[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.

[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.

¿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)

[Variation in the frequency of chronic diseases and risk factors in primary care: 1985-1995]. / Variación de la frecuencia de las enfermedades crónicas y factores de riesgo en atención primaria: 1985-1995.

OBJECTIVE: To study the variation in the frequencies of chronic illnesses in Primary Care between 1985 and 1995. DESIGN: A repeated crossover study, carried out with the same information-gathering procedures in two periods 10 years apart. SETTING: A Family Medicine clinic at a Health Centre. PATIENTS: Frequencies of chronic illnesses, obesity and tobacco addiction in 1,677 patients who attended a Family Medicine clinic between September 1994 and August 1995, were collected. In order to examine the variations, these were compared to the findings of a similar 1985 study of 1,356 patients by the same main researcher and in the same clinic, in which the same diagnostic criteria were used. MAIN RESULTS: Frequencies of almost all chronic illnesses had clearly increased from 1985 (average of 0.88 chronic illnesses per patient) to 1995 (average of 1.99 chronic illnesses per patient), especially in the cancer, Endocrinology, mental disorders, circulatory, respiratory, genito-urinary, skin and muscle-skeleton groups. Variation was not very important in coronary Cardiopathy, Cerebrovascular Accident, chronic Obstructive Pulmonary Disease, peptic ulcer/gastritis/dyspepsia, gall bladder illnesses, Hepatopathies and Renal Lithiasis. CONCLUSIONS: The rising tendency in the frequency of chronic illnesses between 1985 and 1995, with a comparison of comparable and stable series, supposes the need for a significant increase in community social-health resources at the Primary Care level.

[Perception of the success of primary care health promotion in the province of Toledo]. / Percepción de éxito en programas de promoción de salud en la atención primaria de la provincia de Toledo.

OBJECTIVE: Identification of factors which can condition the perception by Primary Care professionals of success in health promotion. DESIGN: An observation study of a crossover type. PARTICIPANTS: 106 professionals (doctors, nurses and social workers) from 22 health centres in the province of Toledo, who filled in a questionnaire. MEASUREMENTS AND MAIN RESULTS: A non-conditional, multiple, logistic regression analysis was used. The professional satisfied with his/her work, not a doctor and who worked in a health centre open for less than 3 years, presented, against their opposite values, greater probability (OR 3.01, 2.41 and 1.24 respectively) of having a perception of success in health promotion. CONCLUSIONS: Health promotion undertaken in newly-opened centres, which involves in particular non-medical staff and, above all, is carried out by professionals satisfied with their habitual work, has a 77% probability of being considered successful by these professionals. These factors greatly facilitate its propagation in Primary Care.