Intended for healthcare professionals

Career Focus

Dealing with “heartsink” patients

BMJ 2004; 329 doi: (Published 13 November 2004) Cite this as: BMJ 2004;329:s203
  1. Una Coales, general practitioner
  1. London W1G 6AT

I suggest there are no heartsink patients, only heartsink doctors.


  • Use non-verbal body language and verbal communication to ensure the patient feels listened to

  • Uncover a patient's true agenda to avoid listening to endless lists of minor complaints

  • Give the patient with a long list the opportunity to speak first for 90 seconds—but then explain that the appointment is seven minutes' long. Negotiate which problem needs addressing today

  • Assume control and offer structure to a consultation with a rambling patient

  • Hand over responsibility to the patient. Advise the patient to chase outpatient appointments and referrals

  • Limit the number of investigations and referrals made for the “dependent clinger,” who refuses to take responsibility

  • Share the pessimism of a “manipulative help rejector”—“There is nothing medicine can offer for your illness”

  • Offer empathy to a “self-destructive denier”

  • Acknowledge the effects of symptoms for a somatiser but suggest that psychological distress can cause physical symptoms

  • Set rules for frequent attenders. “I will see you again in four weeks” helps to curb weekly visits

  • Improve your communication skills if your list of heartsink patients increases. Adopt a consultation model such as Neighbour's or use SCORES (Silence, Clarify, Open-ended questions, Reflect back, Empathy, Summarise).


  • Enter into a debate with the “entitled demander”—a patient who consults more than the average 3.5 times per year, makes excessive demands, and uses the phrase, “I know my rights!” Reassure the patient that you are doing your best to ensure he or she receives the best possible medical care

  • Work if you are sick. You will lose control and make mistakes