AMA Journal of Ethics^®

Case

A pharmaceutical company representative drops off samples at Dr. Mann's office about every 2 weeks. Dr. Mann uses the samples and wants to keep receiving them. The rep always asks to talk with Dr. Mann in person and lingers in the office until Dr. Mann makes time between patients to shake hands and chat for a few minutes. Dr. Mann wants the drug company rep to know that he does not want to talk with him each time he visits; the rep's lingering presence in the office is, at best, distracting and, at worst, annoying to the staff and reduces the time Dr. Mann has to spend with patients.

Commentary

This scenario is not uncommon. In a study regarding physicians' perceptions of the pharmaceutical industry, almost 40 percent of the physicians indicated that they found pharmaceutical reps too pushy and aggressive.¹ The key question in this case is how Dr. Mann should confront the rep about his behavior. We first focus on how Dr. Mann should prepare for the confrontation and then we discuss how he should carry it out.

Preparation

After observing an inappropriate behavior, individuals often begin by thinking about how to confront the other party. Those who engage in preconfrontation planning report a number of benefits including that they are better able to fluently present their position, stay in emotional control, and respond to the transgressor's statements than are those who do not rehearse.² When planning how to confront the drug rep, Dr. Mann must focus on how to achieve 2 interaction goals. First, he must express his concerns clearly and efficiently, and second, he must do so in a socially appropriate manner.³ Unfortunately, the manner in which he tries to achieve 1 goal may reduce the likelihood that he will accomplish the other. Efficiency is often achieved by speaking directly to the issue at hand. Dr. Mann may speak with certainty about his perspective on the rep's behavior and tell him to stop. Such behavior achieves clarity but appears to attack the transgressor's image and therefore is perceived to be socially inappropriate. Indeed, confrontations often lead to destructive argument cycles wherein one person demands that the other change, and the other stonewalls by becoming nonresponsive, or one person's complaints prompt the other to counter-complain.⁴ The net result of such cycles is that no agreement is reached and relationships are damaged. Therefore, to avoid a negative cycle, Dr. Mann needs to think about efficiency and social appropriateness when preparing an opening line and constructing arguments.

Opening Line

What Dr. Mann initially says to the rep can set the tone for the remainder of the confrontation. Research indicates that Dr. Mann will be most effective if he follows 5 rules:

1. He should begin the conversation by being assertive, but not accusatory. Assertive language takes the form of "I" statements that indicate that Dr. Mann takes responsibility for his views or feelings about the situation (eg, "I am falling behind in my appointments.") whereas accusatory language is expressed through "you" statements wherein he blames or demeans the rep (eg, "You are causing me to fall behind in my appointments."). Confrontations that begin with "you" statements cause others to feel greater anger, defiance, irritation and alienation, and less sympathy than do "I" statements.⁵

2. Dr. Mann should be willing to share responsibility for the problem (eg, "We have been meeting too much.") rather than shifting the responsibility solely onto the rep. (eg, "You have been meeting with me too much.") Statements in which the speaker expresses shared responsibility with another are viewed as more effective and socially appropriate than are those that attach all of the blame to the other.⁶

3. Dr. Mann should avoid using strong emotional descriptions (eg, "You are really making me angry.") to describe how he feels about the rep's behavior. Research indicates that the use of the term "anger" in an opening line causes another to feel greater anger and defiance than simply stating that one feels distressed.⁵

4. Dr. Mann should clearly indicate in his opening statement (a) the problematic behavior, (b) the consequences of the behavior, and (c) his feelings about it (eg, "Our meetings are distracting me from meeting with patients, and that bothers me."). These 3 statements capture the core of Dr. Mann's concerns, and research shows that including all 3 make another more open to the complaint and willing to change.⁷

5. Finally, Dr. Mann should be empathic (eg, "I know you are trying to provide me with updated information about your products, but our meetings are getting in the way of helping my patients."). Often others have a legitimate reason for their behavior and expressing concern for that viewpoint leads to a less negative view of the confronter.⁸

Having described some guidelines, how should Dr. Mann initiate the confrontation? Here is an example: "I have been meaning to talk to you about a problem I have in my office that you can help me resolve. Lately, my staff and I have had difficulty getting through our scheduled patient visits and this really bothers me. So many other meetings are happening during the day, it is hard for us to efficiently give our patients the attention they need. For the sake of our patients, I must do something to insure time for their appointments. Although our meetings are often helpful, we can't meet each time you stop by the office. Even our brief conversations throw off the schedule. I would be grateful if from now on you check with my receptionist about our appointment schedule and whether there is available time for us to talk. If we are completely booked, then we won't be able to meet—even for a short time. I have to get the office back on schedule."

Notice that the statement clearly identifies the problem, consequences, and solution. It does not hold the rep personally responsible for the problem and indicates that, at certain times, such meetings are appropriate and enjoyable.

Constructing Arguments

A confrontation typically does not end with the opening statement and sometimes the other person chooses to argue the point. Hence, Dr. Mann needs to anticipate possible replies and to prepare responses that acknowledge the rep's point of view while maintaining Dr. Mann's initial stance.

Based on research on confrontations, here are potential responses from the rep with possible replies.⁹

1. The drug rep may indicate that he had no idea that his visits were disruptive and that he did not intend that to be the case.
   Dr. Mann's reply: "I know that you did not mean to create this problem and by checking ahead, we can prevent it from occurring in the future."
2. The rep may attempt to justify his frequent contact by noting the importance of passing along new information about products.
   Dr. Mann's reply: "You are a valuable resource to me and I appreciate that. Many of our discussions, however, have little to do with medicine and we cannot afford to continue them."
3. The rep may attempt to minimize the problem by noting that he only "pops in to say hello for a little while."
   Dr. Mann's reply: "Most of our conversations start that way but more often than not, we talk for much longer."
4. The rep may try to deflect personal responsibility by explaining that such contacts are encouraged by his supervisor and that to keep his job, he must do them.
   Dr. Mann's reply: "I understand that you have a job to do but you would have more of my attention if we talked at more appropriate times."
5. The rep could try to "turn the tables" by either chastising Dr. Mann for not raising this issue sooner or by insisting that Dr. Mann encouraged such visits. This is the most difficult since the rep is now blaming Dr. Mann. In such a case.
   Dr. Mann's reply: "I enjoyed our discussions and I saw no reason to raise this issue until they became a problem. Now they are and we must do something about them."

When anticipating reactions and preparing responses, Dr. Mann should create clusters of arguments that can be used flexibly once the conversation begins rather than articulated in a scripted sequence.¹⁰ In other words, he should not prepare as though he will say "x," the rep will respond with "y," and then he will counter with "z." Confrontations are rarely that predictable. It is better to prepare for a variety of sequences.

Confronting

Research suggests that Dr. Mann should be mindful of a number of things as he approached the conversation with the drug rep. First, he should avoid negative start-ups. Often individuals will initiate a confrontation when they are angry, which increases the likelihood that they will be too forceful, causing the other person to feel under assault and prompting defensive behavior.¹¹ Hence, he should avoid initiating this discussion on days when he is stressed or when the rep's behavior has been especially annoying. Second, once the discussion begins, it is important for Dr. Mann to stay in emotional control. That means he should avoid reciprocating the other person's negative emotional behavior and, instead, enact behaviors to help assuage the person's negative emotional reactions.¹² For example, if the rep raises his voice, Dr. Mann should continue to discuss the issue in a calm tone. Third, Dr. Mann must manage the process. Indicate to the rep when the conversation is getting out of hand and suggest more appropriate approaches to discussing the problem.¹³ "We aren't getting anywhere by arguing. Let's stop, think about some solutions and meet later to discuss them." Finally, stay focused on finding a mutually acceptable solution rather than on parsing blame for the problem. For example, "We aren't getting anywhere by blaming each other. We both want to help patients and I think we can find a way to do our jobs so that can happen. I am willing to listen to your solutions." Blaming is a destructive sequence whereas finding a solution is constructive.¹⁴

Clearly, confrontations are risky endeavors, but when done skillfully they can effectively prevent or stop problematic behavior.