If you’re a woman in medicine who is feeling burnt out and exhausted, it’s likely you’re getting advice to do more self-care — take yourself out for lunch, get a manicure, do some yoga. Sure those things are great, but, let’s be clear, this is not self-care. I often find that when I’m feeling exhausted and down to the wire, self-care ends up as another item on my to-do list. And, counter-intuitively, I end up feeling guilty if I don’t get to it (I should be doing self-care better!) or if I do indulge, I feel bad that I’m not tackling something else on my to-do list. Why is this? We keep being told that self-care is what is going to solve all of our problems, so why isn’t it working?

It’s because this “faux self-care” that we are being offered is not actually feeding us. If feeling confident and empowered were as easy as spa days and meal delivery service, life would be much easier! Self-care is the internal hard work of making tough decisions for yourself and by yourself. It starts with recognizing that you have limits, and you really do have to choose what you prioritize because just like everyone else, you are human. It’s actually not that pleasant of a process, because it means you have to set boundaries.

It means that you have to learn how to say no, and recognize that it’s nobody else’s responsibility to say no for you. This is especially difficult for women in medicine, because many of us have gotten to where we are by putting on that superwoman cape, and playing the role of savior. Or, perhaps, martyr?

It means taking less pride in being busy and efficient. We need to stop letting our hyper-productivity-oriented medical culture disconnect us from our values. For women in medicine, martyrdom is almost an epidemic. What martyrdom gets you is exhausted, burnt out, and still running at full speed pretending that you love to help everyone else, but actually just oozing resentment. It’s a formula that’s set up to fail.

For me, setting boundaries means pausing whenever anyone asks me to do something, and remembering I have three choices. I can say yes, I can say no, or I can negotiate. For a long time, I didn’t recognize I had option 2 or 3. For most of us in medical school and residency or fellowship, it did not feel like we had the option to choose. Especially if you are a high achiever, there’s a way that hyper-productivity can be exhilarating. It means that you are better than those other people! What we didn’t recognize was the cost.

And, now, as a psychiatrist specializing in women’s mental health, and a woman with more life experience, I’ve learned that we always end up paying, in one way or another. So, part of learning to set boundaries is internalizing the fact that you do have limits and there is nothing wrong with that. What’s broken right now in medicine is the system, not us as physicians. The problem with resilience or faux self-care is that it puts the burden of change on the individual, and exonerates the system. You can make as many to do lists as you want, have the best meal delivery service in the city, and eventually, you will reach your limit. And, you will always feel ashamed for reaching your limit, because that is what our medical culture prescribes. You will feel like it’s your fault, and you should do more, but in fact, when you have boundaries, it’s possible to see that you’re running a race that has no finish line.

So, why does medicine keep selling us this panacea of resilience and self-care? I think because it puts the burden on us as the hyper-achieving physicians. And, we have certainly shown that we are capable of doing everything, plus much more than is asked of us. Doctors do not need to be more resilient. In fact, doctors have been too resilient, and that’s part of what got us into this situation. We thought that if we put our heads down and delivered more (ie. master clinicians, experts at billing, running the office, oh and, saving lives) eventually, the powers that be would be satisfied and we would be taken care of. But, that’s the tricky thing about boundaries; nobody else can set them for you.

You should also know that it can feel bad to set boundaries. Self-care is valuing your own feelings and thoughts, despite knowing that you may let other people down. It means being able to tolerate other people’s disappointment and trust that it is not a moral failing on your part. Forget the image of self-care you have in your mind of you luxuriating at the spa. Self-care means going through your list of work projects and sending that email saying your plate is full so sorry, you won’t be able to make that meeting. This is what it feels like to be responsible for taking care of your own emotions. Many of us did not develop this muscle growing up, and so, it’s not unusual to feel the growing pains when you start doing this as an adult. But, in my experience, facing those growing pains directly pays off multiple times over. You end up learning to value your time, your feelings, and your goals. And, perhaps counter-intuitively, when I am setting boundaries, I find myself feeling generous, full and willing to give more to others without feeling resentful. I also find myself able to indulge in “faux self-care” without feelings of guilt or pressure to perform. Once the resentment and guilt creep back in, I know it’s time to start cleaning house. Setting boundaries in order to take care of myself is not a one-time thing, it must be repeated regularly until it becomes second nature.

If practicing self-care means regularly setting boundaries, one difficulty is the qualities that got us into medicine, and kept us here, are precisely the ones that work against us. We want to be needed and valued by our patients, we are conscientious to the point of perfectionism, we recognize the inherent privilege and burden of taking care of people in their most vulnerable state, and are more comfortable sacrificing our own needs in the service of others. Inherent in this is the assumption that eventually if we make ourselves small enough, we will get that “A”!

Make no mistake; setting boundaries is an assertion of power. We’ve been told over and over again that we don’t matter, and when we do, we’re certainly worth less than men. For women in medicine, setting limits and asserting boundaries is about saying this is what works for me, and this is what doesn’t. It’s having the audacity to say, I exist and I matter.

Pooja Lakshmin, MD is a board-certified psychiatrist and Assistant Professor of Psychiatry & Behavioral Sciences at the George Washington University School of Medicine. She is passionate about women’s mental health. You can find her on twitter @PoojaLakshmin. She is a 2018–2019 Doximity Author.