Class
4
Session Six and Session Sixa
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Session Six Projections for 2010 (based on the
PriceWaterhouseCoopers analysis at
PWChealth.com)
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The American Public is aging. The baby boomers hit 65 in 2010.
Italy, Germany, then Canada will be like Florida. The entire
United States will be like Florida of 2000 by 2025.
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There are three forces operating on this aging population.
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Empowered consumers
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e-health
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Genomics
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Empowered consumers are impatient patients in an environment of
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managed care,
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shopping for assisted living
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direct to consumer advertising (note, this is one area where internet advertising
is successful)
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IMPLICATIONS:
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demand for personalized health care
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growth of healthcare intermediaries
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development of health care brands
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Relevant fact: in 1970 33% of health care spending was "out of pocket"
for patients.
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In 1999 17% was out of pocket (while the entire health care "pie" had
approximately doubled) and the pressure is to push the percentage back up.
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Consumers who pay out of pocket want control. The big increase is in
pharmaceuticals, with spending up 16% out of pocket in general is only up
3-4%.
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E-Business Analysis (de rigor in these days).
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Internet sites are progressing form brochureware (an internet site that is
basically just a brochure) to personalized (more information, tailored to
users) to transactional (people can buy something, like books) to service
providing.
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80% of surveyed doctors had patients discuss information found on-line.
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37% said their patients were more knowledgeable.
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31% said their patients were less knowledgeable (as a result of misinformation).
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Genomics
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+ consumerism = global communities.
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+ consumerism = prevention related activities (of the top ten killers, 9
have prevention elements).
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+ standardization
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+ difficult choices (privacy issues, risk management issues)
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The three forces of genomics, e-business and consumerism lead to 4 trends.
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Health Insurance and Public Financing are converging.
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1990 40.5% of health care financed by government, 1998 46%
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Compare Europe where 10% was privately financed in 199 but the growth rate
is 5% or so a year increasing (e.g. 15% in 2000, 20% in 2001).
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Many policy makers feel that there is a 50/50 chance that Medicare will move
to a defined contribution system.
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Standardization
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Information is spreading
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Processes are standardizing (the descendant of critical path technology is
standardized health care processes)
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web blather
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consolidated storage of health care records in standard format
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Workforce Changes
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Difficult Choices
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One tier or two tier health care system
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Who pays for technology?
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Who decides which technology is used
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Implications and Trends
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Venture Capital has gone from 15% invested in health care ventures to 3%.
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Health Care will become a true service industry, with successful branding.
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Session Sixa Reframing (continuing the framing discussion and
analysis).
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Reframing is the collection of methods by which we change our frame of mind.
There are many methods and techniques that can be used.
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First, change vocabulary. Delete the term "but" and substitute the
term "and."
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Second, listen, acknowledge and reflect. Active listening "I
appreciate that ...." -- with no "but" afterwards!
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Third, respond and engage, your active listening should be not only
of the overt words (second step) but of the agenda (which is the entry point
for reinitializing need based analysis and solutions).
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Note, reframing steps one to three are all ways to move towards exploring
interests. Exploring interests often gets negotiation and solution
seeking back on track or reveals that you need to shift to positional bargaining.
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Fourth, to the extent that there are emotional attacks, remember that
which you feed, grows, that which you starve, fades.
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Share a common concern
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Ask a question
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Look for other issues
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Reaffirm Common Goals
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Fifth, enable face saving (a difficult task).
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Restate the line in the stand as based on a predicate "I know that you said
"X" because of "Y" (e.g., you use this method because it is accepted
as the best for patient outcome and that is why you've stated that
you will never change unless research proves another method to be
better). (bold face is the actual statement, italic is the predicate
you've added).
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Then, offer a different perspective on the predicate "Since the predicate
no longer applies, the line in the sand doesn't apply" "Given that
"Z" is true instead of "Y" then maybe we can do "U" instead of "X."
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Sixth, ripeness.
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Remember, negotiation consists of cycles against a time frame.
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Teach the parties that the process has cycles and that the cycles can get
out of sync.
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Discuss the concept of ripeness with the parties.
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Seventh, Map the cycles and map the frame.
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Mapping can be a very powerful tool to allow people to start seeing and
understanding connections they have missed.
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Map the timeline, issues/positions, and cycles that the negotiations have
gone through.
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Map the frame -- especially the relationship between the parties, actors,
players, subjects and each constituency.
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Map each party -- which teams they are on (especially in health care, people
are often on multiple teams), which managers they report to, who the actors,
players and subjects really are. Consider the peace process in Israel.
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Each party needs to understand themselves and understand the other side in
order to find solutions that will work.
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Map the stereotypes that each party is reacting to or assuming.
Explore the emotional baggage that may be hindering or hampering each
party. Let the people talk and listen to them. Let yourself talk
and listen to what you are saying.
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Eighth, Social tools.
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Humor.
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Going to dinner or on a walk.
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Ninth, provide anew metaphor or turn of phrase.
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This is what spin doctors attempt to do.
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A way of looking at things that completely changes them.
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e.g. "the heavy petting scandal."
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Is this "health care reform or insurance reform"
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Any metaphor that provokes resistance is probably a failure ("meat is murder"
provokes resistance while "veal is cruel" tends to get some people to quit
eating veal).
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REMEMBER: change threatens those who benefit, it is often an uncomfortable
journey and problems are to be expected, resistance is natural.
Between Classes
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Handouts (to review)
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Reading Assignments
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Pages 179 to 206, 237 to 267 of Renegotiating
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Assignments
Class
5
Session Seven
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Further Policy Issues and Perspectives.
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System Issues
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The system is organic, not mechanical and is comprised of multiple disconnected,
or loosely connected, layers.
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The "system" is vastly different from what the public believes (e.g. physicians
are not uniformly hospital employees).
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"System" implies reason, planning and control when none of these exist.
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Cultural Context of Health
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Priorities are formed by spending, which responds to pressure. We have
a treatment system, not a health care system. Compare with the dental
system (which is oriented towards prevention). Remember "what ought to be"
(what policy makers insist that people should do on their own -- i.e. prevention)
vs. "what is" (remember the vandalism example).
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The moral imperative to never deny care.
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Health care as rescue is the metaphor and it displaces cost/benefit (the
child at the bottom of the mine shaft).
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The insurance mind-set: insurance is protection from the cost of disaster
(It is, after all, "casualty" insurance that forms our mind-set).
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The demand of sunk capital to obtain a profit slightly better than the market
provides (I took a risk, I spent money, I deserve to make money from this
machine or testing facility).
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Dilemmas/Contrasting Forces.
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Health care receives both revenue and regulation from governments, but not
all of its revenue or its regulation from governments.
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Policy in health care requires mastering technical expertise and assessing
difficult situations.
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Governments treat health care as an entitlement.
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Health care is expensive.
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Insurance isolates all participants form direct market forces.
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Almost every health care issue is a moral issue as well.
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Economists are doing statistical analysis of the system and challenging its
assumptions and beliefs -- sometimes correctly, sometimes in a manner of
complete disconnect.
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The money in health care draws the attention of people who want some of it.
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The first solution is usually the wrong one in a complex situation that has
not previously been assessed.
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Real life examples of unusual results (e.g. anesthesia in labor an option
available 9-5 in some parts of Canada, Oregon's health care as triage, HMOs
with exercise and stop smoking programs vs. "ought tos"). But, reframe
that to "should my health care program pay for my exercise" or "should I
get a discount from costs or a rebate if I exercise" -- the change of the
question is an excellent example of reframing.
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Limits:
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Health care is not magic. It does not guarantee a cure in every situation,
eternal youth for every patient.
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Health care is not a limitless resource.
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Change = conflict.
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Perceptions and history limit our ability to understand and change our frames.
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Initial solutions = wrong solutions.
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Involvement = pre-existing agendas (and pre-set solutions). People
who have a motive to be involved usually have an agenda that they serve.
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Dealing with Politicians
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Ask yourself, which question are they really asking?
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Ask yourself, who should be asking that question and who is the question
being asked for (or on behalf of).
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Ask yourself, for this problem, do we need a system or a isolated solution?
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Ask yourself, for this problem, is a central system more of a hindrance than
a help?
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Ask yourself, if I narrow my role, will I be ignored?
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Ask yourself, if I expand my role, do I become more important.
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Analyzing Roles and Changing Roles. (Points 3-5 below)
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It is useful to discuss with any group how their role has changed. Nurses,
administrators, staff and doctors have all changed their roles over the last
twenty years. Changes in roles create conflict, worry (including FUD)
and confusion.
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Discussing changes in roles help people redefine themselves and their roles
and help them to revisualize conflicts. This works with every group.
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The view from management's chair (Chapter 8).
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Management serves:
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many, many conflicting constituencies.
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itself. Every group serves itself.
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There are changes in the model that is being managed.
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Seeking to proactively maintain health vs. provide treatment.
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e.g. walk-in clinics to ease loads on ERs.
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Etc.
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Process Model Issues.
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Each exchange when there is a problem involves allowing reasonable venting
followed by productive exchange (and the implication that all initial statements
are just part of that venting).
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Managers should be creating and teaching the frame, an active process of
what management is rather than spin doctoring.
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Changes in anticipation.
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Older managers gave up income to be a part of health care with the understanding
that while they would make less money, they would help people and do good
in the world.
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Many (not necessarily most and not all) younger managers expect to make more
than the market rate and are often (not always) oriented much more strongly
towards making money. They see how much the doctors make and feel that
they are entitled to proportionate income.
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Management Model.
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Communicate expectations, set limits, be predictable and firm.
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Create an institutional culture (and make sure it applies to management and
each faction).
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Avoid alienation.
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Intervene and rsolve conflict by asking questions instead of making statements.
(See pages 193-194 of book).
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Clarify First, Last and Always.
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By education.
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By planning and providing a vision of that plan.
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By framing and reframing.
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Respond to financial pressures: management is at the center of the
financial pressures in health care.
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Notes on Nurses.
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Nurses, more than any other group, are the focus of constant reframing efforts.
Consider that to the public, a BSRN and an LVN are the same (and, not
too long ago, Nurse Practioners and CNAs were seen as the same). "The
great white cloud" (or, now, "the great pastel cloud").
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The issue of "getting doctors to prescribe the right medicine" and why that
won't change quickly.
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Reductions in nursing staffing vis a vis patient fatality rates.
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Unions: why yes, why no (we will revisit unions later, but the growth
of agency nursing has slowed the spread of unions).
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The most patient contact, the least long term relationship.
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Nursing is a large involved constituency that is not well understood by the
general public and often almost ignored in public policy planning.
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Notes on Doctors -- from the 1950s to the year 2000.
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Doctors were:
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male.
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obeyed.
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independent.
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cost-plus fees.
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had power to control environment.
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detached.
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revered.
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in a pyramid based on age and specialties.
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The public sees (regardless of reality)
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Attempts to preserve the status quo as self-serving rather than in the public
interest.
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AMA as "American Monopoly Association" (a common phrase in business and economics
classes in most universities).
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The public is increasingly demanding and hostile towards doctors.
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Other changes.
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Applicants to medical school are increasingly driven by income (even as income
for doctors starts to drop).
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Increasing in numbers as a part of the entire population (consider that a
student who would automatically be admitted to Brown has only a 40% chance
if discovered to be pre-med. Prep school orientation is generally "how
we will get your pre-med student into an Ivy League school by disguising
what he or she is.").
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Increasingly competitive (fights over seats in class rooms were not commonly
talked about twenty years ago).
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Doctors have reduced patient time and continuity, which has led to reduced
respect by patients for doctors.
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Most conflicts involving doctors involve AGE, GENDER, TURF, and are over
bottom-line results of MONEY, POWER and CONTROL.
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Flash points:
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"50-something" "peak of earning" doctors vs. "40-something" "I'm entitled
to the same income and respect" physicians.
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Gender battles.
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Turf battles.
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Who owns the patient: primary care physician or the specialist?
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Who prescribes medications: the doctor or the nurse?
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Who prescribes medications: the doctor or the insurance company (generics,
substitutions)?
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Who decides on hospital equipment: the doctor or the manager?
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Who controls equipment: the doctor or the federal government?
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Who makes the ultimate decisions: the doctor or the patient?
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Who makes the ultimate decisions: the doctor or the insurer?
CAVEAT (What I meant
to say)
Between Classes
-
Handouts (to review)
-
Advanced Negotiation Concepts
-
Personality Driven Disputes (checklist and guide sheet).
-
Reading Assignments
-
Pages 271 to 315 of Renegotiating (Positional Bargaining)
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Other Assignments
-
Consider metaphors for your negotiation style.
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Consider why discussing and analyzing negotiation styles is important.
Copyright 2000 by Stephen R. Marsh
http://adrr.com/smarsh/