Teaching negotiation skills to medical trainees enhances their leadership development
Praniya Elangainesan, BSc, Apurva Dixit, BHSc, and Abi Sriharan, PhD
In health care, negotiation is a crucial skill that physicians apply in many contexts, from delegating clinical duties to navigating work terms. Various strategies and approaches can improve the efficacy of these interactions, and it is increasingly important for medical curricula to be adapted in a way that fosters the development of certain skill sets centred around leadership. Negotiation falls into this category and is crucial in developing both management and clinical capacities. Although the literature identifies the relation between knowledge and skill in negotiating, there has been limited integration into curricular activities. This article provides an overview of negotiation strategies as examined in the literature. It includes the commonly used positional negotiation strategy as well as the more effective principled negotiation strategy developed by the Harvard Negotiation Project. We compare the usefulness of these two strategies using a real-world scenario and summarize the literature exploring the gap in the skill of negotiation among trainees. This can also serve to identify ways in which it can be incorporated as a standard in medical education. Overall, with the push for leadership development, we propose that negotiation should not be a skill that is expected to be gained through work experience, but as a formal part of the medical education curriculum.
KEY WORDS: medical learners, medical education, negotiation, medical curriculum, medical training, leadership skills
Elangainesan P, Dixit A, Sriharan A. Teaching negotiation skills to medical trainees enhances their leadership development. Can J Physician Leadersh 2022;8(4):142-146
The Royal College of Physicians and Surgeons of Canada uses the CanMEDS framework to guide competency-based training of physicians.1 The role of collaborator receives a huge emphasis throughout undergraduate and postgraduate medical training through the lens of interprofessional collaboration. Although one of the key concepts encompassed in the CanMEDS role of collaborator is constructive negotiation, this concept is often not formally addressed in medical curricula.
According to Anastakis and colleagues,2 negotiation can be defined as “a strategy to resolve a divergence of interests, real or perceived, where common interests also exist.” Negotiation is typically thought of as a business skill and is not well taught in medical training. Yet this important skill is needed, as a physician may engage in all sorts of negotiations, such as arranging work contracts or discussing clinical duties. Many medical trainees feel that they have inadequate negotiating competency. For example, Berkenbosch et al.3 found that Canadian and Danish medical residents felt that their negotiating skills were poor. Similarly, a needs-based assessment in the Netherlands found that 60% of residents did not feel confident in their negotiating skills.4
Medical education must adapt to the needs of trainees to ensure that they are well equipped for their future careers. A systematic review found that little attention is paid to management in the medical curriculum, although students recognize there is a need to develop such skills.5 Although negotiation is perceived as important in fields of business and management, it is also a crucial yet often overlooked skill in health care. Studies demonstrate that with improved negotiation skills, collaboration among physicians also improves.6 Physicians require collaborative work in their career in many cases, ranging from hospital committees, advocacy and citizen groups, and legal professionals.
Specifically, with the increasing importance of the role of a physician leader, greater emphasis is being placed on the ability to negotiate by balancing limited resources with good patient care.7 In general, physicians also participate in negotiation during clinical duties in delegating tasks and resources to care teams as well as administratively in finalizing work terms.8 This overview aims to explore the types of negotiations that a physician may be involved in, identify the different strategies of negotiation, and outline how negotiation training can be implemented in medical education.
Types of negotiation and current best practices
The most common strategy is positional negotiation, which is based on taking a side and successively taking and giving up one’s position until a compromise is reached. Parties can play the “soft” or “hard” negotiating game. Soft negotiators aim to maintain the relationship with the other party, by being trusting of the other side and avoiding confrontation by accepting losses to reach agreement. Hard negotiators demand concessions as a condition of the relationship and are usually distrusting of the other party. However, both strategies can lead to inefficient outcomes and/or damaged relationships.
Principled negotiation, a different approach developed by the Harvard Negotiation Project, focuses on merits rather than the people or positions. Principled negotiation is based on four themes: people, interests, options, and criteria. The negotiator separates the people from the problem by having them work on issues together as partners rather than against each other. The underlying interests of the parties, rather than their positions, should be explored. A party’s interests are based on their needs or concerns, which may not be obvious at the onset. However, when one delves into getting to know interests, both compatible and incompatible interests can be found and used to maximize benefit for both sides and minimize undesired outcomes.
Furthermore, multiple options should be explored for mutual gain rather than focusing on only one option. Often, people go into negotiations with a pre-set goal. However, lack of flexibility may cause them to miss better, less noticeable options that benefit both parties. The focus should be on the exploration of options, with the decision coming later.
Finally, objective criteria should be used to reach a result. It is easy to be guided by emotions; however, that may lead to an unfair or unwise outcome. One should give in on principle not pressure. By engaging in principled negotiation, parties can reach amicable and efficient outcomes. This information, as well as additional details about the principled negotiation strategy, can be found in Getting To Yes by Roger Fisher and William Ury.9 A video created by the Erich Pommer Institut also provides a detailed summary of this technique.10
In practice: developing leadership through principled negotiation
Let’s explore the two negotiation strategies through an example. In rural medicine settings, limited access to resources, such as diagnostic imaging, impose challenges to care. In this case, a trauma patient arrives at 11 p.m., and the physician is concerned about missing a source of internal bleeding. He wants imaging done immediately to avoid possible decompensation overnight. This will require the technician to come to the imaging centre after standard working hours.
In positional negotiation, the physician may take the stance that the technician must come in at night, whereas the technician may feel that this is outside work hours and they are not obligated. Discussion may lead to worsening of their relationship, as the physician refuses to budge and the technician feels pressured by the physician’s authority.
In principled negotiation, the problem is that the patient requires urgent imaging and no technician is available at late hours. The physician is worried about the patient’s clinical status and feels that this information is critical to the patient’s management. At the same time, the technician has spent several late nights at the hospital and has not spent time with his family lately. By exploring the problem and interests together, they both come up with options including seeing whether other imaging modalities can be used that don’t require a technician, assessing whether the imaging will change immediate management, asking if another technician is available, or agreeing that the technician will come in tonight but get to leave early the following day. Finally, they refer to objective criteria, in this case, hospital policy to decide on an option independent of their will. Ultimately, they choose to have the technician come in tonight with reduced hours the following day and also plan a meeting with the department head to create a scheduling system to prevent these types of situations.
Compared with a positional negotiation approach, which could have contributed to feelings of resentment or frustration, principled negotiation helps develop a more supportive and compassionate workplace culture. The physician’s use of principled negotiation also represents a positive form of leadership that creates a collaborative environment among team members.
Integrating negotiation training into curricula
In general, medical residents indicate a need for incorporating negotiation training into teaching.11 Although literature on including negotiation training in medical school curricula has been limited, there has been success in other professional programs. For example, in the biomedical science graduate program at West Virginia University, a training program helps students develop skills in conflict resolution and negotiation.12 It includes didactic lectures, but a major emphasis is on interactive role-playing activities. Based on surveys conducted to evaluate the efficacy of these sessions, this training appears to give students new tools to negotiate.
In medical schools, similar strategies can be employed while planning for additional curriculum development in this field. To identify the key factors to consider when integrating these concepts into curricular teaching, a report evaluated a program to teach negotiation skills in a health care setting in Australia.13 The researchers identified key themes that could be translated into the medical education setting. These included providing more flexible training hours, providing specific tools for negotiation, creating opportunities to practise negotiation, and addressing long-term sustainability. Although negotiation skills have not generally been incorporated into medical education, using knowledge gained from parallel professions and other training settings could be valuable in informing curriculum development.
A key component of skilled negotiation is the attitude of the participants. The literature suggests that different attitudes are taken by medical residents during negotiations based on who they are having the discussion with. For example, assertiveness was predominant among supervisors, but empathy was predominant among nurses.11 As a result, how to negotiate in health care must be understood in the context of the hierarchies present. Differences in personality, culture, or religious beliefs between negotiating parties may appear as barriers preventing an outcome that is satisfactory to both parties. However, the art of negotiation requires adaption, which is integrated into the principled negotiation approach. It is important to respect the other party’s beliefs and customs, but also avoid assumptions or stereotyping. Making assumptions may harm the working relationship and prevent both parties from reaching a win–win outcome. Thus, to successfully negotiate in these circumstances, one needs to listen actively to the other party and adapt their approach to negotiation in a way that is persuasive to their way of thinking.
Unless medical trainees engage in business training, they are unlikely to be taught negotiation and many other basic business skills. Instead, it is expected that these capabilities will be gained through experience in the health care field. However, negotiation is a concept that falls under the collaborator competency and is an important part of being a skilled physician. Similar to the push for leadership development for medical trainees, management development is also required. Teaching medical trainees the principled negotiation approach may lead to more fruitful outcomes.
We propose that the skill of negotiation be taught beginning at the undergraduate level of medical education. Medical schools and residency training programs must provide trainees with the tools to navigate conversations and discussions. This will serve to best position students in their careers and, as a by-product of improved training in negotiation skills, we may be able to facilitate further leadership development among our future physicians.
3.Berkenbosch L, Schoenmaker SG, Ahern S, Søjnaes C, Snell L, Scherpbier AJJ, et al. Medical residents’ perceptions of their competencies and training needs in health care management: an international comparison. BMC Med. Educ 2013;13(1):1-2. Available: https://tinyurl.com/mryn3dhe
4.Berkenbosch L, Brouns JWM, Heyligers I, Busari JO. How Dutch medical residents perceive their competency as manager in the revised postgraduate medical curriculum. Postgrad Med J 2011;87(1032):680-7. https://doi.org/10.1136/pgmj.2010.110254
5.Abbas MR, Quince TA, Wood DF, Benson JA. Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development. BMC Med. Educ 2011;11(1):1-8. https://doi.org/10.1186/1472-6920-11-93
6.Ebrahim EK. Negotiation as a management strategy for conflict resolution and its effect on enhancing collaboration between nurses and physicians. Egypt Nurs J 2020;17(1):13-22.
7.Clay-Williams R, Johnson A, Lane P, Li Z, Camilleri L, Winata T, Klug M. Collaboration in a competitive healthcare system: negotiation 101 for clinicians. J Health Organ Manag 2018;32(2):263-78. https://doi.org/10.1108/JHOM-12-2017-0333
8.Brzezynski B. Special feature: negotiation: it can pay a lot to learn a little. BC Med J 2014;56(9):452-3.
9.Fisher R, Ury W. Getting to yes: negotiating agreement without giving in (second ed.). Toronto: Penguin Books; 1991.
13.Clay-Williams R, Lane P, Camilleri L, Johnson A. Report of the evaluation of negotiation skills training at Townsville Hospital and Health Services. North Ryde, Australia: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation; 2016. Available: https://tinyurl.com/yutcs53t
Praniya Elangainesan, BSc, is a medical student at the University of Toronto and a graduate student at the Institute of Health Policy, Management and Evaluation, University of Toronto.
Apurva Dixit, BHSc, is a medical student at the University of Toronto and a graduate student at the Institute of Health Policy, Management and Evaluation, University of Toronto.
Abi Sriharan, PhD, MSc, is an assistant professor and program director, System Leadership and Innovation, at the Institute of Health Policy, Management and Evaluation, University of Toronto.
Author attestation: PE and AD conceptualized the article. AS reviewed and advised on the concept. PE and AD completed the literature search, prepared the draft manuscript. AS reviewed the final manuscript and provided comments. PE and AD made the edits for the final manuscript. All authors have reviewed and approved this submission.
Conflicts of interest and funding: The authors have not received any funding for this work and do not have any conflicts of interest to declare.