We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires fl exibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and fl exible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would defi ne common goals, cocreate care plans, and engage in refl ective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients. INTRODUCTION Delivering primary care to patients with multiple morbidities is challenging.1 These patients typically consult multiple clinicians, use multiple medications, and compared with patients with a single chronic illness, have higher psychological distress, longer hospital stays, increased use of emergency facilities, and higher rates of mortality. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] Clinicians who care for them face competing demands, complexities of polypharmacy, diffi culties in applying practice guidelines, and increased potential for errors. 22,23 Clinicians also face increased diagnostic and treatment challenges as different combinations of conditions can interact in unpredictable ways. [24][25][26] These challenges occur in the context of comprehensive primary care that includes preventive care, coordination of specialist care, and consideration of patients' priorities in a longitudinal, mutually trusting relationship. 26,27 These challenges are only partially addressed by accurate disease-specifi c data and clinical guidelines: the former cannot guide comprehensive decision making that acknowledges patients' preferences and life context, while the latter are often irrelevant for patients with multimorbidity.28 Our guiding premise in this article is that caring for these patients is often a Hassan Soubhi, MD C A R ING F OR PAT IENT S WI T H MULT IM OR BIDI T Yknowledge-intensive activity which requires amplifi cation of existing professional know-how and insights into coordinating complex assessments and continuous interprofessional care that often goes beyond biomedical needs. We propose a practice m...

BackgroundExperts estimate that the prevalence of antibiotics use exceeds the prevalence of bacterial acute respiratory infections (ARIs).ObjectiveTo develop, adapt and validate DECISION+ and estimate its impact on the decision of family physicians (FPs) and their patients on whether to use antibiotics for ARIs.DesignTwo-arm parallel clustered pilot randomized controlled trial.Setting and participantsFour family medicine groups were randomized to immediate DECISION+ participation (the experimental group) or delayed DECISION+ participation (the control group). Thirty-three FPs and 459 patients participated.InterventionDECISION+ is a multiple-component, continuing professional development program in shared decision making that addresses the use of antibiotics for ARIs.Main outcome measuresThroughout the pilot trial, DECISION+ was adapted in response to participant feedback. After the consultation, patients and FPs independently self-reported the decision (immediate use, delayed use, or no use of antibiotics) and its quality. Agreement between their decisional conflict was assessed. Two weeks later, patients assessed their decisional regret and health status.ResultsCompared to the control group, the experimental group reduced its immediate use of antibiotics (49 vs. 33% absolute difference = 16%; P = 0.08). Decisional conflict agreement was stronger in the experimental group (absolute difference of Pearson's r = 0.26; P = 0.06). Decisional regret and perceptions of the quality of the decision and of health status in the two groups were similar.Discussion and conclusionsDECISION+ was developed successfully and appears to reduce the use of antibiotics for ARIs without affecting patients' outcomes. A larger trial is needed to confirm this observation.

BackgroundThe misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care.MethodsA pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program.ResultsAmong 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%.ConclusionsThis trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making.Trial RegistrationClinicaltrials.Gov NCT00354315

BackgroundFocused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents’ proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone.MethodsJunior residents (n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents (n = 15) were the traditionally trained group and were not provided with the educational interventions.ResultsAfter the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher’s exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher’s exact test p = 0.0055).ConclusionsOur study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.

Reflection is the mechanism by which we contemplate and try to understand relatively complex and sometimes troubling ideas for which there is no obvious solution. Reflection allows us to transform current ideas and experiences into new knowledge and action. Personal experiences and organizational feedback can trigger reflection, whereas a lack of time, available colleagues, and social networks detract from the ability professionals have to reflect. Educational programs can encourage reflection through the judicious use of case-based discussion, formal and informal needs assessments, and commitment to change exercises. Learning journals and personal learning projects are self-directed methods that facilitate reflection. In the workplace, critical incident techniques and debriefing of cases provide opportunities for thoughtful inquiry. Additional study is needed to understand how and why reflection works to transform surface learning into deep learning and change in practice; how reflection enhances the integration of reading, collegial interchange, and classroom discussion into practice; and how technology can enhance reflection.