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 …

Medical Students and Physicians: Who is Teaching Whom

Medical Students and Physicians: Who is Teaching Whom

I have recently returned from the 19th International Balint Congress in Metz, France.  What a privilege and an opportunity it is to share and witness the stories that are told in Balint groups with health care professionals from around the world.  In addition, we have the opportunity to listen to scientific papers that are presented by colleagues interested in a better understanding of the doctor patient relationship.  And finally, we have the rare experience of listening to three award winning medical student papers about a specific patient they have cared for and about, along with their reflections of what they have learned in this process.   By the way, the next International Balint Congress will be in Oxford, UK in the fall of 2017.  Check the IBF web site for info.

I continue to be intrigued by the Balint group process and I continue to believe one of the challenges in communicating the value of participation in Balint groups is demonstrating this value in some sort of quantitative way.  Why?  Because if you are not already converted, Balint group participation is not a simple formula for insuring successful patient engagement, and it does not provide simple answers for the challenges that some patients present, and it definitely does not easily or comfortably fit into the tight, fast paced and demanding schedules many physicians endure.  Why should I take even more time away from my private life to fix the problem of not enough time in my private life?

As I alternated attending first, my Balint group, and then medical student papers, and followed again by my Balint group, I observed an interesting irony in this juxtaposition: case presentations about challenging patient encounters in these Balint groups and described by experienced clinicians contrasted with medical student papers about healing relationships with their patients.  Stepping back to look at the bigger picture of the conference, it seems like this is a case of the apprentice teaching the master.  Students don’t need their own Balint groups - they have had the luxury of time with their patients!  In fact, moderators of student paper presentation often remark that it is nice to recall or be reminded of these meaningful experiences that seem less available in practice.  

Not only do these student essays provide evidence of a source of lost joy for physicians, but they also reflect (I believe totally unintentionally) a process that well functioning Balint groups seek to recreate - really getting to know the patient!  Being at this International Congress also gave me access to the recently published The student, the patient and the illness: Ascona Balint Award Essays 2015.   Reading these papers revealed a familiar process of:

identifying barriers to relationships or patient engagement, 

exploring biases and preconceived ideas, 

discovering patient stories, 

developing emotional self awareness 

and making emotional connections. 

In the Forward to this collection of essays, Don Nease, the President of the International Balint Federation, observes that we accompany these medical students on a  

 “…journey (that) passes through stormy seas of illness and emotion toward the  destination of holistic wellness, not just the absence of physical disease. That destination is not always reached, yet through it all the students demonstrate a need to maintain a sure feel on the rudder of their own emotions and a sense of trust in the winds of human relationships.  By accompanying their patients on their journey the students illustrate that even when physical healing is not possible a sense of wellness need not be lost.” 

(Thank you , Don, for this description!)

To me, one of the most interesting of Michael Balint’s suggestions is to consider the doctor as a drug - the idea that doctors impact patients in no less a way than do pharmaceutical agents.  In fact, I recently presented a workshop at the Forum for Behavioral Sciences in Chicago titled:  The Doctor as Drug - Teaching a Pharmacology of Relationships.  However, as I read these student essays and think about the outcomes of Balint group discussions, I wonder who this drug is most impacting - the patient or the doctor!  So, I read and reread the student essays and started to write the patients’ and the ‘doctor’s’ emotions reported by these students.  Stay tuned for that report!

The Balint Evidence Gap - Part 2

The Balint Evidence Gap - Part 2

Where is the magic in a medical visit?  What does it look like or sound like?  What does the doctor say or do that is healing?  What does the patient need?  What are the conditions that support a healing process?  

Interestingly, we can consider the same questions about a Balint group - where is the magic in a Balint group?  What does it look like or sound like?  What do the leaders or participants say or do that are healing?  What are the conditions that support a healing group process?

It’s not a stretch to suggest that most magic in medicine or in Balint groups doesn’t just happen.  It’s the result of great training, good planning and people who are remarkably well tuned into themselves and each other - especially emotionally.  Patients, like Balint group presenters, come to us (the doctor or the group) in need.  They say: “Help me understand my symptoms (or my patient).”  The doctor knows the continuity patient well - the group and its leaders know each other well after they have been meeting for a while.  Michael Balint suggested that the doctor is the most frequently prescribed medicant.  What has not been deciphered is the pharmacology of that medicant.  What are the mechanisms by which the doctors do their healing - the dosing, titration, side effects, etc.  I believe that digging into the components of a Balint group’s process poses the same challenge - what is the pharmacology of the group?  What are the mechanisms of action?  I believe that deciphering these steps will help researchers target primary effects and distinguish primary, secondary, and tertiary effects which might help distinguish among the variety of measures used to demonstrate the effectiveness of Balint group participation.    

With all of this in mind (including the three ‘models’ I listed and described in Part 1),  I’d like to return to a research approach I introduced several postings ago - Realist Methodology. 

The hallmark question is:  What is working, for whom and under what circumstances?  C-M-O configurations refer to Contexts, Mechanisms and Outcomes.  Realist methods assume that not everyone is impacted in the same way by a particular intervention or mechanism.  At the same time, not everyone is starting at the same line or level.  I’m not sure one can control every variable; however, let’s acknowledge that not all Balint groups are the same!  So, let’s start with several stipulations that matter!  

1. Unless the leader(s) are trained in group process in general and/or Balint group process specifically, it cannot be considered a Balint group.  As will be seen below, without the establishment and maintenance of an emotionally safe group environment (a key responsibility of the group leaders), group members will not have the conditions to consider their own emotional struggles with patients.

2.  All group members have varying access to their own emotional experiences, their own level of emotional humility and their own emotional maturity.  Much of these personal characteristics are a function of one’s own developmental history in our families of origin.  These variations will play out in the dynamics of the group and, along with the leaders’ skills, will determine the pace and depth of the group’s development.

3.  There are significant differences in the impact of patient care experiences among health care professionals who are in school, in training or in practice.  Troubling patient interactions have a very different emotional impact on the observer (who has no responsibility for the patient’s care), the trainee (who has a preceptor to go to) and the physician in his or her own office.  

When I consider the process of a beginning Balint group, each step bears attention.  The diagram below represents a teasing apart of the complexity of a Balint group’s process into a series of C-M-O configurations.  I suggest that there is an initial context - C¹, followed by an initial mechanism - M¹, which yields an initial outcome - O¹.  This is then followed by a second level of C-M-O and a third.  It is possible - in fact, not unusual - that a previous outcome (O²) can become the next context (C³).  The diagram below details one way to diagram these early steps in a Balint group - follow the arrows: 

                                                                    

When I think about the Balint group member’s experience, empathy does not emerge as an immediate result.  Using an Emotional Intelligence framework (see the previous post), empathy fits into the social awareness quadrant, and I think it may be a tertiary result only after better self awareness (recognizing one’s own emotions, expanding one’s own emotional vocabulary), and even self management (delaying one’s reaction or judgment).  What if we thought about these effects as a multi-level process, and then devise a measuring approach to take this into account? 

If I think about a psychoanalytic framework, do I want to ask group members if they became aware of being defensive, or if they were aware of the impact that their patient had on them, or if they thought of alternate ways of managing the challenges our patients bring to us?   This process took in depth explorations by Salinsky and Sackin's group.

If I think of the Johari window, do I want to ask about the presenter’s reaction to sharing a private concern about a patient (hidden quadrant) or do I want to explore the presenter’s awareness of revealing a blind spot?

And finally, are already validated questionnaires about empathy, burnout and others sufficient measures of the Balint group experience, or might we consider developing a method or categories to assess and rate the outcome of qualitative interviews?

What do you think?  Join the conversation …

The Balint Evidence Gap

Balint group participants and enthusiasts (myself included) could not be more emphatic about the value of the process, its beneficial impact on group members and the need that practicing physicians (and other health care professionals) have to process the emotional impact of their work.  However, at the same time that this chorus of support exists, there is an equal but opposite sentiment about the effects of Balint groups due to the paucity of measured evidence in support of these benefits.  It’s not that there is zero evidence in support of Balint groups.  It seems that the more quantitative efforts to measure Balint group benefits have been equivocal - with no clear result.  How could this be?  Why is there such a gap?  

At the same time that I’m asking myself some of these questions, I became aware of a recent publication in Patient Education and Counseling (June 2015): “Research on Balint groups: A  literature review” by Van Roy, Vanheule and Inslegers - all from Ghent University in Belgium.  What a valuable effort!  They summarize and organize published Balint related papers by the type of participants, the type of evidence or the instruments used, topics raised and the results or findings.  In the words of the authors, “Research on B(alint) G(roup)s proves to be diverse, scarce and often methodologically weak. However, indications of the value of BG work were found. Therefore, further research is strongly indicated.”

As I reviewed this paper, one observation that puzzled me is the wide range of different measuring instruments that have been used.  My belief has always been that Balint group participation teaches empathy, so using the Jefferson Empathy Scale makes sense - but these results are unconvincing.  I also buy into the value of Balint group participation in preventing burnout, so using the Maslach Burnout Inventory makes sense - but these results are also unconvincing.  These are two of the most commonly used measures, and then I see all the many other measuring instruments reported in the literature.   

     Is it possible that in our uncertainty of what to measure or in 

     our differing ideas of what to measure we are unclear about our target?

I finally read John Salinsky and Paul Sackin’s book: What are You Feeling Doctor: Identifying and Avoiding Defensive Patterns in the Consultation.  This book represents an incredible commitment to the Balint process and to each other.  A group of physicians agree to not only get together regularly to Balint their challenging cases, but they also agree to put themselves under each other’s gentle, but still  analytic microscope to try to make conscious their unconscious processes in responding to their patients.  Interestingly, their target for study is neither empathy nor burnout!  Their target - appropriately enough given Michael Balint’s analytic orientation - is their own defensive patterns. And their idea is that if we become more conscious of how we unconsciously distance patients, we can choose responses and reactions that are less distancing while still taking care of our own needs.  

     So I ask myself: Are our defense mechanisms a reasonable target for our measuring efforts?  While Salinsky and Sackin clearly make the case that defensive patterns intervene and interfere in the doctor patient relationship, their discovery is not the result of a balint group discussion.  It required an extensive seminar like strategy.  While their entire project is a most valuable and revealing contribution to our understanding of conscious and unconscious processes, I’m not sure that it gets us closer to identifying a target outcome to measure.  In the back of my mind, I continue to consider the prototype Realist methodology question: What is it that is working, for whom and under what circumstances? 

One of my several opportunities to lead Balint groups is with third year medical students from University of South Florida’s (USF) Select program.  Their last two years of med school are conducted in Allentown, PA at the Lehigh Valley Health Network’s campuses.  Because I am a member of their faculty, I had the opportunity to participate in a three day Emotional Intelligence (E.I.) Immersion program.  While E.I. is not new to me, it was good to participate with colleagues who are part of these medical students’ training.  And, it gave me another opportunity to think about Balint in yet another  different framework.

                     

As one can see from the above diagram, this is a 2 X 2 grid that considers both recognition and regulation of self-awareness and social awareness.  As you can also see from the examples in each quadrant, empathy is part of social awareness.  I suspect most people would place defense mechanisms in self-awareness, and it makes sense to me to place doctor patient relationships in self management and relationship management.  Cases that are offered to Balint groups may be the result of inadequate self management or less than ideal social management.  Using this model, my target behavior would be neither empathy nor burnout; it would be one of the components of self awareness!  

Finally, a third model has emerged on my Balint radar.  I have the advantage of having conversations from time to time with my department chair, Will Miller.  He was our keynote speaker when the ABS sponsored the 2011 International Balint Congress in Philadelphia.  And he and I typically share ideas about doctor patient relationships.

     Will shared this variation of the Johari Window that he worked on for another project.  If you are not familiar with this model, it was described by Joe Luft and Harry Ingham in 1955.  In it, Joe and Harry juxtapose what is known and unknown about ourselves and about others to yield a 2 X 2 grid with four distinct quadrants.  In our residency, we introduce it as a way to encourage residents to solicit feedback which can make them aware of blind spots.  It is also an opportunity for residents to explore and experiment revealing aspects of their secret or private selves (like fears or medical mistakes) to reduce sources of shame or embarrassment.  The perspective this diagram adds to the Balint discussion is that the disclosure or offering  of a case to the group is in fact revealing something that is secret.  In turn, the group’s explorations of that case serves as possible feedback to the presenter which may contribute to reducing one’s blind spots.  What is known to self but unknown to others gets revealed by a presenter; what is unknown to self but known to others gets exposed by the group.  Now with this perspective, what would be a more direct target behavior to measure?

Michael Balint suggested that participation in his seminars led to a small but perceptible change in physicians.  A colleague, Clive Brock, says that participation in Balint groups makes good doctors into better doctors.  I wonder if in consideration of these three very different models, we (who are interested in the Balint evidence gap) might give more thought to a remedy for this evidence gap.   What specifically are the changes balint group participants experience and what are the conditions that support and allow these changes?  And how do we measure them???  I’ll attempt to answer, or at least address some of these questions in my next post.  In the meantime, I invite your reactions / reflections / and especially any new ideas stimulated by these thoughts.   

What's wrong with the doctor-patient relationship?

     It has been two months since I posted anything here, but it has not been because I have had nothing to say.  Quite the contrary!  I have the privilege of having a summer research intern - supported by my LVHN Department of Family Medicine and the LVHN network - and together we have been working on this question from a number of angles.  Stay tuned for a series of posts catching readers up with my thinking!

     Today, I'm starting with a response to the title question from a practicing physician who will remain anonymous, and who, I believe, speaks for many physicians.  This response is a reminder that many, maybe most, medical encounters are satisfactory or better for both doctors and for patients.  Maybe the number of intruding forces create a shared burden that neither doctor nor patient wants to shoulder.

    "I was thinking about this question after our (conversation) today  (actually, trying to think about this question from the perspective of practicing physicians).  My answer goes something like this…

     I like most of my patients just fine…true, it’s easier to relate to some, than to others…but, I do my best to be fair and open-minded...to try to understand where each is coming from…what it is that they struggle with…how it is that I can try my best to be of comfort and service… I try to give each person who sees me the same care and attention…sometimes, I succeed more than at other times…but, the intent to provide appropriate and thoughtful care to each of my patients is there, nevertheless…    

     What’s wrong in our relationship…?  Actually, there’s too many other people who are intruding into what used to be a private and even sacred relationship…

     -the insurance company wants to determine who I can and cannot see…and what I can and cannot offer to them…(and the government tells me that this is not the case…”you can keep your doctor”…laughable…)

     -the medical-industrial complex has come up with an extremely complex system whereby I have to match my diagnosis of record with intricate documentation parameters in order to get paid a professional’s wage…if I don’t do the documentation correctly (by their definition), payment is lowered or even refused…

     -the lawyers want to sue my _ _ _, just for dedicating my life to this art and wanting to do my best to help people and make my community just a little bit better…

     -my employer has determined how much time I can spend with each patient (“on average”) in order to see enough people and to bill enough for each encounter so that we can “keep the lights on”…since when did business people become in charge of how I should best spend my time?!?

     -the general public thinks that I have much more money from this than I actually do…(not that I entered medicine to get wealthy…I did not…what I mind is the projection that some place on me as having more money and feeling more entitled than I actually do…most of my physician colleagues are like me as well…more interested in helping and serving than in getting wealthy in the process…)

     -Various medical supply companies are always sending me official looking documentation trying to get me to sign for some medical trinket that my patient doesn’t really need…sometimes the patient gets mad at me for declining such trinkets…

     So, I think that my relationship with patients is just fine…not sure that I need a group to tell me that…what I need is to have all of the other people and processes that interfere with my patient work to get the f  out of our way so that my patient and I can do the work that we need to do together."

The Doctor is like a Drug, and Empathy is the Mechanism of Action

This was originally written in March, 2015:

It seems like the medical world is catching up with Michael Balint!   A headline on a recent Kaiser Health News posting says "Efforts to Instill Empathy among Doctors are Paying Dividends"  This is actually a well written article that highlights a number of efforts to teach physicians a contemporary variation of the old notion of ‘bed side manner.’  These newer programs are based on neurophysiology, have a hint (but only a hint) of an awareness of true psychosomatic medicine (stay tuned for another posting on this topic!), bring attention to one’s own emotional state and provide evidence of the benefit of listening to the patient’s story in the form of trusting relationships and reduced burnout.  They go by catchy names like Oncotalk, Vital Talk, and Empathetics: The Neuroscience of Emotions.  Google these program names - I think you will be impressed.  They come from programs at Duke and Mass General, and there is also a reference in this article to the well known Narrative Medicine program at Columbia as well as the Jefferson Empathy Scale from Philadelphia’s Jefferson Medical School system.  

TEACHING EMPATHY:

However, all these programs beg the question of what is the best way to teach empathy!   There seems to be a tension - especially among medical trainees - between more didactic approaches (such as the programs identified above) on the one hand, and more inductive or socratic approaches - like Balint groups or other reflective activities - on the other hand.   In my own teaching experiences, I have heard medical students describe emotion laden situations and literally say “I did not know what to say!”  How sad and scary and what a lost opportunity.  It seems to me that the more didactic programs fit right into the typical learning paradigm for medical students and residents - tell me what I need to know and what I should do.  What does it mean when  a patient looks puzzled in response to hearing a new diagnosis?  What should I say in response?  This kind of approach may actually be helpful to a resident who has not paid attention to their own or to other people’s facial expressions.  It may also be helpful to provide a number of alternate responses.  However, it will be crucial to help residents learn to engage their own personhood in reaction to patient struggles.

In turn, this typical medical learning paradigm may help to understand why more emotion based and inductive approaches are less comfortable for medical professionals in training.  These approaches require physicians to shift gears, so to speak.  They require engaging different parts of our brains - or at least integrating our left and right brains - to better understand “What is needed in this situation.”  If the only time residents have to shift gears is for this once or twice a month, hour long Balint (or other reflective) group process, it is no wonder that they may question what this is all about and say you have not explained how this will help me treat patients.  I think about the adage “When I’m wrestling with alligators, it is difficult to remember that my goal was to clear the swamp.”  Somehow, ‘just’ listening doesn’t seem like it will help me figure out what’s happening for or to this patient - especially in the context of off the chart numbers from their blood tests or alarming results from a scan!  However, the reminder “Don’t answer a feeling with a fact” is easier, and maybe more comfortable than trying to access one’s own emotions.  Maybe if my choices are to be an 'expainaholic' (as referred to in the Kaiser article) or to be a listener, being a listener becomes possible.

HUMAN BEING vs. HUMAN DOING:

Medical training, practice and economics are so tied into rapid diagnosis, proper laboratory tests, appropriate use of scans and other technology, and judicious choices of specialist referrals that it is easy to forget one of Osler’s maxims: “It is better to know what kind of person has the disease than to know what kind of disease the person has.”  

Not only are physicians and other medical professionals lulled into a “What can I do for the patient” mentality, they forget that listening to the patient’s story can be a billable ‘procedure.’  So often, I hear residents tell a story of being the first person to whom a patient has shared her history of abuse, and then say they did nothing for that patient.  This is a teaching moment that is not didactic - it is human!  And this resident and her colleagues who hear the story of this encounter also learn by being touched emotionally by the trusting relationship inherent in this report.  All medical professionals have this opportunity to have their humanity stirred by patient revelations, and all the patients who have such a professional to talk to have begun a process of healing.  It is our human being-ness, not our human doing-ness that is the mechanism of action in this our patient’s healing process.  

THE DOCTOR IS LIKE A DRUG:

Philip Hopkins, a member of one of Balint's first group seminars, has quoted Balint (in Integrated Medicine: the Human Approach, H. Maxwell, ed.): “The discussion quickly revealed - certainly not for the first time in the history of medicine - that by far the most frequently used drug in general practice was the doctor himself…”  Hopkins adds “…there was no pharmacology described anywhere about this important ‘drug’.”  This is in contrast to “… carefully controlled experiments with which every new drug is introduced…”  Maybe the focus on empathy is a beginning of developing a pharmacology of that drug we call the doctor.

Balint's Enigma

This was originally written in February, 2015:

From time to time, people who know of my involvement with Balint work ask me about evidence demonstrating that Balint works - whatever ‘works’ means and however it is measured.  So I have had an interest in research to validate and support professional investments in conducting and participating in Balint groups.  I have however struggled with how to approach this challenge.  

Coincidentally, the North American Primary Care Research Group’s (NAPCRG) winter meeting was held in New York City this year - a two hour drive for me - so I decided to attend.  I not only attended NAPCRG, I attended a pre-conference workshop on Realist Methodology.  And I got hooked enough to use this platform to begin an exploration into a research approach to explaining the value and power of Balint work.  Rather than charge forward, I’m thinking I want to get a better picture of what has already been explored and what we can learn from these explorations.  I don’t think there has been a literature review about the benefits of Balint groups, so I began asking questions using a ‘Realist’  approach.

The core Realist question and challenge is to ask: What is working, for whom, and under what circumstances!  Just asking the question this way intrigued me and started a thinking process about the impact balint has with different groups of participants.  What if we examine ‘data’ separately - qualitative and quantitative - depending on who was in the group.  Surely, medical students, residents and physicians in practice would have very different experiences in a Balint group.  Also, measures of empathy (Jefferson scale) and burnout (Maslach inventory) would yield very different conclusions about Balint work.  

One other challenge that Realist Methodology provides is to ask what theory we are testing when we do research about Balint group participation.  Clearly, the overarching approach of Michael Balint is psychoanalysis.  Balint groups are clearly not testing out psychoanalysis.  So, more specifically, how might we articulate a theory on which this process or intervention is based?  This is a very interesting endeavor - try writing down what you think the theory is behind Balint groups, and do it in a way that is testable.  I believe that Balint groups are really an intervention - an intervention into the training of residents or an intervention into the practice of medicine.

Realist Methodology would call an intervention like Balint groups a mechanism, and the result is referred to as an outcome.  The different conditions, different nature of the participants (medical students to practicing physicians), or other distinguishing factors are referred to as contexts.  We might even think about the participant’s receptivity to emotional factors or the nature of their blind spots as contexts to consider. The oversimplified equation then is: C + M = O.  In what contexts will any of a number of mechanisms lead to certain outcomes?  A Realist review is called a Synthesis because it is more than a listing and summary of references - it includes an analysis along the lines of this equation.  In short it seems like a re-examination of reported results through a Realist lens.

One direction this has taken me is to dive back into our (Balint proponents) history, published or not.  It has led me to discoveries written by not only Michael and Enid Balint, but also writings by John Salinsky and Paul Sackin, Greco and Pittinger, Andrew Elder and Oliver Samuel, additional volumes in Balint’s Mind and Medicine monograph series, and finally Philip Hopkins who I want to quote and paraphrase:

Hopkins started as a surgeon but this work failed to satisfy his desire for relationships with patients.  When he was able to shift into general practice, he says he felt ‘lost’ and unprepared by medical school.  “I realized why I had not been fully satisfied by my surgical work when I was treating only parts of my patients.  I found I was interested in patients as people…” 

This need that was not satisfied by ‘refresher courses’ led to Hopkins’ responding to “…an announcement in the medical press in 1950 inviting general practitioners to attend ‘an introductory course in psychotherapy for general practitioners …’ at the Tavistock Clinic in London.”  Hopkins also references another announcement in the medical press in 1952 “…inviting general practitioners to attend ‘a course of research cum training meetings for the purpose of studying psychological problems in general practice.’ ”  As part of these initial seminars, Hopkins also refers to Balint’s oft quoted observation that the most commonly applied mendicant was the doctor him (or her) self, and that there is no pharmacology of this most often used drug.

I’d like to offer a digression which I will connect very shortly.  I recently saw the movie The Imitation Game (which I cannot more highly recommend!).  It is the story about Alan Turing who was instrumental in breaking the code of the German’s WW II cryptography machine - Enigma.  In the movie, there is a conversation that the young 15 year old Alan (Turing) has with his one friend while at Sherborne school for boys:

YOUNG ALAN 

What’s that you’re reading?

Christopher shows him: “A Guide to Codes and Cyphers.”

CHRISTOPHER 

It’s about cryptography.

YOUNG ALAN 

What’s cryptography?

CHRISTOPHER

It’s complicated. You wouldn’t understand.

YOUNG ALAN

I’m only fourteen months younger than you. 

Don’t treat me like a child.

CHRISTOPHER 

Cryptography is the science of codes.

YOUNG ALAN 

Like secret messages?

CHRISTOPHER

Not secret. That’s the brilliant part. 

Messages that anyone can see, but no one knows what they mean, 

unless you have the key.

YOUNG ALAN (confused)

How is that different from talking? 

CHRISTOPHER

Talking?

YOUNG ALAN

When people talk to each other they never say what they mean. 

They say something else. 

And you’re supposed to just know what they mean. 

Only, I never do. So how is that different?

CHRISTOPHER (handing him the book)

Alan, I have a funny feeling that you’re going to be very good at this.

I find this idea of talking as a code fascinating.  I never thought about it this way, and yet, clearly, my training as a psychologist helps me to ask questions about what is not said, but implied - or questions about the sources of people’s beliefs - or other kinds of questions as well.  So, I’m thinking about this metaphor of a code and wonder if it might be useful in understanding some of what a Balint group does for participants: provide an entry to the code of unspoken emotions - the patient’s AND the doctor’s.  Clearly this is not the kind of code with a specific 1:1 key.  But maybe this idea could somehow contribute to developing a specific theory of Balint work.  And maybe it is a code that contributes both to empathy, burnout prevention as well as to overall higher emotional intelligence.  

I also love Hopkins’ (unintended) metaphor of being lost.  Whether we think of being lost in a forest or a ghetto or any other place that is strange to us, figuring out the language, the clues, and the signs that help us find our way is another possible route to understanding and explaining the value and power of Balint work.

If you have followed this far, what has this stirred up in you?  Feel free to share your reactions!

P.S. If you are interested in learning more about Realist Methodology, check out the web site www.ramesesproject.org  there are many resources including links to manuals, videos and many other references.

Healing, Fixing or Both?

This was originally written in November 2014:

     One of the profound difficulties that doctors face during their training and practice is that some of their patients, over time, will be physically declining - no matter what the doctors do.  Physicians' goals are to delay that inevitability for as long as possible while hopefully improving a patient's quality of life!  Some conditions cannot be cured.  However, one saving grace that (frequently) accompanies this awareness is the recognition of the value of joining with the patient on their health seeking journey - regardless of the outcome.  It is a privilege, albeit painful at times, to be involved and included in a patient’s most intimate and emotional moments in their lives.  I believe more healing is done in the simple acts of humanity like caring, witnessing and validating rather than ordering and performing labs, tests and procedures. 

     Working with Family Medicine residents has alerted me to the struggle many physicians have at understanding that their healing impact on patients far exceeds their ability to diagnose and treat ailments!   A second struggle is the recognition that healing is what can happen when two human beings share a moment of intimacy.  This aspect of doctoring seems such a contrast to the nitty gritty of Dx and Tx - it requires shifting gears, slowing down, and focusing more on the person who is bringing in the illness than on the illness the person is carrying.  As part of an effort to identify these two gears, I started to generate a list of these contrasts in how one functions as a physician.  See what you think - Add some others in your comments - Share your thoughts about what might be a good (or better) contrasting term for healing.  I used fixing - I thought about curing or treatment - what other contrasts are there for healing?

• Healing is a process / fixing is an act. 
• Healing is chronic / fixing is acute.
• Healing takes time / fixing is immediate - a prescription, a procedure.
• Healing is providing space and opportunity / fixing is providing solutions.
• Healing is being cared about / fixing is being cared for.
• Healing requires trust / fixing requires compliance.
• Healing is for the person / fixing is for the injury.
• Healing is for the dis-ease / fixing is for the disease.
• Healing supports the relationship / fixing supports the diagnosis.
• Healing is validating / fixing is being cured.
• Healing is being / fixing is doing.
• Healing is accepting / fixing is changing.
• Healing is communal / fixing is individual.
• Healing is cultural / fixing is biological.
• Healing is emotional / fixing is logical.
• Healing is asking / fixing is telling.
• Healing is curiosity / fixing is labeling.
• Healing is understanding / fixing is knowing.
• Healing is listening / fixing is talking.
• Healing is reassuring / fixing is dismissing.
• Healing is patient centered / fixing is doctor centered.
• Healing is: ‘You know what’s best for you.’ / fixing is: ‘I know what’s best for you.’
• Healing is in the relationship / fixing is in the intervention.

How much healing are you doing when you are fixing?

How much fixing are you doing when you are healing?

What are your experiences - as a patient or as a health care professional?

I know I have been to a Balint event if ...

This was originally written in November 2014:

I was sitting in the last row of the 5:30 AM shuttle from the Marriott Hotel to the Denver airport.  The van was almost full, and we were making one last stop.   Out of the fancy hotel entrance came a somewhat disheveled man in his mid-30’s, I’m guessing, carrying only a shopping bag from Walmart.  Although most people are dragging luggage, I really didn’t think much of it.  Until I heard two female

airline attendants (who were sitting in front of me) begin to make total fun of this Walmart shopper, criticizing his appearance, his ‘luggage,’ and his gait.  It was loud enough for everyone on the van to hear, and I’m sitting in the back thinking: “Wow,  you two are brutal!”   I was a little surprised at my reaction.  I’m not always so sensitive to how people who I don’t know treat each other.  And then I remembered - I’m just coming from the American Balint Society’s First National meeting in Estes Park.  

              

      It happens without knowing it and without intentionality.  And, obviously it doesn’t have to only be a Balint Intensive.  There are norms to all group gatherings. They may be implicit or explicit.  At Balint meetings - even International Balint Congresses or International Balint Leadership meetings - the norms have become implicit because they carry over from learning the Balint method.  These norms include confidentiality, ownership (speaking for oneself), respect for others' views, and honesty (speaking one's truth).  

     The result of these habits of self management yield an emotionally safe learning environment.  When we are confident that our group leaders will maintain this safe environment, we unconsciously relax our typical alertness and our defenses.  What is left is a heightened emotional sensitivity, and this adjusted state of being contributes to the quality of the work of the Balint group.  This is an unconscious relaxing of our typical state of awareness.  So, when we leave the event, we do not consciously revert to some default self protective, less sensitive 'normal' state of mind.  What sometimes happens is that we have an experience where we realize we are still in our "Balint" mode, and that awareness helps us ease back into our typical lives.

Join us whenever you have an opportunity to attend a Balint 'event.'  It could be a Balint Leader Intensive - training to lead a Balint group, or a Balint Weekend - a chance to present cases of patients who stay on your mind, or even the next Balint society meeting or an International Balint meeting - like the one scheduled in Metz, France in September 2015. You will begin to experience and appreciate what it means to be in a Balint state of mind!  You may also realize that this Balint state of mind is not our default, and then you might wonder what are the implications for learners who have to shift from their default state of mind to Balint and then back to default!

I wonder if there are implications for scheduling your local Balint group or for helping residents ease into the process.  I know I have to be very conscious about my own self awareness when I want to shift into a 'safe' learning mode.  What do you notice at the beginning of your Balint groups?  Is there anything you do to help this process?  How about a mindfulness moment?  Any other cues in addition to "Who has a case?"  I would be interested to hear others' experiences.  Thanks for sharing!

Welcome to Doctor - Patient Connections!

The doctor can be the most powerful drug a patient experiences;  AND - physical dis-ease - no matter what the cause - can be one of the most unsettling circumstances people, who become known as patients, endure.  The connection between doctor and patient may be the primary determiner of the course of the patient’s healthcare outcome and experience.

This blog - Doctor - Patient Connections - will focus on this relationship between doctors and patients.  Central to this focus is the Balint method.  Balint is a group process designed to create a safe environment for a regularly meeting group of physicians (and/or other health care professionals) to explore and better understand the nature of the relationship between a doctor and one of his or her patients who stays on their mind.  To learn more about the Balint method, I encourage you to explore the web site of the American Balint Society.

The purpose of this blog is to explore the issues and challenges (for both doctors and patients) of providing and receiving great health care.  In particular, we will also explore the experience of leading a Balint group as well as participating in a Balint group.  This also means that we will be taking a look at the patient's perspective.

Comments on these posts are welcomed.  There may be an occasional guest blog.  There will be NO confidential doctor or patient information published, either in a post or in a comment.   

I hope the audience will be anyone and everyone who is interested in, involved in and invested in the nature of doctor - patient relationships.  You do not have to be a member of the American (or any other) Balint Society to follow or comment on posts in this blog.  Our hope is that we can make a connection with you, our readers and our co-travelers on our healthcare journeys.  If you would like to receive notices of new postings, click on "Subscribe" next to the RSS icon.