Friday, 17 Nov 2017

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The Negotiator

This is going to be my third visit with this patient and I’m not looking forward to it.

In the first two, I discovered how sick she was and how, despite my handouts, efforts, insights and words, my educated medical expertise was totally wasted.

If I had said she was an albino and needed to avoid the sun, I would have expected she would only go out at night, invest in sunblock and do research on the rock and roll Winter brothers. Instead, she comes to each visit with sun-burnt, counter scenarios and ill-conceived plans based on mysticism more so than medicine.

I’m frustrated or fed-up. I see this next encounter as a contest of wills, instead of what it’s supposed to be. The fact that I’m dreading the visit makes me think either she is a difficult patient or I’m a poor communicator and physician.

Or maybe what we have here a teaching moment from “Cool Hand Luke”– “what we have here is a failure to communicate”. We talk, but we are not communicating, as there is no common ground, nor understanding.

What I’m hearing from her are a series of cockamamie thoughts, approaches, excuses and care alternatives. But what I’m not hearing from her is that she is afraid of what she doesn’t know or understand. Not realizing she doesn’t know what she doesn’t know, she relies on what she thinks she knows. Which is, medicines are bad.

We can agree, however, on how sick she is when she was in the hospital with her inflammatory malady complicated by its inflammatory consequences. She agrees she doesn’t want to go there again.

To be fair to her, what she hears from me is a bunch of technobabble and science gone bad inside her, and for no good reason. Only to be rectified by doses of chemicals that cost more than an Audi A8.

What she never got from me was hope, goals and rules -designed to explain and frame the malady and its challenges.

But it’s not as easy as hope, goals and rules. It’s much worse. It’s a negotiation.

“Getting to YES”, is a book about negotiation. I was first introduced to it by an administrator who I was tormenting before I left a job many years ago. Negotiations about my clinic were going poorly, as I firmly believed their proposed changes would be disastrous, while they countered with hallowed optimism and salary guarantees. Somewhere along the way they asserted that I was intentionally difficult and needed to change my attitude. (Pause here for those of you who know me and are now siding with the administrators, “oh yeah…. he can be a pain”. Read on, I may surprise you.)

A gentleman amongst administrators suggested I read this book as “it may help”. I read the book and learned a great deal. I nevertheless changed jobs and had a much happier ending than did the administrators.

The book is a good read and shows how negotiation is pervasive in our everyday lives, regardless of career or life status. The book doesn’t teach hard or soft negotiation styles, but rather "principled negotiation” which was developed during the Harvard Negotiation Project.

Principled negotiation is hard on the merits and soft on the people. Rather than focusing on what each will say, do or won’t do, you should focus on the merits of the issue, find areas of agreement and gains and resolve conflict based on fair (maybe measurable) standards. 

Negotiation is the art of give and take. Isn’t that what we do in medicine? But wait, it’s usually the doctor giving and the patient taking – that’s not negotiation, that’s dictation. Negotiation is a process whereby discussion leads to insight, concessions, compromise and ultimately cooperation.

Like it or not, you have to be a good negotiator to be a good physician. Chalk it up to one of the many things not taught in medical school or residency. The practice of medicine is learned by time, experience and the ability to learn from mistakes and triumphs. Hence my introduction to negotiation.

Negotiation with patients need not be adversarial and there will only be losers if you take the view that they need to believe you to get well and do as you say.

Conflict can easily negate your best intentions. Why is it that nearly half of all prescriptions go unfilled? Or that 48-73% of lupus patients are proven noncompliant and that 5 years later less than have are taking meds as prescribed? If not conflict, these stats are driven by mistrust, fear, intellectual inertia and more. Many of these problems can be overcome by effective patient negotiation.

Some Rules on Negotiation

  1. Negotiation on important matters, must be done face to face. Not be email, cell phone or texting. That would be bad medicine and management.
  2. Separate the patient from the disease. The patient needs to know they are not the disease. Lupus or RA or trigger finger is something they have acquired and now have to deal with – just as they would a flat tire or leaky roof.
  3. People issues are different from the problem (disease) has to be identified and dealt with in a different manner. Whether this stems from patient, family, behavior, finance etc. You need to better define expectations and rules for successful outcomes.
  4. Focus on goals and rules – what follows is accountability
  5. Shared decision making – patient encounters cannot be unilateral deliverance of prescriptions and plans. They cannot be outright rejection of the doctor’s treatment options so as to pursue nutritional advise or reflexology.
  6. Recognize the difference between dealing with substance versus the process by which you will deal with substance.
  7. Write it out and distribute for later review.
  8. Don’t take positions. Bargaining over positions escalates conflict and defines what separates your thinking. The more parties, the more positions the less agreement achieved.

When is negotiation called for? Some medical encounters are easy, devoid of conflict or problems. Thus, negotiation has its place and time. It is certainly in need whenever there a dilemma, misunderstanding, times of important treatment decisions, or future planning (e.g., pregnancy, travel, insurance changes) to mention a few.

My visit with my patient was a rough one. I wasn’t nice. But I was honest, pointing out the disparities in our communications. Each had to agree we needed to do better. We needed to agree on common goals and rules to live by. I had to listen and write down her priorities, concerns and begin to address those more sincerely and efficiently. She had to recognize that she is the CEO of her condition and needs to act accordingly. Accountable, forward thinking, smart and surrounded by those capable of giving good life and health advice.

The book referenced above is subtitled “negotiating agreement without giving in”. Neither had to give in, both left the room with a new plan and clearer goals.

I’m looking forward to my next visit with my patient.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He is the Executive Editor of RheumNow.com and Co-Editor of the online textbook RheumaKnowledgy.com. Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

Rheumatologists' Comments

Jack: Excellent ,thoughtful and well written.May I suggest two additional sources of info:A) any book on game theory which describes the end results of negotiation B :." What's Wrong with me? by Meghan O'Rourke in the New Yorker,2013.Might help with your next visit.
The author's viewpoint is understandable however he/she sounds frustrated by the power struggle with the patient for control. I suggest that the best way to win is not to play. I will talk about myself and my feelings about the situation (sad, mad, scared,glad) and ask the "magic question"-"How can I help you?" Once the patient commits to their own request, the patient will be less likely to be non-compliant as they are making the rules. In these situations,the more I talk about me and the less about them, the less defensive or oppositional the patient is. I tell the patient what I can and cannot do in case they have unrealistic expectations or a hidden agenda.