The art of saying no: Doctors need to learn how

People always are lobbying for a physician's time, from the patient who brings a long list of questions to an appointment to the practice manager who wants to discuss new office protocols. With all of the requests, it's a wonder a doctor can stay even remotely close to a planned schedule.

Those who can stay on task typically trace their success to saying one thing: No.

While saying no can carry a negative connotation, there's an art to it that can save your productivity while preserving your relationships. When time is money, there has to be a recognition of priorities and a balance between what's immediately in front of you and what's to come down the line, physicians said.

Saying no "is not a skill that you get taught in medical school," said internist and palliative care specialist Gail Gazelle, MD, president of Palliative Care Associates P.C. in Boston and assistant clinical professor at Harvard Medical School. "Demands are enormous and ever-increasing. To get through your day, you have to be able to say no firmly but kindly."

Obviously, emergency situations call for an immediate response. But it's the nonemergency issues that can affect your schedule or force you to make decisions that could appear unpopular to the recipients of your message.

Style points count when you have to say no because you don't want that person -- whether it's a patient, staff member or pharmaceutical sales representative -- to feel alienated by your response. While some doctors might say it's impossible not to alienate people by refusing their request, the consequences of not saying no could be dangerous as well.

For example, the physician who chooses to address each issue as it comes up, vital or not, runs the risk of fracturing his or her efficiency and making a patient who actually has an important issue wait much longer than expected for an appointment.

Or, by constantly saying yes, you could test your patience by listening to mundane requests when you know you should be moving on to other tasks. The growing irritation could manifest in one outburst of emotion as you finally decide you have had enough.

A change in mind-set

While these are hypothetical situations, consultants said they highlight the need for both time management skills and a commitment to your priorities. Joseph Grenny, an organizational development consultant in Provo, Utah, and co-author of the book Crucial Conversations: Tools for Talking When Stakes are High, suggests a step-by-step approach to reviewing requests that starts with changing your mind-set.

"We don't want to disappoint, so in our minds we start conjuring images of bad things that will happen when we say no," Grenny said. "You need to know the risk of saying no and not saying no."

Realizing those risks requires weighing issues rationally and trying to see the possible consequences of your decision. If you decide you need to say no, you first should "acknowledge that you do value and affirm" that person's motives and needs, Grenny said. Then, you should share the competing need, he said.

"You shouldn't say, 'Can't do that, bye,' " Grenny said. "If you share what you need to say yes to while affirming their needs, they may not be happy, but they'll understand."

The problem is many physicians don't go into that level of detail, consultants said. Instead, they will resort to nonverbal cues such as getting up and putting a hand on a doorknob as a patient appointment winds down, or walking away from a staff member to signal the end of a conversation. While those cues can be helpful signs, doctors should use them with a verbal explanation of why they have to move on, consultants said.

The "one last question" phenomenon with patients is the situation where physicians probably face the toughest decision. Many times that last question might be unrelated but important, said Janelle Barlow, PhD, president in the Las Vegas office of Time Manager International, a management and productivity consulting firm.

"When a doctor walks into the exam room, so many times they are reading your file," she said. "The feeling I get is I am that file. If patients feel like they're not being heard, they tend to hang on to what they want to say."

If the issue is important, the physician has a dilemma: address it now and take even more time or put it off until later. Depending on your schedule and how long that particular appointment has run, you could answer the question at that time.

If you say no, however, you need to soften the blow, consultants said. Phrases such as "This is an important topic, and I want to give this the time it deserves," or "This is different from your original appointment topic but still warrants a conversation. Could we schedule another visit?" can prove your interest while keeping you on task, consultants said.

Those phrases can have an even more desirable effect if you set your agenda with the patient ahead of time, Dr. Gazelle said. When the patient pulls out a long list of questions, you could explain the situation and ask that he or she addresses the most important issues in the 10 minutes you have.

Setting an agenda offers guidelines in a way that doesn't make the patient feel slighted, she said. If you have covered several topics and run out of time, you could remind the patient of your earlier request and ask about scheduling another appointment, Dr. Gazelle said.

Helpful gestures

With time and experience, physicians also will be able to anticipate the types of questions they won't be able to answer and refer the patient to someone who can, said Billie Blair, PhD, president and CEO of Leading and Learning Inc., a management consulting firm based in Los Angeles. It's good to have information on social service issues that might arise and be outside of a doctor's realm of expertise, she said.

"You want to send them away satisfied and served," Dr. Blair said. "It's bad form to say, 'I don't do that.' We say to our clients they should give patients other resources or send them to the receptionist, who has a list of sources for them."

When Rebecca Unger, MD, a pediatrician with the Northwestern Children's Practice in Chicago, has to say no to parents of her patients, she provides an explanation and often offers her pager number, so they can find a later time to talk that is mutually convenient.

"I give it out a lot because it's such an easy way to be accessible," Dr. Unger said. "Parents feel calm with it. If they need me, they can call me."

Patients appreciate the gestures physicians offer when they have to decline a request at that moment. David Newman, a New York-based psychotherapist, wrote a book entitled Talking with Doctors, which details his journey through the medical system while fighting a malignant tumor at the base of his skull.

While specialists were extremely busy and sometimes running quite late, Newman said, he appreciated it when doctors offered to reschedule his appointment or gave him their cell phone number. One doctor even walked him out to his car, he said, which had "immense value" in a stressful situation.

Sometimes you can get around saying no by dramatically changing how you practice. Matt Killion, MD, an internist in Philadelphia, decided a few years ago to start a primarily Medicare and fee-for-service practice, although he accepts some small commercial health plans. He also has a small retainer practice, in which 50 of his 1,200 patients enroll.

Dr. Killion has a policy of not entertaining presentations by pharmaceutical representatives, and his staff understands not to interrupt a patient exam unless it's an absolute emergency, he said.

Staff members, meanwhile, remain productive without needing answers to questions immediately. Doctors say those who are properly trained will save their issues for between appointments. Others create a system that requires a physician's regular participation. Dr. Killion described a box near his office manager's desk that contains phone messages and prescription refill requests. It's up to him to work through those messages each day, he said.

"My job is to go through that box before I go to lunch," Dr. Killion said. "Anytime I have a free minute, I run back to the box and try to keep up."

More physicians are running back to their computers as well. E-mail is becoming a preferred method of communication because it allows physicians to put off conversations until later, when they can respond when they have more free time.

Communicating with patients via e-mail still might be challenging for some doctors, but it's a great way to manage those conversations with staff and pharmaceutical representatives, they said. It also could be a great way to follow up with colleagues.

"You can set the tenor with, 'It's great to hear from you,' and then you can ask them to send an e-mail," Dr. Gazelle said. "E-mail is a way of containing the conversation without burning that bridge."

You always run the risk of damaging a relationship or bruising an ego when you say no, but if you remain consistent and compassionate, patients and others will understand, consultants said. Plus, they should grow more mindful of your time, allowing you to say yes more often in the future.

"It's extremely hard because many of us want to be people-pleasers," Grenny said. "When people get better at these conversations, their productivity goes up."