The Circle of Change

Book Title: The Circle of Change

Author: Jeffrey S. Trilling, MD

Publication Details: Outskirts Press, 2023, 181 pp., $14.95, Softcover

Jeffrey Trilling, MD, is a primary care family physician who practiced medicine for 33 years and served as the Chair of the Department of Family Medicine at Stony Brook University School of Medicine for 18 years before retiring. Throughout his career, he focused on the physician-patient relationship. Currently he is writing and teaching at Stony Brook’s Center for Medical Humanities, Compassionate Care and Bioethics. His self-published book, The Circle of Change, presents a model of how clinicians can move forward from impasse with their patients. Dr Trilling maintains that impasses prevent patients from getting the best care and can be resolved by asking “the right questions” (p. xv).

The Circle of Change model provides a framework for eliciting psychosocial components of illness to identify and work through problems. The six steps of the model include (1) exploring assumptions of “the perceptual frame,” including explanatory models of the illness; (2) identifying repetitive patterns of behavior between the physician and patient (ie, the impasse); (3) learning the patient’s story, which results in the formulation of a new perceptual frame; (4) cocreating a new perceptual frame to be shared by patient and physician; (5) evaluating the utility of the new perceptual frame; and (6) addressing problematic or negative consequences of the change. Steps 1, 2, and 6 help the clinician with problem formulation. Steps 3, 4, and 5 help with problem resolution. Dr Trilling compares his model to a set of training wheels that later become unnecessary. With practice, clinicians hopefully become adept at eliciting the patient’s explanatory models, uncovering negative consequences of change, and identifying unproductive patterns in physician-patient interactions. These skills allow for productive interactions between physicians and patients.

Dr Trilling effectively uses patient and nonpatient examples of conversations to demonstrate aspects of his model. Examples typically include patients disclosing crucial information, providing clues about how to move forward. He repeatedly calls for paying attention to the psychosocial aspects of an illness for a better understanding of the patient’s symptoms. One theme throughout the book is to use “gentle curiosity” to address impasse and conflict (p. 12). Paying attention to one’s own emotional reactions is encouraged because “Raised hackles may simply indicate you have not yet asked the right question” (p. 81).

The strength of the book is its message of focusing on assumptions and perceptions that need to be brought to light to truly understand patients and their patterns of interactions. The importance of investigating how problems are viewed by the physician and patient is discussed thoroughly. The need to explore the consequences of change is also convincingly argued. Dr Trilling offers examples of the types of questions that can help uncover critical information.

The weakness of the book is its lack of concise writing. Polished writing is especially important given that many readers are likely to be past the point of needing the training wheels of this model. Novices who could benefit from learning the model and experts who could benefit from using the model as a teaching tool do not have a succinctly articulated guide.

Being an academic, Dr Trilling discusses how his model can be scientifically tested and analyzed. He cites two studies he coauthored in the early 1990s supporting the model. However, these were pilot studies with small samples sizes. No further studies of the model are cited by the author. Why no one followed up with additional research is unclear. Data supporting the model would make a stronger case for its use. Furthermore, fewer than one-third (18 out of 63) of the citations were dated after the year 2000. While referring to classic works about the physician-patient relationship can be informative, PubMed shows more than 1,500 articles in this area since 2000.¹ The work in this area has been replete with studies showing evidence for the role of clinician compassion in benefitting patients’ physical health, psychological health, and motivation for self-care while driving down costs and improving the quality of care overall.² While the Circle of Change model may be one way to facilitate the physician-patient relationship to overcome impasse, it is not presented in the context of any other work currently being done in this area.

The Circle of Change presents a model addressing important facets of the physician-patient relationship in family medicine. Dr Trilling clearly cares about helping patients via overcoming clinical impasse. However, further work on the validation and generalizability of this model is needed to make a compelling case for its adoption.