I am sure we are all familiar with this situation. You see a patient's name in the appointment book and your heart sinks. You know that it will be a long, stressful appointment with no satisfactory outcome for either you or the patient. This is the 'heartsink' experience.
Heartsink patients share a number of characteristics. They are generally frequent attenders, also known as 'fat file' patients. An informal study asked optometrists to think of their most recent heartsink patient. None of the respondents reported any trouble bringing a heartsink patient to mind. The results showed that 83 per cent of the heartsinks discussed were female, and 94 per cent were over 40 years of age, 72 per cent were over 50 years of age. Although this was only a small sample (20 optometrists) it echoes the findings of Tomlin1 and others2 in general medicine. The only major difference being that they found in their studies that the majority of their heartsinks were also single, either widowed, separated or divorced.
We also asked the optometrists who responded to briefly describe how these heartsink patients made them feel. The responses we received included angry, frustrated, anxious and intimidated. A couple of practitioners even said that these patients made them want to give up practice or even wish that either they or the patient were dead.
Although he wasn't the first to describe the phenomenon, O'Dowd3 coined the term 'heartsink patient' and defined a heartsink patient as 'giving the doctor and staff a feeling of "heartsink" every time they consult.' It is important to note that it is not the patient who experiences the heartsink, it is the doctor and staff.
Practitioners who perceive themselves as having an increased workload and lower job satisfaction have also been shown to have a greater number of heartsink patients - as have practitioners with less experience and training.4
'Heartsink' describes our reaction to these patients, not the patient themselves. A patient who may be heartsink for one optometrist may be an enjoyable patient for another optometrist.
Groves, who called these patients 'hateful', described four types of problem personality:5
? The 'dependent clinger'. This patient is pathetically grateful for all the optometrist has done, but is desperate for reassurance and shows this by returning repeatedly with an array of symptoms
? The 'entitled demander'. This patient seek attention through intimidation and threats. He views the optometrist as a barrier to receiving services and complains when every request is not met. This patient evokes fear in the optometrist
? The 'manipulative help rejecter'. This patient returns frequently to tell the optometrist that the treatment is not working and looks for emotional support. If any symptom is relieved it is replaced by another. He makes the optometrist feel guilty and inadequate
? The 'self-destructive denier'. Although this patient may suffer from a serious condition, he makes no modification to his lifestyle and seems hell bent on defeating any attempt to help him. He can become profoundly dependent and seems to derive satisfaction from his own destruction. This patient can make you wish that he would just die and get it over with.
These attitudes may be easier to understand if we consider the patient's 'locus of control.' Locus of control refers to an individual's expectations of where control for subsequent events lies, or who is responsible for what. Internal controllers believe that their hard work and persistence will influence future results, whereas a external controllers believe the result will be the same regardless of what they do - the hand of fate.6 As with all things, it is not black and white and there are degrees within the locus of control. Wallston looked at these beliefs and how they influenced people's attitudes to their own personal health. He concluded that there were actually three states of control:7
? 'Internal control'. These people feel responsible for their own health. They are likely to take action to improve their health (jogging or gym membership) However, they are more likely to blame themselves if their health fails
? 'Powerful other'. These people believe that others are responsible for the state of their health, both good and bad. (If I do what the doctor tells me I will stay healthy. I only smoke because my friends make me.) These people are less likely to change their lifestyle to preserve their health but more likely to seek help from health professionals
? 'External control'. These individuals are least likely to take responsibility for their own health and tend to be fatalistic - 'I might be run over by a bus tomorrow'.
Heartsink patients threaten our professional and emotional well-being. These threats may be:8,9
? Threat to our professional identity. The majority of us will have entered the profession in order to help people. If we are unable to help someone this will threaten our raison d'être and leave us feeling frustrated
? Threat to our time management skills. These patients are demanding of time as well as emotional input and this will often mean that we will run late on subsequent appointments
? Threat to our confidence. We can feel out of control during the consultation. Patients can exercise control by the amount of information they choose to reveal and when they choose to reveal it
? Threat to our trust in the patient. For a satisfactory outcome there needs to be mutual trust between the optometrist and the patient and this can be eroded by the patient's behaviour
? Threat to our knowledge. These patients will attend with reams of information downloaded from the internet and will challenge or disbelieve some or all of what we tell them.
Other factors which can contribute to the heartsink experience include:
? The patient that reminds us of someone else. Subliminal reminders can affect how we react to a patient. Powerful feelings from our past can be triggered by a patient's mannerisms, attitudes or how he looks, sounds and smells
? Compassion fatigue which is a form of burnout. Figley defined burnout as 'physical, mental and emotional exhaustion caused by long-term involvement in emotionally demanding situations'. We enter our profession with a strong sense of wanting to care for others, to make a difference by helping and believing in the decency of people and our ability to make a difference. Burnout is a long, insidious process from which there is little chance of a full recovery. Symptoms are depression, boredom and loss of compassion. The contributing factors include professional isolation, ambiguous success, unreciprocated giving and failure to live up to one's own expectations.10 It is possible to adapt to burnout and continue to work by becoming less empathetic and more withdrawn. However, compassion fatigue is a sudden overwhelming feeling of helplessness and confusion, of being unable to effect a successful patient outcome. Fortunately, if addressed early enough there can be complete and rapid recovery11
? It is possible that a strong negative reaction to a patient in an otherwise caring and compassionate optometrist may reflect how that patient is feeling. We are simply mirroring his emotions. Try to identify the emotions that you are feeling and then put yourself in the patient's place. Developing empathy will help resolve this situation. Get to know your patient well and develop a good relationship.12
All of this focuses on the patient's characteristics, but what can we do? First it is important to take a good history and symptoms. The patient may be as frustrated as we are. The reason he keeps returning with the same symptoms may simply be that he feels we have not heard what he is saying. Taking a thorough history with frequent checks to confirm with the patient that you both agree on the important points reassures him we are taking him seriously and shows we are ready to act where necessary.
Even if we only saw the patient a couple of days previously, it is still important to take a history and symptoms. We cannot assume that he is returning with the same problem. If we do assume this it is likely to lead to a dysfunctional consultation, with no satisfactory outcome and the possibility of late arising concerns from the patient. We also need to make sure that the patient is a partner in the process and we need to validate his presence in the consulting room.9
Consider the psycho-social aspect of the problem. A relatively trivial clinical problem may be causing the patient distress, a self-limiting and resolving problem such as a sub-conjunctival haemorrhage can be a major problem to someone who is getting married that week.
If the notes are long and complex, summarise them. It may help to write them out and share them with the patient to see if the recurrent problem (for instance headaches) coincided with any key life events or activities. This can be taken a step further by asking the patient to keep a diary of symptoms and feelings which can then be reviewed. For a patient with multiple unresolved symptoms, ask him to write a problem list in order of importance. Remember that the clinical importance is not the same as the importance of the symptom to the patient, and it is these concerns that have brought him in to see you.
A brief but thorough examination of the patient is recommended as it reinforces the fact that you are taking his concerns seriously. If the patient feels he has been fobbed off or rushed through he will not comply to any treatment regime and will simply return.
Be explicit about what you and the practice can offer. Part of the heartsink experience appears to occur when patients do not automatically respect the normal boundaries of our expertise. As a result, we may be drawn beyond our normal boundaries in an attempt to help. Being taken out of our 'comfort zone' is never pleasant. Although this is well intentioned and aimed at helping the patient, it can actually increase patient disillusionment and decrease empathy.9
Frequent attenders
Ideally, we want to avoid this cycle starting in the first place. This can be achieved by educating the patient as to how they will know if the problem is better or worse and when he should return. For instance, when putting someone on a lid scrub regime, explain that the symptoms, greasy vision and watery eyes, may be worse to start with, but the patient needs to continue twice a day for a fortnight and only then if the problems are worse to return.13
If a pattern of frequent attendance has already been established, we need to lessen the patient's dependency. Encourage the patient to take responsibility for his own health. Canvass his ideas on his problem. Investigate his health beliefs and together agree a time until the next appointment and try to increase that time scale on each subsequent visit. Agree with the patient a limit to the number of times he can phone you between appointments. Explaining that it is not helpful to see the patient again before this time is also important.
One overlooked cause of frequent attendance is the optometrist. Over-caring optometrists can create dependency. We all need to feel wanted, and one way of achieving this is to ask the patient to return to see us frequently. Unfortunately, this dependency is created for the optometrist's benefit and not the patient's. It simply flatters our ego.1
If you are scheduling an appointment for a heartsink patient, book a time that suits you. Allow yourself time to prepare mentally for the meeting and give yourself time afterwards to collect your thoughts before seeing your next patient. Offering the first appointment on Monday morning or the last appointment on Friday before a weekend away might not be the best time.14
Consider a delayed response. If someone asks if you can see him now 'for a quick look', explain that it is not convenient and book a time that is. Similarly, if you have a patient on the phone, arrange a time that is convenient for you to phone back. This will break the cycle of the patient always getting what he wants when he wants it. Squeezing these 'extras' in increases your workload and stress.
Counter-productive strategies
Do not ignore the problem. It won't go away! In fact, it may become worse as the patient will be aware of the barriers that you are erecting.
Accusing the patient of being problematic is likely to provoke an angry response and arguments.12
Avoid telling the patient there is nothing wrong - this will cause your colleagues problems as it will lead to 'optometrist shopping'. The patient will try someone else until he finds an optometrist who agrees there is a problem.
Avoid unnecessary referral, it reinforces illness behaviour. 'All these investigations confirm that there is something wrong with me.' Hospitals have a 'disease-based' culture and failure to find a cause can lead to referral from one speciality to the next, repeating the cycle.15
Coping with heartsink
Despite the understanding and techniques that will allow us to minimise the heartsink experience, it is inevitable that we will still see some heartsink patients and we need to look at ways to minimise the impact they have on our own well-being.
Seeing heartsink patients can cause us psychological distress, and leave us physically and mentally exhausted. Strong emotions take time to subside and we need to avoid taking these with us as they can affect our next consultation. Take time to relax, share a joke with other members of staff, put the kettle on or even step outside for a breath of fresh air. It is a worthwhile investment of your time to ensure a smooth-running clinic.10
In the longer term we need to share our problems. Heartsinks can be damaging and we need to protect ourselves. This may be with a colleague, a mentor or a support group. This sharing of our burden allows us to reflect on the process and consider what we did well and how we can improve, as well as gain an understanding of the patient away from the highly charged atmosphere of the consulting room. Self-awareness is essential. Discovering why a patient is one of our heartsinks can reveal a lot about ourselves and indicate areas for professional and personal development.16
Practitioners may sometimes have to accept their powerlessness. This can be as simple as accepting that we cannot 'cure' everyone. It may mean having to redraw our own professional boundaries and expectations. Not all patients expect to be cured. Their expectation of the process may be less than our own. A patient's goal may just be to manage a condition rather than seeking a cure. Although it can be hard, we need to lower our expectations to meet those of the patient.9
Finally, we need to accept that there are some people with whom we will never develop the right chemistry. In this instance it is better to suggest that they see a colleague in the future. It isn't a reflection on your professionalism, so don't take it personally. ?
References
1 Tomlin J P. The profile of frequent attenders in a group general practice. Priory Medical Journals.
2 Mas GX, Cruz DJM, Fananas LN, Allue BA, Zamora CI, Vinas VR. Difficult patients in primary care: a quantative and qualitative study. Atencion Primaria, 2003.
3 O'Dowd TC. Five years of heartsink patients in general practice BMJ 1988.
4 Butler CC, Evans M. The heartsink revisited. British Journal of General Practice, 1999 March.
5 Groves JE. Taking care of the hateful patient. New England Journal of Medicine, 1951.
6 Banard P. Applying psychology to health. Hodder & Stoughton 1996.
7 Ogden J. Health Psychology OUP 2000.
8 Elder N, Tobias B. How respected family physicians manage difficult patient encounters. Journal Of the American Board of Family Medicine, 2006.
9 Mathers NJ, Gask L. Surviving the heartsink experience. Family practice, 1995.
10 Benson J, Magraith K. Compassion fatigue and burnout, Australian Family Physician, June 2005.
11 Pfifferling J-H, Gilley K. American Academy of Family Physicians 2000.
12 Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. American Family Physician, 2005.
13 McKee I. HeartsinksWhat can we do? The Foundation Years, 2007.
14 Tracy C. Surviving and thriving with difficult and demanding patients. BMJ Careers, 2004.
15 Mehay R. Dysfunctional Consultation Lecture Notes Bradford VTS Online Educational Resources.
16 Tan Y. The heartsink patient, The College Mirror, College of Family Physicians Singapore 2004.
? Andrew Millington is an optometrist practising in Chepstow