1 Heartsink and difficult patientsSue Rendel
2 Definitions Different types of difficult patients Why are they important? What is the source of the problem? How to deal with heartsink and difficult patients.
3 Definitions “There are patients in every practice who give the doctor and staff a feeling of heartsink every time they consult. They evoke an overwhelming feeling of exasperation, defeat and sometimes plain dislike that causes the heart to sink when they consult.” O’Dowd 1988 BMJ Heartsink patient Difficult patient Dysfunctional consultation
4 The classic four types of difficult patients Grove 1978Dependent clingers – Repeated requests for attention, reassurance, urgent demands for explanation, affection and medication. Entitled demanders – Patients that exude an innate sense of deservedness; they use intimidation, devaluation, and guilt induction to place the doctor in the role of “the inexhaustible supply depot”. Manipulative help-rejecters – Patients who return to the surgery again and again, almost smugly satisfied to report that, once again, the treatment or regimen hasn’t worked. Their pessimism appears to increase in direct proportion to the doctor’s effort and enthusiasm. Self-destructive deniers – Appear to find their main pleasure in defeating the physician’s attempts to preserve their lives. This may represent a chronic form of suicidal behaviour.
5 D Colquhoun The never get betters Not one but twoThe medicosocially deprived The wicked manipulators The sad
6 Gerrard T and Riddell J Black Holes Family complexityPunitive behaviour Personal links to the doctors character Differences in culture and belief Disadvantage, poverty and deprivation Medical complexity Medical connections Wicked manipulative and playing games Secrets
7 Why are they important? Doctor factorsBecause they can generate negative emotions: Stress/anxiety Fear Anger Low Morale (Heart Sinks) Helplessness
8 Why are they important? 2 Patient reasons Societal reasonsBecause they can end up having unnecessary investigation and/or treatment A heart-sink patient is probably an unhappy patient (life, doctor, ill health, past negative experiences) My life as a heart-sink patient, BJGP vol Acknowledge lack of help, act on it and don’t just order more tests to get me out of the room Resource intensive Money Time
9 What is the source of the problem?The patient? The doctor? Doctor patient relationship? Societal forces?
10 Patient factors Unrecognised psychiatric disorders (eg, anxiety or depression) Undiagnosed physical illness Somatisation Alcoholism Borderline personality disorder Previous experience of poor or disappointing care Well-founded need for information or in-built critical approach to problems Egotistic elements and an excessively demanding attitude. Female>male Age >40 Single, widowed or divorced Marital/family problems May be very isolated Lower tolerance for minor illness Concomitant serious illness Experience of serious relationship dysfunction and rejection in early life
11 Doctor factors 1 Mathers et al BJGP June 199560 GPs from Sheffield area Structured interview and questionnaire Number of heart-sink patients 1 – 50 per list (FTE) 4 variables significant: Workload Job satisfaction Training in counselling/communication skills Post graduate training (MRCGP, MRCPsych)
12 Doctor factors 2 Strong assumptions as to how patients should behave and how medicine should be practised Narcissism or arrogant personality, convinced of their rectitude Poor communication skills, doctor centred fail to understand role of psychosocial factors Over patient-centred, needs to be liked by everyone, creates dependency. Cultural gaps that go unrecognised Lack of experience Stress or overwork. Both of the above may lead to over prescribing, investigating, referrals etc.
13 So what do you think? Do you have characteristics that might predispose to the doctor factors? How would you identify them?
14 Doctor patient relationshipParent, child, adult (Berne, Games People Play) Doctor and patient may be emotionally attached to each other Collusion, relationship might be filling a need in both co-dependency
15 Heathcare system factorsGrowing multicultural societies: communication problems and different or unrealistic expectations from doctors Increase of patient mistrust following high-profile cases Pressure to reduce the cost of care and increase physician productivity decreasing the amount of time for consultations Lack of continuity of care Easy access to wide-ranging, and sometimes confusing, information via modern technology
16 How to deal with difficult/heartsink patients.Steinmetz and Tabenkin The ‘difficult patient' as perceived by family physicians. Family Practice 2001; 18: 495–500. 15 board certified family physicians in Israel, long structured interview Empathy Non-judgemental listening, patience and tolerance. Direct approach, defining length of time and content in advance Referral, passing the buck? Recommend another doctor Humour Involve patient’s family Sharing doctors personal experience with patient
17 Another approach Successful GP Intervention with frequent attenders in primary care Bellon BJGP 2008 7H and T ( 7 hypotheses and team) GPs analysed their frequent attenders to identify the area in which the issue was likely to be (hypothesis) Biological, psychological, social, family, cultural, administrative- organisational, or related to the doctor–patient relationship. Then discussed with the team and generated a management plan.
18 Dependent clingers How to recognise them:frequent attendance for simple problems, reassurance, “pill for an ill”, ask for repeated Rx and services, ask for favours, flatter you to excess “only you can help me doctor”, refuses to see other GPs Feelings generated in GPs: how sad, exhaustion “sucked dry”, aversion and avoidance. May be GP fault for allowing/generating doctor dependency How to handle them: set boundaries and limits, eg number of consults a month, be in the driving seat, encourage self help and self coping, accept problem is theirs not yours, consistent and firm, recognise your own feelings and control them, housekeep
19 Entitled demanders How to recognise them:demanding or manipulative, want something “now”, instil a sense of fear, guilt or intimidation by devaluing the Dr. threaten with legal action, see doctor as barrier to what they are asking for, “if you don’t then be it on your head”, somatisers, personality disorders, can become aggressive think about personal safety. May have had longstanding psychosocial upset leading to abnormal illness behaviour Feelings generated in Drs: anger, resentment and fear How to handle them: with care, be pleasant and try to establish a rapport, try not to say no straight away, negotiate a management plan, if you do give in to wishes make it clear it is part of the management plan, always think about personal safety
20 Manipulative help-rejectersHow to recognise them: keep coming back to tell you the treatment was no good, despite this they keep coming back to you. They are doctor dependant. Same old story you can often guess before they sit down. They have preconceived ideas and may aim to seek an indissoluble relationship with doctor. What is the secondary gain from this behaviour, often comes from family and friends. Resolution of symptom with be replaced by another. “that will never work” “ Only Dr X can help me” Feelings generated in Drs: sense of hopelessness, inadequacy, dissatisfaction, overburdened ,frustration. How to handle them: set boundaries and limits, identify what the patient wants and set limits on what they can have, share the load, challenge patterns eg by agreeing with their views “ yes you are right that probably won’t help” consider delayed response.
21 Self Destructive DenierHow to Recognise them: usually feel they can’t control their life the doctor can. May have chronic illness but have remediable risk factors they can’t change. Want a miracle pill instead. Feelings generated in doctor: anger, frustration, resignation How to help them: explore their health belief structure and work out with them what it might take to change, encourage self help, get them to take ownership of the problem
22 Identify a patient you have seen that has engendered the “heartsink” or left you feeling anxious and frustrated Describe the patient to your colleague and try to work out between you where the issue is likely to be: Biological, psychological, social, family, cultural, administrative- organisational, or related to the doctor–patient relationship.
23 General management techniquesDiscuss your perceptions of the illness behaviour Discuss the patients methods of denial Be honest, but kind in your honesty Discuss your own feelings Start again with reviewing notes and taking a history include the family history Compile a life chart using significant events in physical and psychosocial areas Get the patient to keep a diary Implementing a holding strategy Learn to become a mirror not a sponge
24 Help outside the consultationAsk yourself what are the patient’s problems, why does she evoke the feelings she does in you, Recognise that the feelings generated in you might reflect the patient’s own feelings (countertransference) Recognise and accept that these feelings are normal Recognise that not all problems have solutions Video a consultation with a difficult patient( many are often keen to help you learn) Discuss the case with others and use groups like Balint groupsVideo a consultation with a difficult patient( many are often keen to help you learn)
25 Chew-Graham CA, May CR and Roland MOChew-Graham CA, May CR and Roland MO. The harmful consequences of elevating the doctor–patient relationship to be a primary goal of the general practice consultation. Family Practice 2004; 21: 229–231. We suggest that doctors have overestimated the importance of sustaining their relationships with some patients, when doing so only maintains incapacity. Communication skills training in medical schools and in training for general practice27 is rightly aimed at finding ways to improve the quality of doctor–patient interaction in ways that benefit the patient. However, clinicians need also to find strategies that permit them to recover their authority and to empower themselves in the circumstances and the types of patients that we describe herein.
26 And finally… What are you going to do differently as a result of this session?