How can doctors set and maintain boundaries? With Claire Davies

[00:00:00] Mat: Welcome to Doctors at Work. My name’s Mat Daniel and this podcast is about doctors’ careers. Today I’m having a conversation with Claire Davies, and we have a discussion about how doctors can set and maintain boundaries. It’s very common for us to be asked to do more and more or to do things we don’t want to do or things that we think shouldn’t be done that way.
And boundaries then can be a way that we can set parameters how we think the world should be. Claire tells me that boundaries are not about saying no, nor are they fixed rigid walls. Boundaries are something that is decided and negotiated on a case-by-case basis. Understanding and demonstrating that you get the other person’s perspective can be really helpful if you have to say no.
And also taking a pause is something that’s useful rather than rushing into saying yes. And if you’re really struggling with boundaries, then maybe start small. So, think of something very small that you can do, a small boundary or a small way of saying no, and then you can build up from there onwards. It doesn’t have to be an argument with the medical director.
It can be something much simpler than that. And in fact, most boundaries are the small everyday occurrences rather than necessarily big things. Although big things happen, of course. Most importantly, knowing yourself is key to deciding where your boundaries are and what you say yes to and what you say no to.
I hope the podcast is useful.
Welcome, Claire. Tell me a little bit about yourself.
[00:01:43] Claire: Hi, Mat. Thanks for inviting me on the show. Yes, my name is Claire Davies. I’m a GP in Hackney and Tower Hamlets, East London. And I also work coaching doctors, exhausted doctors, mainly really values driven doctors, who work in areas of deprivation to prioritise themselves as well as others and rescue their careers, hopefully.
[00:02:09] Mat: Thank you very much, Claire. And I invited you today because I think I was interested in having a discussion with you about boundaries. What exactly are boundaries?
[00:02:20] Claire: Yes, boundaries are different things. So, they are our own code of how we want to be treated by other people. The standards that we’re hoping and expecting from other people, how to treat us with respect.
They’re about getting our own needs met as, as well as everybody else’s. And they’re also a way I really believe of bringing us home to ourselves. Sometimes we get a bit lost as ourselves in medicine. And if we start to set some boundaries, it sets the boundaries where we begin as people and medicine ends.
So, once we start to put some boundaries in place and look at ourselves, I really think it’s a big thing for personal growth.
[00:03:04] Mat: So, with boundaries, how do problems with boundaries show up amongst us doctors?
[00:03:10] Claire: I think quite a lot of doctors can have people pleasing tendencies and that I do speak about that from a place of general practice, and it may be different in some of the other specialties in hospital medicine.
But that means where, our boundaries are distorted that we are. Caught in a trap sometimes of doing too much for other people and the boundaries are blurred or the boundaries are extended as to beyond what they should be. We are taught to put patients first and that’s really important that we do put patients first, but in order to help people.
What actually helps people sometimes is also have a boundary, so they know what they need to do for themselves as well as what the doctor is going to do for them. Many times, about having a clear boundary can really actually be more helpful to people than fuzzy boundaries.
[00:04:11] Mat: And why are fuzzy boundaries a problem?
[00:04:13] Claire: So fuzzy boundaries are a problem because the other person may not understand what behaviour is expected from them in that situation, such as, for example, with a patient, it may lead to them not being able to do the things that they need to do for themselves, for their health, which is super important.
And from a GP perspective, often more helpful than anything we’re saying or prescribing. It can mean that people think it’s okay to behave in a certain way which is actually not that dignified for them and can be quite distressing for staff and, it can mean that.
People think, find it quite confusing sometimes not knowing what’s expected of them. This is having unwritten rules is really confusing and there’s a whole lack of clarity around that for people.
[00:05:12] Mat: It’s interesting because I was expecting we were going to talk about boundaries and fences that we build around ourselves as doctors.
And what I’m hearing you say is that actually those things are good. They’re good for the culture around us. Yeah. You know how we behave and what’s acceptable. So, the boundaries are good for the culture around us and boundaries are good for. for other people, particularly maybe when it comes to taking ownership and taking responsibility of their own action.
[00:05:40] Claire: Yeah, I think boundaries is an interesting term. I don’t really like the word. I always think of, for some reason, someone saying, oh, she’s very boundaried, isn’t it? Isn’t she? It’s it got this image of someone that just says no to a lot of things. And it’s actually maybe not, they might not, might not be a team player or quite hard, quite hard lined about everything.
But it’s they are not walls, they are flexible. So just before we came on, we were talking about an example and in primary care, we really try to reduce our antibiotic prescribing. If I’ve been there for 12 hours on a Friday night and it’s 8pm, I’m likely to be more flexible with my boundary on that because I’m really tired and I don’t have.
As much energy for what might be a really difficult conversation. We can apply them a little bit flexibly to ourselves as well. That’s part of looking after ourselves sometimes and being kind. And I really hope there are no microbiologists listening to this, but that’s the way I, I do.
So, what, what do what am I capable of at this time? What do I have the energy for?
[00:06:49] Mat: It’s interesting. It’s the reality of life, isn’t it? It’s the reality of human nature and I’m pretty sure that the patients on the other side will be thinking I’ve been at home already. I know I shouldn’t be having antibiotics.
I’ve tried my best, but my child’s screaming and in pain and I know I shouldn’t have antibiotics, but I can’t put up with the screaming and the pain. So, I suspect that would probably be the other side. Of the story. Yeah, so it’s interesting the terminology because I think I use the word fences and we started talking about boundaries.
And now we’re talking about them being flexible. So, can you tell me a bit more about this idea that it’s not a fixed thing?
[00:07:30] Claire: There’s a quotation and I can’t remember where it’s came from, but it says boundaries are not walls, but a picket fence so people know where the door is. Let me give you two examples.
You can be someone who has a big team of trainees who have a lot of issues and difficulties, and your door is always open to them. And you realize that you cannot keep doing as much as you can. You need to be. Signposting them to other resources to enable them to tackle part of their problems.
And you can go to a place where they’re, I’m just not dealing with that anymore. Or you can decide I’m, I’m dealing with less of it, but a big crisis hits, and your door is open for them. It’s flexible or perhaps something might really touch you in the moment. And just think, that’s really tagged at my heartstrings.
I’m going to step in here. I think boundaries, it sounds like quite a hard concept, but it’s really about using our compassion and intuition and looking at everyone’s perspective in the moment as to how we’re going to apply them at that time. I can’t tell people to say, I would always say no to that.
And I don’t think that’s helpful because every situation has got nuance.
[00:08:49] Mat: Yeah, I like the fact that it’s a picket fence. I suppose the other bit of that analogy is that people can also see, you can see through it, and they can see through it. So, I if I have a picket fence around me, I can see what’s on the other side and then other people can see what I’m like and what I’m capable of.
And yeah, so that’s a much better analogy. How do we make those decisions? You said that we’re deciding. Do we say yes to things? Do we say no to things? So how, what would be your advice for somebody who’s thinking, okay. Where exactly are my boundaries or where exactly is my picket fence and where exactly is my door?
How does a doctor make those kinds of decisions?
[00:09:31] Claire: So just speaking generally, rather than with patients, this is something I was taught by an someone who was coaching me years ago to ask, if I’m being asked something, what, what am I going to, what’s, what am I going to need to pay here?
Because sometimes I was saying yes, in the moment is our hours, weeks, days, months. Potentially years of pain and resentment. So, it’s about pausing and really saying what is this going to cost me? Is it something I really want to do? Who is it going to benefit? I think something you said earlier about perspective is really important.
So, understanding the other person’s perspective and the potential impact on them. And, asking what is this my role? What are my needs? That’s not something we very often ask, sometimes I guess in a heartbeat can be days of payback and the other person’s gone and they’ve forgotten about it.
They’ve moved on and all the energy and the drain has transferred to you. Those are just a couple of questions to ask and pausing is really important. We don’t have to say yes to everything straight away. I often say I need to think about this. But we’re obviously not going to think about whether we’re going to a cardiac arrest.
We, we need to go. There are lots of things that we really do have to do, which is why it’s even more important that we have a think about those. things that are a bit blurry or not necessarily ours or, we may not have capacity for.
[00:11:11] Mat: Yeah, I like that idea of pausing because I think often, we do just jump in and we say yes, don’t we?
So how do doctors get into the habit of pausing before they just say yes?
[00:11:24] Claire: How to get into a habit is just starting and practicing, isn’t it? So, I think it’s really helpful to have some knowledges of things like mindfulness or body awareness because it just grounds us in the moment or feeling your feet on the floor if you can. And building a habit.
And if it’s a completely new thing, we might need a reminder. I have things stuck inside my purse, when you open it, il this is my goal today. So just a reminder, I think about pauses before responding. Some things don’t need a response. Not all emails need a reply.
So, thinking before we respond, sometimes if we don’t respond, sometimes problems sort them out, sort themselves out without us doing anything. So, it’s just about pausing, taking a step back, thinking what my options here.
[00:12:20] Mat: And you mentioned that sometimes we have to say no, for whatever reason, it isn’t the thing for us.
So, we haven’t got the capacity or it doesn’t align with where our careers are going. And that often it’s quite difficult for us to say no, particularly, as you say, because a lot of us are people pleaser. So, what would be your advice for somebody who needs to get better at saying no.
[00:12:44] Claire: So that, one thing is to be very clear in your mind what you’re saying yes to, so you may be saying yes to going home at a more reasonable time, you may be saying yes to a better night’s sleep, you may be saying yes to more time studying for a really important exam or something, doing something you really love that you know is going to just benefit your well-being.
So being really clear about that in your mind there’s delivering saying no, but then there’s also knowing that pushback will happen and just being prepared for that. People will do that. They will respond how they respond. And that’s their choice too. react that way.
That’s often not about us. And it is a big thing. It was a big thing for me in the past. And people will come along and say, just say, no, it’s a complete sentence. And it just, so isn’t, you have to break it down into the components. You, one thing. You can really do is start with something really small, just do something really small say, so you’re not washing the cups up that are all there dirty in the outpatient sink.
Because we do get asked to do these things as doctors. Now, someone else just has to do it all. take back an item that’s to a shop that’s slightly dissatisfactory. See how we get on. Just do something little and practice it and see how you get on. If it doesn’t work, you just review the process.
What went well, what didn’t go well how could I do it differently? So, we don’t have to go in all guns blazing with the medical director for head-to-head. It’s not about that to the beginning. It’s about doing, it’s about what little things could I do differently here, ask for more clinic time. I need a longer appointment time for these patients.
[00:14:37] Mat: Yeah. I love that concept of just starting small rather than thinking that you, rather than starting with the biggest thing in the world. Yeah. Just starting small. Why is it so difficult for us to say no?
[00:14:53] Claire: I would like to ask you a question because you’re a surgical surgeon. Is it, is, how is it for surgeons to say no? Cause we work in different, probably very different work cultures.
[00:15:05] Mat: Personally, very difficult. Yeah, personally, very difficult. Yeah, I suspect most of the colleagues that I have. Not all, but most of the colleagues that I have, I think will find it difficult to say no. And if we, let’s say there’s lots of patients waiting or there’s somebody who needs to be seen or somebody’s got a problem.
There’s always a pressure to say, yes, you’re going to see another patient. And, and yes, you’re going to do another clinic. I guess how I personally have dealt with that is I’ve recognized that it’s the same question all the time. So, I’ve changed my clinic structures to make sure that there is space, that kind of would be my practical tip.
But that’s effectively, that’s me avoiding having to say no, isn’t it? So, it’s me engineering situations where I don’t have to say no, because. Instead of having a clinic that’s always overbooked, I have a clinic that is appropriately booked and then, one extra patient doesn’t matter or, or whatever.
So probably engineered situations that mean that I don’t have to say no. The people that are really good at saying no. It’s interesting because at the beginning you, you said that there’s a perception of boundaries as people who always say no. And, and yes, I can think of people that I know.
that I would say they were really good boundaries because they always say no. And that’s same as you outlined the beginning that’s my perception of boundaries and they probably have different values to you or I, or even the rest of us maybe. And that’s all right, isn’t it?
Because we’re all different. And it’s not that they don’t do the work. It’s just that they’re. that they’re very good at choosing what they say yes to and what they say no to. So yeah, I’ve lost my train of thought now. But yes, it’s difficult. Probably fairly similarly difficult when you feel pressured to deliver for others.
Okay, so here I’ve got it. So, for me, it’s a challenge between what I need and want and deserve versus what other people need and want and deserve. Yeah, that that’s my personal challenge. Does that resonate?
[00:17:08] Claire: I think totally. And I With, I think with patients it’s really difficult because, especially when, it’s people’s health it, that, that is really hard.
I’m going to respond by giving a few examples of where people do put boundaries in place. I’ll tell you one thing is when GPs make referrals on the phone to the hospital, to the surgeons, you’re good at saying no to us. About when we try and refer in appendicitis. That’s a place where people put boundaries in whether that’s right or wrong.
And that’s an interesting, that’s a whole dynamic in itself. Just to give some examples of people that I’ve spoken to or worked with, and often the boundaries. Can be looked at more around what’s going on in service delivery job plans and things like that. And I’ve heard examples where there’ve been big changes to job plans and the whole department has just rolled over and accepted it unhappily.
And then someone wants to leave. So, where’s the boundary there? The boundary is that they don’t want the job anymore because they didn’t say no to the other stuff while it was happening.
[00:18:17] Mat: Yeah, I think that’s a good example. And when you were talking about the interface between primary care and secondary care, that sort of reminded me of this concept that it’s important to see the other person’s perspective.
And again, I’m guessing, there’s a reason why somebody in primary care. would refer the patient and perhaps the person in the secondary care doesn’t see the bigger picture, because maybe you’re focusing on your particular subspecialty bit. I suppose it probably works the other way around also that maybe the person that’s referring primary care doesn’t necessarily see the implication of what’s going to happen in secondary care.
So, I think that the key there for better communication is. It’s understanding the other person’s perspective, isn’t it? So not one silo trying to send something to the other silo, but having an appreciation of what happens on both sides and how we can all work together to do what’s right for the patient, yeah?
Rather than erecting fences as it were. Yeah, so I like that concept of it’s important to see the other person. I suspect also it makes it easier. to maintain that picket fence, if you can demonstrate that you’ve heard the other person’s perspective. So, if you’re going to say no to somebody, I’m guessing it’s easier if you explain, why you’re saying no not necessarily in referral, but in general.
[00:19:40] Claire: So personally, I think listening to the other person, really so that they know they’ve been heard. I think that’s, I think that’s really important. You’ve probably had some time when you’ve asked for something and they just said no, I don’t think they even listened to that or, a letter where you get You send a letter and you get a standard letter back into the, I don’t think they even read that.
And it’s it could leave you on a really bad setting. And it’s disrespectful. So, hearing the other person is really important. If we can understand their perspective, it’s really important. Sorry, I’ve forgotten what the initial. what your question was. Can you remind me?
[00:20:22] Mat: Yeah, about the importance of seeing the other person, both if you’re going to say no. Yeah. Demonstrating that you understand the other person’s perspective, just has been super important. Yeah.
[00:20:35] Claire: So just to get sorry, it’s all the primary care examples, but that’s what I do. I can, I’ll say what I’ve done, just repeat it, I often say with the child, I’ve checked everything that I can in this setting and his chest is clear and his ears are throat are fine, as you’ve seen, I’ve had a look and he has, he’s doing this, and he looks really well.
So, from a medical perspective that, this is what I think. So, in this situation, I think antibiotics are not going to be useful. So, I explain, explaining why. In that setting I’ve made that decision. Sometimes saying no and then going into a lot of justification as to why will just lead people into fanning away and to say you could do that or you could do that, or you could go home at this time or so and so can cover you.
So, you have to be careful, so people start pushing back or challenging you going into a lengthy justification it’s by the experts and saying no is felt to be not useful.
[00:21:40] Mat: Yeah, and it’s interesting that then you get to the stage when you just think, oh, I might as well have just said yes, but of course, there’s then there’s a cost to that.
How do we know you know what How do we make decisions about what we say yes to and what we say no to?
[00:21:58] Claire: That’s a big question. And it, I think it, it depends on the context. So obviously when we’re talking about practicing medicine, we’re going to base it on our expertise. In our life, we’re going to look at what we have capacity for, what our other responsibilities are. Outside of work, we’re going to look at what we want for ourselves, and we’re going to look at our energy levels and we’re going to look about our, we’re going to look at our value, our personal values to help us guide those decisions, which you wrote an excellent article about the other day, it was really good.
But that’s going into a separate topic because some listeners might not understand what personal. Values are we might look at our personal strengths so I’m, I know I’m good at managing conflict, so I’m going to deal with this situation, even though it’s rather inconvenient, but this is what I do.
This is, it does that help?
[00:23:00] Mat: Yeah, I’m interested in hearing. Your take on values, what how would you explain values to people and how can values help people make those choices about where they position the picket fence and the gate?
[00:23:13] Claire: Okay. You can probably come up with a better definition of values off your top of your head than me. Can you do the values definition please Mat?
[00:23:23] Mat: Oh gosh. Okay. I’d say that values. Values would be about how we want to behave now and always, what kind of person we want to be, and a guiding compass to the kind of life we want to lead. How’s that off the top of my head?
[00:23:39] Claire: Brilliant. Yeah, you can tell you have a master’s.
[00:23:42] Mat: How can people use values to help them decide where they set their… their picket fences and what they say yes to and what they say no.
[00:23:52] Claire: Thanks for that, Mat. I, thinking back for a long time ago, I don’t know why I’ve thought of this example. And there’s little bits of boundary all the time in this story, but I used to lead a team of, Doctors many years ago in the humanitarian sector had about six doctors.
It’s not an easy task to lead other doctors because people are very, often very strong minded and assertive and intelligent. But one of my one of my values is fairness. And it’s just going to be fair, right? The Rotary is going to be fair. The annual leave Rotary is going to be fair.
The meetings are going to be fair. Everyone’s going to have a chance to speak. And that means that there will be some boundaries put in place about, what people are requesting. And there’s going to be, there are going to be some things that are contentious, but it was really important for me.
That my team carried a fair share of the load as far as is possible. It’s never completely possible. There’s always stuff going on. I used fairness. That’s really important to me. It’s really important to me that the person without a voice is heard. And that might mean putting a boundary in place in a meeting, asking saying somewhat to someone, thanks for what you said, you’ve said a lot.
I’m going, you’re going to invite someone else to, with a quieter voice, to give their opinion. That’s just a little boundary, isn’t it? I’d like you, it’s, you’ve had your time.
[00:25:24] Mat: And that’s a great example of how knowing what’s important to you that then helps you act and helps you decide how things are going to be, yeah. So, my, my final question then, what would be your top two or three tips for doctors at work?
[00:25:41] Claire: In general, or around boundaries?
Mat: In boundaries related.
Claire: So have a think and see what you could do differently. It’s really overwhelming for so many people now. But when you take a step back on that, often people can find a couple of small things and doing a couple of small things can add up to a big difference. So don’t despair, have a look around and see what you could do differently.
client recreated the boundaries between her and some very long difficult conversations and got them more contained. So, she learned some better skills to, to do that. The second thing is to start small Maybe if you know someone who you think does it really well, who, someone who you respect and inspires you, look at how they do it.
They’re probably, if they inspire you, they’re probably doing it in line with some kind of value that you have. That you might not know about what inspires you about them and the way they do it, maybe they’re very compassionate, maybe they’re a great listener. I can’t think of, it’s only the big list of values, but there’s something about, look at something about the way they do it.
And, and see what you can learn from that because, get a coach, we’re both available. But doing things together. Amplifies your power, to have an accountability buddy in your department, your favourite work pair and talk about how, what you’re going to do differently together, have each other’s backs.
It makes a huge difference.
[00:27:17] Mat: And go on, you were going to offer me top tips for doctors in general then, in general at work, what would be your top one or two tips?
[00:27:26] Claire: Oh, just be kind to yourselves and be compassionate to yourself and take care of yourselves. You can’t, you’ll never be able to do it all.
Make sure you look after yourself. And part of that is good boundaries and learn your strength, personal strengths and values and know yourself. And lots of things then become easier.
[00:27:47] Mat: That’s a great one to finish with. So, thank you very much, Claire.
[00:27:51] Claire: You’re welcome. It’s been a pleasure, Mat.