About a week ago I read an interesting article in the August Journal of Comorbidity entitled: Training doctors to manage patients with multimorbidity: a systematic review http://jcomorbidity.com/index.php/test/article/view/87/308 Only two studies satisfied their criteria for inclusion and these were about Multimorbidity workshops. One of the studies appeared to favour workshops over online modules but both studies were judged to be at risk of bias because of methodology so it is hard to draw conclusions apart from that more research is needed (noting the paucity of research in this area generally). It is certainly challenging to conduct research and evaluation in this post-graduate context.
Multimorbidity is a clinical area of interest for me and one where I introduced teaching for GP registrars a while ago so I was motivated to look at this again. I thought that this blog should not just raise topics in medical education but could also introduce some ideas about teaching specific clinical topics given that different methods may be more appropriate to different disciplines. The issue of the teaching of the topic has emerged following the increasing recognition of multimorbidity as a growing challenge for the health care system, not to mention its funding. At some point clinicians and educators started to realise that multimorbidity was more than the sum of its parts and this is very relevant in an era of sub-specialisation. Some educators are also concerned that GP registrars do not have adequate experience managing complex older patients so in 2014 I decided to trial and evaluate a specific teaching approach. In the process we also looked at registrars’ clinical experience plus feedback from them and from supervisors about what is actually perceived as useful in GP training in this area. We collected the usual routine feedback and evaluation data that you tend to collect as part of a commitment to quality improvement and augmented this with some specific questions about how the approach worked (because it was different).
In this, and a couple of other posts, I’ll look at
- A framework for a workshop program
- GP registrars and multimorbidity
- Practice teaching ideas and multimorbidity teaching overall
A framework for a workshop session
Given the pessimism around both managing and teaching multimorbidity, and my conviction that the negatives are somewhat overplayed, we took an optimistic and evidence-based approach which built on the co-morbidities already well-covered in training (eg hypertension, diabetes, hyperlipidaemia, chronic renal disease, COPD etc). We treated guidelines as a resource for clinical judgment but emphasised the primacy of being patient-centred. This is overt in the guidelines from the American Geriatric Society https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450364/ and is even more appropriate in general practice. The structure was as follows:
- We followed a Flipped Classroom model with pre-viewing of some online resources (links, powerpoints) on a blog site which had been set up previously for aged care, polypharmacy and multimorbidity. This introduced the concepts to registrars. It could also be accessed at any time after the session.
- A conceptual matrix for thinking about Multimorbidity was presented briefly at the workshop http://www.bcregan.com/MM/ In later sessions this was presented just as a few powerpoint slides.
- A specifically designed multimorbidity template (updated more recently) for management planning was used in small groups in order to work through registrar cases and / or pre-prepared cases.
- Registrars completed feedback forms in order to evaluate the process and the usual feedback on achievement of Learning Objectives was completed.
The “matrix” model was presented at an AMEE conference in 2014. http://www.amee.org/getattachment/Conferences/AMEE-2014/AMEE-2014-APP-Data/10H-SHORT-COMMUNICATIONS.pdf It was used as a conceptual framework for thinking and learning rather than as a clinical tool and was an attempt at a 2D version of the multi-dimensional thinking and multi-tasking that goes on when managing patients with multimorbidity. It was a reminder to think about:
- The interactions between conditions, between medications and between conditions and medications
- The knowledge gaps that might exist for the doctor
- The relevant guidelines
- Patient information resources
- The patient perspective in negotiating management decisions (the most important aspect)
The matrix gave contrasting examples of “easy” and “complex” patients with five co-morbidities. In some ways it was an attempt to simplify complexity – but not too much – and add a conceptual framework to something that can appear random or chaotic.
These were reported on at the GPTEC conference in Hobart in 2015 Teaching multimorbidity is important, do-able and effective and requires a multi-pronged approach. multimorbidity-gptec-aug-2015
The feedback was positive. The small-group discussion was judged to be valuable and pre-prepared cases were the most useful. The most surprising incidental outcome was that subsequent Learning Plans were noted to include several which (unusually) listed managing multimorbidity as a priority!
In this first twelve months the multimorbidity session was run separately for both Term 1 and Term 3 registrars.
- 75% Term 1 and 50% Term 3 accessed the online resources prior to the session
- Interestingly the overall package was evaluated more highly by Term 3 (an average rating of 4.7, on a scale of 1-5, in agreeing to the statement that The session (online resources, ppt and small gps) presented a potentially useful way of looking at patients with multimorbidity
- Learning objectives were evaluated after the sessions and, again, Term 3 were more likely to agree strongly that these were achieved (ratings of 4.1 to 4.6)
- Both groups found the small groups helpful
- Free text comments showed that the “patient-doctor agenda” focus had been appreciated and some new concepts were found to be useful.
- Comments and ratings raised the issue of timing – whether the most effective learning in such a complex area occurs rather later in training after gaining some clinical exposure (and despite the fact that they were less likely to access the online resources prior to the session). This would be a good topic for future research. However, funding is focussed on Terms 1 and 2.
Given that most learning occurs in the practice environment we then turned our attention to that aspect. Meanwhile we continued evaluating the approach over the twelve months and monitored the registrars’ confidence levels. We thought this was important because a lack of confidence is probably the first barrier that hinders initial engagement with the area. Once registrars are engaged, and if not feeling too intimidated, we reasoned that they would identify learning needs and respond to them. In addition, it is not a simple area in which to assess “knowledge”, and “effective management” is extremely difficult to measure.