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There are small handmade wooden boundary fences lining the pathways in the woods at the end of my street. Originally fashioned and placed by a local group of citizens for the purpose of park conservation, the idea was, if you stay on the marked pathways, the rest of the forest can thrive and grow. Some locals were initially disgruntled by the prospect of being limited to certain pathways, as if their walks were suddenly bound by these old logs lashed together. But the truth is, the boundaries designated pathways that had already been worn by foot traffic. People were already following these paths.
The formalization of the pathways were not so much a limitation, but rather served as protection. Protection for the plant and wildlife, and protection for the walkers who might not be as familiar with those woods. By defining the boundaries of the pathway, the integrity of the woods, the ability to experience this little natural wonder in the city, could continue. Over time, the boundaries have been embraced as part of the park experience, allowing everyone, whether daily user or first time visitor, to use with ease, and the woods, to flourish. The boundaries, once negatively viewed as limiting, have instead proved to be a positive development, allowing a mutually beneficial relationship.
The technical definition for boundary, according to Merriam-Webster, is something that indicates or fixes a limit or extent. A boundary is a line in the sand, an impassable border, a sheer cliff face without handholds to scale up or a bridge to cross over. Boundaries can simultaneously restrict and protect us. They can define us. They can make situations easier and they can make situations more difficult.
So too, in medicine, and especially in emergency medicine. We build boundaries to protect our personal lives, define our professional lives, and serve as firewall for our wellbeing. We care for our patients in an environment filled with physical boundaries: plexiglass windows, counters, curtains, screens, walls, sterile drapes. We work on teams where boundaries defined by education and training mark what we may or may not feel comfortable speaking out about.
Boundaries in emergency medicine are frequently tested. Our patients’ stories may strike us in such a profound way that they seep from a professional space into a deeply personal one. Or the reverse may happen where a family member may suddenly thrust us from the comforts of our personal relationship into the role of caregiver or medical advocate. Boundaries are pervasive in medicine and medical training, though they might escape our recognition as such.
Boundaries may also serve as constraints, limitations and restrictions that force us to think more creatively about how we approach, analyze and find solutions to existing problems.
Learning to navigate those boundaries as a physician-in-training can feel like groping around in the dark, blindfolded, knocking into objects and getting bruised in the process. Similar experiences may occur later in our careers when we navigate the waters of becoming a new attending, or academic promotion, or retirement. How to work within and around the boundaries we are given is part of the art of medicine. We hope that this module will help you to conceptualize, contextualize, and reflect on all of the boundaries in your practice, regardless of whatever stage in your career you may be.
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