Doctors are driven by a deep-rooted desire to help and serve. It’s a calling that motivates most doctors to enter the medical profession. Armed with extensive skills and experience, they are adept at tackling almost any medical challenge. But doctors are leaders in the community and, as leaders, saying no is part of their job. Dr Debbie Norval believes that this responsibility is especially pertinent to aesthetic medicine, where the best way to help some patients is to turn them down.
We are living in a “yes” and instant world, in an age when saying no is something people don’t often hear. Today’s society thrives on instant gratification and quick fixes. Yet, before saying yes to any treatment, a doctor’s duty is to conduct a thorough medical assessment, including a comprehensive drug history and examination, before recommending any course of action.
The easy no
There are several clear-cut reasons for a doctor to decline a patient’s request.
Legal reasons to say no
Doctors have to say no if the request involves illegal activities, such as using unlicensed or unregistered products. Lack of informed consent is an obvious reason to say no until the patient fully understands the implications of their request.
A doctor should say no to performing procedures outside their professional area of expertise or competence. Instead, they should refer patients to appropriately qualified healthcare professionals.
Ethical reasons to say no
Doctors should say no where the risk of harm outweighs the potential benefit. Resource constraints are another valid ethical reason, particularly when giving in to a request would divert essential resources from more urgent cases.
In aesthetics, there’s often the temptation to supersede another doctor. Supersession is when a doctor takes over the care of a patient from another doctor without proper justification and communication – e.g. “Can you quickly write my HRT script? My gynaecologist is fully booked.” However, giving in to such requests is unethical.
Medical reasons to say no
A doctor should say no to a medical treatment if it is inappropriate, unnecessary, likely to cause harm, or has no evidence-based benefits. Other medical grounds for refusal to perform a treatment include contraindications due to drug interactions and underlying conditions such as active autoimmune conditions or ongoing sinus infections.
A doctor can say no to a patient who refuses to comply with medical advice or protocols. A patient who won’t adhere to pre- and post-care instructions for a chemical peel will end up with poor outcomes or complications.
Additionally, an aesthetic doctor can say no to high-risk procedures where potential complications outweigh the benefits, such as dermal fillers in the nose in a patient who has had previous nose surgeries.
The less easy no
Unrealistic expectations
“Take away my pores!”
Think of those patients who want shiny, porcelain skin like the filtered models on Instagram. Picture the 60-year-old patient who pulls away lax, loose folds of skin on their jawline, expecting a result after one treatment. Or the patient who insists that they cannot have any bruising, as they have a party on Saturday.
Patients often come in having already researched treatments extensively, hoping for results like their favourite social media influencer. However, these expectations are often more wishful thinking than realistic goals, leading to requests for treatments that may not be suitable or safe for that individual.
When faced with unrealistic expectations that cannot be safely or effectively met, it’s essential for doctors to gently steer patients toward more realistic options. Managing expectations is not just about outcomes – it’s about maintaining smiles and safety in equal measure!
Budget blusters
“Do you offer discounts?”
Here we are talking about the patient who wants their doctor to turn back time with a budget of R1,000. Rather say no than give a low dose or inadequate treatment with no visible or lasting results.
Aesthetic treatments are expensive. Before saying yes to a patient, consider whether they can afford a full course of treatment. Do they understand that results may last a limited period of time? Do they understand that they have to maintain treatments to keep up the results? Ageing is constant, and anti-ageing treatments don’t stop.
Aesthetic doctors should be sensitive to a pensioner who is getting carried away with excitement and not thinking straight, or to the newly divorced 40-year-old who has a new partner and is spending a disproportionate amount on their treatments. If a patient appears to be undergoing treatments they cannot afford, or if there is a risk of financial exploitation, it is ethical to gently put the brakes on the patient.
Mental health
“I’m so fat!”
How does the patient feel about himself or herself? What upset or distress might be behind the request for treatment? The doctor should not be afraid to ask difficult questions. How is the patient’s mental health? An aesthetic treatment might not be the remedy for these concerns.
Body dysmorphic disorder (BDD) is a mental health condition where a patient is obsessively preoccupied with perceived flaws in their appearance. Individuals with BDD often spend a huge amount of time focusing on these perceived flaws, leading to severe distress affecting their quality of life and daily functioning. They may repeatedly undergo unnecessary cosmetic procedures in an attempt to fix these (typically imagined) imperfections.
Aesthetic doctors should be on high alert for BDD. The incidence in the general population is 2% but between 8–14% among patients seeking cosmetic treatments. It is important in these patients to say no gently and firmly, as well as support them with wisdom and kindness, so that they don’t run off to a less ethical doctor who might exploit them.
The aesthetic doctor can make use of readily available validated symptom scales to screen for dysmorphia, such as the Body Dysmorphic Disorder Questionnaire (BDDQ) and the Body Dysmorphic Disorder Symptom Scale (BDD-SS).
“I’m really not sure, doc.”
The vulnerable
When treating a patient, aesthetic doctors would do well to ask themselves this question: “What is the vulnerability of this individual and how can I best serve the person in front of me?” And if saying no is the best thing they can do at that moment, then that is the right thing to do.
Examples of vulnerable patients include the elderly, the mentally unstable, the young, and the impressionable. Also consider patients who are feeling insecure and have low self-esteem or self-worth. Then there are those who need you to say, “No, not now,” so that they have time to reflect, process, and plan.
The manipulative patient: A masterclass in unwanted flattery and pressure tactics
“My, Dr Debs… You’re the best!”
It’s often too late by the time the doctor realises they’ve been sweet-talked into something that isn’t necessarily right for that patient. These patients are demanding and pushy, traits often disguised among flattery and praise. Patients with narcissistic tendencies often fall into this category. They butter up their doctor, creating a false sense of connection, or play the victim, laying guilt on the doctor for their normal ageing process or blaming them for unsuccessful treatments.
Doctors should be on high alert to feelings of being pressured and manipulated, and should say no with firmness and authority – before they find themselves agreeing to lipolytics in a patient with zero body fat.
The celebrity lookalike
“Give me that Angelina jawline.”
When patients ask for a specific celebrity feature – e.g. a Kate Middleton nose or Kim Kardashian buttocks – this is a red flag and a good time to say no.
Each patient is unique, with features that usually suit them perfectly well. While it’s lovely to accentuate a patient’s own cheeks or eyes, changing them to look like someone else rarely works.
What looks good on Angelina or Beyoncé might be decidedly bizarre on another person.
Copying the BFF
“I’ll have what she’s having.”
Patients sometimes ask to have the same treatment as their friend who had a brilliant result. This is also a reason to say no. What works for one person’s unique facial features may not be the right treatment for another.
Social media mania
“I need Barbie-Tox!”
A good doctor says no to TikTok trends, Facebook fanatics, and Instagram spam. These treatments are rarely based on scientific and evidence-based medicine. Easily recognised by trendy names like Barbie-Tox, Russian Lips, Fox Eyes, Doll’s Lips, and Pixie Nose (SMAS Tox Lift and Mousse Lips are the latest!), these treatments may be harmful in the long run. Other trends, such as buccal fat pad removal, fall out of fashion within a year and then have to be reversed.
The late Friday afternoon last patient of the week
“Won’t you just quickly…”
This is a good time to say no to that last tempting request for a quick filler or thread-lift. It’s typically the patient who has booked for their routine botulinum toxin and, at the last minute, asks for lip fillers. The doctor is tired, looking forward to their weekend, and might not be focused. This is a recipe for a serious complication like a vascular occlusion, with the whole weekend ruined with emergency hyaluronidase injections and visits to the hyperbaric oxygen chamber. An astute doctor will say no and schedule the treatment for a later date.
Too much at once
“I want it all!”
A wise doctor will say no to too many treatments in one session. The more treatments, the greater the risk of complications. Certain treatments also affect the efficacy of others, so it is better to plan treatments with appropriate spacing.
Perception drift
“More, more, more!”
Perception drift describes the mental shift that happens when a patient has repeated aesthetic treatments. Each alteration causes the brain to swiftly adjust to the new image, erasing memories of the previous, more natural appearance. Over time, the brain forgets the original face and focuses on new aspects to improve. The individual’s baseline for “normal” keeps shifting with repeated treatments.
It helps when the doctor compares current results to the patient’s original photos to keep the patient grounded in reality, preventing the slippery slope of perception drift.
Perception drift can result in “alienisation”, where patients start to look bizarre and unnatural. It is the aesthetic doctor’s responsibility to say no to more of these treatments, having the patient’s best interests at heart and maintaining their natural appearance – unless they want their patient starring in the next alien invasion movie!
Running low on time
“Just quickly!”
When the appointment is booked for 30 minutes and time is running out, but the patient wants the doctor to just quickly squeeze in another treatment. It’s simple: the answer is always no!
When the patient dictates how much time the doctor will need
“It’ll only take five minutes, doc…”
This is a serious red flag. Only the doctor knows how much time they will require to safely and competently perform a medical aesthetic procedure. Patients may believe that it’s a quick and easy procedure, but there is a lot of preparation before a procedure, including written informed consent, the correct reconstitution of products, the correct markings, proper disinfection, and pre- and post-care.
No procedure is “easy” and all have potential complications, especially if rushed. Safe procedures take time.