Turncoat Physicians: Why Do They Turn Against Other Physicians?

The personalities of physicians and hospital administrators are polar opposites. Comparisons on the Myers-Briggs Type Indicator show that physicians are more introverted, feeling, and perceiving than administrators, who tend to be more extroverted, thinking, and judging.1 Over time, however, physicians who leave practice for administrative jobs in corporations, health systems, or industry tend to assimilate the characteristics of the men and women in the C-suite.2,3 Once physicians begin to buddy-up with the “suits,” they are prone to losing their focus on patient-centeredness and disregarding their colleagues in the trenches.

Case Examples

For example, many lawsuits have been brought against health insurers for breach of contract and bad faith regarding benefit determinations. In these cases, health insurance medical directors have denied patients medically necessary services and treatment, often life-saving. Perhaps the most egregious case was a medical director who admitted to never reviewing patients’ medical records when deciding whether to approve or deny care.4 In at least one instance, the medical director also said he knew virtually nothing about the patient’s disorder (common variable immune deficiency) or how to treat it.

Another example is a case that was widely discussed online, that of Dr. Anne Phelan-Adams, a family practitioner who lost her license after 35 years of practice.5 Following an emotionally traumatizing divorce, Phelan-Adams used drugs and alcohol to self-treat her symptoms. She writes: “Although nine months had passed since I recovered from this crisis, a diplomate of the American Society of Addiction Medicine (ASAM), who spent less than 15 minutes reviewing my case, diagnosed me with alcoholism and addiction, and ‘recommended’ inpatient treatment at the facility where he was the medical director. He made it clear that if I refused his recommendation, he would, within 48 hours, report me to my board as ‘noncompliant,’ putting my medical license in jeopardy.”

Phelan-Adams further commented; “Although I continued to see my personal therapist, attend group therapy, and take an antidepressant, I would not—could not and did not—accept his recommendation. Five months later, more than a year after I had recovered emotionally, my career in medicine was over. To this day I wonder: How could a board-certified specialist in addiction medicine get a diagnosis so wrong and do so much damage, yet not be accountable for his malfeasance?”

Turncoat

Phelan-Adams may never have an answer to her question. But one thing is certain. The term “turncoat physician” is apropos for physicians who have joined the dark side and neglected—even retaliated against—their practicing colleagues. In the process of becoming acculturated, physicians working as executives in corporations, government agencies, and healthcare systems can also become desensitized to the plight of patients.

The concept of being a turncoat has its origins in the Latin word renegare (to deny), and refers to a person (a renegade) who changes to the opposite party or faction and reverses principles. The term turncoat comes from the ancient practice of wearing a badge or pin on one’s coat signifying which party or leader is supported. Individuals then disavowed their allegiance by turning their coats of armor or quite literally turning their uniform coats inside out to match the color of the opposition. Turncoats are viewed as traitors.

Caught between the desire to help patients and responsibilities to manage costs, physician executives deal with conflicting expectations.

The modern-day equivalent of a turncoat in medicine is a doctor who exchanges the white coat for a business suit. Increasing numbers of physicians are finding private practice difficult or uncongenial and are turning to administrative opportunities as an alternative. However, caught between the desire to help patients and responsibilities to manage costs, physician executives deal with conflicting expectations. Moreover, the influence of physicians in health systems has limits, creating tension as they try to exert their authority in a sea of nonmedical executives.

Traitor Complex

In a similar vein with turncoat, the term traitor complex has been applied to MD/MBA students.6 Students from six dual-degree programs were interviewed about their career plans (approximately 65 MD/MBA programs currently exist). An interesting finding from the interviews was the frequency with which these students expressed concern about other physicians’ perceptions of their plans and desire to seek business training while still in medical school.

Of 40 students interviewed, nearly half discussed the concept of being a traitor to the medical field, an idea firmly planted by senior medical staff, who opined that business-oriented medical students deprived “real” students of the opportunity for admission to medical school. A student commented, “One physician called me a traitor because he said I couldn’t have both business and patient interests in mind at once.” The fact is, more than ever, organizations are striving to focus on patients while keeping the tension between business and patients in balance. Contrary to the concerns that MD/MBA programs steer students away from medicine, most of these students are interested in a combination of clinical practice and administrative duties; only a small percentage expect to assume administrative jobs with no clinical practice.7 After graduation, the vast majority of MD/MBA students go on to extensive postgraduate medical training and diverse careers, whether in health systems or industry.8 The positions of Medical Director and Chief Medical Officer are magnets for management-minded physicians, and there are newer roles in technology, informatics, and even physician wellness programs that tap into the talents of business-savvy and clinically proficient physicians.

Man-in-the-Middle

Given that physicians appear to have a bright future in the corporate world, it is only natural to ask why some would turn against their colleagues in the trenches and act with indifference or disdain. Dr. Diana Chapman Walsh, an expert in public health and social behavior, attributes such behavior to the “man-in-the-middle” syndrome.9 In her seminal book Corporate Physicians: Between Medicine and Management, Dr. Walsh analyzed in depth what happens to medical care when medicine is practiced by an individual who is both a physician and corporate officer. She writes: “Company physicians have been medicine’s man-in-the-middle, like the shop foreman whose misfortune it is to owe allegiance to bosses above and workers below. Foremen find ways to adapt or manipulate their situations; corporate physicians do too. But lacking predictable rules of role, company physicians have to work at the accommodation: seldom is it as straightforward for them as it is for private physicians, whose primary obligation to their patients seems relatively clear-cut.”9

From a psychological perspective, one may infer that, unconsciously, identification with the aggressor plays a role in shaping the “rules of the road.” This defense mechanism turns victims of aggression or harm into acting like the aggressor. Identification with the aggressor is central to the Stockholm syndrome, in which kidnapping victims establish an emotional bond with their captor and take on their cause. Corporate physicians (the victims) may develop favorable feelings and behaviors toward the aggressor (the organization), and negative attitudes towards practicing physicians who are not aligned with the organizations’ goals and objectives. This may explain, in part, why corporate physicians behave rudely, disrespectfully, or arrogantly toward their practicing colleagues, resulting in health insurance denials or punitive measures appropriated by regulatory and licensing boards.

Detached Doctors

Family practitioner and medical educator Dr. Sanaz Majd provides further insight into the behavior of physicians. She opines that rude, stoic, and cold behavior may develop in some physicians in order to cope with the daily practice of medicine, the so-called “detached doctor phenomenon.”10 Majd writes: “Sometimes, it’s necessary for physicians to build a concrete wall to guard their emotions. Otherwise, it would be challenging to function through our day-to-day lives as healers. Because, truly, after seeing a sick patient after sick patient, if you allow yourself to feel too much, it can significantly wear you down and render you dysfunctional.”

The process of becoming detached from patients begins as early as the first year of medical school, when students must dissect a human cadaver. In conversations with medical students, Majd found that a few did reveal their emotional struggles (whether it was spiritual, religious, or personal) during gross anatomy lab. However, when the instructor asked the students, “How are you all emotionally dealing with dissecting a cadaver?” none of them spoke about their thoughts and unsettling feelings provoked by the corpse in front of them. Only “very talented and socially adept physicians learn to balance compassion with emotional detachment,” according to Majd.

Loss of Empathy

Research has shown that later in medical school, in the third year, the ability of medical students to empathize with patients sharply declines.11 This is precisely the time when empathy is most essential, because students are freed from the classroom to embark on their clinical rotations and become involved with patients. Many students never regain their empathy as their education and training progress—they are confronted with a perfect storm of factors leading to burnout: excessive workloads; long working hours; night and weekend call; comprehensive documentation requirements in EMRs; and time spent at home on work-related matters. Burned-out physicians possess negative, cynical, and hostile attitudes—not only toward patients, but also toward colleagues, treating them as objects rather than human beings.12

Practicing defensive medicine to reduce the risk of malpractice litigation further erodes empathy and contributes to emotional detachment. Trainees and physicians are afraid of being sued for malpractice. Every patient could be viewed as a potential adversary. So obviously, the physician becomes a detached figure rather than an attached healer. Studies that have measured empathy, however, have shown that higher scores correlate with better patient satisfaction and outcomes.13-16 Why not measure the empathy scores of physician executives or, for that matter, medical school applicants? Medical schools could choose applicants based on both their academic performance and their potential to become caring physicians, as indicted by their empathy scores.

Reverse the Trend

The answer to the question “Why do physicians turn against other physicians?” is complex and, ironically, has its roots in the medical profession itself—education, training, and practice. To cope with the vicissitudes of medical school, students become detached and less empathetic. Residents and early-career physicians have a high likelihood of developing burnout,17 and they begin practicing defensively, which also increases their detachment from patients. Subsequently, in mid-career, physicians may feel trapped between medicine and management and unconsciously identify with the aggressor (e.g., corporations, health systems), harboring anger and cynicism, culminating in behavior that is offensive and retaliatory to their peers.

To reverse the trend, medical schools must begin accepting students who demonstrate not only superior grades and MCAT scores, but also high empathy scores. Wellness programs must become standard in academic medical centers and corporations. Medical students who show an early interest in population health and the business of medicine should be encouraged to pursue leadership pathways rather than be labeled as traitors. Contrary to prevailing thought, the addition of “MBA” after a medical degree does not create a turncoat.

Conclusion

I have worked both sides of the aisle in my 40-year career—my time has been divided equally between practicing psychiatry and working in industry. I have prided myself on being a physician leader who understands the business of healthcare yet has always focused on the medical foundation and tenets of care. Perhaps the kindest words a physician ever uttered were that I was a “double agent”—not a turncoat—because he recognized that, despite the fact I was an insider, I always had patients’ best interests in mind. To be sure, there are physician executives who stray from that course and act punitively toward patients and their colleagues. I pray the bad actors are made accountable for the diagnostic assessments and treatments they advise (or deny), especially if they stand to gain from their actions.

References

1.    O’Connor SJ, Shewchuck RM. Enhancing administrator-clinician relationships: the role of psychological type. Health Care Manage Rev. 1993;18(2):57-65.

2.    Aranda R, Tilton S. Myers-Briggs personality preferences may enhance physician leadership success in non-clinical jobs. Physician Exec. 2013;39(3):14-20.
https://pdfs.semanticscholar.org/e6c1/ec28c076c602c93b674ccf0f9295cd64052a.pdf.

3.    Claes N, Storms H, Brabanders V. Personality of Belgian physicians in a clinical leadership program. BMC Health Serv Res. 2018;18:834.
https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/s12913-018-3645-1.

4.    Drash W. Aetna settles suit alleging claim-denying medical director never read patient’s records. CNN. April 26, 2019.
www.cnn.com/2019/04/26/health/aetna-settlement-california-investigation/index.html.

5.    Phelan-Adams AL. I was a physician for 35 years. It took me 15 minutes to lose my medical license. Doximity. September 30, 2019.
www.doximity.com/doc_news/v2/entries/22861137.

6.    Sherrill WW. The traitor complex: MD/MBA students struggle with medicine vs. management dilemma. Physician Exec. 2005;31(1):48-9.

7.    Sherrill WW. MD/MBA students: an analysis of medical student career choice. Med Educ Online. 2004;9(1):4353.
www.tandfonline.com/doi/pdf/10.3402/meo.v9i.4353?needAccess=true.

8.    Krupat E, Dienstag JL, Kester WC, Finkelstein SN. Medical students who pursue a joint MD/MBA degree: who are they and where are they heading? Eval Health Prof. 2017;40:203-218.

9.    Walsh DC. Corporate Physicians: Between Medicine and Management. New Haven: Yale University Press; 1987.

10.   Majd S. Here’s the disturbing psychology of how doctors get through their day. Business Insider. August 13, 2015.
www.businessinsider.com/heres-the-disturbing-psychology-of-how-doctors-get-through-their-day-2015-8

11.   Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84:1182-1191.

12.   Patel RS, Bachu R, Adikey A, Malik M, Shah M. Factors related to physician burnout and its consequences: a review. Behav Sci. 2018;8(11):98. www.mdpi.com/2076-328X/8/11/98/htm.

13.   Hojat M, Shannon SC, DeSantis J, Speicher MR, Bragan L, Calabrese LH. National norms for the Jefferson Scale of Empathy: a nationwide project in osteopathic medical education and empathy (POMEE). J Am Osteopath Assn. 2019;119:520-532.

14.   Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86: 359-364.

15.   Rakel D, Barrett B, Zhang Z, et al. Perception of empathy in the therapeutic encounter: effects on the common cold. Patient Educ Couns. 2011;85:390-397.

16.   Mercer SW, Higgins M, Bikker AM, et al. General practitioners’ empathy and health outcomes: a prospective observational study of consultations in areas of high and low deprivation Ann Fam Med. 2016;14:117-124.

17.    Panagioti M, Geraghty K, Johnson J. Association between burnout and patient safety, professionalism and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med. 2018;178:1317-1331.