The culture of a medical practice rests on the ability of people to bring their expertise, commitment, and talent to work. Narcissists threaten organizational culture with traits such as entitlement, grandiosity, lack of empathy, and behavior that prioritizes self-interest rather than team or patient outcomes. This article is addressed to physician leaders who must ensure that staff and physicians help create and contribute to, rather than harm, the work environment. The damaging effects of a toxic personality include harm to patients and to the practice’s reputation, quality outcomes, morale, and finances. Difficult interpersonal interactions and the persistent nature of the traits mean that feedback is difficult and course correction unlikely.
Only about 5% of the population has a narcissistic personality disorder, but they create the majority of Human Resources (HR) nightmares in medical groups and hospitals. It is the responsibility of physician leaders to be able to spot narcissistic traits. Why? Because leaders have to make sure they don’t hire, don’t allow others to hire, and don’t promote, a narcissist.
“He finds a way at every meeting to question my credentials to be the Chair—and then he derails the agenda!” — physician leader describing a narcissistic colleague
Leaders must discipline those who abuse power and who put their personal agendas above the needs of patients or colleagues. Unfortunately, the deck is stacked against physician leaders who stride into this arena without being prepared to deal with the entitled, dismissive behavior of narcissists. The best strategy? Don’t hire them in the first place.
Before spelling out some of the behaviors to look for, I will describe why it is crucial to keep narcissists off your team. Narcissistic personality disorder is a constellation of traits that are persistent (not intermittent) and include profound entitlement, lack of empathy, and preoccupation with garnering admiration and power. It is ego-syntonic, which means narcissists view their own traits favorably. I once had a disciplinary discussion with a dermatologist who had gutted the morale of her department and precipitated numerous complaints. She was flummoxed that I could not grasp how wrong everyone in her department was. When I told her she was not a good fit with our medical group she said: “I fit in here perfectly well—someone has to address the incompetence of the dermatology staff. I’m wondering whether you are a very good fit for your job.”
According to Cavaiola and Lavender, in their book Toxic Coworkers, “People with personality disorders will often see their symptoms as virtues that they are quite proud of and don’t wish to change. The fact that personality disorders are ego-syntonic makes people with personality disorders particularly exhausting to deal with, because they have no particular desire to transform themselves—they don’t believe there’s anything to change.”(1)
The Harm Done
In remarkable contrast to their outsized self-assessments, narcissists do a lot of harm. Narcissists are likely to:
Increase costs by:
Causing the creation of expensive work-arounds because people avoid them;
Increasing staff and physician turnover due to abusive interactions;
Requiring costly disciplinary interventions and terminations; and
Spurring staff to “discover” their FMLA and sick leave benefits.
Narcissistic physicians can cause:
Delayed referrals, because colleagues wait until someone else is on call; and
Delayed alerts from nurses about patients, because nurses do not want to deal with the condescension, criticism, and blame.
Narcissistic nurses and staff can cause:
Harm with interactions that disregard patients’ feelings in order to prioritize staff convenience;
Shame and harm to vulnerable patients with careless or judgmental comments;
Loss of patient confidence in the quality of care by physicians and others; and
Reduced compliance with treatment plans and follow-up visits.
Deep-six morale by:
Creating mistrust and fear and thus reducing participation and innovation;
Degrading collaboration when they assume their desires will be prioritized;
Creating drama and conspiracy theories, especially regarding leadership; and
Convincing leaders of their indispensability by highlighting or inventing the shortcomings of others.
Narcissists’ hair-trigger for perceiving inequity and discrimination means they are more likely to file frivolous claims.
Entitled behavior (“the rules don’t apply to me”) increases the likelihood that they will trigger others to file harassment claims and union grievances.
Narcissists are more likely to blame and name others when patients are dissatisfied rather than seek solutions for all—their behavior and comments can create a fertile environment for malpractice claims.
Physician leaders, who are responsible for guiding their teams to excellent outcomes, cannot risk allowing a toxic personality to jeopardize their group, their patients, and their own leadership credibility. Avoid hiring people with narcissistic traits—and if it is too late for that, tackle whatever level of discipline is needed to protect your teams and high performers. If clarity of expectations and documentation of potential consequences does not rein in the unacceptable behavior, then take the steps needed to expel the narcissist from the organization. Above all, be exquisitely careful when promoting people into leadership positions (and if someone else is the decision-maker—be vocal with your concerns). According to Larson and LaFasto, “The most severe complaints about team leadership from team members involve leaders who are unwilling to confront and resolve issues associated with inadequate performance by team members.”(2)
Behavioral Evidence of Toxicity
A constellation of behaviors and traits is outlined in this section. By being hypervigilant in ferreting out narcissistic traits at the time of hire, you are investing in a future with less drama and fewer disciplinary conversations.
“I am so very special. There’s no one like me—I deserve the best.” Narcissists see themselves as special and require the spotlight to be squarely on them. Their exaggerated sense of self-importance means you won’t hear about the contributions of others. Heck, you won’t even hear about the existence of others—unless somebody needs to be blamed.
The narcissistic staff person or physician colleague is likely to be one of the first people to swoop in to “orient” and “help” a new organizational leader. This ease of ingratiating themselves with leadership is evidence of grandiosity—after all, the narcissist belongs with other special people.
RED ALERT: Narcissists perform very well on stage, and are often compelling and articulate as they describe their unique and heroic accomplishments. The narcissistic candidate gives an outstanding performance during an interview.
Blame, Criticism, and Contempt
“Because you’re not special like me, I am free to treat you like dirt.” The phrase “kiss up and kick down” applies to the narcissist’s tendency to flatter those perceived as particularly powerful and special, and abuse everyone else. The disdain and condescension that narcissists display to people, especially subordinates, is soul-destroying. In the recruiting process, it is important to get feedback from everyone who has had interactions with the candidate before he arrives in your office: the receptionist, the credentialing staff, office administrators, and the recruiters. When I coach leaders who are dealing with tough performance management conversations, I ask them to notice if they’re feeling incompetent or inadequate during the conversation. That can be a clue that they are dealing with a toxic personality. The narcissist’s tendency to externalize blame and disdain others means they can quickly turn the tables even on skilled leaders who attempt to give much-needed feedback.
Contempt for others can show up in an interview setting if your candidate has not learned to mask his disdain for those perceived to be less important. A memorable interaction for me as a young leader was an interview with an experienced physician in another specialty. He could not imagine the relevance of our meeting—or for that matter, the relevance of me. He slid his chair back, thrust his gut out with his hands behind his head and elbows splayed wide, and dripped with disdain at my probing questions. Too bad we can’t always count on having such a neon sign of narcissism! More likely, your candidate will be cognizant of your authority, and her grandiosity will manifest as a charming commitment to help you overcome obstacles and create superb outcomes.
In an interview setting, listen for the narcissist to point out how things went wrong in previous work settings and see where she assigns fault. If the candidate has even a modicum of interview skills, she will not bad-mouth previous colleagues and work places. However, she might tip her hand by being incapable of telling a convincing story of her own failings (a convincing story is one in which she actually failed—not a story where the grand finale reveals she was right all along).
Elevation to Leadership Exacerbates Grandiosity
Narcissists are attracted to leadership positions and will work hard to attain their rightful position above the proletariat. Other personality disorders can be aggravating to deal with, but the propensity of narcissists to end up in leadership roles makes them potentially lethal to an organization. A lack of empathy or respect for others ought to disqualify anyone for a physician leadership role or any kind of office management or staff supervisory role.
Beware the staff person who comfortably ingratiates herself to you, has many ideas for organizational “improvements,” and plops down in your office with a conspiratorial air to share her concerns about her teammates. The narcissist will find fault with her colleagues, see the physician leader as her peer, position herself as indispensable, and vie for a supervisory role. To an overextended chief, chair, or CEO, she will look like an answer to the chaos. Don’t be lured into that trap. The narcissist will create chaos and drama that she will then, with great fanfare, convince you that only she can fix.
In top leadership positions, narcissists exemplify the adage “power corrupts.” A need for adulation combined with thin skin means the narcissistic leader gets zero feedback, gives zero credit to others, and makes hiring decisions and initiatives that serve them, not the organization. The tendency to demonize people gets worse as power further disinhibits their behavior. Rock-solid leaders and ethical clinicians with the courage to speak up find themselves in the “out” group. Excellent nurses, administrators, and technicians see the organizational culture collapsing around them and abandon ship before things get worse. Great doctors, high-quality programs, and reputable organizations become casualties of narcissistic leaders and their divisive cliques of self-serving sycophants.
Sexual Harassment and Compliance Violations
Because the rules do not apply to them, narcissists are likely to step over the line with sexual harassment, crude humor, compliance violations, and feathering their own nest. Whether or not a claim of hostile work environment is filed, there will be clues that the work environment is rocketing toward ugly. Excellent nurses, technicians, and other essential employees leave when a narcissist is allowed to abuse power, violate boundaries, and ruin careers.
The Good News: Narcissists Leave A Bloody Wake
How could that be good news? The stability of narcissistic traits means there will be no shortage of damage done in the past—whether in previous work, training, or academic or other settings. This sad fact is the ticket to detection—you must wade into the past of a potential hire. You must check references, because we know the best predictor of future behavior is past behavior. You must check references!
A person with authority and “skin in the game” has to be the one to contact references. Although it has become the norm to crumble in the face of the daunting reference-checking process, this is not the place to compromise your hiring strategy. All sorts of behavioral and competence problems can be introduced if you do not check references assiduously—but the one you will be particularly vulnerable to is the narcissistic personality.
If the physician leader delegates reference-checking when hiring staff, it is critical to ensure alignment regarding the strategy, criteria, and probationary period. When hiring a physician, the reference-checking chore belongs to the physician leader—not to HR, headhunters, or whoever draws the short straw. And “check references” does not mean “wait for those three carefully crafted letters from people hand-picked by your future nightmare.” (Yes, I hear the outcry. There are unending protests about the difficulties, downright impossibility, or perhaps illegality of reference checking as well as all other versions of “can’t, can’t, can’t . . .”) You can get the total scoop on reference-checking at the Fahy Consulting Blog.(3)
According to Iris Hale, VP of HR with Mercy Health Physicians, “We have to make the strategic decision to walk away from toxic candidates even if it’s for a hard-to-recruit position. The fact is they bring down the morale of the whole team. It’s so important to get alignment on this because it can be ridiculously hard to convince a medical group president or the CEO of a hospital to walk away from that toxic pediatric urologist who took seven years to find” (personal communication).
To avoid infecting your organization and bumping off high performers, be sure to recognize the profile of a narcissist and be prepared to dig deep to get a clear picture of a candidate’s past behavior. A toxic hire in any role at any level in the organization is to be guarded against. But an entitled, contemptuous, disinhibited physician is of particular danger and can destroy the culture and reputation of your team and stymie all but the most experienced of leaders. Above all, be afraid of the double whammy that makes you and your organization vulnerable: (1) a narcissistic candidate is likely to wow everyone during an interview—particularly future colleagues desperate for the relief that a competent candidate promises; and (2) lackadaisical reference-checking is a vulnerability your confident candidate will exploit.
BEWARE THE RECRUITING DOUBLE WHAMMY: Narcissists can interview exceedingly well and have a sparkling resume. Many managers shortcut the reference-checking process (aka your best hope of averting the treacherous hire).
Don’t let it happen. It’s our job as leaders to protect our patients, nurses, high-performing teams, and the reputation of our groups and the medical profession from the havoc wreaked by toxic personalities. Let the narcissists go elsewhere so our leadership energy can be spent supporting the real high performers.
Cavaiola A, Lavender N. Toxic Workers in the Workplace: How to Deal with Dysfunctional People in the Workplace. Oakland, CA: New Harbinger Publications; 2000.
Larson CE, LaFasto FMJ. TeamWork: What Must Go Right/What Can Go Wrong. Newbury Park, CA: Sage Publications, Inc.; 1989:36.
Fahy P. Two things needed to hire the right person: tenacity and references. The Fahy Consulting Blog. April 24, 2015..
Subtle Narcissistic Traits
Individuals with a full-blown narcissistic personality disorder create significant problems in the workplace, and their behavior usually is visible and dramatic. More difficult to identify, but equally problematic, are individuals with more subtle narcissistic traits:
Blaming others when things go wrong while easily accepting credit when things go well;
Lack of empathy for the perspective of others;
Difficulty functioning on a team; and
Performing best in a role that doesn’t require cooperating with others.
These subtle traits will create havoc in a patient care setting. Recruiting someone for a team or promoting an individual for a leadership role requires scrupulous questioning for the presence of these subtle signs to avoid the workplace toxicity a narcissistic personality will unleash.
—Jill Steinbruegge, MD, Psychiatrist and former SVP, Permanente Federation, and former SVP, America’s Essential Hospitals
If you work for a narcissist, the word disinhibited will have special meaning for you. Narcissists violate norms in a distinctly disrespectful way, particularly as they gain power. This is the guy who talks with his mouth full (and doesn’t notice when he splatters your report), makes cruel remarks, and turns his back when meeting one-on-one with someone. Lack of empathy means your irritation or disgust doesn’t register or matter. You are invisible.
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