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Promoting empathy among medical students by Balint group (supporting all

students/trainees)P Jaury, C Buffel du Vaure, E Galam, ME Vincens, C Ghasarossian, L Bunge, C Lemogne

Royal College of Psychiatrists, Belfast

Thursday 21th September 2017(Thanks to Peter Schoenberg)

121/09/2017 Pr Philippe Jaury Université Paris Descartes

Introduction The EMPATHY Study (1)

• The social aim in medical education is to train physicians so as to apply all of the necessary professional skills, including clinical empathy.

• “Clinical empathy" is the combination in the therapeutic relationship:

• - of unbiased, intellectual, and affective UNDERSTANDING of the experience of others,

• - of SOLICITUDE, an appropriate, warm, affective involvement,

• and of an adequately regulated capacity for EMOTION (A Maury 2015).



• In French medical schools, the second cycle is strongly structured by the national ranking exam (ECN).

• It is well known in pedagogy that evaluation often determines course content.

• Students understandably and legitimately focus on the maximum acquisition of the knowledge and skills necessary to pass the ECN with as high a rank as possible.

• They thus neglect the skills that are not evaluated during this examination.



• Nonetheless, the physician-patient relationship, communication, and thus empathy are an integral part of professional skills and must therefore be taught appropriately.

• But it is difficult to apply standard methods of instruction and standardized procedures of evaluation to these topics.

• Our research takes place in this context.


Patient Relationship Training – PRT (1)

• Since 1973, the medical school at Bobigny (Paris XIII) has offered fourth-year students (DFASM 1) a course in the patient relationship, inspired by Balint groups (M Balint

1966, AM Reynolds 1976, L Velluet 1978).

• The discussion that led to setting up this course was based on three lines of thought (L Velluet, P Jaury 2005):


PRT (2)

• 1) The fourth year (DFASM 1) is a key moment in the medical school programme. It is when students first deal with patients in a position of responsibility.

• Their function is defined, albeit still modest. Listening, observing, performing physical examinations, and taking diverse samples for investigation.

• These tasks put them in direct contact with the patient's physical and psychological reality in the context of hospital setting.

• This first encounter can induce anxiety. Closeness to distress and death is not easy and can be a source of anxiety too.

21/09/2017 Pr Philippe Jaury Université Paris Descartes 6

PRT (3)• 2) These first experiences determine the development of the

professional personality of future physicians and their subsequent evolution.

• In the hospital setting, students face exclusively institutional models of identification.

• The teachers' instruction must therefore also respond to the need to present to students very early on different models to help them to refine their choices about their future practice,

• to improve their judgement,

• and to avoid the development of attitudes or stereotypes that may be very difficult to modify later on (A Missenard 1970, P

Wiener 1971).


PRT (4)

• 3) Finally, students’ first encounters with patients play a major role in how these future physicians develop their individual capacity to manage relationships with patients.

• The discovery of differences in attitudes linked to a very broad range of psychological structures, of either physicians or patients, makes it essential to make students aware quite early of this aspect of medical practice.


PRT (5) • Since 1998 this training has been offered to externs (DFASM 1) at

the University of Paris Descartes medical school (as an elective) and to interns working with general practitioners in their offices (required course) (L Velluet, P Jaury 2002).

• The course was conducted in homogeneous groups of 8-15 medical students, all in the same year.

• The group met 7 to 8 times a semester,• with the same leader, trained to lead this type of group. For this

study, leaders were all accredited by either the (French) Balint Medical Society or the Association of Balint Training.

• The students and the group leader sit in a circle for these meetings, without a table, telephone, or a medical file, and they do not take notes.

• The meetings last 90 minutes.


PRT (6)

• Three rules are stressed at each meeting: confidentiality, a non-judgemental attitude, and the message "I".

• Two to four clinical cases are discussed at each session.• The "casework" technique is employed, based on the

Socratic method (εὑρίσκω = "I find") (WR Bion 1961, R Kaes

1976).• The group leader asks if a student wants to present

either a case experienced during the work placement that presented a problem about a relationship, communication, or conscience,

• or a follow-up about a case that the group has previously discussed.


PRT (7)

• The student reports the case and the patient as he or she experienced them, without going into biomedical details and avoiding generalizations as much as possible.

• Then each group member can intervene, as they like: ask for clarification, or detail, express an opinion, ask a question, describe a phantasy, a thought association…

• The group leader then asks the narrator to reply.

• The leader should respect any silences,

• should also channel any possible aggression by the group or a group member,

• and try to help the group to refocus on the patient.


PRT (8)

• Unlike in Balint groups, the leader may theorize about a case report, pointing out relevant aspects of the student-patient relationship in the case,

• and sometimes presenting some basic ideas of psychopathology that students need to be familiar with.

• Nevertheless, group leaders should not reach any firm or definitive conclusions, to avoid becoming an expert,

• or appearing to set norms or to recommend a particular course of action.

• The work will focus on being able to recognize identifications/projections/representations/attitudes and counter-attitudes…


History of the EMPATHY Study (1)

• An initial qualitative evaluation was conducted and published by the Department of General Medicine at Paris Descartes in 2005 (L Velluet P Jaury 2005, J Jouquan 2002).

• We then worked on the possibility of a quantitative evaluation at the request of the university administration.

• Because some studies have reported a diminution in empathy at the beginning of the fourth year (M Hojat 2009), it seemed useful to try to assess PRT groups for learning about empathy.

• Empathy scales have been developed; the best known is the Jefferson Scale of Physicist Empathy (JSPE), which we have validated in French (F Zenasni P Jaury 2012).


History of the EMPATHY Study (2)

• The initial (feasibility) study was conducted, published (G Airagnes, P Jaury 2014), and presented at several international conferences, including the 19th International Balint Conference in 2015.

• There was a significant and positive difference in empathy between the students who took this course and a control group.

• The principal bias of this study was that the course participants were volunteers; an additional weakness was the relatively small number of students.


The EMPATHY Study (1)

• We therefore conducted a more complete study with students from three different Paris medical schools (Paris 5, Paris 7, and Paris 13).

• These students were randomly allocated either to a group undergoing 7 PRT sessions or to a group with no such course.

• The PRT groups were led by 10 trained leaders (6 GPs, 2 psychoanalysts, one gynaecologist, and one cardiologist).

• Clinical empathy was assessed before and after the course by an online self-administered questionnaire and then by actor-patients during two simulated consultations (OCSE).


The EMPATHY Study (2)

• 264 participants were needed to show a difference with a risk of 5% and a power of 90%.

• The principal endpoint was the mean scores on the JSPE MS (Medical Student), a specific scale for medical students which we have just validated in French (A Marmontel, A Bitoun, P Jaury 2017).

• The means were compared with Student's t test.

• Of 451 students who participated in the study, only 352 could be included in the study, because of a randomization problem at Paris 13.


Results: Paris Descartes and Paris Diderot (P5 and P7) (1)

• Among 352 randomized participants, the intervention group displayed significantly higher JSPE-MS© score at follow-up than the control group (P=0.002).

• The JSPE-MS© score increased from baseline to follow-up in the intervention group, whereas it decreased in the control group (P=0.006).


Results: Paris Descartes and Paris Diderot (P5 and P7) (2)

• For the secondary analyses we used Consultation And Relational Empathy Measure (CARE) scale rated by standardized patients during Objective Structured Clinical Examination (OSCE).

• The Care scale showed that the score increased in the intervention group for men and those with high levels of self-reported empathy at baseline.


University Paris 13

19

Linear regression adjusted for the confounding factors, P = 0.022


CONCLUSION

• Our study confirmed that a Balint-type doctor-patient relationship training increases the empathic skills of fourth-year medical school students.

• (publication under review).

• This training is now a required course at Paris Descartes for all DFASM 1 students (430).


THANKS FOR YOUR LISTENING


• 1 Maury A. : l’empathie clinique. Thèse de Doctorat en Médecine. Paris : Université de Paris Descartes, 2015.• 2 Reynolds A.M., Velluet L. : L'enseignement de la médecine générale en 2ème cycle. Revue de Méd.

Psychosomatique. 18. (4) 1976 : 355-357.• 3 Reynolds A.M., Velluet L. : Une méthode pédagogique originale : La table ronde de médecine générale. Revue

de Méd. Psychosomatique. 20. (1) 1978 : 69-72.• 4 Balint M., Gosling ER., Hildebrand P.: Le médecin en formation. Paris Payot. 1979.• 5 Velluet L., Catu-Pinault A., Fabre-Jaury M., Jaury P. « Formation à la relation thérapeutique en D2 » La Revue

du Praticien-Médecine Générale 2005 ; 19 (700/701) : 902-904.• 6 Missenard A. : Modèles du médecin. Problèmes d'identification et formation psychologique. Revue de Méd.

Psychosomatique. 12. (1) 1970.• 7 Wiener P. La constitution de la personnalité professionnelle en médecine. Revue de Méd. Psychosomatique.

13. (1) 1971.• 8 Velluet L., Jaury P. « Des groupes Balint pour les résidents : pourquoi pas ?» La Revue du Praticien-Médecine

Générale 2002 ; 16 (585) : 1305-6.• 9 Bion W.R.: Experiences in groups. Londres, 1961, Tavistock publications. Trad. Franç. PUF 1965.• 10 Kaes R. Anzieu. D. : Désir de former et formation du savoir. Paris Dunod. 1976.• 11 Jouquan J. : L’évaluation des apprentissages des étudiants en formation médicale initiale. Pédagogie

Médicale 2002 ; 3,1 :38-52.• 12 Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a

longitudinal study of erosion of empathy in medical school. Acad Med. 2009 Sep;84(9):1182–91.• 13 Zenasni F, Boujut E, Buffel du Vaure C, Catu-Pinault A, Tavani JL, Rigal L, Jaury P, Magnier AM, Falcoff H,

Sultan S. Development of a French-language version of the Jefferson Scale of Physician Empathy and association with practice characteristics and burnout in a sample of General Practitioners. The Int J Pers Cent Med. 2012 sept; 2(4): 759-766.

• 14 Airagnes G, Consoli S, De Morlhon O, Galliot A-M, Lemogne C, Jaury P. Appropriate training based on Balint groups can improve the empathic abilities of medical students: a preliminary study” Journal of PsychosomaticResearch 76 (2014) 426–429.

• 15 Bitoun A, Jaury P, Malmartel A. Evaluation de l’empathie des étudiants en médecine: validation du JSPE-MS en français CNGE Grenoble 2016.


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