By Dr. Leila Haghighat, Vitals contributor
Midday, fifteen patients with osteoporosis trickle into a virtual meeting, each with the results of a recent bone density scan close at hand.
“Alright, is everyone ready?” asks Dr. Amy Culver, a family medicine physician leading the group. “Keep out the three numbers that you were sent through My Health Online. We’re going to need them because we’re about to start.”
So begins an Osteoporosis Shared Medical Appointment, or SMA.
Over the next ninety minutes, Dr. Culver walks the group through what osteoporosis is, why bones weaken, and what patients can do about it. Simple illustrations and concise bullet points make the science of bone health accessible. Patients raise virtual hands with questions or type them into the chat. Toward the end, Dr. Culver returns to those three numbers, helping patients make sense of their own bone density results.
The session offers something that can be difficult to provide during a traditional office visit: time.
SMAs supplement individual care by bringing patients with a common condition together for in-depth education and discussion. Clinicians at the Palo Alto Foundation Medical Group (PAFMG) offer SMAs for health concerns ranging from menopause and chronic pain to weight management and newborn health. Dr. Culver’s osteoporosis program, based in Santa Cruz, is among the longest running.
More Time to Talk About Bones
Dr. Culver started the Osteoporosis SMA in 2018 after recognizing a recurring problem. She and her husband, a rheumatologist, struggled to convey the importance of bone health in the limited time available during traditional medical appointments. Dr. Culver also found herself repeating the same information from patient to patient.
“People fracture while they’re trying to figure out how to understand their bones, and we want them to understand it sooner,” she said. “If you lose time, you lose bone.”
Inspired by an SMA developed by a colleague, Dr. Culver curated her own educational slides, assembled a support team, and encouraged colleagues to refer her patients with osteoporosis. Today, she runs four to five sessions each month alongside advanced practice clinicians she has trained, serving patients from Scotts Valley to Watsonville. Dr. Culver estimates more than 7,000 patients have participated since the program began.
Making Sense of Three Numbers
Back in the virtual room, the three numbers Dr. Culver asked patients to have ready start to make sense. The T-score reflects bone density, while the two FRAX scores estimate the 10-year risks of a major osteoporotic fracture and hip fracture.
Dr. Culver walks patients through their results and explains how clinicians interpret these numbers. Patients can then bring that knowledge into subsequent conversations about treatment.
“It really puts the power of decision-making into the patients’ hands,” Dr. Culver said. She finds that patients often arrive at follow-up visits better prepared to ask questions and participate in decisions about their care.
The group setting also helps patients see that they are far from alone. Globally, 1 in 3 women and 1 in 5 men older than 50 years of age experience a fracture from osteoporosis during their lifetime.
Questions start coming in the chat.
“If someone doesn’t have a gallbladder and is prone to kidney stones, what amount of calcium should be used?” one patient types.
“Please repeat how often a bone density test is recommended,” another asks.
Some questions are straightforward. Others reflect how individualized osteoporosis care can be. Dr. Culver says every session brings something new.
Sorting Through Osteoporosis Myths
The questions give Dr. Culver an opportunity to address misconceptions that can make patients hesitant about treatment.
Some arrive worried about osteoporosis medications and their potential side effects. Others wonder whether calcium and vitamin D supplements alone can substitute for prescription therapy.
Dr. Culver explains the role of nutrition and supplements in supporting bone health, while helping patients understand when medication may be recommended to reduce fracture risk. She also discusses how osteoporosis medications are used and monitored over time and why treatment decisions depend on an individual’s health history and fracture risk.
The goal isn’t to make every treatment decision during the group session. It’s to give patients enough understanding to have a more productive conversation when they do.
From Group Learning to Individual Care
Afterward, patients can attend a second, more in-depth session and are referred for an individual visit with their doctor, or one of the advanced practice clinicians she has trained. There, they can discuss medications, laboratory testing, specialist referrals, and next steps specific to them.
The combination is deliberate: learn together, then make decisions individually.
“Patient satisfaction is through the roof,” Dr. Culver said.
Dr. Culver won a PAFMG Innovation Challenge award to spread her Osteoporosis SMA in 2018, which successfully spawned five more osteoporosis SMAs across PAFMG. This work led to her role as an Associate Medical Director of SMAs, through which she mentors other clinicians interested in developing their own SMA . She is seeking additional philanthropy and grant support to study outcomes of her program to prove the clinical benefit of engaging with patients in this way.
For Dr. Culver, the goal is to build on what started with a handful of slides and a simple idea of giving patients the time and space to better understand their health.
“It’s been really successful,” Dr. Culver said. “And I want to spread the word because there’s all these negative things happening in medicine nowadays, and this is definitely a positive.”
