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  1. “ARIADNE AND THE MINOTAUR” QUALITATIVE TOOLS TO ADDRESS MULTIMORBIDITY IN FAMILY MEDICINE

    Jose Luis Turabian, Health Center "Industrial Park". Toledo

    20 August 2015

    We have been pleasantly surprised to read the paper of Christiane Muth et al (1). There is an interesting coincidence because we have been working on this topic using metaphors, and we have created, for educational purposes, a patient named “Mr. Minotaur”! – “Which is the best treatment for a patient of 46 years, with angina, hypertension wrong controlled, left ventricular hypertrophy, heart failure, diastolic dysfunction, diabetes mellitus type 2, diabetic nephropathy, dyslipidemia, obesity, anxiety-depressive syndrome, alcoholic liver disease, alcohol abuse, smoking, bronchial asthma and chronic urticaria, legal and economic problems, and which is religious, with poor therapeutic compliance, frequent attendance with an occasionally hostile behavior, and living in a marginal area ...?”-, and the students had to face it and get out of the maze (2, 3). So, we would like to add some considerations to this topic.

    The “Ariadne principles”, derived from the myth of Theseus and the Minotaur, is certainly a lovely analogy to provide orientation in decision making in multimorbidity during primary care consultations (4). However there is no unanimity on how Theseus was able to leave the labyrinth - the most widespread form is by wire, but other stories say that Theseus escaped by other methods.

    What tools or methods we have for decision-making in complex patients - to exit the maze? Of course, the Evidence-Based Medicine. But for a biological, psychological and social overall response, this approach is not enough. There are other qualitative tools, which are: 1) The contextual analysis (the meaning of an element from its place in the set); 2) The historical analysis (the tracks that reconstruct a story); 3) Chaos theory (unstable systems); 4) The analysis of the temporal response (the response to the variation in income); 5) Sociological analysis (biology is shaped by the social); 6) The relational analysis (matrix relations under study); 7) The ecological analysis (the relationships between organisms and the environment); 8) The ethical analysis (moral values); and 9) The strategic analysis (resources and potentials) (4).

    Following metaphors, the multimorbidity is often a hieroglyph secret or key saved. They are like the "boxes with secret" as the famous painting by Holbein the Younger, "The French Ambassadors", painted in London in 1533 and now on display at the National Gallery (5).

    Patients treated at family medicine are complex because their health problems tend not to rely on one single dominant element, as in secondary care -making a musical analogy, these would be “melodic” patients- but have several elements interspersed -patients “symphony”- that can be subordinate to a principal item. From the position of family physician can be very difficult to find this key element.

    But, to exit the maze, we must find these “Master Issues” or problems with "energy" - are those what gives us a blow to the stomach, which makes us faster tin heart, that moves us on many levels. This type of problem has a great "density of emotions", human elements, social symbols, is complex, multiple and dramatic or theatrical. The medical history is articulated as a stage; all things in make us look, lead us, to a certain point -as when we look, for example, The Kiss of Judas, of Giotto di Bondone, 1302-1305, cool in the Scrovegni Chapel in Padua (6). Within the complexity of the case, we will have to recognize or discover the basics: it would be like removing the 'figurative' and discover the "composition": when we discover the basic element of the problem, the sound is more pure. This complexity is simplified and can show a more harmonious distribution among the various elements. Qualitative tools that are shown here may help us in this task: find the melody in the symphony (4).

    REFERENCES
    1.-Muth C, van den Akker M, Blom JW, Mallen CD, Rochon J, Schellevis FG, et al. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Medicine 2014, 12:223. http://www.biomedcentral.com/1741-7015/12/223
    2.-"Mr. Minotauro, the story continues”. The Window. 2nd edition. September 2014. Forum for Exchange of Good Practices. Sescam. Health Service of Castilla La Mancha.
    3.-J.L. Turabián, B. Pérez Franco. Album of models for qualitative tools in the Family Medicine decision making. Other maps to describe a country. Semergen. 2014;40:415-24. http://zl.elsevier.es/es/revista/semergen-medicina-familia-40
    4.-Bower P. Better management of multimorbidity: a critical look at the ‘Ariadne principles’. BMC Medicine 2014, 12:222. http://www.biomedcentral.com/1741-7015/12/222
    5.-The Ambassadors (Holbein). Wikipedia. [homepage on the Internet] http://en.m.wikipedia.org/wiki/The_Ambassadors_(Holbein)
    6.-Giotto. Wikipedia. [homepage on the Internet] http://en.wikipedia.org/wiki/Giotto

    Competing interests

    There are no conflicts of interest.

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