Introduction
University students are subject to several types of stressors associated with the entrance into a new developmental stage; young adulthood. This is a time when young adults are faced with issues such as developing intimate relationships, choosing a career pathway, moving away from their family of origin and possibly facing first-time employment (Erikson, Reference Erikson1968). The transition from second-level education to third level is accompanied by efforts to cope with high stress levels in adaptive or maladaptive ways (Shkulaku, Reference Shkulaku2015).
Medical school is recognised as a stressful environment that often has a negative effect on students’ academic performance, physical health and psychosocial well-being (Singh et al. Reference Singh, Hankins and Weinman2004; Yusoff et al. Reference Yusoff, Abdul Rahim, Baba, Ismail, Mat Pa and Esa2013; Hill et al. Reference Hill, Bowman, Stalmeijer, Solomon and Dornan2014; Saravanan & Wilks, Reference Saravanan and Wilks2014). There is a sizeable body of evidence reporting increased levels of stress, anxiety and depression in medical students compared to the general population (Dyrbye et al. Reference Dyrbye, Thomas and Shanafelt2006). Iqbal et al. (Reference Iqbal, Gupta and Venkatarao2015) reported that greater than half of the medical student study group they examined presented with symptoms consistent with stress, anxiety or depression.
Empathy is described as the ability to share emotions with others: the ability to integrate emotional resonance, the ability to emotionally regulate and the ability to gain emotional perspective (Decety & Jackson, Reference Decety and Jackson2004). Loss of empathy with a subsequent negative impact on resilience has been reported in medical students as they move through the clinical phases of their training (O’Neill et al. Reference O’Neill, Fosterb and Gilbert-Obrartc2016). According to Hojat et al. (Reference Hojat, Vergare, Maxwell, Brainard, Herrine, Isenberg and Gonnella2009), empathy scores of 456 medical students remained static for their first two pre-clinical years but significantly declined at the end of third year persisting until graduation. This decline in empathy and resilience may relate to academic workload, harassment from senior colleagues, stress, anxiety or depression associated with course pressures and negative role modelling (Anghoff, 2001; Sung et al. Reference Sung, Collins, Smith, Sanders, Quinn, Block and Arnold2008; Neumann et al. Reference Neumann, Edelhäuser, Tauschel, Fischer, Wirtz, Woopen and Scheiffer2011).
Resilience is regarded as an emotional competence, which can be considered as a behaviour or virtue to be improved or acquired. It encompasses four cognitive dimensions: commitment, perseverance, self-efficacy and self-control (Atkinson et al. Reference Atkinson, Martin and Rankin2009; Tempski et al. Reference Tempski, Martins and Paro2012). Resilient individuals are characterised by positive coping, hardiness and optimism and these characteristics correlate with improved mental health and more positive adaptive behaviours when faced with negative life events (Connor & Davidson, Reference Connor and Davidson2003).
Medical teachers recognise that students who are not able to examine and come to terms with their own psychological lives find connecting empathically with others to be difficult (Meitar et al. Reference Meitar, Karnieli-Miller and Eidelman2009). Shapiro (Reference Shapiro2011) suggests that, for doctors, being aware of and subsequently being able to modulate and manage emotions in themselves and others is a necessary, indeed critical, element of good patient care.
According to the Irish Medical Council (IMC) Foundation For the Future: Guidelines for Medical Schools and Medical Students on undergraduate medicine, students need ‘space’ to reflect on their own professionalism or professionalism through professional journals, narratives, reflective pieces, in-group discussions and as part of the feedback process with teachers (IMC, 2016).
The most common approach used for developing reflective capacity in postgraduate medical professionals occurs in the context of a regular, collaborative and secure reflective supervisory relationship (Tomlin et al. Reference Tomlin, Hines and Sturm2016). This can be achieved by the formation of a group in which one person is typically more experienced than the others but holds no authority or power (Priddis & Rogers, Reference Priddis and Rogers2017). This reflective process is characterised by regularity, trust and respect with a shared sense of safeness leading to openness and curiosity within the group (Weatherston & Barron, Reference Weatherston, Barron, Scott Heller and Gilkerson2009).
One such form of reflective practice that marries neatly with these aforementioned concepts is a Balint group which were first developed by Michael and Enid Balint in an effort to offer a supportive, non-judgemental context for frank discussion of the emotional aspects of illness on the doctor–patient relationship including transference and counter-transference issues. The aim of a Balint group was and is to encourage a greater awareness of emotional factors contributing to, or resulting from, the patient’s condition (Sung et al. Reference Sung, Collins, Smith, Sanders, Quinn, Block and Arnold2008). Balint groups have been recognised to increase empathy, decrease fatigue and reduce burnout thus enhancing continued alignment with the meaning of one’s career in health (The American Balint Society, 2016). Balint groups differ from problem-based learning as their over-arching aim is to develop empathic abilities rather than medical knowledge (Clement, Reference Clement, Lovat and Toomey2009). To address the topic of emotional processing and its associated impact on empathy and resilience in undergraduate medicine, there has been a continual movement to introduce Balint groups to undergraduate medical students worldwide (Roter et al. Reference Roter, Frankel, Hall and Sluyter2006; Johnston, Reference Johnston2012; Parker & Leggett, Reference Parker and Leggett2012, 2014; Shoenberg, Reference Shoenberg2012; Perry et al. Reference Perry, Lauden and Arbelle2013).
In the first study of its kind in Ireland, the authors examined empathy and resilience in a prospective study after the introduction of a Balint group for fourth-year undergraduate medical students during their 6-week psychiatry rotation at an Irish university.
Methodology
Design
This was a single-site study assessing the effect of a Balint group on empathy and resilience in fourth-year medical students during their psychiatry rotation. Empathy was assessed using the Jefferson Scale of Empathy – Student Version (JSE-S Version) while the Brief Resilience Scale (BRS) examined resilience. Focus groups after the course of Balint groups were held to evaluate emerging common themes. Ethical approval was granted by the Research Ethics Committee (REC) at the Royal College of Surgeons in Ireland.
Study participants
The study was conducted from February 2017 until April 2018 at Blanchardstown Hospital, Dublin. Eligible students were fourth-year medical students undertaking their 6-week psychiatry rotation at this hospital. Ten students were allocated to the hospital per rotation. Over the study period, a total of five 6-week Balint groups were offered. The number of eligible students was 50. Students were invited to join the study (i.e. opt-in) and there were no exclusion criteria.
At the start of each psychiatry rotation, a presentation was delivered to the study group detailing both the principles of Balint and the aims of the study. Students were provided with a comprehensive information leaflet and written consent was obtained.
Setting
Each Balint group met in the academic centre of the study site and each group met at the same time every week for 1 hour. An accredited Balint group leader (SM) led the Balint groups. The aim of the leader was to maintain the boundaries and rules of Balint, as well as protecting the student presenter from interrogation and questioning while focusing the discussion on the emotions and fantasies of the group members around the related story (Kjeldmand, Reference Kjeldmand2006). An experienced Balint co-lead was also present (SF) to manage time in relation to case presentation and group discussion. The Balint lead and co-lead would meet after each Balint group to reflect on their own experiences of the Balint group in keeping with their roles.
Intervention
Each meeting mirrored a traditional Balint group. Initially a group settling in exercise of greeting took place where each member was invited to describe how he or she felt by using one word thus relaxing and opening-up the group dynamic. Group members would then be invited spontaneously to present a particularly touching, upsetting or interesting clinical encounter that involved interpersonal problems (Airagnes et al. Reference Airagnes, Consoli, De Morihon, Galliot, Lemonge and Jaury2014) lasting 10–15 minutes. Individual group members could then ask up to three clarifying questions of fact relating to the case. The presenter then ‘sat back’ and refrained from any further dialogue. This process is the equivalent of clinical reasoning and its purpose is to highlight the ‘trouble’ in that specific doctor–patient story (Mahoney et al. Reference Mahoney, Diaz, Thiedke, Mallin, Brock, Freedy and Johnson2013). For the proceeding, 15–20 minutes the group reflected on what they felt was going on for the student and their patient. The presenter was then invited to rejoin the group discussion for the remaining 15 minutes and to contribute, if they wished. The role of the leader was to encourage the Balint group to expand their usual ways of thinking, by exploring their own emotive response to the case and to rethink the meaning of what are often interesting inconsistencies (Balint, Reference Balint1979, Reference Balint1985). The extent of the patient’s history no longer remained the focus rather the effect of the patient and their story on the doctor became the motivating issue (Balint, Reference Balint1957). The type of dialogue employed was underpinned by a psychodynamic style of discourse, namely study of the psychological issues that motivate human emotions, feelings and behaviour (Lazaratou, Reference Lazaratou2017). This process was repeated each week for the duration of the 6-week Balint group.
Outcome measures
Participants were asked to bring their completed pre-Balint questionnaires (JSE-S Version and BRS) to the first Balint group. One week after the final Balint group in each course, the Balint lead and co-lead met with the participants. The completed post-study questionnaires were collected and a focus group was conducted.
The primary outcome measure was the JSE-S Version which is a 20-item Likert scale assessment tool measuring domains of medical student empathy ranging from ‘understanding what is going on in your patients’ mind’ to ‘I do not enjoy reading non-medical literature or the arts’ to ‘I believe that emotion has no place in the treatment of medical illness’. This scale is well validated with several studies supporting criterion-related validity and construct validity (Loureiro et al. Reference Loureiro, Goncalves-Pereira, Trancas, Caldas-de-Almeida and Castro-Caldas2011; Tavakol et al. Reference Tavakol, Dennick and Tavakol2011; Montanari et al. Reference Montanari, Petrucci, Russo, Murray, Dimonte and Lancia2015; Spasenoska et al. Reference Spasenoska, Costello and Williams2016). It has been translated into 53 languages and has been utilised in over 190 publications.
The BRS was used as a secondary outcome measure. No gold standard questionnaire exists for assessing resilience (www.ieeurope.orgxs). Although many scales for assessing resilience have been developed, they are not widely adopted and no one scale is clearly preferable (Connor & Davidson, Reference Connor and Davidson2003). Ahern et al. (Reference Ahern, Kiehl, Sole and Byers2006) carried out a review of instruments measuring resilience and despite a thorough search strategy and reporting of psychometric tests used, they did not critique the validity of the psychometric testing of each scale discussed.
A post-Balint group, qualitative focus group, was conducted following each 6-week intervention. The purpose of this focus group was to discuss the students’ experience of Balint and note any issues of concern. Focus groups are noted to benefit the group participants through participation and empowerment (Pini, Reference Pini2002) and are recognised as useful tools for examining perceptions, feelings and suggestions about topics, products or issues (Jones et al. Reference Jones, Newsome, Levin, Wilmot, McNulty and Kline2018).
Statistical analysis
Data were all normally distributed and analysed using paired sample t-tests (two-tailed alpha = 5%) comparing pre- and post-intervention scores using the JSE-S Version and BRS.
Results
Participants
There were a total of 28 (n = 28) study participants. Balint groups ranged in size from six to eight members. Four 6-week Balint groups were provided. One full 6-week Balint group did not take place during the time period. No individual participant dropped out of the study. Data were complete as all participants completed the pre-and post-questionnaires fully and participated in the post-Balint focus group.
Empathy measures at follow-up
Results from the JSE S-Version showed a significant improvement in mean empathy score of 116 in the post-Balint group compared to 109 in the post-Balint group (p < 0.0001) of a potential score of 140, with a mean change in score of −7.79 (95% confidence interval (CI) −10.90–−4.67).
Resilience measures at follow-up
Results from the BRS showed a mean resilience score of 3.77 in the post-Balint group compared to 3.98 in the pre-Balint group with the mean change of 0.21 (95% CI −0.2945 to 0.7210) not being statistically significant.
Emerging themes at follow-up
Following conclusion of each Balint group, a focus group was conducted to discuss the students’ experience of Balint and to note any issues of concern using pre-prepared questions facilitating discussion. Transcripts of focus groups were then reviewed and specific themes emerged.
Themes discussed were as follows:
1. A new understanding of reflective practices
‘I always thought reflection was a chore but in Balint it’s fun and exciting and keeps you thinking’.
‘It’s good to talk things through like this because we’re in a safe place where there is no judgment’.
2. New insights into case dynamics
‘I never thought about it like that, I guess I could have been a positive when at the time I just felt in the way’.
‘You know it’s mad to think that where I was seated had an impact on the patient and you know it makes so much sense because he could see me yet I didn’t know my role’.
3. Negative role models
‘This old guy just grabbed his shoulder and dragged him up to the bed & said – do you think you will ever be a Doctor? – it was so humiliating for him’.
‘He turned to me & he said – I am a good teacher now listen to how I break bad news – and then he turned to the family & said your Mum is dying. I just wanted to disappear’.
4. Feelings towards the patient
‘It’s really awkward watching a man cry, especially a man that looked like him; big, muscular and not soft looking at all’.
‘When they were told their baby was going to die, I couldn’t look at them & then I did & I saw such sadness. I didn’t know what to do with those feelings’.
5. An increased sense of professional identity
‘When I think of it like that & how I would have dealt with it I can see me as a Doctor, you know, not just the student I am now’.
‘I don’t want to be like that with my students; I want them to enjoy learning, not be frightened like he was’.
6. A shared sense of belonging with other students
‘Balint has made this group kinda close, like some of us didn’t know each other before but now we have heard how we all have similar expereinces & that has made us closer, it’s a bit silly but it’s been a bit special’.
Discussion
This study aimed to establish and evaluate the effects of a 6-week Balint group on fourth-year medical students during their psychiatry rotation. Students reported increased self-reported empathy and significantly increased externally evaluated empathy on completion of Balint groups but no change in resilience measures.
Study strengths include its prospective design, qualitative and quantitative analysis of empathy and resilience and that it is the first such study to be undertaken with medical students in an Irish setting. However, important limitations need to be acknowledged. Firstly, there is no control group limiting generalisability of these findings. Secondly, the sample size is relatively small and, as such, may have been underpowered to detect significant differences in resilience for example. We were unable to compare the students that self-selected from non-participators and this self-selecting sample may be biased towards greater empathy and resilience. Finally, as in any small group study, there are a number of confounding variables over the course of this study that might have affected scores such as whether lectures and practical teaching in psychiatry could have improved empathy or whether impending exams could have affected post-group scores in resilience or empathy. It would have also been useful to have more baseline data regarding general and mental health to evaluate predictors of response which we intent to include such scales in a future randomised control trial of Balint groups among medical students.
The lack of change in resilience scores in this study may also relate to the absence of well-validated tools for assessing and measuring change in resilience. The BRS was initially developed as a tool to assess the ability to ‘bounce back’ or recover from stress. Unfortunately, no empirical validation of this scale or other satisfactory scales has yet been published.
A number of studies have reported a decline in empathy throughout medical school particularly in the clinical years of undergraduate medicine (Neumann et al. Reference Neumann, Edelhäuser, Tauschel, Fischer, Wirtz, Woopen and Scheiffer2011; Chen et al. Reference Chen, Kirschenbaum, Yan, Kirshenbaum and Aseltine2012; O’Neill et al. Reference O’Neill, Fosterb and Gilbert-Obrartc2016). There has been a resulting drive to promote medical students’ empathic abilities with the introduction of theatre groups (Dow et al. Reference Dow, Leong, Anderson and Wenzel2007), videotaped case analysis (Suchman et al. Reference Suchman, Markakis, Beckman and Frankel1997), narrative medicine (Goupy et al. Reference Goupy, Abgrall-Barbry, Aslangul, Chahwakilian, Delaitre, Girard, Lassauniere, Roche, Szwebel, Dantchev, Triadou and Le Jeunne2013) and Balint groups (Airagnes et al. Reference Airagnes, Consoli, De Morihon, Galliot, Lemonge and Jaury2014) with only Balint groups showing increase in empathy levels using a randomised controlled design.
In the only randomised controlled trial (RCT) of Balint groups relating specifically to medical students and empathy, Buffel du Vaure et al. (Reference Buffel du Vaure, Lemongne, Bunge, Catu-Pinault, Hoertel, Ghasarossian, Vincens, Galam and Jaury2017) conducted a two-site study comparing 155 students in the intervention group (7-week, 1.5-hour Balint group), with 144 students in the control group (no Balint group). Overall, the intervention group displayed significantly greater change in empathy compared to the control group using the JSE-S Version.
In the present study, real-life clinical stories were presented in keeping with Balint tradition. For students discussing their own experiences as a clinician in training brought reality into the Balint group unlike the study conducted by Airagnes et al. (Reference Airagnes, Consoli, De Morihon, Galliot, Lemonge and Jaury2014). The ‘realness’ of the Balint group may have had a positive effect on empathy as shown through the focus group themes, and this is in keeping with the findings of the RCT conducted by Buffel du Vaure et al. (Reference Buffel du Vaure, Lemongne, Bunge, Catu-Pinault, Hoertel, Ghasarossian, Vincens, Galam and Jaury2017).
Torppa et al. (Reference Torppa, Makkonen, Martenson and Pitkala2007) conducted a qualitative grounded theory-based approach (Glaser & Strauss, Reference Glaser and Strauss1967), to the data they gathered to find emerging issues and themes based on transcripts made during and immediately after each Balint group. Themes that emerged over a 15-week Balint group practice (n = 9) were feelings related to patients (including managing negative emotions), building professional identity, negative role models and co-operation with other medical professionals.
A similar study by Old & Malone (Reference Old and Malone2016) found six main themes emerge from a 6-week Balint group practice (n = 9): medical students’ lack of role in the hospital setting, lack of respect of patients, negative role models, feelings related to patients including empathy, constructing professional identity and making assumptions and judgements about the patient. In addition, this study also examined the students’ perceived gain from attending a Balint group. These gains ranged from the ability to share experiences and opinions professionally with peers, the ability to reflect through dialogue, the ability to work better with group dynamics and the ability to professionally respond to emotions along with a perceived protective mechanism towards mental health.
Both of these studies mirror findings in the present study. Birden et al. (Reference Birden, Glass and Wilson2013) carried out a systematic review examining the most effective way to teach professionalism to medical students. Their findings showed that role modelling and personal reflections, ideally guided by faculty, are the important elements in current teaching programs and are widely held to be the most effective techniques for developing professionalism.
Conclusions
The results of the present study provide preliminary evidence of the efficacy of Balint groups to promote the humanistic value of empathy among medical students at an Irish university. However, the findings of this study did not show a positive correlation between Balint and resilience. Further evaluation of the efficacy of Balint is needed, and we are currently awaiting ethical approval to conduct a RCT examining burnout and empathy in medical students during their first clinical rotation.
Financial support
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Conflict of interest
The authors have no conflicts of interest to disclose.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The study has received formal ethical approval and was conducted in accordance with these parameters.
