Primary Care Physicians' Decision-Making Processes in The

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PEER REVIEW HISTORY BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from

BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below.

ARTICLE DETAILS

TITLE (PROVISIONAL) Primary care physicians’ decision-making processes in the context of multimorbidity: protocol of a systematic review and thematic synthesis of qualitative research. AUTHORS Rodrigues, David; Sousa, Paulo; Basílio, Nuno; Antunes, Ana; Antunes, Maria da Luz; Santos, Maria Isabel; Heleno, B

VERSION 1 - REVIEW

REVIEWER Carol Sinnott University of Cambridge, UK REVIEW RETURNED 18-May-2018

GENERAL COMMENTS Will quality assessment be used to exclude studies? A number of cognitive reasoning models are discussed in the introduction – how will these be used in the analysis? Clarify how you will deal with studies on decision-making in the context of co-morbidity. Attention is needed with language and syntax throughout (e.g. use of dysrationalia). In your primary studies, will you extract all data for analysis or just http://bmjopen.bmj.com/ that related to decision-making? How will you delimit data on “ decision-making” as being different from any other data dealing with GPs’ views/perspectives on clinical care of patients with multimorbidity? In the discussion, page 9 paragraph 3 you mention that you are using this review to test a hypothesis. How will you use your data to test this hypothesis?

Further to the last point, how do you judge “flaws” in decision on October 2, 2021 by guest. Protected copyright. making for multimorbidity? Against what benchmark can you say if decision-making for patients with multimorbidity is optimal or not? A limited numbers of terms are proposed for the primary care/general practice and the decision-making strings of the search; perhaps this is a pragmatic decision, favouring speed over breadth of search but this should be addressed in the text. For example, you mention family physicians in the methods section but this is not one of the terms in the search. Multimorbidity is a MeSH term now- it does not appear that this is included in the search. Prior work on cognitive biases in primary care is available in this review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093937/ There is a slight contradiction in the aims- you seek to understand what “primary care physicians perceive to contribute for better decision-making with patients with multimorbidity and which are the main barriers in this process”. But you are also interested in system one decision-making which is intuitive rather than conscious. Do you think PCPs will be able to describe the influences on their BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from system 1 decisions? How will this issue affect your data?

REVIEWER Tim Stokes Department of General Practice & Rural Health, Dunedin School of Medicine, University of Otago, New Zealand REVIEW RETURNED 28-May-2018

GENERAL COMMENTS This paper is a study protocol. It reports a planned systematic review and thematic synthesis of qualitative research - GPs/FM/PHCPs accounts of managing patients with multimorbidity. The research question focuses on medical decision making between patient and practitioner.

Overall the systematic review itself if appropriately designed and reported.

The following points need addressing:

1. There is a need for more clarity on the aims and research question (objectives) and why the methods chosen can address these. (p. 5, LL1-7). The overall aim is appropriate. The specific research question, as worded, seems to be too specific and makes assumptions about what will be found in the qualitative synthesis in advance (e.g., "what info do PCPs perceive to contribute ...")

2. Related to (1) above, I am unclear exactly how system 1 and system 2 thinking (introduction) will actually be explored and synthesised during the review process. This needs more clarification both in introduction and in objectives section.

http://bmjopen.bmj.com/ 3. The abstract needs re-wording to reflect fact that the research focuses on General Practitioners/Family Medicine/PC practitioners.

4. Overall the quality of the written English is acceptable. However there are instances throughout the paper of grammatical errors.

on October 2, 2021 by guest. Protected copyright. REVIEWER Sophie Hill Centre for Health Communication and Participation, La Trobe University, Australia. REVIEW RETURNED 01-Jun-2018

GENERAL COMMENTS This is a protocol for a qualitative evidence synthesis (QES) that could make a very valuable contribution to literature and practice, given the severe neglect by researchers of the challenges of multimorbidity (MM) both for doctors and for patients. TITLE: When I read the title I assumed it was a QES about both doctors’ and patients’ experiences of decision making in the context of MM – but it is in fact only focussed on doctors. This is perfectly fine but I suggest a small re-phrasing the title to: ‘Primary care doctors’ decision making processes in the context of multimorbidity: protocol … ‘ etc. STRENGTHS AND LIMITATIONS: I agree that you have to note a BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from limitation but I do not think a focus on doctors treating people with multimorbidity is a limitation – it is a major strength, given the dearth of relevant research and guidance. Is there something else you could say for a limitation of method? One possible option is to say that you will only be considering doctors’ experiences of decision making for MM and that another review would be needed for patients’ experiences of MM. RATIONALE: I really liked to introduction to this protocol. METHODS – SEARCH STRATEGY: You state you will be considering all relevant studies that fit your inclusion criteria. I don’t expect this will be too large a number but had you anticipated that you may find 50-100 studies – and considered what you will then do or if you should sample from the set? Perhaps you could add a comment on this issue as sampling has been a strategy needed in some QES topics. STUDY RECORDS – OUTCOMES AND SYNTHESIS STRATEGY. I did not understand this sentence, so could you please consider explaining this a bit more, particularly the term’ textual pooling’. The sentence is ’The findings will be presented in a narrative form, where textual pooling is not possible’. OVERALL COMMENT: The protocol is written in clear English for the most part but I would recommend that you give it to a colleague with high English proficiency as there are a few terms that could be better expressed.

VERSION 1 – AUTHOR RESPONSE

Reviewer: 1

First, we would like acknowledge the Reviewer’s constructive comments. Please find the requested answers below. http://bmjopen.bmj.com/ Will quality assessment be used to exclude studies?

No. All studies that fulfill eligibility criteria will be included for analysis. Quality assessment will be taken into account while assessing the confidence in cumulative evidence using Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach as described on page 7.

The following changes were made in the manuscript: on October 2, 2021 by guest. Protected copyright. The following sentence clarifying this matter was added to Risk of bias in individual studies section: "Quality assessment will not be used to exclude studies."

A number of cognitive reasoning models are discussed in the introduction – how will these be used in the analysis?

The dual process theory (the model that states that decision making is the result of the integration between two cognitive systems, the intuitive and heuristic based system 1 and the analytical rational system 2) will be the theoretical lens through which thematic synthesis will be performed. Thematic synthesis will be theoretically driven by the dual process theory through a deductive approach. Moreover, the researchers will remain aware of new concepts that may emerge from the data itself.

The following changes were made in the manuscript:

In the introduction, page 4, line 5, the sentence "This theory has been applied in clinical decision making, underlining the relevance of physicians’ intuition and the high-level interactions between analytical and non-analytical processes(23) and proposing clinical reasoning and decision making as BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from the result of a permanent interaction between the two systems.(22)" was rephrased to: "This theory has been adapted for clinical decision making and proposes that clinical reasoning and decision making are the result of a permanent interaction between the two systems.(22) This will be the theoretical framework of this systematic review.”

Also, in Outcomes and Synthesis strategy section on page 7, line 7, the following sentence has been added to the paragraph: “Analysis will be theoretically driven by literature on cognitive reasoning models such as the dual process theory (22) through a deductive approach. Moreover, the researchers will remain aware of new concepts that may emerge from the data itself.”

Following the Reviewers commentaries, the authors acknowledged that too much focus was being made in cognitive biases. Particularly in the Introduction, the “The theoretical framework of medical decision making” section as written in the original submission could induce the readers to misinterpret the real aim of this systematic review. So we decided to simplify that section as follows:

The original writing was:

“Croskerry defined optimal medical decision-making as the one that is logical, evidence based, follows the laws of science and probability and leads to decisions that are consistent with rational choice theory.(22) But this outcome is not possible in most situations mainly due to dysrationality in decision-making which means that different types of cognitive bias compromise rationality when making decisions.(22) Cognitive psychology research has shown that people tend to use simple strategies and seek adequate solutions that make sense in their environment in what Gigerenzer called ecological rationality.(23,24) This heuristic or intuitive approach can be highly economical and effective. However, it has long been cited as a source of cognitive bias, particularly when facing complexity and uncertainty.

(25) As such, its results may not always lead to the best decision for patients.

Cognitive biases in medical decision-making are a growing research topic, with some work including http://bmjopen.bmj.com/ primary care physicians, but little is still known about their implications on physicians’ decisions and more research is demanded.(26)

Multimorbidity is an interesting condition to explore how physicians use system 1 and system 2 in their decisions, in which decisions intuitive approaches work and in which dysrationality may hinder the best decision to patients."

The rephrased text is: on October 2, 2021 by guest. Protected copyright.

“Croskerry defined optimal medical decision-making as the one that is logical, evidence based, follows the laws of science and probability and leads to decisions that are consistent with rational choice theory.(22) But this outcome is not possible in most situations mainly due to dysrationality in decision-making which means that different types of cognitive bias compromise rationality when making decisions.(22,23) Cognitive psychology research has shown that people tend to use simple strategies and seek adequate solutions that make sense in their environment in what Gigerenzer called ecological rationality.(24,25) While this heuristic or intuitive approach can be highly economical and effective, it may not be appropriate when physicians are confronted with complexity and uncertainty.(26)

Multimorbidity is an interesting condition to explore how physicians use system 1 and system 2 in their decisions.”

Also the last sentence of the introduction section “we need to better understand the way we think and the way our cognitive and affective biases affect each of our medical decisions.” was rephrased to “we need to better understand the way we think and which forces play a role and affect each of our BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from medical decisions.”

Clarify how you will deal with studies on decision-making in the context of co-morbidity.

The multimorbidity definition used in this work is the coexistence of two or more long-term conditions in one patient. This may include studies on decision-making in the context of comorbidity.

Attention is needed with language and syntax throughout (e.g. use of dysrationalia).

"Dysrationalia" is an expression used by Croskerry et al. in Croskerry P. A Model for Clinical Decision- Making in Medicine. Med.Sci.Educ. (2017) 27(Suppl 1): 9. doi:

10.1007/s40670-017-0499-9. The authors realise that the word is not commonly used in English and that was why it was in italic in the text. The authors asked for a professional native English evaluation.

The following changes were made in the manuscript:

"Dysrationalia" was changed to dysrationality (p4 LL13; p4 LL35; p8 LL16; p8 LL22)

In your primary studies, will you extract all data for analysis or just that related to decision-making? How will you delimit data on “decision-making” as being different from any other data dealing with GPs’ views/perspectives on clinical care of patients with multimorbidity?

We will extract all data from the results and discussion section of included studies. The researchers will look for PCP views/perspectives on situations where a course of action or recommendation was followed among one or several possible alternatives. This may be textually explicit or may be inductively interpreted from the content.

The following changes were made in the manuscript:

Under Eligibility Criteria - Context and phenomena of interest the following operational definition of http://bmjopen.bmj.com/ decision was added: “For this purpose, “decision” will be considered a situation where a course of action or recommendation was followed among one or several possible alternatives.”

Also, in the subsection "Data items" under the section "Study Records" was updated in order to include the following explanation: "The researchers will look for family physicians’ views/perspectives on situations where a course of action or recommendation was followed among one or several possible alternatives." on October 2, 2021 by guest. Protected copyright. In the discussion, page 9 paragraph 3 you mention that you are using this review to test a hypothesis. How will you use your data to test this hypothesis?

The wording was unfortunate and was rephrased according to the comment. We will not test any hypothesis. What we meant was that the findings from this review may or may not support ideas that the authors have about cognitive bias that PCP may have when deciding with multimorbidity patients.

The following changes were made in the manuscript:

In the discussion section, the last sentence of the second paragraph “This systematic review will provide evidence that will support or contradict or hypothesis.” was rephrased to: "This systematic review will provide evidence that will support or contradict that ideia."

Also in the discussion, in the third paragraph, the sentence "If our hypothesis holds true, it will then have the potential to impact health practice and policy by identifying the main barriers and promoters of good decision making in primary care with multimorbidity patients." was rephrased to "Results from this systematic review will have the potential to impact health practice and policy by identifying the BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from main promoters and barriers of decision making in primary care with multimorbidity patients."

Further to the last point, how do you judge “flaws” in decision making for multimorbidity? Against what benchmark can you say if decision-making for patients with multimorbidity is optimal or not?

We will not make that exercise. We do not propose to identify flaws in decision making so we will not compare decisions against any standard or optimal benchmark.

A limited numbers of terms are proposed for the primary care/general practice and the decision- making strings of the search; perhaps this is a pragmatic decision, favouring speed over breadth of search but this should be addressed in the text. For example, you mention family physicians in the methods section but this is not one of the terms in the search.

The search strategy was rebuilt in order to include a broader number of terms referring to key strings. Please see the complete search strategy in additional file 2.

Multimorbidity is a MeSH term now- it does not appear that this is included in the search.

The strings were updated in order to include a wider possibility in MeSH terms, including multimorbidity. Please see the complete search strategy in additional file 2.

Prior work on cognitive biases in primary care is available in this review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093937/

Thank you for the reference. The cited review focused on externally identified cognitive bias associated with medical decisions. Our review asks a different questions and focus on a different perspective, namely the perceptions or views of primary care physicians while making decisions with their multimorbidity patients. We believe that our work will add a

different and complementary perspective to the topic. However, the article is relevant for the http://bmjopen.bmj.com/ introduction and potentially for future contextualization of the findings of this review and we will add to the cited references as reference number twenty three (please see below).

The following changes were made in the manuscript:

Under The theoretical framework of medical decision making on page 4, the second paragraph was rephrased to: on October 2, 2021 by guest. Protected copyright. “Croskerry defined optimal medical decision-making as the one that is logical, evidence based, follows the laws of science and probability and leads to decisions that are consistent with rational choice theory.(22) But this outcome is not possible in most situations mainly due to dysrationality in decision-making which means that different types of cognitive bias compromise rationality when making decisions.(22,23) Cognitive psychology research has shown that people tend to use simple strategies and seek adequate solutions that make sense in their environment in what Gigerenzer called ecological rationality.(24,25) While this heuristic or intuitive approach can be highly economical and effective, it may not be appropriate when physicians are confronted with complexity and uncertainty. (26)

Multimorbidity is an interesting condition to explore how physicians use system 1 and system 2 in their decisions.”

There is a slight contradiction in the aims- you seek to understand what “primary care physicians perceive to contribute for better decision-making with patients with multimorbidity and which are the main barriers in this process”. But you are also interested in system one decision-making which is intuitive rather than conscious. Do you think PCPs will be able to describe the influences on their BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from system 1 decisions? How will this issue affect your data?

We are not expecting PCP to be able to describe the influences on their system 1 decisions but we are expecting that we, as researchers, may be able to make inferences about system 1 and system 2 decisions by analysing PCP perceptions on what forces play a role in their decision making. As an example, it could be envisaged that time constraints in medical encounters may promote pre established heuristics (that will lead to certain decisions) instead of a more time-consuming and rational system 2 strategy (that might lead to another decision). Testimonials including "The majority of GPs emphasized the struggles they had in fitting in the support that was necessary into a 10-min appointment, which was described by one as constantly.. rationing out time..." from O'Brien et al. 2011 may support that argument.

Reviewer: 2

We thank the reviewer for the critical insights. Please find the requested answers below.

The specific research question was rephrased according to the comment.

The following changes were made in the manuscript: on page 4, the paragraph "The main research question under study is the following: According to available qualitative research, which information do primary care physicians perceive to contribute for better decision-making with patients with multimorbidity and which are the main barriers in this process?" was rephrased to: "The main research question under study is the following: http://bmjopen.bmj.com/

According to available qualitative research, which facilitators and barriers are perceived by primary care physicians on decision-making with patients with multimorbidity?"

A similar question was made by reviewer 1 and the answer will repeat some arguments. The dual process theory (the model that states that decision making is the result of the integration between two cognitive systems, the intuitive and heuristic based system 1 and the analytical rational system 2) will be the theoretical lens through which thematic synthesis' will be performed. Thematic synthesis will be theoretically driven by the dual process theory through a deductive approach. Moreover, the researchers will remain aware of new concepts that may emerge from the data itself.

System 1 is obviously quite difficult to study. We are not expecting to find PCP's views or perspectives describing the influences on their system 1 decisions but we are expecting that we, as researchers, may be able to make inferences about system 1 and system 2 decision by analysing PCP's views or perceptions on what forces play a role on their decision making. As an example, it could be envisaged that time constraints in medical encounters may promote pre-established heuristics (system 1) instead of a more time-consuming and rational system 2 strategy. Testimonials including "The majority of GPs emphasized the struggles they had in fitting in the support that was necessary into a 10-min appointment, which was described by one as constantly.. rationing out time..." from O'Brien et BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from al. 2011 may support that argument.

The following changes were made in the manuscript:

In the introduction, page 4, line 4, the sentence "This theory has been applied in clinical decision making, underlining the relevance of physicians’ intuition and the high-level interactions between analytical and non-analytical processes(23) and proposing clinical reasoning and decision making as the result of a permanent interaction between the two systems.(22)" was rephrased to: "This theory has been adapted for clinical decision- making and proposes that clinical reasoning and decision- making are the result of a permanent interaction between the two systems.(22) This will be the theoretical framework of this systematic review.”

Also, in the Outcomes and Synthesis strategy section the following sentence has been added (page 7): “The analysis will be theoretically driven by the literature on cognitive reasoning models such as the dual process theory (22) through a deductive approach. Moreover, the researchers will remain aware of new concepts that may emerge from the data itself.”

3. The abstract needs re-wording to reflect fact that the research focuses on General Practitioners/Family Medicine/PC practitioners.

The final sentence of the abstract/introduction was rephrased according to the comment and was reformulated to "The aim of the present review is to identify and synthesize available qualitative evidence on primary care physicians' perspectives, views or experiences on the process of decision making with multimorbidity patients.”

4. Overall the quality of the written English is acceptable. However there are instances throughout the paper of grammatical errors.

The authors asked for a professional native English evaluation.

http://bmjopen.bmj.com/

Reviewer: 3

We thank the reviewer for the contribution to our manuscript. Please find the requested answers below.

TITLE: When I read the title I assumed it was a QES about both doctors’ and patients’ experiences of decision making in the context of MM – but it is in fact only focussed on doctors. This is perfectly fine on October 2, 2021 by guest. Protected copyright. but I suggest a small re-phrasing the title to: ‘Primary care doctors’ decision making processes in the context of multimorbidity: protocol …

‘ etc.

The title was rephrased according to the comment.

The following changes were made in the manuscript:

The title was changed to "Primary care physicians’ decision making processes in the context of multimorbidity: protocol of a systematic review and thematic synthesis of qualitative research"

STRENGTHS AND LIMITATIONS: I agree that you have to note a limitation but I do not think a focus on doctors treating people with multimorbidity is a limitation – it is a major strength, given the dearth of relevant research and guidance. Is there something else you could say for a limitation of method? One possible option is to say that you will only be considering doctors’ experiences of decision BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from making for MM and that another review would be needed for patients’ experiences of MM.

The authors agree with the comment and the sentence was rephrased to "Limited to primary care physicians' experiences in decision-making with multimorbidity patients. Another review with patient perspectives would complement the phenomena and better inform the development of implementation strategies.

RATIONALE: I really liked to introduction to this protocol.

The authors are grateful for the encouraging words.

METHODS – SEARCH STRATEGY: You state you will be considering all relevant studies that fit your inclusion criteria. I don’t expect this will be too large a number but had you anticipated that you may find 50-100 studies – and considered what you will then do or if you should sample from the set? Perhaps you could add a comment on this issue as sampling has been a strategy needed in some QES topics.

From our knowledge and study of the literature we would be very surprised to find more than 30 studies. Having said that if the reality turns out to be a greater number a purposeful sampling method may be applied following Benoot C., Hannes K., Bilsen J. (2016). The use of purposeful sampling in a qualitative evidence synthesis: A worked example on sexual adjustment to a cancer trajectory. BMC Medical Research Methodology, 16 (21), 1-12.

The following changes were made in the manuscript:

The following sentence was added to Selection process subsection in the Study Records section: “If the included studies are fifty or more a purposeful sampling method will be used to select the ones from which data will be extracted.”

STUDY RECORDS – OUTCOMES AND SYNTHESIS STRATEGY. I did not understand http://bmjopen.bmj.com/ this sentence, so could you please consider explaining this a bit more, particularly the term’ textual pooling’. The sentence is ’The findings will be presented in a narrative form, where textual pooling is not possible’.

This sentence tries to explain that findings of the synthesis process will be presented by grouping textual excerpts from included studies that represent similar meanings or themes. Whenever that grouping (or textual pooling) is not possible a narrative form will be used. on October 2, 2021 by guest. Protected copyright.

The following changes were made in the manuscript:

For clarity the sentence (page 7, second paragraph) was rephrased to: “Findings of the synthesis process will be presented by grouping textual excerpts from included studies that represent similar meanings or themes. Whenever that grouping is not possible a narrative form will be used.”

OVERALL COMMENT: The protocol is written in clear English for the most part but I would recommend that you give it to a colleague with high English proficiency as there are a few terms that could be better expressed.

The authors asked for a professional native English evaluation.

Lastly, we would like to acknowledge the careful revisions from the three reviewers, to whom we are grateful for their critical insights and suggestions that allowed us to improve our manuscript. We hope the answers provided are aligned with the editor and reviewers’ quality criteria, and we look forward to hearing from you in due time regarding our submission and to respond to any further questions and BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from comments. re made.

VERSION 2 – REVIEW

REVIEWER Carol Sinnott University of Cambridge REVIEW RETURNED 26-Sep-2018

GENERAL COMMENTS Dear Editors and Authors This paper is much improved, and the review will make an interesting contribution to the literature but there is one important issue that requires further clarification from the authors. It appears that a key feature of this review is determining what interferes with optimal decision-making for patients with multimorbidity. Optimal decision-making is defined using a definition from Croskerry as: “ logical, evidence based, follows the laws of science and probability and leads to decisions that are consistent with rational choice theory”. But the authors go on to acknowledge the limitations of science and medical knowledge with respect to multimorbidity. How is optimal decision-making achievable then in the light of above? The authors also point to the importance of holistic, integrated and person centred decision-making. These decisions, which many think are more desirable in the setting of multimorbidity, may often not be evidence- based or follow the laws of science or probability. I asked in my earlier comments how the authors would judge decision-making to be flawed:

against what benchmark would the data be compared. The authors’ http://bmjopen.bmj.com/ response was confusing – that were not going to compare decisions against any optimal standard. How then can they tell what gets in the way of “optimal decision-making”? If I have misunderstood and they are just looking at decision-making, this needs to be clarified in the text. This will also require greater explanation on what they see as promotors and barriers – decisions are made in every clinical encounter, and not necessarily always active- by not doing a test or starting a medication, a (sometimes on October 2, 2021 by guest. Protected copyright. passive) decision has been made. What type of decision-making are the authors seeking promotors and barriers for? If not optimal, is it holistic, patient-centred, shared? Other comments: Suggest that line 43 page 4 (of the clean copy) needs to rephrased into the third person i.e. need to understand the way PCPs think…. In line with your response, please state in the text that papers addressing both multimorbidity and comorbidity will be included. It may also be worth bearing in mind the literature on the differences between these terms: https://www.tandfonline.com/doi/abs/10.3109/13814789609162146 and https://www.sciencedirect.com/science/article/pii/S0895435618305432 Suggest adding reviewers 3 suggested reference on purposive sampling to your methods.

BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from

REVIEWER Professor Tim Stokes Department of General Practice & Rural Health Dunedin School of Medicine University of Otago Dunedin New Zealand 9054 REVIEW RETURNED 17-Sep-2018

GENERAL COMMENTS The authors satisfactorily have addressed the reviewers' comments

REVIEWER Sophie Hill La Trobe University Australia REVIEW RETURNED 24-Sep-2018

GENERAL COMMENTS Thank you for addressing my comments.

VERSION 2 – AUTHOR RESPONSE

The authors would like to thank the reviewer’s very constructive comment that, once again, helped us to improve the manuscript and make it clearer. We also thank the bibliographic references suggested. We add one of them to the manuscript.

Our first aim is to identify and synthesize available qualitative evidence about primary care physician decision-making processes when attending patients with multimorbidity. In other words, we are interested in identifying what are the descriptions and reflections of physicians about their own medical decisions in patients with multimorbidity. http://bmjopen.bmj.com/ Our manuscript assumes that there some medical decisions are better than others, and it is possible to improve the decision making processes when caring for people with multimorbidity. It is challenging to define what optimal medical decisions are. While the authors’ are heavily influenced by the evidence-based movement, we are aware there are other equally relevant perspectives. Irrespective of the underlying decision model, we think that when physicians reflect about their decisions, they have their own implicit criteria of optimal decision making, allowing them to identify barriers and facilitators to that optimal decision. Identifying these facilitators and barriers is a necessary first step to on October 2, 2021 by guest. Protected copyright. understand the underlying decision models and to design effective implementation strategies that lead to better decisions with multimorbidity patients.

So, to the reviewer’s question on “how the authors would judge decision-making to be flawed: against what benchmark would the data be compared?” our best answer has two parts. Firstly, the authors will not list medical decisions reported in the primary studies and judge decisions as correct or flawed. Secondly, we assume that primary care physicians have an implicit optimal decision making model that determines what those physicians perceive as barriers and facilitators to decision with multimorbidity patients. So, the benchmark will be the study participants’ implicit model of optimal decision-making. Irrespective of the numerous possibilities of theoretical models that may underlie primary care physicians decisions, there is some consensus that rationality is a characteristic of good decision-making.

The authors realise that the second paragraph on page 4 may induce the reader to think that we are going to look for optimal decisions as defined by Croskerry or dysrationality cognitive processes. So, for clarity and simplicity, we decided to rephrase that paragraph to the following adding some BMJ Open: first published as 10.1136/bmjopen-2018-023832 on 3 April 2019. Downloaded from arguments:

Croskerry defined optimal medical decision-making as the one that is logical, evidence based, follows the laws of science and probability and leads to decisions that are consistent with rational choice theory.(22) Under this definition, rationality is an essential characteristic of good decision-making. Resulting from the analysis of different theories and models, a core set of five principles of rational decision has been proposed.(23) These principles determine rational decision as the one that weights benefits and harms in order to achieve a goal; it is usually surrounded by uncertainty; it is informed by human cognitive architecture (dual processing system); it depends on the context and epistemological, environmental, and computational constraints of human brains and finally the decision is closely linked to ethics and moral values.(23) Substantial gaps still limit our understanding of how these principles interact with cognitive bias leading to dysrationality in our decisions.(22,24) Multimorbidity (with its implicit uncertainty and complexity) is an interesting condition to explore these gaps.(25).

We have rephrased into the third person the line 43 page 4 as suggested.

In the methods section, eligibility criteria subsection, we now state that we will address papers that study multimorbidity as well as comorbidity.The “context and phenomena of interest” subsection under the section Eligibility criteria was rephrased to:

Context and phenomena of interest

The context of the studies is primary care and the review will include studies that evaluate family physicians’ perspectives/ opinions/ perceptions on decision-making concerning the management of multimorbidity patients. For this purpose, “multimorbidity” will be considered as the co-occurrence of more than one chronic condition in an individual. We recognized that many studies until now did not made a clear distinction between multimorbidity and comorbidity and for that reason studies considering comorbidity may be included.(34) . http://bmjopen.bmj.com/ As suggested, a reference to Benoot C, Hannes K, Bilsen J. The use of purposeful sampling in a qualitative evidence synthesis: A worked example on sexual adjustment to a cancer trajectory. BMC Medical Research Methodology. 18 February 2016;16(1):21. was added in methods section.

VERSION 3 – REVIEW

REVIEWER Carol Sinnott

University of Cambridge on October 2, 2021 by guest. Protected copyright. REVIEW RETURNED 05-Feb-2019

GENERAL COMMENTS Thank you for your response- it has helped me understand the direction of the review much more clearly.

REVIEWER Sophie Hill La Trobe University, Australia REVIEW RETURNED 20-Oct-2018

GENERAL COMMENTS The reviewer completed the checklist but made no further comments.