Five years of heartsink patients in general practice., 1988, O'Dowd et al.

[Chandelier]

Five years of heartsink patients in general practice.

O'Dowd, T. C.

Abstract
"Heartsink" patients exasperate, defeat, and overwhelm their doctors by their behaviour.
A group of such patients was followed up over five years in a general practice, and this paper describes what happened to them.
As a group they were often in employment and in stable relationships, though women were over represented.
Half the group were subjected to a management plan which seemed to make them less heartsink over the five year period.
While heartsink patients often have serious medical problems, they are a disparate group of individuals whose only common thread seems to be the distress they cause their doctor and the practice.
Heartsink as a phenomenon has features that are unique to general practice.

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[John Mac]

 

[Chandelier]

This thread was inspired by a post from @angryhacademic on Twitter:

[Quotes from the paper provided as two screenshots]:

Introduction There are patients in every practice who give the doctor and staff a feeling of "heartsink" every time they consult. They evoke an overwhelming mixture of exasperation, defeat, and sometimes plain dislike that causes the heart to sink when they consult. Ellis, a general practitioner, coined the phrase "dysphoria" to define "the feelings felt in the pit of your stomach when their names are seen on the morning's appointment list." Groves, a psychiatrist, used the term "hateful patient" and defined four stereotypes: dependent clingers, entitled demanders, manipulative help
rejectors, and self destructive deniers.

The problem-It became apparent to me in my first year in the practice that there was a group of patients who were causing stress to the practice. These patients seemed to be dissatisfied with the services provided, placed many demands on the practice, and were often
frequent attenders with seemingly endless complaints. This group of patients caused a feeling of "heartsink" in staff in the practice which was often borne with resignation but occasionally led to pejorative remarks being made. With the help of my partner and the receptionist I compiled a list of such patients or families. I reviewed their case notes and summarised each family's reasons for consulting and outlined their
present management.

Tweets:

Five years of heartsink patients in general practice (1988)
bmj.com/content/bmj/297/6647…
"While heartsink patients often have serious medical problems, they are a disparate group of individuals whose only common thread seems to be the distress they cause their doctor and the practice"

Over a period of months, the GP practice held lunchtime sessions to discuss each identified heartsink patient with the aim to formulate a management plan and provide support to the healthcare worker dealing with the patient.

Due to time restraints and "doubt that the effort was worth while" these meetings stopped making 2 groups: with vs without a management plan.
It is unclear to me if the patients were informed they were part of a little research project that would be published.

9/28 had serious health conditions, 19 had "multiple vague complaints".
In the following 5 years, 3 of the 19 were found to have serious medical complaints: colon cancer, Addison's, and stroke.

The colon cancer patient "rarely visited after her operation and remains well". The other 2 patients "continue to consult frequently and are well"→ were they well or did the GPs fail to recognise the problem?

"Thus 12 of 28 either had or developed serious medical problems"→ did they not have a serious condition or was there a diagnostic failure because the GPs didnt like the patients attitude so made assumptions?

Following the aforementioned discussions, consultation rates declined, whilst it stayed the same for their family.

→ Authors blame this on the Hawthorne effect, but i wonder if the patients sank into a state of helplessness knowing the GPs wont help, considering some of these patients left the practice, 2 specifically due to dissatisfaction

I cant help but feel that in supporting the GPs, the biases about these patients were reinforced and that fundamentally changed the power dynamics and communications/trust broke down.

"Heartsink patients are a great source of stress to doctors, and the feeling of heartsink may be the only common thread joining a disparate group of difficult patients."→ not that they had conditions the GP failed to recognise?

"In this study getting more information about the patient and family seemed to make them less heartsink"→ this is great for the GP but what about the patient? This may have been a terrible time for them

"With a greater understanding of the patient, it is likely that the doctor was relieved of any clinical insecurity and became more positive about the patient."→ they are just making things up, they didn't measure any of this

"Undoubtedly, the negative feelings such patients aroused in us made us feel "unprofessional," causing puzzlement, frustration, and disappointment."→ this sounds like a GP problem with insecurity, poor training, confirmation bias, and poor emotional regulation

"It is reassuring to know that the heartsink patients in this group do not seem to have suffered from missed diagnoses, but like the results of other studies have shown many had chronic medical and psychologicalproblems."→ this seems contradictory??

If they had chronic medical conditions then maybe those were not managed well. I'm also not sure how they know nothing was missed (diagnostic overshadowing comes to mind)

The beginning of the next article "Difficult patients: black holes and secrets" is previewed and that looks equally ridiculous

I'm not denying that some patients are "difficult" but i highly doubt that they are difficult for funzies. I'm also not denying the stress and pressures of being a doctor, that mixed and conflicting feelings will likely come up, nor that they shouldnt be supported.

Its the flagrant lack of introspection that gets me. The patient is difficult, not that the medical system has failed to help properly. And in all honesty, I'm not that convinced things have meaningfully changed since the 80s

I wonder how many of these heartsink patients were ND...

 

[Chandelier]

Difficult patients: black holes and secrets., 1988, Gerrard et al.

Gerrard, T. J.; Riddell, J. D.

The despair, anger, and frustration that we feel with certain patients is part of our everyday lives; we are all familiar with that feeling which overwhelms us when we see Mr or Ms X's name in the visit book.
We have been taught that these feelings often originate in the patient, and we try to use this insight to help them.
These patients usually attend frequently; it is not this that causes difficulty but the style and the content of the consultation.
They often seek out a particular partner in the practice and then stay with him or her, and this special relationship can cause intense rivalry and resentment between partners.
One doctor's list of difficult patients is not the same as another's, and this must reflect the needs and personalities of different doctors.
We have found that a long case meeting to discuss these patients and the feelings they produce can be invaluable, but we also believe that further analysis of these particular patients as outlined in this paper can be helpful.
We looked at the first 25 names that came to mind and found that they all had one or more of 10 key characteristics as described below.
We have given examples based on real cases and suggested ways to understand and unlock patient and doctor.
(Throughout the doctor is assumed to be male for the purposes of simplicity.)

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[neurophusion]

Some copy editing suggestions:

There are patients [doctors] in every practice [or field of medicine] who give the doctor and staff [patients and carers] a feeling of "heartsink" every time they consult [with them or see their name in published papers]. They evoke an overwhelming mixture of exasperation, defeat, and sometimes plain dislike that causes the heart to sink when they consult [with them or see their name on medical referrals]. Ellis, a general practitioner [Jane Doe, a typical patient], coined the phrase "dysphoria" to define "the feelings felt in the pit of your stomach when their names are seen on the morning's appointment list" [or newspaper]. Groves, a psychiatrist, [John Doe, a carer] used the term "hateful patient" "psychopathic doctor" and defined four stereotypes: dependent clingers [second-rate researchers who endorse low quality methodologies to keep the gravy train rolling], entitled demanders [entitled academics who abuse their eminence], manipulative help rejectors [media seeking opportunists], and self destructive deniers [of the genuine characteristics of ME/CFS].

 

[AliceLily]

I don't think ND needs to be made a scapegoat here as someone was questioning. We might not come across in a way that is 'normal' to others but we are not stupid and see through a lot of bullshit talking. ND people are vulnerable to being made a 'spectacle'. I am getting old now but I get very concerned for the young ND on the receiving end of it.

 

[Trish]

What does ND mean?