Views & Reviews From the Frontline

The pursuit of imperfection

BMJ 2013; 347 doi: (Published 01 August 2013) Cite this as: BMJ 2013;347:f4780
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}

Tall, young, slim, bright, sporty, polite, athletic, controlled, musical, socially polished, good looking, sensible, and obedient, with straight white teeth: these traits of perfection are the aspirations of many parents and adults alike. And medicine is a candle to the perfect and perfectionism—a perfect degree, status, job, and career. But time is life’s great leveller, slowly turning, shaking, and unravelling all our misguided youthful aspirations, laying waste to perfection.

And perfectionist traits are particularly vulnerable to attrition in the mêlée of medicine. The unrealistic expectations of a medical career make many doctors miserable. And although perfectionism can be a veneer for insecurity, it can too be a cover for corrupting vanity, superiority, undue concern for the views of others, conceit, being controlling, jealousy, deference, avarice, elitism, and intolerance. And perfection is neither obtainable nor desirable because it spawns intellectual medical absolutism.

And we should fear absolutism, absolutely. Concrete and brittle, absolutism authors the authoritarian dogma on both sides of the political divide. An absolutism and perfectionism creates repressive conformity, making individuals and organisations both deaf and blind to criticism. Medicine’s perfectionism is expressed in today’s faith in clinical guidelines and the unstoppable drive towards total protocolism. But those who are most certain are most certainly wrong.

Medicine needs the flawed and imperfect—the short, disobedient, disaffected, irreverent, irrelevant, fat, awkward, difficult, blunt, challenging, smokers, exasperating, infuriating, ugly, drinkers, funny, rude, direct, insensitive, foolish, contrarians, nerdy, unhinged, forgotten, old, bananas, confident, foolish, loud, dissident, quiet, secure, non-conformists, brave, adequate, open, accepting, honest, once addicted, out of control, unorthodox, argumentative, meek, broken, and those that care and don’t care by equal measure. Medicine should be a melting pot of humanity’s strengths, but most importantly, of our frailty and weaknesses too, the perfectly imperfect.

To be flawed is to be normal, to be human. Imperfections as a doctor offer insight into others, allowing doctors to relate, persuade, and convince patients. Flaws make us real and more sceptical, perhaps more likely to ignore those thoughtless inflexible guidelines and diagnostic algorithms. Our imperfections immunise us against the certain disappointments of life, protecting us from the unravelling effects of time.

Indeed, the pursuit of artificial physical perfection through plastic surgery has only made society uglier. Likewise, the pursuit of perfection in medicine will only make us sicker, through unnecessary but unquestioned interventions and overdiagnosis. Medicine must embrace the difference and spurn wooden, perfectionist medical ideologues. The salvation of modern medicine lies not in the hands of the perfect, but in those of the imperfect.


Cite this as: BMJ 2013;347:f4780


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Follow Des Spence on Twitter @des_spence1

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