Sur mesure pour le patient : étude qualitative sur l’apprentissage de la prise en charge de la multimorbidité en médecine de famille
DOI :
https://doi.org/10.36834/cmej.81580Résumé
Introduction: The rising prevalence of multimorbidity poses a significant challenge to healthcare systems. However, medical education predominantly emphasizes single-disease frameworks, offering limited guidance on how learners can navigate the complexities of managing co-existing health conditions. Given the high incidence of multimorbidity in family medicine, this study aimed to explore the experiences of family medicine residents in managing multimorbidity, with the goal of informing curriculum development.
Methods: We conducted a qualitative study comprising four focus groups (mean duration 47 minutes) with a convenience sample of 28 family medicine residents learning in urban and rural settings. Data were analyzed inductively using reflexive thematic analysis. We drew on generalism and adaptive expertise as sensitizing theoretical lenses to support thematic development and our final interpretation.
Results: Participants described a shift from their undergraduate focus on "getting the list" of diagnoses toward a more nuanced, patient-centred approach to multimorbidity, which they characterized as "bespoke to the patient." Throughout residency, learners reported increased confidence conducting more flexible consultations—incorporating social determinants of health, the unique patient’s context, realizing and navigating how healthcare structures impact, and sometimes impede, patient care. Balancing competing priorities became a key feature of their evolving practice, supported by exposure to diverse patient populations, meaningful preceptor relationships, and varied clinical environments. Residents increasingly identified their role coordinating the patient’s care team, leveraging a generalist perspective to organize care and address complexity.
Conclusions: Family medicine residents described learning to manage multimorbidity as a developmental process of acquiring generalist adaptive expertise, supported through working in a variety of learning environments. Encouraging preceptors to explicitly share strategies—such as managing limited time and navigating health system constraints—may further enhance resident education in caring for patients with multimorbidity.
Téléchargements
Références
1. World Health Organization. World report on ageing and health. Available from: https://www.who.int/publications/i/item/9789241565042 [Accessed on May 1, 2025].
2. Pearson-Stuttard J, Ezzati M, Gregg EW. Multimorbidity - a defining challenge for health systems. Lancet. 2019;4(12):E5999–E600. https://doi.org/10.1016/s2468-2667(19)30222-1.
3. Xiao X, Beach J, Senthilselvan A. Prevalence and determinants of multimorbidity in the Canadian population. Latham-Mintus K. ed. PLOS ONE. 2024;19(1):e0297221. https://doi.10.1371/journal.pone.0297221.
4. Álvarez-Gálvez J, Ortega-Martín E, Carretero-Bravo J, et al. Social determinants of multimorbidity patterns: a systematic review. Front Public Health. 2023;11. https://doi.org/10.3389/fpubh.2023.1081518.
5. Singer L, Green M, Rowe F, et al. Trends in multimorbidity, complex multimorbidity and multiple functional limitations in the ageing population of England, 2002–2015. J Comorbidity. 2019;9. https://doi.org/10.1177/2235042x19872030.
6. Smith SM, Soubhi H, Fortin M, et al. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ. 2012;345(sep03 1):e5205–e5205. https://doi.org/10.1136/bmj.e5205.
7. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380(9836):37–43. https://doi.org/10.1016/S0140-6736(12)60240-2.
8. Damarell RA, Morgan DD, Tieman JJ. General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research. BMC Fam Pract. 2020;21(1):131. https://doi.org/10.1186/s12875-020-01197-8.
9. Muth C, Blom JW, Smith SM, et al. Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. J Intern Med. 2019;285(3):272–288. https://doi.org/10.1111/joim.12842.
10. Kernick D, Chew-Graham CA, O’Flynn N. Clinical assessment and management of multimorbidity: NICE guideline. Br J Gen Pract. 2017;67(658):235–236. https://doi.org/10.3399/bjgp17X690857.
11. Reeve J, Dowrick CF, Freeman GK, et al. Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions. JRSM Short Rep. 2013;4(12):2042533313510155. https://doi.org/10.1177/2042533313510155.
12. Reeve J. Medical generalism, now! Reclaiming the knowledge work of modern practice. 1st ed. CRC Press: Boca Raton; 2023.
13. Lewis C, Wallace E, Kyne L, et al. Training doctors to manage patients with multimorbidity: a systematic review. J Comorbidity. 2016;6(2):85–94. https://doi.org/10.15256/joc.2016.6.87 .
14. Penner K, Wicklum S, Johnston A, et al. Teaching multimorbidity to medical students. Clin Teach. 2024;21(6). https://doi.org/10.1111/tct.13794.
15. Dennick R. Constructivism: reflections on twenty five years teaching the constructivist approach in medical education. Int J Med Educ. 2016;7:200–205. https://doi.org/10.5116/ijme.5763.de11.
16. Mylopoulos M, Kulasegaram K, Woods NN. Developing the experts we need: fostering adaptive expertise through education. J Eval Clin Pract. 2018;24(3):674–677. https://doi.org/10.1111/jep.12905.
17. Woods NN, Mylopoulos M, Nutik M, et al. Defining the specialist generalist: The imperative for adaptive expertise in family medicine. Can Fam Physician. 2021;67(5):321–322. https://doi.org/10.46747/cfp.6705321.
18. Cupido N, Ross S, Lawrence K, et al. Making sense of adaptive expertise for frontline clinical educators: a scoping review of definitions and strategies. Adv Health Sci Educ. 2022;27(5):1213–1243. https://doi.org/10.1007/s10459-022-10176-w.
19. Sockalingam S, Mulsant BH, Mylopoulos M. Beyond integrated care competencies: the imperative for adaptive expertise. Gen Hosp Psychiatry. 2016;43:30–31. https://doi.org/10.1016/j.genhosppsych.2016.09.002.
20. Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. 1st ed. SAGE Publications; 2006.
21. Stalmeijer RE, McNaughton N, Van Mook WNKA. Using focus groups in medical education research: AMEE guide No. 91. Med Teach. 2014;36(11):923–939. https://doi.org/10.3109/0142159X.2014.917165.
22. Varpio L, Ajjawi R, Monrouxe LV, et al. Shedding the cobra effect: problematising thematic emergence, triangulation, saturation and member checking. Med Educ. 2017;51(1):40–50. https://doi.org/10.1111/medu.13124.
23. Braun V, Clarke V. Supporting best practice in reflexive thematic analysis reporting in palliative medicine: a review of published research and introduction to the Reflexive Thematic Analysis Reporting Guidelines (RTARG). Palliat Med. 2024;38(6):608–616. https://doi.org/10.1177/02692163241234800.
24. Crabtree BF, Miller WL. Doing qualitative research. 3rd ed. SAGE: Thousand Oaks, CA; 2023.
25. Kelly MA, Wicklum S, Hubinette M, et al. The praxis of generalism in family medicine: six concepts (6 C s) to inform teaching. Can Fam Physician. 2021;67(10):786–788. https://doi.org/10.46747/cfp.6710786.
26. Kawamura A, Harris I, Thomas K, et al. Exploring how pediatric residents develop adaptive expertise in communication: the importance of “shifts” in understanding patient and family perspectives. Acad Med. 2020;95(7):1066–1072. https://doi.org/10.1097/acm.0000000000002963.
27. Gardner NP, Gormley GJ, Kearney GP. Learning to navigate uncertainty in primary care: a scoping literature review. BJGP Open. 2024;8(2):BJGPO.2023.0191. https://doi.org/10.3399/BJGPO.2023.0191.
28. Lee A, Kennett S, Khera S, et al. Perceptions, practice, and “ownership:” experiences in continuity of the patient-doctor relationship in a family medicine residency. Can Med Educ J. 2017;8(4):e74-85. https://doi.org/10.36834/cmej.42288.
29. Konkin, Williams, Brooks, et al. Investigating clinical courage: an international survey of rural doctors. Rural Remote Health. 2025. https://doi.org/10.22605/RRH8852.
30. Peabody FW. The care of the patient. JAMA. 1927;(88):877–882. https://doi.org/10.1001/jama.1984.03350060057032.
31. Masava B, Nyoni CN, Botma Y. Scaffolding in health sciences education programmes: an integrative review. Med Sci Educ. 2022;33(1):255–273. https://doi.org/10.1007/s40670-022-01691-x.
Téléchargements
Publié-e
Comment citer
Numéro
Rubrique
Licence
© Martina Kelly, Kristy Penner, Aaron Johnston 2025
Cette œuvre est sous licence Creative Commons Attribution - Pas d'Utilisation Commerciale - Pas de Modification 4.0 International.
La soumission d’un manuscrit original à la revue constitue une indication qu’il s’agit d’un travail original, qu’il n’a jamais été publié et qu’il n’est pas envisagé pour publication dans une autre revue. S’il est accepté, il sera publié en ligne et ne pourra l’être ailleurs sous la même forme, à des fins commerciales, dans quelque langue que ce soit, sans l’accord de l’éditeur.
La publication d’une recherche scientifique a pour but la diffusion de connaissances et, sous un régime sans but lucratif, ne profite financièrement ni à l’éditeur ni à l’auteur.
Les auteurs qui publient dans la Revue canadienne d’éducation médicale acceptent de publier leurs articles sous la licence Creative Commons Paternité - Pas d’utilisation commerciale, Pas de modification 4.0 Canada. Cette licence permet à quiconque de télécharger et de partager l’article à des fins non commerciales, à condition d’en attribuer le crédit aux auteurs. Pour plus de détails sur les droits que les auteurs accordent aux utilisateurs de leur travail, veuillez consulter le résumé de la licence et la licence complète.
