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Mayo Clin Proc. 2010 July; 85(7): e49.
PMCID: PMC2894730

Breaking the Cycle: How to Turn Conflict Into Collaboration When You and Your Patient Disagree

Reviewed by David J. Gullen, MD, MACP

by  George F. Blackall,  Steven Simms, and  Michael J. Green,  167 pp, with illus,  $39.95,  Philadelphia, PA,  American College of Physicians (telephone: 800-523-1546),  2009, ISBN  978-1-934465-18-9.

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Type and Scope of Book:

A multiauthored book that shows how to apply “systems principles” from family therapy to difficult relationships between physicians and patients.


This book describes an approach to challenging physician/patient relationships that was developed by George Blackwell (pediatric hematologist/oncologist), Steven Simms (psychologist and family therapist), and Michael Green (internist and medical ethicist). Using systems principles derived from family therapy, the authors created the “Symptomatic Cycle” framework and the “Physician as Collaborator” model as a format for analyzing difficult interactions among physicians, patients, and other members of the health care team. The initial chapters describe the key aspects of the 2 frameworks. Subsequent chapters use a case-based approach to demonstrate how to apply them. The cases represent common, difficult relationships.


The clinical examples are well-selected, well-presented, very “real” and common dilemmas in patient care. The authors highlight the importance of understanding the patient's perspective and building relationships with patients and others involved in their care. The “ARCH” approach to dealing with an impasse incorporates many of the core principles of relationship building.


For some of the cases, applying the model felt a bit “forced.” The authors' methods do encourage physicians to examine how their own behavior can create difficulties with patients. However, the key issues of understanding the patient's perspective, understanding the affects that one's own emotions have on an encounter, and understanding the importance of partnering with patients to develop a mutually acceptable approach could use more emphasis.

Recommended Readership:

All physicians, especially those in primary care.

Overall Grading:

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Articles from Mayo Clinic Proceedings are provided here courtesy of The Mayo Foundation for Medical Education and Research