The First National Physician Suicide Awareness Day occurred in September. And days before that, the new film on the subject, “Do No Harm” brought out hundreds in New York City to remember lives lost and explore ways to do better. Believe it or not, I had no idea these events were on the horizon for those particular weeks when I embarked on a series of four blog posts tied to that very theme. Sometimes, the Universe conspires with us all to help us make a change!
Today, I want to talk about one of the biggest barriers to our efforts to reduce physician suicide — our shared tendency to perfectionism. Frankly, “tendency” isn’t a strong enough word at all. How about if we call it our completely out-of-hand, mutually agreed upon, over-the-top, zealous, all-out, just-can’t-get-enough, unmitigated devotion to seeking perfection?
First of all, the trajectory of medical education from the admissions process right on through fellowship selects for perfectionists (I count myself among them!) and cultivates perfectionistic tendencies. The competitive nature of medical school admissions selects for highly capable students, many of whom have been rewarded lifelong for “perfect” school performance. High-stakes testing and the fear of not matching to a residency program further pump up the pressure.
Next, physicians-in-training get frequent messages reinforcing the notion that anything less than perfection in their work simply will not do. Why? Because those of us further along have bought into that mindset ourselves, just as many of our teachers did before us. Some of us convey those expectations to our trainees and each other in a cruel way, others kindly. Either way, it’s bad for us and our mental health. We would do better to reframe our thinking and our world, but to do that, we’ll have to figure out what the current pattern is and what to replace it with.
WHAT IS PERFECTIONISM?
In her books and TED talks, Dr. Brene Brown repeatedly makes the point that perfectionism is not the same as striving for excellence. She states unequivocally that perfectionism is NEVER a strength and in fact, gets in the way of our burgeoning excellence. “It’s a twenty-ton shield that we lug around,” she writes in The Gifts of Imperfection, “...(one) that’s really preventing us from taking flight.”
What does she think we’re trying to shield ourselves from? Our fears and vulnerability. Fear that we’re not good enough. Fear that we might be criticized. Fear that we might do the wrong thing. Sounds about right, doesn’t it?
If perfectionism isn’t a search for excellence, what exactly is it? The constellation of beliefs that:
1) Perfection is possible,
2) It is my job to pursue it, and
3) My value as a human being is proportional to my ability to achieve it.
WHAT’S WRONG WITH THAT?
Unrelenting perfectionism damages our health and our relationships in at least five distinct ways:
1) It sets us up for disappointment
We perfectionists — Brown says she’s one and I’ve definitely been there and done that! — believe that we ARE what we accomplish and how well we accomplish it. Anything short of perfection constitutes failure. I guess that might be all right if continual, or even semi-regular, perfection were actually humanly possible. Unfortunately, it’s not.
Realistically, whenever we engage in any activity with the hope of success, we simultaneously engage with the risk of failure. We may compartmentalize that thought at the moment of action in order to minimize distraction or indecision and maximize success, but it is reality nonetheless. And the more complex the undertaking -- marriage, running a business, launching the space shuttle, or practicing medicine -- the more it is so.
2) It results in depression and anxiety
“Perfectionists are prone to depression and severe anxiety, and they are more likely to commit suicide when things go really wrong,” writes Dr. Christine Carter of UC-Berkeley’s Greater Good Science Center.
Why? We’re too vulnerable to dualistic, all-or-none thinking. Whereas a non-perfectionist might view an outcome as falling anywhere on a spectrum from very bad to downright wonderful, perfectionism creates an inner on/off switch. An outcome is either perfect or it's not. According to Carter, since perfection is not often possible, “perfectionism creates a steady state of discontent, (and a) stream of ...fear, frustration, and disappointment.” An easy path to depression.
And as for anxiety, “when you are a perfectionist, you can't enjoy even your successes—there is always something you could have done better.”
”But wait,” my inner critic argues, “of course we want perfection; we want it for the patient!” Just know that this pattern can become volatile when our individual or collective imperfection, which is to say our humanity, results in harm or near-harm to a patient. After a patient experiences an unexpected outcome, even if we cannot say why, it becomes very hard not to judge ourselves for failing to meet our own unattainable standard.
It takes real effort and time — sometimes years — to come to terms with the reality that a terrible event does not mean that we are not excellent healers. Valuing our lives exclusively for what we accomplish and how well isn’t just bad for our day-to-day well-being; it can endanger our lives when something goes terribly wrong. And if Sir William Osler was right that “medicine is a science of uncertainty, and an art of probability,” then eventually something will.
3) Perfectionism is a drug
Do you remember learning about Skinner in Psychology 101? One of his most important discoveries was that sporadic, erratic rewards reinforce a behavior far better than constant, predictable rewards. So it goes with perfectionism. Every now and then, it feels like we got things “just right.” Apparently, for us perfectionists, this gives us a dopamine rush like certain drugs or sex would do. Over time, we become addicted to achieving perfection.
This makes me wonder, what happens next to us when things go awry? Do we turn to other harmful options? Does our intermittent stream of “perfect” moments convince us that we are in control of life? And then, if life shows us otherwise, do we turn to chemicals or other stimuli to soothe that worry? In other words, does the addictive nature of our perfectionism position us to develop other, more dangerous addictions?
4) It stunts our growth
In her excellent book Mindset: The New Psychology of Success, Dr. Carol Dweck makes it clear that a search for unattainable perfection stunts attainable growth. She describes her experience in this way:
“I (initially) thought human qualities were carved in stone. You were smart or you weren’t, and failure meant you weren’t. It was that simple. If you could arrange successes and avoid failures (at all costs) you could stay smart. Struggles, mistakes, perseverance were just not part of this picture.”
Her own data proved her wrong. After studying children and adults, she found that people tended to fall generally into two camps:
those with a “fixed mindset,” who hold that the abilities people have are fixed, innate gifts, and those with a “growth mindset,” who firmly believe that with practice and work, abilities grow.
Her research shows that those who embrace a fixed mindset seek to avoid failure, which for them, reflects badly on their inherent gifts. Sounds a lot like perfectionism, doesn’t it? This fear that they are stuck causes them to interpret failure as “I'm worthless” or “I'm a loser.” Those with a growth mindset, on the other hand, eagerly reframe failure as a challenge, an opportunity for growth. And for them, that's what it produces. Thankfully, she also found that it’s possible to shift our mindset with practice.
In Fail Fast, Fail Often, Drs. Ryan Babineaux and John Krumboltz take a similar view. Perfectionism produces paralysis, they claim, and “most significant accomplishments arise out of hundreds of mistakes and failures.” They posit that joy is to be found in taking chances, and that the most successful inventors and entrepreneurs look for ways to jump in and begin a task. Like Thomas Edison, they see each “failure” as just one more way that doesn't work.
Of course, I get that we can’t just run right out and apply this fail-forward mindset in every situation in medicine. After all, we don't want to deliberately risk patients' well-being. However, I do think that I personally handle it better when things don't go well if I recognize that growth in all of life relies upon nearly endless failure, and embrace the desire to exercise my muscles for tolerating failure more in other areas of life.
5. It makes it hard to take good advice
“Where perfectionism exists,” says Brene Brown, “shame is always lurking.” After all, if we presume that our imperfections reflect poorly on us, it feels hard to expose our flaws to others. Unfortunately, that outlook makes it tough to seek and receive good advice.
Surgeon Atul Gawande hints at this experience in his New Yorker article “Personal Best.” When he challenges himself to invite a senior colleague to coach him in the OR, the unease he describes reveals his struggle with the perfectionist tendency just under the surface in the culture of doctoring.
In nearly every other arena of endeavour, however, guidance is seen as essential. Legendary NBA talent scout, Stu Inman, built his career on openness to outside advice. As Dr. Adam Grant tells it in the amazing Give and Take, Inman met Bruce Ogilvie, “a pioneer in sports psychology who came onto the sports scene when psychologists were referred to as ‘shrinks’ and any player going to visit one was seen as a problem.” Thanks in part to Inman's willingness to embrace the new discipline, it no longer strikes us as strange that an athlete's greatness is as much about the mind as the body.
Fun fact: Want to know when Inman met Ogilvie? Nearly 60 years ago! In a recent post, I wrote about the fact that we STILL see a physician who goes to see a psychologist as a problem. That puts us sixty years behind the NBA! And in my blog post entitled "The Duties of a Physician", I wrote about the fact that the ancient Greeks knew that our first duty was to “heal the mind.” Now THAT puts us 2000 years back!
I think it's high time we got a move on. Time to abandon our perfectionist mindset. Maybe we can learn to love ourselves just as we truly are, flaws and all!