• DOI:10.1093/occmed/kqt085
• Corpus ID: 18992341

The heartsink consultation in occupational health practice.

@article{Nimmo2013TheHC,
  title={The heartsink consultation in occupational health practice.},
  author={Steven Nimmo},
  journal={Occupational medicine},
  year={2013},
  volume={63 6},
  pages={
          390-2
        }
}

• Steven Nimmo
• Published 1 September 2013
• Medicine, Psychology
• Occupational medicine

Editorial the heartsink consultation in occupational health practice The term 'heartsink patient' was first used by O'Dowd in 1988 to describe patients who engender a feeling of intense dysphoria in doctors. Terms used to describe that dysphoria include 'exasperate', 'overwhelm', 'anger', 'inadequacy' and 'frustration'. While these patients present with a range of diagnoses and socio-demographic factors, the common threads are frequent attendance, dissatisfaction with and multiple demands made of health services, and the feelings of helplessness and defeat that they engender in health care professionals [1]. The heart-sink concept was first described by Groves some 10 years earlier in his paper on the 'hateful' patients that doctors most dread [2]. He described four groups of patients that evoke aversion, fear, despair and even malice; dependent clingers, entitled demanders, manipulative help-rejecters and self-destructive deniers (Figure 1). Groves recognized that the feelings that heartsink patients engender in doctors may be important clinical indicators of the patient's own psychological state. It has been estimated that each UK general practitioner (GP) has a median of six heartsink patients, with a range of 1–50 [3]. Further, ~10–20% of patient encounters are described as 'difficult [4]'. Difficult interactions result in two to three times higher investigation and referral rates [5]. This is therefore a common problem with significant health care cost implications. A number of patient factors associated with heartsinks have been identified, including dysfunctional family dynamics, medical complexity, medical family connections , differences in culture and health beliefs, disadvantage and deprivation, manipulative or punitive behaviour towards the doctor and keeping secrets [6]. Other factors include somatizing illness, personality disorder and major psychopathology [4]. Most heartsinks have several risk factors. In one study, more than half of the variance in the number of heartsinks on each doctor's list could be explained by doctor factors, including greater perceived workload, lower job satisfaction, lack of training in counselling and/or communication skills and lack of appropriate postgraduate qualifications [7]. One possible explanation for this is that heartsink patients are attracted to doctors with those characteristics. However, the heartsink phenomenon is likely to be associated with both doctor and patient factors and is a function of the doctor–patient interaction. Ridd et al. identified four main elements in the doc-tor–patient relationship: knowledge, trust, loyalty and regard [8]. These are developed over time as a result of continuing longitudinal care and patient consultation experience. And each element depends on the patient's opinion …