Primary Care Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland.
Int J Clin Pract. 2021 Sep;75(9):e14187. doi: 10.1111/ijcp.14187. Epub 2021 May 5.
Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term.
A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool.
A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient.
Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.
大多数初级保健咨询都涉及患有多种疾病的患者。然而，关于全科医生（GP）在长期随访这些患者时的临床推理过程，研究甚少。本系统评价的目的是总结已发表的证据，说明 GP 在长期管理患有多种疾病的患者时如何进行推理和做出决策。
我们于 2019 年 6 月对 Medline、Embase、PsycINFO 和 ERIC 数据库中的相关文献进行了检索。检索词选自五个领域：初级保健、临床推理、慢性疾病、多种疾病和多种疾病问题。纳入了发表在英文和法文的定性、定量和混合方法研究。使用混合方法评估工具进行了质量评估。
共评估了 2165 篇摘要和 362 篇全文文章。32 项研究符合纳入标准。结果表明，GP 在长期管理多种疾病过程中的临床推理是关于设定持续进行的护理中间目标，以适应患者的不断变化，并有助于维持其生活质量。在缺乏针对多种疾病的指南的情况下，没有单一的正确计划，但存在相互竞争的优先级和不可避免的不确定性。因此，GP 必须同时考虑和权衡多个因素。在多种疾病的背景下，GP 将他们的推理描述为本质上是直觉的，并认为它不太准确。然而，这些临床推理过程更加分析，因为它们可能会思考并根植于对个体患者的深入了解。
尽管 GP 在长期随访患有多种疾病的患者时面临的挑战越来越为人所知，但目前文献中关于 GP 发挥作用的临床推理过程的信息有限。GP 往往低估了他们临床推理的复杂性和丰富性，这可能会对他们的实践和教学产生负面影响。
