The patient who's an instant expert... The one who's in denial about their lifestyle... The one with a list... It's enough to test a GP's patience, says Dr Martyn Lobley

Imagine your GP arriving at the office for morning surgery full of the joys of spring. She greets her reception team and the throng of patients milling around the booking-in desk with a cheery "Good Morning" before taking her appointment list off the top of the printer.

Scanning the list of names, some familiar, others not, she sees that Mrs K has booked herself in for yet another 10 minutes of, well, that's the point.

In the past hundred or so consultations, nothing her GP has said or done seems to have had the slightest effect on Mrs K's health and well-being. Yet still she reappears with astonishing frequency. Little wonder that the GP's heart sinks a little when she sees the name.

To label a patient as a "heartsink" might seem a little pejorative but it eloquently sums up the "here we go again" feeling that the mere mention of a particular name can provoke. In the days when doctors kept records on paper, their files would invariably be at the point of bursting at the seams. These days the results of their thousands of diagnostic tests and first, second and third opinions simply take up terabytes of NHS hard drive space.

The average GP has around a dozen to cope with on his or her list of patients and they are classified as follows. If a particularly harassed-looking GP tells you that he's just finished a "heartsink safari", that means that in the course of a single surgery, he has encountered at least one of each of the following Big Four. The Big Four, the first of those below, are "recognised" sub-types who appear in the medical textbooks. But there are others that any and every GP will recognise.

Of course there are those, many of whom might be composing a letter to the editor even now, who believe that there are no such things as "heartsink patients", only burned-out "heartsink doctors" who don't have the skills required to deal with complicated psycho-socio-somatic problems. But that's rubbish, obviously. If you see yourself here, you risk driving your doctor to an early grave.

The Entitled Demander

This patient really doesn't like doctors. GPs, consultants, they're all the same. We are merely obstacles in the way of obtaining a diagnostic test and/or a prescription for every symptom, no matter how unlikely that symptom is to be the result of a significant medical problem. The concept that investigation and treatment might prove more harmful than allowing nature to take its course is completely alien. If, for example, we perform a CT brain scan on every patient who presents with a headache – something that the Americans are perilously close to achieving – then the radiation doses from those millions of CT scans will cause more brain tumours than the scans would ever have uncovered in the first place. Try telling that to an Entitled Demander. He or she knows his or her rights. If I can't order a CT scan, then it's my job to refer on to a consultant who can. Who certainly will do so, if only to get the patient out of the room.

The Dependent Clinger

What's not to like? A patient who brings home-grown vegetables from the allotment, remembers the names of their GP's children and even drops off a Christmas card and a bottle of something drinkable in the third week in December. But they also bring along symptom after symptom after symptom, none of which falls into any recognisable pattern of illness. As soon as one set is dealt with, another appears. When they are investigated, another batch follows or some of the previous symptoms relapse like old war wounds. The thing is, because this patient is inherently likeable, their doctor is especially keen to reassure them by ruling out any sinister underlying cause for the bizarre collections of aches, pains, numbness, weakness, tiredness and low mood that they present. No convincing cause is ever found and the doctor's role consists of trying to put together pieces from one jigsaw – just in case the picture is of something worrying – whilst being peppered with pieces from other puzzles.

The Manipulative Help Rejecter

This patient just loves to tell me what a crap job I'm doing. If the game of "Why don't you?" "Yes, but ... " ever becomes an Olympic event, then a fist full of medals is assured. Whatever suggestion I make that might be helpful is not so much refuted as ridiculed. "You might want to lose a few pounds ... " (polite code for "the human hip joints were not designed to carry the weight equivalent to a brace of pigmy hippos") means that the patient would have to start smoking again, and I wouldn't want that to happen would I? "How about starting with some gentle exercise?" "What, with these feet? You must be having a laugh ... " and so on ad infinitum.

The only consolation that the doctor has is that the patient's family, who are twisted around her little finger, are invariably suffering more.

The self-destructive denier

Uniquely among the heartsink fraternity, these patients are often, and quite seriously, ill. They qualify for heartsink status as a result of their preternatural ability to externalise. Nothing, repeat, nothing about their illness is their responsibility. Patients with emphysema who simply cannot give up smoking, alcoholics who continue to drink even though their liver is failing, diabetics who wolf down litres of fizzy drinks. Experience tells me that however difficult it is to persuade people to change their lifestyles (or to take their medicines) to prevent their first heart attack, it's a doddle getting them to make every effort to prevent their second. It's just a shame that first heart attacks are fatal in one in three cases.

The Internet Surfer

Why should he waste time in some pantomime question-and-answer session when he knows that he's suffering alpha-one hydroxylase deficiency and having salt-losing crises on a daily basis? It came up right there on when he typed his symptoms into Google. His GP wants to ask lots of tiresome questions about his previous medical history, mood, what medicines he's already taking, the whole yada yada. He'll just put the doc straight, he needs to see the Head Doctor. After a few minutes with him his GP will probably agree.

The patient with a list

She has 10 minutes and a list of five symptoms, which ought to be plenty of time to sort them all out. Her doctor will almost certainly want to look at it as soon as she produces it, using the excuse that the symptoms might not mean much individually but taken as a whole might provide a useful diagnostic clue. Suppose her list included tiredness, thirst, numbness, fainting and needing to pee all the time? That might indicate diabetes to a GP but each of those symptoms has at least a dozen causes – that's 12 x 12 x 12 x 12 x 12 = 248,832 possible diagnoses her GP needs to work through before the patient will consider herself properly investigated.

Patients who save the best bit till last

Doctors enjoy working under pressure, so these folk help us keep on our toes by neglecting to mention the real reason for their visit until the very last minute of their consultation. They'll use up the first few minutes in idle chatter, then move onto something fairly trivial like a pulled muscle in order to allow the doctor to "warm up" mentally.

When they're convinced that he's up to speed, they'll hit him with the "constipated and bleeding on the toilet" combination. It shouldn't take more than a minute or two to sort out. If Doc tries the "I'm sorry but we're out of time for today ... " line and asks him to make another appointment, the patient will just sit tight and stand his ground (if that's anatomically feasible).

The expert patient

No one knows more about, say, diabetes, than a person living with the condition, so their opinions count for far more than all that book reading and stuff their GP was supposed to do in training. Half a day spent surfing the internet or reading an information leaflet is more than enough to justify the epithet "expert". This allows them to join self-help groups and expect their fellow patients to view them as a proper clinician. If they have an uncommon condition, it is mandatory to form a single-issue pressure group and insist that all doctors spend an hour a week studying its diagnosis and treatment even though it is statistically unlikely that they will ever see another case.

The one who won't get caught out

For one reason or another, most doctors like their patients to take the medication they prescribe. Even if most modern medicines help only one or two out of every dozen patients who take them get better any more quickly than if they were left untreated, it's impossible to predict who the lucky ones might be and they'd wish anyone who gets a prescription to be a winner.

The only exception to this is the patient who demands and receives an unnecessary course of antibiotics, in which case the doctor is silently wishing every side-effect in the book (plus a few as yet undiscovered ones) upon the person who's spent the previous 15 minutes belittling his diagnostic skills and therapeutic acumen.

Doctors will ask: "Have you been taking your tablets/using your inhalers/checking your blood sugar/rubbing the ointment in regularly?" The only acceptable answers to this question are: "Every day/religiously/as though my very life depended upon it." Beware of the GP who appears to give patients permission to be honest by asking: "How often do you forget to take your tablets?" Doctors who play mind games like that with their patients ought to be struck off.

Dr Martyn Lobley is an NHS GP in south east London and one of the authors of Dr Tony Copperfield's Sick Notes (Monday Books, £8.99). To order this book for the special price of £8.54, including free P&P, call 0870 0798897 or go to