5. Creating Brave Boundaries - with Dr. Sasha Shillcutt

Did you know that a significant cause of physician burnout is a lack of boundaries? We had the privilege of speaking with Dr. Sasha Shillcutt, a physician, gender equity researcher, speaker, author, and Founder/CEO of Brave Enough.

Dr. Shillcutt experienced burnout multiple times, and setting boundaries played a powerful role in helping her to overcome it. In this episode, we discuss why boundaries are important, how to create them, and learning to find your “20 seconds of brave.”

What you'll learn:

  • Boundaries don’t just keep the bad out, they also keep the good in
  • The importance of an “immediate no”
  • Boundaries can help you show up as your most authentic self
  • When you say no, you are living in integrity with yourself
  • How to live your priorities

Featured in this episode:

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Michael: Hey everyone, and welcome to another episode of Doctors Living Deliberately. Hi Arpita. 

Arpita: Hey Michael. How you doing?

Michael: I am doing great. And today I'm super excited because we are gonna talk about boundaries. And so I wanted to start by asking you what do you, what do you think about boundaries? 

Arpita: I think that I probably have actually always had them, but not really recognized what they were. I thought when I had boundaries that I was quite frankly being bitchy. And more recently, as I've learned more and more about boundaries, what I've recognized is my boundaries are you know, really to protect me, keep me feeling safe, but a lot of my boundaries were evolved around my anger, and so the new ones that I've kind of put in place are more related to like, for example, with my husband when he's angry, not taking on those mirror neurons and being angry around him, my boundary is if you're angry, I might just leave. So it's kind of been interesting, like figuring out how I've put new boundaries in place around what is kind of where I do my work. How about you tell me about your boundaries. Do you have boundaries? 

Michael: Yeah that's a good question. So yeah, I think, you know, for me, medical training was always about saying, Yes. It seemed like if you said no, you were saying no to opportunities, and so I, I don't think I had really good boundaries around work and medicine. And so this is kind of new, relatively new work for me and something that I've been learning a lot about since finding physician coaching. And this is why I am super excited for our guest today who is an expert on boundaries, and she's gonna kind of fill us with all the knowledge. And so why don't you go ahead and, and let everybody know who's here with us today. 

Arpita: All right. I am so excited. We have Dr. Sasha Shillcutt here from University of Nebraska. She is an amazing, badass cardiac anesthesiologist. She is the founder of Brave Enough and newly an author of this amazing book, Brave Boundaries. And so we're excited to have Dr. Sasha here today. I'm gonna have you really kind of give it justice Sasha. Tell us a little bit about yourself and what you're all about, your book with boundaries. We're so excited to hear more.

Sasha: Well, thank you both for having me on. I'm really excited to chat with you and your audience today and share some of the things that I've learned in the last two decades of practicing medicine. As you said, I'm a professor and cardiac anesthesiologist at the University of Nebraska, so my day job is really taking care of critically ill cardiac patients and getting them through heart transplant, lung transplant, things like that. I'm also the mom to four kids, so you can imagine that those two things together have led me down a path, early in my career and then mid-career and then whatever I am now to burnout. And I've burned out probably three different times, I would say, like hardcore burnout in medicine. And this last time I really sought help outside of the normal kind of structure of medicine on like, why am I here again? So in 2013 when I burned out, I realized I was saying yes to things I didn't wanna do. And I started Brave Enough, which is my company for women physicians to help them learn how to do work-life control. And then embarrassingly in 2020, I thought I had it all figured out and I burned out again. And this time I burned out doing things I liked doing.

So I realized that I needed to seek help. I went to therapy for the first time in probably 10 years, and I said, something's wrong with me. I'm supposed to have all these answers. I'm supposed to be coaching women, and I have a great life. I love my kids. I love my job, I love my company, but I'm burned out again and the therapist said, you need boundaries. And I was like, boundaries? Like aren't those for people going through like toxic relationships? And she said, yeah, you have a toxic relationship with yourself and you have this hero complex where you are trying to help everyone and everything. And even though you're saying yes to things you want to do, you're saying yes too much to them. And so I went into the literature because it's what we do, right? As physicians, we just research like, oh, I'm just gonna YouTube and Google myself out of this place and learn all about boundaries. And every book that I read was really talking about either a toxic relationship with a family member or a partner or something. It really didn't describe boundaries in the context of work-life balance and boundaries with yourself. So that's what led me to write this, my second book on Brave Boundaries. Because it takes courage. It takes like massive courage to say no to people that you love and people that you do life with every day. And people, your patient, your boss. 

And so this is really why I wrote this book. I wrote it for physicians for professionals who are trying to show up authentically as themselves and not disappoint people, which is really impossible to do. And so the book is about, strategies to kind of take a boundary inventory and look at your life and go like, oh, I'm good here. I have really good boundaries in this area. But over here it's like wild animals roaming free. And to understand that if you want to set boundaries, boundaries keep the good in, they don't just keep the bad out. You know, like you talked about the anger with your husband, and that's kind of how we traditionally think about boundaries, like to protect ourselves. But any good thing in your life, like the work that you two are doing, this could become toxic if you don't have boundaries around it. Right? And that was what was so, so mind blowing to me. 

Arpita: Like, are you listening to that, Michael? Yes. So we, and we've caught ourself doing that, right? Where we have to be like, all right, this is not becoming enjoyable. We're pushing ourselves too much. And so totally applicable right there with what you just said. So do you have anything to say about that Michael? 

Michael: Yeah. No, I mean I think that's spot on. And you know, you mentioned a lot of the discomfort comes from this expectation of not wanting to disappoint people. And also kind of referencing what you were just saying, not wanting to disappoint ourselves. We have such high expectations of ourselves and, and so you were getting into like creating boundaries not only to keep out the bad, but to keep in the good. And I think that that can be such a, a challenge for people in learning to make that shift because it is uncomfortable because people are gonna be disappointed in you. So how do you coach physicians around the fact that like, people are not gonna be happy when you create this boundary or you may not be happy because you're saying no to things that maybe you wanted to do, but just don't have the bandwidth for? 

Sasha: That's a great question and I love that you brought it up because it's so real. Like the fact that you feel disappointed in yourself and to the person that you want to show up for. So, what I like to do is I like to tell people to find their 20 seconds of brave. And what that is, is to like say no, say no instantly. I am all about saying no immediately. So when someone asks you to do something or the email comes to your inbox and you know, like before the neuron is even synced with the other neuron, you're like, this is a no for me. I can't do it for whatever reason. I don't have the capacity, I don't wanna do it. Whatever. But you also feel like that pit in your gut, like, ugh. So what normally happens is we ignore it. We ignore the no and a no that is ignored always becomes a yes because then two weeks go by and then you're like struggling with the guilt that you haven't gotten back to the person. Or you see them in the hospital and you're like, oh crap, I don't wanna give them eye contact. And then it becomes a yes, right? So I'm all about the immediate no. And what comes with the immediate no is a feeling of disappointing yourself and disappointing others. It literally happens to every person unless you're a narcissist. So if you feel the crappiness, yay you because you're probably not a narcissist. So you feel that disgusting, like, I'm gonna disappoint people, I'm a bad person. That shame feeling. And you just find your 20 seconds of brave to last through it and you say no instantly. No, thank you for asking, no. Period. 

And what happens is we know that if you look at the science of confidence in people actually being authentic, it comes from taking action. So the more times you do that, the more times you show up authentically and you're like, no, this is a no for me, but thank you. Or I can't do this, but thank you. The more you actually get better and more confident at saying no because, you have a narrative in your brain like, this person's gonna hate me. This person's gonna go to the doctor's lounge and talk bad about me. This person's gonna think I'm selfish. This person's gonna think I'm a bad doctor, but none of that's true. Like they're gonna ask you again and they're gonna get it, and they're actually probably gonna respect you more that you showed up and said no right away so they can go find someone else to do the thing. Right?

Arpita: A hundred percent. I think that's so spot on and it's that guilt that we're fearful of. Or maybe we won't be approached again. Or maybe this is an opportunity we're never gonna get again. And I, I think part of it, you referenced this in your book. I have, I like earmarked the pages that loved and really, I really love and resonated with me. But one of the things that you wrote in here is the more you give yourself away, the more people will take away from you. Not everyone who takes from you will give back to you when you need it. It does not mean you shouldn't be you and freely give, but you must choose whom you give to and more importantly your why. And I think that really resonated with me because I do, do free work. A lot of times, you know, I'll do lectures and then I have to pull back and recognize, do I want to do this? What's my why behind doing it, and does it really sit well with me? And I tend to find myself overextending and wanting to give freely. Right? Just to spread that magic and then having to pull back. So can you speak a little bit about that, like how you can decide what you want to give away freely with intention and maybe how to decipher when you should and when you shouldn't. If you're kind of, if people are struggling with that?

Sasha: It's a great point. And the thing that we have to recognize is the more we are people who show up and we're committed, the more we're gonna be asked to do for free. I think I have this like really wrong belief that like the higher I climbed, the less people would ask me to give away my time and, and attention and expertise. But it's actually the opposite as you both have experienced. Right? So, what we need to do is we need to actually understand what is the motivation behind this? So for example, if someone says, will you speak to this group for free? 99% of the time, I say no. Because that is a boundary for me. However, if it's like a student group that I know has zero budget, I will do one or two of those a year. And so I'm like, yeah, because this person, I'm not doing that in 2023. I just did this last week for a student group for free. So my, I have these boundaries and I know, like for speaking example, like what I do and what I don't do, and it's such an easy algorithm for me. It takes all the pressure off me because I used to be like, oh, this, this cause is really good and they're having this gala and I'll get a nice dinner and they want me to speak for free, or they want me to speak at, you know, 10% of my normal budget or whatever. And I would say yes and then I'm over-committed, burned out, and then I'm angry.

And the second thing that happens is when we do work for free, but outside of our boundaries, we have an expectation of that person. Like, well, I'm doing them a favor, they're gonna do it for me. This was me for a decade. Like, sure, I'll edit their paper at the last minute because they'll do it for me. Right? Or, sure, I'll show up for them or take this call for them on Friday night because they'll do it for. Not true. Like how many times have you shown up for somebody and like crossed your boundaries, gone above and beyond, and then, the reverse doesn't happen. So this happened to me, especially as a woman in medicine because there's very few women professors in medicine and I'm one of the six percenters, so I get asked all the time to write letters of recommendation for women. Like, Hey, I'm doing this, I'm doing this. Will you write a letter of recommendation. And I, like, one year I wrote something like 26 letters of recommendations, which takes probably four to six hours of letter. And then I was like, well, I'm doing this because these women will do it for me. So I was going up for an award and I messaged, like I sent out an email to like four women. Hey, will you write this letter for me? And all four of them said, I don't have time. And I was like, Ugh, right? Like knife in heart. And then I got angry and then I got bitter. And then I was like, you know why? This is my fault. Because I did their service with an expectation that they were gonna do mine. So now I don't do that anymore. I'm like 10 letters of recommendation a year. First come, first serve. I don't care if you are the Queen of England. I'm not writing you number 11. Like, you know, like this is a boundary I have with myself and I have no expectations for the people I write letters of recommendation, like zero. But it took me a long time to understand that like that was in my power, right? Like I had the power to say no. I had the power to understand my. 

Michael: Yes. I wanna highlight two very important points that you just made so that the listeners really get them. Number one is when you are saying yes to one thing, you are inevitably saying no to something else. So don't think that just because you've said yes, you've escaped saying no because you have said no. It's just to the thing that you actually really wanted to be doing, right? So when you were, you know, writing those letter. you were saying no to these other things that you really wanted to be doing. And that's where the frustration came from afterwards. And so when you say no, you are living in integrity with yourself. You get to then show up for the things and the people and the activities that you really want in your life. So that was one of the, that was the first point that you made. 

And then the other point, which is also so important is that the biggest stressors in our lives tend to come when we are not honoring our boundaries, right? When we are living beyond them. And then that's when all the frustration comes back at us. So can you speak a little bit to that? How do you help people kind of navigate those big stressors and, and find out what is the thing that they should be focused on when they're creating boundaries?

Sasha: Yeah, so in the book I really discussed like six different elements of, or buckets I call them, of boundaries. And a lot of times we don't realize that what we're really angry about, and that's why I love the work that Arpita does all about anger is a lot of times it's because someone has crossed our boundaries and or we have not honored our own boundaries exactly like what you have just alluded to. If you are constantly in a state of frustration where you feel like, Ugh, I never have time for myself, or I'm constantly in conflict with this, or I'm overwhelmed, I never get to the yeses that I want, right? I'm not showing up for myself. I guarantee that you lack boundaries for with yourself. And so what I talk about in the book is, what are those priorities? Because boundaries really just allow you to take your calendar out and look at it and go, yeah, I'm living my priorities, versus I'm living someone else's priorities and I'm living to please others. It's a very simple concept. If you don't know what those priorities are for yourself, and many of us don't take the time, make the time to do that, you don't know what boundaries you need, right? Like I love public speaking. I love getting up on stages, I love teaching. I can say yes to maybe 10% of the asks I get because it would become toxic. Like I've been in those years where I'm like never seeing my family. I'm traveling a ton. I'm angry at myself that I've committed to this. I don't even wanna be there. Is that the type of speaker that you wanna hire on your stage? No, but it's all been on me, and so now I'm like very intentional. Like I know my why, I know what I love to do, but I gotta keep it positive and safe. If you don't have that inventory with yourself, which I talk about in the book, you have no concept of what you should say yes to or what you should say no to. 

Arpita: And I think a piece of what you just said there, that calendaring component is huge here because when we don't have some sort of a system to lay out our plan to figure out if it's actually gonna fit. And again, with putting me time first, like that's the very first thing I always tell clients. If you have to put that in first in your schedule for the week, however it want, you want to go for a walk for an hour, you wanna meditate, whatever it is. That has to be first, and then you build all the other things around it. And so for me, that is essential is having a calendaring system to say, Hey, is it even realistic for me to plan for this? And I think we, we've been going back and forth about, you know, conferences coming up and we have, like, my son's football schedules just came out last week finally. I'm like, okay, now I have to figure out which conferences I can go to because that's my priority and I'm gonna schedule everything around that. So that's my boundary there. But yes, I mean there's another piece that again, I literally wrote in my book, "bomb dropped". Because this was just amazing and I think if you could speak to this, this might help a ton of women and even men, but it's referring to how when we are moms and busy physicians and we refer to our husband as helping us with things, right? And, I can tell you it's page 36 and 37. The whole page is marked up. I think I sent you a picture of it, over messaging. Like, look at this. Can you speak to that a little bit about how women and our perception of our spouses helping us and what that actually ends up turning out to look like.

Sasha: Yeah, so I talk a lot in the book about boundaries at home, and some of the hardest conversations I've had to have are actually with my best friend, who is my biggest supporter, my husband. And when I ask a lot of women that I coach, and I'm sure if I asked men, I don't coach men, but I'm sure if I did, if I asked them like, what's the hardest conversation to set a boundary? It's gonna be with your partner. And we don't think about that. We're like, oh, no, work is the problem, but we actually are missing this whole piece. And so as women, we've been socialized to really see ourselves as the primary caregivers, the caretakers, like the domestic goddesses, so to speak. And we know this from research too. It's not just like, anecdotal, we know that women physicians, when compared to male physicians at same rank and FTE do about nine more hours of domestic work, independent this is what's so interesting, of what their spouse does. So even if you have a stay-at-home spouse, or you have a spouse that works part-time, you're still doing more of the work compared to men who have a spouse that stays home and does that. So, it's really interesting. And this concept of when I went to therapy in 2020, the therapist was like, well, what's going on at home? Like, how, you know, you're so overwhelmed. And I was like, oh, my husband's awesome. He helps me with this. He helps me with the kids. He helps me. And she's like, do you hear what you're saying? And I'm like, I mean, here I am, this person who's like, thought I had this whole like feminist, like you know the patriarch you're figured out and she's like, everything you're saying is your husband helps you. Like he's the helper. Like you are the responsible person for all the things. And he's like the helper. He's like, your sidekick. And I was like, well, he is. And she's like, no, no, no. He has the children. He has just as much stake in the game as you do to run the house to help with the kids. And I was like, oh my gosh, you're right. And once I started having those conversations with him, like, I'm feeling bad because I'm not doing these things because I can't get to them this week. Can you do these things? He was more than happy to be like, yeah, I got that. Now is it gonna look like homemade lasagna? No, it's probably gonna be Jimmy Johns. I had to get over that, right? Like, that's my husband's way of his boundaries. He's like, I'm not cooking like I'll get takeout or whatever. And that's totally fine. But I'm saying like, we have to understand that a lot of times, and it, it's for men too. Maybe if you're a man you like really wanna start going to the gym, but you don't wanna even bring this up with your spouse because you're looking at her and she's like, or him and or whoever, and you're like, oh gosh, they don't get to go to the gym. So I better not ask to go to the gym. Right? Like, I really wanna set this boundary for myself. I wanna start doing this thing, but I don't wanna hurt that person or make that person suffer. So with more time, so I'm just gonna hold back. These are conversations that we actually really need to have with one another and our partners at work as well. Like we need to have open conversation about our boundaries and our priorities, and we need to show up authentically and showing up authentically is being brave enough to have these boundary conversations.

Michael: Do you have a microphone in my house? Because that look, that example that you just gave is a real life example that actually is a hundred percent relevant to me in my life. I was a gym rat up until the pandemic started in 2020, gave up going to the gym because of everything that was going on and now, and my wife and I have this conversation over and over again about how that will take more time away if I leave. Right? And so this is kind of like, this is a huge, you know, discussion that is ongoing, but I just wanna say like you are a hundred percent right. These are not like gender specific issues with boundaries. Like maybe the individual issues are different based on, you know, what men and women need or what just an individual needs, maybe it's not even gender specific, but these boundaries are so important. These discussions are so important. And so fellas, this book that we're referencing, Brave Boundaries, right, was written from the perspective of a female physician for female physicians, but the content is relevant to everyone. And so ladies, if you are married to a male physician or just know a male physician that could benefit from some boundaries. You need to get them this book because this book is everything that they need to figure this stuff out for themselves. A hundred percent. 

Arpita: And I'm just gonna add, like talking about those expectations and essentially what we call a law match. You know, when we have our partners in life and we have these unsaid expectations of what we're gonna do, like for example, on the weekend, I have to take care of this. He's gonna have the kids and I'm gonna go do it. if you don't actually have that communication in advance and plan for it in advance, inevitably you're gonna show up to the weekend and you both have plans and assuming the other person's taking care of the kids or doing whatever, and that causes the clash, right? And so a lot of this is having the awareness of just planning in advance, having the expectations verbalized. And so that's again, what it goes back to is having those boundaries that, okay, maybe I'm gonna set Wednesday or Thursday of the week to sit down with my spouse or my partner and say, what do we both want to get done this weekend? What do we both need to accomplish and how can we make that happen? So we both get there. And it's just made such a big difference in our lives too, my life personally doing it with my spouse. And it's not like it's perfect. We'll, have screw ups here and there, but for the most part it's a lot better. So Sasha, I think this has been an amazing time speaking with you and giving our audience a little bit of perspective about boundaries. Tell us a little bit about what's coming up for you this year, how they can reach out to you and other opportunities that you have. For our listeneners. 

Sasha: Well, thank you both for this real open and vulnerable conversation. I just appreciate it so much. And I love the two host dynamic. This has been really fun for me to get to come on here and to hear both of your perspectives. If you go to becomebraveenough.com you can see that I have a bunch of events coming up. I do retreats, small group retreats, and I have a large conference in the beginning of October every year for women physicians at the Omni in Scottsdale. It's wonderful. It's great. It's like no other C M E event that you're gonna find. I also have a once a year class I'm teaching through Stanford University for women physicians on time and work-life balance and really taking control of your work and life. And that's coming up in March. You can find all about that on my website as well. 

I just wanna say again, thank you for having me on the show and you know, when you get to that point where you are scared to set a boundary. Just remember what you do in your real life. Like we do some pretty freaking scary things. So anytime you wanna set a boundary and you get that fear, just think like, wait a minute, I'm taking care of like complex diseases or doing like complex procedures. I can do this. 

Arpita: Yes, yes, 100%. 

Michael: A hundred percent. Couldn't agree more. Dr. Sasha Shillcutt, Brave Boundaries. Thank you so much for being here and hopefully at some point you'll come back and chat with us some more about this. Cause I think that this is such an essential topic and so important for helping physicians to overcome burnout, moral injury, all the things. Thank you again so much for being here. 

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