Handling Difficult Conversations in the Medical Field with Zwade Marshall MD, MBA

Hello, my friends, and welcome to another exciting episode of Negotiate Anything. This show is produced by the American Negotiation Institute, and with over 5 million downloads and listeners in over 180 countries, listeners just like you have made this the number one negotiation podcast in the world. Hi, my name is Kwame Christian, and I am the founder and CEO of the American Negotiation Institute. Here at AI, we believe that the best things in life are on the other side of difficult conversations, and we are passionate about providing you with the best content that will help you to make your difficult conversations easier, both at work and at home. Lastly, I want to remind you that we offer consulting and conduct trainings, both virtually and in person all around the world. Our focus is in three main areas. First, negotiation and conflict resolution. Second, leadership. And lastly, diversity, equity, and inclusion. Check the link in the description below to learn more about how we could work with you and your team. And now, without further ado, let's jump into the interview.

Zwade. Thanks for joining us, my friend.

Thank you for having me, Kwame. It's a pleasure to be here with you.

Yeah, it's a pleasure to have you. So how would you get us started? By telling us a little bit about yourself and what you do.

Sure. So my name is Wade Marshall. I'm a physician, an anesthesiologist, and interventional spine specialist by training. I have the distinct pleasure of growing up in a family where my cousin is a brilliant attorney and negotiations expert, and so I'm a part of the family. Kwame is my cousin for your listeners. And we're both Guyanese. Our moms are first cousins, and they were also really good close friends on top of being cousins. And so there was an intentional effort in my upbringing, though. I grew up in Guyana and Kwame grew up in Ohio for our families to bring us together as two young males in our family. And so he's an attorney, I'm a doctor, and I think we both are the prize and joys of our collective family units as well. So thank you for having me on, cousin.

No, it's my pleasure. It's my pleasure, everybody. You know, you have that person in your family where you're always compared to them. Zwade was that person for us, always being super accomplished. And so it's exciting to have his expertise on. And so, Zwade, tell the folks about your background in medicine and in business.

Sure. So, born and raised in Guyana and then moved to the US to go to college at Emory. So I got a full ride to Emory University back in 2001 did a Bachelor's in economics. I always kind of liked the way money works and the way economies are molded by finance. And then took a year between college and medical school to be a high school mathematics teacher. One of the most transformational years in my life. Talk about negotiations like I learned to negotiate with with kids and you kind of get a true glimpse into the human condition. It was a Title 1 school free lunch program for 90% of the students there and it shaped my worldview and perspective and also helped me today to kind of understand where my patients are coming from. So after teaching high school math, I went on to Emory for my medical training and did the dual MD MBA degree. Chose to go to business school at Emory as well. Goy sueta. Because it was around the time when the Affordable Care act was being conceived and it felt as though if you weren't at the table, you were going to be on the menu. And I wanted to understand more about how money and economics molded the practice and the delivery of health care systems. And so was an operations major or focus in business school. And then that was kind of my calling card when I applied into residency. Leaving Emory, I interviewed widely and ended up at Harvard for my anesthesia training. I was chief resident there and then did my interventional spine pain training at Harvard as well. This is now 6 years ago I moved back to Atlanta, became a partner at a large private equity backed interventional spine group. Private equity in medicine is another discussion for another day. But it certainly shapes the way care is delivered and left that model to open my own practice. So we're sitting in my office right now, regenerative spine and pain specialist in metro Atlanta and I take care of pain patients with spine but also with joint complaints. Many of them are in narcotic medications and need to see me as a way to get them into a more functional state. Decreased medication regimens and also increased functional ability from interventions as well as that is fantastic.

And listeners now you see why Zwade was the cousin that we were always this is great. And so just a bit of a preview here. So with this episode, what we're going to do is we're going to focus on zuade as a doctor. Dr. Marshall. So we're going to talk about the difficult conversations you have in your role as a doctor. In the future we're going to have you back on to talk about some of these really fascinating business negotiations that you have come on because they're really interesting from an intra organizational negotiation perspective and from an exiting an Organization perspective and then an inter organizational perspective as well. Your, your expertise is vast in that regard. So we're excited for this to be a strong start. So with this episode, we get to start off with a listener question. And this is from Mike Fish. And so he's a podcast listener and he's a physician. And he says, I'm wondering if you have an episode or could do one regarding negotiat difficult situations. For example, there can be drug addicts who constantly want to negotiate for more drugs and drugs are not in their best interests. There's also a negotiation for social situation in which patients want to remain in the hospital because they're too anxious to go home or they might be homeless. I'm sure the physician in your family could provide some input too. Thanks, Kwame. And here we go.

Here we go.

So we have you here. Let's address that first question about pain. People who want more narcotics, but it's not in their best interest, how do you approach that conversation?

Sure, I think it's really cool that Mike Fisher, I think you said his name is a doctor. Listening to negotiating podcasts. I thought I was the only kind of nerd that consumed this kind of content. But I think it's part and parcel to the struggle that physicians have in terms of balancing medicine but also negotiating the sphere of dealing with patients who may have a preconceived notion about what is best for them and having a physician who has more data understanding some of the consequences of those decisions. And so the pain management conundrum is an age old conversation that I think we've been having more actively over the course of the last decade because of the opioid crisis. Now, a part of the challenge with pain, this is to the heart of Mike's question, is that pain is this complex, emotional, subjective experience. It's wholly subjective. We don't yet have a pain meter or a pain monitor. We can't measure your pain score, that we measure a blood pressure or a heart rate. And therein lies the crux of the matter. Because you have to trust that the patient that's explaining to you they have a complicated pain condition is really experiencing that complex pain condition. In the time now of this scrutiny around pain medicine and pain medications and the millions of Americans who are overdosing and dying from narcotics and opioids, it has put the doctor in a very precarious position of protecting him or herself while also delivering care for patients. So to practice medicine in this space today, you have to hold two competing thoughts in your Head simultaneously, one of them is your main responsibility. The kind of age old adage of medicine is first do no harm. And we're trying to establish a therapeutic rapport with a patient who's struggling because they're there to see you, while at the same time appreciating the fact that there are government entities and law enforcement agencies that are prioritizing, prosecuting physicians for patients that have opioid addiction issues. And so I intend to delve into the actual pain conundrum a little bit more in a few moments.

No, that is a great synopsis of the challenge because as a doctor, you want to provide relief, you want to help people in need, and at the same time, sometimes doing so in the way that they're requesting makes things worse. And you have the reality that you have a family, you have a staff, you can't and you like freedom.

Orange is not looking at me, Kwame.

Exactly, exactly. You look great in white right now. So you want to make sure that you're not crossing any ethical lines. And so now that we have a good understanding of what the challenge is and why it's so difficult, in your experience, what is a good first step?

Sure. So the first step is establishing the ground rules. And so the first visit is an exploratory visit. And it's a time in which we're going to be asking questions, detailed questions about the patient's pain complaint in an effort to do a few things. It's to validate their concern and also to convey to them that you can appreciate that their pain is as real to them and thus it's real to you as a treating physician as well. And so it's exploring all the kind of detailed character questions about the pain condition while simultaneously going a little bit deeper into social circumstances, place of employment, type of work, hobbies, whether or not they have kids. What are their functional goals? Divorcing a pain condition from a pain score. Because I can't treat pain to a pain number, since numbers are really subjective. What I can treat to are goals. Some patients may say, doc, I just want to be able to stand in church and sing the hymns and not have to sit down in the pew when the choir is standing. Others may say, I just want to go out with my grandkids and take them for walks. I've got a three year old grandson who loves going to the park. I want to be able to do that. And if I can establish with the patient that those goals are important to me for them, that begins to establish that therapeutic alliance I treat lots of athletes and golfers who are afraid that my recommendation will be to stop golfing, stop biking, stop swimming, and when they meet a doctor that says, I can appreciate that this is a part of your identity and my goal is to keep you doing the things that you love so that Quality of Life index does not go down. It goes a very long way in building the trust for the time when the decision making comes into what do I recommend as the treatment option? If my recommendation differs from their expectation, at least we've got some mutual understanding on what the goals are to begin with.

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The key word that you said there, Zwadeh, is trust. And you're doing this in such a profound way. I want to break this down for the audience so they can see the gems that they could apply in whatever their situation is. So first, when we're talking about trust, it comes down to the capability of you to deliver on what it is that you say you're going to do, and then also your willingness to deliver on what it is that you're saying you're going to do, and then the belief that your goals are shared. And so from the beginning, what you're doing is you're controlling the interaction by saying, all right, here's what I'm not going to do. I'm not going to just have them come in and them tell me what to do. I'm going to control this interaction and say, this is what you do. You're going to come in, this is the process, and I'm going to lead you through that process. And so that in itself, taking that leadership role in the interaction establishes that credibility. And so you're managing the process throughout, but you're also, while taking control of the process, doing it empathetically. You're demonstrating that you understand what they want and why they want it. And then you're saying, what is your goal? And then you're articulating the fact that their goal is in fact your goal. And when you put all of those things together, you have a high level of trust, trust going into the rest of the relationship.

I love the way you summarize that. And I think of it as seeding some of the control that patients come in thinking that doctors are dictators in many respects, where we say, here's the plan, you either abide by it or get out. And in this day of activated, engaged patients who are their own advocates, we can no longer speak to people as a physician as though you are, you know, what's best for their bodies. And so being able to give them some of that control, of being able to tell me the story, tell me their goals, and then I am buying into their plan as opposed to the reverse. It gets folks a lot more relaxed and comfortable with my recommendations.

Absolutely. And yeah, I think when you said the word dictator, we have to think about another word that comes into mind, which is leader. And so as a doctor, you are a leader. And the difference between a leader and, and a dictator is that with a dictator, the people below you, they don't have choice. You know, you're taking that autonomy and agency away from them completely. But with leaders, you have followers, the choice to follow, that's something that they have control over.

Sure, sure. And I think because there's some information asymmetry where I know more about some of the broader aspects of pain than the patient can, I'm fitting their narrative into diagnostic algorithm as we're speaking. Right. And so what that empowers me to do is to help to direct their treatment plan where they will end up subscribing to it or even requesting it, because I'm leading them down a path as they tell me their story and I'm fitting them into the algorithm. So I'll give you an example. Many patients come in already in high dose opiates. And because of all the scrutiny around opioids and medicine, their previous physician may have been closed down or may have, may have retired. And they're looking to find a new doctor who'll prescribe the same regimen they've been on before. And so you can tell when someone's telling you their pain history and emphasizing the fact that oxycodone and oxycontin is what works best for me, it's always worked well. Nothing else seems to help. And in that, many doctors will respond and react immediately to those comments, whereas my position is I'll write it down, I'll nod affirmatively, I'll even ask about others that they've tried and affirm that it makes sense that those medications may work for your pain. And then later on in the conversation, I'll ask about things like constipation, bowel habits, whether or not there's any impotence or erectile dysfunction, any mood swings or lability in depression or anxiety. All of those things are side effects of high dose narcotics. And so as we get towards the point of the consult where I'll go over a treatment plan, I'll then circle back to some of the symptoms that's affecting their functionality and attribute those symptoms to the high dose opioids and explain why. A part of the treatment plan will be to responsibly decrease the medications while also doing alternative therapies that can be more effective and very helpful to them. See a light bulb go, go off where some may want to object, but they kind of feel trapped where they can't at this point because we've had this very pleasant, amicable, empathetic conversation and now it's there. It's their job from the social contract to now kind of continue in this amicable way to give me the trust. And so you'll see them looking skeptical, but thinking, I'll give it a try. And then I think what kind of brings it all together is having that constant feedback from me saying that I'm with you in this journey and I get that it's going to be tough, but just give this other intervention a try while we do these other things that are going to be very helpful for your overall health. And it's gone far.

This is fantastic. And I feel obligated to cite Dr. Robert Cialdini, the author of Influence, because we just interviewed him earlier today and he talks about the principle of consistency, where if you said something in the past, you feel obligated in the present to remain consistent to what you said. And essentially what you're doing through this process, through curiosity, is you're giving them the opportunity to share what they want and why they want it, you're helping them to articulate their goals. And then what you're doing is you're saying, hey, based on what you said before, actually this treatment plan helps you to meet your goals. And this is why. And so in their mind that that hesitation that you're sensing is their desire to remain consistent.

Sure.

But that consistency is leading them down a path that they did not Anticipate.

That's exactly right. That's exactly. I'll get that book. You mentioned it earlier to me, and I do whatever you tell me to do, Kwame. So I'll certainly take a listen and I'll tell you that this entire construct is challenging for doctors because we're under time constraints, right? The way compensation medicine has changed, you're watching the clock. And so having a patient kind of go through their own narrative at their own pace, it's time prohibitive to allow them that kind of agency to speak at ad nauseam. And so some of the things that I do to kind of help to gather data outside of the actual examination room is that we have a lot of surveys and app based modules that they must complete prior to the first visit. The other thing is resisting the urge to interrupt when someone says something that you vehemently disagree with. So let them have their peace and have it be said, because those interruptions fracture that therapeutic alliance where in that moment, the patient sees you as more adversarial than someone who's there to foster that therapeutic alliance. And for me, it comes a little easier because I grew up with a pronounced stutter. And so, like the King's Speech, I would rehearse words I wanted to say all of my youth in my head 15 or 20 times before I said it. So in the natural course of a classroom environment, I'm sitting there thinking that I want to say these 15 words. And in the time I'm rehearsing it, I'm getting to hear so much other input that by the time the output comes out, it seems so much more profound because I'm editing, I'm using inputs that I've heard while I was editing and rehearsing. And it allows me to kind of process better. Being in business school, I was able to kind of focus intentionally on that personality or that output defect and make it into a strength where I embrace the rehearsal, I embrace listening, I make notes. Because people will tell you what they want. They'll. In a negotiation, if you let folks speak, they'll give you the answers. You'll know their motivation, you'll know the outcome that they're desiring. And if you just let them the freedom to get their bit out, not only do you have the information you need to get to an amicable outcome, but they then buy into your philosophy because you appear to be empathetic and reasonable in the interaction.

This is a really great point. And it's something that so many people struggle with. It's something that I still struggle with. Because it's that need to correct. Like, no, I recognize that wasn't a misspeak. It's I, with every fiber of my being, rejected what it is that you just said, and I need to correct you. So. So let's break it down, because again, people. We. People could just say, hey, don't interrupt, and then we move on to the next thing. There's a challenge. Everybody knows they shouldn't interrupt, but we do it anyways. So let's break down just some mindset tips that people can keep in mind when it comes to not interjecting or on every single point that you disagree with. Sure.

So I think there are a few things there, and I love the way you frame that. I think the first point, though, is if you give them the ability to speak and make their positions known fully, then at the time that you create your response, you're not just responding to a point, but you can dismantle the entire construct. So you'll have all the information that you need to thoughtfully and carefully craft your rebuttal at a time that they're not expecting you to be giving them a rebuttal, but you're putting together a cogent kind of plan or a summary of the conversation. And so you'll have more information from their perspective to be able to respond in a more appropriate manner. And so that ability to let them just kind of speak their piece and then after it's all said, respond fully to everything, using the expertise. Using the fact that there are informational tidbits that you can add to give color and context and validate some of their points while then disputing and refuting the other ones that are not valid. It creates an overall more positive impression from the patient's perspective.

Absolutely. And, Zwane, this reminds me of one of our earlier episodes we had, I believe it was December of 2019 with my friend Dan Oblinger, hostage negotiator. And he's been in the.

I heard that episode.

Yeah, yeah, he's great. And so he's talking about deception, and the way that he addresses deception is very similar to the way that you're talking about addressing things that you disagree with and not interrupting. Because the metaphor he used was he thinks about deception as like. And so a little bit of it peeks out of the bushes, and you want to jump on that, but you don't. He's like, no, I want to hear the whole thing. I need to see the entire animal. And it's just like what you said, because It's a brilliant way of describing it and I've never heard it broken down in this way. You can address a specific point or you can almost like a sniper, very precisely address the entire construct and dismantle the entire construct after you've given them the opportunity to express themselves fully.

That's right. And then you've got a patient who is now engaged, who understands that you've heard that they feel heard and validated because oftentimes by the time they see someone like me, they've probably seen four or five other doctors, they've seen their internist, their orthopedic surgeon, their neurologist, and you don't know what experiences they've had. But, but principle to what we're doing is ensuring that they feel heard and validated, that their pain and their pain experience is real, even though we can't see it or measure it. And I'm going to go ahead and now address that, having got all the facts to make an informed decision. And what's the next step?

And this serves as a really fascinating metaphor for emotions as well because like you said, pain is subjective. I can't with some kind of meter, determine how much pain you are in fact feeling. Similarly, we have to leave it to somebody's self reported measure of emotional discomfort. And a mistake that I see people making all the time is they don't believe somebody else's subjective interpretation of how they're feeling. Oh, just toughen up, it's okay. That is not acknowledging how people feel. That doesn't address it because now they feel through the rest of the conversation. No, Kwame doesn't believe me. I need to impress upon him just how emotionally distraught I am. And so it's almost like we should treat emotions in the same way that you're treating pain. They have a self reported measure. I'm going to reflect back my understanding, acknowledge that that emotion and let them know, hey, I understand where you're coming from, I believe you. Let's work together to find some way to alleviate it. But let's find the right way. But we have to work collaboratively to get there.

Absolutely. And funny you mentioned emotions because there's an emotional component to pain. Right. Is this complex emotional subjective experience. And, and oftentimes one of the most salient treatment regimens for the chronic pain patient is a pain psychologist to help with mindfulness therapy. But try suggesting that as your first recommendation, you'll lose every single patient. Right. And so as you listen and you're informed and you make your recommendations that Involve, you know, some medications, maybe a spine injection or two, physical therapy, and then a pain psychologist with the goal to help the patient appreciate exactly what toll that pain is having on their life, and if they've become pain centered or pain centric, where it's now a part of their identity, and helping to kind of disconnect that identifying feature of their personality with their pain syndrome, and helping them see that they're more than just that. And so it's the pain doctor's job to do more than just put a needle in or give up, give a pain medication, but to help Pat see the bigger picture.

Absolutely. And with the time that we have left, there's one last thing I want to address, which is time. And you've touched on this because we have the reality that there is a limited amount of time that we have for these conversations. And given that fact, how do you try to get so much of the richness from this process and this interaction, but also manage to do it in a time boundary that can be really challenging at times?

Sure. So I'll admit I haven't figured it out perfectly. It's still a struggle. It's an ongoing struggle. I think there are times when you've got a really challenging patient who you'll just have to invest the time with and be late for the next appointment afterwards, because you just need to invest the time up front with this person. And these are all people with families and lives and experiences and prior surgeries. And so you cannot treat them all the same. And so the question was framed, how do you manage time? Well, a part of it is managing the person and at times the time is not the priority. But then there are things that you can do to help to optimize the time you do have. The first rule is sit down during the encounter. Studies have shown that if you sit, and this is a doctor specific kind of recommendation, when you enter a patient's examination room, you can stand while they're sitting, you can examine them and speak to them or at them while they're sitting. And you're standing and you leave the room in three minutes or 10 minutes or 15 minutes later. And the interaction from their perspective is that you were rushed for the visit. It if you sat down eye to eye and treated the examination in kind of in phases. So you sit, introduce, you greet, you question, that could be three and a half to four minutes, then you get up and you examine, then you sit again and then you summarize and then you leave the perception of that patient that you spent 80% more time with them than you actually did because you were sitting. That's a research article that was published in jama about 12 years ago in the pain space, and I employ that daily. The other thing is that making myself accessible to the patients through my staff, we have portals. There are ways for them to text into the portal. And I've got a team of extenders that will reply to questions and then escalate it up to me if the question is nuanced or complex enough that it warrants a physician's perspective. And so having that access to the practice, not necessarily to me, but to a healthcare professional, also gives them a release and an outlet to feeling as though they're being heard and someone cares about their overall care and treatment.

I love this, and I think there are three main things that everybody can take from this. The first one is there's no easy answer for this. When you have a time limitation, but you have a really tough conversation, there's no easy answer for that. And I think that's important because some people would just throw their hands up and say, I guess I'm not going to do anything because I can't figure out the answer. Hey, newsflash, there is no great answer. You just have to do the best with what you have. And I think that's really, really important for people to understand. So it normalizes the experience and they're not so hard on themselves based on their performance because of the time limitation. The second thing is the reality that time is subjective. And so even though the study that you gave, where it says the perception of the person was that you spent 80% more time than you actually did, this is focused on physicians. I think we can replicate this in the business world, too, if we were to, let's say, avoid distractions. If I'm constantly looking at my phone, people are perceiving as I have better things to do, checking my email, doing all these other things, looking at the clock, people are going to perceive that I'm rushed. And it's likely it's going to have a similar impact as the sitting study that you described, too. So I think for the listeners, you need to think about different ways that you could be signaling that you are not completely there and the impact it's going to have on the perception of the other person. And then lastly, how you're strategically extending the conversation. Yes, the reality is I have this much time, but that doesn't mean the conversation ends. And so you encourage people to continue interacting with you through you. Maybe directly to you through messages, but also through your team with a lot more availability. And then they still have that feeling that you, through your organization, are still caring about the communication and your response.

Beautifully said. I agree with all of the above.

Cool. Before you go, can you let the listeners know again about you and about your practice and how they can get in touch?

Sure. Again, it's Dr. Zwade Marshall. I'm@regenerative spines.com that's S at the end of spines and I'm based in Atlanta, Georgia. I do consults by telemedicine as well, and I'm happy to have any conversation with anyone that's struggling with chronic pain and needs to speak about responsible and empathetic ways of getting their function and their life back.

Love it. Zohadi. Thanks again, my friend. Really appreciate it.

It's my pleasure being here with you, Kwame. Thank you for having me.

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Will see you in the next episode.

I'll catch you later.