Negotiating With Your Physician
by Jeanne M. Likins, PhD, JML Associates
with Joseph Flood, MD, FACR

 

Ms. Jones has had back discomfort for a long time and sees Dr. Smith as her primary care physician in her HMO. Ms. Jones requests x-rays to assist in her diagnosis. Dr. Smith disagrees, saying she would rather Ms. Jones try a program of exercise and medication first. Ms. Jones gets angry and leaves, still having back pain.

Negotiation is one of the most important communication skills. We use negotiation in our relationships with others including, importantly, our physician. Differences or conflicts often may be understood or resolved by using skillful negotiation. Understanding some basic ideas about this process leads to more fruitful and functional interactions with others, especially when needs or views differ. Negotiation aims to achieve an outcome in which each party is satisfied (a win-win situation) and the relationship is not harmed.

We all negotiate every day. Whether it is with a spouse, children, co-workers, or our physician, negotiation is how we communicate what is important or necessary for us. Negotiation is the identification and expression of our interests or needs. It is also understanding and respecting the interests or needs of the person with whom we are negotiating. We want to do this in ways which will maintain or improve our relationships and achieve mutually acceptable and workable outcomes or solutions.

When we don't get what we seek with an initial effort, there are two common reactions. We may become aggressive and try to insist on our way. We are fighting for what we want. Or, we may flee and avoid the situation. This "fight or flight response" produces a win-lose or a lose-lose struggle and puts healthy relationships at risk. Even though it may be tempting at the time, neither flight or fight is conducive to effective negotiation. Neither will satisfy our needs over the longer term. Each can increase the level of stress we feel.

 

Identifying Your "Interests"

Ideally, negotiation should begin with an assessment of the "interests" of both partners. Each needs or wants something from the relationship or situation. If we can identify our own interests and encourage our physicians to do the same, effective negotiation will be facilitated. By understanding what both partners seek, it is much easier to meet those needs mutually.

Interests are the "why" of what we want, and are broad. Interests offer an array of possible ways to meet our needs. Discussing interests offers a broad tent within which to accommodate the needs or interests of both parties. This creates a win-win or a "both gain" situation. It also preserves or improves the relationship between the negotiating partners. In this way, interest-based negotiation adds value to relationships, permitting them to continue, and possibly, to grow.

 

"Positions" Ineffective

When we interact with others, we employ a variety of methods to get what we need. Certain techniques are more effective and will work better in some circumstances or with particular individuals. Frequently, however, parties begin by stating a "position" or staking a claim. They want (or hope) the other will agree. Positions are the "what" of what we want and they are narrow or specific.

Communicating about positions (as contrasted with interests) leads to a series of proposals and counterproposals which may ultimately become confrontational. Typically, this responds to the needs of only one party, producing a win-lose arrangement. Or, neither person gets what they want (lose-lose) which is not satisfying to anyone. This is competitive communication and relationships may be negatively affected by hurt feelings, misunderstandings, disappointment, and anger.

 

Two Illustrations

A conversation focused on interests is an inherently different dialogue than a debate grounded in positions. When a patient insists on a referral to a specialist, this is stating a position, something specific that the patient wants from the physician. It is different from the patient who expresses an interest in having a complete evaluation of their situation which might include seeing a specialist.

In this case, the patient's request is broader and there are several different ways to meet this need. An interest-based approach leaves room for physicians to express their needs or views on how to achieve good patient care in an effective and efficient way that doesn't overutilize resources. Also, it doesn't waste patient time or create additional anxiety.

In another situation, we may be having problems with our medication. A positional approach is to tell the physician we want to be taken off that medication. An interest-based approach is to describe how we are responding to the medication and to explore the situation with the physician. This might include learning that the medication requires a longer period of time before a reliable evaluation can be made, or that the problems we experience are (or are not) worth the benefit the medication provides.

 

Communication Challenges

Other difficulties can arise. Patients may not feel comfortable sharing their perspectives, anxieties, or experiences. We may feel uncertain about how to explain what is happening or we may be worried about the seriousness of our condition or our reaction to medicines. We may be intimidated.

We may also have mixed feelings about our health concerns or who should be responsible for meeting our needs. Often, we don't know the specialized language of medicine or the significance of risk factors or probabilities of particular outcomes or treatments. All of these issues can create barriers to effective communication and may impede our negotiating skill.

We must understand that physicians, too, must learn to be facile in communication, including negotiating. Like patients, physicians fall along a continuum in their skills and interest in these matters. This underscores the importance of choice of physicians. The competitive medical marketplace may provide you with greater satisfaction as you are empowered to choose.

Ineffective communication may alienate others and generate distrust or hostility. It may encourage the interaction to be combative which may damage or even destroy the relationship. Left unattended, these styles of communication can lead to a series of fractured patient-physician relationships, and patients who are thwarted in their goals of achieving or maintaining good health.

Effective communication, on the other hand, promotes satisfying outcomes. There are things we do which add value to our relationships and which facilitate shared satisfaction, a sense of collaboration, and mutual gains. Here are some communication techniques which can help you in effective negotiations.

 

Negotiating Techniques

1. Identify your needs in advance. This is especially helpful in time-limited interactions, such as with your physician. Sometimes we are uncertain or unclear about our needs. What is it you want? Are you seeking information, reassurance, or consolation? Do you want a referral to a specialist or a community resource? Assessing your interests--knowing what you need or want--is vital to any productive interaction with others. Knowing if you are frightened, angry, or sad about your situation can be helpful, too.

2. Make notes about what you want to discuss. This improves communication and may reduce anxiety as well. If there are multiple issues, noting your priorities is important. Sometimes it is useful to rehearse what you want to say so that the words come more readily to you.

3. Choose your words carefully. This will allow you to say what you mean in a manner most readily heard by others. So often, we say what we mean as we understand our own message. We may give insufficient attention to how our words are heard by others.

4. Use questions rather than statements. Questions open up discussion and encourage exploration of issues. Questions encourage dialogue and learning which can clarify interests or needs. Statements have the opposite effect and invite counter statements which often escalate the situation.

5. Edit your value judgements before speaking. Such judgements are your perceptions or prejudices about the issue or other person. They may not be shared and may be inflammatory, provocative, or insulting to another person. Value judgements are routine triggers which block understanding, escalate conflict, and frequently damage relationships.

6. Think of the interests of your physician. If your physician's interest is to make the best clinical assessment of your situation, you may better appreciate why he or she asks so many questions. This also explains why she or he wants to be precise about the course of events leading to your symptoms or concerns. Also, physicians who are expected and held accountable for the judicious use of resources have interests we need to know.

7. Maintain a win-win perspective. If you see your physician as the problem or the obstacle, it creates a win-lose situation that will not meet your needs. It requires collaboration for patients and physicians to be partners. "How can I make this interaction mutually satisfying?" is a question to ask one's self when striving to create win-win situations.

8. Try not to escalate the discussion. It is seldom beneficial. This occurs when one person stakes a claim for something and the other counters the claim and/or attempts to deny the original position or to discredit the other person. When we state positions, we implicitly solicit counterpositions. This electrifies the spiral of conflict. It sweeps up whatever is in its path, like a tornado, and take its toll both on the people and on our shared relationship. Escalation may seem assertive, but may not be functional.

9. Separate the people from the problem. Communication problems may develop when you feel that your concerns are not fully heard or that the physician doesn't encourage discussion of decisions. This can cause feelings of frustration, competition, anger, or confrontation on both sides. Separating the people from the problem allows us to more clearly focus on the problem while minimizing the damage done to the relationship. Interest-based negotiation empowers us to focus on both the issue and the relationship. In contrast, positional stances are more likely to confuse the problem with the person. This forces us to choose between the substance of the concern and the well-being of the relationship.

10. Rephrase what the other person has said. This strategy can be particularly useful at points of impasse. It interrupts the cycle of conflict and allows you to ascertain to what extent you have heard and understood the other person. In the heat of conflict, we may not feel like we care about understanding the other person. In the end, however, we will reach a workable outcome only if this understanding is mutual. Rephrasing also helps when we need a moment to gather our thoughts before proceeding in a negotiation.

11. Know when to walk away. Many differences cannot be heard, digested or addressed at a particular time. This is especially true if the situation has become heated, if anyone feels overwhelmed or intimidated, or if the partners are swept up in the spiral of conflict. Frequently, a time-out or break from the discussion is all that is needed to move toward a mutually satisfying outcome.

12. Evaluate outcomes or solutions before concluding. They need to be mutual and workable. The results of effective negotiation must be satisfactory to the partners and also be practical or workable. If this is not the case, the partners may not follow through and/or the outcomes cannot be implemented or come to fruition.

Like other life skills, effective negotiation involves practice. Happy negotiating!

 

Sources for Additional Information

(Along with these titles, Dr. Likins has put together a more extensive list of books which may also be helpful in negotiations. If you'd like to receive this list, please contact FMAA.) Getting the BEST From Your Doctor: A Nuts and Bolts Guide to Consumer Health by Wesley J. Smith. Published by Center for Study of Responsive Law, Washington, D.C., 1994.

Getting to YES: Negotiating Agreement Without Giving In by Roger Fisher and William Ury. Published by Houghton Mifflin Company, N.Y., 1981.

The Savvy Patient: How To Be An Active Participant in Your Medical Care by David R. Stutz and Bernard Feder. Published by Consumers Union of United States, Mount Vernon, N.Y., 1990.

Smart Patient, Good Medicine: Working With Your Doctor to Get the Best Medical Care by Richard L. Sribnick and Wayne B. Sribnick. Published by Walker Publishing Company, Inc., N.Y., 1994.

(Jeanne M. Likins, Ph.D., began her career as a college student affairs educator and has held positions at The American University and The George Washington University in Washington, DC, at Baldwin-Wallace College in Ohio, and at The Ohio State University. She is currently President of JML Associates in Columbus, Ohio, where she lends her expertise to the Community Mediation Services of Central Ohio and to the Dispute Resolution Program of the Franklin County Small Claims Court. She is also involved in mediation training--with school children of all ages, as well as with adults.)

 

Copyright © 1999 Fibromyalgia Alliance of America. All Rights reserved. Reprinted with permission.