The Power of No: The Importance of Setting Boundaries and Realistic Goals

Educational Objectives

The goal of this program is to improve personal decision-making. After hearing and assimilating this program, the clinician will be better able to:

1. Note key factors associated with working toward achieving a promotion vs tenure.
2. Focus on qualities most valuable with regard to achievement of career goals.
3. Evaluate reasons which permit or prevent an individual from saying “yes” to an opportunity.
4. Recognize a people pleaser.
5. Use appropriate strategies to say “no” to an opportunity.

Summary

Importance of time: time is finite and shared between career, family, and self; having goals and priorities of wellness is not considered selfish, and no guilt should be associated with putting oneself first; it is best to look forward, make an aligned list of answers to use as opportunities arise, and curate and focus on what personally makes the most sense

Art of saying “no”: mastery of the art of saying “no” improves an individual’s abilities to direct career and personal life, and direct focus away from de-energizing individuals and negative interactions; Steve Jobs: "It is by saying no that you can concentrate on the things that are really important"; Warren Buffet: "The difference between successful and very successful people is that very successful people say no to almost everything"; Greg McKeown: “If individuals do not prioritize their life, somebody else will”

Know when to say “yes”: have a “yes” list before mastering how to say “no”; knowing when to say “yes” helps establish personal boundaries; identifying personally important details facilitates saying “yes” to only the aligning opportunities; in cases where aligning opportunities fail to appear, it is helpful to interact with somebody engaged in work which aligns with those personal goals and offer assistance; people generally do not say “no” to someone offering assistance; understand that it is not necessary to learn something now to be able to eventually learn how to do it; be able to say, “Is it possible with the right training and the right cultivation, I could be an effective person here or be fulfilled in that engagement?”; saying “yes” means to want to try and fail, rather than not try at all and never know; know the responsibilities for a position of interest, career trajectories and priorities, and opportunities for development, scholarly productivity, and fulfillment may not all align with personal career trajectory; however, analyze these things and be open-minded to the possibility; individuals may step down from a position at any time when personally unable to commit; avoid fearing overcommitment on tasks that may align with goals out of concern that stepping down is impossible

Promotion vs tenure: specific pillars and domains must be met for promotion within an academic pathway; it is not always necessary to take the lead; rather than seek promotion, some people prefer to remain on their current academic pathway; the clinical-minded individuals are the ones that usually step forward in order to permit others to appropriately engage in this way and to provide appropriate group task representation; if an individual desires promotion, it is important to devote time to opportunities that align with that career trajectory and avoid misaligning opportunities; avenues include research, education, teaching, and clinical and patient care service; having protected time is not always guaranteed; some institutions are removing protected time (even if already allocated) because of staff shortages and other financial constraints; focus on providing optimal work when accepting a position; it is important to know how to partner with people and delegate work; people may ask individuals to do things that align with future goals but only after a demonstration of commitment and ability to deliver; different areas of focus exist for promotion vs tenure; though excellence in all areas is not necessary, some engagement in each area is required; partnering with others is important for participation in, eg, case studies, research papers when leadership is not possible; the partnership is mentioned in the curriculum vitae and assists in promotion

Education: physicians need to take initiative to reach out regarding educational opportunities which align with career goals; nonclinical opportunities include, eg, continuous medical education, resident or fellow lectures, presentations, interdisciplinary lectures; visibility, recognition, and respect received by attending and participating in meetings are important

Service: committees exist in almost every hospital for different domains; having a voice for a particular area does not necessarily equate with leadership, as contribution through suggestions and comments also provides visibility

Leadership: though running the board can seem intimidating, it assists with understanding and engaging with individuals; consider involvement in other types of administrative duties

Busy vs productive: physicians should decide how to invest their time; professionals spend 51% of their time managing information; 90% of professionals discard documents or emails without reading them; seek career opportunities which are considered productive rather than busy; placing self-wellness before any commitment is imperative to maintain balance; physicians who are burnt out would be unable to keep any commitments; an individual cannot fully commit to work, sleep, family, fitness, and friends on a daily basis without a degree of sacrifice; Nora Roberts likened balancing commitments to juggling balls and said, “The key to juggling is to know that some of these balls are made of plastic and some are made of glass, and you need to keep the glass ones in the air…you need to prioritize catching the glass ones”

Reasons to say “yes”: include alignment with personal mission, relationship development with key leaders, networking for meaningful connections, exposure to avenues not ventured (physicians may not know the potential of an opportunity prior to its presentation), long-term benefits, engagement in fulfilling endeavors, and building skills in leadership, education, and research; short-term commitment can sometimes lead to the desired opportunity; it may be worthwhile to help someone now who may be able to assist in the future; discover personal passion; refrain from overachievement; know to say “no” unless an opportunity aligns with personal goals

Fear of saying “yes”: may arise due to fear of overcommitment, the possibility of disliking the task, poor work environment, mismatch with personal skills or career path, imposter syndrome (ie, uncertainty about personal ability to perform a task), time commitment and lack of bandwidth, perceived pressure associated with the task, inability to walk away once committed, or uncertainty about the motivation behind the opportunity

Struggle with “no”: saying “no” is neither selfish nor damaging to a relationship; being a people pleaser does not mean that everybody needs to be pleased; an individual can only make 80% of the people happy; align with someone who can act as a partner if saying “no” is a struggle to do; telling oneself that saying “no” is not an act of selfishness is a process; individuals may, eg, want to appear valuable, have a fear of missing out, be introverted; succumbing to emotional bullying and avoiding offending or disappointing individuals are in direct contrast with prioritizing self-wellness

Qualities of a people pleaser: include having trouble with disagreeing, frequently apologizing, having too many things to do at one time, feeling uncomfortable with disagreement, avoiding conflict, fearing negative emotions, sugarcoating statements, desiring to be liked, worrying too much about what other people think, and having an inability to say “no”

Pitfalls to saying “yes”: include overcommitment, burnout, and relationship stress; a need for introspection exists when an individual comes home and cannot spend meaningful time with the family or engage in personal hobbies; the divorce rate in the United States is highest among physicians; relationship stress often comes from overcommitment in relatively unimportant areas; other pitfalls to saying “yes” include inability to fulfill existing commitments or underperformance at work

Strategies for saying “no”: be direct and straightforward; start with positive statements (eg, “I appreciate the opportunity, but I cannot commit to that”); replace “no” with another word; resist the urge to offer excuses; offer an excuse only when appropriate; take ownership of the decision; ask individuals to follow-up later if unable to make a decision at that point; avoid lying about availability; offer an alternative; describe lack of bandwidth (eg, “Thank you for asking; what you are doing sounds like a valuable effort, but as I am overcommitted at this time, the only way I could make room for this is to not fulfill a commitment I already made”)

Common approaches to saying “no”: include accommodation (say “yes” when wanting to say “no”), attacking (eg, “Why are you asking me this? You are always asking me these things; why aren’t you talking to somebody else?”; reactive and defensive mechanism; it is preferable to respond rather than react), and avoidance (trying to avoid the question through any possible means)

“Positive no” approach: ie, yes-no-yes strategy; the sentence starts with a matter-of-fact assertion and declaration of intent (ie, express your “yes”), then delivers a final “no” (ie, assert your “no”), and it proceeds to seek a solution (ie, propose a “yes”); a normal “no” starts with a “no” and ends with a “no”; however, a positive “no” starts with a “yes” and ends with a “yes”, leaving a good impression at the end to open the possibility of engaging in a future project

Pearls for saying “no”: say “no” to the opportunity, not the person; request time to consider; ask clarifying questions to determine if the opportunity aligns with goals; discuss challenges to acceptance and suggest how to overcome them (includes, eg, delegating other commitments, requesting protected time or compensation, formalization of protected time); examples of responses — eg, "I absolutely support what needs to be done; however, I am fully committed; I can re-evaluate in the fall, but thanks for considering me, maybe you could try (person)", "Your project sounds valuable and exciting; I am currently seeking opportunities to do (task), as I am preparing for _______ role; if you hear of any opportunities in that area, I would be interested", "That sounds great; I do not have the bandwidth to accept another opportunity, and I committed to my family to not further commit time outside of my work, so when my current project is completed, we can re-evaluate"; have predetermined responses

Things to consider when saying “no”: always be respectful and honest; answer from a place of authentic, thoughtful consideration; do not be afraid to ask for time to consider, then follow up; discuss with a trusted mentor or friend outside of the work circle; own the decision

Seeking opportunities that align: identify leaders on an aligning career path and ask questions (rather than saying, “Commit time to me”, say “What did you do to get along this path? What types of things would you suggest?”); interact with individuals at similar career stages and support one another; set personal sights far beyond what is perceived to be achievable; reach out to the decision makers and indicate personal interest in preparing or applying for a position; frequently re-evaluate progress and opportunities

Readings

Anderson A. The art of saying yes. Am J Nurs. 2016;116(11):63-66. doi:10.1097/01.NAJ.0000505596.08697.dc; Anderson RJ, Bloch S, Armstrong M, et al. Communication between healthcare professionals and relatives of patients approaching the end-of-life: a systematic review of qualitative evidence. Palliat Med. 2019;33(8):926-941. doi:10.1177/0269216319852007; Bohn R, Short J. Measuring consumer information. International Journal of Communication. 2012;6:980–1000; Cox S. Stay focused in the frenzy. Nurs Manage. 2015;46(10):40-44. doi:10.1097/01.NUMA.0000471580.93443.60; Hertzler L. View from the top: when opportunity comes calling, be prepared to say 'yes,' says longtime leader. Biomed Instrum Technol. 2019;53(4):297-300. doi:10.2345/0899-8205-53.4.297; Hinton AO Jr, McReynolds MR, Martinez D, et al. The power of saying no. EMBO Rep. 2020;21(7):e50918. doi:10.15252/embr.202050918; Hviid K, Smith LH, Frydendall KB, et al. Visibility and social recognition as psychosocial work environment factors among cleaners in a multi-ethnic workplace intervention. Int J Environ Res Public Health. 2012;10(1):85-106. doi:10.3390/ijerph10010085; Kaufman SB, Jauk E. Healthy selfishness and pathological altruism: measuring two paradoxical forms of selfishness. Front Psychol. 2020;11:1006. doi:10.3389/fpsyg.2020.01006; Mullangi S, Blutt MJ, Ibrahim S. Is it time to reimagine academic promotion and tenure? JAMA Health Forum. 2020;1(2):e200164. doi:10.1001/jamahealthforum.2020.0164; Oxman AD, Sackett DL. Clinician-trialist rounds: 13. Ways to advance your career by saying 'no' - part 1: Why to say 'no' (nicely), and saying 'no' to email. Clin Trials. 2012;9(6):806-808. doi:10.1177/1740774512463177; Scott DM, Kelsch MP, Friesner DL. Impact of achieved tenure and promotion on faculty research productivity at a school of pharmacy. Innov Pharm. 2019;10(4):10.24926/iip.v10i4.2153. doi:10.24926/iip.v10i4.2153; Swartz TH, Abdul-Mutakabbir JC. Striving for equity in academia: embracing the power of no in decision-making. FEMS Microbiol Lett. 2023;370:fnad112. doi:10.1093/femsle/fnad112; Temoshok L. Complex coping patterns and their role in adaptation and neuroimmunomodulation: theory, methodology, and research. Ann N Y Acad Sci. 2000;917:446-455; Wang E, Golden A, Butterworth PJ. How to say no. Perm J. 2002;6(4):70-71.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Goeller was recorded at the 2023 Annual Convention and Conclave of the American Osteopathic College of Anesthesiologists, held September 30 to October 3, 2023, in Saint Petersburg, FL, and presented by the American Osteopathic College of Anesthesiologists. For information on future CME activities from this presenter, please visit https://www.aocaonline.org/. Audio Digest thanks Dr. Goeller and the American Osteopathic College of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 2.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 2.00 CE contact hours.

Lecture ID:

AN662601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.