Myths of Invincibility
Origins of Disruption and Distress in Physicians
John R. Whipple, MD; Scott Stacy, PsyD; Peter Graham, PhD; Monica Söderberg, LSCSW
My Story--Introduction
As a son of a plastic surgeon, I grew up idealizing the life of a physician.
From a young man's perspective, I admired the autonomy my father and
his colleagues seemed to have to conduct their careers as they wished.
They seemed to tackle life or death decisions with grace, humor and
dignity. Popular media perpetuated this myth as “Marcus Welby, MD”
showed doctors seriously debating ethical and medical dilemmas with
equanimity and always a happy ending to every episode. Even
“M.A.S.H” characterized doctors in a positive light as they performed
“meatball surgery” and superseded the authority of the US military to
address the traumas of war.
I have gone from wanting to emulate the heroes of my childhood to
appreciating the unique challenges of a life in medicine. Beginning with
the rigors of medical school at the University of Virginia, I began to
realize that being a doctor was not as easy as it looked. During my third
year rotations, I also came to realize that there was more to healing than
procedures or prescriptions. I was struck with the traumatic adjustments
patients and doctors go through as they fight through episodes of illness.
Their stories and the interpersonal conflicts inspired my decision to
become a psychiatrist. I entered residency training at the Karl Menninger
School of Psychiatry in 1987 and became a staff psychiatrist at
Menninger in 1990. It was at Menninger that I was first confronted with
the struggles of other doctors, who presented for outpatient assessments
due to boundary violations, psychiatric complaints or chemical
dependency problems. This early introduction to doctors in distress
eventually lead to my current position as medical director at Acumen
Institute in Lawrence, KS.
Along the way, I have also worked as the medical director of an inpatient
psychiatric facility and a community mental health clinic. These forays
into administrative leadership positions provided me with a unique view
of health care delivery and the institutional challenges that an
organization faces as it interfaces with strong-willed physicians.
Methods of Assessment
Fitness to practice assessments for disruptive and distressed physicians consist of a
multi-disciplinary evaluation that includes review of collateral information from the referral
source, face to face interviews with the physician, computer generated personality and
symptom questionnaires, urine drug screens and in some cases, therapeutic polygraph
interviews. At Acumen Assessments, the Rorschach Inkblot Method (RIM) and ShedlerWesten Assessment Procedure (SWAP-200) are used with other standardized
psychological tests to obtain a comprehensive profile of the clinicians current state of
mental functioning. This multiple dimensional approach to diagnostic conceptualization
of a doctor’s difficulties allows for targeted intervention that promotes sustainable
change.
The Different Faces of Distress
N=608 Physicians
Impaired:
Disturbance of Conduct due to
physical, mental or
Substance abuse disorder.
Distressed:
Subjectively experienced
disturbance in well being
or function.
These physicians feel victimized and while they identify with those persecuted by others,
they are not aware of their tendency to persecute in response. They disavow
identification with the aggressor but hostility permeates interpersonal functioning. Past
traumatic experiences and their basic lack of trust in others to provide nurturing
validation informs anaclitic and melancholic depressive tendencies. Schizoid withdrawal
to avoid further intrusion by perceived dangerous interactions maintains their
psychological status quo and prevents positive reparative experiences from occurring.
Alternatively, histrionic or hysterical dynamics are pervasive as the physicians seek out
external containment even as they push others away.
Implications: Administrators and clinicians will do well to note that these physicians are
inclined to minimize feelings of helplessness and resulting anxiety because it is hard for
them to admit that they need others help. Whenever resentment or feelings of being
mistreated are identified by the physician, feelings of helplessness and unresolved
dependency needs fuel their rage. Their unresolved longings for assistance needs to be
highlighted throughout treatment/coaching. In the absence of nurturing
support/validation, the agitated, dysthymic state of mind and suspiciousness about
others’ intentions is maintained by a conditioned response.
Myth of the Savior II: “I’d rather be right than
liked!”
Disruptive:
Disturbance of Conduct
noticed by others that
impacts clinical
relationships.
The Intensity of Distress impacts
level of care!!
Characterologically based negativity and hyper-vigilant anxiety predominates as these
doctors anticipate attack, exploitation or abandonment. These doctors’ are preoccupied
with persecutory fantasies, tend to distort others’ intentions and project self-critical
elements onto others. As such, verbal attacks occur on others for perceived neglect
when, in fact, the doctors fall short of their professional obligations.
The Origins of the complaint impacts
intervention
Implications: These physicians tend to make things more complicated than necessary
and in the process, lose sight of the interpersonal context of fostering positive
collaboration. These doctors struggle with their inefficiency and project these
shortcoming onto clinical teams. In this way, the “system” is defective instead of their
mental alertness, cognitive processing and narrow perspective. Setting limits on the
scope of professional activities may be needed to decrease their tendency get involved
in everything. These physicians want an external “action plan” that eliminates their
deficiency. Administrators and clinicians need to acknowledge imperfection in medical
delivery systems and help them accept it. Dismissing the imperfections fuels their self
righteousness. Fairness is also paramount to gaining their respect. As such,
consequences for mistakes have to be consistent. They must understand that their role
is to work within the system; not fix it.
The Myth of Invincibility: “If I don’t do it no one
will!”
• Present Complaints: Arrogance, condescending, impulsively angry,
Clinical “bully”
• Motivational Themes: Grandiosity and compulsive activity hides
emotional vulnerabilities
• Developmental Etiology: Driven to success, victims of bullying and
over-idealization of larger than life mentors
(Acute Distress) Axis I: Bipolar Spectrum, ADHD
Figure 1: Personality Disorder (Axis II) T-Scores
• Presenting Complaints: Oppositional Defiance, Hyper-critical of
others and Undermining administrative efforts, Controlling
• Motivational Themes: Self-righteous, morality bolsters self-esteem
• Developmental Etiology: Over-identification with Idealized Parental
Figures
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Myths & Stories
(Acute Distress) Axis I: Dysthymia, primary, early onset
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Figure 1: Personality Disorder (Axis II) T-Scores
Myth of the Savior I: “I must protect the
innocent!”
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Figure 2: Factor T-Scores (Shedler & Westen [2004b] factor scores)
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As a psychiatrist who assesses and treats impaired, emotionally
distressed and disruptive physicians, I want to share my insights into the
doctors’ struggles as their human vulnerabilities confront the ‘myths of
invincibility’. These medical myths, furthermore, continue to inform the
expectations of doctors even as their roles change in modern medicine.
While they are still expected to be at the beck and call of their patients or
institutions, doctors, in many cases, are also placed into double bind
situations of ‘felt helplessness’ that jeopardize both the physician's
professional integrity as well as their personal health. This conflict, both
internal and external, leads to the high rates of suicide, divorce,
substance abuse, and disruptive conduct documented in the physician
wellness literature.
• Presenting Complaints: Hostility, Anger Dyscontrol, Disorganization of
time, neglect of administrative tasks
• Motivational Themes: Identification with the Victim
• Developmental Etiology: Unresolved Childhood Trauma
(Acute Distress) Axis I: PTSD, Major Depressive Disorder.
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Dr. Red
Dr. Green
Dr. Blue
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Figure 1: Personality Disorder (Axis II) T-Scores
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Figure 2: Factor T-Scores (Shedler & Westen [2004b] factor scores)
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Dr. Red
Dr. Blue
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These physicians justify their risks or their conduct because they feel as if they work with
patient populations that have few alternatives or that they are the best at what they do.
Their grandiosity can escalate, under duress, into frank hypomania.
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Dr. Red
Dr. Blue
On psychological testing, these physicians clearly elevate into pathological levels of
narcissism. They cannot understand why others’ see them as disruptive to care, since
they feel that their medical mission is far more important than ‘petty’ complaints about
them. The self vs. others’ experience-perception is related to tendencies to disavow
negative emotional experience through compulsive, self-assertive action. They pursue
their agenda with a determined, head down, “full speed ahead” demeanor that ignores
the sensitivities or concerns of others. Impulsive or reactive episodes of anger occur if
others’ interfere or question their approach to practice. Their compulsive, domineering
style keeps them unaware of their own emotional needs as well as those of others.
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Figure 2: Factor T-Scores (Shedler & Westen [2004b] factor scores)
Typically, these physicians feel as if the department or institution does not have
enough quality resources, and that physicians are expected to do too much with too
little. They feel decisions are made contrary to their opinions as if they are not heard.
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This poster represents a sampling of our work together.
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Finally, my story would not be possible without the
collaboration and companionship of my brilliant partners:
Scott Stacy, PsyD; Peter Graham, PhD and Monica
Söderberg, LSCSW.
Dr. Red
Dr. Blue
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In this presentation, developmental and present day risk factors that
contribute to physician burn out and impairment will be discussed.
Motivational themes, intentions and personal myths will be shared as
gleamed from the case histories of representative physicians in distress
seen through the work at Acumen Assessments and Acumen Institute
(n=608). By sharing the stories of real doctors who are struggling as
well as the intra-psychic factors that drive them, this presentation may
help inform executive decisions that allow for sustainable well-being in all
the parties involved.
Dr. Red
Dr. Green
Dr. Blue
Dr. Red
Dr. Blue
Psychological testing suggests a poverty of warmth, joy or internalized feelings of
nurturance. In this absence, interpersonal slights and demands subsequently are not
balanced by self-soothing affects that carry the moment or discharge burden.
Thought process tends to be overly complex, muddled and bound up in rather
obsessive attention to insignificant or obscure details. This type of thinking lends itself
to privately elaborating self-determined priorities that exclude the needs of others. In
fact, they alienate others since they do not understand why others do not see the
problems like they do—e.g. the right way.
Implications: These physicians need clear, set limits to their professional activities,
which may cause a double bind for the institution, since they tend to be high producers.
Limiting “add-ons” to their schedule–make them choose which procedure is most critical- or elective procedures the day after call may help. Do not extend the clinical day for
their urgency. Appealing to their narcissism and mirroring their value is key but their
disruptive conduct must be condemned. These doctors can be effective leaders, which
may be a carrot to use, but they must model professional conduct prior to promotions.
1.
2.
Shedler, J & Westen,D. (2004b) Refining DSM-IV Personality Disorder diagnosis: Integrating Science & Practice, Amer. J. of
Psychiatry 149, 358-362.
Stacy, S., Graham, P., Athey, G. (2008). The Use of the Rorschach in Professional Fitness to Practice Evaluations. In
Gacono, C., Evans, B., & Kaser-Boyd, N. (Eds.), The Handbook of Forensic Rorschach Psychology. Mahwah, NJ: Lawrence
Erlbaum Associates.
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