Heartsink: When Medicine Meets Misery

It’s hard to know who reads these things. Maybe nobody. Maybe I’m just slinging words into the void like darts at a fogged-up dartboard, hoping one of them hits something that matters.

But if you’ve ever worked in frontline medicine — especially in general practice — you’ll already know what I mean when I say heartsink patient.

It’s not a diagnosis.

It’s not in the books.

But we all know it.

It’s that moment when a name hits your eyes or triage list and something inside you drops.

Not because you’re heartless.

But because you already know: this is going to be hard work.

The People Who Break the Clock

Heartsink patients come in flavours.

• Some of them arrive with fixed ideas: they’ve Googled their diagnosis, chosen their treatment, and now they just need your signature. Any deviation becomes a fight.

• Some of them are flailing—lost in a sea of vague symptoms, long histories, trauma, and sadness. They aren’t demanding. But they are heavy. Emotionally, psychologically, clinically.

• Some are repeat players. Complex from every angle. Long histories, longer problem lists. Multiple meds, multiple clinicians, a list of consultants longer than most people’s friend lists. Every part of the system has seen them. None of it’s worked.

And through it all, they’re still unwell.

These aren’t bad people. Most of them aren’t even trying to be difficult. But they’re walking collisions of chronic illness, generational trauma, social chaos, systemic failures and sheer bad luck. The sort of people you suspect life has quietly given up on—and they’ve just not been told yet.

Back-up to why you’re not a monster here…

The term “heartsink patient” was coined by GP Tom O’Dowd in 1988, describing those who “exasperate, defeat, and overwhelm their doctors by their behaviour”. But it’s not just medical folklore—it’s a well-documented phenomenon with real impacts.

UK GPs report having between 1 and 50 heartsink patients each, with a median of six per doctor.

Research shows that 60% of the variance in heartsink patient numbers can be explained by four factors:

• Greater perceived workload

• Lower job satisfaction

• Lack of counselling training

• Lack of appropriate postgraduate qualifications

The frequent attenders among them are costly. The top 3% of frequent attenders account for 15% of all primary care appointments, with a fivefold increase in hospital expenditure compared to normal attenders.

These patients attend on average 30 face-to-face GP consultations over 2 years, compared to the average patient who visits 3.3 times per year.

What’s clear from the research is that these patients aren’t just “difficult”—they’re often dealing with complex combinations of mental health issues, social problems, and multiple chronic conditions. Many present psychosocial issues in physical terms, representing social determinants of health that medicine struggles to address.

Why It Hurts

The thing about heartsink patients is that they hit you where it hurts: the part of you that still gives a shit.

Because you want to help. But you know — deep down — you probably won’t be able to.

Not today. Maybe not ever. Their problem is too big, too entangled, too everything. There’s no fix. No clever shortcut. No pill that undoes twenty years of system failure.

And ten minutes on a Monday morning isn’t going to touch it.

They’re exhausting not because they’re dramatic, but because they force you to confront your own limits.

And medicine doesn’t train you well for powerlessness.

When the Whole List Starts to Sink

Here’s an honest truth for clarity: if everyone on your list feels like a heartsink, that’s not about them — it’s about you.

You’re burnt out. You’re running on caffeine, adrenaline, and irritation. And you’ve got nothing left in the tank.

That’s a warning light. Not a shame signal. It just means you’ve hit your limit. And if you don’t notice it soon, you’ll lose the part of you that remembers why you took this job in the first place.

What Actually Helps?

There’s no magic bullet. But these help me:

- Continuity: Keep them with you, if you can. Familiarity shrinks consultations and builds trust. They don’t have to start from scratch every time.

- Boundaries: You’re not their saviour. You’re their doctor. Be kind, but clear.

- Honest documentation: For your sake and your colleagues’. Especially when you say “no.” It’s not defensive medicine. It’s just continuity for your future self.

- Label it (gently): “Complex case—prefer continuity.” It’s not a slur. It’s a signal to the system.

- Own your slip-ups: If you snap, go back. Say so. Repair the damage. Some of the strongest clinical relationships I’ve built came from those moments.

And if you just can’t do it that day? That’s okay. Don’t martyr yourself. Defer. Delay. Protect what’s left of you. There’s no glory in imploding.

Heartsink as a Mirror

These patients don’t just test our knowledge. They test our systems. They test our empathy. They show us the cracks.

They’re the ones who fall through every net. They’re the evidence that society is slowly unthreading. And because we’re the last people still answering the phone, they land on us.

And we feel it. In the pit of our stomach. In our eye-rolls. In the way we triage them last without even realising.

Because misery is hard work. Especially when it’s chronic. Especially when you’re barely coping yourself.

What Makes a Heartsink Patient?

Honestly? It’s not just them.

It’s context. People become heartsinks because of trauma. Because of grief. Because of poverty and loneliness and systems that run on understaffed wishful thinking.

Some of them get dumped on by luck. Some just never stood a chance. Some were failed by other services, then dumped on us like a hot handover. Some are so chronically unwell that just existing is painful, and you’re the only place they can vent it.

They’re hard to help. But they’re not hard to understand—if you stop and really look.

One Last Truth

You will have a list of names in your head. If you’re in primary care, I guarantee you do. You’ve probably shared them in whispers with colleagues over coffee.

“Mister So-and-so came in again.”

“Oh God. That one?”

“I thought they were yours this week!”

We laugh. It helps. But there’s a thread of guilt in there too. Because we know that behind those names are people who are suffering. And we can’t fix it.

I should address that somewhere else but to put cards on table that kind of Gallows humour is normal, and ok in moderation.

It shows that we survive it the only way we can: boundaries, biscuits, dark humour, and trying again next week.

Because they’ll be back.

And so will you.

Stay Heavy

—DW