“Stan, If you don’t ask for what you want, don’t expect the Neurosurgeon, God or the Tooth Fairy (in that order) to do it for you…”

Unfortunately no puntastic titles this time…

I have had the fortune and privilege of working with doctors from different cultures and countries during my training in the NHS. The other week I overheard one of the new dutch clinical fellows say to the medical registrar: “Oh, I’m sorry I didn’t know that…. we do it differently in Holland…”.

This got me thinking about how, as ED docs, we end up doing a lot of negotiating with other specialities. Is there a “one way fits all” template or does there need to be separate methods for negotiating with different specialties? Does it matter what the cultural background is of the doctor you are negotiating with? Are there any helpful hints out there to help us? Are you Samuel L Jackson or Kevin Spacey?

I came across this tweet today. Its from a post, in the Harvard Business Review, about how to negotiate international deals. It got me thinking whether this could be applied to medicine? I realise that this doesn’t apply to everyone. The NHS is a multicultural organisation. This post aims to get you to think about whether we need to recognise people’s cultures and how it may impact on your negotiations with them.

Click on the link below for an explanation of the the graph:

https://hbr.org/video/embed/4631884629001

Here are some of the points it talks about:

1. Adapt the way you express your disagreements

It may be appropriate to say “I totally disagree” or ” I think you are wrong” in certain circumstances or to people from certain cultures. The post gives an example that if a Russian tells you he disagrees with you, its not a bad thing. Its actually an invitation to start a debate. However if you said this to others that are less confrontational but emotionally expressive, it may shut down the negotiation.

The trick is to listen to certain verbal cues: “upgraders” and “downgraders”.  Upgraders are words you might use to strengthen your disagreement, such as “totally,” “completely,” “absolutely.” Downgraders—such as “partially,” “a little bit,” “maybe”—soften the disagreement.

“Russians, the French, Germans, Israelis, and the Dutch use a lot of upgraders with disagreement. Mexicans, Thai, the Japanese, Peruvians, and Ghanaians use a lot of downgrades.”

Im sure we can all think of specialties and individuals that use upgraders and those that use downgraders with their disagreements…

“Tact, is the ability to tell someone to go to hell in such a way, they look forward to the trip”

2. Know when to bottle it up or let it all pour out.

When talking to certain specialities or individuals, it may be appropriate to be emotional expressive. For instance, putting a friendly arm around someone or raising your voice. However other teams or people from certain cultural backgrounds, may find your self- expression as  being unprofessional or intrusive.

People who are emotionally expressive may also avoid confrontation and disagreement. They would see self expression as a sign of honesty, yet be offended by negative comments. If you were to strongly disagree with them, that may end the negotiation.

However, some specialties and doctors may take open strong disagreement as a positive as long as it is expressed calmly and factually. (Which ones am I talking about?)

“So you need to recognise what an emotional outpouring (whether yours or theirs) signifies in the culture you are negotiating with, and to adapt your reaction accordingly.”

3. Learn how the other culture builds Trust

There may be a fractious or phenomenal relationship between the ED and a particular specialty or indeed between you and another clinician. A solution eventually comes down to whether you trust each other.

Trust can be Cognitive or Affective.

Cognitive trust is based on the confidence you feel in someone’s accomplishments, skills, and reliability. This trust comes from the head.  You know your stuff. You are reliable, pleasant, consistent and can demonstrate that skill. I trust you.

Affective trust arises from feelings of emotional closeness, empathy, or friendship. It comes from the heart. We laugh together, relax together, and see each other on a personal level, so I feel affection or empathy for you. I trust you.

For some individuals there is a line drawn between cognitive and affective trust. Mixing the two together would be seen as unprofessional. However some people need that emotional bond as well as cognitive trust.

Say you are the ED SpR on a set of four nights and you are working with a medical registrar that is known for being obstructive. How could you manage this? There are several ways including escalating to defcon 7 and calling the consultants to sort it out. What if you build an affective bond with them: make them a coffee or talk about common interests. Don’t do this at the same time as you are trying to refer someone though.

Now I’m not saying this will work for those set of nights. You will have to be patient. But it will be worth it, because I can guarantee that you will end up working with them many times that year and in other hospitals as you both progress through your training. They will be more receptive to you in the future. You will have built up an affective and cognitive trust.

Now which speciality is going to take the elderly patient, with a plethora of medical problems, that has a frontal contusion and small SAH after a fall from standing? How are you going to negotiate that?

I know most of us that work in the ED  think “Referrals are not a negotiation…just take the patient”. Until we reach the hedonistic state of ED Nirvana, where the entire hospital’s culture shifts to accepting referrals from ED without obstruction, we need to be able to negotiate.

The trick is to be aware of key negotiation signals and to adjust both your perceptions and your actions in order to get the best results.

KR

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