Appropriate training based on Balint groups can improve the empathic abilities of medical students: A preliminary study

Highlights

• We examine the effects of a Balint-based training in fourth-year medical students.

• General, but also more ecological measures of empathy are proposed.

• Students rate their emotional reactions in response to written case-reports.

• A positive effect is found only for ecological conditions.

• Balint-based training may enable to better handle difficult clinical situations.

Abstract

Objective

Although empathy is critical in a doctor–patient relationship, empathic abilities seem to decline throughout medical school. This study aimed at examining changes in empathic abilities of fourth-year medical students who participated in an optional certificate based on Balint groups.

Methods

Thirty-four students were included in the “Balint group” certificate and compared with 129 participating in other certificates. Before the training sessions and 4 months later, they filled up the interpersonal reactivity index (IRI) and were asked to rate their emotional reactions in response to two case-reports: the first described a woman with diabetes, borderline- personality traits and a history of childhood trauma; the second, a woman with histrionic traits suffering from multiple sclerosis and hospitalized for functional symptoms. A principal component analysis extracted four factors from the 8 questions asked: empathic-approach (e.g. finding the patient touching), rejecting-attitude, intellectual-interest and fear of emotion contagion.

Results

At baseline, there were no socio-demographic or psychological differences between groups. At follow-up, an increase of IRI fantasy-scale (p = 0.02) and a decrease of IRI empathic-concern (p = 0.006) were observed, regardless of the group. Empathic-approach only increased in the “Balint group” and for the first case-report (p = 0.023), with a difference between the groups at follow-up (p = 0.003).

Conclusion

Results suggest that Balint groups may enable medical students to better handle difficult clinical situations such as those presented by borderline personalities. Our findings encourage assessing training initiatives designed at helping young medical students to take into account the emotional component of a doctor–patient relationship.

Introduction

Physician's empathic abilities are essential to build a strong doctor–patient relationship, which is known to improve treatment adherence and clinical outcomes [1]. Empathy refers to the ability to share emotions with others, without confusion between self and others. It integrates emotional resonance, emotion regulation and perspective-taking [2]. Most standardized evaluation scales of empathy, including those that have been used among physicians such as the Interpersonal Reactivity Index (IRI) [3], [4], distinguish between affective and cognitive empathic abilities. A decline in empathy throughout medical school has been observed [5] mainly at the end of first and third year [6], although other findings tend to moderate these conclusions. First, very weak or even no decreases were also found [7]. Second, since empathy is critically modulated by contextual factors [2], this decline may be more about the perceived importance of empathy within the context of the doctor–patient relationship than about empathic abilities per se [8]. In IRI-based studies, the most affected dimension is the “Empathic-Concern” [9]. Several factors could explain this phenomenon: teaching methods [10] (e.g. prioritizing a purely biomedical approach); selection procedures which may not be in favor of the most empathic students [5]; influence of models [6]; and coping strategies based on emotional distancing [11]. However, the IRI may fail to capture the actual implementation of empathic skills within the context of the doctor–patient relationship [12]. As a consequence, interventions aiming at promoting empathic skills among medical students should not only use general measures of empathy such as the IRI, but also more ecological, clinically-relevant measures.

Several interventions aimed at preserving medical students' empathic abilities have been developed such as narrative medicine, which encourages students to put themselves in the place of the patients by narrating their story in the first person [13], theater groups [14], experience sharing in small groups [15], or videotaped case analyses [16]. Balint groups are specifically designed to help health-professionals and medical students in developing their empathy skills in order to reduce interpersonal difficulties. Ability to listen, according to Balint, refers to the inclination of a caregiver to take into account emotional issues of the doctor–patient relationship through using his or her empathic skills as assessed by the IRI [17], [18], [19]. Participants are asked to react to a particularly touching, upsetting or interesting live clinical situation that involves interpersonal problems. Theoretical and practical training of facilitators is systematized. These interventions differ from problem-based learning in that they aim to develop empathic abilities rather than medical knowledge [20].

In Paris Descartes University of Medicine, all the fourth-year medical students participate in a Narrative Medicine seminar and have to choose one optional certificate among thirteen. All of them consist of lectures in different specialties (e.g. cardiology, microbiology, and surgery) that the student wishes to study further, excepting the optional certificate entitled “doctor–patient relationship training”. In this last certificate, students are divided into small groups, structured as Balint groups, and instead of lectures, participants interact with each other according to specific procedures. This study aimed at examining changes in empathic abilities observed in students who participated in this last certificate as compared with those who did not.