S6E18: Setting Boundaries in Medicine

Harjit: My producer calls me a problem child because I forget everything, but honestly, I'm just forgetful.

Margaux: I love how you called Chloe "my producer." Since when do you refer to her as "my producer"? A, she's our producer, and B, she's Chloe.

Harjit: She is our producer, but I like saying my producer because it makes me feel famous.

Margaux: That's important.

Harjit: Yes. I love feeling famous. Okay, wait, that was too much. I don't love feeling famous, you guys. It was a joke. Okay, I think we can start.

Hi, everyone. This is Harjit with the "Bundle of Hers," and today I want to talk about boundaries. And guess who my guest is? JK, she's my co-host.

Margaux: Margaux.

Harjit: I've learned about boundaries from Margaux, and Margaux has seen how I have fallen through boundaries and hopefully gotten better at them.

Margaux: I would also say I've learned a lot about boundaries going through medical school, and I think we've all learned together, we being the OG crew, Bushra, Leen, you, and me, and now the new Bundles as well.

But I think boundaries are something that is interesting as women. We're socialized to not have or put up, and for people who are male in our society are taught to push through boundaries and be the enforcers of boundaries. And so interesting navigating how to fight, and acknowledge, and unlearn a lot of these cultural socializations.

But I would say I've learned a lot from you too, Harjit. And that's why I really wanted to talk about boundaries with you. For all our listeners out there, pre-meds, pre-residents, as we renamed med students on our former episode, and pre-attendings as residents are now known as, boundaries are very important as you navigate medical training, and I think it's super important to preventing and mitigating burnout.

Harjit: I appreciate, Margaux, that you kind of talked about being a woman and boundaries because that's kind of where I want to start. I've been thinking a lot about how boundaries are tied to identity. Some ways that I even think about boundaries or don't think about them is because of the cultural or societal norms around my identity.

So it's not the identity I created but the one I was either born with or look like, and then I realized that that identity, that seen identity, carries these contexts with it.

I at first thought, "No, this is just my identity. It's just my identity to be very loving, caring, kind. It's just a part of my Sikh identity to think about community. It's just a part of my identity as a woman to think about family." And it was during these times that I was like, "That means my boundaries are a little loose."

When I say loose, I know that might sound bad, but what I mean to say is it's okay if people ask me something twice and I change my answer the first or second time. It's okay for me to want to help out with a lot of things because, "Oh, I'm the helper," right?

I really tied my boundaries to my identity. That's what I'm trying to say. I think my power really came when I realized that I can have my identity and boundaries together, and they didn't need to conflict with each other.

But I think I always thought that me having a little bit more open boundaries is me just being flexible and me just being open-minded, right? But then also understanding you can still be flexible and open-minded but have boundaries.

So a lot of my understanding of boundaries was complicated because of my identities, and that's one thing that I really realized growing up. So I really appreciate that you brought up being a woman, how your understanding of boundaries kind of was formed growing up.

Margaux: I think you hit on something else too, which is that it's a very complex thing. And when you are sitting down to think about how you navigate boundaries, or at least for me, there's definitely an innate genetic . . . I mean, we're psychiatrists, so we're definitely going to go into the biopsychosocial model here, but I think there's definitely an innate component, whether it's genetic or just your personality style, that maybe predisposes you to a certain way you feel about conflict or setting boundaries.

I think innately some people are just way more feisty and are definitely going to advocate and put up those walls, and other people that might just feel a lot harder innately.

I think the second component for when I sit down and really reflect on it, I think in the U.S., our generation, authoritarian parenting was really predominant. And a difference between authoritative and authoritarian is that authoritarian is the parent is telling you what to do, you have no autonomy, you have no real options, and it's really fear-based.

Whereas now a lot of people have moved more towards an authoritative parenting style or talking about that more, which is where you have a relationship with a child where you're trying to let them solve problems together and it's not fear-based. It's more coming from an understanding.

But I say all of this that being raised in an authoritarian kind of parenting style, you are really taught to ignore your own needs and boundaries as a child and listen to those in power. And so, for me, that is something that I have to actively work to unlearn every day.

Harjit: I really like that you say that, Margaux, because I really was like, man, in medicine is when I first realized that I have a problem with boundaries because I was burning out physically. Not even mentally. My physical exhaustion was getting too much.

So to tell a story about that, I remember that I had been sick three or four times intern year, but there was not a single day I took off intern year because I was like, "I can't do that because if I leave, someone else is going to get pulled," and then I felt bad, etc. And what I did was I wasn't respecting my boundaries, and that was burning me out physically.

But then I was thinking back, and I was like, "How did I become like this?" I thought back to my childhood. I think the reason I struggled so much with boundaries is because I never was taught the concept of boundaries, and I also wasn't taught that I could say yes or no to things. It was very much like, "These are your duties, this is what you do, this is how you talk, this is how you act. If someone above you, be it your parents, be it your teachers, they feel like this is good for you, that's what you do."

And I think because of that, not having boundaries was so ingrained in me, and I've realized it's the people who struggle with setting boundaries that get taken advantage of the most in the system.

And then I'm thinking back to when I was a child, and yeah, sometimes not having great boundaries would allow people to be exploited in a lot of ways, right? Like emotional labor, physical labor, all these things.

And that's why I think a lot of times societally, when we look at it in a societal perspective, that's why a lot of underrepresented identities . . . For example, I'll talk about myself as a woman. I feel like I have a more propensity to be exploited in this system of healthcare medicine as a worker than, say, someone who was taught boundaries.

Margaux: And I would say there's also the expectation that you wouldn't set boundaries. Or at least for me as a woman too, I feel like when I do practice setting a boundary that's maybe not expected, it comes with maybe surprise from the other person, like, "Wait, that's not your role in society. What are you doing?"

But I would agree with you, Harjit. I also think in medical school, and maybe more so in residency, is when I really started to feel the negative impacts of not having good boundaries with at least my work and labor practices. Labor practices sounds so weird. But with regards to how much time and effort.

And I think that it really was maybe more in medical school when I would look around and see how much everyone was studying for tests, and when I would put in the extra time, the benefit was actually not that much better, but it was so detrimental to my mental health and my mental wellbeing.

So maybe I'd get one or two extra points on a test for giving up all that extra time to study, and I just realized . . . one day I was like, "It's not worth feeling this physically, mentally, and emotionally awful to do that."

And so I started setting the boundary of, "You know what? If I pass, I'm still going to get an MD and I'm happy with that." And I think that was the first big boundary that I set that was a transgression.

Harjit: That's actually so amazing, because I was thinking about how it wasn't until I had that breaking point with my professional boundaries did I start examining my personal boundaries.

So I struggle a lot with personal boundaries within my personal relationships, and especially friendships, right? It's just been a huge struggle for me. And I think personal relationship boundaries are difficult, especially if you grow up in a home where that's not something that's really advocated for or taught.

So I will say there's a lot of boundary stuff I have with my family, but that's different, because that's who I was born with. There are a lot of complicated factors there, which we can go into a whole other discussion, but then I was thinking I make friends, I choose friends, I choose partners, and I should be utilizing my boundaries with these people.

And what that means is a boundary could be as simple as, "That didn't feel good, so can you not do that to me again?" It could be as simple as, "Yeah, I understand that you want me to do this, but this is what I want to do."

And what I realized is when I set better boundaries in my personal life or within my personal relationships, I would be better able to understand my own identity because I'm making my own decisions and choices.

I guess, Margaux, I want to ask you this question because I've grown a lot from you. When people say, "Hey, I want to start working on boundary setting," what advice would you give them?

Margaux: That's a really big question, mostly in part because I'm still working on it a lot myself, but I would say one of the most powerful things that really got me started thinking about boundaries and why it's important or how to start thinking about boundaries is from the school of social media. I learn everything on Instagram and TikTok.

But I saw a meme or some quote that said, "When you set a boundary, you'll be able to tell who your real friends are and who was actually benefiting from your boundaries, because those people who are benefiting purely from you not having boundaries are the ones who are going to be upset by the boundaries that you set."

And that really changed my framework of how I thought about boundary setting and the people around me. But again, it comes back to this innate socialization and unlearning because it was so uncomfortable.

I really am or was trained to be a people pleaser, and still have a lot of that in me, and so to set a boundary and then have someone be upset is really difficult. But I have to keep reminding myself they were benefiting from my not having boundaries and that's why they're upset that I'm now putting it up.

Whereas if you set a boundary, someone who is really truly in a reciprocal healthy relationship with you is going to respect that and maybe come to the table with more questions and want to lift you up in your boundaries.

Harjit: I think that's really good advice. And it's also very poignant because I've been thinking a lot about relationships in my life, and I've noticed that when I did set certain boundaries, it can upset people. But that's a very painful process because you really feel deep love for a lot of people, right?

And it's sad and it's painful, so this isn't easy. Boundary setting isn't easy. You can lose opportunities. You can lose people. Some might argue you can lose jobs, but then was that job even good for you in the first place if it actually is hurting you, right?

I think boundary setting is so important. I would say start with the small choices, right? Something will feel off with even the smallest choices. Every day I didn't call in sick when I was really sick increased my anxiety and that felt bad.

And so start listening to yourself. Start recognizing what feels good and what feels bad, and I think that really helps with boundary setting.

Margaux: I have a good example for what you were just saying of starting small. One thing that I really learned . . . and it comes back to connecting with your identities and finding the power within them. I really started in med school to also embrace my identity as an introvert. I had found myself so stressed and feeling like I needed to say yes to every social event that I was invited to, and slowly I just started saying no.

And at first, it felt bad because I felt a little bit of fear of missing out, but also like I was letting down people around me and that people were going to forget about me. Then I would stay home, and I wasn't feeling as stressed or as spread thin, and it started to feel really good.

And I really rooted into that identity, and then it became easier to say no to all the extra things that I was being invited to. But I could then intentionally decide what I did want to do, and those events that I would go to felt more special and more meaningful and not stressful.

And so that's just another example of how you can really take small steps, and it doesn't have to be a big, huge boundary that you're setting with your boss or your friends immediately, but practicing boundary setting can come in little ways.

Harjit: Yeah, I really like that because I think starting small is what really helps you develop skills so that you can then utilize them for bigger things.

As a woman in medicine, as a Punjabi woman in medicine, as a Sikh woman in medicine, I have realized that boundaries can really be my power. And I've been thinking a lot about how we're taken advantage of a lot when we don't have good boundaries, and I was thinking about boundary setting in the workplace, right?

I'm sure it could tick a lot of people off when you're not giving as much as you used to, and maybe some other person is taking advantage of how much you're giving, so they're not doing as much. It is really hard because you feel like you're disappointing people, and then you feel critical of yourself, like, "Oh, my God. I'm actually not great at my job. I'm actually doing a bad job," but you were doing more than what was supposed to be yours. And then when you're gone, people will realize that you were doing so much.

It kind of reminds me of somebody in our kind of staff that left, and now four other people are hired in that one person's job, but the boundary must have been set and that's why this person had to leave, right? So consequences of boundary setting are pretty big, and it makes sense why we're socialized to not set boundaries.

So I like, Margaux, how you said a lot of it is we grow up with this, and we're basically grown up to be this way, but now is the time that we deconstruct because it does take a mental and a physical toll.

And as someone in medicine, I guess I just want to say that practicing boundary setting as a leader, as a doctor, is actually great because it teaches people who are your co-residents that might be working with you, med students that might be working with you, staff that might be working with you, it can teach them those skills too. Sometimes boundary setting is by example, and I think it's an important part of our leadership as physicians and something that I hope that I can continue doing.

Margaux: In that vein, one piece of advice I would hope to impart on all the new interns that are heading out to start their new lives as pre-attendings, or residents, is that you can start setting boundaries with yourself. The system will try to make you work more and exploit you.

Essentially, we are very cheap labor for hospitals and make hospitals run, but you do not need to spend hours and hours writing your notes. As long as you've got the safety and communication piece in your note, you do not need to write eloquent sentences and long lengthy things.

As best as you can, don't take your work home. Leave it at work. Set a boundary with yourself that your shift is over at 5:00, and so you should try to go home and have that time for yourself.

It is so hard to do that because we are living in productivity culture driven by capitalism. It is so hard to unlearn that and to fight that, but that's one of the biggest boundaries that you can set for yourself as a medical trainee that can make a huge difference for how you feel about your job in the next three years, or however long your residency program is.

Harjit: I really like that you say that, Margaux, because these practical tips that are basically just boundary setting. I'm still learning a lot about this topic. I think it's kind of been the big thing in my life right now for the past couple of years, is what are boundaries, what do they mean, and how people can be annoyed when you set boundaries and how that feels.

In my brain, boundaries seem like walls. I don't like walls. I don't like fitting into molds. I like being kind of this free-flowing, flexible person. And I think that's how I justified for years that that's why I don't set boundaries, because it's so freeing or whatever.

So I kind of wanted to deconstruct that a little bit because I don't think I was thinking about it the right way. I actually think boundaries allow you to be more free because what they do is they allow you to kind of project who you are internally out to the world, so you don't have those molds.

And internal boundaries versus external boundaries is a whole other topic, but I think that that's where a lot of my growth has been coming the last couple of years. Boundary setting actually leads you into a life, kind of assists you to going into a life that you want to live or want to be with.

Margaux: I love that analogy. I think we are trained or socialized to think that a boundary is a firm, big wall, and that's why they're so difficult to put up. They feel so bad when they're put up in front of you from other people and why you should push into them because there's just this innate . . . When there's a wall, why not push it?

But I love what you say about boundaries are really you projecting your identity out. I think of it kind of like a bubble around you that is, "This is who I am. This is what I want for myself and what I . . ." It's a transparent thing, right? It really can inspire conversation about who you are and what you want. Like Harjit, she's recording a B-reel during this episode. Talk about being free and doing what you want.

Also, I think another thing that we've constantly talked about in this podcast is thinking critically about the walls and boundaries that are placed on us in social situations. We've talked about dress code, and professionalism, and things like that.

So I think it can go two ways of when you feel like you're coming up against a boundary. Whether it's a really close friend that is setting a new boundary with you and you feel closed off by that, I think one of the best things you can do is question, "Okay, why am I feeling . . . Was I benefiting from this person not having a boundary? And why are they now setting a boundary?" If that person is really meaningful and that relationship is important to you, then approaching with curiosity and respect about what this new boundary means.

Harjit: We talked a lot on this episode about boundary setting. Boundary taking is so hard, and I love that you brought this up because, oh man, can it be uncomfortable sometimes when people set boundaries for you.

I think that it is really hard, but it allows you to examine then things that maybe you want to grow and work on.

There is one relationship in my life that I've been good with boundaries, and it's one of the most fulfilling relationships I have because I was much older when I got into this relationship. It's actually so beautiful to know that two people setting boundaries can be really powerful.

Margaux: Yes, I agree. I think it enhances your relationships. But yeah, when someone sets a boundary with you, it's good to examine yourself. But I also say if it's a professional or systemic boundary, it's okay to push it and examine it that way too, like when your attending tells you that you need to stay late and you're like, "Eh, no. I'm not working extra time."

Harjit: Yeah, that's totally true.

Margaux: I think to sum up and kind of reflect back on this episode, one of the most important things to start thinking about boundaries is to acknowledge boundaries that you might not be setting that you wish you were, why it's difficult to set boundaries, why it's difficult for you to accept boundaries that are set for you, and just sitting and examining and thinking. That's always the first step for anything, is just acknowledging and reflecting.

Then the second part actually, taking action, is harder. I, like I already said, learn a lot on TikTok and Instagram. There are a lot of people, creators, influencers, who have boundary setting sentences that you can practice to yourself that you can have ready when the situation arises that you need to set a boundary.

So those are great people to . . . Just search on TikTok "boundary setting," and I'm sure you'll find so many great resources. That's how I do it, honestly.

And I think just always being open and honest about the situations you encounter is the best way to proceed.

Harjit: Yeah, it's great to use those resources to learn a little bit more about boundaries. I kind of wanted to end on why boundaries are important for our patients. So as someone who's in mental health, both me and Margaux, one of the biggest skills that any person who suffers from a mental illness needs to learn is boundary setting. So I want to reiterate how important this topic is, because boundary setting really can help you on your path of better mental health.

Yes, we're talking about this in the context of our lives, but this is very, very important for all of our patients who struggle with mental illness, or any type of emotional turmoil. Basically, everyone can benefit from this, but these are literal skills that we teach our patients and I find it so interesting that we ourselves struggle with them, right?

So I was just thinking about how important this topic is because that's basically every meeting I have with a patient, I talk to them about boundaries and how important boundary setting is for their mental health and their mental wellbeing.

That's just another plug of why this is so important. I really urge all healthcare professionals to understand stuff about boundaries so they can be providers that teach their patient skills if needed. And it's really been something that I've been thinking a lot about.

With that, we are going to wrap up this episode. I am really excited that you'll all get to hear about our thoughts on boundaries that are both comfortable, uncomfortable, all the things above.

If you have any thoughts on boundaries or any stories surrounding boundaries, please reach out to @bundleofhers on Instagram and share your story with us, and we have these beautiful pins that we would love to give to you.

With that, I'm really happy you could be here. Please listen to us wherever you get your podcasts. Please follow us at @bundleofhers. Until next time, bye.

Margaux: Bye.