Balint Groups as a way to prevent “Burn Out” of Physicians.

Benyamin Maoz, Israel

In modern times physicians have to work under a heavy professional stress. Among the reasons of this stress one can mention the following factors:

1. An overwhelming amount of information, which even doctors who specialize in a relatively small field are not able to absorb. The continuity of the concern: “how shall I keep up to date?”

2. Frequent and often contradictory instructions, which doctors get from health are providers and other authorities.

3. Demanding patients, who are often partly informed by the media, but usually do not take any responsibility for their illness.

4. A continuing shortage of time, certainly when urgent cases, or home visits, disturb the schedule.

5. More intra-psychic worries, as: “This is not the profession which I dreamt of when I decided to study medicine”.

Doctors frequently ask for more training in organizational-economic-administrative areas and also in communication skills.

But one of the few places where subjective feelings of dissatisfaction, anger, frustration etc can be discussed in an empathetic and supportive atmosphere, is the  Balint group.

I shall give some illustrations concerning this issue, from groups which I have conducted. In addition, I shall present the results of an evaluation of a Balint group, in which the professional satisfaction was measured “before” and “after”, demonstrating the importance of Balint groups in the prevention of “burn out”.

 Balint in Berlin (1921-1924)

Michelle Moreau Ricaud
Dr. En Psychologie, Maitre de conférences, IUT, Universitè Francois Rabeleis, Tours
Psychanalyste, Vice-Prèsidente du Ivème Groupe Organisation Psychanalytique de
Langue francaise (OPLF)

If political reasons and  the difficulties of being and living in his own country pushed Michael Balint to emigrate in the 1920s, I would like to suggest that
the choice of Berlin was psychically determined.
I would like to underline how this stay was important for him, first as the place of intellectual training both in fundamental sciences and in human sciences, modern medicine and psychoanalysis. In addition it was a crucial time for his commitment to the psychoanalytic method.
His whole life was to be determined by the various experiments made in this “Metropolis”, a town commensurate with his ambition.

Medical care for patients with a history of migration.

Marzio E.E. Sabbioni, MD

Twenty percent of the Swiss population are immigrants, most with a marginalized status and employed in unqualified jobs with increased health hazards. Outcomes in foreign patients, e.g. those with chronic pain or somatoform disorders, are considered to be worse than in Swiss patients. Possible measures to improve outcome were developed in interdisciplinary collaboration with cultural anthropologists and will be presented combining case material and the discussion of concepts applied and refined in our institution to meet the diagnostic and therapeutic issues raised by patients with a history of migration. The focus will be laid on migration-specific history taking as an important tool in the care of these patients. 

"Why do medical doctors suffer a specific professional 'burn-out' syndrome?"

by Dr Michel DELBROUCK

The author wants to explore the specificity of the Burn-out Syndrome of medical doctors and other healers with a psychoanalytic and environmental (MEANING?) approach.
He describes the triple majors symptoms (MEANING?) of the Burn-out Syndrome and reflect on the complexity and causation of this specific Burn-out Syndrome.
Therefore, he develops two topics * Psychoanalytic reasons for choosing this profession (type of personality, environment, personal and family story, ...) * The predicted characteristics in medical and therapy students which may prevent future Burn-out, based on two recent studies from ten year Balint group, and another on a random sample of nurses.
He attempts to explain this specific syndrome by the existence of four problems or failures characteristic of this occupation :
- The specificity of the job
- The impact and repetition of the trauma presented by the patients
- The deep and unconscious reasons for chosing the medical profession
- The physical and emotional isolation
If the healer could ask himself some questions like ...
- Why have I choose this healing profession?
As a preventive measure could I make use of my awareness of some characteristics of my personality already present when I was a student? ... he could avoid exhaustion and specific communication troubles in doctor-patient relationships.

Pleasures of doctoring as reflected in Balint groups.

Andre Matalon MD (1)
Martine Granek-Catarivas MD (2)
Stanley Rabin PhD (3)

(1), (2) Department of Family Medicine, Tel-Aviv University and (3) Department. of Psychiatry, Soroka Medical Center, Ben Gurion University of the Negev, Israel.

Family physicians deal with uncertainty, with difficult patients and seriously ill people facing death, disability or pain. Furthermore, stressful situations, mistakes, feelings of guilt, grief and helplessness as well as medico-legal issues often threaten their well being. Balint groups that were originally aimed to help doctors to deal with the psychological aspects of their patients and focus on the doctor-patient relationship, may have an added function: to foster the job satisfaction and pleasure of doctoring through the group process. Reflection, identification, cohesion and support in the Balint group, acting as an alternative family, may buffer the doctors` prolonged stress and consequent burnout.

In this presentation we review the written records of a six month Balint group of third year residents in family medicine. We describe the physicians’ shared feelings of being a family physician, their feelings of accomplishment, and their expression of the pleasure in doctoring. Various examples of the positive aspects involved in caring will be discussed.

Common themes in Balint groups involve talking about pain and suffering. Pleasurable aspects of their work are however often ignored. We maintain that pleasurable insights achieved in Balint groups are of the highest importance for the well being of physicians and their patients and a strong antidote for professional stress, burnout and isolation.

Should doctors observe a moral duty to care for themselves?

Andrew Dicker, GB

There is a belief among doctors, deeply embedded in the medical tradition, that the interests of patients must always come first. A countervailing point of view holds that unless doctors take care of themselves they are unlikely to be able to offer optimal care to their patients. While this premise may be self-evident it is rarely, if ever, articulated in public. What is required at the moment is a coherent justification which would make it unethical for doctors not to care for themselves before they attempt to care for others in a professional capacity.

The reasons for many medical traditions, capable of influencing the behaviour of doctors, may be attributable to the historical paternalism which has pervaded the medical profession. Paternalism is also the source of the error which underlies the rhetorical imperative that patients must come first.

Doctors need a sound ethical basis to motivate them to ensure that their own physical, mental and emotional needs are met before they attempt to meet the needs of their patients. I attempt to show that doctors have a moral duty to look after themselves before they look after patients. 

Defining Balint work
- is there a heartland?
And which are the neighbouring contries?

Henry Jablonski, Sweden

I will firstly try to say something about Balint work in the 21st century as a part of a humanistic, holistic approach to the medical profession.

The ideas of Michael Balint for enhancing the professional capacity of the general practioner have spread over the world during these 50 odd years since Balint met with his first groups of British GPs in the small conference rooms at 41, Portland Place off Oxford Circus in central London.

The work has inspired many doctors both in the somatic and psychiatric fields and a lot of group activities have been set up - and also vanished - bearing the name of Balint.
In this paper I attempt to discuss the essential ingredients of a Balint group. I discuss these issues from various perspectives:

1. The general purpose of a Balint group - the explicit goal and its consequences for the practical contents of work.
2. Some aspects of the boundaries and the "work contract" of the group
3. Demands on the group members
4. Demands on the group leader

I propose a core definition:
A Balint group consists of clinicians who meet, as equals and because each of them wishes to do so. They meet on a regular basis over a longer period of time for the purpose to discuss and come to a better understanding of their own clinical work, their own meetings with their patients. Within the group a MUTUAL CONSULTATION is taking place. 
To facilitate the working process, the group members cooperate with an EXTERNAL CONSULTANT who also has the role of group leader. This person must be well acquainted with the working conditions of the group members (culturally attuned) and be able to add psychoanalytical/psychological aspects which are relevant for the purpose of Balint work.

I try to discuss the advantages and difficulties of Balint work and the adjacent territories of other kinds of group work, such as group therapy, educational groups, supervision groups for students and doctors-in -training, mentoring groups, other clinical conferences, other professional reflection groups, and team meetings, etc.

I discuss a variety of Balint-inspired groups and the modifications of the original framework that are demanded of such groups, their members and their leaders.