How is it possible that endemic bullying persists in medicine despite myriad initiatives to improve awareness, mutual respect and medical culture?
In some cases, we can blame health systems issues, such as medical workforce shortages, lack of funding and unsafe hours. But in other cases, we must take collective responsibility for failing to hold individual doctors to account for their damaging behaviors.
Most doctors readily change after being counseled about poor social skills, rudeness, bullying, sexual harassment, discrimination or racism. But others refuse to accept they have a problem and risk damaging their reputation, position, and career.
Why would doctors do this? And why is it so difficult for others to call them out and intervene effectively?
One of the reasons may be due to narcissistic personality disorder (NPD), which occurs in up to about 6 percent of the general population. In my experience of working in clinical and board leadership roles across many different medical workplaces for nearly three decades, doctors with untreated NPD may manifest bullying behaviors in a number of ways.
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. 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.
To avoid being reported, doctors with NPD may slowly undermine their victims with repetitive nit-picking and sarcasm, drip feed low-grade abuse that is difficult to call out, avoid eye contact, roll their eyes with disdain when no one else is looking or give out backhanded jabs dressed up as jokes. Intermittent stonewalling and private taunting are also tough to prove.
It is particularly difficult to call out an employer or supervisor who has NPD, as on the surface, they may appear to be trying to help their victim. In reality, they may be quietly investing their time into their subordinates for “a return,” exploiting them financially, expecting them to work unreasonable hours, taking credit for their achievements, performance managing them unfairly, focusing on their vulnerabilities with patronizing concern, or making veiled threats about job or training security to keep their victims in their place.
Nothing is ever good enough, which creates excessive fear in the workplace, paradoxically reducing the performance of other doctors and endangering patient safety. Others find it difficult to challenge the doctor with NPD as they twist words, misconstrue situations or are easily slighted by routine peer review, constructive feedback or minor criticism.
More severe behaviors of NPD include pathological lying, nasty competitiveness or smear campaigns against other people. This often occurs without the knowledge of victims, who are unable to defend themselves against false rumors because they are the last to find out. The falsehoods often focus on what hurts doctors most, for example, being accused of failing to pull one’s weight, a lack of integrity or — worse — incompetence.
When confronted, the bully lacks empathy and may pretend nothing has happened. To maintain their superior status, power, and control, the perpetrator may also play the martyr or accuse a victim of being toxic, dishonest, mentally unstable or “not up to it,” which causes further harm. A doctor with NPD is often quick to threaten legal action for defamation while continuing to spray lies about others, which is a very effective way to split people. As a result, the complainant is sometimes wrongly accused of poor behavior, rather than supported by others in the workplace.
A common myth assumes victims of bullying are oversensitive, weak individuals who are unable to stand up for themselves. More often, bullies target high achieving victims who they envy. When a target lacks boundaries in relation to self-protection and self-care, they try to appease and tolerate the bully for too long. The mind games are irrational, and there is nothing the victim can do to “win” or fix the situation when the rules keep changing. Any individual intervention only makes matters worse while the perpetrator continues to enjoy “playing” with their victim.
In response, victims naturally become upset, hyper-vigilant and defensive, and when their stressed demeanor confirms the doubts of colleagues about their mental health, they may gradually lose their support network. Recommending self-care strategies, resilience training and cognitive behavioral techniques in this situation can be harmful because further responsibility is placed on the shoulders of the victim to change, but this doesn’t stop the bully’s destructive behavior.
Change is also difficult because doctors with NPD usually don’t regard narcissistic traits as negative as they feel superior to other doctors and often say so directly or indirectly. Witnesses fear getting involved for fear of becoming a target themselves and remain silent when it appears “there are always two sides to a story.” In some recent high profile cases, hospitals, medical services, and other health providers have turned a blind eye to bullying, particularly when doctors are senior, generate healthy incomes or have skills that are in high demand in an area of workforce shortage.
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