Boundaries for women physicians [PODCAST]

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“I learned the hard way what can happen when physicians—especially women physicians—lack personal boundaries. Before hitting my low point, I had no boundaries. I had been raised to give, give, give, and, when times became tough, to give more by working harder. In medical school and training, we were taught to not have boundaries, but rather to do everything in the service of our patients who should always come first. Now I realize that we physicians must put ourselves first. We are hurting ourselves—and doing a disservice to our patients, colleagues, and families—when we put everyone and everything else before our own needs. After all, we are our most precious resource and must use that resource in the best way possible.”

Tammie Chang is a pediatric hematology-oncology physician and co-founder, Pink Coat, MD. She can be reached on Instagram @tammiechangmd and at her self-titled site, Tammie Chang, MD.

She shares her story and discusses her KevinMD article, “Boundaries for women physicians.”

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Transcript

Kevin Pho: 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. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. Today we welcome back on the show Tammie Chang. She’s a pediatric hematology-oncology physician and the co-founder of Pink Coat, MD. She’s also the author of the book, which we’re going to talk about today, Boundaries for Women Physicians: Love Your Life and Career in Medicine. Tammie, welcome back to the show.

Tammie Chang: Oh, thank you so much, Kevin. It’s so great to be back and to see you all again.

Kevin Pho: So we’re going to talk about your book in a little bit, but for those who didn’t get a chance to listen to our first episode together, just briefly share your story and journey to where you are today.

Tammie Chang: Oh, you got it. I’m 10 years out of training from my peds heme-onc fellowship, and like I shared before, and I’m very open about this intentionally, it was actually only three years ago, and I keep thinking it’s longer than three years, that I was one of those physicians who struggled with deep burnout, severe depression, and being suicidal. That time of my life, which was only three years ago, has really been the catalyst for everything in my life now and today and everything I do.

It’s why I do Pink Coat, MD. It’s why I do all this physician wellness work. It’s why I’m so driven and motivated to help make this better for all of us, because I know that I’m not alone in my struggles. There’s so much astounding data about suicide and physicians that I was never aware of, and I’ve been in this for my whole adult life, just like all of you listening. That’s what drives everything I do today, and I feel that this is my absolute why, my purpose in life, and I commit to doing this for the rest of my life.

Kevin Pho: So over the last three years, during your work with Pink Coat, MD and with physician burnout and suicide, tell me some of the things that you’ve done to move the needle in that area.

Tammie Chang: I hope so. What actually changed everything for me three years ago was this, because I wasn’t fully honest with everyone around me. I didn’t even tell my husband what was going on, to be honest, and I definitely didn’t tell people at work what was going on. It wasn’t until I reconnected with Luisa Duran, who is now my Pink Coat, MD co-founder. She’s my longtime friend from Brown. We were in college and medical school, eight years together, from freshman orientation at Brown. We were 18, and we had a 20-plus-year friendship and trust.

She was the first person I really told the truth to, and at that time she had also been struggling as well but hadn’t had anyone to talk to about it, because she was isolated as the only woman in her practice. We shared our stories and realized that there’s no way we could be the only two women doctors struggling out there. We started to dig into the literature and the research, and we realized there was a ton of data that had already been published by a lot of people over the years, but we had never heard of it. Why had we never heard of it? We’re all about data, right? And we love our professions so much.

So that spurred us on this whole journey of what we can do to shed light on the reality of what’s really happening behind the curtain, and how we provide evidence-based solutions, because a lot of people have already shown excellent solutions to a lot of these problems that we’re dealing with, and yet they’re not put into practice or not easily available for other people. So that’s why we’ve done what we’ve done. We hope, we strive, we call it a bubble of love, because there are few places in this world, and definitely few in medicine, where there is that safety and the trust and that unconditional love that we certainly have for each other. That’s what we strive to do for everyone around us, whether they’re part of Pink Coat, MD or not. It’s who we strive to be for other people.

Kevin Pho: And you talk more about your work in your book. Of course, it’s titled Boundaries for Women Physicians: Love Your Life and Career in Medicine. Now, before talking about that book, just tell me how it came together.

Tammie Chang: Oh, it was actually because I was somehow inspired to write just a short blog article for you, KevinMD. I’d always wanted to do something for KevinMD, and I was like, “Oh, I can’t do something like that. That’s too fancy for me.” I ended up doing it, and it struck a chord with so many other women physicians. That was about a year and a half ago, maybe February 2021, and at that time I said, “You know what? I’m just going to share it, because if it helps one other person, it’s worth this work.” Writing a book is another way to share a message even more, in a broader way, just like you helped to amplify the voices of so many of us who don’t feel like we have a voice. So that’s where it started. It was just that blog article that I wrote only a year and a half ago, maybe almost two years ago now.

Kevin Pho: So when you wrote that blog article almost a couple of years ago, you said there was such a big response. Give me an example of some of the response that you got from that article that eventually led to this book.

Tammie Chang: I think you not only shared it through KevinMD, but it was also on Doximity. So then I was getting messages from people from Doximity and through KevinMD who were saying, “Oh, yes, this still resonates for me. That struck a chord. Yes, that’s what I struggle with. It’s so hard. Why can’t I say no, even though I know I need to say no? Why is this so hard?” It was the same theme over and over again.

I personally know that, for me, the reason I got to that deep, dark place that I got to three years ago is because I never knew what a boundary was. What we’re trained to do in our medical training and medical school is to just give, right? We’re altruistic. We’re giving human beings. The vast majority of us are drawn to this by a deep sense of calling to help other people, but we don’t learn how to not overhelp, right? We don’t learn how to not give until we have nothing left for ourselves. I felt, at least for me, I knew that was why I struggled the way I did. It was like, if I can do something to help anyone else learn a nugget of a lesson so that they don’t have to struggle the way I did, it’s so worth it. And that’s what started this whole journey for me.

Kevin Pho: All right, so let’s talk more about the book. What are some of the main messages that you want readers to come away with?

Tammie Chang: The big thing is to step back. I’m so glad there are so many books now written on boundaries, and there have been a couple of other books written by others in our medical community about boundaries. I’m so glad, because I think the more we bring it up, the more we talk about it, and each of us explains it or thinks about it in a different way, it’s going to resonate with people in a different way. So I’m like, the more the better.

This concept of personal boundaries didn’t exist until the 1980s, and I was born in 1981. I’m a child of immigrant parents. They definitely were not raised with the concept of boundaries, and for the vast majority of us who are practicing today, our parents were not raised with that. So we were not raised with that concept or that value or that belief, and so it’s understandably so uncomfortable today, because it’s not what we saw around us in our parents or, when we were raised, even the adults at school.

And definitely once we got into medical training, it’s like we’re trained to do the exact opposite. We are extolled for going the extra mile. I don’t know about you, and probably many of you listening, but I came in on weekends. After work, I stayed till midnight. I was there on holidays to check in on my patients, and that’s what was considered a good student, and it’s what I felt like I should do for my patients. So I just want to step back and give that perspective, because I think when we even bring up this concept, it’s such an uncomfortable topic for all of us.

Kevin Pho: So give us an example of how those boundaries are sometimes ignored in medicine. You certainly can draw from examples from your own practice, I know, but also from stories from the other physicians that you talk to. Just paint a picture of how those boundaries are sometimes ignored in medicine.

Tammie Chang: Oh, yeah. I think it happens every single day. It could be on a small level, as in how available we are in general to staff, to patients, and to colleagues. We’ve been trained to be available 24/7. A lot of the struggles with the EMR are that we are charting after hours or charting on weekends. We’re spending our vacation time to catch up on charting. That’s one very obvious example of how we don’t have boundaries, because we’re just always working.

I still have so many colleagues who leave their pager on 24/7, just in case they need to be available or just in case something could happen, even though they’re not the point person on call. And yes, that’s how we were trained, but it doesn’t serve us when we’re adults in the real world trying to sustain ourselves in this career that is becoming harder and harder by the day. There was just another big headline in the New York Times today that just came out about distressing levels of physician burnout, and you know that better than anyone; you talk to all of us personally. So that’s another example.

Kevin Pho: Yeah. So how hard is it to change that mindset? Like you said, the reason why a lot of us go into medicine is because we are so altruistic; we are so giving. And you’re right, the concept of boundaries is sometimes foreign to a lot of people who generally go into medicine. What are some things that we can do to re-establish those boundaries?

Tammie Chang: That’s such a great question. The first thing that I do, and I work with people as a leadership coach too, because that’s what really helped me, that’s what saved me really in my darkest time, was re-evaluating what my core values were, what my why and purpose was, and being able to articulate it with clarity, because the vast majority of us haven’t had the chance to explore that in our lives, even through all those years of training.

Through that experience, for instance, I came to realize that I used to think my core values were compassion and service, which is probably the case, I would bet, for a lot of our fellow physicians. But I came to realize through all that coaching that my core values are actually joy and love. The way I express my love for other people is through compassion and service, but not never-ending compassion, not never-ending empathy, because ultimately I’m not a joyful person, or I’m not able to give love to anyone, if I’m not OK, or if I have nothing left to give. I’m depleted, right? So I give that example. That’s my own personal example, and it’s going to be unique to every single other person.

But it’s really about defining and taking that time to allow ourselves to be honest about what our priorities are in life, which are our core values. What is a non-negotiable for you? Family is a big one for a lot of people, and how many of us are really honoring our family as our core value in this profession? That’s one of the first things that gets put on the back burner, because we just are working all the time. We miss school performances, we miss practices, etc. So that’s another example too of a way to think about it as well.

Kevin Pho: So what happens when those core values, and you mentioned family to be one of them, are in conflict with your professional obligations? Because a lot of times, if you want to spend more time with your family, if you want to go see those soccer games with your kids, that’s going to put you in tension with what your clinic wants, what patients want, and what your administrators want. So how do you navigate that tension?

Tammie Chang: That’s such a great question. I think that’s the biggest one everyone asks, right? The reality is, I think it’s also a mindset. It’s thinking about all those others, because those are all other people. They’re human beings too. We’re really all on the same team; we’re not on two sides of the team. They are human beings too, who also have families, and they have core values, and they probably struggle with setting boundaries too.

So what I encourage others to do is to go from a place of compassion and love for our fellow human beings and just explain why this is so important to you, not in a way that’s mean or demanding, and not that anyone’s ever mean, but demanding or angry or argumentative. It’s really from a place of compassion, to say, “This is so important to me that I make it there,” because, for instance, my father, as a physician, could never make it to my recitals as a kid, and I have never forgotten that and haven’t been able to forgive him for that, right? Being able to share that with others helps them understand the deeper why. And the reality is, I would wonder, they probably have had that experience, or a similar experience, too, so they can relate to that.

So I think it means coming from a place of compassion and empathy, sharing your core values and the deeper why behind them, slowing down and taking the time to explain it, and asking them to also help you to achieve that. And also asking them what they need, right? Because there is a reason why they are asking for these things. They have pressures that are put on them, and they’re worried about their jobs too. They have tremendous stress. So how can we work together to find a solution and be on the same side of the table?

Kevin Pho: Yeah, I think you bring up a good point, because sometimes when I talk to patients in the exam room and I tell them I’m only working a couple of days a week, they say, “Why aren’t you working five days a week?” And it’s because I want to spend more time with my family. I think it’s a little bit ironic that those who are able to have that balance, those who are able to cut down, can actually stay in medicine longer than those who see like 30 patients a day, because those are the physicians that tend to burn out quicker and, ironically, drop out of medicine sooner.

Tammie Chang: Yeah, it’s so true. I think that actually really speaks to it. It’s not because, and we know this, right, we see this in the data, it’s not because we’re not resilient enough. We are among the most resilient people on Earth, in any profession. It’s because of the way health care is delivered today and the pressures that we are seeing on our health care systems right now. We’re in the midst of another; the financial crisis is astounding and universal in health care today.

My role in my day job is as medical director of provider wellness for my large health care system. I have 5,000 physicians and APPs; that’s my role and my scope. And it’s hard to know how to really move that needle, like you said, on a day-to-day basis, when we know that more than 80 percent of what’s going on is due to our health care system. What I want to see someday, and what drives me in all this work, is how we make health care not only sustainable but compassionate, more joyful, full of the meaning, which is why we came here, in a way that provides the best care not only for our patients but also for those who are taking care of the patients. That’s my dream for all of us, and I know that you get to talk to many other people on this podcast who feel that way. I hope that we can, and I know that we can, do it together. It’s just going to take a lot of work and a lot of time to do that together over time.

Kevin Pho: So tell us another main message that readers can come away with in your book.

Tammie Chang: Yeah, I think another big message that I want to hone in on is to learn this, and I think especially on top of being physicians. I don’t mean to minimize in any way what men go through, because I think what women go through is just as difficult in another kind of way, but women, we really struggle to take care of ourselves and put ourselves first, and I think physicians as a whole do.

There have been some really great publications coming out of the Stanford group recently, the Stanford WellMD group, showing how we have higher imposter syndrome and the worst self-compassion among professions. Can you believe that? We are so much harder on ourselves than we are on anyone else in our lives. So if we can give ourselves even just some of that compassion that we so strive to give to other people and our patients, I know we will be better off in the long run.

Kevin Pho: So what are some of your tips for women physicians to improve self-care?

Tammie Chang: I always think it comes back to those core values. That’s the litmus test. Are you honoring your core values in this moment, in this part of your day, in this interaction, in this job, in the way it’s structured, or with the people who are your leaders, your supervisors? Is that being honored? Because that has to come first, and if we put that on the back burner, it shows up in other ways down the road for all of us. So I think it comes right back down to that again.

Kevin Pho: We’re talking to Tammie Chang. She’s a hematology-oncology physician. She’s a co-founder of Pink Coat, MD and the author of the book Boundaries for Women Physicians: Love Your Life and Career in Medicine. Tammie, what are some of the take-home messages that you want to leave with the KevinMD audience?

Tammie Chang: Oh, give yourself the same grace and compassion that I know you have dedicated your lives to give to others.

Kevin Pho: Tammie, thank you so much for coming back on the show and sharing your time and insight.

Tammie Chang: Thank you. Thanks so much for having me again.

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