Negotiation Strategies as a Pathway for Creating Equity in Medicine

She was excited to start her first job after residency. She was told that her skillsets and her interests were highly marketable. However, when it came to her interviews, she received feedback that she was perceived as aggressive. As she went on in the process, she felt herself shrinking.

She felt powerless.

Once she started working, she was placed on multiple committees because she was one of the only Black women at her institution. She noticed that she was spending numerous hours daily on committee work and barely had enough time to focus on her clinical-related activities.

While at work, she was constantly questioned by her colleagues regarding the orders she would place. Despite introducing herself as a physician, her patients often complained that they were never seen by the doctor or mistook the male nurse or medical student as their physician.

She had twice as much responsibility without the compensation, protected time, or recognition as her male colleagues.

She didn’t feel valued.

These are common situations that women of color, especially Black women, encounter as attending physicians, fellows, residents, and even medical students. The frequency of these interactions can lead to higher burnout rates, poor workplace performance, and ultimately attrition from medicine. These daily occurrences contribute to the large disparities seen within the medical field. There are known equity issues in medicine between women and men that are further compounded by race. In medicine, there are few women and even fewer women of color in senior leadership positions.^1,2 Even when women have similar leadership positions to men, they earn significantly less than their male counterparts. In the United States, women physicians “make between 17% and 28% less than men at all career stages.”³ Women physicians who are racial and ethnic minorities in medicine face further pay disparities, earning between $0.69 to $0.77 for every dollar earned by their White male colleagues.³ Furthermore, Black women at an institutional level face both gender and minority tax burdens.⁴ They end up in institutions where they are expected to do work in diversity, equity, and inclusion (DEI) spaces with little administrative or financial support.⁵ Women are more likely to do work that benefits their institutions such as committee work; however, this work may be less valued at the time of promotion review.⁶ Ironically, Black women who lead DEI initiatives often begin to feel isolated or get pushed out of the organization if their views are not in line with the position of their organization.⁵

A contributing factor to disparities in pay and leadership representation is the backlash that women, especially women of color, face when they attempt to advocate for themselves using conventional negotiation strategies.⁷ When they do negotiate and advocate for themselves, women of color, specifically Black women, are often afraid of pervasive stereotypes such as being labeled as aggressive or angry.⁸ This enhances negotiation challenges.⁸ The study Bargaining While Black: The Role of Race in Salary Negotiations demonstrated that when Black applicants negotiated, “job evaluators [were] less willing to make concessions,” which ultimately resulted in lower starting salaries for Black applicants.⁹ Faculty and trainees of color face these unique challenges, which are compounded by gender when negotiating. Therefore, it is essential to transition away from “typical” negotiation tactics and toward strategies that take into consideration the role of bias.

It is also vital to understand that negotiations also occur in daily interactions, outside of traditional salary and contract negotiations, such as when talking to patients about their medical treatments, dealing with a difficult patient, or peer encounters. Although inexperience, gender, and institutional barriers are commonly cited reasons why individuals may feel inadequate when negotiating in these situations, the intersection of gender and race is critical here as well.^9,10 Traditional negotiation frameworks usually do not take into consideration these intersections. For example, when women are taught and use gender-specific negotiation strategies, these can be perceived as “inherently adversarial in nature.”¹⁰ Therefore, it is important to inform and shift a person’s mindset in when, where, and by whom specific negotiation strategies can be best used.

Negotiation Training

Similar to fields such as law and business, offering negotiation curricula in medicine can address some of the unmet needs at the intersection of race, gender, and negotiation.^11,12 Starting early in training, in medical school, is essential. Negotiation content can be incorporated into existing medical school courses as well as residency curricula. Examples include existing case studies, simulations, and DEI training sessions. These interactive sessions must include the numerous informal scenarios in which negotiations occur, to practice strategies. This is in addition to traditional leadership courses that emphasize salary and contract negotiations and often occur toward the end of residency and fellowship training. Instead, these sessions should emphasize a mindset shift that many situations are actually negotiable (Table). These teaching sessions can also address the power disparities that are frequently encountered throughout and after training.

Table.

Enhancing Negotiation Experiences: Key Concepts and Strategies for Effective Negotiations

Negotiation Concepts
Concept	Definition	Example	Implication
Hard positional bargaining	Individuals negotiate according to their position or what they want to get out of the situation. A form of distributive bargaining where both parties view the conflict as a win-lose situation.	An institution may ask a Black woman physician to take on DEI-related roles and both the institution and the physician see this as a “yes” or “no” argument.	Can strain the relationship in a negotiation. Detrimental to the party with lower social power.
Mindset shift	Negotiations are not limited to formal negotiations of contracts and salaries. Understanding that negotiations are not necessarily adversarial in nature. Includes informal situations and approaches with a positive mindset.	When a Black woman physician encounters a patient who does not acknowledge her as their doctor and is against the treatment options presented. The physician does not view the patient’s assumption as fixed but as a negotiation opportunity, by reintroducing herself and understanding her apprehension regarding treatment options and possible alternatives.	Research shows that women do not ask and perceive fewer situations as negotiable. Viewing the situation through a solutions-oriented lens instead of a situation with unfavorable and unfair circumstances increases willingness to engage in a negotiation that produces positive outcomes. Allows for shared decision-making in physician- patient encounters.
Benchmarking	A negotiator can demonstrate industry standards or establish precedent from similar institutions as a negotiation strategy.	When a Black woman physician is asked to fill uncompensated DEI roles in addition to their daily responsibilities, they can bring in examples of similar reputable institutions that have reduced clinical time so that the physician has more time to fulfill their DEI responsibilities.	Sharing a precedent at a similar institution will relieve the negotiator of the pressure of making a persuasive argument and remove bias in the negotiation.
Leveraging allies	Negotiators in positions of lower social power can leverage allies who are higher in both formal and informal authority and have shared goals.	A Black woman physician meets with a trusted colleague to get their buy-in ahead of a meeting where they will ask a director for a shift reduction in order to fulfill their DEI-related responsibilities.	When peers in positions of higher social power ally with their lower social power colleagues, they relieve them of the burden of advocating for themselves.
Best Alternative to a Negotiated Agreement (BATNA)	The most advantageous alternative to take when negotiations are unsuccessful.	A Black woman physician is unable to get buy-down (reduced clinical time) for her committee work, but the best alternative may be for the institution to provide her with administrative support.	Provides the negotiator with alternatives, thus reducing the stakes in the negotiation.
Intentional sequencing	Mapping possibilities and preparing the most strategic sequencing of events to give the negotiator the greatest advantage.	A Black woman physician preemptively asks the nurse to introduce or recognize her as the doctor when meeting the patient.	Allows the negotiator to be proactive and operate from a position of power as opposed to being reactive to the turn of events.
Present the win-win scenario (aka “I-We”) strategy/shared interests	Solutions where each party benefits from the final agreement.	When a Black woman physician frames her request for a shift reduction for the purpose of having the capacity to fulfill DEI-related roles, the request should be perceived as being in the ultimate interest of both the organization and the individual.	Meets all negotiating parties’ underlying interests can reduce the opportunity for bias in a negotiation. Preserves the relationship in the long term.

Abbreviation: DEI, diversity, equity, and inclusion.

Note: Adapted from Fisher R, Ury W, Patton B. Getting to Yes: Negotiating Agreement Without Giving In. 2nd ed. Harper Business; 1992.

Negotiation curricula should deemphasize hard positional bargaining and instead emphasize collaborative negotiation skills, such as win-win framing, which are proven to be more effective.¹³ The Table outlines key negotiation concepts for daily interactions. Interactive, required negotiation training integrated into current case conferences, simulations, and other curricula to highlight critical negotiation strategies, especially for Black women, will increase trainee success and potentially improve program goals in diversity and retention. Incorporating negotiation strategies can empower these women to advocate more effectively for themselves as well as their patients. Offering negotiation curricula is a critical step at the institutional level in creating a system where women of color feel valued and are operating on an equal playing field.

Other useful negotiation strategies include identifying the best alternative to a negotiated agreement (BATNA), either in the moment for daily interactions, or proactively, in planned negotiations. Thus, if the desired outcome is not attainable, there are backup options, rather than a “win-lose.” For example, if a patient refuses recommended treatment suggested by a Black woman physician, the BATNA may be a mutual agreement to return later to the discussion. If a residency program is unable to obtain administrative support for a resident who is leading DEI initiatives, a reduction in shift or clinic hours may be the BATNA. The intentional sequencing strategy is also helpful in negotiation. This requires anticipating preference outcomes in a proactive way. An example of intentional sequencing would be an attending introducing a new resident or fellow throughout the day as doctor during interactions with staff and patients, rather than reacting during an encounter.

Peer Allyship in Negotiations

Allyship is essential for mitigating negotiation obstacles and creating an equitable work environment, instead of expecting trainees to handle difficult situations on their own. For established leaders, allyship may include sponsoring and supporting a Black woman for a new role or mentoring around career obstacles. However, negotiation allyship is not limited to those who are in positions of power. Being an ally includes gentle gestures that can have profound effects. If similarly trained in these daily negotiation strategies, a colleague can provide more informed support during a difficult patient encounter, such as when a patient does not acknowledge their Black woman physician as a doctor. A colleague can address the Black woman physician as doctor and clearly defer to her expertise, as she talks to the patient. Recognizing the opportunity and employing negotiating strategies immediately can foster an atmosphere that is committed to diversity.

Institutional Support During Negotiations

The institutional environment is critical to Black women successfully employing daily and high-stakes negotiation strategies. Institutions also must understand that negotiations can occur in frequently low-stakes as well as high-stakes encounters. Institutions should approach negotiations not as a loss versus gain but instead an opportunity to highlight shared interests for the organization and the negotiator. It is beneficial for institutions to be open to negotiator suggestions, such as using benchmarks employed by comparable institutions for the same role or duties. For example, when a Black woman is presented with an opportunity with increased responsibilities, such as DEI committee work, the institution should recognize and be open to the need for support. This could be through reducing clinical time, increasing administrative support, or funding advanced training. This approach is likely to increase success for the Black woman in a new role and for the institution in a more productive committee, with less participant turnover. This approach requires institutions to explicitly consider prevalent stereotypes—the intersection of race and gender—and employ strategies to mitigate their effects, to reach mutual agreement. Institutions can further support trainee and faculty success by requiring and funding negotiation training that considers the effects of intersecting identities. Creating a supportive environment is essential for negotiations to be successful.

Conclusions

Daily and high-stakes negotiations pose unique challenges for Black women medical trainees and faculty, due to stereotypes surrounding their intersecting identities of race and gender. To effectively address these barriers, it is essential to adopt strategies that have been effective in other fields, such as business. By integrating these strategies into existing medical school, residency, and fellowship educational experiences, we can cultivate a safe space for negotiations practice. These strategies include mindset shifts from perceiving negotiations not as win-lose but as win-win, recognizing negotiation in everyday interactions, using benchmarks in discussing the need for support or funding, including allyship in negotiations, considering best alternatives, and intentional sequencing. By implementing these measures, we can work toward creating a system that values and empowers Black women medical trainees, enabling them to thrive in their careers.

Thereby creating a system where she feels valued.