What my 10 year old is teaching me about boundaries [PODCAST]

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“As I’ve been coaching physicians, I’ve realized that many of us have a tendency to just ‘grin and bear it’ when it comes to the challenges and stresses of the medical profession. We often tell ourselves that things will get better tomorrow, and we just have to hang in there until we finish our training and become an attending. However, this approach can prevent us from developing the language and awareness we need to understand and articulate our values, and to set boundaries around them.

Living sustainably, both personally and professionally, requires alignment with our values and the presence of healthy boundaries. That’s why I wrote the article on retraining ourselves to develop these skills. We may have grown up in a certain way, but we can always learn to express our needs and boundaries more effectively.

Physicians, in particular, often struggle with setting boundaries because we tend to be people pleasers. We want to help others and make them feel better, so we may have a tendency to always say yes, even when it’s not healthy for us. This can lead to burnout, so it’s important to reintroduce boundaries into our lives.

One way to think about boundaries is as a fence around our ‘yard,’ with our values and what we stand for as the ‘house’ inside the fence. The fence keeps out what we don’t want and allows in what we do want, and the gate allows us to negotiate and adjust our boundaries as needed.

To set boundaries, it’s important to first get clear on our values. What matters to us? What do we stand for? Once we have a sense of our values, we can identify what gets in the way of living them and then set boundaries to protect them. For example, if service is a value, we can ask ourselves what is acceptable and not acceptable in terms of how we offer our service to others.

Boundaries also require language and communication. We need to be able to express our boundaries and needs to others, and to negotiate and adjust them when necessary. This can be difficult for many of us, but with practice and support, it is a skill that can be developed.”

Yvonne Ator is a physician and personal and executive coach for physicians.

She shares her story and discusses her KevinMD article, “What my 10 year old is teaching me about boundaries.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Yvonne Ator. She’s a physician and a personal and executive coach for physicians, and her KevinMD article, which we’ll talk about today, is titled “What my 10 year old is teaching me about boundaries.” Yvonne, welcome to the show.

Yvonne Ator: Ah, thank you so much. This has been a dream come true, just so you know. I’m a huge fan.

Kevin Pho: Thank you so much for reading and coming on the show. Now, before getting to your article, just briefly share your story and journey to where you are today.

Yvonne Ator: Yeah. I have an MD and an MPH. I was the quintessential idealist who immigrated to the U.S. from Nigeria, born in the U.K., in England, and wanted to change medicine and change the world through medicine, and found myself burning out. That was a shock to me because, you know, this is the American dream; you’re supposed to live it. I was really shocked to see that with the thing I had sacrificed everything for, I now had to choose between living and doing it, and I chose to save myself.

And so, through a series of events, including my dad actually dying during a physician strike, I chose to focus on physician well-being, and I’ve been doing this for the past decade. I’m really interested in physicians who went into medicine to help people, like I did, and find themselves struggling with overwhelm, compassion fatigue, disillusionment, and burnout: people who have sacrificed so much to make a difference and find themselves struggling. These are the people I feel really passionate about, mission-driven, heart-centered physicians, because I feel like without those professionals, in general, in every field, we’re in trouble. So that’s a brief, very brief, summary of my path.

Kevin Pho: So I talk to a lot of physician coaches on the show, but you’ve been doing this for a decade, which is a very long time in the physician coaching industry. So contrast the situation now with when you first started 10 years ago. Has it gotten better? Has it gotten worse when it comes to physician burnout? What’s the situation like compared to when you first started?

Yvonne Ator: So when I first started, my dad had just died in Nigeria during a physician strike in 2011, and I was like, “OK, I see something coming in America. I don’t know what.” I could hear the rumblings of burnout, but we didn’t have language for it at the time. No one was talking about burnout. I was seeing something that I couldn’t put my finger on. And so back then, there was no language, and no one was talking about it, so I feel like I was just kind of out there with this machete, trying to find my way.

I knew I wanted to transform the culture of medicine. I knew I wanted to be the support that I wish I’d had when I was struggling, but there was no one and there was nothing, so I was just kind of fumbling my way. When I was having conversations with the powers that be in medicine, the administrators and the executives, people were looking at me like I was crazy, and there was just no interest in physician well-being back then.

Fast forward to now, and it’s been better and worse in some ways. It’s better in the sense that there’s language for it now. People are really starting to discuss it since the pandemic.

Kevin Pho: What’s the language that we’re talking about, other than physician burnout? What are some of the terms that you’re hearing more frequently now?

Yvonne Ator: So things like perfectionism, boundaries, shame in the workplace, and bullying; things like, you know, work-life balance, which is kind of a misnomer, because I think about it more like work-life harmony, or integration, or homeostasis. And then things like, one, being willing to invest. Now there’s a willingness. There’s still somewhat of a reticence, but there’s more of a willingness to talk about it. The shame is less. There are more avenues for having conversations, and there are obviously way more physician coaches, and there are more programs in the system to support physicians.

But in terms of what I’ve seen that’s worsened, there’s still more exploitation, still expecting physicians to do more with less, and just generally in health care, I think since the pandemic, I’ve definitely felt like the squeeze has been tighter. So even though there are more avenues for well-being, people are in survival mode and have no time to get out and do the work that they need to do to come back to themselves.

Kevin Pho: What’s the typical profile, and there may not be one, but what’s a typical profile of a physician who comes to you for coaching help? What kind of questions and what kind of issues are they dealing with?

Yvonne Ator: So the physician who comes to me for help, and maybe it’s because of how I show up in the world, is usually someone who was kind of multi-passionate before they came to medicine, so very good at many things, and who has now focused only on medicine and is finding that they’re completely exhausted all the time. There’s this sense of hopelessness in a way, where it’s like, “No matter what I do, I just can’t seem to get over this hump.” By the time they come to me, they really need the help, but they also have the sense of wanting to return to who they were before they came into medicine.

They feel like they’ve orphaned different parts of themselves. Maybe they played guitar before medicine, maybe they volunteered, or they wanted to go into medicine with the idea of doing mission trips, or, you know, of being more connected to their communities, as the family doctor or the physician in the community. And they find themselves completely isolated, completely focused on work, and nothing else matters. Nothing else exists except for work, and they barely have time for their family.

So by the time they come to me, they feel like they’ve orphaned all of these different parts of themselves, and they’re wanting to come back to finding the person who went into medicine to begin with. Who was that? That’s why I call my work the Thriving Idealist. Who was that person who wanted to change the world through medicine, and where’s that person gone? They’re wanting to bring that person back, reconnect with the reason why they came into medicine in the first place, and find a way to thrive personally and professionally while making the difference that they set off to make in the world. So that’s usually the kind of profile: very heart-centered, but starting to feel really disconnected from the heart; very mission-driven, wanted to make a difference, and sacrificed everything to make that difference, and they find themselves going, “What am I doing? Where am I? Who am I?”

Kevin Pho: So your KevinMD article is titled “What my 10 year old is teaching me about boundaries,” and I often hear about the lack of boundaries leading to burnout. So tell me the events that led up to it. Why did you decide to write this?

Yvonne Ator: So it’s funny. I’ve always wanted to write an article for KevinMD, and I was sure it was going to be about physician strikes, because, you know, I felt like physician strikes were coming, and that’s a topic for another day. But I noticed that the people I was serving, like everyone right now, are really just wiped out, to the point of not being able to do anything.

And I wanted to speak to what I was seeing in my house, which was that because my kids had heard me use this language, you know, maybe they’ve heard me talk about boundaries, they’ve heard me speak to groups, and all of that, they were now starting to use it. And I realized that one of the reasons why we’re in the trouble we are in medicine is that we’ve been trained to disregard our boundaries. We’ve been raised up, so to speak, to ignore our needs, our values, and our wants, or our necessities.

But seeing how my kids were growing up in my home, they had the language to say, “This is OK. This is not OK. This is acceptable. This is not acceptable.” “Hey, Mom, I don’t like the way you did this. Please, can you do that?” They were using their words. And as someone who, yes, I was born in the U.K., but my family is Nigerian, coming up from that immigrant family, you just didn’t do it. You just didn’t say things like that. “What are you talking about, boundaries? What’s that? I sacrificed everything to bring you to this country. What do you mean?” So it’s like, you know, to have my kids feel safe enough and empowered enough to articulate, “Hey, this is not OK,” or, “Hey, I like this. More of this, please.”

And so, as I’ve been coaching physicians, I realized that because of how we came up, it’s like, “No, you just grin and bear it. You know, it’ll get better tomorrow. Just hang in there until you finish med school. Hang in there until you finish residency. Hang in there until you finish, you know. It’ll get better when you become an attending.” You just keep hanging on and never really develop the language or the sense: What are my values? What’s important to me? What do I stand for? What’s violating that? And how can I set parameters around these values, these things that I value, so that I can live in a way that’s aligned for me? Because the only way we can live sustainably is if we’re in alignment with our values and if we have those boundaries intact.

So that’s how that article came about. It’s like, wow, imagine if we retrained ourselves. You know, maybe we grew up one way, but you can retrain and reparent yourself to learn these skills now, so that you can use the words to express, “Now I would like a day off. I’ve been working for, you know, 60 days straight,” and, “This is not OK,” or, “This is not healthy.”

Kevin Pho: Yeah, I think the people who get selected to go to medical school inherently, you know, rarely say no. They tend to be people pleasers. That’s why they go into the profession in the first place. They want to help the world. They want to make people feel better. So inherently, there’s a character trait that wants them to always say yes, and sometimes that does negate a lot of the boundaries. So what are some ways that physicians can reintroduce some of those boundaries? Because if you are completely boundaryless, that, I think, is a surefire way to get to burnout.

Yvonne Ator: Yes. So I like to think about boundaries, and I love Boundaries by Townsend and Cloud. I like the visual that they have. I think I saw it there, and I just kind of expanded on it: this idea of boundaries being a fence around your yard. So imagine a fence around your yard. Your house is you and all the things that you value. So think about your values: What’s important to you? What do you stand for? What would you like? What are you creating in your life, or what kind of life would you like to live? Let that be the house. And then the boundaries are the fence around the yard, and then you have a gate in that fence.

Sometimes people get scared of setting boundaries because they think it’s just a wall. You know, no, it’s like a fence with a gate. So when you have a fence, the fence keeps the things you don’t want out and the things you want in. But then there’s a gate that negotiates. If something’s not working for you anymore, you can open the gate and let it out, and if you want other things, like better relationships, then you can open the gate and allow those in.

So there’s this idea: What do I stand for? So number one is getting very clear about your boundaries. This is your values. This is the first thing I tell anyone: What are your values? What matters to you? If I ask you, “What are your values?” can you rattle them off to me? Is it creativity? Is it service? Is it love? And if you stand for those things, or those things are valuable to you, what gets in the way of you living those? Is it spending 500 hours on the EMR? Is that what’s getting in the way? And so how do we protect that? That’s where the boundaries come in.

I like the definition of boundaries as what’s OK, what’s not OK, what’s acceptable, and what’s not acceptable. I’m certified in all of Brené Brown’s works, so Dare to Lead, the Daring Way, and all of that, and I really like the language in there. She says, you know, what’s OK, what’s not OK, what’s acceptable, and what’s not acceptable. So if I want to live the value of service, what’s OK for me to do? What’s not OK for me to do? What will I allow around me, and what will I not allow? Will I allow myself to serve until I am completely exhausted, or will I put time limits around how much time I’m serving? What’s OK and what’s not OK in terms of making time to create? Am I able to make the time to create? Is it OK for me to go for months without creating something and find myself completely dry emotionally and spiritually? Or is it OK for me to, you know, once a week, maybe on a Saturday afternoon, whip out the guitar and play? So be able to get clear about your values, and then start to set the boundaries.

And then the third concept I like to think about is the concept of living BIG, B-I-G. What boundaries do I need in place, that’s the B, so that I can live in integrity with my values, that’s the I, while assuming that people are doing the best that they can, and while I’m doing the best that I can? So if you’re in a system where there are schedules and, you know, everything is determined ahead of time, OK, you know that the administrators or your supervisors are doing the best they can. What boundaries do I need in place so I can live with the fact that they’re doing the best they can, while also wanting to live my values? So that means being able to have the hard conversation in order to live BIG.

This idea of living BIG is living in alignment while assuming people are doing the best they can, because if we don’t assume people are doing the best they can, or that we’re doing the best we can, then there’s no gate. Now everything’s just a wall: my way or the highway, or I do what they want and I don’t have any of my needs met. So being able to live BIG allows for the boundaries, the fence and the gate: What’s important to me? But also, I’m doing the best I can and they’re doing the best they can, so how can we negotiate this? What kinds of conversations do I need to have? But definitely, be able to use your words. So that’s one thing I really like about the boundaries: the idea that it’s a living document. It’s a living thing.

And I think a lot of us are in survival mode and feel like we don’t have the bandwidth to have the conversation. So that would be another thing I’ll say: Take care of yourself, whether it’s meditation, running, exercising, or journaling, so that you have a little bit of margin, a little bit of space, to sit down and go, “What matters to me?” Articulate it, and then have the conversation, and then put things in place. If you’re in survival mode all the time and not able to take that time, then your life just flies by, and before you know it, you’re 63 and wondering, “What happened to my life? What did I do here? This is not the life I wanted to live.” I’ve had a lot of people come to me in their 60s and say, “It just went by. It just all flew by, and I don’t know what I did with my life.” And that’s something I wouldn’t wish on anyone.

Kevin Pho: So tell me a success story. Tell me a case study, or a story where someone implemented some of the ideas that you just mentioned, and that moved the needle in their professional life.

Yvonne Ator: There’s one who was a director of a hospital nearby, here in San Diego, who will remain nameless. She was a mother of a young kid and was also pregnant at the time, and she was working, of course, the 80-hour weeks, and then directing different programs, and was just burning the candle at all the ends. It wasn’t just both ends; it was all the ends. And we sat down and created a plan. I think at first she wasn’t having any time, and at one point she even had her baby and was still trying to answer all the calls, and not wanting to take time off even to care for the baby.

And so we were able to come up with a plan where she was able to take some time off, re-delegate certain duties that she had as a director, and cut down her clinical hours. That’s not to say that you shouldn’t work, but it’s being able to create more margin so that you can show up for the things that you care about. Now, she really cared about physician well-being at her hospital, actually, but didn’t have enough time to do that. And so she was able to cut out the things that were not in alignment with her values. There was some administrative work she was spending a lot of time on that she couldn’t care less about. She didn’t care about the meeting. She didn’t care about it. And so we were like, “Why are you spending any time there?”

So let’s just look at your values. You know, her values were service, and I think generosity, and connection, really wanting to connect with the people she was working with, and also being willing and wanting to connect with people at home as well. And so, being able to look at her priorities: At the time, her priorities were her relationship with herself, her relationship with her spouse, her relationship with her kids, and then her immediate family, and then her work community. Looking at those priorities, and then applying those values to her life, she was able to see, “OK, here I’m spending,” I think at that point it was like 60 or so, on things that she didn’t care anything about, because she was expected to. And so once we discovered that those were things she didn’t care about, she was able to cut them out and then redistribute her time to things that she cared about: physician well-being, and then really spending more time. She wanted to spend more time with patients, and then to be able to spend more time with her family and her kids, and then have the baby.

But I’m really proud of her, because one of the things I love about my work is that you’re not just affecting one person. You’re affecting patients, you’re affecting families, and you’re affecting generations through the kids, and for me, that’s really important. So I was really proud of her, because it was a very scary thing to do. A lot of times we feel like if we say no, the world will stop, or people will stop loving us, or people will alienate us or cut us out, while the people who really matter will understand. Because when we set boundaries, it’s a way of telling people how to treat us. It’s a way of telling people how to love us, if I even want to bring that word into medicine. And so if we don’t set boundaries, people don’t know how to treat us. If I don’t say, “This is not OK,” then people will think it’s OK and just keep treating you that way. But most times we think, “Oh, they’re just doing it on purpose.” Most people don’t wake up in the morning and say, “Hey, how can I make Kevin mad today?”

Kevin Pho: Yvonne Ator is a physician and a personal executive coach for physicians, and her KevinMD article is titled “What my 10 year old is teaching me about boundaries.” Yvonne, what are some of your take-home messages that you want to leave with the KevinMD audience?

Yvonne Ator: Yes. So I wrote down a couple of things that I wanted to share. I’m going to put on my glasses. So the first thing I wanted to share was that no one’s coming to save you. You have to save yourself. So if you’re in a situation where your boundaries are being violated, it’s up to you to set those boundaries, to speak up. So you have to save yourself by expressing those boundaries.

The other thing that I really want to share is that you can’t do this alone. No matter how much you bubble-wrap yourself, life is going to happen, and it’s going to hit, and sometimes it’s going to hit really hard. Who do you have around you? Who are you allowing around you? Sometimes your boundaries require that you allow people who nurture you, who support you, who get you and what you’re about, and who are aligned with your values, and that you have those people close and lean on them for support. Everyone has blind spots.

So if you feel isolated, which is another thing I see in our community, where people are so lonely and isolated, and this is actually a really big problem, you can’t do this alone. Reach out for support. Reach out for a coach. Cultivate a small square squad, which is just a group of people whose opinions really matter to you, who really care about you, and who can be empathetic towards you without judging you. Have at least two to three people that you can have around you who can mirror back empathy towards you as you try to negotiate these boundaries, as you try to set them, or else it will feel like you’re alone and you’re crazy. And so those two things, I think, are really important.

And the third takeaway that I think is really important is to make room for what really matters, and practice. So whether it’s making time for your exercise or making time for your journaling, make time to create the life you want. Make the time, or else you’ll blink and your life will be gone.

And so those are the three takeaways. I mean, I could talk forever, obviously, but those are the three things that are really showing up for me as really important: Make the time for what really matters to you, get clear about what really matters to you, and then set the boundaries to protect them. But also make sure that you take care of yourself, so that you can have that time to communicate those boundaries. And again, support: No one can do this alone. You need to make sure you have a community of people, or at least a coach, or a mentor, or someone who supports you as an empathic partner as you do this.

Kevin Pho: Yvonne, thank you so much for sharing your time and insight. Thanks again for being on the show.

Yvonne Ator: Thank you so much for having me. It’s been a pleasure.

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