“I always feel like I need to be two steps ahead of everyone in order for me to feel good enough at my job”
“I get anxious that I’ve missed something and I end up staying at work an extra two or sometimes three hours to check that I have done everything properly. It’s putting a real strain on my marriage”
“If I don’t get the patient’s clinic letter written really well, they’ll think I’m
misrepresenting them. So I’m nearly always behind as it takes me ages to get the letters just right”
What is perfectionism?
There are several different components to perfectionism and psychologists have spent many years trying to come up with a useful definition. Canadian psychologists Flett and Hewitt proposed a useful way of looking at it. They describe three types of perfectionism and some people find they are a mixture of all three:
- Where you tend to have very high standards for yourself that, in practice, may be impossible to achieve
- You are generally self-critical and find it difficult to accept your own mistakes and faults
- You may behave as if your mind is like Velcro for bad stuff happening to you and like Teflon for the good stuff (as American psychologist Rick Hanson sometimes describes our minds). No matter how much positive professional feedback you get, it just doesn’t stick and you continue to think you are not quite good enough
- Where you tend to expect that other people should meet your very high, unattainable standards
- You may find it very difficult to delegate for fear of someone not doing it properly and as well as you would
- You may end up very critical of others’ work and standards
- Where you tend to believe that other people or institutions have very high expectations of you, that you find impossible to meet
- You assume you won’t get approval / good feedback unless you meet these very high standards
Another way of looking at perfectionism was proposed by psychologist Randy Frost who thought it included these tendencies:
- You are generally very worried about making mistakes
- You have very high standards
- You doubt if people are doing things properly
- You have a great need for organisation
- You have parents with extremely high expectations and are over-critical
Some people would argue that they would prefer their doctor to be on the perfectionist side as they want to ensure they are treated with care of the highest standard and with great attention to detail. To an extent that’s true, but you need to consider if your perfectionism is positive and healthy (adaptive perfectionism) or if it has a significant downside and turns out to be unhealthy for you and your work (maladaptive perfectionism).
Healthy adaptive perfectionism can ensure that doctors continue to keep up their sense of responsibility and professional standards but it is not driven by continual fear or anxiety. This doctor knows the boundaries of what is reasonable and possible in their work and may accept that they did their best in any situation. They derive satisfaction from their work.
Maladaptive perfectionism, however, drives the doctor to keep on trying harder and not delegating enough and feeling guilt and shame that they are not managing things well enough. They can end up with chronic doubt, chronic guilt and an overblown sense of responsibility.
A recent literature review on perfectionism and mental health by Thomas and Bigatti showed that maladaptive perfectionism in medical students and trainees has a significant positive correlation with:
- Suicidal ideation
Their review also showed that the strongest predictor of psychological distress, depression and anxiety in medical students is maladaptive perfectionism.
A large study of maladaptive perfectionism has shown that it has increased over time between 1989 and 2016 in college students from USA, Canada and UK.
Is this nature or nurture - are some people just naturally perfectionistic? Conscientiousness is the one personality trait that consistently predicts job performance and can be considered a strength. However, under extreme stress and excessive work demands, this can be overplayed and can lead on to maladaptive perfectionism.
UK researchers, Curran and Hill, have looked into the various possible reasons why perfectionism is increasing in college students and proposed the following factors. It is not all to do with parenting styles, but also cultural changes at a society level such as:
- The emergence of neoliberalism, which has seen the increasing dominance of competitive individualism over a more collective approach. They describe a shift in cultural values towards materialism, competitiveness, and individualism and unattainable ideals of the perfect self
- The rise of meritocracy where there is the belief that if you try hard enough you can achieve a perfect lifestyle where you get achievement, wealth and social status. The neoliberal meritocracy emphasises the need to strive, perform and achieve. Young people absorb these messages and other research has shown they are getting increasingly unrealistic expectations. Many models that try to explain why people develop perfectionism emphasise the role of unrealistic achievement standards.
- Increases in both anxious and controlling parenting styles
It is easy to see how the healthcare culture in the UK can also play into these environmental factors. The NHS has become very performance and target focused whilst continually grappling with limited resources and increasing demands. Many healthcare workers perceive an increased scrutiny and blaming by the media and the public which can, at times, be demoralising – especially when they are working under extreme pressure.
When doctors are trained using an assessment system based on competency attainment, it is understandable that those doctors who tend to be perfectionistic may become even more so. They need to be careful they do not slip into the maladaptive type. As GP Clare Gerada pointed out, medical students and trainee doctors “are in a perpetual cycle of assessment, scrutiny and grading and comparison with peers”.
There is no one agreed way of managing perfectionism. It would be helpful to treat the causes of it as well as the effects – however, on their own, there is little an individual sufferer can do about the environmental and cultural conditions that contribute to it. You can look at what you can do as an individual to make things better for you, personally.
Antony and Swinson’s book on perfectionism (When Perfect Isn’t Good Enough) provides a useful approach for managing perfectionism in an individual, focusing on the associated thoughts and behaviours. They describe four areas you could start working on:
Making an assessment of your perfectionism
- Keeping a perfectionism diary to identify the sorts of perfectionistic thoughts behaviours you tend to do and what the triggers of these tend to be
- Evaluating the helpfulness (or not) of your standards and how they impact on your life and the people around you.
- Watch out for the tendency to see things in all or nothing terms. This produces a worry that if you slacken some of your standards, you will end up doing sloppy, suboptimal work and you will be criticised, blamed or even sued.
- You can also learn to see that standards for work generally lie along a continuum and are not simply categorical – i.e. excellent or not good enough.
- Listing all the costs and benefits of your perfectionistic standards currently and what these would be if you relaxed some of your standards
- Making clear, well-formed goals for what you want that’s different from now
Working on your perfectionistic thoughts
- This takes a similar approach to cognitive behavioural therapy (CBT). You learn to identify perfectionistic thoughts and catch yourself doing it and then cross- examine them
- List possible alternative thoughts
- Consider the advantages and disadvantages of the original and alternative thoughts
- Find more realistic, beneficial ways of viewing the situation
- One example of a CBT approach is to focus in on your polarised beliefs and assumptions about yourself and others, using the CBT continuum approach (see resources for a link). Getting one’s thoughts and beliefs down on paper (rather than just thinking or talking about them) can help you examine them more fully and identify more useful and realistic beliefs
Working on your perfectionistic behaviours
- Realising that if you continue to do the behaviours associated with perfectionism it will just keep the perfectionistic beliefs and predictions going strong
- Gradually learning to to put yourself in the situations that you avoid because of perfectionism and learning that the outcomes aren’t in fact as bad as you fear (e.g offering to give a talk to your department and seeing what actually happens)
- Gradually learning to stop yourself from doing the behaviours that perpetuate the perfectionism (e.g. staying behind at work for three hours to check all the tests were ordered and done and not delegating to the night team)
- Stopping your habitual procrastination and trying to do things in smaller chunks that are less overwhelming and more easily completed
- Learning to see that many perfectionistic behaviours are actually attempts to get more control over situations and your negative emotions
- Practising mindfulness can help bring you back into the here and now and stop the habitual flight into the future and the awful things that might happen there. There are many useful resources available online now for helping us learn how to practice mindfulness
- Acceptance and commitment therapy may help with this too (see Wilson and Dufrene’s book below).
Doctors tend to be self-sufficient and are trained to work things out for themselves. This is useful for the type of work they do and the responsibilities they have. However, don’t try to struggle on alone with problematic perfectionism. It is a common issue with doctors and should not be seen as a sign of weakness or failure (even though your perfectionistic thoughts might try to tell you this). To seek help and support is actually a sign of wisdom.
Help and support is available from allied healthcare services – like CBT sessions with Practitioner Health or applying for coaching at Professional Support Unit. At the PSU, we see many doctors who struggle with various degrees of perfectionism.
If you are suffering with associated anxiety and depression, again, seek support from your own GP or through services like Practitioner Health or DocHealth.
Selected papers on perfectionism in doctors and students:
- Perfectionism is increasing over time: A meta-analysis of birth cohort differences from 1989 to 2016. Thomas Curran and Andrew Hill, Psychological Bulletin, 2019, Vol 145, No 4, 410-429
- Perfectionism, imposter phenomenon and mental health in medicine: a literature review. Mary Thomas and Silvia Bigatti, International Journal of Medical Education, 2020; 11: 201-213
- Perfectionism in doctors. Mike Peters and Jenny King, BMJ, 2012; 344; e1674
- Unhealthy perfectionism. Clare Gerada, BMJ 2019; 364; 1438
- Shame and perfectionism among doctors. Clare Gerada, BMJ, 2020; 368: m393
- Perfectionism and maladjustment: an overview of theoretical, definitional and treatment issues. In P L Hewitt and G L Flett (eds), Perfectionism: theory, research and treatment, American Psychological Society, 2002
- ‘When Perfect Isn’t Good Enough’ by Martin Antony and Richard Swinson, New Harbinger Publications, 2009
- Things Might Go Terribly, Horribly Wrong: A guide to a life liberated from anxiety. Kelly Wilson and Troy Dufrene, New Harbinger Publications, 2009 (about acceptance and commitment therapy)
YouTube videos and Apps
There are many interesting videos, TED talks and podcasts about perfectionism online – it is useful to get really curious about perfectionism and hear how different people understand it and suggest dealing with it.
For example, a useful podcast is available on Dr Rick Hanson’s website where he and Forrest Hanson are in discussion with Dr Diana Hill: Being Well, Perfectionism and Unhealthy Striving. [https://www.rickhanson.net/being-well-podcast/]
General overview of CBT techniques:
An example of a worksheet on the CBT continuum technique (Accredited to www.thinkcbt.com):
- PSU Coaching service – https://london.hee.nhs.uk/professional-development/coaching-service
- Practitioner Health – www.practitionerhealth.nhs.uk
- DocHealth – www.dochealth.org.uk
PSU website content – Perfectionism – Carol Parkes,