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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Open . 2026 Apr 15;16(4):e116435. doi: 10.1136/bmjopen-2026-116435 Search in PMC Search in PubMed View in NLM Catalog Add to search Effectiveness of Balint group interventions for physician burnout: a systematic review and meta-analysis protocol Jianfeng Li Jianfeng Li 1 School of Medicine & Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Jianfeng Li 1 , Hangcheng Jiang Hangcheng Jiang 1 School of Medicine & Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Hangcheng Jiang 1 , Xinyu He Xinyu He 1 School of Medicine & Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Xinyu He 1 , Wei Xi Wei Xi 1 School of Medicine & Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Wei Xi 1 , Rui Zhu Rui Zhu 1 School of Medicine & Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Rui Zhu 1 , Shanping Chen Shanping Chen 2 Department of Geriatric Medicine, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Shanping Chen 2 , Xia Zhang Xia Zhang 2 Department of Geriatric Medicine, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Xia Zhang 2 , Daan Nie Daan Nie 3 Department of Cardiology, Hunan University of Medicine General Hospital, Huaihua, Hunan, China Find articles by Daan Nie 3 , Xin Zeng Xin Zeng 4 Department of General Practice, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Xin Zeng 4 , Chuan Zou Chuan Zou 1 School of Medicine & Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China 4 Department of General Practice, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Find articles by Chuan Zou 1, 4, ✉ Author information Article notes Copyright and License information 1 School of Medicine & Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China 2 Department of Geriatric Medicine, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China 3 Department of Cardiology, Hunan University of Medicine General Hospital, Huaihua, Hunan, China 4 Department of General Practice, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. None declared. ✉ Dr Chuan Zou; [email protected] Received 2026 Jan 6; Accepted 2026 Mar 26; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084958 PMID: 41985952 Abstract Abstract Introduction Physician burnout is a global crisis compromising healthcare sustainability and patient safety. Balint groups, a structured case-based discussion intervention focusing on the doctor-patient relationship, are increasingly used to mitigate this distress. However, existing evidence regarding their efficacy remains fragmented. This systematic review and meta-analysis aims to evaluate the effectiveness of Balint groups in reducing physician burnout and improving secondary psychological outcomes, while also assessing implementation characteristics. Methods and analysis We will search MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, PsycINFO and major Chinese databases (China National Knowledge Infrastructure, Wanfang Data and SinoMed) from inception to 31 May 2026, supplemented by grey literature and trial registries. The formal search has not yet commenced and is planned to begin on protocol publication. We will include both randomised controlled trials (RCTs) and non-randomised studies of interventions (non-randomised trials (NRTs), including non-controlled before-after studies) that evaluate Balint groups for practising physicians. The primary outcome is the change in burnout severity, with priority given to the emotional exhaustion subscale of the Maslach Burnout Inventory; however, data from other validated tools, such as the Oldenburg Burnout Inventory, will also be extracted and synthesised if reported. Secondary outcomes include stress and anxiety as psychological comorbidities closely associated with burnout, and job satisfaction, adherence and medical errors as its downstream occupational consequences. Two reviewers will independently screen studies, extract data and assess risk of bias using the Cochrane RoB 2.0 tool for RCTs and the Effective Public Health Practice Project tool for NRTs. Data synthesis will be conducted separately for RCTs (between-group effects) and NRTs (within-group effects) using random-effects models. Heterogeneity will be explored via subgroup analyses (eg, career stage) and, where data permit, meta-regression. The certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Ethics and dissemination Ethical approval is not required as this study synthesises primary data from published research. Findings will be disseminated through a peer-reviewed journal publication and conference presentations to inform interventions for physician well-being. PROSPERO registration number CRD420251142526. Keywords: Burnout, Meta-Analysis, Systematic Review, Physicians Strengths and limitations of this study. This review exclusively targets practising physicians and residents, deliberately excluding medical students to isolate the specific impact of Balint groups on occupational burnout rather than educational stress. The restriction to English and Chinese language publications may exclude relevant studies, particularly from German and French literature. Data synthesis will be conducted separately for randomised controlled trials and non-randomised studies, ensuring that high-level evidence is not diluted by lower-quality designs. Subgroup analyses based on career stage (residents vs practising physicians) will provide nuanced insights into whether the intervention’s effectiveness varies by professional experience level. The strength of the final conclusions may be limited by anticipated heterogeneity in intervention implementation (eg, duration, frequency) and a potential scarcity of high-quality randomised controlled trials. Introduction Physician burnout has evolved from a peripheral concern to an existential threat to the integrity of global healthcare. Defined as a syndrome of emotional exhaustion (EE), depersonalisation and reduced personal accomplishment rooted in chronic work-related stress, 1 it is significantly amplified by structural constraints such as the narrow scope of practice, particularly in primary care settings where physicians grapple with unmet clinical demands. 2 This crisis reverberates across three interconnected spheres: for clinicians, it undermines mental health, with early-career physicians facing higher burnout rates than their mid-career colleagues, 3 and is linked to a startling prevalence of suicidal ideation driven by lost professional purpose. 4 For patients, the consequences are tangible: burnout erodes the trust essential for effective care and increases the risk of medical errors. 5 At the system level, it fuels a cycle of attrition that exacerbates physician shortages 6 and escalates costs, exceeding $4.6 billion annually in the USA alone due to turnover and lost productivity. 7 The persistence of this crisis suggests a fundamental mismatch between the drivers of burnout and current solutions. Dominant interventions like mindfulness-based strategies 8 and cognitive-behavioural therapy 9 primarily target individual coping mechanisms. They often fail to address interpersonal and systemic stressors, yielding only modest or non-significant effects on key burnout dimensions and associated psychological stress. Furthermore, organisational interventions and digital tools frequently lack long-term sustainability or translatability in real-world settings. 10 Balint group discussions, rooted in psychodynamic principles, offer a distinct alternative by specifically targeting the doctor-patient relationship—the very dimension often sidelined by existing strategies. 11 Unlike standard case discussions, Balint groups are structured sessions where physicians explore the emotional dynamics of challenging encounters. Their therapeutic value is defined by mechanisms such as catharsis and perspective-taking. Empirical evidence supports their potential: Swedish general practitioners participating in Balint groups reported significantly higher job satisfaction and lower burnout compared with non-participants. 12 Similarly, family medicine residents showed reduced burnout scores that persisted longer than those achieved through mindfulness. 13 Meta-analytic data further confirm that Balint groups significantly enhance empathy, a key protective factor against burnout, with greater effects observed in practising physicians than in students. 14 Despite these promising signals, the evidence base remains fragmented and insufficient for policy guidance. No prior systematic review has exclusively focused on Balint groups for physician burnout, as existing syntheses often dilute the focus or neglect burnout as a primary outcome. 15 Critical knowledge gaps persist, particularly regarding high-risk specialties like emergency medicine, where burnout prevalence is high but Balint research is lacking. 16 Moreover, the literature is plagued by methodological inconsistencies in study design and outcome measures that make cross-study comparisons difficult, 17 as well as high risks of bias such as small sample sizes that increase type II errors. 18 Therefore, a rigorous systematic review and meta-analysis is urgent to synthesise this disjointed evidence. This work aligns with the JAMA Charter on Physician Well-Being, which specifically calls for ‘evidence-based, relationship-centred interventions’ to rehumanise healthcare, 19 and responds to the WHO’s warning that unaddressed burnout will undermine universal health coverage by 2030. 20 By clarifying the efficacy, moderators and implementation challenges of Balint groups, this review aims to provide actionable guidance for medical educators and policymakers, shifting the focus from individual coping to restoring the relational core of medicine. Objectives This review synthesises global evidence through systematic retrieval, rigorous appraisal and meta-analysis to elucidate the effectiveness of Balint Groups in mitigating physician burnout, pinpoint core influencing factors and establish optimal pathways for implementation. It provides an evidence-based foundation for medical institutions to develop precise intervention strategies and addresses the critical gap in high-quality synthetic evidence within this field. Methods This protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols and the Cochrane Handbook for Systematic Reviews of Interventions. 21 We registered this study protocol in the International Prospective Register of Systematic Reviews. 22 Eligibility criteria Population We seek to determine whether Balint group interventions effectively reduce burnout and stress among physicians. Consequently, eligible study populations include practising clinical physicians encompassing residents, attending physicians, associate chief physicians and chief physicians across all seniority levels, without restrictions on gender, age, years of practice or type of healthcare institution (such as hospitals or clinics). This excludes medical students, nurses, pharmacists and other non-clinical physician groups. Criteria for inclusion and exclusion are given in table 1 . Table 1. Inclusion and exclusion criteria. Criterion Inclusion Exclusion Study design RCTs; NRTs with or without controls (eg, non-controlled before-after studies) Case-control studies, cross-sectional studies, systematic reviews, clinical case reports, qualitative studies, editorials Population Practising physicians and resident physicians Medical students, nurses, pharmacists and other non-clinical physician group Intervention Interventions explicitly based on Balint groups Interventions without explicit focus on Balint groups Comparator RCTs: active controls, waitlist or usual care; NRTs: no comparator required – Outcome Primary: burnout measured by validated instruments (eg, MBI, OLBI, CBI). Secondary: stress, anxiety, job satisfaction, medical errors, adherence Self-report questionnaires without validation Language English and Chinese None Open in a new tab CBI, Copenhagen Burnout Inventory; MBI, Maslach Burnout Inventory; NRTs, non-randomised trials; OLBI, Oldenburg Burnout Inventory; RCTs, randomised controlled trials. Interventions The intervention of interest is the Balint group, defined as a structured case-based discussion group focusing on the doctor-patient relationship and the emotional content of clinical work. 23 We will include interventions that explicitly state a foundation in Balint’s theory or method. Modified Balint groups (eg, online delivery, shortened duration) will be included if they retain the core components of case presentation and reflection on the doctor-patient relationship. 24 Study design and comparators Randomised controlled trials (RCTs) will be included, alongside non-randomised trials (NRTs) such as non-controlled before-after studies (NCBAs). 25 For RCTs, both active and waitlist control conditions will be considered. While excluding NRTs could neglect valuable evidence, combining them with RCTs risks overestimating the treatment effect. Consequently, RCTs and NRTs, including NCBAs, 26 will undergo separate subgroup meta-analyses to evaluate how study design characteristics influence the intervention effects. Outcome measures This systematic review and meta-analysis primarily assesses changes in burnout and stress from pre-intervention to post-intervention. All outcomes require measurement via validated self-report questionnaires. When studies use the Maslach Burnout Inventory, 27 we will specifically consider the EE subscale. This approach aligns with recommendations against aggregating the inventory’s distinct facets, mirroring methodology employed by other relevant meta-analyses and primary studies. Data from other validated burnout instruments (eg, the Oldenburg Burnout Inventory (OLBI), the Copenhagen Burnout Inventory (CBI)) will also be extracted and synthesised where reported; standardised mean differences (SMD) will be used to enable pooling across different scales. 28 Effect sizes (SMD) will be interpreted as small (0.2), moderate (0.5) and large (0.8). Secondary outcomes are conceptually organised along a pathway from individual psychological impact to occupational and systemic consequences. The first category encompasses psychological comorbidities closely associated with burnout, including perceived stress and anxiety, which frequently co-occur with and may exacerbate the burnout syndrome. The second category captures downstream occupational consequences, including job satisfaction, treatment adherence and self-reported medical errors, which reflect the functional impact of burnout on clinical practice and patient care. Search strategy To ensure a comprehensive and multidisciplinary literature search, we will meticulously screen nine major electronic bibliographic databases: MEDLINE, PsycINFO, Web of Science, CINAHL, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure (CNKI), Wanfang Data and the Chinese Biomedical Literature Database (SinoMed). As this is a protocol paper, formal searching has not yet commenced; the systematic search is planned to begin on 1 June 2026, covering all nine aforementioned databases from inception to 31 May 2026. Our search strategy will prioritise sensitivity to capture all potentially relevant studies; consequently, we will apply no publication date restrictions. Searches will be limited to studies published in English or Chinese, as these are the languages in which the review team has reading proficiency. Search terms will specifically target (1) Balint groups, (2) burnout and (3) terms related to the professional title of physicians. For Chinese databases, search terms will be adapted and translated into Chinese to ensure accurate retrieval. Exemplary search strategies for PsycINFO, Web of Science, MEDLINE and CNKI are available within the online supplemental material . To identify studies within the grey literature, we will proactively contact leading experts in Balint group research and medical education. This includes authors of eligible studies, authors of pertinent articles and conference abstracts identified during our database search, and authors of significant reviews. Furthermore, we will conduct exhaustive backward citation searches of all included studies and relevant reviews, alongside forward citation searches using Google Scholar, aiming to uncover additional relevant sources. Finally, should access to the full text of certain references prove unavailable, we will promptly reach out to the respective study authors. Study selection We will employ Zotero 29 primarily for initial citation management and automated de-duplication of records imported from multiple databases. Following this automated step, manual de-duplication will be conducted by the reviewers to ensure accuracy. The deduplicated dataset will then be exported to Rayyan, 30 a specialised web platform, to facilitate independent blinded screening of titles and abstracts by two reviewers (JL and HJ). Full texts will be retrieved whenever at least one reviewer deems an article potentially eligible. Subsequently, both reviewers will independently assess the full texts to verify each reference’s eligibility. Should discrepancies arise unresolved by discussion, a third reviewer (XH) will arbitrate. Cohen’s kappa will quantify inter-reviewer agreement. 31 All exclusion rationales will be meticulously documented. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we will illustrate the literature search and selection process within a detailed flow diagram. Data extraction Information from eligible studies will be independently extracted by two reviewers (JL and HJ) using a standardised form. Extracted data encompass: Study details: authors, publication date, country, experimental design, control type. Population characteristics: sample size (treatment/control), mean age, sex proportion, dropout rate, career stage (resident/practising physician). Intervention specifics: delivery format (online/offline/mixed), average single session duration, total sessions, home practice requirements, guided exposure time, theoretical basis (traditional Balint/modified Balint), group size, leadership qualifications and intervention adherence, which will be operationalised as the session attendance rate or the percentage of participants completing the full intervention protocol, as reported by individual studies. Outcome measures: burnout measured by validated instruments (eg, MBI, OLBI, CBI). Secondary: stress, anxiety, job satisfaction, medical errors, adherence. Implementation-related data: facilitator characteristics (professional background, eg, psychoanalyst vs trained General Practitioner; Balint training experience), setting (hospital-based vs community-based; work-integrated vs external), participation type (voluntary vs mandatory), fidelity assessment methods and reported barriers/facilitators to implementation. Extracted data will be entered into Cochrane Collaboration’s Review Manager (RevMan V.5.3) and statistical software R. Where insufficient data preclude effect size calculation or methodological quality assessment, we will contact the respective study authors for clarification. Risk of bias assessment in individual studies Two reviewers (JL and HJ) will independently perform risk of bias assessment. If discrepancies cannot be resolved through discussion, a third reviewer (XH) will be consulted. For RCTs, we will use the Cochrane risk of bias tool for randomised trials V.2.0 (ROB V.2.0). 32 ROB V.2.0 is a domain-based evaluation considering bias arising from (1) the randomisation process, (2) deviations from intended interventions, (3) missing outcome data, (4) measurement of the outcome and (5) selection of the reported result. The risk of bias in each domain will be rated as either ‘low risk of bias’, ‘some concerns’ or ‘high risk of bias’. Furthermore, a corresponding overall risk-of-bias judgement for each study will be made. For uncontrolled or NRTs, we will use the Effective Public Health Practice Project quality assessment tool for quantitative studies. 33 It rates study quality in eight sections: (1) selection bias, (2) study design, (3) confounders, (4) blinding, (5) data collection methods, (6) withdrawals and dropouts, (7) intervention integrity and (8) quantitative analyses of single studies. In each section, the evidence will be rated as ‘strong’, ‘moderate’ or ‘weak’. A corresponding global rating will be determined for each study. If the number of included studies is sufficient, we will perform sensitivity analyses by excluding high-risk studies. Cohen’s kappa will be calculated to determine the agreement on the quality rating of each study between reviewers. Risk of bias across studies If accessible, we will retrieve study protocols and trial registrations to identify potential bias stemming from selective reporting of results or selective publication. To assess publication bias, we will thoroughly examine funnel plot asymmetry and perform sensitivity analyses employing diverse publication bias tests. 34 35 We will employ the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the overall quality of evidence, scrutinising five critical dimensions: (1) risk of bias, (2) inconsistency of results, (3) indirectness of evidence, (4) imprecision of effect size and (5) publication bias. 36 Evidence quality will be categorised definitively as ‘high’, ‘moderate’, ‘low’, or ‘very low’. This GRADE assessment will crucially influence data synthesis by informing the strength of the evidence considered. Data synthesis We will rigorously assess heterogeneity among included studies using I² statistics and detailed forest plots. 37 Following Cochrane handbook guidance, I² values will be interpreted as follows: unimportant (I² <40%), moderate (30%–60%), substantial (50%–90%) or considerable heterogeneity (75%–100%). 38 Meta-analysis will be conducted using a random-effects model (DerSimonian-Laird method) if studies prove sufficiently homogeneous (I² ≤60%) or if heterogeneity is adequately reduced through prespecified subgroup differentiation. The Hartung-Knapp adjustment will be applied if fewer than 10 studies are included. To enable comparison across different validated instruments, the SMD with 95% CIs will be used; when multiple burnout instruments are reported in a single study, the MBI will be prioritised. Two separate meta-analyses will be conducted: the first will summarise RCTs using between-group effect sizes based on post-intervention data or change scores; the second will summarise non-randomised and uncontrolled studies using within-group effect sizes derived from pre- and post-intervention data. The primary conclusions will be based on RCT evidence, while NRT results will serve as supplementary evidence. Forest plots will be generated for each outcome, stratified by career stage (residents vs practising physicians). The certainty of evidence will be assessed using the GRADE approach. 39 RCTs will start as 'high quality’, controlled non-randomised trials as ‘low quality’, and uncontrolled before-after studies as ‘very low quality’ due to the inability to rule out regression to the mean, Hawthorne effects and temporal trends. Results from uncontrolled studies will be interpreted with caution, acknowledging that causal inferences cannot be drawn. A structured summary of findings table will be presented. We prespecify two subgroup analyses: RCTs versus NRTs to evaluate design-related differences, and residents versus practising physicians to explore career stage as a moderator. Where data permit (≥10 studies per covariate), meta-regression will examine potential moderators such as intervention duration and group size. Sensitivity analyses will include comparing fixed-effect versus random-effects models and leave-one-out analysis. Publication bias will be assessed via funnel plots and Egger’s regression only if ≥10 studies are available. Feasibility and contingencies: Based on preliminary searches, we anticipate identifying 3–5 RCTs and 10–20 NRTs. If fewer than three RCTs are eligible, or if heterogeneity remains prohibitively high (I² >75%) despite subgroup analyses, we will conduct a narrative synthesis following the Synthesis Without Meta-analysis reporting guidelines. Patient and public involvement Patients and the public were not involved in the design or planning of the study. Ethics and dissemination This study is a meta-analysis protocol based solely on published literature and does not involve human participants, identifiable personal data or new data collection; therefore, ethical approval was not required. The relevant departmental contact is Dr. Jing Shen, Director of the Department of General Practice, The Fifth People’s Hospital of Chengdu, Affiliated to Chengdu University of Traditional Chinese Medicine. Email:[email protected]. Dissemination statement Findings from this systematic review and meta-analysis will be disseminated through a peer-reviewed journal publication and conference presentations to inform interventions for physician well-being. Additionally, all data extracted from published studies will be made available as online supplemental material in the final published review to ensure transparency. Data availability statement Data sharing is not applicable to this article as no new data were created or analysed in this study. This is a protocol for a systematic review and meta-analysis. All data extracted from published studies during the upcoming review process will be made available in the online supplemental material of the final published review. Supplementary material online supplemental file 1 bmjopen-16-4-s001.docx (22.5KB, docx) DOI: 10.1136/bmjopen-2026-116435 Footnotes Funding: Supported by Joint Innovation Fund of Health Commission of Chengdu and Chengdu University of Traditional Chinese Medicine (WXLH202406005), Health Commission of Chengdu Municipality (Project Number: 2024156), research programme of Chengdu Health and Family Planning Commission (No. 2025474), Natural Science Foundation of Hunan Province (No. 2025JJ70444), the educational reform project of Chengdu University of TCM (JGJD202309) and scientific research project of Sichuan Medical Association (No. Q2024053). Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2026-116435 ). Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Not applicable. 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Review Process File Copyright and License information PMC Copyright notice bmjopen-2026-116435.reviewer_comments.pdf (268KB, pdf) Open in a new tab Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials online supplemental file 1 bmjopen-16-4-s001.docx (22.5KB, docx) DOI: 10.1136/bmjopen-2026-116435 Data Availability Statement Data sharing is not applicable to this article as no new data were created or analysed in this study. This is a protocol for a systematic review and meta-analysis. All data extracted from published studies during the upcoming review process will be made available in the online supplemental material of the final published review. 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