Balint groups

Jerry Posson, Jerry Posson, why am I thinking about you as I drive home from a busy day at the office? Your name haunts me. Why? Yes, I know you are taking too much oxycodone. Yes, I know you are in chronic pain. But why am I thinking about you after my working day?

How many Jerry Possons do we have in our practices? How often do we find ourselves reflecting on a clinical encounter after office hours? So many encounters do not really cease when we write a prescription or send a patient for a laboratory test or x-ray scan. These experiences can touch us in mysterious, moving, or disturbing ways. In our busy lives as family physicians, there are few venues and opportunities to debrief from these profound personal and professional experiences.

Over the past few years, I have found that joining in conversation with colleagues allows me to further emotionally metabolize these experiences, and prevents me from letting them seep too deeply into my personal life.

Michael Balint was a British psychoanalyst who created a structure for family physicians to safely reflect on these clinical encounters that touch us in ways that might surprise us.¹ A Balint group is a purposeful, regular meeting among family physicians, with a trained facilitator or leader, to allow discussion of any topic that occupies a physician’s mind outside of his or her usual clinical encounters. A Balint group can have many goals. The presenter might realize a more helpful way of viewing and interacting with the patient; the group might learn to view the case from multiple perspectives (clinician, patient, relationship). The goal is to improve physicians’ abilities to actively process and deliver relationship-centred care through a deeper understanding of how they are touched by the emotional content of caring for certain patients.

A Balint group has between 6 and 10 members, with 1 or 2 facilitators or leaders. The group’s composition engenders a sense of shared experiences, hence there are arguments for and against having Balint group members from the same family practice. The format of a Balint group is a case presentation (from memory) for about 3 to 5 minutes and a discussion for 1 hour or more. All group discussion is confidential (as in psychotherapy); a safe environment is created to express negative or difficult feelings. The Balint group leader’s role is to create a climate of safety, acceptance, and trust; establish and maintain the group’s norms by letting each member take a turn speaking; and to promote movement toward the group’s task of grappling with the presenter’s case. A group leader must understand group process and make use of his or her own personality and style to move the group forward.

There is much evidence in the literature that participation in a Balint group increases a participant’s coping ability, psychological mindedness, and patient-centredness.^2,3 For me, what began as a 3-month experiment with colleague acquaintances has become a 20-year journey during which enduring friendships have formed. Over the years, we have discussed a spectrum of themes: the “difficult” patient, making errors, work and home life balance, personal crisis and illnesses, office challenges, medical learners, the “system,” the joys of practice, and the uniqueness of our relationship with our patients.

When I mention my Balint group to fellow family physicians or offer academic seminars to my colleagues, I see a longing in their eyes when I describe the collegial support I experience. I wonder why this type of opportunity is seldom present in the Canadian family medicine community. Most family medicine residency programs in the United States have Balint groups as part of the training experience.^4,5 I believe there are only a handful of academic Balint groups in Canada. In Britain, narrative-based primary care groups are now offered to many community family practices.

A Balint group can be adapted to any kind of teaching or clinical setting. Why not here? Why not now? I challenge academic family medicine training programs to reflect on these questions, and I encourage you as a fellow family physician to consider joining or creating a Balint group as a tool for personal and professional resilience.

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