Set out your boundaries and stand by them

4 minute read

It’s fine to have expectations of your patients, as long as you telegraph them in advance. Anything else leads to resentment.

Last week at a review with a regular patient of mine I had the opportunity to get some feedback.

She’s been very happy with my care, but wanted to let me know that when she was initially looking months ago, the website was very offputting with too many rules and regulations to qualify – so much so that she left without proceeding.

For her, the difference between the way the website set her up to believe I’d be and the way I actually have been with her in our interactions was jarring.

It was wonderful feedback, the criticism delicately sandwiched between positive acknowledgements, which allowed me to reflect without defensiveness.

To her, I said “Thank you, it sounds like the website is doing its job, then – because I am not for everyone, as you may recall my saying to you from our initial appointment.”

We plan to continue working together and I encouraged her to leave a candid review, including “Dr Joshi is very strict about the way she works”, which is only the truth.

Given the nature of my work – which includes longterm psychotherapy, skin cancer excisions and primary care dermatology, and typically takes many months – I am interested in working mainly with people who will be disciplined enough to commit and to show up to every planned appointment. It won’t be possible get results if they flake, reschedule and cancel.

I mulled all weekend on the interaction and whether I could or should have said anything different, invited her opinion on what she thought my website ought to do better or be less direct or confrontational about.

Ultimately I reached the conclusion that the way I work is working for me. Given the work I do is longterm, discretionary and requires patient effort for success, I am OK with sifting out the people who are unaligned with those values, so the patients who do get to work with me see results at least in keeping with their efforts and investment by showing up.

Far too many of us bend over backwards trying to accommodate everyone and in the process end up abandoning ourselves, leading to burnout and resentment.

For me, resentment is the first sign of a boundary violation, and to minimise the risk of this happening, I am OK with signalling my expectations to people before they make an appointment to see me so they know what to expect and there is no shock when they show up.

If that does not work for them – and it will not for most – then I am, quite simply, not the doctor for them.

The bulk of my appointments are 30-45 minutes and some as long as 60+ minutes. If someone cancels even a week prior, I won’t be able to fill that spot because people need to plan around their work, events and potential downtime.

So I am very firm with people: if you are not serious, I won’t take you. This avoids the unspoken resentment so many of us seem to accept as the price of doing business in health.

It need not be this way and it is absolutely reasonable to be clear about your terms of engagement. The people who are disciplined enough to show up are not the people who will be deterred anyway.

If we have firm boundaries in place, we have the freedom to occasionally make an exception because we choose to, instead of feeling regularly angry and resentful. Along the way, this seemingly simple solution may be the answer to greater job satisfaction, with patients who value their work with you and show up. It then becomes a symbiotic partnership to help them achieve their stated goals.

Either way, we choose which path we want to be on. There’s a bit of pain either way: that of anger and resentment, or of enforcing boundaries that some people will push back against.

In my case, this feedback has served to help me make this decision even more overt in my communication so that it becomes even clearer to people to help them choose who and what is best for them – nine times out of 10, that means it may not be me, and I am 100% all right with that.

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.

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