Fear of Saying No (FOSNO): Setting Boundaries With Our Patients and Ourselves - Monica Chatwal

August 25, 2023

In this interview, Monica Chatwal talks with Alicia Morgans about her publication "Fear of Saying No: Setting Boundaries with our Patients and Ourselves," in the ASCO Education Book for 2023. Dr. Chatwal, together with the ASCO Ethics Committee, emphasizes the growing need for personal boundaries within the rapidly changing landscape of healthcare and oncology. The article explores the balance between maintaining high-quality patient care and ethical standards, while encouraging clinicians to set boundaries that enable them to be more engaged, satisfied, and focused on personal well-being. Key takeaways include the importance of intentional commitments, the “rule of tens” to evaluate urgency, and recognizing that goals and responsibilities can be met at different life stages. Challenges like the availability of email and saying no to invitations are also discussed, with Dr. Chatwal personally reflecting on these topics in light of her impending maternity leave.


Monica Chatwal, MD, Moffitt Cancer Center, Tampa, FL

Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, MA

Read the Full Video Transcript

Alicia Morgans: Hi. I'm so excited to be here today with Dr. Monica Chatwal, who's an assistant professor of medicine and a GU medical oncologist at Moffitt Cancer Center. Dr. Chatwal and her co-authors published a wonderful article in the ASCO Education Book for 2023, really helping us think through the fear of saying no. Thank you so much for being here with me today.

Monica Chatwal: Sure. Thank you. So thank you so much for having me in to talk about this piece I've been really passionate about and had the opportunity and privilege to work with Doctors Kamal and Marron on, and with the entire ASCO Ethics Committee, is really how this developed. And our article was entitled, Fear of Saying No: Setting Boundaries with our Patients and Ourselves, and actually is accompanied by an ASCO Education session at this year's annual meeting.

So some of the rationale behind why we discussed this topic and presented this topic was that this idea of boundaries and saying no seems to be coming up a bit more as the climate and setting of medicine and healthcare has been changing so rapidly and drastically in the past couple of years. And we know that oncology is such a demanding profession. There's a lot of complexity, demands of the practice that can make setting some of those personal boundaries very challenging.

In particular, from the vantage point of the ethics committee, we really wanted to talk about the idea of potentially setting some of these personal boundaries without necessarily compromising high-quality patient care and by continuing to meet high-quality ethical standards and what that looks like. And so this was something that we put together to really focus in on boundaries and to explain that boundaries really allow us as clinicians to be more present, to be more engaged, to be more satisfied with the work that we do, and to maintain and really encourage our personal well-being.

And so some of the key takeaways I wanted to focus on that we discussed in the piece are really to be intentional with our intentions. It's really easy to go through our careers, whether academic or in private practice or in pharma and whatever that may look like, to have certain goals and try to accomplish certain things in the way of clinical trials or committees that sometimes may not always meet our personal goals. And so it's important to be intentional about what we choose to do and really make sure that what we are choosing to commit to really fits in that larger picture and to consider the rule of tens.

And so this was a really interesting concept that I was introduced to by Dr. Kamal, who mentioned some of these things that come up and arise, some patient issues or issues that come up along the way or emails we get, seem so urgent and so dire in the moment, but it really is important to kind of take a step back and be more objective about those issues and say, "Is this something that's going to bother me in 10 minutes, in 10 days, in 10 months, in 10 years? Is this still something that is going to weigh heavily on me?"

Another key takeaway is that we can or want to have everything, just maybe not at the same time. And so as passionate clinicians, particularly in our early careers, it may feel like we want to have everything. We want to be the best at everything that we do. We want to be the best clinician. We want to have high-volume care. We want to be effective physicians. We want to be PIs on all of the clinical trials. We want to write first-author papers. We want to lead committees. But it's just not practical or feasible sometimes to have all of that at the same time, particularly when we want to also have a certain quality of life and balance our personal lives with some of that.

And so it's important to remember that we can have everything, just at different phases in our life. And so we have to be cognizant of that and acknowledge that there are ebbs and flows in our career and in our lives, and maybe there are some things we need to say no to. And so that's really what kind of comes back to that fear of saying no, or FOSNO, that coin we turned during the session, that we have this fear of saying no. We have this fear of missing out. But it's okay to really acknowledge and accept that that's okay to say, and some of those opportunities may come back around.

It's also really important to have not just mentors who mentor us through our careers and through some of our research opportunities and academic opportunities and work opportunities, but also those who help us with our work/life balance and really role model and respect that and can kind of help us rebalance our thought process and our vantage point to acknowledge the fact that sometimes we need to say no to some of these opportunities and sometimes we need to go after them.

And then the last key takeaway is really to continue to find, review and embody meaning and purpose, not just in our professional lives, but also in our personal lives. We are full, well-rounded human beings, and there are things that we love to do even outside of patient care. And though we love our patients and we really have a lot of passion for what we do as oncology clinicians, and that truly for most of us is our calling, we are something else outside of the hospital, and that is okay. Most of us like to be with our families. We have hobbies. We have things we enjoy doing. And that continues to give us meaning and purpose in ways that are equally as important as caring for our patients. And so it's important to remember and really continue to nurture that.

And so I just wanted to kind of touch on this. I'm not going to go into it in-depth, and this is something I would encourage everyone to go back to the article to look at, but this was just a nice table that we put together on examples of issues that come up when we talk about burnout, and potentially some suggestions that hopefully will help others in making a move and setting some of the boundaries that we may come across.

Alicia Morgans: Well, thank you so much for a wonderful presentation, and I congratulate you and the team of authors for really helping us put ourselves in perspective, our work, our personal lives, our care about our patients and for our patients, because I think that this boundary-setting thing is something that in other professions is considered more routinely but in medical care is really not considered.

And I'll just think back to training when... This was pre-COVID, of course. People would get sick, get a cold, and of course they would come in anyway, and they would suck it up and not infect anyone else, but they would stay on rounds, or they would be in their clinic, or they would do whatever they're doing, and it was almost a sign of weakness if you ended up not coming in. And this is something that's built into the training of medicine from very early times. It's that dedication and toughness, that we have to take care of others well before taking care of ourselves. So I wonder, as you're thinking about this, are there examples you want to give of how we could do it the wrong way? And maybe using your framework and the way that you think through things to make a better decision in our real-life situations.

Monica Chatwal: Right, and I totally agree with you. I think that was kind of also the concept behind this is that there has been almost a generational shift. In the way that most of us were trained in medicine before, there was this concept and idea of really pushing through, toughing it out, and that's what makes you a better physician. But the question is really, does that make you a better physician? Does being there 24/7 mean that you're providing better care? Sometimes not. And so I think that's what this generation of trainees, medical students, residents, fellows are starting to pick up on and really recognize and appreciate to say, "Maybe medicine isn't everything, and I need to take a step back, and I have family and I have friends and I have hobbies." And it's interesting to kind of see that generational shift and how that may transition into how medicine continues on in the future.

I think some examples of perhaps issues that may come up are things like we've talked about time limits in our paper. So there is this concept of leaving on our portal access or leaving on our emails on our phones active 24/7. And so when we do sit down to have dinner with family or we do sit down to watch a movie, you kind of have that natural inclination to just scroll through mindlessly, and you may come across an email or something that you say, "Maybe I can just address this in five minutes, and I'll just reply back." But I think that sets the wrong notion. If you're doing that, it may seem harmless to send back that email at 9:00 one night, because you think, "Well, it's easier to just do this now," but then you're setting that precedent in the future to say, well, you're going to be available at 9:00 PM or 10:00 PM to answer those calls or emails. And so that's really where we address that in that table to say you need to be clear and direct with your expectations and with your communication abilities and not waver from it, because that's what people hold you accountable to. And that's one example.

Alicia Morgans: Absolutely. It's interesting in academic medicine and also private practices and other settings, we are invited to do an advisory board, or we're invited to go to a meeting or to do this speaking engagement, and sometimes those are things that are really important and meaningful to us, and sometimes it's just, well, it's interesting enough, and if I don't do it, they won't invite me next time. And I wonder, how do you think through that? Because I think that that is something that many of us struggle with on an ongoing basis, and we are constantly trying to make those assessments and judgments and feeling guilty about saying no to one or yes to another. What do you think about that?

Monica Chatwal: This is actually such perfect timing, because I am planning on going away on maternity leave within the next two to four weeks as the time ticks down, and in the past couple of months I've been invited to several different patient summits and to give talks and prostate-specific advisory boards, and all of these things that I never had really gotten invited to earlier on in my career are now starting to emerge, and I'm getting so excited for those opportunities, but obviously will now have a newborn. And so to be able to really think through what is feasible has been difficult certainly. And to say no has also been very difficult. That fear of saying no, that FOSNO, has come up very frequently.

But I think I have been much better in knowing that I have a much different purpose in my life right now, again, going back to you can have it all, just not at the same time. And this is not the right time. And I think it does take us all a little bit to get to that point. Two years ago, when I was having my first child, I struggled with some of this too and probably wouldn't have said no to a lot of things, thinking I could do it all. But I think that changes over time, and you start to reprioritize and understand, again, what is important to you. And at the end of the day, that's really what matters.

Alicia Morgans: It is so important, and it's interesting, as you said, also to sort of see that evolve over time. And I love the rule of tens, because it might still irritate you or stress you out in 10 minutes, but will it bother you in 10 months or 10 years? No, it definitely will not. So that's a really nice way of reframing what seems so critically important right now.

I guess my last question is really around Brené Brown's comments about boundaries. And I have a good friend that I've worked with in the behavioral health world as a research collaborator who said at some point to me when I was trying to say, yes to too many things, "Everything you say yes to is something... There's something else you're actually saying no to." And he had me read Brené Brown's book. And so I just thought that was really an interesting way to frame it. I wonder if you have thoughts on that. Saying yes to this means I'm actually saying no to that, in some cases your family, some cases something else. But what do you think?

Monica Chatwal: No, I totally agree with that. And I had not really been exposed to Brené Brown previously until I dug into this topic a little bit more, and I know others have had much more experience with her, and very interesting how she discusses boundaries and on an overarching level and how important they really are to us as human beings in general, regardless of what career path we're in or area of professional life.

But I do agree with that. I think that's something that we think about on a day-to-day basis. If I take on that extra patient and stay the other hour at the end of clinic, I'm also compromising spending that hour with my kids before they go to sleep. Or if I end up taking on this role as the chair of this committee that meets at 7:00 AM every Thursday morning, well, now I can't necessarily drop my child off at school, and that's one less hour I get to spend with them or with my husband. And even if you don't have a husband or children that's still compromising other parts of your life. Maybe that's the time that you like to go to the gym or you like to go running.

And again, that's what I like to really home back in on and acknowledge is that we are still human beings. There are still things that we really love to do and enjoy and we should nurture and continue to value, because at the end of the day, that's really what continues to make us who we are and helps us in our relationships with our patients. And so it's important to not forget that aspect of things.

Alicia Morgans: Well, I think that the messages that you and your writing group have shared are phenomenal and really important take-home messages for all of us who are watching UroToday, whether we're clinicians, whether we're working in the pharmaceutical industry, whether we are patients. These are really topics and thoughts that apply to us as people. So thank you so much for bringing this to the fore, for putting this wonderful article into the education book, and for sharing your expertise with me today. I really appreciate it.

Monica Chatwal: Thank you so much, Alicia.