Dr Claire Davies on ‘drama triangles’ and how to step out of them to avoid complaints
I once had a young male patient who had a constellation of vague but worrying symptoms, including weight loss. He had a spectrum of mildly abnormal blood tests and didn’t look great. It was hard to know what to do with him.
I spent a lot of time ringing around various consultants discussing his problems, but his symptoms didn’t seem to belong to any speciality. I also tried to refer him to one of the on-call teams who felt he didn’t warrant admission.
I managed to organise an urgent abdominal ultrasound, but the radiology department never sent out the appointment to the patient. Eventually, he was admitted with widespread carcinoma.
The hospital apparently told the patient that his GP should have referred him earlier. A few weeks following his admission, the patient wrote a letter of complaint saying that I had completely missed his cancer and had done nothing whatsoever about his symptoms. I was upset.
My own memory is different, of course: a lot of time spent consulting with him, phone call follow-ups and ringing secondary care. I am sure that many of you have experienced similar stories, because medical mistakes do happen, and we can’t please everyone all of the time.
However, it is common to hear of GPs receiving complaint letters after they feel they have gone the extra mile.
What are ‘drama triangles’?
Sometimes a complaint can be better understood by learning about psychiatrist Dr Stephen Karpman’s ‘drama triangle’ concept. He proposed that in conflict, there are often three people involved: the victim, the persecutor and the rescuer. Triangulation occurs with people switching roles between each point.
While my patient’s devastation was completely normal and understandable given the diagnosis, I had inadvertently entered a drama triangle with his complaint. So, I as the GP was the rescuer, the patient ended up as the victim and the hospital staff as persecutors. After the patient was rescued by the hospital, he then took on the role of persecutor towards me, and I became the victim.
Victims in drama triangles may sometimes present as powerless. They may recruit rescuers to validate their feelings and also persecutors to validate their positions. But this doesn’t last, and at one point, the victim will pull the switch and jump into another role.
Drama triangles can whizz round for a while unless we learn to recognise and step out of them. And each of us tends to have our own comfortable entry point. Unsurprisingly, the default point of many doctors is in the rescuer role. After all, we’re here to help, right?
We are also vulnerable to patients who present in their own default as victims or hospital staff who criticize GPs and may be unconsciously taking on role of the persecutor.
How can we step out of them?
To recognise when a drama triangle is at play and step out of it, ask yourself the following questions:
- Are you doing more than 50% of the work here?
- Could you be stepping in to help when actually help may not be wanted?
- Are you taking more responsibility than you should?
It can be helpful to think of keeping the responsibility in the middle. Using ‘we’ instead of ‘I’ or ‘you’ in certain consultations can help. Asking open questions about the way forward is also a useful way of sharing responsibility.
Acey Choy created the concept of the ‘winner’s triangle’. In this, persecutors can choose to take instead an assertive approach. Rescuers can still be caring but act more as coaches, with open questions that help the patient think for themselves, and victims can move into a stance of being creative.
We may become aware of our own warning signs. I now notice for myself that if I am suddenly making an awful lot of phone calls about a particular patient (as in my example), then I may be taking on more than my role. I could have been more insistent with secondary care that that particular patient needed a rapid outpatient appointment.
Drama triangles are clearly not applicable to every situation. If the patient is haemorrhaging to death in the waiting room, then yes, you should definitely be doing more than 50% of the work here!
But for situations that involve navigating systems, social and personal or emotional issues, or patients taking some responsibility, then drama triangles are at play all of the time.
If we can spot drama triangles, which take place with our patients, colleagues and families every day, we can avoid complaints and ultimately serve our patients in better ways.
Dr Claire Davies is a GP, coach and writer in East London
What was the point of the ultrasound?
Referral as 2ww, or direct access CT depending on local pathway.
If rejected, refer to another specialty.
Yes, I know its easy to say retrospectively. However, you had high index of suspicion something serious was going on to make you ring various departments.
This is the double edged sword of 2WW rule referrals. I’ve heard many times of GPs who diligently tried to investigate thoroughly their vaguely ill patients. only to be evicerated by the retrospectoscope when the malignancy was later revealed.
The “lazy”/smart GP has a ridiculously low threshold for 2WW referrals, safe in the knowledge that though they may be tanking the NHS, they are bulletproof no matter what the diagnosis turns out to be.
Meanwhile, the conscientious GPs who cling to the myth of their noble gatekeeper role must suffer the slings and arrows of outrageous fortune for trying to do their job properly..
And whilst our medicolegal system remains rigorously rigged against us, we should all learn the lesson to refer 2WW with the flimsiest of evidence, or be forever damned as incompetent fall guys..
Thanks Claire for your insights: your story emphasises how vulnerable we are as GPs and how clinical General Practice is what can be thought of as a ‘high risk’ profession
Claire I am now retired but you only need to experience this issue once to bring into sharp focus how do deal with these situations. I am not sure about all this triangle business or if it can apply in this instance. The Golden rule is to keep the patient invested in the process by explaining for example that you are referring for an US and when you expect they should reasonably expect to receive an appt.
If they have not heard then they must phone you to allow you to follow it up.This means that the situation remains live and open not closed.
This process can be applied to most systems. Yes i know about wait times ect but this is beyond your control
For every action you take regarding the patient expect an investment from the patient and an undertaking of joint responsibility moving forward.
The first sentence in your article speaks volumes.You wont make this pathway choice again.
Isnt it unprofessional for hospital doctors to criticise GP’s glibly without knowing the full facts?
Interesting triangle but until the balance of power and justice are adjusted, expect the complaint. The system is broken and it pays the patient to complain and sue.
I wish the hospital doctors wouldn’t say these flippant comments to patients. Usually doctors who haven’t worked in GP and don’t realise, unlike them, we can’t order a CT chest/abdo/pelvis on whoever we want.
But of course, Claire, it is only ever one you have gone the extra mile for, that cames back to spite you. If you had felt guilty at the time for sending them away with short shrift, they would probably praise you to the ends of the earth. It does not make much sense does it. I suspect the attitude at hospital has a lot to do with it!
Yes, Paul and Emily, you are quite right it is unprofessional and contrary to GMC guidelines (I have not read the RCN ones), but now hospital staff are allowed to rubbish GPs because they can hide behind ‘duty of candour’ even when their criticisms are unfounded or even malicious. GPs are not allowed to do likewise, of course.
Important to remember that the hospital doctor may not have said the GP should have referred earlier. This is the patient’s interpretation of what was said.
The specialist may have stated a simple fact like “unfortunately because it’s so advanced, treatment is less likely to work”, and the patient may have added the bit about this being the GP’s fault.
Key here is the latest colorectal 2ww guidelines re: bleeding, bowel habit, weight loss, abdo pain.
I was caught out by this too and at times it’s almost impossible to keep up with the guideline changes.
Now retired but last I checked all > 40s with abdo pain and wt loss need 2ww referral.
This is different to bleeding, and bowel habit and positive FIT which is > 50, even doing a FIT is for > 50’s.
Anyway there is latitude for ‘6th sense’ for worrying other symptoms on 2ww particularly wt loss.
In my case pt early 40s abdo pain and wt loss only, exam normal, bloods and calprotectin normal.
Unable to have FIT as 40.
2ww pathways are a nightmare anyway because they are so prescriptive, reject referrals if all workup not done, and labs won’t do tests where there is an age cut-off.
I never heard back so assume no action taken!
Anyway as everyone has said, sod it and do the 2ww first off if you can to avoid a world of pain.
Forgot the important bit – I had referred urgent abdo CT not 2ww – ca with mets, the referred 2ww, pt had rapid deterioration and died.
I did a 2ww for old chap w mild jaundice, weight loss anorexia debility. Was rejected. Had to go in as emergency through A&E 🤯
Another similar w significant anaemia had to be admitted for transfusion as couldn’t get 2ww to accept.