I have been a consultant for almost six years now. I love putting on my black DFTB scrubs, waving hello to the comms clerks as I walk past triage, and doing what I think is a good job. I am no longer a new FACEM, despite what I think, and I’ve reached that point when advanced trainees are starting to ask me for career advice. I think back to what I had been told.

“Join lots of committees,” they said.

“Say yes to everything.”

Looking back, I am not so sure that this is the best advice. Has it done me any good? It has certainly helped my career. But there is much more to life than your job. Perhaps, just perhaps, it is better to learn to say no?

The first no

You may not remember your first time, but I’m pretty sure your parents do. Were you snuggly strapped into your highchair trying to figure out why you needed to open your mouth for that limp, overboiled, spear of broccoli? No, here doesn’t come the aeroplane. Were you dragging your heels around Woolworths, clad in an embarrassing mismatch of brown corduroy and mustard yellow polyester when it was time to leave the plastic heaven of the toy aisle? No, you scream as you fall to the floor in the perfect imitation of premier league midfielder. Or were you just lying there, minding your own business, enjoying the warmth of freshly laid poo in your nappy, when some do-gooder decided you needed to be naked and cold (and clean)*?

Those two letters hold such power. They are often our first show of defiance so why don’t we want to use them more as we get older? Maybe, it is the sense of embarrassment? We feel for the harassed parent as they leave their wailing child to their tantrum on the filthy linoleum. Do we then display negativity bias, our brains recalling in exquisite detail, these confronting turns? As we grow older, programmed to please, rather than upset, we choose to say yes instead.

Why? – E – S spells YES

We crave approval. Our sense of self-worth is inherently tied in with our need for acceptance by the tribe. By pleasing people, and saying yes, we then avoid conflict. It is easier to answer in the affirmative than feel the social tension of a request denied so there is this innate sense that we should conform to the norm of saying yes. If we say no they might turn their burning gaze of approval away from us and we will no longer belong. Making the active decision to say no means you are turning away from the tribe and deliberately turning down the emotional reward offered.

But, we are not responsible for other peoples feelings. If we can learn to say no, graciously, then our lives might be a little easier.

Perhaps, we say yes because it is easier than thinking through all of the options? Paralyzed by choice we answer a request on autopilot. At that exact moment in time, with your director standing in front of you, you don’t want to hesitate and so you blurt out the first thing that comes to mind.

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But by saying yes, what are you saying no to? Are you saying no to playing in the park with your children? Are you saying no to catching up with a friend that you haven’t seen for ages because they have been self-isolating? How comfortable are you with saying no to your own self-care? In the same way that we rehearse hard conversations, in our head or with friends, we can practice our new script until it becomes a new auto-response.

Let me get back to you later about that. I need to check my other commitments.

You may, indeed, want to take up the opportunity offered. But only do so after carefully weighing up the costs and benefits.

There may be a deeper, darker reason for saying yes, too. Being busy can be a way to avoid being. Living a distracted life makes it easy not to think about the hard things. I know I have been guilty of this. It is much easier to get on and write another blog post, or join that committee, or pick up that extra shift than think about where your life is heading. It is not sustainable. It is also not good self-care.

The myth of the perfect life and FOMO

In this never-off world, we are exposed to a heavily curated alternate reality – one where all of our friends are writing papers, presenting at conferences and transporting critically ill patients around the country in helicopters, all the while maintaining elegantly coiffed hair. With greasy thumbs swiping up and down our timelines, we compare ourselves to that Finsta-life and wonder why we have less. We wonder why don’t have what they are having and we feel a sense of sadness.

Patrick McGinnis called this FOMO – the Fear of Missing Out. This is a form of loss aversion and so we say yes to things because we worry that we are going to miss out on some remarkable opportunity that will catapult us into that perfect life. We worry that the opportunity will never again present itself, in part, because we find it hard to see our own merits. We think that good things only ever happen to us on account of luck or serendipity. Because we cannot always see our own goodness we rely on the validation of others. And how do we gain that validation? We say yes.

The problem with saying yes (to everything)

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It is easy to say yes. It is far easier to say yes, than no. But what does it lead to? If you say yes to everything, then nothing is important.

Tsundoku

We all have them – on the bedside cabinet, in the office, on our electronic devices – that pile of unread books, spines unbroken, stories unread. They sit there, tempting us with their bright and colourful covers. “Read me,” whisper untouched pages, knowing that once you have picked them up, you will become lost in the strange flow of time that only books can create. There is a Japanese term for this memorial of words and lost worlds – tsundoku. And, like your boss asking you to do that one extra shift, you might find it is time to say no too. Instead of saying yes to all of the books, it might be time to create what Umberto Eco would call a library of the unread. When you can find out the answer to almost any question with a click of a button, isn’t it better to know where to find things rather than to have them lodged in your own private memory palace?

While I am not denying the value of a perfect piece of fiction, it is easy to say yes to every colourful cover in the bookshop. We need to place more value on our time and learn to say no. We need to set boundaries and focus on what actually is important. What projects are sitting on your bedside table of ideas? What requests have you said yes to that are left unfinished, or perhaps not even yet started? Every time we add a new book to our tsundoku we are reminded of our failure to complete that thing we started. By saying no, you are actually committing to being able to say yes to something else.

On boundaries

When the COVID pandemic began and work shifted, from office to home, boundaries became blurred. It was easier to ‘just send a quick email‘ before closing the laptop for the night. Before you knew it, you were ensnared in a reply-all thread regarding which dressing you should stock for paediatric cannulation (Editor’s note – Tegaderm teddies, obviously) and your children were scratching at the door like extras from a George A. Romero movie. It has been hard to switch off when working from home but until someone pays me to look after my own children they cannot dictate what I do when I am not at work. Firm boundaries need to be set.

Have you ever checked your e-mail at 8pm on a school night and been tempted to respond? It’s easy, especially if you only need to dash out a couple of lines. What you are doing is eroding the boundary between work and not-work. You are setting an expectation that you will respond, even if you are not at work. I used to be that person – the one that would respond to enquiries at 10 o’clock at night. Achieving Inbox Zero would give me a teenty tiny dopamine hit. But I never considered the cost. I never considered what I could have been doing instead. I’m a huge fan of Greg McKeown’s Essentialism and responding to an e-mail late at night is just not essential. It does not need to be done.

And the funny thing is if you leave a problem for a day or two it often seems to sort itself out. Someone else volunteers for the job. The lost vein-finder shows up. Management changes their mind on PPE requirements (again). It has been a long time coming but now I say no to checking my email obsessively and just wait.

So, having considered the importance of saying NO, here is some guidance on the how.

1. Focus on the request not the feelings

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You are saying no to the ask not the asker. Don’t worry that you will hurt your bosses feelings because you are saying no to something. This is a refusal, not a rejection. All you are doing is setting boundaries. If you already have a lot on your plate ask what task they want you to de-prioritize in order to take on a new project. That way you are asking them to make the choice, not you.

Thanks for thinking of me. I’ve already got a lot a other projects on the go at the moment for you. Which one would you like me to drop?

2. What’s the alternative?

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Perhaps you have been asked to give a talk and your digital diary is full? This is an opportunity to practice allyship and show your support for a colleague that might be better placed to take on the task. We know that, despite women being in the majority in paediatrics, they are much less likely to be invited to speak at an event, or be listed as first author. This is the perfect opportunity to suggest that a colleague who is much more qualified than you take the (virtual) stage.

I’m sorry but I have a lot on next month so the answer will have to be NO. But let me give you the name fo three amazing women that would do a far better job than I ever could.

3. NO is a complete sentence

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You don’t have to say why. You do not have to over-explain. “I cannot do the extra shift because I am spending time with my family.” That is enough. You don’t need to over-explain and go into details about what you are going to do. You are setting the boundary between work and home. You just need to say no with confidence. It’s too easy to bargain with someone that over-explains.

If you do feel the need so say something after the no then make sure you use the word because. In one of those classic social psychology studies that could only be performed before the dawn of the internet a group of experimenters would approach people lining up to use a rigged photocopier. An actor, weighed down with a pile of textbooks (pre-internet, remember) would struggle to the front of the queue and ask to skip the line. Langer et al. (1978) found that just by adding the word because, the actor was much more likely to be allowed in, even if the excuse made no sense. It was the word because that seemed to work wonders.

No, because I would like to spend some time with my children.

4. Sorry is NOT the hardest word

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“I’m sorry, I can’t” seems like the polite way of turning someone down but you do not need to express regret. You are not sorry. Reframe it. You are saying yes to other important commitments, to the things you want to do. Just because you ran the medical student teaching program last year, it does not mean that you have to say yes again this year.

No.

5. Just say NO

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Those of you who grew up in mid-80’s Thatcher-ite Britain will recognise the song. There are some requests where the answer is obvious. Channel your inner Zammo and just say no.

NO.

What are your real priorities? Is this important? Will it actually matter in a years time? Five years? If you had to give the talk that you have asked to give tomorrow would you say yes? Perhaps, if it is not a ‘Hell Yeah‘, then it should be a no?

*No was definitely the first word out of my middle daughters mouth in exactly the circumstances described. The other two managed shoe and more.

Selected references

Guadagno, R.E., Asher, T., Demaine, L.J. and Cialdini, R.B., 2001. When saying yes leads to saying no: Preference for consistency and the reverse foot-in-the-door effect. Personality and Social Psychology Bulletin, 27(7), pp.859-867.

Kline, S.L. and Floyd, C.H., 1990. On the art of saying no: The influence of social cognitive development on messages of refusal. Western Journal of Speech Communication, 54(4), pp.454-472.

Izraeli, D.M. and Jick, T.D., 1986. The art of saying no: Linking power to culture. Organization studies, 7(2), pp.171-192.

Langer, E., Blank, A., & Chanowitz, B. (1978). The mindlessness of Ostensibly Thoughtful Action: The Role of “Placebic” Information in Interpersonal Interaction. Journal of Personality and Social Psychology, 36(6), 635-642.

Patrick, V.M. and Hagtvedt, H., 2012. “I don’t” versus “I can’t”: When empowered refusal motivates goal-directed behavior. Journal of Consumer Research, 39(2), pp.371-381.