Relationships with patients

The problem with labelling a patient “heartsink” is that not only is it an offensive term, it can blind clinical judgment

Difficult or “heartsink” patients, so called because of the literal feeling a doctor gets upon realising they are next on the surgery list, are often the result of a doctor’s emotional response to a difficult situation. Heartsinks may be frequent attenders, have medically unexplained physical symptoms, or may consistently aim to prolong the consultation for as long as possible.

The problem with labelling a patient “heartsink” is that not only is it an offensive term, it can blind clinical judgment and can cause a doctor to underestimate the severity of physical symptoms.

In any practice, there will be patients with whom you have a challenging relationship. Some authors have attempted to classify these patients:

• Patients who make frequent visits with seemingly unlimited needs often have low self-esteem and decision-making capacity. This is the most commonly seen challenging patient.
• Highly demanding patients who use intimidation and denigration to create feelings of guilt.
• Pessimistic, long-suffering patients who ask for help but are convinced that nothing can be done.
• Patients who don’t comply with treatment, whether through their own negligence, a self-destructive character or another reason.
• Patients who try to manipulate your feelings by flattery (see also “The amorous advance”, below).
• Patients with multiple symptoms which are hard to explain. “Somatisers” may have underlying psychosocial distress.

Attention should be paid to improving the relationship, perhaps by trying to understand the underlying reasons for the patient’s problems

It is important to have strategies for dealing with challenging patients. These might include:

Communication skills – some suggest that challenging patients reflect a breakdown in the relationship between doctor and patient. There is no point in ascribing blame to the patient – instead attention should be paid to improving the relationship, perhaps by trying to understand the underlying reasons for the patient’s problems.

Negotiation and agreement – setting clear goals and limits for the patient – for example, outlining when a consultation is, and is not, acceptable.

Sharing – share the problem with colleagues and come up with approaches together. Remember that it is important not to pigeonhole these patients, for the following reasons:

• It may lead you to miss something important in their presentation (see the case study “Frequent attenders”). Always put yourself in a position to make a proper clinical judgment about the patient.
• If a patient asks to look at their records, finding inappropriate labels such as “difficult” or even “heartsink” will only serve to make the relationship worse.

MPS Educational Services runs Mastering Difficult Interactions with Patients, a workshop that provides techniques on how to handle difficult patients effectively and how to manage your own internal response.

More information >>

The amorous advance

Drawing the boundaries between being friendly with patients, and their mistaking this for something more, can be difficult. Some patients may use their perceived friendship with you to gain advantage, or others may be genuinely attracted to you. There are a couple of things to remember:

• If approaches are unwanted and sustained, then this is harassment and you should take it seriously, and discuss it with colleagues and your trainer. Arrange for care of the patient to be transferred to a colleague.
• The GMC, in Good Medical Practice, states: “You must not use your professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them.”

Removing patients from lists

Patients should have received a warning in the last 12 months before being removed from a list, unless in exceptional circumstances

The steps a practice must take when removing a patient are clearly set out. Your local commissioning body may well have a policy on the issue. Where the relationship between doctor and patient has irrevocably broken down, the practice should have taken steps to try and restore it, for example by arranging a meeting with a patient.

Patients should have received a warning in the last 12 months before being removed from a list, unless in exceptional circumstances, where a warning might be harmful to the physical or mental health of the patient or put the safety of practice staff at risk.

If GPs remove violent patients from their list, the commissioning body then has a responsibility to arrange treatment of these patients in a safe location. Violent patients, or those who make others in the practice fear for their safety, can be removed with immediate effect, but the police must be involved.