Abstract
Cynicism and burnout are well-described among new medical school graduates. At the new medical school in Washington state, the trend toward placing importance on wellness and creating a culture of healing was present from the outset. To encourage reflective practice, Balint groups were introduced as a method to teach students to think deeply about patient relationships and to address particular curricular objectives, including to demonstrate empathy for healthcare trainees and for patients, and to practice active listening skills in the context of the student Balint groups. The approach presented here will focus on the introduction of Balint groups into the pre-clerkship curriculum as a longitudinal tool to prepare students to use the method with more facility in their clerkships. The presentation at the 2022 American Balint Society Annual Meeting highlighted the introduction of Balint groups to the clinician faculty using the Intensive on the Road format, the introduction of Balint groups to pre-clerkship medical students, and the use of Balint groups in the pre-clerkship curriculum. The operational aspects, including faculty recruitment and retention, as well as student groupings and scheduling, were addressed in the context of the overall theme of monitoring student progress toward open communication about their challenging patient relationships. Programmatic evaluation and current trends were emphasized, along with the anticipated evolution and future directions of the program at our community-based medical school.
Introduction
The Elson S. Floyd College of Medicine at Washington State University is a new land-grant, community based medical school located in Washington, with four regional campuses spread throughout the state. The second publically funded allopathic medical school in Washington, the College of Medicine (WSUCOM) graduated its first student cohort in May 2021 and received full accreditation in June 2021.
The first cohort of 60 students matriculated in autumn 2017. Student wellness and creating a culture of healing was present from the outset – with an emphasis on frequent low-stakes opportunities for students to reflect and develop their self-awareness. Personalized coaching and forging relationships with faculty and other students from the beginning of the curriculum were key tenets in the program. In keeping with the school’s emphasis on wellness and creating a culture of healing, the centrality of teaching about doctor patient relationships became an early, pre-clerkship focus. Faculty leads and key administrators helped to incorporate Balint groups into the clinical skills course as part of the art of learning “reflective practice.” The aim of these preclerkship groups was for learners to be equipped with tools to prepare them to more fully participate in Balint groups during their clerkships and in residency training, as a hedge against cynicism and burnout.
Methods
In late winter 2018, Janet Walker (clinical skills faculty at WSUCOM and American Balint Society [ABS] member) and Kathy Knowlton (ABS member) conducted a faculty development workshop for prospective Balint group facilitators. At the end of this workshop, the faculty were excited and had bought into the possibilities of Balint groups for preclerkship students. The ABS subsequently conducted an Intensive on the Road Balint Leader Training for 12 faculty members in Spokane in August 2018. These faculty were clinician educators recruited from the WSUCOM clinical skills course and academic department and from a local psychology team. The Intensive was very successful, and all participants were willing to proceed in leading student groups.
Procedure
In the fall of 2018, the first cohort of students (now in their second year of medical school) were divided into groups of 10, taking care to ensure their Balint facilitators were not their academic advisors nor were they in positions to grade students in other areas of the curriculum. Clear instructions were given to the students about “double confidentiality,” that is, what happens in the groups stays in the groups with no continued discussion of cases after the group concludes, and that there would be no “assessment” of students other than attendance of these mandatory groups.
An introduction to the Balint method was delivered to the entire class, followed by a faculty Balint group fishbowl. Faculty presented an authentic, in-the-moment case, which the other group members worked through. Students surrounded the faculty group and observed and heard verbal and non verbal interactions, and had the opportunity to discuss their questions and comments after the session. The students then went directly to their first Balint group. The groups met monthly, from Oct 2018 to May 2019. Facilitator pairs would debrief after every group, and then would meet with all facilitators to further debrief that same afternoon.
There were a few tweaks to the usual Balint method. These students had some, but limited clinical exposure, requiring that we be less stringent about more distant experiences that did not involve continuity, and that we allow preceptor-centered experiences. We also incorporated more process check-ins to help students better understand the Balint method. This same process of introducing and conducting monthly Balint groups was incorporated for the second cohort of students in their second year.
Required monthly Balint groups have been continued throughout the third year clerkships for each class since the first cohort. In the midst of the pandemic, however, students’ direct clinical exposure reduced dramatically in their first and second years. There was concern about the already heavy and increasing burden of an entirely virtual curriculum on both students and faculty. . Thus, the model of starting Balint groups in the second year was suspended, but monthly required Balint groups have continued for third year clerks, and have been virtual from mid-2020 until the end of the 2021-22 academic year.
Evaluations
Evaluations were obtained from the first two cohorts of students at the end of their second academic year. The majority felt the environment was safe and the groups were valuable in their development as physicians. Of interest, several students volunteered to describe their experience in testimonials for a short video about Balint groups. Students reported that after sharing a troubling encounter that they might have mulled over in their own mind for months, the Balint group allowed them to hear perspectives from all the different group members, leaving them with a more balanced way of thinking about what they had experienced. The second cohort rated their experience even more highly than the first cohort.
The first cohort rated their third year Balint experience lower, noting that although half still felt safe participating in their groups, only a third felt that the discussions were useful in processing and reflecting on challenging experiences.
However, after experience, word of mouth and seeing the video created by students from the first class, the second cohort noted during their third-year clerkship of monthly Balint groups that: (1) Balint groups are useful in processing and reflecting on challenging experiences (80%) (2) I feel safe speaking in my Balint group (82%) (3) The timing of Balint groups supported the development of my reflective practice skills (47%)
Narrative comments that were positive emphasized the value of the groups, the empathetic leaders and the normalization of the enduring effect of complex patient encounters. The more critical comments focused on feeling that the groups should not be required or were not helpful.
Challenges
Several hurdles were encountered from the outset of this endeavor. It was difficult initially to convince the educational leadership administration to support funding the Intensive on the Road for faculty leaders; support was ultimately obtained from both the College as well as from an anonymous grant. Another challenge was balancing protecting the confidentiality and privacy of the groups against publicizing and amplifying the point of the groups by ensuring the whole program knew and bought into the Balint methodology. Lastly, the pandemic wrought havoc in so many ways, including dispensing with Balint groups for second year students.
Future plan
The model adopted since the pandemic has been to introduce Balint groups toward the end of the second year, utilizing an introduction, the video produced from the first cohort, and a faculty fishbowl group. This introduction leads into required monthly Balint groups throughout the third-year clerkships. Each successive cohort has demonstrated increasing facility with the reflective practice method integral to the effectiveness of the Balint group.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
