How to Say “No” to a Patient

In his seminal book, “How to Win Friends and Influence People,” Dale Carnegie wrote: “Tomorrow you may want to persuade somebody to do something. Before you speak, pause and ask yourself: ‘How can I make this person want to do it?’” This is undoubtedly a sentiment to which every physical therapist, occupational therapist, and speech-language pathologist can relate. After all, when treating any patient, motivating them (i.e., making them want to stick with therapy) is half the battle. So, when a patient is resistant to your treatment plan—or makes demands that outright contradict evidence-based practice—nurturing motivation and buy-in becomes your first priority.

To that end, we’ve asked some industry experts to weigh in on how to approach these sticky situations—and how to steer patients in the direction they need to go without completely invalidating their feelings and concerns. To that end, here’s how to say “no” to a patient—without really saying “no.”  

1. Seek understanding from the get-go.

When it comes to dealing with difficult patients—or difficult people in general—it’s all too easy to go on the offensive and reinforce your authority and expertise. However, this approach is unlikely to produce the results you’re after. Even if the patient relents, chances are their opinions haven’t changed—they’ve simply stopped vocalizing them. After a while, those internalized frustrations begin to fester and breed distrust and resentment, which is the last thing you want in a patient.

Cater to the primal need to be understood and accepted.

Instead, reframe your approach as an opportunity to influence and understand. According to Scott Hebert, PT, DPT, Senior Director of Product Management at WebPT, “In order to influence, you have to understand two key primal urges people have: the need to be understood and the desire to be accepted. Embrace this and use it to your advantage.” Hebert further explains that “your goal should be to listen intently, demonstrate empathy, and show a sincere desire to better understand what they want and why.”

That said, there may be times when a patient has strong beliefs that interfere with your treatment plan. In those instances, “take a moment to pause, step back, and listen,” Hebert advises. “Take your time to uncover why the individual has these beliefs and what the real drivers are. Then, use open-ended questions to better understand their position.”

Employ active listening with every patient—not just the difficult ones. 

For Dianne Jewell, PT, DPT, Ph.D., FAPTA, President and CEO of Sheltering Arms Physical Rehabilitation Centers, the patient’s first visit is the perfect moment to have this conversation—and she advises having it with every patient to (ideally) avoid conflict in the first place. As she explains, therapists are more likely to avoid a difficult situation if they do the following on the first visit:

• Ask patients what they know about their condition and how to treat it. “That may unearth issues like a treatment technique they read about online that you can respond to before it becomes a disagreement,” Jewell says.
• Describe how you use evidence to guide your decisions to use—or not use—certain treatment techniques.
• Explain how you will determine what is safe or unsafe (e.g., risk of injury, risk of symptoms reoccurring, compliance with physician’s orders, etc.).
• Listen carefully to the patient when asking them about therapy goals so you can manage their expectations. As Jewell explains, “Statements like ‘I want to be able to play in the next home game in two weeks’ when the prognosis for recovery indicates at least four weeks is necessary is a clue to intervene and explain why that isn’t likely or wise.”

2. Leverage “tactical empathy.”

In his book, “Never Split the Difference,” Chris Voss discusses the concept of tactical empathy, which amounts to:

• recognizing a person’s perspective, and 
• vocalizing that recognition.

Root out the emotional source of the patient’s behavior.

When employing tactical empathy with a difficult patient, your end goal should be to truly empathize and acknowledge your understanding of why they feel the way they do. Hebert explains, “In many cases, there's a strong emotional component to someone's recovery—whether it’s pain, fear, stress, grief, anger, or all of the above—and it’s important to recognize these emotions and get to the thought process behind them.” These thoughts are often the true source of the patient’s aversion.

Once you’ve identified the root cause, validate their concerns by using empathetic language. Statements that begin with “it seems like,” “it sounds like,” or “it looks like” are great for demonstrating active listening. “Once these negative emotions are identified, neutralize them using a positive, compassionate, and solution-based approach,” Hebert says.

Use your expertise and experience to address the patient’s fears.

Let’s say you have a post-operative patient recovering from an ACL tear whose goal is to get back on the basketball court—but they insist on advancing through their post-op protocol faster than their surgeon wants. By using tactical empathy, you may find that this individual is worried about the impact this injury will have on future prospects (e.g., a college scholarship or their spot on the school team). Once you understand that their fear is rooted in concern for their future, you can validate and respond directly to the source of fear by saying something like, “It seems like the fear that this may impact your prospects of playing college ball is what’s driving you to move through therapy too quickly.”

After receiving the patient’s acknowledgment, follow up with a positive, compassionate, solution-based statement such as, “I’ve worked with a lot of athletes—many of whom have experienced the stress and anxiety that comes with recovering from a serious injury. I know you’re worried that any delays will impact future playing prospects, but injury during the recovery process is the number-one reason for a long recovery time. Our goal is to make sure that doesn’t happen so we can get you back on the field as quickly as possible.”

As Hebert puts it, “By working to understand the true emotional driver, you can reposition your ‘why’ to better match the patient’s needs.”

3. Refer the patient to another provider—if necessary.

Depending on the situation, it may be appropriate to refer the patient to a different provider. Per Jewell, “If practice leadership supports it, the therapist may even be able to refer the patient to a colleague in a different practice. If there is a referring physician in the mix, then communication with the doctor also may be indicated.”

If this type of scenario plays out, it’s vital to frame the conversation as an opportunity to connect the patient with the right provider. After all, the difficulty may come down to a simple difference in communication style, and the patient may find it easier to connect with a provider who has a complementary way of communicating. For example, a patient from a different cultural background may communicate in a way that seems challenging from your perspective, but it could simply boil down to cultural differences or even a language barrier. However, a therapist who is familiar with—or better yet, part of—the patient’s culture or who speaks the patient’s first language is likely better equipped to relate and communicate past these barriers. (This is also why diversity and cultural sensitivity among rehab therapists are absolutely essential.)

4. Defer to company policy.

Many practices have an established procedure for handling difficult or demanding patients. According to Jewell, “The practice leader or leadership team should set the tone for these situations. The company culture and/or specifics in policies and procedures should be a therapist’s guide, because the goal is to keep the patient a ‘raving fan’—even when you have to say no.”

Moreover, some practices prefer to have a manager step in to mediate patient-provider disagreements. Others may include language in their informed consent paperwork that mandates patient compliance with the set treatment plan. “The challenge there is that most patients don’t read the fine print, and most front desk staff and therapists don’t review the details,” Jewell explains. “Nevertheless, it’s good for a therapist to know the content of that document if it exists.”

5. Get introspective.

Finally, whenever you have a difficult patient, it’s always important to look inward and reflect on any personal areas of opportunity. Hebert notes, “If all your patients are difficult patients, it probably means you’re a difficult therapist. Being a rehab therapist is a tough job. Constant pressure around efficiencies and the stress of documentation can make it tough to get through the day.” However, it’s absolutely essential to examine your own role as the provider before passing blame to the patient.

According to Sarah Lyon, OTR/L, the owner of OT Potential, “When the therapist-client relationship is on the rocks, the first questions you need to ask are of yourself. Maybe the situation is pushing you to lean more into the values of participatory medicine. Or, maybe a self-management approach is needed.” Only once you’ve done this self-work should you sit down with the patient and talk candidly about the situation. 

When it comes to working with a difficult patient, empathy and active listening can go a long way—a view expressed by Dale Carnegie himself. Ultimately, every person—your patients included—craves understanding and desires to be heard. And if you keep that in mind during every patient interaction, it’ll undoubtedly pay off.