Feb 2004 Table of Contents

BALANCING ACT

The Fine Art of Refusal



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These pointers will help you stand your ground with patients who don’t want to take “no” for an answer.

Fam Pract Manag. 2004 Feb;11(2):80.

This content conforms to AAFP CME criteria. See FPM CME Quiz.

Excessively needy patients are a challenge, even for the best of physicians. You know the type: You’ve given them all the time and medical advice you could reasonably offer, yet they still want an IV hooked up – directly from you to them. What’s the best approach to take with these patients? Start by learning to say “no” more effectively.

  1. Realize that “no” hurts. It hurts when I hear it. It hurts when you hear it. No doubt about it, gratification feels much nicer. With any refusal, try to offer the balm of regret. For example, “I’m very sorry that I don’t have time to answer all your phone calls personally ...” or “I know you really wanted that Xanax and I’m sorry to disappoint you, but ... .”

  2. Try the toddler principle. This is the “I won’t give you that, but I’d love to give you this” approach to saying no. If you have children, chances are you’re familiar with this tactic. Your two-year-old child appears with your screwdriver or sewing shears. You realize that simply yanking away the dangerous item will cause howls, so as you take it away, you extend a harmless egg turner and a couple of shiny cooking pots. Your child might sniffle a little, but you probably won’t get the tantrum. In the office setting, this translates to “I won’t give you the antibiotic, but I will prescribe an analgesic and a decongestant to take care of your symptoms until your viral infection is gone.”

  3. Take responsibility for “won’t” versus “can’t.” Don’t say, “I can’t give you that Xanax.” Your patient knows better. You could give it to him, but you won’t, perhaps because you suspect he’s addicted. If you say you can’t, he’s likely to reappear with multiple petitions, anticipating the day when you give in and finally say, “I can.”

  4. Be firm yet calm. Keep in mind that the excessively needy person often longs for someone to act as parent – not the warm, fuzzy mother or the disciplining father, but the rational authority figure. To play this role, be firm as you say “no” yet be calm and compassionate as well.

  5. Use the “broken record” technique. Explain your reasons for saying “no” in plain language and, if necessary, in writing (see number six below). Don’t prolong your explanation or talk in circles, and don’t argue. If the patient wants to debate the issue, use the broken record technique, in which you simply restate your same message over and over again, as necessary. The other person will soon learn that arguing isn’t going to change your mind.

  6. Work up a contract. For the extremely needy patient, you may want to put your refusal in writing. State what your clinic will do for the patient, what you will do for the patient, and what you expect the patient to do as well. Written documents can be useful because anxiety has a way of inhibiting information processing during the encounter.

  7. Show faith. Remember that your patients believe in you; that’s why they come to see you. Let them know you have faith in them too – because they’ll tend to live up to that faith. For example, if a mildly overweight patient requests orlistat, you could explain why you won’t prescribe it for her and then say, “I believe you can lose this weight in a safer way through moderate exercise five days a week. Let’s try that. I think you can do it.”

Stand your ground

I have found the nay-saying techniques described in this article to be useful on many occasions. For example, adolescents who want a year of home schooling to get away from the stress of their peers have been satisfied with a two-week medical leave for depression and extra help from the school nurse. Patients who persistently call my emergency number for non-emergencies have been redirected to call the regular office line at specific times for a five-minute check-in. Clients with borderline personality disorders have calmed in response to repeated “no’s” delivered nondefensively. Although I continue to hone the fine art of refusal, these techniques have helped me to flourish in a professional environment where I might otherwise shrivel.

Dr. Spickerman is a psychologist in private practice in Marshall, Mo.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.


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