Shared medical appointments: Healing individuals while treating groups

IN A CONFERENCE ROOM AT CLEVELAND CLINIC, nearly a dozen patients, several physicians and nurses, and a social worker chat casually about the upcoming weekend. But then, within earshot of everyone, a physician begins discussing with a patient the results of her bone density test. Rather than granting the two privacy, everyone listens in. At least one other patient takes notes.

During a 90-minute session on this particular Friday afternoon, patients will discuss their most personal health concerns in front of other patients and listen to strangers discuss their problems. This is not a support group, a patient education program, or a group psychotherapy session-it's a shared medical appointment.

A shared medical appointment (SMA) is a physician-to-patient visit in the presence of other patients waiting their turns. Virtually everything-diagnoses, prescriptions, medical histories, and treatments-is discussed in the group setting.

Today, the SMA is conducted by Holly Thacker, MD, director of the Center for Specialized Women's Health at the Cleveland Clinic Foundation.

Jennifer Spolirito, LSW, the SMA behaviorist, greets patients in the conference room, helps them find seats, and instructs them on how the appointment will be run. She asks each to wear a name tag, with first name only, and requires them to sign a confidentiality form pledging not to divulge any information about their fellow patients.

Spolirito is the moderator, providing structure and order, giving health advice, and assessing patients' psy-chosocial needs. A behaviorist often is a nurse, a social worker, or a health psychologist.

Joining her is Mary McDonnell, RN.

"Jennifer or I-whoever is the facilitator for the appointment-am responsible for keeping the appointment orderly and getting Dr. Thacker out in 90 minutes so that she can see her other appointments," said McDonnell.

Thacker has been holding SMAs since July 2002, after receiving a barrage of appointment requests from patients concerned about hormone therapy. To meet the demand, she scheduled several patients at the same time in a conference room, and found it allowed her to educate women and answer their questions.

Today's visit has 10 patients in attendance, and includes a resident physician, an endocrinologist, a behaviorist, and a nurse. Currently, Thacker conducts two weekly SMAs-one for follow-up care and another for physical exams. About 10 to 14 patients attend the follow-up SMA for 90 minutes. The physical exam SMA also lasts 90 minutes, but only six patients attend.

For exams, the group is split in half; three patients are examined in separate rooms, while the other three patients are in the conference room with the behaviorist addressing their medication, psychological, or educational needs.

McDonnell brings a patient into the room. The older woman is confused about why she is seeing Thacker in this forum and not in an exam room.

"Even though the SMA is explained to patients when they schedule the appointment," McDonnell said, "a few are surprised by the format."

"I am here for a bone density test. Why do I need to sit through this and not see Dr. Thacker?" the woman asked.

"Dr. Thacker will be seeing you with the group after your test, and will go over the results," McDonnell explained.

"I have to wait until all these people are seen?" she said, agitated.

McDonnell reassures her that if she is unable to stay for the entire 90-minute appointment, she can be one of the first to be seen and can leave afterward, or she can stay and learn from the rest of the appointments.

Thacker enters the room, says hello, takes off her lab coat, and sits at a computer terminal, her back to the group. One of the advantages of SMAs is that medical records are recorded in real time, meaning physicians won't lose information by waiting hours or days to record their notes.