The Semiprivate Checkup

By Amanda Bower

Kim Strong, 41 and eight months pregnant, lies down on four armless chairs shoved together in the far corner of a conference room at Montefiore Medical Center's Comprehensive Family Care facility in the Bronx, N.Y. She lifts up her T shirt, lowers her pants and watches obstetrician Liza Kunz squirt gel on her big, full belly. As the doctor slides a fetal heart monitor across her skin, Strong isn't the only one listening carefully for the reassuring sound of a baby's heartbeat. Gathered in the room with her are four equally pregnant women. They all arrived as a group to have their obstetrics checkup together.

For American patients used to thinking of a doctor's appointment as a private, one-on-one affair, the idea of a roomful of strangers discussing something as intimate as the progress of their pregnancy may seem strange. But look at it this way: Would you rather wait an hour or two to see your doctor for 10 minutes or meet at a prearranged time and see the doctor--along with up to 25 other patients--for two hours?

More and more doctors and their patients are opting for the latter. Patients enjoy the support and encouragement of people who are in the same boat they are, and get to ask the questions that often slip their mind in the rush of a short appointment. Doctors appreciate the efficiency of giving better information and care to many more patients a day, up to three times their previous number.

"This is an important part of the future of medicine," says health psychologist Ed Noffsinger, who introduced shared appointments to California's giant Kaiser Permanente system in 1996, and is now a full-time consultant in the field. "Most doctors are still using a system that was developed in an era of acute care, when we didn't even have antibiotics. It's a mistake to believe that same model is the best way of looking after people."

The idea Noffsinger has been championing is rapidly catching on across the country, from rural Tennessee to South Central Los Angeles. The VA Medical Center in Bay Pines, Fla., introduced group appointments in the summer of 2002 as a way to combat a backlog of 17,000 patients waiting to be inducted into its primary-care system. Today that waiting list hovers at about 100, and the group model is being extended to Veterans Health Administration centers around the country. Endocrinologist David Shewmon started group appointments in his Wooster, Ohio, practice last January and has reduced the wait time for a follow-up appointment from six months to about a week. In Kalamazoo, Mich., internist Ed Millermaier can get you in for a shared physical next week, but if you want an individual appointment, there's a four-month wait.

Group appointments allow doctors to see more patients a day--and, in many cases, make more money--and advocates argue that these physicians also provide superior care. A Kaiser study by pioneer John Scott, who introduced groups to Colorado in 1991, randomly allocated elderly patients to group or individual care and found that after two years, those who attended the groups regularly had 18% fewer emergency-room visits and a 12% decrease in hospital admissions, were more likely to get flu and pneumonia shots, and cost Kaiser about $50 a patient less each month.

Groups come in many shapes and sizes. Most appointments last 90 minutes to 2 1/2 hours and involve half a dozen to 25 participants. Patients are urged to maintain confidentiality; many doctors require privacy waivers. Physical examinations may be conducted in the presence of the entire group or in private exam rooms before group discussions. Of course, shared visits are not appropriate for every patient. They don't work very well with the acutely ill, the demented or the hearing impaired. Nor are they well suited to one-time consultations.

Insurance payments can also get complicated. There is no American Medical Association--generated billing code for services provided entirely in a group setting, which means that for now that model is best suited to so-called capitated systems, in which doctors are paid a flat salary. Doctors conducting one-on-one exams followed by a group discussion can bill for individual visits, but Noffsinger, for one, is concerned that insurers could reduce those payments once they realize doctors can triple the number of patients they see. "The insurers have more to gain than anybody," he insists. "Their patients are serviced faster and better."

The shared sessions help doctors as well. "Somebody who has had three children," says Kunz, "can tell me more about how to solve a pregnancy ache or pain than any reading I can do."