March 2002 • Volume 8 • Number 3 |
Physicians with experience conducting group visits and team visits took part in a meeting on the topic at the annual Conference on Patient Education Nov. 15 18 in Seattle. Here are the insights and methods of two of the participants.
GROUP VISITS FOR DEPRESSION
The group visit works best when the physician uses it in an area that he or she is enthusiastic about, says Rupal Patel, M.D., of the Florida Hospital Family Practice Residency in Orlando, Fla. For her, this area is treatment of depression.
Working with a behavioralist, Patel runs eight-week clinics that include six to 12 patients with mild to moderate depression. The clinic's patients have at least one other chronic illness. Patients who have personality disorders, severe depression or suicidal tendencies, or are psychotic, bipolar or substance abusers are excluded. Such patients are best referred to a psychologist or psychiatrist, Patel says. But FPs can fill a niche, Patel says, noting that psychologists are often ill-equipped to deal with the coexisting condition in patients who have another chronic illness such as gastroesophageal reflux disease.
Residents help to facilitate the group. Also, a behavioralist is involved in initial coaching and skills building and as an integrative training tool for the residents.
The 90-minute sessions are tightly structured: 10 minutes with the nurse to take vital signs, 5 minutes for warm-up/socializing, 30 minutes for the doctor to perform one-on-one checkups, 10 minutes for group instruction on a didactic topic, 30 minutes for patient interaction and so forth.
TEAM VISITS FOR DIABETES
Gregory Bartel, M.D., used to think he had a good record caring for patients with diabetes. Then he built a registry of his patients and was surprised to learn that only about half of his diabetic patients came in regularly for checkups.
This pushed him to engage in a "team approach" to management of the disease, says Bartel, of the Mayo Clinic in Rochester, Minn. The team consists of a registered nurse, a diabetes educator and the primary care physician. Before each visit, the patient has A1c tests done so the results are available for the appointment, as well as results of home glucose monitoring. While waiting for the appointment, the patient completes a self-management form to identify problem areas.
Then the team goes to work, each member taking turns visiting the patient. The nurse takes vital signs, reviews goals, and asks about progress and concerns. The educator follows and addresses the concerns brought out during the nurse's visit. The physician is reserved for the last 15 minutes, during which the patient's feet are examined and goals are discussed.
The team approach differs from the traditional approach to diabetes management in that the focus is on having the patient set the goal, says Bartel. Before, he would blame poor outcomes on noncompliance. "But the fact is, noncompliance merely means the doctor's goals don't match the patient's," says Bartel. That's why he focuses on having patients take ownership of their goals. "If a patient eats five Big Macs, smokes two packs of cigarettes a day, is disabled and sits on a couch all day, and his goal is to walk to the mailbox three times a week, by golly, that's his goal," says Bartel.
"My role is to reinforce the patient's goal," says Bartel. "I tell my patients, 'Diabetes is serious, and you are the most important person in managing it'."
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Copyright © 2002 by
American Academy of Family Physicians.