Group Medical Visits and Clinician Wellbeing

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\u27 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

Structural Competency: Curriculum for Medical Students, Residents, and Interprofessional Teams on the Structural Factors That Produce Health Disparities

Introduction: Research on disparities in health and health care has demonstrated that social, economic, and political factors are key drivers of poor health outcomes. Yet the role of such structural forces on health and health care has been incorporated unevenly into medical training. The framework of structural competency offers a paradigm for training health professionals to recognize and respond to the impact of upstream, structural factors on patient health and health care. Methods: We report on a brief, interprofessional structural competency curriculum implemented in 32 distinct instances between 2015 and 2017 throughout the San Francisco Bay Area. In consultation with medical and interprofessional education experts, we developed open-ended, written-response surveys to qualitatively evaluate this curriculum\u27s impact on participants. Qualitative data from 15 iterations were analyzed via directed thematic analysis, coding language, and concepts to identify key themes. Results: Three core themes emerged from analysis of participants\u27 comments. First, participants valued the curriculum\u27s focus on the application of the structural competency framework in real-world clinical, community, and policy contexts. Second, participants with clinical experience (residents, fellows, and faculty) reported that the curriculum helped them reframe how they thought about patients. Third, participants reported feeling reconnected to their original motivations for entering the health professions. Discussion: This structural competency curriculum fills a gap in health professional education by equipping learners to understand and respond to the role that social, economic, and political structural factors play in patient and community health

Providing Integrative Medicine to Low-income Patients though Group Visits

Inequalities in health care delivery are perpetuated through a combination of interpersonal, institutional, and structural factors. This dissertation examines the emergence of a new model of care in relation to health care inequalities and resulting racial/ethnic and socioeconomic disparities in health outcomes. I investigate integrative group medical visits (IGMVs) as an innovation in the structure and process of health care in settings with limited resources, specifically safety-net primary care. IGMVs are a clinic-based intervention that aims to improve patient health by combining biomedical care with complementary health approaches such as acupuncture and yoga, as well as peer support and health education. My research approaches IGMVs as a potential site of addressing inequalities, particularly stratified access to integrative health care.This mixed-methods project draws on 52 interviews, ethnographic observation of 20 distinct IGMVs, and an exploratory survey. It provides a national overview of safety-net IGMVs in 11 states as well as an in-depth examination of IGMVs at four organizations in California and Massachusetts. The first chapter describes characteristics of IGMV programs, providers, and sites throughout the US, finding that they are most commonly used for chronic conditions including diabetes and chronic pain. The next chapter examines changing social relations made possible by group visits, including an expanded role for patient knowledge. I find that patients take active roles in each other’s care, supporting, challenging, and advocating in ways that shift patient-provider relationships. The final chapter situates the current opioid crisis and related uncertainties surrounding the treatment of chronic pain through safety-net IGMVs. I show how integrative health care is perceived as a safe risk to take against a national context where prescribing and using opioids is seen as comparatively high risk.This study suggests group visits can restructure patient-provider encounters to interrupt healthcare inequalities, shifting roles and increasing time between patients and providers. My findings point to the promise of group-based care in increasing access to complementary health approaches and providing interdisciplinary care for chronic conditions. Finally, participants in my research articulated how group visits help address trauma at both the individual and community level, in part by breaking social isolation

A crack in the wall: Chronic pain management in integrative group medical visits

Amidst a national crisis of opioid overdose, substantial uncertainty remains over how to safely and effectively address chronic pain. In response to this crisis, safety-net primary care clinics are instituting integrative group medical visits (IGMVs) for chronic pain management. Through two qualitative studies of IGMVs, we found that these groups acted as workarounds implemented by clinicians seeking to innovate upon standard pain management protocols. While clinical uncertainty is often framed as a problem to be managed, in this instance, overlapping uncertainties provided an opportunity through which enterprising clinicians could generate reform at the local level. However, these clinician-led changes were incremental, situational, and partial, and occurred outside of broader systemic reform. In the following article, we draw on 46 interviews with clinicians and staff associated with IGMVs and observations of 34 sessions of 22 distinct IGMVs. We begin by describing the structure of the IGMVs we observed. We analyze the multiple uncertainties surrounding chronic pain and its treatment at the time of our data collection, just before the opioid crisis was declared a national public health emergency. We then demonstrate how clinicians tinkered with existing pain management protocols via their involvement with IGMVs. Lastly, we discuss the conditions of possibility that allowed for the existence of IGMVs at our study sites, as well as the conditions of limitation that restricted the expansion of these groups. Our research points to the potential of IGMVs for treating chronic pain, while showing that IGMVs continue as an innovation by individual clinicians, not as a result of broader reforms