Reframing the “heartsink” feeling can help doctors find a resolution, 2024, Rickenbach

Opinion
Reframing the “heartsink” feeling can help doctors find a resolution
BMJ 2024; 385 doi: https://doi.org/10.1136/bmj.q1427 (Published 27 June 2024)

https://www.bmj.com/content/385/bmj.q1427.short?rss=1

Do you recognise that heavy sensation of feeling weighed down when you can’t see the way forward in a consultation with a patient? If the situation happens repeatedly, the feeling can become anticipatory and associated with just thinking about the scenario.

 

Chat GPT wrote me a CBT plan for such sufferers:

Cognitive Behavioral Therapy (CBT) can be a valuable tool for doctors to manage the "heartsink" feeling when dealing with complex patient cases. Here's how CBT principles can be applied to help doctors in this scenario:

1. **Identifying and Challenging Negative Thoughts**: CBT helps individuals recognize and challenge their automatic negative thoughts. Doctors can be trained to identify thoughts that contribute to frustration, such as "I can't help this patient" or "This situation is hopeless." By challenging these thoughts, doctors can reframe them into more positive and realistic perspectives, such as "I can work with the patient to find a solution" or "This is a challenging case, but we can make progress together."

2. **Developing Problem-Solving Skills**: CBT emphasizes structured problem-solving techniques. Doctors can use these skills to break down complex cases into manageable parts, identify specific issues, and develop practical solutions collaboratively with their patients. This approach can help reduce feelings of being overwhelmed and increase a sense of control.

3. **Improving Communication Skills**: Effective communication is a key component of CBT. Training in CBT can enhance doctors' abilities to communicate empathetically and clearly with patients, which can help in uncovering underlying issues such as relationship problems or mental health concerns. Improved communication can also facilitate joint planning and better management of the patient's needs.

4. **Managing Stress and Burnout**: CBT includes strategies for managing stress, such as mindfulness, relaxation techniques, and cognitive restructuring. Doctors can use these techniques to manage their own stress and prevent burnout, thereby improving their overall well-being and ability to handle challenging consultations.

5. **Reflecting on Beliefs and Values**: CBT encourages individuals to explore and reflect on their core beliefs and values. Doctors can benefit from this by examining any clashes in beliefs or values with their patients and finding ways to address them constructively. This reflection can lead to greater understanding and acceptance of different perspectives.

6. **Enhancing Emotional Regulation**: CBT provides tools for emotional regulation, helping doctors manage their emotional responses to challenging situations. Techniques such as mindfulness and cognitive restructuring can help doctors maintain a calm and professional demeanor, even in difficult consultations.

7. **Organizational Support and Training**: Implementing CBT principles at an organizational level can create a supportive environment for doctors. This can include providing training in CBT techniques, setting up peer support groups, and offering regular debriefing sessions to discuss complex cases. Organizations can also ensure that doctors have adequate time for consultations and access to resources such as social prescribers and mental health support.

By incorporating CBT principles into their practice, doctors can better manage their own emotions, communicate more effectively with patients, and develop practical strategies for addressing complex cases. This can ultimately lead to more positive outcomes for both doctors and patients, transforming "heartsink" moments into opportunities for growth and success.

 

And a mindfulness approach too!!

Mindfulness can also be a powerful approach to help doctors manage the "heartsink" feeling in challenging consultations. Here are several ways mindfulness can be integrated into their practice:

1. **Enhancing Self-Awareness**: Mindfulness practices, such as meditation and mindful breathing, help doctors become more aware of their own thoughts, emotions, and physical sensations. This self-awareness can enable doctors to recognize when they are feeling frustrated or overwhelmed, allowing them to address these feelings before they escalate.

2. **Reducing Stress and Burnout**: Regular mindfulness practice has been shown to reduce stress and prevent burnout. Doctors can use mindfulness techniques to stay grounded and calm, even in the face of complex or emotionally charged situations. This can help maintain their well-being and resilience.

3. **Improving Patient Interactions**: Mindfulness promotes active listening and presence, allowing doctors to fully engage with their patients without distraction. This can improve the quality of the doctor-patient relationship, fostering a more empathetic and supportive interaction. Patients are more likely to feel heard and understood, which can be particularly beneficial in uncovering underlying issues.

4. **Cultivating Compassion**: Mindfulness encourages a compassionate attitude toward oneself and others. Doctors can use mindfulness to develop a greater sense of empathy and compassion for their patients, especially those with complex needs or difficult behaviors. This can help in managing the emotional toll of such consultations and in approaching patients with a more open and caring mindset.

5. **Embracing Uncertainty**: Mindfulness teaches acceptance of the present moment, including its uncertainties and challenges. Doctors can use this principle to acknowledge and accept the inherent uncertainties in medicine and patient care. This acceptance can reduce anxiety about not having all the answers and foster a more collaborative approach with patients.

6. **Managing Emotional Responses**: Mindfulness helps in recognizing and regulating emotional responses. Doctors can practice mindfulness to remain calm and composed during difficult consultations, preventing reactive behaviors and promoting more thoughtful and effective communication.

7. **Organizational Implementation**: At an organizational level, mindfulness can be promoted through workshops, training programs, and the creation of mindfulness-based support groups. Encouraging a culture of mindfulness within healthcare settings can provide doctors with regular opportunities to practice and benefit from mindfulness techniques.

### Practical Mindfulness Techniques for Doctors

- **Mindful Breathing**: Taking a few moments before or during a consultation to focus on the breath can help doctors center themselves and approach the situation with a calm and clear mind.
- **Body Scan**: A quick body scan can help doctors become aware of any physical tension they might be holding and consciously release it, promoting relaxation.
- **Mindful Listening**: Practicing active, non-judgmental listening with patients to fully understand their concerns without immediately jumping to solutions or judgments.
- **Gratitude Practice**: Reflecting on positive aspects of their work and patient interactions can help doctors maintain a positive outlook and reduce feelings of frustration.

By integrating mindfulness into their daily practice, doctors can enhance their emotional resilience, improve patient interactions, and find greater satisfaction and meaning in their work, transforming challenging consultations into opportunities for connection and growth.

 

I think you should publish it as a priority. High time everyone realised that how the doctor feels is what matters.

 

Does anyone ever discuss how to cope with the heartsink feelings of patients when they realise the doctor or nurse they are talking to doesn't believe a word the patient says?

 

Emphasize that this is normal CBT, and that it's for the doctor, not the patients.

 

What beautiful irony this is! You really need to publish somewhere.

 

The irony of on another thread trying to explain how commissioning boards have GPs as staff apparently in order to be able to spot gaps in provision. Vs the guidance sent to them [partners who’ve learned little about the condition and are already incredibly busy] directly in the past and probably incentives to lump and dump

one issue that struck me has been about how someone managed to frame issues created by those running the service and suggesting these things that don’t work and so lead to patients needing more appointments getting away with suggesting to GPs their life is so hard because of those people (who are badly served not bad patients). So on a bad day it’s too easy to fall into that fallacy it’s the patient that’s the problem and not the people who created it causing a problem to the patient.

how about sorting that framing ?

and de-framing those who caused the money wastage on things that didn’t work but were sold as ‘cheap at any price’ based on claims ‘these patients have loads of appointments’ from being heroes for ‘offering to deal with them’. But people who failed and delivered things that aren’t effective at great cost to the service and patient getting iller.

so we don’t have the Einstein Groundhog Day if making the same mistake and wondering why it keeps not working or worse assuming ‘it’s the bastards not wanting to get better’

you know … in a shorter phrase used in other contexts: follow the money [and blame that if it didn’t work]

I don’t think it would need any of these but by but if commissioning just started funding some regional clinics that took a biomed and scientific approach so had a chance of documenting what works and prognoses and could be a base for research that wasn’t just a gravy train or re-iteration. ?

 

I am not quite following (ok did have a g&t which is equivalent to at least 2.5 g&t given my alcohol tolerance) is there any subtext in this?

 

I hope you are enjoying it

I meant that the issue is that the problem of there being no sufficient clinics to study the condition (and be able. To give advice on what works and prognoses and do research) got ‘reframed’ to the problem being the patient.

Instead of being seen as the ones who are let down by the system (which could do better to have a structure that might ever lead to finding treatments) they just framed it to suggest WE ARE the problem. And they on a busy day we will turn up and be big time sucks … but that we shouldn’t be there because we only THINK it’s medical. So poor GPs being overwhelmed because of having to deal with ‘time wasters’

heart sink might be supposed to mean ‘nothing I can do’ but then it was ‘nothing I can offer’ which then became with the sales pitch suggesting me/cfs patients take up loads of appointments and are really difficult and CBT is ‘the treatment’ which would work if they tried hard enough the idea of ‘problem patient’. And a new kind who ‘just doesn’t want to do what works’ and ‘won’t get better’.

for a GP who is exhausted with a lot of other ‘deserving patients’ the irony is that the GPs who are part of commissioning so could be saying a biomedical clinic is needed have been led to reframe things as ‘it’s patients like this that mean I’m so busy , wasting my time’

If only it was the right people who were heard by this group and could say ‘a regional clinic could learn the right advice to manage these and start proper research’ ie there’s a need, it’s been pitched to them to see us a problem patients who should be sent to somewhere that doesn’t work

GPs are at best taught CBT ‘helps people cope’ so think if we keep coming back we just haven’t tried enough with the GET and can’t cope so ‘need more therapy’. Which is in itself just a framing.

the tricky thing is once you’ve co-opted someone to commission something on false promises of ‘it saving money’ then those people themselves can’t analyse that independently often because they made that decision, staked their own reputation on that, and it not being effective reflects on them so….

 

That yet another doctor who not only cannot help but still thinks they can. Doctors can support us, but they will not cure us until we have an actual cure.

 

I definitely empathize with doctors who can't help their patients because treatments are not available or because circumstances mean the patient can't take care of themself. I'm pretty my problems have made doctors feel frustrated at times, not just with ME but several other things that lacked obvious cures (one of them was sensitivity in an apparently healthy tooth).