Ep 003: Setting Healthy Boundaries

Today’s episode tackles something that many physicians struggle with: setting boundaries. Though healthy boundaries are an important aspect of wellness, it is far too common for us to want to do more than we can and stretch ourselves too thin because we don’t know how to say “no,” or because we’re afraid to.

But the truth is, we’re human. We can’t do everything, and setting boundaries that communicate this is an act of self-care that can’t be ignored. If this is something you struggle with, listen in to hear the steps you can take to start setting healthy boundaries in your own life.

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What You’ll Learn In Today’s Episode:

  • Why it’s important to set boundaries.
  • How having weak boundaries hurts us.
  • The shocking percentage of physicians in America who report symptoms of burnout.
  • What’s at the root of such high rates of physician burnout.
  • Reasons physicians may have a hard time setting healthy boundaries.
  • An acronym to keep in mind for dealing with people who constantly test your limits.
  • Key steps to take for setting healthy boundaries.

Ideas Worth Sharing:

At some point in our lives, we have to come to terms that we can’t do it all. We have to choose what we prioritize. - @KathyStepienMD Click To Tweet We need to hold ourselves and each other to the same healthy behaviors we prescribe to our patients. -@KathyStepienMD Click To Tweet No matter our experiences early in life, it’s never too late for us to learn to set healthy boundaries. It’s a skill that can be learned at any time in our lifespan. -@KathyStepienMD Click To Tweet

Resources In Today’s Episode:

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Ep 002: Growth Opportunities and Self-Compassion

Few things are tougher to deal with as physicians than mistakes in medicine or unanticipated outcomes. It’s something we all experience at one point or another, and I know how hard it can be to handle the regret. I also know how challenging it can be to be kind to yourself after something like that happens.

So today, we’re going to discuss what I call FGOs, or Flipping Growth Opportunities. These situations are awful, and we can’t change them, but we can choose to be gentle with ourselves and practice self-compassion. Listen in to hear advice on how to do that, what we can learn from growth opportunities, and a mindfulness exercise to help you be kind to yourself when these situations arise.

Listen to the Full Episode:

Click here to Subscribe to the Podcast in: Apple Podcasts, Stitcher, or Spotify

What You’ll Learn In Today’s Episode:

  • What growth opportunities can teach us.
  • The two types of mindsets we can have.
  • Why it’s so important to have self-compassion.
  • The three aspects of self-compassion.
  • A mindfulness exercise to help in dealing with growth opportunities in medicine.

Ideas Worth Sharing:

It can be difficult to find words to share mistakes in medicine or unanticipated outcomes and regrets … If this is you, know that you’re not alone. It’s something that every physician understands. - @KathyStepienMD Click To Tweet Self-compassion is at the core of compassion, and that’s at the core for being an excellent physician. -@KathyStepienMD Click To Tweet Know that your self-compassion is the foundation for your compassion in the world. -@KathyStepienMD Click To Tweet

Resources In Today’s Episode:

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Ep 001: Giving Ourselves Permission

Welcome to the first episode of Physician Wellness First, the show dedicated to helping physicians learn to take care of themselves so they can take better care of their patients. My name is Dr. Kathy Stepien, and I’m a pediatric hospitalist, as well as the founding director of The Institute for Physician Wellness. Having worked in healthcare for over 30 years, I know what it’s like to experience burnout, and my mission is to help other physicians avoid this common problem.

The medical industry needs support for wellness now more than ever, and nothing is more important for wellness than the topic I’ll be discussing today: giving ourselves permission to set boundaries and identify what we need. Listen in to hear the common reasons we give ourselves for always putting others first, as well as how this hurts us, our patients, and our families. We’ll go through exercises to help you reconnect with your own needs, and end with a guided meditation that will help put you on the right path to wellness.

Listen to the Full Episode:

Click here to Subscribe to the Podcast in: Apple Podcasts, Stitcher, or Spotify

What You’ll Learn In Today’s Episode:

  • Why it can be challenging for physicians to talk about their own wellness.
  • Common reasons we don’t give ourselves permission to attend to our own needs.
  • What permission truly means.
  • Why physician health is so important, not just for us, but for our patients, families, and communities.
  • An exercise to help us turn toward wellness.
  • A guided meditation to use for developing awareness.

Ideas Worth Sharing:

Certainly we can’t truly have physician wellness unless all physicians—regardless of gender, or race, or age, or sexual orientation—are welcome to the table. - @KathyStepienMD Click To Tweet We take the oath to care for patients, but we also need to care for each other, in addition to ourselves … We’re physicians, not martyrs. -@KathyStepienMD Click To Tweet I firmly believe that when we are healthier in medicine, medicine is healthier and we all benefit: us, our patients, our families, our communities. And for me, that’s what it’s all about. -@KathyStepienMD Click To Tweet

Resources In Today’s Episode:

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The Audacity to set boundaries

Psychiatrist Pooja Lakshim wrote a wonderful piece in Doximity about setting boundaries. With her consent, check it out here:

We Don’t Need Self-Care; We Need Boundaries

by Pooja Lakshmin, MD

If you’re a woman in medicine who is feeling burnt out and exhausted, it’s likely you’re getting advice to do more self-care — take yourself out for lunch, get a manicure, do some yoga. Sure those things are great, but, let’s be clear, this is not self-care. I often find that when I’m feeling exhausted and down to the wire, self-care ends up as another item on my to-do list. And, counter-intuitively, I end up feeling guilty if I don’t get to it (I should be doing self-care better!) or if I do indulge, I feel bad that I’m not tackling something else on my to-do list. Why is this? We keep being told that self-care is what is going to solve all of our problems, so why isn’t it working?

It’s because this “faux self-care” that we are being offered is not actually feeding us. If feeling confident and empowered were as easy as spa days and meal delivery service, life would be much easier! Self-care is the internal hard work of making tough decisions for yourself and by yourself. It starts with recognizing that you have limits, and you really do have to choose what you prioritize because just like everyone else, you are human. It’s actually not that pleasant of a process, because it means you have to set boundaries.

It means that you have to learn how to say no, and recognize that it’s nobody else’s responsibility to say no for you. This is especially difficult for women in medicine, because many of us have gotten to where we are by putting on that superwoman cape, and playing the role of savior. Or, perhaps, martyr?
It means taking less pride in being busy and efficient. We need to stop letting our hyper-productivity-oriented medical culture disconnect us from our values. For women in medicine, martyrdom is almost an epidemic. What martyrdom gets you is exhausted, burnt out, and still running at full speed pretending that you love to help everyone else, but actually just oozing resentment. It’s a formula that’s set up to fail.

For me, setting boundaries means pausing whenever anyone asks me to do something, and remembering I have three choices. I can say yes, I can say no, or I can negotiate. For a long time, I didn’t recognize I had option 2 or 3. For most of us in medical school and residency or fellowship, it did not feel like we had the option to choose. Especially if you are a high achiever, there’s a way that hyper-productivity can be exhilarating. It means that you are better than those other people! What we didn’t recognize was the cost.

And, now, as a psychiatrist specializing in women’s mental health, and a woman with more life experience, I’ve learned that we always end up paying, in one way or another. So, part of learning to set boundaries is internalizing the fact that you do have limits and there is nothing wrong with that. What’s broken right now in medicine is the system, not us as physicians. The problem with resilience or faux self-care is that it puts the burden of change on the individual, and exonerates the system. You can make as many to do lists as you want, have the best meal delivery service in the city, and eventually, you will reach your limit. And, you will always feel ashamed for reaching your limit, because that is what our medical culture prescribes. You will feel like it’s your fault, and you should do more, but in fact, when you have boundaries, it’s possible to see that you’re running a race that has no finish line.

So, why does medicine keep selling us this panacea of resilience and self-care? I think because it puts the burden on us as the hyper-achieving physicians. And, we have certainly shown that we are capable of doing everything, plus much more than is asked of us. Doctors do not need to be more resilient. In fact, doctors have been too resilient, and that’s part of what got us into this situation. We thought that if we put our heads down and delivered more (ie. master clinicians, experts at billing, running the office, oh and, saving lives) eventually, the powers that be would be satisfied and we would be taken care of. But, that’s the tricky thing about boundaries; nobody else can set them for you.

You should also know that it can feel bad to set boundaries. Self-care is valuing your own feelings and thoughts, despite knowing that you may let other people down. It means being able to tolerate other people’s disappointment and trust that it is not a moral failing on your part. Forget the image of self-care you have in your mind of you luxuriating at the spa. Self-care means going through your list of work projects and sending that email saying your plate is full so sorry, you won’t be able to make that meeting. This is what it feels like to be responsible for taking care of your own emotions. Many of us did not develop this muscle growing up, and so, it’s not unusual to feel the growing pains when you start doing this as an adult. But, in my experience, facing those growing pains directly pays off multiple times over. You end up learning to value your time, your feelings, and your goals. And, perhaps counter-intuitively, when I am setting boundaries, I find myself feeling generous, full and willing to give more to others without feeling resentful. I also find myself able to indulge in “faux self-care” without feelings of guilt or pressure to perform. Once the resentment and guilt creep back in, I know it’s time to start cleaning house. Setting boundaries in order to take care of myself is not a one-time thing, it must be repeated regularly until it becomes second nature.

If practicing self-care means regularly setting boundaries, one difficulty is the qualities that got us into medicine, and kept us here, are precisely the ones that work against us. We want to be needed and valued by our patients, we are conscientious to the point of perfectionism, we recognize the inherent privilege and burden of taking care of people in their most vulnerable state, and are more comfortable sacrificing our own needs in the service of others. Inherent in this is the assumption that eventually if we make ourselves small enough, we will get that “A”!
Make no mistake; setting boundaries is an assertion of power. We’ve been told over and over again that we don’t matter, and when we do, we’re certainly worth less than men. For women in medicine, setting limits and asserting boundaries is about saying this is what works for me, and this is what doesn’t. It’s having the audacity to say, I exist and I matter.

Pooja Lakshmin, MD is a board-certified psychiatrist and Assistant Professor of Psychiatry & Behavioral Sciences at the George Washington University School of Medicine. She is passionate about women’s mental health. You can find her on twitter @PoojaLakshmin. She is a 2018–2019 Doximity Author.


Charter for Physician Well-being in JAMA

I missed this April, 2018 JAMA article and wonder whether you have too.

Authors Thomas, Ripp, and West propose a set of guiding principles to support physician wellness:

• Effective patient care promotes and requires physician well-being.
• Physician well-being is related with the well-being of all members of the health care team.
• Physician well-being is a quality marker.
• Physician well-being is a shared responsibility.

Link to abstract: https://jamanetwork.com/journals/jama/article-abstract/2677478

The problems are real. Conversations about this topic are becoming mainstream. Let’s all work together for change. We, our colleagues, our patients, our families, and our communities need healthier physicians.

Wellness Within the Culture of Medicine

We’ve looked at person wellness and institutional wellness. Now let’s turn our attention to wellness within the culture of medicine. This is the third level of our physician wellness framework. Western medicine has its own set of customs, traditions and values that are learned early in the course of medical training. The value of sound scientific methods, the importance placed on logic and reason, and the significance of professional integrity are examples. Hard work, sacrifice and commitment are also included. Unhealthy values include harsh judgment, shame, a sense of superiority, and perfection.

When examining physician wellness at the cultural level, we must also address discrimination within medicine. Overt racism, misogyny, ageism and discrimination based upon sexual orientation are everyday occurrences and affect everyone within the culture of medicine.  Think #metoo isn’t valid for medicine? Read “A Mother in the House” at this blog for another opinion. It’s difficult to experience wellness at the same time as discrimination.

At every level, physician wellness depends upon continuous, usually low-tech, activities and habits based upon individual and shared values. Identifying and shaping these shared values is not going to happen on its own. We all have an obligation to speak and act up. We need improved physician health. Our families, our communities, patients, and even the institution of medicine deserves better.

Physician Wellness at the Institutional Level

Over 50% of physicians report symptoms of burnout. This high level tells us that addressing wellness at the personal level is not enough. It speaks to a systemic rather than individual etiology. Organizations have begun to recognize it is in their best interest to keep their physicians happy. Losing even one physician to burnout is expensive. In addition, burned out physicians are liabilities. Mistakes increase. Productivity decreases. Patient satisfaction decreases. Ripple effects touch other members of the team, which leads to further burnout. If for no other reason, physician wellness at the organizational level matters since it affects the bottom line.

Fixes at the institutional level have primarily focused on time. Physicians have too little time to do what we need to do and to do it well. The EMR is regularly blamed as a time sink. Re-engineering the tools, environment, and systems of care delivery can help us save time. However, its not only a lack-of-time issue. What we do with our time also matters. We need systems that allow each person to work at the highest level of their training. Doctors can practice medicine while other team members do what they do best.

Finally, we  need to acknowledge the inherent conflict between the business of medicine and the practice of medicine—something physicians wear every day as we work with our patients.  Making these changes at the institutional level requires a change of institutional values to include physician wellness.

Physician Wellness at the Personal Level

Last week we introduced the idea of physician wellness at the personal, organizational and cultural levels. This framework for thinking about wellness allows us to explore its various aspects. Today we will address the first of these levels–physician wellness as an individual.

Most physicians know a fair amount about personal wellness and share information with our patients regularly. Although much of wellness is basic tenets by which we live, the demands of medical training and practice do not make it easy. Many physicians readily admit it is difficult to walk the talk. However a necessary condition of being the best physician we can be for our patients is taking care of our own health. It really isn’t–nor has it ever been–optional. Organizations and the culture of medicine are beginning to recognize what we already know.

The imaged posted above shows a wellness wheel with aspects of our personal wellness divided into wedges. Wheels roll best when they are round. And so it is with the wellness wheel. When one aspect is excessive, the wheel has a bulge and it thrown out of balance. Likewise, when one aspect is limited, it shrinks and also throws the wheel out of balance.

Of note, symmetry of the wedges is not the goal. The needs of our physical health may be represented by a bigger wedge than the needs of our financial health, for example. At other times, it may be just the opposite. Instead, our goal may be to give the “right” amount of attention to all aspects of our wellness as it is needed. Needs are constantly changing; our priorities and time will vary accordingly. Also note that the division of our personal wellness into the aspects shown in the image is arbitrary. We could make altogether different divisions or even none at all as we recognize each part of our personal wellness affects the other. Finally, we should note that no one can define your personal wellness for you. You know what your needs are and whether you are living a healthy, well–balanced life. You know what requires more attention. There is no competition. There is no judgment. Medicine is hard enough–this is a chance to be gentle with yourself.

Physical wellness addresses habits that support optimal health and functioning of our body. It means being as well as we can with what we’ve got; leading an active lifestyle, eating a healthy diet, getting adequate sleep, and balancing periods of activity with periods of rest. How do we do this given the demands on our time and energy? What works?

Research shows that our social health is also an important contributor to our overall wellbeing. Examples of the social aspect of our wellness in medicine include creating a collegial work environment; enjoying time with friends and family; and developing professional and personal support networks. We all have stories of the toxic work environment. How do you recognize unhealthy situations and what did you do to distance yourself without causing professional suicide? What have you found that helps? How do you balance your social needs with the need for quiet, uninterrupted personal time?

Other aspects of our personal wellness will be explored in upcoming weeks and months. In the meantime, share with us your thoughts about the various aspects of physician wellness at the personal level.

Join us next week as we move ahead in our series to take a deeper look at physician wellness at the organizational level.