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Rudy proves this every day.

Mirror mirror on the ward, who's the most narcissistic of them all?

Why, it's Rudy Canoza, of course.

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Pathologic personality traits in health care

Vittoria Bucknall 1,?, Suendoss Burwaiss 1, Deborah MacDonald 1, Kathy Charles 1, Rhys Clement 1

PMCID: PMC4674404 PMID: 26644545
Abstract
Background:

Stereotypes in medicine have become exaggerated for the purpose of workplace amusement. Our objective was to assess the levels of 
'dark triad" personality traits expressed by individuals working in different health care specialties in comparison with the 
general population.
Methods:

We conducted a prospective, cross-sectional study within multiple departments of a UK secondary care teaching hospital. A total of 
248 health care professionals participated, and 159 members of the general population were recruited as a comparison group. We 
measured 3 personality traits - narcissism, Machiavellianism and psychopathy - through the validated self-reported personality 
questionnaires Narcissistic Personality Inventory (NPI), MACH-IV and the Levenson Self-Report Psychopathy Scale (LSRP), 
respectively.
Results:

Health care professionals scored significantly lower on narcissism, Machiavellianism and psychopathy (mean scores 12.0,53.0 and 
44.7, respectively) than the general population (p < 0.001). Nursing professionals exhibited a significantly higher level of 
secondary psychopathy than medical professionals (p = 0.04, mean LSRP score 20.3). Within the cohort of medical professionals, 
surgeons expressed significantly higher levels of narcissism (p = 0.03, mean NPI score 15.0).
Interpretation:

Health care professionals expressed low levels of dark triad personality traits. The suggestion that health care professionals are 
avaricious and untrustworthy may be refuted, even for surgeons.

I was quietly admiring my astonishing good looks in the mirror of the operating theatre changing room when one of my 
anesthesiologist colleagues brazenly interrupted me: "Typical surgeon - you love yourselves so much we'll need to have the mirrors 
removed in here if we are to get any work done!" I was somewhat bemused by the 2 obvious inaccuracies in this comment: first, that 
all surgeons love themselves and, second, that theatre workflow is ever dependent on the work ethos of the surgical team! I 
immediately went on the counteroffensive by replying, "Don't worry, sudoku writers are on strike this week so we should be finished 
before lunch!"

These lighthearted, tongue-in-cheek exchanges between medical professionals occur around the world every day and are based on 
popular stereotypes that have become exaggerated for the purpose of workplace amusement. One might imagine neanderthalic orthopedic 
surgeons instinctively reaching for a bigger hammer as the singular solution to any problem, grumpy radiologists growling at anyone 
who dares disturb their dark sanctuary and dour internists glacially grinding their way through a ward round, which necessitates a 
packed lunch, comfortable walking shoes and a hospital map.

Many stereotypes have filtered into the public domain, where emphasis on negative traits can be misleading for the general public. 
The callous notion that doctors are self-centred, avaricious and untrustworthy is currently being bandied around the media.1,2There 
is a real danger of these negative stereotypes eroding the high level of regard in which the profession is held. Perhaps the most 
undesirable personality characteristics are those that form the 'dark triad": a trio of Machiavellianism, narcissism and 
psychopathy.3

Those expressing Machiavellian traits are deceptive, self-interested and succeed through the exploitation of others.4-6 Narcissism 
is defined as a "normal" personality trait at low levels and is characterized by the expression of pride, egotism and 
vanity.7,8Psychopathy manifests as antisocial behaviour expressing callousness, remorselessness and selfishness, with little 
empathy and a high level of impulsivity.9,10 It has been proposed that 2 variants of psychopathy exist: primary and secondary. 
Primary psychopathy is believed to be a genetic predisposition to certain behavioural patterns, which include cool, calm, 
meticulous forward planning and emotional dissociation. Secondary psychopathy, however, is an adaptation to environmental factors 
and involves impulsivity and emotional instability, which can place others at risk.11

It is hypothesized that some of these dark personality traits are present within the health care profession and, more specifically, 
within certain disciplines. It is not implausible for one to conceive that the self-assured surgeon could display evidence of 
vanity or that the irrational nurse might exhibit psychopathic tendencies. However, scientific evidence is lacking to support or 
quantify the existence of such personality traits in the health care profession.

The aim of this study was to assess levels of dark triad personality traits among individuals working in health care in comparison 
with the general population.
Methods

This prospective, cross-sectional study was conducted over a 1-year period (August 2013 to August 2014).

We distributed 280 questionnaire packs to health care professionals in a UK secondary care teaching hospital, a university-
affiliated hospital that provides tertiary care. These paper-format questionnaires were placed in communal areas of clinical work 
and relaxation (although areas of relaxation were often unoccupied!).

Health care workers were invited by poster advertisement to voluntarily complete the questionnaires and return them using prepaid 
envelopes. Eligibility criteria included any health care professional in direct contact with patient care, diagnosis or treatment. 
The health care group was further divided into subgroups: surgeons, hospital physicians, general practitioners, acute medical 
physicians, nurses and those with limited patient contact (e.g., radiologists and microbiologists).

Using snowball sampling, we recruited a comparison group comprising members of the UK general population to provide normal 
distributions. A Web link to the 3 questionnaires was shared through online advertising on social media sites. Participants from 
the general population were self-selected. Before being able to access the questionnaires, participants were required to tick a box 
confirming their consent to participate. This then allowed access to complete the electronic versions of the dark triad 
questionnaire. Once completed, the questionnaire results were electronically returned to a central Web address registered to the 
study research team, where data were accessed for analysis.

We measured the dark triad personality traits using well-validated questionnaire instruments. Narcissism was calculated using the 
Narcissistic Personality Inventory7 (NPI), which comprises 40 paired statements, one narcissistic and one nonnarcissistic, whereby 
the participant marked true or false with reference to themselves (Appendix 1, available at 
www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.151135/-/DC1). Machiavellianism was measured using the MACH-IV, 12 a 20-statement 
questionnaire scored using a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree) (Appendix 2, available at 
www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.151135/-/DC1). Similarly, psychopathy was determined using the 26-statement Levenson 
Self-Report Psychopathy Scale13 (LSRP) (Appendix 3, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.151135/-/DC1).

We undertook an a priori power analysis with the methods described by Faul and colleagues14 using G*Power (version 3.1.9.2). We 
determined a required total sample size of 204 participants to achieve 85% power, a significance level of < 0.05 and a medium 
effect size (0.25 based on Cohen15). In psychologic research, the a priori power analysis convention is used to compute the 
necessary sample size as a function of user-specified values for the required significance level, the desired statistical power and 
the to-be-detected population effect size.

Data were transferred onto an Excel spreadsheet (version 14.5.5). Statistical analysis was performed using the statistical package 
for the social sciences (SPSS, version 21). For each cohort, we calculated a parametric data analysis of the 3 personality 
questionnaires and included the mean and 95% confidence intervals (CIs) for the presence of narcissism, Machiavellianism and 
psychopathy. We used analysis of variance (ANOVA), with Bonferroni post hoc adjustment to account for multiple comparisons, to 
determine whether significant differences in scores from the 3 components of the dark triad existed between the cohorts and 
subgroups. Significance levels were set to p < 0.05.

Participation in the study was voluntary, and all responses were made anonymous.
Results

A total of 248 health care professionals from 23 departments (199 medical and 49 nursing professionals) took part in the study, 
giving a response rate of 88.6%. In the health care cohort, 122 were female and 126 were male, and the mean age of participants was 
40 (range 20-67) years. From the general population, 159 people participated; 113 were female and 46 were male, and the mean age 
was 26.6 (range 17-60) years.

The health care group had lower mean scores for dark triad traits than the general population (Table 1). Using ANOVA, we found 
significant differences for narcissism, Machiavellianism and primary psychopathy (p = 0.003, p = 0.007 and p = 0.008, respectively) 
but not for secondary psychopathy (p = 0.06).