Why boundaries should be part of your 2022 physician goals [PODCAST]

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“Setting boundaries can look like setting a time limit for patient appointments, availability for email responses, the number of shifts worked this month. You can set boundaries by saying ‘no’ to low compensation, setting a time limit on conversations with friends, setting a limit on our after-hours availability for work-related texts and emails and taking time off as a ‘pause’ rather than getting to a point where we are so burned out we lose any interest in medicine and leave.

Boundaries help the system keep physicians even though it may be inconvenient in the short term. Boundaries help us design the careers we deserve and the life we want.

What boundaries do you need to preserve the ‘masterpiece’ in 2022?”

Maryna Mammoliti is a psychiatrist.

She shares her story and discusses her KevinMD article, “Why boundaries should be part of your 2022 physician goals.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Maryna Mammoliti. She is a psychiatrist in Canada, and she wrote the KevinMD article “Why boundaries should be part of your 2022 physician goals.” Maryna, welcome to the show.

Maryna Mammoliti: Hi, Kevin. Thank you so much for having me today. I’m very excited to be here. I’ve actually listened to your podcast and read your articles since 2016. Some of the original articles are in my private office; they’re part of the wall decoration. So I’m super excited to be here today.

My name is Maryna Mammoliti. I’m a practicing psychiatrist in Canada. I practice in Ontario, and I also have my professional coaching practice as well, and I have four kids, so that is kind of my credentials. In my psychiatric practice, I work with physicians and health care providers mostly. I focus on ADHD, eating disorders, and trauma, and in my coaching practice, I coach on career changes, leadership, boundaries, and emotional intelligence.

I also love teaching medical students and residents, so I see them in my community practice and at the hospital where I work, at CAMH in downtown Toronto, and I do ER psychiatry at CAMH in Toronto. I think you know Toronto, so you’ll know CAMH and where it is downtown. And I just finished my two-year term as the psychiatry section chair for the Ontario Medical Association, and I am finishing up our book, Saving Lives Without Destroying Yours: Boundaries for the Modern Physician. That has been my pandemic baby, with my colleague Adam Lee. So that’s a little bit about me.

Kevin Pho: So you mentioned that in your psychiatry practice, you see a lot of health care professionals. Now, what are some common issues that you typically see that bring them in to see you?

Maryna Mammoliti: Well, I guess it varies. Originally, when I started off, I would get referrals from their physician health program, but I also have a lot of referrals by word of mouth, and also from other hospitals, usually chiefs of staff and whatnot. Sometimes disciplinary issues bring the physician in; then sometimes it’s addiction. Ideally, people seek out help when they’re struggling, without having other costs attached to that, such as disciplinary issues or significant deterioration in their function. So it really depends.

Luckily, I’ve seen a change, with physicians seeking help a lot earlier than when I started practicing, when people would be really sick when they came to see me. Nowadays, I see people seeking help, seeking psychiatric help, a lot earlier. So it’s very rewarding to see, because at a different stage, there’s a lot more we can do in an outpatient practice without having to involve inpatient care and whatnot.

And so a lot of people have been presenting with burnout, deep trauma, a lot of trauma, and definitely a lot of new-onset diagnoses of ADHD that has always been there but was never diagnosed. But definitely, I see a lot of trauma in the context of the pandemic and the impact of the pandemic on health care providers, particularly physicians.

Kevin Pho: So specifically, as it relates to the pandemic, how much of an increase are you seeing, and what specifically about the pandemic is leading health care professionals to see you?

Maryna Mammoliti: Oh, how much have I seen? I’ve seen a huge uptake in physicians seeking help for mental health. Pretty much most of my week is booked with physicians from across Ontario. And what usually leads people to seek help is, to be honest, a lot of the time, lack of boundaries: lack of boundaries between their work demands, the patients’ demands, and the amount of patients, as well as betrayal, potentially, by their employer or the hospital or the system. Especially at the beginning of the pandemic, that was a big issue here in Canada, when we did not have enough PPE and there was a lot of inconsistency in approach. So there’s a lot of betrayal, a lot of anxiety, a lot of anxiety around survival and safety, potentially.

At one point, our medical association sent out information on lawyers if you wanted to make a will, which was quite scary for many physicians. Here you are, and you have a medical association sending out information on lawyers to make your will. There was a lot of fear, a lot of fear that they’re going to die and not come home to their family, their children. How do you deal with your children? I mean, I have four of my own. It was a big, big issue: Are we going to survive this? Are we going to die? Any deaths of any physicians from COVID were very triggering for a lot of people, as well as the impact of our patients dying, right, and how to grieve and process the loss when you can’t do anything and when you don’t know what you’re dealing with. So that was a big issue at the beginning of the pandemic.

And now it’s more about the anxiety, the lingering effects, the depressive states, as well as how to manage with the public and society when there’s so much hate toward health care providers at this point. And as you know, in Canada right now, it’s very difficult. They declared a state of emergency today in Ontario because of the trucker convoys. So it’s been very difficult, and again, very violating for a lot of health care providers in terms of how they’ve been treated.

Kevin Pho: So you mentioned a lack of boundaries, and you talked more about that in your KevinMD article. It’s titled “Why boundaries should be part of your 2022 physician goals.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Maryna Mammoliti: Absolutely. On a personal level, my boundaries matter to me. When I graduated, and I was a resident, and I graduated and became staff, that’s not something people talked about as boundaries. I mean, everybody talks about boundaries with the patients and all that stuff, professional boundaries, but what about boundaries for you as a physician, to keep you well? And unfortunately, that did cost me initially, at the beginning of my career, in terms of financial cost, and I had to learn from my own experiences.

I chose to no longer tolerate it when my boundaries were crossed at a particular workplace, when I felt harassed by another physician and nothing was done, and I walked away from that place. Initially, it was very frustrating. Initially, it felt like I was walking away from a job that looked like a good job. At the same time, that was the best thing I did, because walking away from that job allowed a lot of other opportunities to open up for me, opportunities I would have never experienced if I didn’t walk away from the previous job.

Now I work with a very supportive team that I love working with, and I’m excited and looking forward to working in the emergency department, even though it’s busy. I also have my private practice and have pursued other opportunities that would have never happened if I didn’t assert my boundaries about how I should or should not be treated interpersonally at a workplace, and what I will tolerate from another physician or not.

And as well, financial boundaries. As a new grad, I didn’t know much about money, what billings are, and how to make money. And so having financial boundaries also made me realize that I was not remunerated what I was supposed to be getting and what I needed. Having financial boundaries also made me realize how much money I was losing out on initially, at the start of my career. And many physicians don’t know what the billings, what the compensation amount, should be, because we don’t talk much about money and compensation with our new grads or residents.

So that is my personal story: I walked away from a workplace because I stated my boundaries. It looked costly at the beginning. It looked like I was losing out. There was nothing that was lost. Again, what I lost was a toxic workplace. What I gained was a ton of freedom, a ton of choice, learning opportunities, new relationships, and networking that I could never have imagined, and truly peace and happiness. That’s what I gained. So that’s my story of boundaries.

And as we talk about why boundaries now: We all kind of have these resolutions, usually in January. We all have kind of goals. The financial people tell you, “What are your goals? What are your tax goals? What do you need to do?” Boundaries is one of those goals. It has to be up there with our financial goals, because there are financial boundaries that you should have as part of your financial goals.

And the pandemic really pushed me to reconsider the priorities, what I said yes to, and what I said no to, with four children in particular, managing them at home and everything else, the exhaustion, and the asks from everybody. And questioning what medicine has been for us really pushed me to do more boundary work over the last two years and really pushed me to write the book. It’s really during the pandemic. The pandemic pushed our boundaries while pulling us in so many directions, the roles we occupy, like parent and physician. At one point, psychiatrists were being trained to become ICU doctors, crossing all boundaries of our knowledge. And what are we like outside of medicine, as a spouse, sibling, friend, pet owner?

So this article is a reminder of those boundaries, that we need to take back the driver’s seat in our life, because the pandemic has really disrupted what our life was for the past two years, let alone we forgot what our priorities have been.

Kevin Pho: Sometimes I think it’s very difficult for physicians to set boundaries, because inherently, by setting up boundaries, that means you’re saying no to something or someone. And as physicians, we’re always trained to help people, right? We’re always trained to do what we can, sometimes at the expense of ourselves, to help people. And sometimes there’s a little bit of tension between that ideal of being a physician and setting boundaries. So tell me, how difficult is it for physicians to set boundaries, and what kind of tips can you give to help them create their boundaries?

Maryna Mammoliti: Look, Kevin, everything has a cost. Having a boundary has a cost. Not having a boundary has a cost. Taking a breath, me opening my mouth, has a cost. So when we talk about setting boundaries, we have to accept there is going to be a cost. If you don’t set a boundary, it’s usually our internal cost. If you set a boundary, there might be external costs. We have to be able to prepare. Can we afford the cost? What’s the anticipated cost? Because the cost sometimes is lost friendships, lost relationships, workplace, financial. Unfortunately, sometimes when we set a boundary, if I set a limit, sometimes with a patient, it might get violent, so I have to be prepared for that when I’m working. But we have to look at the cost.

Look, today I’m talking to you. There is a cost to this. I’m delaying my charting. I’m delaying my patient care, which means I’m going to have to stay later today, which means when I get home later, I’m going to have to accommodate for that cost. At the same time, I’m choosing to take on this cost of our time together, because it’s very meaningful for me. I’m choosing to push my time boundary to have this podcast, and it’s very meaningful to me.

So when you talk about training and why it’s so hard for physicians, we physicians train in a culture that indoctrinates us to function out of fear, obligation, and guilt. Now, fear of disciplinary problems, complaints, fear of losing a job, fear of being a bad student, a bad resident, not hardworking enough. This obligation that is suffocating and beyond reasonable, that we’re kind of obligated to fix and rescue things we didn’t cause. We don’t cause disease. We didn’t cause the problems our patients have. We try our best to fix it. At the same time, we can’t fix sadness. We can do only what we can do with our training, and realizing that limitation is very hard. And it benefits the system when we put the entire obligation onto the physician, because we’re used to that.

And then there is the guilt, and reasonable guilt, again, that the system puts on us when we’re trained. You don’t feel guilty if you say no as a medical student to a case or a learning opportunity, or if you ask to leave earlier, or question anything? And if there is any patient complication, there’s the guilt that is induced in a physician, that it’s somehow their fault, rather than potentially the state of a disease or a predictable complication of a very complicated medical procedure.

So physicians struggle with fear, obligation, and guilt, and a lot of shame that happens out of that as well, and we’re often isolated in that. So it is very difficult for us to say, “Hey, I have needs. I need to sleep. I need to go pee. I need to go eat. I’m sorry, I can only handle this many patients,” or, “I deserve,” or, “I need to be paid this much money, because I have my tuition loan. I have to pay my mortgage.”

We struggle to know our needs. We struggle to know what our wants are. We struggle to know what our abilities are, because those are different for every person, and even our limits. And medical school and medical training prevent us from knowing those, so when we graduate and start as attendings, we struggle to set our boundaries. Because we don’t know who we are and what our needs are, how can we set boundaries?

Kevin Pho: We’re talking to Maryna Mammoliti. She’s a psychiatrist in Canada. She wrote the KevinMD article “Why boundaries should be part of your 2022 physician goals.” Maryna, when you talk to other physicians, either in your coaching practice or your psychiatry practice, and you talk to them about setting boundaries, what kind of response do you normally get from them? And how long does it normally take for your patients to really effectively set those boundaries?

Maryna Mammoliti: Ooh. The response most of the time is, “Why? I feel guilty.” “Oh, I’m scared about what they’re going to say.” “Oh, they’re not going to like this.” And usually it’s the fear of the reaction of the other party involved, right? And usually it’s feeling guilty, feeling bad, feeling afraid, and feeling that they’ve disappointed somebody or something, and so much preoccupation with the reaction of other people rather than, “Wait, I’m actually meeting my need by setting this boundary.” So a lot of fear, a lot of guilt.

And it takes a while. It takes a long time to be able to be comfortable with setting boundaries and tolerating the consequences, and remembering that other people’s responses are a reflection of them. It’s not a causation. You saying no is not a causation of somebody’s behavior. I teach that to my children. My children are quite young, and I teach my children that when they say no, how the other person reacts is not a causation. This is why, when my son gets upset, you can’t say, “I hit my brother because he pissed me off.” It’s not a causation for you hitting him.

When we say no, the other person’s reaction is based on their own needs, based on their own life view and worldview. And that’s what people forget, especially physicians, because we’re so trained to be responsible for other people’s reactions: “You caused this. You did this. It’s your fault. This person reacted this way.” So it’s a very long process. It is not something that’s overnight.

I tell people this: Setting boundaries sounds very basic. So is brushing teeth, but I’m sure it took your parents a long time to get you to consistently brush your teeth. Now you do it automatically, because your parents put in the years of training. Setting boundaries is like that. It’s basic, yet it’s very hard and requires repeated practice, and with more practice, it gets easier, but it is hard.

Kevin Pho: So what kind of practice do you recommend for physicians who are just starting off trying to set their boundaries? Maybe name some small things that they could do to help get that training.

Maryna Mammoliti: Kevin, to set boundaries, they need to know who they are. To set your boundary, it’s kind of like the U.S. and Canada. To set the boundary, the border, you need to know where one country ends and another one begins. So step one is to get to know who you are. What are your needs? What are your wants? What are your abilities and limitations? That’s number one. Before you know that, you can’t proceed.

Number two, you need to look at what boundaries you need, because there might be financial boundaries, personal boundaries, boundaries at your workplace, boundaries with your friends and family, time boundaries. What are the areas where you feel the most trapped and resentful? That resentment and feeling of being trapped is almost like a message telling you that you need some boundaries there. You need to take some control.

Boundaries are like these predictable rules that help us guide the kind of engagement between you and another party. Boundaries give us that kind of space between two objects. Think about the U.S. and Canada. You cross the border, and you have a predictable, different set of rules about driving, or laws, right? That gives you predictability, the boundary. So think of boundaries as that space or set of rules, and you need to see what areas of your life you feel the most trapped and resentful in, to help guide you to where you need some boundaries. So those are some quick, easy tips just to start thinking about boundaries.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Maryna Mammoliti: Well, my take-home message number one is take the plunge. I checked your website at three in the morning while on call, when I got the spot. So if I didn’t check the website, I wouldn’t be here today. So take that plunge. Check the website. Do what you need to do.

Number two, when you say yes to something, you say no to something else. Saying yes to this podcast, I’m saying no to my 15 minutes of lunch. I’ll have it later. There’s always a cost to having boundaries, but there’s a cost to not having any boundaries.

And my last piece is that every physician is a masterpiece, the masterpiece in the museum. Everybody’s going to want a picture with you and a piece of you. If everybody took a piece of that masterpiece, we won’t have anything left. So the ropes around the masterpiece in the museum are the boundary. You don’t have a security guard holding up the rope. You are the one who has to hold those boundaries, every day, all day, because you’re going to have multiple visitors coming to you with demands that are reasonable for them. They’ll want a picture of you. They want to post it on social media. They want you.

And there’s only one of you, so you have to protect the masterpiece, or there’s nothing left of you. And that’s why we feel burned out. That’s why we feel trapped, and we feel like we have nothing left to give at the end of the day, or we don’t know who we are, because that masterpiece is being chipped away with no boundaries. That’s my take-home message.

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