**4. Emotional intelligence, feelings, responses, and burnout**

Hungarian-born British psychoanalyst Michael Balint pioneered Balint groups among practicing physicians in the 1950s to explore the doctor–patient relationship [40]. Balint groups help make physicians aware of their blind spots during their interactions with patients as well as use their feelings and responses to patients as instruments to better comprehend the physician–patient relationship [41]. These seminars consist of longitudinal experiential learning over a period of time as well as a group of residents who periodically meet and are accompanied by two Balint leaders. A case that bothers one of the residents is presented, which is followed by a discussion from the point of view of the patient, doctor, and their relationship with the caveat that medical care not be discussed [42–44]. After, Balint leaders help the residents in the expansion, consideration, and illumination of their thoughts and feelings related to the case from both the patient and physician's perspective. Examples of benefits and detriments to these sessions are found (**Table 4**) [45–47].

Given Balint training is closely linked with the ability to understand and regulate emotions, a quasi-experimental observational study aimed to measure the effects of Balint seminars on EI and burnout among internal medicine residents [48]. Bi-weekly Balint seminars were delivered throughout the academic year. Two major outcomes were measured using validated instruments: EI using the Mayer Salovey and Caruso Emotional Intelligence Test (MSCEIT) and burnout using the Maslach Burnout Inventory (MBI). The MSCEIT, based on a four-branch model of EI, is the most comprehensive measure of EI as an ability [49]. The MBI is the gold standard for measuring burnout [50]. Depictions of these instruments are found in **Figures 3**–**5** respectively. A total of 20 Balint seminars were delivered; however on average, residents attended six sessions. The total post-Balint EI score improved among women versus men. Many residents showed severe burnout levels on at least one of the three domains of burnout at baseline; however, Balint seminars did not have any effect on any of the burnout domains even when accounting for gender, attendance or training level.

Evidence suggests no predetermined gender differences in EI ability among medical residents according to specialty [51]. Nevertheless, Balint seminar results may be affected by gender, learning style, and training year. Indeed, Balint interventions may be more effective among women than men [52]. The openness of women to such educational activities could explain why the female residents improve their EI. Also despite lack of statistical significance in this study, EI still improved in a small number of trainees, which could be due to various learning styles, personality and level of training. Criticisms of Balint seminars include a lack of focus on problem solving and firm structure that may not meet residents' developmental needs [53]. Different levels of training may explain the non-uniform effectiveness of this intervention [54].


**Table 4.** *Pros and cons of Balint group.*

#### **Figure 3.**

*Four-branch model of emotional intelligence.*


#### **Figure 4.**

*Scoring system of Mayer Salovey and Caruso emotional intelligence test (MSCEIT). \* The MSCEIT provides 15 main scores: Total EIQ score, two area scores, four branch scores, and eight task scores. It can be scored using both the consensus and expert scoring methods. There are guidelines on how to interpret the score. The average MSCEIT score is 100 with a standard deviation of 115. There are 7 score ranges based on empirical percentiles.*

#### **Figure 5.**

*Aspects of burnout according to Maslach burnout inventory.*

Finally, EI measurement immediately post-intervention may be suboptimal. In two studies, the influence of an EI educational intervention was only measurable as a delayed positive effect several months after the intervention [55, 56]. Therefore, interventions to improve EI and decrease burnout levels may have more long term effects that may not immediately come to light.
