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This week’s post examines the what, why, and how of perfectionism and its impact on our lives. The specific focus involves charting, but the qualities described here touch on just about everything.
Please note that I’m not intending to judge perfectionists (they do that well enough to themselves!), but simply aiming to shine an illuminating, dad-joke-laden light on the matter.
A Perfect Definition
Perfectionism is the idea that we need to operate flawlessly. Underlying it is the belief that things can be flawless…which is inherently…flawed.
Perfectionists base their self-worth on their achievements. Society rewards performance which selects for and promotes this sort of thinking.
They believe that being better is better. Where they are, their status quo, is never enough.
On the surface, striving to be better sounds like a good thing, right? But the issue is that for perfectionists this mantra is coming from that above-mentioned flawed belief that things can be flawless.
Deeper Dive
The only way they can find happiness is to achieve perfection. Therefore, they put happiness out of reach for themselves.
After all, if you tie happiness and feelings of worth to an impossible standard that you will by definition fail to meet, then how can you ever feel worthy or happy?
Despite often outperforming others, perfectionists never feel like it’s enough.
If you think about it, it’s like perfectionists assign themselves an ability to ascend to a divine state where they can be perfect.
Maybe deep down they know that they can’t be perfect, but they judge themselves harshly, sometimes to the point of self-loathing, in trying to be as close to perfect as possible.
Humor me a hypothetical: Let’s say I take you C.V. (unbeknownst to you), somehow anonymize it, and then read it back to you. Chances are that you’d think that person is amazing, deserving of many accolades, and worthy of praise and recognition.
News flash—that person is you! And chances are you’re pretty awesome! You read this blog after all….
The Truth
Even that realization—that you’ve accomplished amazing things and overcome an untold number of obstacles—while important misses the key, underlying truth.
And that is: our worth is not determined by anything other than the fact that we exist. We are innately and inherently worthy. It is an inalienable part of our existence. You. Me. Everyone.
From here we can understand then that perfectionism is an idealized fantasy that comes from a place of inadequacy and self-doubt. A place of not understanding this truth.
Our Environment Nurtures Perfectionism
At this point, you may be asking yourself how perfectionist tendencies arise. Good question.
From our earliest years, we are inculcated with an extreme bias towards success and being the best.
Take our entire education system. It’s based on testing, which relies on the regurgitation of facts with a lesser emphasis on the application of the material. Critical thinking is even harder to test. Yet consider how much in your life has depended on the results of testing.
We are told to get straight A’s. Got a 96% on a test? It could have been 100%. We are ranked based on our performance at all levels of training—valedictorian, summa cum laude, Alpha Omega Alpha.
Then there’s pimping in med school and residency. You don’t want to be the trainee who doesn’t know the answer. This is the way it’s always been done.
Never show weakness because that is the opposite of strength and success. Never make mistakes because that is the opposite of infallibility.
These are the standards under which we are trained and by which we are judged. Trying and failing in order to learn, iterate, and innovate are paid lip service while success at all costs is promoted constantly. We don’t reward trying.
Those of us in medicine excelled within this system; we progressed towards our goals by being selected for these qualities, with the competition to reach the next level only becoming tougher along the way.
Never was there any reward or emphasis placed on a counterbalance to perfectionism, for trying things and failing. We honed perfectionism our entire lives.
I’m not even going to touch on societal expectations about looks and everything seeming hunky-dory on our social media feeds!
Perfectionism in Charting
So how does perfectionism show up in charting, specifically?
I would argue it shows up in two broad categories—directly and indirectly.
Direct Manifestations
Let’s explore the direct manifestations first.
Unfinished charting is the obvious and primary way perfectionism impacts charting, but this is due to several underlying causes.
Perfectionists tend to double- or even triple-check records or even their notes before closing an encounter. They don’t want to document anything incorrectly so this due diligence is “required” for them. Typos are not acceptabel (see what I did there?).
I had one coaching client who did this for all MRI reports (he was in a specialty in which almost all his patients required MRIs) and prescription monitoring database inquiries. As you can imagine, this slowed him down tremendously. Addressing this behavior was the key to speeding him up.
Some physicians avoid signing off on a chart before all data elements related to the encounter are back, including labs that may take multiple days to result. This creates a constant drag and forces them to revisit and update their note potentially several times over.
One of my clients is a transplant nephrologist who would wait for all the immunosuppressive labs to result before closing a chart. This workflow meant she’d have to go back over prior days’ visits routinely, which kept her charting until 9-10 pm every night. She wanted her notes to be “complete” but didn’t like the fact that that meant she never saw her young children.
Other physicians feel as if the only way they can demonstrate the value they provide patients is via their note. Only by crafting prose a Muse would be proud of can they prove as much.
Similar to this are those who feel they must document every possible diagnosis on the differential as well as every potential outcome to convince others (*cough* themselves *cough*) that they are competent. This is imposterism 101, which is also steeped in perfectionism.
You are an imposter!
Indirect Manifestations
The indirect manifestations derive from perfectionistic tendencies in other areas of our workday that end up impacting charting.
For example, perfectionists often work in extra patients due to a form of people-pleasing and an inability to set boundaries. They don’t want to look bad in the eyes of their patients and/or colleagues as that could mar their worthiness. Obviously, extra patients mean more charting and spending more time at work.
Malpractice concerns can also drive physicians in their obsessive charting. Think of the medical-decision-making section of an ER note. For a red toe, they’ll document “I considered paronychia vs cellulitis vs gout vs septic joint vs turf toe vs Raynaud’s vs phlegmasia cerulea dolens vs struck on foot by orca.”
The concern for missing something ironically, and unfortunately, often increases the likelihood of actually missing something since it occupies real estate in your mind, siphoning off a small portion of your mental bandwidth and attention.
Finally, some perfectionists are paralyzed by their perfectionism, which manifests as procrastination. The mental burden of having to chart as thoroughly as they think they do is so daunting that it’s easier to just avoid doing the work or at least putting it off (a.k.a buffering). That is until the nagging worry about not having completed the charts outweighs the mental burden of doing so.
Coming Full Circle. But, like, a Perfect Circle.
I love that the preamble to the U.S. Constitution states “to form a more perfect union” and not “to form a perfect union.”
Our founding fathers (James Madison here specifically) clearly understood the deleterious effect promoting perfectionism would have had on our nation in its infancy!
Even as I “hand write” this post’s first draft on my iPad, I have to chuckle because the motto of the makers of my iPad’s case is “Always working to be more perfect.” Touché, iPad case, touché.
I’m sure a lot of what I’ve covered in this post applies to most of you reading this. Well, I have a confession: I’m a recovering perfectionist.
Keeping these tendencies in check is a constant struggle, like Bruce Banner trying to avoid becoming The Hulk.
Coaching helped me understand the results perfectionism was creating for me (spoiler alert—not what I wanted) and then gave me the mindset tools to loosen up those standards to which I held myself.
This post is long enough already, so I’ll carve those out into a separate post for next week.
Suffice it to say, perfectionism is one of the main causes for long hours spent charting and something I continue to help physician clients with via Charting Conquered.
In closing, remember that your worth as a person and physician is not tied to your performance or achievements, despite the history of indoctrination to the contrary courtesy of society at large, but especially med school and residency.
No, you are worthy and whole already. As is. You just have to learn to believe that.
Do any of these tendencies seem all too familiar to you? How does perfectionism impact you at work? Let me know in the comments section below.
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