As a General Practitioner, achieving success demands a blend of medical proficiency, proficient communication, and business acumen. The healthcare sector is continually changing, and as a GP, one must adjust to new obstacles while providing top-notch patient care. In this article, we will examine crucial tactics that can enable GPs to prosper in their profession and create a beneficial influence on their patient's well-being.

General practitioners perceive clinical practice guidelines as being better suited for secondary care rather than primary care, as they tend to focus solely on managing specific diseases. This can sometimes make the guidelines "reductionist," which means they may not be a reliable basis for making therapeutic judgments. GPs have observed that guidelines do not take into account the cumulative effects of prescribing multiple drugs for related diseases. As a result, they must carefully consider the advantages and disadvantages of each specific treatment cocktail for every patient. This means that GPs recognize that treating one issue may potentially worsen or even cause new issues for other ailments.

General practitioners expressed concerns that following separate guidelines for each ailment may compromise the safety of patients due to polypharmacy, overdiagnosis, and overtreatment. This approach may also overload patients with therapy, leading to potential issues with patient adherence.

A medical professional noted that reducing the number of medications prescribed to patients with multiple health issues can be a challenging process that requires careful consideration. This is especially true when deciding whether or not to discontinue preventative medications for elderly or gravely ill patients. There are numerous factors to consider, such as the benefits of the medication versus the patient's life expectancy and quality of life. It is important to strike a balance between these considerations, while also taking into account statistical concepts such as absolute and relative risk reduction, the number of patients who need treatment, and the time required to see results. Adequate decision support is necessary to ensure safe and effective deprescription.

General practitioners (GPs) have identified the clinical trial methodology's focus on internal rather than external validity as the reason for the lack of practical and generalizable multimorbidity guidance. The GPs noted that the guidelines often rely on clinical studies that involve younger and less complex patients than those they typically treat in their clinics. As a result, they are aware that the recommendations may not apply to their patients with multiple conditions.

Protocol-driven medicine vs clinical judgment

General practitioners often hold varying views on the feasibility and desirability of implementing evidence-based medicine principles in the context of multimorbidity. These differing opinions are evident both within and across studies. Some GPs leverage their understanding of the limitations of available evidence to prioritize their clinical discretion and professional autonomy. They believe that the complexity of multimorbidity allows them to utilize their experience and unique insights as doctors to better assist their patients. Without this freedom, evidence-based medicine would be more closely tied to their practice.

Some doctors see following guidelines as an obstacle to patient-centered care, despite appreciating them. They believe that guidelines only touch upon the disease and not the whole patient. Certain GPs feel that strict adherence to regulations serves as a protective measure against any legal or professional challenges to their judgment. They adopt a defensive approach and refer to the book to justify their actions. This type of "defensive medicine" is also used when doctors feel the need to deviate from recommendations.

According to some doctors, they often ignore recommendations due to the overwhelming amount of information they receive and a lack of time or interest to review it. This is different from the mindset of general practitioners in countries where following guidelines is mandatory, even if it doesn't match the specific situation. Studies from Australia and New Zealand have shown this contrast. A GP from the Netherlands stated that they struggle to deviate from guidelines unless there are valid reasons to do so. In Norway, doctors see pressure to follow all standards as insecurity caused by being trapped in a guideline "hell".

Clinical uncertainty and perception of risk

General practitioners (GPs) are aware of the potential risks that come with making decisions in situations where there is not enough evidence to provide significant security. This scenario is known as "doing it without significant evidence-based security." It is common for GPs to feel nervous, anxious, or worried about making mistakes and potentially harming their patients or the public. Consequently, GPs may adopt either a "risk to be reconciled" or a "risk to be avoided" approach, as described by Anderson. Positive or bad prior experiences may have strengthened these inclinations.

General practitioners emphasize the importance of building and maintaining a strong relationship with their patients. Patients prioritize this connection above all other aspects of care because they believe it enhances consultation and treatment outcomes and reduces problems associated with multiple health conditions. The doctor-patient relationship can serve as a valuable starting point for understanding patients and their unique living circumstances. This increased understanding can lead to more personalized care for each patient based on a deeper understanding of their needs, treatment options, life goals, and personal values.

Building and safeguarding a continuous patient-GP relationship

General practitioners consider building and maintaining a lasting therapeutic relationship with their patients with multiple health conditions as a crucial aspect of patient care. By understanding the patient's social and psychological factors that may impact their treatment, GPs can view them beyond their current illness. This long-term collaboration is also a valuable solution to the limited consultation time GPs can offer. According to Damarell et al. GPs can provide more thorough care when they have extended consultations with their patients.

It's much easier to develop a relationship with patients when you see them regularly for chronic conditions. This helps you avoid dealing with everything at once and allows the patient to build trust with you. Over time, they become more comfortable sharing their concerns with you, which happens quite often.

Tailoring care to each patient’s unique circumstances and illness experience

Doctors who have a close relationship with their patients can tailor their care to fit their individual needs, even if it deviates from standard guidelines. This personalized approach takes into consideration the patient's ability to handle the financial, emotional, and physical demands of any treatment plan. By maintaining a long-term relationship with their patients, doctors can offer empathy and support during their illness. Some doctors have developed strategies to ensure that both they and their patients are protected, such as involving other healthcare professionals in the patient's care or prioritizing and managing different problems during a consultation. If there isn't enough time to address all of the patient's concerns, any unresolved issues can be addressed in a follow-up appointment.

During consultations, General Practitioners (GPs) may use a "safety netting" method to minimize risks if they are uncertain about the best course of action but are concerned about patient safety. However, this method prioritizes the GP's agenda for the consultation over that of the patient, advising the patient accordingly. Another strategy that GPs use is to identify any common causal pathways between the patient's conditions and focus on treating them. This approach can be presented to the patient as a solution to multiple problems, and the GP can provide guidance on symptoms to watch for and contingency plans in case of any worsening conditions between consultations.

General Practitioners (GPs) offer various recommendations for enhancing the experience of multimorbidity for both themselves and their patients. These recommendations include acquiring more evidence and knowledge, collaborating with other healthcare professionals, having sufficient consultation time, and adopting a different approach to care planning and coordination.

More evidence and knowledge

General practitioners require evidence-based guidelines for prescribing and deprescribing medications for patients with multiple health conditions, especially the elderly. They believe that integrating single-disease guidelines and involving more GPs in their development would enhance their applicability for multimorbidity. Additionally, they request improved reporting of external validity, guidance on prioritizing preventive measures, and access to clinical decision support tools. To enhance their patient-centered care for multimorbidity, GPs may benefit from attending knowledge exchange meetings, refresher courses, or post-academic courses.

Collaboration with other health professionals

General practitioners (GPs) were pleased with the concept of collaborating more closely with pharmacists to deprescribe and conduct drug reviews. It is crucial to conduct drug reviews for everyone and working with a pharmacist is an intelligent choice as they can provide an additional perspective. Two sets of eyes on the same matter usually led to more favorable outcomes compared to just one person examining a patient. GPs envisioned better communication and support for both themselves and their patients through a multidisciplinary approach, along with enhanced cross-sector collaboration.

Adequate consultation length

General practitioners have suggested that longer appointments should become the norm for patients with multiple chronic conditions, allowing for more personalized consultations. By providing at least 30 minutes of consultation time, patients may be able to communicate their concerns more effectively, potentially reducing the need for frequent follow-ups. It would be beneficial to allocate a 40–45-minute time slot for these patients to ensure adequate attention is given. However, doctors have not yet proposed any specific changes to the existing structures, regulations, or payment systems that would support extended consultation hours.

Changed approach to care planning and coordination

General practitioners have expressed the need for treatment plans that take into account multiple health conditions (multimorbidity). These plans should be formalized, negotiated, and explicit agreements between patients and GPs. They should include the patient's goals, concerns, and unique care strategies, and ideally be available digitally. GPs have also suggested engaging care coordinators more frequently to help patients navigate the different healthcare providers and sectors. This role can be filled by a single GP who focuses on improving care plans and creating practical solutions to enhance care coordination.

How GPs perceive their role

General practitioners (GPs) have a crucial role in caring for patients with multiple health conditions. They prioritize holistic care within the biopsychosocial context through a patient-centered approach. This approach aims to comprehend the patient's illness experience, establish common ground, and build a compassionate and trustworthy relationship between the doctor and the patient. This approach aligns with the Sage Consultation Model, which utilizes research, patient, and professional information to create a personalized account of the illness.

General Practitioners place great importance on building relationships with their patients, as this helps to establish trust and understanding over time. They believe that maintaining continuity of care is essential in managing complex health issues and making difficult diagnoses. Studies have shown that having consistent interpersonal connections with their GP can lead to reduced mortality rates, fewer emergency visits, and hospitalizations. Unfortunately, this continuity of care is becoming increasingly difficult to maintain due to factors such as a shortage of GPs, part-time work, government policies prioritizing access to care over continuity, and the expansion of primary care teams into larger practices.

Australian GPs have expressed concerns about integrating pharmacists into their practices, despite recent reviews showing benefits. They want closer ties with pharmacists for medication reviews to address uncertainty in prescribing and lack of consultation time. However, the uptake rate varies by country, with some initiatives like NHS England and the Australian government funding community pharmacists. The role of a practice nurse/nurse practitioner is not mentioned, possibly due to its prevalence in the countries studied. Longer appointments for complex patients are emphasized for better patient enablement and reduced workload stress, but evidence supporting this is mixed. GPs also suggest addressing common risk factors like obesity, smoking, and inactivity, but providing adequate training to GPs remains unresolved.

The issue of multimorbidity is on the rise, and General Practitioners (GPs) are critical in managing patients with multiple health conditions. However, GPs are facing difficulties in dealing with these patients, which can lead to burnout and loss of professionals in the field. This raises concerns about patient safety and the future of general practice. The Royal Australian College of General Practitioners has emphasized the importance of supporting GPs in their role as health caretakers and enhancing their ability to provide comprehensive, patient-centered care. GPs require more support, better remuneration schemes, and structural changes to establish long-term relationships with their patients. This may require significant reforms in government policies and models in place.

This research advances knowledge of the challenges faced by general practitioners while delivering primary care to multimorbidity patients. The age of the earliest publications emphasizes how slowly healthcare system adjustments are being done to enhance GPs' work environments and the caliber of care given to more complex patients. If we want to maintain healthy primary care systems, we must pay attention to its practitioners, comprehend their concerns, and work cooperatively to eliminate obstacles that prevent them from providing individualized, patient-centered care. An emphasis on multimorbidity education opportunities for GPs and their primary care teams, as well as modifications to primary care models and their financial compensation structures, may also be necessary.