It is well established that group

Evaluation of Prenatal and Pediatric Group Visits in a Residency Training Program Cristen Page, MD, MPH; Alfred Reid, MA; Laura Andrews, Julea Steiner, MPH BACKGROUND: It is well established that group visits offer an appropriate alternative to individual care with respect to efficiency, clinical effectiveness, and patient and provider satisfaction and are feasible in the training setting. The purpose of this paper is to describe resident educational outcomes from participation in prenatal and well-child group visits over the last 6 years. METHODS: We surveyed the 48 physicians who graduated from the University of North Carolina Family Medicine Residency from 2006 through 2011 regarding their current scope of practice, the number of group visits they experienced, and the educational value of group visits. RESULTS: Thirty-four (71%) of graduates responded. Twelve respondents (35%) include prenatal care in their current practice, 29 (85%) include pediatric care, and five (15%) include group visits. As residents, all respondents participated in group visits. Respondents most valued what they learned in group visits from patient questions, from the exposure to a bolus of patients at the same stage of development, and from faculty role modeling. CONCLUSIONS: Group visits are a potentially valuable adjunct to the standard training experience, with benefits for learning efficiency, scope of practice, and the promotion of patient-centered care that can be carried forward into practice. (Fam Med 2013;45(5):349-53.) It is well established that group visits offer an appropriate alternative to individual care with respect to efficiency, clinical effectiveness, and patient and provider satisfaction and are feasible in the training setting. 1 7 The Department of Family Medicine at the University of North Carolina has a history of integrating group visits into residency training, particularly for prenatal care (based on Centering- Pregnancy 8 ) and well-child care (WellBabies). In a previous paper 7 we described the rationale, implementation, organization, and key patient outcomes of WellBabies, a model of group well-child visits, in which residents participate. The purpose of this paper is to describe assessment and resident educational outcomes from participation in prenatal and well-child group visits over the last 6 years. Methods Setting Residents are required to complete three 6-week blocks of Maternal and Child Health (MCH) during the second and third years of training. Patients may choose individual care or group care for prenatal and early well-child visits. We schedule three prenatal groups for each cohort of women estimated to deliver during a resident s MCH blocks and subsequent WellBabies visits for each cohort of babies delivered during their MCH blocks. From this total of 12 group visit opportunities, approximately 50% of potential groups were not formed due to lack of patient interest or scheduling conflicts. Variation in resident call schedules and duty hour restrictions further reduce residents opportunities to participate, allowing most residents to participate in three to five group visits. Structure and content of group visits is outlined in Table 1 and has been described in detail elsewhere. 7,8 During the period we studied (2006 2011), 76% of group visits were for prenatal care, and 24% were WellBabies visits. Assessment In December 2011 and January 2012, we surveyed the 48 physicians who graduated from our program from 2006 through 2011. To develop the survey, we conducted individual interviews with senior residents (n=4) and recent graduates (n=7), asking them to assess the quality of the educational experience and to identify salient learning points. From the Department of Family Medicine, University of North Carolina. FAMILY MEDICINE VOL. 45, NO. 5 MAY 2013 349

Table 1: Flow and Content of Group visits in the University of North Carolina Family Medicine Residency Program* Patient volume Visit flow Check-in (5 minutes) Introduction (25-30 minutes) Group bonding (5 minutes) Review/medical (10 15 minutes) Anticipatory guidance (30 40 minutes) Wrap-up (20 minutes) Prenatal Groups 4 8 patients with due dates within 6-week MCH blocks Each cohort is scheduled for 10 group prenatal visits Women arrive in advance, check in, and go straight to group space Women take own vitals and write in chart Facilitator has individual time in room for private concerns, physical exam Facilitator leads introduction into group discussion Patients share something about their lives Facilitator and group discuss major changes for this stage of pregnancy, normal growth Facilitator invites patient questions and concerns about pregnancy Facilitator prompts discussion of routine pregnancy-related anticipatory guidance based on ACOG guidelines (eg, preterm labor precautions, pain management plans for labor, etc) Facilitator follows up on any individual concerns Appropriate lab tests completed If needed, individual visits arranged WellBabies Groups 4 8 infants with birthdates within 6-week range Each cohort is scheduled for 6 group wellchild visits in the first year of life Parents and babies arrive in advance, check in, and go straight to group space Parents help measure and document child s length, weight, and head circumference Parents write questions and concerns on the board Facilitator talks to parents individually, performs and documents physical exam Facilitator leads introduction into group discussion Parents share something new about their child Facilitator and group review growth charts Tummy Time where parents place infants on mats and review developmental milestones Facilitator invites discussion and questions about parenting and concerns about infants Facilitator guides discussion about ageappropriate anticipatory guidance on sleep, nutrition, injury prevention, and violence prevention based on AAP guidelines Facilitator follows up on individual concerns Nurse gives immunizations If needed, individual visits arranged * All visits are facilitated by a resident and an attending physician and last between 90 and 120 minutes. MCH Maternal and Child Health ACOG American Congress of Obhstetricians and Gynecologists AAP American Academy of Pediatrics All investigators reviewed interview transcripts as a group and agreed on grouping of learning points into four categories: (1) the value of faculty role modeling, (2) the value of seeing groups of patients at the same stage of pregnancy or development, (3) the value of patients questions, and (4) the opportunity to practice counseling. We framed these categories as positive statements on the survey (see Figure 1) and asked respondents to rate their agreement with them on a 5-point scale (strongly disagree, disagree, neither agree nor disagree, agree, strongly agree). Respondents who strongly disagreed or strongly agreed with the value statements were also asked to provide open-ended comments. These comments were tabulated and sorted according to themes held in common. As part of the group visit experience, residents could occupy any of six defined roles (and could take more than one role in a given group visit). The survey included an item asking respondents to indicate all of the roles they held during group visit participation (see Figure 2). Respondents were also asked to indicate the number of group visits experienced as a resident (categorized as 1 2, 3 5, or > 5) and whether their current practice includes group visits, prenatal care, and pediatric care. This study was approved by the University of North Carolina Institutional Review Board. Results Thirty four (71%) of the 48 physicians surveyed responded to the survey. Eighty-five percent of respondents include pediatric care in their current practice, 35% include prenatal care, and 15% include group visits in their current practice. The five respondents whose current practices include group visits graduated more recently (three since 2010, all since 350 MAY 2013 VOL. 45, NO. 5 FAMILY MEDICINE

Figure 1: Survey Respondents Agreement With Statements Regarding the Educational Value of Group Visits Experienced as a Resident Figure 2: Number of Survey Respondents Reporting Filling Each of Six Roles in at Least One Group Visit During Residency* *Roles are arranged in descending order of intensity of involvement. 2008) but otherwise did not differ appreciably from other respondents. Seventy-three percent of respondents reported participating in five or fewer group visits during residency; 27% reported participating in more than five group visits. We found substantial agreement among respondents with the statements of educational value, as shown in Figure 1. Combining strongly agree and agree, 97% agreed regarding the value of patients questions to the learning experience; 94% agreed regarding the value of seeing several pregnancies or babies at the same developmental stage, 87% agreed on the value of faculty role modeling, and 72% agreed regarding the value of group visits to practice counseling. No respondent FAMILY MEDICINE VOL. 45, NO. 5 MAY 2013 351

strongly disagreed with any statement. Open-ended comments of those who strongly agreed with the value statements were illuminating. A recurring theme in open-ended responses about the value of learning from patients questions concerned the observation that patients concerns often differ from those of physicians. As one survey respondent noted: Patients don t read the textbooks. Sometimes the most knowledgeable physician will be stumped by the most basic question from a patient or parent. It helped to learn what was important to the patients. Likewise, those who agreed most about the value of seeing a number of patients at the same stage of development pointed out both the efficiency and the persistence of learning in the group setting. For example, one respondent wrote: Seeing multiple pregnancies at the same gestational age as well as children at the same stage really helped solidify that stage in my mind. I know that this helped me because I feel more confident with the specific visits that include gestational ages and pediatric ages that I saw in group visits. Respondents who agreed on the value of faculty role modeling around anticipatory guidance most frequently pointed out in open-ended comments that they found this aspect most helpful to them in the observer role. The least agreed-upon statement concerns the value of group visits in providing time to practice counseling. Open-ended comments of those who agreed with the statement most frequently refer to practicing counseling in the role of primary group facilitator. Since only one third of respondents reported taking this role as residents, it follows that they may have had less opportunity to practice counseling. It is also possible that residents found opportunities to practice counseling by participating in group discussions, which all did. Discussion We found that residency graduates value participation in prenatal and pediatric group visits in their training. In particular they value group visits as an opportunity to learn from patient questions, a bolus of patients at the same developmental stage, and faculty modeling of anticipatory guidance. Readers should bear in mind that our results are based on self-reports and therefore subject to recall bias. They reflect the experience of graduates of a single residency program, all of whom participated in group visits at some point in their training; therefore, we are not able to compare outcomes for those exposed to this training modality with those who were not. While our response rate was acceptable (71%), graduates who did not respond may have reported different experiences. Nevertheless, we believe our findings show promise for group visits in residency training, particularly in three areas. First, survey respondents comments about the efficiency and persistence of learning in the group visit setting have implications for both training time and role modeling. As training time continues to be constrained by mandatory duty hour restrictions, requirements for broad scope training become more challenging to residency programs. Group visits can be structured to address multiple core competencies and milestones in a single training experience. In this way they may be an efficient way to maximize valuable training time and provide opportunities for the faculty role modeling that is required by the Family Medicine Review Committee. Likewise, practices with low volumes of these patient populations may benefit from the efficiency of bringing patients together in a single visit, rather than spread out over infrequent individual visits. Also, low-volume practices may benefit from the patient recruitment advantages suggested by Page et al. 7 Second, a recent commentary from the American Board of Family Medicine (ABFM) expresses concern about family physicians scope of practice, particularly regarding maternity and pediatric care. 9 Our results suggest that exposure to group visits in residency may encourage broader scope of practice. The fact that our respondents specifically identified the group visit as a source of confidence in their current practice suggests a possible link between experience in residency and later practice. And, indeed, the proportion of our respondents who include prenatal and pediatric care in their current practices (35% and 85%, respectively) is substantially greater than that reported by the ABFM (15% practice maternity care; fewer than 75% practice pediatric care) 9 and suggests that the group visit experience in training may play a role in encouraging a broader scope of practice after graduation. Moreover, the fact that 15% of respondents include group visits in their current practice suggests that this training approach may encourage graduates to explore new models of care beyond residency. Finally, respondents emphasis on the value of learning from patients in the group setting highlights the potential for group visits to model patient-centered care, a benefit that may also be found in other group care settings such as chronic illness care. The involvement of other practitioners (eg, nurses, lactation specialists, physical therapists, parenting coaches) in prenatal and pediatric group visits also models and encourages interprofessional care another important dimension of the chronic care model and the patientcentered medical home. Further study will provide a clearer picture of the complementary role of group visits and individual visits in residency education. Evaluation in other residency settings and other patient populations will help clarify 352 MAY 2013 VOL. 45, NO. 5 FAMILY MEDICINE

whether and how group visits influence post-training practice behavior. CORRESPONDING AUTHOR: Address correspondence to Mr Reid, University of North Carolina, Department of Family Medicine, CB#7595 William B. Aycock Building, Chapel Hill, NC 27599-7595. 919-966-4152. Fax: 919-966-6125. alfred_reid@med.unc.edu. References 1. Jaber R, Braksmajer A, Trilling JS. Group visits: a qualitative review of current research. J Am Board Fam Med 2006;19(3):276-90. 2. Osborn LM, Woolley FR. Use of groups in well child care. Pediatrics 1981;67(5):701-6. 3. Ickovics JR, Kershaw TS, Westdahl C, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol 2007;110(2 Pt 1):330-9. 4. Taylor JA, Davis RL, Kemper KJ. Health care utilization and health status in high-risk children randomized to receive group or individual well child care. Pediatrics 1997;100(3):E1. 5. Taylor JA, Davis RL, Kemper KJ. A randomized controlled trial of group versus individual well child care for high-risk children: maternalchild interaction and developmental outcomes. Pediatrics 1997;99(6):E9. 6. Feldman M. Care of the well child: cluster visits. Am J Nurs 1974;74(8):1485-8. 7. Page C, Reid A, Hoagland E, Leonard SB. WellBabies: mothers perspectives on an innovative model of group well-child care. Fam Med 2010;42(3):202-7. 8. Rising SS. Centering pregnancy. An interdisciplinary model of empowerment. J Nurse Midwifery 1998;43(1):46-54. 9. Newton WP. Family physician scope of practice: what it is and why it matters. J Am Board Fam Med 2011;24(6):633-4. FAMILY MEDICINE VOL. 45, NO. 5 MAY 2013 353