Saying No Is Most of the Job

A patient once told me, not unkindly, that I was the first surgeon who had tried to talk him out of something.

He had come for eyelid surgery. He did not need eyelid surgery. What he needed was to be told, by someone with no reason to flatter him, that the thing he disliked about his face was not going to be fixed by an operation on his eyelids — and that having one anyway would leave him with the same complaint plus a recovery period.

He was mildly annoyed. He also came back two years later, when he did need something, and by then he trusted the answer.

The incentive problem, stated plainly

Private surgical practice contains an incentive that everyone in it recognises and few discuss in public. A surgeon is paid to operate. The consultation is priced as a formality; the theatre list is where the economics live. Nobody sets out to exploit that, and the overwhelming majority of consultants do not. But it would be naive to pretend a structural bias does not exist when the person assessing whether you need surgery is the person who would perform it.

The only real defence is to make refusal ordinary. Not heroic, not a story you tell about yourself — routine. A meaningful fraction of the people who come to me for a surgical opinion leave with advice to wait, or to do nothing, or to see somebody else entirely.

What “no” usually means

It is worth saying that declining to operate is rarely a dramatic moral moment. It is usually one of four dull things:

Not yet. The cataract is there but it is not what is limiting you. Come back when it is.

Not this. The symptom is real; the operation you have read about will not address it.

Not me. This is a complex orbital case and there is someone two hours away who does forty a year to my four. Go to them.

Not ever. The risk profile does not justify the gain in your particular eye, and it will not later either.

None of those are interesting. All of them are the job.

The thing that actually gets recommended

There is a commercial argument here too, for anyone who finds the ethical one insufficient. The patients who send me the most referrals are not, in general, the ones on whom I operated brilliantly. They are the ones I turned away.

People remember being told the truth by someone who stood to gain from telling them something else. It is a strange sort of marketing, and I would not recommend building a practice on it deliberately. But it is real, and it has outlasted every other kind of reputation I have had.

The operation is the easy part. It always was.