and covers their lab results and meter printouts. All the time, the peer mentors are conducting education with those waiting to see the doctor or have seen the doctor. Both doctors have educated the peer mentors they have involved in the education.


I have been involved with both doctors either at the start of their training their own peer mentors, or after a few sessions when the peer mentors wanted to ask me questions. We do this by video conferencing and often after hours. I have substituted with one doctor when one of his mentors was in the hospital and this worked out quite well with video conferencing. Depending on the time of year, even if one mentor cannot be present, they have been able to use the video setup to take part.


This has been working very well for the two doctors I work with in Kansas, but that may end this year because they have hooked up with the U. of Kansas and their telemedicine group for more education across more diseases, diabetes being one of them. This happens, but several of the patients have asked if I will still answer emails and send copies to their doctor when I answer them. The husband and wife doctor team talked to me about this and they are talking to the patients, so this has not been resolved yet.


Therefore, apparently SMAs come in many varieties and ways of dealing with patients. I admit I do not wish my lab results made public unless I chose to let someone know outside the SMA. Even when I blog about people's results that are part of our support group, I am very hesitant to do so, but a couple have said use the numbers since I use made up names. Even George commented that he said his A1c in front of us and no one criticized him for what it was. That is the way we are George. And, the situation you were in, we knew you had nothing to compare to and we knew that you will learn.

Just Thoughts from the Last Few Months

Having computer failure and moving to a backup computer is not fun, but it is doable. Having lost many of my favorites and bookmarks is difficult to rebuild and I still have a quite few I have not recovered. I have noticed that many of my favorites are seldom posting blogs. Yes, they post, but not as frequently as they had in the past. I have found some activity on Facebook and Google+; so much of the activity may have gone where they get more immediate response, which can be more rewarding. I say good for them, I will miss them.

I do have accounts with both, but cannot find time for participating. I admit I am tired of receiving invites to play the games on Facebook. I would much rather play one game of solitaire which will be over shortly, and not waste a lot of time I see wasted on Facebook games. I enjoy researching and reading more than playing these games. There are so many good sources of information, some very interesting, and a lot of garbage is published trying to pass itself off as something important.

Part of what irritates me is the small studies done that mean nothing more than a call for more money to do larger and even less meaningful studies. Yes, I am venting. Then I get tired of all the rodent studies that herald a breakthrough. Yet we seldom see much beyond these rodent studies. Why? Because so much just won’t translate to the human body. Then there is the type of studies blogged about very accurately by Tom Ross here. This alone has me wondering how these get by peer review and how they are funded in the first place. It also raises questions about data committees and who else passed the buck. These researchers need to have criminal penalties imposed and do some prison time for their fraudulent use of research funds.

Now back to bloggers. I know bloggers come and go. Some I do miss and wonder what I could have done to encourage them. Others, well I hope you learned something while you were here and nothing serious has caused you to leave. I know from experience that sometimes a thick skin is needed and at other times, you can get emails for help that you cannot answer. Blogging can be very rewarding and at other times, you wonder if you are reaching anyone with something informative.

Then there are times when you receive both good comments (I receive mostly emails) and negative emails. I have been very surprised by what blogs get responses. I have had several over the last couple of months. Were the blogs that good? No, I can honestly say for a couple, I missed a lot and will write more later for some of them. At the same time, I at least opened the door for further discussion and I am learning a lot from one doctor, and for that, I am very thankful. I am also thankful for some of the contacts I have been making. Being a patient does have some advantages and at other times garners some sharp criticism. If I can continue to learn from some of the criticism, then I will have gained.

Several professionals have answered emails and we have started good discussions. A couple have contacted me and their discussions have been even more productive. I have been surprised at the questions and information they have requested and the responses to the information. You never know when something you blog about can open avenues for conversation.

Another activity that has been brought to my attention in the last few months is the use of peer mentors. I was a little shocked when I learned this, but after talking with a doctor using peer mentors and two of the peer mentors, I have learned a lot. The doctor stated that the nearest certified diabetes educator was over 150 miles distant and the closest registered dietitian was over 200 miles distant. The doctor had attempted to use the computer for video conferencing, but could not work around their schedules.

The doctor said he had two patients that he knew spent time researching on the Internet about diabetes and decided to have them in for a session of questions and answers just with him. He was pleased with the interaction with both, but one was not interested in peer mentoring. Therefore, he started with just one person and the first few sessions with patients went very well. In the meantime, both he and his peer mentor looked for others that would be capable. Over the next six months, they found and interviewed six more people, ending up with four peer mentors.

How did I end up being in contact with them? One of the peer mentors had read one of my blogs about shared medical appointments (SMAs) and made the doctor aware of this. The doctor was not sure if this would work for him, but was interested in exploring the topic. Over the last four weeks, we have corresponded about this. The doctors admits he does not like my stance on the American Diabetes Association, but is pleasantly surprised about the alternatives I do present.

My opposition to a one-size-fits-all mantra also got his attention, as did the discussion he had with his mentors about this. He knows that many people do not have the ability to afford the extra test strips to eat to your meter, or to discover how the different foods affect their bodies at diagnosis or at different times afterward. After discussing programs that a few of the test strip manufacturers have, he is now on a mission to see what can be done for his patients. Two of his mentors are writing on his behalf to see what can be accomplished. The office has gathered the numbers of each different meter used by his patients so that they can use this for volume.

He has asked about having SMAs with 5 to 9 people only as this about all his office can hold in the reception area. We have talked about having them at 4:00 PM to avoid interruptions. He does feel this would be workable, and if necessary he can see them going past 5:00 PM. Since he has the computers and equipment from attempting to set up with the CDEs and RDs, he seems willing to try this. His office is now surveying his patients with type 2 diabetes to find out how many would be interested. He is aware from reading my blog that secrecy for some may be an issue. He is investigating the frequency of having the SMAs, but in the beginning will start with quarterly.

He has used the video conferencing with me and has said he hopes I am not disappointed by not being asked to mentor for him. I said no, as I was writing my blogs and would be starting with two other doctors in the coming weeks as a peer mentor for them. I did email him copies of my twelve-blog series and the dates to be published and that if parts of them were useful then I had served as well in supplying education topics. He has forwarded them to his mentors and one has thanked me for them.

I have supplied him with the names of several people with nutrition degrees in his area and he said he was not aware of them, but would be in contact with a couple to see if schedules could be worked out. I have to thank my contacts for the names I sent to him.

Even if I have no other contacts like this, the last few weeks have been very rewarding for me. Complaints aside, I have learned a lot and even one that was especially critical has given me a valuable lesson in how to approach a couple of topics.

Shared Medical Appointments Revisited

It does not seem possible that from May 2010 to now I have gone from being a total skeptic about this topic to an advocate. There are many types of diseases that could benefit from shared medical appointments. Why are they not as popular as they could be? This is a multifaceted situation that troubles many of those that have found success within SMAs.

I have recently talked with two physicians that have been using SMAs with good success. I am apologetic that neither will allow me to use their names and would only talk to me after affirming that I would not reveal their location or the type of practice. I can only say that other doctors are pressuring them to discontinue this part of their practice.

From my own observations, I can say that many doctors do not understand the benefits of SMAs and see no purpose to them. Other doctors view them as a threat and want to have them banned. Now a few doctors may well see them as a threat as they are the ones losing patients to these doctors. A couple of patients have expressed the satisfaction of finding others with the same disease and getting the communication going that they felt their former doctor was ignoring. They said that hope was restored and they felt that they were learning where before they were in a constant battle to have simple questions answered.

To this, I can only say that the medical community climate is changing and doctors that are unwilling to adjust, may be adjusted out of practice. Patients are starting to realize that they have rights and need communication with the doctor.

I have discovered the medical groups in some states are becoming entrenched and protective of their way of life; they are opposing anything new that happens to work. Those doctors that are hospital employees are strongly opposing concierge medicine and anything remotely resembling this. In many areas of this country, hospitals are hiring doctors away from private practice.

I need to get back to SMAs, as they can be a real benefit. Yes, they can benefit people with type 2 diabetes. However, this may be difficult for some doctors to use, as many people with type 2 diabetes want to keep it a secret. Their doctor and office staff can know, but not their neighbors or others in their community. SMAs may reveal this to those they do not wish to have known about their diabetes. Even our informal group has this happen when one of our members knows another person with type 2 diabetes and many of us have been asked not to talk about them with our friends.

One doctor has a small group with the same type of disease. He said that they really delve into different areas of the disease and contact each other outside the SMA. The doctor is now trying to get other types of diseases with four or more patients together for SMAs.

Just think of the information exchange that could take place for diabetes, multiple sclerosis, cancer, and other diseases. Granted, some people will not feel comfortable in SMAs because of their desire for secrecy, but others could really benefit. It is the open exchange of information that seems to help people in SMAs and points to the real benefits.

Other types of SMAs do exist that are more open and patients are encouraged to exchange ideas and information.  This article from the Veterans Administration is also an excellent reference.  I must apologize as two of the links I had here no longer exist as the American Association of Family Physicians has pulled the information because of opposition to SMAs.  The VA reference is still valid, but you will need a PDF reader to view the file now.

Shared Medical Appointments

This is one idea I do keep seeing more and more about. Now that I have discussed concierge medical practices in my last blog, I also feel this needs another look. The primary care physicians (PCPs) are under more and more pressure as their numbers decrease and few are entering the profession. When it comes to diabetes, there are also not enough endocrinologists specializing in diabetes to make it possible for everyone not having a good PCP to find an endocrinologist.

This is where shared medical appointments may become a necessity for many PCPs and endocrinologists specializing in diabetes. Studies have shown that they do work and work well. Often one of the benefits for patients is that they can see they are not alone and this builds bonds within the group participating in SMAs. It is the healing power of group interaction that has been well documented. Groups are inherently therapeutic and the interactions can often do wonders for the entire group.

I have mentioned this in my previous blogs on SMAs that this may not be for all doctors and even some patients, but it needs to be considered. Three general models for the shared medical appointment exist: 1) the cooperative health care clinic (CHCC), created for older patients requiring frequent, broad-spectrum care; 2) the disease-specific CHCC, a diagnostically exclusive group that aids patients with chronic-disease management; and 3) the drop-in group medical appointment (DIGMA), intended for established patients needing a more comprehensive approach to their follow-up care.

There are, however, an almost infinite number of variations of shared medical appointments that a care team may choose to incorporate into their practice, depending on the patient population they serve.

SMAs typically involve a medical provider, a facilitator (a nurse, behaviorist or health educator) a documenter (optional but cost-effective), an educator as needed, and one or two medical assistants (MAs) to check in patients. Administrative support is essential to ensure access, document and code patients’ visits, obtain confidentiality waivers, check in patients and prepare the room.

SMAs may be continuous, occurring at regular days and times and encouraging patients to form a cohesive group. A continuity group comprises the same people with the same physician and the same or similar conditions, or people who share a demographic characteristic, such as postmenopausal women. Membership changes occasionally through attrition or additions, but ongoing attendance is assumed.

Read these two articles about SMAs and the benefits, here, and here. For a rather lengthy description of one for diabetes, read the article in ADA Spectrum. There are many more sources and if you want to read more, use your search engine and enter “shared medical appointments”.