HEARTSINK PATIENTS

1. HEARTSINK PATIENTS Dr J Sperring March 2007

2. Heartsink Patients Coined by O�Dowd in 1988 Following a 5 year study within his Practice Some �heartsinks� were identified (NB Not randomised) and were discussed over 6 months, with problems defined, management plans introduced and support provided for the key clinician. Those discussed tended to consult less, and more frequently consulted with the same doctor

3. Heartsink Patients Female > male Over 40 Socially isolated Low education and social class Associated with chronic disease �Fat folder� Each GP has an estimated 1 to 50 pts on their list, with a median of 6

4. Attend with: Long and frequent consultations Delight when a treatment fails Failure to take responsibility for their own actions (smoking, obesity) A shopping list! Demands for specific treatment Requests for inappropriate certificates

5. Groves 1978 classified 4 types: Entitled Demander: perceives the physician as a barrier to receiving services, can use intimidation. They play the �I�m going to take this further� game. Dependent Clinger: excessively dependent on the physician for reassurance, and returns constantly with an array of symptoms. They play the �poor me� game. Manipulative Help-rejecter: sabotages suggested therapies, they play the �yes but� game Self-destructive Denier: makes no lifestyle contributions to his or her own health and refuses to accept that their behaviour has an effect on their health. The game they play is �kick me��

6. Barsky outlined a management plan: Rule out serious diagnosis, review notes etc. Beware investigating/referring too much as may exacerbate problem. Look for a psychiatric diagnosis i.e. depression, anxiety. Form a collaborative alliance with the patient � see one Doctor regularly, decide frequencies of visits, listen � called �holding� NB beware the Doctor as a drug!!!! Set goals for treatment i.e.. Decreasing symptoms/improve coping strategies as opposed to cure. INVOLVE the patient. Provide limited reassurance, i.e. we have excluded a serious illness, try instead to shift focus to coping with symptoms rather than pathology. Prescribe CBT/anti-depressants if none of the above work.

7. Effect on the Doctor � avoid Burnout! Can be very frustrating, important to deal with feelings evoked (through transference), also insecurity and a sense of failure Goes against what we do everyday � solve medical problems and help people! Doesn�t fit in nicely with the biomedical model we use daily � identifying specific diseases, ordering investigations and prescribing effective treatments Neighbours theory of housekeeping Consider Balint group/discuss with colleagues

8. Every patient a heartsink? If there is a problem with the Dr-Pt relationship it is not necessarily the patients fault Different doctors attract different numbers of heartsinks, indicating that Doctor factors play a large role (Female GP�s apparently collect more!) The same patient may not induce a feeling of heartsink in every doctor they see (Gerrd and Riddell 1998). Doctor factors (MODIFIABLE): Inexperience Greater perceived workload Lower job satisfaction Lack of postgraduate qualifications Lack of training in communication skills And don�t forget there may be HEARTSINK DOCTORS � pts may dread seeing you!

9. BEWARE THE DAY WHEN THEY HAVE A GENUINE ILLNESS

10. �hope lies more in getting the doctor to cope than in getting the patient to change her ways� Dr Paul Hewish 2004