Every time a heart sinks, we search for survivors

Studies have consistently shown that clinicians experience up to 15% of patient encounters as “difficult.”  BMJ 1988, Tom O’Dowd MD; “they give the nurse and doctor a feeling of ‘heartsink”. They evoke an overwhelming mixture of exasperation, defeat, and sometimes plain dislike that causes the the heart to sink.”

Jennifer Edgoose MD in Rethinking the Difficult Patient Encounter Family Practice Management: July/August 2012  writes: “Heartsink may be a better term than “difficult”because it suggests that the problem may not be always be the patient as much as it is how we feel about the patient.”

Indeed, Hinchey in “A cohort Study Assessing Difficult Patient Encounters in a Walk-In Primary Care Clinic, Predictors and Outcomes” found in their Structural Equation Model that the most important single predictor of a difficult encounter was the clinician’s score on the Physician’s Belief Score.

Possibly much of the feelings of Heartsink occurs when the physician’s agenda takes priority to the patient’s needs. As when we expect that the patient should conform to our agenda at this time. We wish that all the cards dealt to us be easy decisions, but one in six or seven (15%) of the cards are not. That’s much better odds than playing poker.


What Heartsink needs in order to appear.

Various external factors that burden our hearts.

  • Heavier workload
  • Symptoms of depression and anxiety
  • Perfectionist tendencies
  • A desire to be liked
  • Lower psychosocial orientation
  • less experience
  • Suffering compassion fatigue

Heartsink is also associated with more than dissatisfaction, both for the physician, and the patient. Common physician responses to “difficult patient encounter” are: helplessness, frustration, stress, failure and burnout. The physicians who believe that they have a large number of difficult patients are 12 times more likely to experience burnout. Patients emerging from these encounters are less satisfied, have lower trust and a greater number of unmet expectations and are more likely to have worsening of their present symptom two weeks after the visit-encounter.



More on Heartsink

An upcoming post  explains how can we might avoid or lessen Heartsink when   consulting “difficult” patients.

Striving for aequanimitas,


John Mary Meagher


[i] Perceived Causes of Family Physicians’ Errors, John W. Ely, MD. MSPH; Wendy Levison, MD; Nancy C. Elder, MD, MSHP; Arch G. Mainous111, Ph.D and Daniel C. Vinson, MD, MHSP. The Journal of Family  Practice, Vol. 40, No.4(Apr), 1995


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