Abstract
BackgroundPeople are increasingly living for longer with multimorbidity. Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. The impact of multimorbidity on the educational needs of doctors is little understood. There has been little critique of how learning alongside healthcare provision is negotiated by patients, general practitioners and trainee doctors. This study asked ‘what is known about how and why concurrent healthcare delivery and professional experiential learning interact to generate outcomes, valued by patients, general practitioners and trainees, for patients with multimorbidity in primary care?’MethodsThis realist synthesis is reported using RAMESES standards. Relationship-centred negotiation of needs-based learning and care was the primary outcome of interest. Healthcare, social science and educational literature were sought as evidence. Data extraction focused on context, mechanism and outcome configurations within studies and on data which might assist understanding and explain; i) these configurations; ii) the relationships between them and; iii) their role and place in evolving programme theories arising from data synthesis. Mind-mapping software and team meetings were used to aid interpretative analysis.ResultsThe final synthesis included 141 papers of which 34 contained models for workplace-based experiential learning and/or patient care. Models of experiential learning for practitioners and for patient engagement were congruent, frequently referencing theories of transformation and socio-cultural processes as mechanisms for improving clinical care. Key issues included the perceived impossibility of reconciling personalised concepts of success with measurability of clinical markers or adherence to guidelines, and the need for greater recognition of social dynamics between patients, GPs and trainees including the complexities of shared responsibilities. A model for considering the implications of concurrency for learning and healthcare delivery in the context of multimorbidity in primary care is proposed and supporting evidence is presented.ConclusionsThis study is novel in considering empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery. The findings should inform future interventions designed to produce a medical workforce equipped to provide multimorbidity care.Trial registrationPROSPERO International prospective register of systematic reviews CRD42013003862Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0234-9) contains supplementary material, which is available to authorized users.
Highlights
People are increasingly living for longer with multimorbidity
We describe novel findings and emergent programme theories arising from the synthesis before describing an explanatory model that interprets the synthesis data into a new emergent theory of how social interactions can function as mechanisms to trigger constructive transformative learning for patients, General practitioner (GP) and trainees with respect to multimorbidity in primary care
No papers identified contained empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery in a single model
Summary
Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. Healthcare and medical education has been delivered using index condition models, i.e. those focused primarily on a single disease with the inherent assumption this is the sole or pre-eminent clinical problem, and often defined in purely biomedical terms. Such models inadequately equip a medical workforce to collaborate with patients to address multimorbidity when the sum of multiple morbidities can have effects greater than the constituent parts [3]. The construct of doctors as healers, with cure the ultimate marker of success, remains a strong societal narrative, it is problematic in the context of multimorbidity arising from progressive incurable diseases
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