Balint Groups as a Means to Increase Job Satisfaction and Prevent Burnout Among General Practitioners

In their article, “Balint Groups as a Means to Increase Job Satisfaction and Prevent Burnout among General Practitioners,” Kjelmand and Holmstrom explored the GP’s experience of participating in Balint groups and its influence on their work life. In this qualitative study, nine specialists working in general practices, who had participated in Balint groups for 3-15 years, were interviewed thoroughly.

One would guess from these few sentences that physicians who voluntarily chose to participate in Balint groups for such a long period were convinced that this activity served their needs well. In this well conducted study, common issues that were salient for participating physicians were highlighted. The final discussion note is that Balint groups might not be a suitable method for all GPs, and other ways of promoting stress reduction and increasing job satisfaction should be offered. With respect to this note I would like to add some ideas from a different perspective.

Indeed general practice is potentially risky and may cause burnout, mental overload, dissatisfaction and perceived loss of control. I would suggest that these are not merely the consequences of work environment burdens and the nature of patients and their problems, but rather are due to the void that exists between what one learns and practices during medical school and residency, and what is actually expected from GPs subsequently in daily clinical practice. Worldwide we study medicine and general practice from the biomedical orientation, but in practice we have to deal with the biopsychosocial (BPS) complaints of our patients. This discrepancy creates a cognitive dissonance that may undermine self confidence. Lack in practical BPS tools for diagnosis and treatment, erodes the GP's feeling of competence and sense of coherence. GPs know how to identify the situation when their patients ask them for more than just a prescription for another drug, but usually do not posses the skills to meet this expectation. In the long run this stressful gap and hidden frustration might result in burnout and exhaustion.

In order to investigate this issue, we conducted a study designed to evaluate how to alter GPs' (non-specialists) BPS-orientation and to learn what influence this change had on their professional competence, performance, job-satisfaction, self-esteem and burnout [1,2,3] We found that the orientation change was significantly more fruitful in a GP group that had studied the BPS clinical method [4,5] through an experiential process. The experiential process included: 1. A weekly Balint group of 10-11 GPs. 2. Role-playing of common types of 10-minute encounters with a patient or a family, followed by discussions in small groups of 3-5 participants. 3. A one-on-one coaching process in which a course facilitator, a physician himself, discussed, in private, with the GP participant his/her individual difficulties in the practice and personal life demands. 4. Analysis of a playback of videotaped doctor-patient encounters of the trainees, (obtained before the teaching program) using a reflective process.

As a consequence of the professional orientation change, there was a significant enhancement in self-esteem of the participating GPs, an increase of job satisfaction and in time spent with their own family. Quite surprisingly, we also found as an outcome measure of the medical encounters of the participating GPs, a significant reduction in prescribed medication, a reciprocal increase of psychosocial involvement suggestions [6] without markedly increasing the duration of the encounter with patients. Several months after the course, we found an increase in burnout measure, probably because GPs' increased self-esteem made them feel confident enough to report burn-out more candidly after the program than before it. Three years after the course our follow up showed that those GPs succeeded to maintain high job satisfaction and self-esteem as well as less burnout (measured by the Maslach Burnout Inventory). They used sentences like: "Now, when I show empathy to patients, I feel their gratitude more often than when I just gave them a medication or another referral" or "It is amazing to discover at the end of a hectic day, that even if only one patient told me that I had given him more than he could expect I felt proud and satisfied".

In a later study,[7] we revealed that using the BPS clinical method enabled the practicing BPS-oriented GP to diagnose and treat patients with unexplained medical symptoms or "heart-sink" patients more effectively. This activity contributes to the GP's feelings of competence and decreases professional frustration. Sense of self-fulfillment comes together with the findings of cost and mortality reduction in those patients.

As a family practitioner (MD) who was trained and certified as a psychotherapist, I can still recall the difficulty and the challenge created by the transition from a typical physician trained to "fix" problems to a therapist trained "to be there" to contain suffering and to show empathy for pain. As a facilitator of a Balint group, it was easier for me to understand GPs who were trying to cope with emotional overload and perceived loss of control while dealing with challenging situations such as working with terminal patients or angry patients. Experiencing daily practice through a three dimensional perspective of the BPS orientation, makes a vast difference from the GP's point of view.

Balint groups offer physicians an excellent way to reflect distress, conflict and debate, receive emotional support and advice from colleagues. By doing so, physicians deal with their plights well. In order to improve the mould of "the doctor as a drug", as Balint had suggested, may I urge from a preventive point of view, that a BPS orientation be studied by an interactive (experiential) methodology. The benefit will likely be that emotional stress related to psychosocial issues in general practice, mental overload and overwhelming relationships with patients will be minimized or prevented. When this methodology is facilitated by a general practitioner who is well experienced in the BPS orientation, the GPs participants are involved in a parallel process: they have the role-model of a physician who helps them become better doctors in dealing with biomedical issues integrated with psychosocial needs. This kind of training will enable them to deal with patients' BPS complaints more effectively. Within this framework, the gap between theory and practice will hopefully disappear and as a result GPs may find BPS oriented medical care more suitable to maintain their work for many years with better self-esteem, greater satisfaction and less burnout. One may assume that health-care expenditures will be reduced as well.

Alon P.A Margalit MD PhD, Moshe Prywes Center for Medical Education, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel. alon@talk2doc.net

1. Margalit AP, Glick SM, Benbassat J, Cohen A. Effect of a Biopsychosocial Approach on Patient Satisfaction and Patterns of Care. Journal of General Internal Medicine. 2004;19(5 Pt 2):485-491.
2. Margalit AP, Glick SM, Benbassat J, Cohen A, Katz M. Promoting a Biopsychosocial Orientation in Family Practice: Effect of two teaching programs on the knowledge and attitudes of practicing primary care physicians. Medical Teacher. 2005;27(7):613-618.
3. Margalit AP, Glick SM, Benbassat J, Cohen A, Margolis CZ. A Practical Assessment of Physician Biopsychosocial Performance. Medical Teacher. 2007;29(8):e219-e226.
4. Eshet I, Margalit A, Almagor G. SFAT-AM: Short Family Therapy in Ambulatory Medicine. Treatment Approach in 10–15 Minute Encounters. Family Practice. 1993;10(2):178-187.
5. Baird MA, Margalit AP. Family Interviewing and Assessment. In: Jones R, Britten N, Culpepper L, et al., editors. Oxford Textbook of Primary Medical Care, Volume 1, Section 9.3. New York, NY: Oxford University Press; 2004. pp. 309-315.
6. Doherty WJ, Baird MA. Developmental Levels in Family-Centered Medical Care. Family Medicine. 1986;18:153-156.
7. Margalit AP, El-Ad A. Costly patients with unexplained medical symptoms: A high-risk population. Patient Education and Counseling. 2008;70:173–178.

Competing interests:   None declared