Documente Academic
Documente Profesional
Documente Cultură
Martie, 2011,
Volumul XIII, Nr. 49
Periodic trimestrial, apare n ultima
decad a lunii a treia din trimestru.
Fondat: 1999
Redactor ef:
Albert VERESS M.D. Sc.D.
Lector: Almo Bela TRIF M.D.,
Sc.D., J.D., M.A.
Tehnoredactor, coperta:
Botond Mikls FORR
Editat de:
Asociaia Balint din Romnia
Tiprit la: Tipografia
Alutus, Miercurea-Ciuc
Adresa redaciei:
530.111 - MIERCUREA CIUC,
str. Gbor ron 10,
tel./fax 0266-371.136;
0744-812.900
cuprins
PROBLEME ETICE DIFICILE
ALE CERCETRII MEDICALE CONTEMPORANE
- Almo Bela Trif, MD, PhD, JD, U.S.A
11
16
E-mail:
berciveress@asociatiabalint.ro
alveress@clicknet.ro
DESCRIERI DE CAZURI
- Ovidiu Popa-Velea, Bucureti
26
Comitetul de redacie:
Tnde BAKA
Doina COZMAN
Dan Lucian DUMITRACU
Evelyn FARKAS
Liana FODORANU
Ioan-Bradu IAMANDESCU
Cristian KERNETZKY (D)
Mircea LZRESCU
Holger Ortwin LUX
Drago MARINESCU
Ioana MICLUIA
Csilla MOLDOVAN
Aurel NIRETEAN,
Iuliu OLTEAN
Gheorghe PAINA
Ovidiu POPA-VELEA
Almos Bela TRIF (USA)
Ionel UBUCANU
va VERESS
Nicolae VLAD
DESCRIERI DE CAZURI
- Psih. Irina de Hillerin
27
www.asociatiabalint.ro
cTrE AuTOri
Se primesc articole cu tematic legat de activitatea grupurilor Balint
din Romnia i din strintate, de
orice fel de terapie de grup, de psihoterapie, de psihologie aplicat i de alte
abordri de ordin psihologic al relaiei medic - pacient (medicin social,
responsabilitate medical, bioetic,
psihosomatic, tanatologie). Materialele scrise la solicitarea redaciei vor fi
remunerate. Buletinul este creditat de
ctre CMR ca prestator de EMC, deci
orice articol publicat se crediteaz cu
25 de credite EMC. Abonamentul la
Buletin se crediteaz cu 5 credite. Redactorul ef i / sau lectorul au dreptul
de a face cuvenitele corecturi de form,
iar n cazul neconcordanelor de fond
vor retrimite articolele autorilor cu sugestiile pentru corectare.
Activitatea Asociaiei:
grupuri Balint,
editarea Buletinului,
formarea i supervizarea liderilor,
colaborare la scar internaional.
Cotizaia se achit pn la 31 martie
a.c. Cvantumul ei se hotrte anual de ctre Biroul Asociaiei. n cazul
cnd ambii soi dintr-o familie sunt
membrii Asociaiei, unul din ei poate
cere scutirea de la plata abonamentului la Buletinul Asociaiei, al crui cost
BIROUL ASOCIAIEI:
Preedinte: Tnde BAKA tundeb13@freemail.hu
Vicepreedinte: Istvn VRADI istvanvaradi@inbox.com
Secretar: Csilla VAJDA-HEGYI cs_hegyi@yahoo.com
Trezorier: Albert VERESS alveress@clicknet.ro
Membri: Rita-Lenke FERENCZ, Holger Ortwin LUX, Attila MUNZLINGER,
Ovidiu POPA-VELEA, va VERESS.
Deoarece revista se difuzeaz i n
alte ri, articolele care nu se limiteaz
doar la descrierea evenimentelor balintiene, trebuie s aib un rezumat n
limba romn i englez, de maximum
10 rnduri dactilografiate. Lectorul i
impune responsabilitatea de a face la
nevoie corectura rezumatului
Pentru rigoarea tiinific apreciem
menionarea bibliografiei ct mai complet i mai corect, conform normelor
Vancouver, att pentru articolele din
periodice ct i pentru monografii (citarea n text se noteaz cu cifre n parantez, iar n bibliografie se nir autorii n ordinea citrii nu cea alfabetic
i doar acei autori care au fost citai n
lucrare).
Recenziile crilor trebuie s cuprind datele de identificare a crii
n cauz - autorii, titlul, toate subtitlurile, anul apariiei, editura, oraul,
numrul de pagini i ISBN-ul. Se tri-
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se refer la lipsa de integritate tiinific, la epidemia de
greeli tiinifice trecute cu vederea din neglijena sau
nepsarea cercettorului insulte directe la nsi noiunea
de CERCETARE TIINIFIC, dup definiia ei din
dicionar. Se pleac de la premiza c integritatea tiinific
este elementul de baz a adevratei tiine, fie c e vorba
de o cercetare de laborator, de un trial al unui medicament
nou sau de observaiile unui psiholog - etolog, care studiaz
comportamentul animalelor. (6)
David Goodstein prezint cazul lui Marc Hauser, doctor
n tiine psihologice, cercettor de frunte n domeniul
cogniiei la oameni i animale la Universitatea Harvard,
care a publicat n 2002 o carte intitulat Moral Minds: How
Nature designed our universal sense of right and wrong
(Minile morale: Cum a proiectat Natura simul nostru
universal de bine i ru). Tot n anul 2002 Hauser a publicat
n revista Cognition un studiu despre nite primate
(tamarinul Saguinus oedipus), un fel de maimuici cu faa
i spatele negre, dar cu o coam alb ciufulit i picioarele
i burtica albe. Hauser a strnit interesul lumii tiinifice
mondiale, afirmnd c acestea animale plcute la nfiare
sunt capabile s creeze tipare generale n procesul de cogniie
- cunoatere, asemenea copiilor mici. n decursul anilor el a
fost citat de 38 de ori, dar n august 2010, consiliul tiinific
al Universitii Harvard l-a gsit vinovat de opt cazuri de
omisiune n cercetare i fraud tiinific. n mod necesar a
urmat retragerea public a concluziilor studiului publicat n
2002. (6)
D. Goodstein ntrevede trei motive aparente ca rspuns
la cea de a doua ntrebare:
Mai nti exist presiune generat de carier orice
cercettor e obligat prin natura muncii lui s publice ceva din
cercetarea personal, ca s i justifice existena. (6) Toat
lumea medical murmur astzi PUBLISH-OR-PERISH
adagio pe care l-am auzit prima oar de la neuitatul Profesor
de Fiziologie Ioan Hulic de la Universitatea de Medicin i
Farmacie din Iai minunat Alma Mater pentru generaii
ntregi de medici, profesori de medicin i cercettori
tiinifici.
n al doilea rnd vine o anumit trstur de caracter ce
se poate vedea doar la unii cercettori acei mai ambiioi
sau cu un surplus de ncredere n sine care cred c tiu
dinainte rspunsul la unele probleme, iar dac ar sta s
demonstreze cu migal ceea ce este de demonstrat, ar pierde
timp preios n cercetare. Ei nu sunt de loc lenei sau ncei,
ba dimpotriv, sunt extrem de vioi ca minte, iar de aceea
sar peste etapele necesare demonstraiei, dintr-o necesitate
teleologic, de a termina cercetarea ct mai curnd. (6)
O a treia explicaie a lui Goodstein cea mai dur dup
prerea mea a fi c cercettorii ce lucreaz cu experimente
greu de reprodus sunt tentai prin nsi natura muncii
lor - s aduc din condei datele sau in extremis chiar s le
fabrice pe loc. El citeaz un alt caz extrem, unde un fizician
n tehnologia semi-conductorilor organici, aflat n culmea
carierei, publica frenetic aa-zise noi descoperiri, aproape
1.
2.
3.
4.
5.
6.
7.
8.
Bibliografie:
R Grant Steen - Retractions in the scientific literature: is
the incidence of research fraud increasing?; J Med Ethics
doi:10.1136/jme.2010.040923; Published Online First 15
November 2010
Jef Akst - Top retractions of 2010: A list of the biggest papers
-- and scientists -- involved in retractions in the last year;
Published 16th December 2010 01:12 PM GMT
Ben Goldacre - Bad Science, published by HarperCollins
Publishers, Fourth Estate in 2009, 370 pages
Trif, A. B. - Ideas and controversies about the role of Bioethics
in passing laws; the consensus conferences, Clinica, vol. II,
nr.5, 1997, p. 43-44.
Trif, A. B. - Experiments on Animals contradictions and
incertitude, Clinica, vol. III, nr.3, 1998, p.46-49.
David Goodstein On fact and fraud; Cautionary tales from
the frontlines of science, Princeton, NJ; Princeton University
Press; 2010
Douglas L. Weed, MD, PhD - Preventing Scientific Misconduct;
Health Law and Ethics; American Journal of Public Health,
1998; 88 (1): 125-129
Patrick Hardigan, PhD Scientific misconduct; Focus on
research NSU HPD, vol. 4; n. 4, December 2010
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movies considering the fact that in their case the visualization
is facilitated by the ready-made visual material that the
viewers adapt to their own imaginative sphere.
So we have affirmed that psychological impact
depends on the possibility of identification. Furthermore,
identification depends on whether the viewers mental
sphere and the movies audiovisual dimensions and its epic
thread share some common features. As a consequence, the
extent of identification is defined by the forcefulness of these
overlaps between the personal and the visually represented
worlds.
We have reached the point when You could ask me: why
Daldry and why The Hours? My arguments roots go back
even to the early 20th century modernist literary stream in
English literature. The main representative of this period
was Virginia Woolf with her stream of consciousness method
of writing. This method imitates the natural flow of thoughts
occurring randomly in the human mind, and creates their
almost mechanic documentation. Mrs. Dalloway is the
novel that wonderfully exemplifies this revolutionary way of
expression, and Stephen Daldrys The Hours constitutes the
adaptation that proves to be capable of adapting the stream
of consciousness method onto a totally different medium, of
creating a natural visual flow of Woolfs mental processes.
This later ability results in the viewers revolutionary
position: Daldry invites the audience to take an active part
in the process of creation of the central literary work, of Mrs.
Dalloway itself.
As a further point You could ask me to justify the later
assumption, and I will gladly do it for you. Henceforward
I am going to present You the main items that confirm
the permanent presence of the stream of consciousness
method throughout Daldrys visual work getting closer
to the viewers natural flow of thoughts, presenting them
the process of a creation instead of the ready-made work,
stimulating them to adapt the visual sphere to their own
mental dimensions, think together, and receive as if the
mental process took place in their own minds. These will also
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The protagonist dies, her alter ego is sacrificed, and
considering the total identification -, the audience becomes
able to experience the catharsis, see the death, feel the death,
experience the death, then rise above the tragedy, exit the
scene, and become purified by the transcendental power of
a tragedy experienced directly by identification, but at the
same time being aware of the receivers position, the constant
ability to move apart and regain the initial conditions.
*This is an extract of the Thesis paper entitled:
Mrs. Dalloway and The Hours
4.
2.
3.
7.
8.
References:
Abel,
9.
1.
Elizabeth:
Virginia
Woolf
and
the Fictions
of
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to 4 years. The physicians were senior registrars and
junior consultants in non-psychiatric department at a large
university hospital. 5-8 physicians in 19 groups met for 90
minutes every other week. Participants were invited to reflect
upon how their personal situation affected their professional
duties as doctors and, conversely, how their professional
duties touched upon personal issues and development.
Balint leaders were psychologists or physicians with training
in psychotherapy.
There are two main sources of analysis. The first one
is notes from 150 instances when 2-4 Balint group leaders,
together with an outside supervisor, met to consider the
developments within the Balint groups some 10 groups. The
second one is the authors own field notes from 171 sessions
in 5 Balint groups who met from 18 to 65 times. The author
is a paediatrician who has training in psychodynamic and
systemic therapy with experience of counselling ill children
and their families and of conducting research in families that
are coping with chronic illness.
The analysis started following a qualitative methods
tradition with the aim of finding concepts useful for
describing how hospital specialists reflected on becoming
and being a hospital specialist. Coding was performed using
everyday terms denoting feelings, reactions, thoughts,
relations and ideas such as "anger", "pride", "undoing",
"loyalty towards colleagues" and "justice". The code words
were combined into concepts. Early in the stage of analysis,
the concepts of contexts of cases, triggering incidents for
the cases presented and main themes in group discussions
were found in a report from medical student Balint groups
[1]. These concepts were found useful in making sense of the
material and were used as three headings in the analysis.
Time process, being a recurrent theme in the
supervision of the Balint leaders, were used as the
fourth heading. Groupings among main themes in group
discussions were formed inductively. An iterative approach
was used, comparisons between previous theory, such as
that of transference and counter-transference, were used
alternately with reading of the field notes and forming new
groupings of concepts and conducting discussions with
research colleagues. An aim is to use terms as defined in the
fourth edition of Diagnostic and statistical manual of mental
disorders from the American Psychiatric Association, DSMIV-TR [2].
Results
The context of the professional situation of the hospital
physicians, as told by members in the groups, is described.
Then I tell how triggering incidents and aspects of cases that
the Balint group members reflect upon in the groups can be
related to the professional context, then how themes of the
group discussions can be connected to triggers of the specific
professional context and, lastly, how the temporal process
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References
1.
2.
Diagnostic and statistical manual of mental disorders: DSMIV-TR. Washington, DC: American Psychiatric Association,
2000.
3.
4.
5.
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10
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satisfy everyone, all the time, on one hand, and the family
messages she received from her father before she chose her
profession on the other hand. In this case, the utilization of
role-playing helped to illustrate the problem. The use of a
wide range of psychotherapeutic approaches help openness
and experiential learning within the group and also tones
down the exclusivity of the psychodynamic approach on
which Balint groups were founded.
Rituals that are seen within the Balint group itself:
Implicit rituals in the ward. The nurse mentions the ritual
of the doctors ward round. Every morning the doctors ask
us to discharge families from the ward. This is not my job!
Why does he take advantage of us?" We looked at the doctors'
ward round as a permanent ritual, which has both overt and
covert messages. The doctors, from their part, want calmness
during the round. They claim that families may interfere with
the process. Yet can this practice not be broken? Perhaps one
member of the family can be present during this almost "holy
ritual" and provide relevant information to the team? In the
11
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Service, the Indigenous Health Service and the Alcohol,
Tobacco and Other Drugs Service. Upstairs is the University
Of Queensland School Of Medicines general practice clinic,
established in the 1970s by the Whitlam Labor government
as a research centre for socialised family medicine.
Other legacies that reformist government gifted to
the Australian people included free tertiary education and
universal health insurance, gradually eroded by subsequent
governments into generously subsidised user-pays systems.
The reforms still prevailed when I entered medical school,
and contributed to the culture of hope and generosity
within which I was taught primary care medicine as an
undergraduate at the Inala Community Health Centre.
While Balint groups were not a part of our undergraduate
program, Michael Balints emphasis on psychological
medicine and the doctor-patient relationship were taught
and practised, and The Doctor, His Patient and the Illness
and The Fifteen Minute Hour were textbooks supporting our
curriculum
Twenty-four years after completing my undergraduate
final rotation in Community Practice, and after 16 years
in private practice as a consultant psychiatrist and
psychotherapist with postgraduate trainings in psychiatry,
psychoanalytic psychotherapy and creative writing, I
returned to public sector practice in order to increase my
involvement in teaching and training, obtaining a permanent
appointment as Senior Staff Specialist at Inala Community
Mental Health.
I found that in spite of those waves of poor migrants,
Inala remained a long way from the ocean; that Michael
Balint had been forgotten; that the second hand clothing
shops at the Civic Centre had been replaced by rows of
Vietnamese greengrocers; that one of the many forensic
patients in my outpatient practice had attempted to burn
down Centrelink and the Civic Centre; that the only place to
park my car was at the roadside next to the park in which a
young woman had been recently murdered and from which a
drug-crazed man wielding a samurai sword had been taken
to the hospital to which my patients are admitted; and that
patients discharged from other services were prone to attend
demanding attention by drawing their machetes.
I found myself working with a team of idealistic mental
health workers bearing the appellation of case managers
nurses, psychologists, social workers and occupational
therapists, struggling to sustain hope in their capacity to
benefit their clients in spite of their heavy caseloads, but
mostly espousing devotion to a highly medicalised model
of intervention. When I was not involved in direct clinical
assessments, which were always performed jointly with the
case managers, I found them to be hungry for support and
advice, especially that which facilitated psychological insight
into their clients problems, and that which left room for
explanations of the failure of medical treatment other than for
the wrong psychiatric diagnosis, medication dose reductions,
12
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Wednesday mornings, in a timeslot usually set aside for
staff development and training. The first meeting was well
attended, but there was a long silence before one of the
participants offered to present a case. In this meeting and
the next, I noticed reluctance on the part of the presenters
to talk about their own feelings, with some cautious testing
of the consequences of expressions of frustration related to
disempowerment.
I attempted interventions that encouraged imaginative
discussion of the feelings and thoughts of those the case
managers believed were powerful in relation to them and
their clients, usually the senior medical staff, among whom
I was numbered. I found some of the defensive responses
painful, including those to the effect that whatever our clinical
director might have to say about the situation, it would be
right. The case managers fear of saying something that
might be construed as subversive or disrespectful awakened
in me wishes to transgress in just such a fashion, wishes that
I attempted to consciously acknowledge but to refrain from
overtly enacting. There were moments when I had to remind
myself of the potential benefits of neutrality and restraint in
leadership, traits that I admired in my co-leader, new as she
was to the Balint process.
The third Balint group meeting fell outside of the
intended fortnightly sequence, due to me being required to
participate in a corporate orientation process that followed
my appointment to permanency. Only one of the case
managers attended. The team leader and I offered her a joint
supervision of the case that was troubling her. It is impossible
to conduct a Balint group with only one participant. I found
this experience quite demoralising, but after debriefing with
my co-leader, I raised the issue again at the team meeting,
where most of the case managers expressed their continuing
interest, but raised various concerns about the timing of the
meetings, and their difficulties attending when pressed by
other commitments. I empathised with these difficulties,
and announced the need for a change in the timeslot for the
group, as much due to changes in my schedule as due to the
problems with theirs.
We settled on an early Tuesday morning time as the
alternative and agreed to meet fortnightly. My clinical
director, although he was not familiar with the Balint
process, supported it by publicly announcing to the team
that the Balint group was to be considered a compulsory part
of the professional development program. I had previously
emphasised the voluntary nature of the commitment, but I
appreciated this expression of support, and I was relieved to
find that the first meeting at the new time was well attended,
and that the presenter, a nurse in his thirties whom I had
noticed as having a capacity for calm and sound clinical
judgement in emergencies, began his presentation by
acknowledging his feelings of demoralisation and frustration
in relation to the patient whose care he was discussing, a 22
year old man born in New Zealand (from whence one in six
residents of Brisbane have originated) to Polynesian parents
who had migrated there from Pacific Islands further to the
north.
The presenter told us that he had been called to advise
and assist the previous day after the patients parents had
called the police to pick up their son from the park where he
had spent the morning lying out in the sun sniffing petrol,
across the road from the family home, within eyeshot of
his mother, who became too distressed to be able to bear to
watch him any longer. The patient had a four year history
of schizophrenia in which the onset of positive symptoms
including command hallucinations, disorganised thinking
and behaviour had followed a period of gradual deterioration
involving increased impulsivity, massive weight gain, lethargy
and turpitude, punctuated by outbreaks of petty crime and
the progressively relentless abuse of psychoactive substances
including alcohol, cannabis, amphetamines and inhalants.
The patient had no interest in his case managers efforts to
involve him in social and rehabilitative groups and to refer
him to the drug and alcohol service. When the patient had
been hospitalised, his condition had considerably improved
with antipsychotic medication and enforced abstinence from
substance abuse, but he rapidly relapsed each time he was
discharged from hospital, in spite of his compliance with
medication being ensured by fortnightly depot intramuscular
injections.
When asked by another member of the group about what
he thought motivated the patients petrol sniffing, the case
manager responded that he thought that it was the pursuit
of pleasure to the exclusion of all other goals, that his patient
seemed oblivious to the mental anguish that his actions
caused his mother, the impotent rage that they aroused in
his father and the feelings of frustration, helplessness and
futility experienced by his case manager.
After the presenter told the group about the case and
a period of factual questions from the group followed, I
invited him to push back and observe the process in silence
until invited to rejoin the group for the last ten minutes.
The patients we work with are a culturally diverse group, as
are the clinicians who make up our team. Case managers of
indigenous Australian, Chinese, Vietnamese, Persian, and
Anglo-Celtic Australian backgrounds have participated in
the Inala Balint group, including several for whom English
is a second language. Sensitivity to cultural difference is one
of the teams strengths. The discussion did not go far before
the issue of the difficulty of making a culturally attuned
response to the problems the patient presented to his family,
his case manager were raised, as was the marginal position
he had taken up with respect to the community within which
he lived. A lot of sympathy was expressed for the patients
mother, and the cultural meaning of eating and growing big
was speculated upon. The intervention I offered in response
13
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to this was to ask the group to imagine what the patients
father might want to say to the group about the problem.
When the case manager rejoined the group, he was able to
express more of his frustration and demoralisation, and to
put words to his sense of being entirely at a loss as to how
intervene helpfully.
After the group, I had half an hour to debrief with the
team leader and address other administrative issues before
seeing my first patient for the day the patient who had been
presented to the group and whom I was meeting for the first
time today, jointly with his case manager, for the purpose
of making an assessment and preparing a report regarding
the relationship of his illness to his recent offending by
driving without a license. Two days later the case manager
approached me and told me about the fresh approach he
had taken in dealing with the patients family asking them
how the patients problem would have been dealt with had it
arisen in a traditional village setting on the island they had
come from. This resulted in a family decision to take the
patient back to that island for a holiday and seek the advice
and assistance of community elders.
Between the fourth and the fifth meetings of our new
Balint group, a malfunction in the air condition caused
water to leak into the ceiling of our clinic, which collapsed
into one of our consulting rooms. Somehow the emergency
16
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Rezumat: Tratamentul medical holistic, ca intervenie psiho-social i psiho-somatic const n interaciunile subiective dintre medic
i pacient. Aceast afirmaie st alturi de idea lui Balint c cel mai folosit medicament n medicina general este nsui medicul. n
consecin, educarea i formarea n medicina psiho-social i psiho-somatic au ca scop principal crearea unor medici capabili s perceap,
s neleag i s-i trateze pacienii ntro manier mai complex dect prin simpla abordare somatic. Comunicarea ntre pacient i
medic este un instrument de valoare n ndeplinirea acestui scop, permind pacienilor s-i exprime punctele de vedere, experiena lor de
via i sentimentele pe deplin. Echipa noastr a investigat relaia medic pacient n cadrul unui studiu de intervenie controlat fcut
nainte i dup un curs avansat de Medicin psiho-social (Psy1) i de Medicin Psiho-somatic (Psy2) cu scopul de a afla dac exist o
mbuntire a capacitii de comunicare cu pacienii. Analiza s-a fcut cu ajutorul sistemului RIAS (vezi adresa website-ului), unde noi
am luat n consideraie schimbrile specifice n capacitile de intervenie. Rezultatele studiului demonstreaz c scopul a fost atins n ceea
ce privete comunicarea i tehnicile de intervenie. Ameliorarea prin intervenie la categoriile Denumirea Strii de spirit i nelegere a
strii de spirit poate fi dovedit, mai ales n ceea ce privete controlul strii de spirit (Modelul NURS; formarea avansat prin cursurile
Psy1 i Psy2 / Camera medical a Austriei).
Cuvinte cheie: medicin psiho-social, medicin psiho-somatic, activitate Balint, relaia medic pacient, Sistemul Roter de analiz
a interaciunii (RIAS)
1. Theoretical Background
In the last few decades, the medical system has
sometimes unfortunately turned away from the human
beings, according to Fiedler (2002[2]). In his opinion, we
have all become captured in a cycle of rapid scientific
improvements, technical advances, and pharmacological
innovations. Recently we have also become trapped in health
care politics and strategies. We cannot escape from this
environment of brand-new surgery methods, medications,
equipment, and exceedingly higher administration efforts,
as a result of which, the disease comes to the fore instead of
the patient.
Fortunately, there are also other movements and forces
that focus on the individual and inter-subjective level.
Communication between doctors and their patients has
become a more prominent topic in the last years (Angelelli
2008[3], Menz et al. 2008[4], Charon 2006[5], Greenhalgh
2005[6]). The objective of improved communication is a
better relationship between doctor and patient, as Balint
in the early fifties of the last century claimed, which finally
leads to a superior understanding and therapy. An important
element in the context of the training and inter-subjective
communication are Balint groups, which facilitate the daily
work of GPs and all other clinical specialists in handling
patients with chronic, psychosocial and psychosomatic
illness.
A primary part of communication within the interaction
of doctors and patients is the mutual process of getting to know
each others subjective perception of realities (Langewitz
2002[7]). Patients cannot develop an idea of their disease
without an adequate understanding of their health problems
and a comprehensible explanation from their doctor. If
physicians or specialists cannot identify the patients point
of view and fail to explain somatic as well as psychic aspects
of the health problem, this leads to uncertainty and fear.
As a further consequence, coping strategies in biological,
17
Referate
2. Research Questions
In this study we investigated the abilities that doctors
acquired in the advanced training of Psy1 and Psy2 in
order to be able to make sophisticated psychosocial and
psychosomatic interventions. The training consists of:
1) 11 weekends per 20 teaching units
2) the acquisition of stress relieving techniques
3) 120 units of Balint groups over a period of 2 years
4) 300 confirmed psychosocial and psychosomatic medical
visits and a written thesis.
The main research questions are:
1.)
Do the communication skills of physicians
and specialists in the medical interview increase after
the advanced training?
2.)
Do the abilities and skills of doctors to
intervene in the medical interview increase after the
advanced training?
experimental group
+ control group
Patient (Actor) => questionnaire
2 times of inquiries
3. Methods
We conducted a controlled intervention study to
investigate the processes of interaction between doctors and
patients during a medical visit. The objective of the advanced
training Psy1 and Psy2 is to enhance the abilities of medical
doctors to create a comfortable atmosphere, to interact
clearly and in a structured manner, to address psychosocial
characteristics of the patient, to permit the patient to speak
and to improve their communication skills in terms of
patient-centred conversation.
Before the physicians and specialists started their first
18
Referate
adequately trained and well instructed actors and actresses,
who practiced their scripts in a special preparation course to
assure that they acted as authentically as possible.
The medical visits were recorded by video. For our
data analysis we chose the Roter Interaction Analysis
System (RIAS) invented by Debra Roter et al. (2002[11];
German translation: Langewitz et al. 2003[10]), which is a
computerised method of coding doctor-patient interaction
during the medical visit. The identification and classification
of verbal expressions are coded directly from videotapes and
not from transcripts. Therefore, assessment is possible of
the tonal qualities, which transmit the emotional context of
the visit beyond the significance of the words spoken. The
communication units are defined as "utterances", which are
the smallest discriminable speech segments for classification
and which may vary in length. The rating is based upon their
general affective impression of both the patient and the
doctor and on global affective parameters, such as anger,
anxiety, dominance, friendliness and interest. All videos
were analysed by the same Balint group-Leader to avoid the
problem of inter-rater inconsistency.
4. Results
The analysis of the experimental and the control group
is based upon 156 interviews with a total amount of 23,510
utterances. 120 videos were made with the experimental
group and 36 interviews with the control group. 52% of the
23,510 utterances were made by the doctors and 48% by the
patients.
4.1.
Sample
At the time of the first data collection, our sample
consisted of 65 doctors (43 female, 22 male). Two years later
at the time of the second data acquisition, 39 (23 female,
16 male) of those 65 doctors participated in the study. The
reduced number of probands was due to the fact that not all of
the surveyed persons completed the postgraduate training of
Psychosomatic Medicine (Psy2) after Psychosocial Medicine
(Psy1).
The experimental group consisted of 56 doctors (39
female, 17 male) and the control group was composed of
only 9 doctors (4 female, 5 male). 73% of the doctors worked
661
791
Transition words
Summarising
1173
1277
1431
1469
Back-channeling
0
200
400
600
800
1000
1200
1400
1600
utterances
19
Referate
4.3.
Transition words
844
Worry or concern
1053
Back-channeling
Giving information - psychosocial
1110
1192
1198
3330
0
500
1000
1500
2000
2500
3000
3500
utterances
4.4.
Interventions in interpersonal
communication
The videos were analysed with regard to all utterances
that dealt with communication techniques.
Orientation statements tell the other person what
is about to happen and what is expected during the medical
visit, to direct the others behaviour and to facilitate the
process of the visit. They serve to orient the patient to the
major topics of conversation. This technique helps the
patient to cooperate. Instruction statements however include
directive statements relating to the examination, including
those in imperative form. They are often used to facilitate
progress through the medical visit and include statements
referring to procedural or administrative aspects (Roter
2006[12]) (see Table 1).
A very essential part of patient-centred conversation is
Waiting, Echoing, Mirroring and Summarising (WEMS).
Waiting comprises a time period longer than 3 seconds
is not an ignorant doing nothing. It is an important
intervention and the advertence and attention is addressed
to the patient, who is invited to speak. In the study at hand,
661 interventions classified as waiting could be registered,
20
Referate
utterances of the patients. This includes communication
techniques by which the doctor reflects back contextual or
emotional information, which he or she has just been told
by the patient. The purpose is to check the accuracy of the
information (Roter 2006[12]). Mirroring represents only 0.4%
of all utterances of the doctors. 80 statements came from
the experimental group before and after training (0.6% of
all utterances from the experimental group) and 13 from the
control group (0% of all their utterances, see Table 1).
Doctors made many summarising utterances with
a total amount of 1,173 (5%), whereas patients made 62
summarising comments (0.3%). The major part (891
statements, 6.5% of all their utterances) came from the
experimental group, whereas the control group only
summarised 282 times (2.9% of all their statements, see
Table 1). This category means giving a resume of the patients
statements in ones own words or making statements that are
shorter than the patients statements but strongly referring to
them. The aim is to feed back the essence of a verbal message.
Besides paraphrases or repetitions, the doctors also ascertain
that they have a correct understanding of the meaning. The
utterances can be in either question or statement form, but
the function is to clarify or to ask for clarification of the
others communication (Roter 2006[12]).
Prosodic interventions are non-verbal expressions and
almost inaudible under-talk that accompanies the patients
words. They are not meant to be responses to the patients
questions, but an invitation to continue the conversation.
Intervention
Frequency of
Utterances (total)
Giving orientation
Waiting
Echoing
Mirroring
Summarising
Back Channel
WEMS
WEMS incl. orientation + back-channel
All statements (doc + pat)
350
661
178
93
1,173
1,469
2,105
3,924
23,510
1,5%
2,8%
0,8%
0,4%
5,0%
6,2%
9,0%
16,7%
100,0%
Frequency of
Utterances
(Experimental Group)
278
2,0%
575
4,2%
154
1,1%
80
0,6%
981
6,5%
1,159
8,4%
1,700
12,3%
3,137
22,8%
13,774
100,0%
Frequency of
Utterances
(Control Group)
72
0,7%
86
0,9%
24
0,2%
13
0,0%
282
2,9%
310
3,2%
405
4,2%
787
8,1%
9,736
100,0%
4.5.
21
Referate
160
159
150
140
120
89,9
100
76,4
80
48
60
49
40
20
0
Utterances of the
physician
Utterances of patient
second survey
Figure 4: Comparison of First and Second Survey (absolute frequencies per visit)
If we focus on all interactions between doctors and patients, which are important for person-centred communication,
such as waiting, echoing, mirroring and summarising (WEMS), the following development over time emerges.
Professional waiting increases from 2.0% to 4.3% after the advanced training, while the control group declines within
the two years from 2.3% to only 1.0%. The percentage refers to all utterances within one group (experimental group or control
group) (see Table 2 & Figure 5).
All in all, echoing occurs relatively scarcely, but ascends from 0.6% to 1.0% after the training of Psy1 and Psy2. The
doctors without training decrease from 0.6% to 0.4% (see Table 2 & Figure 5).
Also the technique of mirroring, which occurs very seldom, rises from 0.2% to 0.7% after the training, whereas the
control group rises from 0.1% to 0.4% (which are 3 and 10 utterances, respectively) (see Table 2 & Figure 5).
Summarising declines in both groups in the experimental group from 5.3% to 4.3% after the advanced training
and in the control group from 6.5% to 4.7%. This result may be explained by the fact that different diseases were presented at
the two different times of survey, and the second illnesses did not require as much information from the patients as the first
(see Table 2 & Figure 5).
WEMS Doctors
Exp. Group First Survey
Total
Waiting
Echoing
Mirroring
Summarising
192 (2.0%)
61 (0.6%)
16 (0.2%)
503 (5.3%)
383 (4.3%)
93 (1.0%)
64 (0.7%)
388 (4.3%)
63 (2.3%)
16 (0.6%)
3 (0.1%)
177 (6.5%)
23 (1.0%)
8 (0.4%)
10 (0.4%)
105 (4.7%)
661 (2.8%)
178 (0.8%)
93 (0.4%)
1.173 (5.0%)
All statements
9.554 (100%)
9.005 (100%)
2.705 (100%)
2.246 (100%9
23.510 (100%)
Category
107
108
109
110
22
Referate
Comparison of WEMS
7
6,5
5,3
4,3
4,3
4,7
4
3
2
2,3
1
1
0
Waiting
(exp. gr.)
0,6
Waiting
(control gr.)
Echoing
(exp. gr.)
0,7
0,6 0,4
0,2
0,1
Echoing
(control gr.)
M irroring
(exp. gr.)
first survey
second survey
0,4
There is a highly significant increase in the use of the relevant intervention techniques of WEMS (waiting, echoing,
mirroring and summarising) in the second survey (p<0.001). While the frequencies of these interventions of the experimental
group increases over time, it decreases for doctors who did not do the training (see Figure 6).
Effect of Interaction WEMS
12
10,74
10
9,65
8,28
6,85
6
4
2
0
first survey
second survey
Experimental Group
Control Group
Regarding the utterances of the patients, they certainly reflect the content of the script, i.e. their role as actors and actresses.
But even more relevantly, they reflect as well how much doctors are capable to open up the time and space for special
utterances of the patients. It is important to impress upon the doctors that important information not only is the product of
questioning and answering but also emerges from the interplay of questioning and answering and is offered unexpectedly and
spontaneously by the patient. Therefore, we investigated how far patients of the experimental group get the chance to bring in
interrelated chains of utterances in the medical conversation. The analysis of verbal fluency is based upon 23,510 individual
utterances altogether. After excluding the back-channel utterances with which the doctors tried not to take the floor from the
speaking patient and to encourage the patient to continue the conversation, there remained 18,679 utterances for our analysis
to determine the trend to longer chains of uninterrupted patient narrations after the training of Psy1 and Psy2. The average
amount of uninterrupted patient narrations increased from 1.37% to 1.83% in the experimental group of trained doctors,
whereas it declined from 1.31% to 1.1% in the control group. This correlation is highly significant and implies that the advanced
training produced the desired effects (see Figure 7).
23
Referate
2
1,8
1,6
1,4
1,2
1
0,8
0,6
0,4
0,2
0
1,83
1,37
1,31
uninterrupted reactions
(experimental group)
1,11
uninterrupted reactions
(control group)
first survey
second survey
4.6.
Intervention
Naming Emotions
Understanding E.
Respecting E.
Supporting E.
All statements (doc + pat)
Frequency of
Utterances (total)
85 (0.4%)
92 (0.4%)
24 (0.1%)
3 (0%)
23.510 (100%)
Frequency of Utterances
(Experimental Group)
71 (0.5%)
70 (0.5%)
20 (0.1%)
2 (0.0%)
13.774 (100%)
Frequency of Utterances
(Control Group)
14 (0.1%)
22 (0.2%)
4 (0.0%)
1 (0.0%)
9.736 (100%)
Furthermore there were several sub-categories such as approval, disapproval, reassurance, and worry or concern, which we
do not want to continue reporting in this context.
4.7.
The described technique NURS (naming, understanding, respecting and supporting emotions) was part of the advanced
training in Psy1 / Psy2 and was reflected in the containing Balint groups within at least two years. Comparing the experimental
group of trained doctors with the control group of
untrained doctors, we found the following differences (see Table 4 and and figure 8).
24
Referate
Handling of disclosed and hidden Emotions - Doctors
Category
107
108
109
110
111
112
113
114
Naming Emotions
Understanding E.
Respecting E.
Supporting E.
Approval
Disapproval
Reassurance
Worry or Concern
All statements
Total
28 (0.3%)
15 (0.2%)
4 (0.0%)
2 (0.0%)
5 (0.1%)
3 (0.0%)
49 (0.5%)
11 (0.1%)
9.554 (100%)
43 (0.5%)
55 (0.6%)
16 (0.2%)
0 (0.0%)
11 (0.1%)
29 (0.3%)
184 (2.0%)
14 (0.2%)
9.005 (100%)
6 (0.2%)
5 (0.2%)
1 (0.0%)
0 (0.0%)
1 (0.0%)
0 (0.0%)
10 (0.4%)
0 (0.0%)
2.705 (100%)
8 (0.4%)
17 (0.8%)
3 (0.1%)
1 (0.0%)
7 (0.3%)
3 (0.1%)
85 (3.8%)
2 (0.1%)
2.246 (100%9
85 (0.4%)
92 (0.4%)
24 (0.1%)
3 (0%)
24 (0.1%)
35 (0.1%)
328 (1.4%)
27 (0.1%)
23.510 (100%)
1,4
1,2 7
1,2
1
0 ,8
0 ,6 1
0 ,6
0 ,4
0 ,2 9
0 ,18
0 ,16
0 ,2
0
0 ,51
0 ,4 8
0 ,0 4
N am ing E m o t io ns
U nd er s t and ing
E m o t io ns
0 ,0 2
F ir s t Sur v ey
T o t al
Seco nd Suer v ey
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Descriere de Caz
their doctors, which is also a characteristic of patient-centred
communication.
Furthermore the results indicate an expansion of the
skills for handling with emotions due to the advanced
training of Psy1 and Psy2, as well as to experience over time.
Utterances that are part of the NURS-technique (naming,
understanding, respecting and supporting emotions) show
a tendency to increase with time. There is no significant
difference between the experimental and the control group.
It must be stated, that the utterances in this area are quite
rare. There is a significant increase of utterances concerning
approval in both groups.
The results indicate that postgraduates of the advanced
training - Psy1 / Psy2, acieve higher communication abilities
and skills, both concerning the permission of the patient
to speak and the advancement of their conversational
techniques.
The techniques of NURS, on the contrary, do not develop
as well as they should.
*This paper was presented at the 16th International Balint
Congress, Poiana-Braov, Romnia
Greenhalgh, T. (ed.) (2005). Narrative-based medicine Sprechende Medizin. Dialog und Diskurs im klinischen Alltag.
Bern [u.a.]: Huber
10
Langewitz W. / Nbling M. / Weber H. (2003). A theorybased approach to analysing conversation sequences. In:
Epidemiologia e Psichiatria Sociale Vol. 12(2): 103-108
References
11
243-251
12
26
Descriere de Caz
giile pe care ea nsi le-a folosit pentru a scpa de povara
psihologic adus de acest caz (ex. concentrarea pe aspectele
pozitive ale situaiei, precum succesul n referirea pacientului ctre spitalul de psihiatrie, unde acesta a beneficiat de
ajutor medical; perceperea unui grad personal de rezilien
pentru confruntarea cu situaii similare din viitor; asumarea acestui gen de situaii ca fiind inevitabile, n special n
contextul sistemului sanitar haotic romnesc). Singura observaie critic a fost legat de posibilitatea grupului de a se
fi concentrat mai mult pe sentimentul iniial al Alexandrei,
de fric (panic).
Participarea la discuii a fost prezent la toi membrii
grupului, fiind de remarcat spontaneitatea majoritii remarcilor, fluena desfurrii edinei i uurina de empatizare cu principalele personaje ale ntmplrii. Este posibil
ca aceste atribute ale ntlnirii s se fi datorat participrii,
deja stabile, a unor membri, la mai multe / toate edine(le)
de grup, de la renfiinarea acestuia. Dei aceti participani
stabili au fost studeni, considerm contribuia lor drept
valoroas.
Toi noii participani au apreciat pozitiv lucrul n grup i
i-au exprimat intenia s mai participe la astfel de ntlniri.
Atmosfera a fost cald, relaxat
27
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