Welcome to the Evolution of Medicine podcast! This episode kicks off our series on group visits and the pioneers who are bringing this practice model to the masses. Today we are honored to welcome the doctor who has been called the godfather of group visits, Dr. Jeffrey Geller.
With more than 20 years of experience running group visits, Dr. Geller shares his extensive experience and wisdom in this powerful 45-minute episode, with highlights including:
- The most effective ways to bring communities together around medical issues
- Challenges he’s faced running group visits, and how he overcame them
- The role of the clinician in the group visit model
- Strategies for success with group visits, whether you’re just starting out in functional medicine, building your functional medicine practice, or part of a medical system
- And so much more
James Maskell: Hello and welcome back to Evolution of Medicine podcast. We are really, really excited to be back for a new series all on group visits. This has been something that has been a theme all the way through the Evolution of Medicine using and leveraging the power of the groups to bring integrative and functional medicine to the masses. And who better to start this conversation than Dr. Jeffrey Geller? He’s a physician that has been running groups more than 20 years. He’s worked in impoverished areas in Massachusetts and has really helped to shine a light on some of the most effective ways to bring communities together around particular medical issues and show the way for so many other physicians who I’ve spoken to over the last 10 years all across the country. So enjoy this. It was a really incredible 45 minutes with Dr. Geller. Enjoy.
James Maskell: A warm welcome to the podcast, Dr. Jeffrey Geller. Welcome, doc.
Jeffrey Geller: Hey, thanks for having me.
James Maskell: So, it’s been, over the last few years, as I’ve gone through and started speaking to people who are interested in the world of group medicine and group visits, your name has come up as sort of like the Godfather in the integrative world anyway. And so I’m really excited to connect and just hear a little bit about your experience.
James Maskell: So, let’s wind it right back to the beginning. What was the first sort of inkling that you thought that group medicine might be something that you wanted to get involved in?
Jeffrey Geller: Well, we’d be going back quite a few years. I was a medical student and I was starting to get an inkling that there was more to health than just the nuts and bolts of you have an illness and then here’s the medicine to treat the illness. It really hit me during my first year of residency as a family doctor. I would notice some patients would have just a stubbed toe and they’d be disabled and their world would be crushed. And other people would have a stubbed toe and they go on living a perfectly healthy, happy life.
Jeffrey Geller: And so, I started to think about what it might be. I came to the idea that it was loneliness or a lack of support. The people who had support, who felt engaged in life, they weren’t struggling, so they weren’t suffering with this illness as much as people who didn’t have support felt all alone. I did some initial research, and it showed that people who are lonely, were using our health center four to six times more often, and people who are lonely, were using the emergency rooms a two to three times more often. So, that got to a good amount of attention. Wouldn’t you know, that when you do research, they then say, well, what do we do about it? And so, I was able to secure some grants and my first thought about how we treat loneliness of course is bringing people together. That’s largely how the thought process went.
Jeffrey Geller: I had other inspirations too. I had a particular patient, we’ll call her Edvijes, who invited me into her life. As a first year intern, life is very busy, a lot of calls, not sleeping that much, but she really encouraged me to go to the library once where her friends were, and they were uninsured and they had health issues and health concerns and they were doing a group together. I think they called themselves Sí Tu Puedes, which in Spanish means yes, you can. And I got to know them. They taught me some Spanish. I taught them a little bit about health, and it became clear to me that the relationship with people was so much more important than the actual information I was giving them. And so I would say that that served as a model for the initial group visits.
James Maskell: Yeah, that’s super interesting. A great starting point and an observation. So that was right at the beginning. When you started to talk to other people in your profession about your observations, what was the excitement level for what you were discussing or their interest?
Jeffrey Geller: Well, I got to say that everyone agrees with you. So when you say loneliness is bad for you, I think everyone says, “Yeah, that’s right.” But loneliness didn’t even have a billing code. And in the medical profession and in research as well, when they look for problems, it has to have a billing code. And so, I think a lot of people were like, okay, it’s a problem, but I can’t bill for loneliness. And, this is true of the psychologic profession in addition to our medical profession. If we can’t bill for it, how can we treat it? I would say, spiritually people are like, “Oh yeah, reduce loneliness, loneliness is bad for you.” Some people would be on board with what I was saying, but fiscally and logistically, people were very much thinking, how could we possibly pull this off? You know? So that was kind of the feeling.
James Maskell: How long ago was this and what was sort of the first steps that you took into starting to think about this group solution and instigating some groups?
Jeffrey Geller: So this would be all the way back in 1997. Back then I was going to that library group Sí Tu Puedes. And, slowly I created one or two groups on my own. I wasn’t billing for the groups. And I quickly learned you can’t create a group for loneliness. In other words, if I were to say I’m starting a group for loneliness, if you’re lonely, please come. People wouldn’t come. I don’t think there’s a general sense of that would be a fun time. I started to think, how am I going to pull this off? I thought, maybe in the context of medical illness.
Jeffrey Geller: So our very first groups were, I’d say our first formal groups were probably in 1997, 1998, were really for treating diabetes. I knew that I was treating their loneliness, but the participants who came, weren’t necessarily aware of that. We were able, through the CDC, to secure funding and through an institutional review board at the University of Massachusetts, we were able to do research on these patients who were coming to the groups for diabetes, and we were not surprised that very quickly loneliness gets better when you bring people together.
James Maskell: Yeah, absolutely awesome. I love that. As a starting point, you could see even then marketing is kind of a plot of medicine, right? Marketing right from the beginning, in order to get people to actually want to participate in the group, you had to be solving an issue that they knew that they had and they weren’t ashamed to have and that they would be willing to participate in.
Jeffrey Geller: Yeah. I mean that, that’s absolutely right. And initially I would say my first group visits that were formal group visits, that were for diabetes, I actually still didn’t have everything together right. I decided the town I work in is a very poor community. Most of the patients are immigrants and English isn’t their native language. A lot of Spanish-speaking people. And I would say, okay, we’re going to have a diabetes group. First thing, you can’t eat rice, rice is bad for you. How do you think that went over?
James Maskell: Yeah, no, yeah, I can understand that for sure.
Jeffrey Geller: Right. And I’d say, “Exercise, Tai Chi is best exercise.” And again, so I think because people liked me, because they liked each other, they came to the groups. But I didn’t quite have the right curriculum off the bat. And, actually a funny story. So we started doing our research for the CDC grant that I mentioned, and I have to formally say what I’m going to do, you have the method section, and so we’re going to teach Tai Chi, we’re going to talk about health, we’re going to do these things.
Jeffrey Geller: And for the first three years it was going very well. People liked it. And then, participants said, “Hey, can we bring our family members?” And because it was a CDC study, I couldn’t allow them to do that. But I said, “Hey, right after your group, I still have this space. You can come and we’ll just have a second group.” But in that second group, they couldn’t afford the Tai Chi instructor because I didn’t have the CDC funding, we couldn’t afford the cooking. So I would say, “What do you guys want to do?” And they would say, salsa dancing, la chata dancing. And I’d say, “But I can’t teach you that.” And they’d say, “That’s okay, we can teach you.”
Jeffrey Geller: I’d say, “What are we going to do for our food?” And again, we’ll make the rice and beans. After three years, we start the second group. And the second group is so much more fun than the first group, that everyone in the first group says, “We want to go to that second group.” And that’s really the start of the empowerment model, which I’ll probably talk about later. Really, you have to find out what your community needs to get healthy, right? You can’t as an outsider go there and impose things.
Jeffrey Geller: So, I definitely learned a lot, and do you think more people want to go to a salsa party than a Tai Chi, don’t-eat-rice group? You bet.
James Maskell: Yeah, absolutely. And that’s spreading the message out. So how were you able to sort of balance, the desire for, just creating like a social club and really having it be something that was in the medical arena?
Jeffrey Geller: Well, so here’s the secret. I don’t know if we want to say the secret of group visits so early. I know that there are going to be many other speakers following. But, the secret is that actually when you reduce stress, people feel special and invested in cared for, which is what reducing loneliness does. It treats the medical illness. And in fact, the research from the CDC study I did, and it’s published I think online for free, we found that people’s loneliness improved, people’s depression improved, but they also lost weight. Now I’m not talking a large amount, but the average participant lost a pound, I believe. Blood pressure reduced by I think five or 10 points, and hemoglobin A1C also reduced, which is a measure of blood sugar and diabetes. So I was able to take that study on loneliness and turn it into real medical care, and often treating loneliness gives you better results than any medication out there.
James Maskell: Yeah, absolutely. Yeah. I can see all the way through our content here at the Functional Forum, we’ve gone from sort of at the macro level and looking at things like the blue zones, looking at sort of population health, right down to, sort of social genomics and looking at how stress is effecting the quality and quantity of our relationships. And in fact, it’s such a micro level and reflected in the macro. So that doesn’t surprise me in any way. So let’s get into the model because I know that since then, just give us sort of like an overview of what’s happened since then. I mean, what has been the scale of the delivery of groups that you’d be able to facilitate there in Massachusetts?
Jeffrey Geller: Yeah, so, we started doing group visits for just about every chronic medical illness. I think prenatal groups were very early on, but our first groups were for diabetes, and then we changed them to two groups for heart disease. And then we realized that, you really shouldn’t be grouping people by disease if you’re trying to reduce loneliness. Again, we’re treating real medical illness. And, a lot of people who start groups have a diabetes group. They have a hypertension group, they might have a group for addiction. But you aren’t necessarily friends with someone just because you have the same medical illness that they do.
Jeffrey Geller: So, we became more service oriented. We’ve developed 20 different types of group visits for chronic pain. We have functional medicine visits, group visits where people sit together and talk about how they’re going to accomplish those things. I would say initially we built up to about 30 different group visits a week. And at our height, we were having 50 different group visits available weekly at our health center. And so, a very large scale treating just about every illness you can think of, ranging from obesity to depression, to addiction with cigarettes or narcotic addiction. We’ve even started a suboxone programs over the years. And, so really we accomplished quite a bit.
James Maskell: Has there been any disease type that has been resistant to the group model?
Jeffrey Geller: Well, I think we’ve had a couple issues with a really, there was only one group that didn’t go well and it was a hepatitis C group, where there was just such a diversity of people in the group, that it was very…and there’s a treatment now, right? So, when you get treated, you’re done, you no longer have hepatitis C. So some of those groups that now have end points, are harder to sustain. Treating loneliness, making someone feel special requires an ongoing relationship. And so, if you’re doing something that’s going to be short-term, you’re not going to be able to support that relationship. So, in hepatitis C clinic, we had some people had gotten it from blood transfusions, other people who are addicted to drugs. We had just a large variety of people, they weren’t able to connect with each other. But it was hard to group those people differently because they all needed the same treatments, if you follow, which is different than an exercise group.
Jeffrey Geller: I have asthma, I don’t know if you have asthma, but we can still be friends, right? So the illness doesn’t determine who you can be friendly with. But if you offer an exercise class instead, you might have someone who needs to exercise to lose weight. You might have someone who needs to exercise for their hypertension. You might need someone who does it because they’re anxious and they’re not sleeping at night. You might need to have someone in that group who just likes to do exercise but then wants to get their health care that way. So, really the groups that are harder to do are the ones where you have more of an agenda that you have to get it done as a clinician.
James Maskell: Got it. Yeah, that’s super interesting. What have you learned about congealing a group early on? Because I know when patients come into it for the first time, they’re not really sure what’s about to happen. Obviously, we have physicians and practitioners listening to this who have run groups and they’re typically congealing a group of people into a sort of a unit is not necessarily something that is trained in medical school. So what are some of the tips that you’ve learned from in the first visit, how do you get people to like each other and want to support each other and participate in the sort of group energy?
Jeffrey Geller: Well, certainly there are a variety of techniques, and I sometimes offer one- and two-day trainings just because it…the icebreakers that you might’ve used in college or in high school, what’s your favorite flavor of ice cream? Those things are very nice and nice to do, but they don’t really…if I knew…what is your favorite ice cream, James?
James Maskell: My favorite is coffee.
Jeffrey Geller: Oh really? I tend to like black raspberry. So does that make us friends?
James Maskell: Maybe ice cream buddies?
Jeffrey Geller: Yeah. I don’t know. So, I guess that’s the first hint is you have to do things that are meaningful. People need to find value and coming to a group. And so, on the first level, if you’re doing something for chronic pain and you have an acupuncture group, people will feel they’re getting acupuncture. If someone is coming for a functional medicine group and you’re actually cooking food, then they’ll be able to experience that. So on a basic level, you need to provide something that gives value to your group.
Jeffrey Geller: But then the meaning that people develop between each other needs a good amount of what I call “disinhibition.” And so, the very first visit is really more about why are you here, and what’s one thing that you would do if you weren’t suffering with whatever you’re suffering with? In a recent diabetes groups, someone said, “I’m here because I have diabetes and I’m suffering because I have to urinate so often. I can’t go to New York City to visit my family. I can’t sit on a bus that long.” And, those emotional type of responses really bond people together. You could probably almost picture someone saying, “Hey, I have an idea. Hey, have you tried this medicine? Have you tried eating differently?”
Jeffrey Geller: And so, I spend a lot of time, the first couple visits really, I’d call it disinhibiting, making people feel like they can say the real truth, creating a very safe space to communicate. My best groups don’t have an end. So a lot of people do group visits. They say we’re going to have six sessions or 10 sessions. And that’s great for an empowered group of people, people who are already well educated and people who aren’t there to treat loneliness. But if you’re really trying to treat loneliness, then you have to take your time and figure out what each group needs. And they have to know that you’re not going to abandon them after six weeks or 10 weeks or what have you.
Jeffrey Geller: And so, a lot of it is just giving people the impression that this is going to be a slow process. We’re not in a rush. We want to get to know who you are. And then providing activities that have some value. Those are the basic secrets. I also like to keep it fun, but of course you often talk about very serious topics, but, trying to keep things fun is also an important aspect. You’d want to go to something that’s fun, valuable and you feel that people listen to you. So that’s what you’re trying to create.
James Maskell: Yeah, absolutely. Yeah, I can certainly see that. You mentioned empowerment a minute ago. The difference seen empowered groups and the disempowered, so that as purely socioeconomic, determination or is there more to it than that?
Jeffrey Geller: Much more to it, but often there is a large socioeconomic part to it. So the empowerment that I use, I define as the ability to try new things. So the ability to try new things is different than the ability to make decisions, the ability to make all decisions. The ability to try new things, I believe, comes from support. So if you have people around you who support you, so if you say an idea and they say, “That sounds like a good idea,” that’s support. There might be parents who can help fund you, right? So maybe you have some financial support. Maybe you have educational support. Maybe you have people who are friends who are in different areas of if you need help with your taxes, they can help with that. If you need help with cooking, they can help with that. One part of empowerment is just having support, and it’s been shown that if you grow up and you have two parents and they own a home who’ve raised you have an easier attempted life and those who don’t have support, who have to do it alone.
Jeffrey Geller: The second part of empowerment comes from actually trying new things and having it be a success. And so, often I find that people reach a steady state in their lives, so they might have diabetes. I guess that’s the example I’m using today. Is that okay, James? Just we’ll use diabetes.
James Maskell: Yeah. No, I mean, it’s the biggest issue in our country and pretty much all the way around the world. My father lives in South Africa. It’s the number-one diagnosis there now. So probably the best one that we could use.
Jeffrey Geller: Yeah. And so, you reach a point where you go, okay, well if I eat breakfast like this and I take my insulin then and if I eat dinner like this and I do that, my blood sugars are okay, my hemoglobin A1C is okay. And people kind of live in that very restricted pattern where if I said, “Hey, can you try eating an avocado?” Geez, I don’t know if I can. And so, just trying new things and having it succeed makes you willing to try more new things. And so, those are the two principles and an empowerment group. And we call those open groups. So the actual terminology is open and enclosed or closed.
Jeffrey Geller: So a closed group is more of a six week session and an open group is geez, it’s open, we don’t know who’s going to come and what that group is going to need to get better, what sort of services they think they need. And so, there’s a very big difference between what I call an empowerment group where you’re helping them build relationships and you’re helping them to explore trying new things, versus an enclosed group where you’re really educating people as to what the best practices are. Both have their place, both are good types of groups to do. But the ones I liked better on those empowerment ones.
James Maskell: Yeah. So, you’re kind of starting from a different level with those groups. I mean, to solve the problems that we have in front of us with chronic illness and with access and affordability to empowerment based medicine, which of these groups do you feel like are sort of the starting points for maybe clinicians or physicians listening or medical groups listening and organizations that are listening that think, “I’d like to get involved with this. We see loneliness.” Where would you recommend that people start?
Jeffrey Geller: Well, I’d say unfortunately or fortunately, money is part of this and these group visits can be a very lucrative way to provide services to people. Certainly, there’s a centering pregnancy, team and model, and that’s a very easy-to-implement way to get started if you’ve never done groups and you take care of obstetric patients. I find that patients who are in chronic pain or have addiction issues or the second, I don’t know if I want to use the word easy, but most accessible patients because they aren’t necessarily working, they might feel very segregated from society and really benefit from the support that they can get in a group.
Jeffrey Geller: And then you can offer them things. So the groups we offer have acupuncture or massage or osteopathic manipulation, that people get while they’re at the group, but that may not be accessible to your clients. I think these open groups where you just take six patients that you know in your practice who are struggling, that are lonely, and mix them with six other patients in your practice who aren’t lonely and are doing well and want to help the world. And you turn to those six patients who are doing well and say, “Hey, I’m starting something crazy. It’s called a group and it’s gonna allow me to spend more time with you. It’s going to allow you to really explore more parts of what you can do to be healthier and you’re doing so well. I want you to help some other people who are in my practice.”
Jeffrey Geller: And then you take six other people in your practice who aren’t doing well and you say, “I want to introduce you to some people who are in the same situation you were in, but seem to have figured out some tricks and how to be better.” And you bring those people together, whatever the illnesses, diabetes, what have you, and just bring them to the group, and start, just as I suggested, who are you, why are you here, what’s one thing you think you can do to be better? And start a conversation going. You don’t have to have the activity. You could say, “What would you like to do next week? What would you like to do next month?” And if they say, “We talked about cooking today and we only own microwaves, can you teach us how to cook vegetables in the microwave?” You say, “You bet.” And then you see them the next week and you kind of follow their curriculum.
James Maskell: Yeah. Super interesting you say that because, one person I’ve heard speak about her experience with groups a lot is, is Terry Walls and she mentioned a couple of things that you said that one is connecting people to purpose in the first visit. But the second thing is that she’s been able to reproduce results with reversing MS in the VA in Iowa, and it’s not like everyone has a Whole Foods on every corner and they’re able to cook in the best situation. These are, these are people that are just regular Iowans going about their business. And so, I think meeting people where they are and starting from there is a great starting point. The other thing she said was with mixing those groups, she said that obviously, people who have had success in the methods that you’re teaching regarding lifestyle medicine or otherwise are much more effective at inspiring the people who are just getting started. Have you found a sort of a magic formula for bringing groups of people together to create value from the peer-to-peer transmission?
Jeffrey Geller: Yeah, well it’s all in the facilitation of the group, and I’ve come a long way in my own learning and really, there’s just a whole lot of things that I don’t think a regular clinician would think about until you start doing groups. I spent a lot of time thinking about the introverts and extroverts in our group. And I don’t mean the Myers-Briggs technical definition of an introvert or an extrovert. I just mean, you sit in a group with people and you say, “This person is talking a lot and sharing and this person’s not talking a lot.”
Jeffrey Geller: And how I’ve come to learn really, some of the secrets are you really want your introverts who are very thoughtful, usually guiding where you go as a group, right? And you need your extroverts to provide that energy. So, there’s just a lot of…I’d say the secret is in the facilitation, how you get to hear the voices of everyone in the group, how you help groups make decisions, and then how you execute those decisions. But even more than a cure for MS or a cure for diabetes, I think actually anxiety, stress, loneliness, those are the biggest problems that I think are causing the underlying inflammation, the underlying, obesity, the underlying issues with societies.
Jeffrey Geller: And certainly poverty causes stress. Where I work, there’s really a whole lot of stressors and sometimes you just come down to we can’t afford the best and it’s actually harmful. If I were to turn to my patients and say, “You should go eat some pomegranates,” I feel like they can’t afford pomegranate, there aren’t any pomegranates in my community. Maybe they’re good antioxidants. But really, to have the support of others and, okay, well, maybe for us we need to eat less fried rice. Maybe the best thing we can do is just do less of the bad stuff. And, really the relationships between people, allowing them to grow, letting people see the good side of each other when you facilitate a group. Sometimes I’m the foil, they don’t need to be friends with me, they just need to connect with someone else that they feel close to. So the simple answer is: The secret is in the facilitation and creating a space that people feel comfortable and safe in.
James Maskell: Yeah, that’s powerful. And as you’ve taught this to other people, what are some of the, some of the sort of the key things that you found that if you can get across to someone who’s about to facilitate their first group, that it goes well?
Jeffrey Geller: Well, I haven’t named these things. But I also am an editor on some journals and I see most of the research that’s done on group visits and there’s actually a journal coming out soon from the Journal of Alternative and Complementary Medicine, all about group visits. And the thing that I notice is it’s much easier for a physician to get their hands around these enclosed groups, you know? And so, they start saying, “I’m going to have a six-week session and I’m going to teach people about diabetes. And it’s not going to be just teaching. It’s going to be fun, so these are amazing curriculums. We’re going to cook, we’ll do some foot exams together. We’re going to learn about breathing techniques, reduce stress.” So they bring in a lot of the complimentary and integrative things.
Jeffrey Geller: We’ll talk about eating the rainbow, right? So they’ll have these great curriculums. And that first group actually usually goes well. They start with 12 people. They usually end with eight. You have some people who just don’t come. And that’s just true of all groups. Then the second group, they say, “Okay, well I’ve learned something from it.” They do it again. And this time, they have 12 come and only six stay. And then by the third time, they realize that, maybe the patients they had who came to the first group that they’d identified that they were maybe more ready for groups than this third trial. So for some reason, a lot of clinicians do one group and they think, “Oh, this is easy.” And then the second one, not as much, and that’s because of the enclosed model.
Jeffrey Geller: We could talk more about that. And so, I would just advise people to be careful about that because underlying and enclosed model isn’t really the treatment for loneliness. James, I’m meeting you now. It’s a second time we’re talking, I don’t know much. I just heard about your father, and I’m learning a little bit about you. But I don’t know that I’m going to see, see you too many more times. So I don’t say, “Oh, tell me about your father. Oh, what’s that like being so far from home?” because, because we’re not building a relationship. I hope we’re building a relationship, James, but we’re not expecting to be good-
James Maskell: Yeah, I understand what you mean.
Jeffrey Geller: Yeah. But, in our groups, that’s what we want. But if you’re having just successions that doesn’t happen. People look at the other participants as, oh, they’re interesting, nice people, but they’re not going to be part of my life. And so, if you can have this concept that you can have an ongoing group that changes the dynamic right there, suddenly people go, “Oh, I had better get to know this person. I might be with them for a while. I’m going to have this diabetes probably the rest of my life. So maybe these are the people I’ll be going through that with.”
James Maskell: Yeah. Wow, that’s really, really interesting that you’d see that. So what are the secrets to channeling a group for long-term? What’s the longest that you’ve had a group in your whole practice? And what are the secrets to keeping them wanting to participate long-term?
Jeffrey Geller: Well, so, one of our first groups, I think came from the diabetes groups that we had initially that were studied. Then those groups that were associated with them where we were doing, la chata dancing and had a lot of fun. That group still continues today. And so, what are we at? 1997, 1998, so 21 years. And that group, initially we would sit and talk and then we decided to do dance and then we became a cooking group for a year or two. And then they decided that what they really needed in our community was a safe place to exercise. They’d heard all everything I knew about diabetes. Over the years, so this is over years, we talked about A1Cs, we talked about foot exams, we talked about diet, nutrition.
Jeffrey Geller: So they knew all that, but they still needed to get their medical care. They needed to get refills of medication. So they still kept coming to the group. And most of them had become healthy. Several of them no longer had diabetes by any measurable scale and so it became an exercise group. And, we said, “Well, what type of exercises do you want to do? Who do you want to teach the exercise?” and even went through that process of helping us hire the exercise instructors. And so, it really was their group. And so, for that group, now they come, we do a 10-, 15-minute check in which does more social, “Hey, is everyone having a good week? Has anyone lost anybody? Anything we need to talk about?” And unfortunately, where I am, there’s a lot of things to talk about.
Jeffrey Geller: And so, we spend 15 minutes and then facilitating. I might break them into small groups, big groups, maybe there’s a new person, I welcomed them. Then they just start doing exercise and while they’re doing exercise, those who need medical attention, I’m in a room right next door, and I see them, I bill them. And, so our health centers has been happy over the years in the past, because we were able to just see so many patients and the patients are happy because they’re getting not just information, not just medical care, but they’re getting something that can really address some of these barriers to health. There are these economic barriers to health. There’s nowhere to really exercise in my town. There aren’t a lot of such safe places. So that group created one.
James Maskell: Yeah, that’s really, really inspiring to see that. One of the things that we found from our Functional Forum groups that we set up over the last few years is that the groups that really maintained, took time to really understand what the group wanted to do rather than the desires of, like, me as the host of the show that it all started off with people would watch on the TV. The groups that really had long-term sustainability, there was at least someone in the group, typically the leader, who really just surveyed the group and said, “Hey, what do we want this to become? Here’s a group of our likeminded professionals all interested in functional, integrative medicine. What should we do together?” What I’ve seen is that those groups that typically decided to take on something together and it standing the test of time, can you see any parallels there with your work?
Jeffrey Geller: Yeah, absolutely. I mean, I think you’ve hit the nail on the head right there. One thing I haven’t mentioned yet in our conversation is this idea of projects. And so, we do have groups that are working on their own health, but then each group takes on a larger project, either to help the community or the world. And when you feel like you’re doing something that’s above yourself, when you’re volunteering and helping others, that’s really one of the secrets to being happier, you know? So in your group, it sounds like there’s a feeling that, if one of the members has a concern, they can bring it up and change the direction of where the group’s going. And I think that’s very empowering, right? It feels great to feel not alone and feel supported in your idea of what you think you need to learn about functional medicine.
Jeffrey Geller: We have a functional medicine group, too, that’s existed for seven years. And the very first time I met them, we actually just played beach volleyball. We hit the ball back and forth. It was because there was a kids group I think right before ours, so that beach ball was just right on the floor. And, what an eclectic group. A lot of people who just wanted to get better but not use medications really. And so, we would sit there and we would talk about food mainly. We’d talk about sleep. We would talk about at the antecedents, the things that happened in their lives, and we couldn’t tackle one for one hour all at once, so it was just little by little we were gaining those things.
Jeffrey Geller: And then eventually, we had a kids group that had been doing gardening, but that kid’s group wasn’t going to be allowed to water a garden, they needed some adults. And so, then that group kind of came and started watering the garden, took over some of the garden bed, and they expanded the gardens in our community. It’s really a nice thing to have a garden. And, people would come visit and they really took ownership of it, and we became a gardening group. People would get healthier. And I would treat them non-pharmacologically. And, we called it our functional medicine group. We ended up going on trips, they wanted to see the foliage in New England. I’m not fond of one-and-done thing.
Jeffrey Geller: So if a group wants to go on a trip, you don’t say, “Hey, I got a bus, let’s go on a trip.” You want to teach them life skills, right? So you say, “Well, how would we do that? Who has a car? How would we pay for it? What day of the week should we go? What if it’s raining that day?” And so, that would take months and months to plan, just a trip to the mountains to see the foliage. And I think the first year we tried to do it, but it took…we weren’t able to pull it together. So, so that’s why it’s good that we had another year come around and we could pull off a trip like that. When you do things together as a group, it deepens the relationships.
Jeffrey Geller: I have gone to the white mountains and seen the foliage with one of my groups. They like me more as a physician. They know about my life and my family. Groups are just really a great way to connect with people on a real human level. And, not everyone succeeds in their health. Certainly, people die. Health is a real struggle for some people and we don’t have control over everything, but at least you feel like there are people who understand you and want to support you and that you’re not alone when you’re in a group.
James Maskell: Absolutely. Yeah. I’m just sort of like thinking in the macro implications of all the things that we’re talking about because I can see, and I can sort of feel as we’re sitting here talking about this, a lot of people listening at home thinking like, “Oh, this is the work that I want to be involved in. This is the real work that is necessary for society, for the health outcomes, for transforming the health of communities.” I see things like the blue zone projects where there’s like a desire to create community and create healthy behaviors in a community. But I see that medical care is sort of like an access point where we can really find people who are struggling and help them and find these kinds of communities.
James Maskell: I’d love to just sort of pick your brain for a minute on the sort of practical implications or the practical parts of this as far as like, paying doctors’ salaries, how these groups are paid for, how the sort of backend organizations set up or has been set up, if you were starting again from scratch, how you would set it up. Because ultimately, there are physicians who are listening to this who might want to partner with their health coach or dieticians and do some of these groups, there are people probably listening who work at medical centers where maybe functional integrated medicine hasn’t been able to make it into those systems because it doesn’t make as much money as doing heart stents for instance. And they’re thinking, “Well, maybe this is a way to do it.”
James Maskell: So can you just share, like, what you’ve learned from the practical financial implications on this and then also, if you were starting from scratch now in a medical system or a doctor’s office, how do you feel is the most sustainable and effective way to get a program like this going in your community?
Jeffrey Geller: Yeah. Well, I have actually a lot to say about that. I don’t know if we’ll be able to see everything in the time timeframe. I actually am going to be starting my own practice and it is going to be an entire group medical visit practice. And as I mentioned, my productivity, meaning the number of patients I see per hour and in a group can be up to eight or 10 patients in an hour. It has such a high level of efficiency and at the same time it provides a higher level of service. And so, this is the type of model that isn’t for every patient, and isn’t for every provider, but the finance of it can work out very, very well for a team.
Jeffrey Geller: I think in functional medicine, one of the issues has been you can need an hour or even an hour and a half visit and in a community health center, like I had been working. That really wouldn’t be approved by our operations. You need to be able to see three or four patients an hour doing things. And so, the best thing to do is to actually establish yourself in a practice, wherever you are. You can’t just show up and do group visits because you really need relationships. And that means relationships with up and down, from the community all the way up to the CEO of your organization.
Jeffrey Geller: After you spend some time and show that you’re committed to being in that community, maybe as quick as six months, you can start noticing the patients that you’re taking care of that would be good in a group. And as I mentioned before, some will be people who are succeeding in, some would be people who are struggling. Then take that group of patients and have them meet once every two weeks. Right? And then take a second group and have them meet at once every two weeks. And so, then you’ve established one hour a week where you’re doing groups. Then you can put groups around those groups, thinking about what your community needs, really listening to what your patients need.
Jeffrey Geller: We’ve started a group for insomnia because a lot my patients were saying they were having trouble sleeping. We started smoking cessation groups. Because I wanted to provide hypnosis to patients. And so, we did group hypnosis. A lot of times, the finances right now are against this one patient, one-hour model and group visits really allow you to get outside of that. And so, there are some easier groups to start. We do suboxone groups for addiction and a 100% of those patients show up. Why? Well, because they want to get their prescription refilled. But I’m able to see a lot more people and they have community and we actually have a good time together. We’ve even written children’s books that have been published nationally. Prenatal groups, as I said, with CenteringPregnancy and Centering Healthcare have done, I think that, those are easy things to put into your organization, as well. The main selling point for people is, I’m going to do a group in a type of model that’s going to see a lot of people, and allow a lot more billable interactions.
James Maskell: And the insurance companies are OK with 26 or 52 billable visits in a year because you’re coming to a group every week?
Jeffrey Geller: Oh, no, no, absolutely not. I actually have very large groups and that’s one of the motivations, I guess, for a closed model. In a closed model, you know that you can just bill someone, six times and that won’t be a problem billing someone for diabetes six times. But in an open model, in our exercise groups, I don’t bill everyone who comes for exercise every day. We may have 40 or 60 people exercising all at once and we ask who needs to be seen, who needs refills, who wants to check their A1C, who’s having a medical illness that they want to check a doctor? And so, we’ll see five or six people in that hour.
Jeffrey Geller: We’ve looked at our patients and our data and we tend to see people bill them five or six times a year for groups. We don’t bill them every time they come. There are some groups, however, like a suboxone group where yes, actually if they need weekly prescriptions, you do bill them 52 times a year. And then prenatal groups, they bill based on the delivery. So their reimbursement is all in the end. That’s something you just have to look at your hours and your time and how many people you’re taking care of.
James Maskell: Beautiful. Well, this has been an incredible start to our series here on group visits. I’m super appreciative for anyone who’s sort of been on the very front edge of just trying things and learning. I think that it’s not a natural skill for physicians to just be implementing and trying new things and seeing what works. It’s sort of more of like an entrepreneurial sort of tinkerer kind of mindset. But I definitely think that it’s what’s necessary when you’re bringing something new into the world.
James Maskell: I agree with you that the one hour or an hour and a half long visits for the delivery of functional integrative medicine are not really going to be sustainable for everyone. As much as we think that, that would probably be the highest level of care, or the high standard care.
Jeffrey Geller: Yeah. I’m not saying it’s bad care. I think it’s great care. But yeah, from the finance end. We do have people who have succeeded…There’s an organization, IM4US, Integrative Medicine for the Underserved, and a really a lot of innovation and bringing integrative medicine to poor and underserved communities. They have an annual conference. Maybe you can put a link up for the people who are listening to the podcast at im4us.org. That’s where I think a lot of this innovative tinkering is happening right now in that organization.
James Maskell: Absolutely. Yeah. No, I’m familiar with the organization. We’ll put all those details in the show notes and for other physicians who are inspired by this presentation and want to get involved or in touch with you, what are some of the ways that they can interact with you to sort of mentor them in this process?
Jeffrey Geller: Well, I think they can reach out through Integrative Medicine for the Underserved. I am part of the annual conference there. I do a pre-conference on group trainings. Also, in September, I’m going to be offering some training as well. But my name and my contact is out there. Maybe we can put a link for people, as well if they want to contact me.
James Maskell: Beautiful. Yeah, we definitely will.
James Maskell: Well, thank you for being, on the front lines of this. I’m very excited about this podcast series that is going to run over the whole of 2019, really showcasing a clinician and physician practitioner leaders who have been running and executing these group models. I really feel like this is an exciting time for medicine as some of the most exciting projects in functional integrative medicine, starting to recognize the power of the group to facilitate behavior change and to make access and affordability at the cornerstones of a really sustainable future for these different, different movements.
James Maskell: So thank you so much for being with us and thanks everyone so much for listening. This is the first in an ongoing series. It might be a close group. It might be an open group of podcasts about the future of group visits, where they’ve been, where they’re going and how to implement them in your community.
James Maskell: We will be back very soon with more. But in the meantime, this is being myself, James Maskell and Dr. Jeffrey Geller. Make sure to tune in for the next series. Thanks so much for listening and we’ll see you next time.
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