Leadership in Medical Education: Negotiating for More

By Michael Gisondi (@MikeGisondi

Physicians are terrible negotiators.

Want proof? Go to a fancy restaurant in a big city at lunch time – maybe across the street from a hospital, so this exercise is fair – and ask for a show of hands. How many lawyers and business executives are eating there? Compared to how many physicians? [Do the same exercise in an urban Starbucks line at 5:30am to get the opposite result.]

Don’t get me wrong: I’m not bitter and I don’t take my job for granted. In fact, I love my job. But it is hard to ignore that physicians sometimes get less than what they could get. Salary. Time. Resources. Office. Schedule. It is embarrassing to admit, but I signed my first contract without ever asking how many hours I was expected to work. (I stayed at my first job for 14 years, so it all worked out, but the fact that I never asked will always make me feel silly about myself.)

We can – and should – do a better job learning and practicing the art of negotiation. We must also take the time to teach our trainees the necessary competencies to negotiate for themselves.

I had the pleasure of learning more about negotiation from one of the best, Margaret Neale of Stanford Graduate School of Business, in a workshop sponsored by the Stanford Medicine Leadership Academy in April 2019. Professor Neale is co-author of the book, Getting (more of) What You Want (Margaret A. Neale and Thomas Z. Lys, 2015), as well as narrator and discussant of the must-watch video, The Sluggers Come Home.

In their book, Neale and Lys argue against the central premise of the very popular negotiation bible, Getting to Yes. “Conceptually, the argument in this book is just wrong,” Neale said, “negotiation is not about getting a deal done, it is about getting the best deal.”


This was the aha moment for me when I read Professor Neale’s book and listened to her presentation. Physicians are collaborative souls by nature and we reward those among us who are experts at conflict resolution. Negotiating conflict among clinicians in the work place is about getting a deal that benefits the welfare of our patients. Negotiating for our own salary and resources is something very different.

I took many notes during Professor Neale’s session, representing information that I found personally interesting and helpful. Everything that follows is credited to her and represents a tiny glimpse into her outstanding book. (I highly recommend reading it cover to cover.)

“Viewing negotiation as a battle is flawed — such a lens causes us to value the win more than the value of what was won. Instead, broaden your definition to include the relationship between those involved. Negotiation is collaborative problem-solving.”

“Negotiation is a process where two or more people decide what each is willing to give and hopes to get in their interaction and, through a process of mutual influence and persuasion, exchange proposals and agree on a common course of action.”

“Meetings, defined: gatherings of individuals who have tangible and intangible resources that other individuals want to access.”

“Three criteria must be met in every negotiation:
• I need to be better off after the negotiation. Better than status quo, my alternatives, etc.
• My counterpart needs to voluntarily walk this path of negotiation with me. Therefore, I need to understand their motivations and goals, so that I can keep them whole.
• I need to frame my proposal as a solution to a problem that my counterpart has. I must frame my requests in such a way that my counterpart sees a better future, as well. Sometimes your counterpart doesn’t see that they have a problem to begin with and you need to be creative in how you initially frame their problem.”

“What is a Good Deal? Need to answer 3 questions:
• What are my alternatives if no agreement is reached? (The party with the better alternative usually ends up with more value in the negotiation; they are more willing to walk away. Think of your alternative as a safety net. Alternatives are outside the negotiation, but they profoundly impact the negotiation.)
• What is your reservation price, i.e., bottom line, i.e., point of indifference? (Your reservation price is a bright line standard that you are unwilling to cross. So easy to say, so difficult to do. The discipline to walk away is your greatest power in a negotiation.)
• What is your aspiration? (Aspirations allow you to leverage up your possibilities. Aspirations are calculated and strategic. You are unlikely to achieve the aspiration, but it will likely increase the value you will realize in the negotiation.)”

“Structure of Negotiation
• Congruent: No dispute
• Distributive: Zero sum, single issue, my gain is your loss
• Integrative: Characterized by asymmetry, my gain does not necessarily equal your loss”

“Select goal-maximizing options:
• Can you maximize the monetary value?
• Can you maximize the relational value?”

“Do you make the first offer or not? How Do You Decide?
• Social roles often determine who makes the first offer (e.g., selling a house)
• When you have the choice, figure out where your greatest comparative advantage lies
• If you are well-prepared, you may choose to receive the first offer (gathers information)
• If you are both well-prepared, you may choose to give the first offer (power of the anchor)
• If you are not prepared, don’t negotiate! – or, maybe make the first offer (power of the anchor)
• Making the first offer is probably better than receiving the first offer”

“The Power of Justification
• Tell your counterpart why you made the offer you made
• More powerful the description, the more objective the justification appears when scrutinized
• Justification mitigates your counterparts’ resistance – explaining why helps!
• Increases the anchoring power of an offer”

“The Power of Asking
• People WANT to accommodate your requests
• We dramatically underestimate our counterparts’ (and strangers’) willingness to accommodate”

“Feeling good or getting more?
• When you focus on your aspiration, you walk away with more than when you focus on your alternative
• When you focus on your alternative, you are more satisfied even though you walk away with less”

“Negotiation Lessons
• Be an adult. Set an aspiration and know that you won’t be satisfied.
• Focus your counterpart on their alternative. They will feel good when you help them.
• Prepare ahead of time!”

“Don’t ask or answer the question, “What is your bottom line?”
• You won’t ever know whether your counterpart is telling the truth
• Instead, reframe the conversation, “How can we find an agreement that makes us both happy?”

“Retention Package Negotiations
• DO: “I have an offer at Yale, but I want to stay here. Can you help me find a way to stay?”
• DO: “I am getting distracted by frequent job offers. I don’t want to keep looking at my way out.”
• DON’T: “I have an offer at Yale and you need to match it, or else!”

“Value Creation is challenging because Value Claiming is still in play.
• How much information do I provide to create value? Create too much value, you may lose your ability to claim enough. Just because the pizza got bigger doesn’t mean that your slice did
• Test the veracity of your counterpart by asking questions for which you know the answers
• Make proposals that include all the issues to be negotiated at once, rather than solving the easy issues first or splitting the difference on individual issues one at a time
• Don’t make a concession without receiving a concession in return
• Always bind issues to one another”

“Three Ways to Enhance Your Negotiation Fluency
• Set Expectations
• Provide Justifications
• Negotiate Packages”

Getting More of What You Want by Neale and Lys (2015)
Influence by Cialdinbi RB (2009)
Ask for It: How Women Can Use the Power of Negotiation to Get What They Really Want by Babcock and Laschever (2009)
Decisive by the Heath Brothers (2013)
Getting Past No: Negotiating in Difficult Situations by Ury (1991)

Stanford courses on Negotiation (There are several courses offered by Stanford Graduate School of Business, with online and on-campus options.)

Featured image via geralt on Pixabay

About the Author:
Michael A. Gisondi, MD is an emergency physician, medical educator, and education researcher who lives in Palo Alto, California. Michael currently holds a position as Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University. He is an ICE Blog Editor. You can contact Michael by visiting his website or following him on Twitter.