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Hamish Wilson
Clinical care is usually straightforward: most patients improve and the goals of being a health professional seem achievable. Sometimes however, it is not so easy; a doctor or nurse in any branch of medical practice may experience quite marked difficulties with a particular patient. Various terms have been used to describe these patients such as 'difficult', 'heartsink', 'problem', or even 'hateful'--but these terms obscure a range of underlying medical conditions including chronic pain, personality disorder, somatisation, and incurable suffering.
It is likely these labels are a reflection of doctors' emotional responses to patients; negative feelings may start with simple dislike or minor annoyance, but can progress to frustration, exasperation, hopelessness, sadness, and anger.
In this context, Schwenk et al noted it is the physician-patient relationship that is the underlying issue, rather than specific characteristics of the individual patient.1 However, it is uncommon for doctors to view their 'difficult' patients as illustrative of a problem in their relationship with a patient; there are relatively few doctors who explore their personal reactions to patients in a deliberate way.
This article proposes that 'difficult' patients can be superb triggers for learning about important issues in modern medicine: awareness of self within the doctor-patient relationship, professional maintenance, models of health care. Various activities in reflective practice are proposed as a method of learning about these issues.
Background
In the UK, O'Dowd initiated discussion of such patients in 1988,2 coining the term 'heartsink' to describe intuitive feelings of impending doom or helplessness when certain names appear in the appointment book. There have been several useful articles in the general practice literature since O'Dowd, which have focused on contributing characteristics of the doctor3 as well as helpful approaches for practitioners.4 In 1994, Norton and Smith identified various issues in 'the transaction' between doctor and patient,5 while an excellent review of the 'heartsink' phenomenon came from Clarke and Croft.6
The overall impression from the literature is that 'difficult' patients consume considerable time and resources, receive many unnecessary investigations, can be litigious, and can cause their doctors considerable anguish. However, rather than blaming the patient, it is helpful to review some of the tacit or unconscious expectations of the modern practitioner.
The assumptions of modern medical practice
Ostensibly, students enter medicine...