Issues in the American medical system are receiving increased attention for their contribution to physician burnout and quitting, but one often overlooked is the contribution of mistreatment by a physician’s colleagues and managers. Mistreatment in the form of “bullying” receives a lot of attention in school systems, but not so much in medicine. In fact, bullying in health care is an endemic problem, especially in — but not limited to — medical training.
A 2021 report by the Joint Commission titled “Bullying Has No Place in Health Care” stated that bullying is “typically deliberate, causes negative effects on the victim, and is an attempt to control employees. Bullying is behavior that is aggressive, intentional, and frequent. Bullies tend to target employees who have inadequate support or are not able to defend themselves from the aggression. An essential component of bullying is that it is perceived as a hostile act by the target.”
The report goes on to give some examples of bullying, such as a manager who is never pleased with performance, gossips or spreading rumors, or intentionally excludes an employee from team meetings. An employee might be told “you are too thin skinned” or repeatedly called to unplanned meetings with the manager where the employee is denigrated.
“Factors that contribute to this problem include a culture that allows bullying (normalization of deviance), poor staffing levels, excessive workloads, power imbalances and poor management skills,” the Joint Commission’s report says. “Specific organizational factors that can lead to workplace bullying are role conflict and ambiguity, work overload, stress, lack of autonomy and a lack of organizational fairness.”
Given how ubiquitous these issues are currently, it is no wonder that bullying has found fertile ground.
Let’s look at two vignettes. The first illustrates the impacts of overt bullying on a trainee, while the second shows how covert, or narcissistic, bullying can happen on a more institutional scale and affect a more experienced subordinate.
“Welcome, medical students! Let’s get started with the Balint Group. Who’s got a case?”
“I do,” a trainee finally says after a long pause. “I was on the inpatient service and I’m pretty sure I saw the attending make an error with the patient’s medication. I wanted to say something, but this attending has mocked me in front of my peers and the residents when I didn’t know the answer, and I’ve heard that she gives bad evaluations if you question her authority. I really wanted to say something, but I felt afraid, and now I feel awful that I didn’t put patient care before my own needs.”
Here we can see the ethical dilemma and moral injury this trainee has been left with at a particularly vulnerable spot in her training.
A second example shows the more subtle form of covert bullying.
Dr. Scott: “Hey, Dr. Mirandez, can I talk to you? I think our chief is targeting me. He only points out the negative parts of my performance evaluations to me. He told me the medical staff feel I’m bothering them when I approach them and he recently passed me over for a promotion even though I had seniority. He said it’d ‘destabilize the program’ if he promoted me. I feel like maybe he’s bad-mouthing me to others. He’s been excluding me from meetings and discounting my contributions in other meetings.”
Dr. Mirandez: “Are we talking about the same person? Dr. Palmer has done so much for me and for the department, and he’s so smart and such a great physician. I think you are reading something into this that isn’t there. Honestly, you sound a bit paranoid.”
In this vignette we can see that Dr. Scott is left with a creeping feeling of doubt as to the validity of his perceptions and a sense that he may not have any support or recourse if he were to try to report this targeting behavior.
Narcissistic personality disorder (NPD) is thought to occur in about 6% of the population. Exact numbers in physicians are hard to quantify, but there has long been a lore about “doctors thinking that they’re God.” Narcissistic traits in physicians may have many different etiologies beyond childhood experiences.
John Banja, a professor and medical ethicist at Emory University, coined the term “medical narcissism” to explain a coping strategy meant to shield a physician from the unpredictability of medical outcomes; for example, even a treatment that is 99% effective may still kill 1% of patients. The fear of making a grievous medical error can lead to a heightened sense of one’s competence to ward off this fear and press onward daily. This medical narcissism can be reinforced by patients in two distinctly different ways: effusive praise for the physician (who doesn’t like to hear that?) and, conversely, blame when a treatment is ineffective or even harmful.
Admitting a mistake to a patient is discouraged by the medical system’s attorneys and malpractice carriers. Add this up and an attitude of arrogant perfectionism can take root.
Another contributor to medical narcissism can be what Robert Millman, professor of psychiatry at Cornell Medical School first called “acquired situational narcissism” two decades ago. Dr. Millman coined this term to describe the phenomenon seen when someone becomes famous and fawned over (e.g., rock stars, politicians, sports figures) to the point that they truly believe the hype that they are better than other people. It’s a short stretch to medicine, where the “saving lives,” effusive patient/resident praise, and rigid hierarchy in medicine that places physicians at the top can go to one’s head.
“Fundamentally, a doctor with NPD is arrogant, feels entitled and believes others have a problem. In subtle or not so subtle ways, they let other colleagues know they are ‘special,’ exaggerating their exceptional skills in patient diagnosis and management,” explains Australian family physician and author Leanne Rowe, MD. “Patients often adore them as they also inflate their achievements in their consulting rooms, while making derogatory comments about the clinical management of other doctors. Consequently, a doctor with NPD may seem charming on the surface and have many admiring followers. Generous one day and dismissive or aloof the next, they justify their quick temper as necessary to keep other doctors on their toes and to uphold a high standard of patient care.”
Physicians with NPD tend to target certain subordinates, particularly those who aren’t demonstrating buy-in to their charm and exceptional skills. Some forms of targeting include:
Taking credit for the subordinate’s achievements
Interrupting or not calling on the subordinate in meetings
Lack of eye contact or rolling the eyes when no one is looking
Making passive aggressive comments
Over-focusing on the subordinate’s weak spots in performance evaluations with patronizing concern
Impugning the subordinate to others behind the person’s back
Making veiled threats about job security to keep the subordinate in line.
Often the targeting is subtle and intermittent, which can lead the subordinate to question their perception of what is happening for quite some time.
It is not a coincidence that there is a concentration of doctors with narcissism in positions of authority. Part of this is because their behaviors may be rewarded and/or subtly encouraged if they maintain the hierarchy of the system. Also, senior physicians can be harder to replace and may generate much income for an institution. From the physician’s perspective, being in an authority position can bring the wished-for attention, recognition, and gratitude that comes from benefitting trainees or others in subordinate positions. Because the praise is never enough, one will often see these physicians attempting to keep climbing the ladder of success.
What can a target of narcissistic bullying do? Often the subordinate will work hard to get back in the good graces of the superior, but this is hardly ever successful once the person has already been targeted. Directly confronting the bully is also largely ineffective, since confrontation is usually met with denial and can bring more harm upon the victim in the form of threats of legal or administrative action, as well as counteraccusations regarding the victim’s toxicity or mental instability. This can further serve to isolate the complainant within the department and potentially hasten a case for being terminated.
“People who engage in this form of manipulation deny reality, even hard facts,” Dr. Caroline Giroux explained in her November/December 2023 article in this magazine on “gaslighting,” the manipulative tactic of altering a victim’s perception of reality to serve one’s own needs. “It works because it creates confusion in the victims and triggers stress response systems or autonomic reactivity (the fight, flight or freeze response) that are at play during traumatic experiences.”
When one is the target of bullying it can lead to devastating professional and psychological consequences. Fear, anger, shock, depression, and anxiety are common feelings. In the case of subtle and insidious narcissistic bullying, a common reaction is to perseverate on the feelings of ineffectiveness or mistreatment. This can be seen as a kind of short-term “infection” of the perseverative need the person with narcissism has to protect their fragile sense of self (the psychological terms are “projective identification” and “narcissistic introjection.”)
What can and should be done about narcissistic bullying, and workplace bullying, in general? Ideally, health care entities should have a confidential reporting system and a robust response to these reports. A workplace culture of “see something, say something,” where physician intimidation is called out and addressed by higher administration, is key to preventing medical mistakes and improving staff morale. The American Medical Association’s bullying mitigation guide recommends “surveying employees anonymously and confidentially to assess their perceptions of the workplace culture and prevalence of bullying behavior, including their ideas about the impact of this behavior on themselves and patients.”
The good news is that when workplace abuse is reported to administration and taken seriously, the remedial measures (e.g., formal warning, counseling, physician education programs) are often effective. In cases of narcissistic bullying by doctors, however, there is rarely an admission by the offending physician of responsibility and there may be a counteraccusation to the accuser. Since narcissistic bullying is often only seen by the victim, it puts the onus on the victim to report it, often with no corroborating support by others. It is thus important when a colleague or supervisor is told about low-grade, intermittent bullying that they adopt an openness to the other’s perspective and evince the courage to support the victim in reporting the abuse.
The good news is that when workplace abuse is reported to administration and taken seriously, the remedial measures are often effective.
Dr. Rowe suggests the following harm-minimization approach to reporting bullying of any kind:
Find the most senior person who can be trusted and explain the situation.
Explain that you are not formally reporting the abuse, but that you are worried that someone else will.
Request that this senior person take the physician aside to make them aware of the impact of their behavior and that they need to stop.
Expect resistance to the story but remain professional and use objective language, such as the following: “I am very tolerant, but I will not tolerate these negative behaviors because they are harmful to other doctors, staff and patients. As I said, I will not make a complaint but someone else will. Do we want that to occur on our watch?”
If you begin to suspect that you are in a pattern of narcissistic abuse, here are some important steps to consider:
Identify what steps you can take to enlist support within the institution both for reporting the abuse and your own self-protection. This includes identifying allies who may be willing to support you and potentially corroborate your account.
Try the harm minimization approach.
If you cannot ensure your safety through these approaches, try to minimize contact with the narcissistic doctor. Do not offer them any personal information or obvious emotional reaction (known as the “gray rock” method), as this can become fodder for future targeting.
Seek emotional support from friends and loved ones, and seek mental health support from a therapist, EAP counselor, and/or psychiatrist to manage the intense feelings and perseverative thinking that can arise because of the abuse. As Dr. Giroux mentioned in her article, one can experience trauma symptoms from the toxic stress buildup of gaslighting interactions.
Prioritize your self-care: exercise, meditation, sleep, spending time with supportive friends and loved ones to help mitigate the physical and emotional effects of the abuse.
Remind yourself that you were targeted specifically because of your beneficial workplace skills and probably because your ability to see through the manipulative behavior marked you as a threat to the narcissistic physician.
Finally, consider looking for a position within a different department or organization if these other strategies aren’t effective. Your position may be at risk anyway if you are being targeted, so being out in front of the choice to leave can be empowering and save much distress later.
If you suspect that you may be the one with narcissistic tendencies, this is potentially an important and healthy realization. Remember, the culture of medicine tends to promote narcissistic behavior and you may not be immune from its effects.
Although insight into the nature and realization of one’s insecurities can be painful, support from a therapist or coach can help you grow and give you the ability to work with colleagues and subordinates more effectively, and to more effectively navigate the uncertainties inherent in patient care.
Email Andrew Smith, Ph.D.
