The role of Balint group training in the professional and personal development of family medicine residents.

This paper presents a study based on the participation of PGY2 and PGY3 family medicine residents in Balint seminars that occurred twice monthly for 24 months. Balint groups were cofacilitated by leader pairs experienced with the Balint method. Prior to residency graduation, 18 of 19 eligible resident physicians (94.5%) completed 30- to 60-min semistructured interviews conducted by a research assistant. Resident physicians were told that these individual interviews concerned "…how we teach communication in residency." The deidentified transcripts from these interviews formed the raw data that were coded for positive (n = 9) and negative (n = 3) valence themes by four faculty coders utilizing an iterative process based on grounded theory. The consensus positive themes included several elements that have previously been discussed in published literature concerning the nature of Balint groups (e.g., being the doctor that the patient needs, reflection, empathy, blind spots, bonding, venting, acceptance, perspective taking, and developing appreciation for individual experiences). The negative themes pointed to ways of possibly improving future Balint offerings in the residency setting ( repetitive, uneasiness, uncertain impact). These findings appear to have consistency with seminal writings of both Michael and Enid Balint regarding the complex nature of intrapsychic and interpersonal skills required to effectively manage troubling doctor-patient relationships. The implications of findings for medical education (curriculum) development as well as future research efforts are discussed.

Quality improvement for prevention of cardiovascular disease and stroke in an academic family medicine center: do racial differences in outcome exist?

OBJECTIVES: We evaluated whether a one-year, multifaceted quality improvement intervention improved adherence to 13 clinical guidelines for lipid screening, hypertension management, and diabetes management among White and African-American adult patients. SETTING: An academic family medicine center. PARTICIPANTS: Six faculty physicians and a clinical pharmacist participated between July 1, 2002, and June 30, 2003. Data from 2860 patients' electronic medical records were abstracted. INTERVENTIONS: Performance reports and lists of patients eligible for each guideline measure were generated. Interventions targeted patients who needed improvement. Statistical analyses used generalized estimating equations to determine the intervention effect. RESULTS: Significant improvements occurred in blood pressure control for all adults (OR= 1.44) and those with hypertension (OR=1.82), measures of total cholesterol (OR=1.10) and high-density lipoprotein cholesterol (OR= 1.27) for all patients, and measure of low-density lipoprotein cholesterol (OR=2.01) and blood pressure control (OR=1.71) for patients with diabetes mellitus. Significant decline was seen in measures of blood pressure for all patients (OR=.60). After adjusting for patient demographic factors, provider variability, and comorbidities, race was not associated with the change observed in any of the measures from baseline to follow-up. CONCLUSIONS: Even though a multifaceted intervention can improve process of care measures for Whites and African Americans, further studies are needed to improve outcome measures, especially in African Americans.

Physician pattern of patient notification of test results.

OBJECTIVE: To discover how community-based family physicians notify patients of test results and whether there are differences based on sex, length of time in practice, reimbursement status, employment status,or percentage of practice in managed care. METHODS: We mailed a survey to 500 randomly selected members of the South Carolina chapter of the American Academy of Family Physicians. All analyses were preformed using SASTM version 8.2. Both descriptive and inferential statistics were used to analyze the collected data. RESULTS: A total of 367 physicians responded (73% response rate). The main outcome variable was the time each physician spent notifying patients of test results: a mean of 20.86 +/- 18.3 minutes per day(range 0-120 minutes/day). Women physicians and those with more than 75% managed care were significantly more likely to spend more than the median time notifying patients of test results. CONCLUSION: Physicians vary in the amount of time they spend notifying patients of their test results, with female physicians and those with more than 75% of their practice in managed care spending more time than do male physicians and physicians with less managed care.

Balint groups: the nuts and bolts of making better doctors.

Balint Group seminars were developed by Michael and Enid Balint based on the application of psychological principles in a group setting for the purpose of developing an improved understanding of the doctor-patient relationship. This article focuses on the development and application of the Balint method to the training of resident physicians (particularly Family Physicians) within the United States. An effort is made to describe the practicalities of resident physician Balint training (e.g., size, frequency, duration of such groups), conceptual underpinnings (e.g., biphasic nature of patient identification, disease versus illness concept, transference/counter-transference, over-identification, under-identification, biphasic nature of physician empathy), and pedagogic goals (mastering empathic skills inherent in being a good doctor) of residency-based Balint groups. In aggregate, this article provides a useful framework for behavioral science educators interested in applying the Balint seminar method to resident physician training. The authors encourage both the continued study and educational application of the Balint seminar method in the training of physicians both within and outside of the United States.

Applying Theory to Assess Cultural Competency.

Using a theoretical cultural competency model, the effectiveness of a cultural competency learning assignment was examined to determine: 1) students' cultural competency levels as reflected through the assignment, and 2) the effectiveness of the assignment as a cultural competency learning activity. Third-year family medicine clerkship students completed a required project to research and reflect upon a patient's "cultural belief." Applying a model of cultural competence development, a content analysis of written project reports determined what level of cultural competence was expressed by students' reflections. Results indicated16% of students were at "no insight", 18% at "minimal emphasis" and 66% at "acceptance." While many students expressed an "acceptance" competence level, not all students expressed the desired level of acceptance about the role of cultural beliefs in medical care. Application of a cultural competency theory to assess learners permits educators to frame performance changes within the context of competency achievement and determine if desired levels of competency have been achieved.

Implementation and assessment of a spiritual history taking curriculum in the first year of medical school.

BACKGROUND: The Association of American Medical Colleges has recommended addressing spirituality in the medical curriculum. DESCRIPTION: To evaluate the impact of a spiritual history-taking curriculum on the skills, knowledge, and attitudes of 1st year medical students. The study implemented a spiritual history-taking curriculum in the 1st year of medical school that included reading assignments, practice history taking, and standardized patient (SP) scenarios with spiritual content. It assessed students' performance in three ways: (a) using a videotaped SP interview, (b) a survey of students' attitudes regarding incorporating patients' religious and cultural views into medical decision making, and (c) a written test question on their first examination. EVALUATION: Students (146) took part in the medical school's spirituality curriculum, which included participation in videotaped interviews; 98% completed the initial survey, and 75% completed the follow-up survey. On the final videotaped SP interview, 65% of students were able to recognize the patient's spiritual concern according to trained faculty observers. On the attitude survey, there was an increased desire to accommodate patients' beliefs, although the magnitude of the increase was generally quite small. Ninety-four percent of students answered the test question correctly. CONCLUSION: Spiritual history taking can be integrated effectively into the existing history-taking curriculum in 1st year medical training.

Student observations and ratings of preceptor's interactions with patients: the hidden curriculum.

BACKGROUND: Professional values and behavior are conveyed to students through both formal and informal curricular activities. PURPOSE: This study examined 1st-year students' observations of community-based physicians' behaviors during a community-based clinical experience. METHODS: First-year students completed a 14-item instrument regarding their community-based physicians' behavior with patients. Responses were on a 5-point scale (1 = never, 5 = all of the time). Descriptive statistics were computed. RESULTS: 119 students completed the instrument (87% response rate). Students rated aspects of physicians' demeanor with patients highest (mean ranges 4.7-4.57). The lowest rated item was the physician's view of his or her professional role (M = 3.39), eliciting patients' ideas about illness and treatment (M = 3.55), and modeling interviewing techniques learned in class (M = 3.71). CONCLUSIONS: Community-based physicians reinforce many professional values associated with positive role-modeling aspects of the physician-patient interaction.