https://orcid.org/0000-0002-6737-7537
Abstract
Multimorbidity is prevalent in general practice and general practitioners internationally report challenges in its management. Understanding the perspectives of general practitioners at the frontline of care is important for system sustainability and accessibility as populations age.
To explore Australian general practitioner perspectives on managing multimorbidity, the factors supporting their work, and those impeding their ability to meet their own standards of care provision.
A qualitative study conducted with Australian general practitioners using semistructured, in-depth interviews and inductive thematic data analysis.
Twelve interviews with general practitioners were conducted. Three main themes were constructed from the data: Multimorbidity as an encounter with complexity and contingency; Evidence constraints in multimorbidity care; and Concerns for patient safety. System structure and the Australian general practice model restrict general practitioners’ ability to provide care to their level of satisfaction by linking short consultation times to practice remuneration. Attitudes toward the applicability of guideline evidence were mixed despite most general practitioners questioning its generalizability. Patient safety concerns pervaded most interviews and largely centered on system fragmentation and insufficient intersectoral communication. General practitioners rely on multiple sources of information to provide patient-centered care but chiefly the accumulated knowledge of their patients.
Australian general practitioners share many multimorbidity concerns with international colleagues. While multimorbidity-specific evidence may be unrealistic to expect in the immediate term, system investment and adaptation is needed to support general practice sustainability and clinician ability to provide adequate multimorbidity care, suitably remunerated, into the future.
General practitioners (GPs) are at the forefront of multimorbidity care.
This care is challenged by insufficient evidence and lack of consultation time.
The Australian small business model rewards GPs for short consultations.
Here, poor communication between primary–secondary care adds to GP workload.
GPs draw on various sources of information to counter complex multimorbidity.
Patient knowledge gained via relational continuity aids safe decision making.
Introduction
General practitioners (GPs) commonly provide ongoing care to people with 2 or more chronic conditions1 or ‘multimorbidity’.2 Multimorbidity can impose a heavy illness burden,3 reducing quality of life.4 People might also feel burdened by the amount of treatment they receive5 when each condition is managed by a different health professional working from a single-condition guideline.6 Without efficient communication mechanisms between providers, patients can be at risk of adverse drug interactions.7
To counter fragmentation, GPs often take responsibility for coordinating the total healthcare needs of patients with multimorbidity. However, there is growing evidence from GPs that this poses multifarious challenges8 based on individual biopsychosocial complexity,9 clinic and system pressures,10 and a lack of generalizable evidence supporting clinical decisions.11 Some report feeling “burnt out” from trying to accommodate this new epidemiological reality within systems not designed for multimorbidity care.12
A 2020 systematic review of general practitioners’ first-hand accounts of managing multimorbidity found that these issues were ubiquitous across 14 international countries, despite the influence of specific national or regional policy levers.13 These levers might be a pay-for-performance scheme such as England’s Quality and Outcomes Framework that links remuneration to clinician performance in meeting certain clinical indicators. They might involve nationally mandated guideline adherence (Norway), or compulsory referral of patients to single disease management programs (Denmark). Despite local variations, GPs report common difficulties. These include an insufficient evidence base for managing multimorbidity, balancing the harms and benefits of medications prescribed by multiple providers, and challenges in dealing adequately with complex physical–psychological multimorbidity within short clinical interactions.13
GP experiences of multimorbidity in Australia warrant attention. In a country where most people (90%) visit a GP each year,14 52% of GP consultations involve a person with multimorbidity,15 and 27% with ‘complex’ multimorbidity involving 3 or more body systems.16 Australia’s unique geographic and sociohistorical context has created pronounced economic and health inequities with Australian Aboriginal and Torres Strait Islander Peoples17 and those living in rural and remote areas often experiencing poorer health outcomes with less access to services.18 Only 3 Australian studies were included in the aforementioned systematic review.13 These studies explored Australian GP experiences on issues related to multimorbidity, specifically polypharmacy,19 deprescribing,20 and comorbid depression.21 They revealed that Australian GPs might avoid responsibility for their patients with multimorbidity when faced with a lack of professional role delineation and difficulties coordinating care with other health professionals.19 They might also defer making a therapeutic decision deemed complex and risky in the absence of a trigger event.20 Where depression was concerned, some GPs viewed multimorbidity as a positive for its diagnosis and management. Multimorbidity brought patients into frequent contact, buying GPs more time, and enabling the growth of a mutually beneficial therapeutic relationship based on trust.21 While these Australian studies are informative, it is difficult to draw general conclusions about the Australian GP experience from them. This study is therefore the first to explore Australian GP perspectives on multimorbidity management more broadly, allowing participants to raise the issues of most interest or concern to themselves.
Method
This study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ).22 A qualitative methodology allowed a flexible, inductive approach to examining a “small number of naturally occurring cases in detail.”23 Within this methodology, semistructured interviews provide the means to collect open-ended data in the form of unique participant perspectives on the area under investigation. Focus interviews were not considered for this purpose, due to the difficulties associated with getting general practitioners together in one place and at one time.24 Investigators varied in qualitative research experience and research experience more generally, ranging from PhD candidate (R.D.) to professor (J.T.). They also bought different background disciplines to the study, representing general practice, palliative care, and occupational therapy.
Context
The study was confined to the Australian general practice setting. The unique characteristics of this setting are described in Table 1.
Characteristics of Australian general practice
| • General practice is funded by the Australian Commonwealth Government by a predominantly “fee-for-service” model. Patients pay a GP practice for specific activities and receive a rebate from Medicare, Australia’s universally available healthcare insurance scheme, in line with the Medicare Benefits Schedule (MBS).25 |
| • GPs can choose to accept the patient rebate as their entire fee for a service (‘bulk billing’), making the service free at the point of care for the patient. In 2019–1020, 87.5% of all general practice services were bulk billed.14 |
| • GPs are mostly paid as a percentage of the billings they generate. |
| • GPs act as gatekeepers to specialist care and Medicare rebates for the patient are dependent on being referred by a GP. |
| • Most GPs work in major metropolitan centers with fewer choosing to work in rural and remote parts of the country.26 |
| • An Aboriginal Community Controlled Health Service (ACCHO) is a primary health care service initiated and operated by the local Aboriginal community. ACCHOs were set up to provide health services to Aboriginal Peoples not well served by mainstream services. They bulk bill all their services and offer a broader range of primary care through additional funding streams. Their GPs are usually salaried. Aboriginal Medical Services also provide medical services to Aboriginal communities but are usually run by state governments.27 |
| • The Government strategy for managing chronic conditions is set out in its National Strategic Framework for Chronic Conditions.28 |
| • GPs have access to 2 specific rebates for chronic disease management: the GP Management Plan (a written and agreed upon plan of action) and the Team Care Arrangement which funds the GP to initiate and coordinate a multidisciplinary team of 2 additional providers for the care of an individual patient.29 |
| • There are no external requirements or financial incentives in Australia for reaching particular targets in the management of chronic diseases. Recent changes provide some financial incentives for practices reporting a small set of measures to the Commonwealth Government. These cover the provision of after-hours care arrangements, adoption of new health technology, and consulting in residential aged care facilities. Aboriginal Community Controlled Health Services can receive incentive payments for providing comprehensive care and follow-up to their patients. |
| • General practice is funded by the Australian Commonwealth Government by a predominantly “fee-for-service” model. Patients pay a GP practice for specific activities and receive a rebate from Medicare, Australia’s universally available healthcare insurance scheme, in line with the Medicare Benefits Schedule (MBS).25 |
| • GPs can choose to accept the patient rebate as their entire fee for a service (‘bulk billing’), making the service free at the point of care for the patient. In 2019–1020, 87.5% of all general practice services were bulk billed.14 |
| • GPs are mostly paid as a percentage of the billings they generate. |
| • GPs act as gatekeepers to specialist care and Medicare rebates for the patient are dependent on being referred by a GP. |
| • Most GPs work in major metropolitan centers with fewer choosing to work in rural and remote parts of the country.26 |
| • An Aboriginal Community Controlled Health Service (ACCHO) is a primary health care service initiated and operated by the local Aboriginal community. ACCHOs were set up to provide health services to Aboriginal Peoples not well served by mainstream services. They bulk bill all their services and offer a broader range of primary care through additional funding streams. Their GPs are usually salaried. Aboriginal Medical Services also provide medical services to Aboriginal communities but are usually run by state governments.27 |
| • The Government strategy for managing chronic conditions is set out in its National Strategic Framework for Chronic Conditions.28 |
| • GPs have access to 2 specific rebates for chronic disease management: the GP Management Plan (a written and agreed upon plan of action) and the Team Care Arrangement which funds the GP to initiate and coordinate a multidisciplinary team of 2 additional providers for the care of an individual patient.29 |
| • There are no external requirements or financial incentives in Australia for reaching particular targets in the management of chronic diseases. Recent changes provide some financial incentives for practices reporting a small set of measures to the Commonwealth Government. These cover the provision of after-hours care arrangements, adoption of new health technology, and consulting in residential aged care facilities. Aboriginal Community Controlled Health Services can receive incentive payments for providing comprehensive care and follow-up to their patients. |
Characteristics of Australian general practice
| • General practice is funded by the Australian Commonwealth Government by a predominantly “fee-for-service” model. Patients pay a GP practice for specific activities and receive a rebate from Medicare, Australia’s universally available healthcare insurance scheme, in line with the Medicare Benefits Schedule (MBS).25 |
| • GPs can choose to accept the patient rebate as their entire fee for a service (‘bulk billing’), making the service free at the point of care for the patient. In 2019–1020, 87.5% of all general practice services were bulk billed.14 |
| • GPs are mostly paid as a percentage of the billings they generate. |
| • GPs act as gatekeepers to specialist care and Medicare rebates for the patient are dependent on being referred by a GP. |
| • Most GPs work in major metropolitan centers with fewer choosing to work in rural and remote parts of the country.26 |
| • An Aboriginal Community Controlled Health Service (ACCHO) is a primary health care service initiated and operated by the local Aboriginal community. ACCHOs were set up to provide health services to Aboriginal Peoples not well served by mainstream services. They bulk bill all their services and offer a broader range of primary care through additional funding streams. Their GPs are usually salaried. Aboriginal Medical Services also provide medical services to Aboriginal communities but are usually run by state governments.27 |
| • The Government strategy for managing chronic conditions is set out in its National Strategic Framework for Chronic Conditions.28 |
| • GPs have access to 2 specific rebates for chronic disease management: the GP Management Plan (a written and agreed upon plan of action) and the Team Care Arrangement which funds the GP to initiate and coordinate a multidisciplinary team of 2 additional providers for the care of an individual patient.29 |
| • There are no external requirements or financial incentives in Australia for reaching particular targets in the management of chronic diseases. Recent changes provide some financial incentives for practices reporting a small set of measures to the Commonwealth Government. These cover the provision of after-hours care arrangements, adoption of new health technology, and consulting in residential aged care facilities. Aboriginal Community Controlled Health Services can receive incentive payments for providing comprehensive care and follow-up to their patients. |
| • General practice is funded by the Australian Commonwealth Government by a predominantly “fee-for-service” model. Patients pay a GP practice for specific activities and receive a rebate from Medicare, Australia’s universally available healthcare insurance scheme, in line with the Medicare Benefits Schedule (MBS).25 |
| • GPs can choose to accept the patient rebate as their entire fee for a service (‘bulk billing’), making the service free at the point of care for the patient. In 2019–1020, 87.5% of all general practice services were bulk billed.14 |
| • GPs are mostly paid as a percentage of the billings they generate. |
| • GPs act as gatekeepers to specialist care and Medicare rebates for the patient are dependent on being referred by a GP. |
| • Most GPs work in major metropolitan centers with fewer choosing to work in rural and remote parts of the country.26 |
| • An Aboriginal Community Controlled Health Service (ACCHO) is a primary health care service initiated and operated by the local Aboriginal community. ACCHOs were set up to provide health services to Aboriginal Peoples not well served by mainstream services. They bulk bill all their services and offer a broader range of primary care through additional funding streams. Their GPs are usually salaried. Aboriginal Medical Services also provide medical services to Aboriginal communities but are usually run by state governments.27 |
| • The Government strategy for managing chronic conditions is set out in its National Strategic Framework for Chronic Conditions.28 |
| • GPs have access to 2 specific rebates for chronic disease management: the GP Management Plan (a written and agreed upon plan of action) and the Team Care Arrangement which funds the GP to initiate and coordinate a multidisciplinary team of 2 additional providers for the care of an individual patient.29 |
| • There are no external requirements or financial incentives in Australia for reaching particular targets in the management of chronic diseases. Recent changes provide some financial incentives for practices reporting a small set of measures to the Commonwealth Government. These cover the provision of after-hours care arrangements, adoption of new health technology, and consulting in residential aged care facilities. Aboriginal Community Controlled Health Services can receive incentive payments for providing comprehensive care and follow-up to their patients. |
Sampling and recruitment
The study used maximum variation purposive and snowball sampling to recruit GPs from across Australia. The study was advertised February 2020 via Primary Health Network newsletters, Twitter, and a mailout to 25 GP practices selected at random using HealthEngine, an online appointment booking platform. Mailed invitations were addressed to a single GP identified within the practice, with the request to forward the invitation to colleagues, especially if unable or unwilling to participate. GPs indicated their interest in participating by emailing or phoning the Chief Investigator to schedule an interview time.
Data collection
Semistructured interviews were conducted March–July 2020 using an interview schedule based on findings of a systematic review (Supplementary Table S1).13 Four people piloted the interview schedule: a GP, 2 primary care researchers, and a PhD candidate with experience in interview design. Some wording was changed for clarity and additional follow-up questions were added based on their feedback. One author (R.D.) conducted all interviews, by phone or Zoom, with training and guidance from her more experienced PhD supervisor (D.M.). These were digitally recorded and transcribed verbatim. Interviewees were compensated for their time and invited to check their interview transcripts.
Data analysis
Data were analyzed inductively and organized thematically.30 This involved a close reading of each transcript within NVivo 12 software version 7 (QSR International), creating codes for each new concept, or assigning data to existing codes. Codes were subsequently collapsed into others, renamed, or iteratively placed in a hierarchical relationship to construct themes. Themes were reviewed and refined by 2 other researchers (D.M., J.T.). Final themes were then critically reviewed by a fourth author (T.S.).
Results
Twelve GPs responded to the invitation (newsletter: n = 4; mailout: n = 4; snowballing: n = 4) and were interviewed while located at a place of their own choice. Interviews last a mean duration of 55 min (range: 27–90 min). Three were salaried employees of an Aboriginal Medical Service and 6 had academic status with a university. GPs had a mean of 26.7 years of experience. Most were female, working part-time, and/or employed in a clinic with an average of 9.8 GPs. The interviewer had met 2 interviewees prior. Tables 2 and 3 summarize these general characteristics.
Individual GP interviewee characteristics
| Code | Gender | Years since primary medical qualification | Work fraction | Number of GPs in practice | aGeographic designation31 | bIRSD score32 | Additional GP-related roles | GP estimated proportion of patients with multimorbidityc |
|---|---|---|---|---|---|---|---|---|
| GP1 | F | 10 | PT | 17 | Metro | 4 | NAd | 40% |
| GP2 | F | 8 | PT | 9 | Remote AMS | 2 | NA | Two-thirds |
| GP3 | F | 9 | PT | 4 | Metro AMS | 2 | Academic | 80% |
| GP4 | M | 20 | FT | 2 | Remote AMS | 2 | NA | 15%–60% |
| GP5 | M | 40 | FT | 10 | Regional | 1 | NA | “They’re probably more the norm than not” |
| GP6 | M | 30 | FT | 16 | Metro | 1 | Aged care | 50%–60% |
| GP7 | M | 34 | PT | 4 | Metro | 3 | Academic | 80% plus |
| GP8 | F | 36 | PT | 16 | Metro | 5 | Academic | 60%–65% |
| GP9 | F | 34 | PT | 10 | Metro | 3 | Academic, Aged care | 95% |
| GP10 | F | 52 | PT | 8 | Metro | 4 | Academic | ”Sometimes I’d likea cough and a cold to walk through the door” |
| GP11 | F | 32 | PT | 18 | Metro | 5 | NA | 75% |
| GP12 | F | 15 | PT | 3 | Metro | 3 | Academic | 20% (works with younger patients) |
| Code | Gender | Years since primary medical qualification | Work fraction | Number of GPs in practice | aGeographic designation31 | bIRSD score32 | Additional GP-related roles | GP estimated proportion of patients with multimorbidityc |
|---|---|---|---|---|---|---|---|---|
| GP1 | F | 10 | PT | 17 | Metro | 4 | NAd | 40% |
| GP2 | F | 8 | PT | 9 | Remote AMS | 2 | NA | Two-thirds |
| GP3 | F | 9 | PT | 4 | Metro AMS | 2 | Academic | 80% |
| GP4 | M | 20 | FT | 2 | Remote AMS | 2 | NA | 15%–60% |
| GP5 | M | 40 | FT | 10 | Regional | 1 | NA | “They’re probably more the norm than not” |
| GP6 | M | 30 | FT | 16 | Metro | 1 | Aged care | 50%–60% |
| GP7 | M | 34 | PT | 4 | Metro | 3 | Academic | 80% plus |
| GP8 | F | 36 | PT | 16 | Metro | 5 | Academic | 60%–65% |
| GP9 | F | 34 | PT | 10 | Metro | 3 | Academic, Aged care | 95% |
| GP10 | F | 52 | PT | 8 | Metro | 4 | Academic | ”Sometimes I’d likea cough and a cold to walk through the door” |
| GP11 | F | 32 | PT | 18 | Metro | 5 | NA | 75% |
| GP12 | F | 15 | PT | 3 | Metro | 3 | Academic | 20% (works with younger patients) |
NA, not applicable.
aBased on data cube for Correspondence, 2017 Postcode to 2016 Remoteness Area.
bIRSD: Index of Relative Socio-Economic Disadvantage. Postcodes of clinics were converted to a quintile (1–5) score based on the 2016 Census summary of an area’s disadvantage relative to other areas. (1 = most disadvantaged, 5 = least disadvantaged).
cBased on the World Health Organization definition provided: “the presence of two or more long-term chronic conditions in the one person.”2
Individual GP interviewee characteristics
| Code | Gender | Years since primary medical qualification | Work fraction | Number of GPs in practice | aGeographic designation31 | bIRSD score32 | Additional GP-related roles | GP estimated proportion of patients with multimorbidityc |
|---|---|---|---|---|---|---|---|---|
| GP1 | F | 10 | PT | 17 | Metro | 4 | NAd | 40% |
| GP2 | F | 8 | PT | 9 | Remote AMS | 2 | NA | Two-thirds |
| GP3 | F | 9 | PT | 4 | Metro AMS | 2 | Academic | 80% |
| GP4 | M | 20 | FT | 2 | Remote AMS | 2 | NA | 15%–60% |
| GP5 | M | 40 | FT | 10 | Regional | 1 | NA | “They’re probably more the norm than not” |
| GP6 | M | 30 | FT | 16 | Metro | 1 | Aged care | 50%–60% |
| GP7 | M | 34 | PT | 4 | Metro | 3 | Academic | 80% plus |
| GP8 | F | 36 | PT | 16 | Metro | 5 | Academic | 60%–65% |
| GP9 | F | 34 | PT | 10 | Metro | 3 | Academic, Aged care | 95% |
| GP10 | F | 52 | PT | 8 | Metro | 4 | Academic | ”Sometimes I’d likea cough and a cold to walk through the door” |
| GP11 | F | 32 | PT | 18 | Metro | 5 | NA | 75% |
| GP12 | F | 15 | PT | 3 | Metro | 3 | Academic | 20% (works with younger patients) |
| Code | Gender | Years since primary medical qualification | Work fraction | Number of GPs in practice | aGeographic designation31 | bIRSD score32 | Additional GP-related roles | GP estimated proportion of patients with multimorbidityc |
|---|---|---|---|---|---|---|---|---|
| GP1 | F | 10 | PT | 17 | Metro | 4 | NAd | 40% |
| GP2 | F | 8 | PT | 9 | Remote AMS | 2 | NA | Two-thirds |
| GP3 | F | 9 | PT | 4 | Metro AMS | 2 | Academic | 80% |
| GP4 | M | 20 | FT | 2 | Remote AMS | 2 | NA | 15%–60% |
| GP5 | M | 40 | FT | 10 | Regional | 1 | NA | “They’re probably more the norm than not” |
| GP6 | M | 30 | FT | 16 | Metro | 1 | Aged care | 50%–60% |
| GP7 | M | 34 | PT | 4 | Metro | 3 | Academic | 80% plus |
| GP8 | F | 36 | PT | 16 | Metro | 5 | Academic | 60%–65% |
| GP9 | F | 34 | PT | 10 | Metro | 3 | Academic, Aged care | 95% |
| GP10 | F | 52 | PT | 8 | Metro | 4 | Academic | ”Sometimes I’d likea cough and a cold to walk through the door” |
| GP11 | F | 32 | PT | 18 | Metro | 5 | NA | 75% |
| GP12 | F | 15 | PT | 3 | Metro | 3 | Academic | 20% (works with younger patients) |
NA, not applicable.
aBased on data cube for Correspondence, 2017 Postcode to 2016 Remoteness Area.
bIRSD: Index of Relative Socio-Economic Disadvantage. Postcodes of clinics were converted to a quintile (1–5) score based on the 2016 Census summary of an area’s disadvantage relative to other areas. (1 = most disadvantaged, 5 = least disadvantaged).
cBased on the World Health Organization definition provided: “the presence of two or more long-term chronic conditions in the one person.”2
Summary of sample characteristics (n = 12)
| Attribute | Participants, n |
|---|---|
| Gender | |
| Female | 8 |
| Male | 4 |
| Number of full years since first medical qualification | |
| 5–15 | 4 |
| 16–30 | 2 |
| 31–45 | 5 |
| 46+ | 1 |
| Work fraction | |
| Part-time | 9 |
| Full time | 3 |
| Number of GPs in practice | |
| 1–4 | 4 |
| 5–9 | 2 |
| 10–14 | 2 |
| 15+ | 4 |
| Clinic location | |
| Metropolitan area | 9 |
| Remote | 2 |
| Regional | 1 |
| IRSD quintile | |
| 1 (most disadvantaged) | 2 |
| 2 | 3 |
| 3 | 3 |
| 4 | 2 |
| 5 (least disadvantaged) | 2 |
| Additional roles | |
| Aged care | 1 |
| Part-time academic | 6 |
| Attribute | Participants, n |
|---|---|
| Gender | |
| Female | 8 |
| Male | 4 |
| Number of full years since first medical qualification | |
| 5–15 | 4 |
| 16–30 | 2 |
| 31–45 | 5 |
| 46+ | 1 |
| Work fraction | |
| Part-time | 9 |
| Full time | 3 |
| Number of GPs in practice | |
| 1–4 | 4 |
| 5–9 | 2 |
| 10–14 | 2 |
| 15+ | 4 |
| Clinic location | |
| Metropolitan area | 9 |
| Remote | 2 |
| Regional | 1 |
| IRSD quintile | |
| 1 (most disadvantaged) | 2 |
| 2 | 3 |
| 3 | 3 |
| 4 | 2 |
| 5 (least disadvantaged) | 2 |
| Additional roles | |
| Aged care | 1 |
| Part-time academic | 6 |
Summary of sample characteristics (n = 12)
| Attribute | Participants, n |
|---|---|
| Gender | |
| Female | 8 |
| Male | 4 |
| Number of full years since first medical qualification | |
| 5–15 | 4 |
| 16–30 | 2 |
| 31–45 | 5 |
| 46+ | 1 |
| Work fraction | |
| Part-time | 9 |
| Full time | 3 |
| Number of GPs in practice | |
| 1–4 | 4 |
| 5–9 | 2 |
| 10–14 | 2 |
| 15+ | 4 |
| Clinic location | |
| Metropolitan area | 9 |
| Remote | 2 |
| Regional | 1 |
| IRSD quintile | |
| 1 (most disadvantaged) | 2 |
| 2 | 3 |
| 3 | 3 |
| 4 | 2 |
| 5 (least disadvantaged) | 2 |
| Additional roles | |
| Aged care | 1 |
| Part-time academic | 6 |
| Attribute | Participants, n |
|---|---|
| Gender | |
| Female | 8 |
| Male | 4 |
| Number of full years since first medical qualification | |
| 5–15 | 4 |
| 16–30 | 2 |
| 31–45 | 5 |
| 46+ | 1 |
| Work fraction | |
| Part-time | 9 |
| Full time | 3 |
| Number of GPs in practice | |
| 1–4 | 4 |
| 5–9 | 2 |
| 10–14 | 2 |
| 15+ | 4 |
| Clinic location | |
| Metropolitan area | 9 |
| Remote | 2 |
| Regional | 1 |
| IRSD quintile | |
| 1 (most disadvantaged) | 2 |
| 2 | 3 |
| 3 | 3 |
| 4 | 2 |
| 5 (least disadvantaged) | 2 |
| Additional roles | |
| Aged care | 1 |
| Part-time academic | 6 |
Three main themes were constructed from the data (Fig. 1): Multimorbidity as an encounter with complexity and contingency; Evidence constraints in multimorbidity care; and Concerns for patient safety. Additional data supporting these themes are provided in Supplementary Table S2.
Themes derived from n = 12 individual interviews with GPs.
Theme 1. Multimorbidity as an encounter with complexity and contingency: “It’s the full biopsychosocial model in managing them” (GP6)
GPs described multimorbidity as an encounter with complexity permeating all aspects of the healthcare system, from variability between patients, applicability of evidence, to policies supporting primary care. Heterogeneity in number and type of conditions presenting in one patient could be confronting and GPs needed time to differentiate conditions and their respective symptoms.
…[T]here are multiple things often going on at once and you have to tease them out and that takes time. And sometimes there’s something new that you haven’t picked before, bogged down in the four or five different chronic diseases that you know about…. (GP8)
GPs were alert to possible adverse interactions between conditions and/or the drugs prescribed to manage them. Most described confounding, intertwining psychological, socioeconomic, and cultural issues that interfered with a person’s ability to self-manage or adhere to treatment recommendations.
It actually takes time to get to know them, as a person, know their medical conditions and know their social environment, their support,…what their home environment is like. It’s just the sheer complexity of everything that impacts on their lives and their medical conditions that are really hard to grapple with on that intellectual, scientific basis. (GP6)
GPs working for Aboriginal Medical Services (AMS) in remote regions of Australia described the impact of socioeconomic circumstances on the health of their communities.
Overcrowding, insecure housing, long public housing waiting list. So, you know, if somebody’s got insecure housing and their diabetes is very poorly controlled such that you would like to start them on insulin but they’re not sure they’re going to be able to access refrigeration and where they’re going to sleep is an issue. (GP2)
Disease- and age-centric interpretations of multimorbidity were also contested, with several GPs describing complex younger patients:
You’ve got the autistic child who’s also non-verbal…non-acting, but they also have asthma. And their asthma is poorly controlled. But then you can’t manage the asthma because you can’t even give them an inhaler. So it’s “Argh. What do we do here?”. (GP1)
AMS GPs emphasized the urgent need to focus efforts on addressing upstream social determinants of chronic ill health. Without this, remote health was like “a kind of balloon that’s got a weakness in it that bulges out and you push that bulge back in and then another one comes out” (GP4).
Converging system and practice challenges: “Time’s the biggest enemy of us all” (GP6)
GPs described a constant tension between the type of care they wanted to provide and practice and system restrictions. All agreed they needed more time with complex patients yet were under pressure to curb longer appointments. They attributed this to Australia’s small business, fee-for-service model of general practice which incentivises moving patients through as quickly as possible. The stress between clinic obligations to produce income—keeping it “financially viable” (GP3)—and patient care, led some to prioritize patient needs over income. As one GP said: “You don’t earn as much money…but I…just spend the time that’s necessary so that I feel I’m doing a reasonable job” (GP8). Other GPs relied on relationships built with their patients to find a balance: “When you have some good relationships with your patients who understand the pressures you can say ‘…I know that’s important to you. I will deal with it. I’ll get back to it. Let’s sort this thing out first” (GP6). However, the breakdown of the GP’s schedule into short blocks of time could jeopardize this relationship by reducing opportunities to hear and validate a person’s illness experience. Many regretted they could not undertake medication reviews nor provide lifestyle education to prevent future health problems. Instead, most spent large amounts of time performing unpaid administrative work and following up information from other health professionals to ensure care continuity for their patients. Consequently, some GPs saw a future when there would be “…a limit to the number of patients with complex multimorbidity that a practice can carry” (GP5).
Contingency problem-solving and conflicting agendas: “You got to try something I guess” (GP1)
Multimorbidity heightened the experience of having to act without necessarily knowing what to do. GPs described having to think flexibly under pressure as conditions or personal circumstances changed, or treatments proved ineffective or harmful. Several of the more experienced GPs managed uncertainty by seeing complex patients with multimorbidity more frequently to pre-empt problems. Others were conscious of multimorbidity’s potential to create conflicting agendas within the consultation.
[A]s a GP, you can say, ‘well, I’m going to concentrate on this particular problem you’ve got. I think it’s really important.’ But the person will arrive and bring up something else. And if you’re a psychiatrist and they say, ‘I’ve got a cold today’, you can ethically ignore that. But as a GP, you can’t ignore something they bring up. So it’s very hard to deal adequately with each problem. (GP9)
GPs were mindful to conserve self-management capacity by not overburdening patients with treatment. One reported practising ‘minimally disruptive medicine’ (GP9), others rationalized referrals and out-of-pocket costs where possible and some preferred to book longer, less financially profitable appointments for patients rather than splitting consultations. GPs also worried about the psychosocial impact of the multimorbidity care experience, particularly on older, more vulnerable people, describing situations where a course of action had to be weighed against inevitable repercussions for the person’s independence and autonomy.
So isolated elderly patients with multimorbidity who are dependent on driving vehicles to go to the town…. You know, I’ve got a couple who I think, ‘do I really need to have that discussion with them and say you can’t drive anymore’? And what am I risking? Because I know as soon as I do that, they can’t come and see me. Their whole life changes. (GP5)
Theme 2. Evidence constraints in multimorbidity care: “You’re treating this person in front of you, not a population!” (GP6)
GPs’ views on guidelines ranged from “I love guidelines because…guidelines are evidenced-based” (GP11), to “…ultimately, they’re often not terribly helpful” (GP4) and “…they are generally very, very poor-quality evidence” (GP6). Even GPs positively disposed toward guidelines were cognizant that they were based on patients with single conditions, yet they adhered closely to them to have a structured, secure base for justifying decisions: So, if [patients] go on to see someone else, they are not going to necessarily question why you’ve suddenly tried to reduce that PPI they may not need (GP1). Others struggled to harmonize evidence: “…[I]f somebody’s got diabetes and they’ve got a bleeding score and they’ve got dementia? How do you craft the diabetes guidelines for that person?” (GP5).
Most GPs deviated from guideline recommendations when they did not fit the person before them. “Almost always the multimorbidity modifies what you do…. [W]e just look at a guideline or protocol and shake our heads sometimes and go ‘we cannot do it with this person” (GP8). Several emphasised the danger of losing sight of the person in the struggle to reconcile evidence founded on population means and the real-life values and behaviors of individuals. They were especially critical of the protocol-driven approach of some hospital specialists:
…[H]ospital-based clinicians who do guidelines don’t know, haven’t got a clue about the real world. … [A]ll their patients are sitting there politely in bed. They’re not going out and drinking unsuitable amounts of alcohol or caffeine or going back to the smokes or sleeping irregular hours or eating stuff that they shouldn’t eat. They’re kind of in a controlled environment. (GP8)
Integrating other forms of knowledge: “[I]t’s thinking based on years of knowledge of them and their bodies” (GP6)
GPs described relying on alternative forms of knowledge when guideline recommendations were deemed inappropriate. Foremost was familiarity with the patient and accrued knowledge of their circumstances:
It’s that relationship that builds up over time that you both know what the next answer’s going to be and what the next question is going to be. And what is most appropriate for that person. (GP6)
This form of intelligence gathering was particularly evident in the AMS context where the gradual approach was essential to a therapeutically beneficial establishment of trust.
Because Indigenous people, particularly in remote communities, see so many different doctors and programs start and stop and come and go, they do watch you and see what you do at first. And then suddenly, when they think ‘Yeah, okay, this person is genuine,’ then you start to get that relationship. And there’s no way you are going to get good results, I think, until you establish that relationship. (GP4)
GPs described relational continuity as a 2-way flow of understanding which could help both parties negotiate a difficult management decision. It could also trigger recognition of changes to a person’s baseline of health in the absence of diagnostic data—what GPs termed “gut feeling.” “You’ve patients who you’ve known for so long and you see them, you just glance at them in the waiting room and you think, ‘Gee there’s something going on there’” (GP11). When at the limits of personal knowledge, GPs might seek advice from other members of the primary care team such as practice nurses who often observe how people cope and function outside the consultation room.
Theme 3. Concerns for patient safety: “Often the right hand doesn’t know what the left hand is doing” (GP1)
Most GPs expressed concern for the safety of patients with multimorbidity within a complex, “fragmented” healthcare system and sympathized with their challenges navigating it. “But it’s hard to navigate the systems, the different billing systems, private-public, health insurance. Oh, gosh. Yes, I think it’s hard for people. Particularly if they’re unwell” (GP12). Fragmentation also occurred at the level of the body with each condition requiring the attention of its own set of specialists. This single-condition approach might jar with the GP’s holistic approach and lead to poor outcomes for the individual:
This is why medical specialist management of these people is a disaster. Because they’re only focused on one disease and not the whole patient. And they see them for a tiny snapshot in time, which potentially does more harm than good. (GP6)
Dangerous lack of communication with specialists
Poor integration and coordination between sectors of the Australian health system often resulted in incomplete or poorly timed information transfer at the interfaces with the risk of communication failures increasing with the number of clinicians involved in a person’s care. “Now the way we often interact with multimorbidity is we interact with a person and who they’re seeing” (GP5). Most GPs spoke at length of their frustrations and concerns with the information they received from secondary care clinicians about their own patients.
Lack of communication is the really dangerous aspect in looking after these people. What you don’t know often becomes a big issue. “I don’t know what tablets you’re on. I don’t know whether they found cancer. I don’t know whether the doctors thought you had leukemia.” (GP5)
Discharge letters could be uninformative, delayed, or absent altogether and often added to the GP’s workload when they needed to be followed up. Without clear communication between all clinicians involved in a person’s care, GPs saw patients as being at risk of inappropriate polypharmacy, medication errors, or of opting out of care, unable to keep up with what was being asked of them. They also saw it as their role as generalists to counteract fragmentation by being “across the range of a person’s problems” and “across the many systems,” to “pull it all together for people” (GP8) which took time they did not have. They also felt a responsibility to keep patients out of hospital where they believed patient problems could be exacerbated. Most GPs interviewed believed part of the solution lay in strengthening general practice through increased funding investment.
… [I]f the care could be augmented, we’d keep a lot of people out of hospital and would save millions of dollars. There’s the will and the way to do that but still the dollars are not stacking up enough for the average practices to take on more and to want to do more. (GP5)
Concern for patient access to allied health and home services
GPs raised concerns over the amount of care patients could receive within the community. Access to district nurses for rudimentary care such as wound dressings was problematic, driving people back to the GP clinic while time and financial considerations restricted many GPs from making home visits. GPs were also concerned with the adequacy of the Government’s chronic care initiatives, labeling the GP Management Plan “…not worth the paper it’s written on” (GP6), “really not sufficient” (GP11), and “…a complete debacle” (GP9). Medicare rebates for preparing these plans were generally appreciated but time remained an issue in completing them to GP standards.
[The care plan is] so inadequate and then people will rely on it and there will be things that aren’t there or are wrong. And there’s been no attempt, again, to fund GPs for the extra time it would take to do it properly. (GP9)
GPs also deemed it too time-consuming to arrange real-time multidisciplinary case conferences under the ‘Team Care Arrangement.’ Yearly caps on the number of funded appointments people could make with allied health professionals under this scheme were also viewed as insufficient. Without further government subsidization, GPs saw access to allied health as financially out of reach for many patients.
In contrast, patient access to nursing and allied healthcare was positively facilitated within Aboriginal Medical Services, providing clinicians could be recruited to remote locations.
It’s all part of the ethos of the Aboriginal Medical Services that the service has taken over, not just the running of the clinic, but the whole gamut of social interventions. That includes diabetes educators, physiotherapists, exercise physiologists, nutritionists to work with people. And often they come out to visit the community and they’re not in the clinic. They’re out in the schools, community centres and so on (GP4).
AMS GPs expressed satisfaction with this in-house, holistic model. It simplified care coordination and fostered an authentic team-based approach firmly contextualized within a community. Non-AMS GPs also praised the model, with one suggesting it be adopted in residential aged care. Geographic remoteness, however, challenged efforts to get patients seen by specialists in a timely fashion, with GPs describing waiting lists stretching years. Remote GPs also faced difficult choices such as using scarce resources to send someone on a long, inconvenient journey for a diagnostic test, or managing them in the community, risking a serious problem arising.
Discussion
This study presents findings unique to the Australian healthcare and cultural context. First, the patient-centered orientation of those interviewed stands at odds with the Australian general practice business model which demands short consultation times for its sustainability. GPs also described a deep gulf between their care approach and how medical specialists working in the secondary care sector or across Australia’s private/public system divide choose to work. They describe feeling “invisible” to these colleagues, evident by the quality of communication between them. They viewed this intersectoral failure as detrimental to the safety of patients and contributing to their already substantial workload.
The study has also highlighted the universality of the multimorbidity problem by corroborating the findings of international studies grounded in the GP perspective.13 It depicts multimorbidity as commonplace in general practice,1 time-consuming and intellectually challenging to manage,33 and not always supported by single condition guidelines.11 Furthermore, definitions of multimorbidity based on condition counts may have utility for policymakers,34 but do not reflect GP experiences of its heterogeneity and complexity.35 Other studies have highlighted that upstream health system funding models and organizational structures impinge on consultation time8 and affect specialist–GP communication.36 According to GPs, these factors threaten patient safety37 and hinder efforts to provide the “whole person” care characteristic of their specialty.38
GPs universally, therefore, appear to face a conflict between clinical uncertainty, recommendations concerned with “standard” patients, small business obligations, and their own sense of professional and ethical responsibility to patients. As highlighted by a recent systematic review of GP perspectives, GPs internationally often reconcile these tensions pragmatically by prioritizing their relationship with the patient and safeguarding its continuity.13 Through relational continuity, they accumulate knowledge of a person’s social context and individual priorities, relying on this knowledge to formulate an appropriate therapeutic strategy and avoid “contextual errors.”39,40
The fact that GPs draw on multiple forms of information when challenged by complexity is suggestive of Gabbay and le May’s more informal, flexible “mindlines” approach.41 This is tacit knowledge-for-practice that GPs create by testing information garnered from a wide range of sources and “melding” it with their own practical, contextual knowledge for making clinical judgments.41 This constructed knowledge appears to provide a more certain foundation for decision-making than guidelines alone. It also takes the focus of individual disease management as the priority shifts to managing multimorbidity’s cumulative impact on an individual’s goals.42
GPs’ explicit understanding that a patient-centered approach is particularly appropriate for patients with multimorbidity is in sync with the nascent ‘guiding principles’ approach to guideline development for multimorbidity,43 and trials of alternative care models.44 Although patients may value this approach to their care, the health-related benefits of strongly individualized, patient-centerd multimorbidity care are proving difficult to demonstrate empirically.45
Strengths and limitations
This study is the first to investigate Australian GP experiences in managing an increasing number of patients with multimorbidity. The interview guide was based on a rigorous synthesis of international qualitative literature,13 and recruited GPs were willing to speak at length on the issues, providing a large amount of rich data for analysis. The study benefited from researcher triangulation with each author contributing a different discipline perspective. The GP author provided valuable insights into the AMS experience while the non-GP interviewer (RD) may have elicited richer details by enabling GPs to be frank about challenges without feeling under professional scrutiny from peers. The study may have been limited by the social desirability of ‘patient-centered’ responses.
Our recruitment process began at the start of the COVID-19 pandemic which quickly put Australian GPs at the forefront of care. Recruitment of interviewees slowed immediately which led us to rely on snowball sampling. However, the fact that 2 GPs recruited this way were academic colleagues of one of the participants may have influenced the findings. We also note as interesting the recruitment of 3 AMS GPs from newsletter announcements as well as GPs with many years of experience. While the data they provided was rich and important, their unique perspectives may not be transferable to GPs of a younger age and those working in metropolitan practices.
The sample size of 12, although small, was adequate based on data saturation. We believe we reached the point at which no new themes were being elucidated at interview 10. Subsequent interviewees confirmed existing themes, adding their own unique perspectives to them. After 12 interviews we deemed the data rich enough to amply answer the research questions. Despite this, we cannot conclude that no disconfirming views exist beyond our sample. A follow-up quantitative survey of a wider range of Australian GPs may serve to substantiate or refute these findings.
Conclusions
Australian GPs describe challenges in managing multimorbidity, some of which they perceive as detrimental to patient safety and to the quality and quantity of care they wish to provide patients. Some concerns, such as the applicability of single condition guidelines to complex patients, are long standing and resonate globally.6 However, guidelines capable of identifying and addressing innumerable combinations of conditions appear to be a long way off, even implausible.34 The most promising approach to multimorbidity may be the patient-centered one GPs are already applying. This suggests GPs need to continue nurturing therapeutic relationships developed over time so that they can, in turn, draw on contextual information for individualized problem-solving when evidence is limited. In Australia, a first step to protecting and building on the relationship aspect of multimorbidity care may be to encourage people to register with a GP or practice of their choice. Interviewees considered the patient-centered, relationship-based approach under threat from health policies and systems, including Australia’s general practice model, which appear to underestimate, even devalue, the time required within consultations to understand, prioritize, and manage complex problems. To get the attention of policymakers on this issue, GPs might generate evidence of the cost-benefits of longer consultations, demonstrating that they can save costs by affording time to address preventative health and producing superior patient-prioritized outcomes. Not lobbying for a better allotment of time has implications for practice sustainability as older populations with complex patients grow in numbers, GPs retire, and the specialty struggles to attract new graduates to take their place.
It may also be important for GPs to take ownership of producing guidelines that take a primary care lens to the issue of multimorbidity. This includes creating and incorporating evidence from studies undertaken in the primary care setting. Research originating from primary care has expanded since the start of this century46 and led to interesting initiatives. For example, in the Netherlands, a National Research Agenda for General Practice has brought together GPs to analyze guideline gaps and create a general practice research agenda based on “the most compelling questions and issues in general practice.”47 Meanwhile, the United Kingdom’s Clinical Practice Research Datalink database of anonymized electronic health record data is providing real-world evidence to inform guidelines.48
Finally, unlike problems of multimorbidity evidence, system issues might be improved with political will and greater investment in the sector. Policymakers may need reminding that GPs already provide value to overall health system performance alongside “better quality, better health, greater equity, and lower cost for whole people and populations.”49
Funding
No funding was received to conduct this study. GPs were thanked for their time with gift cards purchased from a Research Maintenance allocation granted the first author during her PhD.
Acknowledgments
We thank our GP interviewees who gave so generously of their time and insights during a difficult period in history for the medical profession.
Ethical approval and consent to participate
Ethical approval for this study was obtained from the Flinders University Social and Behavioural Ethics Group on 22 January 2020 (Project number 8546). Participants indicated their informed consent by signing a consent form or providing verbal consent (recorded) after reading full details of the study, its purpose, what was expected of them and how they might terminate involvement. They were promised confidentiality.
Conflict of interest
Authors declare they have no conflicting or competing interests.
Data Availability
The deidentified data underlying this article and coding tree will be shared upon reasonable request to the corresponding author.
