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Gold, incentives and meh

Heartsink patient resorts to flattery to win you over

Ms W has been registered with the practice for several years but is new to you. She is 60, attends frequently and has seen all the other doctors at various times. Her summary is lengthy, and today her main presenting problem is pain involving her neck, low back and knees. She sleeps poorly and is not getting out as she used to. She feels tired and dizzy. After listening to her complaints and examining her, you review her medications ­ 10 in total. You suggest a follow-up appointment in two weeks. On leaving, she remarks: 'It is so nice to have a doctor who really listens to my problems.' Dr Richard Stokell offers advice.

How does her leaving remark make you feel?

It's flattering ­ is she right? You do ask open-ended questions and listen actively, but let's spare a thought for the uncaring wretch who was looking after her previously. Would worry be a more appropriate emotion to feel at this stage?

What are the issues here?

This presentation is highly suggestive of a dependent patient. These patients are a major cause of heartsink to GPs.

They tend to use up our most valuable resource (time), push us into inappropriate prescribing and referral and cause frustration and stress.

What do we know about dependent patients?

This group of patients has been described as 'independent clingers'. Their behaviour is based on a belief that you can make all things better ­ that the cure is in your hands, not in theirs.

The result is frequent attendance, immense gratitude and reattendance with the next complaint. They are unlikely to see changes they can make themselves as being an important part of treatment.

What skills can we employ to provide a therapeutic relationship for patient and doctor?

Our challenge is to empower this patient to solve her own problems and erode her unrealistic expectations of our power to cure her. Take a history. We need a broad understanding of this patient. We need to understand the degree of impairment caused by her physical problems and the underlying psychological and social factors. Questions like 'how do you spend a typical day' and 'who are the most important people in your life' can be rewarding.

Try to involve the patient in defining problem areas and looking for solutions. This can start with prioritising the various complaints ­ 'which of these problems was the main one that brought you here today' ­ then on to why this problem prevents her going out and ways in which she might resume activities. If medication is required, say, for pain, try: 'You've had many different treatment for this before, which do you think worked best?'

Avoid unnecessary interventions or referrals and providing a pill for every ill. The latter will reinforce the patient's belief system and lead to polypharmacy. Instead, emphasise the downside of prescribing and the need to stop one drug before starting another.

Referral can be counter-productive and strategies like saying 'you're already attending the gastroenterologist so I would advise you not to see any more specialists until he is finished seeing you' can be a useful compromise.

Organisation skills: doctor-swapping may be a welcome relief, but is likely to perpetuate the problem. Listen carefully at someone else's door and you may hear those words: 'It's so nice having a doctor who...'

Can we share this burden?

The first person to share it with is the patient. The practice nurse can deal with chronic problems ­ coronary prevention, use of inhalers ­ and is less likely to use the medical model inappropriately for other problems.

Good communication: bring problem cases to the primary care meeting, share your emotions, avoid doctor-swapping.

Exercise on prescription can empower patients and help the psychological problems. Other self-help areas can be useful in handling this kind of patient.

Psychology: a recent study suggested cognitive behavioural therapy could be a helpful intervention for frequent attenders.

Why does this matter?

This patient could affect your health. She might also suffer unnecessary and potentially dangerous interventions. Your ability to manage her largely non-organic illnesses and prevent dependence is likely to influence your ability to respond appropriately when in the end she does get a significant illness.

Heartsink patient resorts to flattery to

win you over

This patient could affect your health, and she could suffer unnecessary and potentially dangerous interventions~

Key points

 · These patients use up time and push us into inappropriate prescribing and referral

 · We need to understand their degree of physical impairment and psychological and social factors

 · Avoid a pill for every ill ­ this will led to polypharmacy

 · Bring problem cases to the primary care meeting

 · Exercise on prescription can empower patients

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