The Tyranny of Perfectionism

“My husband was a relentless perfectionist. I adored him. When he committed suicide, I thought that no one would ever love me the way Sam loved me. He took pills and Scotch. The pills were self-prescribed; there was a bill from the pharmacy after he died. He did it in his office. His father also died by suicide, but the family covered it up. They said it was cancer. He was a doctor too. Sam had too much compassion and not enough steel. He was brilliant. I respected his intelligence. He was so classy. People took advantage of him. He was repressed. I represented freedom to him. He couldn’t live in the real world. Problems with his kids from an earlier marriage weighed on him. He got depressed and refused to see a psychiatrist; he just withdrew into a dream world. Then he was gone.” (1)

This sad story is that of a physician’s widow whom I interviewed in 2015. Given that her husband’s father also took his own life, his fate was perhaps driven in part by perfectionism, a genetic vulnerability to a mood disorder and a familial pattern of suicide. What she described to me was a man who constantly strove for excellence in his professional, personal and family life. She described how hard he was on himself and how much he took personal responsibility for situations in which he was not fully at fault or perhaps not at fault at all.

Perfectionism in physicians is truly a double-edged sword. On the positive side is reward. Striving for excellence and precision enables applicants to get into medical school, prestigious residency programs and the “right job” upon graduation. Further, this trait over time helps doctors in keeping on top of their game – enjoying a successful private practice, doing research and getting papers published, teaching and winning awards, advancing in the academy or business of medicine. On the negative side is pain. The inevitable losses and failures of any physician in today’s medical world are very tough for perfectionistic doctors. Not only do they beat themselves up but can become quite demoralized or clinically depressed.

Physicians who are on the extreme end of the perfectionism continuum push themselves over and over again to improve and do better. They are extremely hard on themselves if they make a mistake or don’t excel in virtually everything they do. They don’t relax easily and feel guilty if they lie in a hammock reading a trashy novel or play a video game instead of reading the current issue of the New England Journal of Medicine. Inwardly they are also very competitive with their peers but rarely acknowledge this to their loved ones, medical colleagues, or friends. Some are envious of those who win prizes, awards or honors for their medical achievements. The rewards given to others can make them feel inferior. They may be jealous of doctors in their branch of medicine who make the Best Doctors in America list (although they mock its reliability) or of those who have bigger homes in more prestigious neighborhoods and those who take more exotic family vacations. And marital difficulties are not uncommon because of how much they push their spouses and children to be like themselves.

For clinicians treating perfectionistic physicians I have two recommendations. One, pay attention to your countertransference. It can be frustrating and exhausting trying to treat someone who is so hard on himself or herself – and this calls for either a CBT (cognitive behavior therapy) approach to this repetitive thinking or a more dynamic interpretative approach. Second, be careful not to miss an atypical or masked clinical depression. What was a low level type of self-reproach and self-castigation is now becoming hypertrophied, relentless, and unresponsive to supportive reassurance or reality checks from you. Your patient may be verging on psychosis, delusional depression and despair with pressing suicidal ideation and planning. An urgent and comprehensive biopsychosocial assessment is warranted with psychopharmacological intervention and perhaps brief hospitalization for safety.