As HTML is the "programming" language of the future (!) I have been
learning it by converting my trainee tutorial textfiles to interlinked HTML
doocuments for browser viewing. Using something like hot dog, it doesn't
take very long (see below Rob Pearson's interesting mailing to GP-UK in HTML
format). I am linking this to a journal database of useful articles
downloaded from the internet for _truly_interactive_learning_ ;-)
Has anyone else tried this? Could we share? Any comments?
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<H4><IMG SRC="file:///c|/data/training/resource/txtfiles/1root/wcsicon.gif">Heartsink patients</H4>
Heartsink patients cause doctors anxiety and
stress. They account for 11% of average GP
workload. Most GP's have 20 30 patients on
their individual lists that they would label as
heartsink. Heartsink patients are not always
frequent attenders.
<P>
<UL>
<LH><STRONG>"Irritating" patients</STRONG> </LH>
<LI> take up as much time as possible in the surgery
<LI> produce legions of nebulous complaints all at once
<LI> undress as slowly as possible
<LI> want treatment for multitudinous children and relatives (without notes)
<LI> demand inappropriate certificates
<LI> do everything they possibly can to avoid leaving the consultation room
<LI> describe every treatment you give to them as 'no good'
<LI> assume that you are clairvoyant in respect of there hospital case
records & investigations
<LI> assume that you are clairvoyant in respect of other partners advice
and treatment
<LI> repeat the same life stories incessantly
<LI> think they are less well served than others in life
<LI> ask for inappropriate therapies
<LI> have children who run riot in the surgery
with no hint of parental control
<LI> throw "the useless" medications across the
consulting desk
<LI> casually swear during conversation
<LI> smell
<LI> demand treatment triggered by a TV advert
<LI> demand their "rights be fulfilled" before telling you the problem
<LI> are overfamiliar
<LI> lie
<LI> are happy to talk incessantly , but not listen
<LI> to a word you have to say
<LI> know you can't help but .................
</UL>
It has taken a long time for doctors to recognise that the problem
with some of their patients might be that they are just unlovable.
The standard medical textbooks fail to recognise that some patients
are exasperating. A series of negative feelings can be stimulated in
most doctors by demanding patients. James Groves, a psychiatrist
at Massachusetts General Hospital described in a classical paper
in 1981 four types of "HeartSinkers" :
<OL>
<LH></LH>
<LI><STRONG>The Dependant Clinger </STRONG>: full of thanks for
what is done, but desperate for reassurance at
every turn. They evoke aversion.<BR>
<STRONG> Read Code :</STRONG> E216 Dependant Personality
<LI><STRONG> The Entitled Demander </STRONG>: who has some
chronic illness, but is never satisfied with the
treatment given, always ungrateful he keeps
insisting that more be done and complains
bitterly if every request is not met. They evoke
fear.
<BR><STRONG> Read Code :</STRONG> No useful codes for this one as far as I can see.
<LI><STRONG>The Manipulative Help Rejecter :</STRONG> who
demands attention, but never takes any advice
or treatment given. They evoke guilt.<BR>
<STRONG> Read Code :</STRONG> E21yz<EM> manipulative personality</EM>
with 8I5 <EM>Care / help refused by patient</EM>
<LI><STRONG>The Self Destructive Denier :</STRONG> He is killing
himself slowly, usually from tobacco or alcohol,
but resolutely refuses to take any steps to
change his life. They can prompt malice.<BR>
<STRONG> Read Code :</STRONG><EM> E21y6 Masochistic personality disorder</EM>
mixed with Eu607<EM> Self defeating personality disorder</EM>
</OL>
The additional burden of having to disown these
unpleasant feelings makes errors in diagnosis
and treatment more likely to occur. The doctor
feels powerless to help when all investigations
prove negative, there is no clear diagnosis and
every suggestion made is rejected. This
conflicts with the caring self image created by
the doctor.
<P>
Patients rarely have any idea of the feelings
they generate in doctors. Doctors are unlikely
to confront patients and / or throw them off their
lists. Heartsink patients receive polypharmacy
for isolated symptoms (which may be
demanded and also rejected).<P>
<UL>
<LH><STRONG>Tips</STRONG> </LH>
</UL>
<LI><EM>Make or review the summary of the case.</EM>
This will demonstrate the behaviour pattern,
exclude major pathology, and help the
doctor feel more familiar and confident
through previous personal and colleague
failures !
<LI><EM>Rationing appointments</EM> helps the doctor
survive. Trying to find a clear diagnostic
solution in every consultation will ensure the
continuation of heartsink status. Offer
support within limits to try to improve the
doctor patient relationship.
<LI><EM>Give longer appointments</EM> occasionally,
giving time to allay fears and explain the
effects that medicines will achieve.
discuss difficult cases with colleagues :
understand the reactions that those patients
induce in you.
<LI><EM>If the patient has several nonspecific
complaints</EM>, then first deal with the
complaint that appears most treatable.
try not to refer a patient to a specialist too
quickly since they may view this as an
indication of the doctors frustration.
spell out the goals of treatment clearly and
the patients part in reaching them.
minimise medications so that mistakes in
prescribing are cut down.
<LI><EM>Avoid unnecessary examinations</EM> and
treatment: these only enforce the patients
view that something is seriously wrong.
consider Solution Focused Brief Therapy
(some overlap with N.L.P.)
<HR> Dr Rob Pearson:General Medical Practitioner & RCGP District Faculty Tutor (East Leeds)<HR>
<IMG SRC="file:///c|/data/training/resource/txtfiles/1root/wcslogo2.gif">
Bradley Cheek 1996
<HR>
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