‘Heartsink’ patients in general practice

Dr Andrew Moscrop has carried out an interesting analysis of the impact of my paper on heartsink patients in general practice published 23 years ago.1 I was a young GP when I started the lunchtime management meetings on heartsink patients in the practice, without any intent of it ever being published as a paper and having the impact that it has had. I have been aware of its unselfconscious use, particularly among practising clinicians, as they often use the term in discussion or in presentations to colleagues. I have also been aware that it has been controversial among my academic colleagues who, like me, find it somewhat politically incorrect and difficult to research.

I have seen articles on ‘heartlift patients’ designed to counteract the perceived negativity of the heartsink phenomenon. I have never felt the need to defend or explain, as it is what it is, and I have kept my distance from it. Since the recent BJGP paper, colleagues in Ireland and the UK have expressed surprise to me that the term had a descriptive origin as it has been part of the unreferenced clinical vernacular for so long.

When we originally discussed heartsink patients in the practice in 1982, it was noticeable that the discussions were quite positive and converted a sometimes very negative situation into a more purposeful if authoritarian one. The study contains several weaknesses, of course, and, despite the prompt acceptance of the paper by the BMJ, I developed anxieties about it and considered withdrawing the paper. My most pressing anxiety at the time was that it was self-disclosing. The manuscript accepted by the BMJ had a number of case descriptions that they agreed to remove from the published paper. Rather amazingly, no one thought of seeking ethical approval at the time.

Some think it may be more useful to talk of heartsink relationships rather than heartsink patients. This sanitises the term and moves the focus on to a relationship that means the heartsink feelings are shared between the patient and the doctor. We don't know if this is the case.

As a senior GP now, I recognise the self-sacrificial nature of practice wherein a GP continues to look after a heartsink patient, year in and year out, despite the feelings engendered. I haven't used the term for many years but I still experience the phenomenon after 32 years in practice, albeit much less frequently. Having a vocational training scheme in this academic department, I notice that each year one of our GP-registrars presents a case of a heartsink patient at our grand rounds. I view it as a socialisation process — as a step made by young doctors entering the world of general practice.

The heartsink paper reflected the rough and tumble of clinical life in a way that has resonated with doctors and others for years now. Such reflections on practice still occur but often as humorous opinion pieces by medical writers based on random experiences. There is a continuing need for clinicians to reflect on their clinical experience in a systematic way that provides useful insights that lead to better doctor–patient understanding.

• © British Journal of General Practice, January 2011