Heartsinks

 

Horrible patients...

We all have difficult, demanding and sometimes aggressive patients. This groupwork session will be about learning how to survive and cope with them. 

Firstly, what exactly is going on that causes us to label a patient as difficult or demanding?

Is the source of the problem

1) the patient, or

2) the doctor?

Patients in the first group I think of as “difficult”, the second as “heartsinks” – the problem may not actually lie with them, but with us (counter-transference and all that).  Some writers think the problem is exclusively with neither, but lies in the doctor-patient relationship.

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Heartsinks

The classic “heartsink” patient is, of course, labelled by their own doctor.  One doctor’s heartsink, is not always another’s. 

The term heartsink was first coined by Tom O'Dowd who wrote in the BMJ in 1988 a paper entitled `Five Years Of Heartsink Patients In General Practice'. He followed up 28 individuals in a practice in Wales over a five-year period, who were considered to be heartsink by the practice'.

He started the paper by writing `heartsink patients exasperate, defeat and overwhelm their doctors by their behaviour'. Importantly, he described how they were a source of stress, as they aroused negative feelings and so made some doctors feel unprofessional and frustrated.

A word of warning: Chris Bass, a psychiatrist who teaches on our course once a year warns against documenting this term in medical notes.  It apparently does not sound at all good when read out by a barrister in court. You can label them with something that is factually accurate – “frequent attender” – but not all heartsinks attend frequently. MUPS (medically unexplained physical symptoms) is the current recommended alternative, at least for those heartsinks with a somatising bent….

Every GP knows at least one patient who warrants the term but what does it actually mean? `Heartsink' can mean literally a feeling of a sinking heart or mental fatigue when it is realised that a certain patient has booked a consultation or requested a home visit. In psychological terms, such counter transference is the doctor's emotional response to a patient.

Some of these patients have complex disrupted personal relationships or low self-esteem. Both affect the way they feel physically. This process of somatisation can lead to illness. The term heartsink can therefore sometimes be derogatory and inappropriate.

Is it the doctor's fault?

In the BJGP (March 1999), Butler and Evans describe how GPs estimate that they each have one or more patients that they would describe as heartsink.

O'Dowd in his original paper in 1988 says: `We [GPs] need help with this problem because we are part of it.' It may be a problem of doctor-patient communication and not being able to come to a shared understanding at the end of a consultation.

In the MRCGP orals, one might suggest that given the fashion of evidence based medicine and the seeking of biomedical solutions and cures to symptoms, we take a doctor-centred approach to illness and neglect the psychological, emotional, social and spiritual aspects.

As a Finnish paper put it: `Difficult patients or difficult doctors?'

What can we do to prevent the heartsink feeling?

Be patient-centred. Mathers and Gask in Sheffield reported such an approach in the journal Family Practice in 1995:

• listen to the patient - take a careful history;
• acknowledge to the patient that their symptoms are real;
• explore health beliefs and psychosocial factors;
• try to come to a shared understanding of what is going on;
• try to avoid the feeling that a stalemate has been reached (what has been described as `helplessness in the helpers').

This should be a strategy for heartsink survival. The cure they seek may not be possible, but an appropriate clinical response should not be denied.

What about the doctors?

Maybe it’s not the patient's fault but a reflection of the doctor. As I have pointed out, one doctor's list of difficult patients is not necessarily the same as another's.  It is well known for example that female GPs label fewer of their patients as “heartsinks”.

Mathers et al (1996) looked at GPs in Sheffield. He felt that 65% of the variance in the number of heartsink patients reported on the GPs lists could be accounted for by the following four variables:

• greater perceived workload;
• lower job satisfaction;
• lack of training in counselling and/or communication skills;
• lack of appropriate qualifications (MRCGP etc).

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Difficult and demanding patients

Not a huge amount has been written about problem patients, but here are four stereotypes:

• the dependent clinger;
• the entitled demander;
• the manipulative help-rejecter;
• the self-destructive denier.

A continuing, insatiable dependency on a physician is common to patients in all four categories.

1.      Dependent clingers

Dependent clingers take any form of attention they can get. Their overtures are seductive, and they are grateful for the attention they receive, although they might be naive about the effect they have on a physician.

Dependent clingers produce aversion, which may lead to a psychiatric referral that is doomed to fail.

The best strategy with dependent clingers is early identification of the problem, combined with a tactful but firm establishment of limits.

2.      Entitled demanders

Entitled demanders seek attention through intimidation, devaluation, and inducing guilt in a physician. They might try to establish control over a physician by, for example, withholding payment or instituting litigation.

Entitled demanders evoke fear and an attack upon their entitlement.

With these patients you can support the entitlement but try to redirect it along the lines of the treatment plan.

3.      Manipulative help-rejecters

Manipulative help-rejecters are not hostile, and they do not claim to deserve treatment. On the contrary, they believe that no treatment whatsoever will help them, and they derive satisfaction from repeatedly reporting to a physician that his treatment has failed. If one symptom disappears, another invariably takes its place. These patients do not seek relief of symptoms, but rather an interminable relationship with a physician.

Manipulative help-rejecters cause a physician to feel guilty and inadequate.

The best strategy with these patients is said to be to 'share' their pessimism and try to allay their fear of losing the physician by, for instance, scheduling regular follow-up appointments.

4.      Self-destructive denier

The self-destructive denier unconsciously engages in behaviour that is likely to be fatal. These patients have abandoned all hope and become profoundly dependent. They derive satisfaction from their own self-destruction and from defeating a physician's attempts to preserve their lives.

They evoke all of the negative feelings associated with the other stereotypes, as well as malice and a desire that the patient die and get it over. 

A physician can do little for self-destructive deniers. A psychiatric consultation to determine whether treatable depression exists might be in order. The advice is not to abandon these patients but instead to work with them compassionately and diligently, just as one does with patients who have terminal cancer.

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Survival guides

Here are a few of my own suggestions about how to cope with patients you find difficult:

•  A lot of these patients have got stuck in a groove – they keep repeating the same symptoms over and over again (sometimes because they feel they’ve never managed to get us to listen!) and often provoke the same antagonism in one doctor after another. If you are going to stand a chance of helping the patient, and enable them to make some progress, you are probably going to need to get to know them, so you could:
  • summarise their notes; think about drawing up a life chart (with their help) and identifying important key life events, and linking this to their medical symptoms;
  • ask the patient to keep a diary of their symptoms and feelings;
  • ask them to write a problem list (as they see it) in order of importance.
• Try to identify what feelings the patient evokes in you; these will often mirror the feelings the patients have themselves.
• Consider videoing a consultation with a heartsink, and looking at it with a colleague.
• Manage your own expectations: remember that you may be there to enable the patient to cope, rather than aiming for cure.
• Use reframing skills to get the patient off talking about physical symptoms (the “organ recital”) and on to psychosocial, interpersonal, cognitive and behavioural issues.
• Consider recruiting one of the patient’s close family members as an ally.
• Work out what referrals and investigations and referrals are needed, and arrange these in a logical order early on, rather than “drip-feeding” them.
• Agree with the patient how often you are going to meet.
• Find someone you can offload to yourself – heartsinks can damage doctors, so you will need to take steps to protect yourself by talking things through with someone who will be helpful and supportive.
• Although it generally a good idea to prevent these patients doctor-hopping from one GP to another, don’t forget that (to paraphrase the well-known saying) “one man’s poison is another man’s meat” – in other words, a patient that you find a heartsink might be thought quite innocuous by one of your colleagues. So occasionally it’s not a bad idea to get the patient to see one of the other doctors in the practice….

 

Written by: Martyn

Last update: 29 August 2007