Saying no is hard. Even harder if you happen to be kind. You want to help, to make people smile, you want them to like you. Saying no doesn’t come easy.

We’ve never been taught to say no. Ever since we were toddlers, we’ve been conditioned to say yes. Rolling on the floor in a temper tantrum to express our no was a no-no. People don’t like you if you say no. Say yes if you want to have friends.

In cultures that treasure harmony above all else, saying no is perceived as rude and avoided. Japanese, for example, will say “Chotto” – a little bit – instead of no. Say you’re in Kyoto, trying to buy tickets for the 3:05 to Osaka, and there’s none left. The clerk will smile, fret, fake a complex seizure, rub his hands in distress, look at the Emperor’s picture and mumble: Chotto, then disappear rather than say no.

What he’s trying to say is: there are no tickets for the 3:05 to Osaka. Not a little bit, not a few of them, nothing. Zilch. But he can’t bring himself to say it, because he doesn’t want to be rude to you. That’s nice, but that won’t get you a ticket. Nor will it tell you there’s no ticket, so you can book a hotel room and try again tomorrow. Or go to Tokyo instead. Nope. I mean, Chotto.

Saying no is even harder for us doctors, since healing and helping is our whole raison d’etre. Saying no, especially to patients, feels like we’re abdicating our responsibilities.

For me, as an ER doc, saying no may be easier than most. First, I don’t have long-term relationships with most of my patients, to make me feel like refusing a friend. Plus, we’re often tired, overwhelmed, and frustrated enough to lose some of our need to please. Our priorities are clear: 1. Keep them alive 2. Make it to the bathroom before it’s too late. 3. Move the meat.

Still, saying no comes with consequences.

Your patients won’t like it. Nor will their families.  As soon as you say no to that Percocet script, that unwarranted admission, or that non-urgent MRI, they’ll question your judgment, ask for another doctor, or burst out in four-letter words. They’ll threaten you with a lawsuit. They may key your car, or become violent, putting your staff in danger.

They may ask for the patient advocate. That will buy you a tete-a-tete with your boss, drop your Press Ganey’s, and ding your compensation. All in all, no good news.

Saying no to friends, neighbors, and staff is even harder. They need advice on that pain in their knee. They need somebody to look at their rash. They want you to write a Z-pak script for their cough. You’d love to help them, but you know better. Your malpractice won’t cover you, and if things turn bad, you’re screwed. You don’t want to do it, but you hate saying no.

There are volunteer activities. Your kids need a chaperone for their field trip. The EMTs need a medical director. The library needs a speaker. You want to help, but you’re overbooked. You know you’re burning the candle at both ends.

The hardest of all is saying no to a colleague who needs help. They ask you to cover their shift to visit their sick friend. They need you to come in early so they can take the dog to the vet.  They request a switch that takes away your only free weekend that month, to attend their daughter’s violin concerto. So, for the most part, unless you’re one of those assholes, you do it, whatever it costs. And it costs a lot.

It costs your peace at home. Your spouse made plans for that weekend months ago. He won’t be happy. You promised the kids to take them skiing. They’ll be stuck with their cellphones instead. You told your mom you’d drive to see her. She’ll have to wait for another month.

It costs your well – being. You’ll have to skip your workout, forgo the beer with your friends, or cut your time between shifts. You’ll have to give up the things that keep you sane.

Eventually, it costs you your self-respect. Saying yes again and again, at a cost to your family and yourself, will make you feel used. And maybe you are. You’ll feel taken for granted and disrespected.

Saying yes is expensive. It comes at a cost to your time, your peace of mind, to your family, and your self-respect.

How about saying no? Everybody does it all the time. Why not you?

It’s uncomfortable. But then, so are many other things you do every day. From pediatric codes to fecal disimpactions, from debriding wounds to performing pelvics on bariatric stretchers, none of them is fun. But you do it because it’s your job. Liking has nothing to do with it.

How about saying no as another uncomfortable but necessary procedure in your arsenal? Accept that it’s unpleasant, steel yourself to do it, then do it. Nicely. Just like you smile politely and do that pelvic, debride that wound or open that abscess, you smile politely and say no. Unlike most other procedures, you can practice in the mirror.

“I’m sorry, but my malpractice insurance won’t allow me to write that script.”

“Our policy is to not prescribe opiates for chronic pain.”

“My family is counting on me, so I can’t take that shift.”

How to say no?

Firmly. No “I’m afraid that I might have to decline” or “I’m not sure.” Just say no.

Briefly. Don’t go into lengthy explanations. “no” is a sentence.

Honestly. You don’t need to explain, and you don’t want to lie.

Suggest alternatives if you can. “Motrin works great for back pain.” “Your doctor will order the MRI if they deem it necessary.” “I’d be happy to look at some three-way shift that will help you, but I can’t do that day.”

Then smile, nod, and walk away. You did the best you could: You performed the uncomfortable procedure of saying no. Nobody died. Your family will be glad. You’ll get more respect from those who take you for granted, and you may find yourself under less pressure.

Rada Jones is an emergency physician and can be reached at her self-titled site, RadaJonesMD, and on Twitter @jonesrada. She is the author of Stay Away From My ER, and other fun bits of wisdom, Mercy, and Overdose.

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