Family Physicians’ Mental Models of Symptom Management in Cirrhosis Care

Context: Our previous research found a lack of role clarity, and differences in how primary and specialty care managed cirrhosis care. In this study we explored more deeply, specifically around symptom management.

Objective: To make recommendations for a province-wide cirrhosis management program based on how family physicians conceptualize cirrhosis symptom management, their role in it, and whether or how they incorporate palliative principles into their approach.

Study Design and Analysis: Cross-sectional Cognitive Task Analysis study, using our previously published framework-guided qualitative analysis.

Setting: Private community practices in Alberta, Canada.

Population Studied: Family physicians who saw small numbers (typical for unspecialized practice) of cirrhosis patients. 4 were women, median age 47, median years in practice 16, none in rural practice.

Intervention/Instrument: Knowledge Audit method Cognitive Task Analysis interviews.

Outcome Measures: Detailed description of mental models of symptom management in cirrhosis care. Recommendations based on findings.

Results: Family physicians develop reactive mental models for symptom management, using a case-by-case approach focusing on the most important symptoms or what matters most to the patient, rather than generalized or guideline-based models. Reactive mental models are linked to the lack of formal structure, guidance, and clarity of roles in cirrhosis care, as well as physicians’ need for knowledge on demand (information physicians can access at the place and time of need) for each patient. Family physicians regarded palliative care as part of their responsibility but did not have clear models of when and how to have these conversations. As a result, palliative principles were not a clearly integrated component of their mental models of cirrhosis care.

Conclusions: Improving symptom management in cirrhosis care requires clearly defined roles and responsibilities for all health team members. Creating programs like those for other chronic illnesses (e.g., diabetes, heart failure) to provide the knowledge on demand and operational guidance family physicians was recommended and will be implemented. Tools and supports that integrate palliative care and provide direction for family physicians on when and how to have conversations with patients throughout the trajectory of the illness will be developed.