Medicine is not perfect: the pressure of perfectionism on doctors
Medicine is not perfect: the pressure of perfectionism on doctors
The unhealthy pressure of perfectionism on many people can cause anxiety, low self-esteem, stress and other problems. For doctors, not only is unhealthy perfectionism bad for their own health, it can also lead to poorer patient outcomes.
Perfectionism – appearances can be deceiving
Clinically sound. In a stable relationship. Committed to patient care. Getting regular exercise at the gym. Committed to teaching. Getting on well with their colleagues. Avoid junk food and too much coffee. Sleeping well. Eating fruit and vegetables. An Instagram filled with friends and parties. How many people do you know appear to have perfect lives on social media? What effort do they go to maintain this image? And fundamentally, is their perfectionism real?
Suppose American Ivy League universities, hotbeds of ambition and neuroses similar to medicine, are anything to go by. In that case, appearing perfect can come at a high cost. In a 2015 New York Times article, "Suicide on Campus and the Pressure of Perfection," Julie Scelfo wrote about the spate of suicides across universities in America amid a culture of perfectionism.
The pressure of perfectionism at college and university
About ten years ago at the University of Pennsylvania, six students committed suicide over thirteen months. As a result, the university took a long hard look at its campus culture. An exploration of implicit culture at the university revealed that "Penn Face" was a recognized part of the student experience. Although there is no formal definition for Penn Face, it is "understood as the tendency for Penn students to act as if their academic and social lives are perfect. Penn Face leads you to believe that a classmate has stellar grades, amazing friends, and great mental health." This has the vicious effect of further isolating students who are facing distress or difficulty. This perfectionism behavior is not unique.
At Stanford University, the pressure of perfectionism is called the Duck Syndrome. Imagine a duck frantically paddling its little legs to stay afloat and keep up with the badling of other ducks. The duck is watching everyone else gliding effortlessly through life—achieving professional success, thriving socially, and looking fabulous—which makes the duck feel worse about their own difficulties.
Another report from Duke University on the pressure of perfectionism refers to how female students felt pressure to be "effortlessly perfect" – intelligent, accomplished, fit, beautiful, and popular, all without visible effort.
All of these findings on the pressure of perfectionism came from general undergraduate populations. Many similar studies show specific and consistent links between perfectionism and medical practitioners. However, the concerns with image and drive towards perfectionism reach a darker note in medicine for both the doctor and their patients.
The pressure of perfectionism in medicine
The pressure of perfectionism in medicine starts from the beginning, with the best and brightest (read: most perfectionist, neurotic and conscientious) selected for medical school. While in medical school, these traits are nurtured. Over time, these traits become increasingly clear: attention to detail, high standards, and a deep sense of responsibility. These traits are necessary for 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 between their professional and personal lives. Multiple demands, including clinical work, research, self-care, and relationships, contribute to an environment where it is increasingly easy to lose perspective and just focus on one aspect of their lives to the exclusion of all others.
Combining the pressure of perfectionism while trying to maintain a perfect image (appearing like a happy duck) comes with severe consequences.
Difficulty admitting there is a problem with perfectionism
Doctors are trained to be strong and support others. Still, many doctors find it hard to let their own guard down and for eel like they can trust another, especially when there is so much pressure to be "strong" in medicine.
Doctor-author Abraham Verghese beautifully summarises the difficulty about the pressure of perfectionism and medical culture in their book: "The Tennis Partner: A Doctor's Story of Friendship and Loss:"
"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."
Junior doctors have difficulty setting appropriate limits
The nature of healthcare and the pressure of perfectionism makes it difficult for doctors to set limits without tremendous guilt. The manifests itself most visibly in the junior doctor. They often feel they can't go home on time without compromising clinical care. Or they decide to skips meals during a busy shift. This problem is not helped by a culture of perfectionsim that generally approves of medical martyrdom (i.e. people who put medicine ahead of their own needs and lives and believe they will be rewarded for their ongoing misery).
Medicine is not perfect: the difficulty in dealing with errors and poor patient outcomes
Doctors have intense and easily awakened feelings of guilt in patient outcomes. It takes time and maturity for doctors to recognize that medicine is not perfect. It takes time to acknowledge the limits of medicine- and know that they are not responsible personally for every single thing that happens to a patient.
In the blog "The Second Victim" James Edwards illustrates doctors' immense difficulty in coming to grips with an error. Even when there isn't an identifiable error, junior doctors can feel culpable and guilty when an elderly, multimorbid patient dies, especially if they were the last to see them for a particular reason.
We go to work every day to help and heal our patients. We are socialized to expect perfection of each other and ourselves. But errors occur. You have probably made some; I certainly have.
The pressure of perfectionism can lead to lead to chronic indecision
As Mike Peters wrote in 2012, doctors can experience a well-recognized triad of chronic doubt, chronic guilt, and an exaggerated sense of responsibility. This triad burdens many doctors in a culture of perfectionism – these characteristics prevent rash decisions. They can also lead to chronic indecision.
Junior doctors have higher rates of burnout
In a busy clinical environment with fewer staff and more patients, doctors' perfectionist traits can change them. Vulnerable individuals sometimes turn into obsessive and frustrated people who make seemingly obsessive demands on themselves and their colleagues.
Perfectionist traits in doctors are clearly necessary for good clinical practice. Still, it's important to remember the line between healthy and the pressure of unhealthy perfectionism. Peters wrote about some of the common warning signs of the harmful pressure of perfectionism in medicine:
- 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 minor mistakes
- Procrastination to avoid the possibility of error
Some solutions to the pressure of perfectionism
- Medicine is teamwork. Remember, a whole group of individuals is taking care of a patient – doctors need to ask for help and rely on their support. Doctors rarely work alone, so they shouldn't feel they need to shoulder a patient's responsibility on their 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 a patient's responsibility. If the ship goes down, then everyone goes down…
- Doctors should 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 realize 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 day by day account of a patient's stay).
- Doctors should focus on their successes rather than their perceived failures (i.e., keeping failures in the context of successes as hard as that might be).
- Mistakes and failures are significant opportunities for learning, not self-flagellation.
- Remember that medicine is not perfect.
Ultimately, the junior doctor needs to remember their worth as a person is not determined by their accomplishments.
Postscript - medicine is not perfect
Dr. Abhijit Pal initially wrote this blog on the pressure of perfectionism on doctors in October 2015, when he was reflecting on how common the pressure of perfectionism was amongst doctors (himself included!).
This blog is republished 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. And to remind patients of the pressure of perfectionism that doctors experience.
In Dr. Abhijit Pal's words to readers who are young doctors:
"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 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. They all care deeply about your well-being and want the best for you. Our lives are as precious as our patients' lives."
Abhi is a medical oncologist currently completing the second year of his fellowship in drug development and early phase anti cancer trials at the Royal Marsden Hospital, Sutton in the United Kingdom. In his non existent spare time he is completing a part time PhD through Sydney University in informed consent and clinical ethics during communication with patients with advanced cancer. He has a strong interest in drug development, clinical trials, communication and also in hospital culture, burnout and doctor welfare.