It's Okay to Say 'No': Setting Boundaries in Oncology

Liam Davenport

June 13, 2023

CHICAGO — Oncologists need to learn how to set boundaries in their professional lives and how to address their fear of saying 'no' to sometimes illusory career opportunities in order to protect their well-being and reduce their risk of burnout.

This was the message from speakers at a special session on 'Setting Boundaries' during the recent American Society of Clinical Oncology (ASCO) annual meeting.

Monica Sheila Chatwal, MD, a medical oncologist at Moffitt Cancer Center and Research Institute, Tampa, Florida, suggested that, like a painting in a museum, physicians should have "some level of guardrail" to protect their knowledge and expertise, and also their ability to be able to continue to care for patients.

Having set boundaries "provides more emotional and cognitive flexibility, and less uncertainty, in the relationships that we have with our colleagues, with our patients, with everyone around us," she argued.

"More importantly, boundaries acknowledge that, as humans, we are multifaceted, multidimensional people," and that "we have lives outside of medicine, much as we may or may not want to admit that.

"It's great to be devoted to what we do, but there are so many other aspects of ourselves that make us who we are, and that is wonderful," she said.

A Calling, Not a Job

However, the idea of demarcating one's professional and personal life can go against the still-persistent idea that being a doctor is a calling rather than a job.

"I don't think it matters whether you call it a job or a calling," commented another speaker at the session, Jonathan M. Marron, MD, MPH, Dana-Farber/Boston Children's Cancer.

But even if it is a calling, which implies that "you are supposed to devote all of yourself to the work and not to anything else," there is still a need for setting boundaries, he argued. Saying 'no' and allowing "yourself to be yourself" are important measures, Marron emphasized, as taking time out can make you a better clinician.

Crucial to that is being able to communicate with colleagues and share a degree of "vulnerability," added Chatwal. "Showing that you're vulnerable not only to your trainees, but also to your staff and to your patients really normalizes everything."

"I have nurses who are feeling like they have to work 24/7 and manage their inbox to answer all of their messages, because they feel like they have to keep up."

"But it's nice for me to be able to model that and say: 'Listen, I want you to know it's not urgent, please take 24 hours and we'll come back to it.' "

Communicating With Patients

Chatwal noted that, while there are clear boundaries related to sexual or physical relationships between doctors and patients and around not treating family members or friends, the boundaries pertaining to communication, and "how frequently [patients] have access to us…are not so clearly defined."

The advent of telemedicine has added to that, she believes, as it offers a "patient portal that can allow access 24/7."

"Does that mean we as physicians or providers also give that level of access? Are we supposed to check messages at all periods of time?"

"More and more people are becoming more cognizant of this," she commented, noting that the issue has taken on greater import with the rise of social media and the "ability for our patients to request us as friends."

She pointed out that former president of the American College of Physicians Wayne J. Riley, MD, MPH, MBA, suggested doctors should maintain an air of detachment with their patients, as "it allows us to protect ourselves and continue to provide that great level of care."

On the other hand, she noted that there has been a sea change in how patients see doctors. Whereas in the past, medicine "was very paternalistic" with doctors seen as the "be all and end all,"  now patients tend to be more knowledgeable and Dr. Google "makes them much more engaged in their care."

But this can also cause problems when patients become "demanding for certain treatments," she said.

Limits to Ethical Care?

Marron posed the question: "Is there a limit to my ethical obligations to ethical care?"

He described a hypothetical scenario where a patient has found their doctor's email address online and they now sends "frequent emails, despite very clear instructions to use the on-call paging system for something that's urgent, and the electronic health record messaging system otherwise."

This patient's behavior is "causing a huge amount of stress" for the doctor, and this is affecting their care of other patients, as well as their academic work and home life.

Marron asked the audience: Would it be ethically acceptable to stop seeing such a patient?

Taking a quick straw poll of the audience, Marron noted that there were "not a lot of hands" raised in favor.

He suggested this is because the notion of nonabandonment comes into play,  in which there is an obligation to not let patients go without providing adequate time for them to find an alternative clinician.

In this scenario, for example, the doctor could  find "several local oncologists who are willing to accept the patient," as well as talk the situation through with a trusted colleagues, and only then "compassionately but resolutely" tell the patient that they will be transferred.

Marron acknowledged that this may seem at odds with the theme of this year's ASCO annual meeting, which emphasizes 'partnering with patients.' But he argued that "it doesn't have to be."

When thoughtfully done, setting boundaries "can ethically allow us to give more to, and partner more with, our patients, while supporting our well-being, sense of purpose, and job satisfaction," he argued.

Goldilocks Situation

Speaking more broadly, Marron said that boundaries might be considered on a spectrum.

Too few boundaries can lead to conflicts of interest, loss of balance in the patient–physician relationship, and over-engagement, while too many boundaries may result in insufficient connection with patients, thus reducing the "human element" and increasing a sense of disengagement.

Either way, "we run the risk of having decreased satisfaction what with what we're doing, and decreasing the quality of patient care."

"It's a little bit of a Goldilocks situation: You want to find the just the right balance, somewhere in the middle," he said.

In the past, issues around having too few boundaries related to conflicts of interest. This reduced trust in the medical profession, he commented, which may have impacted patient outcomes, and certainly increased the risk of reduced well-being and burnout.

"Today, we probably still lie on the end of the spectrum with too few boundaries," Marron said, "but in a very different way, as we worry about limited work–life balance, and always being connected."

"I don't think there's anybody in the room who doesn't have some kind of electronic device, either in their hand or not too far from their hand," he continued.

Moreover, "the patients that we're taking care of have a greater amount of complexity than they've ever had before…[with] greater numbers of needs than ever before," and as a result, they require "a greater amount of our time as clinicians."

Just as with the lack of boundaries in the past, this "runs the risk of us having decreased well-being and an increased risk of burnout," he suggested.

Wearing Several Hats

The third speaker, Arif Kamal, MD, MBA, MHS, associate professor of medicine and population health, Duke University School of Medicine, Durham, North Carolina, and Chief Patient Officer at the American Cancer Society, said that every oncologist wears several "hats" in addition to being a clinician.

These may include, in his case, being "a father, a husband, and a brother, and a soccer coach, and a lot of different things."

Kamal underlined that recognizing these various roles is "really important," especially when it comes to the "moment of comparison with others," as there is a temptation to see one's own complexity but not that of a colleague.

"The question is: What are all the other competing priorities that a person faces?"

For example, a person's tally of publications is "just one of many metrics" when it comes to measuring the "success of a career, and, frankly, I'm not sure that's one of the good ones," Kamal said.

He recalled how a mentor of his when he was at the Mayo Clinic had a "remarkable dip" in the number of publications at a certain point in his career, and he explained to Kamal that this was the time "when my kids needed me the most."

"That was really important," Kamal said, "because it taught me a lesson about having mentors in your life that are not only focused on your career and academic success, but also those who are very interested in the other hats that you wear."

Fear of Saying No

One way of setting boundaries is saying no to certain requests, Kamal commented.

He gave an example from his own life — when he was at a soccer game and received  a call on his cell from a patient who has seen test results before he has had a chance to review them.

Kamal also painted a hypothetical scenario, where a doctor on junior faculty, staffing a GI oncology clinic four days a week, is also volunteering to collect and organize new cases for the tumor board, and is writing several letters of intent for pharmaceutical trials. They are saying 'yes' to 90% of the requests for their time, he said, and the result is they go home "most days feeling like their tank is on empty."

"Then this person gets asked by the division chief to serve on the hospital's pain committee," he said, "regardless of the fact that this is not necessarily in their clinical or research interests."

"So this is really a bit of an [out of] left field' request, and how does this person address this?"

Kamal said that a useful concept to consider is something commonly ascribed to teenagers, that of the fear of missing out, or FOMO.

The problem is that, "due to this concept of FOMO, when opportunities come your way, saying 'no' to them gives rise to the question: What if the opportunity never comes back?"

But Kamal also reminded the audience that "without being able to say no to things…your capacity will go down."

"That's really important to recognize, because for a long time, healing professions have been thought of as [having] people that can continue to expand and expand and expand, without calling out this concept of inflation."

This is really about "being true to yourself," and acknowledging that "no one is going to set boundaries for you."

"That was a tough lesson I learned in my career," Kamal commented, and when he looked for guidance, he found that "everyone is struggling with this."

Setting boundaries, he emphasized, requires "a certain amount of looking inward…and it requires some bravery."

"You just have to ask yourself: Is the only reason you're going to do something because of FOMO?" Kamal commented. "Maybe that's okay, but you have to acknowledge that's the case."

Chatwal reported a relationship with Merck. Marron reported  relationships with Genzyme; Partner Therapeutics; ROM Technologies, Inc; Arnett, Draper, & Hagood, L.L.P.; Trentalange & Kelley, PA. Kamal reported  relationships with Acclivity Health; Prepped Health; Private Diagnostic Clinic; AstraZeneca; Care4ward; Compassus; HERON; Janssen Oncology; Medtronic; New Century Health; United Health Group; Janssen Oncology.

American Society of Clinical Oncology 2023 Annual Meeting: Special Session: When the World Becomes a Waiting Room: Setting Boundaries With Our Patients and Ourselves. Presented June 5, 2023.

Am Soc Clin Oncol Educ Book. Published online May 30, 2023. Full text

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