When we become physicians, our goal is to help people, make them better, alleviate their pain, and improve their quality of life. I went into medicine, plastic surgery specifically, because I loved putting people back together. But what happens when things go wrong? When the patient isn’t the right patient for the procedure? When the risks outweigh the benefits?
As surgeons, we have to weigh our desire to help people and perform surgery with our understanding that perhaps surgery is not the right thing for every patient. With life-threatening injuries, the answer is fairly straightforward — we will care for the patient to the best of our abilities. For elective surgical care, maybe not so much.
I work in a specialty in which most procedures are elective — even the reconstructive procedures. When a patient has clear-cut medical contraindications to an elective surgery, saying no is relatively easy. These may include instances in which the patient has severe cardiopulmonary disease or terminal illness — times when we know proceeding with surgery may actually do more harm than good.
Then there are those instances in which the patient may simply not be an ideal candidate for surgery — e.g., they have a high BMI, are actively smoking, or have an elevated HbA1C. These health concerns aren’t clear contraindications for surgery, but there is significant evidence in the plastic surgical literature that patients with such concerns will have a higher complication rate. And in elective procedures, complications aren’t well tolerated by either the patient or the physician.
But how do we say ‘no’?
Early in my career, these conversations did not go well. One woman with a BMI over 40 on whom I declined to perform breast reconstruction stormed out of my office, slamming the door behind her, damaging the wall and door in the process. Another patient who was an active smoker called the office and threatened to swallow a bottle of pills if I did not agree to perform her breast reconstruction. And I have had other patients who have reacted just as strongly — including one who left me a one-star google review.
I am sympathetic to these patients’ struggles, but I also understand the medical risks of performing elective procedures on patients who are high risk. Though I likely would not do this today, in the past I have performed elective surgery on patients with BMIs over 50 — and struggled with the postoperative course which ranged from deep vein thrombosis, prolonged wound healing, and a need for hospitalization. Similarly, I have performed breast reductions and abdominoplasties on patients who smoked, and who then struggled with the tissue necrosis that followed. After the fact, these patients have forgotten my extensive discussions about the risk of surgery. Instead, they feel I have failed them. And they only remember their complications.
These complications and struggles reinforced my desire to say ‘no'. I got better at saying it to patients — discussing their safety and well-being. Ultimately, with an elective procedure that is intended to improve quality of life, certain risks aren’t worth it, and may actually decrease their quality of life.
I also learned that saying no is much easier if patients who are at high risk never enter your office. If their BMI is over a certain limit, if they smoke, or if they have medical contraindications to an elective procedure, sometimes saying no before they have invested the time and money for a personal visit is better for everyone involved — no wasted time, and no wasted co-pay or consultation fee.
But these are medical reasons for saying ‘no’. What about non-medical reasons — the patient has unrealistic expectations (or is that really a medical reason?); or you don’t like the patient; or the patient was rude to your staff; or the patient wrote a bad review about you? Are these also reasons to say ‘no’?
Years ago, a prospective patient had several interactions with my office staff in-person, via email, and by phone — appointments had been scheduled, canceled, and rescheduled. Due to insurance issues, this individual was never actually seen for a consultation and became disgruntled by that development. Ultimately, this person impugned the reputation of our practice via social media and online review sites — stating that we were an inferior practice and threatening to use her knowledge of the health care industry to ensure that others would know this as well. Fast forward a few months when she presented to the ER at the hospital where I perform breast reconstruction and was admitted by the hospitalist service. She had a complication from a plastic surgical procedure performed elsewhere by a surgeon who was out of state. What was my obligation to treat a woman who had already poisoned the doctor-patient relationship in a very threatening and public manner? Could I say ‘no’?
Most of us would have jumped and treated her because it has never occurred to us that we can say no. When I received the phone call and learned that this patient had been admitted, I had to sit down and think. I remembered the words of an older plastic surgeon, who said that he never operates on a patient whom he doesn’t like. If during a consultation he dislikes a patient or believes that he cannot appropriately manage their expectations, he tears the chart, refunds the consultation fee, and says ‘no’. While the word ‘dislike’ can mean many things to different people, I interpreted it as being a sixth sense — that sense that many of us have about patients who don’t seem to understand what surgery is or who believe that surgery can get them a new job, a new husband, or a new career, none of which is possible.
Legally, we may ask: When does the doctor-patient relationship begin and what constitutes the relationship? The Federation of State Medical Boards states: “The relationship between a physician and patient begins when an individual seeks assistance from a physician for a health-related matter, and the physician agrees to undertake diagnosis and treatment of this patient.” This concept implies a conscious decision has to be made by both parties. The AMA also supports this concept, stating: “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.”
Some may find this concept of physician autonomy distasteful or believe that it goes against our calling to serve humanity. I understand this perspective, as we cannot and should not say ‘no’ due to discriminatory biases about a patient’s identity. However, when we have concrete medical concerns, and the patient demonstrates a lack of appropriateness for surgery (which can also mean a lack of mental and emotional fitness for it), saying no may be warranted.
When it came to the threatening patient above, her situation was not an emergency. In addition, I had real concerns about how she would respond to me as her physician. Would she be cruel, violent, non-compliant? The physician-patient relationship is also one of mutual trust and respect — if that doesn’t exist, the relationship will not be beneficial for either person. Fortunately, this patient did not require any additional surgical intervention and was able to return to her operating surgeon for follow-up care after a few days of antibiotics.
So, to answer my initial question, can we say ‘no’? I believe that under some circumstances it is our obligation to do so — to minimize bad outcomes for both the physician and the patient.
Have you ever said 'no' to a patient? Share your experiences in the comments!
Dr. Anureet Bajaj is a plastic surgeon in private practice in Oklahoma City, Oklahoma. She enjoys running, painting, and spending time with her dogs and family. Her IG handle is @bajajplasticsurgery. Dr. Bajaj was a 2022–2023 Doximity Op-Med Fellow.
Illustration by Jennifer Bogartz
