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In this episode, we welcome Scott Abramson, a neurologist with over 40 years of experience in the field. We discuss the topic of perfectionism in the medical profession, and how it can have both positive and negative effects on physician well-being. Dr. Abramson shares his perspective on the importance of being conscientious and attentive to detail in patient care, and the challenges of balancing work and personal life as a physician. He also addresses common arguments against perfectionism, and shares insights from his experience coaching and counseling other physicians on these issues. Join us for a thought-provoking conversation on the perils and benefits of perfectionism in the medical field.

Scott Abramson is a neurologist who blogs at Doctor Wisdom.

He shares his story and discusses his KevinMD article, “Why this doctor prefers perfectionist physicians.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today we welcome back on the show Scott Abramson. He’s a neurologist, and his KevinMD article is titled “Why this doctor prefers perfectionist physicians.” Scott, welcome to the show.

Scott Abramson: Thank you, Kevin, and thank you for having this platform that gives people a chance to expound on alternative ideas to the mainstream.

Kevin Pho: All right, well, thank you so much for sharing your insight and perspective. Now, before we get into your article, for those who didn’t listen to our first episode together, which was about a year and a half ago, just briefly share your story.

Scott Abramson: Yeah, so, Kevin, I was a neurologist at Kaiser Permanente in Northern California. I worked there for 40 years, and during that time, I was very passionately involved with our communication mission, to teach doctors communication skills, and also with our physician health and well-being mission.

Kevin Pho: All right, so tell me some of the challenges that you faced when it came specifically to those communication skills. And what did you find when it came to your work on the well-being committee?

Scott Abramson: Well, as far as the communication issues, I think the thing that was so prominent is, I think George Bernard Shaw said this, he said, “The problem with communication is the illusion that it has taken place.” That is just so common with so many doctors. If you were to just monitor an encounter between a doctor and a patient, you’d ask the doctor, “How’d it go?” He’d say, “Man, it was great. I gave some great education. I did great.” Then you talked to the patient, and they said, “I didn’t understand a word he said.” So that’s what we kind of worked on: bringing that distance closer together.

Kevin Pho: Yeah, I think that what you just described is very common, in terms of that almost diametrical perspective that one gets after that encounter. So how would you go about fixing that?

Scott Abramson: Well, we had a program. It was labeled the Four Habits. It’s not a whole lot different from a lot of other plans out there, but basically, one of the things is getting the patient’s perspective, trying to find out what’s here.

I can boil it down to this, Kevin. For most doctors, our paradigm is this: What’s the matter? What’s the matter? Let’s find it, let’s fix it, let’s explain it, let’s treat it. What’s the matter? But we try to change that dynamic to what matters. What matters to the patient? What do you think this is? What are you afraid this is? How is it impacting your life? I think if I could sum it up in just a brief sentence or two, that’s it: the paradigm, from what’s the matter to what matters.

Kevin Pho: Oh, that’s so well said. That’s actually the first time I’ve heard that, so I think that is a very resonant word. So let’s talk next about your KevinMD article, “Why this doctor prefers perfectionist physicians.” Now, how did this article come together?

Scott Abramson: Well, Kevin, it came together because I read a lot of your articles, and a lot of the articles were about the perils of perfectionism and how perfectionism causes burnout and all this stuff. I don’t know about you, but sometimes when I listen to the TV news, I sort of talk back to the news, and I say, “No, that’s not right,” you know? So when I read these articles, I had that reaction. I felt like I had to talk back to it.

Some of the points that people made, and maybe, you know, you remember some more of these points, but as I recall, they would say, “Well, perfectionism is bad because we do it out of fear.” You know, we’re afraid we’re going to do something wrong. My reaction to that was, so what? I mean, I do a lot of things out of fear, and it’s good. I mean, I’m afraid that I’m going to hurt a patient, so I study more. I mean, a lot of doctors are like this. So my original reaction was, what’s wrong with doing things out of fear? I think it makes us better doctors.

I mean, in the article I wrote, I made an analogy with an airline mechanic. I mean, would you rather be on a plane with an airline mechanic who is perfectionistic and won’t go home till he’s checked everything out and made sure everything’s OK? Or would you rather ride on a plane that had an airplane mechanic who clocked out at five o’clock, had dinner with his family, went to, you know, Pilates class, and was a happy guy? I’d rather have the perfectionistic guy who tortures himself to make sure that everything is OK. Not torture; torture is not a good word.

So part of what people wrote was that it was done out of fear. The other thing was that it isolates people. I read people saying, “Well, you know, if you’re perfectionistic, you look down on the other people who are not so perfectionistic, who leave at five o’clock and go to goat yoga and all that stuff. So you isolate yourself. People don’t like you.” When I read that, I thought, well, so what if they don’t like you? I mean, it’s about the patient and the patient’s well-being. As a matter of fact, maybe they won’t like you because they think you look down on them, but I bet you they’ll respect you. I bet you they will say, “Hey, if I need a doctor for me or my family, that guy may be a miserable guy, but he’s a great doctor. He will check everything.”

Then the third thing that I remember reading about in these articles is, “Well, perfectionism, you know, it causes anxiety, and the anxiety causes depression, and depression causes burnout, and, you know, we need to set boundaries.” That was the word, you know: Set boundaries. “OK, I’m only going to answer so many phone calls. I’m going to leave here at five o’clock. I’m going to have dinner with my family. I’m going to drive home. I’m going to do some mindfulness, do some journaling. I’ll be a happier doctor.”

When I read that rationale, I thought to myself, now, wait a minute. By the way, Kevin, we’re talking about perfectionism now. I’m not talking about pathological stuff, where, you know, you check an email 15 times to make sure the grammar’s OK or you flush the toilet 10 times. I’m talking about the authentic, normal perfectionism that we all have. So when people were talking about how it causes anxiety, it causes depression, it causes burnout, well, this is something that’s ingrained in our DNA.

I would ask those people who have set boundaries, right, who leave at five o’clock, who say, “OK, you know, I’ve answered as much as I can. It’s as good as it gets. I’m going home to my family,” are they really going to be happier? Because are they going to be waking up at two in the morning thinking, “Oh my God, you know, there were these five X-ray things I didn’t check. Maybe one of them has pneumonia. Maybe there were these three phone calls, patients who called me, and they’re waiting by the phone right now for me to call them, and they’re, you know, waiting to hear good or bad information. They’re not going to sleep tonight”? Am I going to sleep better now because I set my boundaries, because I left at five o’clock, because I had dinner with my family? Or am I going to be miserable because I’m waking up at two in the morning thinking I could have helped these people? So it’s a complicated thing. It’s not this. It’s much more complicated, I think, this perfectionism issue.

Now, does it have to be a binary choice? Does it have to be either perfectionism or boundaries? Is it possible to have both? Is it possible to have a physician who sets boundaries, who goes home to eat with their family, yet still maintains standards close to perfectionism? Is it possible to have both? You know, I think it is. I think that’s what we need to strive for.

You see, that was the thing in these articles that sort of upset me: that we’re trying to obliterate this perfectionism from our DNA, and it won’t work, because our perfectionism got us to where we are. I mean, all our lives we said to ourselves, you know, we do it right, we work hard, we produce. I mean, if we brought home a B in middle school, it was a family crisis. You know, we aced our SAT or PSAT or MCAT. So it’s in our DNA.

I think the solution, Kevin, is not to ignore or obliterate perfectionism, but to honor it, to realize it’s there, and work with it from there, to the best of our ability, to help ourselves and our patients. Because I don’t think we’re going to be happy people, or happy doctors, or less anxious doctors if we try to just obliterate it from our minds and do this. I think there is, honestly, and what will work for one person may not work for the next person. I think it’s an individual thing, how we have to do this. But the answer is not in obliterating it. We have to accept it and honor it and work with it.

Kevin Pho: So one thing that you said as part of your story is, you know, would you rather see a perfectionist doctor, or a doctor who strived toward perfectionism yet was miserable, right? So that’s the thing I’m trying to square, right? You know, we talk a lot about physician burnout. You know all the statistics: 60 percent of doctors are reported to have burned out, and some people say it’s because of the expectations that are placed on them. So what about the effect of that standard of perfectionism on the profession as a whole? How do you square that?

Scott Abramson: Well, I think you present this exactly right, Kevin. People use the term burnout, and then, what is burnout? People say it’s moral injury. And what’s moral injury? Well, no, people don’t say what moral injury is. So let me give you an operational definition of moral injury. Moral injury is when our actions don’t meet our values, when our actions don’t meet our values.

I can tell you this: When I worked at Kaiser these 40 years as a neurologist, I faced that every day. It happened to me all the time, bit by bit, you know, little things. For instance, on my home page, you know, which is this thing that patients read when they come to visit you, like a lot of doctors, I would have this sentence. It said, “I treat all my patients as if they were family,” right? As doctors say.

So here’s what would happen, a typical thing. I got a call from a patient Friday afternoon, a Parkinson’s patient, and things were not going right. They needed to be seen. They needed to be seen, but it was Friday afternoon. I couldn’t see them. There was just no way I could see them that day, so I said to my nurse, “You know, tell them to just increase the Sinemet, do this, do that.” But here’s the thing: If I really lived up to my values of treating everybody like family, I would have seen that person. But I didn’t. I couldn’t. In that case, my actions did not live up to my values, and that’s a little bit of moral injury. That’s happening all the time to all of us.

So, you know, again, what’s the solution to that? It’s going to be different for everybody, but it’s a tough situation, and it’s tough on all of us, and it’s going to be tough. It’s tough on every one of us, and that’s the battle we have to face: when our actions don’t meet our values.

Kevin Pho: So for those physicians who are struggling between those two poles that you’re articulating here, what is the path forward for them? You know, I’m sure a lot of physicians do want to strive toward that ideal of perfectionism and be there for their patients all the time, but what is the solution? Because, yeah, it’s very difficult to have it all, right?

Scott Abramson: Yeah, well, I think for some people it may be adjusting their practice. You know, it may be cutting back to three days a week and taking two days off, and, you know, using those days for family, to catch up with paperwork, and all the stuff that we do. It may be job sharing. That sort of thing may work. Of course, that will entail, you know, cutting back on your expenses, and maybe not buying the biggest house on the block or whatever. I mean, that may be one kind of practical thing, and there may be a lot of practical things like that that you could do to rearrange your practice.

I think that some of the answers have to be internal, that you have to think in different terms about your patients. You know, a colleague of mine is one of these guys who, you know, jogs like seven miles every day, eats sprouts, and all this stuff, really healthy. So he’s jogging one day and blows out his knee. And, you know, being a doctor, he knew that in the realm of things, a lot more serious things could happen to him, but he was devastated, because he was invincible. He was invulnerable. You know, he ate broccoli.

So he goes through surgery, everything comes out right, and he can’t wait till the first day of rehab. He can’t wait, because he’s going to work harder and stronger. He’s going to come back better than ever. So he goes to the physical therapist. He’s waiting in the waiting room. The physical therapist comes out, looks at the chart, looks at the guy in the waiting room, and says, “Ah, you’re my 7:30 patient.” The guy looks at him and says, “No, I am not your 7:30 patient. I am the guy to whom you’re going to give his life back.”

If we have a mindset where we think in those terms, that with every patient that we see, in some way, we are going to give them a little bit of their life back, you know, maybe it’s just reassuring them that the cough is not cancer, or that, you know, the rash that’s keeping them up all night, we can get them to sleep. But a lot of times, we think of those things as, you know, “Oh, just another patient. I’m behind. Let me, you know, get these people off the assembly line here.” But if we think in terms of each patient that we see, that we can give them a little bit of their life back, I guarantee you our professional lives as physicians will be imbued with a lot more joy and a lot more meaning.

Kevin Pho: We’re talking to Scott Abramson. He’s a neurologist, and his KevinMD article is titled “Why this doctor prefers perfectionist physicians.” Scott, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Scott Abramson: It’s just as you say, Kevin, it’s complicated: this work balance, this burnout, this moral injury. It’s a complicated thing. I don’t know that I have an answer. It’s going to be different for everybody, but I can tell you the answer is not to try to obliterate perfectionism from our DNA. We have to honor it. We have to work with it, and work with it as best we can, to help ourselves and our patients.

Kevin Pho: Scott, thank you so much for sharing your perspective, time, and insight, and thanks again for being on the show.

Scott Abramson: Thank you, Kevin. I so appreciate it.