How to Say "No" to Partners and Staff

Jeffrey J. Denning


February 10, 2010


It's my experience that physicians are often reluctant to be direct -- with each other, their employees, or the hospital -- when the answer needs to be "no."

Turning down staff and colleague requests is a real problem for some doctors, especially those in solo practice. Even doctors who may be aggressive or assertive in other situations may be "soft touches" for staff, and wind up being victimized again and again. At least in a group, there is more likely to be one doctor who's willing to take a little heat when the answer has to be no.

Here are some situations in which I've seen doctors have a tough time denying a request; I've also included suggestions for what they should have said and done.

"My Partner Is Retiring and Wants Me to Buy Him Out. How Much Should I Pay Him?"

Rule number one: You don't have to buy things just because people want to sell them. In a group of 3 or more, it's desirable for partners to protect each other with a buy-sell agreement to cover death, disability, or retirement. However, one of the drawbacks of a 2-physician practice is that promises cannot be made to each other in this area, because one physician won't need (or be able to pay for) the practice of the other in most cases.

So, if there's no prearranged buyout, what should you pay? Little or nothing. It will be a nice gesture to the widow or to a friend to help him sell his practice to someone else. However, you shouldn't feel obligated to make up for someone else's failure to plan ahead.

"My Manager Wants Me to Let Them Put the Phones on the Answering Service at Lunchtime."

Or, they want you to add a new nonstandard holiday to your list of holidays. Or, they want to close early during the summer. Actually, there's no end to the perks that we've seen staff members request.

When it comes to benefits, employees often lobby hard for more. They may tell you that "most other practices offer the benefit." Then you worry that you might lose them to a competitor, or you question whether you're being too hard-nosed.

Giving employees added time off costs a lot in lost productivity. Closing the office at noon makes a practice less accessible to patients and referral sources. If the compensation package and working conditions are competitive with the market, then you should tell the manager and staff that what they are requesting will harm the practice, which won't be good for them in the long run.

One answer that I like is: "I wish we could all get paychecks and not work at all, but life just doesn't work that way."

"My Best Nurse Wants a Raise."

Exceptional employees are so rare; many doctors think that they need to agree to every request to avoid upsetting the staff member and the office atmosphere. However, in most cases, when employees are really good, it's because they are motivated by higher-order needs than money.

If the only way an employee can get a raise is to ask for one, then the practice has set itself up for this problem. However, if the doctors and manager have done their homework, know what the competitive market rate for each employee is, and have used that information in annual wage reviews, the staff member needs to be reminded of that.

Still, you shouldn't just gloss over the request either. In this situation, you can be right and still lose. Assuming that the compensation package is competitive, you can take the opportunity to expand the dialogue a bit: "As you know, I take a lot of care to pay everyone here fairly, so it sounds to me like there's something else bothering you. Is there anything else I can help with?"

"Our Lease Is Up, and My Landlord Wants Me to Renew It, With an Increase in the Rent, for Another 10 Years."

Rule number two: Don't sign contracts just because people want you to. Be sure you get something in return.

Sure the landlord wants a new lease, at a higher rate, with, maybe, a backrub thrown in. However, he also wants to keep you as a tenant if the market is competitive. If a good tenant leaves, most medical offices will likely sit vacant for a time and need expensive renovations before a new tenant moves in.

Use that advantage to negotiate advantages, such as lower rent, refurbishment, and extensive remodeling. You can also keep your options open by ignoring the requests for a new lease, paying month to month instead. Your leverage in this situation depends on the real-estate scene in your location. If folks are lined up to get space in your building, you will probably be less aggressive in your negotiations. If your building has empty space available, take courage in holding the line on rent increases or in requesting suite improvement.

"My Office Manager Wants to Cut Back to 4 Days a Week in Lieu of a Raise."

There are so many problems here that it's difficult to know where to start. First, what raise? The manager has neatly proposed 2 options that benefit him or her -- more money or more time off. Second, do the math. Cutting 1 day a week is the equivalent of a 25% raise in base pay. Since when do practices offer those kinds of raises?

Of note, the proposal assumes that a practice can do without a manager some of the time. It reveals that the manager doesn't really understand the main jobs: supervising the workers and helping them do the work.

The position of manager cannot be well executed as a part-time job. To deal with this request, not only should you say "no," but you should give a refresher session on his or her job description.

"The IPA Has Announced That We Will Be Capitated Effective the First of Next Quarter. Is This Rate Okay?"

I've seen a lot of doctors sign really ugly managed care contracts because they assume that it's a "take-it or leave-it" deal. They seem to have too much respect for "standard" contracts.

All contracts are negotiable. You might not get what you ask for, and sometimes they'll flat-out decline your requests, but it's worth trying.

The process is actually quite easy. Just cross out the parts that you object to; change terms you feel strongly about; and add language that will protect you. Then sign, date, and return the document. If your changes aren't acceptable, you'll hear about it and the give and take will begin. However, don't automatically assume that the party with the lawyer and word processor has all the power.

"My Hospital CEO Wants Me to Lease Space in Their Satellite Medical Office Building."

You can often see the advantages to a hospital from making incursions into another's territory, and physicians often feel a debt of loyalty to their hospitals. However, you need to evaluate all business propositions on the basis of their business merits in terms of what's best for your practice.

That means adopting a selfish point of view. Maybe that's why this is so tough for so many physicians. Medicine is a humanitarian profession, after all. Many physicians who I've met don't agree with the premise that free-market economics assumes that all parties will maximize self-interest.

Gauge All Requests Against Your Business Plan

Before responding to any proposal, ask: "How will this benefit my practice? Could this actually harm the practice? Will failure to do this harm the practice?"

Before saying no, I recommend listening to all propositions carefully and respectfully. The odds are that most proposals will be rejects because the other parties aren't familiar with your business plan. Bringing you something that will advance your strategy will be a matter of dumb luck on their part.

However, if you have no plan and no evaluation context, it will be harder for you to decide which proposals are winners and which are likely losers.

Consider using your practice management consultant to help you gauge requests and business proposals. We often take on the role of "coach" as our clients get to know us better; we help them resist (or agree to, where appropriate) some of the questionable propositions that come their way.

Jeffrey J. Denning is a Principal Management Consultant with Practice Performance Group, La Jolla, California. Since entering the field in 1971, Mr. Denning has worked in a consulting capacity with more than 300 practices representing over 1000 physicians in 40 states; has conducted more than 500 workshops, seminars, and speaking engagements in the United States and Australia; and written over 30 feature articles for leading industry publications. They include Medical Economics, OBG Management, Pediatric Management, Managed Care, California Physician, and numerous specialty -academic journals. Mr. Denning is also Editor of UnCommon Sense®, a monthly practice management strategy and tactics information service of Practice Performance Publishing, Inc. Mr. Denning can be reached at 858-459-7878 or via the Web at