The Last Word: Saying No

By Dr MJ Rowland-Warmann / 07 Jun 2019

Dr MJ Rowland-Warmann shares her views on when and why aesthetic practitioners should be saying no to patients

Facial rejuvenation accounts for more than 10 million procedures worldwide with the global aesthetics market projected to reach over $17 billion by 2023; within this, the largest share is facial aesthetics.1,2 It’s therefore no surprise that practitioners want to be part of this developing industry. However, it seems that the aesthetics specialty in particular is subject to patients dictating more than they likely would in any other medical profession. For example, it is not uncommon for a patient to present in clinic asking for a specific amount of lip filler or asking for a particular product. I believe that this is possibly in part due to the fact that our discipline is exclusively elective and our patients are fee-paying.

When should we say no?

There is no denying that patients sometimes aren’t suitable for treatments and there are a number of reasons to say no. These include unrealistic expectations, signs of body dysmorphic disorder or an incompatibility with the patient and practitioner. However, within this article I will focus on why and how we should say no when the patient has asked for a treatment that is outside of the practitioner’s scope of practice or experience. I have found that it is often this which results in bad outcomes and conflict between patient and professional.

The difficult choice

The practitioner stands before a difficult decision when declining the patient for treatment; say no, and risk the patient going elsewhere, or say yes, and risk a bad outcome. The upshot of which may be serious harm to the patient, or a costly legal battle.

It’s difficult to be the practitioner who turns a patient down, knowing the patient may go to another practice and potentially put their health at risk. It loses business and many practitioners think if someone should treat, it should be them. The patient is sitting there with a bag of money and someone should take it, right? Wrong.

Hubris may get the better of some practitioners, ignoring caution and ‘giving it a shot’ when they don’t have the experience. For example, a one-day training course may have left them ill-prepared not just technically, but also for selecting patients appropriate for the procedure. Likewise, they may have treated a similar area and think that they will be skilled in another area or may have observed a treatment and feel comfortable in replicating this. I believe that treating patients in these circumstances is not going to do anyone’s business any good. It’s likely to lead to dissatisfied patients and poor outcomes, both of which will have substantially negative consequences for business compared with the immediate win of a few hundred pounds gross margin. Many of us in this specialty would agree that an unhappy patient is a reputational landmine.

According to a report by customer experience research company, the Temkin Group, after a good experience, 23% of people are likely to tell their friends. After a bad experience, this rises to 32% and the failure to manage negative outcomes can result in reputations being left in tatters.5 Bad publicity is simply more virulent than good publicity and can leave lasting damage to businesses.6

The solution

The solutions are easier said than done, as most will mean sacrificing immediate income for the sake of the long-term gain. Just remember, quick wins don’t build an Empire; meticulous planning, intensive training and careful execution do.

In my opinion, mentorship can significantly reduce risk whilst improving skill level. This is widely accepted in every branch of medicine and dentistry, however it is only recently coming to the fore in aesthetics. With that in mind, there are currently a number of associations that are offering these schemes and something that I would advise looking into. With a good mentor, practitioners can treat cases in their own setting, improve their skills and retain business.

I believe that the interplay between clinical ability and case selection can be rehearsed with an appropriately experienced guide, leading to fewer complications due to inappropriate treatment. A good mentor is not one who takes cases away from budding clinicians, but one who supports, guides and develops. I think I speak for most experienced colleagues when I say that I’d rather mentor practitioners to improve skill and avoid complications than to have to receive the referrals when they’ve gone wrong due to inexperience.

It takes an enlightened practitioner to refer to someone else because the patient’s needs are beyond their scope of practice. In my opinion, it shows honesty and integrity as a practitioner. A recommendation against your interests and to someone outside your business creates an enormous amount of emotional capital and these referred individuals will value your honesty and not only refer their friends to you, but, in my experience, will likely return to you at some point.7

Proud of ‘no’

It’s ok to say no; after all, aesthetic treatments are largely elective and not having a treatment never hurt anyone. Reputationally, I would say that it’s actually better to be known as the practitioner who says ‘no’. Patients trust people who demonstrate authority and follow their suggestions. This is because it shows confidence, strong clinical judgement and creates credibility in the eyes of patients.8 In my personal experience, my patient base has been shaped as a result of me saying no and the patients that I do treat have become great ambassadors of my brand. I can also sleep at night knowing I am causing no harm.


In few other medical disciplines do patients dictate so much to professionals; it’s a problem endemic to aesthetics. It’s degrading and commoditising aesthetic medicine. I think that it’s time practitioners think about what direction our industry is heading in, and help correct the course of patient perception to a more favourable and safer path.

There is no reason why aesthetics should be any different to other branches of medicine. Practitioners should always stand their ground on what they believe is ethical, appropriate and defensible. They should be empowered to decline patients for treatment under suitable circumstances. I believe that the long-term benefits of saying no outweigh the short-term financial rewards. 

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