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What is wrong with “heart sink patients”?

Melissa Sweet, health journalist and Croakey moderator, writes:

I suffered an adverse reaction at the Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference in Adelaide this week. It happened when one speaker casually referred to “heart sink patients”.

It’s not as if I hadn’t heard the term before. Anyone who regularly reads the medical mags will know that doctors often use this term to refer to patients who make their hearts sink. There are even guides to help doctors deal with heart sink patients.

Sadly, I am not the sort of person who can quickly unpick my reactions on the spot and provide immediate, useful analysis. So I went away and brooded: why do I find this term, and its casual use, so grating?

Here are a few thoughts:

• It’s generally used to refer to patients that doctors regard as “difficult”, whether because of their health problems (think mental health, drug and alcohol, complex or insoluble) or their personalities (think demanding, complaining or – another medical term I detest – “non compliant”).

• Yet these patients are among those most in need of compassion and care that is sensitive to their needs and situations. Framing them as undesirable patients only helps to reinforce the inverse care law so wisely described by Julian Tudor Hart some decades ago. This law holds that “the availability of good medical care tends to vary inversely with the need of the population served”.

When heart sink patients is a term so widely used, it’s not surprising that it is so difficult to recruit doctors and other health professionals to work in demanding but needy areas like mental health, Indigenous health, and the poorer parts of the country/health system.

So here starts my campaign to find another term for “heart sink” patients. “Needy” perhaps, or what about “deserving”?

Would health professionals and services feel more motivated to try to help patients if they thought of them as “deserving” rather than “heart sink” types?

I somehow doubt this little campaign will find wings, but if it makes even one or two people stop and think about the words they use, it will be worth it. Words are so powerful, after all, in influencing how we perceive others and engage with them.

Comments 10

  1. Miriam Lyons says:

    Hmm, how about ‘underserved’? ‘Deserving’ is true, but might not effectively convey what you’re looking for given the word’s history in the context of ‘the deserving poor’. If a patient is underserved, it implies they need & deserve better service. Just a thought.

  2. Croakey says:

    Good suggestion. It’s probably helpful to do away the moral overtones of “deserving”.

  3. Boofy says:

    I’m not sure I agree. I think that ‘heart sink’ is an accurate reflection of how clinicians feel about some patients. They tend to be the very high need, and difficult to treat people – people who don’t engage, or who sabotage treatment.

    Of course they need help, but recognising that there is a group of people who cause a clinicians heart to sink is a lot better than not recognising it. At least the clinician can be reflective, address their biases and negative thoughts and work for the client. Being unaware of negative thoughts is more likely to lead to overt hostility, barring from services and a complete lack of understanding. At least people are asking ‘why does this patient make my heart sink’, and in answering why, will be able to assist the patient with the answer.

  4. Ian Haywood says:

    The central concept of “heartsink patient” refers to the doctor’s emotional reaction, namely of frustration or despondency about the patient’s lack of recovery. I don’t think ‘underserved’ is useful as there is little point trying to deny the emotion (I’m not saying there isn’t a better term than ‘heartsink’, just offhand I can’t think of one). More to the point, one’s heart can sink and still provide the necessary care. The purpose of talking about heartsink patients acknowledge the emotion, acknowledge it’s origin in the clinician (don’t tell me only doctors have heartsink patients!), and so not the patient’s fault or problem, and then work out what to do about it.

  5. Scooter Zebrowski says:

    I am a doctor, so here is my disclosure of bias up front. Doctors are only human. Sometimes they express human emotions in their communications with colleagues, even to their spouses. Did the doctor say to the patient: “You are a Heart-Sink patient” ? No. If he did, he should be referred to the impaired physician programme. The day political correctness becomes a priority, doctors will have lost all their empathy, emotions and…humanity. If they are not sent to re-education camps by fanaticists.

    Don’t journalists, politicians and lobby groups disempower doctors further, if that is possible, or medicine will be relegated to people you will definitely NOT want to see when sick. Capish?

  6. Scooter Zebrowski says:

    I am a doctor, so here is my disclosure of bias up front. Doctors are only human. Sometimes they express human emotions in their communications with colleagues, even to their spouses. Did the doctor say to the patient: “You are a Heart-Sink patient” ? No. If he did, he should be referred to the impaired physician programme. The day political correctness becomes a priority, doctors will have lost all their empathy, emotions and…humanity. If they are not sent to re-education camps by fanatics.

    Don’t let journalists, politicians and lobby groups disempower doctors further, if that is possible, or medicine will be relegated to people you will definitely NOT want to see when sick. Capish?

  7. Larry Hermann says:

    Very good point Melissa.

    I’m a practicing psychiatrist and it makes me cringe to hear psychiatrists would use such a term. (I’ve never heard it before by the way)

    What I have heard for years is the term ‘worried well’ which i think is similarly demeaning and invalidating of patients’ struggles.

    regards,

    Larry

  8. Croakey says:

    Sydney psychiatrist Chris Ryan has sent in the following comment:

    Heart sink patient: A patient who, through no fault of their own, will require a great deal of care and attention but who seems unlikely to benefit from same.

    Despite Melissa’s long association with the medical profession this is a term she is obviously yet to assimilate. It is a term only used by doctors in conversation with other doctors. Melissa was an invited guest to medical conference.

    The term does not, or at least is not meant to, denigrate the patient at all. Instead, it acknowledges the understandable, but unhelpful reaction of the doctor. It is vital that we doctors can identify and label our reactions to some patients so that we can ensure that we do not allow those reactions to get in the way of the care we provide.

    It is implicit in the term “heart sink patient”, that the patient is both “deserving” and “needing”. It is also implicit in the term that it doesn’t matter how frustrated I am, I must still provide the best care possible. My frustrations are my problem, not my (heart sink) patient’s.

  9. remotegp says:

    Melissa: “Heartsink patient” is a very different term to “non-compliant”. As stated above the “heartsink” refers to the reaction in the doctor. What matters is how doctors deals with that emotion – whether they own it and deal with it, or project it back onto the patients and blame them.
    “Non-compliant” is a value judgement about the patient, and I agree it is demeaning to the patient as, like referring to a patient who leaves hospital against advice as “absconding”, it is a one-sided authoritarian view of a situation where the assumption is that the doctor knows what is best for the patient.
    We are all human beings with our own set of emotional reactions. Doctors get sad, angry, happy and fearful just like everyone else. Not all of us react to the same patients in the same way. My job involves me with many patients others would find to be heartsinks, who I find interesting and want to engage with. And those who I find heartsinks, others will have no reaction to.
    We should celebrate the fact that this idea has spread from psychotherapists and GPs to the rest of our profession. If all doctors have the insight to recognise their own emotional reactions to patients, and learn how to work around these so that patients do not suffer for them, then everybody gains.

  10. Dr Danko says:

    Another doctor here.
    For me, the term “heart sink” has nothing to do with neediness or deservedness. It is actually the opposite of what you think. Indeed, for me it is generally well educated well off middle class neurotic people who give me the most heart sink. In fact, it was one of the reasons I went from practicing in an area of high socioeconomics to a much lower one, and I am much happier!

    For me, heartsink patients are those who don’t need a thing, but their neurosis or exaggerated sense of deservedness take my time away from poorer and sicker folk who actually need me and who I can actually help.

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