This issue of Atención Primaria contains an article that reports an elegantly designed study aimed at identifying difficult patients, describing their profile and characterizing the opinions and feelings these patients evoke in the physicians who see them regularly.1 The study centers on difficult patients; however, the literature contains few items on this topic. The first problem that arises is the label «difficult» or «heartsink» patient. Several authors have tried to identify which group of patients these terms designate. Although many types of patient fit this label, the two most widely accepted definitions refer explicitly to subjective feelings of distress in practitioners who see these patients.2-4
Analyses of the origin of this discomfiture have identified multiple factors, which can be classified into three main groups. The first group comprises patient-dependent factors, the second consists of practitioner-dependent factors, and the third reflects factors that are setting-dependent.
Let us start with patient-related factors. The health problem that leads the patient to seek medical care may itself generate unease because we lack the appropriate training to deal with it, or because its connotations create an unpleasant situation for us. The patient's personality (or that of members of the patient´s family) (including physical appearance, systems of belief, or differing interpretations) and the patient´s circumstances in relation with his or her sociocultural environment, may also cause unease. These elements can lead to problems of incomprehension between the patient and physician, manifested as a lack of information or situations that, because of our own life experiences, evoke certain feelings that are unpleasant for us. The authors of the study cited above1 found difficult patients to have the following characteristics: about 67% were women, and most had more than two health problems often including a psychiatric disorder. Mean age was about 58 years and the patients had retired from their job, or, if they did not work outside the home, had ceased to perform some parenting and housekeeping tasks because of their age and the stage the household had reached in the family lifecycle. Patients were classified on the basis of specific characteristics into the following groups: a) dependent clingers, who often behaved as frequent attenders because of their view of the physician as a professional with unlimited resources; b) emotive seducers, who differ from the former in their use of flattery and false compliments, which they often employ to manipulate the physician´s emotions; c) help-rejecters, who also make frequent visits to their doctor but are characterized by their permanent refusal to accept any type of help on the assumption that it will not do them any good; d) somatizers, whose characteristics are well known; e) entitled demanders, who make great demands on primary care resources with a combination of devices such as guilt and aggressiveness; and f) noncomplying deniers, who systematically fail to follow our advice because of lack of information, negligence or self-destructiveness.2-4 The authors of the study published in this issue of Atención Primaria show that dependent clingers make up the largest group. The findings are in agreement with earlier studies except with regard to the prevalence of difficult patients, which varies widely depending on the detection method used and on differences between studies in the characteristics of participating practitioners.
Practitioner-dependent factors include the physician´s life experiences and personality, as already noted. Also forming part of this group are elements related with the profession, such as training, factors that affect how quickly the physician must work, and the circumstances surrounding the patient-physician encounter, in which lack of training in the management of psychosocial factors is of great importance.3 Theses variables were not analyzed in the study described here; however, what this study did examine was the opinions and feelings these patients evoke in the physicians who see them. There were slight differences between the findings of the present study and those of others. The main limitation of the present study was that difficult patients were identified on the basis of a definition that takes physicians´ feelings into consideration; such studies should be interpreted with caution. When qualitative analyses are sought, as in the present case, it is advisable to select patients on the basis of characteristics other than the feelings they evoke in practitioners.
It is setting-dependent factors which are most closely related with the characteristics of the health center, and particularly with how it is run which in turn is related with how the administrative department is organized, how long waiting times are and how many interruptions occur. The study of difficult patients included in this issue does not mention these factors, although they should be taken into account given their importance in managing patients, and the fact that they are difficult to modify.
The article ends with some conclusions regarding the problems physicians encounter when they see these patients in their practice.2-4 The most important problem is inadequate training, according to the results of the qualitative analysis. This limitation is related with the psychosocial aspects of practice. Shortcomings in biomedical training are usually not confessed, as in this area everything is more tangible: we know where to train, and how to train. The psychosocial element of our professional profile is more intangible, and has to do with health-determining factors that are less easily modifiable; moreover, there is initial resistance on the part of professionals toward such training. However, the study in this issue of Atención Primaria draws attention to the prevalence of difficult patients, and to the considerable differences in prevalence between studies. It would be interesting to see whether the way physicians «select» difficult patients or other types of patient is affected by our training profile, capacity for self-control, or other characteristics.
Unquestionably, effective and efficient management strategies for these patients are not homogeneous, just as difficult patients do not form a homogeneous group. Research on this problem is just beginning, and each patient will require a different approach depending on his or her characteristics and determinants. This is why thus far, most authors note that there is broader agreement on how to evaluate difficult patients then on how to cope with them.
