Sink or Swim... GP VTS 10/12/09

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What is a heartsink patient? -Is it right to think about some patients as heartsink?

What is a heartsink patient? O’Dowd: ‘There are patients in every practice who give the doctor and staff a feeling of “heartsink” every time they consult. They evoke an overwhelming mixture of exasperation, defeat and sometimes plain dislike that causes the heart to sink when they consult.’ 1 ‘The term does not denigrate the patient at all. It, acknowledges the understandable reaction of the doctor.’ 2

What types of patient are heartsink?

What types of patients are heartsink? One doctors list of difficult patients is not the same as another. 3 ‘The ones you see frequently, but who don’t get better or change. The patients who never comply, but always demand. Who have multiple and multifaceted issues, and endless though unmet expectations.’ 2 ‘demanding patients who stay sick; unfocused patients with multiple complaints; and patients with chronic pain who may or may not need narcotics.’ 2

What types of patients are heartsink?

Are some doctors more likely to have heartsink patients?

67% of the variance in number of heartsinks could be accounted for by 4 variables: – Greater perceived workload – Lower job satisfaction – Lack of training in counselling and/or communication skills – Lack of appropriate post graduate qualifications 1 Less interest in psychosocial issues 2 Male GPs 2

Is there such a thing as heartsink doctors?

‘There must be heartsink doctors - doctors that patients dread seeing, not because of what they may tell them, but because of the doctor’s personal characteristics.’ 2

Differing perspectives from the medical profession... AquQ AquQ

Personal Reflections

What can we do to help heartsink patients? We need to: – Look at ourselves – Look at the patient – Look at the doctor-patient relationship

Looking at ourselves Groves stated there may be a reaction of ‘helplessness in the helper; unconscious punishment of the patient; self-punishment by the doctor; inappropriate confrontation of the patient; and a desperate attempt to avoid or extrude the patient from the care-giving system.’ 2 Avoid blaming the person for being less than the ideal patient. Recognize your own feelings. Take a breath and understand that there will always be challenging patients.

Looking at the patient Know your patient well Let patients vent. Challenge the ‘soteriological’ development of medicine within the patient’s psyche. (Good) 4

Looking at the doctor-patient relationship Rejection/Collusion/Empowerment 4 Build rapport. 2 Confrontation. 5 Help patients to be a partner in care. Offer insight into their health, encourage them to take responsibility and your advice, and talk about expectations. 2 Set ground rules. Identify particular doctor, set limits and have agenda. 2 Clear the air. As an article in the journal of the Australian College of General Practitioners advised, “Share the relationship difficulty, by verbalizing it: ‘I’m finding it difficult to help you because...’ Then build a partnership to solve the difficulty. ‘How do you feel about that? Can you think of ways you can help me help you? Is there something I can do to help us work together better?’” 2

Role Play

References 1.O’Dowd T. Five years of heartsink in general practice. BMJ 1988;297: Overcoming that sinking feeling. Why some patients are heartsinks- and how to handle them. Doc Talk. Stuart Foxman 3.Mathers N, Jones N, Hanay D. Heartsink patients: a study of their general practitioners. BJGP 1995;45: Butler C, Evans M. The heartsink patient revisited. BJGP 1999;49: Bligh J. Persistent attenders and heartsink. Editiorials. Medical Education 1999;33:398.