Expanding Access to Integrative Medicine Through Shared Medical Appointments

The concept of shared medical appointments invites awareness to multiple dimensions of a person’s health, putting their health problems into context and encouraging a holistic, well-rounded treatment approach, according to Scarlet Soriano, MD, ABOIM, Executive Director of Duke Health & Well-Being and Director of the Leadership Program in Health and Well-Being at the Duke University Health System in Durham, North Carolina.

“We know that things like a healthy body mass index (BMI) and smoking cessation can support physical and mental thriving,” said Soriano at the Institute for Functional Medicine (IFM) Annual International Conference (AIC) in Orlando, Florida. “But we also have historical realities and present-day realities that profoundly impact people's ability to flourish that go beyond those common health factors.”

Prior to her current role at Duke, Soriano was the Director of Group Visits and Wellness-Based Healthcare Transformation at Boston Medical Center. There, Soriano crafted innovative group visit models with integrative medicine strategies designed to combat healthcare disparities. In her presentation at AIC, Soriano described the benefits of shared medical appointments as well as their potential to transform healthcare and make integrative medicine more accessible.

Defining Shared Medical Appointments

According to Soriano, there are several different models for shared medical appointments, and they can vary widely. Typically, she said groups are made up of eight to 15 people who share some degree of attributes, such as a shared medical condition or shared health goal. Meetings can take place in person or over video call, often with two or more facilitators.  

“Shared medical appointments can be woven in so many different ways, and you can have lots of different flavors,” said Soriano.

Shared medical appointments are not a replacement for individual patient-provider consultation; rather, they supplement one-on-one appointments, oftentimes weaving multiple disciplines and approaches to healthy lifestyle change and disease management. But, to Soriano, what differentiates group medical visits most from traditional care is the focus on strength-based care. 

“It’s about focusing on those strengths and then also this inherent, fundamental value that we have,” said Soriano. “Pairing those two together is this unique way in which shared medical appointments can become very important. And then when you apply an equity lens to that, you are open to a deeper understanding of people's realities, and you can really support change.”

Group Visit Models in Practice

In another session at AIC, Aisha Chilcoat, ND, FABNO, a research fellow at the University of North Carolina (UNC) at Chapel Hill, discussed the benefits of integrative medical group visits. Chilcoat said group visit models allow for more widespread access to integrative medicine modalities.

“We know that there are some barriers to implementing integrative therapies, especially for people who don't have insurance coverage,” said Chilcoat. “One of the reasons why I love this integrative medical group visit model is because it works well, and it provides people who are underinsured access to integrative therapies that they wouldn’t otherwise get.”

In her presentation, Chilcoat discussed a pilot feasibility study in which she and her colleagues at UNC-Chapel Hill observed the outcomes of an integrative medical group visit model for patients with chronic pain. While results from the pilot feasibility study have yet to be published, similar studies have shown promising results.

The model Chilcoat and her colleagues used was inspired by a 2019 study led by Paula Gardiner, MD, an adjunct associate professor in the Department of Family Medicine at Chobanian and Avedisian School of Medicine in Boston, Massachusetts. The curriculum, derived from the Boston Medical Center Integrative Medicine Group Visits Program, lasted nine weeks, each of which included different thematic content.

Gardiner and her team observed the program's impact on 159 predominantly low-income, racially diverse adults with nonspecific chronic pain and depressive symptoms. While the study found no differences in levels of pain or depression, after the trial period, those who participated in group visits had fewer emergency room visits and, after 21 weeks, reported a reduction in pain medication use.

According to Chilcoat, many patients with chronic pain can feel isolated and misunderstood by their families and loved ones. For some people, the most valuable aspect of group visits is connecting with others over shared experiences and feeling less alone in their health journey.

"Some people will say that their pain wasn't eliminated, but they felt like just being in a positive environment and a group setting was helping," said Chilcoat.

In a different investigation, Chilcoat and her colleagues at UNC-Chapel Hill applied the integrative medical group visit model to patients with long COVID. After sharing their experiences with other long COVID patients and learning integrative strategies to manage their symptoms, participants in the study reported feeling more resilient and prepared.

“It’s such an adaptable model,” said Chilcoat. “I've literally seen the impact that it has on people who are participating in it.”

Benefitting from Group Visits as a Provider

Group visits are not only helpful to patients, but they can also benefit providers. According to Chilcoat, it’s much more efficient to educate a group of patients on disease management than it is to have individual conversations.

"I've worked in a cancer hospital for five years, and you're seeing like 12 patients a day, every day,” said Chilcoat. “And a lot of times, you're repeating the same information.”

The group model allows providers to properly educate a large swath of people on the basics of functional medicine like sleep, relationships, and nutrition, something they otherwise might not have time for. In addition, Chilcoat explained that group lessons can foster a deeper understanding of a given topic as they often prompt discussions among patients.

“The learning that you see taking place within the group itself is incredible,” said Chilcoat. She explained that it would usually take her around five to ten individual visits with a patient to relay the same amount of information they learn in one group session. “It's pretty dynamic, and it accelerates all of our learning,” she said.

Group settings also provide a safe and non-judgmental space for people to share their own experiences and any health issues they may be facing. Chilcoat said that some patients are more comfortable sharing personal information with other patients than their doctors.  

“Sometimes people will share things in their history that they do not share with their primary care physician, and then they can have additional testing that they’ve never had before,” said Chilcoat. “Initiating the group session in and of itself serves as a lifestyle and supportive treatment option.”

Incorporating Group Medical Visits in Your Practice: Where to Start

While group visits are more common in larger healthcare systems, the model can also be applied in smaller, independent practices. In fact, Soriano explained that without the administrative hurdles in healthcare institutions, independent practitioners have the unique ability to design their group visit model to fit their patient population.

For integrative practitioners interested in incorporating shared medical appointments into their practice, Soriano suggested designing the program based on the issues most important to you. “A great question for an independent practitioner and for anybody who wants to try shared medical appointments is, what am I passionate about? Because when you care about the subject matter, there's a different sort of energy that comes with that,” said Soriano. “So, aligning self-vocation with need is a good way to begin, especially if you're looking for pockets of patients.”

Then, Soriano said to find opportunities in your own realm. These could be found within your existing practice, or they may require community outreach.

“One of the things that a practitioner could do would be to reach out to community organizations and to say, I have this practice, and I am interested in serving the whole of my community and then provide the criteria for participating in a medical appointment,” Soriano suggested.

Especially when trying to reach a more diverse population, Chilcoat said community outreach is key, but it requires patience. “It takes time to build relationships with communities and community-based organizations,” said Chilcoat. “Community-based participatory research can be done but only with the intent of building relationships and trust.”

Soriano also stressed the importance of having a vetting process. She said for shared medical appointments to be successful, participants must be open and willing to improve their health and be psychologically sound.

To diversify their practice and provide group visits to lower-income communities, Soriano said integrative practitioners should accept a broader range of insurance. For patients who don't have insurance, Soriano said practitioners can lower their costs and offset them elsewhere. For instance, patients with higher healthcare coverage could be charged more than those who are uninsured.

Reflecting on Equity Within Your Practice

“We're living in a time where we talk a lot about diversity, equity, and inclusion. But I don't think people really know what that looks like, or how to incorporate this in a medical setting," said Chilcoat. "For example, what they should be doing, or how they can be involved, especially if somebody does not identify with a vulnerable or marginalized group.”

To Chilcoat, the benefits of functional and integrative medicine are obvious, but right now, many of the people who need it most don’t have access to it. The integrative medical group visit model, she explained, has the potential to make integrative medicine more accessible and widespread.

When reflecting on the level of equity in your practice, Soriano said to ask yourself questions such as;

• Do I create space for clients from historically marginalized groups to share about past or present experiences of discrimination or lack of safety? And;
• What social determinants of health am I comfortable/not comfortable engaging with patients/clients/staff/peers/myself? 

These questions allow practitioners to identify ways to improve equity within their practice. The journey to providing more equitable care is not an easy one, Soriano explained, and it's only accomplished when we are compassionate toward ourselves and our learning.

To Soriano, equity informed; strength-based shared medical appointments are an incredibly powerful tool for not only promoting fairness within a given practice, but also driving systemic change.

“The more we each do the inner and outer work to create environments that can support people across a challenging historical landscape in finding strength and resources to align with their health goals,” Soriano said, “the more we as an aggregate can serve to inform policy. To me, the end goal is to change what healthcare looks like, but we need everyone to do that.”