When "No" is in your Best Interest
It’s most surgeons’ least favorite word. Well, perhaps ‘no’ is on an equal level as the statement ‘I don’t know’.
The decision whether or not to operate is perhaps the biggest decision in the surgeon-patient relationship and should be treated with gravity and thought. After all, as a relatively brash residency “ism” statement harped: “You stick ‘em, you’re stuck with ‘em”. The tone is brash, but the message has merit. If you choose to operate on a patient, it is a commitment to that patient and should be a long-term relationship. Choosing the right patients, especially in aesthetics, is essential, just as is saying no to the wrong patients.
The question sometimes is: “Should we operate at all"?” The decision to move forward with surgery is far more than based on anatomy alone. The decision is not simply about what can be done, so much as what should be done. In some instances, the best answer I can give a patient is simply “no”. It is a word not taken lightly, as there is much vulnerability from the patient in expressing a desire for cosmetic change, in making the decision to enter a surgical office, and in sharing aspects of themselves that are often insecurities. But surgery, especially aesthetic surgery, can be very powerful.
When is the right answer “No”?
- I say no when surgical expectations do not match realistic outcomes. A great result can mean something entirely different from one person to another. Deciphering what patient expectations are is critically important prior to undergoing a procedure. For example, when a 72 year old patient shows me a photo of herself at age 18 as her goal for surgery. Or, when a patient with exceedingly thicker skin shows me a little button nose. Understanding what realistic goals for surgery are is paramount. There are a number of ways to establish mutual goals within the realm of the real: 1) an honest discussion of age and anatomy appropriate outcome goals, 2) the use of morphing software in some instances, and 3) utilization of before and after photographs. All are great ways of ensuring that the surgeon and patient have the same goals. I always tell patients an adage: “If you and I share the same goal, I am much more likely to reach it”
- I say no when the emotional weight placed on the surgery is out of proportion to the rest of the sense of self. Life can be cruel. Any number of reasons - life, relational, surgical - can trigger an individual to pursue aesthetic interventions. Though not always a contraindication for surgery, it is cause for pause. Patients need to be emotionally stable and grounded prior to undergoing a surgery, especially a revision surgery. Sometimes, the answer is not quite a no, but a “not now” until the patient can get to a place where there is a level of acceptance and strength to move forward. Equally, where there is external pressure to do surgery, such as to fix relationships, to transform oneself after heartbreak, or simply high emotional states regarding outcomes, it makes me pause. Time, in most instances, is always our friend.
- I say no when the goal is not natural aesthetics. Our goal are results that whisper. Natural, balanced results. Results congruent with your holistic self. Results that look like you could have been born with them. These are the pillars to my surgical practice. This does not mean that results cannot be dramatic, however, they must be congruent. Occasionally, some desire results that would change their appearance entirely or give a more operated appearance (i.e. cat eye trends, overfilled lips, etc). Variations in aesthetic goals should be appreciated, however, if our aesthetics are not the same, I am quick to refer elsewhere.
- Lastly, I say no when there is no trust. Very occasionally, patients come in and question my judgment or recommendations, training, or age. Well intended questions regarding training or case frequency are always welcomed and encouraged, however, when I sense that there is no trust in that training or in me as a surgeon, I do not proceed with surgery. Trust is paramount. Surgery is not always a linear path - the human body is full of unpredictabilities. Complications happen even in the best of hands and are often out of our control entirely. A relationship built on trust can weather unforeseen outcomes as a team. One lacking trust is absolutely detrimental to a patient’s outcomes and is an added source of stress and anxiety, in an already difficult situation.
In conclusion, the decision to proceed with surgery is to be handled with care. The right surgeon is not always the one who agrees with everything you ask for. Sometimes, it is the one who is willing to say no, to pause, or to question. After all, surgery is a team sport, and trust in your team to help you navigate is paramount to success.
