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At the heart of general practice since 1960

Heartsink

Dr Chris Hall offers some advice on dealing with the various types of patient who fall into

the heartsink category

There are as many types of heartsink patient as there are types of GP. The politically incorrect notion of the weeping middle-aged tissue-wringer is an unfortunate stereotype, for in truth, heartsink status is independent of age and sex (reassuringly I have yet to meet any paediatric heartsinks, though it may only be a matter of time).

You can be certain that somebody, somewhere, has authored a highly incisive treatise on the dynamics of what we shall call the 'challenging consultation', but I doubt that beyond suggesting coping mechanisms, such research can be of much practical use.

Many GPs consider the heartsink patient to be part of life's rich tapestry – indeed, while preparing for the video component of the MRCGP examination the registrar may find his or her heart leaping with joy when Mr Vague sits down and unfolds his list of (current) ailments. How quickly that joy changes to weary resignation when the same patient graces your consultation room for the umpteenth time with the same intractable ailments. You open with 'How are you?' only to be greeted with dough eyes and a familiar resigned shrug of the shoulders.

You try: 'What can I do for you today?'

Bad mistake. 'Dunno, where do I start?' is the usual reply.

A few hints then for a couple of common scenarios.

The frequent attender

This patient may have done the rounds among the other doctors in the practice and may gravitate towards a new face, to 'try you out'. Be prepared – read previous doctors' entries – if multiple investigations initiated by experienced GPs have failed to elucidate a cause for the patient's bizarre ringing feeling in the toes and creeping sensations up both arms, you are likely to gain little from further exhaustive investigation.

Indeed, showing too much interest in the condition can raise the patient's expectations. You may find yourself on the receiving end of: 'I've tried all the other doctors and they don't seem to listen – but you're so different.'

Another mechanism for dealing with frequent attenders is to highlight their pattern of behaviour to them. Establishing the motives behind their frequent visits may bring to the surface a hitherto undeclared anxiety, such as a recent sinister diagnosis in a friend or relative.

You could try to ration their attendances by arriving at an agreed periodic review, but explain that you foresee a time when this arrangement may no longer be necessary – otherwise the patient (or even the doctor!) may come to rely on these meetings.

The list-bearer

That 'sinking feeling' comes early in the consultation as you realise it's not, in fact, a shopping-list being unfolded. The patient may quantify it for you: 'I've got five problems today, doctor.' On the other hand he may just give you a 'Let me see, I've got quite a few, where do I start?' Avoid intervening now, and in my opinion you risk losing control of the consultation.

Politely pointing out the limited time available (always a difficult one if you are already running late) and the impact of a long consultation upon the remaining patients can, in fact, still salvage the situation to the relative satisfaction of both parties. A verbal contract could be made, along the lines of an agreement to give attention to, say, the top two items on the list, with an acknowledgement of the perceived gravity of the remaining symptoms to the patient and an undertaking to follow through. I usually ask the patient initially to give me a brief bullet point from each listed item, to ensure no important clinical 'red flags' are ignored. An agreed follow-up date may then be mutually agreed.

Your own personality

Remember, 'heartsink' patients are called just that for a reason. They can leave the doctor feeling frustrated, tired or despairing. Even if running behind, it can be wise to invest in a moment to take a deep breath and ready oneself for the next patient.

Jotting down a few notes for discussion with your trainer would be an efficient use of this time. Know your own vulnerabilities, try to learn from each encounter and analyse how it makes you feel and how you can improve on this outcome.

Remember, too, that if all else fails and either the relationship or the investigations it has spawned are going nowhere, it is reasonable to suggest to the patient that they see another doctor, 'to get a fresh perspective on the problem'. It is prudent to discuss this with colleagues first, though.

Endless referrals

As GPs we act as gatekeepers to the NHS, and as well as looking after the interests of our patients we have a responsibility to use resources efficiently. This includes expensive referrals to secondary care, which not only have wider resource implications, but can induce anxiety and expectation in those patients we (perhaps unfairly) label as heartsinks.

Often, a seemingly endless chain of investigations ensues (with accompanying patient anxiety), which does neither doctor nor patient any favours. Try therefore, to be appropriate and consistent in referral patterns.

Understanding origins

It often becomes apparent that there may be an unmet need of a non-medical kind, or an entirely non-clinical agenda. Do not forget that, aside from inaction and inappropriate referral, there is a network of resources to tap into: social workers, clinical psychologists, community addiction teams and occupational therapists among others.

Finally, although 'heartsink' patients may not be prime MRCGP video material, remember they, like all patients, perceive they have a reason for attending – be seen to make all reasonable efforts to establish their agenda, do not miss clinical 'red flags', always remain professional and you shouldn't go far wrong.

Dr Chris Hall is a partner in Belfast

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