1. “The Doctor Will See…ALL of You Now”
Transforming Residency Education through Group Medical Visits
Tziporah Rosenberg, PhD, Daniel Mullin, PsyD, Barbara Gawinski, PhD
University of Rochester School of Medicine and Dentistry
Department of Family Medicine
Rochester, New York

2. Learning Objectives
To identify the unique skills residents can acquire through group visits, and discuss how these differ from those traditionally taught in residency and medical school.
To learn skills needed to
decentralize physician’s role,
manage “being outnumbered” by our patients,
teach fundamentals in collaborative group process to FM residents.

3. Our DGV Model
Drop-in group medical appointment (DIGMA) meeting once monthly on the 1st Wednesday
Pts mailed information about group, including which medical/ psychosocial topics to be covered that month
Diversity in attendees

4. Our DGV Model Cast of characters: One attending MD/DO
One resident MD/DO
One Nurse
One MA
Two psychosocial providers
8-12 patients of the faculty practice, all with DM and comorbid health concerns

5. “Medical” topics
Psychosocial topics
Weight loss
Portion control, reading labels
Medication
Depression
Hypertension
Behavior change, motivation
Eyes
Relationship intimacy
Kidneys
Social supports
Feet
Food preparation

6. A Typical Visit 6:00pm- 6:05pm Mindfulness meditation exercise
6:05pm- 6:15pm Check in and ABC Review
6:15pm- 6:45pm Interactive presentation on topic related to DM and management
6:45pm-7:30pm Brief 1:1 medical visits by resident and attending MDs, concurrent session run by psychosocial team

7. A Typical Visit 6:00pm- 6:05pm Mindfulness meditation exercise
6:05pm- 6:15pm “New and good” check in and ABC (diabetes-relevant targets) review
Resident role:
Pick an empty seat, and introduce yourself!
Practice skills in mindfulness meditation (supplement to mindfulness didactic in psychosocial curriculum)
Observe process of patients reporting on success or failure of managing DM
Observe group process of relationship development for patients attending group and sharing new and good things in their lives

8. A Typical Visit
6:15pm- 6:45pm Interactive presentation on topic related to DM and management
Resident role:
Observe role of physician as group leader and teacher.
Observe process of managing many patients at one time, how they facilitate learning from each other. Reframing Pt “symptoms” as relationship styles and characteristics to be used in individual/family and group visits.

9. A Typical Visit
6:45pm-7:30pm Brief 1:1 medical visits by resident and attending MDs, concurrent session run by psychosocial team
Resident role:
Conduct brief (approx 5-7 min) visit with patient not in their regular panel.
DM only focus of visit; others referred back to PCP
Use of diabetic flow sheet, standardized medical group visit form (EMR)
Observation of psychosocial/community activity
Debrief with attending at conclusion

10. Traditional vs. Group Visits
Stand up
MD as expert
Doctor-speak
One on one, 15 minute “do it all” visits
Physiological focus
Group Visit
Sit down
MD as facilitator
Doctor-listen
Community first, with focused 1:1 (DM only)
Biopsychosocial focus

11. Decentralizing MD Role
Talking with, not talking to
Eliciting information instead of offering it
Listening to, adopting their language

12. “…It was an easy conversation in language that was typical for patients... you hear a lot of patients speaking about their diabetes in language that they use instead of hearing a doctor talking mostly in doctor-ese ... Even though we get a lot of teaching on diabetes ourselves, we don't get a lot of exposure to teaching patients in those sessions--we're supposed to figure that out on our own and translate the information into language that patients can understand. A lot of that happens on the spot during a short visit and there can be a lot of fumbling around, time wasted figuring out how to communicate.”
-Resident

13. Decentralizing MD Role
Observing that patients have wisdom that we do not
Embodiment of patient centeredness principles
Our own evolution and group process

14. “[The group] instills a sense of ownership for the patients' own health, as they are encouraged to know their numbers, and see it recorded…so there is definitely a social support component. I think that motivated patients' motivation can inspire more passive members.” -Resident

15. “Being Outnumbered”
The power of the group vs. the power of the individual (provider and pt alike)
Expectation to provide structure
Permission to not have all the answers
Challenge gut-level reactions (“it’s me against them”)

16. Facilitating Group Process
Asking questions, eliciting Pt stories (successes and challenges)
Fostering connections among members, not as much through provider
Use of circular questioning and Pts’ own language
“What do you think?” approach to engagement, then clarifying loose ends or misinformation

17. Modeling Collaboration
Multidisciplinary team of providers who model skills in working together
Flexible hierarchy (among MD and non-MD providers, and between Pts and providers)
Respecting others’ knowing
Screening for complications (ie. depression) and facilitating referral

18. New Perspectives on Success
Changing our view of “success” in outcomes; challenging the lines in the sand
The value of maintenance and not-getting-worse
Building community
Increasing satisfaction
Group members knowing what ABC’s are, what theirs are, and what effects change
Members showing more openness with each other, and their providers

19. “What was unique about the DGV was the opportunity to watch patients' perceptions of their own diabetes parameters.” -Resident
“It provides a sense of community, and that the patients can fight this disease together.” -Resident

20. How About You?
Experiences with resident inclusion in and education through group visits?
Obstacles? Successes?
Other questions and comments?