Narcissistic Personality Disorder is often identified by several criteria, including grandiosity and self-importance; a belief that one is uniquely exceptional; a sense of entitlement; being interpersonally exploitative; a lack of empathy; a need for excessive admiration; envy or a belief that others are envious of themself; and arrogance [1]. With the air of an unparalleled deservingness to rise to such an admirable vocation, several perfect combinations of the aforementioned criteria often confer upon residency programs what appears to be an attractive candidate.

So if the candidate has proven the ability to meet minimum exam score requirements and certifications, scrounge together a curriculum vitae, and smarm their recommendation writers and evaluators more effectively than other candidates on interview day, what risk does recruiting the narcissist present to the unsuspecting program?

Ideally, program leadership can remediate the situation if certain individuals are found prioritizing their own benefit over the interests, well-being, or safety of patients or other program stakeholders. Unfortunately, the gravity of this damage is often surreptitious and allowed to pass, especially as residency cohorts force narcissists to operate as equals with the meek and humble. The competent meek are required in every successful bureaucracy for their honest work in maintaining standards and compliance, despite premonitions of group discordance and the failures of those around and above them.

The security and upward mobility of the narcissistic resident relies on two parties: program leadership who perceive that the precariousness of their own position hinges on the seamless success of their administration, and the quiet competent resident whose aspirations are wasted by an administration directed by fear. The narcissist’s ‘window dressing’ activities enhance their own external image, and at times the outward image of their institution, while regularly deprioritizing and thus hurting the institution’s performance [2]. The upkeep of this superficial image often destroys organizations by putting the group’s morale, cohesion, and reputation at risk [3]. To continue abstracting any public esteem readily available, organization leadership may prioritize the incentive of perpetuating positive narratives, protecting the star narcissist’s veritable fraudulence from being exposed [4]. Fear of this exposure can be well-leveraged by the narcissist’s volatility, all-or-nothing thinking, and poor distress tolerance, all serving as means by which their manipulation of others can be accomplished, and necessitating the asylum that only those with titular authority can provide [5]. Each time a narcissist is allowed to escape accountability, the organization’s moral fiber is internally perceived as compromised, which in turn potentiates the social and organizational pathology. This reinforces that the narcissist’s fears of inadequacy and lack of regard prove useful in the narcissist’s favor, providing further impetus for averring self-importance and deservingness.

Having committed to the narcissistic trainee, administrators may be tempted to choose not to acknowledge the functional liability. Instead, administrators must prioritize cultural and organizational integrity over saving face, and choose not to hedge their failures. Efforts to aid the narcissist in appearing successful only mask the pathology and contribute to narcissistic dysfunction’s ability to spread to affiliates and corrupt affected institutions. Star narcissists, equipped with sterling recommendations from their hostage institutions, advance by beguiling the public and the next set of evaluators, failing upwards from organization to organization.

In residency and especially in psychiatry, it is important for selection committees to acknowledge that endorsements for the narcissist may be made at the behest of the evaluator’s own self-interest or general disinterest. Volunteering the health and potential of an organization, meant to train the next generation of physicians, as ransom in exchange for saving face is irresponsible and presents a danger to the culture of modern medicine as well as to patients who may consequently become less and less the priority.

Disclosures and Acknowledgments

Both Osagie N. Obanor and Joshua F. Ceñido report having no conflicts of interest and have nothing to disclose.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association (2013).
2. Braun S. Leader narcissism and outcomes in organizations: A review at multiple levels of analysis and implications for future research. Front Psychol 8 (2017).
3. Wright A, Stepp S, Scott L, et al. The effect of pathological narcissism on interpersonal and affective processes in social interactions. J Abnorm Psychol 126 (2017): 898-910.
4. Rijsenbilt A, Commandeur H. Narcissus enters the courtroom: CEO narcissism and fraud. J Bus Ethics 117 (2012): 413-429.
5. Kacel E, Ennis N, Pereira D. Narcissistic personality disorder in clinical health psychology practice: Case studies of comorbid psychological distress and life-limiting illness. Behav Med 43 (2017): 156-164.