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Clinical Take-Aways

  • The nature of the hospital setting (acute illness, compressed timelines, unfamiliar environment, involvement of family, increased power differential) makes clinical negotiation both more important and more difficult.

  • Different issues for clinical negotiation tend to arise at the beginning, middle, and end of each hospital stay.

  • Children, people with cognitive or communication disabilities, and patients with limited English proficiency need special attention in the negotiating process.

  • Clinicians working in hospital inpatient settings should:

    • Apply principles of “etiquette-based medicine” (ask permission to enter, introduce self, sit down, explain role, ask how hospital stay is going).

    • When negotiating about admission decisions, show empathy; demonstrate interest; deflect, don’t repel; and use substitution, contingency, and availability when possible, rather than direct confrontation or “scare tactics.”

    • Recognize and respond to patients’ attempts to manage uncertainty (e.g., “why won’t anyone tell me what’s going on?” “all you guys seem to be doing is putting me through more tests”).

    • Discuss goals of care (including criteria for and expected timing of discharge) early and often.

    • Recognize that high-quality hospital care requires a team consisting of health care workers of all stripes as well as patients and their families.


When patients are hospitalized, they enter a very strange world. Not long after admission, patients are placed in isolation or roomed with strangers (who may be very sick or disruptive), their personal belongings are taken away, and their clothes are exchanged for a flimsy hospital gown which opens, immodestly, in the back. They surrender their autonomy, allowing the hospital staff to tell them whether and when to eat, sleep, get out of bed, have their bodies prodded, or have their veins poked. They are often separated from loved ones except during defined visiting hours. Even their sense of time is eroded, as alarms, early morning lab draws, and vital sign checks do battle against uninterrupted sleep.

This dim picture belies the range hospital of experiences. At one end are patients admitted overnight for elective procedures, a short course of intravenous antibiotics, or brief observation. As long as they are not subject to gross medical error or callousness, these patients are likely to emerge relatively unscathed. At the other end are patients with severe trauma, critical illness, or other medical, surgical, obstetrical, or neurological conditions, often complicated by tangled family situations; these patients are not only in for a prolonged and potentially rocky confinement, they are most at risk for posttraumatic stress disorder.1–4 With patients in the first group, there may be little to negotiate. With those in the second, the clinician may need to be prepared to engage skillfully and proactively.

Zoe Murphy is a 19-year-old college student who is brought by a friend to the emergency department because of acute right lower quadrant abdominal pain, shown on CT to be acute appendicitis. She is admitted to the surgical service, undergoes uneventful ...

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