Multimorbidity: we need to be training expert generalists

Alex Pavitt is an academic GP trainee working in a deep end practice in Sheffield.

Our healthcare system is under strain.

With intense and growing pressure for appointments, demand is at an all-time high for primary care consultations. The reasons for this are multifaceted and multifactorial, but have no doubt been exacerbated by the COVID-19 pandemic and prioritisation of acute care.¹

Regarding appointments, patients frequently come with multiple complaints.

To increase patient turnover and appointment availability, one strategy has been to accept and promote the ‘one problem per consultation’ dogma. While this can increase short-term efficiency, it can also widen healthcare inequality by adding barriers for patients with multimorbidity.

Multimorbidity (the co-existing of two or more chronic conditions), is associated with premature death, decline in function and quality of life, and increased healthcare usage.¹ The onset of multimorbidity is a decade earlier in socioeconomically deprived communities, and this growing cohort of patients has been directly disadvantaged during the COVID-19 pandemic — through the prioritisation of urgent and unscheduled acute care.¹ Providing a good quality of care for patients with multimorbidity demands a shift from treatment, protocols, and consultations focused on one disease at a time.

As primary care physicians we must become expert generalists to achieve the best balance of recommended treatment for each condition, tailored for each individual patient. By practicing ‘Minimally Disruptive Medicine’ we can use patient-centred consultations to minimise both the most burdensome symptoms and the burden of treatment for each patient.^2,3 The goal of this approach is to improve quality of life for the patient, which can often lead to improved patient capacity to manage their own symptoms, thus reducing healthcare usage.[/perfectpullquote]

Not all primary care physicians are confident in adopting the role of the expert generalist.⁴ While the numbers of clinical guidance documents and protocols for single diseases continue to increase, there remains just one single piece of guidance from NICE on multimorbidity.⁵

Furthermore, for training GPs like myself there is little emphasis given on its importance in the RCGP syllabus.⁶ Multimorbidity receives just a few lines under the topic heading ‘People with Long-term conditions including Cancer’ in a 290-page document. It is therefore unsurprising that there is a lack of confidence in adopting the role of the expert generalist. Given the huge disparity between the clinical tools availability, lack of training focus and confidence in fulfilling the expert generalist role, and the increasing prevalence of the problem, change is required.

To change clinical practice, we first need to improve awareness and training.

An obvious way to do this would be to provide multimorbidity with a bigger spotlight in the RCGP trainee curriculum.

As a doctor 5 months into my GP training, I feel that changing the topic headline to, ‘Long term conditions, cancer, and multimorbidity,’ would rightly give more emphasis to the increasing importance of understanding and managing multimorbidity. Other healthcare professionals are increasingly supporting GPs — for example, by conducting reviews of long-term conditions, minor illnesses, and medications. This re-distribution of clinical workload is an opportunity to shift the focus of our training to reflect the developing role of the GP as the expert generalist.

By embracing and developing our role as expert generalists, we can increase the intellectual stimulation of our work and also, crucially, improve the holistic care we provide. Changing priorities in the training syllabus would help to reflect the developing role of GPs and champion the important skills many experienced GPs possess. Our healthcare system is under strain — perhaps we also need a systematic shift from focusing on appointment quantity, to focusing on the number of issues GPs deal with each day. We need to consider appointment quality as we work towards embracing and combating the overall problem of ‘multimorbidity’.

References

1. Skou ST, Mair FS, Fortin M, et al. Multimorbidity. Nature Reviews Disease Primers 2022; https://doi.org/10.1038/s41572-022-00376-4.
2. May CR, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009; 339 (7719): 485–487.
3. Boehmer KR, Gallacher KI, Lippiett KA, et al. Minimally disruptive medicine: progress 10 years later. Mayo Clinic Proceedings 2022; 97(2): 210–220.
4. Reeve J, Dowrick CF, Freeman GK, et al. Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions. JRSM Short Reports 2013; 4(12):
5. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management. NICE guideline [NG56]. London: NICE,
   https://www.nice.org.uk/guidance/ng56 (accessed 14 Feb 2023).
6. Royal College of General Practitioners. The RCGP Curriculum.The Curriculum Topic Guides. 2022. https://www.rcgp.org.uk/getmedia/16f67392-7b34-4039-9251-d8181d415273/Curriculum-Topic-Guides_26-10-22.pdf (accessed 14 Feb 2023).

Featured photo by Laurynas Mereckas on Unsplash