Reader Question: Don’t Be the Decider

I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!” . . .
Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR

First of all, I need to add “Bargaining” to the list of manipulative techniques I wrote about earlier! Instead of Nine Manipulative Techniques, we now have Ten. “Bargaining” is an important and commonly used manipulation. Like you, I also have run across bargaining, like this: “Well, if you won’t give me Tramadol, then can I at least have Flexeril?” Often, it comes with a promise: “If you give me the Flexeril, I won’t bother you anymore.”

The goal of Verbal Jujitsu is to deflect and avoid any confrontation. And to do that, you must understand why the confrontation occurred in the first place. The root cause of the confrontation you are describing here is that you are the Decider. To solve the problem, stop being the Decider.

To understand how this works, consider a person buying a new car who wants to pay less than the sticker price on the car window. The salesperson wants to sell you the car for the sticker price. But as soon as you say you want to pay $500.00 less, the salesperson says, “I’ll have to check with my manager.” She then leaves and comes back with the decision, either “Yes or No.” The salesperson is not the Decider.

The Decider is the entity that is authorized to give the patient whatever it is that they want. Your bargaining inmates have identified you as that Decider. You have confirmed that you are the Decider by saying “No” to their requests for a transfer or a bottom floor restriction. Saying “No” implies that you could have said “Yes” if you wanted to. Once that has been established, the inmate thinks all he has to do to is convince you to change your mind. He starts with bargaining but maybe then progresses to a grievance and then a Board complaint, all in an attempt to force you, the Decider, to change your mind.

Of course, you can’t win no matter what you do because if you give in, you have proven that this type of bargaining works. As a result (since all patient encounters are discussed back in the dorms), lots of inmates will want to bargain with you. But if you hold the hard line and don’t give in, you still have lost because your relationship with your patient has now become adversarial, time consuming and stressful.

So what is the solution? The solution is for you stop being the Decider! Instead, the Decider is going to be either a policy or a Committee that you must refer to. Official Policies work well for stuff like second mattress requests, or bottom floor restrictions. Once your facility has adopted a guideline for bottom floor restriction, the bargaining conversation goes like this:

“Well, at least give me a bottom floor restriction.”

“I can’t. There is a policy for those and I have to follow it.”

You’re not the Decider any more; the policy is!

Committees should be the Decider for patients demanding special drugs (like narcotics for chronic pain) or unusual procedures (like an MRI for a minor knee injury). Then your answer again is not “No” (where you are the Decider), but rather “I can’t approve that.” If you don’t have a Therapeutics committee set up at your facility yet, in the meantime say, “I’ll have to talk that over with my Medical Director (or with my colleagues).” Then get back to the inmate later with the message that “they” (the Decider) said no.

I will write about the advantages of setting up a Therapeutics Committee in more detail in a future post. In the meantime, remember to stop setting yourself forward as the Decider.

Like all JailMedicine posts, what I have written here is my opinion, based on my training, research and experience. I could be wrong! If you think I am wrong, please say why in comments.

How do you handle “Bargaining” when you encounter it? Please comment!

4 thoughts on “Reader Question: Don’t Be the Decider

  1. Or, we can simply deny bargaining in the medical office altogether. When bargaining occurs, it is a sign of professionalism going down the drain. In such cases, dully reminding patients that the marketplace is elsewhere might prove to be an effective strategy, especially when acknowledging the hilariousness of the situation… If the patient has a legitimate need, it is never a trade-off. A possible line of defense could be: “Let us not get too carried away and respect each other for who we are. Mistaking our roles here may lead to serious problems, so let’s slow down with requests and hear more about what’s really bothering you, so I can make an informed decision on how to help you, medically”.

  2. I work as a full time PT in Minnesota Corrections and with Dr. Keller for some time. Unfortunately- I am the go-to guy for almost everything patient wants aside from medications- Shoes, braces, restrictions, etc. I do have a couple of suggestions for fellow correctional medical providers

    1- I pretty much have a set standard/criteria for most if not all requests. Take bunk requests- I frame it as a safety issue. After an exam- I tell the patient he has the required arm and leg strength to safely climb the bunk. Patient’s often then say “But my back pain…..”. I simply say the criteria is based on safety/ability and not pain. I just stick to this and tell them I never give bottom bunks for pain symptoms. Patient’s can argue pain forever but they can’t argue about the strength you measured on them when you tested them. Refer to criteria rather than the patient. I often “blame” it on the DOC – make them the bad cop. It is the DOC criteria- I only work here.
    2- Be aware- every authorization is a potential precedent. It takes about 45 seconds for the whole prison to find out the new doctor is giving restrictions.
    3- After I professionally and politely inform patient of my decision on his/her request- if the patient “personalizes” it – I firmly tell them that this is not a personal decision. If they persist- I pretty much wrap up the visit as almost always it devolves into a subjective argument.
    4- If possible- after the exam- summarize your recommended treatment plans. From there- they often try to ask for these items but inform them the medical treatment plan has been made. If they simply repeat the same request- again not much reason to continue a circular discussion.

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