Tuesday, February 21, 2017

Doctors ‘Need Their Space!’

Doctors ‘Need Their Space!’

The day to day work of physicians must sometimes seem like climbing a mountain.  Starting every morning, seeing a full schedule of a couple of dozen patients coming in at 15 minute intervals with a wide range of ailments, symptoms and complaints that may or may not be easily diagnosed, and hoping that you can figure out most, if not all of the diagnostic puzzles seems like a tall order.  Many of these patients are filled with anxiety when they come to their appointments, and they often release it all in the presence of their physician.  The physician tries to relieve the patient’s anxiety while taking on her own uncertainty in the hopes that the patient’s relief is lasting.  And, at the ‘end’ of the day, this physician makes sure her charting is completed, answers phone messages, calls in prescription refills - or not, and is left with many thoughts form the day’s work - thoughts about the patients whose questions could not be answered easily or the serious diagnoses she had to reveal or the patients who struggled with lifestyle habits they couldn’t easily change, or even the patients who ‘push their buttons’ and to whom they develop an allergy.  

Maybe it’s not every day, but I can imagine at the end of most physicians’ days (even sometimes in the middle of the day) having the feeling of needing some space to get away, to let down, to unwind, to process the emotional rollercoaster they’ve been on, to somehow leave the heaviness of that day, to talk to another physician to find out if it is only them.  In short, the goal is to get out of all their patients’ lives and to enter their own life, and to do so without the feeling of just ignoring or even betraying everything I just listened to.  I also could imagine that physician considering how much easier it might be if I just didn’t listen so intently; but that’s not why I got into this work.  I also know that some physicians leave this emotional residue of their work using some sufficiently engrossing distraction or an anesthetic such as alcohol.  It takes strong medicine to mentally separate from unsolved or unresolved patient dilemmas.

“It’s me, not you!” 

Whether they think about it this way or not, physicians have a relationship with their patient panel.  And like in any relationship, there comes a time when we ‘need our space,’ meaning “I need to get away from it.”   I thought of the Seinfeld show and George Constanza’s line when breaking up with his current girl friend: “It’s me, not you!”  It was his effort to get some space without having to explain why or to not blame his girl friend and probably not to own up to his own feelings.  It is a common impulse to blame the other.  For the physician, one might think how difficult it was to see all these challenging patients.  It seems amusing to imagine a physician saying to her practice: “It’s me, not you!”  For George, that was just a ruse; it seems he was wanting to break up, but not have a conversation with his girl friend about why.  He did not believe it was him.  It was his escape.  However, in reality, it’s always me, not you.  It’s helpful in the long run if we are willing to acknowledge our own role and be willing to look there.  When we present a case to our Balint group, it’s about what did I miss? or what am I not realizing? or why is it so difficult for me to listen to this patient? 

Clearly, membership in a Balint group does not answer all of the burdensome feelings that physicians carry.  Even meeting once a week (which most Balint groups do not do) would not be enough.  However, Balint groups - even those that meet only every fortnight - do provide a regular, structured, emotionally safe Holding Space in which the physician can totally let their feelings out, get support for whatever struggle they share, be reminded of the reason they are doing this work, and even begin to understand why some patients get under their skin.  Having a group of any kind - Balint, support, etc. - allows physicians to share any of their emotions with the group, and in doing so, physicians can dissipate some of their own anxieties about the uncertainties of this work.  This is the essence of the supportive nature of any safe group.  It is what allows physicians to enjoy their own life fully, and to return to their work with more compassion to listen and more empathy to give.

Unfortunately, there is no medical school or residency course titled Holding Space 101 or the advanced version, Holding Space 2.0!  If there were, the description might suggest that because of the importance and intensity of their work, physicians may find that from time to time they need to get away either by themselves or with like minded colleagues to sort through or process the emotional nature of this work and the impact it has on them.  This is best done in a place and time where they would have no outside pressures, and they can feel free to explore all their feelings about the people they treat, the struggles they encounter and the limits of what physicians can accomplish.  OR, it can just be a time to let go of tension, re-center or work out frustration through exercise.  It can take the form of meditation, journaling, a walk in nature, or yes, even a Balint group.

I recall years ago when I had a full time psychotherapy practice and my two children were in elementary school, enrolling all four of us in an early evening yoga class on my longest day in my office.  I ended the day by driving to the class, knowing my family would meet me there.  I never minded the exceedingly long day, just knowing it would end with a yoga class with my family.  It was relaxing, energizing and centering all at the same time.  I confess that I did not intentionally think of this time as a holding space or a re-centering time.  However, I have had similar experiences planning other Holding Space activities at strategic times in my week.  

The advantage of Balint groups is that the group and this Holding Space is already there.  It is an established ritual.  I don’t need to do anything except show up.  I feel connected to and accepted by the group.  The leaders are trusted and in charge.  They will respond to the needs of the group and gently shift us into our task.  Their presence helps me be present.  There is a ceremonial beginning: “Who has a case?”  Merely entering the group space helps me let down defenses, there is no need to explain anything, the professional mask relaxes - I have entered a sacred space.  Whether or not I chose to share a patient story, I will engage with the group at an emotional level as we explore the human reactions we all have to these stories.  It is a reminder of the healing nature of the work we do, and I leave this group thankful for so much - not the least of which is my appreciation of this Holding Space.  I have given to the group by my presence and sometimes by my story, and in turn, I have received support, validation and membership in a community of healers.

Saturday, February 11, 2017

The Balint Evidence Gap - Part 3

The Balint Evidence Gap - Part 3

Why is it that many of the participants in the Balint leader Intensive groups I attended have not been nearly as excited or stimulated or challenged or impacted as I have been by this process?  

What possible ways of measuring of the benefit of Balint group participation can accurately reflect the range of varying impacts on various participants?

The questions I am asking (above) have evolved as my exploration of this research challenge has progressed.  What follows is a bit of a time line of my own research journey with a description of my thinking along the way.  I conclude with a set of hypotheses and assumptions that describe my current thinking and direction on this journey.

In 2008, Don Nease, Mike Floyd and Katie Margo presented a poster describing a multi-site multi-group study measuring empathy change in residents as a result of participation in Balint groups.  Their results did not show a clear significant and positive impact, and I was disappointed.  I thought (because I was hooked on the value of Balint!!!) that surely with a larger N and maybe for a longer exposure, we could show results which would convince the world how great Balint group participation is.   For a number of primarily logistical reasons, this approach did not go anywhere.

Much later, at a NAPCRG conference in 2015, I was introduced to Realist methodology - an approach that is geared specifically to social science research. It combines qualitative and quantitative measures, and maybe most importantly addresses the empiricist - constructivist dimension.  (I wrote about this in “The Balint Evidence Gap - Part II” - 8/2/15)

I spent some time learning more about Realist methodology and explored what it might look like if I thought of the Balint group experience in that frame - Context, Mechanisms, and Outcome - which asks: “What are the outcomes that have occurred due to which interventions and under what circumstances?”  The general principles addressed some of my concerns about research on Balint group experiences - differing contexts, including the varying starting points for most participants and the general context of the group, clarifying the mechanisms of change such as leader interventions, clarifications and redirection, and finally the varying outcomes.  While I have not developed these ideas in greater depth, I continue to see the potential this approach has to account for the settings and process of the Balint group experience.

I have also been impacted by the Van Roy, et. al. literature review of published Balint studies.  I was struck by the number of different questionnaires, their lack of definitive results, and also the authors suggestions of the need for better qualitative studies.  I also discussed this in my 8-2-15 post.

Also, although the Salinsky and Sackin book was published in 2000, I did not read it until recently, and I find myself reading and rereading it.  It begins with a challenge that came from a British Balint Society lecture by Tom Main.  He made the profound observation during WW II that those farthest away from the battlefield were the most bellicose and those closest to the front lines were the most reticent.  He then wondered if this was the case in primary care as well.  Stimulated by this question, Salinsky and Sackin write about a five year experiment conducted by a group of physicians who decided to present Balint cases and then to explore what they learned about the ways we protect ourselves from the assaults we experience while on the front lines of primary care.  What I find most interesting about their conclusions is that everyone identified their own unique area of learning related to the nature of their challenging patient interactions.  

An alternate qualitative approach that I have explored emphasizes not only the process of the Balint group but also considers Balint as a culture and explores the ways this culture interacts with or impacts individual experience.  This approach is called autoethnography - an approach that combines autobiography and ethnography.  One key element of this approach is an exploration of participants’ aha moments or epiphanies.  I presented aspects of this approach at the American Balint Society’s national meeting in July, 2016, and I have prepared a more detailed personal exploration in a paper I have submitted for publication.

John Salinsky, in his keynote talk to the American Balint Society’s 2016 national meeting suggested that Balint group participation may have three different levels of impact!  What a Great Idea!  For all kinds of reasons, participants may be impacted at very different levels - from supportive and validating to a more profound impact on personal style in relating to certain patients, and finally to insight about where that personal style came from in one’s developmental experiences.

Finally, I just read a 1966 paper of Michael Balint’s where he asks the question: “Should we analysts accept responsibility for developing psycho-therapeutic techniques to be used in medical practice?”  In addressing this questions, he suggests that “These two roles (Educator or Research Group Leader) are fundamentally different, and in what follows I will try to discuss the consequences of adopting the one role or the other.”  Balint continues: “We should concentrate our attention on what we know a great deal about and which we can directly observe during the report, and this is the doctor's countertransference to his patient.”  And finally, he suggests “… our aim is first and foremost to enable him to make discoveries on his own…”

  1. Since all Balint group participants start at very different places psychologically, it will be difficult to measure any common impact with an empirical or quantitative approach.   
  2. Balint’s own intent is to assist physicians in their relationships with patients who have been troublesome to or for them.  His target is the physician’s counter transference in response to their patient as evidenced in their case presentation.  It is really not empathy!
  3. Salinsky and Sackin focussed on physician’s defensive patterns; one could consider these parts of these patterns their counter transference reactions - and each one had a unique pattern specific to their own life experience.
  4. The best approach to document counter transference reactions will be qualitative with a focus on asking Balint group participants open ended questions, allowing them to reflect on and report their own identification and description of the impact of Balint group participation.
  5. Michael Balint describes both public and private aspects of counter transference reactions in the physician’s reactions to the patient on the one hand and the physician’s unconscious source of that reaction on the other hand.
  6. John Salinsky’s suggestion of three levels of impact could be a guide to scoring and rating and understanding responses to a qualitative inquiry.
  7. Finally, I will report (in the next several months) on the results of a recent request I made to the membership of the American Balint Society to share anonymously any epiphany or aha experiences they have had in the context of Balint group experiences.

I would like to encourage any interested Balint group participants to ask their own questions about documenting the impact of Balint groups.  If you are interested in doing your own autoethnographic exploration and would like some guidance, I would be happy to assist or collaborate.  If you just want to challenge my assumptions or develop your own, I invite your response or reactions.