THE FOURTH “A” IS FOR ARROGANCE

THE FOURTH “A” IS FOR ARROGANCE

John Ehrlichman is the face of arrogance. In the dictionary, next to the definition of arrogance should be a picture of Ehrlichman. Who is John Ehrlichman? He was an attorney and confidant of President Richard Nixon who served as Nixon’s White House counsel and advisor for domestic affairs. Ehrlichman was deeply involved in the Watergate scandal that ultimately led to Nixon’s resignation. I can still see the smug and cocky smirk on his face during his testimony to Congress in 1975 and thought to myself “what an arrogant man.”

Ehrlichman’s testimony in the Watergate investigation did not win him any friends, nor did his attitude endear him to the public. He appeared haughty, annoyed, and above all that was happening. He was convicted of conspiracy, obstruction of justice, and perjury in the Watergate affair and spent a year and a half in prison. Something about his demeanor told me this was not a humble, introspective man. 

An attitude of arrogance is pervasive among people in politics and public life. After all, they are smarter than you! Or that’s what it seems they think. In their minds, they have achieved a level of status and power that singles them out for greatness. You couldn’t possibly know what they know so their way and their opinion is always the right one. Unfortunately, far too many people in the medical profession have the same attitude. It affects the medical profession and the doctor-patient relationship negatively. 

I frequently hear people complain their doctor didn’t listen or interrupted their conversation. “The doctor didn’t want to hear what I had to say. The doctor talked down to me, was dismissive of my concerns, or had his mind made up before I could speak;” the “I’m-smart-and-you’re-not” attitude that destroys trust and confidence. As a previous blog stated, good physicians possess the three “A’s,” Ability, Availability, and Affability. I contend there are many doctors who don’t listen, dismiss your input, make you feel inhuman, and are harsh and non-compassionate. As such, they are displaying the fourth “A,” arrogance.

Arrogance is “a high or inflated opinion of one’s own abilities, importance, etc., that gives rise to presumption of excessive self-confidence or to a feeling or attitude of being superior to others.” It potentially may be at the root of many problems in interpersonal relationships on many levels, the doctor-patient relationship foremost among them. Any doctor who displays an attitude of superiority over others, is dismissive of a patient’s opinions, dehumanizes a patient by referring to them as “a case” or “the gall bladder in 328A”, withholds information from the patient, or is abrupt, unsympathetic, uncaring, or authoritarian is displaying arrogance. It is all too common.

How do people become arrogant? Is it an inbred personality trait or learned behavior? I don’t really know, but I think it narrows down to the difference between being a nice person or not. I think arrogance is reflective of a person’s personality and their level of compassion for the problems of others. 

During the past 10-20 years the medical profession has given itself a few black eyes and bruises. Some physicians have failed to earn the three good “A’s” and have settled into the 4th “A,” instead. Sexually abusing female gymnasts, surgeries that have bad outcomes, fraudulent insurance claims, and coercing patients into unnecessary procedures are examples of arrogant, self-satisfying, and unprofessional behavior. 

Theoretically, students go into medicine for altruistic reasons. They want to help people. Disease, and the diagnosis and treatment of it, is intellectually challenging, and can actually be very stimulating and exciting. To diagnose someone with a disease you recognize from having read about it, gives you a sense of accomplishment. I really have learned something. Or I hear a heart murmur I’ve never heard before; or feel that spleen—it’s the biggest one I’ve ever seen! Successful diagnoses, discovering a physical finding others have overlooked, delivering triplets, or successfully resuscitating a patient can result in a doctor thinking he/she is pretty hot stuff. I must be as good as I think I am. 

That intellectual superiority spills over into the attitude the doctor has toward the common man. Suddenly, the doctor doesn’t have time to listen, doesn’t care what the patient says, doesn’t explain things, and just says, “Leave it to me, I’m your doctor.” It’s here the trouble begins. Patients feel like their feelings are unimportant and their questions are ignored. Interaction with the doctor becomes totally one-sided and confidence and trust begin to erode. 

This attitude needs to be called out by colleagues who observe it. Medical educators need to provide good examples of proper doctor-patient interaction, show compassion, and allow patients to speak. They should observe how students relate to patients and critique them emphasizing proper responses. The time to mold proper behavior is during training before bad behaviors become ingrained. 

A doctor needs to recognize how he/she reacts to an illness or injury of a patient. Do I feel any emotion at all? Does the situation sadden me? Do I feel sorry for the patient’s predicament? Can I remain detached from the emotion of the situation? Should I become emotionally involved in the situation? Most educators would teach students to be stoic, unemotional, and disinterested. If you’re emotionally involved it might cloud your judgement. I can’t see any situation where it would be bad to feel compassion and empathy for a patient. In my mind that attitude doesn’t exist, but it does in many. You, the doctor, are to avoid emotional attachment and merely be the treating physician. Let the nurse or chaplain be the emotional support animal. When that happens, the doctor and patient communicate poorly, or not at all. The one person the patient has trusted, the doctor, is no longer there for emotional support. The relationship is broken. 

“Empathy involves an interest in and understanding of patients’ experiences, concerns, and perspectives associated with illness combined with a capacity to care and an intention to help.” Enhancing empathy in future physicians “is one of the important tasks of medical education.” Clinical empathy “can, and should be, cultivated and enriched, but studies have shown a decline in empathy during medical education….Medical educators have employed a variety of methods and approaches to enhance students’ empathy….exposure to role models” is one method. 

Never during the four years of medical school and three years of internship and residency was I exposed to a physician “role model” who addressed patient interaction. Yes, I observed staff physicians and faculty interact with patients, but can’t recall any who said this is how you do it. The methods and reactions I used were learned on my own and fashioned after the physicians I observed. One such example was Dr. Walter Briney who always asked his patients if there was anything he could do for them today. Is there anything you need? One of the least communicative med school faculty members was the doctor who was by far the best lecturer. On rounds he never talked to the patient, never examined him (all males at the VA Hospital), and was a wealth of knowledge, but was aloof. I wouldn’t call him arrogant, but it was close. 

Dr. G’s Opinion: As I referred to above, arrogance is a personality disorder one develops from an inflated ego. That comes form being full of yourself as a substrate. Arrogant physicians are cocky and self-absorbed long before they become arrogant. The “Three A” physician is the person who was kind and caring to begin with and carries that behavior over into his relationship with patients. 

The arrogance of some physicians also is expressed toward their colleagues. That was the case with the general surgeon at the Air Force Hospital when I was in the service. He had no use for general medical officers like me and made it very clear. He was a surgeon, and I was a lowly GMO. Thank goodness he was only there for one year. The same attitude was true of our internist from upstate New York. He was so disagreeable he was sent to Thule, Greenland his second year.  He was unbearably arrogant and upset a lot of patients. His wife had a disagreeable way about her, too. They were not missed.

I don’t think either of these doctors learned to be arrogant during training. I think they were that way to begin with. I do agree, however, that as they gained knowledge, prestige, and technical expertise, their self-images and egos grew immensely. It carried over to every interpersonal interaction in their lives, and they were universally disliked. My interaction with them was 50 years ago, and I’m still stewing about it! They are the two most memorable physicians I ever encountered.  

The doctor-patient relationship that instills trust and confidence is very important to the patient getting well. A physician’s attitude contributes to that 100%. The patient who dreads the doctor’s visit is an unhappy person, will have a negative impression of the medical profession, and will be skeptical of the physician’s motives. I sincerely hope medical education will place renewed emphasis on physician attitude and patient interaction as much as they do on scientific medical knowledge. 

References: Working Party of the Royal College of Physicians. Doctors in Society: Medical professionalism in a changing world. Clin Ned 2005 Nov-Dec;5(6 Suppl 1):S5-40.

Ruberton PM, et al. The relationship between physician humility, physician-patient communication, and patient health. Patient Educ Couns 2016 July;99(7):1138-1145.

Ziolkowska-Rudowicz E, Kladna A. Empathy-building of physicians. Part I—A review of applied methods. Part II—Early exposure of students to patient’s situations. Pol Merkur Lekarski 2010 Oct;29(172):277-286.

Hoffenberg R. Medical Arrogance Clin Med 2001 Sep-Oct;1(5):339-340.

Cowan N, et al. Foundations of Arrogance: A broad survey and framework for research. Rev Gen Psychol 2019 Dec 1;23(4):425-443.

Milyavsky M, et al. Evidence for arrogance: On the relative importance of expertise, outcome, and manner. PLoS One 2017 Jul 6;12(7):e0180420.

Berger AS. Arrogance among physicians. Acad Med 2002 Feb;77(2):145-147.

Singh M. Intolerance and violence against doctors. Indian J Pediatr 2017 Oct;84(10):768-773.

Rosenfeld PJ, Jones L. Striking a balance: training medical students to provide empathetic care. Med Educ 2004 Sep;38(9):927-933.

Schneider PB. Psychological and psychodynamic education of physicians. Rev Med Susie’s Romande 1997 Sep;117(9):721-725.

Sackett DL. The arrogance of preventive medicine. CMAJ 2002 Aug 20;167(4):363-364.

Shapiro J. Walking a mile in their patients’ shoes: empathy and othering in medical student’s education. Phil Eth Hum Med 2008 Mar 12;(10).

https://www.journals.lww.com/academicmedicine/full text/2002/02000/arrogance-among-physicians