key: cord-0849144-j1l80obr
authors: Thompson-Lastad, Ariana; Gardiner, Paula
title: Group Medical Visits and Clinician Wellbeing
date: 2020-11-18
journal: Glob Adv Health Med
DOI: 10.1177/2164956120973979
sha: 50af5cf36cd3ced545b202beef7e6d9977a2de0c
doc_id: 849144
cord_uid: j1l80obr

There is strong evidence for clinical benefits of group medical visits (GMVs) (also known as shared medical appointments) for prenatal care, diabetes, chronic pain, and a wide range of other conditions. GMVs can increase access to integrative care while providing additional benefits including increased clinician-patient contact time, cost savings, and support with prevention and self-management of chronic conditions. During the COVID-19 pandemic, many clinical sites are experimenting with new models of care delivery including virtual GMVs using telehealth. Little research has focused on which clinicians offer this type of care, how the GMV approach affects the ways they practice, and their job satisfaction. Workplace-based interventions have been shown to decrease burnout in individual physicians. We argue that more research is needed to understand if GMVs should be considered among these workplace-based interventions, given their potential benefits to clinician wellbeing. GMVs can benefit clinician wellbeing in multiple ways, including: (1) Extended time with patients; (2) Increased ability to provide team-based care; (3) Understanding patients’ social context and addressing social determinants of health. GMVs can be implemented in a variety of settings in many different ways depending on institutional context, patient needs and clinician preferences. We suggest that GMV programs with adequate institutional support may be beneficial for preventing burnout and improving retention among clinicians and health care teams more broadly, including in integrative health care. Just as group support benefits patients struggling with loneliness and social isolation, GMVs can help address these and other concerns in overwhelmed clinicians.

There is strong evidence for the clinical benefits of group medical visits (GMVs) (also known as shared medical appointments) for prenatal care, 1 diabetes, chronic pain, and a wide range of other conditions. 2 During a GMV, multiple patients participate in billable medical visits at the same time while engaging in health education, peer support and in some cases complementary and integrative therapies (e.g. acupuncture, yoga). GMVs can increase access to integrative care while providing additional benefits including increased clinician-patient contact time, cost savings, and support with prevention and self-management of chronic conditions. During the ongoing COVID-19 pandemic, many clinical sites are experimenting with new models of care delivery including virtual GMVs using telehealth platforms.

It has been suggested elsewhere that GMVs can address the quadruple aim of improving care through cost-effectiveness, patient experience, population health outcomes, and clinician satisfaction. 3 A substantial proportion of family medicine residency programs now provide some exposure to or training in GMVs and studies note the positive effects of training primary care medical residents in how to provide care in GMVs. 4 However, little research has focused on which clinicians offer this type of care, how the GMV approach affects the ways they practice, and their job satisfaction.

Many GMV publications briefly reference high levels of clinician and staff satisfaction. Qualitative pilot studies focused on clinician experience of GMVs have found described how clinicians'initial fears about using a new model of care developed into confidence in facilitation skills, and clinicians reported having a more positive work experience as well as sharing responsibility for care with their patients. Related literature describes how GMVs can improve clinician and patient experience by providing a model for caring for challenging patients, empowering patients, and supporting positive providerpatient relationships. Many GMV models emphasize patients as experts in their own bodies and circumstances and clinicians as facilitators rather than fixers, reducing the hierarchy between the patient and clinicians. 5 Our research has found that in some GMVs, clinicians act as facilitators rather than sole experts, which is part of what allows them to deliver patient-centered care. 6 Lavoie and colleagues found that group medical visits successfully delivered patient-centered care, in part because providers acted as facilitators and drew on medical knowledge as well as patients' lived experiences. 7 Clinician burnout is correlated with a variety of concerning outcomes ranging from poor-quality patient care (e.g. higher levels of racial bias) to increased levels of clinician turnover. 8 The structural conditions that increase clinician burnout are many, including limited time with patients, feelings of isolation, and lack of coordinated resources to address patients' social needs, and many of these conditions have been intensified during the current COVID-19 pandemic. Workplace-based interventions have been shown to decrease burnout in individual physicians. 9 We argue that more research is needed to understand if group medical visits should be considered among these workplace-based interventions, given their potential benefits to clinician wellbeing.

How Can GMVs Benefit Clinician Wellbeing?

1. Extended time with patients: In GMVs, clinicians and patients typically spend one to three hours together. This is a stark contrast to brief individual visits, which have been made more challenging by the use of electronic health records. Group visits strive to meet all accepted standards of care, using the same medical billing and charting processes found in an individual visit. However, the extended time provides more flexibility for clinicians to include prevention and treatment strategies, integrative therapies, and demonstrations (e.g. how to use an inhaler or glucometer), with the added benefit of peer support and education. Nearly all GMV clinicians continue offering individual care, and many in our research report that replacing some individual visits with GMVs increased their job satisfaction, in part because it provided more variety in their work schedules and time to develop more trusting relationships with patients. Finally, extended time can make health care interactions more enjoyable for staff and patients alike. GMVs often include activities such as cooking and together and learning mind-body practices. 2. Increased ability to provide team-based care: One benefit of GMV models is that they provide opportunities for team-based care through interdisciplinary collaboration. GMVs often include continuity of staffing, and primary care providers are typically supported by one or more team members (e.g. health educator, behavioral health clinician, community health worker). Some models include multiple practitioners to facilitate the provision of whole person care; for example, a psychologist and a nurse-practitioner, or an acupuncturist and a physician. In many cases, clinicians and other staff co-facilitate the GMV, providing interdisciplinary perspectives that draw on all staff members' strengths. 3. Understanding patients' social context and addressing social determinants of health: In GMVs, patients participate in one another's care by providing support, resources and advocacy. 6 Extended time and the presence of peers facilitate patients sharing knowledge and experiences, reducing loneliness while providing clinicians, other health care staff and peers the opportunity to provide referrals and follow-up with needed resources. These can include not only access to needed health care (e.g. mental health or dental care) but also community resources such as legal aid and public benefits programs that address patients' social needs.

Perceiving that their workplace is equipped to address patients' social needs has itself been correlated with lower physician burnout. 10 In addition, understanding and addressing patients' social context may increase mutual trust between patients and clinicians.

The American Academy of Family Practice (AAFP) has endorsed GMVs as a valuable, evidence-based model of care for chronic conditions but has not described benefits of GMVs for clinicians more broadly. Other GMV researchers have suggested that GMVs may prevent or reduce clinician burnout, but there is not empirical data published in this area. Our research has also included interviews with GMV staff co-facilitators who, like clinicians, reported high levels of satisfaction with working in GMV programs. GMVs can be implemented in a variety of settings in many different ways depending on institutional context, patient needs and clinician preferences. GMV models inherently include many elements of current movements in primary care, including patient-centered medical home, team-based care, accountable care organizations, and value-based care models. They are appropriate for many complex patients, can increase access to providers who typically have long waiting lists, and can replace a large proportion of individual primary care visits for preventive care and chronic disease management. GMVs via telehealth platforms are also feasible for a variety of patient populations.

Successful GMV programs generally include substantial clinical and administrative support from staff with designated time to coordinate and co-facilitate GMVs. Buy-in from clinic administrators and front office staff makes successful GMV programs possible. Such programs draw on an array of existing models of GMV billing, training, curricula and staffing. Programs with institutional support can be financially sustainable while increasing communication and support among interdisciplinary teams. This can include co-management of patients among multiple clinicians when appropriate. For example, GMVs that integrate behavioral health clinicians have been implemented successfully for opioid use disorder and group well-child care, among other conditions. Acupuncturists, massage therapists, and other integrative practitioners can be part of collaborative care for patients with chronic pain and other conditions.

In conclusion, we suggest that GMV programs with adequate institutional support may be beneficial for preventing burnout and improving retention among clinicians and health care teams more broadly, including in integrative health care. Just as group support benefits patients struggling with loneliness and social isolation, GMVs can help address these and other concerns in overwhelmed clinicians. Though GMVs are not something that all patients and providers would choose to participate in, they can have substantial benefits for those who opt to be part of them. We recommend that future research explore burnout and retention among health care teams that provide care in GMVs. Mixedmethods approaches could include longitudinal assessment of clinician burnout using validated measures, as well as qualitative assessment of the underlying mechanisms in the group visit process .

Group prenatal care compared with traditional prenatal care: a systematic review and meta-analysis

Characteristics and components of medical group visits for chronic health conditions: a systematic scoping review

The quadruple aim as a framework for integrative group medical visits

Group medical visit training in family medicine residency: a 2015 CERA program directors survey

Shared medical appointments and patient-centered experience: a mixed-methods systematic review

Group medical visits as participatory care in community health centers

Group medical visits can deliver on patientcentred care objectives: results from a qualitative study

Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being

Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis

Physician burnout and higher clinic capacity to address patients' social needs

Thanks to our colleagues at Integrative Medicine for the Underserved and participants in our group visit research for their insightson this topic. Thanks to the anonymous peer reviewers for valuable feedback.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Ariana Thompson-Lastad's contributions were partially supported by a fellowship from the National Center for Complementary and Integrative Health (#2T32 AT003997 and F31AT008747).

Ariana Thompson-Lastad https://orcid.org/0000-0002-4880-1371