Saying No to Patients

Dealing with difficult patients | Facial Aesthetics Mentoring by Julie Scott

As aesthetic practitioners, we’re often lauded for our contributions to building the self-esteem of our patients. Yet, there’s an aspect of our work that is an even more crucial part of our toolkit and that is the ability to say “No”. After three decades in aesthetics, I’ve learned that this decision is just as important as any procedure we perform. It’s deeply rooted in our commitment to our patient’s health and the ethical pillars that have held up my practice through the years. Saying “No” is not a sign of limitation but a mark of professional maturity and understanding.

In my practice, the decision to forgo treatment is a multifaceted judgment call, it’s never just about saying “No”; it’s about recognising when a patient, perhaps reeling from recent emotional trauma, needs space to heal beyond the skin, seeking enhancements for their self-esteem, not because of a partner’s wish or societal nudges. It’s about ensuring there’s mutual trust, that we’re on the same page, and if not, having the wisdom to step back. I respect the limits of my expertise, and if any treatment is beyond my scope of practice, I’ll guide the patient to someone within my referral network who can help, because patient welfare trumps all. And when the scales tip, where the risks outweigh the benefits, or I sense hesitation in their eyes, I trust my medical instincts to put my patient’s health and wellbeing first. Whether it’s clinical indications, managing expectations, or addressing mental well-being issues like body dysmorphia, each ‘No’ comes from a place of professional care and responsibility.

Understanding the Weight of ‘No’ in Aesthetic Decisions

The complexity of refusing a patient lies in the confluence of our professional aspirations and our human instincts. As practitioners, we are innately driven by a desire to heal, to enhance, and to bring joy through our work. This inherent urge makes the word “No” feel like a contradiction to our very purpose.

Why, then, does it often twist in our gut? It’s because our profession is not just about providing a service; it’s about cultivating well-being. When patients come to us, often after extensive research or following our practices on social media, they come with a trust that we’re the ones who can fulfil their expectations. To turn them away feels like a breach of an unspoken promise, a denial of the help and support we’re trained and inclined to give.

The difficulty is magnified in the intimate setting of my consultation room, where the dynamic shifts to a personal interaction—no longer just a practitioner and a patient, but two people sharing a space of vulnerability. Here, the decision to say “No” becomes singularly ours, a solitary verdict where we must balance empathy with ethical practice. 

To mentally manage these difficult decisions, practitioners must often reflect deeply on the ethics and care that guide us. This inner reflection helps reconcile the dissonance between our desire to help and the need to decline. Building a network of peers for support, participating in professional discussions, and seeking mentorship can significantly bolster our psychological resilience and affirm our choices.

This moment of refusal can be particularly anxiety-inducing for practitioners in the early stages of their careers. They may not yet have the breadth of experience to fall back on, and each “No” can feel like an insurmountable hurdle. For those who’ve learnt how to say “No”, the challenge, while still present, may be less daunting. It’s a learned art—recognising that “No” is not a negation but a necessary part of patient care.

Managing Expectations and Maintaining Integrity of Care

The GMC1, NMC2, and GDC3 all converge on a core directive: healthcare professionals must place patient care at the forefront, prioritising safety, needs, and interests, while fostering a practice rooted in consent, efficacy, and trust. 

We must also acknowledge the reality that relationships with patients often begin long before they step into our clinics. Patients arrive with expectations fuelled by the successes they’ve seen us showcase online. This adds a layer of complexity to our interactions, where the decision to decline a request isn’t just clinical—it’s personal.

In these moments, we must draw on our deepest reserves of professionalism and compassion. We find ourselves explaining, educating, and sometimes comforting—because even when we can’t say “Yes,” we still have a responsibility to leave our patients feeling cared for and understood. This is the essence of why saying “No” is so difficult—it’s a direct confrontation with our instinct to serve, a balancing act between the duty to our patient’s well-being and the boundaries of what is safe, reasonable, and in their best interest.

Saying “No” to a patient is, undeniably, one of the most complex aspects of our practice, it’s a delicate balance of judgment, where sometimes the steps aren’t as clear-cut as we’d like. There are instances where practitioners, perhaps out of a desire to please or due to the persuasive nature of a patient, may bypass their better judgment. They might proceed with a treatment that their instincts – whisper against treating. This isn’t the ideal choice, but it’s an understandable human response to a challenging situation. It’s the art of saying “No” that we must refine.

Patients can indeed be compelling, showering compliments or expressing a deep trust that can make it harder for practitioners to hold their ground. This can be especially true when there is a financial component involved. After a patient has paid for a consultation, the decision to then decline the treatment can leave a practitioner feeling uncomfortable. In such cases, whether to issue a refund depends on the situation. If the patient isn’t clinically indicated for the treatment, a refund could be appropriate. However, given that consultations involve valuable professional advice, refunds are not always warranted and I feel it should be left to the practitioner’s discretion.

Another layer of this complexity is the self-doubt that may creep into a practitioner’s mind. Will the patient think I’m incapable or lacking in skill because I’ve said “No”? This doubt can be a significant hurdle. It’s important to remember that our primary role is to ensure the safety and appropriate care of our patients, even if that means turning down a procedure.

For those who have transitioned from the NHS, where the focus is squarely on delivering care, the shift to aesthetics, where services are sought and chosen, can be stark. Here, in aesthetics, we navigate a different kind of patient-practitioner relationship, one where the choices aren’t always as clear, and the decisions often rest heavily on our shoulders. But it’s these moments that truly test – and ultimately showcase – the integrity of our practice and the depth of our commitment to patient welfare.

Communicating ‘No’ with Compassion

Refining the ability to say “No” in a manner that is both compassionate and professional is a vital skill to hone. The tools we use are linguistic and empathetic, designed to maintain the dignity and respect of the patient-practitioner relationship. It’s about framing our responses in a way that conveys understanding and care. Starting sentences with “Sadly, I can’t move forward with this…” or “I wish I were able to…” indicates that while the willingness to help is there, the decision is governed by larger considerations of safety and appropriateness.

When alternatives are available, guiding the conversation towards those is another tool. “While I can’t endorse this particular treatment, I believe there are other avenues we can explore…” This approach not only softens the “No” but also opens a pathway to “Yes” for more suitable treatments, balancing the patient’s wishes with what is clinically indicated. For example, when further dermal fillers are sought, and the request goes beyond what might harmonise the patient’s natural features, I advocate for a less is more philosophy. This mindful approach helps address unspoken concerns like perception drift without overtly naming it. It’s a delicate conversation, that, when navigated with sensitivity, often leads to the patient being receptive to a different treatment approach that enhances their inherent beauty.

For patients struggling with mental health concerns or unrealistic expectations, the tool of redirection is essential. “It seems we’ve reached a point where we should pause and reassess your goals…” or “I’m here to support you, and part of that support is ensuring we don’t take steps that might not benefit you in the long run.” In my clinic, I ensure I have appropriate referral pathways for such circumstances, demonstrating that we are looking out for the patient’s broader well-being, not just the immediate gratification of treatment. These statements and actions show a commitment to holistic care which prioritises long-term health.

Each of these tools – careful language, rational explanation, exploration of alternatives, redirection, and positive framing – are facets of the art of saying “No.” They allow you to stand firm in your professional integrity while ensuring the patient feels seen, heard, and respected. When faced with a negative reaction to such a refusal, practitioners can maintain this integrity by remaining calm, listening actively to the patient’s concerns, and reiterating the rationale with empathy and patience. It’s about providing a space for patients to express their disappointment or frustration, while gently guiding the conversation back to the patient-centred reasoning behind the decision.

Cultivating Trust: The True Value of Patient-Centred Decisions

Saying no can be an incredibly powerful thing. I once had a beautiful young patient who came to me seeking multiple treatments to align with a beauty standard she felt pressured to meet. She believed these changes were essential. However, through the course of our hour-long consultation—a crucial practice in my clinic to ensure comprehensive understanding and patient care—we delved into the heart of her perceptions and desires. This dedicated time was critical, it allowed me to understand her motivations and needs. The length of this consultation underscores its importance, offering a space for both patient and practitioner to assess the most appropriate treatment course.

In that hour, our conversation shifted from procedures to perception resulting in a newfound confidence and reassurance in her own skin, allowing her to see her natural beauty through a new lens. We then embarked on a different kind of journey—one that didn’t involve needles, instead I created a personalised skincare plan, tailored specifically to enhance her natural skin health. As a result of our consultation, she left a glowing review, capturing her renewed self-image and gratitude. She didn’t just become a satisfied patient; she turned into a passionate advocate, referring friends to my clinic, further affirming the power of a thoughtful, personalised approach to patient care.

This moment encapsulates the positive side of a well-considered “No.” It’s about more than refusal; it’s about affirming the inherent value in each individual who steps into our clinics. When patients understand that our advice is rooted in their best interests rather than the clinic’s revenue, trust is deepened. A “No” can become the foundation of a stronger, more honest relationship. It’s a testament to the practitioner’s integrity and dedication to the true well-being of our patients. 

In the landscape of aesthetics, where enhancement meets ethics, the strength to say “No” is as vital as the skill of injecting. Over the years, I’ve learned that these moments of refusal, though often fraught with complexity, are also filled with the potential for growth and understanding. A considered “No” can be the most affirmative response we give, guiding our patients towards a beauty that’s more than skin deep. It’s in these choices that we find the core of our practice—not just in the treatments we provide, but in the well-being and confidence that we foster. I’m reminded that the truest form of care sometimes lies not in what we add, but in what we hold back, knowing that integrity and kindness are the greatest enhancements we offer.

Originally published in https://aestheticsjournal.com/journal/the-aesthetics-journal-june-2024/ 

References

    https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/good-medical-practice

    https://www.nmc.org.uk/standards/code/

    https://www.gdc-uk.org/standards-guidance/standards-and-guidance

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