Now showing: The presentation. Using video recording to enhance Balint leadership training.

Review of video recorded sessions is a powerful teaching tool in medical education, helping students appreciate both spoken and unspoken communications not fully appreciated in the moment. For many years, the American Balint Society has used video review in its Leadership Training Intensive courses, however technical challenges around setting up and operating the equipment have led some faculty to question whether the benefits are worth the effort and anxiety. We describe here an approach to video review in Intensives with a focus on the case presentation. Close attention to the case presentation can uncover important clues about a presenter's feelings and conflicts in a case, clues that may easily be missed on first pass. The Balint group leader listens for clues and cues to the patient's state of mind, and how the clinician is being distracted or deflected from their authentic role. Focusing the video review at an Intensive on the case presentation highlights for novice leaders the importance of maintaining keen focus on this initial section of the Balint group process for information on "what this case is about." Finally, we predict that Balint group leaders who emerge from an Intensive with this new appreciation for close listening to the presentation will not only be more effective Balint group leaders but will also be in a better position to serve as clinical role models, teaching by example to their Balint group members the importance of attending closely to the patient's communications in the patient - clinician encounter.

Post-concussion syndrome and pre-existing mood disorder: A case report.

Sport-related concussions in youth and adolescent athletes most commonly resolve within one week without residual symptoms, with athletes resuming full participation following return to play guidelines. A small percentage of athletes have persistent symptoms that cause significant morbidity, some of whom are ultimately diagnosed with post-concussion syndrome. In these athletes, symptoms in the emotional domain can be more prolonged than other domains, with athletes reporting anxiety and depression months to years following injury. A prior personal or family history of pre-existing mood disorder or attention-deficit/hyperactivity disorder increases the risk of a prolonged duration of symptoms. In this case series, we discuss two cases of post-concussion syndrome in adolescent athletes with a past personal or family history of attention-deficit/hyperactivity disorder, anxiety, and depression treated by a combination of cognitive behavioral therapy and medication with ongoing persistent symptoms. There is increased need for mental health screening in all athletes to identify individuals at risk for post-concussion syndrome. Early identification of at-risk individuals allows the interdisciplinary care team to discuss expectations for the athlete and family regarding duration of symptoms.

Balint groups in family medicine residency programs: a follow-up study from 1990--2010.

BACKGROUND AND OBJECTIVES: Balint groups have been part of residency education for decades. This study updates our understanding of the organization, purpose, and leadership of Balint groups within US family medicine residency programs. METHODS: Accreditation Council for Graduate Medical Education (ACGME)-approved family medicine residency training programs (n=453) were contacted to complete a questionnaire, similar to ones performed in 1990 and 2000. This survey included questions regarding Balint groups, including their composition, management, and goals. RESULTS: More than half (54%) of respondent programs (n=159) have at least one Balint group, compared to 19% in 1990 and 60% in 2000. Of programs without Balint, 24% would like to have a Balint group, and 6% plan to initiate one within the following year. The proportion of groups meeting weekly decreased over time (80.9% in 1990 versus 40.4% in 2000 versus 11.7% in 2010). The proportion of peer only groups decreased (45.2% versus 53.6% versus 35.1%) while the proportion of groups with > 11 members increased (11.1% versus 15.8% versus 27.2%). Less than half of Balint group leaders reported going to formal training at the American Balint Society Leader's Intensive Workshop (41%). "Understanding the patient as a person" was seen as the main objective of Balint groups. CONCLUSIONS: Balint groups are still commonly occurring, but their implementation is changing. Groups are meeting less frequently and are more likely to be larger and heterogeneous. This trend and lack of formally trained/certified leaders may be decreasing the benefit to residents involved in Balint groups.

The legacy of Michael Balint.

Michael Balint's lead article, "Repeat Prescription Patients: Are They An Identifiable Group?" inaugurated the first issue of Psychiatry in Medicine, Vol. 1, No. 1, 1970. A few years later, this Journal would be renamed International Journal of Psychiatry in Medicine (IJPM). Who is this author of over 165 papers, 10 books, practicing psychoanalyst from 1926 to 1970, director of the Budapest Psychoanalytic Institute from 1935 to 1939, consultant at the Tavistock Clinic from 1948 to 1961, President of the British Psycho-Analytical Society from 1968 to 1970, literary executor of Sandor Ferenczi, a foremost theorist of object relations, and international educator and statesman for general practitioners? We would like to review for you some of the formative experiences in Michael's life that wedded psychoanalysis and general practice, and how they contributed to his major educational commitment over 40 years to furthering the understanding and integration of psychosocial factors in the practice of primary healthcare as experienced by doctors all over the world. We would also like to highlight some of his major insights and see to what extent they are incorporated in contemporary medical education and practice. We believe that some of his major insights have been neglected and others have been further amplified and extended. Our intention is to speak not only to medical students who desire to pursue medicine related directly to patient care but as well to seasoned practitioners who continue on a daily basis to care for individual patients and their families.

Executive function and medical non-adherence: a different perspective.

Medical non-adherence is multifactorial: cost, convenience, side effect profile, and cognitive impairment are all implicated in medical nonadherence. We explore impaired executive function (EF) as a cause for medical non-adherence when other causes can be ruled out. EF describes the coordination and manipulation of higher-order cognitive processes involved in problem-solving, planning, and decision-making. EF has three components: working memory, mental flexibility, and inhibitory control. The latter, inhibitory control, when impaired will affect an individual's ability to make choices to produce long-term benefits, in favor of short-term gratification. When applied to adults with chronic diseases, like diabetes, that require lifestyle modification and, at times, complicated medical regimens to forestall long term complications, an intact EF has a role in adherence. EF development is protracted with behavioral corollaries observable from early childhood. Thus, teachers, family physicians, and pediatricians will be the professionals to first encounter and manage such individuals. We suggest screening tests for children in the doctor's office to detect impaired EF, and postulate a cognitive behavioral therapeutic approach for adults with uncontrolled DM and impaired EF.

Traumatic events and mental health in civilian primary care: implications for training and practice.

BACKGROUND AND OBJECTIVES: Primary care research into post-traumatic stress disorder (PTSD) is less developed than primary care depression research. This study documents lifetime traumatic events and past month depression and PTSD in adult patients of a large family medicine residency practice. METHODS: We used a telephone survey of 411 adult patients from a family medicine residency practice in the Southeastern United States. Standardized measures were used. RESULTS: Seventy-nine percent of study enrollees completed the study. Women were significantly more likely than men to have been diagnosed with PTSD (35.8% versus 20.0%) or depression (36.1% versus 21.1%), with a high degree of diagnosis overlap (76.5%). Most adults (>90%) reported one or more traumatic events. Men reported more war zone/combat events; women reported more sexual victimization. More than 80% of patients thought family physicians should ask about traumatic events; only a minority recalled being asked (26.8% men, 43.6% women). Regression models determined that current depression and several traumatic events were significant correlates of current PTSD. CONCLUSIONS: Key gender differences in frequency of lifetime traumatic events, past month depression and PTSD, and patient attitudes about trauma questions existed. Current PTSD was best predicted by a combination of coexisting depression and traumatic events. Discussion explores training and practice implications.

Multiple chemical sensitivities: a presenting complaint in two patients.

M.C.S. presents with non-specific multi-organ symptoms in individuals who do not manifest evidence of specific organ malfunctioning. Experts disagree about whether the disorder is caused by exposure to environmental chemicals in low concentrations or whether it has a psychological basis. This paper (a) describes two patients who were firmly convinced that they suffered from M.C.S., (b) discusses a differential diagnosis of the disorder, and (c) suggests an approach to management.

Resident physicians who continue Balint training: a longitudinal study 1982-1999.

BACKGROUND AND OBJECTIVES: Balint seminars began in London in 1950 on a voluntary basis for general practitioners wishing to explore psychological problems in their practice. By 1964, there was a 36% early dropout rate among the 223 physicians who participated. This study sought to determine if those who leave Balint training during their residency, versus those who continue, have different psychological characteristics. METHODS: A retrospective analysis of 206 Medical University of South Carolina family practice residents from 1982 to 1999 was completed. All residents participated in 6 months of required Balint training and then could leave the Balint group or continue for the remaining 2 years. We examined gender and personality attributes, comparing residents who completed 2 years of weekly Balint training and residents who left after 6 months. Personality attributes were measured with the Myers-Briggs Inventory, the Work Environmental Preference Schedule, the Internal-External Locus of Control, the Fundamental Interpersonal Relationship Orientation Behavior test, and the Personal Orientation Inventory. RESULTS: A total of 132 residents completed 2 years of weekly Balint training, and 74 discontinued training after 6 months. Two-year attendees were significantly more intuitive on the Myers-Briggs Personality Inventory (MBTI). There were no significant differences on other MBTI items, nor were there significant differences in gender or in scores on the other psychological tests. CONCLUSIONS: Based on the rate of discontinuation of Balint training in our sample, Balint work does not appear to be suited to all physicians. With the exception of one MBTI characteristic, no significant differences could be demonstrated between those who did and did not continue participating. Further study is necessary to define other attributes characterizing Balint group attendees and nonattendees.

Identifying acute epiglottitis in adults. High degree of awareness, close monitoring are key.

Epiglottitis can be a rapidly fatal condition in adults. Important clues that should raise clinical suspicion include the tripod sign, fever, stridor, sore throat, odynophagia, shortness of breath, and drooling. These features must be differentiated from those associated with common viral infections. The most helpful diagnostic studies are radiography of the neck and direct laryngoscopy. The patient's airway should be monitored during evaluation to avoid obstruction. Successful management requires teamwork between the primary care physician and personnel skilled in intubation as well as timely consultation with an otolaryngologist. Laryngoscopy and intubation always should be performed by the most skilled personnel because repeated attempts may increase periepiglottal swelling and the risk of airway obstruction. Racemic epinephrine should be avoided because of the rebound effect. Awareness of the possibility of epiglottitis in adults and close monitoring of the airway are the keys to management of this potentially life-threatening condition.