Toxic leadership in medicine

2026-02-05 - 22:56

M Abrar Umar MEDICAL colleges and their affiliated teaching hospitals are among society’s most sensitive institutions. They do more than manage resources; they train future doctors and deal directly with human life. Decisions in these settings often carry irreversible consequences. When leadership becomes psychologically unsafe, damage rarely appears dramatically. It accumulates quietly through fear, silence and decisions made without regard for human cost. This article does not diagnose individuals—that belongs in clinical practice. What can be discussed responsibly are leadership behaviours described in psychology, particularly narcissistic and psychopathic personality traits and the risks they pose when combined with non-clinical authority in medical settings. Narcissistic leadership traits include entitlement, intolerance of challenge and the belief that personal judgment outweighs professional expertise. Psychopathic traits, described behaviourally rather than diagnostically, include emotional detachment, manipulation, lack of empathy and indifference to the suffering of others. These traits exist on a spectrum and may never meet criteria for a formal disorder. Yet when individuals with these traits hold power, the institutional impact is predictable and often harmful. The risk is amplified when leadership is non-medical. Individuals without clinical training may lack understanding of patient care. Non-clinical leaders are not inherently flawed—medicine is a team discipline and administrators can come from diverse backgrounds. The problem arises when they override medical expertise, refuse to defer to professional judgment and make unilateral decisions on matters they do not fully understand. In such environments, harm often manifests through what is quietly denied. Essential diagnostic facilities such as MRI and CT scanners may be dismissed as avoidable costs. Ventilators may be delayed or unpurchased. Neonatal resuscitation officers may not be appointed or are deliberately kept off duty despite repeated warnings. Nursing staff may be dangerously reduced, sometimes leaving a single trained nurse responsible for workloads requiring a team. These are not neutral administrative choices. In tertiary care, the absence of imaging delays diagnosis. Lack of ventilator support turns treatable conditions fatal. Neonatal emergencies cannot wait for office hours or financial approval. When trained staff is unavailable by design, risk becomes immediate. What makes such decisions troubling is not only ignorance but certainty. Clinical concerns are raised. Specialists explain consequences. Nurses describe unsafe conditions. Yet leadership persists, insisting concerns are exaggerated. Confidence without competence and authority without accountability are hallmarks of narcissistic and psychopathic leadership. Human life becomes abstract, reduced to budget figures or obstacles to control. Over time, institutional culture changes. Doctors stop arguing, nurses stop explaining and students stop questioning—not because problems disappear, but because speaking has become unsafe. Fear replaces professional dialogue; silence becomes survival. Academic and clinical missions suffer. Senior professors are ridiculed, qualifications minimized and recognition withheld. Students learn obedience matters more than learning and questioning authority carries a cost. A medical college may function administratively, but intellectually and ethically it hollows out. From a public health perspective, the consequences extend beyond one institution. Medical colleges shape future doctors, teaching hospitals model professional behaviour. When fear, humiliation and ethical shortcuts normalize, these values propagate across healthcare. Communities lose trust, patients suffer quietly and the damage is systemic. Discussing narcissistic and psychopathic traits is not about labelling individuals—it is about institutional safety. Research shows that when these traits combine with unchecked authority and lack of accountability, predictable harm emerges. Not every harmful leader is treatable and not every system can be repaired from within. Some individuals do not seek insight, accept responsibility or change. In such cases, the ethical priority shifts from reform to protection of students, staff, clinicians and patients. Boundaries, shared governance, transparency and independent oversight are safeguards against psychological and clinical harm. Just as medical institutions prioritize infection control, audits and accreditation, psychological safety must receive equal seriousness. Leadership in healthcare must be clinically informed, ethically grounded and accountable to professional expertise. Silence, in medicine, is never neutral. History shows institutions are often destroyed not by incompetence alone, but by personalities equating control with competence and authority with infallibility. When such personalities, particularly without clinical understanding, dominate medical colleges and hospitals, damage unfolds slowly but at immense human cost. Speaking about these patterns is not disloyalty—it is loyalty to medicine. The real question is not only what decisions are made, but who is making them, without expertise, without empathy and at what cost to human life. —The writer is MBBS, MPH, PhD, Professor of Public Health, based in Lahore.