The Balint group and its application in medical education: A systematic review.

INTRODUCTION: The Balint group's seminars were developed by Michael and Enid Balint for the purpose of a better understanding of doctor-patient relationships. This study aimed to introduce the Balint group and its application to the medical science educational program and to provide an up-to-date perspective on Balint group research.
MATERIALS AND METHODS: The study was carried out as a systematic literature search published from January 2008 to September 2018 in the databases of PubMed, Scopus, Science Direct, and Proquest, which were searched with keywords such as the Balint group and medical education along with numerous related terms. Duplicates, non-English language articles were discarded from the review.
RESULTS: A total of nine papers entered the study. Among included articles, four used a qualitative methodology, four used a quantitative methodology, and one applied a mixed methodology. Four main aims emerged from the content of papers: (1) to evaluate resident and medical student experiences in Balint groups, (2) to improve communication skills and reduce burnout level, (3) to assess the Balint group's effects on empathy, and (4) to explore the contexts and triggers of cases presented in Balint groups.
CONCLUSION: Our results help us to the achievement of a better planning and design of an efficient Balint group in medical education. The findings enable the policymakers to make better decisions on the topic. Balint groups may guide medical students (residents) to become more patient centered by improving their communication skills and empathic abilities and reducing the level of burnout.

Introduction

In 1957, Dr. Michael Balint noted the details and objectives of the Balint group in his book entitled “The Doctor, His Patient, and The Illness.” Michael Balint was a general practitioner and began presenting seminars for general practitioners in 1950.[12] He believed that therapists, in addition to their professional medical expertise, needed to have personality traits and skills in developing good contact with the patient.[3] These groups are to help general practitioners to improve the doctor–patient relationship and to achieve a more meaningful understanding of the patient.[4] The Balint group is a small group of clinicians who meet regularly to discuss cases from their practices, with a focus on their work psychological aspects and, in particular, on doctor–patient relationships.[5] In the Balint groups, general practitioners and/or other medical professionals narrate the cases that they find difficult under the guidance of the psychoanalysts who play a leading role. Then, the narrated cases are processed. The goal of the Balint group is to provide a better understanding of the emotional content of the doctor–patient relationship for physicians in order to make them more capable physicians.[36] Olds and Malone, quoting from Michael Balint, stated that traditional Balint groups include >10 general practitioners and 90-min weekly sessions in the presence of a trained leader. With the aim of increasing their knowledge, participants have the opportunity to the reflection of their works through reporting of the desired patient and conducting group discussions in a safe psychoanalysis environment.[7] Balint groups have been used by a number of participants, such as resident physicians, medical students, and hospital staff, and in continuing medical education.[38910] The purpose of this literature review is to introduce and become more familiar with the various dimensions and details of the Balint groups implemented in the last 10 years to address the latest application programs of Balint groups and use in medical education.

Materials and Methods

The present systematic review aimed to address the following questions:

What are the authors' name, year of publication, a country where research was done, study type, and aim of the study, data collection tools? What are the duration, frequency, participants, the other names of Balint group sessions, and information on the leader? What are the findings and themes?

The articles published from January 1, 2008 to September 29, 2018, were searched in the databases PubMed, Scopus, Science Direct, and Proquest, and the search terms were “Balint group” AND “medical education,” along with numerous other related terms. The full search strategies are detailed in Appendix 1. All the databases were searched by one reviewer, and Endnote X7 was used for data management. The duplicates and non-English language articles were excluded.

Appendix 1

Search strategies

“Balint group” or “Psychoanalytical therapy” or “Balint psychoanalytic therapy” and “Medical education” or “Clinical education” or “Medical teaching” or “Clinical teaching”

Each of the titles and abstracts generated by the search strategy was reviewed independently by two reviewers (MY and FH or MY and AO) to determine the potentially relevant articles, and all articles addressing Balint groups associated with medical education as a subject were included. Full-text articles were obtained unless both reviewers decided that an abstract was ineligible. Each full text was assessed independently for final study inclusion.

After reading the full texts of the included articles, each article was critically appraised for eligibility, and any disagreement between the researchers was resolved through consensus if needed. The PRISMA flowchart illustrated in Figure 1 shows the inclusion and exclusion process in the four phases of “identification,” “screening,” “eligibility,” and “inclusion.”[11] The output of the first phase (Identification) was 109 articles found in the four databases. Throughout the first step of the “screening” phase, 33 duplicate works were identified and removed. In the second step, 75 papers were removed to do irrelevant documents, titles, or abstracts. Totally, 13 papers were reminded based on inclusion/exclusion criteria. In “eligibility” phase, the criteria for removing the extra papers were the text not being related to typical Balint group, incorrect participants, and not available full text [Appendix 2]. Finally (at the inclusion phase), nine relevant papers were selected for further analysis [Figure 1].

Figure 1

A study flowchart demonstrates the inclusion exclusion process

Appendix 2

Reasons for excluded full-text article

Title	Author (s)	Years	Reasons for exclusion
Balint seminars: The transatlantic experience through videoconference	Antoun et.al.	2014	Atypical Balint group
Mapping the Balint groups to the Accreditation Council for Graduate Medical Education family medicine competencies	Lichtenstein et.al.	2018	Atypical Balint group
Improving the doctor-patient relationship in China: The role of Balint groups	Jing et.al.	2013	Incorrect participants
The doctor-patient relationship III: A way of listening - The Balint group revisited, 2008	Snyder	2009	Not available

Data were extracted using a data table form to enter relevant information applied in each study. Relevant information was extracted from the included studies: authors' name, year of publication, country, type of study, the aim of the study, data collection tools, duration, frequency, participants, and other names of Balint group sessions, information on the leader (s), findings, and themes. Data extraction was assessed by two reviewers (MY and FH or MY and AO), and disagreements were resolved by consensus.

Results

Based on a systematic review, nine studies were extracted, which were used to form the basis for answering the questions of the study. Among these studies, two studies were conducted in 2012, two studies in 2014, one study in 2008, one study in 2009, one study in 2011, one study in 2016, and one study in 2018 [Table 1].

Table 1

Overview of included papers (the authors’ name, year of publication, a country where research was done, study type, and aim of the study)

Author	Years	Country	Study type	Aim
Torppa et al.[8]	2008	Finland	Qualitative	To explore the contexts and triggers of cases presented in student Balint groups and to clarify the themes in the group discussions
Graham et al.[12]	2009	United Kingdom	Qualitative	To explore the residents’ experiences in Balint groups
Yakeley et al.[13]	2011	United Kingdom	Quantitative	To evaluate the effectiveness of Balint group on doctor-patient relationship
Bar-Sela et al.[14]	2012	Israel	Quantitative	To improve the therapeutic communication skills and reduce burnout level
Parker and Leggett[15]	2012	Australia	Quantitative	To facilitate the understanding of the relational aspects of student encounters with psychiatric patients
Airagnes et al.[16]	2014	France	Quantitative	To examine the changes in empathic abilities of medical students
Parker and Leggett[17]	2014	Australia	Qualitative	To evaluate the Balint clinical reflection groups for medical students
O’Neill et al.[18]	2016	United Kingdom	Quantitative-Qualitative	To explore the ways of heightening students’ awareness of the emotional, nonbiomedical aspects of illness, and the dynamics of the doctor-patient relationship
Player et al.[19]	2018	USA	Qualitative	To evaluate the resident physician experiences in Balint groups

As Table 1 shows, the United Kingdom is the top country in terms of number of studies (n = 3), Australia (n = 2), France (n = 1), United States of America (n = 1), Israel (n = 1), Finland (n = 1) are next in the list.

Among included articles, four used a qualitative methodology, four used a quantitative methodology, and one applied a mixed methodology [Table 1].

From Table 1, it can be observed that aims of studies categorized in four categories: (1) to evaluate resident and medical student experiences in Balint groups (n = 3),[121920] (2) to improve communication skills, doctor–patient relationship, and reduce burnout Level (n = 4),[13141518] (3) to assess the effects of Balint groups on empathy (n = 1),[16] and (4) to explore the contexts and triggers of cases presented in Balint groups (n = 1).[8]

All quantitative studies used the self-report questionnaires, including the Maslach Burnout Inventory, the expectation questionnaire of each meeting, the Interpersonal Reactivity Index, and the ad hoc 8-item questionnaire to assess their reactions in response to written case reports.[141516] In the qualitative studies, researchers mainly used observation and field notes, semi-structured interviews, audio tape, unstructured written feedback.[8121719] And in the only quantitative-qualitative study researchers used pre- and postquestionnaires (to explore students' attitudes toward student–patient relationshps and their expectations of this new component of the educational process), a reflective 1000-word essay (on their responses to one of the cases discussed during the pilot project), and leader's observations.[18]

The duration of each session of the Balint group in the extracted studies was, respectively, 60 min (n = 1), 90 min (n = 3), 75 min (n = 1), and 120 min (n = 1), and three articles did not mention the duration of the sessions; furthermore, the frequency of sessions varied frequently from 3 weeks to 1 year [Table 2]. According to Table 2, participants in six studies are residents and in the five studies are medical students.

Table 2

Overview of included papers (the duration, frequency, participants, the other names of Balint group sessions, and information on the leader)

Author	Duration of Balint group sessions (min)	The frequency of Balint group sessions’	Participants of Balint group sessions’	Other names of Balint sessions group	Information of Leader(s)
Torppa et al.[8]	90	10 sessions every 2nd week and 5 weekly sessions (15 sessions)	6th-year medical students in two groups of 4 and 5 persons (n=9)	Balint work group Balint group discussion Balint discussion	A trained psychoanalyst and one co-leader
Graham et al.[12]	75	12 weeks (12 sessions)	Psychiatric residents and counselors (n=17)	Balint-style group Balint-type case discussion Balint-style training	-
Yakeley et al.[13]	-	3 months/12 weeks (weekly)	4th-year clinical medical students in two groups (n=28)	Balint group	Two leaders
Bar-Sela et al.[14]	90	9 months (once monthly)	Oncology residents (8 junior and 7 senior n=15)	Balint-type case discussion group	A clinical psychologist, the head of the psycho-oncology services, and the head of the palliative care unit
Parker and Leggett[15]	60	6 weeks	3rd-year postgraduate medical students (n=10)	Balint method Balint-like group Balint clinical reflection group	-
Airagnes et al.[16]	120	10 weeks	4th-year medical students (n=163) (Balint group n=34, control group that participating in other certificate n=129)	-	A trained facilitator experienced in Balint groups
Parker and Leggett[18]	-	6 weeks	3rd-year postgraduate medical students (n=42)	Balint clinical reflection group Balint work Balint clinical reflection Balint reflection	Two facilitators (one of them with a background in psychoanalytic psychotherapy and the other was a trainee psychiatrist with a background in psychology, undertaking advanced training in psychotherapies and adult psychiatry
O’Neill et al.[18]	90	6 weeks (1 weekly)	3rd-year graduate students (n=6)	Balint method Balint-style group Balint approach Balint-style approach Balint work Balint practice	A leader (a psychologist) and a co-leader (a medical practitioner engaged in clinical practice, teaching, and medical research)
Player et al.[19]	-	24 months (twice monthly)	2nd- and 3rd-year family medicine residents (n=18)	Balint seminar Balint method Balint training	Two leaders experienced with the Balint method

In 9 extracted studies, besides the name of the Balint group, 18 other names have been used for these sessions. In addition, the number of the leaders were, respectively, from less to more 1 (n = 2) and 2 (n = 5), and two articles did not mention the number of leaders [Table 2].

In this section, we review the main findings and themes of the articles that include:

Torppa et al. in the their study reported three contexts (patient encounters, experiences in medical education, and tension between privacy and profession) and five triggers (witnessing injustice, value conflict, difficult human relationships, incurable patient, and role confusion) of cases presented in student Balint groups and found four themes (feelings related to patients, building professional identity, negative role models, and cooperation with other medical professionals) in the group discussions.[8]

Graham et al. described the experiences of residents in the Balint group as groups were anxiety provoking, groups were instrumental in learning, and some participants struggled to use the case discussion group productively.[12]

Parker and Leggett evaluated Balint clinical reflection groups for medical students and found that the fidelity of the Balint group experience was achieved and that student attitudes were neutral to mildly positive regarding the educational experience and they addressed three themes (dichotomized reflections on the value of the experience, limitations in relevance of the process to the student context, and advice about adaptation of the process to the student context) during Balint group sessions.[17]

Player et al., in order to evaluate the experiences of physicians from the Balint group, were achieved into nine positive valence themes (being the physician the patient needs, reflection, empathy, blind spots, bonding, venting, acceptance, perspectives, and individual experiences) and three negative valence themes (repetitive, uneasiness, and uncertain impact).[19]

Bar-Sela et al. found that participation in the Balint group improved the communication abilities and decreased the burnout of residents.[14]

Parker and Leggett found that the Balint groups facilitate understanding of the relational aspects of student encounters with psychiatric patients.[15]

Airagnes et al. reported that the participation in the Balint Group has increased the empathy among medical students.[16]

Yakeley et al. indicated that participation in the Balint group is effective in increasing students' knowledge of the doctor–patient relationship compared with the control group who had not participated in Balint group.[13]

O'Neill et al. explored ways of heightening students' awareness of the emotional, nonbiomedical aspects of illness and the dynamics of the doctor–patient relationship, and they reported that (1) the conventional Balint method needs to be modified for students at a point in their training where they have not yet been exposed to patients for long enough to develop meaningful patient relationships, (2) heightened awareness of the dynamics of doctor–patient relationships and the importance of psychological/emotional factors (including their own prejudices) when interacting with a patient, and (3) Balint-style groups could be an effective way of encouraging medical students to reflect on the importance of emotions in the doctor–patient relationship. In addition, they also referred to five themes in their study which included (1) appreciation of and enthusiasm for the idea of reflective group discussions about nonmedical aspects of illness and their impact on the doctor–patient relationship, (2) to confront and acknowledge their own prejudices and preconceptions, (3) the students came to embrace the idea of “putting yourself in the patient's shoes” by trying to imagine what it would feel like to be that patient in that situation, (4) a lack of sensitivity to the patient's need for dignity and respect and lack of time to devote to the personal/emotional care of the patient because of the pressure of “throughput” standards, especially in emergency departments, a resulting potential for erosion of patients' trust in the health-care system, and (5) a more prolonged program of reflective group discussions would help in the process of generalizing from specific cases by incorporating the Balint principles into every encounter with a patient.[18] Due to space limitations, only summaries of the findings were presented, and it is suggested to refer to the original articles for more information.

Discussion

This systematic review was aimed at searching, analyzing, and synthesizing available articles for the Balint group in medical education from 2008 to 2018. We reviewed qualitative (n = 4) quantitative (n = 4), and mixed (n = 1) methodology papers.

The qualitative findings suggest that Balint groups aid personal and professional development and help medical students (residents) to understand the impact of their own personality characteristics on the consultation.

The findings of quantitative studies did not always imply that Balint groups increased patient centeredness compared with control conditions. Furthermore, findings indicated that participation in the Balint group is effective in increasing students'(residents') knowledge and abilities of the doctor–patient relationship and potentially also improving their communication skills. The acceptability and educational value rate in studies where Balint groups were optional compared with mandatory were higher.

The major part of the reports of the studies has largely relied on self-reporting by the students/residents. The general consistency of the findings among the papers, regardless of the country in which the study was conducted, makes the results generalizable. All the papers reviewed by this study mentioned the evidence of a variety of educational advantages of the Balint group in medical education. Among these advantages can be mentioned to the improvement of the doctor–patient relationship, the decrease of the burnout, increased empathy, management of stress and anxiety, and positive attitudes and perception about Balint group. This study is the only systematic review examining the application of Balint groups in undergraduate and postgraduate medical students.

Because only English language articles were included, the missing of some studies is possible. Furthermore, books and conference articles were not taken into account. Another limitation of this study is the uncertainty of the quality of articles. Furthermore, the unavailability and nonuse of some databases can be cited as our limitations.

Conclusion

Our results contribute to the achievement of a better planning and design of an efficient Balint group in medical education. The systematic review was an attempt to give a general picture of the variety of Balint groups suggested in the literature and to provide the latest evidence to select the best intervention(s) in medical education using the findings; the resident/students will also be prepared for future professional life. The findings enable the policymakers to make better decisions about the topic. Moreover, the results achieved here can be used as a basis for further studies and the expansion of knowledge in this field.

Considering the progress of medical education, the rapid change in technological advancement, and requirements of patients, the importance of Balint group will have to be more emphasized due to changes in demographic characteristics. In addition to medical education, there should also be changes in the education of other health professionals (such as nursing and physiotherapy) who have close relations with patients.

Given that the study indicated that the Balint group can be used as a way to improve students' communication abilities in medical education programs, it is suggesting that the Balint groups should be used to improve teacher–student relationships also.

Financial support and sponsorship

This study was financially supported by the Research Deputy of the Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.