Research DOI: 10.1308/rcsbull.2015.

331

A stressful job: are

surgeons psychopaths?
And if so, is that such a bad thing?

J Pegrum Trauma Registrar1

O Pearce Trauma and Orthopaedic Consultant 2

1
Oxford University Hospitals NHS Trust
2
Milton Keynes University Hospital
NHS Foundation Trust

331
 Research

D
octors are subjected to a high level of Figure 1 Box and whisker plots showing the difference between Psychopathic Personality Inventory
psychiatric morbidity, with literature – Short Form scores for consultants in teaching hospitals (left) and district general hospitals (right)
showing that various factors for stress 200 200
are present in their roles: long working
hours,1,2 night shifts, divorce, 3 being a
surgeon, 4 medical lawsuits5 and failing to
meet continuing medical demands.6 It will 180 180
therefore not be too surprising that some
of the traits associated with a psychopathic
personality (eg preternatural calmness under
160 160
pressure, or apparent indifference to human
suffering when making life-or-death deci-
sions) are perhaps selected out in those who
rise to the top of our profession. Could this 140 140
Score

Score
mean that psychopaths are over-represented
among the ranks of hospital consultants
versus the general population? You could
120 120
hypothesise further that the career advantag-
es conferred by this personality type would
result in a higher incidence among teaching
hospital consultants versus district general 100 100
hospital (DGH) consultants.
A search of the worldwide scientific litera-
ture, however, has found no studies assessing
the psychopathic personality traits among
doctors in teaching and district general Table 1 The eight subdivisions of the Psychopathic Personality Inventory
hospitals. The present study was designed Subdivisions Definitions
to compare the various personality traits
Machiavellian egocentricity Manipulative, egocentric in interactions with others
among senior doctors across six hospitals
Social potency Charming, influential and able to manipulate others
and to find out which traits predominate.
Fearlessness Eager risk-taking, no harm anxiety or concern
Cold-heartedness Guiltless, callous, unreactive to others’ distress
METHODS
The personality traits were assessed of 172 Impulse non-conformity Unconventional, reckless disregard for social normality

doctors from 3 local teaching hospitals and
3 DGHs, using the short form of the Psycho-
pathic Personality Inventory (PPI–SF) as an
online questionnaire.7 Ethics approval was
unnecessary as the participation process did
not involve patients and was voluntary. In
November 2012, 420 consultant members of
staff at the 6 hospitals were sent a covering
letter with a request to follow the embedded
link to the questionnaire. Only those wishing
to participate completed the questionnaire.
The PPI–SF was used as it is a validated
short version of the full-length inventory.7,8
The Psychopathic Personality Inventory (PPI)
is employed regularly in the assessment and
quantification of mental health. It is divided
Carefree non-planfulness Lack of forethought, fails to learn from consequences
Blame externalisation Rationalises behaviour, blames others
Stress immunity Absence of arousal in stressful situations
into eight subscales (Table 1). The PPI demon- Differences in the results between
strates validity in both forensic and non-foren- hospital type (teaching hospital vs DGH) and
sic settings, with the added benefit of the short hospital subspecialties were assessed. The
form having only 56 questions compared with results were also compared with existing
187 in the longer format. There are four pos- figures for the general population.
sible responses to each of the questions: false,
mostly false, mostly true and true. As a result, Statistical analysis
the PPI–SF scores from 56 (weakest suggestion Paired t-tests were used for continuous
of psychopathy) to 224 (strongest suggestion of variables conforming to a normal distribution.
psychopathy). It has been validated against the Statistical significance was based on a p-value
longer version as a research and assessment of <0.05 and 95% confidence intervals using
tool for psychiatric assessment.7 SPSS® version 22 (IBM, New York, US).

332
Research

Table 2 The mean Psychopathic Personality Our sample size was based on a type I has been shown previously that high achievers
Inventory – Short Form scores (out of a maximum error of 0.05 and a type II error of 0.2. The in various professions (including elite soldiers
of 224) for each of the hospital subspecialties mean PPI–SF score in the general population and company chief executives) are over-repre-
Specialty n Mean p-value* was 119.9 For an effective difference in the sented among high psychopathic scorers.10
score PPI–SF of 10 with a standard deviation of On further analysis in our study, consult-
Medical specialties 71 128 0.243 20, 25 participants each were needed in the ants from teaching hospitals had higher psy-
Surgery 43 138 0.023 teaching hospitals and DGHs. chopathy scores than their DGH counter-
Anaesthetics/ 22 125 0.826 parts (136 vs 128, p<0.01). It is well known
intensive care RESULTS that teaching hospitals attract high-achiev-
Psychiatry 16 130 0.143 One hundred and seventy-two doctors ing individuals and are often involved with
Paediatrics 10 148 0.010 (108 male, 64 female) from six different complex patients. As a result, higher levels
Radiology 10 125 0.375 hospitals responded and completed the of stress immunity and difficult decision
PPI–SF questionnaire (response rate 41%). making are frequently required. This may
Table 3 The frequency of the highest-scoring Their overall mean score was 131 (SD: 21.2, be reflected in their day-to-day personality
personality traits from the Psychopathic Personality range: 87–187). The mean score for teaching and behaviour.
Inventory – Short Form among the 172 participants.
hospital consultants was 136 and for DGH Among the hospital subspecialists,
Some participants had equal highest scores
across more than one trait so the total is >172. consultants it was 128 (p<0.01) (Figure 1). surgeons and paediatricians were the high-
est-scoring individuals on the PPI–SF, with
Subdivisions Frequency
scores of 138 and 148 respectively. There
Machiavellian egocentricity
Social potency
10
19 Empathy is is evidence in the literature that surgeons
have the highest levels of stress.6 Whether
Fearlessness
Coldheartedness
22
24
commonly these traits are selected out in trainees as
they climb the career ladder or acquired as a
Impulse non-conformity
Carefree non-planfulness
16
26
regarded as the defence mechanism is debatable.
This is not the first time that doctors have
Blame externalisation
Stress immunity
1
78
key attribute been found to have increased psychiatric ten-
dencies compared with the general popula-

Table 4 The leading personality traits by specialty

for doctors tion. An Australian study using the General
Health Questionnaire showed that doctors
had a psychiatric morbidity in 28% of cases5
Specialty Traits
The mean score when the PPI–SF was tested versus 19.5% in the general population.11 Our
Medical specialties Stress immunity, carefree
non-planfulness
previously on 985 subjects from the general study does demonstrate that stress immunity
public was 119.9 is a personality trait that is over-represented
Radiology Cold-heartedness, social
potency The subspecialty analysis of the doctors’ among doctors, with higher PPI–SF scores
Anaesthetics Stress immunity, cold- responses was subdivided into medical found in surgeons, paediatricians and those
heartedness specialties, surgery, anaesthetics/intensive working in teaching hospitals.
Psychiatry Stress immunity, care, psychiatry, paediatrics and radiology. This study highlights the importance of
fearlessness and carefree The results are summarised in Table 2. Table stress immunity as an overriding personality
non-planfulness
3 shows the frequency of the highest-scoring trait in the medical profession. Doctors with
Paediatrics Stress immunity, personality traits among the 172 partici- a high degree of stress immunity may be
fearlessness and carefree
non-planfulness pants, whereas Table 4 indicates the leading beneficial or even essential in the provision
Surgery Stress immunity,
personality traits by specialty. of objective care in difficult situations. This
fearlessness may be important in individuals applying
DISCUSSION for subspecialty training. There may be
This is the first study to demonstrate that further benefit in providing support or care
stress immunity is the overriding personality for subspecialties exposed to challenging
trait of doctors. The mean PPI–SF score of 131 situations. This may improve decision-mak-
for our cohort of consultants was higher than ing and could maintain empathy in
the mean for the general population (119).9 It challenging environments.

333

Empathy is commonly regarded as the key
attribute for doctors.12 In 1993 the General
Medical Council published Tomorrow’s
Doctors, placing communication and empa-
thy as the core values in medical training.13
There will be acute situations where stress
immunity may better facilitate empathy in
the medical profession. Detachment from
emotional situations (such as the family of
an unwell child) may be of overall benefit in
terms of the care of the child.
There may be other such areas of
medical practice that require the doctors’
ability to distance themselves from the
subjective world of the patient.14 Under-
standing the personality traits of a doctor
may be advantageous in higher training
selection and career guidance. There is a
risk that patients will be awed and grateful
for treatment instead of being treated with
autonomy. Shared decision-making is the
key concept for patient care. It is not known
if there are particular personality traits
that are advantageous in patient-centred
care and when working in a team envi-
ronment. Further studies need to evaluate
the personality traits and the variation in
personality scores in the medical profession,
and how this influences the doctor–patient
relationship as well as outcomes of surgery
or medical consultations.
The PPI–SF only confers an actual
diagnosis of psychopathic personality when
an individual scores highly across all of the
subdivisions. The concept of psychopathy is
obviously considerably more complex than
a linear scale of increasing psychopathic
tendency with increasing numerical score.
The results and conclusions in this paper
should be interpreted with this in mind.
The PPI–SF is not the only means of
assessment for psychopathy or mental health.
Others include the State–Trait Anxiety
Inventory,15 the General Health Question-
naire,16,17 the Eysenck personality scales18,19
and the revised NEO Personality Inventory.20
However, the PPI–SF was chosen for the
spectrum of personality traits assessed and
the validated shorter number of questions so
the questionnaire could be completed in a
timely fashion.
Our selection criteria could have intro-
duced bias as consultants were emailed
the questionnaire and only those willing
to participate completed the online survey.
The response rate of 41% in our population
compares favourably with the physician
response rates of 14–71% published in the
literature.21,22 Questionnaires are prone to
selection bias; people who were curious or
who had insight into the day-to-day stresses
of the job may have been more curious to
find out their results.
CONCLUSIONS
This study showed that consultants at
teaching hospitals score higher on a scale of
psychopathic personality than DGH con-
sultants, who in turn score higher than the
general population. The prevalence of stress
immunity as the overriding personality trait in
consultants may better facilitate patient care.
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