Reflections of a Type One physician
Jennifer Schneider, M.D.
For me, learning about the Enneagram was an “Aha” experience. Five years later, I clearly recall how, after digesting the introductory chapters in Helen Palmer’s book, The Enneagram, I turned the page to the first type she described, type One, and identified with its title, “The Perfectionist,” even before reading the description. By the end of the chapter, there was no doubt in my mind that she was describing my type, and there still isn’t. However, what puzzled me was that I could relate to everything she wrote about point One except the part about anger, the chief “passion” of type One. Not me, I remember thinking, not only do I rarely act angry, I hardly ever feel anger.
It was only when I began tuning in to my inner monologue that, to my horror, I recognized the constant stream of judgmental thoughts, resentments, and righteous indignation. Yes, type One is definitely me, disguised anger and all. Today, despite a lot more self-awareness, I still at times find myself in a trance of righteous indignation, unwilling to let it go because, after all, I’m right and how could they do this! But I’m getting better, and I can usually recognize my trance and laugh at myself.
Another realization I had early on was how perfectly my Oneness fit in with my career as an internal medicine physician. My sense of responsibility, organizational skills, attention to detail, great follow-through, the way anything abnormal jumps out at me from the page—all of these are definite assets in my medical specialty. I recall feeling sorry for psychotherapists, whose job often entails prolonged listening and then expressing their opinions in indirect ways or not at all—saying a few words of wisdom and letting the client figure out for themselves the right thing to do. Not me! In my job I was not only encouraged, but expected to forthrightly tell my patients how their health required them to proceed, and for years I’d done it in a very direct way:
“If you’re going to get your diabetes under control, you have to lose 30 pounds and start exercising regularly.” “If you continue smoking, you’re putting yourself at high risk of heart disease and lung cancer. Let’s talk about how you can start quitting now.” “The first step to preventing osteoporosis is weight-bearing exercise, namely walking. Are you willing to commit to a regular walking regimen?” “The reason your blood pressure is high again is that you’re not taking your medication. You have to take those pills every day!”
Of course, although it was very clear to me that my recommendations represented the right thing to do, I was certainly aware that not all my patients saw this as clearly as I did. In fact, as most doctors can attest, very few patients actually do make significant changes in their lifestyles, at least for more than the short term. Articles on avoiding burnout in physicians are based on this reality. I recall a visiting doctor telling us:
“A major cause of burnout is the fact that although we spend our days giving good advice to our patients, most of the time they don’t follow it, so physicians feel frustrated and upset. The solution to this is to change your expectations. Stop judging your value as a physician by the outcome. Instead, recognize that all you can do is point out to the patient what he or she needs to do; after that, it’s up to the patient. Recognize that you are doing a good job if you consistently tell smokers and drinkers about the need to quit; don’t consider yourself a failure if they don’t.”
Good advice! For years I’ve been an admirer of Dr. William Glasser’s Reality Therapy. One of its tenets is that the chief cause of unhappiness is when a person’s expectations don’t match the external reality. Glasser advises, if you can’t change the other person or the situation, change your expectations. That’s what the suggestion to physicians is saying—you will burn out if you expect others to do what you say, since you can’t control them. Instead, change your expectations to something you do have control over, which is your performance.
I’ve done that, and I continue to enjoy my work. However, learning about the Enneagram has shown me some ways in which I can be more effective in persuading patients to follow my recommendations, i.e., I can improve both my performance and the outcome.
First, it was a revelation to me that not everyone is willing to do something just because it’s the right thing to do! This line of reasoning is just not going to be persuasive to the type Seven patient whose chief goal is to have fun, to the Nine who wants to avoid physical discomfort, to the Three whose goal is to make “valuable” use of every moment, to the Eight who won’t let anyone tell her what to do, or to the Six who is fearful of change. I realized that I need to adjust my approach to the patient’s own Enneagram style.
It’s not that I set out deliberately to type everyone who walks into my office; I don’t. I’m very aware of how difficult it is to type someone at a distance. Even the experts, for example, disagree about President Clinton’s Enneagram type. In most cases you have to get close enough to a person and have enough one-on-one time to ask him some relevant questions. However, I have a couple of advantages. First, many people find it inherently stressful to get started with a new doctor (no matter how congenial the individual doctor might in fact be), and stress drives people to act out their type more. (Yes, I do become more rigid when stressed…)
Second, the doctor’s role is such that patients expect not only to reveal their bodies, but also their mind and emotions. Questions that in a social setting might be considered irrelevant or intrusive are considered perfectly acceptable within the examining room. This gives me the opportunity to check out an impression I might have received from the patient about what type he or she might be.
Consideration of the patient’s type is particularly valuable when I sense some conflict between us or some resistance to appropriate action, or when I feel uncomfortable with a patient, or when I sense that the patient is uncomfortable with me.
One common scenario which comes to mind involves the type Eight patient, the Boss. In the past, several Eight patients were really put off by my directive style. They challenged me, letting me know clearly that they felt they were in charge, and that I was mistaken if I believed that I was running the interview.
I have modified my approach in recent years. My model of the doctor-patient relationship has evolved into one of a team effort. The patient and I both have the same goal—to optimize the patient’s health. To that end, I make suggestions, and we discuss and negotiate them, and agree on a plan, and then review the outcome on subsequent visits. This is the general outline, but how it’s implemented depends on the particular patient. When I sense that a patient is type Eight, I might say “It’s my job to give you information and make suggestions, but you’re in charge of your body and it’s ultimately your decision.” This helps defuse a potential power struggle. I find that I get along much better with my Eight patients and am able to engage them more effectively in health-promoting actions.
Before I knew about the Enneagram, I recall walking into the exam room where my patient, a high school principal, sat with an aggressive body stance and a list in her hand of the things I had done wrong in my previous three visits with her. Joanne told me in an imperious tone why, based on my previous transgressions, she wasn’t inclined to follow whatever suggestion I might next make. I felt defensive and had a great desire to simply walk out of the room. Instead I held my ground and told her, “It’s clear you’re not happy with my treatment and you seem to feel we can’t work together. Maybe the best thing would be for you to find another doctor.” Joanne’s response was to back down, and suggest that maybe we could work things out after all. For several years thereafter we had a cordial and effective working relationship. In retrospect, I see that in that interaction I stepped out of my “nice girl” type One stance and stood up to her, a good strategy for resolving conflict with a type Eight person.
Moving on to other types, occasionally as I walk into an exam room to meet a new patient, I observe her sitting with arms clasped, feet under the chair, her body pressed against the wall as though she wanted to disappear into it. Her anxious facial expression supports the impression of a fearful person very stressed at having to get established with a new doctor. Whatever her Enneagram type, she appears at that moment to be behaving like a phobic Six. Rather than immediately getting down to her medical history and current medical problems, I have learned it’s more effective to begin by commenting on how scary it is for most people to have to switch doctors, etc. and addressing the fears. With such patients, I also provide additional explanations of whatever I do, and am sure to describe fully the potential side effects or complications of any medication or procedure I recommend.
One challenge which I have not yet effectively met involves several patients in my practice. In each case an authoritative type Eight husband accompanies his meek (perhaps phobic Six, perhaps people-pleasing Two, perhaps mediator Nine) wife to every visit and speaks for her. He tells me what’s wrong with her, what has worked or not worked, etc. If I address her directly, he replies for her. He’s the one who phones to request an immediate referral (for his wife) to a specialist, he’s the one who complains if something wasn’t done to his liking. Once when I asked one of these husbands to wait in the waiting room and had what I thought was a successful visit with my patient, I received an angry letter from him a few days later, explaining that his wife had neglected to mention to me various problems, that she tended to forget what I’d told her, that I surely understood that he had her best interest at heart in wanting to accompany her during her visits, and that he intended to do so in the future, or else find a different doctor for her. The position of such a husband seems to be that he is his wife’s chief protector against a hostile world, which includes, of course, incompetent physicians who must be supervised at every step.
My patient, the wife, of course colludes in this style of doctor-patient interaction. She gladly gives me permission to discuss her case with her husband, and seems to welcome being taken care of so well by her husband. For me, however, this scenario is very frustrating. I have tried to use my team approach (described above), and to include the husband as a member of the team. However, these husbands don’t want to be a team member, they want to be the leader. I would welcome suggestions from any type Eights who read this piece, as to a constructive solution!
Recently one of my patients, Miki, attempted suicide. On previous visits, Miki usually had been accompanied by her life partner Judy, who was always solicitous and very caring. Judy, also my patient, had diabetes and was generally very careful about her health. After Miki’s suicide attempt, Judy came in alone to discuss her concerns about her partner. Judy admitted that because she was spending every moment caretaking Miki, she was neglecting her own health, and her blood sugar was now way out of control. Recognizing that Judy was a type Two, my approach to her was the following: “I know you’re very concerned about Miki. But if you neglect your own health and get sick, you won’t be around to take care of her. One of the best ways you can help Miki is to get your diabetes back in control so that you can devote your full attention to her.” The message clearly caught her attention.
Within my subspecialty of Addiction Medicine, I often speak with spouses of alcoholics and drug addicts. Many of them have fallen into a pattern of neglecting their own needs and of caretaking their addict partners. It’s often hard to tell initially whether they indeed are type Twos or whether they have adopted that style as part of their own disease of codependency. Either way, an effective strategy for getting them to attend Al-Anon, the self-help program for families of alcoholics, is to say to them, “The best way you can help your husband is to go to Al-Anon and learn about alcoholism and your role in the disease.” Once they get there, of course, they learn to stop caretaking, detach from the problem, and begin paying attention to their own needs. But giving them this message in the office would certainly not persuade them to go to the meetings and get the help they need. On the other hand, presenting it as a means of helping their partner grabs their attention.
Another patient, Cindy, came in weighing 30 pounds more than a year earlier. She was now 100 pounds overweight and very discouraged. She had “tried everything” to lose weight and “nothing worked.” She would exercise religiously for a few weeks, then get demoralized and stop. She would diet all day, then overeat in the evening. I attempted various suggestions, but we weren’t getting very far; she was close to tears. Then I decided to try a different approach. I asked Cindy a few questions about herself and within a few minutes had the sense that she was a type One. At that point, I told her we were going to make a list. (I love lists, and I suspected she would too.) I wrote out some concrete brief suggestions about diet, exercise and group support, and gave her the assignment of complying with everything on the list for the next 2 weeks. By the time Cindy left, her mood had changed from pessimism to encouragement, and her motivation was high.
Nirvana, a pianist who played nightly at an upscale hotel, came in one morning because of frequent headaches. She had long, straight, dyed jet black hair, was heavily made up, and wore black from head to toe. A sweet and likable person, she complained of not getting the recognition she deserved, and of being unappreciated and underpaid by her employer. The stress was making her headaches worse. After completing what turned out to be a completely normal exam, I spent the rest of the visit listening to her talk about her visions for her career and encouraging her to tell me about the uniqueness of her music. I gave her a few pills for her headache and reassured her it wasn’t serious. Nirvana has returned several times since, and each time we spend most of our time in talk about her career and her dreams of recognition. I haven’t been able to cure the headaches, but she is convinced she is getting excellent medical care. I believe that the reason is she feels I understand her angst, that I can really hear her and her concerns, and appreciate her talent and her specialness. As a type Four friend of mine said, “What we really want is to feel truly heard.”
To me, the Enneagram is particularly useful when I feel stuck. At that point, I turn my attention to the patient’s Enneagram style and alter my approach accordingly. Several times I’ve been able to salvage a difficult situation and turn it into a successful outcome, one where both the patient and I feel that the visit accomplished the patient’s goals. And what more could a type One physician want?
__________ Enneagram Monthly Issue 54, October 1999
Jennifer Schneider, M.D. is a physician practicing internal medicine and addiction medicine in Tucson, AZ. She is the author of Back From Betrayal: Recovering From His Affairs, and Sex, Lies, and Forgiveness, and co authored with Ron Corn, M.S.W. Understand Yourself, Understand
Your Partner: The Essential Enneagram Guide to a Better Relationship.
It was only when I began tuning in to my inner monologue that, to my horror, I recognized the constant stream of judgmental thoughts, resentments, and righteous indignation. Yes, type One is definitely me, disguised anger and all. Today, despite a lot more self-awareness, I still at times find myself in a trance of righteous indignation, unwilling to let it go because, after all, I’m right and how could they do this! But I’m getting better, and I can usually recognize my trance and laugh at myself.
Another realization I had early on was how perfectly my Oneness fit in with my career as an internal medicine physician. My sense of responsibility, organizational skills, attention to detail, great follow-through, the way anything abnormal jumps out at me from the page—all of these are definite assets in my medical specialty. I recall feeling sorry for psychotherapists, whose job often entails prolonged listening and then expressing their opinions in indirect ways or not at all—saying a few words of wisdom and letting the client figure out for themselves the right thing to do. Not me! In my job I was not only encouraged, but expected to forthrightly tell my patients how their health required them to proceed, and for years I’d done it in a very direct way:
“If you’re going to get your diabetes under control, you have to lose 30 pounds and start exercising regularly.” “If you continue smoking, you’re putting yourself at high risk of heart disease and lung cancer. Let’s talk about how you can start quitting now.” “The first step to preventing osteoporosis is weight-bearing exercise, namely walking. Are you willing to commit to a regular walking regimen?” “The reason your blood pressure is high again is that you’re not taking your medication. You have to take those pills every day!”
Of course, although it was very clear to me that my recommendations represented the right thing to do, I was certainly aware that not all my patients saw this as clearly as I did. In fact, as most doctors can attest, very few patients actually do make significant changes in their lifestyles, at least for more than the short term. Articles on avoiding burnout in physicians are based on this reality. I recall a visiting doctor telling us:
“A major cause of burnout is the fact that although we spend our days giving good advice to our patients, most of the time they don’t follow it, so physicians feel frustrated and upset. The solution to this is to change your expectations. Stop judging your value as a physician by the outcome. Instead, recognize that all you can do is point out to the patient what he or she needs to do; after that, it’s up to the patient. Recognize that you are doing a good job if you consistently tell smokers and drinkers about the need to quit; don’t consider yourself a failure if they don’t.”
Good advice! For years I’ve been an admirer of Dr. William Glasser’s Reality Therapy. One of its tenets is that the chief cause of unhappiness is when a person’s expectations don’t match the external reality. Glasser advises, if you can’t change the other person or the situation, change your expectations. That’s what the suggestion to physicians is saying—you will burn out if you expect others to do what you say, since you can’t control them. Instead, change your expectations to something you do have control over, which is your performance.
I’ve done that, and I continue to enjoy my work. However, learning about the Enneagram has shown me some ways in which I can be more effective in persuading patients to follow my recommendations, i.e., I can improve both my performance and the outcome.
First, it was a revelation to me that not everyone is willing to do something just because it’s the right thing to do! This line of reasoning is just not going to be persuasive to the type Seven patient whose chief goal is to have fun, to the Nine who wants to avoid physical discomfort, to the Three whose goal is to make “valuable” use of every moment, to the Eight who won’t let anyone tell her what to do, or to the Six who is fearful of change. I realized that I need to adjust my approach to the patient’s own Enneagram style.
It’s not that I set out deliberately to type everyone who walks into my office; I don’t. I’m very aware of how difficult it is to type someone at a distance. Even the experts, for example, disagree about President Clinton’s Enneagram type. In most cases you have to get close enough to a person and have enough one-on-one time to ask him some relevant questions. However, I have a couple of advantages. First, many people find it inherently stressful to get started with a new doctor (no matter how congenial the individual doctor might in fact be), and stress drives people to act out their type more. (Yes, I do become more rigid when stressed…)
Second, the doctor’s role is such that patients expect not only to reveal their bodies, but also their mind and emotions. Questions that in a social setting might be considered irrelevant or intrusive are considered perfectly acceptable within the examining room. This gives me the opportunity to check out an impression I might have received from the patient about what type he or she might be.
Consideration of the patient’s type is particularly valuable when I sense some conflict between us or some resistance to appropriate action, or when I feel uncomfortable with a patient, or when I sense that the patient is uncomfortable with me.
One common scenario which comes to mind involves the type Eight patient, the Boss. In the past, several Eight patients were really put off by my directive style. They challenged me, letting me know clearly that they felt they were in charge, and that I was mistaken if I believed that I was running the interview.
I have modified my approach in recent years. My model of the doctor-patient relationship has evolved into one of a team effort. The patient and I both have the same goal—to optimize the patient’s health. To that end, I make suggestions, and we discuss and negotiate them, and agree on a plan, and then review the outcome on subsequent visits. This is the general outline, but how it’s implemented depends on the particular patient. When I sense that a patient is type Eight, I might say “It’s my job to give you information and make suggestions, but you’re in charge of your body and it’s ultimately your decision.” This helps defuse a potential power struggle. I find that I get along much better with my Eight patients and am able to engage them more effectively in health-promoting actions.
Before I knew about the Enneagram, I recall walking into the exam room where my patient, a high school principal, sat with an aggressive body stance and a list in her hand of the things I had done wrong in my previous three visits with her. Joanne told me in an imperious tone why, based on my previous transgressions, she wasn’t inclined to follow whatever suggestion I might next make. I felt defensive and had a great desire to simply walk out of the room. Instead I held my ground and told her, “It’s clear you’re not happy with my treatment and you seem to feel we can’t work together. Maybe the best thing would be for you to find another doctor.” Joanne’s response was to back down, and suggest that maybe we could work things out after all. For several years thereafter we had a cordial and effective working relationship. In retrospect, I see that in that interaction I stepped out of my “nice girl” type One stance and stood up to her, a good strategy for resolving conflict with a type Eight person.
Moving on to other types, occasionally as I walk into an exam room to meet a new patient, I observe her sitting with arms clasped, feet under the chair, her body pressed against the wall as though she wanted to disappear into it. Her anxious facial expression supports the impression of a fearful person very stressed at having to get established with a new doctor. Whatever her Enneagram type, she appears at that moment to be behaving like a phobic Six. Rather than immediately getting down to her medical history and current medical problems, I have learned it’s more effective to begin by commenting on how scary it is for most people to have to switch doctors, etc. and addressing the fears. With such patients, I also provide additional explanations of whatever I do, and am sure to describe fully the potential side effects or complications of any medication or procedure I recommend.
One challenge which I have not yet effectively met involves several patients in my practice. In each case an authoritative type Eight husband accompanies his meek (perhaps phobic Six, perhaps people-pleasing Two, perhaps mediator Nine) wife to every visit and speaks for her. He tells me what’s wrong with her, what has worked or not worked, etc. If I address her directly, he replies for her. He’s the one who phones to request an immediate referral (for his wife) to a specialist, he’s the one who complains if something wasn’t done to his liking. Once when I asked one of these husbands to wait in the waiting room and had what I thought was a successful visit with my patient, I received an angry letter from him a few days later, explaining that his wife had neglected to mention to me various problems, that she tended to forget what I’d told her, that I surely understood that he had her best interest at heart in wanting to accompany her during her visits, and that he intended to do so in the future, or else find a different doctor for her. The position of such a husband seems to be that he is his wife’s chief protector against a hostile world, which includes, of course, incompetent physicians who must be supervised at every step.
My patient, the wife, of course colludes in this style of doctor-patient interaction. She gladly gives me permission to discuss her case with her husband, and seems to welcome being taken care of so well by her husband. For me, however, this scenario is very frustrating. I have tried to use my team approach (described above), and to include the husband as a member of the team. However, these husbands don’t want to be a team member, they want to be the leader. I would welcome suggestions from any type Eights who read this piece, as to a constructive solution!
Recently one of my patients, Miki, attempted suicide. On previous visits, Miki usually had been accompanied by her life partner Judy, who was always solicitous and very caring. Judy, also my patient, had diabetes and was generally very careful about her health. After Miki’s suicide attempt, Judy came in alone to discuss her concerns about her partner. Judy admitted that because she was spending every moment caretaking Miki, she was neglecting her own health, and her blood sugar was now way out of control. Recognizing that Judy was a type Two, my approach to her was the following: “I know you’re very concerned about Miki. But if you neglect your own health and get sick, you won’t be around to take care of her. One of the best ways you can help Miki is to get your diabetes back in control so that you can devote your full attention to her.” The message clearly caught her attention.
Within my subspecialty of Addiction Medicine, I often speak with spouses of alcoholics and drug addicts. Many of them have fallen into a pattern of neglecting their own needs and of caretaking their addict partners. It’s often hard to tell initially whether they indeed are type Twos or whether they have adopted that style as part of their own disease of codependency. Either way, an effective strategy for getting them to attend Al-Anon, the self-help program for families of alcoholics, is to say to them, “The best way you can help your husband is to go to Al-Anon and learn about alcoholism and your role in the disease.” Once they get there, of course, they learn to stop caretaking, detach from the problem, and begin paying attention to their own needs. But giving them this message in the office would certainly not persuade them to go to the meetings and get the help they need. On the other hand, presenting it as a means of helping their partner grabs their attention.
Another patient, Cindy, came in weighing 30 pounds more than a year earlier. She was now 100 pounds overweight and very discouraged. She had “tried everything” to lose weight and “nothing worked.” She would exercise religiously for a few weeks, then get demoralized and stop. She would diet all day, then overeat in the evening. I attempted various suggestions, but we weren’t getting very far; she was close to tears. Then I decided to try a different approach. I asked Cindy a few questions about herself and within a few minutes had the sense that she was a type One. At that point, I told her we were going to make a list. (I love lists, and I suspected she would too.) I wrote out some concrete brief suggestions about diet, exercise and group support, and gave her the assignment of complying with everything on the list for the next 2 weeks. By the time Cindy left, her mood had changed from pessimism to encouragement, and her motivation was high.
Nirvana, a pianist who played nightly at an upscale hotel, came in one morning because of frequent headaches. She had long, straight, dyed jet black hair, was heavily made up, and wore black from head to toe. A sweet and likable person, she complained of not getting the recognition she deserved, and of being unappreciated and underpaid by her employer. The stress was making her headaches worse. After completing what turned out to be a completely normal exam, I spent the rest of the visit listening to her talk about her visions for her career and encouraging her to tell me about the uniqueness of her music. I gave her a few pills for her headache and reassured her it wasn’t serious. Nirvana has returned several times since, and each time we spend most of our time in talk about her career and her dreams of recognition. I haven’t been able to cure the headaches, but she is convinced she is getting excellent medical care. I believe that the reason is she feels I understand her angst, that I can really hear her and her concerns, and appreciate her talent and her specialness. As a type Four friend of mine said, “What we really want is to feel truly heard.”
To me, the Enneagram is particularly useful when I feel stuck. At that point, I turn my attention to the patient’s Enneagram style and alter my approach accordingly. Several times I’ve been able to salvage a difficult situation and turn it into a successful outcome, one where both the patient and I feel that the visit accomplished the patient’s goals. And what more could a type One physician want?
__________ Enneagram Monthly Issue 54, October 1999
Jennifer Schneider, M.D. is a physician practicing internal medicine and addiction medicine in Tucson, AZ. She is the author of Back From Betrayal: Recovering From His Affairs, and Sex, Lies, and Forgiveness, and co authored with Ron Corn, M.S.W. Understand Yourself, Understand
Your Partner: The Essential Enneagram Guide to a Better Relationship.