Negotiation, like tying surgical knots, is a learned skill.

16 Jan 2014
by Carol EH Scott-Conner, MD, PhD, MBA

Endocrine and Breast Oncology Surgeon

Professor of Surgery – Surgical Oncology and Endocrine Surgery 
University of Iowa Carver College of Medicine 

What image does the word “negotiation” bring to your mind? Do you think of a buyer and a seller haggling in some bazaar? Do you cringe, remembering a time when you had to go to your supervisor with a request for resources (and maybe got turned down)? Perhaps you envision a mother trying to get a toddler to do something. Do you think of bribery? Of weakness? Of strength? Of imbalance of power?

We negotiate all the time, in matters large and small. Negotiation, like tying surgical knots, is a learned skill. And that means that you can learn how to do it, just like you learned how to tie a secure knot (even though you had been tying your own shoelaces for decades).  

Negotiation involves give and take between two parties. Give and take implies that each party has something to gain and something to lose. A successful negotiation satisfies both; there is a sense of balance.

In Women Don’t Ask, Babcock and Laschever argue that many women are averse to negotiation. They give numerous examples and quantitate the way in which women sacrifice as much as half a million dollars over their working lives by neglecting to negotiate effectively for their first job. The damage extends far beyond monetary compensation. Failure to negotiate may hamper your ability to succeed, if you “low-ball” the resources and/or support needed to achieve a needed goal.

Suppose, for a moment, that you have been asked to take on a major responsibility such as becoming a Division Director. It’s a huge honor. You’ve actually wanted this job for quite some time. The moment has come, and you are in the office of your Department Chair. You’re quite excited, and yet afraid, somehow, that the offer will be withdrawn if you are too demanding. You will need to negotiate for: a raise (commensurate with your additional resources), some protected time for the administrative functions, administrative support, a commitment to recruit and grow your division, resources for your division (such as clinic space, operating room time, research support). 

How should you proceed? First of all, prepare ahead of time. You wouldn’t go into the operating room without preparation. Don’t assume for a moment that you can just “wing it”.

  1. Do your research. Get as much information about the division as you can. Hopefully you have been doing this along as you prepared to move into an opportunity like this. Basic statistic such as volume and trends in clinic visits, diagnoses, patient satisfaction, surgical cases, complications, length of stay, salaries, size of division relative to other academic medical centers are easily obtained if you dig around a bit.
  2. Do a basic SWOT analysis. What are the division’s strengths, weaknesses, opportunities, and threats? How can you build on strengths, expand into opportunities, correct weaknesses and avoid threats?
  3. Put your findings into the broader context of the Department and the hospital (or university) in which you work.
  4. What are your priorities and goals for your own career? How will this position advance your career? How will it complicate your life?

Next, take this information and make it into a concise set of needs/wants and rationale for each. Rank these. Consider a menu of options. Consider how factors are interrelated; for example, if growth is a priority for this division, then recruitment will require a commitment for additional clinic space and operating room time. Remember that the negotiation process involves give and take. Additional operating time may simply not be feasible at this point, but analysis might reveal that another division is about to lose personnel, or that some surgeons will be moving their practice to an Ambulatory Surgery Center. You may be able to get a commitment to get newly freed up time in the Main OR or to move a significant fraction of your division’s cases to the ASC.

Rehearse your negotiation with a trusted and experienced person. A network of mentors around the country, including friends in other disciplines, can be invaluable. You might (rightly!) not feel comfortable doing this with a colleague in your own department, or even a colleague at a different university. Seek someone with experience in another discipline if necessary. Use your spouse or partner. Go through the discussion. Have your partner throw objections at you. Use the mirror if you have to. Practice countering objections, resistance, even hostility.

Keep a collaborative focus. Both you and the person you are negotiating with want the division to thrive. If the other person does not, you may want to switch jobs or consider turning it down. Think about the priority of this particular division within the larger organizational structure. How does this division affect the whole? Do you provide a crucial service that no one else can do (for example, pediatric surgery) or do you overlap with other divisions (for example colorectal surgery overlaps with MIS, surgical oncology, and GI surgery)?

Lose the emotion. The best advice I ever got about negotiation was to think in these terms: “I care, but not too much” about the outcome. Don’t personalize it. This is not about friendship, or individual worth. This is about what you can do for the organization and what you need to have to do the job.

Get some distance, if you need to. If all else fails, make a graceful exit and return to continue the negotiation after you have both cooled off and reconsidered.

Remember the value that you bring to the organization. This is about maximizing that value, and continuing to contribute.

Let’s take a simpler example. You need better nursing support in clinic. You suspect that the male physicians are assigned more nursing support because they need to be chaperoned when they examine a female patient. You feel that you need to be chaperoned as well, but that your needs are ignored. Go through the same steps outlined above. Collect the data. Come up with a menu of options. Perhaps you can shift clinic days/times to a less busy slot. Perhaps the problem is that you are in clinic when a particularly busy and demanding male surgeon is also there, and he is sucking up all the resources. Options include tackling the issue head-on or switching.

The truth is that you are constantly negotiating. Shall we have dinner at home or eat out? Should we go to a basketball game or a concert? Does my case go first in our shared OR, or does yours? Will you add this procedure on to your full schedule to accommodate my patient? Once you become aware of how pervasive negotiation is, you will find numerous lesser-stakes opportunities to practice. This practice makes you ready for the high-stakes discussions.

What if you are the person in power? Make sure that all the facts are available. Have a menu of options to achieve a shared vision. Don’t take advantage of a naïve junior surgeon. If you feel that the person with whom you are negotiating is naïve, ask them to take some time to look at the data and come back to you with a list of needs. This is not only the right thing to do, it gives both of you a greater probability of success.

In 1995, I became the second woman in American surgery to Chair an academic department at a medical school. Every year, I would met with each faculty member to discuss salaries. The men came in with demands that were often outrageous, but they were usually also armed with data. Too many of the women came in and began the discussion by saying, “the money isn’t important.” I think that women don’t generally go into surgery without a strong sense of vocation. Money doesn’t taint that vocation, it is a just reward for what you do.

It is how people measure success. When I went to Scotland decades ago to meet with a textbook coauthor, I learned the phrase “good value for money.” It can mean a lot of things, but at the most basic it means that it is okay to spend more money if you get higher quality. You provide “good value for money” every day. Don’t hesitate to make sure you are appropriately rewarded and empowered with the resources you need.

The “c” word. I don’t consider myself a crier. However, when I was young, difficult negotiation, one-on-one, with a supervisor used to bring me to the verge of tears. In informal discussion with other women, I know that this is not a rare problem. The remainder of the session would spiral out of my control as I focused on keeping my emotions in check. We all know that crying on the job is almost never a good idea, particularly when you are up against a male surgeon.
I learned not to cry, and you can too. Incidentally, this is not just a female problem. Men cry, too. Rehearsal will help desensitize you. Taking the emotion out is easier if you think of it as an analytic problem rather than an interpersonal one. If all else fails, make a graceful exit and return in the near future with better armor!

Suggested Readings:
Babcock L, Laschever S. Women Don’t Ask, Bantam books, 2007. Get this book and read it!

Negotiation. Wikipaedia. accessed January 2014. This is a very concise and nice guide to negotiation. It identifies three classic styles.

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