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37 Managing Change in Family Medicine Residency Programs
439
Step 5: Empower Others
VIGNETTE: Empower others (Suh)
After years of planning, we welcomed our inaugural
class of residents in 2021, arguably our most important
stakeholders in the success and sustainability of the program. A core pillar of our vision was that this rst class
would be leaders and trailblazers. Empowering residents
to have ownership, accountability, and pride over the continuous improvement of their program was and continues
to be a journey of cultivating a culture of trust and dialogue. Empowering residents began with investing in
time and structure to listen to resident feedback and
ideas. We had multiple modalities for resident feedback—regular virtual PD ofce hours, anonymous virtual suggestion box, weekly PD and PC check-ins during
protected didactics, monthly resident forums, and formal
rotation evaluations. As leaders, we had to be visibly
present to show we cared and we were listening. But
empowering residents has to go beyond caring and listening. We need to actively identify and develop resident
leaders. We did this by creating and expanding opportunities for residents to participate alongside faculty in
department and health system committees, and take ownership of key components of residency curriculum like
the core didactics. In the rst year of our program, resident volunteers joined faculty meetings to provide input
on curriculum changes. We removed barriers by protecting time from clinical duties for residents to participate in
committee meetings. We elevated the expectation that
residents are leaders in their own program. Now in year
three, we have a full-edged Curriculum Committee that
is chaired by Chief Residents with resident representatives from each class. Faculty and program leadership
provide oversight, but residents are the leaders who have
implemented systematic changes to continuously
improve the didactics curriculum. (Joanne Suh, Program
Director)
Empowering others to act begins with creating a climate
and culture of trust where people feel they can contribute
freely, create, and innovate. Leaders must invest in trust
which begins with building and then sustaining trusting relationships over time. Research shows that leaders who spend
the most time and energy developing cooperative relationships among the people they work with are viewed by their
direct reports as the most effective and have the highest levels of engagement by those reports [9]. Leaders build trust by
demonstrating with sincerity and through action that they
need and value the contributions of others. Actions that demonstrate trust include:
• listening and learning from others
• acknowledging and incorporating their ideas
• sharing information and resources that allow others to be
successful [9].
Leaders must model vulnerability, acknowledging they
don’t have all the information and that the success of the
endeavor is dependent on the knowledge and actions of
others.
In addition to modeling trusting behavior for others, lead-
ers can foster and support a culture of trust by creating an
infrastructure that encourages trust and collaboration in their
teams. The team should help determine the goals for the
project, who needs to be included, how often to meet, who
will be accountable for specic actions and follow up. They
should consider other strategies to foster and support collaborative efforts such as rewarding the entire team for accomplishments as opposed to focusing on individual recognition.
Also, encouraging face to face meetings and structures that
develop relationships such as meeting over lunch with time
allocated to eat and enjoy time with others, beginning meetings with a quick ice breaker that allows the team to learn
something new about each other or encouraging smaller
groups to meet to facilitate interactions and relationship
building. Only through intentionally creating trust can people feel safe to make contributions. Leaders must invest in
developing trust; It is the bedrock of being able to effectively
and efciently solve problems.
Shifting hierarchical culture takes time and may require
behind the scenes coaching to help empower team members
to speak up and engage in meetings. The word empower
means to give power to others to do something. This, by denition, means the leader must relinquish control and give
some power away to others to make decisions. This additional responsibility and control leads to investment in the
process and the associated accountability for outcomes.
Leaders set others up for success by investing in their growth
and development and making sure they have access to needed
information and resources. This may include connecting
their team to training programs or others who can further
mentor and develop them to help them be successful.
Inevitably taking on new responsibilities and challenges may
result in some fear and anxiety. Leaders should promote selfcondence by acknowledging challenges while conveying
their own condence in their team’s ability to overcome
obstacles. Leaders can also develop their team by taking a
coaching approach, asking open questions to help develop
440
J. Suh et al.
their team’s problem-solving abilities as opposed to jumping
in to solve problems or immediately giving their opinion
when asked.
Step 6: Generate Quick Wins
It was not uncommon for us to hear mentioned the four
stages of team development at the start of our residency.
If we hadn’t known it before, we grew to become quite
familiar with those stages of forming, storming, norming, and performing. The path wasn’t always linear, at
times circular, but always with hope of moving forward
in the direction of our shared vision. The beginning of
our program was earmarked by a constant cycle of forming and storming, making it challenging to feel substantial progress without much norming and performing
occurring. Engagement and morale, especially among
the residents, stagnated during these initial phases and it
was reected in our annual ACGME survey. Progress
seemed slow, frustrations were mounting, and our best
always seemed to fall short of enough. Looking back, we
can recognize now the tides began to turn as we identied and generated short-term wins. These ‘wins’ encompassed accomplishments such as having more core
faculty involvement in teaching to creating formal resident clinic templates. At the start, residents were identied by number in clinic templates instead of their names
due to the mechanics of incorporating new trainees in a
system where they had not existed. They had also been
working off other attending schedules. With feedback
and frequent improvements, residents soon had clinic
templates formally under their names with their own
panels. These wins were nite, concrete, and most
importantly attainable within a short time frame. Not
always especially profound individually, these wins in
their collective energy lifted our sails. The purpose was
double fold—bolstering the spirit of our team while also
maintaining any momentum we had picked up along the
way. With these short-term wins in parallel with our
larger projects, we found ourselves tipping the scales
toward more norming and performing in our growth as a
new program. We found ourselves moving, onward and
forward once again. (Justin Bui, Chief Resident)
There’s the common aphorism of losing a forest for the
trees. The “Generating Quick Wins” stage of the Kotter
Model reminds teams that there would be no forest if not for
the trees. In the context of change management, this means
that any “win” is an opportunity to uplift and propel organizations toward the larger team vision. It is imperative to keep
in mind no accomplishment is too small or insignicant
when larger change is underfoot, especially in the early
stages of starting a new residency program when the sentiment of “not enough soon enough” can be too common.
Generating quick wins is a requisite for successful project
management without which even the strongest of teams can
nd themselves on turbulent terrain [1].
What is a “quick win?” A quick win in change navigation
is not a gimmick or a slight of hand. It is a signicant organizational improvement, whose collective impact is necessary
for the success of any endeavor. It is something that also does
not occur spontaneously but must be intentional. According
to Kotter, a “good” short-term win possesses the following
characteristics [2]:
1. It is visible. Stakeholders can feel and appreciate the
impact.
2. It is unambiguous. The win is concrete and without a
doubt had surfaced.
3. It is related to the change effort. Stakeholders can see
how the win contributes to the long-term endeavor.
Transformation, especially for such an endeavor as
founding a new program, takes time. Quick wins are meant
to be just that—quick and attainable in the span of weeks or
months. Examples of quick wins in establishing a residency
program could range from setting up a resident workroom
with the appropriate amenities to establishing regularly
scheduled Program Evaluation Committee meetings with
resident representatives.
While being laser-focused on the long-term effort is also of
importance, if one does not proceed with intentional shortterm wins the team can quickly grow despondent with an end
goal that suddenly feels ever more elusive. There is a “newness”
at the start of an endeavor that teams will nd invigorating and
even infectious. Teams will have created a sense of urgency,
shared a compelling vision, and built water-tight teams with
great alacrity. That enthrallment should be embraced wholeheartedly, but groups with best laid plans can still fail an organizational effort. The reality is that great intentions do not
always yield great results, and success should not be dened
by a singular outcome but rather a series of committed incremental steps toward a shared vision. Quick wins have the
power to build momentum, reinvigorate the vision, ne tune
strategies, reward efforts, and quell cynicism [3].
Forming and storming will be inherent to any change
endeavor, especially at the outset of a project. The hope of
any stakeholder is to move toward norming and performing
with an upward trajectory, and Kotter reminds changemakers
that it would be remiss to discount intentional short-term wins
as a vital functioning of a larger operation. Generating quick
wins is indispensable and invaluable just as are all the members of a team who keep an operation aoat, and just like with
every member of a team there is also no win either too small
or insignicant in their contribution to a larger shared vision.
37 Managing Change in Family Medicine Residency Programs
441
Step 7: Consolidate Gains
How might we? This phrase was used during a resident
workshop to brainstorm improvements to both resident
clinic and our didactics curriculum based on feedback
the residents had provided. We split up the residents
and faculty into two groups. The task was to generate
as many ideas and solutions in the form of feedback as
we could; the caveat was that each idea or suggestion
had to begin with “How might we..” for example “How
might we create an opportunity for residents to give
presentations during didactics”. Once these ideas had
been written on sticky notes, the next task was to organize the ideas on a scale based on ease of implementation vs. size of impact for the idea on a large poster and
present this to the rest of the group. By the end of the
exercise, we realized many of the suggestions were
actionable and could be implemented relatively with
ease. The residents felt engaged and some volunteered
to take initiative to implement the ideas. Creating the
posters in this manner was about visualizing and communicating the short-term wins that we would now try
to consolidate as gains we had made. Our program was
moving in a stride and we now were working to sustain
the momentum of change. Both posters currently hang
in the resident work room; a visual reminder of the
progress our program will continue to make. (Matthew
Sayre, Chief Resident)
In order to continue building on the change, it is important to repeat and iterate. The seventh step of the Kotter
change model is about maintaining momentum with changes
that are made; specically consolidating the gains from creating and celebrating many short-term wins [2]. This step is
important for three reasons:
First, by focusing on what works in a change model the
leader(s) can identify positive aspects of the change and demonstrate effectiveness. Kotter argues that for change to be successful, it must be visualized and communicated well [7, 8].
This should be done through multiple communication channels, i.e., multiple forms of feedback both written and verbal,
from constituents back to leaders or through status update
meetings, such as frequent department chair or program
director update letters. An example of this can be done
through group feedback discussions such as creating ‘How
might we’ posters or the WIFM exercise referenced in Step 4.
Second, by creating momentum through the positive factors of change, it can instill faith from the constituents to
continue to believe in the change, which will allow recruitment of other constituents or even new stakeholders to join
the coalition to reach the goal. For instance, when designing
the rotations and curriculum for residents, creating multiple
methods of feedback, i.e., anonymous online forms or town
hall style discussions, emphasizes the importance of constituents at the center of the organization. Establishing this multimodal feedback system allows the constituents to
communicate difcult details and conversations to their leaders, and thus, feel valued and heard. Assessment of the feedback is crucial for determining the factors that both help the
change continue and those that hinder it. This creates the
cycle of improvement for the organization.
Finally, the third reason why this step is crucial for the
change model is that continuing to build on changes that are
succeeding demonstrates the leader’s commitment to the
constituents through modeling and participating in the
change themselves [12]. An example of this includes implementing a leadership curriculum for the constituents. The
goal of implementing layered leadership creates a sense of
self-governing among the residents. It also calls for further
commitment and buy-in for the constituents to the change.
For example, by allowing residents to run the inpatient
service and by empaneling patients directly to them in resident clinics, leaders rely on the constituents to share in decision making, which perpetuates the gains made from change.
Step 8: Anchor Change inCulture
In July 2023, we welcomed our third residency class,
nally lling our full complement. We have a busy resi-
dent clinic where we have continuous quality improve-
ment to improve continuity, quality, safety, and
team-based care. Patients have established trusting and
therapeutic relationships with their resident PCPs, so
much so that they refuse to see other physicians. Our
specialty colleagues frequently refer patients to resi-
dents for primary care, and clinic staff request to be
assigned to work with residents in clinic. It’s hard to
imagine this clinic without residents. It is now part of
our DNA.These are all markers of change management
success. Residents as PCPs in our highly specialized
tertiary-quaternary center is not a new concept anymore.
It is now the norm, and is embedded into the organiza-
tion’s culture and processes. Moreover, there are new
leaders and champions who work collaboratively to
continuously improve the resident clinic experience in
its dual mission for high quality training and high qual-
ity patient care. We have increased the capacity and
adaptability of the entire team to manage change. After
all, the only constant is change! We are preparing for
another big change in the following academic year.
We’re moving to a newly constructed expanded resident
clinic site that is part of the health system’s expansion
(continued)
442
into Arcadia, a suburb of Los Angeles. But we are prepared for this change (and any change on our horizon)
because we have the tools to manage it and our people
well. (Joanne Suh, Program Director)
The 8th and nal step in the Kotter Model is institutionalizing the change where it becomes the new normal. This step
is critical to ght inertia and prevent regression to old norms
and ways of doing things. Not only are new systems, processes, and procedures institutionalized, but the culture has
shifted. It’s not just about doing things differently. Change
leaders have been activated. Individual’s actions and behaviors are the key to bringing about changes in culture, and this
comes at the end of the change process, not at the beginning.
Culture changes with people, and it is this that ensures that
the program will continue to evolve, improve, adapt, and
innovate regardless of what new change is around the corner.
Some strategies to anchor change in culture include:
• Put people rst. Known your people, understand, and
respect their WIFM, activate, and engage all stakeholders
• Communicate often using different tools for different
audiences (a patient story to the Patient Family Advisory
Council, a nancial report to the CEO of the Sponsoring
Institution)
• Invest in leadership development (seek out structured fac-
ulty and resident development programs, integrate leader-
ship skills into faculty development topics)
• Intentionally teach change management to residency fac-
ulty and residents
• Be willing to change, to adapt and to evolve (we reimag-
ined the Kotter model as a cyclical, constantly-evolving
process)
Conclusion
Change management in Family Medicine Residency programs is a vital leadership skill for improving educational
and clinical outcomes, maintaining program relevance,
advocating for the specialty, and training family medicine
physician leaders equipped to meet the dynamic needs of
patients, communities, and healthcare systems.
The task of starting a family medicine residency program
is undoubtedly onerous, but also important and necessary
work. At their core, family medicine training programs are
the lifeblood of the specialty. In fact, the same can be said of
any training program for without them new generations of
providers and the passage of knowledge are lost. Learning
how to navigate change will be essential to the sustainability
of any such program, especially with the awareness that closures are not a rare phenomenon.
J. Suh et al.
The Kotter Model adapted for starting a family medicine
program is outlined in the preceding sections, demonstrating how change is both an inevitability and a necessity.
While the Kotter Model speaks greatly to effecting external
change, there is a noticeable absence of discussion on the
internal change that occurs as a result. Being instrumental in
starting a new residency program, every stakeholder from
DIO to clinic staff emerges an irrevocably different person.
Though every role might be different, the shared journey
leaves each with shared cultivated skills in resilience,
patience, and trust. By nature, change is transformative and
evolutionary, and the natural course is that one also transforms and evolves for having been a part of the change
process.
References
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Manag (Frederick). 2020;39(2):50–65.
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D, Potts S, Pugno PA. Residency training in family medicine: a history of innovation and program support. Fam Med.
2017;49(4):275–81.
4. Crawford L, Nahmias AH. Competencies for managing change.
Int J Proj Manag. 2010;28(4):405–12. https://doi.org/10.1016/j.
ijproman.2010.01.015.
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Negotiation andCollaboration Skills
StanleyJ.Tretter
38
Key Points
• Negotiation and collaboration are key skills needed by
Program Directors to successfully manage a Family
Medicine Residency Program.
• Negotiation styles can vary based on individual personalities, circumstances of the negotiation, and the desired
outcome.
• Styles can include avoiding, compromising, accommodating, competing, and collaborating.
• The elements of a negotiation can be described in various
ways, but the classic model includes consideration of
interests, alternatives, relationships, options, legitimacy,
communication, and commitment.
• Foundations of an effective negotiation consist of assessing your bargaining style, your goals and objectives, relationships, leverage, the other party’s interests, and
authoritative standards and norms.
• Although different situations and circumstances exist, the
standard process of negotiation will involve a preplanning
stage, a planning stage, and then the execution of the
negotiation.
• Successful collaboration requires that you have a good
understanding of what you have to offer the partnership,
as well as what you hope to gain from the other party.
• For larger collaboration initiatives, it is important to have
a structured process to ensure a clear direction, accountability, and measurable outcomes.
Negotiation and collaboration are two skills that are essential
for any successful Family Medicine Residency Program
Director to develop. It is important to understand what they
are, and what they are not. Initially, it may seem that these
S. J. Tretter (*)
Family Medicine Residency Program– Jasper, Indiana University
School of Medicine, Indianapolis, IN, USA
Memorial Hospital and Health Care Center, Jasper, IN, USA
e-mail: stretter@mhhcc.org
are mutually exclusive, in that a negotiation involves two
opposing sides attempting to nd a compromise, whereas
collaboration involves individuals working together for a
common goal. While that may true in one sense, negotiation
and collaboration can also co-exist, and often times this is
what will lead to the best outcomes for all. In this chapter, we
will explore the concept of negotiation, how to best develop
the skill to be an effective negotiator for your programand
yourself, as well as how to utilize collaboration to your
benet.
In its simplest form, negotiation is a skill that we learn at
a very young age. When we want something that we do not
have and we see that someone else can provide it to us, we
learn that we must gure out a way to try to get it. For children, this can simply be “if you don’t give me ice cream, I
will cry and scream!.” That is a form of negotiation that is
quickly determined to be unsuccessful for long. We become
more sophisticated and learn that often we must identify
what it is that others want rst, and then offer to give them
something they want as we get something that we want in
return. An older child might learn, for example, that “if I
want you to take me to the park, I have to offer to pick up my
toys rst.” As adults, and particularly as leaders of programs
and organizations, we learn that there are a number of complexities that must be navigated to be successful negotiators.
We need to understand the different negotiation styles that
exist, and when certain styles might be more effective than
others. We need to understand the various elements of a
negotiation so that we can be prepared effectively. Finally,
we need to understand the situations we might face as a
Program Director that require negotiation, and how we might
adapt our approach accordingly in order to be the most
successful.
Collaboration is another important skill that Program
Directors must learn to navigate. With the complexities
required for graduate medical education (GME), many contributors are required to successfully train family medicine
physicians. A Program Director certainly cannot do this
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_38
443
444
S. J. Tretter
alone and must work with faculty members (possibly both
paid and volunteer), departmental or institutional administrators, clinical staff, community partners, and a number of
other entities and stakeholders in order to create a successful
residency program. As GME evolves, it is becoming clear
that collaboration will be necessary for success. The
Accreditation Council for Graduate Medical Education
(ACGME) developed a task force called SI2025 to study
how sponsoring institutions of the future need to prepare to
adapt to changing educational models, and the need for collaboration between GME and health care systems due to the
evolving requirements for education is apparent [1]. With the
dynamics that must be considered and navigated, effective
collaboration skills are essential for a successful Program
Director. These, too, will be addressed further in this
chapter.
Negotiating Styles
Styles of negotiating can be simply related to the personality
of the negotiator. We all know people who are “peoplepleasers” who will avoid conict when at all possible and
will do nearly anything that is asked of them, often to their
own detriment. On the other extreme, there are those who are
so stubborn that they will only accept things their way and
refuse to make any allowances for others. Most people will
fall somewhere in between this range, depending on the situation. Successful negotiators, however, will understand that
you can adjust your style of negotiating to nd the one that
will be most benecial based on the circumstances of the
situation and what it is that you are negotiating. Bazerman,
etal. described how the individual differences among people
as well as the context of a specic negotiation will impact the
styles utilized in a negotiation [2]. In Richard Shell’s classic
book Bargaining for Advantage: Negotiation Strategies for
Reasonable People, Shell describes ve negotiating styles
that include the range identied above [3]. These negotiating
styles, listed in Table38.1, include avoiding, compromising,
accommodating, competing, and collaborating. We will look
at these, as well as in what circumstances as a Program
Director they may be benecial or harmful in the negotiating
process.
Avoiding At its most basic level, this is a style in which an
individual chooses to avoid conict and therefore is really
unwilling to negotiate unless absolutely necessary. There
may be occasions where this is preferred when the current
situation is felt to be the best option available and no changes
are felt to be necessary. For example, if you and your faculty
recently made a curriculum change based on new ACGME
requirements and residents want to negotiate changes, you
may determine that the new curriculum is best for the
program and decline to participate in any negotiation. An
example, in which this might not be preferred, is one in
which two faculty members have each requested a specic
weekend off, but you need one of them to work. In avoidance, you may take the stand that the schedule stands as the
weekend rotation routinely falls, and you will not make any
adjustments based on their preferences. While this may
seemingly avoid any further attention or involvement from
you initially, the dissatisfaction this will cause among faculty
members may make this style of negotiation (or lack of
negotiation in this case) ineffective and problematic in the
long run.
Compromising This is most often considered to be the
“middle of the road” negotiating style, where each party
makes an equal concession and a compromise is reached.
Neither party gets what they actually wanted but agrees to an
outcome in the middle. In our example of the two faculty
members wanting the same weekend off, a compromise
might be for one to work Saturday while the other works
Sunday. Neither got what they desired, the full weekend off,
so neither was fully satised. Depending on the situation
being negotiated, a compromise might not be preferable
because ultimately neither party may get what they need.
Using the example above, let’s say that the reason each faculty member wanted the weekend off was to attend an outof- town event. While the compromise of each working one
day seems fair, neither could attend the event, so the compromise really was not a successful solution in this case.
Accommodating This negotiation style is based on the con-
cept that one party is trying to meet the needs of the other,
perhaps because of their relationship or a desire to “bank”
goodwill for future use. In the scenario of our example, one
Table 38.1 Negotiation styles, based on Shell’s Bargaining for Advantage: Negotiation Strategies for Reasonable People [3]
Negotiation Styles Description
Avoiding Minimize negotiation to avoid conict
Compromising Look for a “middle of the road” solution
Accommodating Work to meet the needs of the other party
Competing Angle negotiation to “win” at the expense of the other party
Collaborating Both parties contribute in a way to provide success for both
38 Negotiation andCollaboration Skills
445
faculty member might offer to let the other have the weekend
off, with the hope that in the future, the second faculty member could return the favor. This type of negotiation style will
be most effective if the parties involved in the negotiation
have a long-term relationship that is expected to require further negotiation in the future. The end result of one negotiation might be less important than the impact on the future
relationship of the parties. As you work with multiple stakeholders, it will be important to consider what future requests
you may have of them, particularly department leaders, hospital administrators, or community partners, and how critical
a particular issue for which you are negotiating may be at the
moment.
Competing In this negotiation style, there tends to be a
winner and a loser. However, as discussed in the accommodating style, it is important to consider the long-term consequences, because the desire to be the winner may come at an
expense that impacts relationships or future prospects of
negotiation. In the example of our faculty members both
wanting the same weekend off, competing negotiation may
result in neither faculty member agreeing to concede, forcing
the Program Director to make an arbitrary decision that
favors one and upsets the other. Clearly, in this example, this
would be damaging to relationships between the faculty
members as well as between the Program Director and the
faculty member who was forced to work.
Collaborating The nal negotiation style is described as
collaborating, and this is generally seen as nding solutions
that tend to be more creative and ultimately provide benet
to all parties, sometimes in ways that produce more than
either party could have had alone. In the faculty example,
perhaps the two faculty members would nd a third faculty
member who agreed to work on the weekend in question and
each of the other two agreed to ll in for her on a future
weekend. In this case, creative negotiating created a solution
that beneted all parties in ways that were not originally
considered.
These ve negotiating styles constitute the range that can
exist with varying levels of cooperativeness, focus on the
relationships, assertiveness, or focus on one’s own goals.
This has been described by the Thomas-Kilmann model
which illustrates that these styles fall on a continuum between
these two dimensions, as referenced in the “Negotiation
Skills as a Program Director” chapter in Graduate Medical
Education in Psychiatry [4]. One particular style is not nec-
essarily preferred over another, as each has its advantages
and disadvantages based on the particular issue at stake.
Elements ofaNegotiation
In the past 50years, much work has been done to analyze the
negotiation process, in order to try to understand how one
can be most effective and successful in the process. Various
models and descriptions have been developed, including a
depiction of three negotiation elements including issues,
positions, and interests as described by the Lowry Group [5],
and Japhé Mercier of Young Leaders of the Americas initiative providing an account of ve elements of effective negotiation which focuses more on the process involved [6].
However, one of the foundational books on this topic was by
Harvard professors Fisher, Ury, and Patton in Getting to Yes,
rst published in 1981, and revised multiple times over the
years [7]. This has been used as the foundation of the Harvard
Negotiation Method often referenced today [8]. This model
described seven elements of a negotiation, which are listed in
Table38.2. Any type of negotiation, whether in the business
world or of a personal nature, can apply these principles to
better understand how this process works.
To better understand these elements of negotiation, we
can use an example in the world of a Family Medicine
Residency Program Director to demonstrate each of these.
Let’s use the very real scenario of new ACGME requirements that require core faculty to have a minimum amount of
time dedicated to nonclinical duties including teaching,
supervising residents, scholarly activity, and program
Table 38.2 Elements of a negotiation, based on Fisher, Ury, and Patton’s Getting to Yes [7]
Elements Description
Interests Not only what a party wants, but more importantly, WHY?
Alternatives If a party can’t get what they originally wanted, what is the BATNA (Best Alternative to a
Negotiated Agreement)?
Relationships How important is the relationship between the parties after this negotiation?
Options Different possible outcomes—different from alternatives which assume negotiation not
successful
Legitimacy The “fairness” of the negotiated options considered
Communication Beyond words, communication includes the tone, nonverbal cues, and intentions behind what
is discussed
Commitment Once an agreement is made, how committed is each party in fullling the agreement, and do
they have appropriate authority to do so?
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S. J. Tretter
improvement. Let’s say that in your program, core faculty
members have scheduled clinical times that do not allow
them to meet the new requirements, and so you have to
request to hospital administration to reduce their clinical
time to allow for the appropriate amount of nonclinical program time. Obviously, hospital administration will likely be
reluctant to do so, as the reduced clinical time will result in
what they consider non-productive time (i.e., not generating
revenue). This will require the Program Director to explain
why the Hospital must allow this change to meet new
ACGME requirements even though it may have a negative
nancial impact for the hospital. Consider how this example
demonstrates each of the negotiation elements presented
above.
Interests In this case, it is important for the Program
Director to explain to the hospital administration not only
what is requested (each core faculty member needs 60% of
their time, or 24 hours per week, allotted for nonclinical
duties) but also WHY this is needed. Not only is it a requirement of the ACGME, meaning that failure to meet this might
jeopardize the accreditation status of the residency program,
but the rationale behind it is to enhance the quality of the
program by giving core faculty members the time to dedicate
to the increasing demands placed upon them to ensure we are
training competent physicians who will be ready for independent practice upon graduation from the program.
Alternatives Alternatives differ from options, in that it
assumes that a negotiation is not successful, and therefore
the parties have to consider what would happen if an agreement is not reached. In this particular example, there really is
not a great alternative, as failure to meet the minimum standards would place the program out of compliance with
ACGME requirements and ultimately jeopardize accreditation status.
Relationships The relationship that the Program Director
has with the hospital administration is an important element
that cannot be understated. Hopefully, well before any
important negotiation is needed, work has already been done
to cultivate these relationships as they will be critical
throughout the Program Director’s tenure. Trust, understanding, and respect do not occur overnight, and truly need to be
developed over time. Ideally, the Program Director has the
opportunity over time to ensure that key decision-makers in
administration, whether that is a Designated Institutional
Ofcial (DIO), Department Chair, Chief Medical Ofcer
(CMO), or Hospital Chief Executive Ofcer (CEO), depending on the organizational structure of the health care system
in which you are working, have a good understanding of
GME and the value it provides.
Options In this example, it might be a strategy to discuss
with the administration how time could be allocated for different core faculty members in different ways. Perhaps certain physicians tend to be more productive in a clinic than
another or have a skill set that provides value in overseeing
the inpatient service or on Labor & Delivery. There may be
options of time allocation for core faculty that could be
favorable for both the program and meet its needs as well as
for the health care organization that might be preferable but
still meet the minimum ACGME requirements.
Legitimacy As Program Director, you are often the local
“expert” on GME, and so it is important that you have a clear
understanding of ACGME common program requirements
and program specic requirements so that you can share
these with those in administration who are asked to make
decisions affecting the program. In this case, as you present
options to administration, you must consider not only what
will meet the requirements you are given but also what is
most reasonable to all stakeholders, including the health care
organization and the individual core faculty members.
Communication In today’s world, there are many forms of
communication, and when to use which kind varies based on
the situation as well as the style of those involved. How do
you rst reach out to administration to have this discussion—do you call, send an email, or arrange for an in-person
meeting? Do you communicate with one person rst who is
most likely to advocate for you, and then address a larger
group of decision-makers? The answer to this will vary based
on your organization and the relationships you have, but it is
important to at least consider how and what you wish to
communicate in order to have the most favorable outcome
possible.
Commitment It is important to clearly understand who has
the authority to fulll the request you have so that at the end
of the negotiation, there is a clear commitment from both
sides and an understanding of what has been agreed upon.
The commitment ensures that you can move forward without
the concern that this will be challenged again in the future,
requiring you to take further action to negotiate your needs.
In this example, it would be wise to request that any agreement of allocation of time for core faculty members will be
embedded in their contracts to ensure you have an ongoing
commitment that you can count on.
Negotiations are a complex process with many variables,
and there are many different ways to think about this process.
The elements described above are simply one way to think
about this process. If you research the elements of a negotiation, you will nd many different ways that this can be con-
38 Negotiation andCollaboration Skills
Table 38.3 Foundations of negotiation, based on Shell’s Bargaining for Advantage: Negotiation Strategies for Reasonable People [4]
Foundations of negotiation Description
Bargaining style Style adapted by parties based on specic situations, relationships, and target
outcomes
Goals and objectives The outcomes desired by both parties
Relationships How authority, power, and future need for negotiations would be impactful
Leverage Advantages and disadvantages that parties may have that can impact negotiation
Other party’s interests Desires and motivations of the other party that might impact their negotiation
Standards and norms General understanding of what is felt to be acceptable and standard expectations
447
sidered. Another classic text for negotiation is Richard
Shell’s Bargaining for Advantage: Negotiation Strategies for
Reasonable People [4]. He provides what many consider to
be a more practical approach to understanding the elements
of a negotiation in scenarios that we may commonly
encounter.
Shell describes six foundations of an effective negotiation, which include assessing your bargaining style, your
goals and objectives, relationships, leverage, the other party’s interests, and authoritative standards and norms as
described in Table38.3 [4]. This provides another way to
think through the negotiation process to help ensure the best
outcome to meet your needs.
To look at the negotiation process through this lens, we
will use a different example. This time, a lower-stakes example, of a resident who is requesting an exception to your
program’s policy that requires all third-year residents to take
the American Board of Family Medicine (ABFM) board
certication exam prior to graduation. This resident has personal reasons that lead him to believe he is unlikely to be
successful if he attempts his board certication exam in the
spring of his third year, and would like to postpone it until
the fall, after his graduation. However, based on your
program’s requirements, this is not permitted without an
exception granted by the Program Director. In this case, the
resident is the initiator of the negotiation process, but the
same elements apply. Using Shell’s foundations, we can analyze this process in the following way.
Bargaining Style The various styles of negotiation were
discussed earlier in this chapter. Each party will bring a different style to the table, depending on the situation, the individual’s personality, and which style may be most effective
for this particular negotiation. In this particular example, one
would expect an accommodating style, in order to best meet
the needs of the resident in question.
his sitting for the exam in terms of what this would mean for
him individually as well as how that might impact the
program.
Relationships Clearly, as the Program Director, you have
ultimate authority in this scenario to make the decision, so
the relationship between the two parties in this negotiation
places the advantage with you. However, your relationship
with this particular resident can provide you with more
insight regarding his reasons for the request and whether you
feel that they are valid and appropriate. Also, it must also be
considered how relationships might be impacted after a particular negotiated decision. While that may not be a determining factor in your decision, it should be considered.
Leverage What each party might have for leverage can cer-
tainly be important for certain types of negotiation, as you
may decide to concede on a relatively small point in order to
position yourself more favorably for future negotiation. It is
important to distinguish the difference between leverage and
power. Power tends to be more absolute, in that a person in a
position of authority maintains his or her power regardless of
the situation. Leverage, in contrast, can be more dynamic
and change as a situation evolves. For example, if you have a
faculty member with a certain certication that is essential to
the program who comes to you requesting a signicant raise,
the faculty member has signicant leverage if you need a
faculty with that certication in the program and he is the
only one who meets that requirement. However, if another
faculty member informs you that she has just obtained the
same certication, the leverage of the rst faculty member
has diminished. In the scenario of the resident requesting to
postpone his board exam, the resident would have very little
leverage, but you would have greater leverage, for example,
to require the resident to develop a robust self-study plan to
prepare for the exam at a later date.
Goals and Objectives In this scenario, your goal is to have
your rst-time test-takers successfully pass the ABFM board
certication exam, as this is an important metric that is publicly available and a direct measure of the success of your
program. Obviously, you both want the resident to be successful, but you must consider the pros and cons of delaying
The Other Party’s Interests Again, understanding the
motivation for the resident’s request would certainly be
important to determine the validity and reasonableness of the
request. This is where open communication, trust, and listening skills are critical to the negotiation process. As Weiss
reminds us in his essay about effective negotiations, there is
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S. J. Tretter
never a “correct” outcome, but rather the ideal outcome helps
each party to better meet their needs and objectives [9].
Authoritative Standards and Norms In this scenario, full
authority rests with you as the Program Director to make the
decision in this negotiation. However, you would need to
consider what precedent your decision might make, and
what future consequences might be impacted by this particular decision for future residents.
Now that we have considered the various elements that
make up a negotiation, we can examine the negotiation process. All negotiations follow a similar process, but depending on its nature, some variation may occur. Again, some
negotiations are complex while some may be fairly straightforward and low stakes. In every situation, however, there
should be some element of preplanning, which is often done
prior to any specic negotiation, planning, which is specic
to that particular negotiation, and nally, the execution of the
negotiation itself [4].
In the preplanning stage, you must rst determine if this
situation is truly a negotiation or rather just a decision that
needs to be made and communicated to those involved. As a
Program Director, you make a lot of decisions, perhaps with
input from various stakeholders for consideration, but ultimately it is not a negotiation but rather a decision that is to be
executed. However, some situations do require negotiation,
so the ability to identify those will help you prepare for the
negotiation process. Also, as part of the preplanning stage, it
is important to understand the negotiating style that will be
most benecial for this particular situation. As we discussed
previously in this chapter, different styles exist based on the
personality of the individuals, but also may be altered based
on the situation and what will be most advantageous for that
particular negotiation.
In the planning phase, you begin by setting your goal of
what you want to obtain through the negotiation. Oftentimes,
it is helpful to determine what you need and what you want,
so that you have a range of outcomes that go from a minimum that would be acceptable to a maximum that would be
desirable. It is good to have this clearly in your mind as you
enter a negotiation so you can work to ensure that you at least
reach your minimum, or else you may be forced to nd
another alternative, described by Fisher etal. as “BATNA” or
best alternative to a negotiated agreement [7]. For example,
let’s say that are approaching a pediatrics group about taking
your residents on rotation in their clinic as preceptors. If you
calculate that you really need a preceptor 20weeks out of the
year for your residents to meet the needs of the program, but
it would be helpful and allow some additional exibility for
scheduling if they would commit to 28weeks per year, then
you have a clear idea in your mind of your need (20weeks)
and your want (28weeks). This would allow you to enter the
negotiation with a request for a higher amount, but knowing
that you could still have a successful negotiation if you ultimately were granted a lower amount that still meets your
minimum needs.
Also, during the planning phase, you want to be prepared
with as much information as possible prior to entering the
negotiation. In the example above, this might include having
a good understanding of the number of pediatricians currently practicing in the group, their capacity for teaching (do
they also teach other learners such as medical students or
other allied health professional students?), and their interest
in teaching. If there is a particular pediatrician in the group
that you or the residents have a good relationship with or is
well-aligned with the program, would it be benecial to talk
to that person rst to develop an ally who would be supportive of your position during the negotiation? The more prepared you are, the more likely you will be to be successful in
navigating the negotiation process.
Finally, we reach the negotiation itself, which often
includes a discussion of requests that can be seen as offers
and counter offers. In the most basic of negotiations, we can
think of transactional negotiations such as buying a car, in
which the dealer gives you a list price, you make a counter
offer less than the list price, and then the dealer comes back
with another offer that is higher than your counter offer, but
less than the original list price. Oftentimes, negotiations are
much more complex when you consider all the elements that
were discussed previously. In the scenario with the pediatric
group mentioned above, for example, not only would you
make a request for preceptor commitment, but would also
want to relay the potential benets to the pediatricians for
participating, such as developing relationships with potential
future family physicians in the community, educational
resources that the residents can bring to the practice, assistance with a workload of patient encounters and documentation, as well as the altruistic value of contributing to the
medical education of the next generation of physicians. The
idea is to nd what value the “deal” will provide for them,
based on your understanding of their interests, and use the
elements of negotiation as previously discussed to come to
the best outcome for all.
Situations Requiring Negotiation
forProgram Directors
Many different situations can emerge in which a Program
Director will need to negotiate. However, several specic
situations are commonly shared among all Program Directors
and may require some additional comments based on the
nature of the situation.