The Art of Negotiation in Medicine

When we talk about the “art and science” of medicine, the ability to negotiate with patients and colleagues clearly falls under the “art” part. And, while more and more medical schools are recognizing the importance of teaching communication skills, like breaking bad news, I don’t know if any school is teaching the art of negotiation yet. The ability to negotiate probably immediately comes to mind when thinking about dealing with non-compliant patients. But, the ability to negotiate also comes into play (even more frequently?) with colleagues –maybe just in a less dramatic way. A recent post in the New York times explored the many situations in which physicians find themselves negotiating on an almost daily basis.

Calling some patients “difficult” may be a polite understatement –but we will use it here. A difficult patient can range from someone who doesn’t take his or her medication regularly to someone who checks himself out of the hospital AMA. Attempting to negotiate with difficult patients takes skill and can often improve with experience. That said, the article left me with some nice take-aways, like:

1. Ask the patient if you can take a few minutes to talk about the situation. (Asking the patient levels the playing field and gives the patient buy-in.)

2. Acknowledge frustration and express sympathy. (Everyone likes his or her feelings validated. And, this also demonstrates understanding of the situation.)

3. Be humble. Admit if mistakes have been made, or service has been less than stellar, and apologize. (A small apology and a bit of modesty can go a long way.)

4. Ask the patient, in a non-judgmental way, why he or she is behaving the way he or she is. For example, “How come you haven’t been taking your meds twice a day?” or “Why are you leaving the hospital?” (Often answers to simple questions can give important information and can help inform a mutually agreeable solution.)

To negotiate with colleagues is a very different animal. The author referred to modern medicine as a “team sport” often involving many physicians taking care of the same patient. He sited an interesting statistic that said, in 1970, the average inpatient had 2.5 doctors taking care of him or her, while that number has risen to more than 15 per patient today. Thus, physicians may often disagree over care, and to try and persuade a colleague to one’s way of thinking may often be viewed as a challenge or threat to his or her clinical judgement. The author suggested that every interaction with a colleague is an opportunity for a positive or negative interaction. And, instead of viewing the interactions as win or lose, they should be viewed as collaborative and trying to understand the other’s side and working from there –that’s when the negotiations should begin.

Finally, while we love the willingness of physicians to negotiate with colleagues and difficult patients, we would also like to take a moment to do what we do best, which is to comment on the med mal liability aspect of this topic. While negotiating and being flexible, we would like to remind our health care providers to still stick to appropriate standards of care so they don’t expose themselves to undue risk.