The Blog that Ate Manhattan: Paul Levy – You Are Not the Boss of Me. Well, Okay, Maybe You Are.

The Blog that Ate Manhattan: Paul Levy – You Are Not the Boss of Me. Well, Okay, Maybe You Are.

TBTAM has a really well-written piece today about an interview with Paul Levy (and a nice part with some good introspection that most doctors would identify with about why they got into medicine), but she’s very troubled with his response to typical physician negotiating tactics. Read her post for the particulars, then come back here and read after the break.

I have to say that I was listening to the show live, and while I heard the same words, I heard the subtext differently (I’m not speaking for Mr. Levy here, he can do that very well). I heard his responding to the typically horrible way doctors negotiate: it’s all or nothing, him or me, take it or leave it. Frankly, an approach that would make a second grader blush.

The specific example he gave was a physician who says essentially ‘do it my way or I quit’, to which Mr. Levy’s response was that he’d then say ‘Great, when are you leaving, we could use the office space’. I don’t think that’s the position he wants to take with any doc, I think he was trying to demonstrate horrible negotiating tactics and their only true counterpoint, to negotiate in the same style. Mr. Levy no more wants docs to quit than most actually mean they’ll quit, but since most docs learned their negotiating skills from Lord of the Flies, when confronted with horrible tactics he’s left without much else.

As I had heard the conversation that way, I came away very impressed with him, his insight into doctors and their want/need continuum, and their deficits in basic negotiating skills (which has to be very foreign to someone who’s business trained, as negotiation is a big part of their world, at least among equals).

Count me a Paul Levy fan. And a TBTAM fan, for that matter.

Update: Animal Farm was the first novel I used to describe how Physicians learned to negotiate, but that wasn’t quite right.  Lord of the Flies is a much more satisfactory comparison.


  1. Taking you’re side on this one GD – when someone is willing to use ultimatums as a negotiating tactic then the appropriate response is that you’re willing to consider it. And for the record, it’s not just doctors. I’ve had the same “take it or leave it” approach from suppliers and in lease negotiations.

  2. Nurse 1961 says:

    I agree with Paul Levy. If the conversation starts with “do it my way or I quit”, the MD has already closed off any other option. Secondly, if you give in to those kinds of threats, you will soon be out of business because every other MD will be doing the same thing.

    Negotiation is the “art” of getting what you want without giving away what you need.

    After 10 years of nursing, I went back and got my MHA to be able to understand the “administrative” language (couldn’t afford the pay cut so went back to clinical). My instructor wrote a book on negotiation, he taught us that you have to be willing to give to get what you need. And the before you start make sure you have the right team, the right decision making capability, and most of all know what you NEED out of the negotiation process, not just what you want.

  3. I agree with you GD, and I am also a fan of TBTAM. :)

  4. Actually Nurse 1961, negotiation is not quite the art of getting what you want without giving away what you need: It is the art of reaching an agreement that increases the “size of the pie” so that both parties satisfy their interests better than they can without reaching an agreement. You should never make a threat in a negotiation unless you are prepared to carry it out — because a threat harms the underlying sense of trust that you need to stimulate the kind of creativity that produces ideas for joint gains. By making a threat, you have explictly said, “I can do better without making an agreement with you.” When someone does that to me, I do a similar evaluation. If I think I can do better for the hospital letting the person carry out his (it is always a “his”, by the way!) threat, then I will do so. If I think it is still worthwhile talking with the person, trying to find a negotiated settlement that works to everyone’s advantage, I will do so. But, as noted above, it surely poisons the well a bit to start out with the threat.

    If you were to guess, which type of doctor is most likely to start off the meeting with a threat?

  5. I”m copying a comment I made on my prior post, that explains why I think some docs threaten to leave – interestingly, the docs I decribe were all female. Levy states that the docs he’s had ultimatums from were all male.

    So my latest theory (I just came up with it this second..) is that men who threaten to leave do it from a place of unreasonableness and women from a place of powerlessness.
    See my comments below to put some context on this –

    “Perhaps I and the docs I know have had different experiences with hospital administration than others. I have seen situations where what is being expected of a doc is just untenable, and where no support was being given for what they were being asked to do. In these situations, the doc made the painful decision to leave, communicated that, and miraculously, the support appeared, and ultimately, that doc stayed. Sad, but true, that this was what it took. Perhaps if those docs had done a better job at negotiating in the first place, things would not have gotten to that point.

    I think this tactic is used more by docs who perceive themselves as powerless against administration than by those who are just being unreasonable. When decisions are made that affect them without their input. When they are invited to the table at the end of a process, not at the beginning. Again, learning how to negotiate would put these docs in a much better position.

    I have found administrators to be most responsive to other administrators, not to docs. Their bread is buttered, so to speak, within their own hierarchy, and keeping their boss happy is more important to their survival than having a happy doctor. That’s just a fact of life, not a criticism. Getting docs into administration is the solution. Nursing realized this much earlier than we docs, and nurses are present at everywhere in hospital administrations I’ve known. Because the docs tend to be split into departments, they are often pitted against one another rather than working together toward a common goal. I don’t think the department structure has served us well in this regard. Instead, I think it has ghettoized us as the medical center business has evolved.

    Where I work, docs are increasingly being appointed to administrative positions traditionally held by non-docs. And new positions have been created just for docs within administration. The result is an administration that is more responsive to docs, anticipates their needs rather than finding them out later in the process, and focuses primarily on issues that impact quality of care, which all us docs can get behind and that ultimately, are good business.

    I personally would love to take Levy’s negotiating course. I know Dr A wants to as well. Hmm – maybe a little blogger road trip to Boston…”

    Am loving this dicussion.

  6. Nurse 1961 says:

    Thanks Mr. Levy, but I do think it is an art. If it were a science, then all you would have to do is go the statistical model for your answer. But because you are dealing with human emotion, you need to put it in the “art” arena.

    Science is mostly dealing in the black and white, whereas in art can have many gray areas. In negotiation, you have to have some gray area that is your give and take. What am I willing to give up to get in return? Surgery times in return for more days of call in the ED? Specialty coverage without ED call? Working Thanksgiving to have Christmas off?

    It is a lot like the dance of the tango. Sometimes the male (administration) leads and sometimes the female (clinical) leads. As it progresses it is obvious they can not do it alone so in the end the male (administration) takes the lead, but the spotlight ends on the female (clinical). Both win and both lose. But the partners stayed together for the entire dance, in the end they both could walk away. Just as in negotiations sometimes walking away is the right choice, but walking away before the negotiation begins will always be a lose-lose.

  7. Dr Trousers says:

    One of the issues that I find non-clinical people are unable to grasp, is that medicine selects people that have a monster amount of goodwill, and that when a clinician is finally vocal enough to complain or demand better conditions, that goodwill is completely and utterly gone.
    We are negotiating our agreements this year, and our auditing process has turned up many instances of doctors doing far more than is expected of them in the agreement, usually without pay, out-of-hours, because they were selected to be unselfish, vulnerable to guilt trips by staff and patients, with a strong sense of what is “right”.
    I cannot excuse the negotiating tactics of an ultimatum, but without recognizing the work conditions that bred it, is a little backwards. In many cases, it is not until we (collectively) have refused to do the extra work, that our administration has even recognised that it even happened, or needed to happen!
    Unfortunately this kind of culture, where so much of our work is driven by internal characteristics and beliefs, is not amenable to being described and quantified and put down in words in an agreement. There will always be a disconnect between administration and doctors until this can be recognised, (at our hospital, we are trying, but it’s not working!)

  8. Do I have any fans? hehe

  9. BladeDoc says:

    Forget attitude and good will and the like; it’s all about the power. If you are running Boston Deaconess and a doctor does the “I’m going to take my ball and go home” routine, sure you can give him the “Don’t let the door hit you in the ass on the way out” answer. More apropos to most people’s experience is the situation at my hospital (mid-size community/academic) where the administration took a hard line with the radiologists who then quit en masse and set up an outpatient radiology service (and is eating the hospital’s lunch) and then did the same to a neurosurgeon who was not signing his charts on time. He proceeded to take all his cases across town which resulted in a $1-2 million contribution to the margin loss to the hospital.

    As most leadership/negotiation courses teach you have to accurately determine tow things before embarking on a negotiation: 1) whether you’re negotiating from a position of strength or weakness and 2) your “best alternative to a negotiated agreement” (BATNA) — which impacts on 1). My guess is that the Mr. Levy is essentially always negotiating from a position of strength and that his BATNA is that he has to go find some new doctors, of which there are many.

    The CEO of my hospital who THOUGHT he was negotiating from a position of strength and who THOHGT he had a good BATNA is now looking for a job — any positions available?

  10. Not quite, BladeDoc, on this point: “My guess is that the Mr. Levy is essentially always negotiating from a position of strength and that his BATNA is that he has to go find some new doctors, of which there are many.” In fact, that is usually NOT the case. Especially in a highly competitive medical environment like Boston where an MD can literally go across the street to another fine academic medical center. Recall that MDs are not employees, but essentially free agents — and a big part of my job is to help create an environment that they will find personally and profesisonally rewarding and attractive. But every now and then, one of them goes a bit too far and makes an unreasonable threat.

    Nurse 1961 again has some great thoughts. S/he knows, in particular, that it takes two to Tango!


  1. […] and not just in dealing with administrators. Meanwhile GruntDoc was listening to the podcast, too. He didn’t take umbrage at Levy’s comment. In fact he’s a bit embarrassed that doctors display such […]

  2. […] and not just in dealing with administrators. Meanwhile GruntDoc was listening to the podcast, too. He didn’t take umbrage at Levy’s comment. In fact he’s a bit embarrassed that doctors display such […]