Reframing the “heartsink” feeling can help doctors find a resolution
BMJ 2024; 385 doi: https://doi.org/10.1136/bmj.q1427 (Published 27 June 2024) Cite this as: BMJ 2024;385:q1427
Do you recognise that heavy sensation of feeling weighed down when you can’t see the way forward in a consultation with a patient? If the situation happens repeatedly, the feeling can become anticipatory and associated with just thinking about the scenario.
Described as “heartsink” by O’Dowd in 19881 after Ellis outlined it in 1986,2 this experience became widely known by the term “heartsink patient.” This phrase is a misnomer and has rightly had pushback. Labelling a patient with a negative term can be picked up by the patient and see doctor-patient interactions stall, leaving consultations stuck in an unhelpful loop. Furthermore, although the feeling may be associated with a particular patient presentation, the patient does not own it, their doctor does.3 It’s key for doctors to recognise their agency during these “heartsink” moments and that there are steps they can take to overcome the feeling.
The heartsink feeling is important to tackle as it can harm both the clinician and the patient. It contributes to stress, tiredness, frustration, anger, and burnout in the clinician.4 The clinician can become defensive and adopt social limiting strategies, ignoring other cues, curtailing discussion, and cutting consultations short. Or they can become more forceful and directive to try and induce change. These approaches can result in a patient’s passive acceptance of treatment, inappropriate interventions, and worse outcomes for the patient. There’s a risk of care bouncing between clinicians, the central problem remaining unresolved, inappropriate referrals, clinical errors, increased overall workload, and overuse of appointments.
Taking a step back
What can doctors do about this feeling? They can use it as a cue to step back and acknowledge that something is not going right in this consultation. Time is likely needed to review the case and to identify what is a repeat presentation that has been treated in the past, what is only partly resolved, and what is new. Looking at a patient’s records and then asking them to list their problems in order of importance will help to prioritise what should be tackled first.
A longer consultation is often helpful so that doctors can ask the patient about themselves, their past, and their family. Having a better understanding of what a patient faces as a person can offer fresh insight and help to restore empathy to the relationship. And assigning a patient to one doctor can be useful to build in some continuity of care. Continuity has been shown to avoid duplication of work, save resources, and reduce emergency admissions, and is associated with lower morbidity and mortality.5 Accepting responsibility for a patient’s overall care is important and may need wider discussion within the care team so that patients with complex problems are fairly allocated.
Doctors should also consider what it is that makes their “heart sink” in the consultation. Are there too many problems to cover in one consultation? Does the patient have an underlying concern, such as relationship problems or poor mental health, that is hard to untangle from their account of why they’ve come? Is this case outside their normal prescribing or approach? Is there a clash of beliefs or values?
Once doctors have worked out what underlies the feeling of frustration or dread, it is worth considering how to voice it within the consultation, so they can jointly plan how to manage that aspect better. For some doctors, it may be to openly acknowledge the uncertainty of medicine and life, or to accept that doctors do not know all the answers. Rarely, if the professional relationship is broken, shared care or transfer of care to another primary care setting may be required.
Wider organisational response
A proactive organisational response to the impact of heartsink consultations is to set up a “high intensity user service.” One example of this is a clinic initiated by Pier Health in North Somerset, which refers patients to social prescriber support alongside their named GP. Another example is a clinic led by a GP in Liverpool that specifically focuses on complex consultations. The organisation allows more time for each consultation and enables closer continuity of care by setting aside protected time for the doctor and team to review and discuss each case. A patient’s case is worked through with a holistic plan for tackling each problem, including any psychosocial needs. Learning from these clinics underscores the importance of providing support for GPs who are handling complex consultations.
Training and wider workplace conditions can influence doctors’ experience of the “heartsink” feeling. Studies have found that experienced GPs tend to have fewer heartsink consultations46 and might even view these patients as a challenge and an opportunity to look for a successful outcome. Doctors with longer working hours and a higher number of patients with psychosocial or substance misuse problems were more likely to report feeling frustrated with patients.6 Heartsink is also reported more in doctors with less training in communication skills and fewer postgraduate qualifications.4 Better training and less stressful working environments therefore seem to have a protective effect against doctors’ feelings of frustration.
The heartsink feeling can be minimised and can even become a glorious “heart-rise” feeling when doctors unlock a problem or create a way forward with their patients. Yet doctors can’t do this alone. More widespread educational and organisational support are needed to help doctors with complex cases that need time and headspace. It is also essential that increasing workload pressures are tackled nationally if we are to prevent doctors’ feelings of heartsink becoming burnout.
Acknowledgments
Mark Rickenbach will be speaking about this topic at the International Practitioner Health Summit 2024: The Wounded Healer, taking place on 27-28 June 2024.
Footnotes
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I was funded as a clinical adviser for the Health Foundation Continuity of care programme, on behalf of the RCGP, from 2019 to 2022. The clinical leads in this programme raised the issue of how best to handle heartsink consultations.
Provenance and peer review: Commissioned; not externally peer reviewed.