The success of Men's Educational Group Appointments
Article Outline
Men have a higher age-adjusted death rate from many of the leading causes of death, compared with women. Avoidance of healthcare and unhealthy behavior significantly contribute to premature death and disability amongst men. Men do not visit physicians as often as women [1], and tend to under-report their symptoms. Men are more likely to abuse alcohol [2], use tobacco products [1], and often make unhealthy lifestyle decisions, especially while “male bonding”. Men have a significantly higher death rate from motor vehicle accidents [1] and are at least four times more likely than women to commit suicide [3].
Four years ago, we initiated a program, the Men's Educational Group Appointment (MEGA), designed to educate men to take better care of themselves. We hypothesized that changing the nature of the routine physical examination to include an interactive group discussion would enhance patient education by capitalizing upon group dynamics. We hypothesized that inviting a group of men to an appointment would reduce the anxiety associated with the traditional one-on-one doctor's visit, promote attendance, and empower individuals to more thoroughly discuss their health concerns.
The MEGA consisted of a private physical exam and an interactive group discussion of the patients’ laboratory data, as well as men's health issues. The sessions were held during convenient evening hours, one or two times per week. Individuals due for a yearly physical exam were identified, informed of the MEGA option, and invited to participate. Approximately 70% of those invited agreed to participate, and 97% of those who agreed to participate actually attended their scheduled session [4]. Typically, five to eight male patients were invited to each 2
hour session. The age of the participants ranged from 20–65 years. The majority of the participants were from the author's primary patient panel. Consenting patients presented to the laboratory several weeks before their appointment to obtain routine blood work.
To begin each session, patients met in a conference room where they were introduced to the other patients and the members of the MEGA team, which comprised the physician, the physician's assistant, and a medical assistant. Patients were asked to sign a confidentiality waiver form to protect any health information disclosed during the session. Each patient was given a folder containing his laboratory data, and several educational pamphlets on men's health issues.
During the first hour of the session, a medical assistant escorted one patient at a time to an exam room for a private physical exam. After a 10minute exam, and an opportunity to discuss any issue for which the patient preferred privacy, each patient returned to the larger group. While the physician conducted the exams, the physician's assistant reviewed the entire group's laboratory data, and addressed questions relating to the data, and general health issues. Patients’ first names were displayed alongside their fasting blood sugar, lipid profile, PSA value, and colonoscopy due date.
During the second hour, the physician joined the group, addressed any additional questions or health concerns, and delivered a 20–30minute humor-filled presentation to educate the group about the importance of cancer screening, cardiovascular disease prevention, and other men's health issues. During flu season, influenza vaccines were offered to the patients.
In the first year, patient satisfaction surveys revealed high patient satisfaction amongst MEGA participants [4], which were attributed to the strong educational component of the program. Patients reported that the extended patient–healthcare provider interaction (2hours) permitted the providers to address their questions in much greater depth. Patients also indicated that the format enabled them to learn from other patients’ questions, including ones that they probably would not have asked themselves.
The favorable patient satisfaction ratings prompted the question “Does the MEGA model result in improved patient education compared to the traditional one-on-one office visit”? During the second year of the program, patients completed surveys which asked them to compare the amount of relevant medical information they acquired during the MEGA to what they would have expected from a traditional one-on-one visit. We found that the vast majority (96%, n=241) of patients reported that they learned important health information from other patients’ questions that they may not have asked themselves [5]. The overwhelming majority of patients (95%) also indicated that they learned information that they considered valuable for their own health maintenance that they may not have acquired during a one-on-one visit. Enhanced patient education and overall satisfaction with the program was further evident in that 95% of patients stated that they would choose the MEGA for their next annual visit.
These findings suggest that the group approach may be superior to the traditional one-on-one model of health care delivery for patient education. The strongest evidence for this conclusion is the fact that there is a very high number of returning patients. Now, almost 4 years since the inception of the program, the vast majority of participating patients have chosen the MEGA option over the traditional one-on-one visit for their subsequent annual physical exams.
What makes MEGA a more appealing model of health care delivery, and results in improved patient education compared to the traditional one-on-one appointment? The extended patient–health care provider interaction appears to play an important role. Patients consistently report that spending 2hours with two health care providers enables them to have their questions thoroughly addressed, and nearly universally claim benefiting from a presentation, which uses humor to illustrate key points about preventative health. Patients also clearly benefit from male group dynamics. The group approach provides an environment where individuals benefit from a healthy form of “male bonding” and competition, and leads individuals to feel more at ease, in contrast to the one-on-one experience that may be perceived as more of a demasculinating experience.
Culturally driven masculine behavior prevents many men from going to the doctor [6], [7]. During childhood, boys are conditioned to repress physical and emotional pain to avoid being perceived as weak or unmanly. This masculine behavior may ultimately condition men to ignore potentially concerning symptoms and to avoid medical attention later in life. The group approach offered by the MEGA model permits an individual male to figuratively “lower his masculine shield” and seek proper medical care. By observing the participation of other male patients, the individual may realize that his participation does not compromise his masculine identity, and that it is acceptable to seek health care. Once he becomes a member of the group, he further benefits by observing others asking questions regarding health concerns with which he can relate. This in turn may empower him to ask questions that he may not have asked in a traditional one-on-one appointment.
When men come together in groups there is a tendency to make more unhealthy decisions than when alone or in a family context. Studies show that men report more difficulty refusing an alcoholic drink from a male friend, or ordering a healthy dietary option when eating with other men [8]. Such behavior amongst groups of men has resulted in the notion that “male bonding” is associated with unhealthy lifestyle choices. The MEGA model puts a healthy spin on “male bonding”. We have consistently witnessed men share their stories or advice with the other men to help them lead healthier lives. For instance, those who had undergone colonoscopy screening relayed their experiences to put those awaiting their first study more at ease. Patients who exercised regularly offered helpful suggestions to those patients who struggled with consistency. The finding that group dynamics has a potentially beneficial influence on the individual patient parallels the findings of other investigators in the fields of weight loss and alcohol cessation [9], [10].
The MEGA approach also capitalizes upon healthy male competition to motivate individuals to take better care of themselves. At the beginning of each session, individuals observe where their cholesterol and blood sugar values rank in comparison to the remainder of the group. This serves as a powerful teaching tool, as it places the values into a unique, comparative context. Patients who have not heeded their physicians’ pleas to embrace a healthier diet are suddenly awakened when they are surrounded by the faces of other men with more favorable cholesterol readings. This revelation strikes a competitive cord in some individuals, and inspires them to make healthy lifestyle changes in an effort to improve their ranking. This competitive nature also promotes future attendance, since patients want other group members to witness the improvement in their laboratory values the following year. The observation that interpersonal competition can be constructive within groups has been supported in the psychology literature [11].
The economics of the MEGA program are important to consider. We estimate that the program is at least economically neutral, and may even be profitable compared with the one-on-one model. In our program, the physician and physician's assistant together evaluate 8 patients over a 2 hour period, which represents equivalent productivity to one-on-one visits at our institution. Our hope and expectation is that the increased patient education associated with the MEGA model will translate into significant downstream cost savings related to better patient compliance with screening studies and healthier lifestyle decisions.
The MEGA model results in very high patient satisfaction, and appears to result in increased patient education compared to the traditional one-on-one appointment. The real barometer of whether this model is truly successful lies in whether it inspires patients to take better care of themselves, which is the primary goal of the MEGA program. Our current and future work is designed to look directly at outcomes data, by studying whether MEGA patients follow through with screening colonoscopy, cholesterol management, and glucose control better than their counterparts who undergo traditional one-on-one appointments.
Note
The submission of this editorial is in response to the call for papers for the upcoming World Congress on Men's Health and Gender Medicine.
References
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PII: S1875-6867(09)00075-X
doi:10.1016/j.jomh.2009.07.001
© 2009 WPMH GmbH. Published by Elsevier Inc. All rights reserved.
