June is always a bittersweet month, at least in academic medicine. We get to look forward to a new fresh set of faces coming into our training programs, but we also have to say goodbye to those once-fresh faces that have progressed through their medical education journeys. These transitions are never easy, neither for the trainees nor for programs. Yet they are an inevitable part of our lives, and they provide milestones that allow us to assess how far we’ve come.
To those fresh faces entering our specialty: I want to welcome you with some advice as you progress through fellowship.
What is a winner’s triangle, and why is the concept so important? Let’s rheuminate!
Winner’s Triangles
The winner’s triangle is a concept developed by Acey Choy in 1990 and was based on mid-20th century theories about social relationships.1 These theories are part of transactional analysis, a psychoanalytic framework in which social interactions are analyzed to determine the ego state and understand behavior.2 Because this magazine is not The Psychologist, I’ll spare you the details, but will simply say transactional analysis has its origins in Sigmund Freud’s ideas.
One social model that came about from transactional analysis was the drama triangle, described by psychiatrist Stephen B. Karpman, MD, in 1968.3 Dr. Karpman envisioned triangles that mapped onto relationships. At the three vertices are three roles: the victim, the rescuer and the persecutor. According to Dr. Karpman, victims believe they are powerless at the hands of a perceived persecutor and seek help from a rescuer. Unfortunately, according to theorists, these relationships then reinforce each other and take on a life of their own, with people exchanging roles.
Personally, I find this social model overly negative, simplistic, fatalistic, manipulative and misanthropic. It certainly seems to be a product of its time, and although some aspects do resonate, I’m not sure it captures the gist of the human experience. This was the basis for Acey Choy’s innovation, first published in 1990 and further elaborated on in 2009.4 Rather than a drama triangle comprising victims, rescuers and persecutors, the winner’s triangle comprises creators, challengers and coaches. These are the relationships I would strongly encourage all trainees, if not all rheumatologists, to engage in.
Create Your World, Fellows!
In the 21st century, the word creator has a somewhat relaxed meaning. We may hear about “YouTube creators” or “job creators” and immediately roll our eyes. The creator in the winner’s triangle is less about the creation of products and services than the creation of worlds. Creators are outcome-oriented and embrace a sense of agency to create the world they would love to live in. In contrast to the victim role—a term I don’t like—creators contextualize problems within larger systems and consider how they can produce solutions to issues.
For rheumatology fellows and rheumatologists, this is an essential trait. Rheumatology is defined by creativity and a desire for creative solutions. The proliferation of new science within the worlds of immunology and musculoskeletal medicine is not the result of frustration, but rather of imagination—the ability to see a world in which arthritis and autoimmune disease are relegated to minor nuisances. Throughout their journeys, rheumatology fellows are at the leading edge of this creativity. Embracing the incremental steps is what’s necessary to continue the steady progress we have made to improve the world.
It may sound like a lofty goal, but I assure you that becoming a creator is not a burdensome task. Certainly, it requires a mindset toward resolving a dynamic tension between the world today and a dream. Even more important is a conviction that small, incremental steps are leading to our continual growth and to a better world at large. Deriving satisfaction from seeing each patient as a learning opportunity, joy from minor discoveries gleaned from textbooks, journals and The Rheumatologist, and camaraderie from colleagues are all actions of creators within rheumatology. But as Acey Choy mentions, you cannot do it alone. Being part of a winner’s triangle lightens the load, so you can be the most creative creator imaginable.
The Coach in the Corner
Anyone who has ever watched a movie or read a book knows what it means to have a coach. They come in many different shapes, sizes and forms, but they all are supportive of the main character or, in this case, the creator. Coaches dig deep within themselves to find compassion and empathy for others. Unlike the rescuer in the drama triangle, coaches recognize the sovereignty of those who seek their help. Instead of appropriating another person’s problems as their own and solving those problems directly, coaches recognize the agency of the people they coach and help them navigate ways for creators to obtain better outcomes.
Fellows can be excellent coaches, not only to each other, but also to those around them, including faculty members. A key competency that coaches and outstanding fellows share is curiosity. If you sincerely ask your colleagues how they are feeling, you are on the right path to becoming a great coach. If you raise your hand during a conference and provide insights into solving a longstanding clinical dilemma, that’s significant coach-like behavior. Moreover, one model of patient-physician relationships is as the coach (physician) who empowers the patient with their knowledge and skills.5 Fellowship is a great time to learn the competencies enabling this relationship dynamic.
It must be stated that there is a fine line between being a coach who helps solve problems, and being a rescuer who reinforces a relationship to another person based on a problem. My advice to you is to be your own best coach first; think about how to solve your own problems before reaching out to help solve others’ problems. Remain a coach, rather than becoming a rescuer, and maintain your well-being enough to continue being a coach.
Enter the Challenger
The last, and perhaps most misunderstood, member of the triangle is the challenger. The challenger is assertive and may drive the situations in ways that creators and coaches may not immediately appreciate. In the drama triangle, they are considered persecutors, whose actions are controlling and blaming. Challengers may criticize others in the triangle, but do so out of a desire to clarify the needs of a situation or a person. Much like coaches, challengers must be aware of their own limits and not overstep the bounds, disrupting the delicate lines of the winner’s triangle. They must challenge themselves first so a balance can be maintained in prompting a challenge while respecting others’ limits.
Fellows encounter a number of challengers throughout their training, including faculty members, co-fellows and others. Having challengers who are empowered to question assumptions is very important for fostering growth. In fact, it’s hard to imagine that without a healthy relationship to a challenger in fellowship, a creator can enter a growth mindset. Just as importantly, fellows must become challengers themselves. As part of their jobs, they must challenge healthcare systems to be more human centered and empathic. It’s not easy when you feel like you are at the bottom of the hierarchy, but that is why we have roles as coaches and creators.
Strengthening the Triangle
If these roles sound familiar to you in your everyday professional life, I’m somewhat envious. Very few people are naturally gifted creators, coaches or challengers. Even fewer are fortunate enough to have social networks that coincide to form these winner’s triangles. Yet the power of this social model is that we can construct our own triangles.
The first—necessary—step is self-reflection. Transactional analysis, on which the winner’s triangle is based, is all about getting into the right ego state. Embracing well-being, in all its facets, is necessary to get into a state in which we can objectively look at our relationships and find the creators, challengers and coaches that we need to succeed. Of course, there is no easy way to self-reflect. Such activities as meditation, journaling and peer feedback can help us develop the skills for, and practice of, self-reflection and self-awareness. That way, at least one vertex of the triangle can be established.
The next step is to branch out and find the other aspects of the triangle. This depends on the environment. Despite wishful thinking to the contrary, we can’t just mindset our way out of a malignant environment. But we can gravitate toward people who seem to have a knack for creating, coaching and challenging. And, by reciprocity and long-term interactions, we can shape the contours of those relationships so we get robust winner’s triangles. Every environment is different so approaches must necessarily be personalized.
The third and most essential step is retaining those relationships. That is where June and the turnover of fellows comes to be so important. These triangles are embedded within the panoply of other shapes and relationships. Ensuring the winner’s triangle remains sharply delineated yet responsive to changing needs and desires is vital. Critical to understanding the winner’s triangle model is that we rotate through the different roles in the triangle. Gaining greater self-awareness of when we switch roles and how we do so in our relationships can fortify that triangle even more. Alternatively, when triangles no longer serve their intended purposes, we must muster the strength to break those old triangles and create new ones.
A Kaleidoscope of Winner’s Triangles
The last quirk of the winner’s triangle is that we are only looking at it from a single perspective. The fact is that we are coaches and creators and challengers to multiple people in multiple settings simultaneously. Winner’s triangles intersect each other in both expected and unexpected ways. Some triangles may synergize with others and other triangles may lead to interference. Such is the complexity of human relationships. They cannot be reduced to elementary school shapes.
Luckily, rheumatologists do not enjoy simplicity. We revel in the complexity of the immune system’s interactions. The complexities of ligand-receptor relationships are never far from our minds, and we navigate the dangerous, narrow channels of prior authorization daily. Embracing that complexity when it comes to our interpersonal relationships may be the greatest lesson that we can learn from our rheumatology fellowship training.
Winner’s triangles can be deceptive, in that they may seem easy to construct and to dissect, but in real life, they are difficult to generate and sustain. We all have coaches, creators and challengers in our lives, and we are often each of those people. But aligning these people in these roles to mutually empower one another is difficult.
June is a bittersweet month. It’s the last month of stability and certainty in the academic calendar before all the change forces scramble many of our professional relationships once again. But that scrambling is not necessarily a bad thing. We can draw upon our strengths to construct winner’s triangles in the world around us. We can welcome the next crop of rheumatologists into a specialty that coaches, creates and challenges one another for the benefit of our patients. June 2024 will come and go in a blink of an eye. So too will the entirety of fellowship. But, with some dedication, the relationships that enable you to win will sustain themselves forevermore.
Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X @BharatKumarMD.
References
- Choy A. The Winner’s Triangle. Transactional Analysis Journal. 1990;20(1):40–46.
- Seow HY, Wu MHL, Mohan M, et al. The effect of transactional analysis training on emotional intelligence in health professions students. BMC Med Educ. 2022;22(1):383.
- Lac A, Donaldson CD. Development and validation of the drama triangle scale: Are you a victim, rescuer, or persecutor? J Interpers Violence. 2022;37(7–8):NP4057-NP4081.
- Emerald D. (2016). The Power of TED* (3rd ed.). Edinburgh, Scotland: Polaris Publishing. ISBN 978-09968718-0-8.
- Bodenheimer T. Coaching patients to be active, informed partners in their health. Fam Syst Health. 2020;38(2):190–192.
