Understanding the “heartsink” patient

“They are a disparate group of individuals whose only common thread seems to be the distress they cause their doctor and the practice.” O’Dowd, BMJ, 1988

EVERY GP knows exactly what is meant by the phrase “heartsink patient”. The eyes flit over the day’s appointment schedule, and the moment you recognise a certain name on the list, your heart begins to sink.

While the emotional response is entirely the doctor’s, it is the patient who (perhaps unfairly) receives the label. For this reason, I prefer the terminology of “heartsink encounter” or simply “heartsink”.

Before the term “heartsink” entered medical literature, these types of patient encounters were referred to as “the hateful patient”’ by psychiatrist James Groves. Which is to say, the patient that “everybody hates”. In his 1978 exploration in the New England Journal of Medicine, Groves described the experience of countertransference that can occur in “hateful” doctor–patient relationships. He categorised the encounters into four broad groups that stir up different varieties of unease in treating clinicians.

There is the dependent clinger, who creates feelings of aversion; the entitled demander, who may make the clinician feel fear or become hostile themselves; the manipulative health rejector, who brings on feelings of inadequacy and guilt; and finally, the self-destructive denier, who may evoke a sense of malice and even a wish that the patient would succeed in their self-destruction.

Groves considers these experiences of countertransference as a form of “clinical data” that can provide important information on a patient’s psychology and required treatment. For example, if a clinician has lost hope that a patient will recover, it is worth considering that this hope is also lost within the patient , something that should be recognised and addressed. While fascinating, Groves’ reflections are more applicable to the psychiatric care setting and offer insight, but lack practical advice for primary care, where heartsink encounters are most common.

One of the earliest references to the “heartsink patient” can be found in a 1986 issue of the BMJ, where CG Ellis argues that “dysphoria” is the cause of heartsink. Ellis considers dysphoria as a form a persistent misery that is not quite depression and, therefore, difficult to identify and even more so to manage. Ellis points to many features of the heartsink patient that are less psychoanalytical than Groves but just as recognisable. A file “thicker than normal”, a multitude of complaints mixed in with various comorbid conditions, and one or more drug dependencies, despite all medications seemingly completely ineffective. The hallmark of dysphoria, Ellis tells us, is dissatisfaction and you are left trying to “treat the untreatable”. Ellis’s advice is to approach such patients with a mix of unbridled enthusiasm (in the hopes that this is contagious), taking the necessary time and using variety in the clinical approach.

In 1988, a UK-based GP, TC O’Dowd, attempted to research the subject by discussing patients identified as “heartsinks” at practice meetings and formulating management plans. The patients were followed up 5 years after they were recruited to the study. Twenty-eight patients were identified, only nine of whom ended up having management plans formulated, due to time restraints.

Interestingly, but wholly unsurprisingly, the patients included in the study did not seem to have much in common, with the obvious exception being the sense of dread they were causing their GPs and practice staff. O’Dowd found that, over time, the number of identified heartsinks reduced (from 28 in the practice to 19), and that formulating management plans seemed to be effective as only one patient (out of nine) with a management plan remained on the heartsink list 5 years later.

O’Dowd reflects on the heartsink encounters experienced by GPs and acknowledges that “we need help with this problem because we are part of it and thus find understanding it difficult”.

In 1995, 60 UK-based GPs were surveyed in relation to heartsink encounters, and all of those who participated in the study had experienced at least one (and for some, up to 50). These patients mostly caused “angry helplessness”. It was found that GPs with higher workloads had significantly more heartsinks and those with lower job satisfaction also reported higher numbers. GPs with less or no training in communication also had more heartsink encounters, and those with additional training and postgraduate qualifications seemed to report fewer.

The literature thins out on this subject as time passes, perhaps due to a combination of a lack of interest and the fact that it is no longer acceptable to so bluntly describe conflicting personal dynamics within a clinical setting in the way Grove, Ellis and O’Dowd did in the 1970s and 1980s.

It is a shame, as it is a worthy topic of discussion. A heartsink encounter is not necessarily a difficult or challenging patient, and advice on clinical challenges and difficult patients is plentiful. Heartsink encounters elicit a visceral and involuntary response in GPs that can be difficult to overcome and can cause an overwhelming sense of dread and angst that interferes with functioning during the consult and beyond. A heartsink encounter may only occur once a day or once a week, but can take up a significant proportion of emotional energy and cause a GP to experience distress, and negatively impact clinical confidence.

The good news from the available literature is that time in and of itself is likely to be a remedy for heartsink, as time allows for information gathering, continued professional development and the opportunity to fine-tune skills in communication. Reassuringly, although the evidence is patchy, it does not seem that heartsink results in missed diagnoses. While there are many challenging and difficult consultations in the life of a GP, only a minority will result in heartsink.

Heartsink is often transient, and active management using a collaborative approach within your practice can help improve the clinical relationship and allow the GP to unburden themselves with the sometimes heavy weight of a heartsink. The best place to start is a trusted colleague.

Dr Alisha Dorrigan is a Sydney-based GP and Deputy Medical Editor for the Medical Journal of Australia.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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