Saying no to people is a skill to master. Saying no to patients is unique to medical professionals but there are tactful ways of handling it in order to minimize strife and maximize efficiency.

If I am paid $23/patient then I want to see as many patients per hour as possible and being efficient is the difference of $100/hour and $250/hour.

This blog is about personal finances for healthcare professionals so I want to make sure that I am earning my income as efficiently as possible. But if every time you have to say no you feel like ripping your eyebrows out then you’ll burn out. In this post I’ll talk about the best ways to say no, keep your customers happy, and make life easier on yourself.

The Art of Saying No

Physicians are caring/loving individuals even if we come across a little cold at times. The last thing I want to do is say no to a patient – I want to please the patient, I want to do something for them that makes them feel better.

However, my first and foremost obligation is to their health, followed by preservation of my medical license. Prescribing unnecessary antibiotics not only puts them at risk but creates resistant bugs that the rest of the society has to deal with.

We can say no in a very nice and gentle way or we can do it robotically. I have tried both and the latter eats up more of my time than doing it nicely. Doing it tactfully can drastically raise your patient satisfaction scores and will make life easier.

Unfortunately, either way, you will have to confront a disappointed, upset, and occasionally irate patients once you deliver that no. These aren’t bad people, they just weren’t expecting a no.

Smile on the phone.

It feels weird but it works. You have to have a kind face even when they cannot see your mug because studies have found that your facial gestures affect your digital impression.

“No” Scenarios

No, I’m sorry, I cannot refill your Percocet over the phone.
No, I cannot give you a work note for 2 weeks.
No, I cannot give your child an antibiotics for an ear infection.
No, I cannot refill your ED medication.
No, I cannot give you a note in order for you to get a refund for your airline ticket.
No, I cannot give you antibiotics for a pneumonia.
No, I cannot give you antibiotics for this particular UTI case.

These are the most common “no” scenarios that I encounter.

You will be much more effective at your telemedicine work if you can deliver your “no” as a final diagnosis and not leave any room for discussion.

It’s not all bad – plenty of patients will thank you and ask you for some OTC recommendations and move on. Unfortunately, enough others will fight you and try to dissect your MDM – those are the patient interactions I want to address.

My method has helped me prevent far fewer dissectors and experience a lot less friction doing telemedicine shifts. It has also reduced my risk of having to face a medical board or a lawsuit.

The 5-Step Approach To Saying No

1. Smile & be nice. If you aren’t willing to do this then the rest of what I am going to say won’t work for you.

Even if the patient seems dry, upset, curt, or angry from the start, you need to smile, be nice, kind, and add in the common fluff words which medicine refers to as empathy.

2. Collect a very detailed HPI. If you say no after exchanging a couple of short sentences with a patient then you best believe that you are going to be on that telemedicine visit for 15 minutes while they chew you out.

No matter what terminology the patient uses, such as “I have a sinus infection”, stick to your dumbed down scientific terminology. Ask how long they have had their “sinus symptoms” for. Ask them what they have tried. Ask them about the exact details of the pressure, which side its on, what color the mucus is, how it is in the morning versus the evening, etc.

3. Have them do an exam. You want to come across as thorough and caring. Have them press on certain areas, having them describe to you what their tonsils looks like, and reviewing their uploaded images with them will go a long way to build credibility.

4. Deliver your assessment and plan. Once you have all the pertinent information then thank them and proceed to summarize your assessment and your plan which you will deliver along with your dumbed down medical decision making.

This is your final diagnosis or assessment. This is what you will tell the patient to do. And if they asked for antibiotics or something that you need to say no to then this is the time you will tell them no.

5. Reiterate the “no” and end the call. The patient will try to engage you as to why you don’t think they have a sinus infection, as to why you’re saying no to their blood pressure medication refill, and they will resort to raising their voice or asking you to speak to someone else.

“Based on the information I have gathered you do not have a bacterial sinus infection and giving you antibiotics would cause you harm and I couldn’t do that. It could be viral or allergies and you can manage it with the OTC medications I mentioned. Please get seen in person if you think you have something other than what I have diagnosed you with.”

This is when you need to end the call.

“Is there anything else I can do for you?”

“YOU DIDN’T DO ANYTHING FOR ME, THIS WAS A WASTE OF MY TIME AND MONEY!”

“You can contact customer service for any customer care related issues. I hope you follow my recommendations however so that you can get better faster. Do you have any other questions about my treatment recommendations?”

“[CLICK]”

Fighting Your “No”

Wives will put their husbands on the phone in order to bully me into giving them the medication for their child. Women will break down and cry. Men will get angry and threaten me.

My competence, my education, and my loyalty to the practice of medicine is all questioned within one single phone call.

Once you say no, you have to commit yourself to the no. Own that no but not from an ego-standpoint but because you know it’s the right thing for the patient and it honors your practice of medicine.

You don’t owe the patient an explanation for that no. You are the physician with the expertise and knowledge. You would be wasting your time trying to explain the scientific basis behind your decision to a patient who is only asking about it so that they can dissect it apart and throw it back at you.

I don’t re-explain my MDM to their partners on the phone.

I don’t rehash the case all over again.

I remain kind but firm and tell them that I apologize that they don’t agree with my diagnosis but that I have limited resources on a telemedicine visit and that they should be seen in person if they believe they have something otherwise.

95% of the time, no matter how upset or rude the patient is, they will end the conversation because they realize that they cannot engage me in a back-and-forth.

Avoiding “No” Complications

The biggest worry for a physician is that they are going to get a call from the telemedicine customer service and be asked as to why they had such an upset patient.

I have not once had such a call because the few times when I encounter a difficult patient I document the shit out of it in my A&P.

I use quotation marks to write exactly what the patient said and I note that the patient didn’t agree with my plan and that they hung up the phone. And, of course, I document that my recommendation was for them to be evaluated in-person.

Any customer service rep who reads this will know that there is nothing else they can hash out with me. They see my reasoning as to why this wasn’t a bacterial infection or appropriate for a refill and they see what I wrote about the patient.

Poor Patient Reviews

I say no a lot and I have some of the best telemedicine patient satisfaction scores that I’ve come across. I’ve confirmed this with Teladoc and Doctor on Demand.

Most upset patients will leave the conversation hearing that I cared, that I was thorough and that I told them that the reason I am saying no is to prevent a bad outcome.

It’s hard to be terribly upset at that kind of doctor – someone who genuinely cares about you.

I get the occasional 1/5 stars but when all my other cases are 5/5 then it’s obvious that it was an irrational patient. All such negative telemedicine cases are followed up on by the concierge team and upon reviewing my chart and asking the patient as to why they gave me a 1-star it should be obvious that they just don’t like being told no.

Risk of Saying Yes

There are so many antibiotic drops and oral antibiotics being given for URI’s on telemedicine platforms that it’s soon going to blow up in our faces.

I did a telemedicine visit with a patient who called back the same day because the doctor gave her hydralazine by mistake instead of hydroxyzine for allergy symptoms.

Why?! Why prescribe a medication for something like that when there are plenty of OTC meds available. The risk isn’t justified.

If you give amoxicillin to a patient who happens to be on methotrexate but they forgot to tell you and you forgot to ask then you’ll own that patient and their complications – forever.

If their eye redness was due to a herpetic outbreak or an untreated uveitis and they developed complications from it, then you may have to answer for you delaying their diagnosis because you gave them antibiotic drops.

If you gave the 60-year-old woman with nausea and fatigue ondansetron and she was found dead in her home before she could pick up the medication then how will you answer to the missed MI?

Remember That…

No matter how pissed this patient is, you will still earn your $20-ish for that visit.

You will still have another patient to see who likely will be pleasant.

You are a physician and not a customer service specialist.

You don’t have to live with that person.

You still get to crawl into your comfy bed at night while that person will continue to be miserable because they were too upset to listen to you.

You will have multiple amazing and kind patients on your next calls.

And you didn’t risk your medical license by giving this patient something that you cannot later defend in the courtroom.