It is a Monday morning in the spring of 2017. The hot, dusty expanse of the Central Valley of California lies below me as the twin-engine plane I'm riding in dips and then swings onto an asphalt runway that separates walls of pistachio trees that are standing so close to one another it looks like they're holding hands.
For nearly two years, I commuted by plane from Los Angeles to a remote part of California's Central Valley, where I worked in a start-up clinic dedicated to reducing the burden of diabetes and reversing the incidence of prediabetes in a largely Latino population of factory and farmworkers. During the work week I stayed in company-owned housing in a dusty village with a mostly Latino population, a half-hour or more from the nearest ambulance dispatch center and more than an hour from the nearest hospital.
Having attended medical school in Mexico, I am committed to caring for this population. But throughout my career, from my residency in a large inner-city hospital to my current role as a senior primary care physician, I have been frustrated with the one-on-one visit model. I have often felt powerless and hopeless in caring for underserved patients with chronic diseases in the traditional hamster wheel of the 15 to 20 minutes allotted for individual encounters. Patients often felt the same way.
Isn't there a better way to care for patients with chronic disease, a different model that would improve care as well as bring back joy in clinical practice? What's missing?
Why the traditional can fail
"Mariana's here," Julie, one of the medical assistants, announced one Monday as I walk into the clinic's team room after driving from the airport. "She had an appointment Friday, but forgot."
Mariana, a woman in her late 50s, works as a janitor in the agricultural company. She has never been to school and can't read. She lives alone in a rural hamlet, has no cell phone, and depends on her coworkers to give her a ride to her job each day.
She doesn't understand diabetes, the disease that now ravages her body. Mariana's idea of self-management for diabetes is "not eating too many foods that taste sweet."
Jen, the clinic's nurse practitioner, and I have struggled for almost a year to care for Mariana and help her care for herself. We are committed to caring for this underserved population, but we find ourselves more and more overwhelmed with the needs of patients like Mariana.
Culturally sensitive health coaches are assigned to high-risk patients with severely uncontrolled diabetes, including Mariana. But the one-on-one visits with a coach haven't reduced Mariana's glucose control. The goal for most people with diabetes is a level of hemoglobin A1c of 7 or less. Mariana's consistently runs around 13.
I scroll through Mariana's electronic medical record. A recent screening report shows severe retinal damage, caused by the diabetes. Mariana's health coach, Manny, sighs as he sits down next to me in the team room. He tells me he's reached out to Mariana, leaving messages with a daughter-in-law without any response. Jen joins us. She ordered a new insulin pen for Mariana, but none of us are confident in Mariana's ability to manage her medication. But there's something else going on here, beyond difficulties of managing medications or getting to doctor's appointments. I see it in Mariana's face as I join her in the exam room. She's demoralized.
Rolling the exam stool near the chair where Mariana sits, I study her flat, dull expression. I praise her for coming in and having gone to her eye appointment.
Her eyes fill with tears. "Doctora, they told me I could go blind!"
I reach for her hand, tell her we want to help her and that reducing her blood glucose would help prevent further damage.
Like a good student who wants to please, Mariana tells me that she has been checking her blood sugar at home, and it is running 120 to 180. I find that hard to believe, given Mariana's difficulty with reading and manipulating the glucometer as well as her most recent A1c of 13.0. That A1c level reflects blood glucose of 326.
I ask Mariana if her son has purchased a cell phone for her yet, as she had previously reported he might. She sniffs, her face red and splotchy, and chokes back tears. She recounts how busy her son is, how her children really don't know how sick she is, and how she doesn't want to burden them.
I begin to feel a familiar sinking feeling. I am running out of options for her.
In my days as a clinical preceptor, I witnessed the same dilemma when working with residents. They would plop down next to me, sigh and speak hopelessly about treating the triad of diagnoses in patients who presented with diabetes, hypertension, and hyperlipidemia. They'd discuss diet and medication adherence with their patients, yet they wondered if anything was "sinking in."
Invariably, a medical assistant would interrupt and remind the resident that the next patient was outside the exam room, pacing the hall, irritated with the delay.
Thus, the Marianas of the world remain depressed, overwhelmed, and sick. And their clinicians remain powerless, frustrated, and burned out.
Until we don't.
Manny knocked on the exam room door and stepped in. He carried with him a brightly colored flyer announcing an upcoming shared medical appointment where several patients with common health care needs meet together with one or more health care providers. Unlike a traditional one-on-one doctor's visit, shared medical appointments can last one to two hours.
We call our shared medical appointment program Juntos Podemos (which means "together we can"). It's specifically tailored to help address the hopelessness and helplessness of both patients and clinicians in dealing with diabetes. Juntos Podemos usually includes eight to 15 patients, and it couples brief medical exams, prescription refills, and other medical care with education on topics such as the complications of diabetes. But at the crux of the program is peer interaction and sharing experiences, strength, and hope, akin to a 12-step program.
I lean forward and look into Mariana's eyes. Manny sits down.
"I want you to come to this," I say to Mariana, pointing to the flyer in Manny's hand. "I know we talked about this group in the past, but now, more than ever, I would love to see you in our next session."
"We can help you get a ride," Manny emphasizes.
We have been down this road before, and Mariana has declined to participate in Juntos Podemos in the past. But today she dabs her eyes and nods. "Yes, I will come."
Together we can
I have always believed that being a physician is a calling, a vocation. Part of my vocation as a clinician is finding innovative ways to reach patients and help them in their journey toward health. Yet instead of feeling like innovators, many physicians are simply burnt out. Experts consider a loss of agency and control in the processes of health care delivery to be a driving factor.
I feel as if we can reclaim that sense of agency.
In a recent article on the American Academy of Family Physicians website, Victoria Boggiano, a medical student, stated that what attracts her to primary care family medicine is the opportunity to be creative. It is this sense of idealism and passion to innovate that we must preserve and nurture throughout a clinician's professional life.
Shared medical appointments are one creative model for primary care delivery. I became aware of the innovation when I read about the work of Clinica (formerly Clinica Campesina), a federally qualified health clinic in the Denver, Colorado, area. Clinica began to use shared medical appointments more than a decade ago, first with diabetes and then with prenatal care. Cleveland Clinic and Kaiser Permanente also pioneered the model.
It wasn't until 2011, when I began to create shared medical appointments myself while working at an inner-city clinic in Los Angeles, that I understood and finally could articulate what was missing in health care, especially for patients with chronic disease and their clinicians. To me, the shared medical appointment speaks to the soul of our vocation as primary care clinicians in engaging patients, families and communities.
Our shared medical appointment block consists of six or seven weekly sessions that I run with Manny. Each session covers a specific topic, such as living with diabetes, managing medications, and dealing with complications of the disease.
As patients arrive, they help each other weigh in and check their blood pressures with an automatic blood pressure monitor. Julie checks finger-stick glucose for each of the patients.
Today, two weeks after Mariana agreed to join the first session of the new appointment block, she appears. I talk about the importance of helping each other in the journey toward health, and I use the words "there are unseen people in the room" who will also benefit from the patient's participation. They get it.
"My grandchildren, my children, my wife — I'm getting healthy for them and for me," a number of patients say. While Manny encourages participants to share stories, I perform the brief exams, checking their heart, lungs, and feet.
After the exams, we go around the room discussing A1c levels. It is a sort of roll call.
"I don't know," she says quietly.
Mariana is holding her lab results, but she cannot read. Suzy, a peer and coworker sitting next to her, leans over to look at Mariana's lab result circled on the sheet. "OK if I say it?" she asks Mariana. Mariana nods.
"It's 13," Suzy replies.
There is a collective gasp. Hearing the astonishment of her peers, Mariana tears up. Manny urges everyone to quietly focus on how "we are all here to help each other."
Mariana is trying to get control of her diabetes, I tell them. We discuss how she struggles with the lack of a phone, an isolated living situation, and long working hours.
At the end of that session, I ask the participants to buddy up during the week for support. Suzy puts her arm around Mariana's shoulders. "I will be Mariana's buddy," she says. "We work in the same area. I will help her."
For the next seven weeks, Mariana and Suzy attend the shared medical appointments together. After each group session, Jen, Julie, and Manny watch Mariana using the new insulin pen we got for her. They help correct a glaring error: Mariana had been removing the pen before the total dose of insulin was delivered. During that time, Mariana's son finally purchased a cell phone for her at Suzy's urging.
At the end of this block of shared medical appointments, it is time to look at A1c values again.
When it's Mariana's turn, Suzy reads the result and whispers the number into Mariana's ear.
"8.7," Mariana announces proudly.
The group erupts in applause. Many members have seen reduced A1c and weight loss as a result of participating in Juntos Podemos.
Afterward, Suzy tells me: "Mariana is a good person, a wonderful worker, and I was so happy to help her. You know, it helped me, too. I found myself putting down the extra tortilla when I called to check on Mariana's dinner!"
Then Mariana, fighting back tears, speaks. "I am glad Suzy called me," she says, looking at her friend. "She would call me in the morning and give me a ride to work. We ate lunch together, and at night she would call me and ask what I ate and if I took my medication. I began to have more energy, and really I feel so happy that I have this friend to support and help me. I know I will keep it up because she cares. She has been like a gift."
It then occurs to me that Juntos Podemos has given my patients and team alike something that is too often in short supply in primary care: hope.
An urgent matter
Although the shared medical appointment model has been around for at least a decade, it is not widely implemented — primarily because physicians' schedules and metrics are all built around the one-on-one face-to-face visit. This points to one of the biggest obstacles to starting and sustaining use of the shared medical appointment model: the lack of understanding and support by health system administrators.
In a March 2017 perspective in the New England Journal of Medicine, Kamalini Ramdas and Ara Darzi discuss four crucial components that need to be studied to make this innovative model of health care delivery a standard of care. What's needed are rigorous scientific evidence supporting the value of shared appointments, easy ways to pilot and refine shared-appointment models before applying them in particular care settings, regulatory changes or incentives that support the use of such models, and patient and clinician education, they write.
It was not lost on me that their article followed two poignant pieces published in that same March 2017 edition of the New England Journal of Medicine about depression and suicide in medical students and physicians. The link between innovation in medicine and finding meaning and joy in practice is clear.
How we deliver primary care is as urgent a matter for clinicians as it is for our patients.
As we learn more about the shared medical appointment model, perhaps we should study an additional component as well: the power of the shared medical appointment in promoting hope both in the patient and in the clinician.
By fostering interpersonal connections and relationships, Juntos Podemos resulted in more effective disease management and better health outcomes for Mariana. It also restored to us, her clinical team, a sense of agency and autonomy, so essential for preventing or reversing burnout.
In the past, my patients' hopelessness mirrored my own.
Now their hope reflects mine.
Read the original essay as part of the Narrative Matters series in the February 2018 issue of Health Affairs.