036 Boundaries – Revisited

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Summary: This podcast episode features Dr. Phil Dr. Marina Capella discussing the practicalities of setting and maintaining boundaries in direct primary care (DPC) pediatric practices. The conversation primarily unfolds through real-world case studies, illustrating how boundaries are defined, enforced, and how they can flex based on context and physician comfort levels.

Welcome to DPC Pediatrician. We’re Dr. Phil Boucher and Dr. Marina Capella, two DPC pediatricians who are on a mission to share our love of direct primary care with you. Hey everyone, welcome back to DPC Pediatrician. Okay, we… realized that we talk a lot about boundaries.

Like a lot of our conversations, I’m thinking of our recent talk on text messaging. I’m thinking about our recent talk on scheduling have all also incorporated like set boundaries, hold boundaries, those sorts of things. And so we thought it would be fun today to just do some like case studies of how would you approach,

because it’s nice to say, put boundaries in place, don’t answer the phone and those sorts of things. But we have been both in practice long enough that we’ve had lots of times where, the patients come up to the boundaries and it’s not their fault necessarily that they’ve come up to the boundaries.

It’s just that their kid doesn’t get sick at 10 in the morning, you know, when it’s perfectly like, come on in sort of time. And so we wanted to kind of talk through the logistics of how we actually handle some of these boundary issues so that you feel comfortable and understanding or can

hear from us how we approach boundaries in our own practice. We haven’t really reviewed these together. So it’s going to be a little bit on the fly of like, what would you do? What would I do sort of thing? And the first one that I wanted to start with,

you’ll notice that a lot of these are temporally related because it’s rare that at 10 in the morning, people are breaking boundaries. When you’re open and you’re available, there’s not as much boundary breaking that happens. So the first one that I came up with Marina that I want your take on is

is the text message at 7 p.m. My kid has a barky cough and what should I do? And the reason that I bring this one up is because this sort of thing gets cited sometimes in the Facebook groups of I just went over to their house and I gave them

a dose of Decadron or I met them at the office at 11 p.m. at night to give them a dose of Decadron. And for me, that would break my boundaries. I’m not going to leave home for some croup at 11 o’clock at night. But I’ll tell you what I would do in this circumstance.

But I want to hear from you, Marina. What would you do if somebody, you know, let’s just make it more specifically the seven-month-old with the barky cough at 7 p.m. Yeah.

So, I mean, my boundaries are different than yours. And that’s one thing that’s important to acknowledge is that we all get to set our own boundaries, right? And I will reiterate what I said in our past episode about boundaries, which was quite a while ago, but boundaries are not about changing other people’s behavior.

Boundaries are about deciding how you will respond to whatever behavior happens to come at you from other people, right? So, it really helps to kind of think through some of these of like, what would I do given my own personal boundaries that I want to set? How would I respond to someone’s maybe unreasonable requests, right?

Or just urgent requests and whatever the case may be. So in that case, I mean, if I’m already home or I just left the office, which typically I work till six and then I’m leaving around seven on the long days that I do work. But that’s not the case for everyone.

For me, I would really be like, I’m tired. I want to go home and eat dinner with my husband. I really don’t want to figure out how to see them tonight. But croup is something that’s pretty easy to just deal with over text message. And so I would probably do a quick phone call.

or a quick series of text messages, make sure that this truly is croup, right? And that there’s nothing else going on. If it’s severe enough, I would maybe just say, hey, I can send in a prescription for dexamethasone. One dose usually helps a lot.

to prevent some of the dangerous levels of croup that can happen in the middle of the night tonight so and i would also give some you know anticipatory guidance around like cold air and some other comfort measures that they can enact as well for the viral syndrome that their kid is experiencing and that would probably take

me i don’t know five to ten minutes depending on the family and the level of reassurance they need but for me that’s within my boundaries, right? That I’m willing to do, but I wouldn’t want to go back to the office. You know, that’s an hour of going back, having the visit, documenting, going back home.

So I’m curious with your set of boundaries that you have for yourself and your practice, Phil, what would you do?

I would be at home. I would be like seeing the message come in. And then what I would probably do, I mean, we already get like the, we’re not open right now, blah, blah, blah message that I’ve talked about on other episodes too. But if I saw, okay, the seven month old has the croupy cough,

I would probably text them and say, hey, we can definitely get you in in the morning. What I would try and do tonight is get their nose cleaned out. so that they don’t have a bunch of gunk in there and then use cold air, like either going outside if it’s a cool night or, you know,

putting them in front of the freezer or something like that. And then let’s see them in the morning. Now here’s what to do. If they’re having difficulty breathing, if they’re breathing so fast that they can’t eat something along those lines, and I’m going to want you to go to the ER. That would be my typical approach.

And if I didn’t see it until later in the evening or if it was 11 o’clock thing, then I wouldn’t see that. And they would either figure it out or they would follow the advice from our text message reply of either calling our triage line or going to the ER or something along those lines.

Yeah.

That would be my approach to the 7 p.m. text message.

Yeah. And I think that’s totally reasonable because the parents still get some ideas of how they can support their child and also gets a little message about, hey, here are the red flags for when you should go get seen in the middle of the night. Most kids don’t really get to that dangerous.

They can get to like the, oh, my gosh, like it’s a barky cough and he can’t sleep. But most kids with croup don’t get to that level of, you know, dangerous strider needing help. you know, racemic epi and all that stuff. So it’s usually okay. But if I feel like it’s a kid who’s predisposed to that,

that’s when I would do the dexamethasone and just tell them, hey, this is how you crush the tablet. You mix it with something sweet and you give it to them at home, et cetera. That’s so easy to do. So whatever your approach, you can see two different approaches depending on our predispositions and our boundaries.

You know, one other thing that, as you’re saying, that made me think of is about a few months ago, this almost exact scenario happened, except it was at 4.30 and I was getting ready to leave and my son had guitar and it

was a family that I knew really well and actually knew what part of town they lived in and they lived relatively close to where the guitar was. So I said, hey, I’m leaving right now, but if you meet me over by Blue Raven at 6.30, I’ll just pass off a dose of dexamethasone to you

and had crew before the dad was there. He had a nice coffee for me and I gave him the dexamethasone and Mary way. Now, if I wasn’t going to do that, I wouldn’t have specifically gone to that. But the nice thing is in DPC, you can say, okay, this is actually still within my boundaries.

Cause it’s not a big deal. Cause I’m just sitting outside of the guitar place to help this family out. And it made a big difference for them. the same sort of thing happened with dance with my kids dance a kid had a scalp

laceration and texted me right as i was getting ready to leave home to take my girls to dance and i was like well i can’t meet you the office you can go to urgent care and they’ll put a staple in but i’m gonna be dance for the next hour i’ll

bring my staples because i had some at home with me and i’ll meet you in the parking lot and we’ll just put two staples in the head and the parents were just ecstatic and that was still within the boundaries now if i hadn’t been going to dance i wouldn’t have gone to do that,

but it worked out fine that I was able to offer that and the timing worked out right to just, you know, like sometimes those things, the stars align and it’s like, oh yeah, I can do that. That’s not a big deal. Just meet me here. And then we did it. It was really easy.

So I think that’s kind of the nice thing about DBZ too, is that you don’t have to have these hard and fast rules because there’s all these other people that are gonna do it differently or one of your partners will be pissed because you did this thing outside of the scope and then they think that all

parents expect that. You get to pick. You get to do what you like and when it is within those boundaries that are flexible and movable as well.

I have one for you. So this is one that’s come up a few times in the Facebook group and has happened to me many times. So you have someone, a parent who reaches out, let’s say at eight in the morning saying, my kid, I think they might have strep or whatever it is, right?

Can you see them today? And you’re in the clinic, but maybe you’re in the clinic from, let’s say 8 a.m. to one because you have an event for your kid, right? And so you tell the parent, yes, you know, I’m here. I can see you at 9 a.m. And they say, okay, well, 9 a.m.

comes and goes and 9.15 comes and goes and you’ve set aside, let’s say you were generous, you’re new, you’re not that busy, you would set aside an hour, right? which you may or may not do. But then 9.30 comes around. So what do you do by that point?

Like if they’re not showing up on time, at what point do you intervene? Do you check in? Do you let it, you know? And so the story that I had heard once from another pediatrician was something about they checked in after they were late a certain amount of time.

And then the mom said, oh, well, I’m not going to be able to make it till noon. You know, that’s, of course, that’s a bit of a unique response. But when do you intervene with late arrivals, Phil? What amount of generosity do you give?

That’s a good question. I mean, I think this specific one triggers for me or makes me think of like Saturdays. Like we have a short availability on Saturdays and I watch the clock like a hawk. And if they’re a few minutes late on Saturdays, I’m going to be like, hey, are you guys… on your way.

Is everything okay? Because I want to get out there lickety-spit. If they say, hey, we can’t make it till noon or one in the afternoon, I’m going to say, shoot, guys, we’re not going to be available then. So here’s your options. One, we can wait if waiting is an acceptable thing.

Or two, there’s an urgent care at this address that can help you at that time. And since I’ve offered, I don’t feel bad at all about being like, okay, I offered you this time. It was the same day visit. And it i’m not going to delete the dance recital or the baseball game or the trip to

the pool just because they’re not available when they when they ask for it and they’re obviously having to deal with their sick kids so they’re gonna have to figure out how to balance that themselves with their work and other obligations and all those sorts of things that would be my approach of

okay, you guys, I gave you a time. These times work, these times don’t work. You pick, here’s some options of what works. Now, on the regular, if they’re 30 minutes late for the appointment, we will text them and we’ll say, hey, is everything okay?

It’s not a very common thing that I find that parents are exceedingly late or they usually text or call and say, hey, we’re stuck in traffic or there was an accident or they pooped when we were getting in the car and so we had to go in and change. Then we just come back in.

Our schedule is not so full that there’s no buffer, there’s no margin time. We just make those things work. But if they just totally blow off the appointment or then they say like, this won’t work in the later, then I would just give them the options that are within my abilities and also say,

you might just have to go to urgent care if these times don’t work.

Yeah. Well, first of all, what I would do is usually if it’s a day that I know is completely full and I just don’t have other times that I could see them or it’s kind of that weekend that’s like prime time and I don’t want to stay late either, right? I do the same thing.

If they’re about 10 minutes late, I text them and say, hey, are you on your way? Or if it’s a family that’s routinely late, I have my assistant call beforehand, you know, that morning or the beginning of the day and say, hey, are you… Do you know your appointment is at this time?

And are you going to be here? Right. But I think people can get kind of stuck in this sort of issue because of our own inability sometimes to be comfortable setting boundaries. I will say that I really think that there’s a gender discrepancy here. A lot of women, we’ve been socialized to be people pleasers, right?

And we tend to bend over backwards more for our families, parents, patients, right? And so in this particular case, the details I remember were that this parent kept on pushing the appointment to later and later. And that pediatrician was waiting around from like 9 a.m. till noon. And this family hadn’t showed up and kept on saying, oh,

we’re coming a little later, a little later. And she had to be out of there by like 1230 or one. And it breeds a lot of resentment if you allow yourself to be stepped over. And so I think really thinking about this and like,

what would I do and how can I establish a protocol for what I would do in these situations? I really liked your response, Phil, that says, oh, shoot, you know, that’s not going to work for me. Right. It’s completely fine to say, hey, you know, I did offer you something. That doesn’t work for you.

Unfortunately, the alternatives don’t work for me. But here is what you can do. Right. And so if we allow ourselves to get stepped on over and over, the resentment builds and builds and builds. And then we want to text back angrily.

And so you hold it against them.

Yep.

Yeah, exactly. That resentment.

And so if we if we just know what our response is going to be ahead of time in those situations and we decide what a professional response will be without any resentment, it makes it so much easier. But I do see women struggling a lot more. And I think it’s not just us. I think it’s also patience.

Step on us.

a lot more patients that step on the female physicians much more so i 100 realize the privilege of my position to be like no you know go fly a kite i’m not doing that yeah patients have a different tolerance of that depending on who they’re

talking with or female and so i totally get that it’s much more difficult for female physicians to navigate that and not have people push back the way that they would not push back a male physician. So that is absolutely the case.

Yeah. But I still believe that like the more we practice, whether or not our patients are expecting more of us or whether or not we’ve been socialized a different way or if you’re uncomfortable, the more that we practice just, you know, respecting that boundary and reiterating that boundary, for patients, you know, in a non-resentful way, right?

Then the more they will come to just understand that. And when we do see them, we treat them with the utmost care and respect. And they come to love us because of those interactions that they have with us. And they just get trained. People are trainable.

Absolutely. They’re very trainable, for sure. I think that we’re not used to that, but all of the interactions that we have, train them one way or the other. If we’re always responding to their text messages at 9 p.m. at night, they’re trained, hey, they’re actually available at 9 p.m. at night. So that’s convenient for me.

So that’s when I’m going to start sending the messages. If they’re trained to, you can message them, but I’m not going to reply until the morning, then they’re trained to, I’m going to text at 9 p.m. at night, but it’s convenient for me, but I know I’m not going to get a reply until 8.30 tomorrow. Great.

That’s trainable.

Absolutely.

Yeah, I got one for you.

Yeah, let’s do another one.

You do a lot of integrative pediatrics. And there’s a lot of online tests available.

Yep.

A patient brings in lab tests from, you know, they sent their babies poop off in the mail or their saliva, or I don’t know how they, what all these different tests, what sort of samples they take. I’m sure they take all of them.

They send these results to you and they come into the office and they say, Hey, I want you to, not only interpret this thing that I printed off that I got in the mail, but I also want you to treat that. What’s your approach when it comes to the medical side of things?

Because they obviously got it from somewhere, but they lack the prescriptive ability to actually get it addressed. And somebody told them, you’ve got to go in so that they can give you X, Y, and Z. And let’s just say it’s something that you’re not accustomed to or typically would manage.

or maybe even believe in that it’s a thing. How do you approach that?

Yeah. Oh gosh, that whole world of online testing that patients can just order for themselves is a little bit of like a wild west in medicine because there’s some stuff that really is legitimate and evidence-based and there’s some stuff that is completely bogus.

So a lot of it is trying to sift through that and trying to discern whether or not this is a legitimate type of test or a reliable sort of test. Now, because I’m integrative and I really want to get better at helping people with maybe like non-traditional types of evaluations and testing.

And I actually do know about some of those and have learned about some of those. I do my best to really investigate it, to look it up and to help them interpret to the best of my ability. However, sometimes if I feel like it really is something that I cannot understand and cannot understand with just like,

you know, five minutes of searching the internet or searching my resources of information, then sometimes I might say, you know what, this is just not within my expertise. I’m not familiar with this, right? And I wish I could help you, but I can’t. So I would reach out maybe to

I don’t know if they’re consultants with the company or whatever it is. Right. But I also warn parents take it with a grain of salt, because this is a new frontier. And some of this may be evidence-based and reliable and some of this may not be, right?

I know that you’re trying to do the best for your child and you’re trying to get to the root of these problems. So let’s spend our time looking at what I can do, what is within my expertise, and maybe I can help you figure out some alternative things,

even if we don’t completely understand what these test results mean. right i love it i see this a lot in the world of like stool testing all those the stool testing is for like microbiome analysis is actually getting better and better and there is a lot of evidence behind some of that and then the mold testing world

is where i’m still kind of trying to understand it and piece it together i feel like there’s a lot of exaggeration even if molds toxicity really truly can’t be a thing There’s a lot of exaggeration out there of like all of my problems and all of your problems and everyone’s problems are related to mold. Right.

And we just need to rid the world of mold, which is ridiculous. Right.

Right.

So, yeah, I try to be just be honest and say if something is outside my area of expertise and I really don’t feel comfortable that I could get to that. level of understanding to help them with it versus something that I’m a little familiar with and with a little more digging,

I can help them interpret versus something that I think, you know, there’s, there are a few things that I feel like just are not evidence-based and I do my best. Yeah.

Yeah. Yeah.

What about, what about you? What if a parent approached you with that kind of thing? Cause I know you’re in the world a little bit and I’m sure parents have gone out there and tried to figure things out on their own sometimes. Yeah.

I think the nice thing is if you say this is our approach and this is what we typically do when patients come in with these sort of symptoms. And I’m not an expert on this PDF that you brought me. And I think that this is something that I don’t feel comfortable with just because

I lack the knowledge and expertise and training with. Yeah. Yeah. here’s where I think we can start. And maybe you can find somebody that can help with this specific PDF that you’ve brought me in the specific tests. Like, here’s what I can do. Here’s what I cannot do. Same sort of thing.

I think that in DPC, we’re often Maybe I’m over speaking, but I think we’re often reluctant to make patients go somewhere else to get some care because we feel like we can do most of the things because we’ve gotten out of the system where it was refer, refer, refer,

and maybe we’re reflexively avoiding referring when there are opportunities to either refer out or say, that’s just not my area of expertise. Like I just don’t know enough to manage that as well as, as you deserve. And so that’s kind of my approach when it’s like, yeah, I’m not really sure.

and i luckily i have some good mentors in the pandas world too that that i can say yeah you know i’ve talked with dr so-and-so and and we’ve never come up with a good plan for this like this is a little bit too nebulous to to have a good sense of how we should approach that

There might be somebody out there that can help you. And I would also like us to make sure that we’re focusing on these other areas too, rather than attributing it all to one specific thing, like mold, like you brought up. So I think that’s a typical approach when it comes to things.

It’s very similar to yours of like, this is not something that I’m an expert in, but here’s what I think we also can do.

Yeah. I think as long as you don’t end the, like, make them feel judged. Right. And don’t just end the conversation of like, someone else did this. I can’t help you. Like, no, just like, you know, frame it in a kind, respectful way and say, even though I don’t understand that.

There’s so many other things that we can try to figure out and do that I can help you with. Right. That’s a more compassionate approach because parents really, I mean, they’re not trying to anger you. They’re just learning all this, these things on the internet and trying to do the best by their child. Right. Well,

And it’s so confusing because there’s so much information out there and so many non-experts saying that they’re the expert and they can explain all of your kids’ behaviors and sleep issues and all those sorts of things. It’s all this one thing that’s been held back from you or that they’re preventing

you from knowing or those sorts of things. How would you not, as a parent, if you’re frustrated and at your wit’s end and exhausted and anxious about it, be like, this is… person has told me all of the things that I’ve been facing and they say it’s all because of this one specific thing,

then how are you not going to fall into that?

Exactly. Yeah.

And like hope, put your hope in that.

Absolutely. People want to feel better. They want their kids to feel better. There’s a lot of Clever marketing out there for sure. I’m going to ask you maybe just one other one we’ll talk about. What about the parent that is like sending you text messages daily to report on their baby’s stools or urines or their sleep?

How many naps and how many hours? Like that overanxious parent who just feels the need to check in with their pediatrician about every little detail.

How do you manage that? I thought this would come up a lot more, to be honest with you, when I started. I thought we would be getting the deluge all the time of the parents. I think one of the things that protects against that is the fact that they know

that they have something in their diaper bag or when they need us. We’re in their diaper bag when they need us. I don’t have to constantly be seeking all this care. So I found that that happens a lot less than I was expecting when it comes to all

of the little check-ins or the data dumps of here’s what their sleep looked like last night. What should we do? And so my approach when it feels like we’re getting too many communication episodes is to say, hey, I know we’re working on this. I think we need to trend it out a little bit further.

I want you to do these things this week. And then I’m going to check in next week and see how we’re doing and where we’re at with things. And then I scheduled the text message so that I don’t forget. And then Monday morning, we’re around and they get a text message that says, how’s it going with pooping?

How’s it going with sleeping? Whatever it might be. So that we, and then the parents learn, okay, it does take a little bit of time. Like I can’t give all these data points and expect a change. in the plan every single data point because it will never have any consistency.

We’ll never have it take the time that it needs to actually adjust. And so I think it’s a lot of resetting expectations of how quickly something’s going to improve, whether it’s their, their pooping on the potty or they’re sleeping or their meal times or anything along those lines, like it’s going to take some time and that’s okay.

Now we have a couple of parents that will like their kids. I don’t know if they have this in Utah, but they’re on these like check-in checkout programs and they like to use our text messaging line as their like documentation system for their daily check in, check out. So what their behaviors were like today.

And so what we do, I’m, it’s not so onerous that it’s a big hassle is we just let it sit there and they know we’re not going to respond to every single time that they send the little document data dump. And then we can look at it together over a couple of weeks and see

Oh, Mondays were always hard. Oh, Fridays were always hard. Oh, afternoon was always hard. Those sorts of things. We can like have that be the collective space and try and get them to instead like keep a PDF on their phone rather than texting all those.

But we can understand that it’s helpful to be able to share that and then know where that is. So there’s a little bit of both. I think it’s, again, setting the expectations. Like if you text me their check-in checkout sheet every day, I’m not going to reply every day.

And I’m definitely not going to change the plan every day based on, you know, how so-and-so did from one o’clock to two o’clock today. We’re going to trend this out over time and then we’ll make a new plan. Once we have enough data collected in the big picture that we can see if we’re on

the right track or if we’re not on the right track. What about you? How would you handle getting too frequent of communications about minor trends? Absolutely.

Yeah, I think I’ve had a couple of parents, not too many, thankfully, you know, their kids have chronic abdominal pain. Our favorite, you know, thing to deal with as pediatricians. And so they’ll sometimes kind of overtext me about like, oh, you know, she had this today and this today and that today. And I think just…

kind of paring down how I respond. It’s like not making too much of it or sometimes strategically ignoring the text messages,

right?

That can be helpful, but acknowledging it enough that they feel like, okay, I’m there. I’m, I’m seeing it. But maybe just minimal text messages. Oh, you know, thanks for letting me know as long as she’s eating and eating doing, you know, pooping at least this often, or she’s not tender to touch or this or that, you know,

I’ll give them, she should, you know, just stay the course and continue monitoring and we’ll follow up at your next visit in two weeks. Right. So something that acknowledges it and reassures and says, okay, like as long as this. And then if I just kind of like don’t respond immediately because sometimes when we respond immediately and

sometimes it’s just because we happen to see it and we’re available. But if we respond immediately, consistently, it sort of feeds into the parents. perception that, oh, this is important. Exactly. And so just delaying my response times a little bit or strategically not responding when it’s, you know, a 7 p.m.

text until the next day at noon, that kind of thing can be helpful. But honestly, I feel like with those anxious parents or the parents that just have kids with something that they’re really trying to figure out, As long as we are there and we’re checking in frequently in the beginning,

their level of anxiety tends to calm down over time. And the frequency of those messages go down over time, as long as we’re not overreacting to them as well.

Yeah, I think that’s something that the longitudinal experience of DPC is that there’s some parents that will have flares where they’re communicating a lot more and then it drops to nothing. And it’s not this just like consistent thing. And if they keep asking, it’s usually because there’s something missing that we haven’t quite figured out

that’s in the back of their mind that they haven’t asked or they haven’t even figured out that they need to know. And if we can spend a little time like, what is it that’s really worrying about this? Or what is your expectation around

your child or the thing that they’re facing if we can learn that oh yeah you just have the wrong expectations like tone down the expectations of how quickly this behavioral issue or their sleep or their whatever it might be is going to improve

then we’re all in a better place and we can check in weekly about their sleep because it’s not going to change acutely day to day

Yeah, absolutely. And I feel like sometimes when also parents are texting repeatedly about a certain issue, responding, I sometimes will respond with something like, oh, you know, I can see that there’s a lot going on around this. Why don’t you continue to like keep a log of what’s happening and we’re going to see you next Tuesday or,

you know, and then that way you still have like, you know, a point in time when they will be able to speak to you. face to face and address all the concerns, but then they don’t feel like, oh, I don’t have an appointment set up.

And so I’m just going to like dump everything into text messages that should be a visit because sometimes the stuff that’s getting dumped into text messages is way better handled in a visit. So we can also respond in that way.

I don’t want to meet yet because I need a little bit more data. Can you keep a log and then let’s meet in a couple of weeks and discuss this and do this if things, here’s some signs I would say we need to meet sooner,

but otherwise keep a log and we’ll touch base in two weeks at your visit.

Exactly. Yeah, exactly.

Oh, this has been a fun discussion. I hope it generates more boundary questions, you know, because I think this is a topic that we like talking about. We talk about it enough and that it’s really important for the sake of growing your practice and being sustained in your practice and setting those boundaries.

Absolutely. All right. Hope you found it helpful. Until next time.