New skills for general practice: Setting boundaries

In her previous article, Sonia made an argument for redefining what skills we should be looking for in general practice. Here's the first of those skills - setting boundaries.

Why do I think that setting boundaries is a vital career skill?

Without it (and I have observed this in many doctors, not just GPs) there arises a slow but inexorable erosion of what one perhaps thought might be one’s boundary, and one’s concept of “self” becomes invaded. If one has no boundaries, or poorly set boundaries, then it is very easy to become overwhelmed by other people’s demands. If their demands increase (and I think we can be safe in saying that general practice is experiencing an increasing demand from many quarters) then what may have been reasonable boundaries before now aren’t.

If appropriate boundaries are not set early enough on in one’s career or relationships, then one can easily spend a lifetime meeting other people’s needs and prioritising personal needs significantly lower down the list. And that is wrong. Few people are respectful of boundaries even when they are set clearly, so for boundaries that are wishy-washy or not set at all, this is potentially a career or self esteem crisis waiting to happen.

So, boundary setting is a vital life skill and an equally important career management skill. I would even go as far as to say that some GPs who appear to seek radical career change rediscover the joy of clinical practice if they receive some boundary training as part of their career programme.

Why do doctors have boundary problems?

Firstly doctors appear to be encouraged not to set boundaries; something in the culture of medicine, some misguided view that selflessness is needed to be a good doctor. However, the skill of setting boundaries is fast becoming one that must be taught in the first days of medical school in my view.

Where does faulty boundary setting arise?

Firstly there are doubtless many GPs who have had nothing at all wrong with their boundary setting since they qualified, until fairly recently. What has happened in general practice of late means that the settings on the ‘boundaryometer’ need to be changed. This will be apparent to anyone who feels pressure and overload, or a sense that they are being bled dry. Things have changed in the demands put upon general practice, and these have been increasing over a period of decades, but with a recent surge.

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Medical school and subsequent postgraduate training probably doesn’t help, but in my opinion the real problems arise in early life. If good training were provided on this topic early in one’s career that would certainly help to address this, but to establish exactly where one’s boundary setting went awry, some people may need to look at childhood and parent/chief care giver modelling.

Where do boundaries need to be set in life?

Work: colleagues, patients and families; Home: family, friends and social settings. In other words, pretty much everywhere there is a human interaction.

Why is boundary setting so important?

The whole concept impinges on self care (or self preservation in some more extreme settings), in that having clear boundaries helps to keep one well and one’s life in balance. There are many people in your life who will not have clear boundaries, or will simply be blind to (or ignore) your boundaries, and it is up to you to defend them for your own health and wellbeing.

How do you know whether your boundaries are being invaded?

Two feelings generally arise: resentment and discomfort. The first step in knowing whether your boundaries are poorly set or are being actively invaded would be to notice if you feel uncomfortable or resentful about what is transpiring, or has transpired, in a communication with another person.

How does one set clear boundaries?

Easier said than done of course. If you have never had clear boundaries then there is almost a psychotherapeutic element to rectifying this. For most people however, their boundaries merely need reinforcement.

Part of this involves the skill of assertiveness. Indeed, these two skills of assertiveness and boundary setting are intimately related, and trying to use one without the other is probably not going to get you far in the direction of positive change.

This article first appeared in The Sessional GP magazine

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