Understanding and Promoting Clinical Reasoning in Chronic and Multimorbid Conditions: A Call for GPs and Healthcare Professionals — Oak Academic Publishing
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Understanding and Promoting Clinical Reasoning in Chronic and Multimorbid Conditions: A Call for GPs and Healthcare Professionals
UDREM (Unit of Development and Research in Medical Education), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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UDREM (Unit of Development and Research in Medical Education), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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UIGP (Family Medicine Unit), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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UIGP (Family Medicine Unit), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Family and Emergency Medicine Department, Faculty of Medicine, Université de Montréal, Montréal, Canada
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UIGP (Family Medicine Unit), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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CIS (Center of Interprofessional Simulation), Geneva, Switzerland
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Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
1 UDREM (Unit of Development and Research in Medical Education), Faculty of Medicine, University of Geneva, Geneva, Switzerland
2 UDREM (Unit of Development and Research in Medical Education), Faculty of Medicine, University of Geneva, Geneva, Switzerland
3 UIGP (Family Medicine Unit), Faculty of Medicine, University of Geneva, Geneva, Switzerland
4 UIGP (Family Medicine Unit), Faculty of Medicine, University of Geneva, Geneva, Switzerland
5 Family and Emergency Medicine Department, Faculty of Medicine, Université de Montréal, Montréal, Canada
6 UIGP (Family Medicine Unit), Faculty of Medicine, University of Geneva, Geneva, Switzerland
7 CIS (Center of Interprofessional Simulation), Geneva, Switzerland
8 Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
Multimorbidity, defined as 2 or more chronic diseases, is of increasing importance for health professionals. Many factors are at play when it comes to multimorbidity, but we still know very little about how clinicians actually weigh up the different factors—medical, social, and psychological—to reach a particular course of action. Further research is therefore required to explore the ways in which clinical reasoning processes are involved in the follow up of patients suffering from multimorbidities, to highlight their potential risks of errors. A better understanding of these clinical processes will also enrich supervision of trainees and collaboration between healthcare professionals involved in primary care.
Norman, G. (2005) Research in Clinical Reasoning; Past History and Current Trends. Medical Education, 39, 418-427. https://doi.org/10.1111/j.1365-2929.2005.02127.x
Excoffier, S., Paschoud, A., Haller, D. and Herzig, L. (2016) Multimorbidity in a Primary Care Setting. Revue Médicale Suisse, 12, 917-921.
Bower, P., Macdonald, W., Harkness, E., Gask, L., Kendrick, T., Valderas, J.M., et al. (2011) Multimorbidity, Service Organization and Clinical Decision Making in Primary Care: A Qualitative Study. Family Practice, 28, 579-587. https://doi.org/10.1093/fampra/cmr018
Starfield, B. (2001) New Paradigms for Quality in Primary Care. British Journal of General Practice, 51, 303-309.
Montague, T., Gogovor, A., Aylen, J., Ashley, L., Ahmed, S., Martin, L., et al. (2017) Patient-Centred Care in Canada: Key Components and the Path Forward. Healthcare Quarterly, 20, 50-56. https://doi.org/10.12927/hcq.2017.25136
Excoffier, S., Herzig, L., N’Goran, A.A., Deruaz-Luyet, A. and Haller, D.M. (2018) Prevalence of Multimorbidity in General Practice: A Cross-Sectional Study within the Swiss Sentinel Surveillance System (Sentinella). BMJ Open, 8, e019616. https://doi.org/10.1136/bmjopen-2017-019616
Cassell, A., Edwards, D., Harshfield, A., Rhodes, K., Brimicombe, J., Payne, R., et al. (2018) The Epidemiology of Multimorbidity in Primary Care: A Retrospective Cohort Study. British Journal of General Practice, 68, e245-e251. https://doi.org/10.3399/bjgp18X695465
Bartels, C.M., Kind, A.J., Everett, C., Mell, M., McBride, P. and Smith, M. (2011) Low Frequency of Primary Lipid Screening among Medicare Patients with Rheumatoid Arthritis. Arthritis & Rheumatism, 63, 1221-1230. https://doi.org/10.1002/art.30239
Lagu, T., Weiner, M., Hollenbeak, C., Eachus, S., Roberts, C.S., Schwartz, J., et al. (2008) The Impact of Concordant and Discordant Conditions on the Quality of Care for Hyperlipidemia. Journal of General Internal Medicine, 23, 1208-1213. https://doi.org/10.1007/s11606-008-0647-4
Boyd, C., Darer, J., Boult, C., Fried, L.P., Boult, L. and Wu, A.W. (2005) Clinical Practice Guidelines and Quality of Care for Older Patients with Multiple Comorbid Diseases: Implications for Pay for Performance. The Journal of the American Medical Association, 294, 716-724.
van den Akker, M., Buntinx, F. and Knottnerus, J.A. (1996) Comorbidity or Multimorbidity: What’s in a Name? A Review of Literature. European Journal of General Practice, 2, 65-70. https://doi.org/10.3109/13814789609162146
Solomon, J., Raynor, D.K., Knapp, P. and Atkin, K. (2012) The Compatibility of Prescribing Guidelines and the Doctor-Patient Partnership: A Primary Caremixed-Methods Study. British Journal of General Practice, 62, e275-e281. https://doi.org/10.3399/bjgp12X636119
Arora, N.K. and McHorney, C. (2000) Patient Preferences for Medical Decision Making: Who Really Wants to Participate? Medical Care, 38, 335-341. https://doi.org/10.1097/00005650-200003000-00010
Politi, M.C., Dizon, D.S., Frosch, D.L., Kuzemchak, M.D. and Stiggelbout, A.M.J.B. (2013) Importance of Clarifying Patients’ Desired Role in Shared Decision Making to Match Their Level of Engagement with Their Preferences. British Medical Journal, 347, f7066. https://doi.org/10.1136/bmj.f7066
Reuben, D.B. and Tinetti, M.E. (2012) Goal-Oriented Patient Care—An Alternative Health Outcomes Paradigm. The New England Journal of Medicine, 366, 777-779. https://doi.org/10.1056/NEJMp1113631
Smith, S., Soubhi, H., Fortin, M., Hudon, C. and O’Dowd, T. (2012) Managing Patients with Multimorbidity: Systematic Review of Interventions in Primary Care and Community Settings. British Medical Journal, 345, e5205. https://doi.org/10.1136/bmj.e5205
Gensichen, J., Muth, C., Butzlaff, M., Rosemann, T., Raspe, H., de Cornejo, G.M., et al. (2006) The Future Is Chronic: German Primary Care and the Chronic Care Model—The Comprehensive Principles in the Proactive Treatment of the Chronically Ill. Zeitschrift fur arztliche Fortbildung und Qualitatssicherung, 100, 365-374.
Braithwaite, R.S., Fiellin, D. and Justice, A. (2009) The Payoff Time: A Flexible Framework to Help Clinicians Decide When Patients with Comorbid Disease Are Not Likely to Benefit from Practice Guidelines. Medical Care, 47, 610-617. https://doi.org/10.1097/MLR.0b013e31819748d5
Smith, S., O’Kelly, S. and O’Dowd, T. (2010) GPs’ and Pharmacists’ Experiences of Managing Multimorbidity: A ‘Pandora’s Box’. British Journal of General Practice, 60, 285-294. https://doi.org/10.3399/bjgp10X514756
O’Brien, R., Wykey, S., Guthriez, B., Graham, W. and Mercer, S. (2011) 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, 7, 45-59. https://doi.org/10.1177/1742395310382461
Sinnott, C., Mc Hugh, S. and Browne, J. (2013) GPs’ Perspectives on the Management of Patients with Multimorbidity: Systematic Review and Synthesis of Qualitative Research. BMJ Open, 3, e003610. https://doi.org/10.1136/bmjopen-2013-003610
Steinman, M.A., Sudore, R.L., Peterson, C.A., Harlow, J.B. and Fried, T.R. (2012) Influence of Patient Age and Comorbid Burden on Clinician Attitudes toward Heart Failure Guidelines. The American Journal of Geriatric Pharmacotherapy, 10, 211-218. https://doi.org/10.1016/j.amjopharm.2012.04.003
Schuling, J., Gebben, H., Veehof, L.J.G. and Haaijer-Ruskamp, F.M. (2012) Deprescribing Medication in Very Elderly Patients with Multimorbidity: The View of Dutch GPs. A Qualitative Study. BMC Family Practice, 13, 56. https://doi.org/10.1186/1471-2296-13-56
Marx, G., Pusche, K. and Ahrens, D. (2009) Polypharmacy: A Dilemma in Primary Care? Results of Group Discussions with General Practitioners. Gesundheitswesen, 71, 339-348. https://doi.org/10.1055/s-0029-1192004
Fried, T.R., Tinetti, M.E. and Iannone, L. (2011) Primary Care Clinicians’ Experiences with Treatment Decision Making for Older Persons with Multiple Conditions. Archives of Internal Medicine, 171, 75-80.
Ilgen, J.S., Eva, K. and Regehr, G. (2016) What’s in a Label? Is Diagnosis the Start or the End of Clinical Reasoning? Journal of General Internal Medicine, 31, 435-437. https://doi.org/10.1007/s11606-016-3592-7
Audétat, M.-C., Laurin, S., Dory, V., Charlin, B. and Nendaz, M. (2018) Diagnosis and Management of Clinical Reasoning Difficulties: AMEE GUIDE 117. Association for Medical Education in Europe (AMEE), Dundee.
Schmidt, H. and Rikers, R. (2007) How Expertise Develops in Medicine: Knowledge Encapsulation and Illness Script Formation. Medical Education, 41, 1133-1139.
Pelaccia, T., Tardif, J., Triby, E., Ammirati, C., Bertrand, C., Dory, V., et al. (2014) How and When Do Expert Emergency Physicians Generate and Evaluate Diagnostic Hypotheses? A Qualitative Study Using Head-Mounted Video Cued-Recall Interviews. Annals of Emergency Medicine, 64, 575-585. https://doi.org/10.1016/j.annemergmed.2014.05.003
Norman, G., Monteiro, S., Sherbino, J., Ilgen, J., Schmidt, H. and Mamede, S. (2017) The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Academic Medicine, 92, 23-30. https://doi.org/10.1097/ACM.0000000000001421
Croskerry, P. (2009) A Universal Model of diagnostic Reasoning. Academic Medicine, 84, 1022-1028. https://doi.org/10.1097/ACM.0b013e3181ace703
McBee, E., Ratcliffe, T., Picho, K., Schuwirth, L., Artino Jr., A.R., Yepes-Rios, A.M., et al. (2017) Contextual Factors and Clinical Reasoning: Differences in Diagnostic and Therapeutic Reasoning in Board Certified versus Resident Physicians. BMC Medical Education, 17, 211. https://doi.org/10.1186/s12909-017-1041-x
Charlin, B., Lubarsky, S., Millette, B., Crevier, F., Audétat, M., Charbonneau, A., et al. (2012) Clinical Reasoning Processes: Unraveling Complexity through Graphical Representation. Medical Education, 46, 454-463. https://doi.org/10.1111/j.1365-2923.2012.04242.x
Cook, D.A., Sherbino, J. and Durning, S. (2018) Management Reasoning: Beyond the Diagnosis. The Journal of the American Medical Association, 319, 2267-2268.
Cook, D.A., Durning, S.J., Sherbino, J. and Gruppen, L.D. (2019) Management Reasoning: Implications for Health Professions Educators and a Research Agenda. Academic Medicine, 94, 1310-1316. https://doi.org/10.1097/ACM.0000000000002768
Graber, M. (2005) Diagnostic Errors in Medicine: A Case of Neglect. The Joint Commission Journal on Quality and Patient Safety, 31, 106-113. https://doi.org/10.1016/S1553-7250(05)31015-4
Audétat, M., Laurin, S., Sanche, G., Béique, C., Caire-Fon, N., Blais, J., et al. (2013) Clinical Reasoning Difficulties: A Taxonomy for Clinical Teachers. Medical Teacher, 35, e984-e989. https://doi.org/10.3109/0142159X.2012.733041
Gil-Guillén, V., Orozco-Beltran, D., Carratala-Munuera, C., Marquez-Contreras, E., Durazo-Arvizu, R., Cooper, R., et al. (2013) Clinical Inertia in Poorly Controlled Elderly Hypertensive Patients: A Cross-Sectional Study in Spanish Physicians to Ascertain Reasons for Not Intensifying Treatment. American Journal of Cardiovascular Drugs, 13, 213-219. https://doi.org/10.1007/s40256-013-0025-4
Nendaz, M.R., Charlin, B., LeBlanc, V. and Bordage, G. (2005) Clinical Reasoning: from Research Findings to Applications for Teaching. Pédagogie Médicale, 6, 235-254. https://doi.org/10.1051/pmed:2005028
Nendaz, M., Gut, A. and Perrier, A. (2005) Common Strategies in Clinical Data Collection Displayed by Experienced Clinician-Teachers in Internal Medicine. Medical Teacher, 27, 415-421. https://doi.org/10.1080/01421590500084818
Frank, J., Snell, L., Cate, O., Holmboe, E., Carraccio, C. and Swing, S. (2010) Competency-Based Medical Education: Theory to Practice. Medical Teacher, 32, 638-645. https://doi.org/10.3109/0142159X.2010.501190
Audetat, M.-C., Dory, V., Nendaz, M., Vanpee, D., Pestiaux, D., Junod Perron, N., et al. (2012) What Is So Difficult about Managing Clinical Reasoning Difficulties? Medical Education, 46, 216-227. ttps://doi.org/10.1111/j.1365-2923.2011.04151.x
Bodenheimer, T., Lorig, K., Holman, H. and Grumbach, K. (2002) Patient Self-Management of Chronic Disease in Primary Care. The Journal of the American Medical Association, 288, 2469-2475. https://doi.org/10.1001/jama.288.19.2469
Wagner, E.H. (1998) Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice, 1, 2-4.
Blondon, K., Chan, K., Muller-Juge, V., Cullati, S., Hudelson, P., Maitre, F., et al. (2017) A Concordance-Based Study to Assess Doctors’ and Nurses’ Mental Models in Internal Medicine. PLoS ONE, 12, e0182608. https://doi.org/10.1371/journal.pone.0182608
Mylopoulos, M. and Regher, G. (2011) Putting the Expert Together Again. Medical Education, 45, 920-926. https://doi.org/10.1111/j.1365-2923.2011.04032.x