The Doctor-Patient-Family Triangle: Training Residents to Work With Triangulation in the Clinic Encounter

This is is part of the Pecha Kucha: A Special Families and Health Blog Series.


Studio portrait of Valerie Ross.

Valerie Ross, MS, LMFT

At age 9 I took up the cello. It has been one of the joys of my life and surprisingly an important influence in my approach to teaching physicians.

To learn to play an instrument, you perform in front of a teacher who uses everything they know to coach you to play proficiently and musically. They first listen, they demonstrate and teach specific skills like how to hold the instrument or draw the bow, asking questions and offering encouragement. Then you go home and practice and come back for more coaching.

Imagine for a moment if we taught musicians the way we teach most health care clinicians. A learner would rarely play their instrument in front of their teacher. They’d describe their perception of their playing. We’d learn how they think about playing their instrument but not how they actually play. It does not make sense to us to think about training musicians or athletes without observation and coaching, and yet this is the way many health care providers are taught. We need to define, hear, see, and model the concepts and skills we want our learners to practice.

As a family therapist and behavioral scientist in a family medicine residency, I regularly observe residents in clinical encounters; in this context I find opportunities to teach them about the family systems concept called triangulation.  

Two founding fathers of a family-oriented primary care approach, Bill Doherty, PhD, and Mac Baird, MD, observed that the doctor-patient relationship is always a triangle involving the clinician, the patient, and the family.


A clinician can use her or his position in the triangle therapeutically. However, if we are unaware of this triangle, we neglect to think about family members who are not in the room and we risk the possibility of unconscious “triangulation.”

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Family-Centered Integrated Care

This is is part of the Pecha Kucha: A Special Families and Health Blog Series.

Family systems theory is the foundation upon which family-centered care is built. The following patient story illustrates two aspects of this theory. Although Erica is not her real name, her story is real, and she has given permission to share it to help demonstrate the value of family-centered integrated care.


Dan Felix, PhD, LMFT

Erica’s type 1 diabetes had been managed pretty well since she was diagnosed at age 6, but now at 19 she was being admitted to the hospital four or five times a month in diabetic ketoacidosis. Although Erica is not her real name, her story is real, and her story demonstrates the value of integrated care. More importantly, it demonstrates the value of family-centered integrated care.

Erica’s physicians—the family medicine residents who I teach—provided appropriate medical treatment each time she was hospitalized. They then sent her home only to see her back the following week with higher levels of blood sugar. “Why don’t you just take your medication?” was answered only by a gentle shrug of her hospital gown-covered shoulders. I was invited into the case with “Dr Felix, fix her. She’s not right in the head. She claims she doesn’t want to die but she sure is acting like it.” So I chatted with her at the bedside a couple of times, which was enough to convince her to come to see me in the clinic between her hospitalizations.    

At first, we didn’t discuss her diabetes. Instead, I found out that she has been with her boyfriend for several months, which was a big deal to her. Relationships, I discovered, had never come easy for her, especially since childhood during which she endured abuses and betrayals.

During the next appointment, with her boyfriend in the room, we explored what keeps them together and what pushes them apart. With amazing courage, she vulnerably declared her belief that she couldn’t stop being hospitalized because if she did he might leave her. We drew out their cycle. This is the actual paper we used:



Some people have been known to say things like, “I’ll kill myself if you break up with me” as an attempt to keep their relationship intact. She didn’t have to kill herself. Her uncontrolled diabetes was doing that for her. She simply needed to allow herself to be sick and he would rush in like Superman to save the day. He would manage her meds on her behalf to rescue her from this villainous disease that she appeared to have no control over. I remember when he first grasped what was going on. He turned to her and asked, “Is this true?” She sheepishly nodded that it was, to which he responded by abruptly leaving the room unable to look her in the eye. Thankfully he was willing to reenter, re-engage, forgive, and begin to work through it with her.

This cycle had been reiterating for many months. I went back through her medical records at both of the hospitals where my residents had treated her and mapped out a timeline of her hospitalizations.


Notice the drastic stop in blue and green lines (admissions to both hospitals). Why did they so drastically stop? Had we finally found the correct medication and dosage for her? The red lines are the family therapy appointments I had with her, and the purple ones are the outpatient follow-ups she had with our residents. She had traditionally no-showed most of her outpatient appointments because, I suppose, they weren’t medical crises where she was getting her emotional attachment needs met.

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Inspiring, Career Informing, and Irreplaceable

Isabel Chen_F4TScholar2017

Isabel Chen, MD, MPH

Inspiring, career informing, and irreplaceable—these words barely capture the rich and humbling experience of serving in STFM leadership. Taking on the dual role of Resident Representative and Graduate Medical Education Committee member gave me the insight and voice to advance the breadth and impact of our specialty and I am deeply appreciative of the opportunity.

When I started my term, I felt welcomed wholeheartedly by the board and the committee. I found like-minded mentors and role models committed to advancing the training of this country’s primary care workforce so that it serves our trainees, our patients, and our communities at large. These leaders and change agents embodied the best of family medicine and it was an honor to join their company.

This past year was a well-rounded experience for leadership development. Committee work included creating tangible deliverables to STFM members, like our Residency Faculty Fundamentals Certificate Program, and participating in research projects and conference presentations. Serving on the board challenged and strengthened my strategic and organizational skills. I strongly recommend the experience to any trainees passionate about the recruitment, training, and future of our workforce and our impact on this country’s health and wellness!

While I am already mourning the end of my tenure, I think about how deeply STFM has shaped my career path and I look forward to a long career as an active STFM member!

Thank you to all in the STFM family for making this an unforgettable year.