Er den praktiserende læge ved at blive traumatiseret?

Konsultationsrummet, vores hellige rum, hvor vi sidder alene med patienten, er under pres.  Mange vil gerne have adgang til det: Politikere, administratorer, økonomer, jurister, patienter og deres organisationer, vores egne organisationsfolk og vore faglige selskaber osv. Vi oplever en tsunami af nye regler og forordninger, guidelines, pakkeløsninger, kvalitetskontroller osv. Samtidig skal vi forholde os til at være ledere med relationer til kollegaer, personale og samarbejdspartnere m.v. Vi opfatter mange som ubudne gæster. Det, de vil forandre rummet til, stemmer ikke overens med den måde, vi vil være læger på.
Vores respekt i samfundet og vores selvrespekt er kommet under pres. Hvordan skal vi i forandringstider bevare vores integritet og styrke vores resiliens og arbejdsglæde?

Vi har inviteret
Gerhard Wilke, MA, Dip. FHE, Honorary Member I.A.G.P., IGA London,
til at belyse temaet. Læs om Gerhard Wilke her.

Gerhard er gruppeanalytiker og antropolog og har de sidste 20 år arbejdet på mange niveauer af National Healths Service i London, og skrevet bogen: ”Hvordan bliver jeg en god nok praktiserende læge. Overlevelse og trivsel i det nye sundhedsvæsen”. Her beskriver han bla. supervisionsgruppen som et af redskaberne for at kunne overleve. Gerhard har således superviseret praktiserende læger i London i mange år. Aktuelt arbejder Gerhard med supervision af praktiserende læger i samarbejde med the Royal College of Practitioners. Temaerne er resilience, innovation og tilpasning i tider med forandring.
Yderligere oplysninger og et summary: ”Beyond Balint (supervision): A group analytic support model for traumatised doctors”, kan læses via dette link.

Tid og sted: Fredag d. 1. april 2016 kl. 9.30 – 17.15. Liselund Kursuscenter, Slotsalleen 44, Slagelse.

Program: Seminaret indledes om formiddagen med et oplæg af Gerhard og en efterfølgende diskussion i plenum. Om eftermiddagen er der supervisioner af nogle af deltagernes medbragte cases omhandlende dagens tema med Gerhard som supervisor. Efter supervisionerne diskussion af gruppeprocessen.

Målgruppe: Praktiserende læger, uddannelseslæger til almen praksis, supervisorer for praktiserende læger.

 Pris: kr. 2800 for medlemmer, ikke medlemmer kr. 3200, Yngre læger kr. 1900

Tilmelding til sekretær Naja Bonnevie: bonnevie@mail.dk senest 31-01-2016.Skriv ”forårsseminar” i emnefelt.

Betaling til SSSP, reg.nr. 6771, kontonummer 6277531 i Lægernes Pensionsbank med angivelse af deltagernavn.

Vi forventer at kurset bliver godkendt af Efteruddannelsesfonden for en kursusdag.

Link til printvenlig invitation

Martina A. Torppa
GP, clinical lecturer

Our Student Balint groups

• An experimental course of voluntary Balint groups for 3rd -6th year medical students at the University of Helsinki, Faculty of Medicine, Department of Public Health, Section of General Practice in 2002-04 in collaboration with the Finnish Balint Society
• 15 student Balint group sessions, each 90mins, 9 medical students, experienced Balint group leader, two clinical teachers of general practice as co-leaders in each session, all participants were asked for agreement to collect data and use it for analysis

Data and analysis

• Data were the field notes by the co-leaders from each session
• Qualitative analysis; grounded theory based content and theme analysis of the transcripts
• What

1. were the contexts of the cases the students presented?
2. triggered the students to narrate the cases?
3. were the main themes discussed in the groups?

Ref.:

A Qualitative Analysis of Student Balint Groups in Medical Education:

Contexts and triggers of case presentations and discussion themes

Patient Education and Counselling 2008;72:5-11.

Findings

• What was different from traditional GP Balint groups
• How these issues that were processed in student Balint groups touch on professional growth and on future professional identity of the students as doctors.

(Contexts of the) cases

• Patients
• Confusing experiences in medical education
• Privacy and profession
• As professionals we are for the patients.
• Students got an experience of reflecting on confusing expereriences together with colleagues in a safe environment
• Students explored how to be a professional and a private person at the same time.

Triggers for presenting cases

• Wittnessing injustice
• Value conflict
• Difficult human relationships
• Incurable patient
• Role confusion
• These issues are possible sources of inner conflicts for students also as future doctors – the group discussions offered a structured way to process them.

Main themes in discussions

• Feelings related to patients
• Negative role models
• Co-operation with other medical professionals
• Building professional identity
• Students experienced a professional way to deal with emotions and feeling aroused by patients.
• Negative examples of fellow colleaques helped students to clarify their own professional identity .
• Preparation for team work as future doctors.
• Explicit discussions of professional identity were valued by the students; considered as a rare opportunity in the curriculum.

Conclusion

Student Balint groups may

• be a valuable forum to foster the development of medical students’ mature professional identity.
• enhance future doctors’ willingness and capability to reflect on ‘difficult’ issues with colleaques.

The concept of a case needs to be wider than in traditional Balint Groups (where the case is a patient).

A trained Balint group leader is important also in student groups to keep the discussion goal-oriented.

Part of my work involves organising a half day a week course for trainee GPs

Three year course. First two years mainly in hospital jobs. Third year attached to a practice.

• We take on 8 trainees a year so we have a total of 24 plus a few doing only the third year. Every Wed afternoon they get together for our course. In the first hour and a half we usually have a talk by a consultant, a GP a social worker, or psychologist or an accountant. Sometimes we watch a film or discuss a book we have all been reading. Then tea break, talk to each other. Last hour is spent in a Balint group.
• Three groups. Some people are always a way because of holidays, being on call or whatever. Usually about 6 in each group.
• Three program directors, one leads each group. Same people in each group though each year some leave and new ones arrive.
• The Balint group is a unique way of learning about the reality of general practice.
• We discuss real patients with complex problems, medical social and emotional.
• We struggle with doubts and uncertainties. The answers are not in the text book. They are not to be found in the lecture theatre or on the internet.
• The trainees present their difficult cases. The patients they go on thinking about after their day’s or night’s work is done.

What sort of patients?

• Initially patients who make them feel angry or hurt.
• Patients who are rude to them, make them feel useless.
• Patients who don’t know how to behave in a doctor’s surgery
• Demand drugs that are inappropriate: antibiotics, sleeping tablets, opiates.
• Non steroidal drugs that are bad for their stomachs.
• Letters to entitle them to time off work, or never to work again.
• Letters to excuse their failure to appear in court.
• Get them a better flat.
• I just want to see a specialist.
• This is not why I became a doctor!
• People who make them anxious by talking about suicide
• Family violence and the risk of child abuse
• Patients who are too friendly or flirtatious.
• Patients who despite their bad behaviour just might have a serious illness.

Later as they get used to working in the group they start to talk about patients they like and want to help but are not sure how.

Three stages:

1. Share their hurt feelings and their bad experiences with sympathetic friends who have been there too. Collect suggestions about how to manage the patient better.
2. With the help of the group leader, to develop their capacity for empathy. To see the patient as a person like yourself. To see the situation from the patient’s point of view.
3. To understand a little of what is going on between doctor and patient. Understand patient’s feelings and ones own feelings.

Examples of presentations

Olga 44 year old woman of Russian origin. Presenting doctor is obviously pregnant.

Two years of pelvic pain. Had an operation with a wound infection. Believes she has had infection inside her ever since. Husband is alcoholic and stays at home. She works and earns money for both of them. They have a 2 year old girl who is still being breast fed and sleeps in the parents bed. She is being investigated for sleep apnoea. The little girl has also been referred for psychotherapy but no information available, Olga doesn’t want the doctor to contact the psychology clinic. She does not want any psychological help with her pain.

Olga dismisses all the doctor’s suggestions with contempt. She is quite frightening. Sometimes the doctor sees Olga in the park where she takes her own little daughter to the swings. Olga is there with her child. The doctor avoids having to talk to her. The discussion: How can we prove to her that she has no infection? She doesn’t believe the test results when they are negative. Sexual disease clinic? Should she have a laparoscopy?. The more you give into a patients; demands for tests the more she wants. Where will it end. Should the doctor just say, I can’t help you any more? But there is also worry about the little girl. Is she at risk of abuse? Should the social services be alerted?

No solution is found, but the doctor looks happier at the end and promises a follow up report. She has lots of new ideas, she says. She feels less afraid of the patient. She even looks forward to their next meeting.

Maria Spanish woman 37

Presented by male doctor. She is a legal immigrant from S America doing cleaning work. Boss is illegal. Came with ‘repetitive strain’.

Consultations through telephone interpreter. Take 20-30 mins. Doctor has a few words of Spanish. Thought she might have cervical spine syndrome with arm pain and numbness. Referred to neurologist. Not seen yet. Now pain now all over. Tries different pain tabs, physio. She also sees a private Spanish doctor now and then. Feels GP can’t solve the problem but at end she hugs him and thanks him.

Discussion: Boundary issues. Does she want to come home with him? Does he need to restrict the time more. Should she have so much time off work. Presenter says she doesn’t seem to be in pain. Quite active and lively. Phone is a barrier. He should have Spanish lessons! Record consultation and play it to a Spanish friend. That would be really taking her home. No time to ask about her personal life. Why she came? What sort of life she wants? Presenter agreed it would be a good idea to devote a special session to asking her about herself. Meanwhile the doctor was working even if the drugs were not.

Do the trainees value the group?

• Some like it straight away.
• Some can’t see the point at first but get to appreciate it more as time goes on.
• A few wish we would go in for deeper psychological exploration.
• Over three years in the group they get to talk about a lot of cases. They begin to work together as a group. Responding to each other’s thoughts.

Here are some feedback reports:

1. I find it very valuable to discuss cases in the Balint group and I find it interesting when my colleagues come up with different ideas or approaches to deal with difficult consultations.
2. I find Balint very helpful and feel it is an honest and safe environment to debrief difficult cases and always walk away feeling like the burden has been lifted from my shoulders!
3. In all honesty I think overall my Balint group experience has not been a positive one.
4. I think the theory and potential for gaining a different perspective and better understanding of the patient is hugely valuable and very interesting. In practice though, I have found the groups lacking in structure or direction (when I think they would benefit from having more) and unfortunately in some sessions the people who would have the most interesting points of view don’t say that much as opposed to a few people who talk rather a lot.
5. I find Balint tends to polarise opinion, trainees either take to it or they don’t. I find it can be therapeutic, except, unlike the traditional model, there can be several therapists at once. It’s not about solutions, yet it can make you see yourself and your patients more clearly. The most valuable thing I enjoy is understanding how other colleagues think; both about their patients and the world. It’s rare to experience that anywhere else in your average week. Finally it can be uncomfortable at times and that’s no bad thing.
6. During my psychiatry post we had weekly Balint groups facilitated by a consultant in psychotherapy. They differed slightly in that they began when silence fell in the group. The facilitator simply allowed a rather awkward silence to continue until someone spoke. Rather than practical advice for management, the focus was more on how the person dealing with the case was being made to feel and why. Occasionally, the facilitator would offer a completely new perspective. I found exploring why certain unpleasant or difficult patients were evoking these emotions in me and others very interesting.
7. I do find Balint a useful experience to get other people’s points of view but I don’t like it when we are told not to look for answers. Sometimes cases are clinically difficult and discussing those with others who might have more knowledge is just as useful as discussing those which are difficult in other ways. I do think follow up is important as we then find out what happened and often why the difficulty arose etc.
8. I really look forward to the Balint group each week because people are infinitely interesting and it allows us time to think about our patients as people and wonder a bit about their lives and how we fit into them.

FRIDAY 15 MAY 2009 13:30 – 15:00 How can we prepare the future GP to cope with the complexity and uncertainty of a changing health care system?

Aim

The aim of the symposium is to discuss how Balint groups in the Nordic countries and internationally may contribute in different ways to continuing medical education and the wellbeing of the professional starting up in medical school. But it is also an opportunity to discuss strength and limits of this sort of group work.

Presenters

• Martina Torppa, Helsinki
• John Salinsky, London
• Annette Davidsen, Copenhagen
• Dorte Kjeldmand, Eksjö
• Marieke van Schie, Leiden
• John Nessa, Bergen
• Harald Kamps, Berlin

Chair: Helena Nielsen, Copenhagen

1. General practice is a special field of activity. Patients present with all sorts of problems, sometimes big emotional problems, completely unorganized, directly from the street. Often GPs work under great time constraint and have not got the same time for reflection and working through of problems as for example a psychiatrist or a psychologist carrying out psychotherapy.
2. Still much of the GP’s work is some form of psychotherapy and the same psychodynamic conditions as in a psychotherapeutic relationship contribute to the doctor-patient relationship. But often this may not be realized. Holmes has compared the therapeutic relationship in general practice to a long-term psychotherapeutic relationship broken up into smaller chunks. But to carry out psychotherapy you have to be trained, and you have to get supervision.
3. Until now training in psychological interventions in general practice has focused on training imported therapeutic models from the secondary sector and not on generating a framework for understanding patients with psychological illness in primary care. This means that there is no formulated theory for psychological interventions. GPs are often left to what some have called ‘folk psychology’ or ‘implicit personality theories’ which means that the patients do not always receive professional treatment.5Balint formulated that what was important was the very process of understanding the patient’s thoughts and feelings. He also realized the doctors’ need to gain reflexive insight into themselves to carry out this psychotherapeutic task.
4. In the last decades a new concept has been introduced to describe this process of understanding and the form of relationship that should be formed with the patient.
5. Mentalization means the capacity to understand other people’s thoughts, feelings, imaginations, wishes, desires and so on and at the same time realizing your own thoughts and feelings. Being in the other’s shoes but still not stepping out of your own; and also keeping a reflexive insight into your own contribution to the relationship. Actually mentalization means the same as the process of understanding which Balint described and trained with GPs in his training groups. Mentalization involves an active process of understanding; it is about process and agency more than about content. 
6. Mentalization is linked to attachment theory and according to Holmes, Balint anticipated attachment theory by his concept of ‘basic fault’, which means that a person has some needs which cannot be provided for by the primary caretakers. Holmes links Balint’s ideas to current integrative developments in psychotherapy. Balint’s idea was to generate the story that made the patient’s symptoms meaningful and he wanted to help the GPs to make their representations of this story by using their own thoughts, fantasies, emotions and imaginations, which means mentalizing the patient’s situation. Therefore it seems meaningful to use the concept of mentalization as a modern conceptualization of the process of understanding the patient.
7. Balint realized the GPs’ need for training and supervision. He introduced a supervision tradition but later it disappeared in the academic recognition and specialization of general practice.
8. In my PhD. study I have shown that GPs differ greatly as to which form of relationship they form with the patient and that this difference manifests itself both in consultations with psychological interventions and in normal consultations. Different types of GPs could be described using the concept of mentalization. Some were not mentalizing. There is a need to train GPs’ mentalizing skills and we could use the training experience from mentalization based treatment where it is stressed that it is important to train the therapist’s mentalizing capacity. They say:
9. We propose that therapists’ mentalizing skills are central to establishing and maintaining an effective treatment relationship and a therapeutic alliance as Bordin (Bordin, 1979) construed it. Thus, we are developing a training programme to foster therapists’ mentalizing capacities in the treatment process. We aim not only to promote therapists’ attentiveness to mental states in their patients but also to increase their awareness of their own mental states in the conduct of psychotherapy. (Williams et al., 2006) p. 224-225.
10. Balint’s therapy was routed in a psychodynamic thought. It was not manualized but based on a general therapeutic approach. In training programmes of mentalization based treatment it is stressed that the therapy and the training cannot be manualized. Treatment manuals teach specific techniques but not their skilful use. Manuals cannot teach creativity, which is necessary in therapy. But the therapy has to be based on a theory and some well-defined concepts. Mentalization is such a concept describing the process of understanding, but it is not linked to any psychotherapeutic brand and it can be applied in all forms of therapy. However, some structure is needed, and there is a dialectic about providing structure, as unexperienced trainees – and the patients – need some structure to feel sufficiently secure. But – imposing a firm structure is inherently mindless – and premature imposition of structure directly undermines mentalizing as it implies that the therapist already knows what is in the patient’s mind.
11. Therapists’ mentalizing skills are central to establishing an effective treatment relationship. In psychological treatment research an association of a positive therapeutic relationship with clinical outcome is one of the most robust findings. This is also true for general practice. Therefore psychotherapy training should focus on teaching of basic relationship skills by increasing metalizing.
12. Mentalization often fails and it is important to observe that what you think is mentalizing is not pseudo-mentalizing, which means that there is apparent thoughtfulness and both think that they are mentalizing but there is no real emotional understanding.
13. Programmes for training therapists’ mentalizing capacity build on structured exercises. Supervision is in groups and includes demonstration of illustrative videos, role-playing and supervision of own videoclips to identify problems. The focus shifts between watching an expert and practicing. The therapist’s mentalizing capacity remains in the forefront. The supervision addresses the multilayered perceptions and relational dynamics among people who have come for help. In mentalization based therapy the therapist is rather active and asks questions to come to know more about the patient’s way of thinking and feeling and imagining others’ way of thinking and feeling. This inquisitive stance also transpires the supervision. One technique is to ask the trainee to question why they might adopt a particular non-inquisitive approach, e.g. concrete proposals and to think about what impact this is likely to have on the patient. This is a dialectic between structure and open inquiry.
14. A common remark from doctors or psychologists when they hear about mentalization is ‘Oh – but I already do that in this or that therapy.’ However, it turns out that it is extremely difficult to apply mentalization skilfully in practice. Emotional distress suppresses mentalization and it is difficult to practice it under the emotional stress of the clinical situation. You must feel sufficiently secure; otherwise the therapy takes on a mechanistic quality that hinders the establishment and the maintenance of the alliance.
15. GPs training could, as training in mentalization based treatment, be organized as training in supervision groups where the mentalizing capacity is trained. Such training could have a two-fold purpose: to train the GPs in the capacity to understand and to handle the emotional reactions and problems that interfere with the doctor-patient relationship and compromise the treatment in the routine consultations; additionally, to train them to be able to conduct some longer talking therapy sessions with patients with emotional problems or mental disorder. These longer therapies also have a two-fold purpose: often the GP cannot refer these patients to other places, and the patients need treatment. Having these longer therapy sessions and getting supervision on them would gradually influence the GP’s understanding and relationship formation also in the routine consultations. Getting this training in supervision groups with other GPs and with a group leader who is a GP trained in supervision or a professional with a thorough knowledge of general practice will ensure the training in handling the doctor-patient relationship in general practice where a specific therapeutic brand is not appropriate.

M Torppa (1), J Salinsky (2), AS Davidsen (3), D Kjeldmand (4), M Schie (5), J Nessa (6), H Kamps (7), Helena Galina Nielsen (3)

1. University of Helsinki, Faculty of Medicine, Department of General Practice and Primary Health Care, Finland
2. GP education at Whittington Hospital, University of London
3. Copenhagen University, Research Unit for General Practice, Denmark
4. University of Uppsala, Department of Health and Caring Services, Section of Health Services Research, and Eksjö primary Health care centre, Sweden
5. General Practitioner, Leiden, The Netherlands
6. University of Bergen, Norway
7. General Practitioner, Berlin, Germany

Aim: The aim of the symposium is to discuss how Balint groups in the Nordic countries and internationally may contribute in different ways to continuing medical education and the wellbeing of the professional starting up in medical school. But it is also an opportunity to discuss strength and limits of this sort of group work.

Torppa from Finland will present a research study on student Balint groups and how they touch on professional growth and future professional identity as doctors.

From long experience with Balint groups in vocational training Salinsky from UK will talk about how the groups promote better understanding of the doctor patient relationship and promote lasting career satisfaction and better adaptation to change.

Based on her PhD thesis about mentalisation in GPs’ psychological interventions.

• Davidsen will focus on training of mentalisation and empathic skills in supervision groups.
• Kjeldmand shows based on her PhD thesis how participation in Balint groups enhances dealing with complex encounters and gives the GP a higher job satisfaction.
• Schie from Holland will focus on how the groups may contribute to the prevention of burnout.
• Kamps and Nessa will perform a dialogue about Balint groups as reflecting teams and discuss strengths and limits of this sort of group work.

Keywords: Continuing medical education, professional Burnout, job satisfaction