Copenhagen Symposium May 2009, John Salinsky

Part of my work involves organising a half day a week course for trainee GPs

Three year course. First two years mainly in hospital jobs. Third year attached to a practice.

  • We take on 8 trainees a year so we have a total of 24 plus a few doing only the third year. Every Wed afternoon they get together for our course. In the first hour and a half we usually have a talk by a consultant, a GP a social worker, or psychologist or an accountant. Sometimes we watch a film or discuss a book we have all been reading. Then tea break, talk to each other. Last hour is spent in a Balint group.
  • Three groups. Some people are always a way because of holidays, being on call or whatever. Usually about 6 in each group.
  • Three program directors, one leads each group. Same people in each group though each year some leave and new ones arrive.
  • The Balint group is a unique way of learning about the reality of general practice.
  • We discuss real patients with complex problems, medical social and emotional.
  • We struggle with doubts and uncertainties. The answers are not in the text book. They are not to be found in the lecture theatre or on the internet.
  • The trainees present their difficult cases. The patients they go on thinking about after their day's or night's work is done.

What sort of patients?

  • Initially patients who make them feel angry or hurt.
  • Patients who are rude to them, make them feel useless.
  • Patients who don't know how to behave in a doctor's surgery
  • Demand drugs that are inappropriate: antibiotics, sleeping tablets, opiates.
  • Non steroidal drugs that are bad for their stomachs.
  • Letters to entitle them to time off work, or never to work again.
  • Letters to excuse their failure to appear in court.
  • Get them a better flat.
  • I just want to see a specialist.
  • This is not why I became a doctor!
  • People who make them anxious by talking about suicide
  • Family violence and the risk of child abuse
  • Patients who are too friendly or flirtatious.
  • Patients who despite their bad behaviour just might have a serious illness.

Later as they get used to working in the group they start to talk about patients they like and want to help but are not sure how.

Three stages:

  1. Share their hurt feelings and their bad experiences with sympathetic friends who have been there too. Collect suggestions about how to manage the patient better.
  2. With the help of the group leader, to develop their capacity for empathy. To see the patient as a person like yourself. To see the situation from the patient's point of view.
  3. To understand a little of what is going on between doctor and patient. Understand patient's feelings and ones own feelings.

Examples of presentations

Olga 44 year old woman of Russian origin. Presenting doctor is obviously pregnant.

Two years of pelvic pain. Had an operation with a wound infection. Believes she has had infection inside her ever since. Husband is alcoholic and stays at home. She works and earns money for both of them. They have a 2 year old girl who is still being breast fed and sleeps in the parents bed. She is being investigated for sleep apnoea. The little girl has also been referred for psychotherapy but no information available, Olga doesn't want the doctor to contact the psychology clinic. She does not want any psychological help with her pain.

Olga dismisses all the doctor's suggestions with contempt. She is quite frightening. Sometimes the doctor sees Olga in the park where she takes her own little daughter to the swings. Olga is there with her child. The doctor avoids having to talk to her. The discussion: How can we prove to her that she has no infection? She doesn't believe the test results when they are negative. Sexual disease clinic? Should she have a laparoscopy?. The more you give into a patients; demands for tests the more she wants. Where will it end. Should the doctor just say, I can't help you any more? But there is also worry about the little girl. Is she at risk of abuse? Should the social services be alerted?

No solution is found, but the doctor looks happier at the end and promises a follow up report. She has lots of new ideas, she says. She feels less afraid of the patient. She even looks forward to their next meeting.

Maria Spanish woman 37

Presented by male doctor. She is a legal immigrant from S America doing cleaning work. Boss is illegal. Came with 'repetitive strain'.

Consultations through telephone interpreter. Take 20-30 mins. Doctor has a few words of Spanish. Thought she might have cervical spine syndrome with arm pain and numbness. Referred to neurologist. Not seen yet. Now pain now all over. Tries different pain tabs, physio. She also sees a private Spanish doctor now and then. Feels GP can't solve the problem but at end she hugs him and thanks him.

Discussion: Boundary issues. Does she want to come home with him? Does he need to restrict the time more. Should she have so much time off work. Presenter says she doesn't seem to be in pain. Quite active and lively. Phone is a barrier. He should have Spanish lessons! Record consultation and play it to a Spanish friend. That would be really taking her home. No time to ask about her personal life. Why she came? What sort of life she wants? Presenter agreed it would be a good idea to devote a special session to asking her about herself. Meanwhile the doctor was working even if the drugs were not.

Do the trainees value the group?

  • Some like it straight away.
  • Some can't see the point at first but get to appreciate it more as time goes on.
  • A few wish we would go in for deeper psychological exploration.
  • Over three years in the group they get to talk about a lot of cases. They begin to work together as a group. Responding to each other's thoughts.

Here are some feedback reports:

  1. I find it very valuable to discuss cases in the Balint group and I find it interesting when my colleagues come up with different ideas or approaches to deal with difficult consultations.
  2. I find Balint very helpful and feel it is an honest and safe environment to debrief difficult cases and always walk away feeling like the burden has been lifted from my shoulders!
  3. In all honesty I think overall my Balint group experience has not been a positive one.
  4. I think the theory and potential for gaining a different perspective and better understanding of the patient is hugely valuable and very interesting. In practice though, I have found the groups lacking in structure or direction (when I think they would benefit from having more) and unfortunately in some sessions the people who would have the most interesting points of view don't say that much as opposed to a few people who talk rather a lot.
  5. I find Balint tends to polarise opinion, trainees either take to it or they don't. I find it can be therapeutic, except, unlike the traditional model, there can be several therapists at once. It's not about solutions, yet it can make you see yourself and your patients more clearly. The most valuable thing I enjoy is understanding how other colleagues think; both about their patients and the world. It's rare to experience that anywhere else in your average week. Finally it can be uncomfortable at times and that's no bad thing.
  6. During my psychiatry post we had weekly Balint groups facilitated by a consultant in psychotherapy. They differed slightly in that they began when silence fell in the group. The facilitator simply allowed a rather awkward silence to continue until someone spoke. Rather than practical advice for management, the focus was more on how the person dealing with the case was being made to feel and why. Occasionally, the facilitator would offer a completely new perspective. I found exploring why certain unpleasant or difficult patients were evoking these emotions in me and others very interesting.
  7. I do find Balint a useful experience to get other people's points of view but I don't like it when we are told not to look for answers. Sometimes cases are clinically difficult and discussing those with others who might have more knowledge is just as useful as discussing those which are difficult in other ways. I do think follow up is important as we then find out what happened and often why the difficulty arose etc.
  8. I really look forward to the Balint group each week because people are infinitely interesting and it allows us time to think about our patients as people and wonder a bit about their lives and how we fit into them.