09 February 2012

Negotiating patient care

Some years ago, a diplomat recommended to me a book on negotiations called "Getting to Yes." Last month I purchased a copy (from my local independent bookseller!), and I've quickly learned that skill in negotiating is a huge help in clinic.

Our medical school has us interact with "standardized patients"--paid actors who convincingly pretend to be patients with certain diseases. In front of a panel of classmates and professors, I had to convince a hypertensive "patient" who does not like following doctors' orders that she either needed to improve her diet, exercise more, and track her blood pressure at home, or go on medications.

I thought back to my negotiations book. I began the conversation by emphasizing that we were partners on the same team working to defeat hypertension. We tailored the treatment plan to her personal goals. Although she did not want to go on medication, we agreed to she would need to go on them if she failed to meet certain objective criteria (having her systolic blood pressure drop to a certain number within a set number of months). In the end, the patient seemed committed to her customized treatment plan, and I was satisfied with the likelihood that her blood pressure would eventually drop to a reasonable level. There was room for improvement, but the result struck me as a successful negotiation.

Successful negotiation tries to find ways to satisfy both sides' interests. It need not a be a zero-sum game. The book tells a proverb of two sisters who are arguing over an orange. They compromise by dividing the orange in half. Later, one sister eats the fruit of her half an orange and throws out the peel. The other sister throws out the fruit and bakes the peel into a cake. If the sisters had negotiated on the basis of their interests ("I want to bake a cake," rather than "I want the orange,") both sides could have emerged happier.

The doctor-patient relationship could use some strengthening. Patients usually do not adhere to their treatment plan (for example, by skipping medications) or modify their lifestyles. And I talk to many patients who do not feel like their physician understands them or listens to them. There needs to be more of a sense of shared ownership, which is something that successful negotiation encourages.

The good news is that in medicine, doctor and patient usually have the same shared interest: making the patient happier and healthier. It's a good basis for a successful partnership.