David Kerr: The subject that dare not speak its name

David KerrWorking in the NHS must sometimes feel like working for the United Nations. Whilst first impressions are that our own current team of overseas trainees are actually above average in terms of skill, knowledge, and communication, the General Medical Council are worried that some doctors from outside of the UK arrive here with “little or no preparation” for working in the NHS. Apparently one in three doctors registered in the UK received their medical training abroad. The GMC is responding to a number of complaints related to difficulties in adapting to UK culture and ethics including the need to explain treatments and respect confidentiality. As a result, the GMC is planning a basic induction program for new arrivals to help them understand how healthcare is practised here. According to the BBC this idea has been warmly welcomed by the British Medical Association and the Royal College of Surgeons, although not many eyebrows have been raised as to why the UK healthcare system remains so dependent upon doctors from elsewhere.

The main focus of this new initiative will be on “communication skills, knowledge of UK medical ethics, culture, and an understanding of how the NHS works.” Details of the curriculum are not yet available but it is likely that this will generate controversy as to the definition of what UK “culture” actually means or how the success or otherwise of such a program can be measured. One mischievous thought is that the scheme might also include guidance on how to reduce referrals for primary care doctors? One area that is not likely to be covered, however, is the issue of how to deal with patients that the doctor dislikes.

The topic of the heart sink or hateful patient has been around for decades and although it is perceived to be more common in primary care, no speciality is actually immune. Some would argue that the concept is alien and should not exist in this modern age. Debates continue about the genesis of dislike or feelings of hate by doctors and whether the origins lie with the doctor per se rather than the patient. Although it has been around since the late 1970’s, James Groves’ classification remains useful and allows distinction from the much more common challenge of dealing with individuals with medically unexplained symptoms where strong emotions are much less common. Groves recognised 4 groups of heart sink individuals (a) “dependent clinger” who seeks constant reassurance and attention, (b) “entitled demanders” who use guilt-induction, intimidation, or threats of litigation, (c) “manipulative help-rejectors” insisting that no treatment helps and (d) “self-destructive deniers” continuing with their downward spiral from harmful behaviour.

Outside of Western European countries and the US, there has been little work on this area of medical practice and it is unclear whether the existence of this phenomenon is culturally dependent. What is clear however is that the risks of failure to appreciate the existence of such emotions can be significant given the ubiquitous presence of social media on which to bare-all feelings thoughts and opinions. As with complaints that find their way into the mainstream media, the advice is similar for negative comments from patients about their health care providers that appear in the blogosphere – bite your lip.

Doctors new to the NHS need to be aware that this is a topic for thought and reflection and to consider the ethical and moral domains within in which such emotions lie. They might also be aware of the 4 pathways to “cure” and the heart sink patient described by O’Dowd – the patients moves away, you move away, the patient dies, or you die!

David Kerr wears many hats, sometimes at the same time – Diabetologist, editor of Diabetes Digest, researcher, and founder of VoyageMD.com, a free service for travellers with diabetes. He has received consultancy fees and honoraria for participating in advisory boards for Medtronic, Roche, Lifescan, and Abbott Diabetes Care. He also holds a small amount of stock in CellNovo (a new insulin pump company) and Axon Telehealth.