Kaatje Van Roy

A Lacanian view on Balint group meetings: a qualitative analysis of two case presentations.

BackgroundGPs’ subjectivity is an intrinsic instrument in their daily work. By offering GPs a platform to present and discuss difficult interactions with patients, Balint group work be might provide them an opportunity to explore and articulate aspects of their subjectivity. In order to get a more profound understanding of what participation in a Balint group can offer, we focused on the process of change that can be observed during Balint group meetings. To that end, this study scrutinized two Balint group case discussions on a micro-level.MethodTwo cases were selected from a larger data set of 68 audio-taped case discussions in four Balint groups. In order to shed light on the type of change that characterizes the presenter’s narrative, we used Lacan’s theoretical distinction between imaginary and symbolic modes of relating to the other.ResultsIn both case discussions, the GPs presenting the case initially appeared to be stuck in a fixed image of a situation, referred to as ‘imaginary relating to the other.’ Through a range of interactions with the group, the presenters were encouraged to explore different subject positions, which allowed them to broaden their initial image of the situation and to discover other issues at stake. This was referred to as a more symbolic way of relating to the other.ConclusionThis study throws light on the type of change Balint group participation allows for and on the way this might be achieved. We conclude that Balint group work is potentially beneficial to the participating GPs as well as to the relationship with their patients.

What makes up good consultations? A qualitative study of GPs’ discourses

BackgroundIn medical literature, several principles that define ‘good consultations’ have been outlined. These principles tend to be prescriptive in nature, overlooking the complexity of general practitioners (GPs)’ perspectives of everyday practice. Focusing on perspectives might be particularly relevant, since they may affect decisions and actions. Therefore, the present study adopts a bottom-up approach, analyzing GPs’ narratives about ‘good’ and ‘bad’ consultations. We aimed at describing the range of discourses GPs use in relating on their practice.MethodsSemi-structured interviews were conducted with 19 Belgian GPs. By means of a qualitative analysis, the authors mapped patterns in the interview narratives and described the range of different discourses.ResultsFour discourses were identified: a biomedically-centered discourse, a communication-focused discourse, a problem-solving discourse and a satisfaction-oriented discourse. Each discourse was further specified in terms of predominant themes, problems the GPs prefer to deal with and inherent difficulties. Although most participants used elements from all four discourses, the majority of the GPs relied on an individual set of predominant discourses and focused on a limited number of themes.ConclusionThis study clearly indicates that there is no uniform way in which GPs perceive clinical practice. Each of the participants used a subtle mix of different criteria to define good and bad medical consultations. Some discourse elements appear to be rooted in medical literature, whereas others are of a more personal nature. By focusing on the limitations of each discourse, this study can shed new light on some of the difficulties GPs encounter in their daily practice: being confronted with specific problems might be an effect of adhering to a specific discourse. The typification of different discourses on consultations may function as a framework to help GPs reflect on how they perceive their practice, and help them manage some of the challenges met in daily practice.

Reading Balint group work through Lacan’s theory of the four discourses

In Balint groups, (para)medical professionals explore difficult interactions with patients by means of case presentations and discussions. As the process of Balint group work is not well understood, this article investigates Balint group meetings by making use of Lacan’s theory of the four discourses. Five Balint group case presentations and their subsequent group discussion were studied, resulting in the observation of five crucial aspects of Balint group work. First, Balint group participants brought puzzlement to the group, which is indicative of the structural impossibility Lacan situates at the basis of all discourse (1). As for the group discussion, we emphasize ‘hysterization’ as a crucial process in Balint group work (2), the supporting role of the discourse of the analyst (3) and the centrality of discourse interactions (4). Finally, the potential transformation of the initial puzzlement is discussed (5). We conclude by putting forth the uniqueness of Balint group work as well as the potential usefulness of our analysis as a framework for Balint group leaders and professionals in charge of continuing medical education.

Translating medical school social missions to student experiences

There is a growing focus on the social missions of medical schools as a way of expressing an institutional commitment to service, responsibility and accountability. However, there has been little exploration of how a social mission translates to student experiences.

Point-of-care CRP matters: normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care: a cluster randomized controlled trial

Abstract Objective: Antibiotics are prescribed too often in acutely ill children in primary care. We examined whether a Point-of-Care (POC) C-reactive Protein (CRP) test influences the family physicians’ (FP) prescribing rate and adherence to the Evidence Based Medicine (EBM) practice guidelines. Design: Cluster randomized controlled trial. Setting: Primary care, Flanders, Belgium. Intervention: Half of the children with non-severe acute infections (random allocation of practices to perform POC CRP or not) and all children at risk for serious infection were tested with POC CRP. Subjects: Acutely ill children consulting their FP. Main outcome measure: Immediate antibiotic prescribing. Results: 2844 infectious episodes recruited by 133 FPs between 15 February 2013 and 28 February 2014 were analyzed. A mixed logistic regression analysis was performed. Compared to episodes in which CRP was not tested, the mere performing of POC CRP reduced prescribing in case EBM practice guidelines advise to prescribe antibiotics (adjusted odds ratio (aOR) 0.54 (95% Confidence Interval (CI) 0.33–0.90). Normal CRP levels reduced antibiotic prescribing, regardless of whether the advice was to prescribe (aOR 0.24 (95%CI 0.11–0.50) or to withhold (aOR 0.31 (95%CI 0.17–0.57)). Elevated CRP levels did not increase antibiotic prescribing. Conclusion: Normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing. Key points What is previously known or believed on this topic •Antibiotics are prescribed too often for non-severe conditions. Point-of-care (POC) C-reactive Protein (CRP) testing without guidance does not reduce immediate antibiotic prescribing in acutely ill children in primary care. What this research adds •FPs clearly consider CRP once available: normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. •Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing.