The Unique Mental Health Problems of Healthcare Providers: The Role of Perfectionism
As a practicing psychoanalyst and psychotherapist affiliated with several hospitals in Manhattan, I have worked with a diverse array of healthcare professionals. Two decades of work have revealed the unique set of symptoms faced by these individuals. Not only do they confront the rigorous demands, long hours, and high stakes of medical practice, but they also frequently suffer from high levels of anxiety and depression. However, these are mere symptoms of a larger issue: that of perfectionism.
While the academic literature has attempted to illuminate the mental health challenges of healthcare professionals, the current body of research lacks a nuanced understanding of their root causes. The aim of this present article is to delve deeper into the underlying psychodynamic factors that contribute to the disproportionate incidence of depression and anxiety experienced by healthcare professionals. Drawing from my clinical experience, I narrow my focus to the trait of perfectionism, a recurring theme amongst such individuals in my practice.
Stress and Anxiety
Research conducted by Moutier (2018) and Oxtoby (2016) has shown that medical students and physicians suffer from alarmingly high rates of depression and anxiety. Prevalence rates range from 25% to 56% starting as early as residency (i.e., post-graduate training after medical school), a significantly higher proportion than that observed in age-matched cohorts and the general population. Such numbers become disturbing when added to estimates of physician suicide: an estimated 300-400 per year. While the root causes of such pervasive depression and anxiety are complex, they have been linked to work stress, sleep deprivation, lengthy work hours, heavy workloads, institutional stigma surrounding mental health needs, and the discouragement of help-seeking behaviors in the workplace.
Causes of Stress and Anxiety
It is essential that we discover a more nuanced and in-depth understanding of the underlying causes behind the high incidence of depression and anxiety among medical students and physicians. Notably, I have observed, law students and attorneys, who face similar work-related challenges to physicians, do not seem to experience similar levels of mental health issues.
As both Poole and Bolton astutely note, "doctors talk about lying awake worrying about what's happening to their patients” because “.. [they] see [them]selves as 'superhuman'[emphasis added]...with the intention that [they] can cure everything and [their] care is always perfect [emphasis added] ..." Striving for perfection creates a recipe for stress for medical practitioners, particularly when patient care does not meet their––often impossibly high––standards. Similarly, Moutier (2018) notes the fear of punitive consequences and “loss” [emphasis added] of esteem from colleagues. Neither source elaborates on these points; such limited acknowledgments highlight the need for a more in-depth understanding of these psychological phenomena (i.e., superhuman identity, perfectionism, and loss) to address the mental health challenges faced by medical professionals.
My Psychodynamic Understanding of Physician and Medical Student Depression and Anxiety – The Need for Perfection
The need to be perfect often stems from a fear of failure or a belief that perfectionism is necessary for success and respect in one’s field. Unfortunately, this perfectionism, can lead to feelings of inadequacy, shame, and isolation when the high standards are not met.
Through my interactions with healthcare professionals, I have realized that individuals struggling with perfectionism often believe that their ability to connect with others is predicated on their ability to achieve flawlessness. The pursuit of perfection is infused with various meanings. A common underlying theme is that perfectionism will result in being perceived as exceptional and, thus, garnering, respect and admiration. This mindset becomes an integral part of these individuals’ personalities, and those around them become sources of validation. By maintaining the facade of perfection, whether it be through providing impeccable care, writing flawless notes, or making significant contributions in academic settings, they derive a sense of validation and love from others.
Since perfection is an unattainable ideal, this system of thinking eventually breaks down, giving rise to intense feelings of deflation, depression, and anxiety. What is even more distressing is that, when this system collapses, these individuals often experience a profound sense of isolation and loneliness, the catalysts for depression and suicidality. This becomes particularly problematic because perfectionism creates a psychological distance with other people. Ultimately, this makes it difficult for affected individuals to form authentic connections and perpetuates loneliness. In such states, perfectionism is then used as a coping mechanism against these painful feelings, beginning the process again and reinforcing the idea that imperfections make one unworthy of connection and love.
My work with these individuals focuses on helping them see that being human inherently involves uncertainty and fallibility (this is how real and authentic relationships are formed). I couple this work with the development of more adaptive coping strategies to help prevent the patterns discussed above. While this can be distressing for these individuals, it confronts the central tenets of their perfectionism and, hopefully, allows for the formation of genuine connections with others.
Clinical Examples of Perfectionism
The following example from my practice represents the impact of perfectionism on physicians. To protect anonymity, this case is presented as a composite of many patients' experiences.
In this scenario, the physician in question feels that every patient note must be meticulously crafted and error-free. They spend excessive time revising and editing patient notes to ensure they meet their exacting standards. Unfortunately, this often causes them to fall behind in their documentation or not writing notes at all, which leads to administrative trouble. In some cases, this perfectionism interferes with their ability to provide timely and effective care to their patients. The all-consuming nature of perfecting their notes sometimes results in neglecting other aspects of patient care, such as thoroughly reviewing previous documentation and communicating with other providers.
Difficulties communicating with other providers
Their perfectionist mindset limits their capacity for collaborative learning and feedback, as seen in their approach to attending professional meetings. This physician has a reputation for expertise and innovation in their specialty and regularly attends professional meetings to remain current with the latest developments in their field. Rather than being open to new ideas and receptive to others' expertise, they are compelled to constantly demonstrate their own knowledge and ideas, even to the point of dismissing those of others. They cannot listen and learn because they are concerned about having the most knowledge and the best ideas. Ultimately, such actions hinder their potential for personal and professional growth. The physician's perfectionism reinforces a need for validation through the demonstration of superiority in knowledge, terrified and reluctant to acknowledge the contributions of others. As a result, this physician may struggle to stay up-to-date with the latest advancements in their field and may miss valuable opportunities for learning, collaboration and networking. Despite their notable achievements and knowledge, their perfectionistic tendencies undermine their ability to provide optimal care to their patients and––if left unaddressed––may hinder their future professional success.
Treatment Goals for Physicians and Medical Students – A Focus on Loss
In order to effectively address the issue of perfectionism in physicians and medical students, it is important to delve deeper into the fear of loss and the pursuit of the perfect self. While the fear of punitive consequences or “loss” of esteem from colleagues is mentioned by Moutier (2018), this aspect is often overlooked in treatment goals. As a clinician, I find it helpful to work with these individuals to explore what loss means to them and to help them recognize the significance of perfectionism. Nonetheless, abandoning this pursuit can be difficult and represent its own significant loss for the affected individual. Effective treatment must therefore include a process of mourning and acceptance. Furthermore, it is important to help these individuals understand the impact of their cognitive biases, such as the tendency to selectively attend to events that confirm their sense of perfection while dismissing events that deflate their sense of importance. By acknowledging and addressing these biases, I have been able to help physicians and medical students better manage their perfectionism, improving both their patient care and professional development.
Perfectionism can have a profound impact on the mental health and well-being of physicians and medical students. By understanding the underlying beliefs and fears that contribute to perfectionism, these individuals can develop a more balanced and realistic approach to their work and personal lives, ultimately leading to improved quality of life for themselves and their patients.