Un modo de ayudar al «Sr. Minotauro» y a la «Sra. Ariadna» a salir del laberinto de la multimorbilidad: los «problemas maestros» / A way of helping «Mr. Minotaur» and «Ms. Ariadne» to exit from the multiple morbidity labyrinth: the «master problems»

La multimorbilidad parece «infinita» y así no es operativa para tomar decisiones útiles. Presentamos un nuevo concepto: los «problemas maestros», como método cualitativo para facilitar la salida de este laberinto. Para la enseñanza de este concepto se han usado metáforas basadas en el mundo del arte. Estos «problemas maestros» generalmente permanecen ocultos y solo pueden «desvelarse» entre los intersticios de la multimorbilidad, al fijarnos en los detalles del sistema que define el problema. Un problema con «energía» o «problema maestro» es complejo, múltiple y dramático o teatral -todas las cosas de la historia clínica nos hacen mirar hacia ese punto determinado-; es el que nos da un golpe en la boca del estómago, el que hace que nos lata más rápido el corazón, el que nos conmueve a muchos niveles, el que tiene una gran «densidad de emociones», elementos humanos, símbolos sociales, y nos abre soluciones en un paciente (AU)

Multiple morbidity seems to be 'infinite' and so is not easy to make useful decisions. A new concept is introduced: the 'master problems', as a qualitative method to facilitate the exit from this maze of multiple morbidity. Metaphors from the art world have been used to teach this concept. These 'master problems' generally remain hidden and can only 'unravel' between the interstices of multiple morbidity, when the details of the system that defines the problem are explained. A problem with 'energy' or a 'master problem' is complex, multiple and dramatic or theatrical -everything in the clinical history history make us look into that particular question-. It is what gives us a blow to the stomach, which causes our hearts to beat faster, that moves us on many levels, which has a high 'density of emotions', human elements, social symbols, and opens solutions in a patient (AU)

[A way of helping "Mr. Minotaur" and "Ms. Ariadne" to exit from the multiple morbidity labyrinth: the "master problems"]. / Un modo de ayudar al "Sr. Minotauro" y a la "Sra. Ariadna" a salir del laberinto de la multimorbilidad: los "problemas maestros".

Multiple morbidity seems to be "infinite" and so is not easy to make useful decisions. A new concept is introduced: the "master problems", as a qualitative method to facilitate the exit from this maze of multiple morbidity. Metaphors from the art world have been used to teach this concept. These "master problems" generally remain hidden and can only "unravel" between the interstices of multiple morbidity, when the details of the system that defines the problem are explained. A problem with "energy" or a "master problem" is complex, multiple and dramatic or theatrical--everything in the clinical history history make us look into that particular question. It is what gives us a blow to the stomach, which causes our hearts to beat faster, that moves us on many levels, which has a high "density of emotions", human elements, social symbols, and opens solutions in a patient.

El acompañante en la entrevista clínica de atención primaria / The presence of a companion in the primary care consultation

La presencia en la consulta de un adulto que acompaña al enfermo es un hecho significativo que merece la atención del médico. Se han descrito algunas tipologías de los acompañantes y su presencia en la consulta puede mejorar la comunicación, el proceso asistencial y la toma de decisiones participativas, logrando mayor satisfacción del paciente. Las consultas con acompañante son generalmente más largas, y los pacientes acompañados suelen ser mayores, mujeres, con menor nivel educativo, y peor salud física y mental. Pero se desconoce con exactitud cuál es el significado de la consulta con acompañante, si es un dato semiológico a tener en cuenta para el diagnóstico familiar, los posibles riesgos de su presencia, la influencia sobre la medicación, así como el papel causal que desempeña el médico en la presencia del acompañante. Se precisa lograr unas habilidades de comunicación durante la entrevista con acompañante diferentes a las de la consulta solo con el paciente (AU)

The presence of an adult accompanying the patient in the consulting room is a significant fact that deserves the attention of the physician. Some types of companions and their presence in the consultation have been described and may improve communication, patient management, and participatory decision making, achieving greater patient satisfaction. Consultations with companion are generally longer, and patients accompanied are often elderly, women, less educated, and with poorer physical and mental health. But it is not known exactly what is the significance of a consultation with a companion. It may be a semiological fact to keep in mind for the family diagnosis, or it may be the risks of their presence, the influence of medication, or the importance of the doctors themselves that are the cause of the presence of a companion. Different communication skills must be achieved during the interview with the companion in the consultation, rather than with the patient alone (AU)

[The presence of a companion in the primary care consultation]. / El acompañante en la entrevista clínica de atención primaria.

The presence of an adult accompanying the patient in the consulting room is a significant fact that deserves the attention of the physician. Some types of companions and their presence in the consultation have been described and may improve communication, patient management, and participatory decision making, achieving greater patient satisfaction. Consultations with companion are generally longer, and patients accompanied are often elderly, women, less educated, and with poorer physical and mental health. But it is not known exactly what is the significance of a consultation with a companion. It may be a semiological fact to keep in mind for the family diagnosis, or it may be the risks of their presence, the influence of medication, or the importance of the doctors themselves that are the cause of the presence of a companion. Different communication skills must be achieved during the interview with the companion in the consultation, rather than with the patient alone.

Viaje a lo esencial invisible: aspectos psicosociales de las enfermedades / Journey to what is essentially invisible: pysochosocial aspects of disease

Los médicos pueden estar bien equipados para los aspectos biológicos de la enfermedad, pero no para sus dimensiones psicosociales, y este tema ha estado ausente en la medicina de familia. Los aspectos psicosociales de las enfermedades son los factores que intervienen en los modos de reaccionar del paciente frente a la enfermedad, y tienen un papel en la expresión de los síntomas y las enfermedades, y en las implicaciones que producen en la vida de las personas. Además, los efectos biológicos (específicos) y psicosociales (inespecíficos) no son simplemente aditivos, sino que interactúan. Los médicos deben ser conscientes de esta morbilidad psicosocial oculta de los pacientes −lo esencial invisible− y deben incorporar las intervenciones biopsicosociales a la atención médica de rutina para ser más eficaces. Además, el tener en cuenta estos aspectos dentro del marco asistencial aporta elementos propios de la medicina de familia (AU)

Physicians may be well equipped for the biological aspects of disease, but not for its psychosocial dimensions, an issue that has been absent in family medicine. The psychosocial aspects of the disease are the factors involved in how patients react to the disease, play a role in the expression of symptoms and disease, and have implications on the lives of patients. Moreover, the biological effects (specific) and psychosocial effects (non-specific) are not simply additive but interactive. Physicians should be aware of this hidden, essentially invisible patient psychosocial morbidity, and must incorporate bio-psychosocial interventions into routine medical care to be more effective. In addition, to consider these aspects in the context of care contributes to the distinctive elements of family medicine (AU)

[Journey to what is essentially invisible: pysochosocial aspects of disease]. / Viaje a lo esencial invisible: aspectos psicosociales de las enfermedades.

Physicians may be well equipped for the biological aspects of disease, but not for its psychosocial dimensions, an issue that has been absent in family medicine. The psychosocial aspects of the disease are the factors involved in how patients react to the disease, play a role in the expression of symptoms and disease, and have implications on the lives of patients. Moreover, the biological effects (specific) and psychosocial effects (non-specific) are not simply additive but interactive. Physicians should be aware of this hidden, essentially invisible patient psychosocial morbidity, and must incorporate bio-psychosocial interventions into routine medical care to be more effective. In addition, to consider these aspects in the context of care contributes to the distinctive elements of family medicine.

Examinando críticamente los síntomas y diagnósticos que se dan por sentados en medicina de familia. Creando una escuela propia / Critically examining the symptoms and diagnoses that are taken for granted in family medicine. creating an own school

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¿Cómo abrir la puerta de la comprensión de los síntomas en medicina de familia? / How is the door of understanding of the symptoms opened in family medicine?

Para aumentar la capacidad de mejorar la asistencia de la medicina de familia es preciso volver a lo básico: «entender» a los pacientes y a nosotros mismos en los contextos respectivos. Para «entrar» en el significado de los síntomas necesitamos mover adecuadamente «el sintonizador o dial biopsicosocial» -el anillo biológico, psicológico, y social-, para el paciente y para el médico, y «sintonizar» el diagnóstico -como en un dial de la radio; o como la combinación de una caja fuerte que permite abrirla-, y en consecuencia ser más eficientes. De este modo puede surgir un clic de comprensión basado tanto en los aspectos psicológicos como en los físicos de ambos actores y aumentarse significativamente la eficiencia clínica(AU)

To increase the capacity of improving the care of Family Medicine requires going back basics: to understand our patients and ourselves in the respective contexts. To “go into” the meaning of the symptoms we need to move properly, “the biopsychosocial tuner or dial” the biological, psychological, and social ring -for the patient and the doctor, and to “tune in” to the diagnosis, like a radio dial; or like the combination of a safe that allows it to be opened-and therefore be more efficient. This can give rise to a “click” of comprehension based as well both psychological as well as physical aspects of both players and thus clinical efficiency will be increased significantly(AU)

Aspectos no farmacológicos de las medicaciones / Non-pharmacological aspects of medications

La prescripción farmacológica es una de las facetas principales del médico de familia. Es fundamental conocer la farmacología de los medicamentos usados, pero igualmente los aspectos no farmacológicos, como los efectos adversos no específicos (nocebo), el efecto placebo, el incumplimiento, el coste, los significados psicológicos (símbolos, significados, creencias, estigmas), los aspectos éticos, el hecho de ser a veces la prescripción un modo de afrontar el médico su frustración, etc., que producen efectos sobre la salud, modifican el encuentro médico-paciente, y pueden condicionar un cambio de actitud en las prescripciones en la práctica cotidiana (AU)

The pharmacological prescription is one of the principal facets of the family doctor. It is fundamental to know the pharmacology of the medicines, but equally to undestand the non-pharmacological aspects, such as non-specific adverse effects (nocebo), placebo effect, non-compliance, costs, psychological significance (symbols, meanings, beliefs, stigmas), ethical aspects, the fact that sometimes the prescription is a way for family doctors to confront their frustration, etc., that produce effects on the health, modify the doctor – patient relationship, and can determine a change of attitude in the prescriptions in the daily practice (AU)

¿Un caso fácil o difícil? Las formas dibujadas por la vida. Medicina de familia basada en la incertidumbre / No disponible

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¿Se parecen los médicos de familia a las tortugas marinas? / No disponible

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