1. Interdisciplinary Stress Buster: Balint Research and Experience Kristi VanDerKolk, MD Mary Wassink, MD Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # F5 Focus Area D October 17, 2015

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Discuss the benefits of an interprofessional Balint group to medical and behavioral health providers in a Federally Qualified Health Center Define Balint groups and identify their purpose in improving provider/patient relationships Experience and appreciate first-hand the divergent thinking and uncertainty inherent in a Balint group

4. Bibliography / Reference 1.IsHak WW, Lederer S, Mandili C, et al. Burnout during residency training: A literature review. J Grad Med Educ. 2009 Dec; 1(2):236-242. 2.Romani M, Ashkar K. Burnout among physicians. Libyan J Med. 2014;9:23556. doi: 10.3402/ljm.v9.23556. Accessed April 4, 2014. 3.Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385. doi: 10.1001/archinternmed.2012.3199. Accessed April 23, 2014. 4.Seiji Hayashi A, Selia E, McDonnell K. Stress and provider retention in underserved communities. J Health Care Poor Underserved. 2009;20:597-604. 5.Baker DP, Day R, Salas E. Teamwork as an essential component of high- reliability organizations. Health Serv Res. 2006 Aug;41(4 Pt 2):1576-1598. 6.Baker MJ, Fowler Durham C. Interprofessional education: A survey of students’ collaborative competency outcomes. J Nurs Educ. 2013;52(12):713-718. 7.Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative. 2011.

5. Bibliography / Reference 1.Sdf 2.S 3.D 4.D 5.D 1. D 6.D 7.8df 8.Dornfest FD, et al. Balint training: A “how to” manual in development. American Balint Society. http://ambalintsociety.clubexpress.com/docs.ashx?id=122876. Accessed April 4, 2014. http://ambalintsociety.clubexpress.com/docs.ashx?id=122876 9.Perry ZH, Lauden A, Arbelle S. Emotional processing – The use of Balint groups for medical students as a means for improving interpersonal and communication skills and competence. Ann Behav Sci Med Educ. 2013;19(2):16-21. 10.Kjeldman D, Holmstrom I. Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. Ann Fam Med. 2008;6(2):138-145. 11.Cohen S. Perceived stress scale. http://www.mindgarden.com/docs/PerceivedStressScale.pdf. Accessed May 20, 2014. http://www.mindgarden.com/docs/PerceivedStressScale.pdf. 12.West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-21. doi: 10.1007/s11606-009-1129-z. Accessed May 8, 2014.

6. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

7.  Discuss Balint Research  Introduce Balint  Conduct Balint Group  Debrief Group  Question and Answer

8.  Family Health Center (FHC)  A FQHC  Kalamazoo, MI  ~33,000 patients  ~100,000 visits per year

9.  Burnout characterized by Emotional exhaustion Depersonalization Low sense of personal accomplishment  Approximate 50% prevalence among medical professionals  Affects performance, longevity

10.  Baseline survey of burnout at FHC 65% high level of emotional exhaustion 49% high level of depersonalization

11.  Staff participation once monthly Protected time from CEO  Rotating student participation twice monthly Required by third and fourth year family medicine clerkship director Required by third and fourth year pharmacy clerkship director

12.  Physicians and Mid-levels  Pharmacists  Occupational and Physical Therapists  Social Workers  Behavioral Health Counselors  Nurses

13.  No significant difference in pre and post- participation emotional exhaustion or depersonalization  Significant improvement in student perception of confidence communicating with persons from other disciplines

14.  Realizing that we have a very difficult patient population that presents many challenges; the challenges affect not only me and my work but all disciplines in the facility, each having different perspectives. Sharing helped me feel less frustrated and more supported  Interesting to hear other perspectives, how non- providers view doctor-patient relationships  A better understanding of the thought processes of group members; a better connection to other FHC staff  Different areas have different stresses and I learned that what was an insignificant problem for me was very significant for someone else

15.  I was surprised by how widely people’s opinions differed  There’s always a different angle to look at a situation from. You have to think from the patient’s perspective.  How to approach situations in new ways and how to acknowledge my own feelings and own them.  Keeping perspective is invaluable. Keep in mind the wants, needs and roles of both providers and the patients.  Not all problems are solvable, but it can be therapeutic to discuss them.

16.  “…what is too often missing in the day-to-day existence of a physician is the commitment to carve out a clearing for reflection- reflection about the stresses of the day, about patients, about life as a physician, about the ideals that brought one to medicine, about what one cares about, what matters and has meaning, and how one can express that meaning in one’s professional and personal life…”  R.B. Addison

17.  A tool to address the doctor-patient relationship

18.  Born in 1896 in Budapest  After completing psychoanalytic training in Berlin and Budapest, emigrated to Scotland and moved to London where he worked at the Tavistock Clinic.  He and his wife, Enid began the training- research seminars, now called Balint groups  1957 “The Doctor, His Patient and the Illness”

19. One of Michael Balint’s core assumptions is that: “at the center of medicine there is always a human relationship between a patient and a doctor.”

20.  Characteristics of the patient-provider relationship are universal  Health care providers are involved in many situations which evoke powerful emotions  Helps tease out numerous issues around professionalism

21.  M&M  Case discussion group  Support group  Group therapy

22.  Patients we Have ongoing relationships with Who raise inner conflict or strong feelings That leave us feeling baffled or confused We take home and think about

23.  Understand the patient as a person, like ourselves  Improve our self-awareness  Learn self reflection  Improve our ability to communicate  Share our experiences as providers  Rediscover the meaning and purpose of being a provider

24.  Structured leader and group member roles  Single case-focused discussion No case notes or preparation  Emphasis on divergent thinking  Focus on doctor-patient relationship; continuity patient

25.  Focus on continuity patient  On-going  Closed membership  The leader has specialized training

26. Leader

27.  Keeps discussion focused on the physician and patient relationship  Redirects as necessary  Encourage speculation  Acts as a time keeper  Ensures an atmosphere of safety

28. Confidentiality Respect Ownership Honesty GROUND RULES

29. Leader Who’s got a case?

30. Leader I do.

31. Leader Angela is a 79 year old blind woman….

32. Leader Are there any clarifying questions?

33. Leader Presenter

34. Leader Presenter I imagine Angela to be…

35. Leader Presenter If I were the physician, I would feel…

36. Leader Presenter If I were this patient, I would….

37.  “…reflection on our observations can lead to better understanding… Understanding makes us better physicians”  Dr. Michael Balint

39.  Dr. V Why I like Balint

40.  Combining mental and physical health into patient care

41.  Is this the only way?  How can I learn more?

43.  American Balint Society http://americanbalintsociety.org http://a

44. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!