Setting Boundaries in Medicine

I’ve read with great interest lately the articles published about inequities in medicine for female physicians. One of them was recently published in the “Journal of General Internal Medicine” and concluded: “Female physicians spend more time working in their EHR in baskets because both staff and patients make more requests of female PCPs. These differential EHR burdens may contribute to higher burnout rates in female PCPs.”  We know that managing EHRs can be challenging for all physicians, regardless of gender. What can we do to meet the needs of our patients and prevent clinician burnout? 

Although I don‘t have all the answers, I do have a few suggestions about how to stay sane in our current environment of never-ending in baskets. Doing that requires that we identify and set boundaries for how we practice medicine. Recently, younger physicians have identified that this is essential for a satisfying and long career. Those of us who trained in the past, however, were not taught how to have boundaries. In fact, we were taught the OPPOSITE. We were taught the patient always comes first. Although that statement is noble, if we always went by this sentiment, we would all burn out before age 40.  

Young physicians are graduating with high amounts of debt and taking salaried jobs often as employees of large organizations, who themselves are beholden to for-profit insurance companies. These larger groups are happy for us to not have boundaries, because that is more money for them. In fact, Dr. Danielle Ofri wrote a very insightful piece in the “New York Times” titled “The Business of Health Care Depends on Exploiting Doctors and Nurses.”In decades past, doctors were more independent and had significantly more control over their workdays and tasks. That’s no longer the case, and so we must set our own individual boundaries to ensure we will be able to thrive throughout our (hopefully long) careers.

Here are some practical ideas on how to do that:

1. Set expectations for patients and office staff and tell them what they are.  

2. Politely push back if you are being asked to do something you know that other physicians in the same practice are not being asked to do. 

3. Make sure you are not doing something that inadvertently gives you more work or impacts your boundaries.

For instance, you might need to work late at night to catch up on tasks. If you reply to MyChart messages to patients at 10 p.m., then they might think they can reach you at 10 p.m., thus giving you more late night messages. Think about how people might interpret your actions. Instead, finish those clinic notes or do another task others won’t see.

4. Recognize you will never check off all the boxes.

This one is hard for me, as my daily life as an intern consisted of making a long list of things to do, placing a little box by each, and feeling satisfied when I finished checking them all off at the end of the day. EMRs now mean the work never ends. There is always more to do. You must be ok with not always being on top of everything.

5. Ask for your own practice data so you know whether your experience matches the national data we read about in articles.

Some practices can track EHR usage; for instance, number of results, messages, or refill requests you get per day. It can be helpful to understand whether you’re getting more, less, or the same amount of EHR work as your colleagues. If your work is more than others, ask for help changing that. 

6. Find colleagues to vent with and work with to improve your local system.

Having the support and understanding of colleagues cannot be understated.

7. Share the hard parts of work with your learners and also the joys.

You shouldn’t be complaining to your learners, however, you can share with them how you approach handling systemic barriers in healthcare and how this is hard for you too. At the same time, make sure you tell them the stories of why you keep doing this. Which is, of course, your patients. 

8. When you have the energy, advocate for change.

We’re generally bad at advocating for ourselves. This goes back to the time when we were independent professionals with significant control over our lives and we didn’t need to look out for ourselves as much. We’re now mostly employees, and we need to learn how to advocate for our well-being. We can learn a lot from our nursing colleagues, who have extensive experience advocating for their patients and for themselves. Additionally, physician leaders in well-being are recommending practice-level and national changes to make the EHR work better; you can read more here.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.