1. Introduction
In recent years, there has been a worldwide increasing interest in multimorbidity [
1], and this is understandable because of its high prevalence [
2] and negative consequences, as multimorbidity is ultimately responsible for 63% of all deaths worldwide [
3]. Multimorbidity, the presence of multiple chronic conditions or diseases in the same individual [
4,
5,
6], is becoming progressively more common [
7]. Currently, an estimated 50 million people in the European Union suffer from multimorbidity [
8], making it the most common chronic condition [
5]. Also, in America, the number of people with chronic conditions is projected to increase steadily for the next 30 years [
9]. In a recent study in Portugal the prevalence of multimorbidity in primary care was above 70% in adult patients [
10].
Multimorbid patients have a higher number of primary care consultations and health-related costs [
11]. This has significant implications for the healthcare system and patients’ quality of life [
12,
13]. Multimorbidity is thus a major challenge to primary care [
14]. Nonetheless, general practitioners (GPs), practising closely to the community, are highly-trained to provide appropriate and cost-effective care for patients across their life span [
14,
15].
Evidently, primary care will play a significant role in future strategies to deal with multimorbidity. For the development of interventions for improving outcomes in multimorbid patients, it is important to assess GPs’ experiences and opinions regarding multimorbidity and its management [
16,
17].
To date, qualitative studies that have explored the lived experiences of GPs did not find a single unifying result [
18]. This may be the consequence of different research methods and distinct health care systems studied. Consequently, interventions towards multimorbidity in primary care in Portugal will have to take into account the country’s own health care particularities, which are known to local practising GPs. Most of the Portuguese population has health care coverage [
19] and the primary care centre is commonly the first point of contact with the public system [
20]. GPs in primary care centres provide the following services: “general medical care for the adult population; prenatal care; children’s care; women’s health; family planning and perinatal care; first aid; certification of incapacity to work; home visits; preventive services, including immunization and screening for breast and cervical cancer and other preventable diseases” [
20] (p. 100). GPs also act as gatekeepers, and the referrals to secondary care are made through them [
20].
Portuguese GPs’ views and attitudes will be used to inform health care policy and potential interventions and will also add to the existing international knowledge regarding multimorbidity in other National Health Services with a gatekeeping system in place.
The main aim of this study was to access GPs’ knowledge, awareness, and practices regarding multimorbidity and its management. The second objective was to evaluate the clarity and usefulness of the European General Practice Research Network (EGPRN) definition of multimorbidity [
21], recently translated to Portuguese [
22]. This is a comprehensive concept of multimorbidity [
23] that may have a positive contribute for a future consensual definition. A consensus will be important for the comparability of results across studies. The third objective was to study if providing informational material depicting results of our previous studies on multimorbidity, would change current GPs’ views on the subject.
4. Discussion
The current study found high levels of awareness regarding multimorbidity within its participants. In accordance with available literature [
21,
38,
39], no universally accepted definition of multimorbidity was found, and the concept was heterogeneous between respondents [
39]. Interestingly, none of the definitions were incorrect. This highlights the complexity of this area of research and also the importance of finding a consensus on how multimorbidity is defined.
When queried about the EGPRN’s definition of multimorbidity (Portuguese translation [
22]), the sample recognized the clarity and usefulness of the definition for primary care settings. This result may be explained by the fact that EGPRN’s definition is comprehensive [
21], more adapted to the complexity of the multimorbid patient [
23], and eventually superior for clinical purposes than the commonly used definition of co-occurrence of two or more long-term conditions in the same patient [
40].
This study adds to findings from previous studies of GPs’ views and attitudes in multimorbidity [
16,
17,
18,
41,
42,
43,
44]. To our knowledge, this is the first study of its kind done in Portugal. Our sample included sufficient variation in sex, age, academic degree, career level, experience in primary care, and practice type, which provided a deeper understanding of GPs’ subjective perceptions. All respondents were practising physicians and therefore provided real-world data.
A shared view amongst respondents was that multimorbidity is very common and associated with old age, which supports former qualitative research reporting GPs’ perspectives [
41] and is consistent with data obtained from epidemiologic studies [
10].
GPs pointed out several difficulties and challenges while managing multimorbidity. As expected, common consequences of these drawbacks are a significant burden related to patient management and the toll on patient care [
16,
41,
43].
Perceived difficulties and challenges could be classified on the basis of their relation to the GP or the patient into two types, extrinsic and intrinsic.
Extrinsic factors were associated with the healthcare system logistics management (consultation time, organization of care teams, clinical information) and society (media pressure, social/family support). These practical issues seem to be consistent with the ones identified in earlier studies [
43,
44], with the exception of the “media pressure” topic that has not previously been reported in multimorbidity. Partial media coverage may have a negative impact on patient care [
45] and although austerity measures are associated with increased mortality [
46], in the last few months Portugal’s healthcare system was targeted by the media concerning cuts in the health service and mortality cases [
47], which consequently may put pressure on physicians in general and particularly on GPs that manage complex multimorbid patients. This will certainly require further study.
The perceived extrinsic factors demonstrate the necessity for longer consultations [
18,
41,
42,
48]. In Portugal, the average consultation length in general practice is approximately 15 min [
49,
50], similar to Belgium and Switzerland, and longer than Germany, Spain, the Netherlands, and the United Kingdom [
51]. Usually GPs do not have enough time to manage patients with chronic diseases [
52], but when they do, it decreases GPs stress and increases patient enablement [
53]. If impossible, GPs may adopt time-management strategies [
54] and take advantage of efficient health information technologies [
55] to warrant more effective consultations. There is also the need for team-based care [
56] that includes other co-workers in addition to the GPs (e.g., psychologists, nutritionists, dentists, care coordinators, etc.), cooperation with families and social organizations for better patients’ social support [
43,
44], and improvement of referral systems for hospital care [
43]. In Portugal, there is a known lack of coordination between specialist care and primary care with a large number of patients bypassing their GP by visiting emergency departments [
20]. The referral rate from primary to secondary care is approximately 6% [
57,
58], which is similar to the situation in Spain [
59]. The waiting times for specialist care may vary widely from one to six months [
60], and feedback from secondary care providers is received in less than 40% of the cases [
58,
60,
61].
Intrinsic factors related to the GP, patient, and physician-patient relationship were also stated. In the recent review of Cottrell and Yardley [
18] and in the present study, GPs acknowledged the complexity in managing multimorbidity with an increasing workload [
41,
44,
62]. GPs faced difficulties and challenges in delivering holistic care [
16], they experienced feelings of inability to help considering existing resources, and stated lacking competences in dealing with multimorbidity [
41,
43,
44], including uncertainty on how to recognise what conditions and outcomes are most important for the patient and for the GP, how to avoid treatments that lack solid supporting evidence, and how to deprescribe. Inadequacy of guidelines and polypharmacy were also mentioned as major therapeutic challenges, as shown in previous studies [
16,
44]. Difficulties in communicating with multimorbid patients, frequently elderly and individuals with low education levels, may be the reason of poor patient engagement. Some researchers have emphasized that physicians with better communication and interpersonal skills are able to perform more quality consultations [
63].
Characteristics fundamental to family medicine [
15] were mentioned by the respondents in an extremely positive and optimistic way as the tools that could be used in daily practice to manage the challenges of multimorbidity. The current results match those of Le Reste et al. [
23], which indicated that GPs consider these characteristics as a valid contribute to the detection and management of multimorbid patients [
23]. In the study of Luijks et al. [
17] and in the present study, a person-centred approach was considered to be the crucial intervention strategy for multimorbidity. A key element of such an approach in family medicine is the “understanding of the patient as well as his disease” [
64] (p. 24). Some researchers have highlighted the value of individualised care not only for GPs but also from the patients’ perspectives [
18], including a better physician-patient relationship [
65].
The informational material provided concerning data on multimorbidity in Portugal was able to increase consciousness regarding the importance of multimorbidity and at the same time was capable of driving change in the way GPs deal with multimorbidity and multimorbid patients in their daily practice. This material was well received by the GPs. One respondent, a GP 62 years of age, made the following final comment: “There should be more studies like these. Researchers should whenever possible disseminate the results of their previous studies and ask for opinions as did this colleague of ours. Thank you and congratulations.” Providing short informational materials to GPs may also be one way to bring together clinical research and clinical practice, which in turn benefits patients and healthcare as a whole [
66].
The main limitations in this study are similar to the ones presented in previous qualitative studies regarding GPs’ perceptions of multimorbidity. Although not the objective of the study, current data does not directly evaluate GPs’ daily practices but only what they perceive they do [
16]. Future research with a different design should be undertaken to investigate this further. Patient views and also their caregivers were not sought in the current study and will require consideration in following research [
16] in Portugal.
Filipe Prazeres 1,2,* and 
