“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

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.

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

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

“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

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

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

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.

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

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

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

“…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

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

“[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

“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”)

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

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

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

“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

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