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Dealing with stress

"Rarely does medical training itself present a mechanism to cope with and learn from our thoughts and feelings"

As paediatricians we have the privilege to know many young people with complex health needs and equally complex social backgrounds. Those interactions can require a huge degree of emotional resource on the part of the medical team.

So, how can paediatric trainees cope with stress? Recent books such as Your Life In My Hands and This Is Going To Hurt focus on the doctor’s perspective of dealing with difficult clinical situations. Some of us have hobbies, some turn to friends and family, others have slightly less constructive vices - but rarely does medical training itself present us with a mechanism to cope with and learn from our thoughts and feelings. 

In 2017 the East of England School of Paediatrics held its first “Resilience” day.  Among the mindfulness, diet, and sleep hygiene workshops was a group session facilitated by the chaplaincy at Addenbrooke’s Hospital for tea, cake and talking. The feedback on the day was that this session was cathartic (everyone loves free cake), but that it was not constructive, and was mostly an incitement to rant.

Introducing the Balint method

This year we tried something different. Under the slightly disingenuous title of “Interactive Clinical Cases”, we ran structured group sessions called Balint Groups.

The Balint method was developed by Michael and Enid Balint to support clinicians in exploring complex interactions with their patients. It provides a structured approach for a clinician to share a clinical case followed by a facilitated peer discussion on the doctor’s potential thoughts and feelings.

The format is simple.

1. The doctor describes the facts (not their thoughts and emotions) about a particular case. 
2. The group has an opportunity to ask the doctor questions to clarify points of fact, to get a clear picture of the situation.
3. The doctor takes a step back from the group, enjoys their tea and cake, and cannot contribute again until the end of the session.
4. The group is then invited to share how they think the doctor might have felt. Group members may challenge each other, explore ideas, and share their own similar or differing anecdotes for context.
5. At the end, the doctor is invited to return to the group to have the last word as they see fit.

This process is facilitated by a leader who provides the structure for the session. The leader’s agenda is to ensure the space is safe, the information shared remains confidential and the conversation remains focused on the doctor patient relationship.

What the Balint method offers

"Balint encourages us to acknowledge emotions such as anger or fear"

This method encourages clinicians to be honest. As paediatricians we rarely say a bad word about the children in our care; however, Balint encourages us to acknowledge emotions such as the anger we might feel at the young person admitted with self-harm, or the fear we might feel explaining to a parent that we haven’t been able to cannulate their child but need to try again.

The structured and clinical nature of the session allows doctors to share a hypothesised thought in a depersonalised way. This can make it easier to voice the less palatable corners of our clinical minds.

We ran these sessions as a one off, but ideally groups work best when they meet regularly. If all members of the group are able to contribute a case, over time they each gain the benefit of sharing their thoughts, as well as sitting out and seeing what others would think in the same situation. A Balint group can easily be run in 45 minutes, making it perfect for a departmental lunchtime teaching session.

Trainee feedback from the East of England Study Day was extremely positive. Ninety five percent of paediatric trainees rated the sessions as relevant to their training and individual comments highlighted the value of reflection alongside peers within this format.

Some tips to make your Balint group successful

1. Choose your group carefully. Balint works best with peers on an equal footing. It might not be appropriate for a consultant to join the group; they could have their own session!
2. Explain the premise of the group clearly at the start. Be clear that this is a safe space and that what is said in Balint stays in Balint.
3. Acknowledge that some thoughts may be uncomfortable, if a member of the group wishes to leave or not contribute, that is okay.
4. Balint groups are not about providing a definitive answer to a problem. The leader should be able to signpost the group to supportive resources. This could include the Professional Support Unit.