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

Dorte Kjeldmand; Inger Holmström

doi:10.1370/afm.813

Published eLetters

If you would like to comment on this article, click on Submit a Response to This article, below. We welcome your input.

Submit a Response to This Article

Compose eLetter

Title *

Author Information

Contributors
First Name and Middle Initial * First or given name, e.g. 'Peter'. Last Name * Your last, or family, name, e.g. 'MacMoody'. Email Address * Your email address, e.g. higgs-boson@gmail.com Occupation * Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Affiliation * Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

What code is in the image? *

Enter the characters shown in the image.

Vertical Tabs

Jump to comment:

Balint group is one part of the whole
Alon P.A. Margalit, MD, PhD

Published on: 31 March 2008
Balint Groups, Academic Rigor, and the Doctor-Patient Relationship
Clive D. Brock, MD

Published on: 21 March 2008
Burnout among general practitioners
Jochanan Benbassat

Published on: 20 March 2008
Self-Care for Care-Givers
Sharon B. Buchbinder, RN, PhD

Published on: 14 March 2008

Published on: (31 March 2008)
Page navigation anchor for Balint group is one part of the whole
Balint group is one part of the whole
Alon P.A. Margalit, MD, PhD, Beer-Sheva, Israel
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 f...
Show More

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
Show Less

Competing Interests: None declared.
Published on: (21 March 2008)
Page navigation anchor for Balint Groups, Academic Rigor, and the Doctor-Patient Relationship
Balint Groups, Academic Rigor, and the Doctor-Patient Relationship
Clive D. Brock, MD, Charleston, South Carolina, USA
Other Contributors:
Kjeldmand and Holmstrom addressed GPs’ experiences of participating in Balint groups and how these experiences influenced practice. They were interested to know whether Balint training prevented professional burnout. They applied a descriptive qualitative model using an empirical phenomenological psychological design which is a recognized method for deriving meaning from informants’ experiences.
It is of note th...
Show More

Kjeldmand and Holmstrom addressed GPs’ experiences of participating in Balint groups and how these experiences influenced practice. They were interested to know whether Balint training prevented professional burnout. They applied a descriptive qualitative model using an empirical phenomenological psychological design which is a recognized method for deriving meaning from informants’ experiences.
It is of note that the authors looked at the long-term impact of Balint group participation in that their sample involved GP’s with 3-15 years of Balint group experience. The participants were selected from among forty ongoing Balint groups being led by trained leaders. Ten were selected to reflect a balance of sex, age, professional experience and geographic location. Ultimately, nine physician’s participated in the full study.
Data were gathered by face to face interviews at the informants workplace by a Balint trained researcher. Balint group participants felt more competent in their role as GPs, had a greater sense of professional identity, and learned to see parallels between Balint group work and clinical practice. These outcomes enabled them to rediscover the joy of being a physician.
Based upon our experiences as medical educators and clinicians, these findings have face validity. We should note that both of us are credentialed by the American Balint Society as Balint group leaders. We currently co-lead a weekly Balint group consisting of Family Medicine Residents. In the past we have participated in Balint groups (either as leaders or group participants) across a full range of professional training levels (medical students, resident physician, practicing physicians). We also participate in a faculty Balint group regularly.
Kjeldmand and Holmstrom address the concern that their study’s findings are not generalizable to all GPs since many do not find the work useful. This is consistent with observations from our residency program where approximately 65% of eligible residents will volunteer to participate in an ongoing Balint group(1). Those who volunteer to participate are more likely to be intuitive than sensing and also prefer a more conceptual basis for problem solving than prescriptive solutions (1). In addition, the authors acknowledged and controlled for their own preconceived notions and rigidly adhered to their phenomenological method.
These findings are transportable provided there is institutional “buy in” for work which depends on the commitment of time for weekly or biweekly seminars led by 1-2 trained Balint group leaders(2). Competing professional demands can make it a challenge to find the time to regularly engage in this form of group work. However, our sense is that Balint group work can be highly valuable to those physicians who are motivated to use the process to good advantage.
Balint group work is by its very nature “subjective”. This fact leads some professionals to assume that this work is not rigorous or is anti- intellectual. Our opinion, based on extensive experience with Balint group leadership and participation, is that this work is actually quite intellectually challenging and academically stimulating. Balint group participation provides a place for the learning of principles that underlie the effective management of the doctor-patient relationship. Balint work is a success when the participants learn how to manage transferences and countertransferences inherent in professional relationships, through the empathic process. When success is achieved we agree with the authors that participants will be more likely to have a secure sense of professional identity and consequently be better able to function in the doctor’s role.
We would like to see a long term study comparing the joys of practice with a low rate of burnout among participants and non participants in Balint groups.
References:
1. Alan H. Johnson, Clive D. Brock, William J. Hueston, Resident physicians who continue Balint training: A longitudinal study 1982-1999. Fam Med 2003; 35: 428-33.
2. Johnson AH, Nease DE, Milberg LC, Addison RB. Essential characteristics of effective Balint group leadership. Fam Med 2004;36(4):253–259.
Competing interests: None declared
Show Less

Competing Interests: None declared.
Published on: (20 March 2008)
Page navigation anchor for Burnout among general practitioners
Burnout among general practitioners
Jochanan Benbassat, Jerusalem, Israel
Re: "Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners" by Drs Kjeldmand and Holmstrom.
It would be only fair to the reader to note that I am prejudiced in favor of Balint groups, and that similarly to Drs Kjeldmand and Holmstrom, I believe that such groups benefit physicians and help them during their encounters with patients. For me, this study provides addit...
Show More

Re: "Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners" by Drs Kjeldmand and Holmstrom.
It would be only fair to the reader to note that I am prejudiced in favor of Balint groups, and that similarly to Drs Kjeldmand and Holmstrom, I believe that such groups benefit physicians and help them during their encounters with patients. For me, this study provides additional support for the contention that Balint groups are a valuable learning experience for their participating physicians. The findings that, for at least some of them, Balint groups help avoid burnout make sense. As stated by the authors, sharing difficult experiences is a helpful strategy for overcoming them, and the reflectivity, which Balint groups promote, is the first step to the resolution of most problems.
Having said this, I would like to emphasize that the presented findings are not definitive evidence that Balint groups are, in and of themselves, effective in avoiding professional burnout. It may very well be that those who choose to participate in Balint groups differ from physicians, who do not, in their awareness that they have a problem, that they must do something in order to resolve it, and that sharing this problem with others may be helpful.
I believe that the main contribution of this study consists of the results of the analysis of the transcribed interviews. Most probably, future studies will explore further the five themes and their sub-themes, which the authors identified. To the extent, I may commit myself to a prediction, these themes will eventually become part of the content of the undergraduate curriculum. Medical students should consider the challenges of clinical practice at the earliest stage possible in their training, in order to make an informed decision about their future medical career.
Jochanan Benbassat MD The Smokler Center for Health Policy Research Myers-JDC Brookdale Institute Jerusalem
Competing interests: None declared
Show Less

Competing Interests: None declared.
Published on: (14 March 2008)
Page navigation anchor for Self-Care for Care-Givers
Self-Care for Care-Givers
Sharon B. Buchbinder, RN, PhD, Towson, MD, USA
Patient interactions and care-giving on a daily basis are physically and emotionally demanding and potentially draining occupations. While trained to take care of others in the long road to the practice of medicine, physicians are rarely taught how to take care of themselves. In fact, the medical profession has historically prided itself in long work hours, self-sacrifice, and loss of personal time. The fact that laws ha...
Show More

Patient interactions and care-giving on a daily basis are physically and emotionally demanding and potentially draining occupations. While trained to take care of others in the long road to the practice of medicine, physicians are rarely taught how to take care of themselves. In fact, the medical profession has historically prided itself in long work hours, self-sacrifice, and loss of personal time. The fact that laws had to be enacted to limit the number of hours a resident could work in the United States speaks volumes to this long history of self-abuse.
As I have noted before, job satisfaction is “a pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences.”1 Previous research has demonstrated the link between primary care physician (PCP) job dissatisfaction and turnover or quit behavior.2 Physician job dissatisfaction and turnover are important research phenomena because there are high costs associated with recruiting and replacing PCPs.3
In their article, “Balint Groups as a Means to Increase Job Satisfaction and Prevent Burnout Among General Practitioners,” Kjelmand and Holmström have explored the GP’s experience of participating in Balint groups, “a group of physicians who meet regularly and present clinical cases in order to better understand the physician-patient relationship.”4 The authors conducted a descriptive, qualitative study with nine GP’s, asking in-depth questions to obtain data rich in subjective materials. Two of the themes that emerged from their research were of particular importance: professional identity and security.
With respect to professional identity, I was struck by the comments that implied that the informant GP had problems establishing boundaries between himself and the patients. The patients demanded, and the GP gave—until he realized that his professional identity was being eroded with this behavior. The fact that the GP was able to go to the Balint group and share these feelings is an important lesson for care-givers: if you don’t take care of yourself, you won’t be able to take care of others. The Balint group gave the GP permission to keep the focus on himself and, by doing so, enabled the GP to recharge, regroup, and reposition himself in the patient-physician relationship.
The Balint group also provided a sense of security for the GPs who felt free to share their experiences and concerns. The physician group leader, trained to use psychodynamic principles with the focus on the patient-physician relationship, was able to elicit support from the others who could say, “Oh, yes, that happened to me, too.” There is strength in the knowledge that the GP is not facing these issues alone, and that others can give them advice in a safe space.
As a researcher in physician job satisfaction and turnover, I found this to be an intriguing exploratory study. However, while the authors touched on the theme of “satisfaction,” it appeared to be more of satisfaction with the group, not the job. In addition, the article speaks about burnout, but did not measure it with the Maslach Burnout Inventory, which is the gold standard for assessing it. I would suggest that the authors consider this study a good starting point for examining the impact of the Balint group on burnout and job turnover, which is the key outcome measure for job dissatisfaction.
The Balint group offers a model for all physicians, not just GP’s, as a way to decompress and receive emotional support from colleagues. In an era of growing patient demands, an aging world-wide population, increasing workloads, and looming healthcare worker shortages, we must not forget to care for the care-givers.
Sharon B. Buchbinder, RN, PhD Professor and Chair Department of Health Science Towson University Towson, MD
1. Locke EA. The nature and causes of job satisfaction. In: Dunnette M, ed. Handbook of Industrial and Organizational Psychology. New York: NY: John Wiley & Sons; 1983:1297-1349.
2. Buchbinder SB, Wilson MH, Melick CF, & Powe NR. Primary care physician job satisfaction and turnover. Am J Manag Care. 2001; 7:701-713. Available at
3. Buchbinder SB, Wilson MH, Melick CF, & Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care, 1999; 4:1431- 1438. Available at
4. The American Balint Society. What to expect as a member of a Balint group. Available at http://americanbalintsociety.org/pdf/WhatToExpectBrochure.pdf accessed on March 14, 2008.
Competing interests: None declared
Show Less

Competing Interests: None declared.

Main menu

User menu

Search

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

Published eLetters

Plain text

Vertical Tabs

Jump to comment:

In this issue

Citation Manager Formats

Related Articles

Cited By...

More in this TOC Section

Similar Articles

Subjects

Content

Info for

Engage

About

Main menu

User menu

Search

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

Published eLetters

Plain text

Vertical Tabs

Jump to comment:

In this issue

Citation Manager Formats

Jump to section

Related Articles

Cited By...

More in this TOC Section

Similar Articles

Subjects

Content

Info for

Engage

About