Boundaries, Burnout, and Bullshit

I've been thinking a lot about boundaries lately.

That alone probably sets off some amber lights. When people talk about "boundaries," it's often code for something - stress, trauma, resentment, frustration. Something's pressing on the skin.

But for me, it's mostly a reflection on how many hats I wear now. I'm a GP. I'm an academic. I'm a parent. I'm a husband. I spend my days immersed in other people's lives - holding the soapy bubble bath of their chaos, their pain, their fragility, and trying not to absorb it all.

And lately, I've been wondering how much of that I'm actually allowed to carry before the bath starts pouring into my lungs.

Because the truth is, empathy doesn't come free. It has a cost. And boundaries are the only thing that keep the whole thing upright.

Sympathy is Feeling For. Empathy is Feeling With.

Empathy is not a passive act. It's not nodding along. It's co-regulation. It's climbing halfway into someone's pit just long enough to understand the walls, and then having the clarity to know you can't stay there.

The most empathetic doctors I've known are some of the most burnt-out. And not because they cared too little—but because they didn't build walls high enough to survive the flood. I've done it too: over-invested in someone's situation, taken too much of it home, blurred the line between "doing my job" and "trying to rescue someone."

It's tempting - especially when systems fail, and you're the last person actually picking up the phone. It feels noble.

But it isn't sustainable. And it sure as hell isn't safe.

The Boundary Isn't a Wall. It's a Fence with a Gate.

What does that boundary actually look like?

• Sometimes it's deciding not to over-invest in a patient who can't—or won't—engage with the work.

• Sometimes it's choosing not to chase every referral, scan, or blood test just because the patient insists.

• Sometimes it's gently saying no to a treatment they don't need and backing it up with evidence.

• And sometimes it's noticing that you've stopped listening and are just pretending to actively listen while you type eConsults on the other screen. (Don't lie. You've done it. I have too.)

Boundaries aren't about apathy. They're about making sure your care is useful, not just present.

The Pull of Overreach

Let's be honest: it's never been harder to hold boundaries.

Waiting lists are a joke. Services are patchy. Pain clinics, psych, neurodevelopmental pathways—it's all drowning. So the overspill ends up in primary care. In me.

And it's seductive—this slow erosion of boundaries. You find yourself giving more follow-up than you should. More letters. More time. More tests. More bending. Because somewhere in your brain, you know nobody else is going to do it.

But at some point, the person you're over-giving to isn't the patient. It's yourself, trying to rescue a system by overfunctioning inside of it. That's not care. That's a burnout strategy.

Boundary Setting Is a Clinical Skill

There are days I do it well. And days I don't.

I've had patients park themselves in my room and refuse to leave. I've had people spiral into fury because I refused to refer them for a test they didn't need. I've written "prefer continuity—complex case" in the notes so many times it might as well be auto-text.

And I've snapped. Not dramatically. But enough to know I've failed them, and myself. In those moments, I've gone back. I've apologized. Not because they were right—but because I wasn't.

Because boundaries aren't just about firmness. They're about reparation too.

The Cultural Drift Against Boundaries

The real threat to boundaries isn't just patient behaviour. It's the erosion of trust in the medical profession itself.

Patients arrive more brittle now. Defensive. Suspicious. The idea of a GP as a trusted consultant is disappearing. Now we're "the gatekeepers." The roadblock. The ones stopping them from their MRI, their scan, their drug, their answer.

And you can feel it in consultations. It's no longer "What do you think, doctor?" It's "This is what I need. Can you sign here, please?"

That cultural shift makes boundary-setting not just difficult—but dangerous. Because every time you say no, you risk becoming the villain in someone else's story.

The Children Analogy

I say this carefully, but I think it's apt: setting boundaries with patients has uncomfortable parallels with parenting.

Not because patients are children—they're not. But because human behaviour in fear and frustration often regresses. People test limits when they're anxious. They push when they feel powerless. Just like kids, people escalate when they think the boundary isn't real.

And just like with parenting, if the boundary flexes unpredictably, all hell breaks loose.

But consistent, compassionate, clear boundaries? They calm things down. Over time, they create safety.

Even if the first reaction is anger.

If Everything Feels Like a Battle…

If you're finding it harder to say no…

If every patient feels like a negotiation, a conflict, a test…

If you dread your inbox like it's got a live grenade in it…

You're probably not the problem.

But it's a sign your boundaries are under siege, and your empathy is bleeding out under fire. That's the time to pause. Regroup. Delegate. Talk to someone who gets it.

You can't pour from an empty cup. And you can't protect your patients if you're busy trying to save the whole system singlehandedly.

Boundaries Aren't Cruel. They're Kind.

Kind to your patients. Kind to your colleagues. Kind to your family. Kind to yourself.

Because if we want to practise empathy in a world like this—to keep that soft, essential human thread—we have to build fences. Not to shut people out. But to stop the whole house from burning down.

And that means sometimes saying, "This is enough."

And meaning it.

Stay Tough

--DW