Kirkepiscatoid

Psalm 16:

Protect me, O God, for in you I take refuge.

I say to the Lord, “You are my Lord; I have no good apart from you.”

As for the holy ones in the land, they are the noble, in whom is all my delight.

Those who choose another god multiply their sorrows; their drink offerings of blood I will not pour out or take their names upon my lips.

The Lord is my chosen portion and my cup; you hold my lot.

The boundary lines have fallen for me in pleasant places; I have a goodly heritage.

I bless the Lord who gives me counsel; in the night also my heart instructs me.

I keep the Lord always before me; because he is at my right hand, I shall not be moved.

Therefore my heart is glad, and my soul rejoices; my body also rests secure.

For you do not give me up to Sheol, or let your faithful one see the Pit.

You show me the path of life. In your presence there is fullness of joy; in your right hand are pleasures forevermore.

I had the "fence guy" over to my house recently, because my older donkey, Sylvia, had thwarted my great plans from last summer. We had thought we had been clever enough in putting up new fences that would keep long-eared equines from breaking down the fence to eat on the other side of it. But I came home to find that five strands of barbed wire (six in some places) were not sufficient to keep her from turning her head sideways, poking her head through the fence, and eating on the other side, pushing down the wire. It was a sufficient enough gap she thought getting a little scratched was worth it.

So as you can see, I now have NINE strands of wire on the fence, with a very narrow gap at the height she had discovered the breach.

Now, I realize all Sylvia wants is that juicy grass on the other side of the fence. But Sylvia, not being the one who pays the bills around here, and not being the one who will be arrested for a county "loose animal" violation, is not the one who gets to make the rules. As I've mentioned before, my old fence was woven wire with a strand of barbed wire on top. The squares in the woven wire were almost like a ready made step-stool for equine hooves. Over time, the equines learned that all they had to do was smoosh down the woven wire and stick their heads under the barbed wire and they could eat grass on the other side. I was amazed, by the time I finally fixed the fence, that they had remained IN the confines of my pasture.

So last summer, I had the fence replaced with five strands of Gaucho barbed wire (which is pretty sharp.) I had the fence designed so the wire was clipped on the inside, so pushing out wouldn't "pop" the wire off the posts. I had the gates re-hung so they swung inward in the pasture, so pushing against them wouldn't make the gate swing out and reveal instant freedom. I blogged about it here.

My long-eared equines are a constant reminder about how boundaries and limits are a constantly evolving process.

In organizations, "boundaries" seems to be the new buzz word. I am a monitor for the Missouri Physicians Health Program, one of the two agencies who monitor impaired physicians and physicians who are on the slippery slope of impairment and voluntarily join the program. When I first became involved with MPHP, most of our clients were there for substance abuse issues. Although substance abuse is still the majority of what brings people to MPHP, in recent years we have had a real upswing in physicians who come to us because of "boundary violations," mental health maintenance, and "disruptive physician" behaviors.

I've come to realize something very interesting in my work with MPHP, and the reading I do to keep up on things in the physician impairment world.

"Boundaries" gets a lot of press. "Limits" do not. I've noticed the word "boundaries" gets tossed around when sometimes, I think "limits" was what the article was talking about.

I think that discussion needs to change.

Boundaries are what we put out there for others not to cross lines, or lines put out there by society, or our personal oaths and vows in our professions that say "do not cross." Limits are what we set on ourselves not to cross over our own lines.

When we speak of a physician who has been in trouble for "boundary violations," it's really a two pronged violation. One is the violation of the boundary within our oath to not harm patients, translated as "don't have romantic or sexual relations with patients." But there's a second prong. A physician who does that, also commits an additional violation much of the time--he or she has preyed upon the victim's limits, and used the power differential as a weapon.

Honestly, I think a certain subset of disruptive physician behavior (once substance abuse and/or personality disorder is eliminated as the true culprit) is based in "inability to set limits." People with poor ability to set limits constantly get their limits eroded and the only thing left to do is blow up. The problem is, when they react to this erosion, their behavior shatters boundaries all over the place.

I'm going to be honest. Docs with "disruptive physician" issues are my least favorite. Give me a drug addict or an alcoholic any time. A lot of these folks, frankly, are not fun to be around. Borderline personality disorder runs high in that group. They are angry, defensive, and paranoid. They don't have a lot of insight into their own process. They tend to make everything everyone else's fault, including the monitor, and they like to play "threaten the monitor." There's not much joy in monitoring them, not a lot of that "I really helped this person" feeling.

But within this group, there's an interesting subset of docs. There's this little subset of ones that seem rather, well...ordinary...and what one discovers is, in hearing their stories, they are not the type that terrorizes the office staff chronically; they're not the ones who routinely verbally cut up patients and family members, and they're not holding everyone hostage at home psychologically. Their story is one of being fairly normal, but having these massive temper flare-ups and fits of pique, but over time, there's some stressor, and these episodes get closer and closer together. In fact, others describe them as hard working, dedicated, and in the beginning, the episodes are sort of brushed off as "Well, he/she does so much for everyone, I'm sure the stress of that must be awful sometimes."

What I am learning about this subset is that many of them suffered some form of abuse as children. This abuse made it difficult for them to learn to set limits. They were often around people in power who did not have healthy boundaries themselves, so when these folks DID set limits, they were frequently disrespected, ignored, and ultimately eroded. The abuse that the medical educational process heaped on them in clinicial clerkships, internship, and residency replicated the abuse they had at home. They feel unwilling to set reasonable limits, and in some sense, they never really learned what reasonable limits were. They are often in tremendous debt for a lifestyle they feel their family and community expects them to have, but really don't enjoy this lifestyle or even have time for it. Sometimes I get whiffs of the mild end of autism spectrum disorders in their habits or mannerisms.

I'm not presently monitoring any of them, but for some reason, my name comes up in the community of "people who play in the MPHP sandbox" as a trusted person to just get to know. So there are the phone calls and one-on-ones and social networking chats.

But after a while, they almost always force me to consider my own issues with limits. In their stories, I hear bits and pieces of how my own limits have been tested and eroded over the years by people with crappy boundaries. I realize that in my own case, it has a lot to do with the "don't ask, don't tell, and for God's sake don't feel," culture I was reared in, and how this culture, in me, was also cemented in my clinical training years, and the early years as an attending doc. In the times I knew that someone else's crappy boundaries was tearing apart my limits, I knew it, but the fear of telling was so ingrained, I just didn't tell until the erosion reached what I call a "core limit." Instead, I tried to control the other person, lock in on them, and put my focus on them.

I remember a particular surgery attending, who was prone to throwing fits in the OR and lining out the trainees. I would double and triple-check the instrument tray before cases, for fear there was a missing instrument that would cause him to go off. I would carefully line up the charts in room number order so the next chart he would pick up without looking was the right chart. I would hand in tables of all the lab values of patients over several days time so he could see at a glance what was going up or down. What I did not do was research my own cases--I was too busy lining things up for him--and on rounds I would get torn apart by him. Literally torn apart in this cutting, sarcastic way, in front of everyone.

At the end of the rotation, he told me I was one of the best students he ever had and would I consider going into surgery.

I was dumbstruck.

He continued on that I was so "good" because I "took care of things for him."

"But...but...I thought you thought I was an idiot. You ripped me up on rounds all the time."

"Oh, that," he replied. "I knew you knew enough. I also knew you could take it. It's kind of like "slapping the kid next to the kid you want to behave, so they get the message." You made the team better by taking it for the team. But I could tell you could take it, so I mostly used you to get the message across."

I don't know how I kept it all together. I muttered some kind of "thanks" and left. But I was livid for days at how I had been "used." It was my first real adult glimpse that abusers have a sixth sense about their targets.

So when I meet these other docs who have issues with limits, it forces me to examine my own.

These are hard issues to factor in one's own Baptismal Covenant.

"Seeking and serving Christ," in abusive SOB's with personality disorders...well...it's a tall order.

What I have learned is part of it is to set appropriate limits for what I will and will not tolerate in unacceptable behavior, even if to ask, to tell, and to feel puts me in a difficult position with the top end of the power differential. Through my spiritual disciplines, and through working in community, I have learned that I require a certain amount of "alone time," I require spiritual feeding, and I don't always have to shoulder the burden in a community, even if they dump it on me. I can think, ponder, and act, instead of react.

In exchange, I have to trust that God will allow our boundary lines to "fall in pleasant places" when we respect ourselves and obey our own limits.