Lauren Miller is a 4th year medical student at Dalhousie University.
In my final year of medical school, I finally got around to reading Samuel Shem’s 1978 satirical novel about medical internship, The House of God. What struck me most about this book was not the uncomfortable nature of its aggressive humour (most of which has not aged particularly well), but the degree to which it still rings true. Today’s clinical clerks are unfortunately very well accustomed to getting “pimped” or playing the “guess what I’m thinking” game (as is so adeptly portrayed throughout Shem’s novel) – oftentimes in front of an audience. While some do find this a useful practice for learning, there is no doubt that shame and humiliation are the price of admission. Despite recent curriculum initiatives and a widespread push-back against the outdated and toxic shame-based culture of medical learning, we are still a long way away from the ideal of a healthy, non-hierarchical, wellness-centered culture.
Early on in medical school, I read a book that would profoundly impact the way I thought for years to come: The Gifts of Imperfection, by Brené Brown – a renowned researcher in the social sciences, as well as accomplished professor, author, and speaker. While I always knew I was a perfectionist, I had been under the impression that this was a good thing. After all, perfectionism had driven many of my academic and athletic accomplishments — the very things in my life for which I had received the most praise. But what I failed to realize until recently was that this inherent perfectionism had a lot less to do with my own desire for self-improvement, and much more to do with the addiction to the external validation that came along with it. Without realizing it, I had allowed my self-worth to become something that was dictated by others based on what I was able to do, rather than something I intrinsically knew based on who I was and what I stood for.
Lesser known is the connection that exists between external validation and shame, which oftentimes is the unspoken (and subconscious) driver of perfectionism itself. For example, if I have always been celebrated and known for being the “best” (student, basketball player, etc.), then who am I and what is my self-worth when someday I am a smaller fish in a bigger pond – as tends to happen when children grow up – and meet someone who is “better” than me? Just the thought of that is enough to keep most perfectionists hustling so that they never have to endure the identity crisis and shame spiral that are sure to ensue. What drives so many of us to get everything exactly right every time (to the point of driving ourselves into the ground – read: burnout) is not the natural (and healthy) intrinsic desire to learn, but the shame that comes with being wrong or perceived as “less than”. This is exactly the opposite of what we need in order to foster a culture of healthy learning. The culture of medical education as it exists today is to put perfection on a pedestal in an attempt to bring out the best in medical learners. Paradoxically, this quashes the very thing which best promotes a student’s educational growth: admitting when they don’t know something or have made a mistake.
Brené Brown hits the nail on the head in her new book, Atlas of the Heart:
“We’ve learned that achieving mastery requires curiosity and viewing mistakes and failures as opportunities for learning. Perfectionism kills curiosity by telling us that we have to know everything or we risk looking ‘less than’. Perfectionism tells us that our mistakes and failures are personal defects, so we either avoid trying new things or we barely recover every time we inevitably fall short.”
I have made many mistakes along my journey. It’s inevitable. What has changed, however, is the way I look at them. Rather than saying I am stupid after saying or doing something I later regret, I am now much more likely to say I did a really stupid thing. I worked especially hard to remind myself of this during one (slightly traumatizing) morning when I didn’t double check that I had my alarm set for 6:30 a.m. surgical rounds on a Saturday and slept all the way through them. I generally consider myself to be a very conscientious and detail-oriented person, yet this single event immediately sent me into shame and self-judgement, as I ruthlessly chastised myself for being so careless. When I am able to separate myself and who I am from my behaviour and what I have done, it helps to keep the shame spiral at bay. If I can be mindful enough to notice my self-deprecating self-talk (God, why am I ALWAYS so careless) and shift it to a more self-compassionate voice (Gosh, that was a really careless thing that I did – next time, I will be extra on top of it), I can acknowledge the careless behaviour while also holding space for the conscientious person I know myself to be. We need to step away from the destructive culture in which someone must be either this or that and lean into the dialectic truth that someone can be both this and that.
To put the shame to bed once and for all, after any type of identity-jolting event, I will call up either a friend or my partner, tears rolling down my face, to explain to them what has happened. This differs drastically from our reflexive desire as perfectionists to keep our shaming experiences to ourselves because we think we can maintain the illusion of perfection if no one knows what happened, even though it is this very silence and secrecy that actually creates the perfect environment for shame to grow – wild and out of control. On the other hand, as Brown says, when we “speak shame” and allow empathy and connection in, we take away the potentially shaming experience’s power. She explains it like this in Atlas of the heart:
“In a world where perfectionism, pleasing, and proving are used as armour to protect our egos and our feelings, it takes a lot of courage to show up and be all in when we can’t control the outcome. It also takes discipline and self-awareness to understand what to share and with whom. Vulnerability is not oversharing, it’s sharing with people who have earned the right to hear our stories and our experiences. Vulnerability is not weakness; it’s our greatest measure of courage.”
Your imperfections are not dirty secrets — they are a part of what makes you human.
I have been lucky to have had many preceptors over the years who have modelled exactly this type of courageous and vulnerable leadership that I myself hope to embody. They lean into their common humanity by generously sharing stories not only of past triumphs, but of past failures too – and in doing so, they implicitly give us as learners permission to do the same. These individuals are the type of teachers who remind you why you came into medicine in the first place. They inspire you not to be perfect, but to be your absolute best.
Excellent commentary, Lauren. Medicine, despite looking scientific from the the outside, is haunted by a fixed mindset & dogma. To make actual gains in patient safety and to prevent provider burnout, we need to model the airline industry: we need a growth mindset, to embrace failures and discuss learning opportunities. Self compassion is a drug medicine has neglected for the last 40 years. It’s time we take it off the shelf and start using it on a daily basis, embracing our common humanity & fallibilities. As an anaesthesiologist & recovering perfectionist, I like to tell my friends and family that “perfect is a tall and wobbly pedestal” & “vulnerability is growth”. Hallelujah for this next generation & all the Dr Miller’s changing this machine, one mind at a time….
John A Bessell , mid-Wales,U.K.
Being a somewhat OCD personality, perhaps compounded by a grandparent saying that there are two ways of doing a task -properly or not at all, I would remind myself & patients that the aforementioned personality was a good servant, but a poor master. This approach might may ‘leaven the lump’ !
This is an excellent individual approach to a healthy relationship with fallibility. Now, how to get the profession as a whole to recognize that the status quo is utterly incapable of quality practice precisely because we are human and fallible and all the systems isolate us yet still rely heavily on individual competence and responsibility when things go south. 50 hours of quality CME is nowhere near enough to stay competent to deal with every problem by yourself. It’s time for a complete revamp to eliminate artificial hierarchies and make it much easier to access knowledge from each other in as close to real time as possible. Develop real and virtual supportive knowledge communities. There is a role for AI but only if it’s open source. And drastically revise the concept of consultation. We need to build a team based profession, to provide better care for patients and for our own well-being .
Very good article. Perfectionism can really get in the way of efficiency and one’s ability to manage their time wisely.
In a busy family practice, perfectionism can keep you from making decisions, completing work and maintain flow of office. It may well be a big contributor to burnout for some.
Lauren, this is an excellent article and one I can say should be used as a learning tool for all those who follow behind you. The shame our learners feel at times when they make a mistake (or better said, when they have a learning opportunity) is a real challenge to navigate through but you truly hit the nail on the head. Who do you turn to in times like these when you need to just be “you”, be vulnerable, admit you messed up and move on! Its time for learners to be ok with this approach and see it as learning opportunities that will change and shape them into the practicing physician. Excellent approach to model for years to come.
Its ok to get your ego hurt.
Thanks to Lauren Miller for this post – both for what it says, and for having the courage and straightforwardness to say it. Allowing ourselves to experience, to make friends with our own vulnerability, is indeed so helpful to ourselves. It is also the foundation of being authentically present and genuinely connecting with others. For patients, families and colleagues, this is of real value. Perhaps exploring these themes could be a core function of medical humanities curricula…
In sharing our failure with others, it is where the real learning occurs. This is also part of being a leader; being vulnerable and connecting with others. This also helps frame and create a psychologically safe environment where people learn about not being perfect and trying to do our best, while learning from others. Great blog!
You are very fortunate to realize that to do your best, learn from failure, and not beat yourself up at this early stage in your career. I did not and suffered all the shame and isolation that ultra-perfectionism can bring. You will be able to accept the imperfections of others more readily and help them to improve as you move forward with the healthcare Team, to the benefit of your patients. Continue to excel at what you do with the humbleness you confess.
MURI B. Abdurrahman
This is a well-thought out and incise article.