“The customer is always right.” We all know the saying. It’s a truism in business. Businesses need happy customers. Happy customers keep coming back and they tell their friends. Keeping the customer happy is a businessperson’s number one priority.

Except when the business is a medical practice, and the customer is a patient.

That ever-blurring line between patient and customer is one of the most difficult things to walk in medical practice. On the one hand, people need to keep coming through the door in order to keep it open in the first place, and making sure people have a good experience when they come to you for care is important. On the other, sometimes patients want things that are medically unnecessary or even plainly inappropriate. Finessing situations that fall into that latter category while trying to maintain a pleasant physician-patient relationship can be very difficult, and the pressure is increasing.

Just as with restaurants and movies, there is a seemingly expanding list of websites out there that let you rate your doctors. Parody articles in The Onion about physicians doling out controlled substances to help their Yelp ratings make me laugh a dry little chuckle as they find a mark uncomfortably close to home. As reported in a recent Daily Beast article, a new study shows that physicians aren’t that great at telling patients “no,” even when it comes to narcotics. After all, how hard is it really for a disgruntled patient to log into Vitals or Healthgrades and give you a one-star review? How motivated are the generally-satisfied majority of your patients to log on just for the sake of saying something nice about you? Vengeance is a much more satisfying reason to spend the time than bland contentment.

For my part, I can at least say I don’t feel all that much pressure to prescribe controlled substances. (Perk of being a pediatrician, I guess.) But I know a patient who’s unhappy to be leaving without an antibiotic when I see one. Even amongst my colleagues at the office I am particularly parsimonious with the amoxicillin, yet I find myself thinking from time to time “Will it really be all that bad if I just called this kid’s cold a ‘sinus infection’ and gave them an antibiotic? Is one unnecessary prescription going to make all that much difference in the war against drug resistance?”

I’d love to say I never cave, but that wouldn’t be true. I try to make it rare, and it rankles every time it happens, but sometimes I err on the side of treating when I wouldn’t have without the obvious demand for it.

The difficulty isn’t limited to medications. I spend a surprising amount of time talking people out of pointless tests and needless referrals. For some, there is security that comes with just a little more investigating, or with having a specialist weigh in. But just like more treatment doesn’t always mean better care, additional scans and blood draws and consultations don’t always benefit the patient.

Tests are only really helpful if you order them with a focused question in mind, and the more of a shotgun approach I take to ordering them the more likely I am to get a falsely positive result that will require yet more testing to iron out. Sending a patient to a specialist when clinical guidance isn’t really needed (for the management of mild to moderate acne, let’s say) is only a waste of time and money.

Would it be nice to be practicing medicine in a world where I didn’t have to consider expense in making clinical decisions? You bet. I would also like tickets to next year’s Academy Awards. In the real world where I watch the Oscars on the couch in my family room, I also must increasingly keep in mind how much the patient care I deliver costs. While health care expenditures may finally be slowing as a percentage of GDP, they still consume a massive amount. The onus of containing those costs is shifting in part to medical providers, and like it or not I must factor that element into my decisions.

Would I ever let price be the determining factor in ordering something my patient’s health required? Absolutely not. Medical decision-making will always trump other considerations. But when it comes to screening for illnesses I strongly doubt the patient has, or referring to an orthopedist for an uncomplicated sprain, expense becomes more salient. The option to ignore it is vanishing, even for parents with “good” insurance that buffers from the up-front costs. The only way to control those costs is to weigh them against clinical indication, despite patient preferences to the contrary.

Yet every time I have to tell a patient “no” to a medication, test, or referral I don’t think is unnecessary, I have a little twinge of anxiety. No matter how well I feel I explained my rationale, there’s always a worry that behind the polite facade is a seething parent whose respect for me has just crumbled into dust. Is their next stop Angie’s List? Would it would have been in my interest to punt them for a consultation they didn’t need and let someone else worry about the bill? (I sometimes wonder if these same people stand behind their mechanics when their cars are on the lift and question their choice of wrench. Somehow I doubt it.)

Delivering cost-effective patient care is a big enough challenge as it is, and if saying “no” to a test or treatment that’s not clinically indicated means my online reviews suffer, doing my job right means I have no choice but to take that risk.

The customer may always be right, but my office isn’t a boutique—it’s a medical practice.