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428 June 2003 Family Medicine

In the fall of 1950, Michael Balint began his first semi-nar for general practitioners in London at the TavistockClinic.1,2 The purpose of these seminars was to exploredifficult doctor-patient relationships, with the intent ofhelping physicians find new and more therapeutic waysof relating to patients. By January 1964, 223 familyphysicians had taken part in this series ofcase discus-sion seminarsthat eventually evolved into the Balint

training process for clinicians. In the early years of thisprocess (19501954), all doctors who applied to thecourse were accepted. Between 1954 to 1958, however,a reshufflingof participants resulted as physiciansleft groups, and the number of participants in some ofthe groups declined to fewer than four. In these in-

stances, the group with less than four participants wasdiscontinued, and those remaining were reassigned toother groups. Balints assessment of theearly leaverswas that they were eitherseriously neurotic,inse-cure with obsessional defenses,overly anxious,orlimited by time or intelligence. Other early leavers, hesaid, were simplynon-disclosingandnondescript.A majority of those who remained more than 2 years

gained versatilityand tolerancefor handling pa-tients and skill in effectively listening to them as wellas their group peers.

Starting in 1959, a new process, termed themutualselection interviewwas introduced as a way of regu-lating or selecting participants when it became clearerthat Balint training was more suitable for some indi-viduals than others. Similar selection schemes wereundertaken at a number of other institutions in England,Germany, and the United States3 as Balint training be-came more widespread. However, there were never any

ResidentPhysiciansWhoContinueBalintTraining:

ALongitudinal Study19821999

Alan H. Johnson, PhD; CliveD. B rock, MD; WilliamJ. Hueston, MD

From the Department of Family Medicine, Medical University of SouthCarolina.

Background and Objectives:Balint seminars began in London in 1950 on a voluntary basis for generalpractitioners wishing to explore psychological problems in their practice. By 1964, there was a 36%early dropout rate among the 223 physicians who participated. This study sought to determine if thosewho leave Balint training during their residency, versus those who continue, have different psychologicalcharacteristics. Methods:A retrospective analysis of 206 Medical University of South Carolina familypractice residents from 1982 to 1999 was completed. All residents participated in 6 months of requiredBalint training and then could leave the Balint group or continue for the remaining 2 years. We examined

gender and personality attributes, comparing residents who completed 2 years of weekly Balint trainingand residents who left after 6 months. Personality attributes were measured with the Myers-Briggs Inven-tory, the Work Environmental Preference Schedule, the Internal-External Locus of Control, the Funda-mental Interpersonal Relationship Orientation Behavior test, and the Personal Orientation Inventory.Results:A total of 132 residents completed 2 years of weekly Balint training, and 74 discontinued train-ing after 6 months. Two-year attendees were significantly more intuitive on the Myers-Briggs PersonalityInventory (MBTI). There were no significant differences on other MBTI items, nor were there significantdifferences in gender or in scores on the other psychological tests. Conclusions: Based on the rate of

discontinuation of Balint training in our sample, Balint work does not appear to be suited to all physi-cians. With the exception of one MBTI characteristic, no significant differences could be demonstratedbetween those who did and did not continue participating. Further study is necessary to define otherattributes characterizing Balint group attendees and nonattendees.

(Fam Med 2003;35(6):428-33.)


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formal processes identified to help in the selection ofindividuals who might be most suitable for Balint train-ing. For example, no objective psychological testing ofapplicants was undertaken to assess whether certainpersonality preferences were associated with continu-ation in Balint training. As a result, while Balint train-ing might not be for everyone, it is still unclear who itsuits and who it does not.

Balint training has a long history at the MedicalUniversity of South Carolina (MUSC). Balint groupswere first introduced into the MUSC family medicinecurriculum in 1981 on a voluntary basis.4 The next year,it was decided that weekly, 1-hour Balint groups wouldbe mandatory for residents during the first 6 months intheir second year of training, and participation thereaf-ter would be voluntary. This practice continued for thenext 18 years, with the same faculty member leadingthe Balint group. Over the same time period, all resi-dents entering the MUSC Family Medicine Residencywere given an extensive battery of psychological tests,

almost all of which were to measure normal personal-ity attibutes.5 This gave us the opportunity to explorewhether continuation in Balint groups, at least while inresidency training, can be related to certain personalitycharacteristics.

This studys aim was to explore personality attributesthat are more common in residents who continued inthe Balint group past the required 6 months than amongthose who did not. The hypotheses that were tested were

that Balint participants are more likely to be more openminded, process oriented, and have a higher internallocus of control and capacity for intimate contact. Inaddition, we hypothesized that individuals who exhib-

ited preferences for extroversion, intuition, and percep-tion on the Myers-Briggs Type Indicator (MBTI) wouldbe more likely to remain in Balint training for theirentire course of their residency training.

MethodsThis study was approved by the Review Board of

the Medical University of South Carolina.

SubjectsW e performed a retrospective analysis of 206 resi-

dents (137 males [67%] and 69 females [33%]) whoattended the MUSC Family Medicine Residency Pro-gram between 1982 and 1999 and who were exposedto Balint training during residency. A total of 132 resi-dents (65%) continued through 2 years of weekly 1-hourBalint groups after the initial 6-month period of re-quested participation (attendees), while the remaining74 (35%) discontinued weekly Balint group participa-tion after the required 6 months (nonattendees). FourBalint attendees and three nonattendees were excludedfrom analysis because they entered residency after psy-chological testing was completed for their cohort of

residents (ie, these residents did not undergo psycho-logical testing). Eighteen percent of the remaining 206residents were MUSC graduates, 74% were graduatesof 68 other medical schools from 30 states plus theDistrict of Columbia, and 8% were graduates of 10 for-eign medical schools.

Psychological TestsNumeric scores from six psychological tests were

used to assess the various constructs that we wished totest. These tests are shown in Table 1.W e looked specifically at participation in Balint and

three subscales on the MBTI:perceiving,which in-dicates a preference for living in a flexible, spontane-ous manner, seeking to explore life rather than label,schedule, and formalize it;intuition,which indicatestaking in information by looking for the big picture andimaging the connection between the facts; andextra-version,which refers to people who focus attentionon the ou ter world of events and people and derive en-

ergy from doing so.For the Rokeach score, higher scores indicate a moreclosed-minded individual (Table 1). The W ork Envi-ronmental Preference Schedule (W EPS) measures bu-reaucratic orientedness, and scores increase as a per-son becomes more self subordinating, more impersonal,more compartmentalized, more role or rule conform-ing, and more traditional. Rotters Internal Versus Ex-ternal Locus of Control scale yields higher scores with

increasing belief in an external locus of control (ie, abelief that responses to ones behavior are not entirelycontingent on it but are influenced by chance, luck, orsome other external forces). Higher scores on the two

variables derived from Schutzs Fundamental Interper-sonal Relationship Orientation Behavior (FIRO-B) scaleindicate an increase in taking initiative in relationshipsand a greater desire for increased interpersonal inter-action. Shostroms scale measures the capacity for in-timate contact and increases numerically with that ca-pability.

Each of the six tests was administered during the firstmonth of residency under classroom-monitored condi-tions to all incoming first-year residents (excluding theseven residents previously mentioned). Residents com-pleted the tests as a group, and their responses wereanalyzed by one of the authors and remained confiden-tial (except for feedback provided only to the individualresidents themselves).

Data AnalysisThe results of the psychological tests were compared

for attendees and nonattendees using either chi square(for categorical variables) or t tests (for normally dis-tributed continuous variables). Differences were con-sidered significant if the P value was


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Table 1

Psychological Tests

Construct Test Used Open mindedness Rokeach Dogmatism Scale, Form E6

Higher scores=more closed minded

Preference for perception (P) versus judgment (J) Myers-Briggs Type Indicator (MBTI)7

Higher P score=more spontaneousHigher J score=more structured

Preference for intuition (N) ve rsus sensing (S) Myers-Briggs Type Indicator (MBTI)7

Higher N score=more imaginativeHigher S score=more observant

Preference for extroversion (E) versus introver sion (I) Myers-Briggs Type Indicator (MBTI)7

Higher E score=more extravertedHigher I score=more introver ted

Orientation preference (process ver sus bureaucratic protocol) Work Environment Preference Schedule (WEPS)8

Higher score=more bureaucratically oriented

Locus of control (internal versus external) Internal-External Locus of Control (IE)9

Higher score=higher external locus of control

Preference for taking the initiative in relationship, d Fundamental Interpersonal RelationshipOrientation Behavior (FIRO-B)10

Higher d score=taking more initiative in relationships

Preference for a high degree of interaction with others, Fundamental Interpersonal RelationshipOrientation Behavior Scales (FIRO-B)10

Higher score=higher degree of interaction with others

Capacity for intimate contact, c Personal Orientation Inventory (POI)11

Higher c score=higher c apacity for intimate contact

ResultsOver the 18 years of obser-

vation, 65% of our familypractice residents partici-pated in Balint traininglonger than the required 6months (ie, attendees). Annu-ally, participation rangedfrom a low of 36% to a highof 92% (Figure 1). In general,more males than females par-ticipated in the residencyBalint program after the re-

quired 6 months, but this re-flected the overall gendercomposition of the residents.The relationship betweengender and several psycho-logical measures and partici-pation in Balint training forthe entire residency is shownin Table 2. There was no sig-

Figure 1

Medical University of South Carolina Family PracticeResidents: Balint Attendees 19821999


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nificant relationship between gender and participationafter the required 6 months.

The intuition variable on the MBTI showed a statis-tically significant difference between Balint attendees

and nonattendees (Table 2). The other two MBTI vari-ables did not demonstrate a statistically significant as-sociation with attendance at Balint groups. Table 3shows that none of the 16 MBTI types was statisticallysignificantly overrepresented or underrepresented in thesample of 132 Balint group attendees.

As noted in Table 2, no significant difference wasnoted between attendees and nonattendees in scores onthe Rokeach test, the Work Environmental PreferenceSchedule (WEPS), Rotters scale, the FIRO-B, andShostroms scale.

Discussion

We had hypothesized that physicians with certainMBTI preferences would be more likely to participatein Balint groups. We only found, however, that Balintattendees were more likely to be classified as intui-tive on the MBTI. None of the other MBTI psycho-logical types was more common in the Balint groupattendees (Table 3). Thus, Balint group attendees arenot just one type of personthey are a heterogeneousgroup sharing some similar attributes. Further, ouranalysis suggests that neither gender nor characteris-

tics on any of the other psychological tests were morecommon in attendees versus nonattendees.

One would expect significant homogeneity amongresidents following 8 years of comparable, formal edu-

cation and a mutual selection process leading to ma-triculation in the Charleston residency. Therefore, it isnot unexpected to find few significant differencesamong several psychological measures taken in thispopulation, though a larger or more heterogeneouspopulation might have had more differences in the testvariables.

We hypothesized that Balint attendees would be moreintuitive than the nonattendees, and we found a statisti-cally significant difference in this characteristic betweenattendees and nonattendees (P=.05). This finding, how-ever, may be an example of the Type I error (a differ-ence detected by chance, rather than one representing

a true difference). Type I error at a P value of .05 oc-curs five times in 100 by chance, and possessing theMBTI intuitive characteristic made a selection crite-rion for inclusion or exclusion of participation in aBalint group. Rather, it may just suggest a general wayof perceiving that may be more common among attend-ees and also suggest, in part, what creates the particu-lar, speculative, and reflective ambiance of a Balintgroup.

Table 2

Comparative Statistical Analysis of Medical University of South CarolinaFamily Practice Resident Balint Group Attendees and Nonattendees

Test Variable ATTENDEES (n=132) NONATTEN DEES (n=74)

X SD % X SD % P ValueGender .283

Male 64 72Female 36 28

MBTI-P 41 41 .947MBTI-N 76 63 .049MBTI-E 56 51 .500

Open mindedness 131.22 23.62 130.16 22.72 .757Bureaucratic orientation 24.42 6.76 26.02 6.48 .094Internal versus external control 9.68 5.11 8.58 4.48 .124Initiative in relationships, d -2.48 3.07 -2.93 3.22 .999Interpersonal interaction, 26.98 8.6 26.89 8.97 .946Capacity for intimate contact, c 18.14 3.48 18.39 3.26 .608

SDstandard deviation

MBTI-PMyers Briggs Type Indicator (perception)MBTI-NMyers Briggs Type Indicator (intuition)MBTI-EMyers Briggs Type Indicator (extroversion)

Residency Education


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We also hypothesizedthat Balint attendees wouldbe less bureaucratically ori-ented than nonattendeesand that they would be moreinternal than external intheir locus of control. Nei-ther of these hypotheseswas supported by the resultsof our study. And, as noted,we found no differences be-tween attendees and nonat-tendees in any of the otherpsychological test results.

Our findings regardingparticipation rates are simi-lar to those obtained byBalint in his 14-year studyof participants in hisTavistock clinic. His data

showed that 36% of partici-pants drop out of Balinttraining in their initial year.Our results showed that,when given the choice, 35%of residents also drop out oftraining after an initial 6-month period. Balint alsoobserved that those who

discontinued group mem-bership usually did sowithin the first year of par-ticipation. These findings

should be considered care-fully by educators who want to incorporate Balint train-ing into residency programs.Limitations

The conclusions of this study should be interpretedin light of some limitations. Factors creating group co-hesion or fragmentation within the residency were notmeasured and certainly may contribute to residents stay-ing in the group or leaving it.13 Likewise, residentssense of loyalty or attachment to the faculty memberleading the group may influence group participation.

A second limitation is the lack of power that couldbe achieved with the sample size. Two of the psycho-logical variables that we considered (bureaucratic ori-entation and locus of control) showed trends that sug-gested differences in the way that attendees view theworld, but neither of these differences achieved statis-tical significance. A post-hoc analysis concluded that asample size of approximately 400 individuals wouldbe necessary to achieve a power of 80% at an alphalevel of .05 to demonstrate significant differences foreither of these variables, and we only had data on 206residents.

ConclusionsOur results show that psychological measures alone

will not answer the question of who will choose to par-ticipate in Balint training. To the extent that Balint train-ing provides benefit for residents (something not mea-sured in this study), we hope our results illuminate someof the interactions, or lack thereof, of physicians whoopt to participate in Balint training.

Acknowledgment: We recognize with appreciation the financial support ofthe American Balint Society i n underwr iting the cost of data entry that madethis study poss ible.

Corresponding Author: Address correspondence to Dr Johnson, 295 CalhounStreet, Charleston, SC 29425. 843-818-2960. Fax: 843-818-2990.

[email protected].

REFERENCES

1. Balint M, Balint E, Gosling R, Hildebrand P. A study of doctored: mu-tual selection and the evaluation of results in a training programme forfamily doctors. London: Tavistock Publications Limited, 1966.

2. Balint M. The doctor, his patient, and the illness. New York: ChurchillLivingstone, 2000. ( first published in 1957 a nd reedited in 1963).

3. Johnson AH. The Balint movement in America. Fam Med 2001;33(3):174-7.

Table 3

Medical University of South Carolina Family Practice Residents: BalintAttendees 19821999 (n=132)

ISTJ* ISFJ INFJ INTJ

n=7, %=5.3 n=8, %=6.0 n=11, %=8.3 n=8, %=6.0

I=.84 I=1.03 I=.86 I=1.22

ISTP ISFP INFP INTP

n=2, %=1.5 n=1, %=.8 n=17, %=12.8 n=5, %=3.8

I=1.00 I=1.6 I=.91 I=1.12

ESTP ESFP ENFP ENTP

n=0, %=0 n=2, %=1.5 n=23, %=17.3 n=4, %=3.0

I=0 I=1.00 I=1.12 I=.88

ESTJ ESFJ ENFJ ENTJ

n=5, %=3.8 n=7, %=5.3 n=23, %=17.3 n=10, %=7.5

I=.78 I=.73 I=1.24 I=1.19

* For an example, ISTJ is one of the 16 type formulas of the Myers-Briggs Type Indica tor. Its meaning is thatsuch a person is introverted (I) with dominant introverted sensation (S) as his/her dominant psychologicalfunction and an auxiliary psychological func tion of extraverted thinking (T). This person would prefer to leadan orderly, sche duled life (J).

nthe number of Balint group attendees of this particular type

%the percent of that that particular type among the 132 Balint group attendeesIthe ratio of the percentage of that specific type in the sample of attendees (132) divided by the percentage ofthat type in the total sample (206).


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4. Brock CD. The Balint group leadership by a family physician in a resi-dency program. Fam Med 1985;17(2):61-3.

5. Johnson AH. The Personality Inventory. In: Corley JB. Evaluating resi-dency training, second edition. Lexington, Mass: The Collaimore Press,1983.

6. Rokeach M. The open and closed mind. New York: Basic Books, 1960.7. Myers IB. Introduction to type, fifth edition. Palo Alto, Calif: Consult-

ing Psychologica l Corporation, 1973.8. Gordon V. Work environment preference schedule manual. New York:

The Psychological Corporation, 1973.

9. Rotter JB. Generalized expectancies for internal versus external con-trol of re inforcement. Psychologica l Monographs: General and Applied1966;80:1-28.

10. Schultz WS. FIRO Awareness Scales manual. Palo Alto, Calif: Con-sulting Psychologist Press, 1978.

11. Shostrom EL. Personal Orientation Inventory: an inventory for themeasurement of self a ctualization. San Diego: Educational and Indus-trial Testing Service s, 1970.

12. Downie NM, Heath RW. Basic statistical methods, second edition. NewYork: Harper and Row, 1965.

13. Musham C, Br ock CD. Family practice residents perspectives on Balintgroup training: in-depth interviews with frequent and infrequentattenders. Fam Med 1994;26(6):382-6.

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