Early one morning, after a nearly sleepless night on call, otolaryngologist Mel Thacker, MD, asked her colleague in anesthesiology to push back her elective surgeries scheduled for later that day.

“I wanted to make sure I got a couple extra hours of sleep before I went and operated,” said Thacker, co-founder of the Hippocratic Collective. “He was like — ‘nobody’s ever done that before.’” 

When Thacker’s patients learned the reason for the delay — a little extra sleep for the person wielding the scalpel — they expressed appreciation, not annoyance.

“It’s just one of those things where somebody has to go first,” she said. “Whether it’s a boundary, a preference, or drawing a line in the sand, we have to start to change the rules in some way and stop overriding our internal signals that tell us that something isn’t right.” 

Boundaries in medicine are having a moment. A scene in the latest season of the HBO hit The Pitt went viral after medical student Joy Kwon clocked out on time at the end of a chaotic hospital shift. When challenged, she replied: “Maybe all you lunatics need to learn how to set some boundaries.” 

Advocating for your needs and setting boundaries isn’t easy, but neither is burnout. Doctors and psychologists say that setting boundaries can help clinicians preserve their mental and physical health and promote safe patient care.

Boundaries vs Demands

When you set a boundary, you’re not making a demand or simply sharing a preference, said Thacker. You’re kindly explaining what you are going to do in a situation that violates your values. “A boundary is always what we’re going to do; it’s not a threat,” she said.

Although it’s challenging, setting and articulating your limits can help you care for yourself and others, at home and at work.

“We can’t take care of patients if we don’t take care of ourselves, so we have to have boundaries,” said Dawn Sears, MD, clinical professor in the Department of Internal Medicine at UT Southwestern Medical Center in Dallas. “You’re doing it for all the future patients you’re going to treat, and you’re doing it for your future self.” 

The idea of boundaries is simple. The hard part is admitting you need them and drawing the lines.

Why Boundary Setting Feels Radical

“Boundary setting is a critical skill that allows us to run the whole marathon of a career that doesn’t come crashing down in exhaustion, medical errors, and burnout,” said Andrew J. Smith, PhD, an assistant professor of psychiatry and health policy and clinical practice at Dartmouth’s Geisel School of Medicine in Hanover, New Hampshire. Smith, who has treated hundreds of doctors across a variety of institutions, has noticed that “physicians, for a number of reasons, simply do not do this naturally or particularly well.” 

“It’s a challenge for all of us in every profession, but I think that boundary setting is particularly fraught for physicians,” said Angela Passarelli, PhD, an associate professor of the practice of management at Duke University’s Fuqua School of Business in Durham, North Carolina, and co-investigator and coaching director for the Coaching and Resources for Entrepreneurial Women program at the Medical University of South Carolina in Charleston, South Carolina.

Everyone juggles their personal needs with their employer’s needs, but doctors’ ethical duty to patients adds complexity, she said. Physicians also learn early in their careers to discount their own needs.

“We are taught the patient always comes first, and you, your sleep, your need for hydration, your need for food, your need for rest, your need to breathe is not even valid — it doesn’t even enter into the equation,” said Sears. Through years of training with low pay and long hours, Sears says doctors are conditioned to accept this and “basically told, ‘you’ll rest when you’re dead.’” And they believe it.

The rules for shift lengths are stricter today, though not always followed. But the expectation that you’ll always be available to patients and staff — via call, text, pager, email, or electronic medical record messages — hasn’t gone anywhere.

“Boundary setting is morally coded that in order to ‘provide access,’ [physicians must] be endlessly available to over-function and be hyperresponsible, that being ‘good’ means being endlessly available, and setting boundaries means you are behaving in some amoral way,” said Smith.

When he mentions boundaries, some physicians roll their eyes. “There’s a cynicism, like ‘what a cute Pollyanna-ish idea’ that we could even set boundaries,” Smith said.

The Fear Factor

Even if you want to set boundaries, it can be hard to do it in practice. Blame the biology of people-pleasing, the way hum ans are wired to avoid disappointing others. Smith helps physicians notice the loop of behavioral reinforcement that begins when someone makes a request that pushes you past your capacity. You might feel emotional discomfort, perhaps a twinge of anxiety. You want relief as soon as possible.

“In order to make it go away, so we can get back to being really efficient and not having these inconvenient emotions, we say yes on repeat because it closes the loop and gets us back into efficiency mode,” Smith explained.

Then, when you do recognize that you want to set a boundary, you might talk yourself out of it in the name of being a team player.

“There’s always work to be done, and we don’t want to be dumping our work on other people,” said Thacker. “There’s a fear of hurting colleagues, losing a job, or having leadership pinpoint you and put a target on your back.” 

Then there are incentives against setting boundaries. Often, people who lack boundaries receive praise and rewards. “I was appreciated for always taking care of the Christmas party and always taking the extra shift,” said Sears. She started advocating for boundary-setting nearly a decade ago, after ascending leadership ranks and observing how many high-achieving women in medicine were exhausted.

Setting boundaries can feel particularly fraught for groups with less privilege and power. Attrition among female surgeons is high, and research points to poor work-life balance as a top reason.

“Women are leaving because they are starting to see that this is not sustainable. They need to learn how to set boundaries more than anyone,” said Thacker. “People of color and international grads are also up against being targeted more often with performance improvement plans and sham peer reviews.”

Generational differences may also influence how physicians approach boundaries.

“Younger physicians are really curious about a more balanced way to practice, about a different social contract with medicine and their patients,” said Smith. “The pandemic and the financial model in medicine have revealed and illuminated a different path for physicians moving forward.” 

Balancing Meaning and Discomfort

“Those of us who are mid-career or later probably need to do a better job of not painting things as black and white, and role-modeling vulnerability,” said Daniel Saddawi-Konefka, MD, director of Anesthesia Residency Program and associate professor of anesthesia, Harvard Medical School, Boston.

Some asks — like staying after a shift ends — are uncomfortable. You have other things to do, such as spend time with family, exercise, and practice self-care. Those needs must be weighed against the meaning derived from your work.

“I know for me there are days where my kid has a play, and I promised him I’m going to be there. I’ll make sure of that,” Saddawi-Konefka said. “And there are days where there’s not a whole lot going on at home, and the team is in a rough spot, or I made a particular connection with a patient and really want to see something through, and I’ll stay for them, and I try to track that comfort-meaning balance.”

How to Start Setting Boundaries

Instead of saying “yes” to every demand on your time, Smith recommends pausing.

“Slow down, notice the emotion, and take a minute to weigh the request against all the other things that you have going on that day,” said Smith. “When you say yes to one thing, you are saying no to another thing or person in your life.”

Ask yourself: Does this task help me be a better doctor? Colleague? Parent? Spouse? A lack of boundaries can contribute to marital problems, parenting challenges, or a higher risk of making medical errors.

It takes courage and time to develop the skill set to set boundaries. Consider starting small.

“Start with very low-risk boundaries, so the next time somebody gives you a project that you could easily say yes or no to, and you don’t really care about, try some other ways of saying no, and see how it feels, see how they receive it,” said Sears. “Then you can work your way up from there because you don’t want to look like you’ve had a total brain transplant on a random Tuesday.” 

She recommends practicing hard conversations with a coach, a friend, or even yourself on an empty Zoom call.

Eventually, you’ll be able to set consistent boundaries around your work. For example, if you ask your office manager not to double-book you, you can enforce that boundary by explaining that if they double-book you, you will ask them to reschedule one of the patients. And then follow through.

Benefits or Backlash

Some boundaries will be met with respect. Others might irk a colleague or patient.

“I always tell my physician clients that every time you set a boundary, there’s some form of consequence, whether that’s emotional, social, professional, or opportunity-related,” said Smith. “It’s not a reason not to set them — it’s something to expect, look for, and be willing to pay to get the life and work that you want.” 

In fact, a person’s reactions to your boundaries can tell you a lot about them.

“When you start having boundaries, the person who is taking the most advantage of you…will react the most negatively, and they will be extremely upset,” said Sears. She considers their rage or dismissal as data to inform future interactions.

If your boundaries are regularly violated, then it’s time to consider what comes next — even if that means eventually leaving your role to join another organization, said Thacker.

“We think that we are hamstrung by our current jobs and by the rules of the institution,” Thacker said, “but I think we just have to have the courage to decide: what am I willing to tolerate and what am I not. And then follow through and do that.”

The experts cited in this article had no relevant disclosures.