The current status of Balint groups in US family practice residencies: A 10-year follow-up study, 1990-2000.

BACKGROUND AND OBJECTIVES: In 1990, the first and, to date, only objective study of Balint groups in US family practice residencies was conducted to measure their prevalence, composition, leadership, and function. The study reported here collected similar information about Balint groups. METHODS: Surveys were sent to all 464 US family practice residency program directors, with a 1-month follow-up to nonrespondents. The survey included questions about the existence, leadership, meeting frequency, and objectives of Balint training. RESULTS: A total of 298 (64%) residencies responded. Almost half (48%) of US responding residences reported conducting Balint groups, and 40% of those residencies have more than one group. The frequency of Balint group meetings has shifted in the past 10 years. In 1990, 55% of groups met weekly; in 2000, only 15% of groups met weekly. Sixty-five percent of residencies require Balint participation. One third of Balint groups are conducted without a coleader and the number of physicians leading groups is 22%, a decrease of 10% from 10 years ago. Forty-four percent of groups are led by psychologists, an increase of 19% from 10 years ago. Respondents indicated uncertainly about whether their groups were true Balint groups or simply resident support groups. CONCLUSIONS: About half of US family practice residencies operate groups described as Balint groups. They meet less frequently then 10 years ago and are less likely to have a physician involved in group leadership. Some of the groups may actually be support groups rather than Balint groups.

Approach to bloody stools in adults.

The mortality from LIB is less than 5%. The bleeding in the majority of patients with LIB resolves spontaneously and usually leaves no lasting sequelae. Early colonoscopy may shorten the length and cost of hospitalization.

Balint group observations: the white knight and other heroic physician roles.

BACKGROUND: This article reports a typology of five roles that resident family physicians on occasion assume when relating to troubling patients presented in Balint group seminars. The five roles include the white knight (my way or no way), the Pogo look-alike (I feel your pain), the missing link (you made me do it), the surrogate (I can help), and the revolutionary (let me show you). Each role reflects a particular physician's coping behavior in the context of a specific troubling relationship and is driven, in large part, by unrealistic professional expectations. The roles intend to perform a heroic function in rescuing or protecting the patient, the family, or the physician from a distressing medical situation. Balint group work provides participants with the opportunity to derive clinically useful meaning from their presentations. Residents begin to imagine a variety of therapeutic (helpful) roles to replace the ones they were induced to fill. This process has implications for practicing physicians and physician teachers for improving patient and doctor satisfaction and well-being.

Comorbidity of posttraumatic stress disorder and irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) is a chronic disorder that has been found to be associated with psychiatric disorders and a history of physical and/or sexual abuse. To date, the relationship of posttraumatic stress disorder (PTSD) and IBS has not been investigated. The primary purpose of this study was to examine the relationship of IBS and PTSD. METHOD: Fifty consecutive IBS patients admitted to a clinical treatment study were assessed for IBS, trauma history, and psychiatric disorders. RESULTS: Twenty-seven IBS patients (54%) met criteria for a psychiatric diagnosis at some time in their lives. Twenty-two patients (44%) reported a trauma history. Eighteen (36%) were diagnosed with PTSD. Those IBS patients with a trauma history were more likely to have other comorbid psychiatric diagnoses. CONCLUSION: These results suggest that IBS is often associated with psychiatric disorders, indicating that assessment and treatment of these comorbid conditions may be important in the treatment of IBS. PTSD, which had not been previously investigated in relation to IBS, had a high prevalence, indicating the need for careful trauma and PTSD assessment in patients with IBS. Patients with IBS who have a trauma history may be more at risk for other comorbid psychiatric disorders than IBS patients without a trauma history.

Family practice residents' perspectives on Balint group training: in-depth interviews with frequent and infrequent attenders.

BACKGROUND: Balint groups are focused discussion groups that help students, residents, or physicians respond empathetically to their patients and recognize underlying psychosocial elements in patients' complaints. Approximately 40% to 60% of residents who start optional Balint group training show infrequent attendance. The primary objective of this study was to interview frequent and nonfrequent attenders to assess the value of Balint group training from the residents' perspective and to explain why many residents attend Balint group meetings infrequently or discontinue Balint training altogether. METHODS: Two methods were used to discern differences between frequent attenders and infrequent attenders: (1) evaluation of Myers-Briggs Type Indicator (MBTI) data collected at the beginning of the residency program, and (2) semi-structured personal interviews with both frequent and infrequent attenders. RESULTS: MBTI data showed frequent attenders to have higher scores than infrequent attenders in the intuitive dimension. Interviews with Balint group attenders showed strong perception about the value of this training. The majority felt Balint training had improved their effectiveness as family physicians, specifically when dealing with troubling patients. Infrequent attenders mentioned scheduling problems and a variety of emotional/personality factors as reasons for not attending Balint seminars. Frequent attenders attributed nonattendance in others to lack of interest in the psychodynamics of the doctor-patient relationship and differences in personality type. CONCLUSION: Residents who participated in Balint groups perceive this training as helpful in understanding themselves in relationships with their patients. However, the study results suggest that many residents choose not to attend optional Balint group seminars because of emotional or personality variables, such as anxiety about self-disclosure and introversion. While Balint groups are a valuable component of a family practice residency program, it is likely that not all residents will be motivated or capable of deriving benefits from this teaching approach.

Empathy: an essential skill for understanding the physician-patient relationship in clinical practice.

In clinical practice, empathy is the skill used by physicians to decipher and respond to thoughts and feelings in the physician-patient relationship. Empathetic understanding and empathetic response occur in three phases of every office visit: the negotiation phase, the clinical reasoning phase, and the establishment of therapeutic alliance. Masters of empathetic skills is difficult, and before teaching empathy to residents and students, teachers must first develop their own empathetic skills. Development of empathetic skills can occur in Balint training programs, through the use of audio- or videotaped patient encounters, or through one-on-one training with an experienced preceptor.

Gearing balint group leadership to resident professional development.

This paper discusses the sequential phases of typical Balint training groups. The cases presented reflect the presenters' professional developmental time line and serve the participants' developmental needs: exploring professional boundaries and intragroup intimacy. The activities and issues arising in the meetings stem from these developmental needs and help the group members acquire specific skills. Knowing where the group members are in their professional development should help group leaders give a seminar its focus, decide on group membership, and recognize when a group is not developing appropriately.

A survey of Balint group activities in U.S. family practice residency programs.

The investigators conducted a survey of Balint group activities among family practice residencies in the United States. The survey was designed to discover how many programs have Balint groups as well as the groups' characteristics, leadership, and structure. Of the 381 family practice residencies surveyed, 93% responded. Of those, 66 offered Balint seminars to 115 different groups. Most groups met at weekly intervals for two to three years. Most groups were led by family physicians (32%), psychologists (25%), or social workers (19%). Most leaders followed the format of a spontaneous case presentation from memory. Support for residents and resolution of professional role conflict were rated as the two major objectives of training. The leaders rated an understanding of feelings generated when with patients and an enhanced sense of professional self-worth as the most attainable attitudinal changes.

Papanicolaou smear adequacy: effect of different techniques in specific fertility states.

Six hundred fifty-four Papanicolaou smears were studied prospectively to determine the yield of endocervical cells within specific fertility states by technique used. Smears from postmenopausal women had the lowest yield of endocervical cells (32 percent, P less than 0.01). Smears from postpartum women had a higher yield of endocervical cells than those from pregnant women (69 percent vs 59 percent, P greater than .05). Swabbing excess mucus from the cervix prior to scraping uniformly improved the yield of endocervical cells (70 percent vs 62 percent, P less than .02). In swabbed postmenopausal women, use of a Milex spatula had a significantly higher yield than the use of a wooden spatula and a cotton-tipped applicator (43 percent vs 27 percent, P less than .03).

Balint group leadership by a family physician in a residency program.

The historical background of Balint groups is summarized. Specific details about initial recruitment of residents and establishment of guidelines for group function are discussed. The central importance of quality control to the leader is emphasized. Qualifications for a nonanalyst family physician group leader are suggested. Results of resident evaluations indicates the educational merit of such training. Balint training provides pragmatic, clinically-oriented research, which is fundamental for all family medicine residencies.