The perilous plight of the perfectionist physician

It's good to be good, but awful to be perfect, says renowned US psychiatrist and author Glen Gabbard

By Sam Solomon

"I killed a patient," confessed the primary care physician. The man, in his early 60s, was seeking help from psychiatrist Glen Gabbard's office for a mistake he'd made 30 years earlier. The physician had injected the patient with penicillin and then watched him die, within moments, of anaphylactic shock.

"I asked the physician whether he had asked the patient about an allergy," says Dr Gabbard, "and he had. The patient told him he wasn't allergic." The incident tortured the physician; he said he could remember it as clearly as if it had happened yesterday. "He had been haunted for 30 years," Dr Gabbard says in his slow Kansas drawl. "He read all the literature on penicillin allergy. He was just unable to get beyond the torment that he had done something that led to the death of a patient." Dr Gabbard falls silent.

PSYCHOTHERAPY FOR DOCS
Dr Gabbard is a prominent American psychiatrist, professor, academic journal editor and author. He's written dozens of books on psychiatry, including books like Medical Marriages and The Psychology of the Sopranos. He lives in Houston, where he teaches at the Baylor College of Medicine. Many of his patients are physicians and he has become an expert in the growing field of physician wellness.

Sitting in Dr Gabbard's office, physician-patients pour their hearts out, revealing their anxieties and deepest fears and often revealing one common characteristic, he says: an extremely advanced case of perfectionism. Think he's kidding? He's not — perfectionism is, if it becomes so severe that it interferes with a physician's work, a symptom of an obsessive-compulsive personality disorder, says Dr Gabbard.

Still not convinced? Turn, then, to the evidence: a 2004 study in the journal Suicide and Life-Threatening Behavior assessed people hospitalized for depression for their degree of perfectionism, hopelessness and negative cognitive bias. (Yes, there is a scientific test for perfectionism: the Dysfunctional Attitudes Scale-Perfectionism, or DAS-P, developed in 1979.) Perfectionism was shown to be an excellent predictor for a patient's suicidal ideation six months after hospitalization, shattering the common notion that hopelessness is the best warning sign of future suicidal thoughts.

PERFECTLY MISERABLE
In late November, Dr Gabbard was invited to give a keynote address at the AMA-CMA conference on Physician Health in Ottawa. His lecture, entitled "The perils of perfectionism," was intended as a wake-up call to physicians.

"Perfectionism is pervasive among physicians," he says in an interview with the National Review of Medicine. "It's a trait in the personality of most doctors, and it has adaptive qualities because it makes them thorough and careful about diagnosis and treatment."

Isn't that a good thing, though? Most patients wouldn't want to be treated by a physician who was anything less than perfect. But what effect does a perfectionist attitude have on the physicians themselves?

"It varies in terms of its intensity," explains Dr Gabbard. "Sometimes it's quite manageable and people realize they are perfectionistic. Other times it is extreme to the point where people work long hours, ignore their families and have no private lives."

Or even worse, he continues, "It can lead to a sense of burnout after years of striving for perfection and failing. It robs the physician of any sense of gratification in his or her work — he may always have a feeling of 'I could have done better,' and a sense of hopelessness about attaining the impossible." Perfectionism can lead to burnout, depression, substance abuse and suicide.

An example Dr Gabbard often cites is the case of Dr Jonathan Drummond-Webb, a superstar pediatric cardiac surgeon in Arkansas whose 830 surgeries over the course of just 18 months yielded an incredibly low 2% mortality rate. Dr Drummond-Webb was universally admired — the Los Angeles Times called him a "medical miracle worker." He ran triathlons just to stay in shape for the OR; he flew out-of-state to harvest hearts personally; he called ex-patients on Christmas to check on them; his surgical team was the focus of a 2002 ABC documentary series. Then it all came crashing to a halt. In 2004, Dr Drummond-Webb died of an intentional overdose of oxycodone and alcohol. The hospital CEO said, "Some would say they saved 98 out of 100. He looked at it and said, 'I lost two out of a hundred.'"

DOCTORS AT-RISK
In a field where perfectionism can be so harmful, there is a twisted irony that perfectionism is demanded of doctors throughout their education and professional careers.

What can be done? First of all, students must be educated about the risks of perfectionism. Also, role models and professors of medicine must set better examples by encouraging hobbies, family time and vacations. And, finally, says Dr Gabbard, physicians must seek help when mental health problems begin to set in.