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Group medical visits can deliver on patient-centred care objectives: results from a qualitative study Lavoie, Josée G; Wong, Sabrina T; Chongo, Meck; Browne, Annette J; MacLeod, Martha L; Ulrich, Cathy Apr 29, 2013

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RESEARCH ARTICLE Open AccessGroup medical visits can deliver on patient-centred care objectives: results from a qualitativestudyJosée G Lavoie1*, Sabrina T Wong2,3, Meck Chongo1, Annette J Browne3, Martha LP MacLeod4 and Cathy Ulrich5AbstractBackground: Patient-centred care emerged in the late 1960s as a framework to guide providers and decision-makers towards the provision of more effective health care and better outcomes. An important body of literaturehas since emerged, reporting mixed results in terms of outcomes. To date, assessments of the effectiveness ofpatient-centred approaches have focused one-on-one consultations. The purpose of this article is to exploredimensions identified as key in the patient-centred literature in the context of primary health care services deliveredin a group setting. Group Medical Visits (GMVs) offer a novel format for the delivery of patient-centred primaryhealth care services, especially for patients living with complex morbidities.Methods: Drawing on a large study of GMVs, we report on key format and process-oriented elements identified inGMVs, and on their link to improved outcomes. For the purpose of this study, we interviewed 34 providers and 29patients who have been engaged in GMVs, delivered in rural, northern and First Nation communities in BritishColumbia, Canada.Results: Our analysis shows that the delivery of PHC in a group format results in a shift in the role of the provider,from that of an adjudicator involved in imparting norms of self-care, to that of a facilitator who assists the group indefining norms of self-care that are based on medical knowledge but also on the broader context of patients’ livedexperience and on their pragmatic experience. In a group process, peer-patients take on the role of promotingthese norms to other patients. This results in a significant shift in the role of the provider, increased trust, increasedknowledge for the providers and the patients and better patient self-management. Our results also show increasesatisfaction for patients and providers.Conclusions: GMVs offer an alternative format for the provision of PHC that brings together the benefit of a groupprocess and of a clinical encounter. This format can successfully deliver on the promises of patient-centred care.Keywords: Primary health care, Clinical encounter, Self-management, Effectiveness, Chronic diseasesBackgroundPast conceptualizations have framed the clinical encounter(CEs) as a one-on-one interaction between a patient and aprovider, focused on the provision of care for acute andchronic episodes of illness [1, pp. 1087–88, 2, p. 3, 3]. Theprovider was understood as having the primary responsi-bility of evaluating, diagnosing, treating the patient’s con-dition, while exercising independent judgment and actingin the patient’s ‘best interest’. Conceptualizations of therole of the patient, most notably Parsons’ “sick role”, de-scribed the patient as being released from social norms yetobligated to seek care. This role was however largely pas-sive in regard to making decisions, and subservient to the“expert” knowledge of the provider [1].This conceptualization of the CE has been broadly criti-cized for oversimplifying the CE, for assuming that patientvalues and preferences are in tune with the practitioner’s[4], and for framing the role of the patient as that of a pas-sive recipient of information [5]. Boyer and Lutfey haveeloquently argued that while this conceptualization might* Correspondence: josee.lavoie@unbc.ca1University of Northern British Columbia, School of Health Sciences, TLCbuilding 10-3516, 3333 University Way, Prince George, BC V2N 4Z9, CanadaFull list of author information is available at the end of the article© 2013 Lavoie et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Lavoie et al. BMC Health Services Research 2013, 13:155http://www.biomedcentral.com/1472-6963/13/155have aligned with reality in the past, the patient-providerrelationship has changed considerably over the past 50years, as a result of recognizing the significance of socialcontexts in shaping patients’ individual experiences; theexpansion in the construct of the “patient” from one ex-periencing an acute episode to include those managingchronic conditions and those at risk of developing a condi-tion as a result of surveillance technologies; and patients’ability to independently access information to actively en-gage in and/or challenge decision-making related to theirtreatment [6].Along with this conceptual shift, there has been in-creased scrutiny on patient-provider communications inthe context of the CE. Research in medical anthropology,sociology, psychology, economics and health services re-search have focused on patient-provider interactionalprocesses, and on the link between these processes andoutcomes. An extensive body of literature has emergedover the past three decades, aiming to inform an “idealCE” that might result in better outcomes for patients.The “patient-centred” approach emerged in the late1960s. Mead and Bower’s review of the literature [7,8]identified the following key criteria for a patient-centredCE: 1) exploring both the disease and the illness experi-ence (biopsychosocial perspective); 2) understanding thewhole person (patient-as-person); 3) finding commonground regarding management (sharing power and re-sponsibility); 4) incorporating prevention and health pro-motion (the therapeutic alliance); and 5) enhancing thedoctor-patient relationship (the doctor-as-person) [8, pp.1087–88]. Within this framework, providers are calledupon to understand the social and family context, cul-ture and history of their patients. Providers and patientsare expected to interact in ways that are non-biased,demonstrating understanding and acceptance of theother’s potentially diverse background [9].Recognizing that individuals are situated within a broadersocial matrix [10], the literature on patient-centred care ac-knowledges how power differentials can affect the CE[11,12] and emphasizes how leveling power relations canhelp patients feel safer, share their healthcare needs, acceptthe information provided and incorporate this informationinto their own daily lives [13,14]. Pilnick and Dingwall haveargued that power asymmetries are inherent to the phys-ician role: “Physicians… are not just healers of the sick…,but also socially licensed adjudicators on contested or con-testable claims to dependency. They are required to rule onboth the ‘facts’ of the case and on the motivation ofthe patient” [15, p. 1380]. This dual role, we argue, hasthe potential to undermine the objectives of the patient-centred project in one-on-one CE. A 2001 Cochranereview on the link between the patient-centred approachand health outcomes has been mixed [16]. Interestingly, todate, assessments of the effectiveness of patient-centredapproaches have been in the context of one-on-one consul-tations. Format elements such as the length of the consult-ation, the presence of family members or other potentialadvocates, or providers’ payment scheme (salaried or fee-for-service) have not been documented in the research onpatient-centred CEs.In our research, we have identified that Group MedicalVisits (GMVs) can provide comprehensive PHC servicesin a manner that addresses some of the shortcomings ofthe one-on-one CE. While delivering health servicesusing a group format is not new, the delivery of PHCservices using GMVs is relatively recent. In BritishColumbia (BC), Canada, GMVs are emerging as an in-novative format for the provision of primary healthcare[17-19] in areas underserved by PHC providers and forpopulations living with co-morbidities. The literatureidentifies two types of GMVs: (1) “homogenous” GMVswhere those in attendance share a diagnosis (diabetes)or concern (living with chronic pain) (CooperativeHealthcare Clinic, CHCCs; and Physicals and SharedMedical Appointments, PSMAs); and (2) “heterogeneousor mixed” GMVs which are a drop-in format wheresome teaching may be shared (Drop-In Group MedicalAppointments, DIGMAs) [17,18]. In GMVs, primaryhealthcare (PHC) services are typically delivered to agroup of 12–20 patients by their regular provider (e.g.,family practice physician, nurse practitioner). They rangein length anywhere from 60–120 minutes with the aver-age being reported as 90 minutes. Other healthcare pro-viders, and sometimes representatives from communityorganizations (the Canadian Diabetic Association, forexample), may be involved. The content of GMVs oftenincludes the provision of medical care related to a com-mon chronic condition (e.g., medication adjustments fordiabetes management), screening and early detection ofhealth conditions, or routine physical examinations, anda health education or health promotion component [20].The purpose of this article is to identify and describekey format and process elements used in GMVs as iden-tified by providers and patients engaged in GMVs, andexplain how these key elements link to improved healthoutcomes. To do so, we first turn to the work of Kurtz[21] on group-delivered care. We then discuss formatand process elements, and finally link those to outcomesreported by both providers and patients.Framework for understanding GMVsTo better understand the potential role of GMVs inshaping CEs, we draw on the work of Kurtz [21] whoexplored the role of professionals in self help and sup-port groups. Self-help groups such as Twelve-Stepgroups, gather to explore and exchange experiences andinformation on a common problem. They are generallychange-oriented, and the change sought may be personalLavoie et al. BMC Health Services Research 2013, 13:155 Page 2 of 10http://www.biomedcentral.com/1472-6963/13/155or societal or both. Professionals may be invited but peersprovide the main guidance. Mutual support groups, such asthose for parents of autistic children, meet to share and findinformation. Change is not a main focus although positivemanagement of the common problem is an obvious object-ive. In both self-help and support groups, the group playsan important role in terms of information sharing and mu-tual support. However, group interactions are not intendedto be therapeutic. In contrast, psychotherapy groups areprofessionally-led, with group interactions designed for atherapeutic purpose, one of which could be to create op-portunities for the development of basic social skills. In thecontext of these three types of groups, the role of profes-sionals is circumscribed to that of a source of information(self-help and mutual support group) or as an authorityleading the group and ascribing meaning to interactions be-tween group members (psychotherapy).GMVs are a hybrid format. They are comprised of PHCservices that are professionally-facilitated, and incorporateaspects of both a CE and a social group. Past work hassuggested that incorporating the support group conceptinto the CE is important [6,22]. These authors suggest thatgroup support is a socially contextualized experiencewhere power relations are somewhat more leveled becauseof the absence of clinical providers. Research suggests thatsupport groups function with specific structural elementsincluding voluntary participation, and an informal contextwith a flexible, non-hierarchical, non-expert, non-medical,and power-sharing model [23-25]. Included as well areprocess-oriented elements such as: empowerment, advo-cacy for group members, reciprocity, the affiliation withpeers with similar life experiences, catharsis, the generalunderstanding that one can experience self-healing as a re-sult of being helpful to other group members, and thesense of community [26,27]. We argue that in the contextof GMVs, the CE is co-produced by providers and pa-tients. The benefits of the “group function” can be fostered(as opposed to undermined) by the active participation ofa medical provider’s role – particularly because the con-ventional role of medical provider as adjudicator (with at-tendant power differentials) are mitigated by the groupfunction and process. Drawing from this work, we identifyformat and process-oriented elements that are related togroup processes and can inform our analysis of GMVs.We argue that providers and patients’ perspectives are keyto understanding the contribution of the GMV-based CE.We also note that the express purpose of the GMV is toproduce change in patients’ self-management. Accord-ingly, any discussion of GMVs should attempt to addressGMVs’ ability to produce this sought outcome.MethodsThe analysis presented in this article draws on a largermixed-methods study of GMVs conducted in severalrural communities in the Canadian province of BritishColumbia (BC). The purpose of the larger study was toexamine the impact of GMVs on the quality of PHC on-reserve and in northern communities, from patients’ andproviders’ perspectives. Interview data were collected onpatients’ and providers’ perspectives on the access toand quality of PHC provided through GMVs. Approvalwas received from the University of British ColumbiaResearch Ethics board, the University of NorthernBritish Columbia Research Ethics Board and the NorthHealth Research Review Committee.Sampling was purposive [28] and theoretical [29] inorder to capture a wide variation of views. Eligibleproviders were those who had taken part in deliveringGMVs during the previous year. Providers identifiedpossible patients. Eligible patients were those aged 19years and over and who had attended one or moreGMVs over the previous year. Patients who consentedto being contacted were mailed a letter. One week later,potential patient participants were contacted by a teammember by telephone. After signed informed consentwas obtained, participants were interviewed by a re-search team member. Open-ended questions exploredparticipants’ experiences in facilitating or attendingGMVs. Questions addressed critical components in theprovision of a successful GMV, information on anybarriers to delivering or receiving PHC in a group for-mat, and recommendations to improve the delivery ofGMVs for other providers or patients. At the end of eachinterview, participants were given $15 in appreciation oftheir time.Interviews were held in nine different rural communi-ties, ranging in size from 700 to 80,000 people. Thecommunities were chosen based on guidance fromour Health Authority partner. Members of the researchteam directly observed providers delivering a GMV.All interviews were digitally recorded. The recordingswere transcribed and cleaned of any personal identifiers.Transcripts were first compared with the audio record-ings for technical accuracy. Using interpretive thematicanalysis for qualitatively derived data [30], the teamreviewed the transcripts to identify linkages to theoret-ical perspectives as well as any recurring and contradict-ory patterns. A data coding scheme was developed,validated through independent coding and organizedusing Atlas TI software. Coding categories were refinedby at least two team members and an audit trail of ana-lytic decisions maintained as data collection continued.Having also considered alternative interpretations, aconceptual representation with full descriptions of thethemes reflected in the data was developed. Research teammembers and PHC experts evaluated and discussed cred-ibility of the analysis and feedback on the aggregated resultswas obtained from participants [31].Lavoie et al. BMC Health Services Research 2013, 13:155 Page 3 of 10http://www.biomedcentral.com/1472-6963/13/155A total of 63 participants completed an in-depth inter-view to provide their experiences with GMVs. Providerswho were interviewed included family physicians (n=10),nurses (n=7), nurse practitioners (n=2), PHC coordina-tors (n=4), other allied health professionals (n=11), suchas nutritionist and social workers and supportivepersonnel, such as medical office assistants and commu-nity health representatives, who were involved in deliver-ing a variety of GMVs (see Table 1). Table 2 shows thatpatient participants (n=29) were an average age of 62years, mostly female, and married. Patients reported be-ing either Caucasian (55%) or of Aboriginal descenta,where most were First Nationsb (41%). Almost half ofpatient participants reported a household income of lessthan $30,000 CDN.Patient participants attended an average of four GMVsin the previous year; 24 patients attended a homogenousGVM where all in attendance shared a similar diagnosis(pain or diabetes, for examples) and 5 attended a hetero-geneous GMV where diagnoses were mixed. Just overhalf (n=16) reported having three or more chronicconditions, with the three most common conditionsbeing diabetes (59%), high blood pressure (52%), andarthritis (48%).Results and discussionOverall, the patients and providers we interviewedreported a great deal of satisfaction with the GMV for-mat. The following section summarizes key results. Wedivided these results into three broad categories: key for-mat elements, process-oriented elements and outcomes.We draw on the discussion of Kurtz to inform this ana-lysis. Excerpts are interwoven to illustrate these key ele-ments and outcomes.Key format elementsProviders and patients shared a number of elements thatthey portrayed as key to the success of GMVs. We orga-nized these into 3 sub-categories: a) Social event; b)Affiliation; and c) Co-production of the GMV. Each willbe discussed in turn.a) Social event: Patients and providers emphasized theimportance of the social component of the GMV. In thequote below, a provider linked the relaxed atmosphereof the GMV to being able to gather important medicalinformation, and information about the broader contextof patients’ everyday life:“I think that’s a big thing having a group where theycan come in and be seen, when they need to be seen.Interaction, I think the social aspect of it is importantfor people, it’s like meeting old friends and there aresome people who might be with their chronic illnessesthey can’t get out very much, they spend a lot of timeat home. I think that’s a good aspect to them, they lovecoming in, having a cup of coffee with their friendsand just talking about things. And, of course, thenhaving their conditions checked. I think there’s thislevel of comfort too for them, they come in, they knowthey’re being seen, they’re feeling that they’re beingreally well looked after. Because for some of thesepeople, especially the chronic patients, [the GMV]gives them a bit of peace of mind” Provider #6.b) Affiliation: Both providers and patients highlightedthat the social element results in a shift in power, in partbecause of the presence of peers with shared experi-ences, but also because providers share the role of adju-dicator with patients attending the GMV. All stated thatthis was a positive outcome. Many participants reportedthat GMVs provided flexibility and a “leveled playingfield” in which to interact with each other. None of theproviders we interviewed portrayed this shift of powernegatively. The quote below, reflected the general senti-ment expressed.“With a group you have a feeling of being part ofmany, whereas when I’m here with you or with mydoctor, or one-on-one, quite often you’re intimidatedby someone who knows more than you do and it’s justa feeling sometimes of isolation and loneliness becauseyou have the disease and it’s a different feelingcompletely. And I feel a lot more comfortable in groupsthan one-on-one” Patient #16.Both providers and patients suggested that the groupacts as a community in which participants share com-mon experiences. Telling one’s story was reported asvaluable because of its cathartic potential, and alsoTable 1 Demographic characteristics of providers (n=34)Type of provider attending GMV (n)• Family physician 10• Nurse 7• Nurse practitioner 2• Primary healthcare coordinator 4• Other (includes medical office assistant, communityhealth representative, outreach coordinator)11Number of GMVs delivered in one month• Mean (SD) 1.4 (1.9)• Range 1-6Type of GMVs delivered (%)+• Cooperative Health Clinic model/Homogenous 88.6• Drop-in Group Medical appointments/ Mixed 34.3Note. +providers were asked to list all types of GMVs delivered.Lavoie et al. BMC Health Services Research 2013, 13:155 Page 4 of 10http://www.biomedcentral.com/1472-6963/13/155because it creates a way to connect to others with simi-lar experiences. This was highlighted as beneficial.“It seems like people do get to share and feel heard inthat setting very well and very thoroughly. There’s thisreal sharing of stories that I’ve only occasionally heardabout… where the actual telling of your story and therecounting and how you tell yourself your story andreinterpreting it is actually a big part of therapy”Provider #20.“And that sharing in itself is therapeutic to somedegree really, you know, if you have a listener or allthese people” Patient #16.d) Co-production of the GMV: Providers highlightedkey differences between the one-on-one and the GMVformat, in that the GMV is co-produced by the provider(s) and the group. Co-production was achieved by pro-viders giving space for the group process to become acentral component for health education. Since a positivegroup process was seen as key to the success of theGMV, providers reported that they actively sought feed-back on the GMV format from patients.“I think care providers have the real instinct tolecture and it’s [the GMV] totally not about that…Talking at the group is way more about not beingthe expert and letting the group be the expert andthen correcting people if misinformation gets outthere” Provider #13.“We had to shift things around. So what has happenedfrom that point on is it’s patient driven. How did youlike today? Would you like it a little different nexttime? You [patients] help us plan. So the patientsalways were the partner in developing the group, this iswhat we would like next. But they always knew that theycould get their [individual] doctor’s visit that day thatwas one thing that stayed stationary” Provider #29.Providers also reported that GMVs provided themunique learning opportunities.“I think that it [the GMV] has helped me to be morecreative in looking at ways to meet people’s needs.Some of that just comes from the patients themselvesbecause they often have some really neat ideas abouthow to overcome challenges or difficulties in dealingwith the diabetes. So I think that, not only have Ibecome more aware but I’ve also, they’ve given mesome really good tips and ideas. I think there’s stuff Ilearned that I wouldn’t have learned if I had done iton an individual basis. There’s a lot of value thatTable 2 Characteristics of patients (n=29) attendinggroup medical visitsAge (years)• Mean (SD) 62.0 (16.0)• Gender (% female) 65.5Self-reported health (1–5)+• Mean (SD) 2.8 (1.1)Ethnicity (%)• Caucasian 55.2• Other 0Aboriginal (%)• First Nation 41.4• Métis 3.5Marital Status (%)• Married 79.3Income (%)• <$20,000 37.9• $20,000-$29,999 20.7• $30,000-$39,999 20.7• $40,000-$49,000 3.5• $50,000-$59,999 6.9• $60,000-$69,999 3.5• ≥$70,000 0.0• Missing 6.9Number of chronic conditions (%)Range 0 – 7• 0 10.3• 1 6.9• 2 27.6• 3 or more 55.2Chronic conditions (%)++• Diabetes 58.6• Arthritis 48.3• High blood pressure 51.7• Depression 34.5• Heart Disease 20.7• Other: Kidney Disease 10.3• Other: Cholesterol 6.9• Other* 27.6GMVs attended in the last year• Range 1-15• Mean (SD) 4 (3.0)Type of GMV attended (%)• Cooperative Health Clinic model/Homogenous 82.8• Drop-in Group Medical Appointments/ Mixed 17.2Satisfied with care from family physician (%)• Always/Usually 79.3• Sometimes/Rarely/Never 20.7Notes: +higher score=better health; ++patients were asked to report allchronic diseases where they were given a diagnosis.Lavoie et al. BMC Health Services Research 2013, 13:155 Page 5 of 10http://www.biomedcentral.com/1472-6963/13/155comes out of that, that kind of impromptu patientteaching of each other” Provider #28.Key process-oriented elementsProviders and patients shared a number of process-oriented elements linked to the format elements reportedabove. We organized these into 4 sub-categories: a) Safety;b) Mutual support; c) The normative effect; and d) Thechanging role of the provider. Each is discussed in turn.a) Safety: a key theme that recurred in patients’ inter-views was that they felt safer when in a group than in aone-to-one clinical encounter. One patient commented:“If you have a group medical visit on a particularsubject there’s a certain protection there in numberstoo, I mean there’s probably not going to be a whole lotof ‘in your face’ and things done to you or maybe evenmore probing questions but, you always remainsomewhat of anonymous in a group. A little bit morethan just one-on-one, if it’s going to be in a groupmedical visit you might be safer, you might not beprobed, poked quite so much” Patient #16.This was recognized and acknowledged as positive byproviders as well.b) Mutual support: One reason for feeling safer wasthe presence of others to advocate when miscommunica-tion occurred:“You know we try to support one another, it’s kind ofhuman to do that. It’s human to have compassion forother people who have problems and you can showthat and you can feel that from other people whenyou’re in a group, you don’t in isolation. Oh yeah, [in aGMV] it feels great, it feels really good, it feels like Ihave advocates, I have support, I have people, a groupof people that will just come to your rescue if youneeded to be rescued they’re just there to really helpyou along, you know. It’s a great feeling, groups arereally advantageous” Patient #17.c) The normative effect: While many patients reportedfeeling safer in a group, many also reported instanceswhere members of the group intervene in a patient’s carestrategy, pressuring them to take better care of them-selves. The group thus served a protective role againstproviders being “in your face”, but was also more effect-ive in promoting norms of self-care.“And then all of a sudden someone else will starttelling well it’s because you’re not doing your diet stuff,you know, start giving them heck, right, so, um, so itwas a very, very, very powerful for people to see theirown numbers within the context of the group and itwas almost I think most humans are kind ofcompetitive and they look at it and say man I want, Iwant to do better than that” Provider #1.“So many people use denial. And so when you’re in agroup, I think it just changes that dynamic and youhave to face up to the other people, you know what? Inever do my blood sugars, I don’t take care of myselfso that’s a different thing than you’re private aboutwith the doctor and then admitting something in agroup” Provider #23.Whereas patients related negative experiences when,in a one-on-one consultation, providers attempted toimpress upon them the need to change behaviours (i.e.“He’ll give it to you in the office” [Patient #20]), none ofthe patients we interviewed portrayed peer interventionsnegatively.d) The changing role of the provider: Thus, the groupwas reported as playing a normative role in the creationof shared norms of self-care behavior. This was associ-ated with a shift in the role of the provider, from that ofan expert tasked with defining norms of behavior (theadjudicator role described earlier) and imparting thesenorms to the patient (as in psychotherapy groups), tothat of a facilitator of a group process. Two patientscommented on how this shift in the role of their pro-viders resulted in increased trust:“I’ve learned to trust him. I trust him more than I usedto and that’s important, that bond of trust has to bethere. I trust him more when I see that he’s open tolearning and figuring out new things that are onlyhappening in group dynamics” Patient #8.“Do you know…what [GMV] helps me to see is whatthe physician, his devotion of trying to solve a healthproblem and trying to correct it. That actually re-establishes my faith in the medical system because youcan see that they’re really devoted to trying to figureout really what is ailing you” Patient #13.In contrast, providers noted that the social context ofthe GMV allowed patients to talk about their conditionwithin the context of daily life. As one provider explained,providers can develop a better understanding of patients’lived experience, and of barriers to adherence:“I think it was just understanding, when you sort offollow the kind of dialogue that goes on in the groupjust realizing how much other factors were involved inpeople’s lives, that made diabetes not a priority right?And so whether that was, pain or things going on intheir life or, whether its sadness or disappointment orLavoie et al. BMC Health Services Research 2013, 13:155 Page 6 of 10http://www.biomedcentral.com/1472-6963/13/155bitterness about the way diabetes sort of affected theirlives and their choices, food choices. And that peoplewere still struggling with integrating it into their life,right? I think just understanding those things a littlebit better and just to be able to express those thingsseemed to be helpful,…because often otherwise itwould be sort of fruitless dialogue about your numbersaren’t where they are, and then there would be, youhave to take other medication. Yes, I’m doing this, andpeople just wouldn’t step up to the things that theywere doing or not doing. It seemed to be easier to getto the roots of why in the group visits, becauseobviously for people either it wasn’t a priority or theywere still just really upset about it. Or they had lots ofexcuses about why they couldn’t do the daily exercise”Provider #15.This quote also shows that the provider gained in-sights into the factors that affect patients’ day-to-daylives and how this, in turn, affected patients’ ability toself-care on an everyday basis. Another provider offereda slightly different view, emphasizing how power rela-tions remain between the provider and patients in aGMV, but how this is somewhat hidden as a result ofgroup dynamics:“It [the GMV] creates an environment that is thetrickery in medicine- to think people are having asocial gathering and you’re working the crowd anddoing the medical work while they’re having a goodtime, I mean that’s optimal, right, that’s optimalmedicine so there’s no fear involved, there’s no worry,people are enjoying themselves, it’s almost social likeand yet there’s a team going around getting all theinformation that needs to be gleaned from this groupof people and that’s the secret, so you turn it into areally positive experience for the patients so that’s whythey want to keep coming back because I mean ifyou’re going to go see your doctor and you could sitand have a cup of coffee, it’s an enjoyableconversation, people talk about a lot of topics”Provider #1.The idea that the social element acts as a form oftrickery, while noteworthy, was not echoed by other pro-viders or by patients.OutcomeKey format and process-oriented elements create a differ-ent environment for the provision of PHC. While thisstudy did not document clinical outcomes, we did docu-ment proximal outcomes that have been identified in theliterature as key to the provision of effective PHC: a) Bet-ter information sharing; and b) Better self-management.a) Better information sharing: At an individual level,both providers and patients reported therapeutic benefitsto the process of storytelling. One provider commented:“I think when you have a group around the tablelistening somehow…it doesn’t take as long to get outwhat you need to get out because there’s more soakingup of the story going on or something. It seems likepeople do get to share and feel heard in that settingvery well and very thoroughly. There’s this real sharingof stories that I’ve only occasionally heard about…where the actual telling of your story and therecounting and how you tell yourself your story andreinterpreting it is actually a big part of therapy”Provider #20.A patient commented:“And that sharing in itself is therapeutic to somedegree really, you know, if you have a listener or allthese people” Patient #16.Beyond the cathartic value of sharing one’s story, pro-viders commented that patients’ storytelling provides in-valuable teaching material for others:“For some of the patients who came who are strugglingwith trauma issues and low educational levels and all,it seemed to be a great fit because, as opposed to otherways of getting information like written informationor, information in a really power imbalanced settingwith a provider and you in an individual visit, Ithink it was a much more comfortable, accessibleopen setting for people to try and understand whatthey needed to understand. I think it’s an ideal sortof format for marginalized people” Provider #15.Some patients also highlighted the synergistic valueof storytelling in a group format, and how the storybecomes a stepping stone for teaching and learning:“I think for most people they do their best whenthey’re within a group or within a setting wherethere’s more than one person and the focus isn’talways on the one person. I just think that one personmight generate an idea and others can take the spinoff that idea. You can get into greater depth withaspects like that. Sometimes if you’re a little tootimid to ask the questions maybe someone else willask them for you” Patient #16.b) Better self-management: Providers discussed theubiquity of reciprocal learning within the GMV envir-onment. GMVs allowed for natural opportunistic inputLavoie et al. BMC Health Services Research 2013, 13:155 Page 7 of 10http://www.biomedcentral.com/1472-6963/13/155into patients’ health issues by providers and other pa-tients. This first quote shows the providers’ perspec-tives that patients may accept information morereadily from other patients than from a provider:“I think when you’re within a group, whether itmeans to or not, they do a lot of their own work. Theywill self-manage with the group. It isn’t just mesitting telling you what to do. They hear from theirpeers which its, people will change doing something, Icould tell them ten times and as soon as somebodybeside them with the same condition tells them to doit they listen, they do” Provider #4.GMV’s key format and process-oriented elements re-sult in an environment that is motivating, helpingpatients gain the necessary skills, health behaviors, andconfidence to manage their own condition:“I think you come out of the group feeling much moreself-confident and willing to challenge your self-management program, you just feel that yourbatteries are recharged and you can really go after it,till the next group…you want to do more yourself andrely less on others. And say ‘well I think I can do itmyself as much as possible’ but then you alwaysrealize that there are others out there to help you ifyou feel you need that help” Patient #16.“Coming to these group sessions made me realize thatI wasn’t managing my diabetes properly and with thisinformation that came from the doctors and otherpatients together it seemed to make me more awareand to practice better control through the informationthat I received” Patient #2.“Well when you can follow the other people and youcan see what the doctor is doing for their problemsand you can see where you’re because it’s a chronicdisease we can see where we’re heading and try to stopit before we get there. We know we’re going to get thereeventually but we want to slow down getting there”Patient #19.We began this paper by arguing that Group MedicalVisits are hybrid formats that blend a CE with elementsof the support group. Our data has shown that the socialcontext of the GMV does not hinder the effectiveness ofthe CE, but rather adds value to the encounter by pro-viding opportunities for peer learning and mutualsupport. Further, the social context of GMVs allows forcommunication that elicits the patient’s perspectivewithin a social context, and involves patients in choicesin order to reach a common understanding of theproblem and potential solutions. Our results also showthat, contrary to what the self-help literature suggests,the presence of professionals who are actively engagedin the pursuit of clinical objectives, does not underminethe benefit of the group process. Through interactionwith patients, providers reported having gained a moreadvanced communication repertoire, and developedgreater self- and situational awareness. The GMV posi-tions the CE into a broader social context, and as a re-sult, providers may be better equipped to deliver moreappropriate care for diverse and disadvantaged groups.Patients and providers reported that the co-productioninherent to the GMV resulted in patients buy-in and inproviders being more comfortable. Providers reported abetter understanding of the patients’ experience and ofbarriers impeding adherence. They also reported learn-ing from the group. Patients reported feeling safer in agroup. They also shared that seeing providers work in agroup setting increased their trust in the providers. Thisresulted in better information sharing, from patients toproviders and from providers to patients, and in betterself-management.Patients emphasized the benefit of advocating for eachother, especially for some GMV attendees who may beunable or unlikely to advocate for themselves. This typeof advocacy may be necessary in order to support thosewho have suffered historical trauma as they may beapprehensive and unable to seek out the healthcare theyrequire [32]. This can help bridge gaps in cultural under-standing (e.g., beliefs about managing chronic condi-tions) but also affect the nature and quality of serviceobtained by patients; asking more questions or havingquestions asked for them facilitates patients becomingmore informed about their condition with their particu-lar context. Patients who advocate on behalf of othersmay also help peers take advantage of a particular treat-ment approach and draw attention to each other’s con-texts for providers [32]. Such advocacy, however, canonly be fully realized where trusting relationships be-tween patients, their peers and providers exist.A key finding is that providers’ normative behaviours,for example, teachings on the need to change one’s diet,are problematized by patients and at times perceived asdisrespectful when in a one-to-one visit. The same behav-iours are not portrayed as a problem by patients whencoming from peers. Patients reported that peer teachingand peer pressure to adopt better self-care strategies werewelcomed, and understood as supportive. When suchpressures came from providers in a one-on-one CE, thesame behavior was portrayed as abusive or threatening.Our results suggest that GMVs align well with thepatient-centred ideal. While power relations between pro-viders and patients remain in GVMs, the group processappears better able to mitigate the impact of powerLavoie et al. BMC Health Services Research 2013, 13:155 Page 8 of 10http://www.biomedcentral.com/1472-6963/13/155differentials. This is an important finding, and has beenperceived as the key limitation to the successful imple-mentation of patient-centred care [7,15,16,33].Admittedly, the GMV format is not for all patients,nor is it meant to replace all one-on-one visits. Thisstudy is limited since data were collected only from ruralsettings and no data were collected from those who trieda GMV and did not return or from those who refused toattend a GMV. Further work is needed in order tounderstand which services are best delivered in a GMVformat. Still, it is our critical reflection, based on patientsand providers’ perspectives, that the GMV aligns withcriteria identified as key for patient-centred care. Thisfinding may be especially important for the growingnumber of patients living with chronic conditions thatrequire ongoing management. The more in-depth andprolonged communication in GMV-delivered PHC cre-ate an environment where trust is more likely. As well,this environment provide opportunities for the providerto be sensitized to the social circumstances under whichpatients became ill and attempt to self-manage [33,34].The patient's sense of being cared for, as the patients seehow committed providers are to achieving patient treat-ment outcomes, increases trust [35]. Through the GMV,providers can facilitate patient engagement by encour-aging them to tell their own story, actively listen, giveemotional support, and provide reassurance and infor-mation on their condition [36]. This expression of con-cern and commitment to being of help and the clinicalattention to, as well as respect for, social and cultural con-texts, can also increase trust in and commitment to the in-stitutions of the larger society [37].ConclusionsOur study has shown that the GMV offers visits that re-flect the ideal of patient-centred. The GMV answers tothe unique exigencies of the CE: “the dynamics of the re-lationship between healer and sufferer; the heightenedvulnerability of the suffering individual; the necessity forclinical responsibility; the need to translate knowledgeinto individualized or personalized intervention; and theways in which patient and clinician are connected to lar-ger social and cultural domains of community” [37,p. 411]. The GMV does this by sharing the normative as-pect of healthcare between providers and peer-patients. Indoing so, the GMV resolves an important paradox facedby providers: that of their dual role of healer and of adju-dicator. This dual role contributes to undermining trust.Finally, the GMV brings out a meaningful understand-ing of power in the recognition that we all have accessto power, and that power can be a resource for positivechange. Since patients may not have the skills or confi-dence to express what they need or want in relation totheir care, facilitating empowerment in patients througha GMV environment that allows them to transition frombeing passive to active participants in their care can be asolution to better patient outcomes in PHC. Throughforming relationships of care with their providers, rela-tionships that are voluntary, that respect and enableautonomy, accountability, fidelity and humanity [5, pp.449], patients are thus able to negotiate care, treatmentand support appropriate to their situation and to theirattaining the best possible outcomes. While providing alocus for continuity of patient relationships and know-ledge, the presence of combined support and care overan extended duration within GMVs can improve pa-tients’ service use and health behavior [38].Endnotesa“Aboriginal” is defined in the Constitution of Canada,Section 35 of the Constitution Act 1982, and refers to allPeoples of Indian, Inuit and Métis heritage, regardless ofwhere they live in Canada or whether they are “regis-tered” under the Indian Act of Canada.b“First Nation” is a term that came into common usagein the 1980s to replace the word "Indian". Althoughwidely used, no legal definition of the term exists. Theterm First Nations people in this paper applies to bothStatus and Non-Status Indians.Competing interestsThe authors had no competing interests in the conduct of this research orthe preparation of this manuscript.Authors' contributionJL, SW, AB, MM and CU were involved in the design of the study and earlyconceptualization of this manuscript. JL and SW led the coordination of thestudy and conducted a large proportion of the interviews. JL, SW and MCanalyzed the qualitative data, and drafted the manuscript. All authors readand approved the final manuscript.AcknowledgementsThis study was funded by the Canadian Institutes for Health Research andNorthern Health Authority of British Columbia. Dr. Wong was supported by ascholar award from the Michael Smith Foundation for Health Research [CI-SCH-051 (04–1)] and a new investigator award from the Canadian Institutesfor Health Research. Special thanks to the providers and patients who tookthe time to participate in this study. Many thanks to the primary carepractices, and Northern Health Authority employees and communities, fortheir help in data collection, and to research assistants, Lily Farris andBenjamin Barer.Author details1University of Northern British Columbia, School of Health Sciences, TLCbuilding 10-3516, 3333 University Way, Prince George, BC V2N 4Z9, Canada.2University of British Columbia Centre for Health Services and PolicyResearch, Vancouver, Canada. 3University of British Columbia School ofNursing, Critical Research in Health and Health Care Inequities, Vancouver,Canada. 4University of Northern British Columbia, School of Nursing, PrinceGeorge, Canada. 5Northern Health Authority, British Columbia, Prince George,Canada.Received: 12 November 2012 Accepted: 17 April 2013Published: 29 April 2013References1. Parsons T: The social system. New York: The Free Press of Glencoe; 1951.Lavoie et al. BMC Health Services Research 2013, 13:155 Page 9 of 10http://www.biomedcentral.com/1472-6963/13/1552. 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BMCHealth Services Research 2013 13:155.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitLavoie et al. BMC Health Services Research 2013, 13:155 Page 10 of 10http://www.biomedcentral.com/1472-6963/13/155

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