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Group health

In a darkened room in the heart of a vibrant Minneapolis neighborhood, eight people walk in a circle, immune to the honking and flashing lights of cars and buses outside. A faint scent of roasted kale chips permeates the space, the last slide of a PowerPoint presentation glows on a screen, and a blood-pressure machine hums quietly. None of it distracts the participants as they practice a walking meditation led by mindfulness instructor Cass McLaughlin.

“Imagine you’re in a park, or on a beach, that you’re barefoot,” McLaughlin instructs. “Lifting, placing, stepping.”

This isn’t a yoga studio: It’s a public health clinic.

Each of the participants has prediabetes or diabetes, coupled with depression or anxiety. They’ve gathered here every Monday night over the course of six weeks, part of a pilot program of group medical visits for underserved patients.

After checking in and paying a small fee (medical assistance covers everything but the copay), they stream into the conference room and greet each other like old friends. A medical assistant checks their vital signs as McLaughlin, who is also the program coordinator, unveils a table laden with healthy snacks: gelatin flavored with Hawaiian tea, pumpkin seeds, kale chips. An interpreter busily translates conversations among the Spanish-speaking patients to the mostly English-speaking staff.

During these meetings, the group members share details about their lives that go far beyond what’s covered in traditional medical checkups. They offer each other advice on marital issues and problems at work while learning skills for managing their health conditions. Each visit includes the check-in, meditation, instruction on a health-supportive skill (like keeping a sleep journal or locating healthy, low-glycemic snacks), and a mind–body activity. Tonight’s lesson: how to increase your energy through exercise.

Kara Parker, MD, a functional-medicine family physician at Hennepin County Medical Center, leads the group. In this session, she encourages members to think of at least one way to move more often in the upcoming week. “Sitting is the new smoking,” she warns, as she begins a PowerPoint presentation on how movement increases energy.

One participant chimes in that she’s been sitting too long already, and McLaughlin encourages the group to stand. Soon everyone in the room is swinging their arms and legs as Parker clicks through her slides.

When Parker caught wind of a grant to treat disadvantaged patients in 2015, she quickly proposed the group-visit program, which took about four months to launch. It’s something she hopes will become a permanent fixture in clinics and hospitals across the country.

Doctors began experimenting in the mid-1990s with group treatments, in part because of the success of 12-step programs like Alcoholics Anonymous. Many credit healthcare consultant Edward Noffsinger, PhD, with pioneering the group healthcare approach after his own experience as a patient. Since developing his Drop-In Group Medical Appointment model at Kaiser Permanente in San Jose, Calif., in 1996, Noffsinger has helped implement group visits in hundreds of settings.

Also known as shared medical appointments, this treatment approach is edging into mainstream medicine, largely on the strength of evidence that more time spent with doctors — and other patients — leads to better health outcomes.

The roots of the collective approach run deep. James S. Gordon, MD, founder of The Center for Mind-Body Medicine and author of Unstuck: Your Guide to the Seven-Stage Journey Out of Depression, says they may even be primal.

“It’s in our DNA,” Gordon explains, noting that community plays a role in healing in almost all traditional cultures. Even in the era of Hippocrates, considered the dawn of modern medicine, patients went to a temple for healing group rituals.

“In traditional societies, if you have a minor physical or emotional problem, you go to your granny or someone else,” he explains. “If it’s a major issue, you go to the official healer, a shaman, witch doctor, or wise woman. He or she brings together the family, tribe, or community. It’s all part of the healing process.

“We’ve lost that understanding because the power of biomedicine — surgical advances, antibiotics, and other techniques — has made us focus only on the individual. We’ve lost the context of healing and the importance of the group.”

Shared medical visits take a variety of forms, but most focus on developing lifestyle-based skills for healthy eating, movement, sleep, and stress. They can be especially useful for personalized and functional-medicine practices like Parker’s, where lifestyle prescriptions are the foundation of coping and recovery.

“If you’re going to teach people how to take care of themselves, the best way to do it is in a group,” Gordon emphasizes. “If you’re in a group and you’re learning about meditation, food, or movement, you learn from each other and feel supported. You’re not just a patient getting treated. Everyone who is in the group is taking an active role, learning, practicing, and sharing with each other.”

Most patients are enthusiastic about the experience. One survey found that after an initial group visit for surgery post-op recovery, 82 percent of participants said they wanted to attend another shared appointment.

The benefits also extend to doctors, who enjoy being able to offer more guidance to their patients: They can deliver in-depth information to a group instead of delivering cursory overviews in appointment after appointment.

Parker says she also appreciates the chance to see her patients’ strengths. “No matter how patient-centered you are [as a doctor], you still come to a traditional encounter really focused on what’s not going right,” she explains. “But in a group setting, I see the patients — even the ones I know really well — in a different way. They’re empowered and able.”

The following three programs demonstrate the powerful benefits of group visits in action.

Shared Rewards

Program: Shared Medical Appointments Program

Healthcare center: Cleveland Clinic, Cleveland

When Marianne Sumego, MD, walks through one of the dozens of doors marked Shared Medical Appointments Room at Ohio’s Cleveland Clinic, she knows that most of the wisdom her patients take home won’t come from the doctor in the room. It will come from the patients, sitting in a circle, who have similar conditions.

“I could give you so many examples of patients who didn’t want to pursue colon-cancer screening until someone in the group shared a story of finding a precancerous polyp, and how she got through the screening prep, and where she had it done,” says Sumego, who directs the clinic’s group-visit program.

Likewise, diabetes patients might discuss what to do if their bosses limit their lunch breaks, or they share tips on how they’ve learned to manage their insulin levels.

Even if the discussion strays off-topic, most doctors have learned to let the patients lead the conversation. During one appointment, for example, a patient with diabetes described a job situation that limited his ability to control his insulin.

“The group started brainstorming about how to approach his boss and what snacks he could eat instead, and shared their own exercise regimens when working second or third shifts,” Sumego says. The patient left with an arsenal of supportive strategies that Sumego could never have conceived on her own.

“That influence of their peers is something I can’t achieve one-on-one,” she acknowledges.

Cleveland Clinic first implemented shared medical appointments more than a decade ago, formally establishing its current program in 2010. Patients can now choose from more than 170 groups, which cover a number of conditions, including multiple sclerosis, pregnancy, dementia, and heart disease. Patients can even select a group visit as an alternative to an annual physical, where they receive a brief exam and extensive lifestyle counseling. Still, most shared visits are designed to complement and reduce — not replace — individual appointments.

The format varies. Young adults scheduled to have their wisdom teeth removed might attend a single meeting, while expectant moms may meet once or twice a month until the end of their pregnancies. Patients may be encouraged to bring family members who could also benefit from the discussion.

At first glance, the motivation for clinics to offer group appointments — packing multiple patients into a single window of time — may appear to be financial, as the cost is the same for private appointments. But Sumego insists that the driving force for her is the benefit to the patient.

“The shared appointment allows me to expand on things such as lifestyle recipes,” she says. “I’m sharing more and understanding my patients better.”

One patient, for example, lost 170 pounds, resolved her diabetes, and went horseback riding for the first time, Sumego says. The patient credits her group visits, which she still attends, for her improved health.

It’s stories like these that providers share with each other, Sumego says, and they help increase the popularity of group treatment. While internal studies are under way to more precisely evaluate Cleveland Clinic’s program, Sumego is already fielding frequent queries from outside organizations interested in developing similar models.

“The reasons we started it 15-plus years ago are the reasons we continue,” she says, noting that it’s hard to overestimate the value of peer support, added time for patient education, and improved outcomes.

Unlike a pill, group appointments are not a patented technology. The more patients use them, the more everyone receives benefits that many describe as priceless.

Putting the Pieces Back Together

Program: Integrative Medicine Program for Pain

Healthcare center: Central Arkansas Veterans Healthcare System, Little Rock, Ark.

Three years ago, Henri Roca, MD, joined the U.S. Department of Veterans Affairs (VA) in Little Rock, Ark., to lead its pain-management program. A family doctor specializing in integrative and functional medicine, Roca was familiar with group treatments, and he knew they would be vital for recovering veterans, who are accustomed to functioning in teams.

Today, all Integrative Medicine Program for Pain patients work in groups, including one that addresses posttraumatic stress disorder (PTSD) and chronic pain. The costs are largely covered by veterans’ benefits.

Chronic disease does not have an exclusive pill-based solution,” says Roca, explaining that most chronic conditions require a multipronged approach that includes lifestyle strategies. When vets witness other vets working to improve their self-care, it gives them permission to do the same.

“Veterans teach other veterans by their experience,” he adds. This is often a critical missing piece from the traditional doctor–patient relationship; the physician doesn’t always understand what the patient is going through the way a peer does.

After undergoing drug-based medical treatments, many vets have been able to wean themselves from their medications with the help of intensive support from their groups and the variety of lifestyle approaches they learn. (The nine-week core group program includes health coaching and training in self-care skills.)

Roca describes one patient who “went from hardly being able to get up from a chair to being very functional around the house.” The man had subsisted on processed foods before adopting a whole-food vegan diet. He inspired his wife to do the same — demonstrating once again that healing is easier in community.

“He did a big piece of work,” Roca says, “and in doing so, the whole household got healthier.”

Rather than focus on diagnosis, the group sessions are organized by skills that support healing. A fibromyalgia patient and an asthma patient might attend the same group visit on how to improve sleep or nutrition. Someone with chronic pain and another with PTSD might learn about mindfulness together.

“It doesn’t matter how their imbalance has shown up as illness,” Roca says. Effective treatment of chronic conditions almost always requires stabilizing the body through rest, movement, stress management, and improved nutrition — skills that are much more easily learned and maintained with group support.

After analyzing the research on group visits in a 2012 study, the VA began training providers to conduct shared appointments. The study showed the approach improved outcomes for patients with type 2 diabetes. More research is still needed to provide concrete measurements on their efficacy for other conditions, and those studies are ongoing.

Like Cleveland Clinic, the VA is pursuing shared appointments because its healthcare providers have seen positive results. The patients Roca treats in group visits gain a better understanding of their total health, he says.

“A group helps put the pieces together and come up with the whole, because they’re teaching and inspiring each other,” he says. “They help each other find a way back to what is important to them, back to how they want to live.”

Communal Transformations

Program: Group-Visit Program

Healthcare center: Whittier Clinic, Hennepin County Medical Center, Minneapolis

Just minutes into her first group visit, Felicia Hamilton of Minneapolis was ready to drop out. “We were all going around checking in, talking about our symptoms, and I thought, ‘What is this going to be — a whine-fest?’”

Five weeks later, as the series of group visits comes to an end, Hamilton admits she’s going to miss knowing every intimate detail about her fellow group members’ progress.

“Someone’s blood pressure becomes important to you,” she explains. “I want to know if Jessie is sleeping well, if Pat is having headaches, if Kelly has found the right diet. I care about that.”

The six-week rest-and-renewal class was transformative for Hamilton, in many ways. A study conducted by the clinic had identified her as being at-risk for diabetes and depression, and group facilitator Cass McLaughlin called to see if she wanted to join the group. That call, she said, was serendipitous.

Hamilton had just gained more than 50 pounds in a year, a side effect of the myriad medications she’d been prescribed. She says she used to be the type of patient who “waited for the doctor to tell me what was wrong with me.” But when she ended up with a row of medicines on her dresser that she didn’t want to take, she knew something needed to change.

Now, after her fifth group session, Hamilton says, “I see myself taking an active role in my medical life.”

At a recent visit to a sleep specialist, she was able to explain her goals to her doctor, thanks to what she’d learned during the group sessions. She visited a dentist for the first time in years, crediting group leader Kara Parker, MD, for convincing her that she didn’t need to live with unnecessary pain. She also quit a stressful job.

Like Hamilton, many patients and providers begin to see connections between struggles that seem unrelated at first. Parker, for instance, began recommending that her diabetes patients participate in sleep-apnea studies, as poor sleep patterns are an often-overlooked aspect of the disease.

Still, even when providers diagnose apnea, their patients are often averse to treating it with a continuous positive airway pressure (CPAP) machine. When a patient in Parker’s group told the others how transformative her CPAP treatment was, however, the rest decided to get proactive about their sleep issues.

“There’s nothing I can say as a doctor that is that kind of an affidavit,” Parker says.

Patty (a patient who prefers not to use her real name because her employer is unaware of her disability) agrees. A healthcare provider herself, she preaches many of the techniques she’s learning — but practice had been another matter.

“Did I do it enough in my own life at home? No,” she says. “Now that’s shifted for me, and I’m actually integrating [these behaviors] in my everyday life.”

Research backs up the value of social connections, showing that friendships can exert a positive influence on your health in a positive direction. (See “A Healthy Kind of Contagious“.)

“It’s why group visits are created,” Parker explains to patients in a session focused on social connections. “Because that connection affects health outcomes. For a primary-care physician, one of the hardest things is to help people create connections.”

Patients in Parker’s group agree that connection was what they valued most about the visits. “When you get ill, you isolate in fear and feel like people judge you,” Patty says. “It’s hard to find places with like-minded people with the same struggles where you can be authentic.”

That may be what the group appointment does best: provide a chance to get real — and get healed — in good company.

This appeared as “Healthy Together” in the May 2017 print issue of Experience Life.

Staying Healthy Together

health conscious group

Healthy behaviors are as contagious as catching a cold, says Dan Buettner, National Geographic fellow and author of the New York Times bestseller Blue Zones. So why not get people into healthy groups before they get sick?

“Our current healthcare system incents for sickness — no one gets paid unless you get sick or a prescription or a test or you check into a hospital — and yet we hope for health,” he says.

To find participants for Buettner’s Blue Zones city project, his teams host events where participants spend upward of an hour learning how to find like-minded individuals with whom they can join forces to get healthy.

“There’s a selection bias to the people who show up in the first place; they are inclined toward healthy behaviors,” Buettner says. “So by putting health-minded people together in a situation where they’re more likely to make friends, we’re setting up a long-term intervention: influence in the right direction.”

The groups, called moais inspired by the social circles he studied in Okinawa, are asked to organize five potluck dinners together where they feast on healthy foods. (As most of us know, if friends get together around pizza and beer, there’s an equally contagious effect — but less desirable.)

“Who you hang out with has a big impact on what you do,” he says.

How successful are they? There were 120 moais at the start in the launch city of Albert Lea, Minn., and at least half are still meeting five years later, he says.

“We’ve stacked the deck in the favor of long-term health.”

As for those who don’t show up in the first place, the contagion effect still spreads to friends of friends, he says, so early adopters get involved and spread the word. “They raise curiosity, and start to shift the culture. The next wave has already heard about it.”

Ideally, everyone in the larger community eventually receives the ripple effect.

Social connections are one of many factors that Blue Zone cities aim to address; the built environment also matters. If you step out your front door and there are five fast-food restaurants within three blocks, you’re about 40 percent more likely to be obese, says Buettner. So one initiative aims to change zoning laws to limit fast-food restaurants.

But we can change social connections on our own — and even small gains will amount to big rewards.

“If we can help 30 percent of the population get 30 percent healthier, we’re saving hundreds of millions of dollars in projected healthcare costs,” Buettner says.

Image by: Daly and Newton

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