Why Doctors Become Assholes

You’re at risk.

If you’re a medical student or a doctor, you may think your great personality is its own fortress, but medicine is a chronically inflamed environment, and you risk changing for the worse. You will, in fact, change. The quicker you understand why, the better positioned you’ll be to decide how.

Let’s for a second veer away from the way medicine is portrayed. No more patting ourselves on the back, and no more unrealistic expectations. Doctors can (and sometimes are) assholes.

As medical students and doctors, we tend to let the whole world decide what this experience feels like. And the world, for the most part, decided medicine is noble, respectable, and blindly valuable. But we know. From the inside, we know it is fact painful, tribalistic, and perceptually skewed. We sleep less than we eat, we seldom take our own advice and we care for people in exchange for money.

Let’s explore.

As in medicine, there are several stages one goes through in life. It generally takes the first 30 years to figure out that 5 years from now you will still feel like you. Somehow, the future you is always you, not an upgraded premium version. Plain old free-trial you. Over the years you get new skills and learn new spells, but you are driven by the same strings. If you lack the conviction to do something today, you will lack it tomorrow. Motivation is much harder to come by than the ability to actually do the thing. It takes infinitely more work to acquire such a fundamental update as “improved motivation” than it is to do a chore. But for some reason, we seem to think it’s the other way around, so we think it’s more accessible to acquire a structural change tomorrow than it is to wash the dishes today.

Why? Because we’re wired to.

Everyone knows about the non-descript mother who lifted a car to save her stuck baby. Why do we all know that? It's a fun, heart-warming story, sure, but we've heard hundreds of those and can barely name any others. That story about the mother seems to be part of our collective experience. And yet we remember zero details. Who was the mother? Where did it happen? When? We don't know, so something more must be at play.

We all know it because that story is the embodiment of acute inflection points.

It shows the sudden unlocking of full potential.

It means that under the right singular circumstance, like the mother who got immense unforeseen powers, you too can crush Carbon into diamonds—one act to catapult you into a newer better self.

But there's no such magical inflection point in self-development. Once you realize that magical bullets are just bullets to shoot yourself in the foot with, you understand that a better self is not coming to save you.

And with that thought, you substantially improve, maybe for the first time. When we finally integrate the idea that we are responsible for our growth, we get better. We fight against quick fixes and become more accurate at predicting the future. We realize that tomorrow also has a tomorrow, so the things we have to do, we do today, rather than next week. To succeed in medicine, this is an essential first step.

But this comes with a trap. While incremental change is the only sustainable change, danger lurks if you fall asleep at the wheel. Five years later, we find ourselves to be completely different people and we can’t pinpoint when it happened. And this lack of constant careful readjustments is naturally turning us into worse people. We become more pessimistic (and call it pragmatic), more arrogant (and call it experienced), and more dehumanized (and call it adaptable). We turn our back on it for a split second and it snaps into reality. We become part of the problem we swore we wouldn’t condone.

We find ourselves yelling at colleagues, snapping at patients, or cutting it short with family members.

If you’re early enough in Medical School, you may think that could never be you. You may think you are a calm, level-headed person. You may even feel disdain for the people who do that. But it's amazing what a few hundred extra hours of work you didn't sign up for are going to do to you. People snap at their children for less. Good people. People who hate themselves for it after they've had time to sleep about it. You'll be the same. So if you sense a holier-than-thou feeling coming over you, fight it. Understand that you too are going to become less.

The path to assholery is paved with unnoticed personality mutations.

There are two types of assholes in medicine. The Surviving Asshole and the Exposed Asshole. Similar result, immensely different personalities.

I. The Surviving Assholes

The surviving assholes usually have a low threshold for stress. The strength of their otherwise nice personality crumbles under the crushing force of a system that punishes nice. In no uncertain terms, it becomes obvious to them that being nice is making them a soft target for people with stronger, more aggressive personalities. It’s not a medical issue, but a societal one. Being right is no longer required. He who speaks loudest is both lawmaker and enforcer and the nice one - a pawn in a game of checkers.

This is a great way to birth a villain.

Add success to the mix, and the Surviving Asshole is spawned. As they carefully untangle the bowl of insecurities they once were and learn how to find their way around a patient, the confidence that was systematically beaten out of them for years comes back with a vengeance. They start confusing comfort with expertise and begin the slow descent into the “I deserve respect” underworld.

Once they convince themselves that it’s about time they find their voice, the way they use it generally sucks for the people around them. They find justifications for each mean word and regret almost everything, but only internally. They become at odds with themselves and frustrated with a system that forced them into it. They hardly ever think about their role in all of this because they hardly ever sit quietly with themselves anymore.

If you’re in this camp, you already know it. You have a nagging feeling that this is how you’re going to end up. In a sea of complexities, you see two options: give up now and maintain what you perceive as good, nice qualities, or become the surviving asshole. Of course, those are not your only two options. You should strive to overcome this fork in the road and path your way through the fields.

And that begins with understanding how to best deal with surviving assholes.

1. Do your best to increase your threshold for stress.

You are never going to become less afraid, but you can definitely become braver. You have two options. Either voluntarily expose yourself to manageable levels of stress that increase in intensity over time, or optimize for comfort for as long as you can until everything becomes scary and it crumbles all at once. The obviously correct option is the first one, but that’s hard. It takes immense power to convince yourself to sacrifice passing moments of comfort when there are so few of them. But do accept suffering. If you do, fewer challenges will yield a more positive impact. Patients will feel more comfortable and more honest around you. Colleagues will respect you more. You will be more satisfied with your life and career.

Even if you feel survival is all you want- nay, need, right now, a surviving asshole is still an asshole.

2. Don’t take it personally.

You will seldom see more people let very little power go to their heads than in medicine.

Once you truly understand how assholes are made, you will take nothing personally anymore.

In the beginning, that’s horribly difficult. We are meant to feel that danger is relevant to us. This is how we survived for millennia. But surviving literal animal attacks evolved faster than protecting ourselves against assholes who, in turn, protect themselves. We have a hard time conceiving of an attack that’s actually a defense.

It takes time for it to get easier. Unfortunately, just reading about it won’t help you. But reading about it and then holding it in the back of your mind will.

The fog will slowly lift and you will start seeing that people who try to protect themselves in severely misguided ways are everywhere. You will figure them out. And when you do, the assholes who seem to take pleasure in putting other people down will reveal themselves to be weak. We instinctively have a hard time letting ourselves be hurt by weak people, no matter how hard they try. But beware: if you are easily hurt by them, you don’t actually feel they are weak, no matter how often you try to tell yourself that they are.

The reason conflict is so painful in medicine is because the assholes who’ve gotten past your stage in life know exactly what strings to pull. They have been you, and so when they want something, they know what to do or say to achieve it. That keeps you at a disadvantage. But while you are not in control of what other people do, you are in control of how you take it. It’s a cliche, but it’s a cliche for a reason. Learn to take it better, and it will be so.

If you are to leave this article with one lesson, it’s this:

Persecution only happens to the persecuted.

Get better at not feeling persecuted and you will stop being so.

3. Take the pain of being used, but do it intelligently.

Use every last drop of pain you feel at the hands of assholes for your own gain. Any shortcoming somebody shows is a masterclass in what you should be doing differently and profiting from.

Is a colleague making you feel inferior? Be glad they exist. The standards for how doctors behave get lower with each sucky act. Therefore, good, average behavior gets rewarded more. So be good, and you’ll be above average. This will open doors you didn’t know were closed. Instead of feeling threatened or discouraged by colleagues who may attempt to undermine you, view them as opportunities to showcase your integrity. By consistently demonstrating respect, collaboration, and compassion in your interactions, you not only elevate yourself above negative behaviors but also set a positive example for others to follow. The true measure of success in medicine goes beyond individual accomplishments - it lies in the collective commitment to patient care and ethical practice. You will become a leader in your field by the simple act of being yourself.

Do your best to find the positives in the sucky situations you’re going to inevitably find yourself in. For me, it’s this newsletter. Whenever I encounter an asshole in the wild, I enjoy it because I get to observe and write about it. I am reminded that people experience all sorts of pains inside the medical system, but that others will benefit greatly from it. It’s a coping mechanism, but coping done right is exactly what this argument is all about.

Exposed assholes usually suffer from severe cognitive dissonance. They know they are being less, but they can’t help themselves. When they act their namesake, they feel it deep inside their bones. You will never observe this directly, but I guarantee you it’s there. They will fight it inside like the possessed girl fought the priest. If you learn how to alleviate that, you will gain a superpower.

Let them make amends and they will find relief in your presence. It will rarely be obvious that they are doing it, but they will. They will teach you more, show you better ways to do things, and share their experience with more ease in an attempt to counterbalance one of their past injustices. They will continuously try to reach that nice personality they abandoned. If you’re patient with them, you will benefit greatly.

But this only works with real Surviving Assholes. It takes a completely different set of skills to deal with the next category.

II. The Exposed Asshole

This is a different breed. These are people who chose medicine because they have a natural proclivity for being assholes. They just need a ladder to stand on to reach farther. Through the hard work and dedication of generations behind them, medicine got the reputation we talked about in the beginning. Noble, respectable, and inherently valuable. It’s the perfect ladder. Because it’s hard to climb, once you do it’s easy to look down on others and feel special.

Exposed Assholes are people who play nice in the beginning, but show their true colors as soon as they’re comfortable. Through little things at first, but in an ever-escalating manner. From the outside, there’s a temptation to see them in a downward spiral of awfulness, but in reality, a true exposed asshole is just fighting to show themselves. It's almost as if they are compelled to shed their facade once they feel secure enough in their environment.

And the thing they love most in the world is drama. They’ve created so much of it over the years that drama has become their comfort zone. But that’s also their weak point. Don’t engage with it the way they want you to, and they become powerless.

If you think you’ve identified a true Exposed Asshole, dealing with them can be approached with a mix of assertiveness and pragmatism. As opposed to the Surviving Asshole, an Exposed Asshole is different. You can’t just learn your lessons and move on. You can’t profit from their sense of right and wrong. And you can’t improve your threshold for stress hoping to become stronger. Stress will just get needlessly escalated. A moving target with no clear rules.

Here's how you might handle the situation:

1. Set boundaries.

Clearly communicate your boundaries and expectations to the exposed asshole, whether they are your superior or not. Let them know what behavior is unacceptable and make it clear that you won't tolerate disrespect or manipulation.

2. Call them out.

Don't hesitate to confront the exposed asshole directly when they engage in inappropriate behavior. Showcase that they are being exposed as an asshole, and they will usually back off. Be assertive and straightforward in addressing their actions, but avoid getting dragged into unnecessary drama or arguments. Remember, drama is their kingdom. Don’t try to beat them at their own game, unless you are an even bigger asshole yourself (and I rarely recommend that). They hate it when you don’t engage with them.

3. Maintain emotional distance.

Keep your emotions in check and don't allow yourself to be emotionally manipulated by them. Stay focused on the facts and remain calm and composed, even in the face of provocation.

Overall, dealing with an exposed asshole requires a combination of assertiveness, resilience, and strategic thinking. By setting clear boundaries, addressing inappropriate behavior directly, and maintaining your emotional composure, you can effectively manage the situation and protect yourself from undue stress or harm. The advice I give for dealing with Exposed Assholes is intentionally shorter because cutting it short with them will leave you better off.

Regardless of who you encounter, I’ll leave you with this:

Don’t go into the world thinking everybody is an asshole just because they disagree with you. They empirically make up around just 30% of all healthcare professionals. 70% of those 30% are Surviving Assholes. Any specific advice offered in this article might fall short in your situation, but your next step is easier to see from where you stand if you have this clear framework in mind.

As you grow in this field, make sure you don’t become one of them. Make those careful readjustments along the way and evolve consciously. Don’t let life just happen to you. It will mould you in ways you won’t like.

Play the long game. Don’t become an asshole, and you’ll be halfway there.