Thursday, May 14, 2015

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.  

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.

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.  


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.

Tuesday, May 12, 2015

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:

What’s that you’re reading?
Christopher shows him: “A Guide to Codes and Cyphers.”

It’s about cryptography.

What’s cryptography?

It’s complicated. You wouldn’t understand.

I’m only fourteen months younger than you. 
Don’t treat me like a child.

Cryptography is the science of codes.

Like secret messages?

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? 


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  there are many resources including links to manuals, videos and many other references.

Saturday, May 9, 2015

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.