https://orcid.org/0000-0003-3954-5860
The perfect is the enemy of the good.
—Voltaire
Scenario: An inpatient attending physician notices that one intern works much longer hours than her fellow interns. The attending appreciates her conscientiousness and dedication to patients but notices she has trouble delegating tasks and worries she may be exceeding the 80-hour work limit. The long hours may adversely affect her well-being, personal life, and even future career success. The intern seems to appreciate the attending’s feedback about time management strategies but continues to work late.
Physicians take pride in being perfectionists, setting high standards for patient care, teaching, and research. Attention to detail and capacity for hard work are required to succeed in college and medical school. However, when unchecked, perfectionism can become maladaptive, resulting in negative consequences such as anxiety, depression, and burnout in medical students,1-4 residents,5,6 and practicing physicians.6 Some internal medicine residents identify perfectionism as a contributor to learning-related shaming experiences.7 Overwork and burnout are critical problems for physicians, with multiple systemic causes,8 and perfectionism magnifies this risk in many individuals. We believe that early recognition of maladaptive perfectionism can facilitate changes in expectations and behavior, allowing more efficient use of energy and improved quality of life. In this article we outline harms of maladaptive perfectionism, identify characteristics and behaviors that should raise faculty members’ concern, and propose strategies to increase self-awareness of those affected and ways educators can avoid reinforcing perfectionism.
Maladaptive perfectionism is characterized by unrealistic standards, self-criticism, and failure to accept one’s own best efforts.3 The large discrepancy between personal standards and self-perceived achievement9 and other cognitive distortions that often accompany maladaptive perfectionism (negativity bias, all-or-none thinking, personalization, and self-blame3,10 ) negatively affect trainee mental health. The prevalence of maladaptive perfectionism in residents and fellows is unknown,11 but in a 2015 survey with a 93% response rate at a single large US medical school, 25.4% of first-year medical students screened positive for maladaptive perfectionism3 using the validated Almost Perfect Scale-Revised.12 In another study of US medical students in 2019,2 19% of respondents were classified as maladaptive perfectionists based on the Short Revised Almost Perfect Scale.13
Maladaptive perfectionists’ self-worth is overly dependent on striving and achievement.14 Avoidance of negative judgement is a strong motivator.15 Having a “fixed mindset”16 has been associated with maladaptive perfectionism.17 By contrast, a “growth mindset” encourages learning and effort, allowing constructive feedback to be valued and embraced. Those with a fixed mindset feel a need to repeatedly prove themselves; from that perspective, constructive feedback is perceived as an attack on one’s character, and to be avoided.
Maladaptive perfectionism can result in inefficiency, missed opportunities, and suboptimal mental health. For example, excessive time spent aiming for exceptional patient care leaves little time for academic projects, innovation, self-care, and relationships. Fear of not meeting excessively high standards leads to procrastination and avoidance of taking on new challenges.
Helping Trainees Gain Self-Awareness
Common characteristics and behaviors of maladaptive perfectionists4,15 are listed in Box 1. In our experience, perfectionists undervalue their time, so are not motivated to follow time-management advice until they have insight into the problem. We believe medical educators should learn to recognize maladaptive perfectionism as early as possible and provide feedback to help trainees gain insight and motivation to make cognitive and behavior changes that will maximize their effectiveness and help prevent negative outcomes. We have found several techniques to be useful (Box 2).
Conscientious, rule-following, exaggerated sense of responsibility
Low confidence/self-esteem
Detail-oriented
Stay at work later than their peers
Work hard to avoid negative judgment
Have difficulty delegating tasks to others
Take time to make decisions
Procrastinate on projects
Sometimes avoid new challenges
Maladaptive perfectionists undervalue their time. Help trainees gain insight before delivering time management tips.
Ask, “Do you ever think your perfectionism gets in the way of your goals?”
Normalize perfectionistic tendencies as an occupational hazard in medicine.
Note that highly successful people are less likely to be perfectionists.1
Use a Starling Curve analogy: spending more effort on a task increases output to a point, after which output decreases.
Invite a cost-benefit analysis. Have the trainee list, in 2 columns, the benefits of perfectionism vs the costs, then prompt them to consider additional costs (see text).
Be gentle with feedback, to avoid exacerbating feelings of shame or inadequacy.
Express confidence in their ability to grow.
Avoid reinforcing maladaptive perfectionism, such as giving praise for being the last to leave work. Instead, offer praise for triaging and delegating tasks well.
Role model discussing one’s own mistakes, learning from failure, and balancing excellence vs perfectionism.
Encourage a growth mindset, de-emphasizing the idea that some people are more talented than others.
Normalize perfectionistic tendencies as an occupational hazard. The stressors inherent to the practice of medicine, when added to the psychological characteristics of those who seek medical careers, make perfectionism an occupational hazard.15,18,19 Recognizing this susceptibility can help trainees take measures to protect themselves.
Ask trainees if perfectionism ever gets in the way of accomplishing their goals. The Starling curve, a concept learned in medical school, illustrating the association between preload and cardiac output, can be used as an analogy to show that as one spends more effort or time on work, output (quality or quantity) increases, but only until a certain point, after which output actually decreases. For example, the quality of a presentation generally increases with the number of hours of preparation. However, if the presenter stays up late the night before the talk to perfect their slides, they may be too sleep-deprived to speak effectively. The Inverted U20 (also known as the Yerkes-Dodson law21 ) is a variation on this concept.
Perform a cost-benefit analysis of perfectionism. Ask the trainee to take a few minutes to list in one column all the benefits of perfectionism they can think of, and in a second column, all the costs. Then, prompt them to consider additional categories of costs which may not have occurred to them initially: costs to patients, colleagues, people they teach, career trajectory, their organization or society at large. It’s easy for perfectionists to see how their behavior can harm themselves (lack of sleep, exercise, fun activities) and affect friends and family. But they may not have considered that perfectionism affects patients (when an overly thorough physician consistently runs late in clinic), colleagues (missed deadlines when collaborating; missed learning or leadership opportunities due to lack of delegation), students (role modeling of unrealistic expectations and poor well-being), their career trajectory (avoiding challenging opportunities, or completing fewer manuscripts due to procrastination); and their organization or society (spending excessive energy on patient care and documentation, with none left for leadership, quality improvement, advocacy, or mentoring). Being gentle with this feedback, to avoid exacerbating feelings of shame or inadequacy, is important, as is expressing confidence in their ability to grow.
Educators Inadvertently Reinforce Perfectionism
Whether in direct feedback or on written evaluations, educators should avoid praising trainees for being the last one to leave for the day. Instead, positive feedback for improving specific skills and successfully prioritizing tasks by importance or urgency is more appropriate. Leaders of teaching sessions should demonstrate and encourage a growth mindset,22 highlighting personal progress in themselves and trainees, while de-emphasizing the idea that some people are inherently more talented than others. Educators should share how they balance excellence versus perfectionism, cope with setbacks, and learn from failure. They should encourage trainees to utilize a compassionate rather than a critical voice about themselves.10
Additional Interventions
Brene Brown’s popular book, The Gifts of Imperfection,23 gives practical advice about recovery from maladaptive perfectionism. Cognitive behavioral therapy is an effective treatment.24-27 Goals include exploring other aspects of self-worth besides achievement and decreasing self-criticism.14 In a randomized controlled trial, short-term structured professional coaching, which included modules on growth mindset and perfectionism, improved emotional exhaustion, self-compassion, and imposter syndrome of surgical and nonsurgical residents.28
Systemic changes to medical school29 and postgraduate programs can also change expectations and well-being. At one pediatric residency program, a resilience workshop including discussion of cognitive distortions that accompany maladaptive perfectionism was part of a multipronged intervention in 2015 to improve interns’ mental health. The intervention led to lower levels of burnout and anxiety compared to historical controls.30
Conclusion
Based on the Accreditation Council for Graduate Medical Education’s self-awareness and help-seeking subcompetency, trainees should gain fundamental knowledge of factors that impact personal and professional well-being31-33 ; we believe that maladaptive perfectionism is often one of these factors. Medical educators should learn to recognize maladaptive perfectionism, avoid reinforcing it, and encourage self-awareness. By providing feedback that normalizes maladaptive perfectionism as an occupational hazard and broadens their insight into the costs versus benefits of perfectionism, faculty may help affected trainees use their time and energy more productively, improving their mental health and career satisfaction.
References
Author Notes
The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
