Balint groups: psychosocial nonsense or a real insight into the doctor-patient relationship?

We have all come across them, but how should we react? That patient who keeps returning to their family doctor, with volumes of notes, numerous letters from specialists, but no disease is ever found. Or the patient who has not visited the doctor for 20 years and then presents with depression but says he or she does not want to talk about it. And then there is the patient who keeps bringing you gifts. This is where psychosocial medicine comes in. Love it or hate it—you cannot ignore it.

Around the world, medical training is increasingly demanding an understanding of patients' problems that goes beyond the organic nature of disease. Some students resent having to study these "soft" behavioural and social sciences, which take them away from the "real" medicine of anatomy, physiology, and pharmacology. Yet to ignore the powerful influence of health beliefs and emotions is to deny the psychosomatic dimension of many patients' presentations.

A key element is how the doctor responds in the consultation room. Indeed, the doctor-patient relationship itself can be a powerful therapeutic tool. But it is also important to acknowledge how some patients make us feel. Understanding our own emotional responses to difficult consultations can sometimes shed light on the patient's underlying problems.

JUST ART/BRIAN JAKOB/PHOTONICA

To explore these issues in the doctor-patient relationship we attended a weekend in Oxford, organised by the Balint Society. Who are they? Good question-until the advert appeared in the studentBMJ we had not heard of them either.

The UK Balint Society is part of an international federation of 36 member countries which continues the work of Hungarian psychoanalyst Michael Balint and his British wife, Enid. The Balints wanted to integrate psychological thinking into doctors' training and started groups in London in the 1950s where doctors could discuss "difficult" patients and their reactions to them. Participating in Balint groups helped doctors to understand their own and their patients' feelings, thoughts, and motivations. Sounds a bit touchy feely? Well, yes: the sessions do not end with a group hug, but they are a far cry from surgical ward rounds.

The weekend consisted mainly of work in small groups. Each group met for two hours several times during the weekend to discuss prepared cases. One doctor wanted to talk about how she had found herself despising a patient just because the patient had never had a job. Another member spoke about the problems he faced, as a part time family doctor, giving adequate support to a demanding patient. One medical student raised the issue of how he had tried to deal with an inappropriate advance by a patient. After the person had outlined their case, others would offer their perspective on that particular doctor-patient relationship. The weekend also had a number of plenary sessions, in which recent research on the impact of attending Balint groups was presented.

We had different views about the weekend. One of us (BR) became a card carrying member, but the other (WB) had serious reservations. The case studies of patients in the groups were quite intense, with people offering their own analysis of what was really going on in the consultation room. But this sometimes felt like unscientific psychobabble or a therapy session for the doctors involved, and often ignored what the patient had actually said and done, in favour of a "deeper" interpretation. Why did she sit with her legs crossed? Maybe she was abused as a child.

However, the case discussions did provide a rare opportunity to view the patient as a complex, multilayered individual with many motives and life circumstances which might combine to explain their visit to the doctor. It also allowed group members to examine their own emotional responses to patients, something that doctors rarely have a chance to explore in any depth. And in today's climate, in which medical students are taught the importance of empathy and communication skills, the next generation of doctors will probably be more open to this kind of analysis of their interactions with patients.

But will it make you a better doctor? And do busy clinicians really have time for Balint groups? What is clear is that to be a good doctor requires some kind of reflection on your dealings with patients, whatever form that takes. The question that remains unanswered is whether Balint groups offer a practical and evidence based solution. However, we can all agree that to fully understand patients' complaints we need to have an insight into the various dimensions of health and illness, both organic and inorganic. We ignore psychosocial medicine at our peril.

   

           

Responses published this month Articles Responses REVIEWS Balint groups: psychosocial nonsense or a real insight into the doctor patient relationship?       Bruno Rushforth and Wendy Brown (April 2004) Ruth Shaw (May 13, 2004) Read this response REVIEWS Balint groups: psychosocial nonsense or a real insight into the doctor patient relationship?       Bruno Rushforth and Wendy Brown (April 2004) Ruth Shaw (May 13, 2004)       former tutor in medical sociology University of Londond.evans@rfc.ucl.ac.uk Editor-The role of psychosocial factors in health care, first promoted by the Royal College of General Practioners in their manifesto in 1972 has become widely incorporated into the profession of medicine both at the general practice level and also in hospital specialities. Interestingly, Rushforth and Brown(1)pose the question whether Balint groups offer a practical and evidence based style of doctoring for the consultation. This involves being aware both of the need for evidence-based clinical data and also for the nature of the communication in the doctor-patient relationship. By way of example it might be worthwhile to consider Balint groups for G.P. registrars who undertake these seminars as part of their training for general practice. G.P. registrars enter general practice having been trained and educated in hospital medicine. Having absorbed the 'clinical gaze' an initial reaction to general practice is often one of confusion and bewilderment at the training provided for their specialty which provides a new educational setting 'openess' rather than 'closure'. A feature of these groups is that they incorporate both change through peer-review and also change through small-group dynamics. These changes provide a new approach to clinical knowledge and the doctor-patient relationship. In the groups participants present cases from their consultations and gradually through peer-review and group processes the doctor-patient relationship presented in the case is examined. Moreover, as boundaries are lowered between participants, registrars gain insight into how their values, attitudes and emotional responses to the patients affect the consultation and in particular their doctoring-style. G.P.'s however, have been cautious about implementing evidence-based medicine in their consultations. According to Freeman and Sweeney(2), one of the reasons is due to the nature of the doctor-patient relationship which depends on its style and whether it is patient-centred. The aim of their study was to see how a Balint-style group could enable G.P.'s to understand the process of how an evidence-based model worked in general practice. They found that on the whole G.P.'s did not implement evidence-based practice in the consultation and it is certainly hardest in a patient-centred one where the patient contributes to the decision-making. It can be argued that evidence-based medicine is an example of an epidemiological approach in which the guidelines it states help to look afer the patient. Whether this can be incorporated into the very specific process of a Balint-style conultation needs further exploration. Undoubtedly with the Balint-style patient-centred consultations it is less easy to implement evidence-based meidicne. However, Balint-style techniques are particularly well suited to the discussion of chronic conditions incorporating evidence-based medicine. Rushforth B, Brown W. Balint groups: psychosocial nonsense or a real insight into the doctor-patient relationship? studentBMJ 2004;12:172. Freeman A C, Sweeney K. Why practitioners do not implement evidence; qualitative study. BMJ 2001;323:110.