Feeling angry, frustrated, guilty or defeated at the end of some consultations is an experience common to all doctors. These emotions are more often provoked by patients labelled 'difficult', 'heartsink' or even 'hateful'. These terms ('heartsink patient' in particular) have become politically incorrect as they imply judgement (and blame) on the patient, are offensive to the patient and ignore the fact that the emotions generated are the consequence of a complex interplay between patient, doctor and healthcare system. This view claims that difficult patients do not exist, only difficult consultations. The fact remains that certain patients tend to have difficult consultations more often than others and that reflecting on this honestly and looking to understand the dynamic is a starting point to change.

Classification

Early work by Groves in the US produced a well-known classification of 'hateful patients' (those "most physicians would dread to treat"):¹

• Dependent clingers are excessively dependent on the doctor, desperate for reassurance but will return continually with a new array of symptoms. For example, "Thank you, my back's much better but I've got chest pain now."
• Entitled demanders are also inexhaustibly needy but, rather than using thanks and flattery, will use intimidation, devaluation and guilt against the doctor, frequently complaining when every request is not met. For example, "I must see a specialist for my ingrowing toenail right now!" This situation is likely to become more prevalent with the increased rationing of healthcare resources.²
• Manipulative help-rejectors continually return to the surgery to report that treatment failed. Where any symptom is relieved, it is rapidly replaced by another. For example, "None of the painkillers has helped my back; I'm allergic to those other pills; Pain Clinic did nothing. You've got to help me!"
• Self-destructive deniers, whilst suffering from a potentially serious condition, will make no effort to alter their self-destructive behaviours, eliciting and then frustrating medical efforts to help them.

Epidemiology

There are huge inter-doctor differences in what constitutes a 'difficult patient' so establishing their prevalence in practice is dogged by methodological issues. In one study, American doctors rated 15% of primary care patients as 'difficult'.³ Other studies have suggested much lower numbers - but if even 1% of list size is 'difficult', the effect on workload and moral is disproportionate.

Risk factors

Doctor

Some of the variation in experience of 'difficult' or 'heartsink' patients can be explained by:⁴

• Perception of high workload.
• Poor job satisfaction.
• Poorer postgraduate qualifications.
• Insufficient training in counselling or communication skills.

Patient

In one American study, doctor-rated 'difficult' patients were associated with:³

• Psychiatric disorders (particularly multisomatoform disorder, panic disorder, dysthymia, generalised anxiety, major depressive disorder and probable alcohol abuse or dependence).
• Functional impairments.
• High use of healthcare.
• Lower satisfaction with care.

One study in Japan found that patients who took a more active role in the consultation were more likely to be classified as 'difficult' by doctors.⁵

A Finnish study found the following characteristics in frequent attenders:⁶

• High body mass index
• Alcohol abstinence
• Irritable bowel syndrome
• Low patient satisfaction
• Fear of death

History

Taking a history is a fundamental part of a doctor's job and should be done with consummate skill and patience, although extracting a coherent and logical one can be challenging in some instances such as:

• Patients with cognitive impairment, learning difficulties or the thought-disordered.
• Intoxicated patients.
• Patients with speech and language difficulties and those with English as a second language.
• Patients reluctant to divulge information, either through mistrust, paranoia or delusional belief that the doctor is an omniscient magician ("You're the doctor!").

Patients who come with a 'shopping list' of symptoms are frequently dreaded by doctors and stereotyped as 'obsessional' or 'neurotic' and 'time consuming'. More than 75% of patients attending with a written list are female and middle-aged.⁷ Allow the patient to speak first but, where a list is clearly unfolding, it is worth asking the patient to run through the list early on (ensuring that no important red flags are missed) and then mutually prioritize to use the limited time optimally. Acknowledge the perceived seriousness of any remaining symptoms and undertake to follow these through at a later session. Written lists can be seen positively as a communication aid, clearly setting out the patient's agenda and allowing negotiation. Attempting to uncover a patient's true agenda may avoid listening to long lists of minor complaints.

Examination

Many doctors dread dealing with the 'Great Unwashed', reflecting natural reticence to be near and to touch the truly odorous and dirty. The danger is that we either perform a cursory examination or avoid it completely with the risk of missing important signs.
Maintaining personal hygiene when homeless is very difficult. For those with a home, it is important to recognise the self-neglect as an important clinical sign; similarly, a chaotic and filthy domestic environment on a home visit. Consider dementia, depression, undiagnosed diabetes, physical impairment making the activities of daily living difficult or incontinence.
Try to be firm and direct but appear concerned and compassionate rather than judgemental or disgusted. Ask about washing, laundry, toileting. Be prepared for patients to deny problems.

Offer any help that is available (such as incontinence services) and it may be necessary to involve social services or even environmental health in some circumstances.

Management⁸

Examine your own reactions:

• Ask yourself "What is it about this particular person that makes me react negatively to them?"
• "Why do they get under my skin?" - think about subliminal reminders, feelings triggered from our past or present may affect how we react to a patient. For example, sympathy for a hypochondrial patient may be very difficult when a loved one is terminally ill.
• Examine whether our perception of the patient is, in fact, a belief. For example, "He is manipulating me". If it is a belief, what is the evidence and is it reasonable? Are there alternative beliefs that fit the evidence as well/better and that may facilitate a new approach to the patient?
• Consider your communication skills.
• Consider, "Am I a heartsink doctor?"

Frequent attenders

The top 3% of attenders generate 17% of a GP's clinical workload.⁹ They tend to generate 'fat folders' (a redundant concept in the paperless surgery). About 60% of frequent attenders' attendance was for medically unexplained reasons in one study.¹⁰ Average consultation rates in the UK are about 4 per annum so consider the possibility in patients consulting more frequently. They are more likely to be female and to suffer chronic health problems.

Examine the patient's records:

• When did the current consulting pattern begin? (Is it recent or has it been consistent over time?)
• Did the timing reflect any significant life event?
• Consider the consultation pattern - any particular day of the week/out-of-hours or regular doctor?
• What happened when registered with previous practices - has the patient ever been removed from a list?
• Do they consult with the same problem on every occasion?

Possible reasons for frequent attending:

• Depression or anxiety
• Loneliness
• Personality disorder
• Münchhausen's syndrome
• Dysfunctional doctor/patient relationship

Possible strategies:

• Agree a consistent practice-based approach such as an agreed periodic review.
• Do not bend rules (e.g. no double appointments, no 'extra' appointments).
• Agree a regular doctor to manage the patient but other doctors to be supportive.
• Decide and stick to thresholds for referrals and investigations.
• Resist overprescribing and do not use medication as a means to end a consultation.
• Document consultations well, particularly old symptoms.
• Seek advice from other doctors (and tell the patient that this is what you are doing).
• Challenge the patient's behaviour; for example, "I notice that you asked the same question when you last came?" - "What do you feel another consultant will be able to do about that problem?"
• Is there an unmet need of a nonmedical kind? Tap into the broader multidisciplinary team - social workers, clinical psychologists, community addiction teams, and occupational therapists, amongst many others.

Patients with medically unexplained symptoms

Patients come to see doctors concerned about symptoms - many of these will remain unexplained as disease even after thorough assessment and investigation (so-called medically unexplained symptoms (MUS)). 20-25% visits to the GP concern MUS but only 2.5% involve the repeated presentation of such symptoms.¹¹ Many of these patients are considered 'difficult' as we look for pathological or psychological causation, rather than a complex interplay, with the tendency to produce anxious and disabled patients and increasingly bewildered doctors.
Elements of general management of MUS include:¹²

• Appropriate examination and investigation. Thereafter, further investigations should only be ordered if the likelihood of benefit outweighs risk (including psychological harm).
• Reassure: these symptoms are common and rarely associated with disease.
• Elicit particular concerns and address these specifically.
• Try to provide a positive explanation rather than the bland 'there is no disease' message; link psychological and social factors as well as physiological.
• Give advice about coping with symptoms and returning to normal activity.
• Identify and treat coexisting depression and anxiety disorders.¹³

Specific interventions include cognitive behavioural therapy (helping patients to reattribute their symptoms) and rehabilitation programmes. Efforts have been made to develop reattribution therapy in primary care but brief GP training in the technique was not shown to improve the outcome of patients with MUS in one study.¹⁴

Patients with personality disorders¹⁵

Personality disorders are chronic, inflexible and maladaptive styles of perceiving oneself and interacting with others. They are covered in detail elsewhere but are common and may contribute to difficult doctor-patient relationships. One UK study suggested that 24% of general practice attenders had evidence of a personality disorder.¹⁶ Interestingly, having a personality disorder alone is not associated with higher health costs - but it becomes so if personality disorder is associated with a common mental health disorder and/or decreased physical functional status.¹⁷

Personality disorders may cause a number of problems in the clinical setting:

In general:¹⁵

• Diagnosis may not be clear-cut - personality traits do not occur in pure form, and frequently overlap.
• Identify and treat any coexistent mental illness, e.g. anxiety, depression, thought disorder.
• Tolerate the patient's affect; be kind and firm rather than punitive or overinvested.
• Accept dependency and vulnerability.
• Educate and provide clear explanations about medical illness.
• Keep good records of encounters, including what was explained by the doctor and the patient's response.
• Understand that the patient may be attached to their symptoms.
• Refer to psychiatry for assessment and support. Some patients will not accept this and psychiatry struggles with the notion that personality disorders are not easily amenable to treatment.

Problems of personal responsibility

We have moved beyond patients as passive recipients of healthcare; now doctors facilitate their decision-making process and cheer on 'expert patients' and self-management. The doctor, therefore, has a duty to keep the patient fully informed and to discuss therapeutic options but, equally, there is a greater onus on patient responsibility.

Individuals vary as to their locus of control:

1. Internal controllers believe they are in charge of their future health. Health and fitness obsessives tend to fall into this category. They become angry and confused when they become ill despite their efforts. They like to be involved in decision making about their health but are often difficult to convince of a diagnosis or treatment.
2. External controllers relinquish all control over their health and are utterly fatalistic. They want to be told what to do and allowed to ignore the bits they do not like.
3. Those subscribing to 'the powerful other' (usually the doctor). They do not believe they are in control, nor at mercy of the fates; rather, they require an authoritarian doctor to decide what is wrong with them and how to fix it, without any recourse to them.

The secret to health resides to a great extent in the lifestyle of an individual. Smoking, obesity and excessive consumption of alcohol are great contributors to ill-health within our society and, whilst environmental factors increase or decrease their likelihood, no other individual can be held directly responsible for such behaviours. The bottom line of many consultations - "So what are you going to do about my smoking/overeating/boozing, doctor?" - may not be exactly as patients express it but there are certainly some who view it as a problem for the doctor rather than a challenge for themselves. Without personal motivation, intervention is doomed to failure.

Point out the dilemma of rational resource allocation in a health system with a finite budget. Should we ration surgery to those with the best chance of success? Denying arterial reconstruction to those who continue to smoke can be assured of creating a public outcry but it may also be rational. Where patients are demanding of their rights they must be told about responsibility. The outcome of aortic bifurcation grafts¹⁸ or coronary artery bypass grafts,¹⁹ in those who continue to smoke is so poor that its rationale can be disputed. Nevertheless, the rights of smokers to treatment have their advocates.²⁰

System abusers

These take many forms but include:

• Repeated use of emergency appointments for non-urgent problems.
• Repeated instances of 'did not arrive' (DNAs) (including hospital appointments, following demands for referral).
• Repeated lateness for appointments but still expecting to be seen.

12 million primary care appointments (6.5%) are missed every year at a cost of about £162 million. There is a knock-on effect from those who abuse the system (fewer appointments available for others, late-running surgeries, stressed reception staff) which make it work less well for other patients. Qualitative studies suggest that GPs have dual attitudes towards lateness and missed appointments - in some it is excusable, in others reflects reckless disregard and is blameworthy.²¹ Interestingly, they are often sympathetic to the chaotic lifestyles common amongst drug users and alcoholics.

Practices sometimes use contracts with drug users and other 'difficult patients', stating that they will attend for appointments, as booked, on time, sober and politely. The management of drug users and the diagnosis and management of alcohol abuse are discussed elsewhere.

Practices need agreement and a consistent approach. It is worth considering systemic problems that patients may experience - for instance, the difficulty of getting through by telephone to cancel an appointment. Where an individual is repeatedly abusing the system, they should be seen or receive a letter, to ensure they understand the implications of their actions and to make the position of the practice quite clear.

Violent and verbally abusive patients²²

Verbal abuse, insults, violence or threats of violence should not be tolerated. A recent poll suggested that 1 in 3 GPs had been physically assaulted by a patient during their career.²³ If anyone is rude to you in a consultation, clearly tell them that their behaviour is unacceptable. Avoid trading insults as this gives validity to such action. Always stay cool. Be firm but fair. Be prepared to justify your stance afterwards.

• Provide panic alarms.
• Provide training to all staff.
• Have a clear team approach to dealing with incidents. Working in isolation carries real risks.
• Try to avoid seeing patients with a history of violence, alone or at home. Arrange to be accompanied by a colleague and make sure your whereabouts are known before starting a visit.
• Ensure that all of the waiting area can be seen from the reception desk.
• Do not use grilles, barriers or glass screens inappropriately.
• Consult with another team member if concerned that conflict is likely.

Following an incident, debrief the staff member who was subject to the aggression, reflect on one's own behaviour and conduct a critical incident review as a team.

Remove a patient from your list as a last resort. Warn those who are rude or abusive that they risk removal if their behaviour continues unmodified. If removing a patient from the list due to violence, remember to report the incident to the police and obtain an incident number before notifying the primary care trust (PCT) in writing within 7 days in order to comply with contractual obligations. Ensure that arrangements are in place for continuing care of the patient. You also need to write to the patient giving reasons for their removal from the list (unless this would impact negatively on their physical or mental health or put any member of staff at risk).

Pass information regarding risk of violence to other organisations working with a patient on a 'need-to-know' basis. Although all patients have a right to confidentiality, situations may arise where it is necessary to pass information without consent to third parties, such as the police, where you have, or another team member has, been subject to violence to allow for proper investigation.

A few health authorities and PCTs have set up out-of-hours (OOH) 'safe havens' or enhanced services dealing with violent patients.

The detestable

Caring for those you find despicable is tricky - you may know that your patient is a drug dealer, unscrupulous businessman or wife-abuser or that they have committed other crimes that you find repugnant, or that they may hold political or religious views that you find completely abhorrent - but medical ethics and professionalism dictates that you should not allow this to alter your treatment of them. Doctors must strive to do their best for their patients regardless of their personal opinion of them. This is not always easy but does give us the moral high ground.

We do not have to tolerate disparaging remarks about others in a consultation - explain that you find this unacceptable.

Remember there are exceptional and rare situations where you must break confidentiality if you have knowledge of other's criminality (where necessary to prevent or lessen serious and imminent threat to the life or health of others) but seek advice.

Seductive patients and boundary violators

Boundaries exist in the doctor-patient relationship to ensure appropriate behaviour. Cases of sexual exploitation against patients exist, sometimes a consequence of predatory doctors and, in other cases, a culmination of boundary crossing by both parties.
Most doctors (male and female) can describe 'seductive' patients (patients who behave with excess attentiveness, flattery and are sometimes overtly amorous) but problems of sexual harassment and stalking by a patient are more uncommon and potentially dangerous.

Most boundary infringements are relatively minor - in an American survey, three-quarters of the respondents had patients who used their first name, 43% had encountered verbal abuse, 39% had patients who asked personal questions, 31% had patients who were overly affectionate and 27% encountered patients who had attempted to socialise. More serious transgressions, including physical abuse and attempts at sexual contact, were uncommon. Being a female doctor resulted in more personal questioning, inappropriate affection and sexually explicit language.²⁵

Boundary violations are important since they undermine the doctor-patient relationship. In extreme cases, they put you at risk of complaints (often false) and are potentially career damaging. So:²⁶

• Do not ignore your instincts: where attention feels unwarranted and uncomfortable, there is probably reason for concern. Discuss the situation with your colleagues, contact your defence union early and keep a log of incidents and original copies of letters, gifts, etc.
• Have a practice policy on the use of chaperones and do use them to protect yourself.
• Consider an organic cause for disinhibited behaviour such as dementia or space-occupying lesions.
• Usually, a polite but firm explanation that the patient has overstepped appropriate behaviour is enough to modify the situation. It is wise to reiterate this in writing.
• If concerns remain, ask the patient to see another doctor in the practice. Removal from the practice list is a last resort.
• Where a patient is sending love letters, explain that the correspondence will be sent unopened to your defence organisation.

Internet surfers

The uncritical surfer with long downloads has become a 21st century 'difficult patient'. The internet enables instant access to information and health-related resources from the comfort of one's home but anyone can post any unproven idiocy as long as it does not contravene laws about libel, decency or terrorism in the country from which it originates.

Rather than feeling threatened, assist your patient in the task of sifting quality. In general, Department of Health or NHS websites are likely to be reliable. University websites also tend to be reliable - they are identifiable by the 'ac' in their internet address. We need to explain the fallibility of the medium and advise how to be more critical. Where possible, give an alternative and better source of information. The internet sites given at the end of EMIS Mentor Clinical Immediate Reference articles may be a useful starting point.

A useful guide intended for doctors searching for information on the internet may also be of use to patients. ²⁷ it suggests:

• Checking that the site is regularly updated.
• Checking that information is supported by references.
• Observing whether the site is compiled by an individual or an organisation.
• Looking at the 'About us' information to see who sponsors the site and whether commercial interests are involved.
• Seeing whether the site has presence other than online - e.g. an address or other contact details.
• Looking for grammatical or typographical errors indicative of a poorly edited site.

Natural healing

There is a remarkably common bias amongst the general population towards the use of 'natural substances' with the belief that the pharmaceutical industry spends billions of pounds a year to produce drugs of doubtful efficacy and great toxicity whilst 'natural substances' are completely effective and safe. Where natural remedies are untested, their long use and 'organic' origins are not safeguards. Without vigorous testing for efficacy, toxicity, interactions with other substances and teratogenicity, their safety and usefulness cannot be assumed. Alternative or complementary therapies are amenable to scientific validation but, by and large, the quality of the research is poor. Knowledge is growing of toxicity of herbs, especially on the liver and of important interactions (for example, St John's wort).

Try to maintain an open and enquiring mind - it is easy to become identified as another doctor with an entrenched position, attempting to maintain the authority of their clique. Many important pharmaceutical drugs have had their origins in herbal or natural remedies (e.g. aspirin, quinine, digoxin) but these substances have been tested and purified and assayed. Tablets of these substances give a reliable dose whilst herbal preparations can have considerable variation in potency and purity.

Complementary and alternative medicine and therapies may give hope to many patients whose distress is not addressed by more conventional medical practice (many of our 'difficult' patients?) - but we should not be drawn into supporting them without good proof of benefit and lack of harm.

Prognosis

Everyone has bad days - doctors and patients - and forgiving or ignoring a single incident of bad behaviour is often sensible but in General Practice, where some doctor-patient relationships may literally last a lifetime, are we doomed to groundhog day-style repetitions of frustrating consultations with our favourite 'difficult' patients?

British General Practice, in particular, has placed the long-term doctor-patient relationship as one of the primary goals of a consultation. Many doctors work on to maintain relationships with patients, even when they feel powerless to achieve useful clinical outcomes, sometimes colluding with illness behaviour and sustaining incapacity. Some would argue this is a direct consequence of over-elevating the importance of the doctor-patient relationship.²⁸

One longitudinal study has suggested that frequent attendance is more related to disease burden rather than personality and those with high attendance rates tend to revert to normal consulting patterns with time.⁹ Allow this to give you hope.

Difficult consultations should not be seen as an imposition to be disposed of as swiftly as possible but as a challenge to the skills that have been moulded over years of practice and continued personal development. There is great satisfaction in achieving a successful outcome to a difficult case. Try to remain interested in the diversity of human character. When you find that you yearn for the mundane it is time to look seriously at your personal development plan - or your pension.

Document references

1. Groves JE; Taking care of the hateful patient. N Engl J Med. 1978 Apr 20;298(16):883-7. [abstract]
2. Weingarten MA, Guttman N, Abramovitch H, et al; An anatomy of conflicts in primary care encounters: a multi-method study. Fam Pract. 2010 Feb;27(1):93-100. Epub 2009 Nov 30. [abstract]
3. Hahn SR, Kroenke K, Spitzer RL, et al; The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. 1996 Jan;11(1):1-8. [abstract]
4. Mathers N, Jones N, Hannay D; Heartsink patients: a study of their general practitioners. Br J Gen Pract. 1995 Jun;45(395):293-6. [abstract]
5. Kawabata H, Konishi K, Murakami M, et al; Factors affecting the physician-patient relationship regarding patient Hokkaido Igaku Zasshi. 2009 May;84(3):171-5. [abstract]
6. Koskela TH, Ryynanen OP, Soini EJ; Risk factors for persistent frequent use of the primary health care services Scand J Prim Health Care. 2010 Mar;28(1):55-61. [abstract]
7. Middleton J; Written lists in the consultation: attitudes of general practitioners to lists and the patients who bring them. Br J Gen Pract. 1994 Jul;44(384):309-10. [abstract]
8. Campion-Smith C, Cumming R, and Tracy C; Surviving and thriving with difficult and demanding patients BMJ Career focus Nov 2004
9. Carney TA, Guy S, Jeffrey G; Frequent attenders in general practice: a retrospective 20-year follow-up study. Br J Gen Pract. 2001 Jul;51(468):567-9. [abstract]
10. Stewart P, O'Dowd T; Clinically inexplicable frequent attenders in general practice. Br J Gen Pract. 2002 Dec;52(485):1000-1. [abstract]
11. Verhaak PF, Meijer SA, Visser AP, et al; Persistent presentation of medically unexplained symptoms in general practice. Fam Pract. 2006 Aug;23(4):414-20. Epub 2006 Apr 21. [abstract]
12. Mayou R, Farmer A; ABC of psychological medicine: Functional somatic symptoms and syndromes. BMJ. 2002 Aug 3;325(7358):265-8.
13. Aguera L, Failde I, Cervilla JA, et al; Medically unexplained pain complaints are associated with underlying unrecognized BMC Fam Pract. 2010 Mar 3;11:17. [abstract]
14. Morriss R, Dowrick C, Salmon P, et al; Cluster randomised controlled trial of training practices in reattribution for medically unexplained symptoms. Br J Psychiatry. 2007 Dec;191:536-42. [abstract]
15. Ward RK; Assessment and management of personality disorders. Am Fam Physician. 2004 Oct 15;70(8):1505-12. [abstract]
16. Moran P, Jenkins R, Tylee A, et al; The prevalence of personality disorder among UK primary care attenders. Acta Psychiatr Scand. 2000 Jul;102(1):52-7. [abstract]
17. Rendu A, Moran P, Patel A, et al; Economic impact of personality disorders in UK primary care attenders. Br J Psychiatry. 2002 Jul;181:62-6. [abstract]
18. Lassila R, Lepantalo M; Cigarette smoking and the outcome after lower limb arterial surgery. Acta Chir Scand. 1988 Nov-Dec;154(11-12):635-40. [abstract]
19. Ashraf MN, Mortasawi A, Grayson AD, et al; Effect of smoking status on mortality and morbidity following coronary artery bypass surgery. Thorac Cardiovasc Surg. 2004 Oct;52(5):268-73. [abstract]
20. Heath J, Braun MA, Brindle M; Smokers' rights to coronary artery bypass graft surgery. JONAS Healthc Law Ethics Regul. 2002 Jun;4(2):32-5. [abstract]
21. Martin C, Perfect T, Mantle G; Non-attendance in primary care: the views of patients and practices on its causes, impact and solutions. Fam Pract. 2005 Dec;22(6):638-43. Epub 2005 Jul 29. [abstract]
22. Wright NM, Dixon CA, Tompkins CN; Managing violence in primary care: an evidence-based approach. Br J Gen Pract. 2003 Jul;53(492):557-62. [abstract]
23. Devlin M, Tackling violent or abusive patients, MDU journal 23(2) Dec 2007
24. Good Medical Practice, General Medical Council
25. Farber NJ, Novack DH, Silverstein J, et al; Physicians' experiences with patients who transgress boundaries. J Gen Intern Med. 2000 Nov;15(11):770-5. [abstract]
26. Kirkpatrick A; Dealing with amorous advances from patients. BMJ. 2003 Sep 27;327(7417):s100.
27. Health information: finding reliable sources on the internet; BMA August 2008
28. Chew-Graham CA, May CR, Roland MO; The harmful consequences of elevating the doctor-patient relationship to be a primary goal of the general practice consultation. Fam Pract. 2004 Jun;21(3):229-31.

Internet and further reading

• Guidance on the Role and Effective Use of Chaperones in Primary and Community Care Settings; NHS Clinical Governance Support Team 2005
• Removal of patients from GP lists (revised guidance), Royal College of General Practitioners, Sept 2004
• The Suzy Lamplugh Trust; Organisation promoting safety at work
• Stewart M; Reflections on the doctor-patient relationship: from evidence and experience. Br J Gen Pract. 2005 Oct;55(519):793-801.
• O'Dowd TC; Five years of heartsink patients in general practice. BMJ. 1988 Aug 20-27;297(6647):528-30. [abstract]

Acknowledgements