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Clinical Take-Aways

  • Effective clinical negotiation rests on understanding the patient’s concerns, developing realistic goals, and working collaboratively to achieve them. In this way, clinical negotiation overlaps with shared decision-making.

  • The consumerist model of shared decision-making grants pre-eminence to patient preferences, while the clinical negotiation paradigm gives equal weight to professional expertise and experience.

  • Clinicians should:

    • Take a few moments to mentally prepare for each encounter.

    • Allow the patient time to present their complete agenda.

    • Develop a chronological understanding of the current illness.

    • Conduct a focused physical examination, as the exam yields essential information, creates connection with the patient, and signals the clinician’s unique expertise.

    • To better understand how the patient thinks about their illness, ask direct questions, show empathy, and pursue information uncovered in the history of present illness or suggested by the patient’s own statements.

    • Generate a collaborative plan by summarizing what has been learned, suggesting a tentative course of action, asking for the patient’s input, integrating the patient’s feedback, and proposing a modified plan.

    • Confirm shared understanding.


When thinking of negotiation in ordinary life, most people probably imagine two parties with divergent interests facing off across a boardroom table. In clinical practice, however, negotiation mostly takes place between allies, is constrained by the guardrails of professionalism, and is often implicit. The clinician recommends something that is painful (like an injection or blood draw), inconvenient (like taking a medication daily for many years), expensive (like submitting to a treatment not covered by insurance), or risky (like surgery). In collaboration with the clinician, the patient decides whether the potential benefits are worth the costs—measured not just in dollars but also time, sequelae, and risks. Through a combination of words, gestures, and actions, the patient telegraphs their degree of enthusiasm for the recommended treatment. The patient who is not comfortable with a prescribed medication, for example, may not say so explicitly; rather he might simply miss pills, “forget” to obtain refills, or switch physicians. If the physician is attuned to subtle signs of the patient’s unease, she might be able to produce an effective counter-offer: consolidating multiple blood draws, prescribing medicines that are easier to take and cheaper to purchase, suggesting a less-invasive surgical option. If not, the patient will find his own way.

However implicit or explicit the negotiation, it helps to have a strategy.

It is 10:15 am, and already family physician Dr. Charles Kramer has had quite a morning. His 8:20 appointment with Mrs. Lattimore ran over by 15 minutes because she is still grieving over her husband’s death, and Dr. Kramer felt the patient needed extra time to unload. Fortunately, his 8:40 and 9:00 am appointments (an adolescent girl with well-controlled lupus and an older man with type 2 diabetes) went smoothly, and his 9:20 was a “no show,” so now, at 9:40 am, he is caught up. Clicking on the ...

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