Boundary setting in general practice

“The new meaning of ‘first do no harm’ includes a consideration of ourselves as well as our patients. This is not to be confused with selfishness or ‘looking out for number one’. It is about a long-term obligation to our own wellbeing, health and safety, which is essential for the competent medical care of others and our optimal participation in medical life.” First do no harm: being a resilient doctor in the 21st century, Leanne Rowe and Michael Kidd (2009)

THE 21st century has changed significantly since Rowe and Kidd called for “first do no harm” to incorporate self-care for doctors over a decade ago. A pandemic, increasingly complex health needs of an ageing population, widespread mental health problems and a chronically underfunded healthcare system have led to reports of alarming levels of burnout within the medical profession, with GPs experiencing some of the highest levels (here).

In more recent times, self-care has rightly found a place in the discourse around GP wellbeing, however there are limits to what can be achieved through traditional self-care that usually involves ensuring that time spent away from work is restorative and meaningful.

Another cornerstone of self-care that is less frequently discussed is that of boundary setting, which is vital to the professional longevity of every GP. An established set of well thought out boundaries can be transformative in how GPs manage stress and prevent burnout.

Like many medical professionals, GPs can be prone to being both agreeable and conscientious – traits that have been associated with increased levels of burnout. This combination may also be playing a role in many GPs considering leaving the profession and a concerning drop in trainee numbers. In the absence of boundaries, saying yes too often while also trying to provide a high standard of clinical care will inevitably lead to burnout. It is therefore critical  to look at strategies that offer GPs a means of putting on their own oxygen mask first.

Boundaries can provide a structured and tailored approach to not solve, but rather aid in preservation of the self in navigating the various problems and conflicts that arise in general practice. Put simply, a boundary is an invisible line drawn around a person that determines what is acceptable to them and what is not. This line allows for acceptable behaviours and practices to occur within this boundary, while unacceptable behaviours and practices are identified and addressed accordingly. Boundaries ensure a sense of agency and, in the clinical setting, allows a GP to have their own basic needs met during consultations and beyond.

Boundaries come in all shapes and sizes, they can be physical, time-based, emotional or financial. Physical boundaries in the clinical setting are now second nature to most – with a 1.5 metre zone of personal safe space and face mask standard expectations for patients and GPs alike during a face-to-face consultation.

Non-physical boundaries are less clearly defined, however they are just as important in maintaining healthy and safe work environments. They are decided upon based on an individual GP’s experiences, values and goals and will look different from one GP to the next.

Time-based boundaries start with the obvious by ensuring wherever possible that the time-constraints of an appointment are respected. They also extend into creating boundaries that promote protected time for breaks, education and administration. Whilst the appointment book will always require a level of flexibility in order to deliver quality care, recognising when this is and isn’t reasonable is an important step in boundary setting.

Financial boundaries are emerging as pivotal to the viability of general practice, and also for valuing the worth of quality GP services. The current Medicare rebates for GPs inarguably fall significantly short of the cost of the service. Setting the expectation that due to this, consultations will incur a gap fee is very reasonable, and should be considered where appropriate. Unfortunately this will mean increasing out-of-pocket expenses for patients, however due to relative funding cuts it is now a necessity in order to keep GP clinics in operation.

Emotional boundaries are perhaps the most difficult to recognise and control. Maintaining a safe emotional space between GP and patient is a delicate and highly personal balancing act which can aid in fostering emotional independence rather than dependence in patients. When the emotional weight of a patient feels like it is crossing a boundary, it is time to step back and consider what needs to change. This may take the form of sharing the load with a colleague by using an alternating appointment arrangement, organising multidisciplinary care, and in rare instances it may be necessary to terminate a therapeutic relationship with appropriate explanation and handover of care under the guidance of medicolegal advice.

Establishing boundaries requires skills that will sharpen over time, and maintaining them requires sustained effort. Comfort and confidence in saying the word “no” is essential, and learning that an explanation does not necessarily need to follow also helps. The most liberating of phrases can be the most simple. For example, “I don’t prescribe this medication”, “I don’t bulk bill”, “I don’t see walk-ins unless there is an emergency or other extenuating circumstance”, “I don’t take phone calls outside of my rostered hours” and so on.

While boundary setting may be met with initial resistance, it is a long-term investment as boundaries will likely reduce the amount of overall conflict and tension experienced when patients and colleagues know exactly what to expect from you.

Boundaries have their limits and are works in progress, they are fluid rather than static – if one isn’t working, reflect and revisit. Structural and systematic issues cannot be adequately addressed through the individual act of boundary setting. It is also important to note that are times when boundaries either need to be put aside or adjusted. The most obvious example is that of an acute illness or medical emergency, where there is an obligation no matter what the circumstances.

Some boundaries may be incompatible with a workplace culture, the expectations for a specific clinical role or the needs of a particular patient. Recognising this is imperative and sometimes it is necessary to make difficult decisions, such as finding other work . Whilst this will be hard, the alternative is even more so – it is unsustainable to have boundaries constantly tested and resisted.

While clinics can find other employees and patients can find other doctors – it is trite but nevertheless true – there is only one you. You are not replaceable to yourself, to your friends and to your family.

Optimistically, acknowledging this enables GPs to find the workplaces and jobs that are just right for them. While a handful of patients may be a poor fit, the vast majority will respect boundaries and an ongoing and productive therapeutic relationship will be built.

The optimal balance between GP self-care and patient care remains aspirational. Ensuring that practicing GPs and the current generation of medical graduates are instilled with the knowledge, skills and language to effectively identify, set and communicate healthy boundaries will provide a professional safety net that can prevent burnout.

“First do no harm” must be applied to the self. It is worth taking time to reflect on your current practices, especially those that result in fatigue, emotional exhaustion and poor remuneration. Discuss boundaries with colleagues, compare notes, become familiar and comfortable having the same discussions with patients. In doing so you can lead by example to restore a sense of agency and satisfaction from clinical work, improve income and even get home on time.

Dr Alisha Dorrigan is a Sydney-based GP and deputy medical editor for the Medical Journal of Australia.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.