Family medicine teaching strategy for managing patients with comorbidity

Evidence base

Despite the importance of comorbidity, most medical education across the continuum of undergraduate, postgraduate, and continuing professional development focuses on single diseases. Clinical guidelines largely address single diseases, and structured approaches to managing multiple illnesses or conditions are scarce.³ Doctors need to be educated in managing comorbidity,³ and physicians have identified numerous challenges related to providing care to patients with comorbidity that need to be addressed, such as lack of decision-making tools, managing multiple problems in time-constrained consultations, and assessing polypharmacy.⁶ A systematic review found only 2 studies describing comorbidity education for physicians; 1 study reported on a half-day workshop for qualified medical staff as part of continuing professional development, and the other described pre- and postworkshop evaluations by general practice residents.⁶

In this article we present the heuristic of collect, cluster, and coordinate to help family physicians teach undergraduate and resident learners about comorbidity in the family medicine clinic setting.

Teaching tips

Raise the topic. Learners may find managing comorbidity to be daunting; faced with a large patient file and a complex list of medications, learners may feel overwhelmed when asked to address Cynthia’s care in a brief consultation. For example, although learners may be aware of diabetes as a chronic disease and recognize its symptoms, risk factors, and complications, they are less likely to have been taught a systematic approach to managing diabetes that also takes her other chronic conditions into account. This can be compounded by lack of familiarity with health services available locally for Cynthia. Preceptors can help learners by flagging the topic of managing comorbidity as a specific learning objective.

Collect. Reassure learners that they do not have to do it all in a single visit. Where time is limited during a single visit, follow-up appointments can be scheduled. A key strength of family medicine is that problems are visited and revisited, forming the basis of continuity of care.

Collaborative goal setting is important; this includes clarifying the agenda for the visit as well as understanding the patient’s perspective and what matters to them.⁷ Generally, patients have an average of 3 concerns per visit,⁸ and they will often state them in the first 60 seconds of the consultation if given the opportunity. However, patients are often interrupted after stating their first concerns. Studies suggest physicians’ questions tend to be more effective when asked early in the consultation and linguistically formatted to ask about concerns; eg, “Do you have some other concerns?” in contrast to, “Do you have any questions?”^9,10 Apart from eliciting Cynthia’s concerns, learners can also benefit from asking what matters most to her—eg, quality of life, functionality, longevity—to clarify goals of care. However, goals may change over time and revisiting them periodically is also important.

Shared decision making can be used for the visit to set an agenda that reflects patient and physician issues¹¹ and to outline a plan, if needed, for addressing issues that may not feasibly be attended to in the immediate consultation. At this visit, the learner will want to check Cynthia’s blood pressure; they may or may not know that Cynthia’s agenda includes hot flashes until after she is in the consultation room. While we often think learners are familiar with basic communication strategies, direct observation of learners (even for this part of the visit) can help identify ways they can hone skills in agenda setting with patients who have multiple health issues.

Increasingly, family physicians work in teams, and demonstrating to learners how team members work to collect different aspects of a patient’s care can help learners recognize the benefits of the Patient’s Medical Home approach. This can be achieved by asking who else could be involved with Cynthia’s care and by encouraging learners to attend visits with different team members to better understand how they work together.

Cluster. Preceptors can help learners see patient problems as a set of clustered diseases in the same person rather than as a random assortment of individual conditions to be managed separately. Several strategies can help learners cluster issues. In Cynthia’s case, illnesses sharing common pathology, such as metabolic disorders and autoimmune disorders, could be clustered together. Medications can be clustered according to therapeutic group or mechanism of action to help learners think about drug-drug interactions or to identify polypharmacy, which could lead to conducting risk-benefit analyses for ongoing medication use and to optimizing or potentially deprescribing medication.

Using complementary approaches such as the biopsychosocial model or listing problems as immediate, active, or inactive can help learners group issues together and develop an approach to managing multiple issues. At this visit with Cynthia, hypertension and hot flashes may be the more immediate problems, while chronic obstructive pulmonary disease, diabetes, depression, and rheumatoid arthritis will be less active if currently well controlled.

Coordinate. Patients with comorbidity often access care in numerous settings. From Cynthia’s perspective, attending appointments with multiple services can be exhausting and stressful, such as if she were to have 2 appointments in different hospitals on the same day. Practicalities such as transportation, getting time off work, or having an accompanying companion can be logistically challenging. Where available, a Patient’s Medical Home team may allow Cynthia access to services in the local community with the added advantage of shared communication among team members. For Cynthia, involving other team members, such as a chronic disease management nurse or pharmacist, could help with disease monitoring and medication management. Learners can also explore with Cynthia and her circle of support how they participate in self-managed care. Team members could help coach Cynthia to become more active in her health care by knowing more about her health conditions or by keeping track of her information accurately in a binder or app.

Family physicians are often responsible for care coordination and have administrative systems in place to support ongoing monitoring of patient care. Making this hidden work explicit helps learners appreciate how important effective organizational structures are to patient care. For example, when a learner writes a referral letter, they may not know what happens to it; communicate the importance of receiving acknowledgment of referral, documenting and communicating appointment times, advocating for earlier appointments when needed, waiting for correspondence, and organizing next stages of follow-up. Having a learner spend time with a medical office assistant can illuminate the complex communication required to coordinate care. Additional system-level coordination may include giving longer appointments to patients, scheduling regular visits with the same practitioner, documenting follow-up tasks in the electronic medical record, or coordinating care with other members of the primary care team, such as a chronic disease nurse or a pharmacist for an annual medication review. Having frank discussions with learners about billing for appointments involving comorbidity is also important. Learners can participate in daily huddles with office staff where communication about coordination takes place and follow Cynthia through visits with other team members. It can also be helpful to discuss with learners how coordination of care for Cynthia may look in practices without electronic medical records or in rural and remote communities with fewer local resources.

An outline of how preceptors could help learners adopt a collect, cluster, and coordinate approach is provided in Table 1, using Cynthia’s presentation as an example.