A Balint Group in Adolescent Medicine
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Empowering Subspecialty Residents’
Competency in Professionalism
Sara Jassemi, MD, FRCPC; Chris Trevelyan, MSW, RSW; Katherine Hick, MD, FRCPC
October 19, 2018
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I do not have an affiliation (financial or otherwise) with a
pharmaceutical, medical device or communications organization.
Je n’ai aucune affiliation (financière ou autre) avec une
entreprise pharmaceutique, un fabricant d’appareils médicaux
ou un cabinet de communication.
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A Gap Exists in Adolescent Medicine (AM) Training
Professionalism
Adolescent
Medicine is
evolving
Challenging
patient and
family
encounters
Troubling
feelings
Balint Group
Self-efficacy
and selfidentity
Patient care
affected
(Mahoney, 2013)
(Mills, 2015)
What is a Balint Group?
Case presentation
Facilitator
+ Group members
(6-12/group)
Closing discussion
(with presenter)
Clarifying
questions
Every 2-4 weeks,
longitudinal group
Group discussion
(without
presenter)
“Examine the relationship between the doctor and the patient, to look at the
feelings generated in the doctor as possibly being part of the patient’s world and
then use this to help the patient”
(Balint, 1964)
(Van Roy, 2015)
Study Design and Methods
Study Design
•Mixed-methods experimental design; critical paradigm
Study Population
• Adolescent Medicine Subspecialty Trainees (2017-2018), n = 6
Intervention
• Balint Group, once/month, 10 months (Sept 2017-June 2018)
Data Collection
Data Analysis
• Qualitative: Semi-Structured Individual Interviews
• Quantitative: Psychological Medicine Inventory, Clinical Vignettes
•Qualitative: Thematic Analysis
•Quantitative: PMI and Clinical Vignettes Change Scores (Pre and Post)
Themes from Individual Semi-Structured Interviews
 Through the structure, facilitation, and protection of the Balint group in the
academic curriculum, trainees felt permission to reflect on interpersonal
interactions.
 This represented a paradigm shift in the way trainees processed and defined
“traumatic” events.
 Trainees found utility and purpose in their emotions, which transformed
difficult interactions into a learning process.
 This translated into changes in patient care and interprofessional interactions
through the development of presence and understanding.
Paradigm Shift
 Trainees changed the way they
defined “trauma”
 Trainees changed the way they talked
about patients outside of Balint
 Reflective practice in Balint vs
traditional debriefs
 Relationship-focused vs fact-focused
 Academic half-day time
 Preventative wellness
“So actually, that is where I think it was
so rewarding. I mean, I know where to
go if I lose a patient, or if something
obviously traumatic happens. I have a
fantastic program director, I have the
supports in the hospital, but to me,
that’s sort of the obvious. …
It’s kind of like … stress fractures – of
course you know what to do when you
get that stress fracture in emerg …but
it’s each time you pound on it that I
think the Balint group is helpful for,
because it lets you stop each time,
actually stop and acknowledge feelings
that you're having, that you're so used
to sort of.”
Purpose & Utility
 Energizing
 Reframing emotions
 Understanding anger
 Becoming aware of power dynamics
 Reflective practice in Balint vs
gossiping/venting
“What can I learn from maybe this
reaction, or what can I learn from the
energy that is happening right now,
and how can I understand it, to, like,
show up tomorrow and maybe try it a
different way, or sit with it and not
put it all on me.
Or if I'm feeling like I'm getting so
much counter-transference, I can't
care for the patient, rather than get
flustered and, like, sometimes engage
in that kind of talk with nurses and
build-up, I feel like, a little more calm,
I think, and accepting and
introspective.”
PMI Scores improved for most trainees post-Balint
95
90
Total PMI Score
85
Post-Intervention
79.7
80
75
70
65
Pre-Intervention
79.7
60
55
50
Pre-Intervention
Participant 1
Participant 5
Participant 2
Participant 6
Post- Intervention
Participant 3
Average
Participant 4
Average Total Clinical Vignette Appraisal Scores improved
moderately for most trainees after participation in a Balint Group
Pre-Intervention
Post-Intervention
Reviewer Reviewer
Average
Reviewer Reviewer
Average
1
2
(reviewers)
1
2
(reviewers)
Change
score
(Average)
% Change
(Average)
Participant 1
32
33
32.5
36
36
36
3.5
10.7692
Participant 2
38
34
36
34
33
33.5
-2.5
-6.9444
Participant 3
24
29
26.5
30
27
28.5
2
7.54717
Participant 4
28
29
28.5
34
31
32.5
4
14.0351
Participant 5
27
31
29
32
34
33
4
13.7931
Participant 6
28
30
29
31
30
30.5
1.5
5.17241
Pearson Value
Average (all)
0.89714
0.81153
30.3
32.3
2.1
7.4%
Conclusions
 Regularly scheduled and protected opportunities to discuss ongoing physicianpatient and interprofessional relationships were valuable for trainees.
 The facilitation, structure, and focus on relationships in a Balint group
provided a different learning experience than traditional debriefs.
 While not all trainees felt there was a direct impact on patient care, Balint
group participation improved psychological self-efficacy and self-regulation.
 Balint Groups may be a valuable addition to Adolescent Medicine subspecialty
training curricula and to develop key concepts in Professionalism.
Thank you!
Help us improve.
Your input matters.
Aidez-nous à nous améliorer.
Votre opinion compte!
Download the ICRE App,
Téléchargez l’application de la CIFR
Go to: www.royalcollege.ca
/icre-evaluations to complete
the session evaluation.
Visitez le www.collegeroyal.ca
/evaluationscifr afin de remplir
une évaluation de la séance.
You could be entered to win complimentary registration for ICRE 2019.
Vous pourriez gagner une inscription gratuite à la CIFR 2019.
Improvements to Balint Group
 Inclusion of cases with interprofessional interactions
 Spontaneity of case presentations vs. prepared themes of discussion
 Appropriate use of academic half-day time
 Capacity building of Balint facilitation
Psychological Medicine Inventory
Clinical Vignette Scoring Rubric
Permission
 Factors that contributed to safety:
 external facilitation,
 different setting than the hospital,
 protected time,
 support from program,
 small group
 Took time to get used to the format
 Non-judgemental environment
 Validation from peers
 Developing a bond, trust
“Like, I know it’s not me, so stopping
and almost sort of taking, looking
down at the situation and trying to
better understand why they're angry,
to meet them halfway, versus sort of
internalise it... I feel a bit like I can
step out of the situation and the
moment more, rather than a week
later, or not even thinking about it at
all.”
Presence
 Develop understanding and context
 Repair of relationships
 Impacts outside of patient care, at
home or in other relationships
 Feeling comfortable with being
uncomfortable, uncertain, and this
can feel liberating
 Being able to let go and not ruminate
“And then in the sort of acute
situations where you know a family is
really struggling, and some of the
language that they use is really
personal towards you and invokes a
lot of those reactions within you, so
you feel frustrated, you feel targeted,
you feel traumatised almost. I think
Balint has helped me reframe that
emotion.”
Next Steps
 Capacity building for further Balint Group facilitation
 A Balint Group for general pediatric residents
 Application of a Balint Group in other disciplines
 Expansion on how we define Professionalism
 How do we teach and evaluate Professionalism?
Average Total Clinical Vignette Appraisal Scores
Average Total Clinical Vignette Appraisal Scores improved
38
36
34
32
30
28
26
24
22
20
Pre-Intervention
Post-Intervention
Participant 1
Participant 2
Participant 3
Participant 5
Participant 6
Average
Participant 4