S6E16: (The Illusion of) Perfectionism in Medicine

Margaux: Apparently the reason why allergies are so bad in the U.S. is because of tree sexism. So you know how female trees have fruit and it makes a big mess? So, at the turn of the century, the USDA was like, "We recommend only planting male trees for aesthetic purposes so you don't have to clean the roads." So they planted all these male trees that . . . Basically just pollen is tree sperm, right? Yeah, think about that next time you're sneezing.

Hạ: Misogyny ruins everything.

Margaux: Anyway, tree sexism is why we have bad allergies.

Leen: On that note.

Hạ: Great. Thanks, tree sexism.

Margaux: But it ties in.

Leen: Does it? I don't think it does.

Margaux: Because in the way to strive to be perfect, to have perfectly clean streets, they said, "Pick male trees so the female trees aren't dropping all their stuff everywhere."

Hạ: Brilliant. So many snaps, Margaux.

Leen: Wow. And that's how you know we're residents. We are able to BS on the spot. All right.

But for today's episode, we're going to be talking about professionalism. And here in the virtual studio we have Ha, Margaux, Lina, and Leen.

One thing we wanted to talk about today was how perfectionism or the thought of needing to be perfect constantly really affects us in how we pursue medicine and how we study for medicine and how we are eventually becoming healthcare providers or are healthcare providers at this point.

I think a lot of people that go through the medical field can definitely relate to this. In one way or another, whether you consider yourself a perfectionist or not, I really do feel like the environment pushes us to be perfect. And we're always comparing ourselves to those who are perfect per se in our eyes when it comes to medicine or it comes to the standards of what perfect is in medicine. Even though we are all very aware that there's no such thing as anything being perfect.

Hạ: I would love to hear about some of your thoughts, because for me, I felt like I always identified as being a perfectionist for as long as I could remember. As a kid, even in elementary school, it was like you needed to get 100% on all of your tests. You always had to be perfect.

For me, growing up I had to be the perfect Asian child at home and whatever connotation that meant. I had to be the perfect student. And so, for me, perfectionism has just been ingrained into my sense of self and my soul. In a way, I might as well just get it tattooed on my forehead at this point.

And I was just curious about you all. When did you start feeling like you identified as a perfectionist or that was something that you kind of carried around with you?

Lina: Yeah, I relate, Ha. I feel like growing up and maybe part of Middle Eastern household, if I went to my parents with a 98 on a test, it was like, "Well, who got 100? Why didn't you get 100? Why didn't you study those last two points?" And I feel like it was so ingrained, like, "Oh, you have to be the number one. You have to be the top student. You have to make sure that it's 100s on everything."

And I not necessarily recognized it as perfectionism, but I know that I would get so upset if I was anything less than basically perfect. And it was just going through all of my primary education.

And then going into college, I started not even lesser grades and it was like, "Oh, no, I am a failure." And it just goes from one extreme to the other. I'm a failure if I'm not getting these perfect scores. It's always been what my mind and what I'm so used to doing, and it started out really, really young for sure.

Leen: I can definitely relate to that, Lina, especially in the sense that for Middle Eastern family, I remember being told, at least in middle school, it was very prominent in middle school, "What did the other person get? What did the other person get?"

And I really struggled honestly with the fact that I always compared myself to other people because of this notion. And then when you get to kind of an environment where there are so many smart people, so many people who are really good at test-taking, like medical school, and suddenly you're not able to compete to that degree anymore, I really could feel that huge self-esteem kind of get bashed in a sense.

And of course, we've talked before about imposter syndrome and things like that, and I think a lot of that stems from that perspective.

But then I would also say a lot of the perfectionism comes from a cultural standard. And I know at least coming from my Palestinian background, it was when you were a kid being told, "Are you going to be a doctor?" And I'm like, "Yeah, I'm going to be a doctor." Later on, I'm glad that I found my own passions in medicine to drive me towards it. I don't think I would do anything else.

But I remember it's, "You're going to be a doctor and you're going to get the highest grades, and then you're going to get married at this age, and then you're going to be a mom, and then you're going to be the perfect female and an educated version of a Palestinian family we can find."

And when things like that don't go, because naturally you cannot control all those things, you start to feel like, "Man, I'm so far from being perfect." And now you start feeling imposter and you start feeling regrets and you start thinking, "Did something go wrong?"

And then naturally as you start growing up and you start disagreeing with some of the thoughts that your family portrays, for no reason other than you just have different opinions and that's totally fine, then you start thinking, "Man, was the whole world growing up just some sort of façade?"

Margaux: I resonate with . . . obviously, I don't have the same intersections or lived experiences as a lot of you are talking about, but what resonates with me is this drive to be perfect in school, to get good grades.

And when I read the outline for this episode, the first thing that came to mind for me was in eighth grade I was striving to be so perfect, but I couldn't achieve that in getting 100% on tests and grades. So I ended up really perfecting my handwriting to the point where I would only use pencil, and I'd erase and erase, and the paper would tear. I would spend hours handwriting my math homework, my English homework, everything, in what I would think of perfect handwriting.

And this was reinforced because my teachers would comment, "Oh, what beautiful handwriting." Or all my classmates would be like, "Oh my god, I love your handwriting." And so it was a way that I could find validation and this drive to be perfect with not achieving the things that I felt my parents wanted me to be perfect in or anything like that.

But I definitely had a lot of these, when I look back on it, compulsions or neuroses in this drive to be perfect that definitely have popped up at various points in my life.

Leen: I like how you point out that you sought validation through perfectionism. There's definitely something we all sought to gain through these feelings, I guess, in a sense. Perfectionism for me was almost taught as a sense of safety, per se. And not just safety in the sense, "You're going to be successful," but more so, "If you're successful and you're the top person, you'll never not be wanted in a job. You'll never be stranded searching for a future that can sustain you."

And so I think a lot of that from an immigrant standpoint is that perfectionism is what's safe for us. Perfectionism keeps us valid within the society and gives us hope for a future.

Hạ: Yeah, Leen, when you said that, it made me think about when I was younger. It was really funny because my mom would sit down and she would have these conversations with me where she reminded me, "You are an Asian-American and you are a woman, and in this society if you want to even get half to where everyone else, the white American or the male gets to, you have to be two times or three times better to even get halfway there.

"And people are always going to look for ways to bring you down, so you have to be completely perfect. You can't give room for people to judge you. You can't give room for people to see your mistakes."

And that perfectionism doesn't just come into academic achievement. It also came into who I had to be as a person. I had to be agreeable. I had to be friendly. I couldn't show negative emotions. For instance, a lot of other people could be angry, but I couldn't be seen as an angry person. I couldn't ever show any vulnerability or any moment where I was annoyed or not the calmest, most perfect individual, completely blank slate, nothing for people to criticize about.

And I think it's kind of drawn into how I feel even to this day. I get really uncomfortable when I make someone a bit uncomfortable or when I go like, "Oh, did I sound maybe a bit more harsh than I planned to?" Because I just get really, really scared that this means that I won't have the stability that I've been trying to work so hard to get to for my family as a child of immigrants.

Leen: It's crazy how that mentality tends to change. We carry it with us through every phase of what we go through in medicine, right? So I think where you're saying you have to be charming and you have to please people's emotions and things like that, I started remembering that was the biggest struggle for me.

I think, one, being an introvert, being super anxious, I was like, "How do I make people feel comfortable, like me, laugh at the things I say, wanting to be part of my conversation?"

And I really struggled with that in undergrad, so much so I had the biggest anxiety ever. I just was so scared to even talk to professors during office hours or talk to the TAs. It was awful.

And so I always tell people I feel like the person I am today is very much different than the person I was maybe five years ago. It wasn't medical school per se that did this. If anything, it was my friend group.

I think as we started having these conversations, I started realizing, one, I'm not alone in this. Two, it stems from such a very similar kind of root in the sense of whether it's to be perfectionist in order to succeed, to survive. It comes from the immigrant mentality. It comes from wanting to be comparable to other people just to pursue your dreams, right? But there's still always that root within you that you're like, "Man, I'm just not as perfect as the other ones. This is going to hurt my future because I'm not comparable in terms of personality and things like that to others."

Lina: Well, I feel to what you're saying, Leen. Yes, you're more aware of kind of this structure that, "Oh, I don't need to be perfect necessarily all the time in how I speak or how I interact with people or even just kind of my work," but for the longest time ever, at least for me, it is kind of what kept me in a sense safe. It is what made me succeed. It is what got me to a certain place, and I feel like that pressure up to a point stuck with me for so long that it's so hard to shake that off.

And so I'm like, "It worked for me at one point and it got me here, so I probably need to be the way I am or I probably need to keep that going." Whether it's for acceptance from people or getting into medical school, getting into residency and all that, it's like, "It stuck with me for so long that it's hard to shake that off."

Even though I can see, and I've seen just having conversations with you all, the other side of it, the imposter syndrome, the feeling of failure constantly when things are just not perfect, right? And so it's very hard to shake that off. Even going into residency right now, I'm like, "Oh, I need to be perfect at this or this or that." It's a struggle. It's definitely a mental struggle.

Margaux: I think that's such an important point to touch on, is recognizing how perfectionism had served us or what role it took in our identities leading up to medical school, and then how it shows up in our practice in medicine.

So, Leen, what you were saying and, Lina, you just mentioned is when we do clerkships as third-years, when I talk to students, this feeling that if you don't know the answers . . . You're supposed to start on day one knowing everything. I wonder where this stems from and how that impedes our ability to learn.

Because when I interact with students or even think back on myself of showing up on day one rather than with a growth mindset and opening myself up to being like, "Hey, I have a lot to learn here," instead I have this conversation in my head of, "Oh, I need to know all of this and I need to present myself as knowing all of this if I don't know it." How much mental energy is spent on that side rather than being like, "Hey, I don't know this. Can you teach me?"

And I just feel like if we all shifted . . . Like what you were saying, Leen. How you interact with students. If we just all shifted our perspective to being like, "No one is perfect, and you're day one, what do you want to learn? Let's open the books. I don't expect you to know everything because you're here to learn." I think that aspect of being in school has changed so much from "we're here to learn" and you go to school to learn a skill set to "we should know everything when we're showing up."

So I'm just curious how that shows up for you guys, how you've navigated that. I've taken a total black-and-white approach where now I just don't give a . . . you know. And I'm like, "I'm here to learn and I have a growth mindset and I'm not perfect." I kind of have to affirm that for myself every day, but it's not easy and I really struggle with helping other people, especially med students, see that.

Lina: Knowing from experience, Margaux, I feel like I've survived a lot of that struggle and pressure on myself. Just talking to you guys and coming to you, I'm like, "Oh my god, I messed up on this." And I feel like Leen, Margaux, or Harjit, you've always been like, "You're a student, you're learning, and that's okay."

And just having that mindset, having someone in your position as resident, and I've worked with you, Margaux, too, in clinic, just like, "You're a student, you're learning, you're growing, this is why you're here," definitely has helped me take a step back and at least take some of that pressure off of myself.

Yeah, it's a work in progress, but reminding myself that, giving myself that grace has definitely helped me kind of reposition myself, where my thoughts are with that.

Hạ: And I think it's a lot of having to be a bit more . . . thinking about it in a more systems-based level. I also feel it's really nice getting affirmation from people who . . . As Lina said, from you, Leen, Margaux, and Harjit about it. It was really helpful for me when I also got it from the residents that I was working with when they reminded me, "Okay, you are here to learn. It's okay that you make mistakes," or they're honest that they're there to learn too, and that they're making mistakes, and they're trying to figure things out.

And when I had that degree of vulnerability, like when people agreed to all shed away perfectionism and agree that we're all messy, we're all trying to grow, and it's completely okay and we're working together as a team and a community to grow together, I felt more inclined to be willing to open up.

I even thought about it . . . attendings. I had one attending when I was on advanced IM recently. He walked in and he told us on his expectation spreadsheet, "I prefer students who tell me that they don't know. I don't want them to fake it." And that changed my mindset with working with him so much that I was willing to ask questions. I was willing to push. I was willing to take risks and make mistakes in a very careful setting that was really monitored for patient care, right?

I felt that I came out of the experience enjoying the team a lot more, and it was just because it was scheduled all throughout within the resident, attending, and everyone level that this was a place for us to grow. It wasn't a place for us to be perfect.

Margaux: Ha, what I just heard you say is that that attending by saying that or the residents you had worked with set up this space of psychological safety, and so you could then feel safe to learn and make mistakes and not fall into these perfectionist tendencies.

And I think in medicine that's so important because there is a lot of risk in making mistakes. We're working with people's lives and we're making orders and things that a mistake could very well be very bad for a patient, and that responsibility weighs so heavily. I think that's one of the reasons why perfectionism really flows in medicine or is, again, validated. Because when you don't make mistakes, your patients are happy and healthy and alive, right?

But what you also highlighted on, Ha, is that we as humans are inevitably going to be mistakes. Medicine is not an individual sport. It's a team sport. And when your team is functioning together, you feel safe and everyone can make a mistake, but you have your team to support you before those mistakes can get to the patient.

And also, I think it's important to acknowledge we need to also live with that reality too. It's so important that we change our team mindset. So whether you're a resident working with med students or an attending, just even a simple phrase like you said, Ha, "I would prefer you to say I don't know" can make such a big difference. And I think that's so important.

Leen: I think also one thing that we tend to fail to recognize is that, stereotypically, I think people assume that, "Oh, doctors are perfectionists," and maybe they come in with the mindset that treatment is going to be perfect, identifying a diagnosis is going to be perfect. And sometimes we put that pressure on ourselves as well, right? We're like, "Oh, man, it's all about the patient and they're going to think I'm not a credible doctor if I don't come up with everything perfectly and manage things perfectly."

I think beginning of residency, I felt a lot more of that pressure. I think I started encountering interactions where if I don't actually know the answer, and I'm just very clear with that with my patient . . .

For instance, I work in the emergency room. Patients come to the emergency room with complex problems expecting to find an answer within eight hours, right? I tell them, "Hey, I do think there's something going on and we might not be able to find it today, but I want you to keep going to XYZ physicians."

Or even if I just flat out tell them, "I don't know what's going on with you today. I do want you to keep following up with your providers," I've actually had patients be like, "Thank you for not lying to us and just coming up with something."

We have that innate feeling of just wanting to come up with something, give them an answer, be perfect about it, come up with a diagnosis, and I think that's something medical school tends to fail to recognize.

And by stimulating this environment of always being perfect, coming to know everything, arriving on day one being the best, you forget that patients and people are not perfect and neither is medicine. And you forget to teach them how to deal with those scenarios, which is, I'm going to tell you, really frequently actually that we do not know what's going on with you.

Hạ: Yeah, Leen, I really love what you just said. And as someone who's entering residency soon, I feel really comforted hearing about how when you're honest with your patients about the situation that it actually builds a stronger relationship between you and your patients. I think that gives me a lot of comfort.

I think ultimately it helps us really realize that at the end of the day, vulnerability actually builds stronger relationships, whether it's within the team or with your patients, than always maintaining a façade. Maintaining a façade is when we really lose ourselves and when we aren't really able to be honest, to be raw, and to be real. That takes us away from what makes medicine really powerful, and it's the human connection.

So this has been a really incredible conversation on perfectionism and I'm really glad that we were able to have it. I think it's such an important conversation to have and something to keep reflecting on about.

Leen: I know. We have so much to say. We can definitely do a Part 2 on this. Chloe, we got some more ideas. All right. Chloe is going to beat me.

Margaux: Good thing you're in New Jersey.

Leen: She shot down all my ideas. Let me just put this out there. She's like, "How does this tie with identity?" I was like, "It doesn't." Anyway, side note. All right. I love you all. This has been a great episode. Wonderful. Thank you for coming to "Bundle of Hers."

Margaux: No way. This is relevant because interns are starting in two months, three months. So these are important facts to take away, and as med students to start thinking of setting those roots.

But anyway, thank you for listening to "Bundle of Hers." You can reach out on Instagram @bundleofhers to share your story and earn a pin "Power From Identity." It looks great on your lanyard. Spark conversation. And otherwise, get us where you get all your podcasts.

Lina: Bye.

Margaux: Until next time, bye-bye.

Hạ: Bye.