Wellness Committee: Perfectionism: Our Dangerous Frenemy

Ilene Claudius, MD FAAEM*, Al’ai Alvarez, MD FAAEM, and Andrew Grock, MD

Have you ever been terrified of failure? If so, did it keep you going— studying and working long past when you otherwise would have stopped? For so many physicians, perfectionism is a reliable companion in the struggle for success. It pours that third cup of coffee during an all-nighter study session and tells us to ignore a party within earshot of our dorm in order to continue memorizing the Krebs cycle. The goal for perfection and its accompanying fear of failure, drives us to meet the seemingly unattainable standards of high GPAs, stellar test scores, robust extracurriculars, near clairvoyant communication skills, and excellent clinical performance. And so, by the time we are conferred with a medical degree, this companion has become indispensable. And unfortunately, it has a cost.

In the long term, perfectionism evolves into less of a friend and more of a “frenemy.” Though it facilitates accomplishing our goals, it can simultaneously lead to many problems. Maladaptive perfectionism correlates significantly with depression, hopelessness, and suicidal ideation. A German study found maladaptive perfectionism to be the strongest predictor of depression and anxiety. The associated self-doubt can lead to imposter syndrome, which, if unchecked, becomes a self-fulfilling prophecy. Each success is attributed to luck or over-preparation instead of a deserved recognition, and each failure is viewed as a reinforcement of fraudulence, further driving the need to conceal imperfections. Thus, perfectionism is an all-or-nothing perception of success based on unrealistic standards. And with a 58.2% prevalence of depression for US medical students and 40% for post-graduate physicians, it seems unlikely that once we complete our medical training we overcome this and leave each shift focused on our triumphs and pleased with our contributions, and not haunted by self-doubt.

This perfectionism problem is addressed by Benjamin Hardy, an organizational psychologist and author of The Gap and The Gain: The High Achievers’ Guide to Happiness, Confidence, and Success, who suggests separating ideals from goals. Ideals are non-specific and immeasurable, e.g., being excellent at procedures. Goals are specific, measurable, and attainable, such as successfully completing a lumbar puncture 80% of the time. As such, ideals are amorphous, difficult to quantify, and therefore, unachievable. Because of our fear of failure, we are then inundated with intrusive thoughts of the shoulda-coulda-woulda. On the other hand, goals are plausible to achieve through deliberate practice. Goals incorporate mistakes as part of the iterative process, and can be continually refined once met. Aberrantly attempting to meet ideals instead of goals constantly threatens to leave us in the hopeless “gap” of failure. Instead, attempting to meet reasonable goals both inspires us and assures the possibility of success, allowing the perspective needed for a growth mindset.

Many of our favorite faculty members may have unwittingly propagated perfectionism through their own example when we were junior learners. They were excellent clinically, had a long list of publications, were unflappable in stressful situations, always knew just what to say, and had the key trick to nailing a difficult procedure—all while raising the “perfect” family, having an active social life, or telling stories of exciting travel or hobbies. As we look up to them, we idealize their persona and ask, “how does she do it?” or “how did he know that?” This sets us up for unrealistic expectations of ourselves instead of recognizing that clinical excellence is built on both diagnostic successes and failures and the learning that occurs from these moments throughout our careers. It trains us to respect the veneer of perfection and not accept the reality that no one is perfect in every sphere of work and life every day. Even though others may seem to float serenely through their shifts, we are all frantically kicking under the water just to keep afloat.

Unquestionably, personal or professional challenges will arise throughout our careers, and empowering students and physicians alike to take time for self-care and attend to our well-being, including normalizing seeking help, is invaluable. But we can also create resilience to deal with these stressors by enjoying the daily fulfillment associated with achieving tangible, reasonable goals and encouraging others to do the same. Even as we practice inward compassion for ourselves, we must extend empathy to those around us. Let them know that we are not some flawless ideal. We must not let our fear of vulnerability prevent us from normalizing our own inability to be perfect. We should strive to help those junior to us bridge the gap between the ideal and the reality by sharing our own experiences with failures and struggles. We must change our expectations of doing everything perfectly and set reasonable targets for ourselves and our trainees, leaving room for the occasional imperfection. Only then can we truly help them answer, “What is my ideal outcome, and what reasonably achievable goals will move me in that direction?”

References

Director of Quality Improvement, Harbor-UCLA Medical Center

Director of Well-Being, Stanford Emergency Medicine, @alvarezzzy

UCLA Emergency Medicine Department, @AndyGrock

1. Neff KD, Hsieh Y-P, Dejitterat K. Self-compassion, Achievement Goals, and Coping with Academic Failure. Self Identity. 2005;4(3):263-287. doi:https://doi.org/10.1080/13576500444000317

2. Enns MW, Cox BJ, Sareen J, Freeman P. Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation. Med Educ. 2001;35(11):1034-1042. doi:10.1046/j.1365-2923.2001.01044.x

3. Seeliger H, Harendza S. Is perfect good? - Dimensions of perfectionism in newly admitted medical students. BMC Med Educ. 2017;17(1):206. doi:10.1186/s12909-017-1034-9

4. Clance PR, Imes SA. The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychother Theory Res Pract. 1978;15(3):241-247. doi:10.1037/h0086006

5. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med J Assoc Am Med Coll. 2014;89(3):443-451. doi:10.1097/ACM.0000000000000134

6. Sullivan D, Hardy B. The Gap and The Gain: The High Achievers’ Guide to Happiness, Confidence, and Success. Hay House Business; 2021. Accessed September 4, 2021. https://www.penguinrandomhouse.ca/ books/679143/the-gap-and-the-gain-by-dan-sullivan/9781401964368

7. Developing a Growth Mindset by Carol Dweck.; 2014. Accessed September 4, 2021. https://www.youtube.com/watch?v=hiiEeMN7vbQ

8. Rahman A. Duck Syndrome. KQED. Published July 26, 2019. Accessed September 4, 2021. https://www.kqed.org/perspectives/201601138907/ duck-syndrome