How can I say no?

Doctors aren’t there to please

Chris Tiplady, consultant haematologist, Northumbria Healthcare NHS Foundation Trust, says, “You cannot and should not say yes to every request for treatment, tests, or your time. It can be harmful, wasteful, inappropriate—or even illegal. A relationship based on information, openness, trust, understanding, and self-awareness should help when it comes to those difficult occasions when you have to say no to your patients.

“‘No’ is one of those short, primal words from very early in language development. When said, it’s invariably accompanied by obvious, often unconscious, changes in your body language and tone. If that denial is unexpected, questionable, or delivered in a paternalistic way we should not be surprised by the similarly primitive emotions like anger and sadness such a word provokes. The doctor-patient relationship is too important to risk, it must be protected. You will have to say no at some point, and there are steps you can take to reduce the unpleasantness of refusal.

“The relationship you have with patients is key to the delivery of ‘no.’ It’s a relationship that should expect questions and disagreement at times. You are not there to please, you are not your patient’s parent, rescuer, or friend. You are their doctor, that is the basis of your relationship.

“Be friendly, have no favourites, and owe no favours. Be thorough, be kind, and explain everything. Say why, say how, say when, and only make promises you can keep. Answer every question and explain every option. Discuss the what-ifs, the maybes, and the ‘what happens if we don’ts’. Be aware of your tone and your body language.

“That way, when it comes to saying no, it won’t be a surprise, it won’t seem illogical, and you won’t sound like a bad tempered parent.”

Respectfully explain why

Emmeline Lagunes Cordoba, specialty doctor in general adult psychiatry, says, “Learning how to say no is an essential part of any child’s psychological development, as it helps develop independence, autonomy, self-awareness, and boundary setting—all skills needed to practise medicine in a safe and effective way.

“Many adults, however, seem to struggle with the simple act of saying no—because of social pressure, fear of being disliked, a lack of confidence, or simply because they think it’s not allowed.

“Our safety, health, and wellbeing need to be considered when agreeing to a request we know we need, or want, to say no to. For example, saying no to an extra shift when we’re tired and sleep deprived. We might struggle to refuse such a request because we feel guilty that no one else will be able to cover, but it could put not only patients at risk, but also our wellbeing and even our careers.

“So, how can we say no? Well, by explaining the reasons we’re saying it, explaining the implications, suggesting alternative solutions, and sometimes just by acknowledging people’s frustration or disappointment with our response. If we tell managers we are not taking an extra shift because we feel it would be unsafe, we shouldn’t worry about being seen as a bad team player.

“Explaining to a patient the potential side effects of a drug or procedure they’re requesting, and acknowledging their frustration while exploring concerns and offering other options, should not make us feel guilty. In fact, quite the opposite—it should help us develop better relationships with our patients, because they will be able to understand why we are saying no to their request.

“Human relationships are complex, but the best way to deal with complex situations is with communication and respect. The best way to say no to any request is by respectfully explaining the reasons we are saying no.”

It can be tempting to try to please everyone

Rosie Connell, specialty doctor in anaesthetics at Dorset County Hospital, says, “In many cultures saying a direct ‘no’ is considered impolite and it can feel so in NHS culture. Good communication, understanding, and empathy can lessen this blow and enable us to maintain clinical and professional balance.

“Saying no as a doctor can be difficult. Many are attracted to a medical career because of an innate desire to help others, and so it can feel awkward and even confrontational when we have to decline requests for help. Many of us have perfectionist traits, and it can be tempting to try to please everyone when starting in a new post or hospital in order to make a good impression.

“As a foundation doctor I often found ward cover duties overwhelming. Taking the time to explore concerns and expectations when receiving requests helped me triage jobs and understand expectations. It was usually easier to say no once problems had been explored and the staff contacting me for help had felt listened to and understood.

“Signposting and delegating the request to other appropriate services meant I could say no to taking on the task, but could still offer a way forward. As with much of healthcare, communication and mutual understanding are key and can smooth a negative response from obstructive to constructive.

“Medicine can be a hugely rewarding lifetime career, but also a greedy one in terms of one’s own time and emotional resources. The NHS is constantly stretched to do more work with fewer resources and staff are no exception. Requests for overtime or increased duties can reach a point where they feel overwhelming, with a danger of them impacting on general wellness or life outside of medicine. Finding ways to decline and maintain your own boundaries is key to maintaining a healthy work-life balance.

Will it change what the other person thinks of you?

Mat Daniel, paediatric otorhinolaryngology and career development and leadership coaching, says, “Pausing before you answer is a great tip—use this pause to uncover the reasons saying no is so difficult. Broadly speaking, there are two common reasons. The first is our need for approval: we need and want to be liked. In the workplace, we worry that colleagues won’t like us, that they will think we are not team players, or that they will write a bad placement report. This is about your needs versus the needs of others.

“The second is our need to be in control. Many of us want to make sure that things are done the ‘right’ way. We may also want to know what’s going on. Saying no means no longer knowing everything that’s happening.

“When it comes to needing approval, ask yourself if saying no will really change what the person asking thinks of you. Maybe you have a relationship that will withstand a no? Do you need this person’s approval at all? Are you saying yes because your self-worth comes from how others see you rather than from how you see yourself?

“When it comes to needing to be in control, ask yourself if you really need to know everything. Perhaps you should trust others to do a good job—it could help them develop. If saying yes will offer an opportunity for you to shine, ask yourself if you need it and whether it aligns with your overall career direction?

“Understanding what exactly makes saying no difficult is an important step to actually saying no. Remember that yes and no are two sides of the same coin—when you say yes to one thing, you are saying no to another.”