Austad Bjarne, Hetlevik Irene, Mjølstad Bente Prytz, Helvik Anne-Sofie
Sjøsiden Medical Centre, Trondheim, Norway.
General Practice Research Unit, Department of Public Health and General Practice, NTNU, Norwegian University of Science and Technology, PO Box 8905, MTFS, 7491, Trondheim, Norway.
BMC Fam Pract. 2016 Jul 22;17:92. doi: 10.1186/s12875-016-0490-3.
Clinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners' (GPs') experiences with and reflections upon the consequences for general practice of applying multiple guidelines.
Qualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach.
The GPs' responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice 'defensive medicine'. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life.
The GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs' courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.
单一疾病的临床指南在多病症患者的全科医疗工作中常常引发问题。然而，很少有研究关注遵循多种指南的要求对全科医疗产生的影响。本研究探讨了挪威全科医生（GP）对应用多种指南给全科医疗带来的后果的经验和思考。
在挪威中部开展定性焦点小组研究。该研究从四个已有的小组中有目的地抽取了25名挪威全科医生作为样本。访谈进行了录音、转录，并采用系统文本浓缩法（即应用现象学方法）进行分析。
全科医生的回答集中在两个主要主题上：1）应用多种指南给全科医生带来的并发症；2）全科医生应用多种指南时给患者带来的并发症。对全科医生来说，应用多种指南造成了一个极具问题的局面，因为他们觉得有义务实施那些不适用于他们患者的指南：地图与地形往往不匹配的情况屡见不鲜。他们在自身的医疗实践中也感到更大的不安全感，他们承认，这导致了“防御性医疗”倾向的增加。对他们的患者来说，全科医生发现应用多种指南增加了多药联用的风险、过多的非药物治疗建议、医疗化倾向，对一些患者而言，还降低了生活质量。
当必须对患有多种病症的患者应用各种单一疾病指南时，全科医生会经历负面后果，包括多药联用风险增加和过度治疗。我们认为以患者为中心的医疗以及全科医生在必要时不遵循指南的勇气可能有助于降低这些风险。医疗保健当局和指南制定者需要意识到在多病症非常普遍的全科医疗中专注单一疾病可能产生的潜在负面影响。
