Life Support: Negotiating EMS

You’re a paramedic dispatched to a middle-aged male complaining of chest pain. When you arrive at the scene, your patient says he’s feeling better. He can’t or won’t characterize the pain, and denies cardiac history. He mentions an EKG recorded during a physical last year, but he heard nothing more about it. His disdain for doctors is unmistakable

You sense his reluctance to be transported or even examined, so you suggest moving to the ambulance, where you know you’ll have a better chance to continue care. He refuses. By the time you offer a “quick check” on scene, he’s already dismissing you.

The patient is mentating well; you can’t treat him against his will. What you can do is negotiate with him. You probably do that a lot with patients. Also with bosses, coworkers, spouses, parents, friends, teachers, salespeople, service providers, doctors, nurses, and sometimes even your kids.

Most of the time, I don’t think we’re even aware we’re negotiating. Maybe that’s why we don’t often negotiate very well.

Making the most of undervalued techniques

Negotiation isn’t a skill we’re born with, although some of us like to think it is, and would no more consider taking lessons in negotiation than in child-rearing. That’s too bad, because with a little study and practice, negotiation can become an ally, a business partner, or even a rich uncle who leaves you thousands of dollars. If the idea of saving money and getting people to do what you want interests you, read on.

Are you still there? If so, let me congratulate both of us on a successful negotiation. That’s what we’ve just had, you and I. You’re granting me a slice of your discretionary time in return for something you perceive as valuable: this text. I’ve gained a reader who might buy something from one of the advertisers camped out on this page, thereby making my publisher a little happier with me. It’s a win-win outcome—the only kind negotiators should seek.

Why win-win is important

Suppose you were offered a job with East Adipose Ambulance for minimum wage, asked the boss if you might be able to make a little more than that, but were told, “Hey, I can hire anyone off the street for what I pay you guys. Take it or leave it!” (I doubt this is as fictional as I’m making it sound.) You reluctantly accept the offer because you have a family and no other income. End of negotiation. Boss 1 Employee 0, right?

Actually, it’s more like Boss 0 Employee 0, or even Boss -1 Employee 0, although the folks at East Adipose probably wouldn’t realize that. By alienating you, not only with the lowest possible offer, but also with some very unsympathetic rhetoric, they’re practically guaranteeing whatever money they saved on your salary will be more than offset by the cost of your ill will in the future.

It didn’t have to go that way. Your boss could have mentioned frequent overtime as an additional source of earnings, or agreed to re-evaluate your status in six months. Those aren’t magnanimous gestures, but at least they show a willingness to consider your needs.

Negotiating works best when both parties feel they won something. Getting there isn’t as hard as you might think.

Know the balance of power

When I was growing up, “balance of power” was something scary between the U.S. and the Soviet Union: the ability of one giant country to scorch more earth than the other. Back-channel bargaining kept that from becoming anything more than a hypothetical contest.

For peace-loving individuals like you and me, balance of power means knowing your strengths and weaknesses before negotiating. Are you the buyer or the seller in a buyers’ market or a sellers’ market? Do you have something rare and valuable that someone wants, or vice versa? Is there a deadline that has more of an impact on one party than the other?

In our chest-pain case, the patient owns the balance of power. He perceives no advantage to an ED visit and has the right to decline. Unless the medic highlights the elevated risk of sudden death in an imaginative way, there isn’t going to be a transport.

Innovation fuels negotiation. In the early ‘90s I wanted to buy an inexpensive but very popular car—so popular, there was much more demand than supply. The salesman wasn’t going to budge on price until I suggested I might want two cars instead of one. The logic was that my wife’s Corolla had become a high-mileage liability—like my car—and would need to be replaced within a year or so anyway.

The unanticipated possibility of two sales commissions and two profitable trade-ins for the dealer swung the balance of power in my favor, and I got both cars at substantial discounts.

Don’t let them know what you’re thinking

If I’d started my negotiation by admitting how much I wanted that car, I probably wouldn’t have gotten any concessions. Why? Because the dealer would have sensed my desperation and just waited me out.

The caregiver in the opening narrative faces a similar situation. He knows an isolated incident of chest pain without history or other risk factors could be benign. He may not be any bigger fan of doctors and hospitals than his patient. However, if he were to verbalize any of those feelings, he’d put an end to any hope of negotiating transport—a goal arguably best for both patient and provider when chest discomfort is significant enough to require EMS.

To get, be willing to give

Our medic showed he’s willing to compromise when he offered an expedited exam on scene. That suggestion didn’t solve anything, but maybe it would have if the medic hadn’t given up so easily. What if he’d added “Look, I know you don’t want to go to the hospital, and you don’t have to. You’re calling the shots. I’m only saying I might be able to get you some more information about what caused that pain, and then give you a chance to decide what you want to do”?

The medic would be making a concession in his practice, primarily to bring about a desirable outcome for himself and his agency—due diligence—but also to help his patient choose wisely. While it would be cool to catch a life-threatening condition during an abbreviated exam, it’s still a win-win if EMS can just document an above-average effort to assess a patient who then makes an informed decision.

Be willing to walk away

When I walked into that automobile showroom 20+ years ago, I knew I had to be willing to leave without a new car. Being emotionally vested in a particular outcome contradicts a reality of negotiation: you don’t always get what you want, but there’s more than one way to try. Be patient; go home and retool your strategy. Besides, sometimes the mere act of walking out causes the other party to reconsider.

EMS providers recognize limits, too, when negotiating next steps with patients. If our middle-aged male had suggested the medic leave some nitroglycerine in case the pain came back, that would have been a deal-breaker. Sometimes we have no choice but to depart, knowing it isn’t the best outcome for either party.

Negotiation customs vary

In some parts of the world, negotiation is much more commonplace than in the U.S. For example, when I was in Mexico in the late ‘70s, I learned very quickly not to buy anything for more than a few dollars’ worth of pesos without negotiating a lower price—sometimes less than half of what was initially asked. However, gaining a few “concessions” didn’t make me think for a minute I’d routinely come out ahead in a nation of world-class hagglers.

Even if you live in a region where bargaining is the exception rather than the rule, you can gain significant advantages in the workplace and marketplace just by becoming a more knowledgeable, more effective negotiator. Begin by exploring the suggestions in this article. There’s no cost or obligation. Now that’s a deal!