Interactive Group Therapy in the Information Age

Laptop and Stethoscope --- Image by © Royalty-Free/Corbis

Laptop and Stethoscope — Image by © Royalty-Free/Corbis

Imagine attending private lectures and taking all your college exams in your professors’ offices individually, one-on-one. Your instructors lecture you, then pepper you with questions, grading your answers and recording your scores. This is not unlike traditional physician visits. Contrast this to attending classroom lectures and taking online multiple choice exams where a computer algorithm tallies your answers and calculates your grade. Classroom instruction with standardized testing is much more efficient that private tutoring. Hundreds of people can learn and take their online exams simultaneously. What if medical productivity could be similarly improved?

Inefficient Physician Communication. When you visit your doctor you are engaging in what’s known as synchronous communication. You queue up in a waiting room and later both you and your doctor meet one-on-one in an exam room (at the same time). You may spend five minutes talking to a nurse and then 10 minutes talking to a doctor.  A survey found with waiting and travel time, the whole process takes about three hours, on average. Furthermore, many doctors see only about 20 to 25 patients a day. The amount of information conveyed during an office visit is limited — as is the amount of information patients retain. Doctors also must update electronic health records (EHRs) during the exam. Fiddling with EHRs further reduces the amount of useful information exchanged during a 10-minute encounter while your doctor hunts for pull-down menus. The way medicine is practiced is inherently labor intensive, not to mention inconvenient for patients.

Synchronous telemedicine is where you call your doctor or he/she calls back and you talk one-on-one.  That may be a little more convenient for patients, but it’s still labor intensive. Asynchronous telemedicine is like email (or snail mail for that matter).  You email your doctor or call your doctor and leave a message. Your doctor replies via email or by leaving voicemail.  Asynchronous communication doesn’t require both parties to be present at the same time to communicate, but the information flow back and forth can be slow and inhibited compared to talking.

Medical Automation. Mercatus scholar, Robert Graboyes, writes about Lemonaid Health, a type of asynchronous telemedicine on steroids. (Lemonaid Health charges a flat $15 for a prescription for handful of common ailments.) He explains the difference between synchronous and asynchronous communication; and how some medical services require one-on-one time (think an initial visit for a diagnosis), while others can be quickly performed through a series of interactive processes.  As Dr. Graboyes explains, the latter are scalable; aided by a computer algorithm, one doctor could oversee the care of many times more patients than possible if limited to one-on-one office visits. Graboyes’ Inside Sources article is fascinating, definitely check it out.

Now for a thought experiment: imagine logging-in on your doctor’s office website, then being examined by answering questions from an interactive menu. The website algorithm then generates a treatment plan based on your responses for a chronic disease like, say, diabetes. Your doctor could review the results and approve your treatment plan, order prescriptions and maybe insert some specific advice much more quickly than using the traditional synchronous communication (office visit) model. At least in theory, a doctor performing the cursory evaluation of the automated treatment plan could be located anywhere in the world.

Computer-aided diagnostic tools for physicians already exists. Most mammograms are initially read by computer algorithms, highlighting areas where there may be problems or uncertain indications for a radiologist to interpret. An alternative method requires two different radiologists to validate individual interpretations. One radiologist using one computer is more efficient than two redundant radiologists using no computer.

Strength in Numbers. Now let me expand on Bob Graboyes’ discussion. Numerous diseases have support groups, where people suffering with the same disease or condition shares stories and exchange information on symptoms, treatments, doctors and so on. Nowadays most support groups are online. Members may never actually meet in person, yet benefit tremendously from interacting with others. Not only can people exchange ideas, the email chain is archived online for others to read and learn from long after the initial exchange occurred.

Group therapy is therapy sessions provided to a group of patients simultaneously. It is most common in environments where sharing the experience of others with similar conditions is beneficial or peer pressure is needed to improve outcomes. Overweight people have group therapy: it’s called Weight Watchers. Addicts have group therapy: it’s called Alcoholics Anonymous or Narcotics Anonymous. People with mental health conditions used to have group therapy (simply called, group therapy).  Think back to the old Bob Newhart Show in the 1970s. Half a dozen comically-neurotic characters, with a garden variety of mental health issues like depression, anxiety or phobias, would all arrive for a group session at a scheduled time. They would sit around for an hour and each take turns sharing their neuroses while validating each other’s feelings.

I actually attended a group therapy session of sorts the other day. My dog’s veterinary behaviorist charges $150 an hour to evaluate canine behavior problems. Initial evaluations take about two hours. The veterinarian periodically sponsors group sessions where dog owners can come as a group and listen to a presentation on some aspect of dog behavior. The events last about two hours and admission is only $15. Dog owners can learn more from these $15 seminars than most could afford to pay the vet one-on-one.

Interactive Group Therapy. Now imagine rather than a diabetes online support group open to the public, members are enrolled in an exclusive telemedicine group therapy program. Members could share a name or nickname and discuss or message other members privately. However, most interactions would be shared among the entire group. Doctors would monitor the group’s interactions and correct bad information. A physician or nurse practitioner could check metrics that are entered on a periodic basis (weight, blood glucose, activity levels, medications taken, etc.). Based on the inputs and interactions, physicians would review the automated treatment plans, update the medical record and prescribe medications electronically.  People who don’t participate might be contacted by others in the group, a nurse or the computer system. Such a system could upload some metrics (e.g. weight and blood glucose levels) using Bluetooth. Members could share recipes, eating habits, exercise regimens and generally support each other’s efforts — all while under medical supervision.

Interactive group therapy could easily work in a primary care practice to replace in-person routine physicals and wellness visits. I could sign up with my doctor alongside a thousand other guys. We could watch our doctor’s YouTube videos on wellness, the importance of maintaining proper weight, blood pressure, cholesterol and so on. We could routinely upload information on weight, blood pressure and any concerns we have. Our physician could follow up if needed for a nominal fee. Perhaps once or twice a year we could have blood drawn to check cholesterol, hormones, liver kidney, etc. Any readings out of the normal range would alert the doctor, who could call in a prescription or call us in for a one-on-one evaluation.

Comments (20)

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  1. Z Woof says:

    Devon, nobody cares about reducing costs for the taxpayers. The goal is to fleece the taxpayer of every penny with the use of PROPAGANDA. FOX News Chris Wallace has changed the insurance term GUARANTEED ISSUE to PRE-EXISTING PROTECTION. There is no such thing as PRE-EXISTING PROTECTION Life Insurance. There is GUARANTEED ISSUE Life Insurance and it costs 4 times more. There is no such thing as PRE-EXISTING PROTECTION health insurance. There is GUARANTEED ISSUE health insurance and it costs 4 times more too, exactly like Obamacare.

    Senator Joni Ernst (R-IA) said she was going to “UNLOAD” on Obamacare. She begged Iowa voters to, “Give me a SHOT.” Joni Ernst promised that if she was elected she would “make’em squeal” in Washington DC.

    Sen. Joni Ernst released an ad featuring her shooting a gun and criticizing Obamacare and government spending.

    “Joni Ernst will take aim at wasteful spending,” the narrator said in the Ernst ad. “And once she sets her sights on Obamacare, Joni’s gonna unload.”– she is a Lieutenant Colonel. Here watch the 30 second commercial:

    Ha ha, Iowa taxpayers are spending $1,200+ a month to add a child to a State employees’ health insurance. All of the money goes to evil Blue Cross Inc. That is not Washington DC corruption, that is Des Moines, state capitol, corruption.

    The goal is to increase costs and not to reduce them.

    • Allan says:

      The goal is power, money is a vehicle. The citizen is either a vote or an inconvenience.

      “Power tends to corrupt, and absolute power corrupts absolutely.” __Lord Acton

      What do we see in government today?

      • Z Woof says:

        Allan, Blue Cross is charging taxpayers $27,000 a year for a 30-year-old State employee with one child. Blue Cross is cancelling all individual insurance contracts and will only insure employer-groups. Then when the employee gets ovarian cancer and too sick to work Obamacare allows her to switch to Individual insurance which makes the self-employed pig farmers premiums go up and Blue Cross laughs all the way to the bank.

        Blue Cross collects $27,000 a year and as soon as the employee gets cancer they are immediately switched to a different insurance company to pay all of the medical bills. This is too corrupt.

        “Squeal” Script

        Joni: I’m Joni Ernst. I grew up castrating hogs on an Iowa farm. So when I get to Washington, I’ll know how to cut pork.

        Voiceover: Joni Ernst. Mother, soldier, conservative.

        Joni: My parents taught us to live within our means. It’s time to force Washington to do the same; to cut wasteful spending, repeal Obamacare, and balance the budget. I’m Joni Ernst and I approve this message because Washington’s full of big spenders. Let’s make ‘em squeal.

        It was viewed on YouTube almost 400,000 times within 72 hours. Late-night comedians such as Jimmy Fallon and Stephen Colbert spoofed it. Some considered it bad taste but Ernst’s name recognition soared.

        Bill Clinton told a rally he “sort of liked” the ad but accused Ernst of not knowing the difference between pork and people. “I don’t want to hear minimum-wage workers squeal.”

  2. Devon Herrick says:

    Allan / Ron,

    For me it’s about convenience. I’d pay a Direct Primary Care a monthly fee for this type of service. My health would be monitored in real time rather than as a snapshot every few years when my wife gets fed up and makes me schedule a doctor visit.

    • Z Woof says:

      Devon, there is a doctor group in PA that charges $270 a month per family and then charges no co-pays for unlimited visits. They don’t deal with insurance. A School District there is paying for a high deductible HSA Qualifying health insurance then also pays for the unlimited doctor visits at $270 a month.

      Of course when they go to the hospital the teacher still owe $6,850. The School District should put that money in the tax-free HSA and let the teachers decide.

      You don’t want to see the doctor Devon. Last week they told my wife that the odds of her having cancer was way over 50%. She cried for 3 days. Then they called and said she was just fine, no need to come in.

    • Allan says:

      Devon, convenience is an important issue, but convenience is not necessarily medical care. Direct Primary Care sounds good and for many it is good, but it isn’t that good an answer to obtaining care for many serious medical problems. Primary care doctors are not specialists, surgeons, hospitals, physical therapists etc.

      Do you think a Direct Primary Care physician extends past the broad knowledge of an Internist? I’m an Internist with a subspecialty and heavy training in a second sub specialty and I don’t think so. In fact I ran my office almost like the VIP doctors in my area that charge $1,800 per year. 24/7 care with appointments available even on the same day (I left small openings and would stay late if needed.) That is the way medicine is supposed to be practiced. The way medicine is supposed to be practiced has changed because of government, ACO’s, etc. and that is why these new types of physician billing have appeared.

      Do you think Direct Primary Care doctors had a special relationship with their specialists, hospitals, etc.? Understand, I have no problem with them and think they are doing a good thing, but I wouldn’t want the assumption that any of them are any better than any other well trained conscientious physician that practices in the traditional way.

      • Allan says:

        I should have also said that in my practice new patients were taken when we had the time and the 24/7 was only for established patients.

      • Devon Herrick says:

        Allan, I’m not trying to force anyone to use a different type of physician visit. I’m merely discussing some of the potential innovations that could make primary care more convenient and possible increase the touch points patients have with their primary care doctor.

        As an economist, I assume we don’t actually have any idea what will work until it’s put to the test. One problem with our health care system that it over-relies on third party payment. Thus, the parties who pay (insurers) are in no hurry to try out new ways to spend [their] money. However, consumers often do test new services; deciding which ones are worthy of their dollars.

        Interactive group theory could fall flat and be a joke. It could work well. It could work in only a small number of situations and not in many others. But we won’t know for years (if ever) because patients have been conditioned to think that if their health plan doesn’t pay for something they don’t need it and should not have to pay for it.

        • Allan says:

          “I’m merely discussing some of the potential innovations that could make primary care more convenient”

          I wasn’t indicating that you were forcing anyone to do anything. I was just clarifying some points. But, more specifically the use of things like VIP make things worse for many people that don’t utilize their services.

          You probably are asking why that is. Most of us believe that primary care physicians are in short supply. Using VIP as an example let’s take a look at what happens. The average physician might have 1,500 to 2,500 patients that he is responsible for. The VIP doctor is limited to a max of 600. That means for every doctor that goes VIP, 900 – 1,900 patients might end up without a physician.

          • Devon Herrick says:

            I think it’s good to have all kinds of practice models. Some people want the concierge VIP model where they pay $150 a month whether they see a doctor or not. As you indicate, that doctor fires 80% of his/her patients to care for the wealthier 20%. I also like DocTalker Family Medicine, where the doctor or NP charges for blocks of time, but only has a small $25 to $30 per month retainer fee. You can have an in-office visit, a telephone visit or even a house call (within a couple miles of the office). Each service has a different fee.

            What I’m describing in my essay is the opposite of VIP medicine. It’s more herd medicine (you’re part of the herd). What makes my idea different that traditional group therapy is you don’t have to sit in a room full of strangers. You mostly coexist online. I would assume people would come in for an office visit periodically though.

            • Allan says:

              I am for a free for all as to the methodologies of providing care. Let them all compete, but that is not what is happening. Government and its legislation picks winners and losers. I would like you to be able to bargain for the care you wish and for the insurer and provider to bargain with you to reach a favorable agreement for both parties.

              I like the methodology you discuss as long as it is voluntary. In my office practice I had a lot of patients with chronic disease and I had enough patients with certain diseases such as diabetes that I wanted to try group therapy along with individual therapy so various patients could help provide various methodologies they used to satisfy their needs under the controlled circumstances where a physician was involved. Medicare did not permit that type of care and the laws involving Medicare provided a threat to my doing what I thought was a good form of treatment.

  3. Paul Nelson says:

    It is interesting to me that there is a rapidly evolving emphasis on implementing telemedicine. I am probably in error, but I recall no tradition of scientific studies to establish the reliability of its use. We have much more deep-seated problems requiring innovation for their solution.
    My recollection of Primary Healthcare for 40 years is the need to call 911 for someone who arrived in office for an appointment about every 4 years. Not often, but it was usually related to walking into the exam room, making an assessment of very unstable health by looking at the person, making sure I didn’t need to do something immediately, and then discussing the issues with the person and the attendant family present (or calling them). It was usually either a pulmonary embolus, unstable Heart or overwhelming infection.

    • Devon Herrick says:

      If I were to venture a guess about why more people are discussing telemedicine it’s probably because we have the Internet, iPhones and iPads and all manner of apps. Yet we’re conversing with our doctors in the same way our grandparents did 50 years ago.

      An interactive group therapy session could never replace in-office visits. But it could potentially be a cheap way to improve patient compliance between visits for some chronic diseases.

      I don’t see an insurance company paying for this without evidence it would work. However, some patients might it the cost was not too high because the cost of monitoring is being spread over many in the group.

      • Z Woof says:

        The Texas School Districts have $2,500 deductible HSA plans and they charge teachers $30 to use Teledoc. They usually charge about $1,000 a month to add the family on insurance too.

        My clients all have Tele-Doc and the service is free.

        • Devon Herrick says:

          I have TelaDoc, although I’ve never had to use it. I wrote about TelaDoc a decade ago when they were first starting out.

          • Allan says:

            Devon, TelaDoc is something I have no experience with. However, I do have experience with after hour telephone conversations. Malpractice concerns arise. When I first started practice I would do all sorts of things in my office and prescribe all sorts of things by phone, but gradually with time malpractice risks climbed and I reduced my risks by reducing these kinds of exposures.

            One of the cases that scared me the most was of one of my GI consultants who prescribed a laxative for constipation over the phone. Apparently, something else was going on and he was sued. I discussed the case and I found nothing wrong with his care except for the fact that the outcome wasn’t so good. The best of care can have lousy outcomes. The claim was he didn’t examine the patient and had he examined the patient he may have found that another problem existed. I don’t think he lost the case, but I think the case caused harm to other patients that needed advice on the phone in the future.

            I worry that unless malpractice is adequately contained suits will mount and newer technologies like Teladoc will be limited.

      • Allan says:

        “I don’t see an insurance company paying for this without evidence it would work.”

        If the patient was buying his own insurance the insurance company would do what the bulk of the patients wanted and adjust the premiums accordingly.

  4. Z Woof says:

    THIS JUST IN: President Trump’s economic advisor Gary Cohn says the GOP has the votes to pass an Obamacare repeal and is predicting a ‘great week’ in Congress.

    He spoke Monday morning, just days after House Republican leaders sent lawmakers home for the weekend after failing to cobble together enough votes to pass the repeal bill.
    The White House had been pushing hard to score a legislative win in the House before Trump’s 100th day in office Saturday, but came up shore. A new compromise that won the support of conservative ‘Freedom Caucus’ members caused problems with more moderate members.

    Even if the bill passed the House, it would face serious problems in the Senate.

  5. Z Woof says:

    LOSER Liberal Jimmy Kimmel’s new baby is saved by using doctors and nurses at Cedars-Siani Medical Center. BUT, he is so stupid that he thinks Obamacare people on HMOs, that pay NOTHING if they go to Cedars-Siani, should be happy his baby lived.

    Hell, Jimmy Kimmel could just take ONE painting off of the wall and pay for his baby’s open heart surgery. BUT, he uses his sick new born baby to attack President Trump. What a stupid jerk. UNINFORMED Jimmy Kimmel said:

    “–If your baby is going to die, and it doesn’t have to, it shouldn’t matter how much money you make.”

    Kimmel wrapped by calling on the legislators “meeting about this right now in Washington” to maintain the requirement that insurers provide coverage to Americans with preexisting conditions.”

    (“Even that son of a bitch Matt Damon sent flowers,” he added reluctantly through tears.)

    Cry me a river Jimmy Kimmel:

    • Z Woof says:

      This story was all over the news today. Even Bill and Hillary Clinton were tweeting about it.

      Too funny. Jimmy Kimmel really cares about all of the Little-Bitty people in America, ya right.

      He wants everyone on the same team. He should have been told, “I’m sorry, you will have to use LA General Hospital, take a number.”