Mastering the art of saying ‘no’

3 minute read

Having a shared a responsibility for a patient’s healthcare is encouraged. But what does this actually mean? asks Dr Sara Bird

Twenty years of work as a medico-legal adviser has taught me that mastering the art of saying “no” to a patient is one of the most valuable skills for a GP to reduce their medico-legal risk.

But it’s hard to say no, and it seems to be getting even harder to do so. Why is it so difficult?

Paternalism in modern medicine is dead. Patients now expect to be in control of their healthcare. The GP is no longer the fountain of all knowledge. Patients are informed by Dr Google.

The “doctor knows best” has been replaced by patient autonomy and the “customer knows best”.

This change has been partly driven by the law, where the principle of autonomy is one of the central values of our legal system.

By nature, GPs aim to please. Throw into this mix the risk of a complaint, adverse comments on doctor-rating sites and other social media, or even threats to personal safety, and saying “yes” instead of refusing a patient’s request can look like a much more appealing proposition.

But when patients see themselves as the customer, and GPs acquiesce to this model, problems can arise, including risks to the health of patients and medico-legal trouble for GPs.

The medico-legal landscape is littered with doctors who have allowed the pendulum to swing too far towards patient autonomy and lost the focus on their professional responsibilities as a medical practitioner.

There are some things which are an absolute “no”, such as the inappropriate prescribing of large quantities of Schedule 8 drugs to drug-dependent patients. Indeed, this situation accounts for around 20% of the Medical Tribunal cases where doctors are found guilty of professional misconduct.

But there are shades of grey. What about:

• writing a prescription for antibiotics for an apparent viral condition?

• prescribing the oral contraceptive pill to a patient in her 40s who is a heavy smoker?

• providing a sickness certificate for a patient who doesn’t look unwell?

Doctors have a professional obligation to make the care of patients their first concern. The Medical Board’s Code of Conduct tells us that providing good care includes recognising and respecting patients’ rights to make their own decisions.

We are also told that making decisions about healthcare is the shared responsibility of the doctor and the patient. But what does this actually mean in practice? What if the patient’s view of what is in their best interests differs from yours?

The intention of shared decision-making is that patients and their doctors each have a part in the process of making the decision, as well as ownership of the decisions made. This may involve the doctor offering a range of options, including no intervention, and the patient making a choice based on their own needs, values and beliefs.

A mutually acceptable outcome can be negotiated in most cases, but this is not always possible. Patient dissatisfaction in this situation may be inevitable, and is not necessarily a sign of poor medical practice.2

Patient autonomy doesn’t mean you have to comply with a patient’s request. If you need help in saying “no” to a patient in a particular situation, consider deflecting the blame and contacting your medical defence organisation who can tell you: “Just don’t do it”.


1. Elkin KJ, Spittal MJ, Elkin DJ, Studdert DM. Doctors Disciplined for Professional Misconduct in Australia and New Zealand 2000-2009. Med J Aust 2011;194:452-456.

2.  McCartney M. The Conflict of Choice. BMJ 2015;351:h5312.

Dr Sara Bird is Manager, Medico-Legal and Advisory Services for MDA National

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