The trouble with patients

Managing challenging or “heartsink” patients can be stressful and can increase medico-legal risk. GPST editor Dr Peter Livingstone looks at ways of handling these relationships effectively

AS we progress through our GP training I am sure most of us will come across two or three "heartsink" patients at some point. Though it might not be the most sensitive term – you know who they are. The ones who, as soon as you see their notes, make you think "oh no, not again" or "that’s all I need today". Heartsink patients are said to account for 11 per cent of the GP workload and have been defined as "high demand patients with whom GPs have repeated, difficult and extended encounters leading to strong dysfunctional or emotional reactions" such as overwhelming fear, exasperation, anger and frustration.

It’s important to be aware of these patients because there is a risk they may end up having unnecessary investigations or treatment. This can be distressing for them as well as a waste of money, resources and valuable clinical time. From a medico-legal point of view, there is also a risk that heartsink patients who become genuinely ill may be ignored or treated inappropriately because of their history.

Characteristics

Heartsinks can take many forms, but research suggests they are more likely to be female, aged over 40, single/divorced/widowed or experiencing personal problems. If they are single, they are often isolated and may have co-existing depression.

In his article, 'Taking care of the hateful patient', Dr James Groves places heartsink patients into specific groups. Do any of these sound familiar?

  • Dependent clinger – seeks constant reassurance or attention.
  • Entitled demander – demands treatment through guilt-induction or intimidation.
  • Manipulative help rejecter – insists no regimen is helping.
  • Self-destructive denier – refuses to stop harmful behaviour.
  • Somatisers – those with medically unexplained physical symptoms.

As a GP trainee you may feel that you have more heartsink patients than some of your colleagues. Statistics show that doctors are more likely to experience this type of patient relationship if they have a greater perceived workload, low job satisfaction, a lack of competence or a lack of appropriate qualifications.

But there are other factors that can give rise to problematic patient relationships. These can include:

  • a lack of two-way communication
  • failing to understand the patient’s ideas, concerns and expectations
  • failing to appreciate the way the illness affects the patient’s life
  • failing to appreciate the way the patient copes with the illness.

It is important to be aware of how you communicate with patients and to make improvements where necessary. Never become complacent when dealing with heartsinks – they can become very ill so never simply dismiss them.

Ground rules

When dealing with challenging patients, it’s important to build rapport, so listen attentively, empathise, avoid confrontation, make eye contact and seek a solution through a shared understanding of the problem. Patients should be encouraged to take more responsibility for their own health and using diaries can help them gain an insight into their illness.

Studies also emphasise the importance of a firm, structured and consistent approach. It can be helpful to speak to other doctors in your practice about the patient to limit their ability to consult different GPs for different opinions or referrals. You should also recognise your own feelings and keep control of a) yourself, b) the consultation and c) the situation.

For frequent attenders, it can help to agree boundaries or limits on frequency of attendance and to help them create a list of their most troubling problems. Don’t try to handle the work load on your own: delegate to a practice nurse, self-help groups, counsellors or psychologists. In some situations, it might be appropriate to consider a delayed response to encourage the patient to take ownership of the problem.

In the case of a patient I treated, I felt she was using me more as an emotional crutch than as a clinician. Her consultations were often longer and more demanding involving multiple non-specific symptoms. I felt powerless to do anything and we were constantly going round in circles. When I eventually plucked up the courage to ask "how can I help you with these problems?" she said that she simply needed someone to "off-load" on and that I was the only one who listened to her. She knew I wouldn’t judge her and that I could provide a non-biased opinion. She still occasionally comes to see me for a chat but her biological symptoms have all resolved and my consultations run to time.

One final important point to remember is that heartsink patients are the doctor’s problem and not the patient’s. It is a matter of attitude and if you are finding a particular patient difficult then stop to consider why this is. Explore your own feelings towards the problem as this may be a reflection of the patient’s own feelings. If you can find the source of the problem it should help you to address it.

Dr Peter Livingstone is an ST3 at Govan Health Centre in Glasgow and editor of GPST