The consult came through the EMR — placed by a unit secretary: “ENT consult, ear pain.”
My shoulders tensed. I glanced at my clinic schedule. Five patients left that morning.
Within seconds, I had shifted from a middle-aged surgeon seeing patients to a petulant child being told to clean her room.
Should I call the unit? Squeeze it in over lunch? It’s probably referred otalgia. How did an ENT consult become something ordered like a lab?
I opened the chart. A 73-year-old man admitted for stroke. In the note: “right ear pain, no change in hearing.” Plan: “will consult ENT.”
In this hospital system, inpatient consults were placed through the EMR without direct clinician-to-clinician communication. That was the workflow, and no one questioned it.
As I sat there stewing, I grew curious about my reaction. The sensation felt familiar. It reminded me of medical school, when a resident handed me scut work. Back then, I learned to put my head down and comply. Go along to get along. But now a different question surfaced: How many of my colleagues feel this same internal protest and override it automatically? How many policies do we follow reflexively because we were trained to?
Surgical training conditions us to comply. The hidden curriculum is clear: follow the rules or risk being labeled “difficult” or “not a team player.” Tribal shame enforces conformity, and over time, we develop a no-boundary mindset. We quickly learn that our job is to adapt to systemic rules already in place. That dynamic does not end with residency. The authority figure simply morphs into hospital leadership, CMS regulations, compliance checklists, endless micro-policies, and rules no one remembers creating but everyone assumes must be obeyed. So instead of setting boundaries around double-booked clinics, inefficient consult workflows, or elective cases scheduled post call, we endure. We tell ourselves pushing back is selfish.
Behavioral economist Dan Ariely captures this dynamic in his story “The Bureaucracy of a Red Sofa.” Leadership rejected the $160 red sofa he purchased because it wasn’t from an approved vendor, forcing him to buy a $5,000 sofa that complied with policy. The rule overrode common sense. The cost wasn’t just financial; it was psychological.
Rigid, fear-based rules deplete motivation. The burden of bureaucracy is the exhaustion of navigating systems that feel arbitrary and disconnected from meaningful outcomes. When people believe they have no influence, they stop trying to change things.
In health care, that depletion is amplified by identity and responsibility. We assume every policy exists for patient safety. We equate compliance with virtue and fear being labeled troublemakers.
So we do not push back.
Each policy feels minor, but collectively they erode agency. We sigh, click, sign, and tell ourselves this is just how it is. Over time, we begin to feel powerless, unaware that we have the right to define our participation. Boundaries differ from demands because they are not about controlling someone else’s behavior; they define our own.
“You cannot double-book me” is a demand.
“If I am double-booked, I will ask for one patient to be rescheduled” is a boundary.
“Do not consult me through the EMR” is a demand.
“If a nonurgent consult is placed without clinician-to-clinician communication, I will wait to see the patient until I’ve spoken directly with the requesting clinician” is a boundary.
That is the boundary I eventually set but it did not emerge in isolation. Before formalizing it, I spoke with several ENT colleagues. One admitted she felt the same irritation each time a consult appeared without context but assumed that’s just how things were done. Another worried that pushing back would label him “difficult.” We had each been privately overriding the same internal protest.
So we agreed on something simple: for nonurgent consults, we would require clinician-to-clinician communication.
A boundary held by one physician can be dismissed as personality. A boundary held consistently by a group becomes culture. At first, consults continued to populate the EMR. But when we responded uniformly by requesting a direct call before seeing the patient, the behavior began to shift. Residents started calling. Many consults were clarified or resolved over the phone.
What I initially experienced as indignation was a signal. It revealed something important: systemic friction. Reclaiming boundaries restores autonomy. And autonomy is not a luxury; it is a psychological necessity. Without it, even meaningful work becomes draining.
Surgery trains us to tolerate discomfort in the service of excellence. That capacity makes us exceptional. It also makes us susceptible to over-functioning inside systems that were never designed to protect physicians. When unquestioned compliance becomes our default, autonomy erodes, and burnout quickly follows.
We may not control every policy. But we always control our participation. Boundaries are how we reclaim that ground. Practiced consistently, they clarify expectations, restore agency, and gradually shift culture. And when enough of us hold the line, the ship does begin to turn.
Dr. Mel Thacker is an otolaryngologist, certified coach, and co-founder of the Hippocratic Collective. She works part-time as a locum tenens ENT surgeon in western Massachusetts and leads Empowered Surgeons, a coaching platform helping physicians rehumanize surgical culture through mindset and self-leadership.
Illustration by April Brust
