Sunday, October 2, 2016
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.
Saturday, January 30, 2016
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!