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Clinical casebook - the frequent attender

Dr Steve Brown looks at ways of handling heartsink patients, and suggests you view them as a challenge rather than a chore

Dr Steve Brown looks at ways of handling heartsink patients, and suggests you view them as a challenge rather than a chore

Case history

Single parent Jane Wright, 40, is on your surgery list for the morning. Your heart sinks as you realize that she is now coming every week to see you. You look in her records and see she has had 21 appointments with you or your partners in the last nine months. How can this situation be improved?

‘Heartsink' patients present a challenge. And I think ‘a challenge' is the way to approach consultations with frequent attenders. Thinking positively like this is better than becoming frustrated at not being able to change their attending behaviour.

Most surgery consultation rates are around four per patient per year, so if a patient has 21 visits in nine months they are either really ill or are coming when medically they don't need to. It is worth spending an hour or so looking through the patient's records and analyzing their consulting behaviour (see box 1).

Questions to ask yourself when looking through the records

• When did the present consulting behaviour start?

• Were there any life events around that time?

• Does the patient come on any particular day?

• Do they consult out of hours or attend A/E regularly?

• Do they favour any particular doctor?

• What happened at previous surgeries and has any practice removed them from their list?

• Do they come with the same type of problem?

You can then build up a picture. For example I have known patients who always come on a Friday, because they have a fear of being ill over the weekend when they perceive it more difficult to get hold of a doctor. I have also seen patients whose consultation pattern changes significantly when a doctor retires, or who attach themselves to the new registrar.

If they always come with the same problem look at the records to see how it has been managed and investigated so to stop unnecessary duplication.

I would suggest you have a partners meeting to discuss the possible reasons for frequent attending (see box 2).

Reasons for frequent attending

• Depression or anxiety

• Loneliness or other social problems

• Personality disorder with attention seeking

• Dysfunctional doctor/patient relationships with lack of challenge to the behaviour pattern

• Munchausen syndrome

Formulate a plan as a partnership and decide on rules that everybody should stick to. For example I had a patient who kept coming with ‘cystitis'. Some doctors gave antibiotics every time, some sent MSU's every time, and some did a bit of both. It became apparent that the patient was exploiting differences in management, and some of the partners did not realize this was happening. We decided that as most MSU's were negative we should only prescribe if there was a proven UTI. After 3 or 4 consultations the patient realized how we were approaching the problem, and the episodes of ‘cystitis' virtually stopped.

Box 3 general principles of management

• All doctors and nurses to be consistent in management

• Don't bend the rules - so no double appointments or squeezing the patient in for extra appointments

• One doctor to mainly manage the patient but other doctors to be supportive

• Decide on thresholds for referrals and investigations and be strong in the face of cry wolf

• Don't over prescribe and certainly don't use a prescription to end the consultation

• Document your consultations clearly with particular reference to symptoms that are not new

• Don't be afraid to tell the patient you are going to seek the advice of another doctor

• Don't be afraid to challenge the patient's behaviour and don't feel guilty if they are upset

I was once asked to take over the care of a heartsink patient by my senior partner, who was at rock bottom. I felt strong enough to take on the challenge. I was consistent in my advice, but this was difficult initially because there were about six consultations that seemed exactly the same, and where there was a verbal boxing match. I tried to think of the long term benefit to me and the practice. The surprising thing was that the patient stuck with me even although I did not agree to their demand for another referral for an ongoing problem. Their consultation rate went down significantly when they understood the way I was thinking about their problems.

I challenged another patient about their high consultation rate and their reply was "I must have been very ill this last six months then"! I find that the best way to challenge patients is to make observations based on fact such as: "I see that you asked that same question last time you came" or "What do you think another consultant will be able to do about that problem"?

The outcome for Jane Wright was that after looking at the notes I realized her frequent attending had started two years previously. When I challenged her about what happened then she was upset but did not tell me anything new. However two days later she wrote me a long letter saying that her son had gone to prison then for drugs offences and as she had no close friends she had not told anybody. Over the next few consultations I made an effort to show understanding of this problem, and she gradually realized that her headaches and back pain were partly caused by internalizing her emotions. Her consultations reduced by 50% and all the practice staff were relieved!

Dr Steve Brown is a GP trainer in Beaconsfield, Buckinghamshire

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