Workplace Boundaries: The Key to Beating Burnout
Andrea Austin, MD, CHSE, FACEP
In March of 2021, I was burned out and exhausted. It was tough to decipher if it was emergency medicine, my own personal traits, or my current working environment that led to my burnout. As I hit my lowest point, a week of vacation thankfully gave me some time to rest and think more clearly. While I was on vacation, I received a part-time job offer to teach a master’s level medical simulation course. Although this wouldn’t pay all of my bills, it was enough of a start for me to leave my current job.
During my sabbatical, I read a book that changed my life, called Burnout: The Secret to Unlocking the Stress Cycle by Emily and Amelia Nagoski. One of the main themes in the book is that women are at increased risk of burnout related to the concept of “The Human Giver Syndrome.” This syndrome occurs in women due to the patriarchal expectation that women are meant to be beautiful, courteous, accommodating, and always nurturing. If we fail at any of these, then we are shamed and often punished. This concept resonated with me as a woman emergency medicine physician. For example, how many times have you been stopped by patients and asked to fetch blankets or water? We are socialized to be nurturing and accommodating, so we’ll often stop to do these small tasks. Although stopping once during a shift may be reasonable and the kind thing to do in the moment, stopping every time really adds up.
After a few months and many conversations with trusted friends and mentors, I was ready to return to emergency medicine, but this time would be different. Along with Nagoskis' book, I delved fully into Brené Brown’s work. Brown states that boundaries are key to preventing resentment and staying true to our values. For instance, picking up an extra shift when you’re already behind on sleep or other necessary activities at home or work is a recipe for showing up with resentment. Instead, it is better to set a boundary that you’re unavailable for extra shifts this week or month. Although it may be disappointing to a colleague or the scheduler, keeping this boundary allows you to show up as your best self at home and work.
Consultant interactions that are demeaning and condescending are a frequent trigger of my burnout. I recognize that many of the consultants are also burned out, exhausted, or simply having a bad day, but I no longer allow disrespectful interactions. For example, I had an orthopedic surgeon request that I do procedural sedation on a patient that was inappropriate for emergency department sedation. He said that he had never heard of an emergency medicine doctor refusing to do a sedation, and he questioned my competency. Rather than shrinking from this interaction, I firmly stated that he was way out of bounds and that I would never tell him what cases to do bedside versus in the operating room. I ended the call still feeling furious, but I was glad that I stood up for myself. Five minutes later, he called back and apologized. This is the other great part of boundaries — I frequently find when I state that someone has violated a boundary, they often respond by taking accountability and making amends. This is key to healing and creating connections.
Gender bias is another common trigger of burnout. I recently started in a new emergency department, and I’m still getting to know the staff. One day, I had a patient in her 90s with atrial fibrillation, rapid ventricular response (RVR), and severe abdominal pain. Her blood pressure was stable, and her mentation was intact. I decided to wait to aggressively treat her heart rate until I had a better sense of whether there was a component of sepsis or congestive heart failure, as a beta-blocker or calcium channel blocker could block her necessary compensatory tachycardic response. The lead nurse came up to me and said he was worried that I was not treating her atrial fibrillation with RVR. I responded with my reasoning and thanked him for checking in with me on the plan. He then proceeded to say that he didn’t think my plan made sense and that I wasn’t appropriately treating an abnormal vital sign. The old me would have shrunk from this conversation and found some way to placate him with a small dose of diltiazem. Instead, I responded, “Do you talk to all of the attendings this way, or only the new ones or the females?” He had no response. Since this interaction, we haven’t had a single issue.
Patients often try to steamroll past our boundaries as well. As we weather this Omicron surge, one of my boundaries is that patients must wear their mask properly for me to come into the room. Of course, there are exceptions for a patient too altered or ill to put their mask on unassisted. Almost uniformly, the response has been, “Oh, of course! Sorry, I was in here alone.” This small example illustrates an important concept related to boundaries. Frequently, we see behavior that is contrary to our ideals and anticipate a negative interaction when, in fact, we don’t have evidence to support this narrative. I noticed that I was wasting a lot of energy by working myself up for conflicts that weren’t even there. Most of the time, the person is willing to comply with my request to wear a mask. Earlier in the pandemic, I sometimes wouldn’t even ask patients to wear the mask because I was worried about creating a conflict that would affect our entire interaction. However, I would then find myself resentful of them not wearing their mask. Most people will honor our boundaries when asked, which helps to prevent us from losing energy to false narratives or the resentment trap.
Ultimately, we need support to stay within our boundaries. We need to know that when we communicate a boundary, our leadership and hospital administration have our back. However, this is often not the case right now. During this pandemic, we have witnessed many different workers pushing back on toxic work environments. I strongly encourage physicians to take a cue from other essential workers, including nurses, by expecting better working conditions and being willing to walk away. Thanks to learning about other revenue streams for physicians from my friend, Dr. Naomi Lawrence-Reid, I no longer feel that I must tolerate toxic working conditions. Although I hope that most leaders will respond appropriately to our concerns regarding discrimination, bias, security, compensation, etc., the track record has been poor. When working through informal channels doesn’t work, I recommend formal reporting through human resources, medical staff, or other official avenues when misconduct occurs. By holding to our boundaries, we protect our mental and physical well-being, which is best for our patients as well.