Heartsinkand difficult patients
DefinitionsDifferent types of difficult patientsWhy are they important?What is the source of the problem?How to deal withheartsinkand difficult patients.
“There are patients in every practice who give the doctor and staff a feeling ofheartsinkevery time they consult. They evoke an overwhelming feeling of exasperation, defeat and sometimes plain dislike that causes the heart to sink when they consult.” O’Dowd 1988 BMJHeartsinkpatientDifficult patientDysfunctional consultation
The classic four types of difficult patientsGrove 1978
Dependent clingers– Repeated requests for attention, reassurance, urgent demands for explanation, affection and medication.Entitled demanders– Patients that exude an innate sense of deservedness; they use intimidation, devaluation, and guilt induction to place the doctor in the role of “the inexhaustible supply depot”.Manipulative help-rejecters– Patients who return to the surgery again and again, almost smugly satisfied to report that, once again, the treatment or regimen hasn’t worked. Their pessimism appears to increase in direct proportion to the doctor’s effort and enthusiasm.Self-destructive deniers– Appear to find their main pleasure in defeating the physician’s attempts to preserve their lives. This may represent a chronic form of suicidalbehaviour.
The never get bettersNot one but twoThemedicosociallydeprivedThe wicked manipulatorsThe sad
Gerrard T and Riddell J
Black HolesFamily complexityPunitive behaviourPersonal links to the doctors characterDifferences in culture and beliefDisadvantage, poverty and deprivationMedical complexityMedical connectionsWicked manipulative and playing gamesSecrets
Why are they important?Doctor factors
Because they can generate negative emotions:Stress/anxietyFearAngerLow Morale (Heart Sinks)Helplessness
Why are they important? 2
Because they can end up having unnecessary investigation and/ortreatmentA heart-sink patient is probably an unhappy patient (life, doctor, ill health, past negative experiences)My life as a heart-sink patient, BJGPvol61 2011Acknowledge lack of help, act on it and don’t just order more tests to get me out of the room
What is the source of the problem?
The patient?The doctor?Doctor patientrelationship?Societal forces?
Unrecognised psychiatric disorders (eg, anxiety or depression)Undiagnosed physical illnessSomatisationAlcoholismBorderline personality disorderPrevious experience of poor or disappointing careWell-founded need for information or in-built critical approach to problemsEgotistic elements and an excessively demanding attitude.
Female>maleAge >40Single, widowed or divorcedMarital/family problemsMay be very isolatedLower tolerance for minor illnessConcomitant serious illnessExperience of serious relationship dysfunction and rejection in earlylife
Doctor factors 1
Matherset al BJGP June 199560 GPs from Sheffield areaStructured interview and questionnaireNumber of heart-sink patients 1 – 50per list (FTE)4 variables significant: WorkloadJob satisfactionTraining in counselling/communication skillsPost graduate training (MRCGP,MRCPsych)
Doctor factors 2
Strong assumptions as to how patients should behave and how medicine should be practisedNarcissism or arrogantpersonality, convinced of their rectitudePoor communicationskills, doctor centred fail to understand role of psychosocial factorsOver patient-centred, needs to be liked by everyone, creates dependency.Cultural gaps that go unrecognisedLack ofexperienceStress or overwork.Both of the above may lead to over prescribing, investigating, referrals etc.
So what do you think?Do you have characteristics that might predispose to the doctor factors?How would you identify them?
Doctor patient relationship
Parent, child, adult (Berne, Games People Play)Doctor and patient may be emotionally attached to each otherCollusion, relationship might be filling a need inboth co-dependency
Growing multicultural societies: communication problems and different or unrealistic expectations fromdoctorsIncrease of patient mistrust following high-profile casesPressure to reduce the cost of care and increase physician productivity decreasing the amount of time for consultationsLack of continuity ofcareEasy access to wide-ranging, and sometimes confusing, information via modern technology
How to deal with difficult/heartsinkpatients.
Steinmetz andTabenkinThe ‘difficult patient' as perceived by family physicians.Family Practice2001;18:495–500.15 board certified family physicians inIsrael, long structured interviewEmpathyNon-judgemental listening, patience and tolerance.Direct approach, defining length of time and content in advanceReferral, passing the buck?Recommend another doctorHumourInvolve patient’s familySharing doctors personal experience with patient
Successful GP Intervention with frequent attenders in primarycareBellonBJGP 20087H and T ( 7 hypotheses and team)GPs analysed their frequent attenders to identify the area in which the issue was likely to be (hypothesis)Biological, psychological, social, family, cultural, administrative-organisational, or related to the doctor–patient relationship.Then discussed with the team and generated a management plan.
How to recognise them:frequent attendance for simple problems, reassurance, “pill for an ill”, ask for repeated Rx and services, ask for favours, flatter you to excess “only you can help me doctor”, refuses to see other GPsFeelings generated in GPs:how sad, exhaustion “sucked dry”, aversion and avoidance. May be GP fault for allowing/generating doctor dependencyHow to handle them:set boundaries and limits,egnumber of consults a month, be in the driving seat, encourage self help and self coping, accept problem is theirs not yours, consistent and firm, recognise your own feelings and control them, housekeep
How to recognise them:demanding or manipulative, want something “now”, instil a sense of fear, guilt or intimidation by devaluing theDr.threaten with legal action, see doctor as barrier to what they are asking for, “if you don’t then be it on your head”,somatisers, personality disorders, can become aggressive think about personal safety. May have had longstanding psychosocial upset leading to abnormal illness behaviourFeelings generated in Drs:anger, resentment and fearHow to handle them:with care, be pleasant and try to establish a rapport, try not to say no straight away, negotiate a management plan, if you do give in to wishes make it clear it is part of the management plan, always think about personal safety
How to recognise them:keep coming back to tell you the treatment was no good, despite this they keep coming back to you. They are doctor dependant. Same old story you can often guess before they sit down. They have preconceived ideas and may aim to seek an indissoluble relationship with doctor. What is the secondary gain from this behaviour, often comes from family and friends. Resolution of symptom with be replaced by another. “that will never work” “ Only Dr X can help me”Feelings generated in Drs:sense of hopelessness, inadequacy, dissatisfaction, overburdened ,frustration.How to handle them:set boundaries and limits, identify what the patient wants and set limits on what they can have, share the load, challenge patternsegby agreeing with their views “ yes you are right that probably won’t help” consider delayed response.
Self Destructive Denier
How to Recognise them:usually feel they can’t control their life the doctor can. May have chronic illness but have remediable risk factors they can’t change. Want a miracle pill instead.Feelings generated in doctor:anger, frustration, resignationHow to help them:explore their health belief structure and work out with them what it might take to change, encourage self help, get them to take ownership of the problem
Identify a patient you have seen that has engendered the “heartsink” or left you feeling anxious and frustratedDescribe the patient to your colleague and try to work out between you where the issue is likely to be:Biological, psychological, social, family, cultural, administrative-organisational, or related to the doctor–patient relationship.
General management techniques
Discuss your perceptions of the illness behaviourDiscuss the patients methods of denialBe honest, but kind in your honestyDiscuss your own feelingsStart again with reviewing notes and taking a history include the family historyCompile a life chart using significant events in physical and psychosocial areasGet the patient to keep a diaryImplementing a holding strategyLearn to become a mirror not a sponge
Help outside the consultation
Ask yourself what are the patient’s problems, why does she evoke the feelings she does in you,Recognise that the feelings generated in you might reflect the patient’s own feelings (countertransference)Recognise and accept that these feelings are normalRecognise that not all problems have solutionsVideo a consultation with a difficult patient( many are often keen to help you learn)Discuss the case with others and use groups likeBalintgroupsVideoa consultation with a difficult patient( many are often keen to help you learn)
Chew-Graham CA, May CR and Roland MO. The harmful consequences of elevating the doctor–patient relationship to be a primary goal of the general practice consultation.Family Practice2004;21:229–231.
Wesuggest that doctors have overestimated the importance of sustaining their relationships with some patients, when doing so only maintains incapacity. Communication skills training in medical schools and in training for general practice27is rightly aimed at finding ways to improve the quality of doctor–patient interaction in ways that benefit the patient. However, clinicians need also to find strategies that permit them to recover their authority and to empower themselves in the circumstances and the types of patients that we describe herein.
What are you going to do differently as a result of this session?