Understanding GPs’ clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research

Abstract

Background Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow‐up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term. Methods A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed‐methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool. Results A total of 2 165 abstracts and 362 full‐text articles were assessed. Thirty‐two studies met the inclusion criteria. Results showcased that GPs’ clinical reasoning during the long‐term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients’ constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient. Conclusions Although the challenges GPs are facing in the long‐term follow‐up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs’ clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.

Understanding general practitioners’ prescribing choices to patients with chronic low back pain: a discrete choice experiment

“…Clinical decision-making is dynamic and multi-factorial [ 49 , 50 ]. Similar to our main finding, previous research in primary care suggests that patient factors may influence GPs’ decisions less than clinical competence or their knowledge of best practice medicine [ 24 , 50 , 58 – 61 ].…”

“…The evidence indicates the amount of pain relief provided by these two analgesic classes is similar [ 46 – 48 ]. The two patient attributes (LBP with or without referred leg pain (sciatica) and comorbidities) were selected based on discussions with clinical experts (GPs, pharmacists) and evidence from published literature [ 28 – 31 , 41 , 47 , 49 , 50 ] of what GPs believe to be important considerations associated with the management of chronic LBP. For instance, the management of patients with multi-morbidities is complex as it is often associated with polypharmacy and increased risks of harms [ 49 , 50 ].…”

“…The two patient attributes (LBP with or without referred leg pain (sciatica) and comorbidities) were selected based on discussions with clinical experts (GPs, pharmacists) and evidence from published literature [ 28 – 31 , 41 , 47 , 49 , 50 ] of what GPs believe to be important considerations associated with the management of chronic LBP. For instance, the management of patients with multi-morbidities is complex as it is often associated with polypharmacy and increased risks of harms [ 49 , 50 ]. Additionally, GPs may be hesitant to prescribe NSAIDs to patients with gastrointestinal comorbidities [ 41 , 47 ] and avoid prescribing opioids in instances where patients present with comorbidities, such as depression [ 28 , 31 ].…”

Multimorbidity and clinical reasoning through the eyes of GPs: a qualitative study

“…Nevertheless, even if endorsed, this interprofessional collaboration and shared clinical reasoning face many potential barriers. 26 GPs perceive themselves as being in a fortunate position to take on the role of coordinators of care, 26 57 but, despite or because of this perspective, seeking advice from a specialist or a pharmacist may be rarely considered, as GPs want, at first, to optimise the patient's condition. 57 In addition, GPs sometimes consider that specialists tend to be diseased focused and might not adopt a more patient-centred approach.…”

Protocol for a cluster randomised trial of a goal-oriented care approach for multimorbidity patients supported by a digital platform

“…Clinical guidelines help to translate the evidence of clinical trials and other forms of research into clinical practice, policy and healthcare organisation. However, the traditional care approach for people with multimorbidity has been supported by multiple single-organ management guidelines, which is burdensome and potentially harmful 9–13. New, patient-centred approaches have been proposed, emphasising the need to prioritise patient preferences and agreed shared treatment goals 14 15.…”