Written by Raechel Damarell, PhD Candidate, College of Nursing and Health Sciences
Worldwide, epidemiological statistics indicate that the era of the single, acute disease is over. Conditions now come in multiples and are most likely to be chronic, progressive, and life-limiting. This is ‘multimorbidity’—often considered a disease entity in itself for the incommensurate effect it has on patient wellbeing. It is now the norm for GPs to see patients with multiple chronic conditions, many with no prospect of cure, and this proportion is likely to increase as populations age. Meanwhile research on multimorbidity lags far behind the problem. To date there is no universal definition of multimorbidity, nor an agreed way of measuring it, leaving researchers without a common language with which to tackle it. (1)
What we do know about multimorbidity with some certainty is that current clinical practice guidelines and clinical trials oriented to single conditions are now an insufficient base on which to direct care. Similarly, existing models of primary care centred on short, 10-minute transactions do not work for these complex patients. Neither do they work for general practitioners. Outside of Australia, GPs have described such working under intense time constraints—often without professional support from other parts of the health system—as professionally isolating, ‘exhausting’, ‘demoralising’ and ‘soul destroying’. (2) Lack of adequate resourcing and remuneration for the level of patient complexity involved has also been raised as a key reason for a current GP retention crisis in the United Kingdom. (3)
How Australian GPs are faring in our system is still unknown. However, there is a risk that they may be left unable to operate according to the very principles that define the profession if their challenges are not understood. The GP Forward View in the United Kingdom puts these principles well: ‘The GP is an expert medical generalist and must be properly valued as the provider of holistic, person-centred care for undifferentiated illness, across time within a continuous relationship’. (4)
We frequently ask what patients need in a health care system but what about GPs?
What do they need in order to deal with the increasingly complex health problems of their patients? My PhD program of research will ask Australian GPs this very question. Likewise, it will seek to understand their everyday experiences of managing multimorbidity and how they circumvent challenges such as inappropriate evidence or time limitations. I will also examine the state of the current Australian chronic disease guidelines to test the general perception that these resources remain focus on a single condition and give inadequate attention to co-occurring ones.
The biophysiological complexity and dynamism of multimorbidity make it unlikely that guiding research evidence will appear anytime soon. If it does, it will probably not take the forms we are presently used to. Yet it’s what is being done in the meantime, in the absence of evidence and knowledge, that interests me. What are GPs doing differently for these patients? Does a life-limiting illness simplify or complicate decision making even further? Personally, I suspect that GPs are continuing to strive to deliver on their patient-centred principles at a time when their specific skill set is needed more than ever.
References
1. Nicholson K, Makovski TT, Griffith LE, Raina P, Stranges S, van den Akker M. Multimorbidity and comorbidity revisited: refining the concepts for international health research. Journal of clinical epidemiology. 2019;105:142.
2. O’Brien R, Wyke S, Guthrie B, Watt G, Mercer S. An ‘endless struggle’: a qualitative study of general practitioners’ and practice nurses’ experiences of managing multimorbidity in socio-economically deprived areas of Scotland. Chronic illness. 2011 Mar;7(1):45-59.
3. Owen K, Hopkins T, Shortland T, Dale J. GP retention in the UK: a worsening crisis. Findings from a cross-sectional survey. BMJ Open. 2019;9(2):e026048.
4. NHS England. General Practice Forward View [Internet]. London: NHS England; 2016 [cited 2019 Nov 11]. Available from: https://www.england.nhs.uk/publication/general-practice-forward-view-gpfv/
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