The family doctor is the general practitioner who assumes the responsibility of attending to the patient in a comprehensive, biopsychosocial, contextualized manner, focusing on family and community, with continuous care, without selecting patients based on age, sex, disease, organs or body systems. Family medicine training can often feel like a massive, overwhelming banquet of information, and the concepts and theories that belong to family medicine are often difficult to explain and understand. Here, these concepts are explained through metaphors—a way of transforming a concept into something suggestive, interesting, and surprising—, irony—which implies that what is said is not what is meant—, and humor, which can be therapeutic. The series of short articles, "Cooking Up Family Medicine: A Metaphorical Kitchen Guide for Medical Training and Clinical Practice," is thus an ironic metaphor that breaks down the complexity, offering a refreshing, bite-sized approach to the foundational concepts every family doctor must master. It is a series of 10 short chapters / metaphorical and ironic cooking recipes." Inside these metaphorical cookbook articles, you won't find instructions for roasting chicken or baking bread. Instead, you will discover concise, ironic, and highly practical "recipes" designed to help you easily digest and internalize core clinical principles. Each article serves as a quick-to-read kitchen lesson, transforming abstract family medicine theories into actionable for your daily clinical practice. These series of articles provide the perfect ingredients to sharpen your clinical intuition—one delicious concept at a time. This article presents the recipe for “Seafood and meat combo stew” (Management of multimorbidity).

The academic discipline of family medicine is unique and coherent. It possesses knowledge, skills, and attitudes common to other clinical specialties, community medicine, behavioral sciences, and social sciences. However, it uses them in a particular way, thus constituting a recognizable, unified, specific, and differentiated set of skills [1]. But, concepts belonging to family medicine are often difficult to explain and understand.

Metaphors enable us to understand something that is unknown in terms of its familiarity [2-5]. Irony is also a very useful educational tool [6], as it stimulates critical thinking and fosters self-reflection [7, 8]. And the respectful use of humor is important in medical practice [9-11].

Traditional medical textbooks treat knowledge like an assembly line: rigid, serious, and cold. This series of articles adopts a different approach. We treat family medicine like a kitchen. Why a kitchen? Because being a great family doctor is not so much about blindly following a strict protocol, but about knowing how to balance the ingredients. It takes a dash of clinical intuition, a generous dose of empathy, a solid foundation in evidence-based medicine, and, occasionally, a pinch of irony and humor to get through the day. Within these articles, you won't find instructions on how to bake a soufflé. Instead, you'll find a collection of concise, metaphorical "recipes" designed to help you "cook up" the core concepts of family medicine. So, wash your hands, put on your apron (or white coat), and let's get cooking! Bon appétit, doctor. In this scenario, here is the recipe for “Seafood and meat combo stew” (Management of multimorbidity).

The word "stew" is often used to describe dishes with many ingredients. However, these ingredients aren't blended or fused together; rather, in a stew, each component is tasted individually. This dish of "Seafood and meat combo stew" contains a variety of components: beans (high blood pressure), seafood (diabetes mellitus), meats—half beef, half pork—(bronchial asthma and dysthymia), and vegetables (vascular tension headaches and urinary incontinence). This is similar to current family medicine practice, where, especially in older patients, several chronic health problems coexist in the same individual, such as high blood pressure, type 2 diabetes mellitus, bronchial asthma, urinary incontinence, osteoarthritis, dysthymia, etc. For their medical care in primary care, each condition must be considered separately to avoid under-treatment, but also, and especially, to avoid polymedicating these patients and the resulting iatrogenic effects.

Ingredients

- 1/2 kg of High Blood Pressure

- 1/4 kg of Type 2 Diabetes Mellitus

- A piece of Dysthymia

- 150 g of Bronchial Asthma

- 1 or 2 pieces of Osteoarthritis

- 1 Urinary Incontinence

- 2 Vascular Tension Headaches

- 1 subclinical hypothyroidism

-A pinch to taste of cataracts

-A pinch to taste of peripheral venous insufficiency

-A pinch to taste of coronary artery disease

-A pinch to taste of kidney stones

Preparation

Cook the High Blood Pressure in a pot with the Bronchial Asthma and the Dysthymia. When they begin to cook, add a pinch to taste of peripheral venous insufficiencyl. In another pot, prepare the Type 2 Diabetes Mellitus, and in another container, cook the Vascular Tension Headaches. In a separate pan, fry the Urinary Incontinence and the finely chopped Osteoarthritis with subclinical hypothyroidism. Add the Type 2 Diabetes Mellitus and the sautéed cataracts to the Hypertension. When serving, chop up the Vascular-Tension Headaches.

Variations

Different stews exist for Diabetes Mellitus, Bronchial Asthma, Osteoporosis, Hiatal Hernias with Gastroesophageal Reflux, Irritable Bowel Syndrome, Depression, Osteoporosis, Rheumatoid Arthritis, COPD, etc.

Time

Requires ongoing attention.

Cost

High or very high or very very high. Managing multimorbidity is very difficult.

Precautions and Contraindications

Trying to manage each health problem individually does not replace the comprehensive and holistic approach that must be taken.

Multimorbidity is characterized by the coexistence of two or more chronic diseases in an individual and is increasingly common. It often involves the overlap of mental illnesses, cardiovascular diseases, diabetes, cancer, and respiratory illnesses. Multimorbidity has become a public concern because it affects overall quality of life, such as by increasing mortality and healthcare utilization and expenditures [12-16]. Multimorbidity is a critical challenge for general practice and affects secondary care much less due to the asymmetry of responsibilities and the structural design of the healthcare system: specialists can isolate a single disease within their scope of practice, while general practitioners are obliged to manage the complexity of all interconnected pathologies in the same patient [17].

Multimorbidity occurs in approximately half of general practice consultations and accounts for 75% of drug prescriptions [18]. Furthermore, multimorbidity is associated with the medicalization of symptoms and risk factors, an increase in the number of diagnoses of chronic diseases thanks to new detection and diagnostic technologies and new disease definitions, as well as the equating of risk factors with the disease itself. This leads to overdiagnosis, overtreatment, and polypharmacy, resulting in a drastic increase in adverse drug reactions and drug interactions [19]. Thus, polypharmacy is an indicator of multimorbidity.

Multimorbidity seems "infinite" and therefore not useful for making sound decisions. How can we organize this almost limitless data? A first approach is to find "the system that defines the problem." Within the complexity of the case, we will have to recognize or discover what is fundamental: it would be like removing the figurative and revealing the underlying composition. A series of qualitative tools are useful for this: 1) Focusing on the specific patient and their context; 2) Focus on prioritizing problems with "energy" (the "master problems"). These "master problems" generally remain hidden and can only be "revealed" within the interstices of multimorbidity by examining the details of the system that defines the problem. A problem with "energy" or a "master problem" is complex, multifaceted, and dramatic or theatrical—everything in the medical history draws our attention to that particular point—; it is the one that hits us in the pit of our stomach, makes our heart race, moves us on many levels, has a high "density of emotions," human elements, social symbols, and opens up solutions for a patient; 3) Focus on the patient's life history and continuity; 4) Focus on holistic care; 5) Focus on the prognosis (which is shaped by psychosocial factors); and, 6) Focus on simplification (reducing the team of professionals attending to the patient and deprescribing medications) [20].

Identifying the main problems in patients with multimorbidity does not imply making decisions about their management, but rather constitutes the preliminary step [21]. Each patient needs a comprehensive evaluation with a view to developing a personalized therapeutic regimen. By contextualizing and reflecting on the essence and the periphery, it is possible to approach the details or the system that defines the problems [22].

Effective communication and trust between patient and physician become especially important in the management of patients with two or more chronic conditions. The doctor-patient relationship in multimorbidity is a simple and effective tool for addressing multimorbidity. In the absence of evidence-based clinical guidelines, better communication between patient and physician is required to overcome the challenges of managing multiple chronic diseases [23].