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.
The dissatisfied doctor-hopper
“They botched me!”
Doctors are usually fully aware when a patient has been “doctor hopping” – a patient who jumps from one aesthetic practice to the next. These patients often badmouth previous aesthetic doctors.
When a patient complains about the last four doctors they saw, rest assured, the new doctor will be on high alert and may well say no to treatments. After all, the chances of the patient being satisfied this time round are about as slim as finding a unicorn in the waiting room!
On a more serious note, the last doctor doing a treatment takes on the responsibility in case any complications occur, even if they result from a previous practitioner’s poor work. This makes a careful aesthetic doctor much more likely to say no – because who wants to clean up someone else’s mess and end up with a starring role in the next round of complaints?
The wedding in two weeks time
“Goin’ to the chapel, and we’re gonna get married.”
Murphy’s law of aesthetics states: “It is guaranteed that if a bride has a medical aesthetic treatment within two weeks of a wedding, the injectables will cause a haematoma and droopy eyelid, and the laser a third-degree burn.”
The same law applies to the desperate last-minute, mother-of-the-bride fix-up!
An experienced aesthetic doctor will say no to all treatments so close to a wedding. Weddings require careful planning – up to a year before the big day – for the best results.
The BFF appointment crasher
“I hope you don’t mind, but I brought my best friend.”
When a patient drags her excited friend (whom the doctor has never seen before) into their appointment and asks the doctor to “quickly do her tear troughs”, it’s a nightmare for the doctor. The same applies to mothers with their daughters, and wives sneaking in the hen-pecked husband. Doctors must not be pressured by these unplanned requests – for medico-legal, ethical, and safety reasons. It’s a clear no.
An aesthetic doctor should also consider the wisdom of saying no to having two patients in the treatment room at once. It can be distracting, making it difficult to concentrate, which may lead to confusion and mistakes.
Please don’t put your aesthetic doctor under this sort of pressure unless you want yourself and your BFF to walk out with matching complications!
The no-bruising brigade
“Promise me I won’t bruise.”
Patients often ask if they will get a bruise. The answer is, “Yes, of course! If I stick a sharp needle in your skin, you’ll bruise. And if you don’t, consider it a bonus – maybe even a miracle!”
The human body boasts a network of over 100,000 km of blood vessels, particularly rich in the head and neck area.
While there are ways to minimise the risk of bruising, if a patient insists on no bruising and has a big event coming up, it’s time to put your syringe down and say no to the needle.
Suggest they reschedule it for a time when they’re not trying to outshine the disco ball at their best friend’s wedding.
Reinventing anatomy
“Roll out the Russian lips!”
Sometimes, patients ask their aesthetic doctor to perform treatments that are not anatomically sound. When patients expect their doctor to change or remove natural anatomy – like a 25-year-old wanting the “snatched look” with fat dissolving in the submental area, only to find they have a submandibular gland there (sorry!). Or when they don’t want trapezius muscles so their neck can look long and thin – like Barbie. Russian lips typically appear flat, with the loss of the natural 3D curve of the lip tubercles and an unnaturally sharp border.
A good doctor will say no and explain why: science, safety, and anatomy always come first.
The prescription parade
“Won’t you quickly write me a script for my Ritalin? The psychiatrist charges so much for a prescription.”
Aesthetic doctors are inundated with requests for scripts for sleeping pills, antidepressants, antibiotics, analgesics, diet pills, HRT, birth control, cortisone cream, you name it. Most of the time, the aesthetic doctor should be saying no to writing these scripts, advising their patients to ask their family GP or appropriate specialist.
Physician autonomy
Are doctors allowed to say no?
“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.” – American Medical Association’s (AMA) Principles of Medical Ethics. Principle VI
Doctors are entitled to a safe work environment and can stop offering services to a patient who doesn’t adhere to patient responsibilities. The Health Professions Council of South Africa (HPCSA) states that a doctor can refuse to treat a patient for personal reasons, if on reasonable grounds, provided that the patient is not abandoned and is given a referral to an alternative provider.
In private practice, doctors may refuse to treat in cases of non-payment or outstanding bills, provided it doesn’t result in abandonment of care without appropriate notice or referral.
However, the HPCSA also states that a doctor cannot refuse to treat a patient based on race, gender, age, disability, ethnic or social origin, sexual orientation, religion, belief, culture, language, or birth status. Refusal to treat would violate anti-discrimination laws.
But what about other reasons – such as a patient being rude to staff, consistently late, or having been abusive on social media? Could these also be reasons to refuse further care?
It’s important for doctors to have comprehensive terms of service (ToS) that address the key requirements of the Protection of Personal Information (POPI) Act. In South Africa, doctors may include terms related to the refusal of treatment in their ToS, as long as these provisions comply with legal and ethical standards.
What about emergencies?
A doctor may not refuse to provide emergency medical treatment where immediate care is necessary to prevent harm or death, regardless of the person’s ability to pay.
Practising the indirect no
An indirect no from their doctor, accompanied by an explanation, leaves most patients feeling heard and understood. Basic variations include:
- “Well, this could be an option, but let me tell you what other treatments might work well for you.”
- “I am unsure if that is best for you now, and this is why…”
But if a doctor chooses to use the word no directly, they should follow it up with an explanation that is clear and concise, but still empathetic to the patient.
Adding a touch of humour can also help diffuse tension. Remember, it’s about making the patient feel understood and cared for, even when the doctor must turn them down. “I know Dr Google seems smart, but he never passed his medical degree.”
The most difficult no
Doctor, say no to yourself!
Last, but certainly not least, doctors must recognise when it’s time to say no to themselves. It’s a lesson I’ve had to learn and re-learn over a medical career of more than 30 years.
Know your limits
As doctors, we must be attuned to our own well-being and energy levels. If a doctor is tired, overwhelmed, or exhausted, saying no is the safest option.
Just the other day, I was running late, and the last patient of the day came in for a mole removal. Realising she was the last patient of the day, she chimed in, “Oh great, now we have time to also do cheeks, lips, and jawline.” I promptly said no. When she asked why (since time seemed to be abundant), I simply explained that I was too tired.
Trust your gut
If a doctor is feeling uneasy or uncomfortable about a patient or dreading a procedure, they should trust their gut instinct and postpone or totally refrain from proceeding.
That tempting one last jab
Doctors, resist the urge to give that very last unnecessary injection of filler in an area that’s just been treated. Trust me, adding more filler is an open invitation to a nasty bruise. The area that has recently been injected will be hyperaemic (congested with dilated blood vessels), meaning it’s ripe and ready for a complication.
Being the hero
Aesthetic doctors should resist the temptation to fix a colleague’s bad work without being asked. The patient might love their “duck lips”, and the intervention could upset the patient. According to Murphy’s law of aesthetics, it’ll end up with an unhappy patient, a complication, and bad relations with colleagues.
If a doctor is tempted to be the hero and fix a colleague’s mistake, the right thing to do is communicate with the colleague. The original doctor needs to be aware of the problem and ideally manage it themselves. If a doctor manages a colleague’s complication, it should be done in an open and honest consultation with them.
Falling prey to body dysmorphia and perception drift
Aesthetic doctors themselves need to be acutely aware of the risks of falling prey to body dysmorphia and perception drift. While the incidence of BDD in the general population is around 2%, it skyrockets to 16% among aesthetic doctors!
That’s an eye-opening statistic, and clearly, many of the pros are already overdoing it! There is pressure on aesthetic doctors to look their best, produce results, and keep up with industry trends, which can push them to have too many personal procedures.
Unfortunately, doctors with skewed perceptions are more likely to recommend or perform unnecessary or excessive procedures on their patients, leading to potential alienation of their features.
Aesthetic doctors should aim to be a healthy example for their patients. Maintaining a balanced and realistic – as well as age-appropriate – approach to aesthetics is crucial for professional integrity and the long-term trust of patients.
Conclusion
Half of the troubles of this life can be traced to saying yes too quickly and not saying no soon enough.” – Josh Billings, American humourist.
The doctor-patient relationship is one of mutual trust and respect. If this doesn’t exist, the relationship won’t be beneficial for either party, with potentially unfavourable outcomes.
Sometimes, saying no is not only permissible but necessary to safeguard the well-being of patients. While patient satisfaction hinges on understanding and effective communication, the first duty of a physician is to “do no harm” – and this often means saying no.
References:
- Health Professions Council of South Africa (2021). Guidelines for Good Practice in the Health Care Professions: General Ethical Guidelines for the Health Care Professions. Booklet 1. doi: https://www.hpcsa.co.za/Uploads/professional_practice/ethics/Booklet_1_Guidelines_for_Good_Practice_vDec_2021.pdf
- Health Professions Council of South Africa (2016). Guidelines for Good Practice in the Health Care Professions: Ethical and Professional Rules of the Health Professions Council of South Africa. Booklet 2. doi: https://www.hpcsa.co.za/Uploads/professional_practice/ethics/Booklet_2_Generic_Ethical_Rules_with_anexures.pdf
Q: When should an aesthetic doctor refuse treatment?
A: An aesthetic doctor should refuse treatment when it is unsafe, unethical, or medically inappropriate. This includes situations where the patient has unrealistic expectations, underlying medical conditions, body dysmorphia, or requests procedures that could cause harm.
Q: Can a doctor say no to a patient’s request in aesthetic medicine?
A: Yes. Doctors are ethically and legally obliged to say no when a treatment would put a patient’s health or wellbeing at risk, when it falls outside their scope of practice, or when it involves unregistered products.
Q: Why is saying no important in aesthetic medicine?
A: Saying no protects both the patient and the doctor. It ensures treatments are safe, ethical, and based on evidence. It also helps manage expectations, safeguard mental health, and maintain trust in the doctor–patient relationship.
Q: What are examples of when aesthetic doctors may decline treatment?
A: Examples include patients seeking “quick fixes” before big events, asking for unrealistic celebrity features, pushing for discounted treatments, ignoring aftercare instructions, or being influenced by unsafe social media trends.
Q: Can doctors refuse treatment for personal reasons?
A: According to the HPCSA, doctors may refuse treatment on reasonable personal grounds, such as non-payment or abusive behaviour, provided patients are not abandoned and are referred to another healthcare provider.
MBBCh (Rand) Dip Pall Med (cUK) M Phil Pall Med (UCT) Adv Dip Aesthetic Med (FPD)
Dr Debbie Norval graduated as a medical doctor from the University of the Witwatersrand, in 1991. Post graduate training includes a Diploma in Palliative Medicine through the University of Wales, Masters of Philosophy from the University of Cape Town, an Advanced Diploma in Aesthetic Medicine through the Foundation for Professional Development and a City and Guilds Diploma in Adult Teaching and Training.
Dr Norval is the convenor of the Johannesburg Aesthetic Doctors Journal Club and previously sat on the scientific committee of the Aesthetic Medicine Congress of South Africa (AMCSA). She is the Past President of the Aesthetic and Anti-Aging Medicine Society of South Africa (AAMSSA) and also served on the International Advisory Board of CMAC (Complications in Medical Aesthetics Collaborative).
“Dr Debbie Norval Aesthetics” is a busy clinical practice in Parktown North, Johannesburg.
Please note Dr Debbie is not taking on new patients at this time.
- Dr Debbie Norvalhttps://www.aestheticappointment.co.za/author/dr-debbie-norval
- Dr Debbie Norvalhttps://www.aestheticappointment.co.za/author/dr-debbie-norval
- Dr Debbie Norvalhttps://www.aestheticappointment.co.za/author/dr-debbie-norval
- Dr Debbie Norvalhttps://www.aestheticappointment.co.za/author/dr-debbie-norval
