In 1988 Tom O’Dowd first coined the word “heart sink” to describe the feeling a doctor has when they anticipate a challenging patient consultation. This heart sink feeling is a block to providing continuity of care for some doctors. However, providing continuity for a patient with multiple problems is more efficient, and saves time, as well as reducing morbidity, mortality and rates of admission. Techniques to minimise or remove this feeling are needed and are covered below.
The heart sink feeling doctors’ can experience has a disproportionate effect on performance during both the relevant consultation and subsequent ones. It can contribute to burnout, dissatisfaction and workforce pressures. Having the skills to overcome this can make a substantial difference to each GP. Early identification, discussion with colleagues and planning as a practice team can help.
Consider using longer consultations, either occasionally or using a booking message for every appointment. Short consultations put pressure on the doctor and patient to get everything covered quickly. This risks even greater misunderstanding and mistakes.
It is important to have good records with “clear problem lists” which include an indication of previous treatments attempted and their degree of success. The aim is to minimise covering the same issues repeatedly and redoing unnecessary investigations. Building on from previous consultations rather than starting from scratch once again.
Use of a “doctor-patient contract” can help clarify what both the doctor and patient see as appropriate behaviour. Often it is just a letter and it is uncommon to end up with a mutually signed agreement. It is about being focused, clear and specific about the issues and boundaries. Something to refer back to when issues recur.
“Shared care plans” are a softer summary of the next steps and what has already been done. they can include indications for review and what does constitute an emergency.
Look at appropriate times to have contact. This is likely to be central to any contract or agreement. It is unhelpful to deal with issues as an emergency when the GP is busy with multiple other patients and will not be in an appropriate mindset. If safe it can wait.
If language is an issue use translators and/or hearing support aids. Speech to text apps and translation apps can help.
It is crucial to have a lead doctor as a focal point to ensure a consistent approach. This does not mean they have to see the patient all the time, but it stops confusion due to variation if response to patient requests. To share the load consider a “pairing of doctors” and ways to achieve team co-ordination of approach.
Using the “same song sheet” and maintain a consistent approach across all staff so that patients understand what is expected and the boundaries that exist.
The heart sink feeling is only in the doctor and so fully in the control of the doctor, irrespective of the patient. It is your perception of the problem which is important. A positive perception helps you and the patient. A negative perception will weigh you down and can only worsen the consultation you provide.
“Reframing” is about changing the way you think. You may have negative connotations about the patient in your mind so think about the opposite and whether these are more appropriate. Sometimes called negative automated thoughts they can be converted to positive automated thoughts.
“Taking the patient’s viewpoint” may help you. Imagine you are them, sitting in front of you and how they would think about the situation.
It really helps to know their “background and social history”. What their parents did, where they were born, what happened as they grew up. You then think of them more as a person and understand some of the reasons for the way they may be acting. Instead of becoming a problem they become a person who you know and appreciate more. You develop more empathy and will often find your attitude changes completely.
Another approach is to “helicopter” or view from afar. Look down upon yourself and the patient in an objective way to see what is happening between you both. Could things be done differently. What is going through their minds as they sit there with you.
Words to a GP are like a scalpel to the surgeon. Words give you control of the consultation direction and timing, but the skill is allowing the patient ownership of the content so that you get as near to the bottom of the issue as you can.
Consider who is responsible for the patients choice and actions. As a doctor it may feel that they want you to decide for them and when it does not work the pressure is on the doctor. Offering all options and shifting the locus of responsibility to the patient can help along with motivational interviewing techniques to achieve this.
By negotiating the list early on you can prioritise which problem you deal with today and which is deferred. If you do this at the start then when you are asked about one more thing at the end it is easier to say you have run out of time. Hopefully you have also pulled the “one more thing” into the negotiated list at the beginning. This list should include all the patients issues and all the doctors as well. You are asking for them all, which might seem risky, but actually means every issue is considered briefly, listed and prioritised safely.
Agree to address one focused issue at a time and fully before going onto the next within the time you have and no more. Often this will have been covered before so refer back to what was done before to save time.
Take a step by step approach rather than trying to do all at once or feeling pressurised to do so. This is about staged consultations. The “makes use of time” and the natural fluctuation of symptoms and concerns. It is amazing how next time the symptoms are less of a worry or resolve.
Identify ICE early (ideas, concerns and expectations). What are they really hoping to achieve today? They may say “just to let you know and no more”. They may reveal the core reason for attending and allow you to address it early on. eg a test request that is inappropriate. Don’t be afraid to ask more to give you background then return to the difficult expectation armed with more information.
Use appropriate challenge when resistance to change or action is met. Lay out the “options” in full from no action to referral and ask the patient their preference. If none are acceptable leave them with the patient, writing them down to give a clear start point when the issue is revisited by the patient.
Make effective use of cues. These are statements that raise questions about the issue or open new avenues for discussion. Ask about them so you can decide if they are dead ends, or a new way to approach the issue.
Determine behaviour gains and losses. Are they looking for constant reassurance. Is a passive approach easier? Does the sick role help them in the home setting?
Make appropriate use of diagnostic labels for unexplained symptoms. Often people are looking for an answer when medicine does not have one. Knowing others have similar symptoms and a name attached to them is better than no answer at all.
If possible describe the joint physical and psychological impact of all illness, making it a general principle for everyone. “There is the effect of the physical body and the nerves or mind on every symptom in all people” “This is normal and I always work on both areas” This allows you to work on both fronts at once and to bring in counselling, social support or antidepressant type medication if need.
Do remember, support from relatives. Very often this can unlock progress so ask them to join or permission to call them. Relatives may encapsulate the problem in a couple of words that make you realise a way forward. “they are always like this” or “we usually….”. Having relatives onside to repeat the messages or go over the choices and options at home can be a great help.
And last of all practice techniques to end consultations when time runs out. Leaning forward, summarising, listing next steps, standing up, gently gesturing to the door, helpfully opening the door.
Challenging patients may drift around different doctors, but this wastes resources both in the practice and in the wider healthcare system with unnecessary investigation and associated morbidity. Techniques to handle consultations associated with heart sink feelings can improve the wellbeing of both the doctor and patient. At times it is possible to move from heart sink to success when key issues are identified.