"If something is not a "Hell, YEAH!," then it's a 'no!'"—James Altucher, entrepreneur and chess master
Although saying "no" rarely feels like a great option, many of us forget that it is an option.

As orthopaedic surgeons, we are constantly asked to "volunteer" for a committee or to cover an on-call day for a colleague. And because we know that someday we may be asking a colleague to serve with us or to cover our on-call day, we almost always say "yes." Yet the many demands in our lives make it impossible for us to always acquiesce.

A day has only 24 hours; assuming we sleep for 6 to 8 hours and work for 8 to 12 hours, most of those hours are gone before the day even starts. Knock off another 2 hours for essentials such as commuting, eating, and bathing, and we're left with less than a few hours of "free time." Time to play with our kids, catch up with our spouse, get outside in the sun, head to the gym, read a book, watch a movie… whatever.

There are more meetings, conference calls, errands, and activities than we can possibly hope to accommodate. Asserting the power of "no" is the only way to start setting boundaries and reclaiming our lives. Saying "no" (even to a loved one) isn't mean or impolite, it's necessary. It lets those around us understand we have limits.

Yet human nature compels us to say "yes" far more often than we should. The more frequently we say "yes," the more frequently we're expected to say it. That expectation is a slippery slope, and the further down the "yes" rabbit hole we go, the further we expose ourselves to stress.

Why do we do it? Why should we do it?
Without volunteerism, our profession and our patients would suffer greatly. We should all give back to our communities and profession for the tremendous trust placed in us. However, the degree of engagement varies considerably from physician to physician.

As social creatures, we actively seek out the acceptance of our peers, and one of the easiest routes to acceptance is through consistent demand capitulation. Some of us want to be viewed as a "yes" person or "go-to" guy by the leaders we respect. Some of us feel guilty for our relative success and want to give back. Almost all of us carry high levels of self-expectation and competitive natures, fed by our drive to get into medical school, an orthopaedic residency, a good job, and more.

Once we are in those jobs, some of us are overly optimistic about how much time things will take. Coming out of medical school and training, we realize we don't have all the tools to fully employ our core competency—the management of musculoskeletal problems. We seek out opportunities to learn about things such as business, marketing, coding, and advocacy.

Why and when we must (sometimes) say "no"
Said too often, "yes" is a problem. When we are over-extended, the quality of the work we can perform declines. Too many "yeses" lead to emotional exhaustion. Acknowledging that saying "yes" cultivates stress is the first step forward on the journey to being able to say "no."

How can we judge these opportunities and make rational decisions?

First, we must know ourselves. Make a list of your top professional and personal goals. For example, are you interested in building your practice, bringing new opportunities to your community, advocacy, research, or leadership? Does the project under consideration further those goals?

What are your real skills and weak areas? What is your real energy level and capacity for additional, voluntary work? This involves a careful assessment of other factors in your life. Do you have children? How young are they? Is your practice adequately staffed when you are away? Are you in the middle of a home purchase, move, or other major life event?

How about the opportunity itself? Is it (likely to be) fun? Is it useful? Is it visible? This visibility is important if your goals include advancement in your hospital or professional organization. Will it help you build a reputation for things for which you want to be known? Does it fit your interests and skill sets, or could someone else with more background in the area do it more efficiently and better?

Some opportunities are worth considering due to the leaders involved. Will you be working with key players who can open other doors? Are these leaders clear, efficient, and effective? Or are they discursive bumblers offering little more than lessons in frustration?

A classic issue is the "do nothing" committee that some hospitals seem to spawn with increasing frequency. Ask yourself whether this project will be successful and what you can add to it. Needless to say, devoting time or resources to doomed projects is a poor choice, but one made all too frequently.

When considering work for a national organization, like the AAOS, travel must also be considered. Overnight travel has a very different impact on a practice and family than regular conference calls. If your goals include an outlet to connect with peers, travel may be a plus. In that setting, the solitary work of peer review may be less appealing.

Extracting the guilt of saying "no"
Those of us not used to saying "no" may recognize the following series of questions we ask ourselves:

• Will they be annoyed I said no?
• Will they pass me up on the next opportunity?
• Will they think I don't want to be part of the team, or that I don't care about patients?
• Instead, we should be asking:
• Have I already accommodated several requests from this person or organization recently?
• Have I been given ample notice to properly adjust my schedule and plan?
• Am I the best option?
• Am I the only option or are there readily accessible alternatives?
• Do I clearly understand what I'm sacrificing by saying "yes"?
• Am I sure saying "yes" won't affect my other obligations?

As difficult as it might be for some of us, we must get in the mindset that it's OK to say "no thanks." We shouldn't think of that response as the rejection of a request. Rather, it's an acknowledgement of our human limitations. The worst surgeons are those who are not aware of their own limitations and take on cases beyond their skill. The same is true with concessions to spend time in low-value pursuits. Having the ability to say no enables us to say "yes" to opportunities we want to take advantage of. It enables us to live healthier, happier lives.

How to say "no"
Saying "no" may be a problem for people-pleasers. Do not overthink it. If the idea of saying "yes" causes stress, say "no."

For more marginal opportunities, we should give ourselves at least a day to review our priorities and bandwidth. Do not let the question linger, however. Offer a clear, candid response. Banish the guilt and respond with a smile.

In most cases, we do not owe the requester an explanation. Still, if saying "no" isn't a natural skill, the following options are available; rehearse one if necessary.

• I'm sorry. I can't give it the attention needed to do my best.
• I'm sorry. I have another commitment.

Personally, we don't even think anyone is owed an explanation. Just be polite, and if true, express an interest in future opportunities or offer ways in which you could be helpful.

Three checkboxes before saying "yes"
Creating boundaries is essential. For surgeons who want to stay both physically and mentally healthy, time is at an absolute premium. It is our most precious asset—more precious than salary, title, tenure, rank, or any of the other traditional markers of professional status. Gaining control over our lives requires knowing when it's time to draw a line in the sand.
No one will say "no" for us—we must do it ourselves. We must limit "yeses" to those activities that are truly aligned with our passions and responsibilities, understanding the following:

• We really mean it.
• We really have the bandwidth to accommodate the responsibility.
• We say "yes" with complete understanding that we're simultaneously saying "no" to something else down the road.

Eeric Truumees, MD, is a spine surgeon and editor-in-chief of AAOS Now. Jeffrey M. Smith, MD, is an orthopaedic traumatologist in San Diego.

References

1. How to Say No to Taking on More Work
2. 4 Times You Should Say No to Additional Responsibilities
3. The Best-Kept Secrets to Saying No at Work