“Understanding Clinical Negotiation” means finding and holding common ground with patients. The requisite skills are fundamental to patient-centered care. Thus, this book is addressed mainly to practicing generalist physicians, nurse practitioners, and physicians’ assistants, as well as students and post-graduate trainees aspiring to become accomplished clinicians.
Caring for patients can be uniquely rewarding but also uniquely challenging. It is not getting any easier. Over the past half-century, the number of available diagnostic and therapeutic technologies has increased greatly. At the same time, the information environment has changed dramatically. Both clinicians and patients are exposed to a tidal wave of health-related information of widely varying quality. Meanwhile, practice environments have grown increasingly complex, so that patients do not always know who is in charge of their care, where they can go for after-hours emergencies, and how much it will cost. There are times, therefore, when patients and clinicians find themselves at a loss. Ginned up by direct-to-consumer advertising, the internet, and text messages from concerned relatives, patients approach the clinical encounter with more specific and more exacting expectations than in the past. In trying to provide high-value care, maintain patient safety, preserve patient satisfaction, and restrain costs, it is the rare clinician who does not sometimes feel overwhelmed, as the current literature on physician burnout amply testifies. This book argues that knowing what patients want and working with them toward mutually defined goals is the essence of good patient care. Skillful clinical negotiation can also augment the rewards, and help overcome the challenges, of clinical practice.
While the actual writing of this book began in 2019, its genesis is much longer. For almost 40 years, one author (RLK) has taught and practiced general internal medicine at teaching hospitals while developing a research program focused on patients as agents for their own quality of care.1 Working with patients and performing patient-centered research not only is intensely gratifying but has produced gratifying synergies; many research ideas (and almost all of the good ones) emerged directly from issues, challenges, or questions arising in the care of patients in the clinic and on the wards. Over roughly the same period, the other author (RLS) applied the tools of communication science to examine the uniquely human endeavor of health care, while simultaneously contributing to theories and methods that help sustain the field. Although never at the same institution, RLK and RLS have collaborated on numerous projects for over two decades. Their complementary perspectives as a clinician and communication scientist contribute to what we hope is the unique character of this book.
Why Clinical Negotiation?
To some clinicians, the term “negotiation” will sound dissonant, foreign, and disconnected from more traditional framings of clinician-patient communication. After all, books with the word “negotiation” in the title are usually shelved with books on marketing, sales, and leveraged buy-outs, not with books on health and medicine. Yet we have chosen clinical negotiation as our focus for three reasons.
First, the concept of clinical negotiation has a distinguished history. To the best of our knowledge, the term was introduced in 1975 by psychiatrist Aaron Lazare and extended to general medical practice several years later by psychiatric services researcher Wayne Katon and psychiatric anthropologist Arthur Kleinman.2,3 These pioneers in the art and science of the clinician-patient relationship meant for “negotiation” to mean nothing more—and nothing less—than a conversation directed at clarifying and achieving mutual goals. In this sense, clinical negotiation is the intellectual forebear and close cousin of shared decision-making.
Second, framing the clinical encounter as a negotiation not only illuminates the underlying communication processes but extends the range of our analysis. The most critical tasks of the clinician-patient encounter are, we would argue, to identify patients’ most fervent aspirations, clarify goals, and develop appropriate plans. Optimally, these plans should be concordant with the patient’s wishes, aligned with their interests and values, and consistent with professional knowledge. In this sense, negotiation is not merely a tool for conflict resolution but an approach to clinical care in its entirety: from defining and naming the problem, to engaging in mutual exploration of goals and means of achieving them, to agreeing on a diagnostic and therapeutic plan that is both medically sound and personally acceptable.
Finally, clinical negotiation is even more relevant to the study of clinicianpatient communication today than it was in the time of Lazare, Katon, and Kleinman, for the simple reason that there is far more to negotiate about. Health care teams and systems are more complex. The diagnostic and therapeutic armamentarium is larger. Sub-specialization concentrates expertise but further balkanizes the profession. Patients are exposed to a confusing array of health messages appearing in traditional and social media, in direct-to-consumer advertising of prescription drugs, and in marketing materials produced by the very health care organizations from which they seek care.4 In this evolving landscape, finding common ground through effective clinical negotiation is both more challenging and more important than ever.
What the Book is (and isn’t) About
This book is about identifying, understanding, and responding to patients’ wants, needs, desires and expectations in ways that leads to better outcomes for patients and more satisfying health care relationships for everyone. The primary purpose is to equip front-line generalist medical practitioners—primary care physicians, hospitalists, nurse practitioners, physician assistants, or those training for these roles—to recognize the contours of clinical negotiation and how to reach a satisfactory resolution as quickly and efficiently as possible. While our aims are pragmatic, we also hope to show how health communication research has informed our understanding of how patients think, what doctors say, and how clinicians of all stripes can more effectively guide patients and their families towards the pursuit of better health.
This book covers a lot of ground, but in our effort to keep the manuscript to a manageable size and to stay in an authorial lane defined by our joint experience and expertise, many important topics receive less attention than they deserve. Perhaps most pressingly in the current moment (when policing methods, systemic racism, and social unrest are all in the news), our coverage of health disparities, cultural competence, racism in medicine, and diversity and inclusion within the health professions is incomplete. However, we have tried to be sensitive to these issues from a stance of genuine cultural humility5 while still emphasizing universal communication principles. In addition, while we do address the contribution of health care systems and organizations to the clinical negotiation, we focus largely on what individual practitioners can control: their relationship with patients and with other health care professionals. Even there, we do not attempt systematic coverage of the many permutations of interprofessional conflict and cooperation, focusing mainly on clinician-patient, physician-physician and nursephysician interactions.
This book is directed toward a broad audience. In referring to health professionals engaged in the diagnosis and treatment of diseases, we incline towards the term “clinician,” which is meant to be respectfully inclusive of physicians, advanced practice nurses, and physicians’ assistants as well as those who are training to join their ranks. Especially but not solely in Chapter 10 (Negotiating with Physician Colleagues and Other Health Care Professionals), we refer specifically to “physicians” when it seems likely that the scenario under discussion is primarily relevant to medical doctors.
Except for the partial transcripts of Chapter 8, the clinical vignettes presented throughout the book represent composites of our clinical and research experience. All names are fictitious. Regarding the use of personal pronouns, our writing style tends to alternate between he, she, and they, though not necessarily in equal parts. While we have tried to celebrate and mirror the diversity of patients, clinicians, and clinical scenarios that readers will encounter in practice, we apologize in advance for any lapses.
The book’s format lends itself to several learning styles. Practitioners, trainees, and students interested in gaining a thorough introduction to clinical negotiation will benefit from reading the book from cover-to-cover, taking time after each chapter to review the bulleted summary points, answer the discussion questions (or better yet, talk about them with peers), and apply any learnings to their own interactions with patients. This approach will also work well for students training to be physicians, advanced practice nurses, physicians’ assistants, or health care administrators for whom the book is employed as a text in courses covering the clinician-patient relationship, medical interviewing, health communication, or health administration. However, each chapter is relatively self-contained, so that readers drawn to particular aspects of the clinical negotiation can gainfully attend to the parts of the book that most interest them.
The book is organized into three parts. Part 1 (Background and Rationale) prepares readers with the fundamental vocabulary and concepts needed to adopt strategies and handle situations introduced subsequently. In two introductory chapters we define clinical negotiation and patients’ expectations, desires, and requests; introduce a model for clinical negotiation; trace the origins of patients’ expectations (including their hidden meanings); and examine the economic, social, and cultural forces that influence how the clinical negotiation unfolds.
Part 2 (Barriers and Strategies) covers specific structural features of the health care system that influence clinical negotiation; strategies for fostering patients’ full disclosure of relevant information; methods for raising awareness of and managing emotions in clinical care; the power of empathy; and the importance of physician self-awareness and self-control. This part of the book closes with a chapter wholly devoted to our MASTerDOC strategy for undertaking successful clinical negotiation, including modifications for patients from varied cultural backgrounds and patients perceived as “difficult.“
Finally, Part 3 (Applications) considers a wide range of applications including approaches for negotiating around tests, prescriptions, and referrals; negotiating with patients who have been prescribed controlled substances; negotiating with hospitalized patients and their families; and finally, negotiating with colleagues.
A unique feature of this book is the combination of science and practice. The main text tilts toward practice, with just enough health communication research inserted throughout to provide support for the conclusions. Many of the lessons we hope to share are woven around specific clinical vignettes or (in Chapter 8) actual transcripts of doctor-patient interactions. Some chapters begin with a clinical vignette, some do not, but all incorporate scenarios we have encountered in research and practice. We invite readers interested in exploring the theory or practice of communication science in greater depth to read the special “Deeper Dive” sections. These textual insets explore research evidence supporting the principles described in the main text and attempt to unravel some of the more intriguing, elusive, and taken-for-granted features of communication processes and contexts. Those interested in learning even more can consult the extensive references.
Recognizing the pedagogic value of emphasizing key concepts, each chapter begins with “Clinical Take-aways” and ends with a set of summary bullet points. Learners at all levels who incorporate these “pearls” into clinical practice, teaching, or administration will have gained much of what the book has to offer. The take-aways at the beginning of each chapter emphasize actionable lessons that can be applied immediately in practice. The summary points at the end of each chapter provides a more comprehensive review.
Many readers, particularly students and trainees who are using the book as part of a course or communication skills program, may wish to review the “Questions for Discussion” included at each chapter’s end. Like so many questions in health and medicine, these questions often have no clear or definite answer. They are included to stimulate readers to think more deeply about the concepts addressed in the text and to foment discussion among learners, teachers, and peers.
This book is meant to equip clinicians with enough background to confidently apply new communication skills in the office and on the hospital wards. Readers will find plenty of practical pointers, but they will also learn the scientific underpinnings of the various approaches. Understanding the theoretical and empirical basis of effective clinical negotiation takes more effort than memorizing a list of rules, but we believe that assimilating the principles will lead to deeper, more sustained learning and more flexible, effective practice.
We hope this book helps you become an even more skillful and caring clinical negotiator than you are already.
Richard L. Kravitz, MD, MSPH
Richard L. Street, Jr., PhD
RL. Beyond gatekeeping: enlisting patients as agents for quality and cost-containment. In: Springer; 2008.
A. Doctor-patient negotiation and other social science strategies in patient care. In: The Relevance of Social Science for Medicine. Springer; 1981:253–279.
HG. Advertising by academic medical centers. Archives of Internal Medicine
J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved.