clinical

Doctors, Heal Thyselves

We have a monthly Balint- style practice meeting. A Balint group is a group of clinicians who meet regularly and present clinical cases in order to better understand the clinician-patient relationship. Our group is moderated by a real, bona fide psychologist, and serves as a sort of therapy… I think a lot of our practice satisfaction is due to that group.

This week, as several of my colleagues had read my recent posts, we discussed frustrating cases. What clinical scenarios make us wring our hands? What pulls our trigger?

It’s so funny that we all have our own Kryptonite. For one person it’s the anorexics, for another it’s the obese, for another it’s the noncompliant diabetics.

In every one of these meetings, no matter how hard our psychologist colleague-mediator tries to hold us to discussing our feelings and exploring the doctor-patient relationship, we all get overly excited about throwing our clinical advice around. Well, have you tried this technique with the eating disorder patients or This type of counseling has worked well for me for the diabetics…

We all so sincerely want to help. Everyone. Isn’t this why we went into medicine…

But, it struck me that what we kept burying and avoiding, and what she kept trying to bring our type A med student personalities back around to face, was our own feelings. Our frustrations, anger even, when dealing with whatever it is we find difficult to deal with.

Someone will slump forward and admit: I’ve been working with this alcoholic patient for a decade and I’ve just about given up….I don’t know why they keep coming back…I have nothing left to offer… 

Someone will lean forward eagerly and offer: Well, in those cases what I’ve done is…

And our psychologist will firmly interrupt: Wait! First, how does it make you FEEL?

In this most recent meeting, it felt so good to hear that other providers get frustrated as well, even angry. Other providers beat their heads when faced with certain resistances. We’re all human. We’re not impervious to emotions in the exam room…

And that’s OK, especially when we’re willing to face that and learn from it and move forward. Right? We’re not robots, impersonal, metal. Yes, we face each case with our arsenal of hard-earned knowledge, but we also call in our upbringing, opinion, experience, religion… There’s no way around it. It’s a reality.

I will always cringe inwardly when met with the “I want to get healthy, but I just can’t…”

I can answer that complaint with more compassion, be more thoughtful, and craft my responses more carefully. I can use Goalification; I can employ Motivational interviewing techniques; I can put the responsibility back on the patient without getting caught up in their struggle (see last post). But I’ll still inwardly cringe…

How does that make you feel?

10 replies »

  1. I had never heard of Balint until this post, but LOVE the concept. Medicine and the expectations physician carry have changed so much over the years. We struggle with burnout and this sort of activity should be helpful in alleviating some of that fatigue.

    That being said, your post sort of screams out something else to me. We, as physicians, should not bearing all of the responsibility in trying to persuade our patients to embrace a life changing behavior. We need health coaches, dietitians, psychologists, APCs and nursing specialists to support us in treating the patient in a team-based approach. We only have 15-20 minutes in most visits, and that is barely enough time to scratch the surface

    Changing behaviors such as diet, exercise and smoking require education, support and coaching – a whole person approach. We can only do so much alone. But with a care team fulling aligned around a patient care plan, with the doc directing the plan, we can be so much more effective. Docs should be leaders of care team management, but should not have to do this alone. This is really what needs to happen in order to have a better chance of making a difference in more patient’s lives and spreading the ownership of the health of our communities.

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    • I totally agree, Eve. What you describe makes so much sense, and would be far more effective. Can you even imagine??? I wonder if any primary care practices have achieved such a model?

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      • Hi Monique,
        Absolutely. I would say that care team models and care coordination is an integral part of ongoing healthcare innovation. In our healthcare org we have a key initiative titled “Transformation of Primary Care” in which we plan to expand physician patient panels by leveraging APC providers to extend the panels. APCs can typically spend more time with the patient than the physician can. We also hired a psychologist and pharmacist to work in the clinics and support the provider practitioners in both clinical decision making, counseling and patient education. We also have a Centering program for prenatal care. The patients receive their prenatal care in a group of 8-12 women for two hours and it is completely education focused. this concept has also been expanded to the first year in a program called, Centering Pediatrics. Brilliant, right? Education focused, efficient, convenient (after hours or saturday) and offers a “support group” environment for the patients. I would have guessed that this type of innovation was happening everywhere?

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      • Well, on further thought, yes, we do have a lot of this type of stuff over here. It all sounds great, but, in practice… I just haven’t experienced anything that makes a real impact on my day-to-day responsibilities. Honestly, I think our whole idea of what medical care looks probably needs to evolve. Neighborhood- based care, home visits, virtual visits, home-based monitoring… That’s what the future may need to look like.

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  2. Yes, you are correct. Love your innovative ideas. We also need to focus more on wellness, rather than trying to put out fires before they start. It’s really hard and lots of work, but I truly believe that docs can lead our communities to live healthier if they are given the resources to do so.

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  3. I share your frustration with patients that feel they can’t change. It helped me to put a name to it: the psychologists call it an “external locus of control.” When I have a patient who relentlessly blames outside forces for their inability to follow up with a primary provider/fill and take their medications/stop using meth, cocaine, and heroin (all at the same time) — I think “external locus of control.” Like recognizing the borderline who has a preternatural ability to provoke, recognizing this behavior as pathological helps get me over my annoyance with it. YMMV.

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