I had the pleasure to read and review Understanding Clinical Negotiation by Drs. Richard L. Kravitz and Richard L. Street, Jr.1—a tour de force of how clinicians can help promote better overall health through communication techniques backed by rigorous evidence. As a practicing physician, I found the topic to be of particular interest given the current U.S. healthcare environment as it pertains to the ongoing pandemic. Among other issues, this pandemic has caused unique challenges to the way in which we communicate with our patients—the effect is far reaching and touches across the spectrum of healthcare ecosystem.
I strongly recommended this book because it is a mix of deep dives, pragmatic approaches, and case-based illustrations. The authors have an extensive publication background in communication, publishing hundreds of academic papers: Dr. Kravitz is a past Editor-in-Chief of the Journal of General Internal Medicine and Dr. Street is a national award winner from the American Academy on Communication in Healthcare. Both are thought leaders in the area.
The book starts by laying the foundation as to the importance of communication and negotiation that takes place in almost every clinical encounter. The authors take time to explain how clinical negotiation is the appropriate term to describe today’s clinician-patient encounter. This phrase emphasizes the key concepts of mutual understanding and the need to find common ground. The authors highlight the transition in medicine from a more paternalistic or authoritarian model of care delivery to one that is focused on active participation from both clinician and patient.2 The term negotiation helps to include the active discussion with the hopes of reaching a mutual agreement. It is with this definition and framework that the remainder of the book builds.
Early in the text, we are introduced to the “Deep Dive” sections that often accompany many chapters in this book. The first we see is on the “Interruptive Clinician”. Many reading this have likely been taught at some point during training about the issue around clinicians interrupting patients within seconds of the clinical encounter and its negative consequences.3 With these Deep Dives, however, we are provided with layers of context that are more nuanced and impact our daily interactions with patients. One example is a deep dive in Chapter 4 that explores how the meaning of words can often breakdown in a clinical negotiation because medical terms mean one thing to clinicians and potentially something very different to patients. This is juxtaposed to common, everyday language where shared meaning of words is often aligned. The authors then go a step further to explore how words don’t simply mean something, but rather do something that have very real and tangible effects on patient outcomes. Within these sections, the authors are masterful in framing unresolved issues, identifying evidence-based data to help guide decisions. and providing a path forward on ways to scientifically address unanswered dilemmas. A good example in Chapter 8 is the Deep Dive into using vignette studies to measure clinical interactions in a scientific manner. The authors highlight where vignettes are shown to be useful and where there is limitation (external validity, their hypothetical nature, and their variable nature to simulate real life) and discuss the unresolved nature of the scope of the vignettes ability to understand clinician-patient communication and outcomes.
The authors use a combination of bolding important messages, tables, graphs, summary points, and questions for further discussions as a multifaceted approach to offer either a quick references or exhaustive text, as needed by readers. This stylistic approach promotes optimal education and learning beyond standard book pages.
The second part of the book turns to provide the blueprint for clinical negotiation. Reasons for failure or suboptimal patient-clinician negotiation are many and range from organizational characteristics, clinician resources, patient resources, and trust to name a few. The authors take time to explore each of these issues in detail and then to help provide clinicians with tools to navigate these often-difficult situations. The authors stress the importance of introspection on the part of the clinician and the need to be able to bring an empathetic mind to the encounter. In this part of the book, the authors provide a seven step, strategic, and systematic evidence-based approach to clinical negotiation.1 Clinicians of all levels and years of experience can learn from this and find applicability in their everyday practice.
Additionally, in this section, the book pushes us, as clinicians, to better understand our roles when clinical negotiations go awry. Not only are we challenged to be aware of our own implicit bias but also we are motivated to explore those attributes necessary for optimal clinical negotiation. Characteristic drivers, such as humility and curiosity, are shown to help promote an environment that reaches a mutual agreement—alertness of verbal and non-verbal cues are stressed.
The book then pivots to application with a strong emphasis on using published data to guide strategy. As quoted in the book from Lord Kalvin, “when you can measure what you are speaking about…you know something about it.”1 Oft areas of difficult discussion are addressed, including care of the hospitalized patient, negotiating when patient’s preferences conflict with principles of diversity, equity, and inclusion, negotiating through clinical uncertainty, and negotiating goals of care discussion. For example, the book explores clinical negotiation of controlled substance prescriptions, describing the importance of clinical context, tapering strategies, and reviewing optimal approaches on how to place primary focus on symptoms and symptom control. There is framework provided to assist clinicians. The framework walks through how to start with preparation for the encounter and continues up through developing a goal-directed plan. By so doing, the context shows broad applicability not just to patient-clinician discussions around opioids but also around all controlled substances—an area of which there is much less published data.
Understanding Clinical Negotiation provides a balanced approach to any healthcare clinician interested in learning how to better promote their patient’s overall health. The authors highlight areas where data is sufficiently positive and, conversely, where data is lacking or negative.1, 4 Although many stories are tailored towards the generalist, the skills taught and lessons learned have much broader applicability. This book will serve either as a quick reference for specific scenarios or an all-encompassing textbook on a critical topic not often elucidated in modern medical education. To quote the authors, “The trick for the thoughtful clinician is to respect patient autonomy while exercising the professional judgment that years of training and experience have produced.”1
I hope you enjoy this book on clinical negotiation as much as I did!
- Kravitz RL & Street RL. Understanding Clinical Negotiation. New York: McGraw-Hill Education; 2021.
- Kravitz RL. Patients’ expectations for medical care: An expanded formulation based on review of the literature. Med Care Res Rev. 1996 Mar;53(1):3-27.
- Phillips KA, Ospina NS, Montori VM. Physicians interrupting patients. J Gen Intern Med. 2019;34(10):1965.
- Simons Y, Caprio T, Furiasse N, et al. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospital physicians: A pilot study. J Hosp Med. 2014 Mar;9(3):137-41. Epub 2013 Nov 8.
Clinical Practice, Leadership, Administration, & Career Planning, Medical Education, Medical Ethics, Research, SGIM
Dr. Walsh (firstname.lastname@example.org) is an associate professor and division chief of Hospital Medicine at the Medical College of Georgia at Augusta University.
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