Physicians sometimes have to say no to patient requests. Often, the “No” with an explanation suffices. The patient gets it. They understand. They’re not angry. In fact, they may be appreciative.
But not always.
Sometimes “No” is followed by denial, anger, bargaining, depression, etc. Sound familiar?
How one says “No” matters as much as what is said.
An angry patient may go ballistic on the internet. They may file a complaint to the Board of Medicine. Or file a lawsuit in small claims court.
One useful strategy is to substitute the phrase “No, because…” with “Yes, if…”
You are not saying “No, no matter what.” You are qualifying what it might take to get to a yes, even if that yes is a heavy – or almost impossible – lift.
Let’s illustrate.
Say you are an aesthetic surgeon. The patient has a cosmetic issue well within your skill set to resolve. But they reveal they have a strong psychiatric history. Or they have recent life stressors that make near-term surgery unwise. Instead of saying “No surgery for you because you have a psychiatric history”, you might try this. “Surgery can cause a number of new stresses. I’m willing to perform the surgery if you are cleared by your treating psychiatrist/psychologist. I’ll need to be authorized to speak with your psychiatrist/psychologist. Does that seem reasonable?”
You’ve committed to nothing. And you may soon get an ally to solve the underlying dilemma.
A soft no.
Another example.
“Doc, I’m ready for surgery.” You may be less than enthused to perform surgery on this person.
“Sounds good. My surgical schedule is filled for this procedure for the next 6 months. If you’d like to be evaluated and treated sooner, I can recommend X, Y, or Z. That way you won’t have to wait or be exposed to new pricing.”
Kicking the can down the road may, of course, create a new problem in 6 months. But it may buy sufficient time for the problem to go elsewhere or dissipate.
Anyway, pay attention to language – and the different feelings evoked by “No, because” versus “Yes, if.” As Maya Angelou once wrote, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
What do you think?
I disagree with “You’ve committed to nothing”.
You are committing to doing the surgery if the psychiatrist clears the patient to have it.
The better approach is to suggest that if the psychiatric condition fully resolves in the future, then you might consider doing the surgery.
You could then suggest that patients with xyz psychiatric condition do not have the great results the are expected. As a result you do not do surgery on patients with xyz psychiatric conditions.
There was another approach that my close friend (now departed), ENT surgeon used with Jehovah’s witnesses. They would come in with the standard request to not have any blood products. My friend told them that he understood and accepted their request. However, since the surgical procedure might require a blood transfusion to save their life, his religious beliefs prevented him from letting a patient die during surgery from blood loss, when their life could be saved with a blood transfusion. The Jehovah’s witness patients appreciated that he was understanding of their beliefs, but they also understood and accepted, that the surgeon had his own religious beliefs. As a result, they went elsewhere. Now admittedly this was 35 years ago. There are more and more minimally invasive procedures, and blood less has become less and less over time. Example, prostate resection. In the old days a Suprapubic prostatectomy was routinely going to lose 6 units of blood. A retro pubic prostatectomy was routinely going to lose 4 units of blood. Laparoscopic robotic surgery has turned these cases into no blood loss cases.
A simple “I don’t think I’m able to do that surgery. It’s outside of my skill set. Let me refer you to Dr. Jones.” would seem to suffice. Then it’s no longer your problem.
There are other reasons besides overtly psychiatric ones to refuse to do surgery. It’s become pretty well established that smokers have much higher complication rates for endovascular treatment of both unruptured brain aneurysms and for recovering from a subarachnoid hemorrhage–treated or not. For that reason, I refused to treat patients with unruptured aneurysms until and unless they stopped smoking for a month and promised not to start smoking again. I explained the reasons and offered to refer them to a colleague if they wanted to be treated without modifying their smoking habits.
Responses were mixed in terms of what they chose to do, but no one argued or tried to game my rules. And not even one asked for a referral. A couple refused to stop smoking. One of those got as far as being outside my angio suite. I asked him whether he had stopped smoking. He politely answered that he had not. Had, in fact, smoked that morning. I reminded him what the rules were and sent him back to get dressed and leave. Never saw him again.
Another case was that of a woman who came in with a friend. The patient said that she’d stop. Her friend said that she wouldn’t. Didn’t see her again either.
Yet another was a woman who did stop, got treated, and started up again later. Obviously a physician can’t follow a patient around after treating them, nor would it be appropriate to try to do that. But she was honest and later told me that she had resumed the habit. But she had no complication from me treating her lesion.