Blooming narcissus

My textbooks say personality disorders are characterized by inflexible, maladaptive traits that cause people functional impairment. But one oft-noted point is that some traits usually associated with disorders are, in the right line of work, not maladaptive, but rather useful. Schizoid personality types do well on the graveyard shifts, for instance. Obsessive, meticulous types make good accountants. Sitcoms need schizotypals. And so on.

One wonders if there's ever a good time for narcissism. (At this point, it would be tactful for readers to overlook the narcissism of blogging). Putting it another way: what happens when a narcissistic personality has a job where arrogance is encouraged?

With this in mind, I read an article about a well-publicized case in this area. A few years ago, a Boston surgeon left a patient in mid-operation to cash a check across the street. I didn't follow the story too closely, and thought it ended there. But there's always more, and this Boston Globe Magazine profile of that surgeon really brings it to light:

There's an intensity to David Arndt that never seems to slacken, a way in which he seems both hyper-aware of his very public collapse and oblivious to it. Overnight, the high-octane, Harvard-trained Arndt became the doctor who left his patient on the operating table so he could go to the bank to cash a check. In an instant, that summer of 2002, the news went national. But the profound professional embarrassment would turn out to be only the beginning. Within two months, Arndt would be charged with statutory child rape, indecent assault, and drug possession. He would file a "poverty motion," the surgeon in one of medicine's most lucrative specialties asking the court to pay his costs. And then, in a separate case nearly a year later, he would face one more charge, this one for possessing methamphetamine with intent to distribute.

"His downfall is almost operatic in its tragedy," says Grant Colfax, a Harvard-trained doctor who was once one of Arndt's closest friends.

As Arndt prepares to stand two separate criminal trials, Colfax is like many of the people who knew him well and are now left scratching their heads. Their emotions oscillate between two poles: There's the lingering disbelief that such a brilliant and compassionate doctor - some say the most brilliant and most compassionate they had ever known - could seem to self-destruct in such a spectacularly public way. Then, perhaps more troubling, there's that voice inside them, which had been muffled deep for so long, the one that kept telling them it was only a matter of time before David Arndt's self-absorption and sense of invincibility finally got the best of him.

Dr. Arndt seems like a surgery cliche at times: oblivious to any personal defects, but incisively questioning the credentials of everyone around him. At one point in the narrative, Globe writer Neil Swidey, asks:

If David Arndt sounds a little too intense, a little too arrogant, ask yourself this: Aren't those exactly the qualities you want in a surgeon? Because this is what his arrogance looked like for most of his time in the operating room: An intolerance for error. An eagerness to take on the toughest cases. A fearlessness about confronting anyone - be it an orderly or a chief of surgery - who he thought was underperforming.

Swidey gets more insight from former classmates and friends:

Remmler says that Arndt was funny, charming, and "really smart. I felt lucky to have him as a classmate." But, she adds, "he was also really narcissistic, and I guess I knew there was this compulsive streak about him - addictive almost. And so deciding his needs are more important than his patient's life - that sounds narcissistic to me."
...and later...
"David wanted people to pay attention to him and notice him," says Saiya Remmler, the psychiatrist and former med school friend. "To me, it sounds like a gradual, maybe even lifelong, struggle between greatness and tragic flaws." And what might be at the center of this Greek tragedy? She and other physicians who knew Arndt but haven't seen him in years suggest narcissistic personality disorder, where an exaggerated sense of self-importance masks a chronic emptiness.

The point, which is often stressed to me on the wards, is that it's not a disorder until it causes impairment. Personality disorders typically begin in young adulthood, and Dr. Arndt had a protracted adolescence, bumming around the San Fran art scene in his early 20's. Afterward, the scrutiny and supervision of medical school and residency can keep a lot of maladaptive behaviors in check (and reward behaviors that would be maladaptive elsewhere). It's only when he took on real responsibility, in his year as a chief and thereafter, that his life deteriorated. I suspect that if he hadn't been so talented, and in a field where his narcissism less appropriate, his personality would have crashed into reality far earlier, and far more quietly.