"I've been part of a Balint
group as a community doctor for 24 years," says
Ottawa family doctor and university lecturer Miriam
Salamon. Her Balint group, run by psychiatrist Barry
Dollin, may in fact be the longest running group in
the world. "I put it online [on a Balint group
discussion forum] and there hasn't been anybody who
has beaten that." Her pride is apparent.
Dr Dollin's Balint group of family
physicians has been remarkably stable; the group began
with 10 members and now has nine, with only a few personnel
changes over the years. He chalks it up to the group's
impressive chemistry.
Their group operates fairly informally.
The doctors start off just chatting about how things
are going, and then somebody brings up a difficult case
they want to talk about. "I often describe it to
residents as the 'heart-sink patient,'" says Dr
Salamon, "the kind of patient when you see them
on your list for the day you think, 'Oh no.'"
Occasionally, the discussion can
get very emotional; some doctors have broken down in
tears. "The case is taken as far as the doctor
wishes it to go," says Dr Salamon. "But there
are very solid boundaries. You expect the others to
help you, you count on respect -- and that nobody's
going to ask you out on a date. It mimics the boundaries
of the doctor-patient relationship."
Dr Salamon and one of the other
members of her Balint group, Dr Christiane Kuntz, put
together a qualitative study that they presented at
the 2006 AMA-CMA Conference on Physician Health. "One
of the most exciting findings was that the Balint group
is a creative process -- it is a special kind of listening,"
she says. "We address facts and information, address
ethical dilemmas, share our appreciation of medicine.
We work on patient cases, but also other aspects of
medical practice."
The near-total absence of Balint
groups in Canada is worrying to Dr Salamon. Her group
has been so successful and so enduring that some colleagues
have encouraged her to start a Canadian society of Balint
groups, to try to encourage their proliferation. "Whenever
I talk about it at a public forum, people will come
to me and be interested, but it is hard for people to
start them. We are busy private-practice people -- just
to take an hour and half every two weeks is difficult,
and not that many doctors are willing to devote that.
But there is a real need."
BALINTS
FOR PSYCHS
Over the course of just a few years, Dr Katherine Warren
went from being a Dalhousie University psychiatry resident
participating in the department's Balint group to being
the group's leader.
The Dal psychiatry department's
Balint group, started by Dr Joe Burley, is a bit unusual.
The Balint group concept was initially designed just
for general practitioners. Dr Burley figured the idea
could be adapted successfully for psychiatry residents
to help them come to terms with the often emotionally-draining
cases they see in their field. He also made another
change to the concept: the group is "open,"
which means that any resident who is interested in attending
one of the biweekly, lunchtime sessions is welcome to
drop in. An average session consists of six to eight
residents, says Dr Warren.
At one point, she explains, "there
was a consultation between facilitators and participants,
and we agreed to keep the focus on clinical cases that
residents had emotional problems with -- not politics
or complaining about the administration."
The cases brought up by residents
vary, but the subject of conversation is almost always
a difficult patient. "Sometimes it's a person who
is a repeat offender," says Dr Warren, "but
other times it is a patient residents see briefly during
an assessment, and patients who are not following advice.
Residents find that hard. They have torn feelings --
compassion, but also anger at the patient."
Other topics have included how
to deal with a patient's suicide, how to deal with the
complicated feelings that go along with reporting drug-addicted
parents to the child services agency, and what to do
if a psychiatrist is worried about his or her safety.
Sometimes, if none of the residents
have a case to discuss with the group at one of the
meetings, Dr Warren will volunteer one of her own. "Very
early in my years as a staff psychiatrist, I had a patient,
a young man, 19, who was genuinely interested in getting
help for his problems. He had some anxiety. I asked
to speak to his mother, to get some background, but
he asked me not to." It turns out the young man's
mother didn't think he had a problem and certainly didn't
need to be under the care of a psychiatrist. The mother's
interference soon began to put a strain on their doctor-patient
relationship.
The ethical dilemma Dr Warren presented
to the Balint group was how to continue to provide care
to this patient -- no easy solution, no clear course
of action, presented itself. She used that case as a
way to start a discussion in the Balint group about
how a psychiatrist can deal with their frustration when
a patient's family interferes with their care.
Dr Warren's commitment to the Balint
group -- from being a participant to becoming its leader
-- earned her the Dalhousie psychiatry department's
2006 Teacher of the Year award.
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