The Circle of Change

By Jeffrey S. Trilling, MD

The clinician-patient relationship is an unapologetic reminder that clinical practice is an applied science, and that clinical knowledge only becomes useful through human interaction and application. Through dialog, the relationship serves as a powerful conduit for information flow.  This text, utilizing stories of successes and failures I have journaled over 44-years practicing medicine, argues that there is hidden knowledge important to patient care beyond technology’s reach that can only be gained through mutual trust, rapport and the right questions asked. But there are many external factors that constrain and strain the clinician-patient relationship.  Institutional and cultural restrictions foisted upon medical practice are laden with bureaucratic, political, and economic demands which impinge upon time spent with the patient. Correcting the situation is challenging because many of the causative factors are of a societal nature and not within one individual’s influence.  But nurturing the clinician-patient relationship and harvesting information from patients’ stories that may explain conflict, impasse, resistance to plan of care and lifestyle changes is well within our scope and is in fact necessary for good care. As such, it is the clinician’s job to develop skills for impasse resolution and interview techniques to explore the personal, family and cultural relational dynamics and nuances of meaning, lying within the illness narrative. While physicians, physician assistants, nurse practitioners, and others are well-trained to take inventory of the body’s biological systems, practitioners often lack the skill set to ask “the right questions” for exploring psychosocial systems, and therein lies the pedagogic vacuum to be filled. It is the purpose of this text to introduce a meaning-based problem-solving approach, The Circle of Change, as a pragmatic map and compass for gathering and processing patients’ narratives to uncover meaning and care for the illness. The book is written for students, physicians, physician assistants, nurse practitioners, and other health related professionals to enjoy, learn, and grow from their practices as they seek to understand, help, and heal those under their care.

• Language: English
• Publisher: Outskirts Press
• Release date: Mar 31, 2023
• ISBN: 9781977263520

Jeffrey S. Trilling, MD

Dr. Jeffrey Trilling graduated from New York Medical College and completed Board Certification in Family Medicine with added qualification in Geriatrics. For 18 years he was Chair of the Department of Family Medicine at Stony Brook’s School of Medicine, Family Medicine Chief of Staff at Stony Brook University Hospital, and President of Stony Brook Primary Care. He is on the academic faculty in the Department of Family, Population & Preventive Medicine’s Center for Medical Humanities, Compassionate Care & Bioethics at Stony Brook Medicine. Dr. Trilling was past President of the Alaska Academy of Family Medicine and has practiced medicine for 44 years in both academics and the private sector. He has been an ad hoc reviewer for national medical journals, additionally serving as Series Editor for the International Journal of Family Practice. Dr. Trilling has multiple peer-reviewed publications and presentations both nationally and internationally.

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The Circle of Change

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Copyright © 2023 Jeffrey Trilling

v2.0

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"Every patient knows how difficult it is to change unhealthy behaviors and habits, and clinicians are often frustrated by failed attempts to help. This book approaches such clinical dilemmas with the deep wisdom and enduring kindness needed to portray and teach the art of healing dialogue. Dr. Jeffrey Trilling shares wisdom gained from decades of both private practice in Alaska and academic practice at Stony Brook Medicine, as well as from almost twenty years administrative experience as Chair of the Department of Family Medicine at the State University of New York @ Stony Brook. For nearly a decade I have been blessed to teach with Jeff our master’s course entitled Compassionate Care, Medical Humanities, and the Illness Experience." When Dr. Trilling starts to explain the elegant Circle of Change, as he takes the students though its steps, they quickly realize that they are in the hands of a master clinician and a devoted teacher who wants nothing more than to help them as future practitioners to be able to move from conflict and impasse to true healing. Jeff is perhaps the most psychologically brilliant and informed healer I have met over nearly forty years of teaching in medical schools. The students feel that the methodology he introduces, now at last available in book form with this publication, enhances their self-awareness and hones clinical skills to reveal and understand patients’ fears and perceptions that give meaning to their illness experience, explaining previously inexplicable obstacles to change. The Circle of Change may become an instant classic, and we here at Stony Brook could not be prouder. Jeff exudes wisdom, he is profoundly inspirational, and his empathic presence is felt by everyone he encounters. "This clear and elegant book is one of the several best on problem resolution and effecting change that I have ever read."

Stephen G. Post PH D

Director, Center for Medical Humanities,

Compassionate Care & Bioethics

Department of Family, Population & Preventive Medicine, Stony Brook

Renaissance School of Medicine

Author of: Dignity for Deeply Forgetful People

"The Circle of Change is a breath of fresh air for those of us who understand that the clinician-patient relationship lies at the heart of healing, and a wake-up call for those physicians who fail to look beyond technology in their clinical practice. Using extended case examples, Dr. Jeffrey Trilling carefully sets out his case for a contextual model of healing in which the clinician’s responsiveness to the patient’s context and personhood initiates a circle of change that overcomes challenges to healing. Dr. Trilling conveys profound insights gleaned from his decades of medical practice in a simple, engaging style that should appeal to medical trainees, as well as physicians, especially those in primary care."

Jack Coulehan MD, MPH, FACP

Co-author of The Medical Interview:

Mastering Skills for Clinical Practice

"An exploration of the human complexities of health and illness, infused with wisdom from a seasoned family physician, providing medical students with a roadmap of how to respond effectively to patients’ needs in the biopsychosocial domain. Highly recommended."

Ronald Epstein MD, Author of "Attending:

Medicine, Mindfulness, and Humanity"

Dedication

To Raja Jaber, MD--My wife and colleague—whose tireless efforts toward the betterment of patients, boundless respect and curiosity about humanity and its defining relationships, and the intellect, integrity, humility, and compassion that define her—I dedicate this book. This book could never have been written without her contagious interest in the process of change and her subsequently introducing me to the teachings of Paul Watzlawick and his Aesthetics of Change, the Milan Group of Systemic Therapy, and the writings of Virginia Satir and other family systems therapists. This book is also the result of her introducing me to the annual Family in Family Medicine National Conference where we met like-minded colleagues across the country, such as Macaron Baird, Janet Christie-Seely, Michael Crouch, William Doherty, Ronald Epstein, Kathy Cole-Kelly, Arthur Kleinman, Susan McDaniel, and many others who inspired and encouraged Dr. Jaber and me to develop our problem-solving model, The Circle of Change. But most importantly, I dedicate this book to her for her love and support as my partner in life.

Acknowledgments

To Laura, Brad, Stefan, and Adam—My children—whose lives are a constant reminder of life’s beauty, potential, its stark realities, and the value of giving, gratitude, and challenges. They are my pupils, my teachers, and a never-ending source of love and inspiration.

To my patients—For sharing moments of their lives; for their trust; for the honor to be of some assistance. I am grateful for all they have shown me about life, perception, the significance of the illness experience and its attendant meanings.

To my colleagues—Maria Basile, Richard Bronson, Jack Coulehan, and Stephen Post who offered selfless encouragement, guidance, and support. Each one in their own unique talented way is a world-class contributor to the medical humanities. Working with such role models has helped me to find my own voice as a writer.

Author’s Note of Confidentiality

For confidentiality and privacy, the names of any patients and fellow health professionals in this book have been changed. I have, in many instances, altered details of patients’ stories, and in some cases created composites from those with similar narratives. This was done to be certain that any resemblance of individuals mentioned within this text to actual people, families, or friends is coincidental and unintentional.

Table of Contents

Part One: Placing the Patient-Doctor Relationship in Context

Poem: Fallow Ground or Flower Worth Watering: The Patient-Doctor Relationship

Preface

One: The Case of Ms. Forevermore—An Introduction to Impasse

Educational Objectives

Some Historical Background

• Poem: Physician’s Pilgrimage (at the outset)

The Doctor-Patient Impasse: Ms. Forevermore—We Learn from Our Mistakes

Clinician Frustration

Impasse and Conflict Are Two Sides of the Same Coin

Mistakes and Their Value

Recognizing Negative Feelings as Symptoms

Gentle Curiosity and the Shift from Reactivity to Proactivity

Medical Context and the Contextual Approach

Linear Logic and First-Order Change—in an Acute Biomedical Problem

Second-Order Change When First-Order Change Fails

Systems Hierarchy

My Mistakes with Ms. Forevermore

Notes to Chapter 1

Two: The Significance of the Patient’s Story

Educational Objectives

Mr. Forevermore

Poem: His Problem or Yours?

Medicine Is an Applied Science

The Clinician-Patient Relationship and Its Variations and Impact

The Effecter of Change/the Facilitator of Change

Differences in Style and Expectations as a Source of Impasse

Notes to Chapter 2

Part Two: The Circle of Change / Delineation and Resolution of the Clinician-Patient Impasse

Three: Formulation of the Clinician-Patient Impasse

Educational Objectives

Dr. Thin and Mr. Fat—The Luggage that We Carry

A Zen Conversation

Perception of Symptoms as Part of the Problem

The Inability to Categorize or Diagnose in the Face of Chronicity

The Explanatory Model of Illness

The Consequences of Change

Perceptual Frame as a Function of Explanatory Models and Consequences of Change

Consequences of the Clinician-Patient Impasse

Notes to Chapter 3

Four: Resolution of the Clinician-Patient Impasse: The Components and Mechanics of Problem Resolution and Effecting Change

Educational Objectives

The Man with the Renal Cyst

Component One / Assessment of Assumptions of the Underlying Promlem

Component Two / Generated Patterns and Unwritten Rules

Component Three / New Perceptual Frame

Component Four / Share New Perceptual Frame

Component Five / Reevaluation of Assumptions and Solutions Attempted

Component Six / The Consequences of Change as Obstacle to Problem Resolution (Ms. I’ve Got a Secret)

Notes to Chapter 4

Five: Problem-Solving the Doctor-Patient Impasse Utilizing the Circle of Change

Educational Objectives

The Circle’s 6 Steps

I. Initial Perceptual Frame

II. Generated Pattern

III. New Perceptual Frame

IV. Share Perceptual Frame (a Negotiation)

V. Reevaluation of Assumptions and Solutions Attempted

VI. Consequences of Change

The Reciprocal Nature of Change

The Circle’s First Half: Steps VI, I, and II / Problem Formulation

The Circle’s Second Half: Steps III, IV, and V / Problem Resolution

Can Compassion Be Taught in Medical School? / An Example of Reframing

Negotiating the New Perceptual Frame: The Gentle Art of Reframing and Cocreating New Perceptual Frames

Notes to Chapter 5

Part Three: Refining Our Approach

Six: Eliciting Explanatory Models and Consequences of Change

Educational Objectives

Eliciting the Patient’s Story: Asking the Right Questions / a Four-Month-Old HeadacheEducational Objectives

Circular Questioning with Gentle Curiosity

Some Great Opening (Open-Ended) Lines

Notes to Chapter 6

Seven: Research Implications and Applications

Educational Objectives

The Paradigm Clash between Context and Reductionism

Biomedicine’s Attentiveness to the Risks of Reductionism

Scientific Reductionism in the Social Sciences

Qualitative Research

Quantitative Research

The Circle of Change as a Qualitative Tool to Generate Hypotheses

Perception of Illness within the Family (What Is So Important?)

Explanatory Models of Illness: A Qualitative Pilot Study

Analysis of Attribution Models

Analysis of Patients’ Worries or Fears

Analysis of the Family’s Influence

Analysis of Differences between Patients and Families

Attribution Models, Consequences of Change and Chronic Sleep Symptomatology: A Quantitative Pilot Study

Removing the Training Wheels / Transcending Technical Terms and Structure

Poem: Physician’s Pilgrimage

Notes to Chapter 7

References

Part One

Placing the Clinician-Patient Relationship in Context

Fallow Ground or Flower Worth Watering:

The Patient-Doctor Relationship

You are like a bouquet left in the dust by unrequited love.

Abandoned floral card untouched—unread—its

message trodden by the unaware, the harried and distracted.

Hidden meanings, unspoken fears, explanation of the inexplicable

lie entombed within the illness narrative.

waiting—withering—and unnoticed.

What obscures your importance behind cloaked veil?

Inflowing data swarm like bees,

distracting us from knowledge you proffer for our taking—

knowledge only to be gained through mutual trust, rapport,

and the right question asked—

with gentle curiosity.

Unaware of ourselves as we are of you,

we relinquish relationship’s gift of discourse—opened windows,

whose light of understanding illuminates problem’s cause.

Compassion fostered through simple listening—

that first step

on the road to true healing.

Jeffrey S. Trilling

Preface

The clinician-patient relationship is an unapologetic reminder that the practice of medicine is an applied science, and that medical knowledge only becomes useful through human interaction and application. Through dialogue, the clinician-patient relationship serves as a powerful bilateral conduit for the flow of information. This text argues that there is hidden knowledge important to patient care beyond technology’s reach that can only be gained through mutual trust, rapport, and the right questions asked. When the relationship between the patient and practitioner is strong and empathic, information with the potential to enhance prevention, diagnosis, and management of disease and illness is more readily shared within the clinician-patient dyad. Problematic issues at the root of suffering may then be more easily recognized, delineated, understood, and resolved.

But, as in any relationship, conflict and impasse may arise and impede the flow of information with serious consequences: (1) patient nonadherence, resulting in ineffectual treatment plans; (2) premature diagnostic closure, increasing potential for misdiagnosis; (3) patient stress and dissatisfaction, which encourages doctor shopping, resulting in overutilization of medical services, multiple clinician fees, fragmented care, and repetitive testing that increase financial burdens on patients and society; (4) clinician fear of litigation and/or patient harm by omission, which leads to emphasis on expensive and invasive high-technological procedures that have their own morbidity and mortality; (5) primary care clinician burnout hallmarked by loss of professional meaning, alienation and emotional detachment, increased errors, and abruptness with patients, staff, and family; (6) and finally, conflict and impasse that may create the perception that clinicians lack compassion and are insensitive, mechanistic, technocratic, inhumane brutes.¹

While this list of consequences is not all-inclusive, it does paint a picture of a medical system gone wrong—a system strikingly comparable to the one in which we practice today. What is the cause? What is the cure? There are many external factors that constrain and strain our relationships with patients. Institutional and cultural restrictions foisted upon the practice of medicine are laden with bureaucratic, political, and economic demands, all of which impinge upon a clinician’s time spent with the patient. The resultant dissatisfaction felt by both practitioner and patient may result in consequences like those described above. While that comes as no surprise to those practicing today, correcting the situation is challenging because many of the causative external factors are of a societal nature and not within an individual’s influence. They require intervention at larger, more complex levels than that of the singular clinician, requiring a degree of unification difficult to achieve among conflicting interests of clinicians, corporate boards, and politicians to effect change in local, state, and federal systems. But nurturing the clinician-patient relationship and harvesting information from patients’ stories that may explain conflict, impasse, and resistance to a plan of care are well within our scope and are in fact necessary for good doctoring. Importantly, while the patient’s story with its hidden fears, attribution models, and other meaning-based explanations of illness may be accessed and assessed through skillful conversation, there is currently no known technology able to capture and decipher such information. The patient’s story and attendant meanings are impervious to