Principle-Based Negotiating for Resources and Funds in Graduate Medical Education

The goal of designated institutional officials (DIOs), program directors, and faculty is to produce excellent physician graduates of residency and fellowship programs. This requires that graduate medical education (GME) leaders be facile in meeting accreditation requirements, fostering an inclusive environment, promoting learner education and faculty development, and aligning with departmental and sponsoring institution priorities. It also necessitates that GME leaders be skilled advocates for the resources and funding necessary for success. Yet, there often exists a gap between the C-suite and GME leaders’ viewpoints regarding funding educational priorities. Bridging this gap occurs through negotiation—a training imperative for GME leaders and program success.

GME substantially underpins the effective functioning of hospital systems and clinics. However, the value of GME is often underappreciated by leaders in hospital administration. C-suite individuals may be unaware of how GME benefits their operations, such as in providing patient care, ensuring the hospital meets regulatory standards, optimizing patients’ experiences, and advancing institutional culture as a learning health system.¹  To change that dynamic, meaningful relationships must exist between GME and C-suite leaders. Communication is key, and C-suite leaders are accustomed to communicating in ways that are rarely taught in medical school.²  The principles of negotiation and the communication style of the C-suite are necessary skills for GME leaders.

The vital role of GME in delivering health care service and an institution’s success can be leveraged in negotiation. Establishing the value proposition in this partnership is the foundation for funding negotiations. GME leads from a standpoint of strength and collaboration, best proven through results-oriented outcomes. Education leaders must make these outcomes explicit either as financial incentives or other valued assets (eg, stature of the learning health system) to the C-suite, so they better understand the fiscal importance of GME funding for the organization.

Negotiation requires effective communication, and active listening is a key component. This intentional communication aims to provide education and achieve mission alignment while also building strong relationships.³  To be successful in advocating for resources, you must be a subject matter expert in the accreditation and education needs of your program(s), GME funding and budgeting, key hospital metrics and quality initiatives, and the hospital’s or system’s financial realities.

As a GME leader, to be an effective negotiator you must:

1. Assess how much control and influence you actually yield. If you have total control of your request, no negotiation is needed. If you have partial control with high influence, the amount of negotiation required is minimal. However, if your partial control is paired with low influence, this is where your negotiation skills can be maximally effective. Unfortunately, if you have no control and little influence, often a negotiation proxy (a substitute with authority to represent you) is needed for success.

2. Determine what you are negotiating for. What do you really want? Be prepared to use accreditation requirements to demonstrate how the funds will address an organizational need through results-oriented outcomes and/or produce assets for the organization.

3. Understand who you are negotiating with. Do your homework so that you understand: (1) who they are; (2) what they value; (3) what motivates them; (4) their scope of influence and control; (5) whether they can give you what you want; and (6) where there is a shared mission and/or desired outcome of excellent patient care.

4. Prepare and employ the basic steps of any negotiation. Use your skills as an effective teacher to create a compelling and cogent storyline for your negotiation dialogue in 3 steps (Figure). First, grab the attention of your audience—often with a compelling statistic or story. Then establish the need—specify the gap between the current and goal state. Third, provide a solution that is perceived as a win-win for GME and the organization.

5. Use a “principled,” not a “positional,” negotiation style. Buying a car uses positional negotiation. Principled negotiation preserves relationships. It strives to separate people from the problem. Tackling the problem together and addressing areas of mutual benefit allows C-suite leaders to understand the value of GME and be willing to invest in shared successes. Finally, identifying objective criteria for defining success can be a useful technique to facilitate negotiation.

6. Practice prior to your meeting. Effective negotiation requires practice with feedback. Recruit a colleague in a similar role or organization to minimize the post-meeting concern of, “I wish I would have thought of that during our negotiation…”

1. Review and reflect on your institution’s strategic plan. These documents are generally published on institutional websites. Convey the key components of your message, including how it fits into the institution’s strategic plan, in 2 to 3 well-crafted sentences. This “elevator pitch” is imperative to piquing leaders’ interest in your proposal.

2. Learn to make a business case. Proposals that require significant resources must be associated with a business case that includes a rationale and budget justification (see the business case Rip Out in this series⁴ ). Proposals that are not profitable, or at least budget neutral, must have a clear mission-based rationale. Learning to write a business plan will enable you to communicate with the people who hold the purse strings in a language they understand.

3. Advance your skills. Learning to negotiate is not easy. It requires understanding how your vision, and its associated space, personnel, and financial requirements, fit within larger institutional priorities and mission. Thus, becoming fluent in the language of strategic planning is imperative. Resources include negotiation-related workshops, online seminars, and readings, particularly from the Harvard Business Review.

4. Build relationships with stakeholders. Establishing a regular meeting cadence with key stakeholders can be useful. These meetings may include C-suite leaders, program directors, as well as residents and fellows. Establishing and maintaining these relationships means that when you do need to advocate for change or resources, you already have common ground on which to build a collaborative negotiation.