When I was in medical school (longer ago than I care to admit), there was a popular (if somewhat cynical) theory among the students that the top third of the class makes the best researchers and professors, the middle third the best clinicians, and the bottom third the most money. In other words, the bottom third would probably have the busiest practices.
As I look back over the years, and considering my own class experience, I find the theory reasonably accurate. I also find it applicable to the residents in plastic surgery that I have helped to train over the past four decades. Seen from a slightly different perspective, the corollary to this theory is that you do not necessarily have to be a brilliant scholar to be a highly successful surgeon. As I look at some of my high-profile colleagues, I am struck by certain personality characteristics that the most successful among them have in common: that odd combination of charm, sensitivity, and warmth often referred to as “bedside manner” by the public.
Unquestionably, competence is the ultimate criterion of success in our craft, but I have seen any number of situations where the surgical result was frankly poor, yet no claim was filed. In contrast, all of us have also seen great results in unhappy patients. Often when you probe enough, you find out that the problem is not rooted in the physical results but rather in the interplay of personalities or the “chemistry” between surgeon and patient. It is easy to dismiss these conflicts by attributing them to unfulfilled expectations. Perhaps if there had been greater candor or better rapport, the surgeon might have sensed that this was a dubious candidate whose expectations were in fact unrealistic to begin with.
Personality characteristics, regrettably, are not teachable in a classroom. They are a combination of the individual's genetic program and what he or she learned at mother's knee. All of us recognize colleagues we know who are extraordinarily gifted surgeons but who are perceived as cold or aloof. Their exceptional talent and intelligence sometimes make them appear impatient and contemptuous or arrogant and patronizing.
Within the ranks of private practices, large group and academic personnel, there is an almost stereotypical caricature mindset of which sector has the most “prima donnas.” Whereas none of this has any solid basis in fact, there is little question that “ego” problems among those of us who have undertaken to convert the homely into the beautiful often play a seminal role in the typical interpersonal relationship conflicts. Just look around you. No one disputes the fact that “need recognition” is the fuel that propels all humans to greater efforts and innovation, which in turn benefits humanity. History is filled with examples of great advances in all fields or human endeavor driven by the quest to excel (i.e., channeling one's ego needs in constructive directions). Unfortunately, this energy sometimes becomes distorted, and that can create a variety of problems, some of which unfortunately wind up on the slippery slope of the malpractice attorney's doorstep.
My psychiatry professor, a brilliant, intuitive, and witty character, had a theory that medical students go into the various specialties not necessarily because of a burning interest in those specific types of problems but because they were motivated to do so by their individual personality makeup. Surgeons, he felt, had a weak ego structure and a substantial need for recognition. Whether all this is valid or not, I think it is fair to say that when ego need is channeled into directions other than excellence in surgery (e.g., money, status, power), the physician often becomes the subject of controversy.
Although there are no studies relating medical liability claims to personality factors (it would be virtually impossible to structure a valid one), I am always greatly impressed by the importance that experienced defense attorneys and claims professionals place on this aspect of the doctor's defensibility. It is difficult to exaggerate the role that personality—whether that of the defendant or of the expert witnesses on either side—plays in the attorney's game plan. It does not matter whether he or she is assaulting the occupant in the witness stand or preparing the client's defense. Exit polls consistently reveal that juries are at least as heavily influenced during deliberations by their feelings about the players as they are by the facts in the case. Regrettably, it is the stress that malpractice litigation induces in the average physician that understandably tends to distort that doctor's normal personality pattern. This, in turn, could make the difference between a defense's and plaintiff's verdict. Until the unlikely time arrives at which we can shift to an effective alternative dispute resolution scheme, surgeons must accept that behavior and personality pattern play an absolutely critical role in the outcome of a malpractice action.
Not too long ago, we looked at the art of communication in relation to medical liability. Although it plays a vital role, accurate communication skill sometimes bears little relationship to personality. How many times have you asked a new patient who has been seen by an articulate, competent colleague, why he or she did not have his or her surgery there. How many times have you heard the reply “because I did not like him”? You may see yourself as warm and fuzzy, but the patient may perceive you as a bit of a cold fish. Once again, it is a matter of interpersonal chemistry.
In a number of large claims, an experienced defense attorney or claims professional's job is made vastly more difficult by a surgeon's difficult personality. A number of carriers have instituted communication and behavioral modification workshops for those they insure. On the whole, they have been a flop because busy doctors look on this type of effort with ill-disguised disdain. In the realm of aesthetic surgery, we understand the concept of “body image” better than anyone else. However, body image encompasses more than merely how you think you look in your mind's eye; it also covers who and how you seem to others. In the pressure cooker of malpractice litigation, those little surface cracks on your shell, camouflaged by professional “cool,” may quickly become alarming crevasses.
If you have ever had a major illness or if you have ever taken care of severe burns, you will understand how dependent the patient becomes on those who are taking care of him or her. When you are the target of a malpractice lawsuit, it is not very different from an illness. It is as much of an insult to your integrity (your mind and soul) as the blood clot is to the lung or the heart.
That is when you become vulnerable. To survive, you must put your trust in your claims representative and defense counsel. You may think no one can really feel your pain, but both of these litigation professionals understand what you are going through. This time, you are the patient. Although we all know that doctors make the worst patients, in this setting, regardless of the circumstances, your own personality characteristics may determine whether the verdict comes back as 12 to 0 for the defense or as several million dollars in punitive damages (Fig. 1).
Oh wad some power the giftie gie us
To see oursels as ithers see us!
It wad frae monie a blunder free us,
An' foolish notion.
To a Louse (1786)
—Robert Burns, 1759–1796