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Renegotiating health care: an interview with Leonard Marcus, PhD. (Conflict Management).

Q. HOW DID YOU become Director of the Program for Healthcare Negotiation and Conflict Resolution at the Harvard School of Public Health?

Marcus: I got into the field of negotiation and conflict resolution when I was teaching courses on health care organizations and health policy at Mass General Hospital back in the mid-80's. I received a fellowship in the Kellogg National Leadership Program. Each year, the Kellogg Foundation selects about 40 people for the purpose of encouraging leadership, generally across the country.

One of the provisions was that they support and fund study on a topic, however fellows must choose an area that they've never studied before. I had originally chosen health care finance and they found that I had written one paper on that subject, so they said no, you've got to find something that you've never studied. I thought long and hard and came upon the topic of negotiation and conflict resolution. Their provision also was that you couldn't study this by merely reading books, you had to really jump into the topic. Over the three years I traveled to the Middle East, the Soviet Union, and China and interviewed people, looked at the questions of conflict resolution. I also studied with people in this country at Harvard. at George Mason University, with people at CDR Associates in Colorado, and truly developed a broad understanding of the field and its applications.

When my fellowship ended, I asked my new conflict resolution buddies. "Well who is doing this work in health care?" That link--between the growing, still rather young field of conflict resolution and what was going on in health care--really hadn't been constructed and I shifted my career interest to look at negotiation and conflict resolution as it pertained to health care.

In 1990 I had a faculty position at Boston University with an emphasis on negotiation and conflict resolution and a grant from the National Institute for Dispute Resolution (NIDR). NIDR sponsored our training in negotiation and conflict resolution with the assumption that we would be creating a new field of practice.

Here in Massachusetts, I went to the medical society, hospital association, and nursing association and I asked them to recommend their best and brightest. The Boston Globe did a story about the fact that I was looking for potential mediators and we received 160 applications. I interviewed 60 people and we chose 25 to be in that original class. Though they received the training for free, their expectation was to become the leaders of this emerging field.

It was back in 1990 that we really got off the ground. The program was instituted at the Boston University School of Public Health. In 1995, we had an opportunity to move the program to the Harvard School of Public Health and we have been here ever since.

Q. I just read your book, Renegotiating Healthcare, Resolving Conflict to Build Collaboration, co-authored with Barry Dorn, MD, Phyllis Kritek, Velvet Miller, and Janice Wyatt. Why did you give the book this title?

Marcus: We recognized that we are, in effect, renegotiating the very assumptions and premises that have guided the health care system over the last few decades--the advent of managed care, reimbursement changes, the financing of health care, a shift towards primary and preventive care. Nationally, we are changing these key assumptions and premises. We know from the social science research in the field that conflict and change are often closely associated with one another. And that certainly has been the case with the changes that have been going on in the health care system this decade.

There has been a tremendous change, when we consider what the system looked like ten years ago. Managed care penetration, Medicare reimbursement after the Balanced Budget Act, the organization of health care--all are very different now. Medical practices are being organized in new ways. We hoped that the book would be a guide for that process of renegotiation.

The second part of the book's title, "Resolving Conflict to Build Collaboration," is an acknowledgement that while conflict can be destructive, it also can provide opportunities for people to look at where there are problems, to identify and correct those problems, and end up on the other side with something even better than what they began with. We are hoping that people will recognize the opportunity to turn problems into solutions and that the book provides guidance in that effort.

Q. I believe the conflict escalated after the defeat of the Clinton health care plan and the for-profit industry rushed in to fill the vacuum, and it seems this explosive growth of managed care has generated more heat than light.

Marcus: It is true that the Clinton efforts--and certainly the fact that this intervention did not have its intended results--put a spotlight on the health care system. But don't forget they were responding, in part, to a set of forces and factors that were affecting the health care system that preceded their work and that still continues. The pressures regarding the economics of health care were there before the Clinton work and there have been increasing pressures afterwards. The problem of the uninsured certainly was not solved by that task force. That was there before they had begun their work.

By placing health care in the spotlight, the task force set the pace into faster motion. There were a lot of changes that occurred right after that initiative fell apart. And those changes, in fact, caused a great deal of conflict.

There has been a very encouraging interest in the work that we are doing and I think, in part, it is a response to the fact that people are seeing a lot of conflict. That conflict is associated with the changes and people are looking for constructive ways to resolve them.

Q. I was interested in the structure of your book. It is really three books. One is your guideline on the terminology and dynamics of negotiation. Secondly, there is a section by your co-authors. And thirdly, there is this novel woven into the ends of these chapters to illustrate what happens in human terms. Why did you pick that structure?

Marcus: The editors said, "we publish textbooks, we don't publish novels," when I told them that I wanted to include a novel in the book, Negotiation doesn't always work according to a textbook. And sometimes you try a technique out on Tuesday and it is very, very effective, and then on Thursday you try exactly the same technique when you are in a medical staff meeting or trying to lead a group of people through a meeting, and it doesn't work. That is because negotiation is based on context and it is a very human process. Negotiation success depends on all of the different qualities and characteristics that we humans bring to the process. The story line was a way to bring some of these concepts and methods and techniques to life.

The editors were rather reluctant, but they said, okay give It a try. I handed them the first three chapters of the book, we got together for lunch and their first question was, what happens next in the novel? They were intrigued about what was going to happen to the patients, nurses, and doctors because they, in fact, were involved in some real life conflict. We are hoping that readers will have a much broader understanding, not only for what we are saying but, more importantly, for how they can use what they've read in their day-to-day work, The novel demonstrates just how complex the work of health care is and how human it is and how much we need to be able to understand the many different factors that go into making our work in health care a success.

Q. Your section about the bidding contest for the one dollar bill illustrates that conflicts can escalate way out of hand due to the pride and the dynamics of the system. Do you think that is happening Out there, that it becomes a warlike game in which the conflict is kind of like the cold war between Russia and America and we have too many warheads out there?

Marcus: Exactly. I had a conversation with someone today and he described how two organizations had each spent tens of millions of dollars competing with one another in what was almost a war in which one side's setback was celebrated by the other side. Having spent tens of millions of dollars, neither side won. So it was truly a mutual defeat. And what was lost was a great deal of public benefit, a great deal of money in a time when the system, of course, is under a lot of financial and economic pressure. And, the problem also led to a lot of lost opportunity, because while they were busy fighting the war, they weren't doing what they were supposed to be doing in their role in the health care system.

So that it is very, very costly. And the cost, at times, can be measured in financial terms, or in the clinical arena in terms of decreased patient safety or reduced effectiveness of the work that we are trying to accomplish. The cost of conflict has to be measured in human terms.

I think the greatest benefit to finding methods for collaboration would be in better accomplishing what we are all committed to in the health care system. That is not to say that there won't be conflicts and differences of opinion, but that those conflicts will focus our attention on how to build improvements. The intent is not to say that we will always agree on everything, but rather that when a conflict or difference of opinion does occur, it not be the cause for war or the escalation of our disputes. It is really a matter of saying let's sit down, have a way of constructively discussing these issues and differences, and figure out how we can move forward, We always say that the product of negotiation can be only as good as the process used to come up with its result,

And the arms race exercise, as you just said, is an example of how people can get so caught up in the conflict that they can't even see the costs of escalation and the potential benefits of resolution,

Q. So one of your functions is to move beyond this right/wrong, yours/mine, win/lose mentality to achieve a collaborative effort?

Marcus: Yes. Many times people get locked into dichotomous thinking. If I didn't win, it meant that I lost. And there are a lot of other options other than just winning. One of the contributions that we are hoping to offer is to broaden the thinking. We say in this field that we are trying to create options and that is, in essence, what negotiation is all about.

One of the themes introduced in the book is "whole image negotiation." These three words reflect what we consider to be unique about negotiation in the health care system. The word whole, which is closely linked to the word heal, refers to the fact that we have to be very clear about what we are trying to accomplish. And if you look at that as sort of the whole picture, our ability to accomplish these ends depends on our interdependent work. So the key word we see in health care negotiation is creating "fit," between specialists and primary care physicians, between leadership of a medical care organization and those people who are on the medical staff. A fit between doctors and nurses, between physicians and administrators. A fit between what we are doing as a system and what the community needs.

The second word is Image, which stands for imagination and points to the importance of bringing innovative thinking to the negotiation process. We say that the top negotiators have one thing in common--an imagination. They are able to find creative solutions to problems that simply aren't in the mindset of the disputants. And the final word is negotiation, achieving mutual gain and benefit for those people who are part of the process by negotiating based on interests and not positions.

The abbreviation for those three words is WIN. It is not a win for one side over the other, Ultimately, if you can create the right fit, it is a win, not just for the physicians, or for the primary care people over the specialists or vice versa. It is a win that everyone can share.

Q. One word that keeps popping up continuously is "reframing." What is the function of reframing and its importance in conducting a successful negotiation?

Marcus: One of the book's themes is the importance of looking at a problem from different perspectives. Many times, when we're mediating a dispute, if we ask one person about the problem, they give us one definition. We turn to the other person and hear a completely different definition. And we say, no wonder you can't solve "the problem," you are both bringing different problems to the table.

Refraining refers to each side learning how the other views the problem, so that they can come up with a new understanding through the negotiation process. Reframing is the ability to develop that new or deeper understanding for the purpose of solving the problem in a way that provides mutual satisfaction.

Q. One of your collaborators is Barry Dorn, MD, with whom you write a column for the AMA News. How did that collaboration develop and how did you feed off of each other to understand the health care system?

Marcus: Barry Dorn was part of the original group that was trained in negotiation and conflict resolution back in 1991. I interviewed Barry who had applied to be part of that program and at some point I asked what interested him in negotiation and conflict resolution. It turned out that he was reading From Beirut to Jerusalem by Tom Friedman and coincidentally I was also right in the middle of reading the book. He mentioned a part of the book called Hamas rules, which is a gruesome example of positional negotiation. I had just read that section and we started talking about it and really connected during that conversation. And what I recognized in Barry, in addition to the fact that he is a marvelous person, was that he had tremendous potential to mediate, negotiate, and teach. And we've joked many times about that first meeting--that in spite of the fact that he was an orthopedic surgeon, I thought he had potential as an interest-based negotiator.

We worked together closely to develop a training program for physicians, which quickly became popular across the country. We worked with a number of different hospitals and medical centers, and the President's Council of the American Medical Association back in 1992. Soon it became clear that this was a topic and activity that would be in great demand.

Barry is really the leader nationally in this field in medicine. He has developed many of these concepts and techniques in collaboration with our group. And he is doing mediation, training, and facilitation with medical groups around the country. He is extraordinary. He is able to go into a situation, quickly come to an understanding of it, help the physicians who are involved come to a better understanding of what the problem is, and bring them as efficiently and effectively as possible to a solution. In a field where time is of the essence and a wrong decision can be so costly in so many ways, that capacity to bring people to a solution of a complex problem, in a clear and direct way with an understanding of how to move the process, is a real gift. He also has a great sense of humor and he tells me that every time he resolves a conflict he rewards himself with a cigar.

Q. What about your other three collaborators? One is a consultant and a former hospital executive, one is in public health, and one is in nursing. Do they and Barry participate as the faculty in this program you do for physicians?

Marcus: There are a number of activities that they are involved in. Each of them is active nationally in leadership positions. Jan Wyatt is the Chief Executive Officer of a national consulting firm called Health Care Negotiation Associates (HCNA), which provides mediation, training, and speakers in conflict resolution and negotiation for health care organizations. She's probably the leading person in this field from the perspective of hospital administration and management.

Jan brings such a rich experience to this field, in part because she was a hospital CEO. She was Vice Chancellor at an academic medical center. She really understands the system from the inside and she is a brilliant facilitator, mediator, and consultant. She has extraordinary analytic skills and understands how to build a process to get people moving efficiently toward a resolution. And then how to create buy-in for a solution, because she has recognized that if there isn't buy-in, the chances of the success of that solution simply are very low. She is able to work with hospitals, health care organizations, and medical groups to find solutions that will really work. She guided two hospitals through the merger process.

Velvet Miller also is doing work through HCNA. She has had an extraordinary career working in public health. She was Assistant Commissioner for Medicaid in New Jersey so she understands the bigger picture of health care and reimbursement and is committed to closing disparities in health and health status for people in this country. She is a beloved member of this team. She is an exciting and gifted teacher.

Phyllis Kritek is at the University of Texas in Gaiviston. She recently authored another book called Reflections on Healing: A Central Nursing Construct. She is nationally recognized as a leader in the nursing field of healing. And, of course, one of the analogies that she draws is that conflict resolution and negotiation in the health care system metaphorically is very close to the healing process--a conflict well resolved provides a healing opportunity for those who have been a part of it.

From the outset, we have had a gifted, committed, and passionate group of people who were part of the writing of the book.

Q. Phyllis calls her chapter, "Nursing, Negotiating at an Uneven Table." As I read it, I got the feeling that nurses have been under appreciated as central players in the health care system. Was part of her mission to even the table a bit more?

Marcus: It is not only to even the table, it is also, very importantly, to help people recognize when the table is uneven. And there are really two sides: that nurses, women, or minorities who feel that they are at an uneven table recognize the situation and that people who create uneven tables realize what they are doing, as well as the downsides of that uneven table. She is committed to providing opportunities for people to negotiate at a more level playing field, believing that the outcome will benefit from the full contributions of all parties involved, rather than being dominated by one particular person who might not see the full picture.

Q. Barry Dorn's section on the "bygone doctor" was brilliant in describing the agonizing, wrenching change these older doctors are going through as they try to adapt to modern realities. That was extremely well done.

Marcus: Barry captures the transition that medicine faces today, and, in fact, it is a whole new way of thinking that affects each generation of physicians very differently. Barry, now in his late 50's, started his medical career at a different time than the baby boomers or the more recent medical graduates did. And those realities, especially as they change, have been difficult.

As he sometimes says. doctors were given a script when they walked out of medical school that told them what they were going to be doing at every phase of their life, how much they were going to be making, and that they would be making more each year. And the changes over the last decade have really altered that script in very dramatic ways. It has been difficult for physicians to adjust to that as their career progresses.

Q. What might participants expect to gain from the course you teach?

Marcus: We teach people the methods of negotiation and conflict resolution, multidimensional problem-solving, and the process that weve developed called the "Walk in the Woods." It is not only a matter of hearing lectures and learning in a didactic way. In fact, most of the week-long course is focused on interactive negotiation exercises and simulations. People conduct simulated mediations in front of a video camera and are critiqued. It is very much hands-on.

We will have 48 people in the group in the year 2000, and it is limited to 48 people. We have ten faculty, so a lot of individual attention and instruction is given. It is also an opportunity for people to step back and look at what they are doing in their career and how they might want to re-think it. One person came up to me at the end of a program and said: "Lenny, I thought I was going to come here and learn how to change other people. What I've learned in the process is that if I am going to be able to do that, I have to be able to look at myself and change myself as well."

Our conference center is a 24-hour learning environment for participants to develop a new set of skills, as well as a better understanding of themselves. One of the things that we say is as a negotiator or as a mediator, what you do, what you say, how you are perceived is part of the tool of your negotiation. As a negotiator or a mediator you are constantly being observed and assessed and we give people an understanding of what others are seeing, what messages they are sending, and what they themselves need to perceive and understand.

Q. You are in an exciting field at an extraordinarily important time. I notice that you wrote in the AMA News on May 17th, that the time has come to stop making war and start making peace. You are in the bridge building business, aren't you?

Marcus: If you are about to drive your family over a bridge, you would like to think that the people who poured the concrete, laid the steel beams, and constructed the road that led up to It were working together in harmony, so that the bridge does what it was intended to do. Similarly, in the health care system, if someone comes to us for care, they have the expectation that we have the same level of coordination, cooperation. and collaboration in our work. And even though there are many difficult issues that are facing us--financial, professional. and organizational--we still must maintain that commitment to work together.

My collaborators and I are passionate in our desire to provide people with the tools and techniques and way of thinking that can help them do that. We put an enormous amount of effort into this and each of us is doing It with our true heart and soul because we really believe in what we are doing. We've seen how people have been able to adopt this work, make their work more productive and satisfying, and be of greater benefit to those people they are serving. We say that our teaching and writing, in some ways, is like planting seeds in that we hope people will be able to benefit from it and use it to make their own work more satisfying and productive.


Leonard Marcus, PhD, is the Director of the Program for Healthcare Negotiation and Conflict Resolution at the Harvard School of Public Health. The program researches ways in which interest-based negotiation and mediation can resolve patient-physician conflict and offers a one-week advanced course. A number of projects are based at the program, including the Medical Liability Mediation Assessment Project and the Harvard Blood Forum, which is leading an examination of national blood policy issues. He is the co-author of Renegotiating Healthcare, Resolving Conflict to Build Collaboration, which explores conflict resolution and negotiation in an industry besieged by change. He helped co-found two conflict resolution organizations: The Center for Health Care Negotiation (CHCN), a non-profit mediation service for resolving consumer complaints, and Health Care Negotiation Associates (HCNA), a consulting firm that works to resolve organizational (hospital mergers) and professional conflict, mostly among physicians. P lease call 781/861-6116 to contact the CHCN or HCNA, 617/432-0204 to learn more about the Program for Healthcare Negotiation and Conflict Resolution, and 800/956-7739 to order the book (San Francisco: Jossey-Bass, 1995, $41.95).

Richard L. Reece, MD, is a prolific health care writer and Editor-in-Chief of Physician Practice Options. He can be reached by calling 888/457-8800 or via email at
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Author:Reece, Richard L.
Publication:Physician Executive
Article Type:Interview
Geographic Code:1USA
Date:Jul 1, 1999
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