Journal Briefs: Urology Practice: Urology Shared Medical Appointments
By: Sigrid Carlsson, MD, PhD, MPH; Behfar Ehdaie, MD, MPH | Posted on: 03 Sep 2021
Carlsson S, Clauss C, Benfante N et al: Shared medical appointments for prostate cancer active surveillance followup visits. Urol Pract 2021; 8: 541.
Patient quotes about SMAs:
“I appreciate the team here at MSK. The shared medical appointment was helpful because we got answers to questions we didn’t know enough of to ask. I know I was not alone but now I feel part of a community.“
“A benefit was hearing from the Doctor in more than just a minimum appointment period. Hearing him gave me confidence in him again and I felt I had a relationship with him.”
Imagine each patient having an hour with their urologist rather than just 15 minutes. This is now possible for certain urology visits though the use of an innovative clinic systems redesign called “Shared Medical Appointments” (SMAs), a concept first introduced by Dr. Edward B. Noffsinger at Kaiser Permanente, in which multiple patients are seen in a group format for their follow-up visits.1 At our institution, Memorial Sloan Kettering Cancer Center (MSK), we have a large active surveillance clinic; more than 90% of our patients with low-risk prostate cancer choose active surveillance. Ensuring in-depth discussions and high-quality patient care for our patients is a challenge if only a few minutes of the urologist’s time is allotted in a traditional individual medical appointment, including time for physical examination, renewing prescriptions, discussing the management plan, answering questions and addressing patients’ concerns.
To accommodate for the rapidly increasing patient volume and growing number of followup visits and to guarantee high-quality cancer care for our patients, we sat down in the health care team to discuss methods to address patients’ needs and ensure that they feel cared for in our active surveillance program. Against this background we initiated a quality improvement project, as recently published and described in detail in Urology Practice®, where we launched the concept of SMAs for active surveillance followup visits, led by a urologist (B.E.) and his health care team.2 Our SMAs included patient education, a common clinical management discussion with documentation in real time, support from the health care team and social support from peers, as well as one-on-one physical examination. Caregivers were welcomed to attend these appointments as well. SMAs have been used for a long time in chronic disease management such as diabetes, but its use in urology has been limited to a few settings, for example, kidney stones, post-prostatectomy/cystectomy, overactive bladder, erectile dysfunction and elevated prostate specific antigen (PSA).1,3–5
We ran 4 SMAs during 2019 (3×6 patients and 1×8 patients). We did not break any bad news during the SMAs. Before inviting patients to a SMA, we screened the patients’ medical charts and pathology reports; anyone who had progressed to higher grade disease would instead be recommended individual appointments as usual. SMAs took place in a conference room conducive to group discussion: a bright room with a central table and with patients facing each other and the urologist. One-on-one physical exams (digital rectal examination) took place in separate exam rooms in the urology clinic. Each SMA lasted for about 71 minutes in total.
The feedback from patients was very positive. Most patients rated their satisfaction with the SMA as extremely high, and almost all said that they would attend another SMA in the future. These findings are in line with a prior study by Jones at al that found that 4 out of 5 patients attending a urology SMA rated their experience as excellent and opted for another SMA.3 Furthermore, all our SMA patients said that they would recommend this visit type to a friend or family member with prostate cancer. The group dynamic was open and pleasant; patients had no difficulties with sharing personal information and felt comfortable to ask sensitive questions about urinary and sexual function in the group setting. Hearing similar stories from other patients was felt to be educational, helped answer questions and validated patients’ own experiences. Patients also appreciated having more time with the urologist, which improved the sense of trust in their provider.
In summary, our promising initial experience supports a role for SMA for active surveillance followup visits. Our report suggests that this model of care can ensure patient satisfaction and improve the contact time for individual patients (eg 1 hour vs 15 minutes) while being time-efficient and reducing resource utilization for the health care providers (eg 8 visits/hour instead of 8 visits/2 hours) and using the standard billing processes. Pending additional larger-scale reports and experiences, in the future SMAs could be expanded to a wide variety of settings in urological care and survivorship and may include telemedicine SMAs.
- Rhee E and Baum N: The shared medical appointment: a proposed model of medical appointments. J Med Pract Manage 2013; 29: 172.
- Carlsson S, Clauss C, Benfante N et al: Shared medical appointments for prostate cancer active surveillance followup visits. Urol Pract 2021; 8: 541.
- Jones S, Rackly R and Vasavada S: The group shared appointment: how it works and how it helps: new model of care increases patient access and service and improves clinical efficiency. Urology Times 2005; 33: 15.
- Fletcher SG, Clark SJ, Overstreet DL et al: An improved approach to followup care for the urological patient: drop-in group medical appointments. J Urol 2006; 176: 1122.
- Jhagroo RA, Nakada SY and Penniston KL: Shared medical appointments for patients with kidney stones new to medical management decrease appointment wait time and increase patient knowledge. J Urol 2013; 190: 1778.