The pathological continuum of medical narcissism

[Guest guest]

http://webmm.ahrq.gov/perspective.aspx?perspectiveID=19

 

 

In Conversation with…John Banja, PhD

 

Editor’s Note:

John Banja, PhD, is Assistant Director for Health

Sciences and Clinical Ethics and Associate Professor

of Clinical Ethics at Emory University School of

Medicine.

 

Dr. Banja, whose doctorate is in philosophy, is

currently participating in AHRQ-funded studies

designed to help clinicians communicate more

effectively in emotionally charged situations after

errors or unforeseen outcomes.

 

His book, Medical Errors and Medical Narcissism,

covers issues around the appropriate, ethical

disclosure of medical errors by health care

professionals.

 

Conversation

 

 

Dr. Robert Wachter, Editor, AHRQ WebM & M: Tell us what

you mean by medical narcissism.

 

Dr. John Banja: I see two kinds of narcissists in

medicine. The first is a representative of what is an

increasingly bygone era. This is the “advancedâ€

narcissist: an arrogant, imperious, prima donna

physician around whom the world turns. We can all

recognize this person, and while I am told they are

still around, I rarely meet one.

 

The second kind is much more common.

This is the very bright, compulsive, hard-working

individual who lives in a very stressful world, who

carries entirely too much stuff around in his or her

head, who—and this is a great tragedy—is immensely

self-preoccupied or internally focused with all that

needs to be done, whose baseline emotional state is

one of mild to moderate anxiety, and who has forgotten

to be empathic.

 

That lack of empathy is his or her outstanding trait.

It is not that this person wants to seem distant or

uncaring, or rude or arrogant.

Rather, his or her adaptation to the environment has

resulted in a set of coping behaviors that seems to

exclude patients and their families.

 

This is a person who has forgotten how to listen, who

is used to dominating conversations, who interrupts

constantly, who uses technical language that patients

cannot begin to understand, and who always seems to be

in a hurry to be somewhere else. This physician has

forgotten how to monitor his or her relational skills.

 

 

This person’s narcissism consists in his intense

experience of himself. He “feels†himself and his

world intensely, so that when an error comes along,

two things happen: first, the natural

self-protectiveness that any of us feel when we’ve

screwed up is particularly aroused in this person (so

that he might search for a way to rationalize or

excuse the error to avoid its disclosure), and second,

if he does discuss what happened to the harmed party,

his poorly developed relational skills may trigger an

empathic disaster.

 

RW: Do you think medical narcissists are largely born

or bred? Does the profession attract or make them?

 

JB: The literature on narcissism suggests that it’s

probably a product of nurturing more than anything

else. This nurturing could occur early in childhood or

it could occur in medical school or, most probably, in

residency. Robert Millman has discussed a phenomenon

he calls “acquired situational narcissism,â€

illustrated by professional athletes and movie stars,

whom he has counseled over the years.

These folks often are born into socio-economically

disadvantaged situations, but in their early 20s, for

example, they find themselves millionaires and the

center of attention. And they begin to develop

pompous, condescending, very self-preoccupied types of

behaviors.

He believes that it’s a function of the situation

that they are in. I often think that the physician

lives in a peculiar, if not downright unhealthy,

emotional environment.

First, it’s a very stressful world.

Second, doctors are often surrounded by people who are

overly polite or overly respectful, if not simply

genuflective. They’re also exposed to individuals who

are challenging, irritating, annoying, or

difficult—patients projecting their misery and anxiety

on them and asking all kinds of challenging questions.

 

 

Medical narcissism develops as either a poorly

regulated response to the adulation (for all the

marvelous things health providers know they do) or as

an overly defensive response to the countless threats

to the professional’s self-esteem that occur every

day.

 

RW: Is the main issue in medical narcissism as it

pertains to patient safety the inability to recognize

or acknowledge an error when it occurs, or is it the

inability, once an error is recognized, to confront it

and perhaps apologize for it, in the most mature and

appropriate way?

 

JB: The answer depends largely on where on the

pathological continuum of narcissism you are. The more

pathological in terms of the narcissism, the easier it

is for you to say “I couldn’t possibly have done that.

Someone else is to blame.â€

 

As I started learning about errors, how they happen,

and how complex and multi-factorial they often are,

one thing that surprised me was how there is a nugget

in virtually every scenario that could be used to spin

the story away from the error.

You could use this nugget to say, “I don’t know that

this really was an error,†or “I don’t really know for

sure that this error caused the harm.â€

Or, “I don’t know that the harm was all that horrible

or all that bad.â€

Or, “I don’t know that this was really my fault.â€

Or, “This was somebody else’s fault.â€

 

That opportunity for rationalization is always there,

and for the advanced narcissist, he or she almost

reflexively takes advantage of it. For most health

care providers—in other words, those who are not

advanced narcissists—it’s more the fear of the

malpractice suit, the fear of censure from their

colleagues or licensing boards, or the discomfort of

embarrassment and humiliation that influences their

concealment of error. Research has shown that the

feelings of embarrassment and humiliation are often

significant barriers to health care professionals

acknowledging their errors and discussing them with

their patients.

 

RW: Let’s assume that you committed a terrible error

and the patient died. I am the patient’s family

member. Can you disclose and apologize to me in the

way that you think it should be done?

 

JB: Okay, I would say, “Mrs. Jones, this is very

difficult for me to tell you and it will probably be

even more difficult for you to hear. But an error

occurred when your Mom was here at the hospital last

week.â€

And I would stop at that point, and wait for her

response. If she looked at me in shock and said, “An

error?†I would say, “Yes, there was an error in the

course of her care. Would you like me to tell you

about what happened?â€

And let’s assume she said yes. I would say to her

something like, “Mrs. Jones, what happened was your

mother was supposed to receive 10 units of insulin,

and there was an error—she actually got 100 units of

insulin. And we believe this medication error caused

the problems that she had.

It caused her heart to stop. It caused our having to

take her down to the ICU where, as you know, we were

not successful in resuscitating her. I am sorry beyond

words, Mrs. Jones, but it would have been wrong to

keep this a secret from you. This must be a terrible

shock.†I would speak slowly and pause between

sentences such that if Mrs. Jones wanted to interrupt

me she could. But I would tell her virtually

everything, because if I don’t and she goes to an

attorney, that plaintiff’s attorney is going to find

out everything anyway. So my philosophy is, you either

tell them now or tell them later.

 

RW: In your role as an ethicist, is there a tension

between doing it because it’s the right thing to do or

doing it because you believe that it’s the pragmatic

thing to do in terms of diffusing the malpractice

concern?

 

JB: Error disclosure is obviously the ethical thing to

do. However, I don’t stress that very much when I talk

to health care professionals because, quite frankly, I

don’t think that their ethical relationship to a

patient is the first thing that enters their mind

after a medical error. I think what they think about

after an error is, number one, “How can I reverse the

harm to the patient?†and, number two, “What’s going

to happen to me as a result of this?â€

 

When I got into this research back in 2001, I was

going around the country talking about truthful

disclosure, especially to lawyer or risk management

groups; many people looked at me as though I was

absolutely mad.

 

I’ll never forget, I once purposely sat next to a

certain audience member at lunch, because he gave me

the dirtiest looks during my talk earlier that

morning. At lunch, I said to this person, who I

thought was a physician, “I have a hunch I didn’t

convince you.â€

And he looked at me and he said, “I’m the head of

legal counsel here at this hospital, and everything

you said this morning was diametrically opposed to

everything that I know and have learned about how to

handle these kinds of cases.â€

 

Truthful and comprehensive error disclosure is a

paradigm change for health care professionals and

legal counsel. But it seems like the medical

malpractice groups are buying into this idea that a

generous, empathic, compassionate, truthful, ethical

disclosure of error may very well contain or limit

lawsuits. And systems like the VA and the University

of Michigan are reporting significant decreases in

their claims frequency and severity after adopting

full disclosure policies.

 

RW: One point you made nicely in your book is that,

although institutions obsess over how to handle the

errors and whether to have a “blame-free environment,â€

only the patient can absolve the provider of blame.

Given that, what is the role of the institution in

working with their providers to manage this process of

disclosure?

 

JB: There’s a two-pronged answer.

Number one, as a provider, in disclosing the error

truthfully and ethically to the patient, you have

discharged your responsibility to that individual

because you have apologized, you have informed the

patient, and now the next steps are in the patient’s

or family’s lap.

From the standpoint of the organization, though, you

must look at this erring nurse, pharmacist, physician,

or whomever, and ask, was this individual’s act

blameworthy and punishable, or not? JCAHO and safety

experts talk about creating blameless and non-punitive

environments, and that’s good. We want individuals to

feel that they can report their errors so risk

management can look into the organization’s latent

system failures that may have caused them.

However, James Reason and others have made the point

that a totally blameless, non-punitive environment is

irresponsible, if not impossible.

Some errors will be so egregious and terrible that it

would be ethically irresponsible for the institution

not to punish the individual.

 

The challenge for institutions is to look at the

conduct of the individual and decide whether or not

this is a blamable or a non-blamable act.

And where I and some other people have come down in

drawing the line that discriminates blamable from

non-blamable is, did the individual violate policy and

procedure? Because if he or she knowingly, willfully,

or recklessly violated policy and procedure, that

would seem to me to differentiate punishable errors

from the non-punishable ones. Importantly, I do not

think that we should look at the outcome of the error

in terms of deciding whether to blame or not to blame.

 

 

RW: The line of reasoning that disclosure is not only

the right thing ethically, but may very well be

helpful pragmatically in lessening malpractice risk,

presupposes that the patient or family member and the

plaintiff’s attorney ultimately would have found out

about it.

But as we know from the Harvard Medical Practice

Studies, a lot of errors never reach the light of day.

For many institutions and providers, some errors

probably would not have come to light except for the

disclosure. How do you balance that issue, or, at the

end of the day, is this really mostly about doing the

right thing?

 

JB: There’s no question that, if your institution

adopts a policy of comprehensive error disclosure,

you’re inviting people to sue you. Consequently, I

hope we’ll have good research that will show us that

even though you might get sued a lot, your claim

severity—the cost of all the litigation and

payouts—will be much more manageable.

Also, if you start making these kinds of

discriminations in your mind—“They’ll never find out

about this particular error, but they might find out

about this one, so we can conceal the former but we’ll

have to disclose the latterâ€â€”I think you’re going down

a slippery slope real fast, headed toward nothing but

trouble.

 

RW: There is a tremendous tension between physicians

feeling like there’s a certain level of empathy that

they’d like to express to patients after an error, and

some risk managers, who have traditionally said,

you’re just opening up huge cans of worms that will

take us decades to close. Each one, of course, is

right from his or her narrow perspective.

 

JB: Much of this issue has to do with the way the

story reflects the moral character of the storyteller.

If you give the patient a lawyer-crafted story that

doesn’t acknowledge that there was an error, that

doesn’t say there was harm, or doesn’t say there was a

mistake, but instead you’re dancing around the

periphery saying, “We had this problem, and we’re

sorry that it happened,†then you’re taking a big

risk. The patient will walk out of there wondering,

“What did he say to me, was there really an error, was

there really a mistake?†The more my suspicions are

aroused, the more negative I’m going to be toward you

because your story is a reflection of you.

Patients and their family members absolutely will not

tolerate thinking that their physician is being

deceptive or is withholding the truth. The very idea

is infuriating, so it shouldn’t be a mystery why they

go to a lawyer.