“I’m not sure if this is a good enough post, but …”

I couldn’t resist this title - it is the essence of what follows!

“This isn’t really a case, but …” or “I’m not sure if this is a case, but …”

Everyone who leads Balint groups recognizes this disclaimer.  Even experienced Balint group members and leaders say the exact same thing!   So, this is not a function of not knowing or not having enough Balint experience.  I recently sent a request to members of the American Balint Society asking if they had experienced ‘aha’ moments or epiphanies during their Balint leader training experiences.  One of the responses to this request began with “I’m not sure if this is an epiphany or not, but…” and I had to smile.  And then it turns out that the case or the epiphany is a particularly profound case or observation with issues or connections that the presenter did not anticipate or did not recall before they started talking or writing.  

Why does this happen? and Why are we surprised? or Why do we chuckle? 

I would like to suggest that these disclaimers are the result of two competing un- or less conscious trains of thought:

First, there is the allegiance and even the obligation to the group and one’s desire to provide a ‘good enough’ case for the group to consider.  We either recall or recreate in our minds the experience of the last case which we all concluded was profound.  We partly forget that the previous week’s case started with the same disclaimer.  In other words, we did not know that it would be a profound discussion.  But, we compare the beginning of today’s case to the end of last group’s case.  We do not yet know that our case may also provide the profound experience of previous cases - and we do not recall that the last case began with the same disclaimer.

The competing impulse is that although this case is on our mind, we may not be able to see what is under the surface or what others see.  We all have our blind spots; or we conveniently forget to include  something that does not seem relevant.  What is profound to me is that the case has enough emotional energy to surface in the physician’s mind, even without her knowing what is brewing under the surface.  It is implicit in the nature of reflective practices that we don’t know what’s ‘there’ until we ‘go there.’   Think of an ice berg!   We can see what’s above the surface, and we sense that there is a lot more below the surface - but we have no idea of what it might be, and we certainly do not know its significance.  I can’t help but wonder if there would be less delay in cases surfacing if group members had more awareness and reassurance that any case that stays with us has enough emotional valence.  

I recently wrote about the process of reflection as a three step process (IJPM, Vol. 49 (1) 95-105, 2015).  The first step is recognizing that there is something there - it comes in the form of a sensation, a thought or a feeling.  It is simply the thought of a patient, for some reason.  I called this step “You have to be it to see it.”  The next two steps are naming that thought - the recognition and naming that I might have a case - and then the sharing why a patient stays on my mind.   Step two is “You have to name it to tame it.”  We cannot talk about or discuss a case without giving it a name.  Step three is “You have to share it to bear it.”  The group is the witness to the story, and the support and validation helps us carry the emotional load.  It is the power of the group that all group members recognize after the group has settled in to its process and routine.  

Sometimes, the case is barely at step 1 - just a fleeting thought without major discomfort.  Other times, group members can’t wait to talk about a case of theirs.  Mature group members all recognize the scenario of “This might not be a case…” and they now know there’s much more to it and will do the encouraging of the hesitant presenter.  I also believe that as groups mature, there is a bit less of the obligation to provide the group with a good enough case and a bit more of a self care motive.   “I have a case I could use some help with.”

Our Reactions?  I think that the more experienced we are, the less we are surprised.  We have heard this before; we know there is often a very good case hidden in the uncertainty.  As leaders, we hear the denials and treat them as if they are a neon sign - here is where the emotional juice is likely to be!   The chuckle or a smile?  I’m guessing that they are just signs of recognition - and maybe some reassurance that there will often be some things to talk about here and possibly some surprises for the presenter.  In fact, it may be even a better case than one that seems obvious - there may be some surprises for the leaders as well.

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.

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…”

MY WORKING ASSUMPTIONS AND HYPOTHESES:

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.

Difficult Doctor-Patient Relationship Questionnaire

I recently attended a professional conference and listened to several research reports about relationships between doctors and patients.  One of the reports included in their data was from a ‘Difficult Doctor Patient Relationship Questionnaire.’   The investigator shared some of the items in this questionnaire, and I was surprised that they were all so subjective and included such negative descriptions of the patient.  There were no questions about the doctor from the patient’s point of view, although I guess they would be similarly subjective and negative.  Frankly, I was annoyed!  this seemed to me another example of the doctor blaming the patient for being sick and having multiple sets of symptoms.  It is your fault for being so complicated!

I was curious about the content of the rest of these questions, so I investigated further and found two forms - a ten item form and a 30 item form.  All of the questions were consistent in only asking about a negative and very judgmental picture of the patient.  Also to my surprise this ‘validated’ research instrument was published in the Journal of Clinical Epidemiology in 1994 and used in research published in the Annals of Internal Medicine in 2001 and in other reports discussing this topic.

While it might be useful to record and report the number and nature of patients who are seen in these ways by their physicians, this is only one side of the relationship equation.  So, I wondered how these patients might view their physician.  I changed only one word in each question - replacing “patient” with “doctor.”  I’m a firm believer of not asking anything of others that we do not ask of ourselves!   How would you answer these questions about your doctor or how would your patients answer these questions about you?   What would it take to train or to teach doctors to not be difficult?  Or is this just a product of having a bad day? or what else???

On a 1 - 5 scale, with 1 = Not at all and 5 = A Great Deal, answer the following questions: 

How difficult is this doctor’s personality?

How enthusiastic to you feel about seeing this doctor?

How unreasonable were this doctor’s expectations today?

To what extent does this doctor have health related problems due to drug or alcohol abuse?

How frustrating do you find this doctor?

How upbeat did you feel after seeing this doctor today?

How negative did you feel about this visit?

To what extent are you frustrated by this doctor’s vague comments?

How demanding was this doctor today?

Do you find yourself secretly hoping this doctor will not return?

How manipulative is this doctor?

How tense did you feel when you were with this doctor today?

Does this doctor understand your explanations about physical symptoms?

How much are you looking forward to seeing this doctor’s next visit after seeing them today?

How pleased are you with your working relationship you have with this doctor?

To what extent does this doctor neglect health related self care, e.g., diet, hygiene?

How difficult is it to communicate with this doctor?

Hmm …  doctors do have ‘labels’ for some patients - like heart-sink. However, heartsink is really more about the doctor’s feelings and not about the patient.  Patients do not try to be difficult; they are struggling with complicated sets of symptoms and they are trying to understand their diagnosis because they do not have any relief.  Their body is telling them something is wrong; sadly, their doctor (healer?) is having difficulty identifying what is wrong.  The answer is not to blame the patient.  At worst, listen, validate their experience and be willing to keep talking to explore possibilities.  Even worse than not knowing is being left alone and then being blamed.  The Difficult Doctor-Patient Relationship Questionnaire seems to be more of a measure of how much blame some doctors attribute to their most challenging patients.  It may also be an indirect measure of how burnt out a doctor has become.  It is a sad reflection of what can happen to both doctors and patients in a system that is not designed for the most complex patients.  

What is a Balint group and how does it relate to doctor-patient relationships?

 What is a Balint group and how does it relate to doctor-patient relationships?  This question comes up a lot for me because part of my identity is that of a Balint group leader.  In the U.S., I help to coordinate Balint group leader trainings.  I am particularly interested in Balint groups because I believe it is one of the most powerful methods to help physicians sort through the challenges they sometimes have with some of their patients.  I have been involved in the American Balint Society and I have become friendly with colleagues around the world through a mutual interest in Balint groups.

However, when I try to explain the Balint group process is to other professionals, they nod in acknowledgment, but there is no ‘Wow’ factor in their reaction.  It’s a bit of a disappointment to me.  When the same people observe or participate in a demonstration of a Balint group, they respond with amazement to what they just observed or experienced.  Maybe the problem is my explanation, or maybe you just cannot explain an experience - you have to have the experience.  This problem is a similar challenge to the research question: How does one measure an experience or its impact?   

Balint is not a discrete medical intervention like taking a medication or having surgery.  Those treatments are interventions that are easily researched with experimental and control groups, using placebos and randomized, double blind methods.  Balint group experiences are more about personal and professional development of one’s identity as a physician (and maybe even as a person).  Participating in a regularly meeting Balint group is an experience that may DISRUPT the physician’s pre-determined thinking about their patient or even about themselves, but it does so in a very indirect, thoughtful and respectful way.  

This is the power of Balint - it is not brute force power; it is subtle power.  It is actually the power of not using force.  It is the power of possibility.    It is the power of a culture that values the components of a meaningful healing relationship - listening, emotions, intimacy in relationships (talking about what is meaningful), self awareness and self management.  And, there is a parallel between the doctor-patient relationship and the Balint group-doctor relationship that can produce a meaningful healing experience.  It is the same power in relationships that physicians often use in treating their patients.  Doctors can also disrupt a patients pre-conceived notions about their health or their illness.  In that way, their healing continues long after their doctor’s appointment.  Hopefully, the Balint group experience stays with participants because these discussions are also disruptive.

This difference between an intervention and an experience stimulates for me a question: 

                 What is missing in my typical descriptions of a Balint group?  

• How does one explain the impact of two leaders who function solely to guide the group and to protect group members from themselves?  When leaders are watching the process, I am free to delve into the content of the case without concern about how others in the group will respond.  I know that the leaders have my back!  What possible parallels are there to that separation and clarity of roles, or to the trust that develops between leader and group member - and, could I use that parallel to explain Balint?  
• How does one explain the freedom to speculate about people’s emotional reactions without needing to be correct?  Where else can we share three (or more) different ideas to explain the same event, and not be or feel wrong?
• How does one explain, yet alone describe, the tolerance of ambiguity and uncertainty?  When one does not have to fix a situation, there is much less pressure to generate a good enough or even a better or a best solution.   
• How does one explain the absence of competition among group members?  And in what other ways does a less competitive environment impact the group members and their conversations?  
• How does one explain an emotionally safe learning and sharing group environment?  We are not even aware we have dropped some of our usual defensiveness until we return to our usual world of competition, stresses, and accountabilities.

Some of what I have written above reminds me of an anecdote that captures an aspect of what is unique about Balint.  A number of years ago, I was invited to prepare a talk for a meeting of the International Balint Federation that was held in Chicago.  I talked about the possibilities of using the Balint method with other groups of professionals who had similar types of relationships as doctors with their patients.  In making my case for a broader decimination of the Balint method, I referenced the image of a poster that was created in Portland, OR.  It pictures a group of paintings propped up in front of a museum and in the foreground is the back of a man wearing a trench coat, and he is holding it wide open.  He is presumably wearing nothing else because the caption was “Expose Yourself to Art.”  

I described this image to the group and wondered out loud what a parallel poster saying “Expose Yourself to Balint” would look like.  In the Q. and A. after sharing my thoughts, one questioner astutely suggested that this is part of the problem - participating in a Balint group involves exposing oneself.  I have thought about that observation frequently when I wonder why more people do not participate in Balint.  Exposing oneself feels risky.  I’m concerned about how others will view me after I share my case.  I don’t want anyone to try to change my mind when they hear how I react to some patients.  And until I participate in a Balint group, I don’t know or I can’t imagine what it would be like to feel free to share these thoughts and feelings.  How potentially freeing, and how scary!

Balint is a Culture!

More specifically, it is a culture of relationships; even more specifically, it is a culture of healing relationships between and among health care professionals, their patients and each other.  

Balint is a culture of being as well as doing - The Balint process encourages participants to be in touch with the feelings that get stirred up when they are with their patients - or the feelings that get stirred up when they are with a group of colleagues and hear a case that is presented.   These emotions that get stirred up are at least as important as the medical intervention - they are essential in helping to develop the kind of relationship essential to the healing process.  These emotions and the healing relationship that emerges are at the core of patient centered care.

Balint is a culture of slow, not fast - it takes time to recognize all that transpires in the space between doctor and patient, yet alone within ourselves about our own and our patient’s humanity.  Developing a healing relationship requires an investment of time to listen to and hear the patient’s story and then time to listen to and hear our own self talk about that story.

Balint is a culture of listening, active listening, listening to understand - it is easy to think we understand what is wrong and what is needed if we focus more on the symptom than on the patient.  

Balint is a culture of intimacy, personal and emotional safety - it is helpful to identify what we do to encourage or discourage relationships with our patients as well as with each other.

Balint is a culture of process more than product - creating an emotionally safe, non-judgmental learning environment is essential to being open to our colleagues’ perspectives.  

Balint is a culture of sharing, generosity - We all take a risk by participating, and we all trust the group leadership to protect us all from ourselves as well as each other.  It is the training of our leaders that helps us have the freedom to dig deep into each of our emotional wells to discover, to learn, and to grow.

Balint is a culture of personal and professional growth - The benefit of regular participation includes what we learn about ourselves as people as well as in our work roles.

Balint is a culture that values a diversity of points of view, that celebrates differing perspectives, that invites the less popular constructions of an experience - Often the less popular voice is the less frequently expressed voice and it may be the one we need to hear.  

   Balint is a culture that encourages, values and supports meaningful healing relationships between doctors and patients.  Participation in a Balint group led by a trained leader is an opportunity to learn about the impact that emotions have on doctor-patient relationships, to learn about our own emotional reactions to a wide range of patients and patient challenges, and to share with colleagues one’s own emotional challenges.

Becoming part of the Balint culture requires only a willingness to look at and share of oneself, be open to others’ perspectives, recognize the impact that emotional reactions have on relationships and on health, and realize that, as Michael Balint once said, the doctor is like a drug in his or her impact on patients.   Participating in Balint groups or Balint leader training provides a common experience and an immediate bond among participants, a shared language and in interest in similar goals.

Given all of these descriptors of the Balint culture, it makes no sense to me to do a group that is Balint-like or what some may call Balint-light.  Either the group will be safe enough to explore emotional reactions to patient dilemmas or it’s not.  Either a group is free of judging or it’s not.  Either a group runs the risk of marginalizing a member or it doesn’t.  Either a group member can feel safe to name and acknowledge having a socially undesirable feeling or they can’t.  Balint means a safe space - a group cannot be kind of safe or safe-like.  

If the idea of an emotionally safe group is appealing, try learning how to achieve that goal.  Balint leader trainings are one way to learn, but they are not the only way to learn about group leadership.  And it may take more than one attempt to learn, develop and eventually feel competent at group leadership.  The rewards for the group are immeasurable.

Is Empathy Playing Hide and Seek?

 Is Empathy Playing Hide and Seek?

  I think that there are at least two ‘belief orthodoxies’ in the Balint community: “Participation in Balint groups teaches empathy,” and “Participation in Balint groups combats (if not prevents) burnout.”  It is not surprising, then that so many efforts at documenting (researching) the impact of Balint rely on measures of these two ‘outcomes’ - Jefferson Empathy Scale and the Maslach Burnout Inventory.  However, as I have written previously, most of these research efforts have only modestly positive results.  While it is possible that in fact these are two of the outcomes that Balint group participants may experience, I believe that these two ‘outcomes’ are indirect or second or third tier effects, and that the Balint group process and experience is much more complex and multi-level.  One framework I have used to explore this complexity is a ‘Realistic' research approach which seeks to identify the varying contexts under which an intervention or mechanism of action has its impact and produces some outcome (the C-M-O configuration). 

The implication of “Participation in Balint groups teaches empathy” is that empathy is lacking among participants of Balint groups.  Very often, the cases that are brought to the Balint group are cases in which the physician has difficulty connecting with the patient or a case in which the physician experiences some interference in his/her developing a full understanding of his/her patient’s challenges.  I would like to suggest that these physicians are not lacking empathy at all; however, they have become distracted in the course of providing medical care.  (Thanks to Clive Brock for this idea of distraction!)

What could possibly be distracting a physician who is meeting with a patient seeking their help?   In order to get a better sense of possible or likely distractions, one need only look at a typical day of a physician.  They are scheduled to see patients every 15-20 minutes and very often patients have multiple concerns that need to be evaluated.  There is probably a long list of return phone calls and prescription refill requests to respond to, and the doctor has to record everything he or she does in their electronic health record.  Add to this already full day complications from a patient’s chronic illnesses, interference from insurance regulations that limit payment for preferred treatment strategies, concerns about patients who are seeking narcotics for their intractable pain, delivery of worrisome lab results from patients he saw yesterday,  and on and on.  

Empathy has not disappeared!  Rather, empathy is hiding!  Or possibly empathy is hidden - hidden behind defense mechanisms, hidden behind prejudices about narcotics (or other pet peeves), hidden behind the need to see and fix patients quickly, hidden behind false reassurances, hidden behind medical jargon and procedures and tests.   On many days, many doctors feel like they are under siege.  When any of us feels this way, we hide - we try to disappear- we need time to recoup - 

Nature to the Rescue:

A couple of days ago, after several miserable days of rainy, cloud covered skies, my wife and I were taking a walk in the park, and we were enjoying the emerging sun shine as the cloud covered skies finally began to clear.  My wife commented that “It was great that the sun has finally come out.”  And I thought to myself and then said out loud “The sun hasn’t just come out!  It has always been there - it’s the clouds that have moved, no longer blocking the sun!”   

And it hit me right away!  I have been thinking and doing some writing about the idea that physicians do not lose their empathy.  I would like to make the case that Balint groups do not need to teach empathy!  In fact, like the sun covered by clouds, empathy is always there.  Physicians who are typically empathic did not lose their empathy.  However, it is likely that any one of a number of things have intervened, interfered or otherwise distracted them from a more generous acceptance of their patient’s plight.  So now, the question becomes what is the nature of the interferences or distractions that professionals experience in their efforts to deliver medical care? 

When we are thinking about the sun, the interferences are cirrus, cumulus or stratus clouds, or a low pressure front or a nor’easter.  Wouldn’t it be interesting to have categories of interferences between doctor and patient?  What would the implications be for research?  Clive Brock has published a paper about the roles doctors take on and ways they interfere with the doctor's goals.  It's nice to play the white knight, but there are limits to his ability to rescue!  Maybe Balint group participation teaches emotional intelligence - albeit, indirectly - but E.I. just the same.  Could I possibly give up my fantasy of being a white knight?  I’ll take this on as a future post!  Maybe readers might also make their suggestions …