by Deepak Malhotra and Manu Malhotra | 12:00 PM October 21, 2013, Harvard Business Review
A 54-year-old man presents to the Emergency Department (ED) with crushing chest pain and is found to have an ST-elevation myocardial infarction (heart attack). The patient needs a heart catheterization with likely stent placement, but he insists on leaving the ED. The emergency physician is unable to convince him otherwise despite confirming that he understands the risks and consequences of his decision. He leaves and returns via ambulance several hours later in cardiac arrest. Could this story have ended differently? Quite possibly, yes. But not with skills that are taught in medical school. Now consider a host of other conflicts: from interdepartmental turf wars, to poorly designed agreements between hospital systems and insurance providers, to the difficulties encountered in aligning hospital goals and incentives with those of contracted physician groups. In these and many other interfaces within our health care system, the limitation is neither incompetence nor ill intent, but rather a dearth of negotiation skills and acumen.
Negotiation is the process by which two or more parties with different interests or perspectives attempt to reach agreement. The domains in which negotiation is relevant can vary widely. We might negotiate business transactions, international agreements, marital disputes, or just about any kind of conflict. Regardless of the context, however, negotiation is fundamentally about human interaction. Whether we are discussing money, terms of peace, spousal relations, or healthcare policy, the fundamental question that negotiation theory helps us tackle is this: how might we engage with others in a way that yields better outcomes and understandings? As anyone involved in the health care system knows, hospitals and health professionals are faced with this question every day.
With that in mind, we explore some of the ways in which a negotiation lens may be of value to medical professionals, administrators, and other stakeholders in the health care sector. In facing the inevitable tradeoff between breadth and depth of coverage, we have opted to focus on only a handful of core insights from the field of negotiations, while devoting more attention to providing examples of how these insights can be applied to doctors and hospitals. As such, this is not an overview of what is possible, but a mere sampling.
Here, then, are three insights that expert dealmakers and diplomats use in their practice and which can easily be applied within the healthcare arena.
Focus on Interests, Not Positions
Positions are what people want; interests are why they want it. One of the greatest obstacles to resolving conflicts is our tendency to focus on positions—which are often irreconcilable—rather than on underlying interests, which may actually be compatible. For example, trauma surgeons and emergency physicians at a Level I Trauma Center will often both demand that they should be in charge of trauma resuscitations. Since only one person can be in charge, the positions are fundamentally incompatible. But what are the underlying interests of each party? The trauma surgeons value the role of “Captain of the ship” as it is a requirement for Level One certification by the American College of Surgeons. The ED physicians may care little for that title, but are concerned about preserving the educational experience for their residents. A compromise that names the trauma surgeon as the Captain of the ship and allows the ED residents to lead the resuscitations and do the procedures addresses the interests for both parties.
Too often, health professionals fall into the trap of thinking that there is one correct answer (solution, diagnosis, prescription), and that it will win the day; but human interactions are more complicated than that. Consider the patient who was having a myocardial infarction and was informed that he needed a heart catheterization. Even after having all of his questions answered, he insisted on going home without having the procedure. The doctor could have dismissed this as irrationality and allowed the patient to leave against medical advice, but instead, in this case, he decided to dig deeper and ask, why, precisely, are you unwilling to do this? It turns out that the patient had a dog at home and he was concerned about abandoning the dog, possibly for days. A brief discussion followed by a phone call to a friend helped arrange care for the dog and allowed the patient to agree to the procedure.
Effective health professionals, like exemplary dealmakers, understand that having a learning mindset is essential in negotiation: you are there to figure out how the other person sees the world, what is driving their behaviors, and what precisely is keeping them from agreeing to your seemingly reasonable demands.
Framing Matters: It’s not just what you say, it’s how you say it.
There is an old anecdote about two monks. The first says, “I asked the abbot if I could smoke while I prayed, and he said no.” The other monk replies, “That’s strange. I asked the abbot if I could pray while I smoked, and he said yes.” When communicating, clearly the substance matters; but style and structure matter as well.
Over the past four decades, social psychologists, behavioral economists, and negotiation theorists have catalogued a wide variety of ways in which information can be communicated more effectively to nudge others towards collaboration and compliance. Let’s consider just one of the many healthcare domains in which such skills may apply: HIV testing is considered an important issue from a public health standpoint, but patients are often reluctant to sign up for it. Research on what has been called the status quo bias demonstrates that at-risk patients may be significantly more likely to get the tests done if the choice is framed as “opt-out” (the default is set at getting tested, but you have the choice to refuse) rather than “opt-in” (the default is not to be tested, but you can choose to do it). The key is to understand that going against the default option presents a psychological barrier—and this knowledge can be leveraged to increase testing. Other research, on loss aversion, offers yet another way in which to increase compliance: patients may be more likely to get the tests or treatments if the information is not presented as “here are the benefits of…”, but rather as “here is what you stand to lose if you refuse”. The same tactic may improve negotiation outcomes when it comes to securing funding for capital investments, research, safety initiatives, or hiring.
As another example of the relevance of framing, this one in the policy domain, diverse stakeholder groups (e.g., FDA, legislators, insurance companies, hospital systems and doctors) often negotiate over the appropriate risk/reward balance pertaining to new procedures, drugs or innovations. Research shows that our risk tolerance shifts depending on the way options are framed. People are relatively more likely to accept risk when choices are presented as means of avoiding losses and they’re more risk-averse when the same choices are presented as opportunities for gains. Consider, for example, a hospital administrator who must decide between two growth initiatives: opening a new clinic in a growing area versus the riskier option of merging with a neighboring hospital. Let’s say both initiatives have the same anticipated level of success (i.e., the same expected value), but the merger has both higher potential upside and potential downside (i.e., higher variance). Research suggests that when the options are considered with a “gain frame” (e.g., “we are doing well financially, now let’s try to do even better”), the less risky option of opening a new clinic will be relatively more attractive. But if the decision-maker adopts a “loss frame” (e.g., “margins have been shrinking and we want to avoid further erosion”), the preference may shift towards the riskier option of merging.
Negotiation Space: Keep an eye on all of the parties that are relevant to this negotiation, not just those who are at the table.
A 75-year-old man with a mild congestive heart failure exacerbation is seen in the ED and is treated and released with instructions to follow-up with his primary care provider. How likely is it that the follow-up appointment actually occurs? What would make it more likely? In Detroit, where one of the authors is an emergency physician, the doctor may now do the following: he asks the patient for the phone number and permission to call his daughter and recruits her to make sure he will make the appointment. She promises that he will not miss it. What many physicians have learned is that the daughter is a key player in this interaction and can significantly impact the likelihood of success.
A negotiation strategy is more robust if it takes into account all of the relevant parties; if someone can influence the negotiation or is influenced by the negotiation, you need to take that person into account. Should this person be involved in the discussion or kept out of it? What role might they play in the plan’s implementation? Might they be a spoiler? What do their interests and incentives tell us about their likely actions and reactions as the negotiation unfolds? With whom should we discuss matters first, and who should be approached later if we are to work towards consensus or cooperation?
Similar issues arise in myriad contexts, such as board room decisions that go badly in practice because front line medical professionals (doctors, nurses, etc.) are not brought into the discussion, or legislative and policy decisions that fail to take into account how the interests and perspectives of health care professionals and other stakeholders will support (or obstruct) the hoped for outcomes. A decision or policy may seem brilliant (or at least the best option) when considering the interests and constraints of the people at the table, but may become a terrible idea the moment you broaden your vision to include other parties that are relevant.
Negotiation, like the delivery of healthcare, is at its core about understanding and engaging with people more effectively. Health care professionals and administrators who develop the skills of effective negotiation will find that they are better equipped to heal, collaborate and innovate.
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