To be good enough
Can Fam Physician. 2009 Mar; 55(3): 239–240.
Staff physician in the Division of Paediatric Emergency Medicine and Clinical Pharmacology and Toxicology at the Hospital for Sick Children in Toronto, Ont, and an Assistant Professor in the Department of Paediatrics and Public Health Sciences at the University of Toronto
Professor and the Founding Director of the academic fellowship and the graduate studies programs in the Department of Family and Community Medicine at the University of Toronto
The concept of a “good enough” mother originated in 1953, and the principle of good enough (POGE) is successfully used in the business world, particularly in the very lucrative software industry. However, the concept of a good enough doctor or a good enough health care system has not gained popularity among the general public or the medical community. Most physicians aim for perfection while struggling to balance personal and professional lives, and most health care systems try to provide patients with the latest diagnostic and therapeutic interventions despite escalating costs and limited resources. This article discusses the origin, key features, and merits of the POGE. We believe that excellence in medicine can be achieved by ensuring results that are good enough rather than by aiming for perfection.
An unrealistic ideal
Up at the crack of dawn and working long into the night, this heroine magically creates extra hours each day juggling kids, schedules, chores and career. Navigating jungles of toys and mountains of kiddie stuff she prepares tasty-yet-healthy snacks, tames dust bunnies and banishes stubborn stains. With an invisible third arm and a never ending pursuit of work/life balance she can help with a school project and answer an all-important business call while wrist deep in dirty diapers. Part teacher, part doctor, part chauffeur, part boss … she’s all SuperMom.1
This is the description of a new action figure, not a real person. That being said, many women and men in the modern world are trying to balance personal and professional lives and are feeling stressed about not being able to do everything perfectly. Fortunately (or unfortunately) the SuperDad action figure has not yet been created,2 although they have created BossMan, MoneyMan, and GeekMan as male counterparts to the SuperMom toy3—not to mention pre-existing action heroes such as Superman, Batman, and Spiderman who save the world.
It would not be an exaggeration to say that most parents try to provide the best for their children, and many feel guilty when they are not able to do so. Aiming for perfection in both professional and personal lives appears to be the norm in modern society, and the concept of good enough is neither familiar nor entertained as something worthy of consideration.
A good enough mother
Dr Donald Winnicott was a pediatrician who introduced the “good enough mother” in 1953.4 He took a softer approach than Freud in his views about the role of parents, which popularized his teachings. Dr Winnicott recognized the need for children to realize that
a mother is neither good nor bad nor the product of illusion, but is a separate and independent entity: The good-enough mother ... starts off with an almost complete adaptation to her infant’s needs, and as time proceeds she adapts less and less completely, gradually, according to the infant’s growing ability to deal with her failure. Her failure to adapt to every need of the child helps them adapt to external realities.4,5
Dr Winnicott’s teachings boiled down to the fact that a good enough mother was better than the perfect mother.
The principle of good enough
Could the ideas behind the good enough mother be adapted to other aspects of life? In general being good enough in everything you do is better than being outstanding in some areas and bad in others. It would not be wrong to surmise that good enough is the best one can do in any given situation to satisfy the requirements at hand. For example, if you invite someone home for lunch you need to provide food around noon. Serving simple sandwiches at lunchtime is good enough—and better than attempting to serve a 10-course meal at 7 pm and calling it lunch.
Choosing good enough over perfect is an old idea among software developers. The POGE or the good enough principle is a rule for software and systems design.6 It favours quick-and-simple designs over elaborate systems designed by committees. Once the quick-and-simple design is created, it can evolve according to user requirements. Ethernet, Internet protocol, and the World Wide Web were developed based on the POGE.6,7 More and more people in the business world seem to be embracing this principle, as evidenced by a recent newspaper article on creating a great POGE-based camcorder.8
The essence of good enough lies in the minds of practitioners, not their practices. It takes the real world into account and accepts that benefits always come with problems. The paradigm is one of improving while doing, learning from failure, coping with complexity, and adjusting to human foible.7
Good enough doctors
The general public expects physicians to be perfect: doctors who can diagnose and treat any illness while being excellent citizens and great role models. The medical community tries to maintain this image of infallibility in a misplaced sense of “we owe it to our patients to be the best of the best.” However, all physicians have to make choices—no resources are unlimited. Rising health care costs, an aging society, an explosion of new medical information, the limitations of modern medicine, competing personal lives, and a universal time limit of 24 hours in a day provide reality checks for many physicians. Physicians should aim to be and train others to be good enough doctors instead of perfect ones.
Richard Smith explores the good enough concept in his address to medical students.9
Being a good enough mother is to be a good mother, whereas the attempt to be the best will guarantee that you won’t be (indeed, you may be a highly damaging mother). Similarly, you should aim to be a good enough medical student and doctor. One of the curses of doctors is that they have such strong stereotypes. Doctors are upstanding, trustworthy, clever, strait-laced, conservative, authoritarian, inhibited, wealthy, right wing, and—often—dull. Many doctors are none of these things, but as a medical student you may feel a pressure to conform to the stereotype. Don’t. A lifetime spent trying to be something you are not will destroy you.9
The idea of being good enough in family medicine has been explored in the recent past, but it does not seem to have gained awareness or popularity in the general medical community.10,11
Excellence through good enough
We should not confuse good enough with merely good. To claim that any given thing is good enough is to agree with all of the following statements6,7:
There are sufficient benefits.
There are no critical problems.
The benefits sufficiently outweigh the problems.
In the present situation, and all things considered, further improvement would be more harmful than helpful.
Good enough is not mediocrity. It has to do with rational choices as opposed to compulsive behaviour. The good enough approach is a way to drive ongoing improvement and achieve excellence by progressively meeting, challenging, and raising our standards as opposed to driving toward an illusion of perfection. A best practices approach to any endeavour is to start with good enough and raise the bar to achieve excellence—because being an excellent doctor should not compromise a good enough personal life.
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
Cet article se trouve aussi en français à la page 241.
1. Happy Worker [website] SuperMom action figure—bio. Toronto, ON: Happy Worker Inc; 2008. [Accessed 2009 Jan 19]. Available from: www.happyworker.com/supermom/bio.
2. Miles S. Mums get SuperMom action figure, but where is SuperDad? Ascot, UK: Pocket-lint; 2008. [Accessed 2009 Jan 19]. Available from: www.pocket-lint.co.uk/news/news.phtml/2596/3620/SuperMom-GeekMan-Bossman-moneyman-toys.phtml.
3. Happy Worker [website] Our toys. Toronto, ON: Happy Worker Inc; 2008. [Accessed 2009 Jan 19]. Available from: www.happyworker.com/toys.
4. Winnicott DW. Transitional objects and transitional phenomena; a study of the first not-me possession. Int J Psychoanal. 1953;34(2):89–97.[PubMed]
5. Winnicott DW. Mirror-role of the mother and family in child development. In: Lomas P, editor. The predicament of the family: a psycho-analytical symposium. London, UK: Hogarth Press; 1967. pp. 26–33.
6. Collins WR, Miller KW, Spielman BJ, Wherry P. How good is good enough? An ethical analysis of software construction and use. Commun ACM. 1994;37(1):81–91.
7. Bach J. Good enough quality: beyond the buzzword. Computer. 1997. [Accessed 2009 Jan 19]. pp. 96–8. Available from: www.satisfice.com/articles/good_enough_quality.pdf.
8. Walker R. Flipped out. New York Times. 2008. May 25 [Accessed 2009 Jan 30]. Available from: www.nytimes.com/2008/05/25/magazine/25wwln-consumed-t.html?_r=1&scp=1&sq=pure+digital&st=nyt.
9. Smith R. Thoughts for new medical students at a new medical school. BMJ. 2003;327(7429):1430–3.[PMC free article][PubMed]
10. Wilke G, Freeman S. How to be a good enough GP: surviving and thriving in the new primary care organizations. Abingdon, UK: Radcliffe Medical Press; 2001.
11. Lindsay M. Good enough general practice. BMJ. 2005;330(7485):236.
Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada
The phrase " the good enough mother" was coined by the British pediatrician and psychoanalyst D. W. Winnicott in his famous book Playing and Reality.
In discussing the mother (or other caretaker's) adaptation to the needs of the baby, Winnicott thought that the "good enough mother" starts out with an almost complete adaptation to her baby's needs. She is entirely devoted to the baby and quickly sees to his every need. She sacrifices her own sleep and her own needs to to fulfill the needs of her infant.
As time goes by, however, the mother allows the infant to experience small amounts of frustration. She is empathetic and caring, but does not immediately rush to the baby's every cry. Of course, at first the time-limit to this frustration must be very short. She may allow the baby to cry for a few minutes before her nighttime feeding, but only for a few minutes. She is not "perfect" but she is "good enough" in that the child only feels a slight amount of frustration.
From Illusion to Reality
The fascinating thing about Winnicott's notion of the good enough mother is that he connects the mothering process to the child's cognitive development and the development of a healthy concept of external reality. At first the baby experiences the mother as part of himself. The baby is in love with his mother and experiences her not as a separate person,but as a part of himself. As time goes by, the moments apart from the mother's total emphatic attuning to her baby's needs spark the beginnings of the baby's mental activity and sense of an external world.
If the mother's complete adaptation to the baby's need goes on too long, and does not decrease naturally, the baby's growing sense of a real external world apart from himself is interrupted. He lingers in the magical world of illusion and hallucination. That is, he believes that simply having a need will lead to its immediate fulfillment. This, says Winnicott, is an illusion although a necessary illusion.
Although Winnicott insists that if the baby does not feel small amounts of frustration, he will not form a concept of external reality, he emphasizes that the earlier phase of mothering is equally essential for the baby's healthy development. The ability to have an illusion is a necessary prerequisite to developing a sense of reality.
"at the start, [the mother's] adaptation needs to be almost exact, and unless this is so it is not possible for the infant to begin to develop a capacity to experience a relationship to external reality, or even to form a conception of external reality."
A Balancing Act
So being a "good enough mother" is fairly complex. It involves a balancing act between two equally important processes for a child's healthy cognitive development and even his future happiness: 1) At first, the mother or caretaker must devotedly attend to the infant's every need; 2) The mother must gradually allow the baby to experience a need apart from its immediate fulfillment--although naturally this time period must be very short at first and increase with time.
In sum, with good enough mothering, a child has the ability to to live in two worlds: the world of illusion, fantasy and magic, on the one hand, and on the other hand a world that does not always conform to his wishes.
Copyright © Marilyn Wedge, Ph.D.
Marilyn Wedge is the author of a new book, A Disease called Childhood: Why ADHD became an American Epidemic (Penguin Random House Group).