Thoughts on Perfectionism

Earlier this week, I listened to one of my favorite podcasts. The hosts discussed fearlessly saying yes to opportunities in life and in work, and the importance of learning on the job by trying and making mistakes. One of the hosts admitted that she fails often in her path to success, and that most people probably do. Then, as a joke, she added, “Except heart surgeons! Never fail on the job, heart surgeons. You can’t make any mistakes!!” All the hosts laughed, and they moved on.

This joke has been pinging around in my brain all week. Jokes are funny because they contain elements of truth. In this instance, I think the truth component is that society expects physicians and health care providers to be invincible - 100% accurate 100% of the time. Health care providers hold themselves to the same standard of perfection. No one wants to be on the receiving end of a medical error, and there is a booming medical malpractice industry to insure providers who are trying their hardest and to give a legal voice to patients who feel wronged. But here’s the piece of the truth that we ignore in the perfection narrative – health care workers are humans. They sometimes make mistakes, even when trying their best. Just like everyone else does at work.

I interact with a lot of physical therapy students in my job (and will encounter exponentially more when I start teaching in the fall). My spouse encounters medical students and residents in his job, and we have noticed the same pattern. Today's students are high strung. They have worked tirelessly to get to this point in their education, and they work tirelessly in their clinical training. They have perfectionistic tendencies. They want the best outcomes for their patients, and they are terrified of making mistakes. They may even ignore the interpersonal aspect of medicine on their quest to get things “right”. But, these fledgling health care workers need to try by learning on the job and failing – just like anyone learning a new skill set. In residency and in clinical rotations, students get to work through clinical decision making in a relatively risk free environment. They can practice going through an entire thought process without putting patients in danger. The student stage is the optimal time to make mistakes without having patients suffer the consequence.

Unfortunately, students have so internalized the cultural messaging from both society and the older generation of providers that they are afraid to make mistakes during their training. They are hesitant to prescribe “the wrong” exercise to a patient, or to formulate a hypothetical plan of care because they don’t want to look like they don’t have all the answers. This is dangerous. The time to make mistakes is when students are operating under the supervision of an established clinician, not in their first jobs where they no longer have the same level of supervision and mentorship. If a certain amount of “on the job learning” is necessary for success in ANY career path, then we need to make sure that students feel supported and encouraged to share ideas and practice their skills before entering the work force. That’s why cultural messages about who is “allowed” to make mistakes are so dangerous.

I think that health care providers have historically perpetuated the image of perfection and flawless decision making. It could be a point of pride to belong to that group of heart surgeons who supposedly never make mistakes. It must feel validating, after years and years of hard work, to be included in a group considered to be extra smart and above the typical errors that every day humans experience. Except, believing oneself to be infallible is toxic and leads to maladaptive perfectionism. It requires a huge amount of courage and vulnerability to admit a mistake, or even a not knowing, in this context where society expects perfection from providers AND providers expect perfection of themselves.

During my training, I had one amazing clinical instructor. I think about her almost weekly as I encounter situations where I'm not exactly sure about the best course of action. I was her student in an outpatient neuro clinic during my second clinical rotation. People came to this facility from all over the country, and a few patients traveled internationally to be treated there. I was exposed to so many rare diagnoses and unusual presentations, and I felt intimidated, especially as a student. My clinical instructor shared with me that, often, she tried her best during any treatment session to identify a patient's impairments, and sometimes she had no further insight or experience than what she was observing in the moment. She freely admitted to patients when she needed to do more reading in order to answer questions about prognosis or expected course of therapy. Her honesty and vulnerability actually lead to patients trusting her more. They felt that, when she provided information, they could confidently trust her because they knew that, if there was anything she was unsure about, she would be honest about that too. The clinic closed for 45 minutes at lunch time, and the therapists used this time to discuss patients and share treatment ideas/knowledge. It was a collaborative effort every day.

By admitting her continual learning process, this clinical instructor gave me radical permission to not know, and she shared proactive solutions to act in my patients’ best interest – go home, look up the research, consult with coworkers, and refer to another clinician if I feel that would be most appropriate. But this type of openness and collaboration is not always the case, particularly in medical education. Historically there has been a culture of shaming and humiliation when medical students or residents make errors or admit to not having an answer. Older physicians view it as a badge of honor that they survived the hazing of their early training days. To survive in that type of culture, however, these physicians had to steel themselves against negative emotions and looking "weak". Receiving any type of compassion from others would be viewed as weakness, because to need compassion somehow admits imperfection. This fear of compassion leads to a block in the outward flow of compassion (as discussed in last week’s post). Thus our medical climate of “doctor always knows best, and he never listens to his patients” is perpetuated by the way students receive their training.

If we want to break that cycle and have compassionate, patient centered care as the standard, we need to take a hard look at our training processes and cultural messaging. It’s impossible for students to keep their hearts open to patient suffering if these same open hearts have to absorb shaming and humiliating messages every time a mistake is made. Training in the health care field is a time of intense learning. It’s the time to make mistakes and practice independent reasoning, all the while being supervised so that patients are protected. People in all other careers freely admit to this type of on the job learning. We cannot pretend that people interested in health care are somehow born knowing everything they need to know, and are somehow capable of applying all new concepts accurately in a nuanced way immediately. We need to give students radical permission to not know everything, and we can do this by practicing with courage, honesty, and vulnerability in front of them. We also need to speak out when friends and family make offhand comments, such as in the podcast, about physicians needing to be invincible. Medical culture plus societal pressures create the perfect storm for maladaptive perfectionism, which only serves to hurt all of us.