tag:blogger.com,1999:blog-9489095473681426912024-02-19T18:10:44.883-05:00Doctor-Patient ConnectionsCommentary on the human elements of medical care. In particular, the focus is on the experience of being a patient, the experience of being a physician or other health care professional, and the resultant impact on the relationship between patient and physician. These are the key factors on the quality of health care for the patient and on the physician's satisfaction and sense of meaningfulness in their work.Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.comBlogger23125tag:blogger.com,1999:blog-948909547368142691.post-48556324914692904882021-04-02T09:09:00.000-04:002021-04-02T09:09:30.178-04:00Doctor-Patient Relationships - COVID-19 Edition<p> <span style="font-family: "Helvetica Neue"; font-size: 12px;">Welcome Back to Doctor-Patient relationships - a COVID-19</span><span style="font-family: "Helvetica Neue"; font-size: 12px;"> </span><span style="font-family: "Helvetica Neue"; font-size: 12px;">Edition!</span></p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">It has been quite a while without new posts - while I do not have a simple understanding or explanation for the hiatus, I do notice that in the last few months, I have conducted several webinars on Self Care in the time of Covid-19! </p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>For Psychologists - sponsored by PPA</p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>For Veterinarians - sponsored by PMVA</p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">I have no doubt that all other healthcare professionals have similar needs to these three groups. And the need for self care has never been greater! The emotional pain and toll that healthcare professionals have experienced is unprecedented. </p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">I have also recently written several papers for The Pennsylvania Psychologist about what psychologists have reported experiencing in this last year as well as a reflection looking back at how Covid-19 has impacted us personally and professionally (“Witnessing History”). There have been many others writing about and discussing the challenges of healthcare of any kind - and one of the most helpful and significant (I think) is an interview of Christine Runyan, Ph.D. by Krista Tippett for the podcast “On Being” (<a href="https://onbeing.org/programs/christine-runyan-whats-happening-in-our-nervous-systems/">https://onbeing.org/programs/christine-runyan-whats-happening-in-our-nervous-systems/</a>). I’d like to highlight some of what she said and add some of my own commentary:</p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">We all read and hear about the pervasive nature of depression and anxiety among so many people during the past year, the increased demands for psychological services, and the increase in suicidal thinking and even deaths. Dr. Runyan’s comments about the impact of Covid-19 are <b>helpful</b> because she explains what has been happening to us physiologically. They are <b>significant</b> because if we do not understand why we feel like we start our days with less than a full tank of gas or feel like we are down a quart of oil (what are your metaphors?), it is human to wonder what’s wrong with me or why am I having such difficulty getting through the day! </p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">The physical and psychological toll that Covid-19 has taken is real, it compromises our capabilities, it has taken away our “go to” remedies of social and physical connections with family and friends, and according to Dr. Runyan, it has even compromised the connections between our mind and our body. Every aspect of what we do and how we do it has been changed, our routines have been modified, so many parts of our personal and professional lives that we took for granted can no longer be assumed, and it feels like, in some ways, we really are starting over to recreate the lives we have been living. </p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">A stark reality is that our reactions have been <b>normal responses to abnormal situations</b> - Dr. Runyan correctly reminds us that we should not interpret these normal reactions as pathology. Another stark reality is the we will not be returning to <b>“the old normal.”</b> We have all changed - we will be searching to establish <b>a new normal.</b> The adaptations we have made to manage our lives during a pandemic plus social upheaval plus political disruption will not all be temporary. Compared to an ‘old normal,’ in the post-pandemic world, there will be more working from home - there will be more meetings conducted virtually - there will be more attention paid to health and safety precautions - there may be more geographic dislocations - and there may be many other changes or shifts in how we live and work and play yet to be seen. And hopefully, there will also be more attention paid to self care, especially for those health care professionals who take care of others.</p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">At the same time that I’m busy talking and writing about self care for others, I am also confronted by my own increased self care needs! While beginning the preparation of the first of several webinars, my co-presenter sends to me a list of topics we might consider including. This occurred pre-2020 election, and I was experiencing so much personal emotional disruption from the combination of my own sequestration (my garage door did not open for days at a time!), the maddening and increasingly extreme political environment and the surfacing of multiple racial divides. It took several days plus a long email diatribe back to my co-presenter for me to be able to orient to the task at hand! This response gave him permission and/or the example to unload the multiple frustrations he was experiencing as well. We had never before seen these challenges or limitations before planning or organizing our combined efforts. And then we realized that Covid-19 struck again. We could not get back “in gear” until we realized how and why we were “out of gear.” </p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">Stay tuned for additional posts - I have lots of ideas and thoughts about so much that has had an impact on doctor-patient relationships, and I plan to share them with anyone who cares to read about them.</p>
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<p style="font-family: "Helvetica Neue"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;">Finally, whether or not you were wondering, I have no personal or professional interests in recommending Dr. Runyan’s interview other than highlight information and resources that I believe are valuable. We do know each other as respected colleagues who do and did similar work in Family Medicine residencies and beyond. </p>Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-11309152879240076012018-03-29T20:59:00.002-04:002018-03-30T05:06:22.957-04:00I thought you really meant ‘How are you?’<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: "Helvetica Neue"; font-stretch: normal; line-height: normal;">
<span style="-webkit-font-kerning: none;"><span style="font-size: large;">You asked me “How are you doing?” </span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">I thought it was more than a social check-in.</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">Sensing something different than the usual</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">You seem interested, until …</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">And then, I’m not sure what happened</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">I could tell you tuned out</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">What did you detect?</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">Did you even realize something changed?</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">Did it sound like self pity?</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">Or was it something you couldn’t fix with a pill?</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">Did you just not have patience for more?</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">Or were you getting more than you wanted?</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">I heard it in your voice</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">It wasn’t what you said</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">It was a hesitation, a change in cadence, a different flow</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">I didn’t expect a lot in response - I don’t think.</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">I would have liked validation. </span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">Just stay with me for a moment; </span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">Nod, say 'Uh huh,' slow down for a second</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">You had lots of options</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">“I’m sorry” would have been enough</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">“I’m sorry you are burdened by that” would have let me know you heard</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">But … “Better than the alternative” was diminishing</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">And I could also say “Dismissing?”</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">I could feel the distance between us</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">As you backed away emotionally</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">I felt my own ‘leaving myself’</span></span></div>
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<span style="font-kerning: none;"><span style="font-size: large;">While I dismissed my own vulnerability.</span></span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com1tag:blogger.com,1999:blog-948909547368142691.post-35786997052753182802017-08-05T08:07:00.001-04:002017-08-05T08:07:25.715-04:00“There is nothing else we can do for you!”<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: 'Stone Sans ITC TT'; font-size: 18px; line-height: normal;">
<span style="font-kerning: none;">“There is nothing else we can do for you!”</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>In a plenary presented to the American Balint Society’s first National meeting (Estes Park, CO - 2014), Andrew Elder quoted from a presentation made by Ian McWhinney years earlier in 1998 at the 11th International Balint Congress in London to describe Balint’s radically different approach to improve medical communication:</span></div>
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<span style="font-kerning: none;">“The implications of Balint’s ideas for medical education have not yet been addressed. We speak of adding skills and competencies, but not of teaching a new way of being a physician. The difference between these two ideas is fundamental: one is additive, the other transformative; one assumes that the status quo is adequate but incomplete, the other that the status quo is fundamentally flawed; one sees the solution in terms of additional tasks, the other in terms of a transformation that will affect everything the physician does.”</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>This state of medical education remains true today, almost 20 years later. The bulk (maybe the whole) of medical education today is about amassing information about how the human body functions and all the ways that it malfunctions, along with all the remedies we have to correct those malfunctions, from pharmaceuticals to surgeries to alternative interventions. However, every doctor knows medicine’s dirty little secret: that for some patients, doctors will come to the end of their knowledge to understand what is happening and will be at a loss to suggest remedies that will be effective. Some doctors will continue doing what they know, despite the futility of these efforts. It may be too painful to acknowledge their and medicine’s limits. Some other doctors may say “There is nothing wrong with you physically” or “There is nothing we can do for you.” </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>This model of medical education is “additive” in McWhinney’s words. All that is needed is more knowledge about how the body works. Think of a </span><span style="-webkit-font-kerning: none; font-family: 'Noteworthy Light'; font-size: 18px; line-height: normal;"><b>vertical axis</b></span><span style="font-kerning: none;">, and the task for physicians is learning all that they can. Medical culture does not acknowledge that there is a limit to what is known and what is knowable. It also does not help doctors know what they can do for a patient when they get to that limit or even along the way to getting there.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>McWhinney’s (and Elder’s and Balint’s) message is that there is another part of medical education that teaches doctors (and other medical professionals) what else they can do for their patients when they run out of answers or remedies. Consider, for a moment, that there may be a </span><span style="-webkit-font-kerning: none; font-family: 'Noteworthy Light'; font-size: 18px; line-height: normal;"><b>horizontal axis</b></span><span style="font-kerning: none;"> - an axis that is measured not in any quantitative way, but rather in an emotional way. This is not an axis of knowledge - it is an axis of our humanity. It is an axis of our ability to emotionally connect with the emotional experience of our patients - to their vulnerability, and of course, this axis touches our own vulnerability. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Maya Angelou captured the power of emotional connection: “I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” When we listen to and acknowledge our patients’ stories, we help them feel validated, less alone, understood and we even help them to better understand themselves. This is different than trying to solve a medical puzzle with a set of differential diagnoses or the dilemma of which blood test to order or which technological advancement will unlock the mystery of my patient’s ailment. It’s not multiple choice; there is no right answer. This answer does not come from knowing - it comes from being, from feeling.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>It so happens that the road to becoming a physician does not have many stops at the stations named Humanity or Feelings or Emotions. Most physicians know and acknowledge they exist; however, stopping there is often seen as a delay at getting to their destination - a station named Differential Diagnosis and the eventual destination - Treatment. Too many doctors function as if they are on an express train and have learned to not make every stop.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Being in a Balint group helps to unlock some of the keys to helping a patient heal - a distinctly human experience. Too often the image of the patient in bed 2, room 615 does not connect with an image of that same person, as a functioning human being in their own world wearing civilian clothes rather than a hospital gown. We only see that person in their bed!</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>What does Balint teach? Getting to the doctor’s goal is not the whole picture. Doctors have feelings too, and they may be part of the challenge in making a connection with this patient. We all have blind spots, and sometimes colleagues can help us see them, if we are open enough. And much more ...</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>There are other ways this horizontal axis can be taught. There are a wide range of reflective practices that can be helpful. Ron Epstein has researched and written about the impact of the ‘simple’ practice of mindfulness. Narrative medicine helps doctors write out their own stories, and reading what they have written to colleagues releases emotions they were not aware they held. Taking time to step away from the office and the hospital to reflect on ones experiences can add perspective to ones work and begin to help make a series of many discrete events have more meaning. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The ultimate goal - the way health care can be the most effective for both the healers and the patients - is to learn to integrate both these vertical and the horizontal axes. Not all patients are looking for deep connections - many just want to be fixed. What’s the diagnosis and what’s the remedy! However, it is the ones with chronic ailments or undifferentiated symptoms - often the most challenging patients to sit with - that most need the empathetic connection with their physician. Healing is better accomplished when all the medical knowledge that is available is integrated with the caring, gentle hand of the healer who is comfortable addressing the emotional component of the illness experience. Medical education needs Balint groups! These aspects of healthcare are best taught in the protected environment of groups of colleagues where the humanity of the healers is also valued and given the opportunity to emerge. There IS something else we can do for you! We can listen, and, in a variation of Osler’s words, “…get to know the patient who has the symptoms.”</span></div>
Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-7754510704283035922017-04-21T11:12:00.002-04:002018-06-28T15:42:31.389-04:00Observations from the Gurney:<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Tahoma; font-size: 18px; line-height: normal;">
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<span class="Apple-tab-span" style="-webkit-text-stroke-width: initial; white-space: pre;"> </span><span style="-webkit-text-stroke-width: initial;">Whether it is in a hospital or in a doctor’s office, there is a profound shift in the nature of an adult - adult relationship when one of the adults is a patient and the other adult is a physician!</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">Who waits for whom - always?</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">Who is lying down or sitting on an examination table (like a specimen) - always?</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">For the patient, it’s all about being wounded and feeling vulnerable.</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">It includes a feeling of less power, less control, emotional (as well as physical) vulnerability, uneven footing, and, at times, depersonalization.</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">While physicians may feel confident in their mastery of medical knowledge, they may encounter similar emotions in their challenges or worries about how to transfer that knowledge.</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">What is the best way to communicate or have a discussion with the patient and the patient’s family about what they know and what they don’t know?</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">Their own emotional roller coaster may include fear, uncertainty, discomfort and even anxiety, sadness and yes, at times, powerlessness.</span></div>
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<span style="font-kerning: none;"><b>The one part of this scenario that should not have to occur is depersonalization.</b></span><span style="-webkit-font-kerning: none; font-size: 13.3px; line-height: normal;"> </span></div>
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<span style="-webkit-font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>I was recently hospitalized the night before my birthday, and discharged the day after my birthday. On my first full day in the hospital, April 11, I can't count the number of times nurses, techs and other staff asked me my date of birth (while checking my wrist band) and before administering one service or another. When I said April 11, there was </span><span style="-webkit-font-kerning: none; text-decoration: underline;">no</span><span style="-webkit-font-kerning: none;"> sign of recognition that today’s date is April 11 - today is this patient’s birthday! They could have commented (if they noticed): “What a bummer! You’re in the hospital on your birthday!” To one of them, asking: "Date of birth?" I said: “Today,” and she looked at me strangely (it was not the automatic response she expected!), and it took a few moments to catch on. It is evidence of how much of what goes on in the hospital is truly mindless. Any type of mindlessness cannot be good for patient safety or for professional satisfaction. What a lost opportunity to have the human connection every patient craves and each health care professional needs! </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Too often, patients become a number, a date of birth, a condition, a diagnosis or just the occupant in bed 74b. I had more </span><span style="font-kerning: none; text-decoration: underline;">“human”</span><span style="font-kerning: none;"> conversations with the people transporting me throughout the hospital for one test after another than I did with most other hospital personnel. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Gawande writes about becoming a Positive Deviant, and the first of his five suggestions is <b>“Ask an unscripted question.”</b> A script helps to insure we are getting all the information we need; however, if it’s only the script we use, we are on automatic pilot and that’s not good for patient OR physician! My take on this is that if the only things we know about a patient is their medical history and medical condition, we are not treating a person - we are treating a diagnosis, or a wound or an organ. We might as well be back in medical school with our cadaver. </span><br />
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<span style="font-kerning: none;"> <span class="Apple-tab-span" style="white-space: pre;"> </span>Did you ever have the experience of a physician in the hospital coming in to your (or a relative’s) room to give you results of a test? I don't know if physicians realize it, but when the results are good, they come into our room, remain standing, tell us the result and leave right away. When the results suggest a larger problem, they pull up a chair, sit down and say "The results from your (fill in the name of the test) are back and ..."</span></div>
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<span style="font-kerning: none;"><b>My physician sat down!</b> I knew immediately that the MRI showed it was more than a TIA. I’m not sure where my mind went or my blood pressure or my emotions. I’m not even sure if I heard everything she said next. Of course, she stayed a while to talk about the new next tests that were ordered, etc. Whose needs are being met when doctors decide to sit down vs. remaining standing? How nice it would be if physicians sat down no matter what the results are. Even with good results, they could talk with us and help us realize the extent and source of our relief and our fears. Those are part of the patient’s reality as well.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>One other thought / realization I have had while recuperating: <b>diagnoses protect physicians from the emotion of the patient’s experience</b>. It is part of the labeling subculture - necessary for the treatment and billing part of our medical culture, but not sufficient for the caring and healing parts of the subculture we profess to be. </span></div>
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<span style="font-kerning: none;">Communication focussed on the diagnosis allows professionals, who are acting professionally, to stay in their head and to protect their heart and gut. Even during the H & P, the questions are all about what happened and has it happened before, and there is less room for “That must have been scary!” or “You must have been wondering what was happening to you…” </span></div>
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<span style="-webkit-font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>This lesson was highlighted for me recently when a 3rd year medical student - who is in one of my Balint groups - told and eventually wrote beautifully about a series of encounters with a patient on one of his first rotations to observe real patient care. He commented that he really did not know how to do anything medical, so he just talked with this patient and listened. The result in the course of just several days of sitting down and listening to his patient’s story was the development of a profound connection between a patient and a health care professional - a medical student who was not yet a doctor. It seems we have it so backwards or upside down when the person with the fewest ‘medical’ tools in a medical system has the most time to sit and listen, while those with the most ‘medical’ tools have the least time to sit and listen! </span></div>
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<span style="font-kerning: none;"><b>When was listening (not just hearing) considered outside the realm of medical tools?</b></span></div>
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<span class="Apple-tab-span" style="-webkit-text-stroke-width: initial; white-space: pre;"> </span><span style="-webkit-text-stroke-width: initial;">A crucial part of the patient’s healing comes with telling the story - sometimes more than once.</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">We do not have to be psychologists to ask what an experience was like or what remaining fears and worries patients have.</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">We can engage our humanity, validate their emotions, reassure them of our continued participation in their health and recuperation or readjustment journey and then take a deep breath knowing that we have met them where they are.</span><span style="-webkit-text-stroke-width: initial;"> </span><span style="-webkit-text-stroke-width: initial;">We don’t have to be brilliant - just human - and that in itself is healing (sometimes for us as well).</span><span class="Apple-tab-span" style="-webkit-text-stroke-width: initial; white-space: pre;"> </span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-13515407299160785372017-04-02T10:09:00.000-04:002017-04-02T10:09:11.944-04:00What is your doctor's Relationship Quotient?<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; line-height: normal;">
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<span style="-webkit-text-stroke-width: initial;"><span style="font-size: large;">What do I say to a patient who tells me about childhood memories of assault, or sexual abuse, or a traumatic experience? </span></span></div>
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<span style="-webkit-font-kerning: none;"><span style="font-size: large;">What do I say to (or do for) a patient who tells me about their (shameful) addiction to drugs, or alcohol, or pornography, or eating, etc.?</span></span></div>
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<span style="-webkit-font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>To have or to be open to having an emotionally authentic conversation yet alone a relationship with any of these people is to open one’s heart to the human condition in ways that are out of the ordinary. With any new person, we begin at a comfortable distance, and then when we hear their story, we have some automatic, reflexive reaction which may include adjusting that figurative or emotional distance (increasing or decreasing). We may unconsciously erect some protective barrier, or we may possibly embrace the pain and woundedness in our presence. We would like to think we can remain objective, non-judgmental, non-blaming and very self aware, but no matter how often we have heard these stories, it's difficult <b>not</b> to have some reaction. What about our (unknown or unnamed) biases? What attracts us to one individual? What repels us from others? Do we even know what’s happening inside ourselves when it is happening?</i></span></div>
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<span style="font-size: 12px;"> </span><span style="font-size: large;">What is it about some people that make them interesting to us? What is it about some others that make it more difficult for us to connect with and be more understanding?</span></div>
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<span style="font-size: large;">How do I ask questions that are on topics that may be very sensitive to ask and complex to delve into - like sexuality, drug and/or alcohol use, abuse experience?</span></div>
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<span style="-webkit-font-kerning: none;"> There is a significant body of literature supporting the <b>primacy of the relationship between therapist and patient </b>or <b>physician and patient</b> over the particular treatment method or approach of the professional. Simply stated, the most important factor in patient care is the nature of the relationship between the doctor and the patient! Technique is secondary. Physician time spent establishing a relationship is never wasted time! And yet, professionals will argue back and forth about the merits of different techniques or approaches, and they pay less attention to relationship building processes. Research has measured the time it takes some physicians to interrupt a patient’s story in seconds! Interruptions may get us to the core of the symptoms more quickly, but we bypass the patient in the process.</span></div>
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<span style="font-kerning: none;"> As early as 1957, Michael Balint wrote about “… the doctor as drug,” suggesting that the physician’s impact on the patient can be akin to the impact (or side effect) of a pharmaceutical agent. With pharmaceutical agents, the side effect is almost always negative. Once in a while, a medicine is chosen because a known side effect is a desirable one for a particular patient. If we think about “the doctor as drug,” it is an opportunity to have NO negative side effects. In fact, the relationship that is developed can be a multiplier of the purely medical treatment regimin. But this is dependent on the physician’s <b>Relationship Intelligence </b>or their <b>Relationship Quotient</b>!</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>So, a natural question to ask is what are the components of Relationship Intelligence and how does one develop such a skill? It is clear that emotional intelligence is a necessary component - necessary, but not sufficient - especially in the form of listening to self and to others. </span><br />
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<span style="font-kerning: none; font-size: large;"><b>Why is listening such a challenge?</b></span></div>
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<b>Emotion trumps Logic:</b> I often think about a Maya Angelou quote: "I may not remember what you did for me, but I will always remember how you made me feel." It is so ironic because so many physicians will first remember what they did for the patient and only when probed might recall the emotion in the encounter. This is an example of how there can be such a dichotomy between the patient experience and the physician experience. The patient may be sitting with emotionally and physically painful secrets they have never shared - until today. The physician is prepared to ask a few diagnostic questions, chose among several medications they will prescribe and smoothly leave with encouragement and a plan for the next appointment. Doctors are prepared to open the door to the examining room, but maybe not prepared to open the door to the patient's life.</div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"><span style="font-family: arial;"><span style="white-space: pre;"> </span></span><b style="font-family: arial; white-space: pre;">Listening as a billable code:</b><span style="font-family: arial;"><span style="white-space: pre;"> Part of physician's training is to think about how to code this visit to justify billing the insurance company. It's not the first thing on the doctor's mind, </span></span></span></span><br />
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"><span style="font-family: arial;"><span style="white-space: pre;">but they are quick to know that this is a Level 2 or Level 3 visit, for example. They also need </span></span></span></span><br />
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"><span style="font-family: arial;"><span style="white-space: pre;">to be clear about documenting all of their findings in order to justify the medical diagnosis </span></span></span></span><br />
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"><span style="font-family: arial;"><span style="white-space: pre;">and the codes for treatments - especially </span></span></span></span><span style="font-family: arial; white-space: pre;">procedures. Doing a procedure or sending a </span><br />
<span style="font-family: arial; white-space: pre;">prescription to the patient's pharmacy feels like I'm doing something. "Just" listening does </span><br />
<span style="font-family: arial; white-space: pre;">not feel like I'm doing something - no matter what the patient says. </span><br />
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<span style="font-family: arial; white-space: pre;">I wonder if we are </span><span style="font-family: arial; white-space: pre;">teaching the subtleties of listening well enough!</span><br />
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<b> Emotional Arithmetic: </b>When we share good or exciting events in our lives with people who care, the joy gets multiplied. When we share sad or bad events that we experience in our lives, the pain is divided. Sharing our experiences is always a positive - primarily for the sharer. Good things get better; sad or painful things get lessened by virtue of their being shared. However, the experience is different depending on whether we are sharing or we are listening. To fully listen and only listen is a gift! It is like saying (silently): "Let me help carry that load." And to fully listen is to acknowledge the story and to validate the emotions.</div>
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One challenge is to avoid several traps. One is the trap of trying to fix it - it's in our DNA! We are helpers, fixers. We get some of our goodies by relieving pain and suffering. It is easy to forget that really listening, uninterrupted, helps! Another trap is to try to reframe it or put it in a more palatable context - another form of fixing it. Another trap is sharing our marginally similar experience as a way of saying "I know how that feels." which we probably could never know. It is a helpless feeling to "just" listen, yet it is such a gift!</div>
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<b>The Patient vs. The Schedule</b> (all the other patients): When the visit I thought would be routine becomes a drama, my schedule flashes before me and I think about all the other patients I will be seeing and to whom I will have to apologize for being so late. It is so unfortunate that physician's schedules have to be so tightly booked that there is little time for even one drama to pop out and require adequate time. it is unfair to patients as well as to doctors. And the only remedy the way schedules are set up is to make everyone who follows a bit later than they planned or expected. No wonder listening is so challenging.</div>
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<span style="font-kerning: none;"><b> Balance</b> <b>Content with Process</b> - Paying attention to what is said in addition to how it is said is crucial in understanding the complexities in what is being communicated. Recognizing a patient’s reluctance or their anxiety or the tension with which they share information adds to the meaning that sharing may have; it may help to recognize or uncover additional layers of information crucial to understanding that patient 's story. Sometimes, patients do not have the emotional vocabulary to fully express how they are feeling. Sometimes, the best they can do is to demonstrate the anxiety by being anxious or the tension by showing us their tension. It is our task to identify those emotions, to provide the emotional vocabulary. It is another subtlety of listening.</span></div>
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<span style="font-size: large;"><b>The Role of the Physician in the Community?</b></span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>This emphasis on relationship seems in marked contrast to current trends in health care which emphasize efficiency, cost containment and the bottom line, patient improvement as measured by laboratory test results, and patient satisfaction measured by a brief questionnaire. In contrast to more highly valuing healing relationships, this emphasis on efficiency and patient (customer?) satisfaction is more of a focus on the business of medicine. I have wondered how good the Press-Ganey scores would be for Shamanic healers.</span></div>
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<span style="-webkit-font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Balint groups are such a reminder of what components are essential for developing relationships that can be healing. Maybe Balint's impact is to help physicians develop better Relationship Intelligence which leads to better connections with patients and ultimately better care! Part of the process may be revealing or uncovering blind spots. Another way to think about this is that Balint group participation helps physicians to integrate their professional role with their human role. It helps us to listen to ourselves as well as to listen to our patients. We both need to be acknowledged and to be validated! </span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-35796271709872462652017-03-12T10:27:00.001-04:002017-03-12T10:27:32.881-04:00Measuring Balint Group Impact: A Proposal<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>I loved the idea of three levels of impact from Balint group participation that John Salinsky suggested in his keynote address to the 2nd ABS National meeting in July, 2016. Sometimes, a participant is impacted profoundly - an aha phenomena or an epiphany - and other times, the impact is more subtle, more along the lines of support and validation, but no epiphany. I just recently heard a Balint group member ask out loud “What part of me is she (the patient) touching?” and the group continued to discuss this for each of them who felt provoked. I also heard one participant say “I just realized …” and she went on to identify new awareness stimulated by the case and the group discussion. These are examples of knowledge creation as I described it in a previous post. One remaining challenge is to organize or systematize these ‘learnings.’ One place to begin is to review Salinsky’s levels that follow; can you discern distinct content areas within each level? What descriptors would you use?</span></div>
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<span style="font-kerning: none;"><b>Bronze level</b></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You receive all the benefits of the generic small group effects</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You are a member of a group of really nice people doing the same difficult but often rewarding job as yourself</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You have a safe protected space to talk about your work, your feelings, even your mistakes</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You can get advice from colleagues</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You feel that family medicine is not so bad after all</i></span></div>
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<span style="font-kerning: none;"><b>Silver level</b></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You receive all the benefits above, and in addition:</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You develop more interest in the patient as a person</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You have more time to explore their life history</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You have learned to be a better listener</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You are more relaxed at work, with a greater tolerance </i>(and more compassion, more patience)<i> for difficult patients</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You find work more satisfying, patients less persecutory</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>Your feelings are still ambushed by personally disturbing patients</i></span></div>
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<span style="font-kerning: none;"><b><i> </i>Gold level</b></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You receive all the benefits of Levels 1 and 2, and in addition:</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You are aware of projected patient feelings (countertransference)</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You are willing to accept a share of painful feelings, helplessness, anger, irritation</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>You have developed greater self awareness. You recognize why some patients disturb you.</i></span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>Maybe your clinical practice changes for the better. “As they became more accepting of themselves, they were more open to their patients.” (Gosling, 1996)</i></span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>As I reviewed these descriptors provided by Salinsky and I recalled themes that emerged from my own exploration of personal ‘aha’ moments, it seemed that one could separate out three different areas of content that register an impact from participation in a Balint group. The next challenge is to describe distinctly different levels of impact in each of the three areas, I’m proposing we consider a grid such as the following:</span></div>
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">More aware of one’s emotions (sensitivity)</span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Aware of counter-</span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Others have difficult patients</span><br />
</td>
<td style="border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 55.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 117.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Appreciate patient complexity - get to know the whole patient</span><br />
</td>
<td style="border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 55.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Discovery of reciprocal Dr. - Pt. reactions; limited but significant change</span><br />
</td>
</tr>
<tr>
<td style="background-color: #e3e4e4; border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 13.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 98.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #efefef; border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 13.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 90.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #efefef; border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 13.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 117.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #efefef; border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 13.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
</tr>
<tr>
<td style="background-color: #e3e4e4; border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 55.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 98.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;"><b>Dr. - Group Relationship</b></span><br />
</td>
<td style="border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 55.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 90.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Valuing safe, protected space to discuss patients</span><span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 10px; font-variant-ligatures: common-ligatures; line-height: normal;"> </span><br />
</td>
<td style="border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 55.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 117.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Value the role of the Balint group relationships to one’s practice</span><br />
</td>
<td style="border-color: #000000 #000000 #000000 #000000; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 55.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Helvetica; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Healer vs. Doctor: Greater appreciation of the impact of this work</span><br />
</td>
</tr>
</tbody>
</table>
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<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;">Table 1: Balint Impact Framework</span></div>
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<span style="font-kerning: none;"><br /></span></div>
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<span style="font-kerning: none;"><br /></span></div>
<div>
<span style="font-kerning: none;"><div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Three content areas I am suggesting are:</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;">the impact on the individual self, </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;">the impact on the doctor-patient relationship and finally, </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;">the impact of sharing my work with a group of colleagues. </span></div>
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<span style="font-kerning: none;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>In each of the three content areas, the first level of impact is more externally focussed, the second level is more internal, and the third level is more interactional, relating the doctor to their group as well as to their patients. Thanks for this observation goes to Kathy Knowlton, with whom I discussed this framework. We had the benefit of some time together after presenting a full day Balint experiential workshop to about 20 participants at the American Group Psychotherapy Association meeting in NYC (along with Laurel Milberg and Eran Metzger). </span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal; min-height: 16px;">
<span style="font-kerning: none;"></span><br /></div>
<div style="line-height: normal;">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Fresh eyes and new ideas are at the core of Balint groups themselves as well as doctor-patient relationships. Writing can also be part of this generative process! As I read what I have written, I’m realizing that these three levels parallel my observations and description of steps in reflective practice which I wrote about previously: (</span><span style="font-family: Arial;"><span style="font-size: 14px;">“A Guide to Introducing and Integrating Reflective Practices in Medical Education,” The International Journal of Psychiatry in Medicine, Vol. 49 (1) 95-105, 2015)</span></span></div>
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<span style="font-kerning: none;"></span><br /></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>See it to be it (recognize what is happening)</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Name it to tame it (names allow us to talk about experiences)</span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Share it to Bear it (sharing troublesome events reduces the trouble)</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span></div>
<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;">Below is a table of examples that fit into these three levels of each of three content categories:</span></div>
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<tbody>
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<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 3.0px 1.0px; height: 21.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 74.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 3.0px 1.0px; height: 21.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(255, 255, 255); color: white; font-family: Trebuchet MS; font-size: 18px; font-variant-ligatures: common-ligatures; line-height: normal;"><b>Level 1</b></span><br />
</td>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 3.0px 1.0px; height: 21.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 119.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(255, 255, 255); color: white; font-family: Trebuchet MS; font-size: 18px; font-variant-ligatures: common-ligatures; line-height: normal;"><b>Level 2</b></span><br />
</td>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 3.0px 1.0px; height: 21.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 111.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(255, 255, 255); color: white; font-family: Trebuchet MS; font-size: 18px; font-variant-ligatures: common-ligatures; line-height: normal;"><b>Level 3</b></span><br />
</td>
</tr>
<tr>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 3.0px 1.0px 1.0px 1.0px; height: 42.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 74.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(255, 255, 255); color: white; font-family: Trebuchet MS; font-size: 18px; font-variant-ligatures: common-ligatures; line-height: normal;"><b>Self</b></span><br />
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 3.0px 1.0px 1.0px 1.0px; height: 42.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Feeling <b>support and validation</b> from colleagues</span><br />
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 3.0px 1.0px 1.0px 1.0px; height: 42.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 119.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">More willing to <b>acknowledge painful feelings</b></span><br />
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 3.0px 1.0px 1.0px 1.0px; height: 42.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 111.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Aware of <b>counter-transference</b></span><br />
</td>
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<tr>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 56.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 74.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #f0f0f0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 56.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">It’s <b>a relief</b> to talk about this patient</span><br />
</td>
<td style="background-color: #f0f0f0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 56.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 119.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Become a <b>better listener</b></span><br />
</td>
<td style="background-color: #f0f0f0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 56.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 111.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Greater recognition of my <b>emotional reactions</b> to patients</span><br />
</td>
</tr>
<tr>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 70.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 74.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 70.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 70.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 119.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">My feelings still get ambushed by disturbing patients</span><br />
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 70.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 111.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Greater <b>self-awareness</b> - Recognize why some patients disturb you.</span><br />
</td>
</tr>
<tr>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 49.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 74.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #f0f0f0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 49.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #f0f0f0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 49.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 119.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #f0f0f0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 49.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 111.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
</tr>
<tr>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 63.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 74.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(255, 255, 255); color: white; font-family: Trebuchet MS; font-size: 18px; font-variant-ligatures: common-ligatures; line-height: normal;"><b>Dr.-Pt. relationship</b></span><br />
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 63.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">I’m <b>not the only one</b> who has difficulty with this type of patient</span><br />
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 63.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 119.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Develop more interest in the <b>patient as a person</b></span><br />
</td>
<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 63.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 111.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Changes in the Dr. lead to changes for the patient – more <b>perspective</b></span><br />
</td>
</tr>
<tr>
<td style="background-color: #a5a5a5; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 56.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 74.0px;" valign="top">
<div style="font-family: Helvetica; font-size: 12px; line-height: normal; min-height: 14px;">
<br /></div>
</td>
<td style="background-color: #f0f0f0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 56.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 127.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;"><b>Getting advice</b> from colleagues - Hearing how colleagues handle these patients</span><br />
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<td style="background-color: #e0e0e0; border-color: #ffffff #ffffff #ffffff #ffffff; border-style: solid; border-width: 1.0px 1.0px 1.0px 1.0px; height: 56.0px; padding: 4.0px 4.0px 4.0px 4.0px; width: 119.0px;" valign="top">
<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Appreciate the <b>complexity</b> in Dr.-Pt relationships</span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Recognize the type of patient that <b>triggers</b> my reactions</span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Valuing <b>safe and protected space</b> to talk about work, patients, and concerns</span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;"><b>Recognize the role of colleagues and the group process</b></span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Having an appreciation of primary care work</span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Increased <b>satisfaction</b> with work - less bothered by patients</span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">Moved and touched by the sense of <b>community</b> in the group</span><br />
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<span style="-webkit-font-kerning: none; -webkit-text-stroke-color: rgb(0, 0, 0); color: black; font-family: Trebuchet MS; font-size: 12px; font-variant-ligatures: common-ligatures; line-height: normal;">More <b>relaxed</b> at work</span><br />
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>This chart takes the examples Salinsky listed and organizes and, in some areas, expands them into three distinct areas. What is crucial in order for this chart to be useful is the need to delineate three distinct levels of impact so that the difference from one level to the next is a qualitative shift within the same general content area. For example, some of the discoveries participants have about themselves as a result of these case discussions start with a sense of being less alone, and feeling validated and supported at one level. At a second level, they may become aware of being a better listener and more aware of their own emotional experiences, and finally, at a third level, they may develop an awareness of how they react to certain patients and why. I believe there is a similar progression in each of the other two content areas - doctor-patient relationships and the broader perspective of the physician’s role.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>I believe that this or an amended version of this framework can be helpful to identify the knowledge creation that results from participation in Balint groups, and it can further delineate content areas as well as the level or depth of the impact. I also wonder if it might be interesting to use this chart to organize the comments people make when given the opportunity to summarize their learnings or experience at the end of a Balint group’s contract or even after completing a Balint leader Intensive. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The origin of my exploration was John Salinsky’s presentation of his musings about levels of impact. His thinking emerged from returning to Michael and Enid Balint’s book, </span><span style="font-kerning: none; text-decoration: underline;">A Study Of Doctors</span><span style="font-kerning: none;">, written along with Gosling and Hildebrand in 1966. In this book, Michael Balint suggests that his seminars were not for just any G.P.! And he developed a Mutual Selection Interview process to aid in identifying who would best benefit, AND to identify who might be disruptive and should be discouraged from attending. </span></div>
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<span style="font-kerning: none;">What if we had a system for screening residents or only required six (6) months participation and allowed it to be optional after that (as I believe some programs do)? More on this to come!</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>What are your thoughts about the structure of this chart? What is missing or what would you organize differently? Let’s brain storm together!</span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-62229075528656092152017-03-05T07:21:00.001-05:002017-03-05T07:21:01.173-05:00The Power of Ideas - Bridging a Gap?<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span> If you did not attend the American Balint Society’s (ABS) 2nd National Meeting in July, 2016, you missed a lot! You missed the opportunity to spend several days with a group of folks who speak the same language (Balint-ese, I’ll call it), <b>and</b> there were great paper presentations, reports on new directions and programs the ABS is creating, Enid Balint essay contest winners and, of course, we all participated in Balint groups that met for each of the four days. Our next National meeting will probably be held in 2018. Details will be on the ABS web site when it is scheduled and announced. In the meantime, if you need a Balint fix, I encourage you to attend the International Balint Congress to be held in Oxford, U.K. from September 6-10, 2017. Check out the IBF website for more details (there’s a link on the side of the blog and on the ABS website). </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>And “we now return you to: <b>The Power of Ideas!”</b> </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>At last summer’s ABS National meeting, two presentations that profoundly impacted me were the invited Keynote presentation by John Salinsky from the U.K. - our society’s midwife (mid-husband?) - and a theoretical paper by John Muench. Neither paper knocked my socks off at the time, but I have had the opportunity to read and reread them (<i>Shameless Commerce: you too will have an opportunity to read them in an upcoming issue of the International Journal of Psychiatry in Medicine</i>). </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Salinsky’s Keynote (<i>“What Really Happens in Balint?”</i>) was entertaining - as he always is. However, as usual, I did not fully appreciate the wisdom of his observations. Among his comments about what really happens in a Balint group is the notion that there may be different levels of impact from participation in Balint groups. John suggested they could be called Gold, Silver and Bronze levels (in this Olympic year - 2016), and he went on to identify a number of characteristics of each level.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>This idea intrigued me! So, I recently began a conversation with John about these levels, and he shared with me that one source of this idea was embedded in Michael Balint’s curiosity about physicians who discontinued attending his seminars (</span><span style="font-kerning: none; text-decoration: underline;">A Study of Doctors</span><span style="font-kerning: none;"> by Michael and Enid Balint and colleagues and published in 1966). Recently, I, myself was wondering why everyone who attended Intensives with me was not as excited or passionate about Balint groups as I was - a similar question focussed on people’s differing reactions to the Intensive or to the Balint seminar experience. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>So, one unanswered (and possibly unasked) question is: <b>“What accounts for the differing ways that Balint Leader Training Intensive participants or even ongoing Balint group members are impacted by that experience?” </b> The answer is not obvious based on the participant evaluations which are universally positive. Another way to think about this question might be: What draws people to Balint? and What keeps people at a distance? As one might imagine, I have some thoughts about ways to research and answer that question! Maybe you have some ideas too - feel free to chime in about your ideas in comments at the end. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>A second question to consider is: <b>“Can the delineations between Bronze, Silver and Gold levels be distinct enough for these levels to be meaningfully useful?” </b> While I encourage the reader to consider what the content of such levels might be (we all know the value of fresh eyes!), I will also tease you with a promise to share my own variation on John’s very useful beginning - ‘coming attractions.’</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>John Muench’s presentation (<i>“Balint Work and the Creation of Medical Knowledge”</i>) intrigued me in some very different ways, <b>and</b> he totally lost me at the time of the presentation. For me, it was the kind of talk that really required more context than the allotted amount of time could provide. I thought he could have even used an extra slot to provide context for his context. John briefly outlined a history of scientific inquiry and discussed revolutions in scientific thinking along with an exploration into epistemology - the study of where knowledge comes from (Kuhn, 1963, Toulmin, 1990). Having a chance to read the paper at my own pace helped to open up these ideas (<i>again, look for the upcoming issue of IJPM</i>). In particular, John discusses the humanist - rationalist dichotomy or dimension, and the resultant tyranny (my word) of evidence based medicine manifested in the primacy or even exclusivity of placebo controlled, double blind studies. As you might guess, John describes the failure of medicine to incorporate the kind of experience and <b>knowledge creation</b> that a mature, regularly meeting Balint group produces. He does so using Aristotle’s distinction of types of knowing, and in particular, references ‘phronesis,’ a type of practical knowledge which might be viewed today as professionalism. This is distinguished from ‘techne’ which fits more in the realm of the rationally justifiable. If you are interested in diving into this, John would recommend Aristotle’s Nicomachean Ethics, and in particular Book VI, Intellectual Virtue (or maybe he would say “Just read my paper.”). </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>While I might not have done justice to John’s paper, the idea of Balint groups as a creator of knowledge may modify one’s thinking and approach to documenting the impact of Balint group participation. Maybe, instead of trying to measure someone’s score on a scale of empathy or burnout or even job satisfaction, <b>we might want to think about how could we describe the new knowledge that is created</b>. The Van Roy et. al.’s literature review of Balint related publications (2015) suggested that more, well designed qualitative research studies were necessary to document the Balint group participation impact. <b>Now, does it make sense to think more about Salinsky’s three levels of impact and how we might develop such a scale of qualitative changes experienced by Balint group participants? </b>If one proposes a qualitative shift in the way a physician thinks about their patient, measuring more or less of any variable (empathy, burnout, psychological mindedness) is by definition quantitative and insufficient. Michael Balint, himself, spoke about a small but significant change in the doctor’s personality. Let’s use our experience to define the nature of these changes. We see them; we even experienced them ourselves. How shall we describe them in ways that capture these qualitative changes?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span> </span></div>
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<span style="-webkit-font-kerning: none; font-size: 14px; line-height: normal;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="font-kerning: none;"><b>Stay tuned for the following Coming Attractions:</b></span></div>
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<span style="font-kerning: none;">My next blog post with Salinsky’s three Olympic-named levels and my thoughts about a next step!</span></div>
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<span style="font-kerning: none;">The IJPM issue this summer focussed on the ABS 2nd National Meeting</span></div>
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<span style="font-kerning: none;">The IBF’s International Balint Congress in Oxford, U.K. - September 6-10</span></div>
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<span style="font-kerning: none;">The next ABS Balint Leader Training Intensive in Pittsburgh - October 2017</span></div>
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<span style="font-kerning: none;">The ABS 3rd National Meeting - Summer 2018 - to be scheduled</span></div>
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<span style="font-kerning: none;">And your own thoughts and reactions which I invite you to share in the comments section of this blog post - Thank You!</span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-2704875545225745642017-03-02T14:25:00.001-05:002017-03-02T14:25:14.579-05:00“I’m not sure if this is a good enough post, but …”<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 14px; line-height: normal;">
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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 <b>“I’m not sure if this is an epiphany or not, but…” </b>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. </span></div>
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<span style="font-kerning: none;"><b>Why does this happen?</b></span><span style="-webkit-font-kerning: none; font-size: 14px; line-height: normal;"> and </span><span style="font-kerning: none;"><b>Why are we surprised?</b></span><span style="-webkit-font-kerning: none; font-size: 14px; line-height: normal;"> or </span><span style="font-kerning: none;"><b>Why do we chuckle? </b></span></div>
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<span style="font-kerning: none;">I would like to suggest that these disclaimers are the result of two competing un- or less conscious trains of thought:</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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 <b>beginning of today’s case</b> to <b>the end of last group’s case</b>. 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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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.”</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span><b>Our Reactions?</b> 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.</span></div>
Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-80562158497115298572017-02-21T09:56:00.001-05:002017-02-21T09:56:03.616-05:00Doctors ‘Need Their Space!’<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 16px; line-height: normal;">
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span><i>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? </i></span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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 <i>Holding Space</i> 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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Unfortunately, there is no medical school or residency course titled <b>Holding Space 101 </b>or the advanced version,<b> Holding Space 2.0</b>! 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.</span></div>
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<span style="font-kerning: none;"><i><span class="Apple-tab-span" style="white-space: pre;"> </span>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. </i></span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>The advantage of Balint groups is that the group and this <i>Holding Space</i> 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 <i>Holding Space.</i> 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.</span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-13266061494004789862017-02-11T16:23:00.001-05:002017-02-11T16:23:29.317-05:00The Balint Evidence Gap - Part 3<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Arial; font-size: 16px; line-height: normal;">
<span style="font-kerning: none;">The Balint Evidence Gap - Part 3</span></div>
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<span style="font-kerning: none;"><i>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? </i> </span></div>
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<span style="font-kerning: none;"><i>What possible ways of measuring of the benefit of Balint group participation can accurately reflect the range of varying impacts on various participants?</i></span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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)</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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: <i>“What are the outcomes that have occurred due to which interventions and under what circumstances?”</i> 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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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. </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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.</span></div>
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<span style="-webkit-font-kerning: none; font-family: Arial; line-height: normal;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Finally, I just read a 1966 paper of Michael Balint’s where he asks the question: “</span><span style="font-kerning: none;">Should we analysts accept responsibility for developing psycho-therapeutic techniques to be used in medical practice?</span><span style="-webkit-font-kerning: none; font-family: Arial; line-height: normal;">” In addressing this questions, he suggests that “</span><span style="font-kerning: none;">These two roles</span><span style="-webkit-font-kerning: none; font-family: Arial; line-height: normal;"> (Educator or Research Group Leader) </span><span style="font-kerning: none;">are fundamentally different, and in what follows I will try to discuss the consequences of adopting the one role or the other.</span><span style="-webkit-font-kerning: none; font-family: Arial; line-height: normal;">” Balint continues: “</span><span style="font-kerning: none;">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…”</span></div>
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<span style="font-kerning: none;">MY WORKING ASSUMPTIONS AND HYPOTHESES:</span></div>
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<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: 'Arial Black'; font-size: 14px; line-height: normal; margin: 0px;"><span style="font-family: Helvetica; font-size: 12px; line-height: normal;"></span><span style="font-kerning: none;">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. </span></li>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: 'Arial Black'; font-size: 14px; line-height: normal; margin: 0px;"><span style="font-family: Helvetica; font-size: 12px; line-height: normal;"></span><span style="font-kerning: none;">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!</span></li>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: 'Arial Black'; font-size: 14px; line-height: normal; margin: 0px;"><span style="font-family: Helvetica; font-size: 12px; line-height: normal;"></span><span style="font-kerning: none;">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.</span></li>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: 'Arial Black'; font-size: 14px; line-height: normal; margin: 0px;"><span style="font-family: Helvetica; font-size: 12px; line-height: normal;"></span><span style="font-kerning: none;">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.</span></li>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: 'Arial Black'; font-size: 14px; line-height: normal; margin: 0px;"><span style="font-family: Helvetica; font-size: 12px; line-height: normal;"></span><span style="font-kerning: none;">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.</span></li>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: 'Arial Black'; font-size: 14px; line-height: normal; margin: 0px;"><span style="font-family: Helvetica; font-size: 12px; line-height: normal;"></span><span style="font-kerning: none;">John Salinsky’s suggestion of three levels of impact could be a guide to scoring and rating and understanding responses to a qualitative inquiry.</span></li>
<li style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: 'Arial Black'; font-size: 14px; line-height: normal; margin: 0px;"><span style="font-family: Helvetica; font-size: 12px; line-height: normal;"></span><span style="font-kerning: none;">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.</span></li>
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<span style="font-kerning: none;">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.</span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-39181176163248585362016-10-02T10:49:00.002-04:002016-10-02T10:49:57.233-04:00Difficult Doctor-Patient Relationship Questionnaire<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 13px; line-height: normal;">
<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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!</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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.</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>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???</span></div>
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<span style="font-kerning: none;">On a 1 - 5 scale, with 1 = <i>Not at all</i> and 5 = <i>A Great Deal</i>, answer the following questions: </span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How difficult is this doctor’s personality?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How enthusiastic to you feel about seeing this doctor?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How unreasonable were this doctor’s expectations today?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>To what extent does this doctor have health related problems due to drug or alcohol abuse?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How frustrating do you find this doctor?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How upbeat did you feel after seeing this doctor today?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How negative did you feel about this visit?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>To what extent are you frustrated by this doctor’s vague comments?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How demanding was this doctor today?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Do you find yourself secretly hoping this doctor will not return?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How manipulative is this doctor?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How tense did you feel when you were with this doctor today?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Does this doctor understand your explanations about physical symptoms?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How much are you looking forward to seeing this doctor’s next visit after seeing them today?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How pleased are you with your working relationship you have with this doctor?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>To what extent does this doctor neglect health related self care, e.g., diet, hygiene?</span></div>
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<span style="font-kerning: none;"><span class="Apple-tab-span" style="white-space: pre;"> </span>How difficult is it to communicate with this doctor?</span></div>
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<span style="font-kerning: none;">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. </span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-47811655896457720332016-01-30T09:32:00.000-05:002016-02-09T06:42:31.986-05:00What is a Balint group and how does it relate to doctor-patient relationships? <div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 12px; line-height: normal;">
<span class="Apple-tab-span" style="white-space: pre;"> </span> What is a Balint group and how does it relate to doctor-patient relationships? <b> </b>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.</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>However, when I try to explain the Balint group process is to other professionals, they nod in acknowledgment, but there is no <b>‘Wow’</b> 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, <b>or maybe you just cannot explain an experience - you have to have the experience. </b> This problem is a similar challenge to the research question: How does one measure an experience or its impact? </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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. </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>This is <b>the power of Balint - it is not brute force power; it is subtle power.</b> It is actually the power of <b>not</b> using force. <b>It is the power of possibility.</b> 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.</div>
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<b><i>This difference between an intervention and an experience stimulates for me a question: </i></b></div>
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<b><i> What is missing in my typical descriptions of a Balint group? </i></b></div>
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<li><i style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 12px;">How does one explain the impact of two leaders who function solely to guide the group and to protect group members from themselves? </i><span style="font-family: "helvetica"; font-size: 12px;"> 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.</span><span style="font-family: "helvetica"; font-size: 12px;"> </span><span style="font-family: "helvetica"; font-size: 12px;">I know that the leaders have my back!</span><span style="font-family: "helvetica"; font-size: 12px;"> </span><span style="font-family: "helvetica"; font-size: 12px;">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? </span><span style="font-family: "helvetica"; font-size: 12px;"> </span></li>
<li><i style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 12px;">How does one explain the freedom to speculate about people’s emotional reactions without needing to be correct? </i><span style="font-family: "helvetica"; font-size: 12px;"> Where else can we share three (or more) different ideas to explain the same event, and not be or feel wrong?</span></li>
<li><i style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 12px;">How does one explain, yet alone describe, the tolerance of ambiguity and uncertainty?</i><span style="font-family: "helvetica"; font-size: 12px;"> </span><span style="font-family: "helvetica"; font-size: 12px;">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.</span><span style="font-family: "helvetica"; font-size: 12px;"> </span></li>
<li><i style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 12px;">How does one explain the absence of competition among group members?</i><span style="font-family: "helvetica"; font-size: 12px;"> </span><span style="font-family: "helvetica"; font-size: 12px;">And in what other ways does a less competitive environment impact the group members and their conversations? </span><span style="font-family: "helvetica"; font-size: 12px;"> </span></li>
<li><i style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 12px;">How does one explain an emotionally safe learning and sharing group environment?</i><span style="font-family: "helvetica"; font-size: 12px;"> </span><span style="font-family: "helvetica"; font-size: 12px;">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.</span></li>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.” </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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!</div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com1tag:blogger.com,1999:blog-948909547368142691.post-25485613228147601212015-12-27T20:16:00.001-05:002016-01-22T15:22:05.586-05:00Balint is a Culture!<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 15px; line-height: normal;">
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<i>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. </i></div>
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<span style="font-size: 13px; line-height: normal;"><i>Balint is a culture of being as well as doing</i></span><span style="font-size: 14px; line-height: normal;"> </span><span style="font-size: 11px; line-height: normal;">- </span>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.</div>
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<span style="font-size: 13px; line-height: normal;"><i>Balint is a culture of slow, not fast</i> </span><span style="font-size: 11px; line-height: normal;">- </span>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.</div>
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<span style="font-size: 13px; line-height: normal;"><i>Balint is a culture of listening, active listening, listening to understand</i> </span><span style="font-size: 11px; line-height: normal;">- </span>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. </div>
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<span style="font-size: 13px; line-height: normal;"><i>Balint is a culture of intimacy, personal and emotional safety</i> </span><span style="font-size: 11px; line-height: normal;">- </span>it is helpful to identify what we do to encourage or discourage relationships with our patients as well as with each other.</div>
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<span style="font-size: 13px; line-height: normal;"><i>Balint is a culture of process more than product</i></span><span style="font-size: 11px; line-height: normal;"> - </span>creating an emotionally safe, non-judgmental learning environment is essential to being open to our colleagues’ perspectives. </div>
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<span style="font-size: 13px; line-height: normal;"><i>Balint is a culture of sharing, generosity</i> </span><span style="font-size: 11px; line-height: normal;">- </span>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.</div>
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<span style="font-size: 13px; line-height: normal;"><i>Balint is a culture of personal and professional growth</i> </span><span style="font-size: 11px; line-height: normal;">- </span>The benefit of regular participation includes what we learn about ourselves as people as well as in our work roles.</div>
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<i>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</i><span style="font-size: 11px; line-height: normal;"> - </span><span style="font-size: 12px; line-height: normal;">Often the less popular voice is the less frequently expressed voice and it may be the one we need to hear. </span></div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span> <span class="Apple-tab-span" style="-webkit-text-stroke-width: initial; font-size: 12px; white-space: pre;"> </span><span style="-webkit-text-stroke-width: initial; font-size: 12px;"> Balint is a culture that encourages, values and supports meaningful healing relationships between doctors and patients.</span><span style="-webkit-text-stroke-width: initial; font-size: 12px;"> </span><span style="-webkit-text-stroke-width: initial; font-size: 12px;">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.</span></div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>Given all of these descriptors of the Balint culture, it makes no sense to me to do a group that is <b>Balint-like</b> or what some may call <b>Balint-light</b>. 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. </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.</div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-6420950599898464302015-11-03T07:21:00.000-05:002015-11-03T07:29:54.624-05:00 Is Empathy Playing Hide and Seek?<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 16px; line-height: normal; text-align: center;">
Is Empathy Playing Hide and Seek?</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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 <i>contexts</i> under which an intervention or <i>mechanism</i> of action has its impact and produces some <i>outcome </i>(the C-M-O configuration). </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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. <i>(Thanks to Clive Brock for this idea of distraction!)</i></div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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. </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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 - </div>
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<b>Nature to the Rescue:</b></div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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!” </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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! <b>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. </b>So now, the question becomes what is the nature of the interferences or distractions that professionals experience in their efforts to deliver medical care? <br />
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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 …</div>
Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-1364213727948914932015-10-15T17:07:00.000-04:002015-10-15T17:10:41.754-04:00Medical Students and Physicians: Who is Teaching Whom<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 15px; line-height: normal; text-align: center;">
<b>Medical Students and Physicians: Who is Teaching Whom</b></div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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?</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span><b>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. </b></div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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 <span style="font-kerning: none; text-decoration: underline;"><b>The student, the patient and the illness: Ascona Balint Award Essays 2015. </b></span> Reading these papers revealed a familiar process of:</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>identifying barriers to relationships or patient engagement, </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>exploring biases and preconceived ideas, </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>discovering patient stories, </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>developing emotional self awareness </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>and making emotional connections. </div>
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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 </div>
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<span style="font-size: 11px; line-height: normal;"><i> “</i></span><i>…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.” </i></h3>
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(Thank you , Don, for this description!)</div>
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<i><span class="Apple-tab-span" style="white-space: pre;"> </span></i>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!</div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-61490039929528354132015-08-02T12:33:00.002-04:002015-08-02T12:34:48.296-04:00The Balint Evidence Gap - Part 2<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 15px;">
The Balint Evidence Gap - Part 2</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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? </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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?</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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. </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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. </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>The hallmark question is: <b>What is working, for whom and under what circumstances?</b> 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! </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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. </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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 - C<span style="font-size: 10px;"><sup>1</sup></span>, followed by an initial mechanism - M<span style="font-size: 10px;"><sup>1</sup></span>, which yields an initial outcome - O<span style="font-size: 10px;"><sup>1</sup></span>. 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 (O<span style="font-size: 10px;"><sup>2</sup></span>) can become the next context (C<span style="font-size: 10px;"><sup>3</sup></span>). The diagram below details one way to diagram these early steps in a Balint group - follow the arrows: </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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? </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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?</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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?</div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-22594541844210817992015-07-26T08:02:00.001-04:002015-07-26T08:38:14.071-04:00The Balint Evidence Gap<br />
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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? </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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, <b>“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.”</b></div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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. </div>
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<b> Is it possible that in our uncertainty of what to measure or in </b></div>
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<b> our differing ideas of what to measure we are unclear about our target?</b></div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>I finally read John Salinsky and Paul Sackin’s book: <span style="font-kerning: none; text-decoration: underline;">What are You Feeling Doctor: Identifying and Avoiding Defensive Patterns in the Consultation</span>. 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. </div>
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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? </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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! </div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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.<br />
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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?</div>
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<span class="Apple-tab-span" style="white-space: pre;"> </span>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. </div>
Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com2tag:blogger.com,1999:blog-948909547368142691.post-5115562574194589192015-07-25T09:47:00.000-04:002015-07-25T09:47:14.105-04:00What'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!<br />
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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. <br />
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<i> "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></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>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… </i></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>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…</i></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>-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…)</i></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>-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…</i></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>-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…</i></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>-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?!?</i></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>-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…)</i></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>-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…</i></div>
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<span style="font-family: 'Times New Roman'; font-size: 16px;"><i> </i></span><i>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."</i></div>
Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-18222356943237293752015-05-14T11:03:00.000-04:002015-05-14T11:26:27.324-04:00The Doctor is like a Drug, and Empathy is the Mechanism of Action<div>
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<span style="line-height: 18px;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">This was originally written in March, 2015:</span></span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">It seems like the medical world is catching up with Michael Balint! A headline on a recent Kaiser Health News posting says "<a href="http://kaiserhealthnews.org/news/efforts-to-instill-empathy-among-doctors-is-paying-dividends/" target="_blank">Efforts to Instill Empathy among Doctors are Paying Dividends</a>" 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. </span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">TEACHING EMPATHY:</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">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.</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">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.</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">HUMAN BEING vs. HUMAN DOING:</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">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.” </span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">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. </span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">THE DOCTOR IS LIKE A DRUG:</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">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.</span></div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com5tag:blogger.com,1999:blog-948909547368142691.post-3725620348618209652015-05-12T12:23:00.002-04:002015-05-14T11:11:12.658-04:00Balint's Enigma<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 15px;">
This was originally written in February, 2015:</div>
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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. </div>
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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.</div>
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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. </div>
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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.</div>
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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.</div>
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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:</div>
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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…” </div>
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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.</div>
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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:</div>
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YOUNG ALAN </div>
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What’s that you’re reading?</div>
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Christopher shows him: “A Guide to Codes and Cyphers.”</div>
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CHRISTOPHER </div>
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It’s about cryptography.</div>
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YOUNG ALAN </div>
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What’s cryptography?</div>
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CHRISTOPHER</div>
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It’s complicated. You wouldn’t understand.</div>
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YOUNG ALAN</div>
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I’m only fourteen months younger than you. </div>
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Don’t treat me like a child.</div>
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CHRISTOPHER </div>
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Cryptography is the science of codes.</div>
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YOUNG ALAN </div>
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Like secret messages?</div>
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CHRISTOPHER</div>
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Not secret. That’s the brilliant part. </div>
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Messages that anyone can see, but no one knows what they mean, </div>
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unless you have the key.</div>
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YOUNG ALAN (confused)</div>
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How is that different from talking? </div>
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CHRISTOPHER</div>
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Talking?</div>
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YOUNG ALAN</div>
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When people talk to each other they never say what they mean. </div>
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They say something else. </div>
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And you’re supposed to just know what they mean. </div>
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Only, I never do. So how is that different?</div>
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CHRISTOPHER (handing him the book)</div>
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Alan, I have a funny feeling that you’re going to be very good at this.</div>
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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. </div>
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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.</div>
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If you have followed this far, what has this stirred up in you? Feel free to share your reactions!</div>
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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.</div>
Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com4tag:blogger.com,1999:blog-948909547368142691.post-44120438660514416342015-05-09T09:37:00.001-04:002015-05-09T09:37:33.655-04:00Healing, Fixing or Both?This was originally written in November 2014:<div>
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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. </div>
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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?</div>
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<li><span style="-webkit-text-stroke-width: initial;">Healing is a process / fixing is an act. </span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is chronic / fixing is acute.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing takes time / fixing is immediate - a prescription, a procedure.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is providing space and opportunity / fixing is providing solutions.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is being cared about / fixing is being cared for.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing requires trust / fixing requires compliance.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is for the person / fixing is for the injury.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is for the dis-ease / fixing is for the disease.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing supports the relationship / fixing supports the diagnosis.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is validating / fixing is being cured.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is being / fixing is doing.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is accepting / fixing is changing.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is communal / fixing is individual.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is cultural / fixing is biological.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is emotional / fixing is logical.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is asking / fixing is telling.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is curiosity / fixing is labeling.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is understanding / fixing is knowing.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is listening / fixing is talking.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is reassuring / fixing is dismissing.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is patient centered / fixing is doctor centered.</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is: ‘You know what’s best for you.’ / fixing is: ‘I know what’s best for you.’</span></li>
<li><span style="-webkit-text-stroke-width: initial;">Healing is in the relationship / fixing is in the intervention.</span></li>
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How much healing are you doing when you are fixing?</div>
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How much fixing are you doing when you are healing?</div>
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What are your experiences - as a patient or as a health care professional?</div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com1tag:blogger.com,1999:blog-948909547368142691.post-13105582914953196812015-05-09T09:16:00.000-04:002015-05-09T09:27:08.099-04:00I know I have been to a Balint event if ...<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 15px;">
This was originally written in November 2014:</div>
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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</div>
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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. </div>
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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). </div>
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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.</div>
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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!</div>
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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!</div>
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Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0tag:blogger.com,1999:blog-948909547368142691.post-8509187734711224512015-05-09T08:26:00.000-04:002015-05-09T08:26:55.622-04:00Welcome to Doctor - Patient Connections!<div style="-webkit-text-stroke-color: rgb(0, 0, 0); -webkit-text-stroke-width: initial; font-family: Helvetica; font-size: 15px;">
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.</div>
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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 <a href="http://americanbalintsociety.org/content.aspx?page_id=0&club_id=445043" target="_blank">American Balint Society</a>.</div>
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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.</div>
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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. </div>
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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.</div>
Jeffrey L. Sternliebhttp://www.blogger.com/profile/08361269381895133232noreply@blogger.com0