By Karen Foster MSc.
My first blog, describing what I characterised as an epidemic of narcissism in medicine, was written based on my own experiences supported by additional information from friends and colleagues. However, after it was published I received quite a bit of feedback and was asked a number of questions such as how and why this level of narcissism is so prevalent in the medical world. I did not have answers for these questions, so began the journey for a better understanding.
Firstly it would be prudent to formally define narcissism. The Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV) states, pathological narcissism is a pervasive pattern of grandiosity, self-focus, and self-importance. Furthermore, it goes on to explain that narcissists are preoccupied with fantasies of their success, of their power, of their own superior intellect and of their beauty. Narcissists demand attention and admiration but can respond with great hostility to minor threats to their self-esteem. They often display a sense of entitlement with the expectation of special treatment. They are reluctant to be reciprocal with favours, they lack empathy, social skills and are exploitative of others.
These traits exist on a continuum, ranging from extreme (representing pathological narcissism as a clinical disorder) to less extreme, but still problematic (representing narcissism as a personality trait). Narcissistic personality disorder is often only diagnosed when it is severe and pervasive in the personality, and is causing the individual problems just as it is regularly the case with addictions. However, it would be unlikely that a narcissist would identify this personality defect in themselves, as the nature of the condition is a defence against what may be perceived as threatening feelings via emotional dissociation and denial. This also explains why someone exhibiting rather extreme narcissistic symptoms never self-seeks psychological treatment until this is imposed on them after their actions have necessitated some form of intervention. Treatment is rarely successful.
But don’t we all have at least some form of narcissism? Many specialists, including Freud, say that yes, we do have a certain dose of it and that it’s actually healthy. This is referred to as healthy ‘narcissism’ which is characterised currently as an important ingredient of self-esteem and a factor in resilience to social stresses like marginalisation and actually enables us in self-efficacy. It aids us in functioning effectively. This constitutes realistic self-interest, helps us achieve our goals and gives us the ability to form relations with others and our environment. Those with a healthy amount are usually talented, capable and functioning well in society. Therefore, it would be logical to assume that we all know people who are represented on this narcissistic spectrum. In fact, we all would have a place somewhere on it, it is the extent to which the level of narcissism negatively affects our lives and the lives of those around us which is of concern, with the absence of empathy regarded as the biggest problem.
So far, I have given a formal explanation of narcissism explained how we would all be represented somewhere on a spectrum. However, when applying this back to physicians, it may be necessary to look at this from a different perspective, as it’s unreasonable to suggest that all people who enter the profession of physician are born with or inherit their unhealthy degree of narcissism during development.
Robert B Millman, Professor of Psychiatry at Cornell University, has coined the phrase, “acquired situational narcissism”. This is a form of narcissism that develops in late adolescence or adulthood, brought on or “triggered” by wealth, fame and the other trappings of celebrity and has the same symptoms as “narcissistic personality disorder”, except that it shows up later. This is very often triggered by the experience of “power”. Basically it is a dysfunctional response to success. Here it is the environment that creates the narcissism, where there may have only initially been a trait, or as previously stated, a healthy and functional amount of narcissism. This Millman described as reinforcing pre-existing, latent personality or identity traits.
John Banja, whom I referenced in my first blog, also spoke of how reinforcement can create an identity, but he used it within the context of medical narcissism, stating that these inherent traits are reinforced during medical (physician) training. He believed this was a defence mechanism against loss of self-esteem and thus making them reluctant to disclose any error on their part to their patients. This has been evidenced in the likes of Professor David Southall and Professor Roy Meadow. Southall, as reported in the newspapers, falsely accused Steven Clark of murdering his two children, and was subsequently charged with professional misconduct and “struck off”. Meadow appeared as an expert witness in Steven’s wife Sally’s consequent murder trial and the GMC also struck him off the British Medical Registrar for giving “erroneous” and “misleading” evidence which lead to her conviction and imprisonment. Narcissism entitles one to act outside one’s area of expertise, and both of these physicians were identified as having done so, with great negative consequences.
Therefore the education of physicians needs to be considered here also. Many of these physicians have been through the public school system and many are also graduates of Oxford or Cambridge. Again, speaking to friends and colleagues who have had this educational experience, it has been explained to me that from the time one starts their education, to the day they graduate, they are repeatedly told by those responsible for their education, that they are special, the most intelligent, and above all else superior to everyone else, just by virtue of being educated at Oxbridge. Referencing Banja again, any narcissistic traits may well be reinforced during this education and then subsequent medical training. Speaking with a number of physicians, I have been told that their supervising physicians expected them to be errorless and later after their training had finished and they had officially qualified, their patients also expected them to be perfect. Therefore the expectations placed on the potential physicians are great enough to develop an idol like persona, and then to effectively create “acquired situational narcissism”. The same triggers that Millman refers to such as wealth and the godlike role society gives them can be applied in a very similar way.
So, combining the clinical diagnosis of narcissism with Banja’s theory of medical narcissism and lastly Millman’s explanation of acquired situational narcissism, it would be reasonable to predict from these and the journey a physician takes to attain his education and then the position society places him could create an epidemic of narcissism in medicine. This may explain the behaviour of physicians as they come to believe that one ought never appear ignorant, uncertain, hesitant or wrong. So when this professional self-image is challenged, these persons are tempted to withdraw, or become hyper-defensive or just plain arrogant. Demonstrably, when presented with a patient with knowledge they display the condescending and arrogant attitude as previously discussed. These are role-related, identity-based behaviours and can be very concerning when these issues negatively affect the health outcomes of their patients.
My last blog ended with the call for patient-centred medicine, and this extrapolation from that blog is the same reason why we need to promote this. Patient-centred medicine’s emphasis is on groundedness, that is that the treatment and care should emerge from the patients’ needs. What we currently experience is physician-centred medicine which advocates that a physician should work autonomously, without question nor challenge, as they are the only ones that have the necessary knowledge and understanding, and this is often to the patient’s detriment. This is a reflection of paternalism and this subject has been widely researched and written about by Angela Coulter who calls for a removal of paternalism in medicine. She states that the public’s expectations are changing and that patients are now wanting to be involved in their care, as although it is acknowledged that physicians are well informed about diagnostic techniques, the causes of disease, and prognosis etc, patients are the experts when it comes to their own experience of illness, their social circumstances, their own habits and their behaviour. Therefore the current physician-centred medicine model that we presently experience creates and maintains an unhealthy dependency on a draconian and narcissistic model that desperately needs to be changed.
Millman, B. (2001, December 9). Acquired Situational Narcissism. The New York Times.
Banja, D. (2005), Medical Errors and Medical Narcissism: Jones and Bartlett Publishers, Inc .
Coulter, A. (2002), The Autonomous Patient: Ending Paternalism in Medical Care: The Stationery Office