The aim of clinical negotiation is for the clinician and patient to find common ground, bridging the clinician’s professionalism and experience with the patient’s goals and values.
Well-executed clinical negotiation facilitates patient empowerment, shared decision-making, and patient-centered care.
Many forces conspire against successful clinical negotiation; becoming an expert clinical negotiator is a career-long journey.
View clinical negotiation as a fundamental clinical skill.
Approach each clinical encounter in a spirit of curiosity.
Privilege patients’ goals and values without abandoning their own claim to expertise.
SECTION 1.1: INTRODUCTION
After a few years in practice, clinicians find that some encounters with patients are routine. The patient’s symptoms are few and easily categorized. The diagnosis is straightforward. The clinician and patient know and trust each other. The intended treatment is firmly established by evidence and reinforced by professional experience. The patient accepts the diagnosis, adheres to therapy, and makes a full recovery. Good feelings abound.
Other clinical encounters are more fraught. Symptoms are prolonged, distressing, or not readily mapped to an accepted medical ontology. The patient and clinician don’t know each other, don’t trust each other, or both. The diagnosis is elusive. An endless series of diagnostic studies and consultations leads nowhere. Confusion and uncertainty push the patient’s tolerance and the clinician’s equanimity to the brink.
Between these extremes resides the majority of clinical encounters.
Mr. Vaughan is a 34-year-old construction worker seeing his new internist. He is generally in good health but requests referrals to cardiology because “there is heart disease in my family” and to dermatology because of mild-moderate acne.
Ms. Carluchi is a 45-year-old nurse with intermittent low back pain, worse over the past week following a particularly demanding shift at the hospital. The pain is moderately severe, located to the right of the midline, and without radiation to the extremities. Neurological examination is benign. She asks for time off work and wonders whether an “MRI might show what’s really going on so we don’t have to keep guessing.”
Mr. Gonzalez, 85 years of age, is a retired agricultural foreman who recently immigrated from Mexico to live with his son, daughter-in-law, and granddaughter. His son, a math teacher at the local community college, is worried about the patient’s declining cognitive function and possible depression. The patient has been offered antidepressant medication in the past but has adamantly refused.
In each of these situations, the physician’s immediate reaction may be one of resistance or defensiveness. A cardiology referral in the absence of heart disease? A magnetic resonance imaging procedure for uncomplicated acute-on-chronic low back pain? Both requests are out-of-step with best practice, and both may represent low-value care. Refusal to consider effective care for a serious mental health condition? With that kind of attitude, maybe the patient should see someone else!