Emerging themes on GP view’s on multimorbidity and social complexity, and the patient-doctor relationship in Deprived Areas

Problem

The doctor-patient relationship has been the subject of much critical attention and there has been a shift in practice from the once paternalistic model to a more patient-centred one. The RCGP model has developed to reflect these principles with an expectation that the new approach is reflected in all GP-patient consultations. There has also been a move to empower patients by giving them more autonomy over their health, encouraging self-management, and promoting shared decision making. It is recognised this model may not suit all patients. For example, in areas of high socio-economic deprivation, patients are less likely to wish to take an active part in decisions regarding their care. Multimorbidity is also more prevalent as socio-economic deprivation increases. However, multimorbidity refers only to clinical diagnoses and not the attendant social complexity often more apparent in these areas. The proportion of practices that are post-graduate training practices is lower in deprived areas compared to those in more affluent areas. Qualitative interviews were carried out to ascertain the view of GPs working in deprived areas in Scotland on GP speciality training. As well as eliciting the views of these GPs on training the transcripts produced rich descriptive data of the experience of GPs working in deprived areas. The aim of this paper is to describe emergent themes from these transcripts regarding the patient-doctor relationship and the influence of social complexity, in the context of mulitmorbidity.

Approach

Ten in-depth interviews were carried out in practices in deprived areas across Scotland to ascertain views on GP speciality training. Data were audiotaped, transcribed and a thematic analysis was undertaken.Emergent themes relating to the patient-doctor relationship and social complexity were recognised during the original analysis. Two researchers (MM and SM) re-analysed the transcripts independently, to look more closely at these themes

Findings

Patient-Doctor Relationship:The GPs described how they felt the patient-doctor relationship was impacted by the areas they worked in. This included using paternalism in consultations as perceived patient preference, and that they felt their patients struggled with shared decision making. Building trust, and continuity, were recognised as key and required significant time to do.Social complexityThe significant impact of social complexity on multimorbidity, increasing GP workload and treatment burden, was universally described. The impact of social complexity (including low health literacy) was also felt to be a significant barrier to patient self-management.

Consequences

This small study highlights there is a perceived need to adapt the recommended patient-centred communication modelThe increased workload (often hidden) described is currently not being measured. The GPs also perceived increased burden on patients from social complexity, impacting significantly on their ability to self-manage. Further exploration is required to clarify these themes further.