The Juice is Worth the Squeeze: Psychiatry Residents’ Experience of Balint Group

Abstract

Introduction

Balint Groups provide physicians with a forum to develop their capacity to empathically engage with patients, through exploring patient-provider relationships. The Dalhousie University Department of Psychiatry implemented a mandatory Balint Group as part of the junior resident curriculum. The purpose of this study is to explore how residents describe their experience of participating in this Balint Group.

Methods

Psychiatry residents in their first year of training participated in a focus group to discuss their experiences of the Balint Group. Data was analyzed using content analysis.

Results

Three main categories were identified: the purpose of, the process of, and participation in the Balint Group. Process was subdivided into Balint Frame and Institutional Factors. Participation was further subdivided into vulnerability, reflection, fellowship, and validation.

Conclusion

Residents attributed fellowship with their peers, self-efficacy and hope in their work to their participation in the Balint Group. While there was an adjustment period, residents grew to accept, and even appreciate the group. Lack of problem-solving became accepted as part of the purpose of the group and this acceptance was attributed to having other avenues within the program to address problems raised in the discussion. Feeling disconnected when the session ended was described and was related to the abrupt termination of the virtual session or having to exit the group early to return to clinical duties. While the virtual nature of the group was not explicitly identified as a challenge, having to leave early was. While these institutional factors can be mitigated through programmatic implementation, they are not a deal breaker to implementing a Balint Group in a residency training program. Even in a lunch hour or virtual environment our data suggests that the juice is worth the squeeze.

Introduction

Balint Groups are closed groups of physicians who meet regularly to explore thoughts and feelings of their patients and themselves in the context of a patient-provider relationship. ¹ These groups serve as an opportunity for physicians to develop their capacity to empathically engage with patients. ² They also serve as a safe and supportive forum for physicians to explore their own emotions and reactions to difficult cases ² . While Balint Groups were initially introduced with General Practitioners, ³ with the aim to incorporate psychiatry into general practice, ⁴ they have also been introduced into medical education programs, where they have been found to guide trainees in becoming more patient-centric as they improve communication, levels of empathy, and reduce personal feelings of burnout. ⁵ Balint Groups have been a part of residency training for decades but are now more commonly requiring mandatory attendance with continued investigation into the ideal size and frequency of Balint Group sessions. ⁶ The literature suggests that residents initially report Balint Groups to be stressful as it can invoke a fear of being judged upon expressing personal feelings in a group setting, particularly with respected staff as facilitators. ⁴ However, the benefits of undergoing this stress are developing feelings of trust, connectedness, and empathy early in physician careers. ⁴ Although attempts are being made to investigate the efficacy of Balint Groups and its impact on physician behavior ¹ there remains limited research in this area particularly from the participant viewpoints. The purpose of this study was to assess how psychiatry residents experience Balint Groups.

Methods

This project has received Research Ethics Board approval through Dalhousie University. All eight psychiatry residents in their first year of residency (PGY-1) at Dalhousie University were invited to participate in a focus group held virtually on MS Teams, where discussion was stimulated in a semi-structured manner to better understand their experience within a program-sanctioned mandatory Balint Group. Three PGY-1 residents participated in the focus group which was held at the end of the academic year. Responses were recorded using a handheld recorder. De-identified transcripts were analyzed by both researchers using qualitative content analysis. ³ Discrepancies were identified and discussed until consensus was achieved.

Results & Analysis

Residents’ experiences of participating in the Balint Group were categorized into three broad categories: experiences related to the purpose of the Balint Group, experiences related to the process of Balint Group and experiences related to participation in Balint Group. Each of these broad categories were further subdivided to produce the coding frame (Figure 1).

Figure 1.

Coding Frame.

Purpose

Participants described the purpose of the Balint Group as initially ‘frustrating’ [Table 1 - 1a]. They experienced the group as different from the problem-solving focus of much of their other learning experiences, which led to feelings they described as being ‘unresolved’ [Table 1 - 1b]. Through the year, they described coming to accept what Balint was and was not. They contextualized their initial discomfort as being both related to their early stage of training and to being unaware of other avenues to problem-solve. As they progressed in their training and became aware of other means to address issues within the department, they were able to engage in Balint without feeling frustrated. They became comfortable with the feeling of problems being unresolved; however, this is described as something they came to accept, rather than appreciate.

Table 1.

Exemplary Quotes - Purpose.

Table 1: Theme - Purpose
#	Exemplary Quotes
1a	part of my initial hesitancy towards Balint, and it was almost like, quite frankly, a frustration for the first part of the year . Because you know as brand new PGY1s trying to figure out how to do things the right way , I feel like in scenarios that are presented, or scenarios that I think about presenting, I want to know what I could do to change it to not feel that way. [Participant B]
1b	at the end it's not solutions driven, and I think that's part of the point of Balint. Like it's not about problem solving , but sometimes I would leave thinking; Oh yeah, like OK, if this issue does come up in the emerg, what should I do or what's the policy behind that? Or you know, my kind of my rational thinking brain would be left like a little bit uncertain . And I know that's not the point of Balint but that is one area where I thought I still feel like these issues are a bit unresolved . [Participant A]

Process

The process of the Balint Group was divided into two sub-categories, Balint Frame, which were structural components that are core features of Balint Groups regardless of the institutional setting, and Institutional Factors which were program-driven decisions related to the implementation of the program within the Dalhousie University Department of Psychiatry.

The Balint Frame was described as ‘structured’ and ‘rigid’ [Table 2 - 1a] which mostly generated initial ‘reluctance’ [Table 2 - 1b] and ‘hesitation’ [Table 2 - 1c]. Initially the structure was felt to be restrictive and generated anxiety about how to participate in the correct way. One member reports appreciating the ‘predictability’ [Table 2 - 1d] that the structure offered from the outset and by the second half of the academic year, all participants came to appreciate the structure. They described it as ‘helpful’ [Table 2 - 1e], particularly in how it contributed to keeping the discussion productive and maintaining an equal positioning between participants, where all participants could speak.

Table 2.

Exemplary Quotes - Process.

Table 2: Theme - Process
Subtheme	#	Exemplary Quotes
Balint frame	1a	I did find it challenging at first when you just didn't really know or understand the structure and as we kind of alluded to earlier, it seemed a bit rigid at first. And it was kind of like what are the rules? Am I supposed to say this right now? Is it OK to speak about this? Is this when we're talking about this question? I had a lot of uncertainty about how exactly I was supposed to proceed. [Participant A]
	1b	my initial, not frustration but reluctance, with Balint because it was so structured . And it felt like t here were a lot of rules around what you could speak and how you could speak . And I found that a little off-putting, to be honest with you, I found it to be a little restrictive . [Participant A]
	1c	I was quite hesitant towards Balint Group at the beginning of the year. I actually had p robably a lot of negative feelings towards it because it was exactly what Participant A said [rules, rigid structure]. So, I was surprised that I ended up starting to look forward to it. And otherwise, I mean, I think I've now got into the flow of things and it's serving its purpose. So, I think overall it’s just an enjoyable experience at this point . [Participant B]
	1d	It's nice in that there’s this kind of a structure that is predictable and I know how it's going to go , and I feel like we all just kind of fell into the routine of it . Having that structure and keeping us on track was quite nice . [Participant D]
	1e	once I become more familiar with the process and saw how it worked a few times, and participated in presenting a case, I found that the structure was very helpful. Because I think it stopped the conversation from going off the rails too much and descending into ranting or complaining or a like a really negative space. It was a way to keep it more productive almost. [Participant A]
	1f	I think I’ve gotten more comfortable , only because chances are … I know the other avenues now …So, in terms of Balint, I really do go into it now thinking “ what will I experience during this hour? ” without a need for a sense of resolution to whatever gets presented. [Participant B]
Institutional factors	2a	Sometimes you even have to leave like 15 minutes early because you have to drive somewhere, if you're off service, and so then it's like super unresolved . Like how did that conversation even end at the end of it? [Participant A]
	2b	… the supervisors that we've had in Balint, I find it so key that they constantly remind us that you know, Balint is separate from our relationships with them in other roles . Because you might work with the same supervisor in Balint then in a role where they’re your clinical supervisor. And just the reassurance that you are not being evaluated in Balint is really, really important. And I do find that my experience anyways has felt, I felt reassured by them bringing that up. Just because then you can be more open and vulnerable, and I think that that would need to continue in order for me to continue to feel like I can participate fully in Balint. [Participant B]
	2c	I think there's more of a hierarchy of residents. … Whereas here it's only one year ahead of us, so we were all junior residents , which was nice . [Participant C]
	2d	Also, we've never done it in person and then all the sudden you turn your computer off and you’re just in this room by yourself. I almost feel like afterwards it would be nice to have some sort of group pick me up just to get back on your feet. And I wonder if it would be better if you were in person for that reason , I don't know, but just the sheer nature of turning my computer off and then just sitting in that emotion for like 3 minutes. [Participant B]
	2e	one of the things about Balint that I find to still be challenging is just the time that we do it at . So, we always do it at lunch and it's right before we usually jump into … in PGY1 you go back to service, or you would go back into teaching . But you can have this, you know, quite a heavy conversation and be left feeling pretty emotionally drained and then all of a sudden, it's like you know you have to flip and go back in to being, you know, sometimes very happy and perky. So, I just, I think that still is one of the challenges for me is I don't know what I'm getting into, and I don't know how I'm going to feel afterwards. [Participant B]

Institutional Factors related to the scheduling of the group (during the lunch hour session), the format of the group (virtual), the stance of the facilitator (non-evaluative), the co-participants (junior residents), and the fact that it was mandatory. The scheduling of the group was described as a challenging factor as some residents, depending on their training rotation, would have to leave the group early to report for clinical duties. Even when the session did end on time, the virtual nature of the group led to feelings of an abrupt ending to the session. The Balint Group was not evaluated beyond attendance. This was experienced as ‘really important’ [Table 2 - 2b] and allowed for authentic participation. It was perceived as unproblematic for facilitators to have dual relationships, where they may assume a supervisory (and thus evaluator) role in other areas of training; but it was important to distinguish these two roles and reassure residents their participation in the Balint group would not impact their clinical rotation evaluation. Participants described it was ‘nice’ [Table 2 - 2c] that the group was composed of members in a similar stage of training and not in a senior stage of training.

Participation

Participation in the Balint Group was further divided into four sub-categories. The most discussed was fellowship, followed by validation, reflection, and vulnerability.

Fellowship was discussed as a sense of community and belonging between participants in the group. Unlike other educational sessions, Balint Group was where they got to ‘know’ [Table 3 - 1a] one another. Residents described this as ‘increased comfort’ [Table 3 - 1b] and ‘connectedness’ [Table 3 - 1c] with peers in the group which strengthened as the year progressed. For some, building relationships with their colleagues was ‘one of the best things’ [Table 3 - 1a] about the Balint Group. They describe a ‘shift’ [Table 3 - 1d] in themselves, and their peers, becoming more ‘candid’ [Table 3 - 1e] and ‘honest’ [Table 3 - 1f] as the group progressed. They also described a sense of ‘freedom’ [Table 3 - 1d] in what they could say and no longer needed to ‘censor’ [Table 3 - 1g] themselves. Not only did participants build trust with each other, they also described a trust with the program, when they ‘figured out [they would] not be kicked out for what they said in Balint’ [Table 3 - 1g]. In addition to becoming more comfortable with their colleagues, they also described a sense of ‘support’ [Table 3 - 1h] with one another as they worked through challenging cases within the Balint Group.

Table 3.

Exemplary Quotes - Participation.

Table 3: Theme - Participation
Subtheme	#	Exemplary Quotes
Fellowship	1a	compared to a lot of our other sessions, these ones helped me get to know my fellow residents in a more intimate way almost . Certainly, got more comfortable with our year and the upper year that we did it with, I’d say that was one of the best things about it for me [Participant B]
	1b	I think that it's improved my relationships with my co-residents for sure , especially with the other cohort that I didn't really know as well. I think it really increased the level of comfort and respect that we … that I feel like we have for each other. [Participant D]
	1c	there was an increased level of comfort in sharing these experiences amongst the members . And outside of that I felt more connected as a PGYx . I feel like I really got to know some of the PGY1s through doing the group, hearing their experiences, and I feel more connected to them as colleagues . [Participant D]
	1d	And I think it was a really great shift, as we got further into the year, when everyone became more comfortable to speak and would speak with a little bit more freedom [Participant A]
	1e	what I remember from the beginning is that people were a little bit more formal. It was more of almost a case presentation it seems like, just a little bit more structured, and people seem to be holding back a bit, and then I think about halfway through the year, the way people presented cases was a bit more casual. People were a bit more candid with their emotions and what they were actually thinking and feeling, and that's when I think things started going a bit better because it felt a lot more authentic. [Participant A]
	1f	It was just awkward at the beginning and I think again, now that everyone is more comfortable and open with each othe r, everyone is on the mic and ready to go. They’re all very raw with their perspectives , which makes it so much more valuable. I really appreciate the honesty. [Participant B]
	1g	We’re already in the program, so yeah, we can stop censoring ourselves after a little while. They’re not going to kick us out for what we said in Balint Group , we finally all figured out. [Participant C]
	1h	I think it’s really good to help with burnout . Every time I leave Balint, I feel supported and feel like I can do th is. And yeah, so I would say that I mean, I don't know what residency looks like without Balint, but I do think it's a good wellness initiative that perhaps I would feel more burnt out if I didn’t know I had Balint . It's a strong statement, but I do think it plays a role in burnout, relieving burnout. [Participant B]
Validation	2a	A lot of my emotions were negative towards the situation and when the group brought forward how they would feel, it was sort of similar and so that felt nice to know that others would feel the same in that situation . [Participant C]
	2b	So, I think for me, one of the best things was being vulnerable and then having that validated by other people , even from staff members and senior residents, to come back and say “Yes, I have felt that way too and I would have reacted in the same way”. And especially as a junior learner, it’s a very insecure time starting residency so to know that what you’re experiencing is on par with others, I found was extremely helpful in my, especially my first year . I think that was probably my most valuable lesson that I got out of it. [Participant A]
	2c	I actually found it to be an incredibly helpful experience and to hear other reactions was very validating . And also, kind of opened up some perspectives that I hadn’t considered. I think that the best part about it, especially with experiences on call, they can feel very lonely, very isolating. And to hear that others had been through similar experiences and could relate or could provide some kind of comfort and validation to really difficult experiences, it really helped me to let that experience go . [Participant A]
	2d	it also gave me a bit of a sense of hope from the upper year reside nts, like the second years at the time, even though part of the benefit for me for Balint was like validation in terms of “Okay, they are still experiencing challenges just like I'm experiencing challenges” but also the second years seemed to somehow have a little bit more control or just seem to be more competent , as they were talking about the Balint cases.
Reflection	3a	And also, kind of opened up some perspectives that I hadn’t considered . [Participant A]
	3b	Then for me too, probably putting ourselves in the shoes of other physicians , be it the emerg doc, be it the internal medicine resident, and I think that's a valuable experience to build again, empathy into what their perspective would be in that case . So, I think it does also help me build relationships with the interdisciplinary staff. [Participant B]
	3c	I think that it has helped improve my sense of empathy in times where I personally found that challenging… And that's something that's come up a lot in groups and being able to take the perspective of what it must be like for those patients . [Participant D]
	3d	we're getting better at putting yourself in other people shoes and that sort of thing [Participant C]
	3e	And also, kind of opened up some perspectives that I hadn’t considered . [Participant A]
	3f	I feel like what was surprising to me was realizing that this isn't so specific to myself and helping to gain perspective on first of all, other people feel this way too and second of all, there are so many factors that lead it to be challenging outside of me just not being good at what I do. So, I think that it was surprising to me to realize that it's more than just myself that makes this hard. [Participant D]
	3g	I think it’s really good to help with burnout . Every time I leave Balint, I feel supported and feel like I can do this . And yeah, so I would say that I mean, I don't know what residency looks like without Balint, but I do think it's a good wellness initiative that perhaps I would feel more burnt out if I didn’t know I had Balint . It's a strong statement, but I do think it plays a role in burnout, relieving burnout. [Participant B]
	3h	I mean, I really as I recall it, felt a lot of frustration , that’s an emotion I remember feeling quite a bit. Frustration with difficult patient encounters and with the system . Like why are things this way? And why can't we do this? Why did this happen? Definitely lots of feelings of sadness. Just sadness for patients going through really difficult times, sadness for my colleagues who had obviously experienced very borderline traumatic experiences on call. Some hopelessness sometimes . [Participant A]
	3i	I can think of one case that was presented where I really didn't want to put myself in the shoes of someone because of my own biases and how I think they were involved in the case I was presented. And I definitely think it forced me to do that and I definitely grew, I think because of it . [Participant B]
	3j	maybe it's forced me to take a bit of a pause before I say the first thing that's on my mind going into a certain assessment. [Participant C]
	3k	I think overall it did help to foster more empathy and I think that you know, as people in psychiatry, we tend to be people who have empathy. That's part of the reason we're drawn to this specialty. But I did find in very challenging situations, truthfully, mostly in psychiatry rather than off service. It kind of helped me step back a little bit and think what is this person in front of me experiencing right now ? Like what is this other position or other member of the healthcare team experiencing right now? I think it gave me a bit of a perspective on other people's experiences and how they might be struggling in situations [Participant A]
	3l	it has made me feel like maybe to try to be more of a leader there and to shift my goals from trying to discharge patients who we traditionally discharge to more just trying to help them in the moment as much as I can . And make it a good experience, as good of an experience for them and myself, hopefully as it can be, rather than to try to discharge. And to feel more comfortable with my goals if that kind of makes sense. Yeah, rather than getting caught up in some of the dynamics in that department. [Participant C]
	3m	I think it's an outlet to promote burnout that's more, I think softer on other people and patients than some of the venting that I would do with people in my personal life. So, I do think that yeah, it's maybe a more positive outlet to let go of some of these emotions than traditional means . And maybe it'll affect the way that I vent to my partner or my family or my friends a bit. Keep it a little bit more patient-centred and positive, yeah. Or at least be able to see it through that lens a little bit.
Vulnerability	4a	I hesitated a bit to present , because it is, it probably should be noted, kind of an intimidating experience to present especially as a junior resident with slightly more senior residents in the room and well-respected staff members . [Participant A]
	4b	there’s a large degree of vulnerability in presenting a case or participating in any way, shape, or form in a Balint Group. Like you’re really exposing insecurities, very negative emotions…negative emotions toward patients . Things that you hope as a psychiatry resident, that you’re not going to be angry and resentful toward patients. And the fact is that sometimes you are [Participant A]

Validation was another prominent theme discussed by residents. Residents felt validated when talking about experiences in both case presentations and discussions. In listening to others, they learned ‘others would feel similar’ [Table 3 - 2a]. One resident commented that ‘one of the best things was being vulnerable and then having that validated by other people’ [Table 3 - 2b]. It was under the process of feeling validated by their peers that residents also commented about ‘finally’ being able to ‘let that [case] go’ [Table 3 - 2c].

Reflection was characterized by residents imagining the thoughts and feelings of themselves and others within the presented case. This was described as ‘perspective taking’ [Table 3 - 3a] and ‘putting themselves in the shoes’ [Table 3 - 3b] of others. Residents perceived themselves as ‘improving’ [Table 3 - 3c] and ‘getting better’ [Table 3 - 3d] at this. They described ‘opening up’ [Table 3 - 3e] to new ways of thinking about challenging encounters, which could lead to ‘feelings of self-sufficiency; ‘realizing there’s more than just themselves that make this hard’ [Table 3 - 3f] and that ‘[they]’ve got this’ [Table 3 - 3g]. It was not always perceived as a comfortable experience. Residents described feelings of ‘sadness’, ‘hopelessness’ and ‘frustration’ [Table 3 - 3h]. One resident described an experience where reflecting on another’s perspective ‘forced’ them out of their ‘comfort zone’ [Table 3 - 3i] Despite the feeling of discomfort, they reported they ‘grew’ [Table 3 - 3i] from the experience. Residents described this as ‘a pause’ [Table 3 - 3j] to ‘step back’ [Table 3 - 3k] and consider what others may be experiencing, which allowed residents to reflect on their own role in the clinical encounter and to reframe the encounter as a ‘leader’ [Table 3 - 3l] in a way that prioritized patient care and separated interpersonal dynamics between health-care teams and systemic pressures.

Vulnerability included a general sense of ‘hesitancy’ [Table 3 - 4a] that preceded participation. Participating ‘in any way, shape or form’ [Table 3 - 4b] was experienced as ‘exposing’ [Table 3 - 4b] insecurities and perceived weaknesses.

Discussion

Residents described a variety of experiences in their participation in a program sanctioned Balint Group. There was a definite adjustment period as residents came to accept and appreciate the Balint Group’s purpose and processes. Residents described an initial ‘reluctance’ [Table 2 - 1b] to engage in Balint Group and described it as being ‘awkward’ [Table 3 - 1f]. These experiences were often described as being problematic in the first half of the academic year which suggests that some of this may be explained by normative reactions of adjusting to new expectations, such as negotiating participation in a new group and engaging in new ways of thinking about, and talking about, challenging clinical encounters. While it is tempting to try and mitigate this adjustment period by directly addressing the why and how of Balint, some residents described that despite being informed of this, it was something that they just had to ‘experience’ [Table 2 - 1f].

As residents came to appreciate the Balint Group, they described the group as enjoyable [Table 2 - 1c] and experienced an increased sense of cohesiveness between co-participants and universality in shared experience.^7,8 The group was perceived to be supportive and generated both a sense of hope and increased self-efficacy [Table 3 - 2d]. One resident spontaneously suggested that Balint Group was ‘a sort of wellness thing [the program] brought in’ [Table 3 - 1h]. Another participant later offered that they ‘believed [the Balint Group] helped to mitigate against burnout’ [Table 3 - 1h] as it provided an opportunity to share challenging patient encounters and speak authentically about thoughts and emotional reactions to clinical encounters.

Residents described that through participation in the Balint Group they gained a sense of hope and self-efficacy. This is supported by research associating Balint Groups with improved empathy, supporting professional development and decreased rates of burnout. ⁹ They have also been associated with self-efficacy. ¹⁰ Burnout is a clinical syndrome characterized by three domains: depersonalization, ¹¹ emotional exhaustion and low personal accomplishment. ¹² Residents described a shift in how they understood perceived negative patient encounters as not solely a reflection of their competence; ‘it’s more than just myself that makes this hard’ [Table 3 - 3f]. This suggests that Balint Groups may act as a wellness intervention in promoting self-efficacy in their role as physicians by creating a sense of emotional readiness to engage in their work and a willingness to engage in discussions related to challenging patient encounters in a ‘softer’ [Table 3 - 3m] way. With increased attention on reports of burnout in medical professionals, ¹⁰ including medical trainees, ¹³ this is an important consideration. Training programs have an increasing responsibility to support residents in the professional development of the competencies required to effectively care for patients - including maintaining their own well-being. ¹⁴ These findings offer support for the inclusion of Balint Groups in the post-graduate medical education curriculum.

Residents described feeling disconnected when Balint Group sessions ended [Table 2 - 2d]. While disconnection from the group discussion can be considered part and parcel of any Balint Group session, the experiences described by residents highlight the abruptness of the virtual session being terminated as the technology switches off. Leaving the group early also contributed to a sense of being disconnected from the group discussion. It was not uncommon for residents to have to ‘leave 15 minutes early’ [Table 2 - 2a] and resume clinical duties with others who had not participated in the Balint Group [Table 2 - 2e]. This challenge was solely attributed to the scheduling of the Balint Group - during the lunch hour session and was the only feature of the Balint Group that was consistently described as challenging. While these feelings of disconnection and isolation were clearly mentioned in our data, it is not talked about in the literature. This may relate to the Balint Group being virtual. In a virtual Balint Group, there is a loss of informal interpersonal interactions that bookend the group work. While this raises important considerations for implementing a virtual Balint Group, our data also suggests that the Balint purpose and process can be maintained in virtual groups. They offer an acceptable and feasible pivot to overcome factors that may otherwise be considered a barrier to implementation. For example, in the context of the COVID-19 global health pandemic, they offered a safe gathering venue. They also have the potential to overcome challenges associated with ensuring equitable training opportunities across distributed medical education training sites. As such, ongoing research in this area will be of interest.

While disconnection from the abrupt or early termination of the group was felt to be challenging throughout the academic year, coming to terms with case discussions being unresolved came to be accepted. One resident described it as ‘if it does feel unresolved now, it doesn’t bother me as much as in the beginning, because I have the expectation that Balint Group is not for problem-solving, it's for processing’. While this shift in expectation was largely felt to be secondary to having other avenues to raise concerns within the program, our data suggests that there is a shift in tolerating sitting with uncomfortable emotion and unfinished business.

There are limitations to this study. It was conducted with a small sample of PGY-1 residents from one residency program which limits generalizability. It is possible that some of this cohesiveness may be attributed to other activities in the residency program, these were not part of the focus group discussion. Ongoing research in the qualitative experiences of residents’ participation in Balint Groups may provide further insight into the benefits and limitations of this curriculum intervention.

Conclusion

Residents in the Balint Group clearly developed a sense of fellowship and trust in the group and the experience became enjoyable and valued over the course of the academic year. Residents described increased hope and self-efficacy in participating in case discussions and themselves suggested that the Balint Group may help to mitigate burnout. While there was an adjustment period as residents became accustomed to participating in the Balint Group, over time they grew to accept, and even appreciate the group. Lack of problem-solving became accepted, rather than appreciated, and this acceptance was attributed to having other avenues within the program to address problems raised in the Balint Group discussion; however, our data suggests that there may also be an increased tolerance to sitting with unresolved problems as they arise in clinical encounters. Residents described a sense of feeling disconnected from the group following the Balint Group session, which seemed to be attributed to the abrupt shut-down of the technology or having to leave the group early to return to service. While the virtual nature of the group was not explicitly identified as a challenge, having to leave early was. In fact, the only feature that remained an ongoing challenge throughout the year was the scheduling of the group which conflicted with clinical duties that trumped participation in the Balint Group. While these institutional factors can be mitigated through programmatic implementation, they are not a deal breaker to implementing a Balint Group in a residency training program. Even in a lunch hour or virtual environment our data suggests that the juice is worth the squeeze.