Doctors negotiate every day, almost constantly — sometimes dramatically, often imperceptibly. They hold family meetings to resolve sensitive end-of-life issues. They address barriers to medication adherence. They encourage patients to receive uncomfortable screenings like colonoscopies and mammograms. They refuse treatments that are requested but not medically indicated. Yet they receive almost no formal instruction in how to do so.
Dealing with medical colleagues creates an additional layer of negotiating complexity—especially in busy academic centers with competing demands on specialists’ time. Medicine is increasingly a team sport. In 1970, only about 2.5 full-time clinical staff cared for the average hospital patient; today, that number is greater than 15.
Doctors consult other doctors many times a day to discuss potential treatment options and decide on the best course of action. They work closely with residents, students, nurses, physician assistants, care coordinators and others to implement those plans. At each interaction, opportunities for collegiality and efficiency — or rancor and resentment — abound. That can mean the difference between a timely or delayed blood draw, accepting or refusing a consult, or getting those biopsy results today versus tomorrow.
Recognizing the importance of negotiation, medical schools are starting to invest in communication training for students — and it seems to be paying off. Research suggests communication training can improve patient adherence, diagnostic accuracy and chronic disease management. But good communication, by itself, is only part of the solution. We need to teach doctors how to negotiate.
Negotiation, in this context, is not about winning or losing, or haggling over price or scare resources. It’s about exploring underlying interests and positions to bring parties together in a constructive way. It’s about creative, innovative thinking to create lasting value and forge strong professional relationships. It’s about investigating what is behind positions that may seem irrational at first to understand the problem behind the problem.
The medical profession is no longer one in which doctors dictate a given treatment course to patients, who are then expected to follow it. Rather, clinicians and patients deliberate about treatment options, weigh costs and benefits together, and determine the best course of action. This approach requires eliciting patient concerns and addressing underlying fears to arrive at the most effective strategy for maximizing health and well-being. As diseases like H.I.V. and some cancers that were once uniformly fatal become chronic conditions, and a greater diversity of treatment options becomes available, the ability to negotiate long-term care plans will only grow in importance.
Physicians are also increasingly assuming leadership roles. They are expected to negotiate with a vast array of third parties, including health plans, governments and pharmaceutical companies. Health care changes double down on this expectation. The Affordable Care Act creates incentives for doctors and hospitals to band together to create networks known as Accountable Care Organizations — provider groups responsible for caring for an assigned patient population. Under new Medicare rules, providers can be paid less if they have low patient satisfaction scores or excessive readmissions. As quality metrics and cost-effectiveness play a larger role in reimbursement, physicians will need to negotiate with governments and insurers to establish fair and reasonable performance measures.
Each medical encounter, then, becomes a multiparty mini-treaty signed by doctor, patient and family members — and sometimes, consulting physicians, ancillary staff, insurers, hospitals and governments. Law, business and public policy schools all offer classes in negotiation, recognizing the interdisciplinary and interdependent nature of their professions. Isn’t it time medical schools did, too?
Remember, almost everything is negotiable.
Dhruv Khullar is a dual degree candidate at the Yale School of Medicine and Harvard Kennedy School, where he is a fellow at the Center for Public Leadership. Follow him on Twitter:@DhruvKhullar.
Teaching Doctors the Art of Negotiation - The New York Times