[Nociplastic pain and associated functional disorders: Update, diagnostic tools, and communication strategies for the general practitioner]. / Douleur nociplastique et troubles fonctionnels associés.

Nociplastic pain and associated non-pain symptoms are frequent health issues in primary care. Professionals may feel apprehensive about their management and face challenges due to the complexity and chronicity of the somatopsychic conditions. A thorough understanding of nociplastic mechanisms, associated clinical elements, and the biopsychosocial model are necessary for individualized evaluation, identifying affected patients, selecting dedicated treatments to desensitize the central nervous system, and building a solid partnership between the patient and the clinician.

La douleur nociplastique et les symptômes non douloureux associés constituent un problème de santé fréquent en médecine de premier recours. Les professionnels peuvent avoir de l'appréhension dans la prise en charge, être confrontés à des défis en raison de la complexité et de la chronicité de la pathologie somatopsychique. Une connaissance approfondie des mécanismes de la nociplasticité, des éléments cliniques associés ainsi qu'une utilisation du modèle biopsychosocial sont nécessaires dans l'évaluation individualisée, l'identification des patients concernés, la sélection de traitements dédiés pour désensibiliser le système nerveux central (SNC) et la construction d'un partenariat solide entre le patient et le clinicien.

[Prescription of psychotherapy provided by psychologists : a new role for general practitioners ?] / Prescription de psychothérapie dispensée par des psychologues : nouveau rôle des généralistes ?

This article focuses on the new model for prescribing psychotherapy provided by psychologists that has been in effect in Switzerland since July 1, 2022. Psychologists can now practice as independent providers with a prescription from a primary care physician for a given number of sessions. This new law, which should facilitate access to mental health care, introduces new administrative issues for general practitioners and transforms their relationship with their patients and psychologists. This phenomenon is part of a broader system of care that is changing and requires a great deal of adaptation on the part of front-line workers. Close collaboration between prescribing physicians, psychologists, psychiatrists and patients is therefore essential.

Cet article traite du modèle de prescription de psychothérapie prodiguée par les psychologues appliqué depuis le 1er juillet 2022 en Suisse. Les psychologues peuvent désormais exercer leurs activités en tant que prestataires indépendant-es sur ordonnance d'un-e médecin de premier recours, pour un nombre de séances donné. Cette loi, qui devrait faciliter l'accès aux soins de santé mentale, introduit de nouveaux enjeux administratifs pour les généralistes et transforme leur relation avec leurs patient-es et les psychologues. Ce phénomène s'inscrit plus globalement dans un système de soins qui change et demande beaucoup d'adaptation de la part des intervenants de première ligne. Une étroite collaboration entre médecins prescripteurs, psychologues, psychiatres et patient-es est désormais indispensable.

[Persistent Postural-Perceptual Dizziness (PPPD) - A clinical case and essentials for the primary care medicine]. / Vertiges posturaux-perceptuels persistants (VPPP) - Cas clinique et notions essentielles pour le généraliste.

Persistent Postural-Perceptual Dizziness (PPPD) is a chronic functional disorder that manifests with symptoms of dizziness, unsteadiness or non-spinning vertigo that lasts for at least three months. These symptoms are exacerbated by upright posture, active or passive motion, and exposure to complex or moving visual stimuli. This -pathology has been known for a long time ago. Still, after an expert's consensus in 2017, this term was born, and some precise diagnostic criteria have been defined based on identifying key symptoms in the patient's clinical history. Treatment is multimodal, incorporating -vestibular rehabilitation, cognitive-behavior therapy, and serotonergic medication.

Les VPPP ou vertiges posturaux-perceptuels persistants (Persistent Postural-Perceptual Dizziness (PPPD)) sont une pathologie fonctionnelle chronique, caractérisée par une sensation de déséquilibre, d'instabilité ou de vertige non rotatoire. Les symptômes peuvent être exacerbés par la position debout, la mobilisation active ou passive et l'exposition à des stimuli visuels complexes ou en mouvement. Si la pathologie est connue de longue date, c'est suite à un consensus d'experts qu'est né ce terme en 2017, et que des critères diagnostiques clairs ont été définis, qui se basent sur l'identification de symptômes clés dans l'histoire ­clinique du patient. Le traitement est multimodal, ­comprenant une réhabilitation vestibulaire, des thérapies cognitivo-comportementales et une médication sérotoninergique.

[Practical management of post-COVID-19 condition. Update and illustration by clinical situations]. / Prise en charge pratique de l'affection post-Covid-19. Mise à jour et illustration par des situations cliniques.

Persistent manifestations of COVID-19, known as «long COVID¼ or post-COVID-19 condition (RA02, CIM-11), affect many infected individuals, with a 24-month prevalence depending on the studies context (18 % in a recent Swiss study). The diversity of clinical presentation, the sometimes complex diagnostic methods, and the multidisciplinary management highlight the importance of a holistic approach, with practical advice for assessing work capacity in the outpatient setting. This article offers an update and synthesis of current knowledge concerning post-COVID-19 condition with practical recommendations for primary care medicine, illustrated by real clinical situations.

Les manifestations persistantes du Covid-19, connues sous le nom de « Covid long ¼ ou affection post-Covid-19 (RA02, CIM-11), concernent un nombre significatif de personnes infectées, avec une prévalence à 24 mois de l'infection variant en fonction des études et du contexte (18 % dans une étude suisse récente). La diversité de présentation clinique, les méthodes diagnostiques, parfois complexes, et les approches multidisciplinaires pour la prise en charge soulignent l'importance d'une approche holistique. Cet article propose une mise à jour et une synthèse des connaissances actuelles concernant l'affection post-Covid-19, avec des recommandations pratiques de prise en charge en médecine de premiers recours, illustrées par des situations cliniques réelles et des conseils pratiques pour l'appréciation de la capacité de travail.

[Psychiatric liaison III: Research]. / La liaison psychiatrique III : recherche.

Liaison psychiatry consists of an activity of consultation for patients affected by somatic diseases and of an activity of liaison for clinicians. The liaison work can take different forms, such as teaching of patient-physician relationship, supervision or support. To illustrate psychiatric liaison research, we present four studies conducted in our service, which explore (a) the relations between medical students' mental health and their interpersonal competence, (b) the dreams of medical students and what they reveal of their subjectivities, (c) the stakes for primary care practitioners when asking for a specialist's consult, and (d) the situated clinical practice. These studies contribute to nourish psychiatric liaison, which can use their results for training or support of clinicians.

La psychiatrie de liaison comprend une activité de consultation auprès des patient·es en soins somatiques et une activité de liaison auprès des clinicien·nes. La liaison psychiatrique peut prendre des formes diverses, tels l'enseignement de la relation soignant·e-soigné·e, des supervisions ou le soutien d'équipe. Dans cet article, nous présentons 4 études menées dans notre service qui s'intéressent : a) aux liens entre la santé mentale des étudiant·es en médecine et leurs compétences interpersonnelles ; b) à leurs rêves et à ce qu'ils révèlent de leur subjectivité ; c) aux enjeux de l'appel aux spécialistes pour les médecins de premier recours et d) à la pratique clinique en situation. Ces études contribuent à nourrir le travail de liaison qui peut s'appuyer sur leurs résultats dans la formation et le soutien des soignant·es.

[2021 scientific breakthroughs in ambulatory general internal medicine]. / Avancées scientifiques 2021 en médecine interne générale ambulatoire.

Psychotherapy diminishes depression relapses when antidepressants are reduced or stopped. Delayed antibiotic therapy is effective and safe while treating community-acquired respiratory infection. Physical rehabilitation after hospitalization due to acute cardiac decompensation is useful in frail patients. Six hours of sleep appears to be associated with a higher risk of dementia in people aged 50-70 years. Patients modify healthcare use after losing their referring physician. Screening for atrial fibrillation in healthy patients aged 65 or older is not beneficial. Physicians' ECG reading skills decrease in the absence of regular training. Patients hospitalized with COVID-19 are often clinically, psychologically, and economically impacted.

La psychothérapie diminue les rechutes de dépression lors de la réduction ou de l'arrêt des antidépresseurs. En cas d'infection respiratoire communautaire, l'antibiothérapie retardée est efficace et sûre. La réadaptation physique après une décompensation cardiaque aiguë est utile chez les patients fragiles. Un sommeil de 6 heures semble être associé à un risque plus élevé de démence chez les personnes de 50 à 70 ans. Les patients modifient le recours aux soins de santé après la cessation d'activité de leur médecin référent. La recherche de fibrillation auriculaire chez les patients de 65 ans ou plus en bonne santé n'est pas bénéfique. Les compétences médicales de lecture d'ECG diminuent en l'absence de formation régulière. Les patients hospitalisés pour un Covid-19 sont souvent impactés aux niveaux clinique, psychologique et économique.

[Social integration income medical advisor : update in 2021]. / Dispositif de médecin-conseil pour le revenu d'insertion : état des lieux en 2021.

The social and professional measures suggested to beneficiaries of the Insertion Income have demonstrated their effectiveness. However, presence of mental disorders complicates their implementation, causing difficulties for both beneficiaries and social services. The integration of psychiatrist as medical advisors, as for the canton of Vaud, helps to support the role of medical advisors. Psychiatric intervention aims to strengthen the detection of mental conditions and to improve the relationship between the social worker and his·her beneficiary. The integration of a consultation-liaison psychiatry model in the role of medical consultant seems to bring undeniable advantages and avoidance of stigmatization and chronicization of mental disorders.

Les mesures d'insertion socioprofessionnelles proposées aux bénéficiaires du revenu d'insertion (RI) ont démontré leur efficacité. Cependant, la présence de troubles psychiques complexifie leur mise en place, engendrant des difficultés tant pour les bénéficiaires que pour les services sociaux. L'intégration de psychiatres dans l'équipe des médecins-conseils du RI, à l'instar du canton de Vaud, est une réponse pour y faire face. L'intervention psychiatrique vise ainsi à renforcer la détection des troubles psychiques et à améliorer la relation entre l'assistant·e social·e et son·sa bénéficiaire. L'intégration d'un modèle de psychiatrie de consultation-liaison dans le rôle de médecin-conseil semble apporter des avantages indéniables et permettrait également de lutter contre la stigmatisation et la chronicisation des troubles psychiques.

[Case discussion groups : « training or treatment ¼ ?] / Groupes d'échange de pratique : «training or treatment¼ ?

Since the creation of Balint groups in the 1950s, the concept of meeting among doctors to discuss difficult clinical situations has spread widely, whether or not in line with Michael Balint's initial model. While the latter had thought of these groups as training, their therapeutic role was quickly questioned in the medical literature. At a time when we are seeing and concerned about the poor mental health of primary care doctors, we wanted to show that the added value provided by participation in a practice exchange group is both formative and therapeutic. In this sense, the participation of GP in such a group is part of the recommendations to improve the quality of care, prevent caregivers from burnout, and improve their professional satisfaction.

Depuis la création des groupes Balint dans les années 50, le concept de se retrouver entre médecins pour échanger sur des situations cliniques difficiles s'est largement répandu. Alors que Michael Balint avait pensé ces groupes comme une formation, leur fonction thérapeutique a été très tôt questionnée dans la littérature médicale. Á l'heure où l'on constate et s'inquiète de la mauvaise santé mentale des médecins de premier recours (MPR), nous avons voulu montrer que les plus-values apportées par la participation à un groupe d'échange de pratique sont probablement mixtes : formatrices et thérapeutiques. Participer à un tel groupe fait désormais partie des recommandations non seulement pour améliorer la qualité des prises en charge, mais également pour prévenir le burnout des soignants et améliorer leur satisfaction professionnelle.

[«â€ Group medical practices†¼ project†: collaboration between primary care medicine and institutional public psychiatry]. / Projet «â€ cabinets de groupe†¼â€ : collaboration entre médecine de premier recours et psychiatrie.

Collaboration between primary care medicine and psychiatry is a well-known challenge. In order to improve access to psychological care for patients undergoing primary care, the «â€…group medical practices ¼ project proposes a collaborative care model in which a psychiatrist employed by a public psychiatric institution integrates group medical practices in order to provide assistance to primary care physicians. It is thus able to evaluate patients directly in the practices and to offer supervision and consilium spaces to primary care physicians.

La collaboration entre la médecine de premier recours et la psychiatrie représente une difficulté bien connue. Pour améliorer l'accès aux soins psychiques des patients suivis en médecine de premier recours, le projet «â€…cabinets de groupe ¼ propose un modèle de soins collaboratifs dans lequel un psychiatre employé d'une institution psychiatrique publique intègre des cabinets de groupe afin d'apporter son aide aux médecins de premier recours (MPR). Il est ainsi en mesure, d'une part, d'évaluer les patients directement au sein des cabinets et, d'autre part, d'offrir des espaces de supervision et de consilium aux MPR.

[Psychogenic polydipsia†: a (still) unknown psychosomatic entity]. / Polydipsie psychogène†: une entité somato-psychiatrique (encore) méconnue.

Psychogenic polydipsia, as well referred to as «â€…potomania ¼, is a clinical entity that can be found in psychiatric as well as in physical care settings. Its diagnosis is based on the detection of an excessive fluid intake along with a polyuria, after excluding any potential somatic cause of this clinical presentation. Given the different somatic complications and care complexity, early detection and multidisciplinary interventions are necessary. This article offers a literature review on this topic.

La polydipsie psychogène, également dénommée «â€…potomanie ¼, est une entité clinique que l'on rencontre en milieu psychiatrique, ainsi qu'en milieu somatique. Son diagnostic se base sur la détection d'une consommation excessive d'eau et d'une polyurie, après exclusion de toute cause somatique pouvant être à l'origine du tableau clinique. Vu les diverses complications somatiques et la complexité de la prise en charge, la nécessité de la détection précoce et d'une approche pluridisciplinaire est primordiale. Cet article propose une revue de la littérature scientifique sur ce sujet.

General practitioners referring patients to specialists in tertiary healthcare: a qualitative study.

BACKGROUND: There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners' perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center. METHODS: Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results. RESULTS: Participating general practitioners distinguished two kinds of situations regarding referral: a) "clear-cut situations", in which the decision to refer or not seems obvious and b) "complex cases", in which they hesitate to refer or not. Regarding the "complex cases", they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients' emotions, earning specialists' esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress. CONCLUSIONS: General practitioners' referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.

[From a different angle : supervision of general internal medicine practitioners by psychiatrists and its benefits]. / Déplacer le regard : apports de la supervision psychiatres/médecins généralistes.

The supervision of general internal medicine practitioners by psychiatrists is an opportunity to take a step back from the daily medical practice. In this article, we adopt an interdisciplinary perspective on these supervisory practices, combining a number of insights and perspectives from both psychiatry and sociology. We aim at initiating a broader and more rigorous reflection on such supervisions, which remain little theorized although they are clearly appreciated by those who benefit from them.

Les supervisions de médecins généralistes/internistes par des psychiatres sont l'occasion de prendre du recul par rapport à la clinique quotidienne. Dans cet article, nous adoptons une perspective interdisciplinaire sur ce dispositif, en mobilisant conjointement certains apports et perspectives issus de la psychiatrie et de la sociologie. L'enjeu est d'entamer une réflexion plus ample et rigoureuse sur ces pratiques de supervision qui, si elles sont manifestement appréciées de ceux qui en bénéficient, restent peu théorisées.

[What remains of our Balints ?] / Que reste-t­il de nos Balint ?

In addition to providing psychiatric care to patients with somatic diseases, liaison psychiatry plays a role in the teaching of the relational aspects of medical practice. This series of three articles offers a critical reflection on this topic and examples of educational programs developed at Lausanne University Hospital. In the Department of Ambulatory Care and Community Medicine, an intervention inspired by Balint groups offers to residents in general internal medicine the possibility of working through their clinical experiences and their evolving professional identity.

En plus des soins psychiatriques qu'elle propose aux patients souffrant de problèmes somatiques, la psychiatrie de liaison joue un rôle important dans la formation aux aspects relationnels de la pratique médicale. Cette série de trois articles propose une réflexion critique sur ces enjeux et présente certaines des formations mises en place par le Service de psychiatrie de liaison du CHUV. Dans le cadre de la consultation de médecine générale de la Policlinique médicale universitaire, un dispositif inspiré des groupes Balint offre aux médecins assistants un espace pour élaborer leurs expériences cliniques et les transformations identitaires qui accompagnent leur formation. Nous espérons ainsi contribuer à former des médecins capables d'un retour réflexif sur leur pratique et conscients des enjeux personnels et sociétaux qu'elle mobilise.

Intensive and Brief Psychodynamic Psychotherapy in Severely Depressed Inpatients: A Case Study and Thematic Analysis.

Introduction: Psychotherapy added to usual hospital care is beneficial. This study reports on two contrasting cases, one responder and one nonresponder, from a randomized controlled trial on the effectiveness of intensive and brief psychodynamic psychotherapy (IBPP) for depressed inpatients, in which reduction in depressive severity was maintained for up to 1 year after completion of IBPP. We aimed to explore how the psychotherapist and patient interacted to work through the themes of focalization (described in the IBPP manual) and how their work was part of a potential process of change. Methods: This case study is part of the general framework of mixed methods in psychotherapy combining quantitative analysis of data collected in a randomized controlled trial with a qualitative case study. Results: Two general categories emerged-(1) becoming the subject of one's depression and (2) regaining a sense of support-which combine specific functions. In the first, the functions relate to interactions in line with the psychoanalytic work of mourning, which aims for an appropriation of depressive symptoms. In the second, interactions have as their functions the construction of a therapeutic space and the restoration of an epistemic trust by acknowledging the patient's melancholic state and maintaining emotional contact. Work related to regaining a sense of support was observed in both cases, whereas work related to becoming the subject of one's depression was more specific to the responder case. Discussion: These results highlight the importance of interventions that help generate a sense of support and mobilize the internal processes of symbolization, understanding, and appropriation, leading patients to develop the capacity to give meaning to their symptoms and to understand the personal psychological factors related to the depressive episode.

A Cross-Sectional Study of the Prevalence and Determinants of Common Mental Health Problems in Primary Care in Switzerland.

Objective: This study investigated the prevalence of the most common mental health symptoms in a large primary care patient population and characterized their determinants. Methods: Data came from a 2015-16 cross-sectional study of a primary care population in Switzerland. An investigator presented the study to patients in waiting rooms, and 1,103 completed a tablet-based questionnaire measuring stress in daily life, sleep disorders and anxiety and depressive symptoms. Diagnoses and treatments were recorded. Results: Moderate-to-high anxiety and depressive symptoms concerned 7.7% of patients; 27.6% felt stressed at least once a week; 17.2% had severe sleep disorders. Sociodemographic determinants were associated with psychiatric symptoms: female sex, young age, and frequency of consultations with a GP. Participants taking psychotropics had high levels of mental distress. Conclusion: Even though most patients were regularly monitored by their GP, a significant number of mental health problems were found. GPs should be provided with concrete tools to manage these patients better. Collaboration with mental health specialists should be encouraged in primary care settings.

Clinical impact and misdiagnosis of functional ophthalmological symptoms: a case report.

BACKGROUND: There is a high prevalence of somatoform disorders and medically unexplained symptoms. When it comes to deciding whether a patient is able to work, it is essential to differentiate a somatoform disorder from a factitious disorder. The case presented demonstrates the impact on disability benefits and the subsequent psychosocial repercussions of misdiagnosing between a factitious disorder and a somatoform disorder. CASE PRESENTATION: A 42-year-old Caucasian woman worked as a 100% fiduciary accountant until the age of 32 when she was placed on medical leave due to persistent trigeminal neuralgia. Afterward, she developed total blindness, not explained by a physiological process, accompanied by distress in a crucial emotional context. We evaluated the patient for a revision of a disability income after a diagnosis of factitious disorder with severe consequences such as disability income suspension and family conflict. Our psychiatric examination concluded the diagnoses of pain disorders related to psychological factors and a dissociative neurological symptom disorder with visual disturbance. CONCLUSIONS: Blindness not explained by a physiological process may accompany trauma and psychological distress. Differentiating this pathology from factitious disorder or simulation is essential from an insurance medicine point of view, but also for its treatment.

Psychiatric consultation in general practitioners' daily practice: a qualitative study on the experience of consultation-liaison psychiatry interventions in primary care settings in French-speaking Switzerland.

BACKGROUND: Mental disorders are frequent in primary care settings, which is challenging for primary care physicians. In Neuchâtel (Switzerland), a Consultation-Liaison psychiatrist integrated three primary care group practices, proposing both clinical interventions and supervisions/psychiatric training. Primary care physicians' experience regarding this collaboration was investigated. METHODS: A qualitative study was conducted. Three focus groups were organized in each primary care group practice involved in the project (10 primary care physicians participated in focus groups). Data were analysed with thematic content analysis. RESULTS: Six major themes emerged from our analysis, describing primary care physicians' collaboration with psychiatrists: 1) Impact on a difficult to reach and "reluctant to consult" population; 2) Fluidity of the intraprofessional collaboration; 3) Influence on the doctor-patient relationship; 4) Positive emotional experiences; 5) Psychiatric counselling and training; 6) Long-term prospects for the project. CONCLUSIONS: Consultation-Liaison psychiatrist's presence came as a relief for participating primary care physicians, facilitating accessibility to mental healthcare, introducing a common culture of care, and offering "in-situ" psychiatric training. Primary care physicians felt that their relationships with patients benefited from such interventions, being better able to deal with complex emotional experiences and found patients more confident regarding proposed care. Models of psychiatric intervention provided in primary care must establish settings of collaboration that reinforce relationships between primary care physicians, psychiatrists, and patients.

Risk Perception Related to COVID-19 and Future Affective Responses Among Healthcare Workers in Switzerland: A Mixed-Methods Longitudinal Study.

Objectives: Whereas early findings suggest that risk perceptions related to COVID-19 affect psychological well-being in healthcare workers (HCWs), the temporal associations between these variables need to be clarified and HCWs lived experience further explored. This study proposes a mixed evaluation of COVID-19-related risk perception and affective responses among HCWs. Methods: A longitudinal mixed-method study was conducted. HCWs (N = 138) completed measures of COVID-19 risk perceptions, depression, anxiety, burnout and secondary traumatic stress (STS) at baseline and 6 months later. A subsample (n = 20) participated in semi-structured interviews exploring both risk perceptions and affective responses. Results: Main quantitative findings showed positive associations between worry to contaminate others and depression (IRR = 1.04, p < 0.05), anxiety (IRR = 1.03, p < 0.01), STS (b = 0.3, p < 0.05), and perceptions of lacking protection (IRR = 1.04, p < 0.05) with anxiety scores. Four themes emerged from the thematic content analysis: 1) life was turned upside down; 2) skills were put in quarantine; 3) dealing with patient discomfort; 4) balance to be found between protection and restrictions. Conclusion: These findings emphasize the importance to develop tailored interventions, such as group discussion sessions, to optimize risk perception and help manage uncertainty.

Difficult patient-doctor encounters in a Swiss university outpatient clinic: cross-sectional study.

INTRODUCTION: Previous research has shown that multiple factors contribute to healthcare providers perceiving encounters as difficult, and are related to both medical and non-medical demands. AIM: To measure the prevalence and to identify predictors of encounters perceived as difficult by medical residents. DESIGN AND SETTING: Cross-sectional study at the Department of Ambulatory Care and Community Medicine (DACCM), a university outpatient clinic with a long tradition of caring for vulnerable patients. METHOD: We identified difficult doctor-patient encounters using the validated Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10), and characterised patients using the patient's vulnerability grid, a validated questionnaire measuring five domains of vulnerability, both completed by medical residents after each encounter. We used a multiple linear regression model with the outcome variable as the DDPRQ-10 score, controlling for resident characteristics. PARTICIPANTS: We analysed 527 patient encounters performed by all 27 DACCM residents (17 women and 10 men). We asked each medical resident to evaluate 20 consecutive consultations starting on the same date. OUTCOME: One hundred and fifty-seven encounters (29.8%) were perceived as difficult. RESULTS: After adjusting for differences among residents, all five domains of the patient vulnerability grid were independently associated with a difficult encounter: frequent healthcare user; psychological comorbidity; health comorbidity; risky behaviours and a precarious social situation. CONCLUSION: Nearly a third of encounters were perceived as difficult by medical residents in our university outpatient clinic that cares for a high proportion of vulnerable patients. This represents twice the average ratio of difficult encounters in general practice. All five domains of patient vulnerability appear to have partial explanatory power on medical residents' perception of difficult patient encounters.