Heart Sink patients

There are certain patients whose usually frequent appearance makes the doctor's heart sink. With such a wide and subjective description there is considerable variation in terms of who fits the picture and who would be described as such by whom. Essentially they are those patients who leave us with negative feelings (anger, frustration, inadequacy) on completion of the consultation. It is the result of an interaction between two people, and represents a problem in the doctor/ patient relationship. Remember, they may view you as a heart sink doctor, or they may be projecting their difficult feelings onto you. This may be therapeutic for them, but it leaves you feeling miserable.

Although this article will refer to heartsink patients in terms of the doctor/ patient relationship, as other members of the primary healthcare team take on more autonomous clinical roles, they can also expect to be subjected to such demands.

With so vague a definition, it is impossible to be certain about incidence.

• Studies have suggested that most GPs have about 8 to 10 of such patients but the figures vary considerably, some suggesting 20 to 30.
• Some doctors have the patience of Job. Others are less tolerant. Some doctors seem to attract such patients. Others manage to devolve them to partners or registrars.
• Female doctors may suffer more than males as there is a common belief that being female makes one an expert in gynaecology, obstetrics, family planning, paediatrics and neurosis, both male and female.
• Heart sink patients are more likely to be female and so more likely to seek a female doctor.

Different authors have found a variety of criteria that predispose a person to be a heart sink. The following tend to feature in many lists:

• Female preponderance
• Over 40
• Socially isolated, usually single, separated or widowed or marital problems
• Low tolerance for just putting up with minor illness
• Low education and social class
• Poor insight
• They may well have serious chronic illness too

Symptoms

The features that vex doctors are legion but few patients will exhibit more than a few components. They include:

• Constant and delighted assertion that the treatment was useless (can I try another?)
• Failure to take responsibility for his or her own actions such as smoking or obesity
• Long as well as frequent consultations
• Many nebulous complaints all at once
• Want treatment for various children and relatives (without notes)
• Demand inappropriate certificates
• Repeat the same life stories incessantly
• Ask for inappropriate therapies
• Throw "the useless" medications across the consulting desk
• Casually swear during conversation
• Smell
• Demand treatment triggered by a TV advertisement or the Internet
• Demand their "rights" before explaining the problem
• Are over familiar
• Excessive scepticism about medical science along with a naive acceptance of "junk science" and totally unsubstantiated claims of efficacy and safety of unlicensed products
• Are happy to talk incessantly, but not listen to a word you have to say
• Know you can't help but .................

Signs

• They often have physical illness too but most often present with upper respiratory tract infections or back pain
• Other physical signs can include a "shopping list" of symptoms that they produce or a pile of print-outs from the Internet

• Somatising purely social problems including loneliness¹
• Projecting feelings onto you, representing some father/mother/authoritative figure. These feelings belong to them, not you
• Clinically depressed
• Myxoedema
• Genuine illness but not be coping with it
• Inadequate personality
• Learning difficulties
• Cultural problems with unrealistic expectations of doctors

Assure yourself that the polysymptomatic patient is not presenting with organic disease and this does not have to be from a multi-system disease. The patient who wakes breathless at night, sleeps poorly, feels tired all day, has anorexia yet weight gain and a dragging sensation in the right hypochondrium could have heart failure.

Remember that even hypochondriacs die of organic illness. When it strikes, it is less likely to be taken seriously.

• Try to avoid unnecessary investigations and unnecessary referrals but do not miss organic disease.
• If you think that they are depressed but are uncertain or think that they may be reluctant to accept it, try a validated questionnaire such as the Hospital Anxiety Depression Scale.

A condition that does not feature prominently in the literature on heart sink but which strikes terror into the hearts of most doctors is ME or chronic fatigue syndrome. Michael O'Donnell defined it in The Sceptic's Medical Dictionary as a disease in which the sufferer is far too lethargic to do anything except to argue most vehemently with anyone who suggests that it may possibly have a psychological component. There is EBM for this disease. It needs graduated physical and mental exercise and possibly antidepressants too. The problem is getting patients to accept this rather than gamma globulin injections or any other remedy that they have found on the Internet.

It is necessary to understand how people think and this requires listening to them, not just in the consultation but on the street and in the supermarket. There is nothing that people with drab lives love more than to recount in vivid detail their lurid ailments with a blow by blow account of their visits to the doctor. The one thing they love even more is to recount the epic of "seeing the specialist". The latter is defined as anyone who works in a hospital and wears a white coat. In many parts of the country doctors apparently never simply speak to patients but "turn round and say". The amount of rotation associated with speech is enough to make anyone dizzy.

Non-Drug

• Look upon the heart sink patient as a challenge, and try to identify the true agenda.
• Try to identify the pathology in the doctor/ patient relationship, remembering that it is a two-way process. If you have lost control of the situation, take it back.
• Some people have suggested summarising the notes may help but it has no benefit .²
• Nowadays the consultation is supposed to include a discussion of options for management with the patient and involving them. Even "patient compliance" is now called "concordance". Use this to make them take responsibility. Empowering the patient may feel like the last thing you wish to do but it is a powerful tool. It stops the patient from taking the "child role" as in Eric Berne's Games People Play³ and makes them take a more "adult role" with more personal responsibility. Involve them in the decision making so that they cannot so simply blame you when it does not work. About 4,500 years ago, General Sun Tzu, a Chinese warlord wrote in "The Art of Strategy" often called "The Art of War", "Those who have supreme skill use strategy to bend others without coming into conflict."⁴
• The line to be taken depends upon the nature of the problem but here are a few hints:
  • If they are failing to take responsibility for their actions such as smoking and gluttony, discuss a management programme with them, including their own responsibilities. It is not all up to the doctor and you are devolving power.
  • If they talk about rights, discuss their responsibilities.
  • If the medicine was "useless" ask them what they expected and interrogate them on compliance.
  • If they wax lyrical about "complementary therapies" ask them if they would be happy for you to prescribe a drug that has not been tested for efficacy, toxicity, drug interactions or teratogenesis but someone at the pharmaceutical company knew someone who benefited once. If they laud the safety of anything natural, ask if that means that anthrax, smallpox, snake or scorpion venom, deadly nightshade and death-cap mushrooms are all quite harmless.
  • Use patient diaries and other methods of self recording to produce more insight and linkage between events.
  • Be quite forthright in asking them what they seek to achieve from these frequent consultations but be prepared for an inane reply such as, "I just want to get better", of "I thought doctors were supposed to help people". Set rules extending frequency to monthly consultations.
  • If they are rude tell them so.
  • Be firm about one appointment for one patient or only appropriate certificates.
  • Listen to their long list, then negotiate which problem to address in today's consultation. The polysymptomatic patient is probably depressed or not coping with life. Rather than approaching each symptom in turn, look for the source and try to address that.
  • Some produce an opening line like, "I don't like doctors," which is really very rude but they seem to lack insight. We may think that the feeling is mutual but not everyone is bold enough to vocalise such as response. A better response might be, "Then why do you come?"

Drugs

• Try to avoid prescribing placebos or antibiotics for self-limiting viral infections.
• Agree periods without any medication if this seems appropriate.
• Do not let them discard "useless" drugs before an adequate trial and question compliance.
• Make drugs just part of a package of management.

Surgical

This should be most strenuously avoided. We need to protect both our less loved patients and our colleagues in hospitals. Allowing them surgery would be almost as inappropriate as a Munchausen syndrome.

• Beware the day when they have a genuine illness. It is easily missed.
• If you are too forthright and upset them they may choose "to shop elsewhere". However, try to discourage "doctor shopping."

Prognosis is not good.^5,6 Hope lies more in getting the doctor to cope than in getting the patient to change her ways.

Perhaps we should also accept that the heartsink patient is suffering, even in the absence of a biomedical abnormality. Perhaps general practice should reassert its acceptance of suffering, whatever its origin and presentation.⁷ This is more difficult when we feel that we are being made to suffer too.

A heartsink survival kit has been produced to help doctors to cope.⁸ We are used to the concept of patients suffering but the idea of the doctor suffering too, and not because of empathy with the patient, is novel.

Even being totally intolerant does not repel such patients. A study found that 60% of the variance in the number of heartsink patients that general practitioners reported on their lists could be accounted for by 4 explanatory variables:

• Greater perceived workload
• Lower job satisfaction
• Lack of training in counselling and/or communication skills
• Lack of appropriate postgraduate qualifications.

No other variables considered could account for the variance in the number of heartsink patients. The best way of reducing their numbers seems to be that doctors should reduce their workload, reduce their stress levels and increase their educational commitment.⁹