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At the heart of general practice since 1960

My success with sign language


I see more than my own kids

Three GPs share their approach to a practice problem

Case history

All the doctors in the practice have their share of heartsinks but one patient, Mrs X, is making your life a misery by booking her next appointment as she leaves. She also rings for telephone advice on an almost daily basis and turns up whenever it's your turn to see the emergency extras.

Her complaints are a mixture of acute trivia and ongoing 'yes-but' chronic problems. The former are quick and easy to sort out but you reached an impasse on the others a long time ago. Mrs X isn't unpleasant or aggressive but after seeing her yet again tonight ­ an emergency itch-without-rash ­ you realise you are seeing more of her than you are your kids. What's to be done?

Dr Robin Fox

'It's critical we as a practice do not give this heartsink

any mixed messages'

I need to empower her to find solutions within herself. At our next consultation I would arrange a 30-minute appointment at the end of a surgery. This would be to explore the psychosocial factors that have led to the current situation. I would ask her to write down in advance bullet points of why she feels she needs to see me so often. With luck something might come of this.

If not I would try to look for some common ground. From my perspective things cannot continue as they are. Her leaving my list to find another GP is likely to pass the problem elsewhere and I would prefer to avoid this. I would suggest that she have one routine 10-minute consultation with me per week.

I would explain I would not be able to consult for longer than 10 minutes and that I would leave things up to her as to how best to use this time. The aim would be to slowly reduce this frequency. We do run a same-day emergency clinic. I would explain that this was for same-day emergencies only. Long-term problems will not be discussed in this clinic.

I would write this clearly in her notes on the computer summary page (initial screen for all doctors) to ensure this plan is absolutely clear. I would also agree this management plan with staff at the next practice meeting in order that the plan is clearly known to all relevant members of the primary care team. It is critical that we as the practice do not give any mixed messages. I would write to Mrs X formally agreeing this management plan.

Robin Fox completed the VTS in July 2002 and is a partner in Bicester, Oxfordshire

Dr Tonia Myers

'If this is doctor dependency she needs to be weaned off me'

Clearly the situation with Mrs X is getting out of hand and it is time to address the problem head on. Unfortunately, with 'advanced access', frequent attenders seem to be attending even more frequently, probably because appointments are now more freely available.

Mrs X sounds like she may be a somatiser, possibly with underlying anxiety or depression. Next time she attends I will be direct and say that she has been seeing me rather a lot lately and that sometimes worsening physical symptoms can be a sign of 'stress'. Has there been anything worrying her recently?

She may be a bit shocked at being confronted and become defensive, but more likely she will admit to being anxious or own up to family problems. Although this will be a difficult and time-consuming consultation, if done tactfully it will save a lot of time and emotional energy (for both of us!) in the future. If we can agree that she has underlying psychological problems, then these can be addressed and the options of counselling or cognitive therapy, self-help or antidepressants can be broached if appropriate.

If on the other hand this is a simple case of doctor dependency then she needs to be weaned off me. I would try to take control by making her next appointment for her myself on the computer, rather than letting her do it herself at reception.

I would say that for her own convenience it is best for her to have a routine appointment rather than to have to hang around for ages as an 'extra'. The date of her appointment can be negotiated and will probably be longer away than she would choose, but sooner than I would!

Agreeing a regular review date is often a successful way of containing these patients. In the interim, I would reassure Mrs X that she can still phone in an emergency ­ stressing the word 'emergency', in the hope that she will get the picture.

Tonia Myers completed her VTS in 1989 and is a GP in Highams Park, London

Dr Des Spence

'Try being rude, off-hand and abrupt, it works a treat ­

but you'll hate being a GP'

A very wise doctor once told me 'you get the patients you deserve', which sends shudders down your spine but is very often true. Why do some doctors have more heartsink patients than others? Why do certain patient types gravitate to certain doctors? Do doctors encourage patient dependence? Is it really your fault if you have a loads of heartsinks?

However, the bottom line is that heartsinks are the bread butter of general practice. Either get used to it or head off for a career in biochemistry or pathology. The problems of heartsink patients are varied but many have a personality that seeks and needs constant reassurance.

I use a two-pronged attack: distraction, 'what about the football, eh', and half listening. I use referral only as last resort because the medical model sets off a chain reaction of unnecessary investigation and needless anxiety. In this scenario you have a number of choices.

First, acceptance. This is general practice for God's sake. The career-long continuity with heartsinks puts many doctors off, but that is how general practice works.

Second, challenge this woman. Very gently ask her why she attends so often. Perhaps tell her that her frequent attendance drags you down. You might be agreeably surprised by her reaction and answer, and this might allow you to set new boundaries. However, in real life problems tend not to be solved as easily as this!

The last solution is the commonest, oldest and most effective. Be rude, off-hand and abrupt. It works a treat. No more heartsinks....but you'll hate being a GP.

Des Spence is a GP in Glasgow and a tutor in general practice at the University of Glasgow ­

he completed the VTS in 1995

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