Can group visits be an ideal way to practice primary care?

After a long day on the internal medicine ward at St. Elizabeth’s Medical Center, I rushed across town to lead that evening’s two-hour group diabetes visit at Union Square Family Health Center in Somerville, MA.  So when my preceptor asked me if I’d lead the group on a field trip after the two-hour visit, it was the last thing I wanted to do.

Although we had discussed taking our Brazilian patients to the local supermarket to practice reading labels in English and to learn about healthy alternatives to Brazilian staples, I was so exhausted that the request was downright irritating. Yet like any medical student asked a favor by their preceptor, I smiled and said I’d love to take the group to the supermarket.

After five weeks with an ever-dwindling group of Brazilians newly diagnosed with diabetes, I was starting to wonder if our group visits were even making any difference at all. Group visits are a care model where several patients suffering from the same chronic disease, such as diabetes, high blood pressure, or obesity, meet together regularly with physicians and support staff such as MAs and nutritionists to learn about their disease and how to manage it themselves. Extensive research has shown that group visits are an extremely effective way to care for chronic diseases in a primary care setting where 15-minute visits simply aren’t enough to teach patients how to manage their disease. Unfortunately, my initial enthusiasm at a chance to pilot a group visit series at my favorite community health center had been extinguished by their poor attendance and my imperfect Portuguese. Now I was just tired.

Yet an hour later, my attitude couldn’t have changed more. The moment we arrived at the supermarket, our patients immediately began to show me just what a difference we’d actually managed to make in five short weeks. The pride I felt as they adeptly demonstrated the unhealthy ingredients outlined on the labels of some of their most beloved Brazilian staples invigorated me. Swapping techniques for cooking brown rice correctly and discussing how to supplement the standard Brazilian meal with local fruits and vegetables that don’t even have names in Portuguese, our patients relished the chance to show me they’d become stewards of their own health.

Although the standard Brazilian diet of rice, beans, meat, and fresh fruits and vegetables is generally healthy, many Brazilian immigrants in the U.S. find themselves faced with supermarkets full of produce that is unfamiliar to them. Furthermore, like many immigrants, Brazilians often realize that on a limited budget, unhealthier, nonperishable foods are much less expensive than healthier fresh fruits and vegetables. Despite these challenges, our group managed to find ways to overcome these obstacles and arrive at a sustainable, healthy diet that incorporated fruits and vegetables that were previously unknown to them, such as some types of squash, as well as entirely new snacks like hummus. I arrived home that night renewed and excited to plan next week’s final group session.

These immigrants’ struggles were not foreign to me. Growing up below the poverty line, with no health insurance, in a single-parent family in urban Massachusetts and spending my summers in Québec with my grandparents who spoke little English, the problems inherent to health in immigrant communities were not news to me. When I started college, I found myself drawn to studies of Latin America and the Caribbean because I saw the clear connection with my own people’s story – that of an immigrant family living in a world where creating a healthy lifestyle is a challenge and the destruction brought about by chronic disease is a fact of life.

I have been drawn to a career in medicine since high school when I saw how lack of access to health care and consequent poorly controlled chronic disease could ravage the health of my family.  I realized that providing primary care to underserved urban immigrant communities would allow me to address these issues while merging my love of languages and cultures with my passion for social justice and my enthusiasm for medicine. Furthermore, Boston’s immigrant demographics, with large populations of Brazilians, Haitians, and Dominicans, would allow me the ideal context to obtain the skills I desired. When my longitudinal family medicine preceptor invited me to participate in this group visit project tailored to Brazilians, I jumped at the opportunity to finally bring together all of my passions and pilot the sort of innovation I hoped to implement as a family physician.

Although occasionally frustrating, the group visits ultimately confirmed that what I envisioned as an ideal way to practice medicine could actually exist. The demands on primary care physicians working with the underserved are fundamentally different from the demands on other physicians. Although evidence has long shown us how to prevent complications and progression of chronic disease, primary care physicians are charged with figuring out how to actually implement those guidelines. The importance of innovation in primary care cannot be overstated because it calls upon physicians to use skills that medical school does not cultivate. Although we might be taught how to run a study that shows the importance of diet in preventing diabetic retinopathy, we’re never taught how to ensure that our patients are actually eating healthy foods. Although this means that true innovation in primary care might take some different brainpower than expected, sometimes it just means a visit to the grocery store.

Joshua St. Louis is a medical student who blogs at Primary Care Progress.

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