In the midst of a 1989 pilgrimage to the Nazi concentration camp where his father had been a prisoner more than 40 years earlier, Leonard Marcus had a revelation that he would eventually share with thousands of healthcare professionals. Against the bleak backdrop of Auschwitz, site of one of the greatest atrocities against humanity, Marcus was inspired to change the way people in U.S. healthcare saw conflict.
"I just had this strong sense that we human beings have to learn better ways of dealing with our differences," says Marcus, a veteran consultant on negotiation and mediation.
Barry Dorn was a brash young orthopedic surgeon in the 1980s, the self-confessed "local bomb-thrower" of the Massachusetts Medical Society, who would spar with anybody over malpractice reform or the evils of managed care. The assertive traits that made him a feared political firebrand, however, eventually spilled over into his practice. "I had gotten to the point where I was actually argumentative with certain patients," he admits.
Perhaps at times like these, when things seem particularly dark or out of kilter, people are inspired to find and commit to an entirely new approach.
Marcus and Dorn serve as lead faculty for the Harvard School of Public Health Program for Health Care Negotiation and Conflict Resolution in Boston. The program offers an annual weeklong session for healthcare professionals. Students must go through a selective application process to attend the course, which costs $3,250. Since 1989, Marcus, Dorn and other instructors have introduced about 500 healthcare administrators, physicians and others to a new mind-set and trained them in a set of skills that one former student describes as "a breath of fresh air."
The program teaches problem-solving and creative implementation and helps participants broaden their perspectives. It inculcates the belief that every negotiation offers the potential for everybody involved to get something they want. And it asks participants to embrace conflict as a valuable part of life and learn to effectively manage it.
Those skills may well be essential in achieving change in America's troubled healthcare system. There is plenty enough trouble to work with.
Last month, an Institute of Medicine report charged that quality problems "are everywhere, affecting many patients." Fifteen months earlier, an IOM report estimated that as many as 98,000 Americans die each year as a result of medical errors in hospitals. The healthcare system is a "nightmare to navigate" patients said in a 1996 survey.
Solutions for such systemic problems have been rare. In the past decade, the healthcare marketplace has experimented with new financing schemes and encouraged mergers and system growth. Major payers that once reimbursed generously have taken money away, then added cash back to the system. Some states have tried heavy-handed regulation, while others have tried the laissez-faire approach. And the troubles keep on coming.
A theme of the IOM's recent Crossing the Quality Chasm report, which calls for an overhaul of the healthcare system, is the need for providers to focus on coordination, teamwork and communication. The report's authors identify current training as well as institutional, labor and financial structures in healthcare as factors that tend to stymie teamwork.
These inherent limitations make traditional approaches to negotiation and dispute resolution a challenging fit for many healthcare environments.
According to a story shared by Marcus, negotiating guru William Ury, who helped broker nuclear weapons treaties between the Soviet Union and the U.S. during the Cold War, was asked to mediate a dispute between physicians and administrators at a Boston teaching hospital. "He said, `You know, Len, a hospital makes U.S.-Soviet relations look like a piece of cake,' " Marcus recalls.
Marcus' resume includes negotiating peace among stakeholders of a national transplant organ bank in the midst of internal turmoil that was bubbling over into the national media, and mediating negotiations between a statewide Blue Cross and Blue Shield plan and a large integrated delivery system. The realization of his vision 12 years ago in Poland comes through in sharing his passion and knowledge with the people who will bring teamwork, negotiation and conflict resolution to healthcare.
Playing new roles
Martin Diamond lives in a world that is typical in healthcare today. He is president and chief administrative officer of John Muir Medical Center in Walnut Creek, Calif., which, less than five years ago, merged with nearby competitor Mount Diablo Medical Center in Concord, Calif., to create 946-bed John Muir/Mount Diablo Health System.
"You can imagine, we have our challenges now that we are one," says Diamond, who attended the weeklong Harvard negotiation and conflict resolution course in 1997.
John Muir/Mount Diablo owns a physician practice with more than 70 doctors, and its managed-care network includes a 450-physician independent practice association. Together these partners craft a package of hospital and physician services to offer to managed-care plans. Diamond estimates that managed care accounts for almost half of the system's revenue.
"We have a lot of dynamic tension among ourselves to get to the point where we can work with a health plan," he says.
Recently, when internal negotiations bogged down over some key financial issues, Diamond says the physicians and administrators used a new structure that allowed each party to make its case during a set amount of time, then allowed another period for discussion of each proposal before participants moved on. The approach helped the physicians and administrators break through to a solution.
"We imposed a structure that we had never tried before, and everybody felt good about it," he says.
The hiring of a new director of managed-care contracting for the system presented potential for a rift among the partners. The IPA considered hiring its own contracting agent. When they came down to the final few candidates, the system's selection committee--including representatives from the hospitals, the IPA and the owned physician group--scrapped the typical interview process and instead conducted a role-playing exercise with the finalists based on a scenario prepared by the committee. Doctors were administrators, administrators were doctors and the candidates jumped in to draft a mock proposal to deliver to the managed-care plan. The system, with the IPA included, hired a single contracting executive who, by Diamond's account, has been successful in his role.
Diamond says the idea for the role-playing came from his Harvard experience. "You begin to understand the importance of being creative."
Creative approaches to solving a conflict, infusing of a sense of "humanness" into negotiations and considering a wide array of perspectives are all part of the body of knowledge Marcus and Dorn strive to impart.
"The skill that we really want to teach them is multidimensional problem-solving," Dorn says.
When doctors and patients talk
Graduates find applicability in areas beyond managing the internal strife among partners of integrated delivery systems. Dorn considers the work being done by faculty and graduates to improve physician-patient relationships among the program's most important areas of focus.
Health Care Negotiation Associates, a Lexington, Mass.-based for-profit company through which Marcus and Dorn do occasional consulting work, has been engaged in a pilot program with the Massachusetts Board of Registration in Medicine to mediate consumer complaints against physicians. Harvard program faculty member and Health Care Negotiations Chief Operating Officer Joan Roover says the voluntary program has mediated about 40 complaints since it began in 1994.
Most of the complaints the program handles involve miscommunication between physicians and patients. Although less dramatic than cutting off the wrong limb, these oversights and affronts can snowball into a damaging lack of rapport.
Plaintiffs bringing cases to the mediation program include a mother whose child accidentally stuck herself with a discarded syringe in a doctor's office, a woman who felt she had been inappropriately touched by a male doctor during a pre-employment physical and a man who was dissatisfied with the results of his minor surgery. Roover says that although the exchanges are often emotional, both parties generally come away from the process satisfied with the opportunity to have been heard and to have heard from the other side.
"If we create better opportunities to sit down and communicate with patients and families, we can provide information in such a way that we may be able to decrease the number of suits," Roover says.
A forum for openly dealing with mistakes or errors allows healthcare systems to learn. Roover says that an important focus of the program being conducted through the Massachusetts physician licensing board is the follow-up; in many cases policies and protocols are developed to help avert the same problems in the future. Marcus says he hopes that the work of Roover and others in managing patient-physician conflicts will contribute to an understanding of these disputes and their potential resolution.
The Massachusetts physician licensing body's use of mediation for settling these types of disputes, believed by Roover to be the only such program in the country, is a limited example of how unfortunate incidents can be used for a positive purpose.
The typically misunderstood role of conflict in healthcare organizations is something that Marcus and Dorn hope to revisit with their students.
"I think one of the things they come out with is that it is not bad that they are dealing with conflict; it is part of their jobs," Marcus says. Conflict is inherent in healthcare, caused by professionals' mutual commitment to provide high-quality care. "It comes out of, interestingly enough, our passion," he says.
And conflict is fed by a culture and training regime that has traditionally programmed physicians to believe that for the sake of the patient, doctors must always be right.
"It is our job to single-handedly and authoritatively solve problems," says program graduate David Acker, M.D., making light of the mind-set traditionally imparted by medical schools. Acker is chairman of the obstetrics department at Brigham and Women's Hospital in Boston. He says the secret to fighting the tendency of doctors to become "problem-solving machines" is to expand the circle of people providing advice on a solution. "The ideas don't come from me; they come from the people you expand the circle to," Acker says.
Traditional models of dispute resolution in healthcare and beyond involve one side's proving the validity of its point or simply overpowering the other. "The key in healthcare conflict resolution and negotiation is not getting to `yes'; it's creating a fit," Marcus says. The Harvard program's "whole image negotiation" model focuses on making sure that everyone involved in the process gets something positive out of it.
Program graduate Richard Iseke, M.D., vice president of clinical affairs at 189-bed Lawrence (Mass.) General Hospital, remembers a conflict over a clinical schedule he had with a physician on his staff. Although the doctor admitted the schedule was logical, which Iseke assumed was the key point, she continued to be upset. When Iseke stopped trying to explain the logic and just listened to the physician explain her concern, he was able to understand and work toward an agreeable solution.
"All of a sudden the light bulb went on that in fact she had a point," Iseke says. "The certainty that we are right sometimes precludes us from seeing any other right."
The Harvard program devotes an entire module to the skill of effective listening, a gift Marcus says he associates with outstanding leaders. Some suspect that failure to hear others and be empathetic may be at the root of some of the most pressing issues in healthcare today.
"I think that is why nurses are leaving," says Roover, a former health system executive. "They don't feel like anyone listens or cares about them."
Turning to new alternatives
This week, a group of 40 physicians and healthcare administrators will descend on the secluded campus of Babson College in the Boston suburb of Wellesley, Mass., for this year's Harvard conflict resolution leadership course. They will undergo an intensive learning experience that some graduates say has changed their lives forever. Faculty require a heavy dose of advance reading and, in the Harvard tradition, case studies that require role-playing. Camaraderie develops among the participants, who immerse themselves in the art and science of healthcare negotiation and conflict resolution.
It is a tiered approach to learning involving a reorientation of the student's mind-set, an understanding of strategy and familiarity with tactics. Marcus' "walk in the woods" model for negotiation was built on a process that U.S. and Soviet leaders inadvertently discovered during a lull in arms talks in the 1980s. In an informal way, it builds on each party's interests, ultimately considering a broad scope of possibilities and creative means to achieve them. It also allows for plenty of humor, which Marcus refers to as "negotiation lubrication."
The Harvard School of Public Health's Division of Public Health Practice includes conflict resolution and negotiation in its master's degree in public health curriculum. Harvard Associate Dean Deborah Prothro-Stith calls effective communication among the most important training for the healthcare profession. "It is as critical as a physician being able to talk with and negotiate with a patient in a one-on-one way to come up with a therapeutic plan," she says.
The American Association of Health Plans has encouraged lawmakers crafting a patients' bill of rights to build in independent review programs, instead of immediate access to the courts, as a way to appeal health plans' access-to-care decisions.
"If the healthcare arena were more skilled and trained in healthcare conflict resolution we would have (already) turned to other alternatives in the public policy debate," says AAHP President Karen Ignagni.
If Marcus, Dorn and their colleagues have their way, healthcare professionals will find that turning to other alternatives can shine a new light on longstanding problems.