“The best is the enemy of the good”

 – Voltaire

Perfectionism – appearances can be deceiving

Clinically sound. In a stable relationship. Committed to patient care. Regular exercise at the gym. Committed to teaching. Getting on well with colleagues and consultants. Involved in research projects. No junk food. Eating vegetables. A Facebook wall filled with friends and parties. Sleeping well. How many people do you know who appear to have perfect lives? What effort do they go to maintain this image?

If American Ivy League universities, hotbeds of ambition and neuroses similar to medicine, are anything to go by, it appears that appearing perfect can come at a heavy cost. In a recent New York Times article, “Suicide on Campus and the Pressure of Perfection”, Julie Scelfo (6) writes about the spate of suicides across undergraduate universities in America over the last few years in the midst of a culture of perfection.

The pressure of perfectionism

At the University of Pennsylvania (an exclusive Ivy League university in America), six students committed suicide over a thirteen-month period (2013 – 2014) and the university took a long hard look at its campus culture – in an exploration of implicit culture, it revealed that “Penn Face” was a recognised part of the student experience. Penn Face described the practice of acting happy and self-assured even when sad or stressed, which has the vicious effect of further isolating students who are facing distress or difficulty.

Scelfo (6) goes on to write that this behavior is not unique with another report from Duke University referring to how female students felt pressure to be “effortlessly perfect” – smart, accomplished, fit, beautiful and popular, all without visible effort. At Stanford University it’s called the Duck Syndrome – a duck appears to glide calmly across the water, while beneath the surface, it frantically, relentlessly paddles.

These findings came from general undergraduate populations, however, the concerns with image and drive towards perfectionism reaches a darker note in medicine with many studies showing specific and consistent links between perfectionism and medical practitioners (2).

Perfectionism in medicine

It starts from the very beginning, with the best and brightest (read: most perfectionist, neurotic and conscientious) being selected for medical school. While in medical school these traits are nurtured with it becoming increasingly clear that high standards, attention to detail and a deep sense of responsibility are in fact necessary in medicine – in fact conscientiousness is the personality trait that most consistently predicts job performance. Ultimately when students become doctors in today’s environment, it becomes a juggling act with multiple demands including, clinical work, research, self-care and relationships where it becomes increasingly easy to lose perspective and just focus on one aspect to the exclusion of all others.

Perfectionism and trying to maintain a perfect image (appearing like a happy duck) comes with serious consequences.

Difficulty admitting there is a problem (1)

Doctors are trained to be strong and support others, but many doctors find it hard to let their own guard down and feel like they can trust another, especially when there is so much pressure to be “strong” in medicine. In “The Tennis Partner: A Doctor’s Story of Friendship and Loss”, doctor-author Abraham Verghese beautifully summarises the difficulty when perfectionism and medical culture meet – “Doctors are “horribly alone. The doctor’s world is one where our own feelings — particularly those of pain and hurt — are not easily expressed. . . . There is a silent but terrible collusion to cover up pain, to cover up depression; there is a fear of blushing, a machismo that destroys us (4).”

Difficulty setting appropriate limits

The nature of healthcare makes it difficult for doctors to set limits (1) without great guilt. The most common manifestation of this is the junior doctor who feels they can’t go home on time without compromising clinical care or the junior doctor who skips lunch or dinner on a busy shift. This problem is not helped by a culture which generally approves medical martyrdom (people who put medicine ahead of their own needs and lives).

Difficulty dealing with errors and poor patient outcomes

We have strong and easily awakened feelings of guilt in patient outcomes (1) and it takes time and maturity to recognize the limits of medicine – we are not personally responsible for everything that happens to a patient. James Edwards’ blog on “The Second Victim” illustrates the immense difficulty physicians have in coming to grips with an error. Even when there isn’t an identifiable error, junior doctors can feel culpable when an elderly, multimorbid patient has passed away if they were the last to see them for a particular reason.

Difficulty making decisions

Peters writes about a well-recognised triad of chronic doubt, chronic guilt and an exaggerated sense of responsibility that burdens many doctors in a culture of perfectionism – these characteristics prevent rash decisions but they can also lead to chronic indecision (2).

Higher rates of burnout

In a busy clinical environment with less staff and more patients, perfectionist traits can result in changing vulnerable individuals into obsessive and frustrated people who make seemingly obsessive demands on themselves and their colleagues (2).

Perfectionist traits are obviously necessary for good clinical practice but it’s important to remember the line between healthy and unhealthy perfectionism. Peters writes about some common warning signs of unhealthy perfectionism in medicine (2):

• All or nothing thinking (no one understands how important this is)
• Failure to delegate (no one will do it as well as I can)
• Inability to forgive oneself or others for small mistakes
• Procrastination to avoid the possibility of error

Some solutions to the pressure of perfectionism

• Medicine is teamwork and remember a whole group of individuals are taking care of a patient – ask for help and rely on your supports. You’re rarely working alone and don’t feel you need to shoulder responsibility of a patient all on your own. When faced with a complex patient, even consultants will often “load the ship” in the guise of asking for help, where they involve other consultants to share responsibility of a patient. If the ship goes down, then everyone goes down…
• Seek feedback from senior colleagues about whether the level of your anxiety and time allocation is appropriate (for example, many junior doctors will write very lengthy discharge summaries only to realise later that more is actually not better for the busy GP who wants an accurate and succinct summary of a patient’s stay in hospital not a day by day account of a patient’s stay).
• Focus on your successes rather than your perceived failures (keep your failures in the context of all your successes as hard as that might be).
• Mistakes and failures are important opportunities for learning, not self-flagellation.
• Ultimately, remember your worth as a person is not determined by your accomplishments.

To end on a lighter note, check out this Buzzfeed collection of 24 things that give perfectionist’s nightmares – you’re not alone!

Things all perfectionists have nightmares about

Originally published: Sunday 25 October 2015

Postscript April 2017

I wrote this blog on perfectionism in October 2015 as I reflected on how common this trait was amongst doctors (myself included!). We are reposting this blog as a reminder for all junior doctors to take care of themselves in their pursuit of delivering the highest quality care possible to their patients. Perfectionism can impact on mental health and you may feel like you are not keeping up, but remember that there are more than likely people around you who are frantically paddling underwater while remaining calm on the surface.

If you are struggling, seek help – there is no need to exhaust yourself trying to keep up appearances. No doctor would walk past a struggling and distressed patient – give yourself the same time and attention that you would give to a patient. Give yourself that sleep, give yourself that exercise, give yourself that time with your wife/husband/partner/family/friend/pet/book. If the simple things aren’t helping, pick up the phone and call for help – this could be your GP, the EAP, a friend, a senior doctor or a helpline.  Remember that you are part of a community of friends, family and colleagues who all care deeply about your wellbeing and want the very best for you. Our lives are as precious as our patient’s lives.

References

1. Miller, M.N., McGowen, R., 2000 Physicians are Not Invincible, Southern Medical Journal, 93 (10)
2. Peters, M., King, J. 2012 Perfectionism in doctors, British Medical Journal, 344, e1674
3. Perfectionism: The Double Edged Sword – UCSF Medical Student Wellbeing Program
4. Verghese, A. 1998 The Tennis Partner, Harper Perennial, United States of America
5. Radiohead “Fitter, Happier” from OK Computer (1997)
6. Scelfo, J. 2015 Suicide on Campus and the Pressure of Perfection. New York Times

Useful Resources

• Employee Assistance Program
• Doctor’s Health Advisory Service
• Beyond Blue Doctors Mental Health Program
• Lifeline