Musculoskeletal Hand Pain Group Visits: An Adaptive Health Care Model

Patient Satisfaction

One concern with shifting clinical duties to non-physician clinical staff is patient satisfaction. An abbreviated interaction with physicians can make patients dissatisfied with medical care independent of eventual clinical outcome [12]. However, it has also been demonstrated in an outpatient hand surgery clinic that quality of time spent with the physician may have a greater impact on satisfaction than quantity of time [13].

Our group visit is structured to allow high physician-patient visibility and interaction. The introductory remarks by the physician engage patients with the physician early in the visit and establish a group and individual rapport. The physician introduces the clinical team and the idea of patients being seen by other clinical staff up front, which establishes comfort for later patient–staff interaction. This is also an important time for patient education, which has been shown as a significant determinant of patient satisfaction in the outpatient setting [14]. The patient education at the beginning of the visit answers questions by one person that another person may not have considered, and generates patient questions to be addressed individually with a clinician. One common example is when a person considering carpal tunnel surgery hears from a person who has recently completed the procedure and can talk about their operative experience.

In the group room, the physician and staff can move between patients quickly and efficiently without waiting for turnover of rooms and resources. The structure of the visit allows staff to dedicate more time to patient care by bypassing the extra time required when patients are roomed individually. The group/communal structure also allows patients to see the staff at work, as compared to time spent waiting alone in an exam room in the traditional office. This enables patients to appreciate the efforts of the clinical staff and avoids giving the impression that the physician is inattentive or cursory in patient interaction.

Medical Education

An important consideration at any academic medical center is education. However, education often introduces redundancies and inefficiency into the medical care visit. The work a trainee does is either extensively overseen or the clinical questions are repeated by a supervising provider. However, it is possible to increase efficiency and utility of trainees in the group visit setting while maintaining educational value.

Given the relatively narrow scope and the nature of conditions encountered in the hand clinic, medical decision making for many patients is limited to a “straightforward” or “low complexity” level. These designations assume a limited number of diagnoses, management options, and amount and complexity of diagnostic workup. Most importantly, risk of complications or morbidity/mortality at these levels is minimal to low. For these conditions, a supervising physician can allow a trainee more independence to practice employing simple treatment and management guidelines and progress to working independently when addressing simpler conditions as the trainee’s experience grows. As independence grows, trainees can build confidence in medical management as well as focus on other core educational competencies once they are comfortable with the evaluation and management of a limited scope of conditions. Conditions such as trigger fingers, hand arthritis, ganglion cysts, and carpal tunnel are those the trainee is likely to encounter in a primary care practice. While there may be a decrease in direct physician teaching, the trainee gains clinical autonomy and experience in educational core competencies such as patient communication, patient education, systems-based practice, procedural skill, cultural competency, and interdisciplinary teamwork [15,16].

Lessons Learned

The success of the group visit required buy-in from hospital and physician leadership, the clinical team, and multiple partners in the hospital system. The hospital administration supported group visits as an integral component of the Urban Health Institute. Buy-in from key hospital leadership ensured resources and dedicated space for the group visit program. Grant support allowed additional programmatic support to acquire the necessary assistance from information services, EMR support, legal, and marketing. Physician buy-in was the most significant piece to the success of an individual group visit. Accepting the movement away from physician autonomy to team-based care is challenging for many providers. Physician willingness to start a high-demand group visit, recognition of the start-up inefficiencies, and working with the administrative and clinical team on program improvement strategies has succeeded in launching a sustaining group visit model.

Conclusion

There is a need for an adaptive and economically viable model of patient care to meet increasing demand, as well as provide care for indigent populations in a way that is more economically sustainable than providing care through the emergency department. The development and implementation of an urban hand group visit at our institution has demonstrated that such a model, based on group visit models more commonly seen in primary care, can be effectively implemented in a subspecialty care setting. This model is capable of increasing patient access to care and effectively handling increased patient volume with room for cost-effective growth in the future, all while maintaining quality of care. We anticipate further subspecialty clinics within hand pain to emerge, such as a group visit dedicated specifically to carpal tunnel syndrome or hand arthritis. This will allow each group to be more focused and will streamline education and mutual support among the patients.

Corresponding author: Steven Kaufman, MD, 3 Cooper Plaza, Suite 211, Camden, NJ 08103, kaufman-steven@cooperhealth.edu.

Funding/support: The Nicholson Foundation.

Financial disclosures: None reported.