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Clinical Take-Aways

  • Health and well-being are influenced by clinical and social determinants.

  • As a form of interpersonal communication, clinical negotiation takes place within a broader ethical, policy, and organizational context.

  • Clinicians should:

    • Acknowledge the importance of shifting societal norms, evolving policies, practice structures, time constraints, and reimbursement priorities as influences on the clinical negotiation.

    • Not be too hard on themselves when external factors pose challenges to finding common ground with patients.

    • Be prepared to advocate for public, organizational, and clinical policies that support the patient-clinician relationship.


So far, we have shown how every clinical encounter, from the most banal to the most challenging, can be understood as a kind of negotiation. As we hope we have made clear, we are not talking about the type of negotiation where there are winners and losers, though if the negotiation is managed poorly, it can surely feel that way. The clinical encounter is not a business deal. Instead, it is a dialog in which the clinician and patient seek mutual understanding and agreement about how to move forward. In other words, a successful clinical negotiation helps the clinician and patient find common ground.

We have also shown how patients’ expectations for care are influenced by their experience of symptoms, their perceptions of vulnerability, their personal histories, and their exposure to outside sources of information. Toward the end of Chapter 2, we discussed how patients’ expectations are shaped by the economic, sociocultural, and organizational context. In this chapter, we continue our investigation of context, but from a different perspective. Here we are interested not so much in how context shapes expectations as in how context sets the stage for clinical negotiation and influences outcomes. The clinician facing structural and organizational barriers to care must act like a swimmer in a riptide. It is futile to swim directly against the current. Rather, one must angle obliquely past the undertow, making one’s way slowly to shore.

Mrs. G is a 68-year-old widow and retired bookkeeper who lives in one of the semi-rural exurbs within the catchment area of a large academic medical center. Her medical problems include hypertension, type 2 diabetes, stage 3 chronic kidney disease, recurrent sinus infections, and chronic low back pain. She has received care in the Internal Medicine resident clinic for 15 years. By now, she is used to the turnover of residents every 3 years. She just saw her new intern, Dr. P, last week. The visit was scheduled for 10:30 am, but Dr. P was running late, and Mrs. G was not seen until 11:15. When Dr. P missed noon conference last week, the chief resident admonished her that “attendance at noon conferences is mandatory for all residents. You really need to be there.”

The visit was rushed. The chart had not been fully updated, and Mrs. G was not ...

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