چکیده (انگلیسی):

Background:People 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?’
Methods:This 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.
Results:The 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.
Conclusions:This study is novel in considering empirical evidence from patients, GPsandtrainees 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 registration:PROSPERO International prospective register of systematic reviews CRD42013003862