CPD Article: How to Say No
A practitioner’s guide to the art of saying no by Julie Scott, RGN NIP PGDip(Aes)
Introduction
Sleepless nights worrying about dissatisfied, disappointed patients – their unrealistic expectations; manipulative behaviour; the threat they might leave a negative review; the worst-case scenario that they might experience a complication. These are all real concerns we face as practitioners, all things that could happen if we say yes when we should have said no. By developing the skills to know when a patient needs to hear ‘no’ and to deliver it with care, we can prioritise patient safety and well-being in every decision whilst concurrently protecting ourselves.
Saying no is not a simple refusal to treat. Instead, saying no should be viewed as an art which requires empathy and clear communication, underlined with respect and professionalism. This is a challenging feat, as an amalgamation of challenges make saying no a difficult conversation to have. Ultimately, everything boils down to safety versus satisfaction in a manifestation of carefully balancing meeting patients’ wants and needs whilst always putting safety first.
Patients who need to hear “no”
Though it is tough, the importance of saying no cannot be understated. Rooted in ethical responsibility and patient care, it builds trust and protects patient health. While it can at first feel as though you are letting your patient down, saying no is an essential component in maintaining the integrity of care and demonstrates professional maturity. Still, it is vital to have a solid understanding of when you should consider saying no, so let us dive into some examples.
1. Patient selection
Patient care starts before treatment. Keep an eye out for patients who arrive at their consultation full of unrealistic expectations and misinformation, perhaps cultivated from social media, as well as patients who are seeking unnatural results. These can all be indicators for a high-risk patient who may be chasing extreme or damaging outcomes they have identified from unqualified sources.
2. Mental health concerns
It can be difficult to distinguish between normal dissatisfaction and mental health disorders in patients who focus on minor flaws and experience a sense of emotional distress from their appearance. However, it is crucial to remember that as aesthetic healthcare professionals it is not our job to diagnose. Instead, take these signs into account when deciding if treatment could deepen the patient’s obsession and increase their distress before going ahead with treatment.
3. Medical contraindications
Any health conditions which may increase the risk of procedures, ranging from issues like clotting disorders which may lead to serious complications, to active infections which could worsen with treatment, should be acknowledged and reflected in the patient’s treatment plan. If in doubt, always get clearance from a GP or consultant.
4. Practitioner-shopping patients
Patients who hop between different clinics are likely to prioritise cost over quality and safety, often making misguided decisions and setting unrealistic goals. As a result, they are likely to be dissatisfied with the outcome of their treatment. This approach to aesthetic treatments neither benefits the patient nor the practitioner.
5. Gut feeling
Sometimes our instincts may flag that something about a patient is somehow off; it is important that as practitioners we give importance to that feeling. Overly demanding patients are prime candidates for dissatisfaction, while over-anxious patients or those suffering from depression may complicate their treatment and recovery, while narcissistic patients’ unrealistic expectations are often backed up with a lack of empathy. As a practitioner, you have the discretion to not treat anyone who undermines your trust and communication and should exercise this when necessary.
While the patient is selecting you by choosing to book with your clinic, how far down the patient journey you take the patient remains under your control. For example, at consultation you can tailor their treatment plan to their unique circumstances and desires to foster mutual trust and understanding. The subsequent cool-off period then serves you and the patient, giving both parties time to identify any concerns and reflect on possible risks.
How to say no
The pressure to say yes can feel omnipresent - patients have an expectation that the practitioner will want to treat them and a general desire to please can make it difficult to say no out of concern for losing the patient or your reputation. In order to overcome these challenges, it is critical to acknowledge the limit of care you can offer.
You can set the tone for saying no before the patient even arrives at your clinic. Generating a balanced online presence in which you manage reviews and expectations while staying true to ethical principles helps your patients develop realistic goals during the research stage of their journey.
To avoid being coerced in a situation where saying no is the right option, trust that gut feeling and your judgement to set boundaries which prioritise ethics. Confidence is key, but it can also be hard to hold onto. If a patient has wants and needs which are especially difficult to balance, reach out to your peers for support. The weight of saying no is heavy; as we try to balance our professional aspirations with our human instincts we open up vulnerable conversations, taking on the emotional impact for both patient and practitioner. This responsibility in going beyond simply refusing treatment and extending compassion towards our patients is part of our role - the ability to maintain trust through honest and clear decision making. Seeking advice from experienced colleagues on how to handle ethical dilemmas in aesthetic practice and participating in professional forums to exchange insights on maintaining ethical standards in patient care are both valuable tools for adjusting to this responsibility.
The key to overcoming fear of disappointing patients is recognising that your ‘no’ is an act of care. These ethical decisions enhance your professional growth and credibility and, in my experience, each conversation that ends in a ‘no’ is one step towards becoming more confident and comfortable with the word. Delivering this message clear and compassionately is the key to a productive conversation where your patients leave feeling seen and understood.
Below is my protocol for saying no to patients. These steps are designed to fully address your patients’ needs, whilst also serving as your path out of the woods:
- Acknowledge their reaction
- Listen to their story
- Show empathy
- Explore their expectations
- Offer them next steps
- Thank them for sharing
Employing language which centers your patients is a subtle yet effective way to demonstrate that their safety and satisfaction is your priority. For example, at consultation instead of addressing step one by observing “I can see you are not happy”, combine step one and two in inviting them to open up with “Tell me what upsets you”. These open-ended requests should encourage your patient to elaborate in a way which provides more insight on their personality; in addition, it suggests that you wish to listen, subsequently making them feel heard. Once I reach step five, to offer a path forward while managing their expectations I do not ask my patients what they believe I can do, but instead explain what I can offer them. The final step, thanking them for sharing, brings the conversation back to them and ensures we make the decision together. This promotes autonomy in decision making and reinforces our expertise as healthcare practitioners without patronising our patients.
Conclusion
Whether we do or do not treat a patient, it is vital that they leave feeling understood in themselves and with an understanding of the care which we as medical aesthetic practitioners are able to provide. A conversation between patient and practitioner should not fill the patient’s cup with tea leaves, from which the future can be murkily extrapolated, but with warm, restorative tea that provides knowledge and a refreshed connection to a patient journey which serves their best interests.
Trust is inextricable to successfully saying no, so practice compassion, develop empathy, and listen with nothing but the intent to listen. Like an owl, guided through the night by their sharp vision and quiet wisdom, trust your instincts. You may see what others have missed and lead yourself to the right decisions.
