The sin is not perfectionism but poor leadershipBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1301 (Published 01 March 2011) Cite this as: BMJ 2011;342:d1301
All rapid responses
I refer to the rapid responses by Drs Anand(1), Collum(2) and
Hudson(3)in response to the letter by van As(4).
I agree that some doctors can demand too much of the perfect result
or care of a patient, especially to those clinicians (doctors nurses or
allied health) who does not share the passion or sunscribe to the exacting
standards. However in terms of the skill based clinical practices such as
the art of surgery, some practitioners (especially trainees) mistake the
idea of surgical wound tidy-ness and anatomical reduction (especially in
the case of orthopaedics) as trying to achieve the impossible heights of
When a surgeon learns new skills from someone who does it well, then
the surgeon is aware of what can be achieved in good hands. Whether or not
the learner can make it is a matter of practice and teaching and
ultimately psychomotor dexterity.
The patient often can only determine how good a surgeon is by 2 ways:
1. How good a surgical scar looks
2. If there is any 'complication' (as 'perceived' in the eyes of the
This is different from the surgeons' viewpoint and standard which is:
"if this patient is me or part of my family, will I be happy with
what I have done"
especially when many of them have been under the pupilage of
excellent master surgeons.
Furthermore, at the end of the day the consultant in charge of the
care of the patient have the final say; if certain surgery is expected to
be done to a particular way or standard, then the trainee surgeons should
try to do it that way, or ask the consultant to attend the case if it is
not possible in their hands.
Many surgeons ultimately realise that they will choose the best
skills learnt from different mentor in their training and also strive for
personal pride in their own work; we dont need spectators to applaud for
'Good enough' for some of us is simply not good enough!
1. Anand JK, Re:Perfectionistic Physicians BMJ (Published 4 March
2. Collum JK, Re:Perfectionistic Physicians BMJ (Published 4 March
3. Hudson P, Perfectionistic Physicians BMJ (Published 4 March 2011)
4. van As A, The sin is not perfectionism but poor leadership. BMJ
342:doi:10.1136/bmj.d1301 (Published 1 March 2011)
Competing interests: I strive to attain orthopaedic orgasm when I achieve perfect anatomical reduction of fracture fragments in my work.
I hope Rapid Responder Hudson will forgive me for saying that
some people (plastic surgeons included) strive for perfection for the
sake of their own conscience; they are not bothered about applause from
other, lesser, mortals.
Competing interests: I favour perfectionism
Perfectionism is desirable, but sadly not always achievable. The
failed pursuit of perfectionism results in disappointment, and the
blinkered pursuit of perfect care for some is likely to produce less than
perfect results for others. A single individual's human resource and
capability is finite - those that strive for perfectionism perhaps do not
realize this; that is why such traits lead to failed human relationships,
poor work life balance, and an association with adverse events and
Realistic, pragmatic, balanced physicians accept that the goal of
'good enough' care for all is entirely respectable. In fact, the current
rhetoric of quality improvement champions systems and policies that 'raise
the bar' for all. Or, put another way, the system should support
individuals to provide the best care they can reasonably provide. Adequate
patient care should not be dependent on a minority of individuals who
devote more than they should to their job, damaging themselves, and
sometimes those around them2.
Finally, the myth that one must possess the traits of masochist
perfectionism to succeed in certain branches of medical practice must be
1. Miller MN, McGowen R. Strategies to Avoid Burnout in Professional
Practice: Some Practical Suggestions. Psychiatric Times. Vol. 27 No. 208
2. Feinmann J. "Disruptive" doctors are often found to be
perfectionists, agency reports. BMJ2011;342:d876. (17 February.
Competing interests: No competing interests
Voltaire said the "perfect is the enemy of the good". Unfortunately
the compulsivity that characterizes perfectionistic doctors is often
associated with other traits like rigidity, and stubbornness. Because many
of them feel they are only valued if they are perfect there is an
increased risk of suicide, and they often need help. But society in
general, and the medical community in particular, often applauds them.
Clearly blame is not appropriate, but neither is praise.
Competing interests: No competing interests