In Health Reform, the Power of a Positive No

By Holly Hayes

Those of us in the mediation field have likely read The Power of a Positive No by William Ury. I was reminded of this book when I read the New York Times article this week, “In Medicine, the Power of No.” See the full article here.

William Ury’s preface begins with a discussion of his daughter’s illness and his family’s “long journey through the medical system.” He says, “I realize the process has called on all of the skills I have learned over the years in helping others get to Yes with their negotiation issues. I also realized that, for me personally, the key skill I needed to develop to protect my daughter and our family was saying No.” Everyone says no, the difference for Ury was that “my Nos needed to be nice.”

As you might have guessed, David Leonhardt in the New York Times asks, “How can we learn to say no?” The article outlines a three-step process about learning to say no in medicine, more often:

The first is learning more about when treatments work and when they don’t. ‘All too often,’ the Institute of Medicine reports, the data is ‘incomplete or unavailable.’ As a result, more than half of treatments lack clear evidence of effectiveness, the institute found. It says the most promising areas for research include prostate cancer, inflammatory diseases, back pain, hyperactivity, and CT scans vs. M.R.I.’s for cancer diagnosis.

As part of the health act, a Patient Centered Health Research group will have an annual budget of $600 million. Relative to total health spending, that’s a paltry sum. But it’s real money relative to what’s now being spent on such research.

The second step — and maybe the most underappreciated one — is to give patients the available facts about treatments. Amazingly, this often does not happen. ‘People are pretty woefully undereducated about fateful medical decisions,’ says Dr. Michael Barry of the Massachusetts General Hospital, an advocate for sharing more with
patients.

When patients are given information about potential benefits and risks, they seem to choose less invasive care, on average, than doctors do, according to early studies. Some of them choose home care like https://homecareassistance.com/la-jolla/. Some people, of course, decide that aggressive care is right for them — like the cancer patient (and palliative care doctor) profiled in this newspaper a few days ago. They are willing to accept the risks and side effects that come with treatment. Many people, however, go the other way once they understand the trade-offs.

The health act requires Medicare and other agencies to help hospitals and doctors give patients more information — which is practically a no-lose proposition. In the course of receiving more control and more choice, two distinctly American values, patients will probably help hold down costs.

The final step is the bluntest. It involves changing the economics of medicine, to reward better care rather than simply more care. Health reform doesn’t go nearly far enough on this score, but it is a start.

The tax subsidies for health insurance will shrink, which should help people realize medical care is not free. And doctors who provide good, less expensive care won’t be financially punished as often as they now are.

None of these steps will allow us to avoid the wrenching debates that are an inevitable part of health policy. Eventually, we may well have to decide against paying for expensive treatments with only modest benefits. But given how difficult that would be for this country, it makes sense to start with the easier situations —
the ones in which ‘no’ really is the best answer for patients.

Space will only allow a summary of William Ury’s wise words on this topic. He outlines, “The Three Great Gifts of a Positive No”:

According to the sages of ancient India, there are three fundamental processes at work in the universe: creation, preservation, and transformation. Saying No is essential to all three processes. If you can learn to say No skillfully and wisely, you can create what you want, protect what you value, and change what doesn’t work. These are the three great gifts of a Positive No.

We welcome your comments on this topic.