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Difficult patients in primary care: a quantitative and qualitative study
Pacientes de trato difícil en atención primaria: una aproximación cuantitativa y cualitativa
X. Mas Garrigaa, JM. Cruz Doménecha, N. Fañanás Lanaua, A. Allué Buila, I Zamora Casas and R Viñas Vidala
a Especialistas en Medicina de Familia y Comunitaria, ABS Santa Eulàlia Sud, L´Hospitalet de Llobregat (Barcelona), Spain.
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    "textoCompleto" => "<p class="elsevierStylePara">Introduction</p><hr></hr><p class="elsevierStylePara">In connection with doctor-patient relationships&#44; how to manage difficult &#40;heartsink&#41; patients &#40;DP&#41; is a frequent topic of conversation among primary care physicians&#46; These patients evoke a variety of feelings that often include elements of emotional tension&#44; and can contribute to the dreaded professional burnout&#46; Conversations among practitioners suggest that distress is widespread&#44; and in contrast to the situation for specific &#40;especially organic&#41; diseases&#44; there seems to be no common set of skills or strategies for dealing with these patients and improving physician-patient relations&#46;</p><p class="elsevierStylePara">A number of studies have examined relations with DP&#46; Most describe their characteristics&#44;<span class="elsevierStyleSup">1-5</span> the feelings they most often produce&#44;<span class="elsevierStyleSup">2&#44;6&#44;7</span> or strategies for managing such patients&#59;<span class="elsevierStyleSup">2&#44;5-9</span> other studies have proposed ways to classify them&#46;<span class="elsevierStyleSup">6</span> However&#44; few studies mention the prevalence of these patients or the numbers of visits they make&#46;<span class="elsevierStyleSup">5&#44;10-13</span> In Spain&#44; a notable study by Blay Pueyo<span class="elsevierStyleSup">14</span> defined and characterized problem patients&#44; and proposed strategies for improving their management&#46; Another noteworthy study by Sanz-Carrillo et al&#46;<span class="elsevierStyleSup">15</span> reported practitioners&#180; reactions to somatizer patients&#46; Other texts&#44; such as that by Borrell&#44;<span class="elsevierStyleSup">16</span> are of a more general nature&#46; We are aware of no studies that report the opinions of medical team members regarding DP in qualitative terms&#44; or that describe the prevalence and profile of these patients&#46;</p><p class="elsevierStylePara">The aims of the present study were to identify DP seen by members of a primary care team&#44; to describe the profile of these patients&#44; and to analyze the opinions they generate in the physicians who see them in their daily practice&#46;</p><hr></hr><p class="elsevierStylePara">Participants and methods</p><hr></hr><p class="elsevierStylePara">Setting</p><p class="elsevierStylePara">The study was carried out in the Santa Eulalia Sud urban Basic Health Area &#40;L&#180;Hospital de Llobregat&#44; Barcelona&#44; Spain&#41;&#46; The staff consists of 9 family physicians and 3 pediatricians who serve a population of 23 000 inhabitants&#46;</p><p class="elsevierStylePara">Sample and participants</p><p class="elsevierStylePara">Six family doctors took part in the study&#46; Two temporary staff doctors were excluded&#44; as was one new staff member whom it was felt did not yet know his patients well enough to provide information on their profiles&#46;</p><p class="elsevierStylePara">Heartsink patients were selected and classified during the period from March to May 2001&#46; The inclusion criteria were chosen by consensus among the participating physicians as being straightforward and readily applicable&#58; the criteria of Ellis &#40;patients who cause a knot in the stomach when their name appears on the list of patients with an appointment that day&#41;&#44;<span class="elsevierStyleSup">7</span> and the criteria of O&#180;Dowd &#40;patients who produce distress or discomfort in those who see them&#41;&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">From the list of the patients with a scheduled appointment &#40;requested by the patient or scheduled by the physician&#41; or an emergency appointment&#44; the physicians identified patients who satisfied the inclusion criteria noted above&#46; The study variables were number of DP seen&#44; number of visits made by DP&#44; age&#44; sex&#44; type of DP&#44; family structure&#44; level of education&#44; occupation and comorbidity &#40;associated medical or psychiatric problem&#41;&#46; Groves&#180; classification<span class="elsevierStyleSup">6</span> was used to identify difficult patients as dependent clingers&#44; entitled demanders&#44; manipulative help-rejecters or self-destructive deniers&#44; and the categories emotive seducer and somatizer were added as recommended by Blay Pueyo<span class="elsevierStyleSup">14</span> &#40;Table 1&#41;&#46;</p><p class="elsevierStylePara"><img src="27v31n04-13044896tab01.gif"></img></p><p class="elsevierStylePara">Discussion group</p><p class="elsevierStylePara">A qualitative study was done to record the opinions and experiences these patients generated in the physicians who saw them&#46; Because of its ease of application and suitability for the aims of the present study&#44; we used a focus group approach &#40;discussion group&#41;&#44; a qualitative analytical and research technique that consists of a semistructured conversation guided by a moderator with the help of a flexible script based on a series of open questions&#46;<span class="elsevierStyleSup">18-22</span> All 9 staff physicians at the center participated in the discussion group&#46; The three physicians who did not participate in the patient selection phase were included&#46; Although being a staff member for only a short time before the study was done may have influenced how they identified DP&#44; we felt that this would not influence their opinions about these patients&#46; The staff health technician at the center acted as the discussion group moderator&#46;</p><p class="elsevierStylePara">A script that served as the basis for the discussion included the following issues&#58; quantitative and qualitative magnitude of the problem &#40;emotional impact&#41;&#44; feelings evoked&#44; management strategies&#44; perception of management skills and need for training&#46; The discussion group met during 1 hour during working hours&#44; and the meeting was tape-recorded for later data analysis&#46; The recording was analyzed by the moderator and one of the participants to identify the opinions expressed most frequently or most strongly&#44; although all opinions considered of interest were noted&#46;</p><p class="elsevierStylePara"><img src="27v31n04-13044896tab02.gif"></img></p><p class="elsevierStylePara">Results and discussion</p><hr></hr><p class="elsevierStylePara">Characteristics of difficult patients</p><p class="elsevierStylePara">The 82 patients identified &#40;average of 13&#46;6 patients per physician&#41; represented a prevalence of 0&#46;7&#37;&#44; and generated 2&#46;3&#37; of all visits during the study period&#46; Two-thirds &#40;67&#46;1&#37;&#41; were women and 32&#46;9&#37; were men&#44; and mean age was 57&#46;8 years &#40;standard deviation 15&#46;2 years&#41;&#46; The general profile was that of a woman classified as a passive clinger type of patient &#40;41&#37;&#41;&#44; with primary level education &#40;62&#37;&#41;&#44; retired &#40;35&#37;&#41;&#44; married with children &#40;35&#37;&#41;&#44; and with two or more medical problems &#40;74&#46;4&#37;&#41; and at least one psychiatric problem &#40;40&#46;2&#37;&#41;&#46;</p><p class="elsevierStylePara">Figures 1 to 4 show the how difficult patients were distributed according to Groves&#180; classification&#44; educational level&#44; occupation and family structure&#46;</p><p class="elsevierStylePara"><img src="27v31n04-13044896tab03.gif"></img></p><p class="elsevierStylePara"><img src="27v31n04-13044896tab04.gif"></img></p><p class="elsevierStylePara"><img src="27v31n04-13044896tab05.gif"></img></p><p class="elsevierStylePara"><img src="27v31n04-13044896tab06.gif"></img></p><p class="elsevierStylePara">Few studies have evaluated the prevalence of DP and the number of times they visit their doctors&#46; Mathers et al&#46;<span class="elsevierStyleSup">23</span> reported a mean of 6 DP per participating physician&#44; with considerable variability ranging from 1 patient to 50 &#40;i&#46;e&#46;&#44; from &#60;1&#37; to &#62;3&#37; of the physician&#180;s list of patients&#41;&#46; The mean number of DP per physician in the present study was higher&#44; and similar to that reported by Schwenk and colleagues&#46;<span class="elsevierStyleSup">12</span> We found less variability between physicians &#40;12 to 19 patients identified as DP&#41;&#44; and like Mathers et al&#46;&#44; we found that all participants had at least one DP among their regular patients&#46;</p><p class="elsevierStylePara">The prevalence of almost 15&#37; reported by Hahn et al&#46;<span class="elsevierStyleSup">11</span> was notably high&#46; In their study&#44; DP were identified with the help of a questionnaire that participating physicians responded to&#44; which may have avoided recall bias&#46; We believe the facts that the physicians who participated in the present study had held their primary care post for 5 years or longer&#44; and were responsible for similar numbers of patients&#44; helped to stabilize the number of DP&#44; either through mechanisms of mutual adaptation or because patients were allowed to change physicians&#46;</p><p class="elsevierStylePara">We note that earlier studies have reported the proportion of DP visits as 15&#37;&#44;<span class="elsevierStyleSup">10</span> 20&#37;<span class="elsevierStyleSup">5</span> or even 30&#37;&#46;<span class="elsevierStyleSup">13</span> Jackson and Kroenke<span class="elsevierStyleSup">10</span> studied only first visits&#44; a factor that introduced significant bias because of the difficulties associated with the first physician-patient encounter&#46; The study by Hahn et al&#46;<span class="elsevierStyleSup">5</span> was done in a hospital setting&#46; The rate of DP visits of 2&#46;32&#37; in the present study represents a mean of 30 visits per day per physician&#44; one visit by a DP every 2 days&#44; or 14 difficult encounters per month&#46; We consider that although the prevalence of DP in the present study is lower than that found by others&#44; these patients are more frequent attenders&#44; an important consideration given the impact of these visits&#46;</p><p class="elsevierStylePara">With regard to the characteristics associated with DP&#44; we found&#44; as did many earlier studies&#44; that more such patients were women&#44;<span class="elsevierStyleSup">1&#44;4&#44;7&#44;17</span> and that DP often had complex medical problems &#40;both physical and psychological&#41;&#46;<span class="elsevierStyleSup">3-5&#44;10&#44;11&#44;17&#44;24-27</span> Although John et al&#46;<span class="elsevierStyleSup">4</span> found no differences in family composition&#44; we noted&#44; as did O&#180;Dowd&#44;<span class="elsevierStyleSup">17</span> that married persons clearly predominated&#46; O&#180;Dowd also reported a higher employment rate &#40;67&#37;&#41; than we found &#40;25&#37;&#41;&#46;</p><p class="elsevierStylePara">Magnitude of the problem</p><p class="elsevierStylePara">In consonance with these results&#44; all members of the discussion group felt that the number of DP they saw was not large&#46; However&#44; dealing with these patients involved considerable psychological or emotional distress&#46; The problem can therefore be considered to be qualitative rather than quantitative&#46; All physicians had at least one DP&#44; but they were surprised at how few such patients they actually saw&#44; as they had assumed when they were invited to participate in the study that they would identify many more&#46; We agree with O&#180;Dowd<span class="elsevierStyleSup">17</span> that the scarcity of published quantitative data might lead to the perception that the problem is greater than it actually is&#46; This might be explained by the phenomenon of gradual mutual adaptation with time&#44; as reflected by the statements <span class="elsevierStyleItalic">&#171;With time I get to like them&#187;</span> and <span class="elsevierStyleItalic">&#171;I think the two come to an understanding&#46;&#187;</span></p><p class="elsevierStylePara">Feelings evoked by difficult patients</p><p class="elsevierStylePara">Most of the feelings described by Groves<span class="elsevierStyleSup">6</span> were expressed by the participants in the present study&#44; although with subtle differences&#46; The most frequently reported feelings were irritability &#40;<span class="elsevierStyleItalic">&#171;I get nervous&#187;&#44; &#171;I get uptight&#187;&#44;<br></br> &#171;I realize that without meaning to&#44; I raise my voice when I speak to them&#187;</span>&#41; and frustration&#44; which were noted in relation with all groups of DP&#46; Most participants felt that frequent attenders&#44; a group represented mainly by &#171;dependent clinger&#187; patients&#44; were readily perceived to be difficult patients &#40;<span class="elsevierStyleItalic">&#171;They&#180;re like glue&#187;&#44; &#171;They stick to everything&#187;</span>&#41;&#44; and that their degree of dependency can generate feelings of defeat &#40;<span class="elsevierStyleItalic">&#171;On the day you see them&#44; you end up feeling drained&#187;</span>&#41; as well as insecurity &#40;<span class="elsevierStyleItalic">&#171;In spite of your years of experience&#44; they manage to make you feel insecure since you can&#180;t solve their problem&#187;</span>&#41;&#46; This was an important point for many participants&#44; as it led some to resort to referral to other practitioners to <span class="elsevierStyleItalic">&#171;cut down on your own responsibility&#46;&#187;</span> Although the aversion described by Groves as arising in the relationship with dependent clinger patients was not mentioned per se during the discussion session&#44; the tendency to refer the patient to another physician might be understood as a consequence of this feeling&#46; With regard to manipulative help-rejecter patients<span class="elsevierStyleBold">&#44;</span> the guilt feelings mentioned by Groves were not alluded to&#44; but participants reported feelings of impotence because they could not do anything about the patient&#180;s problem&#46;</p><p class="elsevierStylePara">We note that although experience accumulated through years of practice might be thought to provide physicians with more skills to manage these situations and patients&#44; physicians continue to experience unease&#58; <span class="elsevierStyleItalic">&#171;I still have problems&#187;&#44; &#171;I thought I had it under control but some patients still throw me off balance&#46;&#187;</span> The information published to date regarding the influence of experience is contradictory&#46; In their study of predictors in physicians who saw difficult patients&#44; Jackson and Kroenke<span class="elsevierStyleSup">10</span> found no differences in the number of DP identified in connection with years in practice&#46; However&#44; Crutcher and Bass<span class="elsevierStyleSup">13</span> reported that more experienced physicians had fewer problematic encounters&#46; Strategies used with difficult patients</p><p class="elsevierStylePara">Each practitioner described his or her personal strategy&#44; acquired over the years&#46; Referral was used often&#44; but was perceived as a strategy that yielded poor results and was aimed at keeping the patient from complaining or reducing the physician&#180;s distress rather than at solving the patient&#180;s underlying problem&#46; To understand the reasons that led patients to create difficulties&#44; physicians reported occasionally making determined efforts to comprehend the causes or keys to a patient&#180;s particular attitude by asking themselves <span class="elsevierStyleItalic">&#171;Why hasn&#180;t the patient ever smiled at me in all these years&#63;&#187;</span> or <span class="elsevierStyleItalic">&#171;Why isn&#180;t the patient ever satisfied with anything I do&#63;&#187;</span> Some physicians turn to someone in the patient&#180;s immediate circle who might help him or her to understand the patient&#58; <span class="elsevierStyleItalic">&#171;I try to talk to a relative and ask him or her what the patient is normally like&#46;&#187;</span> This approach&#44; which has been proposed and evaluated by others<span class="elsevierStyleSup">3-5&#44;17</span> as an intervention that can improve the situation&#44; is difficult within the setting of practices with large patient loads&#46;</p><p class="elsevierStylePara">Negotiating and making pacts are considered necessary and useful strategies for managing heartsink patients&#44; and often make it possible for the patient and the physician to reach agreement&#58; <span class="elsevierStyleItalic">&#171;Look&#44; this is the last time I&#180;m going to write out prescriptions for you&#59; next time I&#180;m not going to do this&#46;&#187; &#171;I&#180;ll write out this prescription&#44; but first let me explain why I think I shouldn&#180;t be doing this&#46;&#187;</span> Another strategy is to try to place limits on the reasons for visiting the doctor&#58; <span class="elsevierStyleItalic"> &#171;With some patients&#44; especially the passive clingers&#44; you could spend all day talking and they&#180;d still never get tired of listening&#44; since they need you to solve their problems&#46; In this group it is very important to be able to stop them from coming&#44; to limit their reasons for coming in&#44; and if necessary to give them an appointment for an interview outside regular hours to be able to spend more time talking with them &#40;but even then they&#180;d use up the time allotted for their scheduled appointment and would never leave&#46;&#41;&#187;</span> It is also important to make patients understand that <span class="elsevierStyleItalic">&#171;as a doctor you have two thousand patients to look after&#44; not just one&#46;&#187;</span> This is a way to try to reduce the patient&#180;s dependency&#44; as Groves<span class="elsevierStyleSup">6</span> noted&#46;</p><p class="elsevierStylePara">Consultation with other members of the health care team is rarely used during regular team meetings&#46; Instead&#44; personal experiences are commented on informally&#44; usually in the hallways&#59; this <span class="elsevierStyleItalic">&#171;gives us a chance to get it off our chest&#46;&#187;</span> However&#44; participants in the present study agreed that being able to talk about patients could be a valid tool&#44; especially when for some reason the patient changes physicians&#58; <span class="elsevierStyleItalic"> &#171;If the relationship with the previous physician was bad&#44; it might well turn out to be bad with me too&#46;&#187;</span> In such cases knowing about a difficult patient in advance would allow the physician to prepare a strategy to prevent problems&#46;</p><p class="elsevierStylePara">Need for training to cope with difficult patients</p><p class="elsevierStylePara">Most participants felt that specific training in physician-patient relations was inadequate&#46; Almost all had completed a basic course in clinical interviewing&#44; but had not subsequently studied the course contents in depth&#46; Thus practitioners adopted strategies or maneuvers that they had learned on their own&#58; <span class="elsevierStyleItalic">&#171;You learn from your mistakes&#46;&#187;</span> It is worth recalling here that in the study by Mathers et al&#44;<span class="elsevierStyleSup">23</span> less training in communication skills and inadequate postgraduate training were associated with the perception of larger numbers of patients as difficult&#46; Other authors<span class="elsevierStyleSup">2&#44;10</span> have noted the usefulness of specific training as a tool for improving the management of heartsink patients&#46; Continuous training in aspects of the physician-patient relationship is therefore considered necessary to equip the practitioners with skills that will allow them to make headway in difficult situations&#46;</p><p class="elsevierStylePara"><img src="27v31n04-13044896tab07.gif"></img></p><p class="elsevierStylePara">Conclusions </p><hr></hr><p class="elsevierStylePara">The profile of heartsink patients in our setting was similar to that described in earlier studies&#44; but the prevalence and rate of visits were lower than expected&#46; Nonetheless&#44; members of the team of physicians who see these patients reported difficulties in dealing with them&#44; emotional distress&#44; and inadequate skills to cope with them&#46; Specific training in strategies to improve the physician-patient relationship is essential&#46; As Ellis proposed&#44;<span class="elsevierStyleSup">7</span> we should be able to assist our patients and&#44; while not curing them&#44; help them to resolve their conflicts&#44; and at the same time &#173;as noted by Powers<span class="elsevierStyleSup">8</span>&#173; decrease our level of frustration and the danger of burnout&#46;</p><p class="elsevierStylePara">We believe our study should be broadened to examine another aspect of the problem&#58; as Jewell<span class="elsevierStyleSup">2</span> asked&#44; on the basis of Balint&#180;s view&#44; how much of the problem can be attributed to physicians&#63; Undoubtedly&#44; knowledge of physician-associated factors which&#44; according to some authors&#44;<span class="elsevierStyleSup">10&#44;23</span> can be considered predictors of &#171;difficult encounters&#44;&#187; should help to improve the physician-patient relationship under adverse conditions&#46;</p><p class="elsevierStylePara">Acknowledgements</p><p class="elsevierStylePara">We thank Dr&#46; Ferran Flor&#44; health technician at our center&#44; for accepting the role of moderator of the discussion group and for reading and suggesting revisions to an earlier version of the paper&#46;</p><p class="elsevierStylePara">&#160;</p>"
    "pdfFichero" => "27v31n04a13044896pdf001.pdf"
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        "resumen" => "Objetivo&#46; Identificar a los pacientes &#171;de trato dif&#237;cil&#187; &#40;PD&#41;&#44; describir su perfil y las opiniones y vivencias que generan en los m&#233;dicos que los atienden&#46; Dise&#241;o&#46; Estudio descriptivo transversal&#46; Metodolog&#237;a cuantitativa-cualitativa&#46; Emplazamiento&#46; Centro de salud urbano&#46; Participantes&#46; Los PD seleccionados diariamente del total de pacientes atendidos en 6 consultas de atenci&#243;n primaria&#44; entre marzo y mayo de 2001&#46; Se identificaron mediante los criterios diagn&#243;sticos de Ellis &#40;pacientes que provocan nudo en el est&#243;mago al leer su nombre en el listado&#41; y O&#39;Dowd &#40;pacientes capaces de producir distr&#233;s&#44; malestar&#41;&#46; M&#233;todo&#46; Se recogi&#243; informaci&#243;n sobre los PD visitados&#44; n&#250;mero de visitas realizadas por PD&#44; edad&#44; sexo&#44; clasificaci&#243;n&#44; estudios&#44; ocupaci&#243;n&#44; estructura familiar y comorbilidad&#46; Se utiliz&#243; la clasificaci&#243;n de Groves modificada &#40;pasivo-dependiente&#44; exigente-agresivo&#44; manipulador-masoquista&#44; negador-autodestructivo&#44; somatizador&#44; emotivo-seductor&#41;&#46; Analizamos las opiniones que generan a partir del discurso producido en un grupo de discusi&#243;n &#40;9 m&#233;dicos del centro y un moderador&#41;&#46; Dise&#241;o&#46; Se seleccion&#243; a 82 pacientes &#40;prevalencia del 0&#44;7&#37; &#91;el 2&#44;3&#37; de las consultas realizadas&#93;&#41;&#44; de los que el 67&#44;1&#37; eran mujeres&#46; La edad media era de 57&#44;8 a&#241;os &#40;DE&#44; 15&#44;2&#41;&#46; Predomin&#243; la paciente pasiva-dependiente &#40;41&#37;&#41;&#44; con estudios primarios &#40;62&#37;&#41;&#44; jubilada &#40;35&#37;&#41;&#44; casada y con hijos &#40;35&#37;&#41;&#44; con dos o m&#225;s patolog&#237;as m&#233;dicas &#40;74&#44;4&#37;&#41; y al menos una psiqui&#225;trica &#40;40&#44;2&#37;&#41;&#46; Los sentimientos que predominantemente generan en los m&#233;dicos son irritabilidad y frustraci&#243;n&#46; La mayor&#237;a coincide en que estos pacientes son escasos pero ocasionan un impacto emocional intenso&#44; cree que sus habilidades y estrategias para manejarlos son limitadas y considera necesaria formaci&#243;n espec&#237;fica para mejorarlas&#46; Conclusiones&#46; Aunque cuantitativamente los PD no se consideran un problema relevante&#44; provocan un gran desgaste emocional&#46; Se consideran necesarios formaci&#243;n&#47;entrenamiento espec&#237;ficos en entrevista cl&#237;nica dadas las dificultades que presenta su manejo&#46; &#160;"
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        "resumen" => "Aim&#46; To identify difficult &#40;&#171;heartsink&#187;&#41; patients &#40;DP&#41;&#44; describe their profile&#44; and report the opinions and experiences they evoke in physicians who see them&#46; Design&#46; Descriptive&#44; cross-sectional study based on quantitative and qualitative methods&#46; Setting&#46; Urban health care center&#46; Participants&#46; Difficult patients were selected daily from among all patients seen in six primary care practices during the period from March to May 2001&#46; Patients were identified according to the diagnostic criteria of Ellis &#40;patients who cause a knot in the stomach when their name appears on the list of patients with an appointment that day&#41; and O&#39;Dowd &#40;patients who cause distress or discomfort&#41;&#46; Method&#46; Information was obtained on the number of DP seen&#44; number of visits made by DP&#44; age&#44; sex&#44; type of DP&#44; level of education&#44; occupation&#44; family structure and comorbidity&#46; Type of DP was determined with a modification of the Groves classification &#40;dependent clinger&#44; entitled demander&#44; manipulative help-rejecter&#44; self-destructive denier&#44; somatizer&#44; emotive seducer&#41;&#46; 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&#46; Results&#46; A total of 82 DP were identified &#40;prevalence &#46;7&#37;&#44; i&#46;e&#46;&#44; 2&#46;3&#37; of all visits&#41;&#46; Most &#40;67&#46;1&#37;&#41; were women&#46; Mean age was 57&#46;8 years &#40;standard deviation 15&#46;2 years&#41;&#46; Dependent clinger patients predominated &#40;41&#37;&#41;&#46; Most patients had primary-level education &#40;62&#37;&#41;&#44; about one-third were retired &#40;35&#37;&#41;&#44; and about one-third were married and had children &#40;35&#37;&#41;&#46; Most had two or more medical diagnoses &#40;74&#46;4&#37;&#41;&#44; and many had at least one psychiatric diagnosis &#40;40&#46;2&#37;&#41;&#46; The feelings these patients evoked most often in physicians were irritability and frustration&#46; Most physicians agreed that these patients are rare but have a severe emotional impact&#46; Physicians believe that the skills and strategies they have to help them manage these patients are limited&#44; and consider specific training necessary to improve them&#46; Conclusions&#46; Although DP are not a relevant problem in quantitative terms&#44; they cause considerable emotional distress&#46; Specific training in clinical interviewing is felt to be necessary given the difficulties in managing these patients&#46;"
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                  "referenciaCompleta" => "Heartsink patients. Br Med J 1988;297:857."
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos