Approach to a Theory of the Epidemiology from General Medicine: Its Morphology, Ethology, Distribution and Ecology. “The Pampa is much more than a Bunch of Grass"

Morphology

It refers to the form of the epidemiology in GM and its evolution. One of the differential aspects of epidemiology in GM is the epidemiological importance of continued care over long work years of GP.

This continued attention over the years is a task of "naturalist" or "ethnographer" who performs a qualitative study. Experienced naturalists warn the novice, that to capture animals there is no use disperse traps disorderly in the jungle, because although at first it seems that the movements of animals do not follow any order, immediately notice that most of them have very rooted, follow the same paths year after year appears in certain districts at certain times, and disappear in others, depending on the abundance of food, and will always drink water to the same places... So, before starting to place the traps there in any place, you wait patiently and carefully investigate the surroundings, you try to see which routes are used, where the wild fruits ripen and which holes are used as sleeping rooms, during the day, by night animals. In the same way the GPs uses many hours , perhaps many years, in their continued attention or care, contemplating the patients and studying their customs, problems, patterns..., so that it is easier for them to understand the new problems and solve them [16].

Truly, a look at the activities in the daily life of the GP shows great similarities between qualitative research and its practice. The experience of being a GP is similar to that of being an ethnographer who carries out a qualitative study. The GP works in the same surgery for a long time, developing relationships with his patients and their contexts, and realizing their visions and knowledge. In this way the GP is able to better interpret the signs and symptoms of the diseases that these people present. In the surgery, the GP, as an ethnographer, conducts an interview with a patient and, for this, he needs to establish empathy and to try to understand and interpret the perspective, experience, feelings and values of the patient. As an ethnographer, the GP has to interact with a great variety of people, many of who have different ways of understanding reality and vastly different stories and life experiences. Both GP and ethnographer negotiate their relationships with these different people in order to minimize the barriers to comprehension. But, unlike the ethnographer, the GP is orientated to practice and must therefore treat every patient [16].

Beyond being an experimenter or an orthodox epidemiologist, the GP should be a naturalist. To do so, he must look through the eyes of a researcher to see the nature of the pain that is presented to him. We rarely remember that many more than fifty per cent of modern medicine is due to the simple and pure observation of the pathological and its correct interpretation.

Detailed study of the natural history of the disease has been one of the most fruitful in the field of medicine. With the observation and proper description of the natural history of the disease, it has been able to understand its course and in this way, detect the disease in an early manner and prevent its sequelae [16, 17]. This continuity of care is the factor that implies a specific form of application of screening in GM: “Case- finding” [18]. The primary purpose of screening tests in a healthy population is to identify those individuals who have some pathology, but who still do not have symptoms. In GM, the most commonly used strategy is opportunistic detection or "case finding", in which a series of tests are performed according to age, sex and possible risk factors present in the person consulting for any reason thing. So, it involves actively searching and systematically in at risk people, rather than waiting for them to present with symptoms or signs of active disease. "Case-finding" is a epidemiologic method for taking advantage of patient visits [13, 19, 20, 21, 22]. Examples of case-finding can be: sexual partner ascertainment in syphilis outbreaks, or the study of family contacts in a family outbreak of keratoconjunctivitis, or household/work contacts in food-borne outbreaks, or the two-question case-finding instrument for detecting depression in primary care [1, 23].

On the other hand, individual disease depends on the context. The patient is a spokesman for the sick or problematic context (family conflict, social problem...). Therefore, symptoms may be forms of expression of biological alterations, or group or family alterations, or symbols or ways of coping with a situation. One of the factors that influence the type of symptoms is the stage of the family life cycle in which the patient is. This perspective considers that social and physical situations and the final behavior, and the biological and psychosocial processes, affect not only the possible risk of disease, but surround or frame the symptoms of the affected persons. For example, when an acute coronary syndrome occurs, the different stages of the patient's family life cycle may give rise to different symptoms for each of these stages [24].

In GM we can see "turning points" or transitions of patients and their contexts. These transitions are related to: a) The life cycle of the individual and the family; b) The sudden loss of stability c) The recurrence of problematic factors; and d) The accumulation of a number of problematic factors. During a transition, people experience stress and anxiety. But if it is exceeded there is an increase in knowledge and skills. Therefore, a practical epidemiological approach could be not only to see "problems" in the patients, but also their "transitions" or "turning points" as a part of continued care in GM [17, 25].

Distribution

It refers to the configuration and structuring of the phenomena related to health and its determinants in specific populations, and the application of this study to the control of health problems. In GM this implies both a longitudinal and vertical vision that the GP has on health / illness starting from the continuity of care [26]. GM is an important source of information on the occurrence and distribution of chronic disease in the population. So, GM has important epidemiological connotations, presenting a unique opportunity to study natural history of a disease. In medicine a priority objective of the studies must be the knowledge of the natural history of the disease. In developed countries around two-thirds of any population consults in a Family Medicine service at least once a year, and more than 80% contact once every 5 years.

Further, the collection of data in GM is cumulative and continuous: "The path of all patients begins and ends with the family doctor." Certainty of a diagnosis is not only important for the patient, but also for morbidity studies [13]. GP works includes the natural history of disease and the human life cycle, and so, no one is better able to observe, from family history, the ultimate consequences of any health problem [27].

The longitudinal view of the GP allows you to know the "Numerator" of prevalence data. A great accessibility of patients to their GP, and the role of first contact with the patient, it allowing in GM the estimation of the probability of health problems of the population (diagnoses, clinical onset, symptoms). Also, the GP is working with a population as a "denominator" to obtain prevalence data. Many health problems can only be identified within a population as a "denominator" (attack rate, incidence and prevalence) [6, 7, 8, 9, 28].

Vertical vision is based on family attention or family focus care. From the beginning of the life cycle to death, the family affects, and is affected, by the health of its members in many ways: Genetic transmission, transmission of life habits and values, family events, the social interaction, the effects on the family of the exponent patient, and his treatment, the effects of the health / disease in the family relationship, etc [29].

Ethology

It refers to the behavior of epidemiology. In GM this implies the use of significant and basic limited variables. The specific characteristics of the work in GM involve a "common sense• which comes from ordinary experience. A first particular piece of information that comes out of epidemiologic studies in GM is common sense: at this level of care it is feasible to carry out epidemiologic studies using the common means of family medicine, based on common experiences, and with an artisanal methodology that is not sophisticated, and the results of which do not differ substantially from other large sophisticated and complex studies. This fact is not usually highlighted. Common sense comes from ordinary experience in the GP surgery [30]. So, in the age of high technology, is there still any value in craft research? Yes, there is. As C. Wright Mills says, it is necessary to relativize the methodology and maximize the imagination [31, 32].

Epidemiology in MG plays with a limited number of pieces. It's like a kind of "puzzle" with only a few pieces but that are these basic determinants. We can remember that "puzzles" are games in which it is about correctly coupling the pieces. As they get more complicated they increase their number of pieces ..., from 30 to 100, up to a decidedly very high number: 2,000 to 15,000 pieces... But, basically between the "easy" and the "difficult" puzzle there is no difference: it is always to attach the bits or irregular shapes to form a figure or a whole with them. Certainly, a greater number of pieces requires more work, it is more difficult and that may have to be more sophisticated. However, it is common to fall into the false idea that with more number of elements also increases the difficulty of the game, when, in fact, it depends on other factors.

In this false premise, epidemiological studies are becoming increasingly difficult, with a greater number of variables included in the analysis, and increasingly sophisticated statistical techniques are required to be able to couple this set of variables and form an intelligible result.., although Sometimes it is clinically irrelevant or of little practical use, or the result is not even understandable. Epidemiology can happen as in puzzles: it is common to fall into the false idea that if more variables are included and the more complex the statistical analysis techniques are, the more important or better the results will be, when, in reality, it depends on other factors (not on the unthinking increase of variables to analyze, nor on the complexity of statistical techniques). It is part of the law that says "if we put garbage, we get garbage" [33].

From the point of view of GM, "the number and shape of the puzzle pieces of epidemiology" are invariable. There are a number of basic forms or variables, and the rest can be obtained, as in the Chinese Tangram or game of the seven elements, by division of the previous ones, and thus form with the basic elements certain variables or figures [34].

Epidemiology from GM has a specific number of elementary forms, which can be considered according to the old principle that "in the limitation of resources the teacher is seen." The results of some large or technically complex epidemiological studies were already known years earlier, from much more modest studies at the GM level. The same example could be applied here that the Pythagorean Theorem would have been already demonstrated thousands of years before in China by Li Hung Chang through the help of “Tamgram” [34]. But do this is necessary reflection and intelligence to increase and enrich the epidemiological imagination [31, 32].

The initial simple or "geometric" approach of the epidemiological view from GM can be converted into a more complex or "algebraic" approach. And vice versa, the epidemiological approach can be simplified and with this approach the majority (though not all) of the epidemiological problems in medicine can be solved; the limit of this simplifying transformation is in its coherence with the principles of the GM [35].

Ecology

It refers to the relationships of living beings and variables with each other and with the environment in which they live. In GM it implies an interrelated or integral panoramic vision of complexity. But also, in MG it implies an emphasis on simplification, simplicity and economy of means for the solution of scientific puzzles.

It is not often that a scientific advance arises from a single observation. Scientific advances are based on answers to a series of questions that have remained unanswered in the past. The solution of scientific puzzles is like a game of chess. The chessboard represents the problem as a whole. The black pieces represent all the basic questions without answering. The white figures represent the answers that the researcher offers to the basic questions. A scientific advance responds one after the other to all the questions that had been a mystery. Alternative explanations are discarded and the problem is being isolated: a scientific advance is equivalent to giving "checkmate" to a scientific or medical problem. The solution is generally seen as simple once it has been made.

Einstein said: "the most important scientific discoveries are so simple that they can be formulated in such a way that everyone understands them." It is not often that new fundamental discoveries, which can provide relevant elements and even change the course of medicine, are carried out inside a laboratory. Most are born in an environment that stimulates creative thinking. The solutions often have nothing to do with new surgical techniques, new medical instruments or new drugs ... The solutions are usually simple and partly known, extended and cheap ... The epidemiological work of the GP is much more than numbers and statistics; the quantitative can be the internal axis, but the GP sees the borders and in- between spaces of quantitative data, where generations of people leave their stories of health and disease. The epidemiological experience of the family doctor is nourished by environments, contexts and spaces [36].