The Circle of Change

Jeffrey S. Trilling

Description

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.

Sujets

• Medical
• Médecine
• Physician
• Patient

Informations

• Publié par: Outskirts Press
• Date de parution: 31 mars 2023
• Nombre de lectures: 0
• EAN13: 9781977263520
• Langue: English

Extrait

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The Circle of Change All Rights Reserved. Copyright © 2023 Jeffrey Trilling v2.0
The opinions expressed in this manuscript are solely the opinions of the author and do not represent the opinions or thoughts of the publisher. The author has represented and warranted full ownership and/or legal right to publish all the materials in this book.
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PRINTED IN THE UNITED STATES OF AMERICA
"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
Cir