Perfectionism in doctors

The launch of the UK Association for Physician Health (UKAPH) has brought together a group of doctors and other health professionals concerned with the care of doctors. Perfectionism is a common trait among doctors.1 2 3 This is a good thing for patients and for healthcare organisations, but it can also leave doctors vulnerable to health problems and other difficulties.

People who are perfectionists strive for flawlessness, set excessively high standards of performance, and tend to be overly critical of their behaviour.4 5 Perfectionism can have some important benefits—not least, attention to detail, a deep sense of responsibility, and maintenance of high standards. It could be asked, “Would patients want anything less?” There is continuing debate about whether perfectionism is “good” or “healthy,” with the understandable view from the medical profession and the public that perfectionism is an essential driver of high quality patient care. But herein lies the rub: current pressures to do more, faster, and with fewer resources all militate against a perfectionist approach, and this can change vulnerable doctors into obsessive and frustrated people who make seemingly impossible demands on themselves and their colleagues. Increased scrutiny from regulatory bodies, the media, and the public all fuel anxiety and fear of making a mistake or having personal weaknesses exposed. If patients expect their doctor to achieve the unachievable, this can result only in a fallen hero.

The characteristics of “unhealthy perfectionism” and “healthy perfectionism” have been the subject of some scrutiny.6 7 Healthy perfectionism is not underpinned by the same level of anxiety as unhealthy perfectionism, and it produces more functionally useful outcomes. Unhealthy perfectionism can lead to reluctance to delegate and a tendency to micromanage and to be relentlessly critical—all of which can produce dysfunctional outcomes for the individual doctor and for the team. As an example, when treatment fails or the doctor cannot help a patient, a healthy perfectionist would probably accept that no more can be done, whereas a neurotic perfectionist might feel guilty and carry on relentlessly, regardless of the negative impact on himself or herself and on the patient.

It is perilous to collude with a culture of perfectionism in which doctors are expected to be infallible and errors are viewed as a “failure of character.”8 A compulsive triad of chronic doubt, chronic guilt, and an exaggerated sense of responsibility that burdens many doctors has been described.3 These characteristics can act as brakes on rash decisions, but when they become chronic they can lead to indecision, which may undermine the confidence of patients and colleagues alike.

Is perfectionism a trait or a learned behaviour? Personality research suggests that the tendency towards perfectionism is a consequence of extreme conscientiousness—the personality trait that most consistently predicts job performance.9 High work demands and environmental pressures probably interact with personality to trigger perfectionism. Extreme stress causes strengths such as conscientiousness to become overplayed and to develop into dysfunctional behaviours.10 Although conscientiousness is a stable trait that cannot (and, arguably, should not) be changed, more could be done to spot the early signs of maladaptive perfectionist tendencies and prevent them from developing further.

The following are some early warning signs of unhealthy perfectionism: all-or-nothing thinking (“no one understands how important this is”); failure to delegate (“no one will do it as well as I can”); inability to forgive oneself or others for small mistakes; procrastination to avoid the possibility of an error; dissatisfaction with success; and a continual striving for yet more achievement without praising others. As a doctor becomes increasingly frustrated at being unable to tackle inefficiencies, work relationships can start to break down.

How can the perils of perfectionism be dealt with? Effective team working acts as a buffer to the individual doctor who is trying to take on too much personal responsibility. Clinical leaders should establish a culture of constructive feedback that can help to identify doctors whose perfectionism is becoming a problem and provide boundaries for it. Timely feedback and coaching can help to increase the doctor’s self awareness and to provide practical strategies for managing the more unhelpful aspects of perfectionism such as avoidance, procrastination, and reluctance to delegate. Cognitive behavioural approaches have been shown to be useful.11 When their perfectionism is clearly causing a problem, individuals must be open to examining the effects of their behaviour on others rather than retreating into wilful blindness. To quote a recent BMJ letter: “It seems the sin is not the perfectionism that is demanded but . . . how the demand is communicated.”12 Finally, at an institutional level, managers need to recognise that excess pressure from external drivers and targets may have negative outcomes for doctors and for patients.