Originally published in Forum, Vol 20 No 6, December 2000
By Leonard J. Marcus, Ph.D. and Barry C. Dorn, M.D. Leonard Marcus is Director, and Barry Dorn is Associate Director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health.
We negotiate all the time. At first glance, most physicians assume that negotiation involves merely the tangibles of medical practice: space, reimbursement, contracts, equipment, and staff. In fact, negotiation encompasses more than that. Negotiation also affects intangibles: information, respect, reputation, participation, and expertise. In its most basic form, negotiation occurs with each interaction among colleagues, other providers, insurers, and other health professionals. Whenever we are involved in a decision or action that affects or involves someone else, and in which one party does not have complete control, the interaction can be defined as a negotiation.
As patients become better educated health care consumers, negotiation becomes a natural framework for guiding the physician-patient relationship. Every interaction requires an exchange of information, confidence, hope, and credibility: the "negotiation intangibles" necessary for constructing the diagnosis and treatment plan. Ultimately, both patient and physician derive benefit when each is part of a constructive process and a satisfying outcome.
A 34-year-old woman had seen her internist with complaints of a pea-sized right breast lump that would decrease in size following her period. Her history included a maternal grandmother with breast cancer. At a repeat examination after her menstrual cycle, the internist documented that the lump had decreased in size. The physician instructed this patient to schedule a mammogram, but she did not follow up. Eighteen months later, a biopsy revealed a poorly differentiated tumor with lymphatic involvement. A suit against the internist was settled in the high range.
In this example, a broader discussion may have first revealed the depth of the physician's concern with the patient's family history as well as the gravity of the persistent lump and need for further investigation. It may have uncovered the patient's fears of a positive finding coupled with doubts about payment issues. The physician and patient could then have worked together to identify emotional and financial support leading toward a clear diagnosis and treatment plan.
In the give-and-get of the physician-patient interactions, you want to exchange useful information with your patients; you want them to become invested in their care plan. If patients have concerns or reservations, you want to know what those are. This is the only way that you can obviate their worries and make them feel invested in and comfortable with the plan. The more information you have, and the more accurate and timely it is, the better you are able to combine your expertise with their experience to devise a responsive, balanced plan with which they'll comply.
Good negotiation requires good communication skills. Patients want their physician's attention, expertise, and ongoing concern. Patients want a doctor in whom they can have confidence: someone who will be their advocate. Steps in the negotiation process include:
If the exchanges between physician and patient are honest, forthright, and respectful, then the chances of having a constructive clinical relationship that reaps mutually beneficial goals are enhanced. Both you and your patients will find greater satisfaction by the range of measures that ascertain success: quality and cost effectiveness along with personal and professional accomplishment.
