title: [Difficult patients in primary care: a quantitative and qualitative study].
abstract: OBJECTIVE
  To identify difficult (heartsink) patients (DP), describe their profile, and report the opinions and experiences they evoke in physicians who see them.
  
  
  METHODS
  Descriptive, cross-sectional study based on quantitative and qualitative methods.
  
  
  METHODS
  Urban health care center.
  
  
  METHODS
  Difficult patients were selected daily from among all patients seen in six primary care practices during the period from March to May 2001. Patients were identified according to the diagnostic criteria of Ellis (patients who cause a knot in the stomach when their name appears on the list of patients with an appointment that day) and O'Dowd (patients who cause distress or discomfort).
  
  
  METHODS
  Information was obtained on the number of DP seen, number of visits made by DP, age, sex, type of DP, level of education, occupation, family structure and comorbidity. Type of DP was determined with a modification of the Groves classification (dependent clinger, entitled demander, manipulative help-rejecter, self-destructive denier, somatizer, emotive seducer). We analyzed the opinions DP generated by examining the discourse produced during a discussion group session with 9 physicians from the participating health center and a moderator.
  
  
  RESULTS
  A total of 82 DP were identified (prevalence.7%, i.e., 2.3% of all visits). Most (67.1%) were women. Mean age was 57.8 years (standard deviation 15.2 years). Dependent clinger patients predominated (41%). Most patients had primary-level education (62%), about one-third were retired (35%), and about one-third were married and had children (35%). Most had two or more medical diagnoses (74.4%), and many had at least one psychiatric diagnosis (40.2%).The feelings these patients evoked most often in physicians were irritability and frustration. Most physicians agreed that these patients are rare but have a severe emotional impact. Physicians believe that the skills and strategies they have to help them manage these patients are limited, and consider specific training necessary to improve them.
  
  
  CONCLUSIONS
  Although DP are not a relevant problem in quantitative terms, they cause considerable emotional distress. Specific training in clinical interviewing is felt to be necessary given the difficulties in managing these patients.
authors.affiliation: Especialistas en Medicina de Familia y Comunitaria. ABS Santa Eulàlia Sud. L'Hospitalet de Llobregat. Barcelona. España. 22716xmg@comb.es
authors.forename: X
authors.initials: X
authors.lastname: Mas Garriga
authors.forename: J M
authors.initials: JM
authors.lastname: Cruz Doménech
authors.forename: N
authors.initials: N
authors.lastname: Fañanás Lanau
authors.forename: A
authors.initials: A
authors.lastname: Allué Buil
authors.forename: I
authors.initials: I
authors.lastname: Zamora Casas
authors.forename: R
authors.initials: R
authors.lastname: Viñas Vidal
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D006123:Group Practice / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D005791:Patient Care / Q000523:psychology*; D010817:Physician-Patient Relations; D010821:Physicians, Family; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires