Leadership & professional development: Strategies to disagree productively: Persuasive DISNT

Dissents speak to a future age. It's not simply to say, “My colleagues are wrong, and I would do it this way.” … the dissenter's hope: that they are writing not for today, but for tomorrow. As hospitalists, we often have experiences and insights that can improve how decisions are made within healthcare organizations. In expressing these perspectives, we may need to disagree. However, dissent is not always well-received as people crave validation, a predictable environment, and the ability to move quickly toward goals.1 Our failure to disagree effectively can be harmful, not only to our patients and systems but also to our own motivation and relationships. To maximize your success as a leader, dissent should be used with forethought and implemented strategically. We have developed a framework for disagreeing productively, DISNT, adapted from the literature and refined for clinicians. Dissent is important, and its delivery is key to making it effective. The first step in dissenting effectively is determining the value of disagreement. We calculate this using the same value equation we use in medicine: outcomes over cost. When the urge to dissent arises, begin by considering the expected positive outcomes as a result of your disagreement. Will speaking up change the outcome? What is the magnitude of this impact? There are also costs. What is the risk to your social capital? How may the group's decision-making process be disrupted by this dissent? Only if the positive outcomes outweigh the costs should you proceed. It is essential to demonstrate that your disagreement is grounded in your desire to impact shared aims by illustrating your commitment to the group and to the goals of the organization.2 Next, you can turn your attention to highlighting the logic and rationale behind your dissent. The most effective leaders we have observed have developed the habit of structuring arguments that are simple and include supporting evidence. These leaders quickly earn an audience's trust by anticipating their questions and having answers ready, and even more impactfully, show how their own view has evolved over time in response to new information. Negotiating partnerships involves enlisting amplifiers, people who generally agree with your point of view, and engaging your opposition, those who have a different opinion about the best course of action. In this step, premeeting is particularly useful.2 When meeting with allies, ensure that you are correct in understanding their support and seek to strategically employ them to advance your ideas. An example might be, “I'm happy to raise the concern. Might you be willing to support me by sharing your perspective during the meeting?” When meeting with opponents, rather than challenging them head on, seek to understand their perspective and, counterintuitively, consider asking for their advice. For instance, you could say, “This is an important topic. I'm curious to hear what people who disagree with me think about this issue.”3 Remember that you are dissenting because you want to solve the problem more than you want to be proven right. Finally, if your dissent proves successful, anticipate that you may not receive overt credit for the redirection. Resist the urge to say, “I told you so.” Instead, transform your success into future impact by leveraging the goodwill and social capital you have gained through effectively promoting change in your group. Disagreement is inevitable and can be challenging, but done correctly, dissent can improve decision-making and ultimately amplify our impact as clinicians and leaders. The authors declare no conflict of interest.