Saying "Yes" to Saying "No": A Conceptual Framework for Setting Boundaries in Plastic Surgical Practice

In most clinical specialties, including plastic surgery, saying "no" to unnecessary, ill-timed, or simply frivolous referrals is discouraged and never taught. Carried forward into practice, this inability leads to overwhelming workloads, chaotic schedules, loss of professional autonomy, and exhaustion-well-known triggers for burnout. Providing communication tools to politely frame a refusal without jeopardizing professional relationships is essential.

This narrative review provided a broad overview of existing literature on the topic across medical and nonmedical customer-service sectors, combined with the authors' own experience. It established a context for a comprehensive summary and used the available material to create vignette-based training modules for residents and junior attendings.

Specifically, the traditional teaching is to always say yes to all clinical consults, no matter what they are or how overworked one already is. In contrast, publications on physician-burnout strongly recommend setting boundaries, none of which teach physicians how to do so. Although communication skills are taught during training, specific skills for politely refusing referrals, especially if inappropriate or ill-timed, are lacking.

Using the reviewed material and our experience, a rich source of teaching materials, including clinical vignettes, was created that can be used by program leaders and younger faculty to say "no," while maintaining honesty, professionalism, and positive referral relationships. Removing the stigma of self-guilt associated with saying "no" when appropriate, and doing so via clear and respectful communication, builds credibility, maintains professional autonomy, demonstrates integrity, and also ensures that patients receive the best possible care.