Reflective Practice and Leadership in Medicine and Medical Education Michael Balint and Balint Groups

Note the following is abstracted from a chapter titled “Leadership Dimensions of the Physician’s Role: A Transitional Approach to Training in Pediatric Hematology/Oncology.” ¹⁵

Michael Balint was a Hungarian analyst and general physician. Freud saw instincts as the main motivating force in human development. Michael Balint radically departed from Freud. He saw behavior from the start as an interpersonal overture or demand reflecting a basic need for closeness to others. He also rejected Freud’s view of love as sublimated sexuality, and instead saw affectionate tenderness as a primary quality. Most importantly, he saw development as a reflection of the reality of the culturally conditioned interactions between infant and mother rather than a product of fantasized interactions. Balint viewed transference and counter-transference as the product of a unique interaction between a particular patient and a particular therapist. Further, the form of this interaction was interpreted as a reflection of the actual, not fantasized circumstances of both participants. This framework seems very compatible with social learning, social constructivist, and general systems perspectives.

Balint moved to England and began work at the Tavistock Institute. In the 1950’s he and his wife Enid Balint began offering seminars to general practitioners that drew on his object-relations perspective and the Hungarian model of psychoanalytic supervision. The seminars were designed as an opportunity for physicians to learn how to enhance the “therapeutic effect” of their doctor-patient relationships. In the Hungarian model of psychoanalytic training the training analyst supervised cases in the context of the trainee’s own analysis. Physicians participating in classical Balint groups are invited to discuss “difficult cases” without preparation or reference to case notes – relatively free associations. The group then reflected on the transference and counter-transference issues of each case as a means of increasing the physicians’ insight and empathic connection to their patients.

The Balint Group design has a long and illustrious history in medical education – particularly for the education of primary care physicians for their clinical role.^{5, 6, 16-20} Balint groups place emphasis on personal awareness and insight into personal style, character, preferences, values, etc. These dimensions come into play in the RP&L method but the physician’s personal style is viewed as one among many systemic factors and is not the primary focus. The primary focus of the RP&L method is observing patterns of interaction, articulating hypotheses to account for the patterns and testing the hypotheses through action. RP&L methods also emphasize the organizational dimension of analysis and not only the patient-physician dyad.

Reference List

1. Accreditation Council for Graduate Medical Education. The ACGME Outcome Project. Accreditation Council for Graduate Medical Education . 1-17-2007. Ref Type: Electronic Citation

2. The Association of American Medical Colleges. Learning Objectives for Medical Student Education: Guidelines For Medical Schools. Association of American Medical Colleges . 1998. Association of American Medical College. Ref Type: Electronic Citation

3. General Medical Council. Tomorrow's doctors: Recommendations on undergraduate medical education. London: GMC; 1993.

4. Schön DA. The Reflective Practitioner: How Professionals Think in Action. New York: Basic Books, Inc.; 1983.

5. Balint M. The doctor, his patient, and the illness. Lancet 1955; 268(6866):683-688.

6. Clarke D, Coleman J. Balint groups. Examining the doctor-patient relationship. Aust Fam Physician 2002; 31(1):41-44.

7. Heifetz RS. Leadership Without Easy Answers. New York: Belknap; 1994.

8. Skeff KM, Stratos GA, Bergen MR. Evaluation of a medical faculty development program: A comparison of traditional pre/post and retrospective pre/post self-assessment ratings. Evaluation and the Health Professions 1992; 5(3):350-366.

9. Levinson H. Organizational Diagnosis. Cambridge, M.A.: Harvard University Press; 1972.

10. Bion WR. Experiences in Groups. London: Tavistock; 1961.

11. Armstrong D. Organization In The Mind : Psychoanalysis, Group Relations And Organizational Consultancy Occasional Papers 1989-2003. London: Karnac Books; 2005.

12. Hirschhorn L. The Workplace Within: Psychodynamics of Organizational Life. Cambridge, MA: MIT Press; 1990.

13. Lawrence WG. Exploring Individual and Organizational Boundaries: A Tavistock Open Systems Approach. London: Karnac; 1979.

14. Frugé E, Adams C. Applications of the Tavistock group relations model in community mental health and protective service systems. Residential Treatment for Children and Youth 1995; 13(1):29-54.

15. Frugé E, Horowitz M. Leadership dimensions of the physician's role: A transitional approach to training in Pediatric Hematology/Oncology. The Transitional Approach in Action. 2004 p. 129-154.

16. Brazeau C, Boyd L, Rovi S, Tesar CM. A one year experience in the use of Balint Group with third year medical students. Families, Systems & Health 1998; 16(4):431-436.

17. Hull SA. The method of Balint group work and its contribution to research in general practice. Fam Pract 1996; 13 Suppl 1:S10-S12.

18. Merenstein JH, Chillag K. Balint seminar leaders: what do they do? Fam Med 1999; 31(3):182-186.

19. Samuel O. How doctors learn in a Balint group. Fam Pract 1989; 6(2):108-113. 20. Turner AL, Malm RL. A preliminary investigation of Balint and non-Balint behavioral medicine training. Fam Med 2004; 36(2):114-

Image credit: Boats and Waterfalls by Marc Horowitz