AAOS Bulletin - August, 2006

The dark side of perfectionism

Striving for perfection can undermine results

By Ronald A. Ripps, MD

In his autobiography, Geno—In Pursuit of Perfection, University of Connecticut women’s basketball coach, Geno Auriemma, starts by discussing his scars, both physical and emotional. “The emotional scars aren’t easy to see,” he writes. “I’ve acquired them from a life of questioning myself, of constantly trying to prove myself.”

A perfectionist, Auriemma notes that nothing is ever as good as it could have been. “I have never coached the perfect game, and my players have never played the perfect game,” he says. “And when that flawed game is over, I am convinced it is my fault, even if we win big.”

Disabling perfectionism can rule the personal and professional lives of physicians as well, according to John-Henry Pfifferling, PhD, of the Center for Professional Well Being. The rigorous, competitive training that physicians complete and the cultural pressures we are under to perform to the highest standards help to internalize a relentless drive for perfection in our profession and in our lives.

A standard of perfection is systematically nurtured and rewarded by medical educators, litigators, accreditation groups, risk managers, the media, our patients and our communities. Simply put, society demands perfection from physicians as a minimum standard, and physicians are both the victims and perpetrators of that belief.

There’s one in every practice

Every practice has at least one perfectionist on its staff. We can all recognize this person—the one who takes feedback (which is interpreted as criticism) very poorly, who violates office policy (like rearranging patient sessions) on a whim—because this individual feels that his or her status excuses him or her.

Although generally perceived as obnoxious by other members of the group, this individual’s substantial contribution to covering the overhead often prevents any confrontation. These individuals often do not take time off, and I know of at least one practice that had to fine a partner for not taking his allotted vacation time. As the quest for perfection consumes the individual, feelings of distrust, hypercriticism of others, stubbornness, sarcasm, wealth hoarding and the need for control are magnified.

There is a connection between perfectionism and serious interpersonal and bio-emotional problems. A perfectionist is not comfortable with himself or herself, but constantly feels that he or she is under surveillance by a highly evolved, critical “judge.” The perfectionist wrestles with decision making, as his or her internal conversations foment brooding and doubt. He or she cannot accept even positive comments and becomes exhausted under the scrutiny of his or her own constant internal observer.

As Dr. Pfifferling notes, “The greater the hypercriticality of the physician, the more apt he is to be unable to receive or know how to dispense civil and constructive criticism.” This individual may be highly intelligent and have insight into others’ behavior, but cannot see his or her own perfectionism as the source of his unhappiness.

The perfectionist physician may experience peer sabotage; why should those whom he or she derides cooperate with him or her? This individual has trouble collaborating and is often the subject of complaints alleging a “hostile work environment.” The perfectionist is a workaholic, but also someone who is self-doubting, in denial and with low self-esteem.

You are what you do

In the medical field, says Dr. Pfifferling, perfectionism equates accomplishments and self-image. The cultural environment imprints the constant internal judge. This is a common adaptation in families where the parents bestow a preponderance of conditional approval. Children grow up with the sense that “whatever I do won’t ever be good enough.”

People who have this attitude presume that their peers expect nothing less than outstanding results. When they are among peers, their feelings of being less than perfect impair honest and timely feedback. The costs of this model are high. Perfectionists are rarely satisfied with what they do and have trouble laughing at themselves. To others, they appear to be overly harsh on themselves, arrogant or aloof. Each successive project becomes more taxing, difficult and unattainable. They get caught in a self-fulfilling prophecy, always having more work to do. They feel it is their duty to set higher goals than those of their peers and coworkers, and their obsession to exceed them. They constantly find imperfection in their work and the work of others.

Learning to let go

Once perfectionists understand the need to reduce the harmful effects of perfectionism, they must learn to let go of guilt, to freely make choices and to move forward, knowing that they do not always have to prove themselves. Other lessons include learning to accept the uncertainty of things, becoming comfortable soliciting other’s opinions and appreciating the solace one can enjoy in the words, “I don’t know.”

Letting go requires disassociating self-esteem from “results,” learning to appreciate and praise the contributions of others and accepting that laughing at oneself is not a sign of weakness. It also involves accepting harmless mistakes and taking time to “smell the flowers.”

Working with a perfectionist

Orthopaedic practices with a perfectionist as a partner should try to refocus the group’s attention on the “big picture.” Other physicians in the group shouldn’t feel defensive when the perfectionist says they are flawed or deficient, or that the practice is sorely in need of corrective action. Instead, they should affirm that no one can please everyone, that we are all fallible and that the role of “God” is already filled.

Helping the perfectionist rebalance is crucial for collaborative functioning. Because social pressures for perfectionism will not change, the group needs to maintain equanimity as a higher priority. Ultimately, the perfectionist has to acknowledge that refraining from workaholism and other examples of perfectionism is an act of freedom.

Ronald A. Ripps, MD, is past president of the Connecticut Orthopaedic Society. He can be reached at ronripps@worldnet.att.net. John-Henry Pfifferling may be reached at the Institute for Professional Well-Being, (919) 489-9167.

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