Abstract
With over half of GPs recently reporting their morale levels as either ‘low’ or ‘very low’ in a recent British Medical Association survey, it is essential to consider how we can build and maintain resilience. The GP workforce crisis is clearly a multifaceted problem; however, reflecting upon what might affect job satisfaction is an important part of its solution. When Tom O’ Dowd coined the term ‘heartsink’ in 1988, it was to describe consultations that evoked unpleasant feelings in doctors. It was not to label particular patients. This article aims to examine what GPs commonly find difficult and provide a framework for managing such cases.
The GP curriculum and difficult consultations
Recognise, monitor and manage personal emotions arising from the consultation Recognise how personal emotions, lifestyle and ill-health can affect your consultation performance and the doctor–patient relationship Formulate appropriate diagnoses, rule out serious illness and manage clinical uncertainty Recognise the opportunities offered by continuity of care and how a long-term relationship can be used to enhance therapeutic concordance with evidence-based interventions
The history of ‘heartsink’ patients
O’Dowd (1988) defined the term ‘heartsink’ in his landmark paper, recognising the visceral sinking sensation that a doctor experiences upon seeing certain patients on their list. The phenomenon had also been examined by others prior to this, such as Groves (1978), who described difficult patients as ‘hateful’. The flow chart in Fig. 1 exemplifies his four main patient types: dependent clingy, entitled demander, manipulative help rejecter, and destructive self-denier.
Flow chart based upon Groves’ four patient types (Grove, 1978). ICE refers to ideas, concerns and expectations.
Quote from ‘A Farewell to Heartsink?’
Given the complexities of the ‘doctor–patient’ and ‘bio-psycho-social’ relationships, there always have been and will be difficult consultations. It is also logical that as these relationships change, so do the nature of the difficulties.
With an abundance of information accessible for patients, the doctor’s role has moved on from that of a privileged ‘gatekeeper’ of information. Patients commonly attend consultations with pre-conceived expectations and demands, with doctors often now taking on the roles of translating or negotiating. Additionally, doctors can feel a lack of control with more rigid policies about what they can offer patients. They can also feel a need to practice defensive medicine, with increased threats of litigation. Such changes can lead to barriers and hostility, so advanced skills are required to manage this situation.
However, advances in medicine and how patients are now involved in their own care can also provide solutions. We are more able to accurately detect serious pathology for our patients, and therefore should be able to prevent over-medicalisation. Patients can become more involved in their care and take responsibility for their own health with evidence-based preventative medicine. Also, patients can gain a clearer insight into their difficulties with a plethora of information available and there is widespread recognition of the importance and impact of psychological wellbeing.
What makes a consultation ‘difficult’?
In a study of 500 primary care doctors, 15% of patients were reported as difficult (Jackson & Kroenke, 1999). There were patient factors that are more common in these cases, such as depression and anxiety, which is not surprising as transference (the unconscious redirection of the patients feelings onto you) of emotions is common during a consultation. Factors also recognised are female sex, age over 40, low functional status and increased contact with healthcare services. A light-hearted representation of a classic ‘difficult patient’ is shown in Fig. 2.
‘The List’ cartoon.
However, references to ‘difficult patients’ are now being challenged, as it is increasingly recognised that it is not the patient or the doctor that causes the difficulties, but the interaction itself. There is an argument that patient factors such as age, sex or culture simply represent communication differences that if not met, can result in missed messages. Questions have been raised as to whether the ratio of male-to-female ‘difficult patients’ would even out with improving consultation skills or, more controversially, reverse with the increase in female doctors (Strous, Ulman, & Kotler, 2006).
A UK survey focusing on doctor factors showed that overworked, less experienced or under-trained (particularly in communication skills) doctors reported higher numbers of ‘heartsink’ patients (Mathers, Jones, & Hannay, 2005). Patients’ needs are at risk of not being met, and they can even be exposed to harm, with frequent attenders having more prescriptions, referrals and tests (Smith, 1995). This confirms a need to examine our own experiences and practices.
Examples of specific difficult cases
Medically unexplained symptoms
Case example of MUS.
Their symptoms can reflect and cause underlying distress, which may or may not be acknowledged by the patient. Patients with MUS can feel a need to fight for their symptoms or for a diagnosis, as well as have feeling of shame or worthlessness if their experiences are not validated. This may be confounded by a vulnerability or history of abuse that if not handled carefully could perpetuate or worsen distress, leading to the patient disengaging or attending more frequently (Stone, 2014).
Frequent attenders
The average number of GP consultations per patient per year was last clearly published in 2008 at 5.5. The figure is higher for under-5s and over-80s (Health and Social Care Information Centre, 2009). Medical complexities and co-morbidities are growing, and primary care services have to adjust for this situation. As appointments are becoming even more precious, irritation builds towards those who are perceived to not use them appropriately. However, notorious ‘frequent flyers’ often do have multiple genuine and complex health problems, which add to the difficulty in their management.
Manipulative and demanding
It is clear that there are several potential gains from a doctor–patient consultation. Examples range from the conscious attempts of a substance misuser to acquire a prescription, to the subconscious attempts of a dependent patient to share or transfer their own psychological distress. Without recognition and boundaries there is a risk that patients’ true underlying needs will not be met. Therapeutic relationships can become unhealthy relationships and result in long-term destruction and blurring of professional duties.
Beyond the comfort zone
Unless recognised and confronted, lack of confidence in managing certain presentations can result in recurrent ‘heartsink’ experiences for doctors. They can cause a disproportionate amount of worry or feelings of aversion. If not managed appropriately, the cases can build and become even more problematic and overwhelming.
Management tips
This section looks at ways to avoid consultations from becoming difficult, or manage them if they do. These suggestions relate to the general approach to the consultation, use of advanced communication skills, and how to reflect and learn from challenging interactions.
Recognise patterns in presentations
The same approach for diagnosing medical conditions can be applied to recognising problems such as MUS. As well as the explicit signals from symptoms, the patient’s psychosocial context and understanding should also be assessed (Stone, 2014).
Listen to the patient
Allowing the patient to speak for a reasonable time is particularly important in the first meeting, even if they bring a list. It can then be explained that you recognise they are experiencing a number of difficult problems, but that there are time constraints. Then offer a follow-up appointment or try to immediately deal with their most concerning problem. This allows for trust and a narrative to be built (Stone, 2014).
Do adequately assess for serious underlying pathology
This includes performing an appropriate physical examination. It is worth bearing in mind that rarer multisystem disorders, such as systemic lupus erythematosus or Lyme disease, are far less commonly missed than depression and anxiety. Manage uncertainty and reassure patients if organic disease is not found, limiting unnecessary investigations. Rather than a preoccupation with finding a diagnosis the focus should be on ‘care not cure’ (Epstein, Quill, & McWhinney, 1999).
Validate symptoms that cannot be explained
Even if you cannot explain them, it important to acknowledge that the patient is experiencing symptoms and distress. When this does not occur, patients have reported feelings of blame, shame and worthlessness, particularly if there was a history of trauma or abuse (Stone, 2014).
Share your understanding
Involving the patient in their care and explaining your thoughts about what might be happening in an honest manner allows a trusting relationship to be built. This can prevent symptoms becoming ‘fixed’ or difficult to move on from and reduce unnecessary, but potentially harmful, interventions (Ring, Dowrick, Humphris, & Salmon, 2004).
Establish clear shared plans and expectations
Planning well-spaced follow-up appointments with the same doctor means that patients are less likely to use urgent slots and see several different doctors. Consistent messages to patients and having clear boundaries can help both doctor and patient, particularly for substance misusers and dependent patients. Make it clear what is acceptable (e.g. daily supervised opiate substitution at the pharmacy) and what is not (e.g. calling you at home). Encouraging the patient to recognise their own responsibility in their health can also be helpful.
Understand what influences a consultation
Showing empathy to patients is vital for an effective consultation. As this is not possible unless the patient’s feelings and situation are understood, try to build a narrative of the patient considering how they are really affected by their presenting problems. Also important is to acknowledge how feelings can pass between humans. Examples include transference and countertransference: the subconscious transfer of emotions towards the patient and back from them. Another psychological term is projective identification, which is the process of subconsciously projecting a thought or belief onto another person and then identifying with it (Stone, 2014).
Do not be afraid to respond to distress and explore it further, even if there are time pressures. Studies have shown that patients do expect their psychosocial difficulties to be addressed and want emotional support (Levinson, Gorawara-Bhat, & Lamb, 2000; Salmon et al., 2009). Doctors can worry that acknowledging emotional cues can prolong the consultation; however, it has been shown that when cues were noticed they then reduced (Zimmermann et al., 2011).
Do not underestimate the therapeutic relationship
Studies have found that doctors tend to decline training in psychological interventions (Salmon, 2007). Cognitive-based therapy techniques can be a powerful method to initiate changes (Stone, 2014). In some cases, patients may benefit from referral to specialists, such as chronic fatigue or pain clinics, or for formal psychological assessment.
Consider your own learning needs
Take study leave opportunities and find a quick and easy way to identify your own learning needs. An example would be Patient Unmet Needs and Doctor Educational Needs that could be implemented simply by having a notepad on the desk and regularly or opportunistically checking off each item. There are online applications that also facilitate this approach. Consider on-the-spot learning with the patient using online resources. For example, you could say: ‘Let’s look at this together’.
Reflect on difficult cases
Reflecting is a skill that most doctors are well trained in, focusing on what could be done differently. There are many different methods varying in formality. Regular meetings with peers or a multi-disciplinary team can be helpful ways of processing things and identifying solutions. Balint groups now feature frequently in training from medical school and can also be done in general practice.
Key points
It is usually the doctor–patient interaction that is difficult rather than one individual Underlying distress can be reflected in the patient’s presentation and the doctor’s response, and it is important to recognise how this can occur Key communication skills such as listening, empathy, motivational interviewing and validation are essential to understanding a patient’s needs and providing care Screen for illness, especially depression and anxiety, but limit unnecessary investigations and interventions as there is a risk of iatrogenic harm and missing opportunities to address bio-psycho-social needs Make joint clear plans by sharing understanding with the patient, encouraging them to take responsibility and having firm boundaries