JULY 2008


"A special kind of listening"

Longtime Balint group members share their stories

For more information please see:
Sharing circles prevent physician burnout

So why are there so few Balint groups in Canada?

"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."

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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