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Negotiating the Tightrope

Am I a Dictator in the Realm of Critical Decision-Making?

Shilpi Mittal, Teleneurology and Telestroke Medical Director, Thomas Jefferson University Hospital

Navigating the complex world of healthcare often places us, as physicians, at the crossroads of critical decision-making. Traditionally, these decisions are viewed through a medical lens, focusing on diagnosis, treatment options, and clinical outcomes. However, my recent journey through a negotiation course illuminated a different perspective, revealing the intricate negotiations inherent in patient care. I aim to explore how the principles of negotiation intertwine with the decision-making processes in a medical setting, particularly in critical care situations where there is significantly high-risk care associated with a high degree of uncertainty.

The Revelation and Integration of Negotiation in Medicine

The realization dawned during my course in negotiation. The daily interactions with patients, the discussions of treatment plans, and the decisions made in critical care settings closely mirrored the dynamics of negotiation. This epiphany was transformative, almost like my own “eureka” moment. Medicine, I realized, is not just about clinical expertise; it's a delicate balance of understanding patient needs, negotiating treatment options, and aligning these with medical best practices. This transformative realization reframed my perception of patient care. Each discussion about treatment options, each decision about a patient's care plan, was not merely a medical judgment; it was, in essence, a negotiation with various stakeholders: the patients, their families, and the medical team. These negotiations, however, were distinct from conventional business negotiations; they were imbued with ethical considerations, emotional undercurrents, and the critical importance of life and health. In the realm of critical care, where decisions often have life-altering consequences, the negotiation process takes on a unique form. It requires a delicate balance between imparting medical expertise and respecting the patient's autonomy and values. This balance is critical in creating a shared decision-making process, a fundamental aspect of patient-centered care. We need to present the best evidence from scientific research in the most neutral manner possible, while still staying on track as a guide to help patients make the best clinical decision. Our years of experience and learning help us devise the strategy to provide key insights to the patients so that we can collaboratively create value in this very crucial clinical decision-making negotiation process.

A Night of Decisions: The Case Study

One stark example of this negotiation process in action occurred on a late December night. I received an urgent call about a 92-year-old patient who had suffered a mild stroke. Such patients are often dismissed as insignificant cases, as they are most likely to recover without any intervention, but these same patients may end up having devastating or life-changing clinical outcomes without thoughtful, timely treatments. As I interacted with the patient and her family through a telemedicine robot, I was keenly aware of the negotiation process that was about to unfold. The patient's condition presented a complex decision: whether to administer a life-saving but highly risky medication. This decision is not only high risk but also highly time-sensitive, as our brain loses millions of neurons every minute. In discussing the treatment options with the patient's family, I found myself utilizing key negotiation concepts. The approach was reminiscent of integrative negotiation, where the goal is to find a mutually beneficial solution – a win-win situation. I offered the aggressive treatment to minimize any risk of future worsening of existing symptoms and also discussed the possible significant side effects of the medication with the patient and her family. Information about the medication's benefits and risks was presented carefully, ensuring clarity and transparency. This approach was akin to establishing the ZOPA (Zone of Possible Agreement) in negotiation terminology. The ZOPA in this context was the range of treatment options that would be medically sound and acceptable to the patient and her family. On one end of the ZOPA was taking this medication and getting the full possible chance of recovery from stroke while carrying a potential risk of bleeding, and at the other end was the risk of having incomplete stroke recovery with potentially zero risk of bleeding. Risk always remains in the actual imprecise unpredictability of the outcome, for which I presented the updated details of research from the last two decades related to the medication. Throughout the discussion, I employed various negotiation strategies. I also presented the Best Alternative to a Negotiated Agreement (BATNA), which in this scenario, was opting for conservative management without the medication. Conversely, the Worst Alternative to a Negotiated Agreement (WATNA) – the possibility of severe deterioration without the drug – was also discussed. These concepts were crucial in laying out the entire spectrum of choices to the family. After a thorough discussion, the family decided against the use of the medication. Initially, I was disappointed in myself for not being able to communicate the importance of the medication effectively, perhaps, and I was also underwhelmed by the lack of medical understanding by the family. I curiously asked the family, with a learning mindset, about their rationale for not taking the medicine, and they expressed that my patient, who was aphasic and could not express her own decision, would not have wanted any aggressive treatment based on her legal will and the family was respecting her wishes. I immediately felt relief that this decision, while not aligned with my initial best medical opinion, was very important to my patient who could not speak up for herself. This outcome highlighted the importance of patient autonomy in medical negotiations. It was a clear demonstration of the principle that in healthcare, the success of a negotiation is not measured by persuading the other party to accept one's point of view or opting for the best possible treatment, but rather in reaching a decision that respects the patient's values and wishes, while also being medically sound.

Reflections on Personal Negotiation Style – Lessons Learned and Future Directions

This experience was introspective, prompting me to reflect on my negotiation style. In a medical setting, the negotiation is not about winning or losing but about finding the best path forward for the patient. It requires empathy, active listening, and the ability to present information in a balanced and unbiased manner. This situation also highlighted my tendency to lean towards a decision that “I” professionally deemed medically optimal, which could inadvertently influence the patient's personal choice. It was a reminder of the importance of maintaining neutrality and allowing the patient and family to arrive at a decision that they deemed best. The experience with the stroke patient and her family was a significant learning curve. It taught me the importance of integrating negotiation skills into medical practice, especially in critical care settings. In future scenarios, I aim to focus more on facilitating patient autonomy and ensuring that every decision is a collaborative process. This incident has also emphasized the need to continually refine my communication skills, ensuring that I can convey complex medical information in an understandable and non-coercive manner. I am slowly but constantly working on curtailing my inherent competitive bargaining negotiation style, especially in highly emotional patient care situations, and building on a more collaborative and accommodating negotiation approach. I also realized that sharing multiple clinical offers/options with patients helps them understand that I value their input and signals my flexibility and willingness to accommodate their needs in this process, which is of utmost priority to me as a physician. It is extremely important for me to

“Create value” rather than “claim value” in the world of healthcare. For the most effective negotiation with patients and their families, I need to be an active listener, make a genuine effort to understand their perspective, build trust, and explain my thought process rooted in science.

Conclusion

In conclusion, this case study underscores the intricate role of negotiation in the field of medicine. It highlights the unique challenges and responsibilities of healthcare providers in navigating these negotiations. The lessons learned from this experience are invaluable, not only in enhancing my approach to patient care but also in understanding the broader implications of negotiation in the medical field. In the end, the true measure of success in medical negotiations is not in the outcome itself but in the process of reaching a decision that is based on mutual trust and upholds the principles of patient autonomy, medical ethics, and compassionate care.

Acknowledgment:

The author would like to extend sincere gratitude to Dr. Aniruddha Singh for his invaluable assistance in proofreading and editing this manuscript.

References:

1. https://www.openaccessjournals.com/articles/negotiating-behavior-changes-withpatients-who-have-diabetes-negotiation-or-coercion.pdf
2. https://uw.pressbooks.pub/fcmtextbook/chapter/negotiating-a-patient-centered-plan/
3. https://www.cunninghamgroupins.com/news/how-to-handle-difficult-patients/
4. https://healthcare-communications.imedpub.com/negotiating-in-a-medical-setting-the-artof-achieving-treatment-success.pdf
5. https://www.sciencedirect.com/science/article/pii/S0277953621007991
6. https://accessmedicine.mhmedical.com/content.aspx?bookid=3083&sectionid=256912160
7. https://www.hsph.harvard.edu/ecpe/negotiating-and-communicating-with-patients/

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Author Bio

Shilpi Mittal

Shilpi Mittal serves as the Teleneurology and Telestroke Medical Director at Thomas Jefferson University Hospital. In this role, she oversees and directs medical services related to neurology and stroke through telehealth technologies. With expertise in leveraging remote healthcare solutions, Shilpi Mittal contributes to advancing neurological care and stroke management at Thomas Jefferson University Hospital

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