For 21 years, I've ostensibly been a practice business advisor. But beyond the graphs and spreadsheets, I've been a keen student of the ophthalmic personality. What role does a surgeon's personality play in his or her business success? And if we dare to generalize, what, indeed, are the roots of the typical ophthalmologist's personality?

At the urging of a client, I recently decided to get more serious about trying to understand what makes ophthalmologists tick. I enlisted the help of an experienced psychologist and asked a few doctors to tell their own stories, either on or off the record.

Whether you're an eye surgeon, employed in an ophthalmic workplace, or the spouse of an ophthalmologist, I think the insights I'd like to share will resonate with you.

"My parents always held out to me how nice it would be if I did better, if I got better grades. And so I always thought I should win. If you're going to play, you may as well try to win, right?" So says Dr. John Corboy, famous in ophthalmic circles for building one of the earliest and largest ophthalmic empires in America, based in Hawaii, and for being a master of the business as well as the science of eye care.

"I learned that we may as well be as perfect as we can, or what are we doing? To me it's incomprehensible to do less than the best that you can possibly do. Be as perfect as you can be, as your staff can be. Always look for better."

And so it goes. The results of perfectionism are wonderful for your patients, and even pretty great from the perspective of most eye doctors. But taken to even slight extremes, the behaviors that create the outward hallmarks of the "ophthalmic personality" can lead to stressed staff, abused patients and -- at least emotionally -- abandoned families.

Dr. Scott Diener, a southern California psychologist, has worked with high-intensity surgeons. He's developed several educated theories about the makeup of upper-crust doctors that are in accord with my own observations as a layman.

"What's the difference between highly trained, highly stressed, highly compensated surgeons and the general public?" Dr. Diener asks. "If you look overall at their history, they have dissociated from some of the normal dynamics in life. If you go through medical school, a rigorous training where you have no life of your own for a very long time, there is really just one focus -- and necessarily so. You don't make it unless this is your total focus.

"I think this training, this focus, ends up acting as a filter so that only certain kinds of personalities come through. And probably the overriding personality characteristic would be narcissism. Now this isn't necessarily the psychological condition that we formally call a personality disorder (which is, incidentally, far more common in males than in females). But it's a kind of light dose of a personality that won't accept criticism, that is highly perfectionistic, that really sees a world that revolves around 'me' rather than around others.

"And that's not to take away some of the humanitarian qualities, but there is that ability to partially or completely dissociate. If you think about it, this is necessary for a surgeon, especially an eye surgeon. You need it to be able to walk into any situation and be effective. So I think that, fundamentally, this filter process that the medical community, and especially surgical specialists, go through selects this kind of personality."

Ophthalmology is perhaps one of the more rigorous filters, which is why some of these behaviors are more pronounced in eye surgeons.

Dr. Diener continues, "You have to keep in mind that this dose of narcissism (mild in most cases) is a long-term personality characteristic, something we can probably trace into early childhood. There is typically a decided influence, most often in the form of parents who are pushing for the child to succeed.

"Again, I would like to emphasize that this isn't a 'disorder,' but a personality with many positives, favorable factors that a mildly narcissistic person wouldn't necessarily want to change. In most cases, the personality pattern of surgeons allows these doctors to function in an extremely demanding world. A full dose may be debilitating, but a half dose is invaluable.

"If this personality goes a little too far, however -- and this is obviously true for some surgeons -- what we find is a really disruptive, life-long pattern with relationships. We'll see lots of ups and downs with marriages, friends, staff. We'll see lots of staff turnover. Clearly these highly filtered and screened professionals have highly charged, very emotional relationships.

"A characteristic I often see is a kind of roller coaster fluctuation of feelings about a person, let's say an office assistant." Apparently, depending on which day you ask him, a surgeon might think a medical assistant is a superstar or a lunk-head. There's no middle ground.

Dr. Diener says it's important to stress the positives of the ophthalmic personality. Patients probably want to have someone who is a commanding personality holding a blade to their eye. They want someone who's decisive, who can be demanding of himself and others. They need someone who is saying to himself, even if he's a little out of touch with reality, "I'm the best and I'm in charge."

"Interestingly, as women have come into the marketplace and become more 'professionalized,' we've seen a lot more of these traits in women," Dr. Diener says. "Some of the highest functioning members of society seem to learn the skill of narcissism, and fortunately most pick up a half dose without over-learning the skill. I really do believe that narcissism is more a matter of nurture than nature. I don't think we'll ever find a gene for the trait."

Is there something truly different about ophthalmologists? "You can err and be overly general because exceptions to all of this exist, but many of the people who find themselves in ophthalmology are very precise, very compulsive because our field is one where you can measure everything," says Dr. Corboy.

"Your refractive error, your visual field, everything. In fact, it's often been said, 'If we can't measure it, you don't have it.' We like to play games late in our residencies where we invite the patient in and we say to him, 'Don't tell me your chief complaint. I'm going to examine you and tell you what's bothering you.' The reason for this sort of audacity is that we think everything can be measured. Perhaps ophthalmologists are the kind of people who lean toward that. My father was an ophthalmologist, so of course I didn't come to it because of any innate traits of my own, mind you, but because of his odd personality!

"I'm a neat-freak. I pick up all the time today because my mama used to say, 'Pick up!' all the time. That kind of attention to detail pays off in our field. Ophthalmology is nothing if not infinitely precise. Your patient is rewarded for your compulsiveness and attention to detail. We're talking microns, whether you zig or zag.

"At the same time, my mother gave me a great dose of reality. No matter what I achieved, my mother was quick to say, 'Get off your high horse, mister.' That echoed throughout my upbringing. I always felt that although I might be a god at the office, I was still just a person at home. The fact that the employees and patients worshipped me had no connection at home. My family didn't give a hoot for that. They judged me by being home on time, being a pleasant dinner companion, being a good father who tucks the kids in at night. I never felt a hero at home.

"Everyone should have that humbling factor in their life, whether it comes from mama or elsewhere. At the very least, we as ophthalmologists should realize that we're all standing on the shoulders of the giants in eyecare who preceded us, and very few of us are really anything all that special."

What should a staff member or fellow doctor do when working with a doctor who has perhaps too large a dose of narcissism? According to Dr. Diener, "Probably the most important thing is how you go about challenging the individual and his authority. This is where you find the most abrasiveness and reactivity. Fellow workers need to develop strategies that support the doctor's authority rather than challenging it.

"If we go back to the example of dealing with doctors who run hot and cold on their feelings about the performance of a staff member, we'll hear them say, 'Our head tech, Susan, has to go!' The best way to deal with this overreaction, to get off the roller coaster, is to first get focused on some of the positive things, and to not directly challenge the surgeon's authority."

As an administrator or department head in a practice, be sure to investigate first and challenge second. Centering on fundamental office rules or principles such as "patients come first" can help. Even the most brittle surgeons will ultimately succumb if they are gently assailed with the facts.

"Here's another point," says Diener. "It's important to carefully structure the relationships between the surgeon and staff. It really is true that familiarity breeds contempt. The kind of office setting where everyone hugs and loves each other sounds wonderful, and it's something that doctors often try to sponsor to replace other unmet needs in their lives. But with this kind of personality, such an environment is not long-lasting.

Inevitably, if you look at the typical highly strung surgeon's relationship style, you're going to have clashes -- the teeter- totter of overvaluation and devaluation. It can be very cyclic. So it often works best if you can set up the kind of office where the staff are very bonded to each other and have a good time together, but the doctors are at a level above."

Note that for many doctors, being above the team and aloof is very painful and isolating; they want to be part of the team that's having fun together.

"As a psychologist I've worked with a lot of high-level professionals who perhaps have a larger measure of this narcissistic trait, up to levels of a disorder, and it's very lonely," Dr. Diener says. "They understand, 'Something is different about me. Everyone else seems to be able to keep these relationships; mine seem to go blasting off into outer space.' "

Dealing with these realities may be at once frustrating and surprising. High-demand doctors, in the main, are not ill or in need of therapy or treatment, per se, unless as surgeons they want to improve. First and foremost, doctors and their senior staff members have to recognize that these traits are helpful at some levels. If you got rid of these traits completely, the surgeon would lose critical talents at other levels, such as decisiveness and the impulse to act.

Staff members, spouses -- even we consultants -- simply have to recognize it. As for the highly strung surgeons themselves, it's important to accept the kind of personality you have and acknowledge that it's largely OK.

Practice growth and development, from a small one-doctor practice to a group, presents challenges for the typical ophthalmic personality, but also interesting benefits. "Growth can often be very positive," says Diener. "The surgical personality does well with a command structure. It validates the authority the doctor desires. The chief problem that can occur is that doctors find themselves doing what they hadn't quite intended, that is, having to manage a different mix and a much larger scale of resources. With a small office practice, the enterprise is very focused. With growth, there are competing demands."

Managing partners in such practices can draw on their natural ability and desire to command. But if that desire and ability isn't present, doctors can find themselves the king of an unintended kingdom. You need to make sure that you don't work hard to get something you really didn't want. I can vouch from the field that doctors who have built extremely large practices often question the scale to which they have grown.

What other personality traits come along with narcissism? "Anxiety is probably the most common," says Dr. Diener. "Other associated personality characteristics can include passive aggressiveness. This can lead to the covert destruction of what has been built up, by not attending to the details associated with a larger practice."

Perfectionism and the desire for control become a sword cutting two ways. In the transition from a small practice to a larger practice, there's an inevitable shift from direct doctor-owner control to control through subordinates. This results in less than perfection, which is difficult for most surgeons to witness in silence. Diener says, "I would set a larger practice up so that doctors with a strong tendency toward perfectionism don't have to be exposed to the imperfections that attend growth."

We're talking about a personality that survives -- and I would even go so far as to say thrives -- on perfectionism, and has made it to the pinnacle. It's asking too much to change it. Surgeons, however, should let managers manage. Exposure to all the normal little messes of running an ophthalmic practice can be extremely uncomfortable. If, as a surgeon, you're reactive to these messes, stay out of the kitchen. Don't purposely expose yourself to the most disturbing details.

However, this doesn't mean that you should be in the dark about the management facts and data of your business's performance. Diener illustrates: "An old maxim of psychology is to go with the resistance. If we have a patient who likes to hoard towels, we fill his room with towels. Likewise, overwhelm the doctor with details, flood him. This can lead to a doctor who feels in control and happy."

At some levels, surgeons are highly refined craftsmen. They've been filtered to be craftsmen. They haven't been filtered to be managers, which is an entirely different skill set. They're especially not conditioned to have their authority challenged. As one doctor put it, "The most pressing thing is to not challenge me. That doesn't mean accept all of my decisions silently. We need to simply work out new strategies for discussion. How we discuss is more important than what we discuss. I'm always going to want to make decisions. Bring me the facts and data. Let's talk. Most important, don't come to me and say, 'You've got to do this or else.' Come at me like that, and you're just setting up a scenario where I will show you the 'or else,' along with the door!"

Absolute contingencies don't work well. Try to select staff members for your practice who are able to communicate at this level and are bright enough to understand this personality type. By this, I don't mean that any staff member or spouse should ever tolerate frank abuse from a doctor, but they'll help to deflect potential abuse if they can learn to communicate in a functional way. As the doctor, you need to develop trust, and know that decisions delegated to staff will be made with as much clarity as you would apply.

What if you're the manager or employee of an over-wound surgeon? No matter what your frustrations are, being starkly confrontational in such settings won't work. You'll lose every time, and ultimately you'll be out of the practice. Ideally, you should choose a surgeon to work for whose judgement and authority you can respect. But even if this isn't the case, constant confrontation and struggles for control won't work.

At the other extreme, being a sniveling, sycophantic staff member is a worst-case scenario. Then, talents of the whole team don't get used, only the talents and judgement of one doctor at the top. It's a delicate balance, obviously, between the extremes of head-butting confrontation and demurring.

As an employee, how can you cope if you find yourself in a practice with a surgeon who displays these behavioral extremes? First, it helps to remember that surgeons are highly intelligent, and -- at least on some interior levels -- very compassionate people. They want to excel across a number of dimensions: financial, professional, and often in their non-clinical passions and hobbies. So even with the narcissistic overlay, these are people who can deal with just about anything the world can throw at them. Most are highly sophisticated, highly competent, and highly confident. At some levels the world has to line up behind these individuals rather than the other way around.

It also helps to stand in the surgeon's shoes and understand that the medical business environment is different, and far more stressful, than most businesses. If a toy company makes a defective toy that chokes a child, the CEO doesn't get indicted. The responsibility is distributed throughout the company. For a doctor, reputation, personal assets, license and the ability to pursue a career are on the line every day. At some levels, perhaps, anything less than at least a mild narcissist couldn't survive. Laid back folks just don't become eye surgeons.

Diener describes three hallmarks that represent a dividing line between highly functional, helpful, narcissistic traits and traits that are disabling. As a surgeon, ask yourself:

• Do I see a pattern of disrupted relationships in my life?
• Am I making decisions, such as staffing decisions, based on feelings about the staff rather than objective information about current and potential performance?
• Am I mad at my head technician because she stood up to me and challenged me or because her performance is flawed?

"Don't get rid of the strength of narcissism that the filtering and conditioning of your surgical training has allowed," Diener says, "but temper your decisions and behaviors so you act in a way that is fact-based rather than emotion-based."

This whole approach should feel appealing and comfortable to most surgeons, who after all are scientifically, objectively grounded. You can be the way you are, be highly functioning (and with this a little overbearing). It will all work out just fine so long as you understand that these traits can get you into trouble with the people in your life.

The paradox is that what puts a surgeon professionally on top, at the pinnacle, causes trouble in his or her relationships. In addition to the talents you've mastered as a surgeon, and all of the other non-clinical talents you possess, you also need to be able to buffer any overly judgmental and perfectionistic tendencies when you interact with the world of mere mortals.

The red flag should go up when you find you're making decisions based on emotions (positive or negative) about a person, particularly staff. Develop the ability to let go and trust them to do their jobs. If necessary, isolate yourself from annoying and distracting details. Make management decisions based on performance, not on whether you like or dislike somebody. As one surgeon put it, "Every day I have to resist the temptation to slip into my old pattern of overvaluation and then devaluation."

By the same token, don't retain staff members who aren't performing simply because they stroke you and make you feel good. Always go back to the objective performance.

New Jersey ophthalmologist Dr. Herve Byron has long lectured and written on the personal challenges of being an ophthalmologist, and he's become one of the most respected voices in the national community on this topic. He described to me how his own path and early motivations probably have much in common with that of his colleagues.

"When I was 5 years old, I was a sickly kid, a kid with chronic ear infections in an era without antibiotics. The treatment was mastoidectomy, a massive operation with a 30% mortality rate. My father was a physician, and he and the other doctors on the case thought a transfusion would help. My uncles were screened, and one was a match. I'm 70 years old now, and I can still visualize us lying on adjacent beds in our living room, with this tube sticking into me. Suddenly the tubing broke, and there's blood squirting all over the walls -- not a very security-engendering experience for a 5-year-old.

I was also a fat kid. In the public school you were supposed to climb the rope. I simply couldn't. My upper body was too weak. We had to jump over the horses in gym -- forget it! This was my pattern. I went to the music class and everyone started to sing. The teacher came over to me and said, 'Herve, mouth the words but don't sing, your voice is terrible.'

"As I now see myself so clearly in hindsight, throughout my educational and then my professional, adult life, I was still this sickly, fat kid who couldn't perform in the gym and couldn't even sing! I've had to keep showing people that I have some value. So in high school I drove myself to being second in a class of 1,800 students.

"Today, people ask me, 'Why are you still doing this, Herve? Why are you still striving?' Until a few years ago when I finally developed some insight into what makes me tick, I really couldn't answer them. Now the anxiety about striving is long gone. It's just a matter of having fun. But for the first 25 years or more of my career I was compelled by those early, difficult experiences to show I had something to contribute.

"I've been through a lot of therapy and have talked to a lot of our colleagues, and the insight I've gained is that ophthalmologists are highly susceptible to depression. We're tightly wound. We have a great ability to use denial. We don't have great support systems. We have lots of quick relationships with patients, and we don't really get involved with them. If and when things fall apart in our lives, they go downhill rapidly.

"When I look out over an audience of ophthalmologists today, about 80% of them look depressed. No emotion. No reaction. Nothing. The tragedy and the danger is they have no idea that they're depressed. Denial keeps us from getting help, unless we have a support system in place.

"There are a number of well-documented screens for this depression. Do you have trouble sleeping? Have you lost interest in eating? Are there difficulties in your sexual life? Difficulty with relationships? Can you perform for more than 8 hours in your office the way you used to? Can you make decisions clearly? Do you find you're withdrawing, not wanting to talk to people? Once I was medicated for my own depression, I could eat and sleep better; I could think and operate better. I wasn't going through anxiety crises every day.

"We're all so focused, and our obsessing, compulsing tendencies lead us to ophthalmology. When I was at the height of my surgical career I couldn't wait to get into the operating room. I couldn't wait to operate on difficult one-eyed patients because I could walk up to the table with supreme confidence. It was a challenge I knew I could handle."

Of course, all the striving in the world can't overcome the inevitable transition from being a surgeon to being a non-surgeon, which can be terribly painful for doctors whose sense of self is so interwoven with their surgical acumen.

Dr. Byron continues: "At 62 or 63 years old, I found that some of the post-op results of some of the younger docs I was working with were better than mine. For a while I was striving to reach to the next level, but the bar had been raised so high. My neck was killing me, my back was killing me. I really was hurting myself physically to keep up. I decided it was time to quit, which was a very difficult decision to make. What else would be left? The trick is to find solace in the conversion from digital to cerebral skills.

"The even greater difficulty is making the transition from being a doctor to being retired. You must transition your skills into something that will give you satisfaction and add value to others and give you a compensatory sense of value."

When making any transition, from training to practice, from being an associate to becoming a partner, from surgical to non-surgical and on into your retirement from medicine, get in touch with your values at each of these points.

"After a lot of life," Byron says, "you realize that time is irreplaceable. Take the time to enjoy whatever it is that you enjoy. You have to be flexible. You have to check over and over to make sure that when you are in transition, the new direction you're taking is right for you.

"Next, you have to stop denying. Eye surgeons have got to be the best 'deniers' in the world. In the face of total disaster, we'll say, 'Everything is great.' We have to get in touch with our feelings. I've come to learn that my gut will make a better decision than my brain every time. If you are a man and have a spouse with good instincts, that's a priceless asset. My dear wife, Bryn, can smell a bad decision or someone who's faking it from a mile away.

"This leads me to what I think is the significant personality difference between male and female eye surgeons. They're driven by different factors, I think. If I were 20 years younger and looking for an associate for my practice, I would choose a woman. They communicate better, they're more driven in ways that I think males are often not when it comes to patient communication and care.

"Women are more pragmatic, realistic, intuitive, with far less denial than males. Male physician pilots have the highest incidence of accident mortality. Female physician pilots have almost no accident mortality. It's because women listen. When the tower says, 'Come back,' they follow directions."

Ophthalmologists need to know where their strengths and deficits are. It's not enough just to be bright and creative anymore. You have to know how to find and motivate people who can sweat the details. I urge surgeons I speak with to be at peace with the reality of change.

You need to be compliant to what's happening in the world of medicine today. That world is more powerful than you are.

Also, communication is crucial. If you're going to have people tolerate working with you, you've got to communicate. If you're interviewing a doctor to join your practice, look first for communication skills. It goes both ways; if you're a lay person in an ophthalmologist's life, you have to become a good communicator. My advice is to know your doctor well enough that you can communicate without a confrontation. And most importantly, timing is essential. Don't confront at the end of the day when you're both exhausted. Instead, choose a set time on a regular basis to do this.

Consulting in settings with poor communication has taught me it's helpful as a surgeon to give colleagues, staff, spouse and even friends permission to give you feedback. If you're comfortable with this, ask them to be bolder than they might otherwise be. If you're the kind of surgeon who can be invite openness, surround yourself with people who can give you intelligent feedback. If you're less willing to have blunt feedback, which is more commonly the case, select just one trusted member of your staff to be a private, on-site coach who can praise your positive personality traits and gently remind you to adjust traits and behaviors that can lower staff morale.

Here's another major theme I've uncovered in ophthalmic circles. Eye surgeons spend the first third of their lives being, by and large, exceptional when compared to everyone else around them. They are the best in grammar and high school, among the brightest in college, the achievers in medical school. Then reality hits for the newly minted ophthalmologist, now living in a universe of about 15,000 other overachieving American eye surgeons: "Hey. I'm no longer the smartest or most talented person in my world. I'm just an average eye doctor." Some doctors I know have a profound difficulty handicapping themselves against the members of a rarified world and being comfortable with an average ranking.

Dr. Corboy has some helpful perspectives on this. "The only thing that's acceptable to me is to be as good as I can be because only then can I accept whatever results come for the patient. The guilt that would attend not being as perfect as I possibly can be is unacceptable.

"I've had to get to bed on time, take a strict diet on surgery day, just because I had to. Every now and then you'll have an unfortunate result, and at least I could say I was as good as I could be.

"There are some docs who obviously take that to the next extreme and say, 'Well, what I've just done for this patient isn't the best in the world that can be done.' And they get very bent out of shape because of that. You have to let go of that and instead think, 'Yes, there is a guy in Boston or Zurich who can actually do slightly better than me, but this patient can't go to Boston or Zurich, and I'm the best this patient is going to get.' There's always someone who's better, taller, smarter, richer. You just have to let go of that. You get peace with that over time. And for some subspecialty areas, such as retina, you never get peace with it, so that's why we refer out the difficult cases. The whole goal is to take the best possible care of the patient.

"Well, we all know people who have gone too far, who lost their family, or for that matter their sanity being overly perfectionistic with their practice. It's probably healthy to want to be the best doctor in town. It's probably unhealthy to want to be the best doctor on the planet. You can get too overwhelmed by perfection. You have to find a wholesome level of discipline and then be gentle with yourself. You have to do the best you can and then let go."

Overachieving. Perfectionistic. Intolerant. Workaholic. Striving. Controlling. Being the absolute best. These undeniable ophthalmologist personality traits are admirable and essential when examined through the eyes of a patient about to undergo surgery. These same traits, carried to extremes, or untempered by a dose of humility and self-effacement, can be profoundly galling to the rest of the people who are a part of every surgeon's life.

Perhaps one day in the distant future we'll have a simple, painless test that will categorize ophthalmologists into various personality types. Perhaps we'll invent an elaborate serum that can be slipped to the most abrasive doctors, without robbing them of the rarified talent so often found in greatest measure among the most difficult individuals.

Until that day, it will fall to those of us who have chosen to serve patients -- by serving doctors -- to do the best we can with what we've got. On the toughest days we simply will have to say, as one might hear a long-suffering parent sigh about their mischievous children, "Bless their hearts, they can't help themselves."