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'Heartsink' patients in general practice: a defining paper, its impact, and psychodynamic potential.

In his 1988 paper ‘Five years of heartsink patients in general practice’,1 Tom O'Dowd is said to have coined the term ‘heartsink’. In that paper O'Dowd refers to a publication in which the term ‘heartsink’ had been employed 2 years previously, but in which the author, CG Ellis, preferred ‘dysphoria’ to describe:

> ‘the feelings felt in the pit of your stomach when their [the patients’] names are seen on the morning's appointment list’.2

O'Dowd believed that Ellis's ‘pit of your stomach’ definition had ‘an intuitive ring about it’; he quoted it and attached it to the term ‘heartsink’, a term which, according to O'Dowd, ‘more clearly refers to the doctor's emotions which are triggered by certain patients’.1

O'Dowd's paper described a study of 28 patients ‘considered to be heartsink’ in his practice. Over 6 months, these patients were discussed by practice staff at a series of lunchtime meetings. The stated function of these discussions was to share information, define problems, formulate management plans, and provide support for the GP assigned to each patient. We are not told whether the discussions elicited heartsink-type feelings among attendees, but, tellingly: ‘the meetings stopped after 6 months because of pressure of time and doubt that the effort was worth while’.1 When the meetings ceased only nine of the 28 heartsink patients had been discussed. O'Dowd determined that: ‘Inadvertently this has provided two comparison groups: one group who had a management plan and one whose care was unplanned and reactive’. Five years later, O'Dowd compared these two groups using outcome measures such as frequency of attendance and whether or not the patients were still ‘considered to be heartsink’.

O'Dowd's study contained several significant weaknesses: unclear entry criteria; questionable comparison groups; ill-defined and inadequately-described interventions; follow-up that was very incomplete; and outcomes …