How can I say no?
BMJ 2024; 386 doi: https://doi.org/10.1136/bmj.q1711 (Published 02 September 2024) Cite this as: BMJ 2024;386:q1711
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Dear Editor
I agree with Rimmer that creating workplace boundaries can be extremely challenging [1]. Not only do most of us go into the profession as we want to help others, but also throughout training we are often rewarded when we overextend ourselves [2]. This can make it incredibly difficult to ‘say no’ without feeling guilty or feeling that you are letting patients and colleagues down. The pressure to say ‘yes’ to additional tasks can be overwhelming, particularly due to a chronically under resourced NHS meaning constant staff shortages, increased waiting times, and higher clinical acuity.
In 2022, the GMC reported 70% of doctors worked beyond their rostered hours on a weekly basis and a quarter of doctors surveyed were categorised as being at ‘high risk of burnout’ [3]. While systematic changes to the NHS are necessary to address these issues, such changes will require significant time and resources. Therefore, it is crucial that we implement quicker, individual strategies.
When managing burnout there is often an emphasis on self-care activities, including sports, mindfulness and other hobbies [4]. While these strategies can be beneficial, they may not address the root causes of burnout. I believe there needs to be more of a focus on teaching clinicians how to create and maintain boundaries with their workload. A recent study has developed a ‘framework’ aimed at improving clinician competence in setting and maintaining these boundaries. This framework includes practical tools and strategies that can be integrated into daily practice, helping clinicians to manage their time more effectively and reduce the risk of burnout [2]. Formal training on creating healthy workplace boundaries could be a valuable tool in reducing burnout, as it empowers clinicians to prioritise their well-being.
By equipping clinicians with the skills they need to ‘say no,’ we could ultimately create a healthier workforce.
References
1. Rimmer A. How can I say no? BMJ 2024; 386:q1711 doi: https://doi.org/10.1136/bmj.q1711
2. Herbst R, Sump C, Riddle S. Staying in bounds: A framework for setting workplace boundaries to promote physician wellness. Journal of Hospital Medicine 2023; Apr 10 doi: https://doi.org/10.1002/jhm.13102
3. General Medical Council. The state of medical education and practice in the UK Workplace experiences 2023. https://www.gmc-uk.org/-/media/documents/somep-workplace-experiences-202...
4. Edwards K, Goussios A. Who is responsible for compassion satisfaction? Shifting ethical responsibility for compassion fatigue from the individual to the ecological. Ethics Soc Welf. 2021; 15(3): 246-262 doi: https://doi.org/10.1080/17496535.2021.1888141
Competing interests: No competing interests
Dear Editor
The reason for medicine becoming a service industry is lack of time and potential extra workload and fear of complaint of declining requests from increasingly busy, stressed and over expectant patients. There just isn’t time to fully discuss request declines - medical certificates are the worst, along with medications of dependence - really hard to decline completely for many reasons; and antibiotics; patients often say they’ know their own body’ and’ know’ when they need antibiotics which is hard to argue against; turning scripts into back pocket script requests may be the best we can do sometimes unless patients are very health literate.
There just isn’t time to fully discuss the depth of knowledge and full explanations we have in these issues with patients who want it now or may complain, especially if you don’t know them, which is increasingly common. Also getting a complaint is so time consuming to deal with and stressful. Many colleagues will hold their noses and acquiesce.
I’m pretty intransigent re inappropriate requests but even I compromise and meet patients somewhere on the request scale in order to get home in time and see my dogs and preserve my mental health. Patients could be better educated on the reasons and issues above pertaining to declining requests to avoid conflict.
Competing interests: No competing interests
Dear Editor
In the context of medical profession, the title “How can I say no?” [1], seems to devalue the fundamental importance of doctor-patient relationship. Nowadays, perhaps, doctors are least concerned about the Hippocratic Oath, “I will use my power to help the sick to the best of my ability and judgement; I will abstain from harming or wronging any man by it” [2] when refusing to grant patients’ wishes. As succinctly put by Parachikov [3], an open question (‘why’?) could suggest an absence of dismissiveness and genuine desire to explore a patient’s wishes rather than an attempt to close down, albeit respectfully. ‘No’, should generally be the last resort and it should come with very clear alternative options including the entitlement to second opinions in line with now well known, ‘Martha’s rule’. There may be time-sensitive occasions (eg.mental capacity issues, end of life decisions) when doctors should not hesitate to direct patients to obtain urgent independent legal advice, although it can be a very uncomfortable experience for the doctor concerned. Needless to say, defensible documentation could save a lot of trouble in these situations.
As if ‘No’ is the only answer or outcome, Tiplady says, “You will have to say no at some point” [1]. Of course, following further consideration and wider consultation including second or even third, entirely independent opinion, “at some point”, the answer may not necessarily have to be ‘No’. We know, no one is always right. Tiplady adds, “You are not there to please, you are not your patient’s parent, rescuer, or friend” [1]; saying, “not your patient’s parent” or “friend” is a clear overstatement and arguably, it would have been sensible to avoid such words. A considerable part of the doctor-patient relationship involves advising and supporting patients with pure advocacy at times; hence, would it be unreasonable for patients to expect that doctors would attempt to “please” them during therapeutic relationships with their trusted doctors? As for the view, not your patient’s “rescuer” [1], if one takes it literally, it would be unnecessary to expand on the wide range of situations when doctors act as rescuers of patients from birth to death; so similarly, why not first attempt to ‘rescue’ patients who make requests which doctors perceive unjust or unreasonable?
When doctors are increasingly embroiled in gatekeeping roles (sometimes with financial interests, thereto), there is an additional risk, their judgement could be clouded by conflicts of interests and subconscious ego-driven desires. This is another factor which doctors in such roles should consciously be aware of when not giving in to patients’ wishes and requests. Despite the overstretched NHS resources, except in grossly unjust and unreasonable circumstances, let’s hope, conscientious doctors would keep ‘No’ as the last answer, only when all other reasonable options are properly considered collaboratively. Such an approach could potentially minimise the NHS’ spiralling litigation costs too, due to doctor-patient conflicts which are likely to continue.
References
[1] https://www.bmj.com/content/386/bmj.q1711
[2] Ip S. Medical doctors have to sign up to a ‘Hippocratic Oath.’ Should scientists do something similar? Long essay. UCL.
[3] https://www.bmj.com/content/386/bmj.q1711/rapid-responses
Competing interests: No competing interests
Dear Editor
Rimmer suggests methods to tackle the many difficulties doctors face in wanting to fully satisfy their patients’ needs and desires(1). However, what if sometimes the answer is not to say ‘no’ but instead ‘why’?. Throughout our medical education, it has always been ingrained in us in the medical profession to explore patients’ ideas, concerns and expectations.
Perhaps a patient’s request for a treatment or test could be looked at as a concern for the unknown? Fear of the unknown has been shown to lead to conflict and irrational behaviour (2).
Perhaps our education focused on evidence-based fact can make us professionals ignorant to the complexity, and simultaneously the importance, of medicine to our average patient. It can be easy and understandable to view the perspective of an experienced doctor as that of higher intellectual value. We must not forget, however, that both parties provide invaluable perspectives towards treatments. Furthermore, no other being is more knowledgable of their own wants and desires as the patient themselves. Providing optimal care and well-being is not possible without considering the goals of the individual.
Therefore, patients must be treated as equals in the doctor-patient relationship. Disagreement amongst equals is of constant debate in epistemology, a philosophical branch which aims to deconstruct the origins of disagreement(3). A medical professional remains an eternal scholar, learning not only from research and new technological advancements, but from the patients themselves. Perhaps an obese patient requesting the trendy new weight-loss drug is in reality not ‘lazy’, but unable to afford healthy food and is working too many hours to exercise effectively. Listening to this hypothetical patient, viewing their treatment as a journey rather than a service provided by an expert following a clinical guideline, may significantly alter clinical decisions and ultimately lead to more favourable outcomes.
With this in mind, one may would argue the best way of saying ‘no’ is simply through compassion and understanding.Through treating patients as part of our multidisciplinary team, as equals, showing empathy for their fears and guiding them on their path to treatment, optimal patient care should not involve a yes and a no. It should involve a collective decision, optimised both through medical expertise and patient priorities. Both medical professionals and patients want the overall most positive outcome for the patient and both perspectives are equally invaluable in reaching optimal patient treatment.
References
Rimmer A. How can I say no? BMJ. 2024 Sep 2;386:q1711. doi: 10.1136/bmj.q1711. PMID: 39222975.
Carleton RN. Fear of the unknown: One fear to rule them all? J Anxiety Disord. 2016 Jun;41:5-21. doi: 10.1016/j.janxdis.2016.03.011. Epub 2016 Mar 29. PMID: 27067453.
Alexander, J., Betz, D., Gonnerman, C. et al. Framing how we think about disagreement.Philos Stud 175, 2539–2566 (2018). https://doi.org/10.1007/s11098-017-0971-9
Competing interests: No competing interests
How Can We Strike a Balance? As a Grassroots Physician in China
Dear Editor,
As a grassroots physician in China, the current domestic healthcare system presents numerous challenges that place significant pressure on our daily work and lives, particularly for newly graduated resident doctors who have just completed their postgraduate studies and entered clinical practice. The combined pressures of research, clinical work, and salaries often make it difficult for young doctors to navigate their early careers.
In recent years, there has been an increasing emphasis on research within China’s healthcare system, especially in hospital promotion and evaluation mechanisms, where research achievements are often prioritized. Publishing high-impact academic papers and securing research projects have become essential milestones in a doctor’s career development. Physicians who excel in research can advance more quickly in terms of promotions, income, and career prospects. However, this focus on research over clinical practice means that many doctors invest substantial time and effort into research, often at the expense of developing their clinical skills.
For newly graduated resident doctors, the pressure to produce research is particularly evident. In addition to their heavy clinical workloads, they are also expected to conduct research within limited timeframes, making it challenging to balance both responsibilities. For those who may not naturally excel in research, the situation is even more difficult. Despite their potential excellence in clinical practice, their career advancement may be restricted due to a lack of research output. This imbalanced promotion system risks diverting doctors from the fundamental purpose of medicine—treating patients and saving lives.
The neglect or inadequacy of clinical skills can lead to an increase in doctor-patient conflicts. When doctors have not sufficiently honed their clinical abilities, they may face difficulties in managing complex cases, leading to patient dissatisfaction and heightened tensions in doctor-patient relationships. In recent years, some doctors have faced issues related to inadequate clinical experience due to an overemphasis on research, which not only impacts patient health but also damages the doctor’s professional reputation.
The frequent occurrence of doctor-patient conflicts is not solely a technical issue but also reflects patients' high expectations for the quality of medical care and services. Improving physicians’ clinical competence is key to addressing this issue, but the current research-driven approach has, to some extent, hindered the development of clinical skills, further exacerbating doctor-patient relations.
Closely tied to research and clinical assessments is the issue of physician salaries. Although the medical profession is widely regarded as a high-paying field, in reality, the income for resident doctors in many grassroots hospitals is not as high as expected. Particularly in major cities with high housing prices and living costs, many newly employed young doctors face significant financial pressure. At the same time, they must juggle both research tasks and clinical duties, often leaving them exhausted, which further contributes to professional burnout.
In conclusion, the current healthcare environment in China is filled with challenges for doctors, especially for grassroots resident physicians. By adjusting the priorities between research and clinical practice, optimizing salary structures, and improving training systems, we can look forward to building a fairer and more efficient healthcare system, improving doctor-patient relations, and enhancing the overall well-being and professional satisfaction of physicians.
Competing interests: No competing interests