Heartsink patients: common types and how to handle them

I wonder whether the really tough consults ever stop haunting you.

A couple of months ago I decided I would stop seeing one of my patients, an in-sightless alcoholic, after she came in one morning drunk (though denied it) and belligerent. My every effort was met with a stream of abuse. My hands were shaking for about an hour after she left. I continue to dissect the visit even now, wondering what I could have done better. In remembering it, I relive the experience and notice anxiety stabbing in my chest.

I don’t think firing every patient you find difficult is the answer. The fact I fired this one I do see as something of a personal failure, but it was the obvious, easiest remedy.

In an emergency we are obligated to attend a patient and I would see this lady if she were having DTs (though I predict she will never stop drinking long enough to have them). However after a great deal of effort and empathy, countless admissions for detox and rehab, I concluded that she doesn’t want to change and there is too much secondary gain for her to ever want to change. Her untreated psychiatric issues can’t be addressed while she continues to drink and she refuses to see a therapist anyway.

Of course I feel guilty for ‘giving up’ on her (read: passing her back to the other doctor she sees at my practice), but on the other hand I doubt she would benefit from seeing me any more and every encounter would drain me, leaving me less able to care for my other patients.

Other doctors have categorised difficult patients- Murtagh does it well. (He also wrote about the subtypes of general practitioner in his famous text book, which is highly amusing).

I have been trying to narrow down the vast array of these tricky customers into neat boxes. See what you think:

The Drainers
They sap your energy- demanding everything of you emotionally but themselves are unreachable, unteachable or untreatable. You invest hours of time, heartfelt empathy and worry about them when you’re not at work. Despite this, they don’t improve.
Common reactions: despair, cynicism, emotional burnout, anger.
Suggestions: Get comfortable with the fact they are unlikely to change. Practice empathising without anxiety and personal distress. Offer them support. Learn motivational interviewing, which takes the pressure off you to ‘make them change’.

The Strainers
They threaten you- undermine your experience, deny your evidence, belittle your knowledge and worst of all, doubt your integrity. They want you to diagnose and treat or reassure regarding every symptom, but then don’t take your advice. They may demand certain investigations or treatments and get aggressive when you say it would be inappropriate for them.
Common reactions: losing your cool, getting defensive, reduction in quality of care (along with reduced ‘care-factor’) or conversely, practicing ‘defensive medicine’.
Suggestions: Lose your ego, debrief with colleagues. Remember your job is to provide the best medical advice but it is up to the patient whether to take it. Shrug it off and write good notes.

The Stressers
They challenge you medically- the undiagnosable mystery conditions, the treatment non-responders.
Common reactions: self-doubt, panic, frustration, beating yourself up both internally and in front of the patient.
Suggestions: Seek a second opinion early and often. Try to stay calm. Look at the evidence and weigh up the pros and cons of further tests and/or treatments. Discuss the case with some colleagues at a clinical meeting. Ring a specialist. Accept what you cannot change and what you cannot know.

A GP I admire in Dubbo came to assess me when I was a registrar. After each consult he asked ‘did you like that patient?’ and ‘why?’, or ‘why not?’

This is a useful thing to do for yourself, I find. Of course in recognising a problem it is not automatically solved, but awareness allows for adjustment of doctor behaviour. It takes two to tango. I’m not convinced it always takes two to make a bad consult, but the most determined, personality disordered patient can only wreak so much havoc in the heart of a truly zen doctor. This brings me to one of my general practice mantras. One of my GP heroes, unflappable in the face of tempests, inspired it. I often think to myself ‘be zen like Ken, be zen like Ken…’ Works a treat.

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