ethics news & views: John Banja interviews himself on his book "Medical Errors and Medical Narcissism"

March 01, 2005

John Banja interviews himself on his book "Medical Errors and Medical Narcissism"

Question: So why the interview with yourself?

Answer: Because I not only know the best questions to ask, I also know the answers. Plus, interviewing yourself is a great way to control the interview.

Question: It’s kind of narcissistic, though.

Answer: True, but that doesn’t mean it’s psychologically unhealthy.

Question: Well, maybe we’ll discuss that later. With a title like “Medical Errors and Medical Narcissism,” do you think any doctors will read the book?

Answer: Well, some will be turned off by the title. But I tried the title out on dozens of physicians as I was writing the book, and I was heartened by a fairly consistent reaction, which was their eyebrows ascending on their foreheads and their saying, “Interesting …” A few looked at me crossly, though, and said, “What’s your evidence?”

Question: That’s a good question. What is your evidence? In fact, what is the claim you’re making in this book, that physicians are pathological narcissists?

Answer: No, I’m not saying that and I make repeated attempts in the book to remind the reader that I am not making that claim. The claim I really want to make is that medical training, in fact healthcare training in general, has lots of narcissistic traps or temptations for trainees to succumb to.

Question: Like what?

Answer: Well, look at the “perfectionist” model that so many physicians were and sometimes still are trained in. Their supervising physicians expect them to be errorless. Their patients expect them to be perfect. It’s easy for physicians to buy into the perfection myth, so it’s no wonder that physicians tend to be compulsive. All compulsives are somewhat narcissistic, incidentally, because they understand their “perfect” work to be an extension of their “perfect” selves.
Then there are what I call “deification projections,” where patients literally deify their doctors. If you have a significant need for approval and respect—and some psychiatrists and psychoanalysts opine that many people who choose medicine as a profession do have that need—the adulation and respect you get from so many patients is a narcissistic aphrodisiac.

And then there’s the dawning realization on the health professional, especially the physician, of all the power he or she has and how easy it is to overwhelm patients with your authority.

Then there are physicians who do incredibly risky procedures on a daily basis. Consider the immense confidence they need to have in themselves to do that kind of work and how easy it is for some to go overboard. Indeed, there’s a bit of literature that suggests that virtually all physicians entertain “omnipotence” fantasies—in other words, “I can do anything” fantasies—at some point during their training, often just as a coping mechanism to get through the emotional trauma of internship and residency. When I consider it all, I’m amazed at how most physicians seem able to resist or overcome these temptations.

Question: So is the idea that health professionals who cultivate these perfectionist traits are going to have trouble managing medical errors when they occur?

Answer: That’s part of the idea. A bigger part, however, is that these persons, in fact, most professionals of any ilk, work on cultivating a self that exudes authority, control, knowledge, competence, adequacy, and respectability. Virtually all professionals do that—it’s the narcissist in us all. We all dread appearing stupid or incompetent.

The problem, I think, is that health care is so unpredictable, uncertain, stressful, and contains such high-stakes, that many practitioners exaggerate their competence. They come to believe that one ought never appear ignorant, uncertain, hesitant, or wrong. They work hard on convincing themselves and others that they are eminently capable, indeed, outstanding, so that when something like an error does occur, the cognitive dissonance it creates is traumatic because it threatens their self-image. In fact, these professionals fare poorly at anything that threatens their inflated or exaggerated sense of self—like communicating a nasty diagnosis to a patient or doing a death disclosure to a family member. They can’t stand anything that threatens their need to feel adequate and “solid.”

Question: So, again, where’s the evidence for this?

Answer: Probably the best evidence is in the form of thousands of people who suspected that they or a loved one was grievously harmed by error, but never had their questions about what happened adequately answered by the health professionals treating them. Instead, these people had to go to a lawyer to find out what happened. The legal literature on medical malpractice as well as a lot of anecdotal literature attests to the frequency with which health professionals become hyperdefensive, shift blame, or just emotionally distance themselves from something nasty that happened. I spend an entire chapter in the book on a single case that epitomizes that “distancing.” But maybe the most interesting thing I stumbled across in my research was the way health professionals rationalize their medical errors.

Question: Rationalize?

Answer: Yes. Remember that calling x an “error” is essentially an interpretation. Now, when your self-interest is at stake, such as in not getting sued for medical malpractice, it’s amazing how ingenious one can become in “re-interpreting” what happened.

An error might become a “medical misadventure” or an “incident;” or we decide we don’t have enough evidence to say absolutely that an error caused the patient’s harm; or we decide that maybe an error did cause the patient harm but that the harm wasn’t so bad; or we convince ourselves that the harm was instead a “blessing in disguise;” or that the catastrophe that happened wasn’t my fault—maybe we decide that it wasn’t anyone’s fault.

We’re all tempted to do that, incidentally. It’s very difficult to call a foul on yourself. When it comes to self-assessment, most of us are easy graders.

Question: So basically these are ways the health professional tries to protect him or herself from the emotional pain of owning up to the error.

Answer: Right, and that’s what I call “medical narcissism.” I’m not saying that healthcare professionals are grandiose, imperious, or arrogant, although a small minority certainly are, but then every profession boasts a minority of obnoxious, overbearing narcissists. What I am saying is that there is a kind of atmosphere in health care that can breed narcissistic inclinations and attitudes that make it very difficult to disclose a medical error to a patient in a truthful, honest and ethical way. And encouraging that atmosphere are the malpractice carriers and hospital lawyers who have long insisted that health professionals not admit liability—in other words, not admit error or apologize for it.

Question: Isn’t there a movement going on in health care today, though, that is bucking that tradition?

Answer: Yes. We’re finding out that disclosing error truthfully and honestly isn’t only the ethical thing to do, it seems to be a very cost-effective strategy as well, especially when it comes to lawsuits.

Question: How can people find out about that?

Answer: Read my book.

Question: So you explain in the book this idea of “medical narcissism” and why it’s so hard for certain health professionals to disclose medical error. What else?

Answer: I offer recommendations for tort reform, developing a “just culture” for reporting errors, instructional strategies for overcoming the narcissistic temptations in healthcare, and a chapter on how to disclose medical error empathically. I also spend a chapter on forgiveness.

Question: Forgiveness?

Answer: Yes. How many times have you ever heard of a health professional saying to a patient, “Mr. Jones, we made this dreadful mistake, and we ask your forgiveness?”

Question: You must have had some inspiration for this book. Who were your shining lights?

Answer: First of all, Ovid, who introduced Narcissus to the world in The Metamorphoses, was a staggering genius who understood narcissism much better than Freud. Most people don’t know the entire myth. It’s extraordinary. The other people from whom I learned a great deal are psychiatrists Glen O. Gabbard, Mark Epstein, and James Masterson. Masterson’s book, The Search for the Real Self, is one of the masterpieces of contemporary reflection on narcissism. It’s absolutely marvelous.

Question: You alluded at the beginning of the interview to the idea that narcissism isn’t necessarily unhealthy…

Answer: Yes. We should all strive to be healthy narcissists—that is, to have the determination and self-esteem to know what we want in life and feel good and confident about pursing it. But healthy narcissists can also give and receive love; they can sustain healthy relationships, and they’re not crushed by failure. Unhealthy narcissists can’t do that. The great fallacy we make in thinking about unhealthy narcissists is that we believe they are excessively in love with themselves. That’s incorrect. Their real pathology is that they are unable to love themselves in a healthy way.

Question: So we should all strive to be healthy narcissists.

Answer: Or strive to overcome the narcissistic formation entirely, as Buddhists would recommend. But that would require another conversation.

Medical Errors and Medical Narcissism. Jones & Bartlett Publishers, 2005. $49.95.

[ Posted by John Banja at March 1, 2005 11:13 AM |