Hey guys. Welcome back to the podcast. I'm Amanda. I'm Laura. I'm Kendra. And we are revisiting an issue that we see in physicians repeatedly, over and over and over. But when we were looking, it's been quite a while since we dealt with this topic head on, and that is perfectionism. So let's talk about what perfection really is and what it isn't.
Many, many of us are trained to think perfectionism is a badge of honor. In fact, even as I say it, like I'm a recovering perfectionist, like I, you know, really take pride in my work and I get things done. I would say that our society very much glamorizes being a perfectionist without really taking into account all of the fallout that comes from that behavior.
Yeah. Psychology though now distinguishes between what truly is healthy high achievement and maladaptive perfectionism. It turns out a lot of us do start medical school as healthy high achievers. That's when you're driven by your own potential and what you think you could contribute to the world.
The literature suggests by year two of med school, the way that we are trained, many of us have moved from that healthy spot into more of a maladaptive perfectionist. And it makes sense because of public shaming and high expectations and comparison—there's a lot of reasons why this happens, but maladaptive perfectionism, rather than putting yourself into the world because you think you can make a difference, you suddenly become driven by flawlessness so that you're not criticized, including by yourself.
That was something that, like my own inner critic is harder than anyone else in the world, but still that's what I'm running from is her flaring up and criticizing. That is a completely different motivation. So let's talk about high achievers versus maladaptive perfectionists, especially physicians.
So a healthy high achiever, they tend to set ambitious but realistic goals, whereas maladaptive perfectionists will set impossibly high rigid standards and still feel like it's not enough. A healthy high achiever will celebrate progress along the way. Whereas a perfectionist will, we call it dismissing the positive. They dismiss their accomplishments immediately. Yeah, anyone could have done that. That's part of the job.
A healthy high achiever sees failure as feedback and a necessary part of growth. You fail forward. A maladaptive perfectionist, first of all, might avoid risk altogether because they're afraid they can't nail it on the first time or if they do go for it and make a mistake or it's not flawless, they might take that not as just feedback or data, but as evidence of a personal failure.
A healthy high achiever will accept negative emotions. That's just part of being human to have some sadness or to be disappointed or even embarrassed. A maladaptive perfectionist believes if you are doing life right, you're happy every day. Or you're having positive emotions every day—you're obviously doing something wrong if you have a negative emotion, you failed somewhere. Since that's not consistent with reality on earth, there's this constant background anxiety. Like you're always waiting for the other shoe to drop or like worry that something's gone wrong, that you're in a low point in life.
Healthy high achievers tend to derive satisfaction from their effort and their capability and their persistence, not just flawless results. They like progress. A maladaptive perfectionist links—oh, this is so dangerous—links their self-worth to their performance. I'm only as good as my last shift. I'm only as good as my last surgery, my last patient review or whatever it is.
And then I'm not certain if we've spent a lot of time about this, but this is very much a characteristic of a lot of us perfectionists—this all or nothing thinking. It's a central cognitive habit of maladaptive perfectionism. Where everything is all or nothing, black or white, it's either good or bad. Today is either perfect or disaster. One complication makes the entire day a failure. One missed note means I'm a fraud.
Why this matters is that medicine is full of nuance and shades of gray. It's full of partial successes, all or nothing thinking erases all of that and turns normal complexity into emotional catastrophe.
So if you're a doctor who finds it hard to celebrate your own success, or who feels like one mistake might wipe out your entire self-worth, or you're just waiting for the big miss of your career, or you're avoiding new opportunities because you might not crush them instantly, you're not just a hard worker. That could be a symptom of maladaptive perfectionism and it's not helping you. It's burning you out.
Yeah, this is kind of ouchie, but like the awareness of this never hits so hard until your kids actually start doing this and you're like, oh man. I'm just like, wow. And you're like, wow. You hear them say something, either the all or nothing thinking or like coming home from school and being like six of the seven classes went amazing, but like missed a quiz. And so the whole day was like trash, just like, oh dang. Especially a two physician household with very maladaptive high achievers. It's just really hitting home. And so I'm like, oh gosh, this is great. I'm so glad I showed up to this podcast today.
Maladaptive perfectionism, though. How does it show up in burned out doctors? Well, we talked about, you know, the groundwork for it, but this really is probably one of the more common or important areas that do contribute to burnout and may not even be labeled as burnout. Or you may not even feel like you're burned out, but just attention here because this is actually a big, big contributor.
We're ER docs, so we can relate to this, but if you go on shift and you know, you start out your day with like a resuscitation that goes well, gets the patient admitted, you know, everything runs according to ACLS, PALS, whatever, and the patient gets admitted and great and you go through the rest of your shift and it's chaos. But then you know, your last couple of patients, maybe you backed into a diagnosis or didn't get a test ordered fast enough. Or maybe you got a patient admitted, but they—you know, did you order this? And you're like, oh no, I didn't even think about that. Right. Or something like that.
Something that might pop in your mind is like, oh my gosh, once again, I'm not good enough. Or, oh my gosh, once again, I missed this lab. Okay. Remember at the beginning of the shift, like you brought someone back from the reaper and they got admitted, right? So this is what we're talking about. It's really honing in and being very focused on the thing that you miss, and you may replay that all the way home because it may have been one of your last couple of patients. And so that is what sticks with you, and that is what you replay on your whole drive home or something.
Same with like a patient—a patient says, thank you, like right. I tend to notice that a little bit more these days, but then you fixate on the one dissatisfied family. Maybe they had to sit out in the waiting room too long, or maybe they anticipated getting admitted, but they don't meet criteria and so you're sending them home. And so that can be a real big dissatisfier. That stuff's kind of out of your control. But that's what we would fixate on, is like, oh no. Three of my patients said thank you. And they were so glad they came in and we cared for them. And then we fixate on the one dissatisfied family.
Or maybe you have an inner critic like mine and you know, thoughts of, I should have known that I should have done more for that family. I can't believe I missed that. You know, just this unhelpful, constant berating of yourself, and it is that still small voice. It doesn't even have to be said aloud because it's there and it's loud enough that it impacts the way you feel at the end of a shift, at the end of the week, at the end of your workday, whatever it is.
This even can make you feel something like fatigue or blue or just feeling solemn or something. So these feelings can come out of this and it's really moral injury. Like, I look around and my colleagues seem to be handling this, or I look and other, you know, successful people, I'm sure go through a lot worse and they can handle it. Why am I not cut out or why can't I handle, or why am I feeling this way? Well, when you start to replay this over and over, it really can start to feel like a physiologic symptom. And that is where that awareness comes in because if you're not getting enough sleep, obviously it's gonna affect your brain and whether you can perform at your best. But if you are just feeling blue all the time, or fatigued, just this generic, I'm just worn out. I'm tired, I'm tired, I'm tired. We like to say that. What is that really? And sometimes we gotta peel that back.
Another way it looks like is avoidance and procrastination and, whoa, I can testify to this—tasks will pile up because, you know, nothing you do actually makes you feel good enough. So if you're trying to tackle like research charting, grant writing, meetings, you know, you're on this committee and that committee, those tasks can pile up and you wanna avoid that because that just looks like an insurmountable hill, one that you do not wanna climb.
And then when that work becomes overwhelming, it seems hard, like those tasks in themselves, if you were to take the tasks out, the circumstance of the tasks out, it's not hard, but we make it hard because if we're not perfect at it, once again, it can start that movie reel of I'm not good enough, I can't do this, I'm tired, whatever.
Then there's a fear of disclosure. So another part—how this shows up is we're not even comfortable enough to admit it, so we just push it down. We disconnect even more. We can't really find a safe space 'cause we don't really wanna show vulnerability at work. Right. Because that was never modeled. And then our loved ones, if they're not in medicine or they don't take care of patients who are in healthcare, they may not get it. Or the other part of that coin is that you may be afraid of what they think of you. Like, oh, they're gonna think I'm imperfect or even incompetent, right? If I even admit that I'm not handling all this, or I'm not keeping all this together. And so you'll delay seeking help or feelings of depression, feelings of anxiety, you know, trauma, anything because of that stigma. And we hear that over and over again when we meet with clients, but even more so as it piles up, it can really take a toll on you emotionally. And so that can turn into just chronic irritability, cynicism on shift and off, which anyone that works in the ER—we're highly cynical. But really depersonalization of patients. And I can remember back vividly recognizing the depersonalization of patients. I'm not really proud to admit that, but it was part of my burnout. I can remember when I was getting to the height of my burnout, I was so annoyed with these patients coming in with these tragic things like really messed up patient. I think we've told you Amanda and I work a level one trauma. We see bad stuff, really bad stuff, and I'm like, oh my gosh. Like can we not just have testosterone during the 4th of July? You know, I would say things like terrible things. Very unempathetic things, you know, just thinking to myself how disconnected I had to be because honestly just seeing bad stuff over and over again. It was how I coped. But when you have this all or nothing thinking it really turns isolated setbacks into identity threats. One complication feels like a total failure, shame, rumination exhaustion, all of these things set in and it's just gonna fuel further avoidance.
Meaning if my shift isn't perfect, why show up if I can't get this work done perfectly? It's worthless. So you're setting yourself up and it just really fuels more procrastination and you're not getting things done, and then it keeps piling up and then you're like, yeah, I'm never getting this done. And so instead of just getting it done, we talk about B minus work. Even C plus work, you know, it's just not gonna get done. And then it magnifies isolation even more. So you fear that the admission of the struggle or if you even reach out for help, then it's professional death basically, and you hide problems instead of seeking that support, even from a colleague or mentor or even reaching out to your IT people for your EMR saying like, I gotta fast track this. Is there some way to make this easier? We can't sometimes even do that. We get in our own way a lot of times.
So for example, if you had 14 stable patients and one complication, your brain erases those 14 stable patients and hangs onto the one. You sleep poorly, you ruminate. You continue to replay it over and over again, and the next day or the next week or the next few shifts, you show up completely depleted and there's really nothing but that is just continually playing through your brain. And so there's nothing else you can think about. You can't get away from it. And so then it just really magnifies that isolation, because like we said, you're not going to reach out for help. It's a real struggle.
Studies show physicians high in self-critical perfectionism are at significantly greater risk of emotional exhaustion, which is what we know is a major factor in burnout and depersonalization, which we talked about. Perfectionism combined with imposter syndrome is one of the strongest predictors of physician distress, even more than the workload. So think about how often you've left a shift replaying the one thing you might've missed, instead of the dozens of decisions that you made or patients you took care of that you nailed. That self-critical loop isn't making you better. It's fueling your burnout, and research backs it up. Perfectionism is one of the strongest predictors of physician exhaustion.
Okay, so what do we do about it? We've got some ideas for you perfectionists out there. There's one or two of you.
It's interesting. My son is playing football for a team that has a very, very long losing streak. And he just started this year, so he's hoping to be part of the solution. He will likely participate in some losing games first though. But it's amazing how these kids—you can see even when they have worked really hard and they've got all these new plays and they're in better shape and they've got this new amazing coach and they're so pumped up and they have a couple of good plays and somebody makes one that's kind of boneheaded and then they just all kind of crumple and I was like they are all or nothing. That's what's happening. There is that mindset of, oh man, we messed up now we're gonna be losers. I actually gave them a little talk this week about it and pointed out that when you think I suck, or I'm a loser, or I'm horrible at that, you can feel it in your body. You can feel it in your brain that you have less—you have less dopamine going on, which is your motivational neurotransmitter, you have less epinephrine to help you get stuff done. You are literally making yourself worse when you think these bad thoughts about yourself. So it's important to be able to reframe them. And you see this in sports psychology all the time. When people make a mistake, one analogy is just flush it—just push it out and go on to the next thing to overcome that. Because when we ruminate on those mistakes, we actually are making ourselves more likely to create further problems for ourselves.
If you can't get out of that, I failed. But you can work towards, I learned. I'm not doing that again. I will not dismiss that complaint again. I won't forget. I won't ever forget to order that again. And I think we can all probably relate to ways that patients have taught us things over our time in medicine. I can think of several mistakes that I've made that I will never make again because I learned so. That's what we're doing. It's called the practice of medicine. Just like my kids going to football practice. They're practicing, we're practicing medicine. We're not gonna get it perfect every time, and we have to be okay with that.
Near misses or misses can be painful, but that is data that can improve future care that we give. If there is one thing that you could develop that would help alleviate your burnout. It is self-compassion. Self-compassion is crucial to living a good life. I heard something yesterday that I thought was so brilliant. It's the reverse golden rule. I treat myself like I would treat other people, and I was like, wow, that's revolutionary. Because you treat other people so kindly, why would you treat yourself like your worst nightmare? Why would you do that? Treat yourself like you would any person doing their very best, who made a mistake. You want to learn, yes. And you wanna be held with compassion and grace. Be gentle. We are all humans. We cannot live without mistakes. It's just part of the process of being here.
Celebrate milestones. When you notice that you are making some change in your neurobiology, when you are getting better about keeping your charting at work, instead of taking it home and charting all night, when you notice that you are keeping your cool better or that you're able to reframe thoughts, pay attention to that and reinforce it for yourself. Keep track of your wins. You could even write 'em down, but definitely notice and say, brain, I'm proud of us. We're growing up. We're creating what we want and not just being victims of this dumpster fire that we work in.
Yeah, that's a good one. 'Cause I remember a client, she had this same thing. She didn't recognize she was getting burned out and she recognized the irritability on shift and how she used to relate to like the nursing staff and techs and everything so well. But the burnout was insidious and she started becoming super, super irritable and she was getting actually called into the office, whatever you wanna say. And so she, after a couple of times, you know, of trying to reframe what she was doing she decided to bring some dark chocolate—those little candy kisses things. And so she remembered that every time she left a room and like noticing how either it was a tension filled environment or maybe kind of stressful 'cause patient was sick or whatever, that she kept her cool. That was her celebration. She's like, open that up, pop it in. I got my dark chocolate and I feel great. And it was that constant reminder of her celebrating just that little thing.
And then she reminded herself to stay calm and then she got out of the room and those little kisses were sitting right there in front of her computer or whatever they were. Brilliant. Yeah. That's perfect. Antioxidants and a little mood lift. Little, little dopamine, serotonin. And she's rewiring her brain. She's like, look. I kept my cool, I'm celebrating it. It's not all or nothing. And then, you know, at the end of the shift she rode home and she started focusing more on the things that did go right and it was almost not that the tension-filled situations were any less or minimized, it was just that she was working on reframing the thoughts that came with, they weren't so big anymore, and so it was just less remembered on the ride home, or something like that. But it's just amazing how it just took up less real estate. I love that so much.
Here's another thought. If you are a ruminator or you think about things over and over again when you come home from work, give yourself 15 minutes to worry. Actually, I'd recommend you keep it in your car and not bring it in your house. Set a timer. You got 15 minutes to think about it. You can write it down, journal it, whatever, talk to somebody about it. Then redirect focus. If your brain tries to offer it up again, redirect. Thank you brain. Yep. We've already done our worry time. Now it's time to be present at home and spend time with the people we love and rest and restore so that I can feel better for the next time I have to go to work. That is a really great way to keep work from taking over your home life. Nothing will burn you out faster than having work with you 24/7 because you can't stop charting at home or thinking about work at home.
Give yourself permission to be imperfect. This is where the B minus work comes in. This is a foreign concept to most doctors. Your charts do not need to be A plus Nobel Prize winning literature. Okay? It needs to be informative and B minus at best. Like nobody is grading this. Get your things in there for billing and for medical legal coverage. But no, too many of us treat them really like literature that is going to be passed down through the ages. No, go write a novel. Okay. HIPAA will not allow this to be published by Simon and Schuster. It needs to be B minus C plus work because you just need to get it done. And when you consciously submit work that is just good enough instead of waiting for flawless, give yourself a pat on the back. Now, I would say if you're doing surgery or sewing somebody up, you can—you can go for A work there. But charts and things that really are not meaningful—seek some connection.
Connection is so healing. Sharing our struggles with safe peers or a coach helps to normalize imperfection and dismantles this toxic culture of silence. I love the saying to be heard is to be healed. I personally feel very healed when I'm able to share something and somebody says, that makes complete sense. And I'm sorry you had to go through that. We see that in our clients all the time, how just having a safe place to talk about some of these things can make us feel so much better so quickly. Therapy and coaching cognitive behavioral therapy based models use a lot of this thought shifting and acceptance and commitment therapy also uses this model where we can, yes, we can accept how we are, we accept what's happening, and then we can choose what to do with what we are thinking, believing and doing—these can help or these can definitely help reduce maladaptive perfectionism and coaching is based in positive psychology, which is all about shifting and using positive neuroplasticity to create what we really want and how we really wanna feel.
All or nothing thinking is something that a lot of us find ourselves doing. Here's like either a good doctor or a bad doctor, depending on how well I performed. It's actually an immature level of thinking. And as our minds develop more, we are able to appreciate more nuance. So notice when our brain is offering up absolutist language, like always, never, a total failure. That was the worst—look at, look at that and realize, okay, that's probably a lower part of my brain, is probably my limbic system offering that up, and it's probably not true. There is a lot of nuance and we can be tremendously good human beings and doctors and make mistakes sometimes too.
Spectrum language, replace binary statements with some graded language, like some wins, some things to learn. Often not. Sometimes this is more nuanced language than the black and white thinking that we talked about. A graded self-assessment. After work or a shift, we can list three things that went well and one thing to improve. It helps us to see some nuance where we can have a mostly good day with some things that we need to work on, or we can have a mostly bad day and find the wins that we had there too.
Behavioral experiments, deliberately submit something just good enough. Track outcomes to dis-confirm catastrophic predictions. So instead of obsessing over your slides for your presentation for all night, three weeks before you are giving it and being so afraid that it's gonna show up there with a typo, do—what happens. You just do it, submit it, look and see what the outcome is and see if all that worrying is actually worth it for you in the end. Thought records, write all or nothing thoughts that you have. Write it down. Look for evidence for it. Look for evidence against it, and then see if there's a balanced alternative in the middle.
Modeling, we can encourage leaders to narrate partial successes and near misses so trainees can learn that mixed outcomes are normal. Hey, we got Mr. Jones out of DKA and he is gonna go home and probably go back and DKA, and that's okay. We can control what we can control. We can't make him take his insulin. So just know healthy striving doesn't mean that we're lowering our standards. It means that we're setting goals that—although if you're a chart perfectionist, please lower your standards, please. It's gonna help you, I promise—means setting goals that fuel you instead of drain you. It's about celebrating wins—even, especially those tiny little wins. Especially wins that involve connecting with other human beings and taking care of yourself. Learning from misses and remembering that you matter, not because you're perfect, because you're not, and there's no amount of obsessing and ruminating that's gonna make you perfect—actually, that's gonna cause you more problems. You matter because you're human. And your worth is inherent in that you don't have to do anything to earn that. You just are worth an infinite amount just 'cause you're here.
Maladaptive perfectionism looks like hard work on the outside, but feels like chronic self-criticism, fear, and exhaustion on the inside. For physicians, it's not just a personality quirk, it's a direct risk factor for burnout. All or nothing thinking is the mental habit that turns nuance into catastrophe. So targeting that thinking with the things that we mentioned above, is central to recovery. The antidote isn't to abandon excellence, it's to redefine it—moving from the impossible flawlessness to resilient human high achievement.
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