Treating ‘heart-sink’ patients in general practice

Evelyn Lewin

18/03/2021 3:54:29 PM

Almost every GP would know the feeling, but there are ways to manage it and improve the doctor–patient relationship.

Worried-looking GP
Experts say it is vital to treat ‘heart-sink’ patients with compassion, kindness and empathy.

When Associate Professor Vicki Kotsirilos first started working as a GP, there were some patients she dreaded seeing.
When she would come out of her consulting room and saw one of these patients in the waiting room, her whole demeanour changed.
‘I felt my heart sink, literally,’ she told newsGP.
Associate Professor Kotsirilos did not just dread these consultations, she also struggled during the appointments.
‘I did find those patients difficult,’ she said. ‘I was probably very short with them.’
The more anxious Associate Professor Kotsirilos became about seeing these patients, the more her frustration would build. She then felt like these patients walked away from consultations feeling disheartened.
Professor Dimity Pond told newsGP she has had similar experiences.
While she still occasionally has ‘heart-sink’ patients nowadays, Professor Pond struggled with this issue more when she first started practising as a GP.
‘I think part of it was I had big expectations of myself when I was a young doctor,’ she said.
‘I thought, “I’ve been to medical school. I passed. I should be able to manage everything”.’
Professor Pond often felt her heart sink when she knew she was about to see a patient who she did not feel she could help.
So, what is a ‘heart-sink’ patient?
‘It’s when we feel a sense of helplessness in the face of patients when they’re actually looking for psychological, social and spiritual answers to what we might think are not medical problems,’ Associate Professor Kotsirilos explained.
‘Despite them seeing many doctors and having many tests, they still come with problems, continued chronic health problems, and we get that sinking feeling of, “Am I really making a difference for them? Am I really helping?”.
‘We’re not sure where to go, where to move, how to help them.’
Professor Pond agrees that challenging patients are more likely to make a doctor’s heart sink.
She has also experienced this feeling when faced with patients who are demanding opioids, benzodiazepines or other medication.
‘They keep pressuring you and you’re trying to do your best by this person because they deserve primary healthcare even if they are dependent on a medication that you can’t give them,’ she said.
‘You know you’re in for a battle, and that’s really difficult.’

Despite both experts admitting to still occasionally feeling this way, they say there are ways to help manage these feelings.
Associate Professor Kotsirilos found reframing her attitude has helped enormously.
Instead of feeling her heart sink when she sees the name of such a patient on her list in the morning, she now cultivates an attitude of gratitude.
‘The fact that they’ve made an appointment is a privilege and we should be grateful to them,’ Associate Professor Kotsirilos said.
‘It’s important to value the fact that they’ve actually made an appointment with you and actually say to them, “Thank you for making this appointment with me today”.’
She says it is vital to embrace that attitude, even if she feels she is not helping a patient medically.
‘They’ve actually rebooked because they are gaining something from us,’ Associate Professor Kotsirilos said.
And yet, Professor Pond says feelings of helplessness are difficult to manage, which is why she often liaises with her colleagues. Because she works part time with a number of GPs who do the same, they often then share their patient load and manage heart-sink patients together.
The GPs check in with each other to see how they are coping with these patients.
‘It’s supportive,’ Professor Pond said. ‘There’s nothing like sharing a problem to make it more manageable, and that’s in a patient’s best interests as well.’

Associate Professor Kotsirilos struggled with ‘heart-sink’ patients early on in her career but has now reframed her way of thinking.

Associate Professor Kotsirilos says the skills demonstrated during an appointment with a heart-sink patient can also make a huge difference in how smoothly such consultations run.
She says showing ‘compassion, empathy and understanding’ is pivotal, and that she reflects upon her own feelings if she feels herself becoming frustrated.
‘When I get that heart-sink [feeling] I think, “Come on, Vicki. Look at them with kindness and empathy”,’ she said.
Booking longer consultations can also help, as it allows for adequate time to ‘make the patient feel what they are saying is important’, according to Associate Professor Kotsirilos.
‘The aim when they’re with us is to just be there with them and actively listen,’ she said.
‘During that time with that patient, bring in that sense of warmth, feeling welcomed, feeling that we’re listening to them, that sense of concern.
‘Be sensitive to their needs and situations and always remain respectful and kind.’
When Associate Professor Kotsirilos feels she has performed all the necessary investigations, referred a patient on as needed, and has exhausted treatment options, she is upfront with her patients.
‘[I’m] honest about my own limitations of my skills or knowledge,’ she said.
‘I say, “Look, I’m sorry, I’m not sure what we can do. You’ve had many tests, which is reassuring that there’s nothing major we can find.  I’m not sure what we can do further for this situation”.’
She then addresses lifestyle factors, telling patients ‘the science shows that when you focus on living a healthy lifestyle … people’s health can also improve’.
‘That way we start the conversation on that more holistic approach centred around their lives, so it’s patient-centred,’ she said.
Associate Professor Kotsirilos also tries to address a patient’s stressors and social history, and spends time helping with stress-management strategies. Through this process, she says, she usually develops a very good doctor–patient relationship.
‘Often we find they may be lonely, they’ve got no one to talk to and that’s why they’re coming back to us,’ she said.
It also helps to debrief with colleagues, says Professor Pond.
‘I think we could benefit from doing this more,’ she said.
She says seeking professional help with an outside source such as a psychologist can also help.
Associate Professor Kotsirilos says feelings of frustration and dread upon seeing patients may be a sign of poor self-care.
‘[As GPs, we need to] make sure we’re sleeping well, exercising and eating well,’ she said.
‘If we find patients are frazzling us or are too difficult, we need to check in on our own self-care [and ask ourselves questions such as], “Do I need more breaks? Do I need longer consultations?”
‘If we’ve got good health and develop good resilience, we also tolerate the more difficult patients.’
Re-evaluating workflow can also help.
‘Make sure you breathe and relax through the consultation and have breaks between patients,’ Associate Professor Kotsirilos said.
‘Before you bring in the next patient, psychologically let go of the last patient.’
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Dr Carli Westmore   19/03/2021 7:02:29 AM

Thanks for the article on heart sink patients. I think it really relevant in these very stressful COVID-19 pandemic times. Having only been in GPT for the past 13 months, I have watched an enormous increase in this phenomena around COVID. It’s nice to know that our very senior colleagues experience this too. I think as a reg, the added pressure of being under the microscope training, with direct feedback from these exact patients impacting upon your progress really magnifies this issue enormously & increase its impact upon new GPs significantly. A lot of, less than well (Doctor shopping - opiate seeking) patients have picked up on the fact that Reg’s are being assessed on what patients think of them, rather than how safe they are clinically & use this added pressure (to keep even the most demanding patients happy to avoid the extra scrutiny of our training bodies) as a tool to try to get what they want sadly. Definitely not all patients but it is becoming a real problem for young GPs.

Dr Andrew Keith Horwood   19/03/2021 9:50:45 AM

I really resonate with your words of wisdom on an approach to “heart-sink” patients and particularly the responsibility (response-ability) that we have as part of this person’s team to offer compassion and, with any luck, creativity. I think that many of these folk are unaccustomed to true friendship, meaning their default position is to complain and seek attention, rather than know how to genuinely ask for help. They ARE their bodies, rather than “I have a body but I’m not my body”.

Offering the sort of care you outline is absolutely vital for these folk – not just because it can lead to better health outcomes, but because it may be one of the few experiences of unconditional acceptance/love that they may have throughout their lives. That alone is good enough reason for our compassion.

Thanks again for your words

DrCameron   19/03/2021 11:21:05 AM

wise words indeed. i think it needs time and experience as a GP to achieve the level of consulting you describe. Instead of not wanting to see this particular patient, actually seeing them as a challenge to yourself and your skills to provide them with the care they need. I see it as next level.

Prof Max Kamien, AM   19/03/2021 12:17:40 PM

One 40 minute consult is usually more effective than 10 ten minute visits.

Dr Louise Marie Edwards   20/03/2021 8:04:37 AM

Great article ! I am in my 26th year of working as a GP and my experience is that, with the more years of life and work experience I have, as well choosing to 'equip' myself with professional development/courses ( last year it was doing RACGP focussed psychological skills training) , these days I don't find the "heart sink situations" nearly as daunting. Whilst there are always some difficult days, in many ways I find this type of work (complex and challenging patients) to be more interesting as my career progresses, in reflection, probably because difficulty is a catalyst for my learning and learning (which is about change for me) is my 'oxygen'.
The only downside is that the Medicare system does not pay commensurate with the true value of the long consultation, and as thus it doesn't support this valuable, patient-centred time in which a healthy therapeutic alliance is created and from which them stems better outcomes for the patient, as well as the health system budget.

Dr Melissa Ann Brown   21/03/2021 12:19:11 PM

I think it is also very important to realise when it is time to suggest a patient sees another GP. I have had to do this a small number of times, when I just couldn't get past my own feelings of annoyance, frustration, anger, and even resentment at certain issues. In this situation, a GP is doing their patient a grave disservice by continuing to see them. Duty of care takes precedence, and duty of care may mean no longer providing care. In these situations I felt enormous relief at referring them elsewhere.