The Story

Over the years, countless healthcare professionals have shared touching stories of mentors who encouraged and inspired them at early stages of their training. Such accounts motivate us to “pay it forward” and serve in that role for the next generation. However, not all have benefited from such inspirational figures. Some of us, in all probability, trained under “anti-mentors”—those whose personality, conduct and professionalism served more as a warning of how not to act. Those stories need to be told as well, for there is much that can be learned. and it is always better to be prepared.

 

Midway through my residency, I was on rotation with a flamboyant subspecialist who was well-known in the local community. One morning he was doing an invasive procedure on an older gentleman when the patient acutely experienced a life-threatening complication. The attending started an IV and left the room without a word, leaving me and a junior medical student alone to attend to the dying patient. After he arrested, I initiated CPR, then a full code was instituted. The code was unsuccessful.

 

After the dust had cleared, the attending pulled me into a side room and launched into me, declaring I was the “worst resident he had ever trained,” backing his accusation with a bizarre litany of allegations that, even at face value, were frivolous and immaterial.

The complication that led to our patient’s demise was almost certainly preventable. This particular episode was just one in a string of untoward episodes I witnessed, while my fellow residents told me of many more.

 

This illustrates an unfortunate reality of the workplace. The attending in question displayed compelling evidence of psychopathy. Mental illness is extremely common (at least 20 percent of the adult U.S. population, and that’s prevalence, not incidence), so sooner or later you will be working with or for someone who is affected. You probably already are. While graduate healthcare professionals have more confidence and experience in handling such people, such encounters can be highly traumatic to young clinicians in training who may be blindsided by such behavior, have no prior experience and do not know where to turn.

 

In researching this article, I interviewed a medical ethicist, a malpractice insurance agent and a clinical psychologist to learn and then share their recommendations for any young healthcare professionals faced with an experience like mine. All three disciplines are germane to such encounters.

 

Perspective of Ethics

From an ethical perspective, there are two dimensions. First, that of the perpetrator. The attending in this account violated fundamental ethical principles by abandoning a patient who faced a life-threatening complication that he induced. As the legal climate has evolved over recent decades, this could even constitute a criminal offence leading to conviction and incarceration.

Second is the perspective of the subordinate or coworker. All of us who serve as healthcare workers have an ethical responsibility to report and address misconduct that might endanger patients. CMDA has issued a position statement entitled “Christian Response to Adverse Outcomes Arising from Medical Error.” With regard to errors that are not our own, it advises we “should work to prevent future occurrence.”

 

There’s also a legal aspect. Most states have legislation in force that mandates the reporting of impaired physicians. Usually this is because of substance abuse, but it’s not limited to that. In my home state of Alabama, for example,

 

“Ala. Code § 34-24-361(b) provides that licensed physicians are required to report to the Board or the Commission any information they may have which appears to show that any Alabama licensed physician may be unable to safely practice medicine by reason of alcohol/drug abuse, mental or physical condition, or any other reason.” [emphasis added] [source]

 

We can actually be held liable for not reporting. Note the reference above to “mental or physical condition,” as we need to examine this more closely.

 

Perspective of Liability

When I was still in the emotional aftermath of my experience many years ago, thoughts of justice filled my head. I fantasized about calling the patient’s survivors anonymously and reporting the circumstances of their loved one’s departure. Thankfully, I never did. It would have been extremely foolish, and the one most harmed would likely have been me.

 

According to the malpractice expert, had a lawsuit been initiated I almost certainly would have been listed as a defendant. Imagine the awkwardness of testifying under deposition (or in a courtroom) in a case that might bring disgrace upon your entire training program. Had the plaintiffs prevailed, it would have been permanently on my record as a judgment against me, to be reported on every future job and license application.

 

According to the experts, if you ever find yourself in such a situation, notify your malpractice provider immediately! Even before talking to anyone else. You should, and must, then notify your program director or department chair, or whoever is above the person of concern within your organization. (If your department chair orders you to tell no one, you are off the hook if you’ve already discussed it with your malpractice carrier). Normally, if you are a trainee and report it to your department chair, you would be in the clear for reporting it directly to the state medical license commission, but that may vary from state to state.

 

Perspective of Psychology

Sometimes, we are dealing with much worse than abrasive, arrogant or reckless personalities. There are significant numbers out there with diagnosable mental illnesses beyond the more familiar depression, neurosis or addiction. This would include those with narcissistic personality disorder, borderline personality disorder, antisocial personality disorder and clinical psychopathy. In social psychology, the “dark triad” is comprised of Machiavellianism, narcissism and psychopathy. The three may present together or in various combinations.

 

Psychopaths are notorious for self-serving ambition, absence of integrity and callous indifference to others. They also tend to be charming, persuasive, charismatic and excellent liars. Somewhere between the average Joe and Adolph Eichmann are plenty of people with psychopathic traits who never descend into violence. Some become CEOs or department chairs. In the upper ranks of management, psychopaths are three times more common than among the general population.

 

A coworker or trainee should not be concerned over making the specific diagnosis, but they should be aware such conditions exist and seriously consider whether the behavior is evidence of something much deeper than “just having a bad day.”

 

While I was clueless at the time, the abuse targeted at me many years ago, when I was pulled aside for a personal attack, is a common ploy among pathologic personalities. It is called “gaslighting,” after the 1944 film where a psychopath schemes to make his wife doubt her sanity. This is one strategy bullies use to control anyone who might resist them. Once you see through the scheme, it is effectively neutralized. Recognizing it is necessary for your own emotional well-being.

 

After such encounters, psychologists stress the importance of talking over the experience with trusted friends and colleagues. As Scripture advises, “…in the multitude of counselors there is safety” (Proverbs 11:14b, NKJV). Don’t suffer in silence. I felt much better after co-residents spoke of similar experiences with the same individual. Not everyone felt that way. Some actually liked him, though they were in the minority. This is normal. Psychopaths and those with related disorders are often charismatic and effective at winning the trust and support of the ones they happen to favor (typically the ones who are flattering and loyal).

 

Such experiences can be emotionally traumatic and leave lasting harm. Workplace situations can be every bit as emotionally stressful as a bad marriage. While Christians are under a moral obligation to try and save a bad marriage, a job is not in that category. It is completely appropriate and healthy to avoid such people when you can. If there is someone you cannot work with, it’s perfectly all right to ask (humbly) to be assigned somewhere else without raising it to Defcon 1.

 

Finally, consider a job change if they are likely to remain in authority over you, or at least keep your options open. Don’t feel loyal to them. They aren’t loyal to you.

 

Conclusion

Some may be very fortunate and never cross paths with a narcissistic or psychopathic colleague or supervisor. For most, it’s less a question of “if” than “when.”

 

When it happens, all three elements above—the ethical, the legal and the psychological—must be recognized and addressed. Our ethical obligation consists of protecting the best interests of our patients. Our legal responsibilities include rapid and frank communication with malpractice insurance providers and medical license boards (according to your own state’s requirements).

 

I would warn us all to be humble, though. We may strongly believe that malpractice has occurred, but we could be wrong. That determination is not ours to make, as it belongs to the insurers and supervisors. Finally, we have a genuine and biblical obligation to protect ourselves from harm, both psychologically and professionally. This includes finding support among trusted friends and families, talking it through and looking out for attempts to deceive, manipulate or otherwise harm us.