Friday, April 21, 2017

Observations from the Gurney:


Whether it is in a hospital or in a doctor’s office, there is a profound shift in the nature of an adult - adult relationship when one of the adults is a patient and the other adult is a physician!  Who waits for whom - always?  Who is lying down or sitting on an examination table (like a specimen) - always?  For the patient, it’s all about being wounded and feeling vulnerable.  It includes a feeling of less power, less control, emotional (as well as physical) vulnerability, uneven footing, and, at times, depersonalization.  While physicians may feel confident in their mastery of medical knowledge, they may encounter similar emotions in their challenges or worries about how to transfer that knowledge.  What is the best way to communicate or have a discussion with the patient and the patient’s family about what they know and what they don’t know?  Their own emotional roller coaster may include fear, uncertainty, discomfort and even anxiety, sadness and yes, at times, powerlessness.

The one part of this scenario that should not have to occur is depersonalization.  

I was recently hospitalized the night before my birthday, and discharged the day after my birthday.  On my first full day in the hospital, April 11, I can't count the number of times nurses, techs and other staff asked me my date of birth (while checking my wrist band) and before administering one service or another.  When I said April 11, there was no sign of recognition that today’s date is April 11 - today is this patient’s birthday!  They could have commented (if they noticed): “What a bummer!  You’re in the hospital on your birthday!”  To one of them, asking: "Date of birth?" I said: “Today,” and she looked at me strangely (it was not the automatic response she expected!), and it took a few moments to catch on.  It is evidence of how much of what goes on in the hospital is truly mindless.  Any type of mindlessness cannot be good for patient safety or for professional satisfaction.  What a lost opportunity to have the human connection every patient craves and each health care professional needs!  

Too often, patients become a number, a date of birth, a condition, a diagnosis or just the occupant in bed 74b.  I had more “human” conversations with the people transporting me throughout the hospital for one test after another than I did with most other hospital personnel.  

Gawande writes about becoming a Positive Deviant, and the first of his five suggestions is “Ask an unscripted question.”  A script helps to insure we are getting all the information we need; however, if it’s only the script we use, we are on automatic pilot and that’s not good for patient OR physician!  My take on this is that if the only things we know about a patient is their medical history and medical condition, we are not treating a person - we are treating a diagnosis, or a wound or an organ.  We might as well be back in medical school with our cadaver.  


Do you want your doctor to give you your test results 

standing or sitting?

  Did you ever have the experience of a physician in the hospital coming in to your (or a relative’s) room to give you results of a test?  I don't know if physicians realize it, but when the results are good, they come into our room, remain standing, tell us the result and leave right away.  When the results suggest a larger problem, they pull up a chair, sit down and say "The results from your (fill in the name of the test) are back and ..."

My physician sat down!  I knew immediately that the MRI showed it was more than a TIA.  I’m not sure where my mind went or my blood pressure or my emotions.  I’m not even sure if I heard everything she said next.  Of course, she stayed a while to talk about the new next tests that were ordered, etc.  Whose needs are being met when doctors decide to sit down vs. remaining standing?  How nice it would be if physicians sat down no matter what the results are.  Even with good results, they could talk with us and help us realize the extent and source of our relief and our fears.  Those are part of the patient’s reality as well.

One other thought / realization I have had while recuperating: diagnoses protect physicians from the emotion of the patient’s experience.  It is part of the labeling subculture - necessary for the treatment and billing part of our medical culture, but not sufficient for the caring and healing parts of the subculture we profess to be.  

Communication focussed on the diagnosis allows professionals, who are acting professionally, to stay in their head and to protect their heart and gut.  Even during the H & P, the questions are all about what happened and has it happened before, and there is less room for “That must have been scary!” or “You must have been wondering what was happening to you…”  

This lesson was highlighted for me recently when a 3rd year medical student - who is in one of my Balint groups - told and eventually wrote beautifully about a series of encounters with a patient on one of his first rotations to observe real patient care.  He commented that he really did not know how to do anything medical, so he just talked with this patient and listened.  The result in the course of just several days of sitting down and listening to his patient’s story was the development of a profound connection between a patient and a health care professional - a medical student who was not yet a doctor.  It seems we have it so backwards or upside down when the person with the fewest ‘medical’ tools in a medical system has the most time to sit and listen, while those with the most ‘medical’ tools have the least time to sit and listen!  

When was listening (not just hearing) considered outside the realm of medical tools?


  A crucial part of the patient’s healing comes with telling the story - sometimes more than once.  We do not have to be psychologists to ask what an experience was like or what remaining fears and worries patients have.  We can engage our humanity, validate their emotions, reassure them of our continued participation in their health and recuperation or readjustment journey and then take a deep breath knowing that we have met them where they are.  We don’t have to be brilliant - just human - and that in itself is healing (sometimes for us as well).


Sunday, April 2, 2017

What is your doctor's Relationship Quotient?

Relationship Intelligence is NOT the same as 
Emotional Intelligence


What do I say to a patient who tells me about childhood memories of assault, or sexual abuse, or a traumatic experience?  


What do I say to (or do for) a patient who tells me about their (shameful) addiction to drugs, or alcohol, or pornography, or eating, etc.?

What do I say to a patient who reveals being in a cycle of abusive relationships?


To have or to be open to having an emotionally authentic conversation yet alone a relationship with any of these people is to open one’s heart to the human condition in ways that are out of the ordinary.  With any new person, we begin at a comfortable distance, and then when we hear their story, we have some automatic, reflexive reaction which may include adjusting that figurative or emotional distance (increasing or decreasing).  We may unconsciously erect some protective barrier, or we may possibly embrace the pain and woundedness in our presence.  We would like to think we can remain objective, non-judgmental, non-blaming and very self aware, but no matter how often we have heard these stories, it's difficult not to have some reaction.  What about our (unknown or unnamed) biases?  What attracts us to one individual?  What repels us from others?  Do we even know what’s happening inside ourselves when it is happening?



 What is it about some people that make them interesting to us?  What is it about some others that make it more difficult for us to connect with and be more understanding?

How do I ask questions that are on topics that may be very sensitive to ask and complex to delve into - like sexuality, drug and/or alcohol use, abuse experience?

How do I establish an agreement / contract with my patient about trust, safety, privacy, availability, shared responsibility?


    There is a significant body of literature supporting the primacy of the relationship between therapist and patient or physician and patient over the particular treatment method or approach of the professional.  Simply stated, the most important factor in patient care is the nature of the relationship between the doctor and the patient!  Technique is secondary.   Physician time spent establishing a relationship is never wasted time!  And yet, professionals will argue back and forth about the merits of different techniques or approaches, and they pay less attention to relationship building processes.  Research has measured the time it takes some physicians to interrupt a patient’s story in seconds!  Interruptions may get us to the core of the symptoms more quickly, but we bypass the patient in the process.

     As early as 1957, Michael Balint wrote about “… the doctor as drug,” suggesting that the physician’s impact on the patient can be akin to the impact (or side effect) of a pharmaceutical agent.   With pharmaceutical agents, the side effect is almost always negative.  Once in a while, a medicine is chosen because a known side effect is a desirable one for a particular patient.  If we think about “the doctor as drug,” it is an opportunity to have NO negative side effects.  In fact, the relationship that is developed can be a multiplier of the purely medical treatment regimin.  But this is dependent on the physician’s Relationship Intelligence or their Relationship Quotient!

So, a natural question to ask is what are the components of Relationship Intelligence and how does one develop such a skill?   It is clear that emotional intelligence is a necessary component - necessary, but not sufficient - especially in the form of listening to self and to others.  

Why is listening such a challenge?

     Emotion trumps Logic: I often think about a Maya Angelou quote: "I may not remember what you did for me, but I will always remember how you made me feel."  It is so ironic because so many physicians will first remember what they did for the patient and only when probed might recall the emotion in the encounter.  This is an example of how there can be such a dichotomy between the patient experience and the physician experience.   The patient may be sitting with emotionally and physically painful secrets they have never shared - until today.  The physician is prepared to ask a few diagnostic questions, chose among several medications they will prescribe and smoothly leave with encouragement and a plan for the next appointment.  Doctors are prepared to open the door to the examining room, but maybe not prepared to open the door to the patient's life.

 Listening as a billable code: Part of physician's training is to think about how to code this visit to justify billing the insurance company. It's not the first thing on the doctor's mind, 
but they are quick to know that this is a Level 2 or Level 3 visit, for example. They also need 
to be clear about documenting all of their findings in order to justify the medical diagnosis 
and the codes for treatments - especially procedures. Doing a procedure or sending a 
prescription to the patient's pharmacy feels like I'm doing something. "Just" listening does 
not feel like I'm doing something - no matter what the patient says.  

I wonder if we are teaching the subtleties of listening well enough!

     Emotional Arithmetic:  When we share good or exciting events in our lives with people who care, the joy gets multiplied.  When we share sad or bad events that we experience in our lives, the pain is divided.  Sharing our experiences is always a positive - primarily for the sharer.  Good things get better; sad or painful things get lessened by virtue of their being shared.  However, the experience is different depending on whether we are sharing or we are listening.  To fully listen and only listen is a gift!  It is like saying (silently): "Let me help carry that load."  And to fully listen is to acknowledge the story and to validate the emotions.
  
One challenge is to avoid several traps.  One is the trap of trying to fix it - it's in our DNA!  We are helpers, fixers.  We get some of our goodies by relieving pain and suffering.  It is easy to forget that really listening, uninterrupted, helps!  Another trap is to try to reframe it or put it in a more palatable context - another form of fixing it.  Another trap is sharing our marginally similar experience as a way of saying "I know how that feels." which we probably could never know.  It is a helpless feeling to "just" listen, yet it is such a gift!

     The Patient vs. The Schedule (all the other patients):  When the visit I thought would be routine becomes a drama, my schedule flashes before me and I think about all the other patients I will be seeing and to whom I will have to apologize for being so late.  It is so unfortunate that physician's schedules have to be so tightly booked that there is little time for even one drama to pop out and require adequate time.  it is unfair to patients as well as to doctors.  And the only remedy the way schedules are set up is to make everyone who follows a bit later than they planned or expected.  No wonder listening is so challenging.

     Balance Content with Process - Paying attention to what is said in addition to how it is said is crucial in understanding the complexities in what is being communicated.  Recognizing a patient’s reluctance or their anxiety or the tension with which they share information adds to the meaning that sharing may have; it may help to recognize or uncover additional layers of information crucial to understanding that patient 's story.  Sometimes, patients do not have the emotional vocabulary to fully express how they are feeling.  Sometimes, the best they can do is to demonstrate the anxiety by being anxious or the tension by showing us their tension.  It is our task to identify those emotions, to provide the emotional vocabulary.  It is another subtlety of listening.

The Role of the Physician in the Community?

This emphasis on relationship seems in marked contrast to current trends in health care which emphasize efficiency, cost containment and the bottom line, patient improvement as measured by laboratory test results, and patient satisfaction measured by a brief questionnaire.  In contrast to more highly valuing healing relationships, this emphasis on efficiency and patient (customer?) satisfaction is more of a focus on the business of medicine.   I have wondered how good the Press-Ganey scores would be for Shamanic healers.



Balint groups are such a reminder of what components are essential for developing relationships that can be healing.  Maybe Balint's impact is to help physicians develop better Relationship Intelligence which leads to better connections with patients and ultimately better care!  Part of the process may be revealing or uncovering blind spots.  Another way to think about this is that Balint group participation helps physicians to integrate their  professional role with their human role.  It helps us to listen to ourselves as well as to listen to our patients.  We both need to be acknowledged and to be validated!  


Sunday, March 12, 2017

Measuring Balint Group Impact: A Proposal

I loved the idea of three levels of impact from Balint group participation that John Salinsky suggested in his keynote address to the 2nd ABS National meeting in July, 2016.  Sometimes, a participant is impacted profoundly - an aha phenomena or an epiphany - and other times, the impact is more subtle, more along the lines of support and validation, but no epiphany.  I just recently heard a Balint group member ask out loud “What part of me is she (the patient) touching?” and the group continued to discuss this for each of them who felt provoked.  I also heard one participant say “I just realized …”  and she went on to identify new awareness stimulated by the case and the group discussion.  These are examples of knowledge creation as I described it in a previous post.  One remaining challenge is to organize or systematize these ‘learnings.’  One place to begin is to review Salinsky’s levels that follow; can you discern distinct content areas within each level?  What descriptors would you use?


Bronze level
You receive all the benefits of the generic small group effects
You are a member of a group of really nice people doing the same difficult but often rewarding job as yourself
You have a safe protected space to talk about your work, your feelings, even your mistakes
You can get advice from colleagues
You feel that family medicine is not so bad after all

Silver level
You receive all the benefits above, and in addition:
You develop more interest in the patient as a person
You have more time to explore their life history
You have learned to be a better listener
You are more relaxed at work, with a greater tolerance (and more compassion, more patience) for difficult patients
You find work more satisfying, patients less persecutory
Your feelings are still ambushed by personally disturbing patients

 Gold level
You receive all the benefits of Levels 1 and 2, and in addition:
You are aware of projected patient feelings (countertransference)
You are willing to accept a share of painful feelings, helplessness, anger, irritation
You have developed greater self awareness. You recognize why some patients disturb you.
Maybe your clinical practice changes for the better. “As they became more accepting of themselves, they were more open to their patients.” (Gosling, 1996)



As I reviewed these descriptors provided by Salinsky and I recalled  themes that emerged from my own exploration of personal ‘aha’ moments, it seemed that one could separate out three different areas of content that register an impact from participation in a Balint group.  The next challenge is to describe distinctly different levels of impact in each of the three areas, I’m proposing we consider a grid such as the following:
                                           


Level 1
Level 2
Level 3
Self
Feeling support and validation
More aware of one’s emotions (sensitivity)
Aware of counter-
transference (specificity)




Dr. - Pt. Relationship
Others have difficult patients
Appreciate patient complexity - get to know the whole patient
Discovery of reciprocal Dr. - Pt. reactions; limited but significant change




Dr. - Group  Relationship
Valuing safe, protected space to discuss patients 
Value the role of the Balint group relationships to one’s practice
Healer vs. Doctor: Greater appreciation of the impact of this work

Table 1: Balint Impact Framework


Three content areas I am suggesting are:
the impact on the individual self, 
the impact on the doctor-patient relationship and finally, 
the impact of sharing my work with a group of colleagues.  

In each of the three content areas, the first level of impact is more externally focussed, the second level is more internal, and the third level is more interactional, relating the doctor to their group as well as to their patients.  Thanks for this observation goes to Kathy Knowlton, with whom I discussed this framework.  We had the benefit of some time together after presenting a full day Balint experiential workshop to about 20 participants at the American Group Psychotherapy Association meeting in NYC (along with Laurel Milberg and Eran Metzger).  

Fresh eyes and new ideas are at the core of Balint groups themselves as well as doctor-patient relationships.  Writing can also be part of this generative process!  As I read what I have written, I’m realizing that these three levels parallel my observations and description of steps in reflective practice which I wrote about previously:  (“A Guide to Introducing and Integrating Reflective Practices in Medical Education,” The International Journal of Psychiatry in Medicine, Vol. 49 (1) 95-105, 2015)

See it to be it (recognize what is happening)
Name it to tame it (names allow us to talk about experiences)
Share it to Bear it (sharing troublesome events reduces the trouble)
Below is a table of examples that fit into these three levels of each of three content categories:


Level 1
Level 2
Level 3
Self
Feeling support and validation from colleagues
More willing to acknowledge painful feelings
Aware of counter-transference

It’s a relief to talk about this patient
Become a better listener
Greater recognition of my emotional reactions to patients


My feelings still get ambushed by disturbing patients
Greater self-awareness - Recognize why some patients disturb you.




Dr.-Pt. relationship
I’m not the only one who has difficulty with this type of patient
Develop more interest in the patient as a person
Changes in the Dr. lead to changes for the patient – more perspective

Getting advice from colleagues - Hearing how colleagues handle these patients
Increased tolerance, compassion and patience for difficult patients
More accepting of myself and More openness to patients


Appreciate the complexity in Dr.-Pt relationships
Recognize the type of patient that triggers my reactions




Dr-Group Relationship
Valuing safe and protected space to talk about work, patients, and concerns
Recognize the role of colleagues and the group process
Greater appreciation of my role as a healer

Having an appreciation of primary care work
Increased satisfaction with work - less bothered by patients
Learn from the group’s parallel process and metaphors

Moved and touched by the sense of community in the group
More relaxed at work
Self-compassion






Table 2: Balint Impact Examples

This chart takes the examples Salinsky listed and organizes and, in some areas, expands them into three distinct areas.  What is crucial in order for this chart to be useful is the need to delineate three distinct levels of impact so that the difference from one level to the next is a qualitative shift within the same general content area.  For example, some of the discoveries participants have about themselves as a result of these case discussions start with a sense of being less alone, and feeling validated and supported at one level.  At a second level, they may become aware of being a better listener and more aware of their own emotional experiences, and finally, at a third level, they may develop an awareness of how they react to certain patients and why.  I believe there is a similar progression in each of the other two content areas - doctor-patient relationships and the broader perspective of the physician’s role.

I believe that this or an amended version of this framework can be helpful to identify the knowledge creation that results from participation in Balint groups, and it can further delineate content areas as well as the level or depth of the impact.  I also wonder if it might be interesting to use this chart to organize the comments people make when given the opportunity to summarize their learnings or experience at the end of a Balint group’s contract or even after completing a Balint leader Intensive.   

The origin of my exploration was John Salinsky’s presentation of his musings about levels of impact.  His thinking emerged from returning to Michael and Enid Balint’s book, A Study Of Doctors, written along with Gosling and Hildebrand in 1966.  In this book, Michael Balint suggests that his seminars were not for just any G.P.!  And he developed a Mutual Selection Interview process to aid in identifying who would best benefit, AND to identify who might be disruptive and should be discouraged from attending.  
What if we had a system for screening residents or only required six (6) months participation and allowed it to be optional after that (as I believe some programs do)?  More on this to come!

What are your thoughts about the structure of this chart?  What is missing or what would you organize differently?  Let’s brain storm together!

Sunday, March 5, 2017

The Power of Ideas - Bridging a Gap?

If you did not attend the American Balint Society’s (ABS) 2nd National Meeting in July, 2016, you missed a lot!  You missed the opportunity to spend several days with a group of folks who speak the same language (Balint-ese, I’ll call it), and there were great paper presentations, reports on new directions and programs the ABS is creating, Enid Balint essay contest winners and, of course, we all participated in Balint groups that met for each of the four days.  Our next National meeting will probably be held in 2018.  Details will be on the ABS web site when it is  scheduled and announced.  In the meantime, if you need a Balint fix, I encourage you to attend the International Balint Congress to be held in Oxford, U.K. from September 6-10, 2017.  Check out the IBF website for more details (there’s a link on the side of the blog and on the ABS website).  

And “we now return you to: The Power of Ideas!”  

At last summer’s ABS National meeting, two presentations that profoundly impacted me were the invited Keynote presentation by John Salinsky from the U.K. - our society’s midwife (mid-husband?) - and a theoretical paper by John Muench.  Neither paper knocked my socks off at the time, but I have had the opportunity to read and reread them (Shameless Commerce: you too will have an opportunity to read them in an upcoming issue of the International Journal of Psychiatry in Medicine).  

Salinsky’s Keynote (“What Really Happens in Balint?”) was entertaining - as he always is.  However, as usual, I did not fully appreciate the wisdom of his observations.  Among his comments about what really happens in a Balint group is the notion that there may be different levels of impact from participation in Balint groups.  John suggested they could be called Gold, Silver and Bronze levels (in this Olympic year - 2016), and he went on to identify a number of characteristics of each level.

This idea intrigued me!  So, I recently began a conversation with John about these levels, and he shared with me that one source of this idea was embedded in Michael Balint’s curiosity about physicians who discontinued attending his seminars (A Study of Doctors by Michael and Enid Balint and colleagues  and published in 1966).  Recently, I, myself was wondering why everyone who attended Intensives with me was not as excited or passionate about Balint groups as I was - a similar question focussed on people’s differing reactions to the Intensive or to the Balint seminar experience.   

So, one unanswered (and possibly unasked) question is: “What accounts for the differing ways that Balint Leader Training Intensive participants or even ongoing Balint group members are impacted by that experience?”   The answer is not obvious based on the participant evaluations which are universally positive.   Another way to think about this question might be: What draws people to Balint? and What keeps people at a distance?  As one might imagine, I have some thoughts about ways to research and answer that question!  Maybe you have some ideas too - feel free to chime in about your ideas in comments at the end.  

A second question to consider is: “Can the delineations between Bronze, Silver and Gold levels be distinct enough for these levels to be meaningfully useful?”  While I encourage the reader to consider what the content of such levels might be (we all know the value of fresh eyes!), I will also tease you with a promise to share my own variation on John’s very useful beginning - ‘coming attractions.’

John Muench’s presentation (“Balint Work and the Creation of Medical Knowledge”) intrigued me in some very different ways, and he totally lost me at the time of the presentation.  For me, it was the kind of talk that really required more context than the allotted amount of time could provide.  I thought he could have even used an extra slot to provide context for his context.  John briefly outlined a history of scientific inquiry and discussed revolutions in scientific thinking along with an exploration into epistemology - the study of where knowledge comes from (Kuhn, 1963, Toulmin, 1990).  Having a chance to read the paper at my own pace helped to open up these ideas (again, look for the upcoming issue of IJPM).  In particular, John discusses the humanist - rationalist dichotomy or dimension, and the resultant tyranny (my word) of evidence based medicine manifested in the primacy or even exclusivity of placebo controlled, double blind studies.  As you might guess, John describes the failure of medicine to incorporate the kind of experience and knowledge creation that a mature, regularly meeting Balint group produces.  He does so using Aristotle’s distinction of types of knowing, and in particular, references ‘phronesis,’ a type of practical knowledge which might be viewed today as professionalism.  This is distinguished from ‘techne’ which fits more in the realm of the rationally justifiable.  If you are interested in diving into this, John would recommend Aristotle’s Nicomachean Ethics, and in particular Book VI, Intellectual Virtue (or maybe he would say “Just read my paper.”).  

While I might not have done justice to John’s paper, the idea of Balint groups as a creator of knowledge may modify one’s thinking and approach to documenting the impact of Balint group participation.  Maybe, instead of trying to measure someone’s score on a scale of empathy or burnout or even job satisfaction, we might want to think about how could we describe the new knowledge that is created.  The Van Roy et. al.’s literature review of Balint related publications (2015) suggested that more, well designed qualitative research studies were necessary to document the Balint group participation impact.  Now, does it make sense to think more about Salinsky’s three levels of impact and how we might develop such a scale of qualitative changes experienced by Balint group participants?  If one proposes a qualitative shift in the way a physician thinks about their patient, measuring more or less of any variable (empathy, burnout, psychological mindedness) is by definition quantitative and insufficient.  Michael Balint, himself, spoke about a small but significant change in the doctor’s personality.  Let’s use our experience to define the nature of these changes.  We see them; we even experienced them ourselves.  How shall we describe them in ways that capture these qualitative changes?

 

Stay tuned for the following Coming Attractions:

My next blog post with Salinsky’s three Olympic-named levels and my thoughts about a next step!

The IJPM issue this summer focussed on the ABS 2nd National Meeting

The IBF’s International Balint Congress in Oxford, U.K. - September 6-10

The next ABS Balint Leader Training Intensive in Pittsburgh - October 2017

The ABS 3rd National Meeting - Summer 2018 - to be scheduled


And your own thoughts and reactions which I invite you to share in the comments section of this blog post - Thank You!