Let’s leave “heartsink” behind
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6542 (Published 10 December 2015) Cite this as: BMJ 2015;351:h6542
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It is perhaps understandable that Simon Cocksedge does not wish to use negative or perjorative terms to describe his patients. Perhaps he wants entirely positive and encouraging relatonships. But 'Heartsink' describes how the doctor feels, NOT the patient. It was recognised by early psychotherapists that it is useful diagnostically and therapeutically to recognise this 'transference'. If the patient leaves you feeling hopeless, or angry, or helpless, it is useful first to recognise it, and secondly to explore why .. Indeed the same is true for feelings of upliftment, joy, etc. Denying or ignoring such feelings can lead to trouble. It also helps to consider what feelings you 'counter-transfer' in therapy, if as Simon says " doctors, as part of their training and development, need to understand the history and significance of this phenomenon, they also need to learn how to refer to difficulties in themselves and with patients, get to know them, and support or even challenge them as necessary."
Competing interests: No competing interests
I tend to disagree. Although very rare, there are distinct physiological changes associated with seeing certain names on a clinic list at least in hospital practice. Perhaps someone will create an app for detecting these changes!!
The switch in nomenclature from hateful to heartsink was welcome but I still think Grove's original classification has value.
Groves J. Taking care of the hateful patient. N Engl J Med 1978; 298:883-887
Competing interests: No competing interests
It's very rare for me to feel that a patient is 'heartsink' but whilst I agree with Simon Cocksedge that using such a word to label a patient probably isn't helpful, I think there's an element of denial or possibly political correctness in not recognising that it can describe just how you are feeling. If my heart sinks, it is because a patient keeps returning to me time after time despite the fact that I have felt unable to help them. I don't feel their seeing me is doing any good, and every time that makes me feel a failure. It's really a label about myself rather than the patient. Recognising how I feel is the first step to learning what I can do about it.
The value of the 'holding relationship' is huge and something we tend to underestimate, but somehow I don't think it will catch on as a term- it would sound incredibly creepy to anyone outside medicine!
For trainees and young doctors, I think it is important that there is a forum where they can express feelings about patients without any of the words being viewed as off-limits or somehow making you a less-good doctor. I suspect the 'current registrars' etc who were asked about this said what they felt was the right thing- I'm sure at that stage I would not have wanted to have admitted, even to myself, that I could think of a patient as heartsink. Small learning groups such as Young Practitioners, non principal groups or self directed learning groups have a vital role to play in allowing reactions to patients and situations to be explored honestly without judgement.
Yes, it would be nice not to have this negative expression, but it would be worse to pretend that we are always proud of our feelings.
Competing interests: No competing interests
Re: Let’s leave “heartsink” behind
We read Cocksedge’s personal view with interest, having recently completed a systematic review into this area ourselves. The idea of difficulty within the doctor-patient relationship is not a new phenomenon. Doctors are trained to provide care and treatment to patients in order to cure or improve their symptoms, yet it can be a struggle to to fulfill this responsibility. Difficulty ensues. This can be viewed as a complex interaction between many factors. The doctor is left feeling helpless or out of control, which may indeed be a reflection of the same emotions their patient is grappling with. This mismatch between wishes and what is possible can elicit troublesome and sometimes extreme behaviours in doctors. As far back as 1957 in The Ailment, Main (1) refers to ‘heroic surgical attack’ when doctors enthusiastically treat their patients to the point of harm.
One might think in reading this personal view, and indeed also from O’Dowd’s original work on ‘heartsink patients’, that these observations are made solely in the field of general practice. Of course, the concept of a difficult relationship between patients and their doctors is in fact widespread and well-recognised in areas as diverse as surgery and respiratory medicine and all fields between. Doctors, and patients, know the problem when they encounter it, but definition and measurement has itself proved difficult. We suggest that practical support measures should be actively and systematically encouraged. Well-established fora such as Balint groups (2) and Schwartz rounds (3), which may serve as useful outlets to discuss and arrive at strategies to help improve these difficult relationships for both the patients and doctors involved.
1. Main T; The Ailment; The British Journal of Medical Psychology; September 1957; 30 (3) 129-45
2. Van Roy K, Vanheule S, Inslegers R; Research on Balint Groups: A Literature Review; Patient Education and Counselling; June 2015; 98 (6) 685-94
3. Lown B, Manning CF; The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork and provider support; Academic Medicine; June 2010; 85 (6) 1073-81
Competing interests: No competing interests