Negotiation: Priceless in good communication

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

The Society of Hospital Medicine held its annual meeting recently in Las Vegas, and Stephen had the opportunity to speak on the topic of "Family Meetings: The Art and the Evidence." As a special edition of Palliatively Speaking, we thought we would highlight one aspect of this subject, with other elements forthcoming in future pieces.

As a hospitalist, I stumbled and stuttered through many family meetings until I eventually found myself on more comfortable ground. Overall, I found them rewarding when they went well but stressful and deflating when they did not. The latter sensation was enough to create some avoidant behavior on my part.

After a few years of practice, my hospitalist group began shadowing one another periodically on rounds to provide feedback to our colleagues in the hope of improving the quality of our communication skills. It was then that I noticed that one of my partners was a master at these meetings. A real Rembrandt. He had the ability to deliver bad or difficult news without the dynamic in the room becoming inflammatory or out of control.

I will never forget watching him mediate a disagreement between a nurse and a patient suspected of using illicit substances while hospitalized. He flipped an antagonistic, heated situation into one where the patient, nurse, and physician all agreed on putting the past to rest and forging ahead with his proposed plan. We all left the room with a genuine sense that we had mutual purpose. In my admiration I realized that some of these skills must be teachable.

While I didn’t act on learning those communication techniques immediately after that encounter, I would eventually be formally exposed to them during my palliative medicine training. As it turns out, I still have some uncomfortable meetings with patients and families, but they come around much less frequently and when they do I now have a variety of tools to deal with challenges.

My appreciation of these tools doesn’t stop when I walk through the hospital doors each evening. I have found them to be invaluable in my personal life. In fact, learning to communicate better has been a source of renewal for me at work and staves off burnout. These techniques include active listening, motivational interviewing, demonstration of empathy, conflict resolution, and also negotiation. For the Society of Hospital Medicine meeting audience, I dissected negotiation, citing how it and the other skills can inject vitality into your interactions.

In any negotiation, it’s all about the other party. You are the smallest person in the room, the least important.

This is counterintuitive. Oftentimes at work we are trying to convince everyone how important we are. The readmissions committee should implement your plan to reduce recurrent hospitalizations. Your fellow hospitalists should recognize your value and make you the leader of the group. Patients show their appreciation for you making the right diagnosis and averting a medical calamity for them. But when you enter a family meeting, the patient and his or her loved ones are the center stage. To be successful you have to listen more and talk less. Get to understand the pictures in their heads and then summarize those thoughts and ideas back to them to show you’ve listened.

Make emotional payments. I don’t get into the meat of the meeting until I’ve done that with the patient and every family member in the room. No one holds family meetings for patients who are thriving and have outstanding outcomes. We have family meetings to figure out goals in the face of terrible diseases, when elder abuse is a possibility, when insurance-funded resources are depleted, and for a host of other difficult reasons.

This means that everyone in the room is suffering, sacrificing, scared, confused, or worried. Acknowledge them. Hold them up. Thank them. Reflect on similar moments in your life and demonstrate empathy. Apologize when things haven’t gone right for them at your hospital. These payments will pay handsome dividends as your relationship evolves.

Not manipulation. The term negotiation might bring up images of used car salespeople. I strongly disagree. In manipulation, one side wins and the other doesn’t. In negotiation, the goal is improved communication and understanding. Manipulation is about one side of the equation having knowledge that the other side is lacking and using that to achieve its means. Negotiators hope everyone at the table has the same knowledge.

This leads to two key principles of negotiations: transparency and genuineness. Patients and families are excellent at taking the temperature of the room when you sit down to meet with them. Share knowledge. Don’t have any hidden agendas. Following this principle builds trust.

Be incremental. Taking patients from comfortable, familiar territory into that which is uncomfortable or unfamiliar should not be done in one giant leap. Let’s use code status (CS) as an example because of the frequency with which it comes up (though I rarely talk about CS without first understanding the patient’s goals and hopes).

Some patients refuse to talk about CS, so I think incrementally. I ask that they consider talking about CS with me in the future. Very few people refuse to consider something. Two or three days later I ask, "Have you considered talking to me about CS?" That by itself opens up the topic for conversation. In the extremely unusual case where they still won’t engage, I then ask them, "What would it take for you to consider talking to me about this?" More incrementalism.

While this is not nearly an exhaustive list of negotiation techniques, we hope it is stimulating enough that you might be curious enough to learn more on your own and try incorporating this into your practice. If you’re motivated to do so, please feel free to contact us for reading suggestions: E-mail [email protected].

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.