Clive D. Brock

Balint Groups: The Nuts and Bolts of Making Better Doctors

Balint Group seminars were developed by Michael and Enid Balint based on the application of psychological principles in a group setting for the purpose of developing an improved understanding of the doctor-patient relationship. This article focuses on the development and application of the Balint method to the training of resident physicians (particularly Family Physicians) within the United States. An effort is made to describe the practicalities of resident physician Balint training (e.g., size, frequency, duration of such groups), conceptual underpinnings (e.g., biphasic nature of patient identification, disease versus illness concept, transference/counter-transference, over-identification, under-identification, biphasic nature of physician empathy), and pedagogic goals (mastering empathic skills inherent in being a good doctor) of residency-based Balint groups. In aggregate, this article provides a useful framework for behavioral science educators interested in applying the Balint seminar method to resident physician training. The authors encourage both the continued study and educational application of the Balint seminar method in the training of physicians both within and outside of the United States.

Executive Function and Medical Non-Adherence: A Different Perspective:

Medical non-adherence is multifactorial: cost, convenience, side effect profile, and cognitive impairment are all implicated in medical non-adherence. We explore impaired executive function (EF) as a cause for medical non-adherence when other causes can be ruled out. EF describes the coordination and manipulation of higher-order cognitive processes involved in problem-solving, planning, and decision-making. EF has three components: working memory, mental flexibility, and inhibitory control. The latter, inhibitory control, when impaired will affect an individuals ability to make choices to produce long-term benefits, in favor of short-term gratification. When applied to adults with chronic diseases, like diabetes, that require lifestyle modification and, at times, complicated medical regimens to forestall long term complications, an intact EF has a role in adherence. EF development is protracted with behavioral corollaries observable from early childhood. Thus, teachers, family physicians, and pediatricians will be the professionals to first encounter and manage such individuals. We suggest screening tests for children in the doctors office to detect impaired EF, and postulate a cognitive behavioral therapeutic approach for adults with uncontrolled DM and impaired EF.

The Legacy of Michael Balint

Michael Balints lead article, “Repeat Prescription Patients: Are They An Identifiable Group?” inaugurated the first issue of Psychiatry in Medicine, Vol. 1, No. 1, 1970. A few years later, this Journal would be renamed International Journal of Psychiatry in Medicine (IJPM). Who is this author of over 165 papers, 10 books, practicing psychoanalyst from 1926 to 1970, director of the Budapest Psychoanalytic Institute from 1935 to 1939, consultant at the Tavistock Clinic from 1948 to 1961, President of the British Psycho-Analytical Society from 1968 to 1970, literary executor of Sandor Ferenczi, a foremost theorist of object relations, and international educator and statesman for general practitioners? We would like to review for you some of the formative experiences in Michaels life that wedded psychoanalysis and general practice, and how they contributed to his major educational commitment over 40 years to furthering the understanding and integration of psychosocial factors in the practice of primary healthcare as experienced by doctors all over the world. We would also like to highlight some of his major insights and see to what extent they are incorporated in contemporary medical education and practice. We believe that some of his major insights have been neglected and others have been further amplified and extended. Our intention is to speak not only to medical students who desire to pursue medicine related directly to patient care but as well to seasoned practitioners who continue on a daily basis to care for individual patients and their families.

The role of Balint group training in the professional and personal development of family medicine residents

This paper presents a study based on the participation of PGY2 and PGY3 family medicine residents in Balint seminars that occurred twice monthly for 24 months. Balint groups were cofacilitated by leader pairs experienced with the Balint method. Prior to residency graduation, 18 of 19 eligible resident physicians (94.5%) completed 30- to 60-min semistructured interviews conducted by a research assistant. Resident physicians were told that these individual interviews concerned “…how we teach communication in residency.” The deidentified transcripts from these interviews formed the raw data that were coded for positive (n = 9) and negative (n = 3) valence themes by four faculty coders utilizing an iterative process based on grounded theory. The consensus positive themes included several elements that have previously been discussed in published literature concerning the nature of Balint groups (e.g., being the doctor that the patient needs, reflection, empathy, blind spots, bonding, venting, acceptance, perspective taking, and developing appreciation for individual experiences). The negative themes pointed to ways of possibly improving future Balint offerings in the residency setting (repetitive, uneasiness, uncertain impact). These findings appear to have consistency with seminal writings of both Michael and Enid Balint regarding the complex nature of intrapsychic and interpersonal skills required to effectively manage troubling doctor–patient relationships. The implications of findings for medical education (curriculum) development as well as future research efforts are discussed.

Post-concussion syndrome and pre-existing mood disorder: A case report

Sport-related concussions in youth and adolescent athletes most commonly resolve within one week without residual symptoms, with athletes resuming full participation following return to play guidelines. A small percentage of athletes have persistent symptoms that cause significant morbidity, some of whom are ultimately diagnosed with post-concussion syndrome. In these athletes, symptoms in the emotional domain can be more prolonged than other domains, with athletes reporting anxiety and depression months to years following injury. A prior personal or family history of pre-existing mood disorder or attention-deficit/hyperactivity disorder increases the risk of a prolonged duration of symptoms. In this case series, we discuss two cases of post-concussion syndrome in adolescent athletes with a past personal or family history of attention-deficit/hyperactivity disorder, anxiety, and depression treated by a combination of cognitive behavioral therapy and medication with ongoing persistent symptoms. There is increased need for mental health screening in all athletes to identify individuals at risk for post-concussion syndrome. Early identification of at-risk individuals allows the interdisciplinary care team to discuss expectations for the athlete and family regarding duration of symptoms.

Improving Physician Well-Being

viously studied. Nearly 40% of the study population consisted of patients with non–ST-segment elevation myocardial infarction, where early PCI for high-risk patients is associated with a mortality benefit and is recommended by the American College of Cardiology Foundation/American Heart Association guidelines.4 Yet, there was no overall difference in mortality across the PCI strategies. This is perhaps explained by the fact that FFR and IVUS are only adjunctive devices used to guide and/or facilitate PCI, which is the ultimate interventional therapy in question. In addition, the patient population also significantly differed in the degree of intermediate coronary stenosis (7.5% in the angiography group had stenosis <75% as opposed to 38.7% in the FFR group and 18.5% in the IVUS group),1 which may influence the baseline risk of mortality. Therefore, comparing outcomes in these highly heterogenous groups is fraught with risk, despite careful attempts by the authors to minimize confounding using propensity matching. Finally, we should be cognizant that while FFR and IVUS are available to guide PCI, the most important determinants of PCI in patients with stable coronary disease are still patients’ symptoms on maximal medical therapy and shared decision making, where patients understand that PCI is only an option to treat symptoms and not an attempt to extend life. Fractional flow reserve may further have a role in deferring PCI in appropriate patients, with either intermediate or obstructive coronary stenosis on angiography, and nonhemodynamically significant lesions.5 Because outcomes of patients in whom PCI was deferred based on FFR or IVUS was not captured by this registry, benefic ial outcomes may be underestimated.1 Ultimately, if judicious use of FFR or IVUS in carefully selected patients can decrease the volume of PCI without adversely impacting symptom control, then “less is more.”