How to encourage reflection on the doctor-patient relationshipBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5227 (Published 17 November 2015) Cite this as: BMJ 2015;351:h5227
- Catherine Louise Murphy, general adult psychiatry trainee, South London and Maudsley NHS Foundation Trust ,
- Jen Perry, general adult psychiatry trainee, South London and Maudsley NHS Foundation Trust ,
- Vikram Suraj Luthra, consultant psychiatrist, Leeds and York Partnership NHS Foundation Trust, accredited Balint group leader, honorary lecturer, University of Leeds,
- Ann Boyle, consultant old age psychiatrist, Leicestershire Partnership NHS Trust, and Royal College of Psychiatrists foundation adviser
Balint groups can help foundation doctors think more deeply about their relationship with patients, write Catherine Louise Murphy and colleagues
The Broadening the Foundation Programme report1 outlined the importance of doctors in training having a secure foundation in community and integrated care and also called for an increase in the number of foundation posts in psychiatry. In England the aim is to have 45% of all foundation doctors undertaking a psychiatric placement by 2017, giving them an opportunity to acquire and consolidate their knowledge of mental illness and their communication and team working skills. They will develop an ability to take a holistic approach to patient care, whatever specialty they ultimately enter.
The Royal College of Psychiatrists has embraced this change and is committed to supporting the development of high quality placements.2 One innovative way of ensuring high quality placements is the provision of Balint groups.
Role of the Balint group
Balint groups offer a safe, confidential space for a group of doctors or other healthcare professionals to reflect on and reach a better understanding of the emotional content of the doctor-patient relationship, thereby improving its therapeutic potential (http://balint.co.uk/about/introduction/). Psychoanalyst Michael Balint alongside his wife, Enid, led the development of Balint groups in Britain in the 1950s,3 and now 23 countries worldwide have their own established Balint Society. In the United Kingdom, Balint groups usually consist of general practitioners or psychiatrists and have six to 12 members, with a leader and often a co-leader. Groups meet from weekly to monthly, and a single group may last just a few months to several years. Trainee or student groups are generally shorter lasting because of shorter placements.
Members who have had patients on their mind discuss these cases with the group. It may be that the patient has been emotionally disturbing, is difficult to understand, or is difficult to engage in treatment.2 These groups are not therapy sessions for the doctors; instead they offer an opportunity for professionals to discuss the interpersonal aspects of their work with patients.4
The first Balint group for foundation doctors in Yorkshire was created by Vikram Luthra in 2011 in Leeds. At the time, there were groups for core trainees, higher trainees, and consultants but nothing for foundation doctors who were curious about the Balint process. Now two groups exist: one for foundation year 1s and one for foundation year 2s.
The groups meet fortnightly and are a mandatory part of doctors’ four month placements. All the foundation year trainers were consulted during the initial organisation period and consequently all agreed to release their trainees for an hour of protected time. At the beginning of a new group, each doctor signs a learning contract, a copy of which is retained for their learning portfolio.
The group process has some general benefits. The doctors may find themselves for the first time in their career working separately from each other, so the group allows them all to meet and develop at their own training level. There is often a shift in the group members’ approach to case discussion as the placement progresses: at the beginning of the placement, members may think about the case from solely a medical perspective, attempting to find a solution to their peers’ cases. This then gradually changes as they discover that this is not the purpose of the Balint group and they become more curious about the doctor-patient relationship. Formal feedback via the deanery survey has shown that Balint groups are generally seen as a helpful process.
It is unrealistic to expect that all foundation doctors will change their career choice to psychiatry after attending a Balint group. However, most of the doctors seem more able to talk about their struggles within the doctor-patient relationship in a more meaningful way by the end of their placement.
Foundation doctors’ Balint groups can be difficult to run. The placement duration of four months is relatively short considering members meet only fortnightly. The group may then struggle to maintain momentum, especially given doctors’ other demands. One possible solution may be to increase the frequency of the group meetings to weekly or to increase the length of the sessions.
Within any group, some doctors may not want to talk about their feelings, and there may be numerous reasons for this. Hopefully, as time progresses, their attitude may change as they settle into the group and get used to this new process. However, if an individual member is hampering the working of the group this may need to be raised sensitively. This can be broached within the group via discussion or outside the group if necessary. Either way, it is important that it is done in an open and honest way without persecuting or humiliating the doctor. The same principles apply to members who are finding it difficult to adhere to the boundaries of the learning contract—for example, arriving late to group sessions.
Practical ideas for Balint groups for foundation doctors
First and foremost, contact the UK Balint Society; it is an incredibly supportive organisation running workshops and events for Balint groups and leadership accreditation. The society has a register of all accredited leaders (medical and non-medical) nationally who may be able to offer advice and help.
Next, consider contacting your local medical psychotherapy department. It is worth while speaking to the leaders of other Balint groups in the area as they will have been through the process of setting up groups and may be able to offer advice.
It is important to explore whether the local associate medical director for doctors in training, or the person who manages foundation doctors, is supportive of the Balint group as he or she will be the key person who will help to build it into the placement programme.
By taking part in Balint groups it is hoped that foundation doctors will gain experience of reflection, listening, and supporting others in the group as well as developing curiosity about their patients. They may also become more aware of their own emotions in the patient interaction. On a practical level, the groups may help to reduce the feelings of isolation and “separateness” that foundation doctors may have in psychiatry.
The introduction of Balint groups for foundation doctors needs careful consideration. Some doctors may not understand their purpose or they may be sceptical of them. Short foundation programme placements can also hamper the development of the group. However, the more frequently the Balint group meets, the more engaged doctors will become. Whether through Balint groups or other methods of reflective practice, the general principle remains the same: the doctor-patient relationship should be at the core of all medical specialties.
We thank Nikki Cochrane and Alexandra Brent, Royal College of Psychiatrists.
Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare that we have no competing interests.