성격 검사와 의학교육 및 의료행위 관련 성과(AMEE Guide No.79)
Personality assessments and outcomes in medical education and the practice of medicine: AMEE Guide No. 79
MOHAMMADREZA HOJAT, JAMES B. ERDMANN & JOSEPH S. GONNELLA
Jefferson Medical College of Thomas Jefferson University, USA
“In the physician or surgeon no quality
takes rank with imperturbability [which] means coolness and presence of mind
under all circumstances and the physician who has the misfortune to be without
it loses rapidly the confidence of his patient.”
Sir William Osler, 1922, pp. 3–4
Introduction
At least two major complementary components contribute to
the performances of physicians-in-training and in-practice.
l
One component includes a set of “cognitive” abilities, which are often
reflected in intellectual capabilities, performances on examinations of
recalling factual information and tests of declarative knowledge.
l
The other component, often described under the rubric of “noncognitive” or personal
qualities, includes features such as personality attributes, attitudes, interests,
values and other personal characteristics (Gonnella et al. 1993, 1998).
Personality in the context of medical education and patient care
성격Personality의 정의
In the context of medical education and patient care, we define
personality as a configuration of characteristics and
behavioral tendencies that comprise an individual's unique features, developed
based on a combination of several interacting elements such as constitutional
predisposition, rearing environment, quality of early attachment relationships,
interpersonal and critical life event experiences, social and cultural
environment as well as formal and informal education.
성격의 설명력
It is reported that intellectual abilities
account for about 35% of the variance in performance, but inclusion of personality information increased the
common variance to 75% (Walton 1987). In a longitudinal study of internal
medicine residents, Girard and Hickman (1991) found that 48% of the variation in clinical ranks and 38% of the variation on
American Board of Internal Medicine (ABIM) examinations could be explained by
psychological and personality variables.
In our own study with medical students, we noticed that a set of personality measurers (e.g.
l
appraisal of
stressful life events,
l
general anxiety and
test anxiety,
l
external locus of
control,
l
intensity and
chronicity of loneliness experiences,
l
extraversion,
l
self-esteem,
l
perceptions of early
relationships with parents and peers and
l
measures of over- or
under-confidence)
could significantly predict performance on medical
licensing examinations (Hojat et al. 1988).
Also, we found that higher scores on measures of self-esteem and extraversion, lower scores on
loneliness, and perceptions of satisfactory relationship
with parents in childhood (Hojat et al. 2004a) could predict global ratings of clinical competence in core clerkships in medical school.
Furthermore, inclusion of a set of the aforementioned personality measures to
the prediction model could substantially increase (from 0.32 to 0.56) the
magnitude of correlations between academic attainment predictors already in the statistical
model (previous academic grades and scores of the Medical College Admission
Test, the MCAT) and the criterion measure (scores on Part 1 of the examinations
of the National Board of Medical Examiners) (Hojat et al. 1988).
In another study, we noticed that ratings
of interpersonal skill, assigned by
residency program directors, were significantly and positively correlated with
reports of satisfactory early relationships with mothers and peer prior to medical school, but negatively
associated with scores on measures of anxiety, neuroticism, and loneliness (Hojat et al. 1996a).
However, research findings, using a variety of personality measures to improve
the predictive validity of academic performance have not been
consistent (Pollock et al. 1982; Aldrich 1987; Weiss et al. 1988),
도구들
A number of personality instruments have been used in medical education
research such as the NEO Personality Inventory (e.g. Lievens et al. 2002;
Ferguson et al. 2003) for measuring the big five factors of personality; the
California Psychological Inventory (e.g. Hobfoll et al. 1982; Tutton 1993,
1996); the Eysenck Personality Inventory/Questionnaire (EPI/EPQ; e.g. Roessler
et al. 1978; Lipton et al. 1984; Westin et al. 1986); the 16 Personality Factor
(16PF) Questionnaire (e.g. Lipton et al. 1984; Green et al. 1993; Peng et al.
1995); the Myers-Briggs Type Indicator (MBTI; e.g. Turner et al. 1974; Tharp
1992); and the Jefferson Scale of Empathy (JSE; e.g. Hojat et al. 2002a, 2002b,
2002c; Hojat 2007), among others.
A paradigm of physician performance
This multidimensional conceptualization of physician performance (depicted
in Figure 1)
Conventional approaches to obtain personality information in medical
education
Admissions interview
medical students
themselves, without any training, sometimes perform interviews with new
applicants in order to supplement the staff and faculty resources needed for
interviewing a large number of applicants. Interestingly, no significant
difference has been observed between faculty and students interview ratings
(Gelmann & Stewart 1975; Elam & Johnson 1992; Eddins-Folensbee et al.
2012).
Letters of recommendation
There is no
convincing empirical evidence in support of the predictive validity of letters
of recommendation in medical schools.
Personal statements, letters of intent and essay
In one study, the
content of candidates' personal statements was analyzed, and no evidence was
found to support its predictive validity (cited in Ferguson et al. 2002).
Because of the
aforementioned shortcomings, Haque and Waytz (2012) suggest that one
appropriate approach for the assessment of personality of
physicians-in-training is to administer psychometrically sound personality
instruments.
A benign neglect
It is interesting to note that despite the recent emphasis placed on
personal qualities relevant to professionalism in medicine (Stern 2006; Veloski
& Hojat 2006), and in spite of the accumulating volume of research by
psychologists on the importance of personality in professional development and
personal, social and professional behaviors, there seems to be a lack of
enthusiasm among medical education leaders, faculty and researchers to take
a fresh and serious look at the assessment and cultivation of personal
qualities in medical education and in patient outcomes.
First, some have lingering
doubts about the role of personality in the performance of medical students
and physicians. Proof is needed for supporting the link between personality,
academic performance, clinical competence and the quality of patient care.
Second, a variety of
personality instruments have been used over the years in medical education
research.
This ambiguity leads to confusion about
choosing specific personality measures with strong associations with medical
education and patient outcomes.
Third, some skeptics may believe that there is no need for independent assessments of personality
attributes, because, they maintain that, indicators of intellectual capability, such
as academic attainment and professional achievements require specific personal
qualities such as achievement motivation, interest, and self-esteem, which are
inseparable factors in academic success. According to this view, personality
factors are assumed to be embedded in any assessment of academic attainment;
Fourth, there are those who believe that personality
attributes are not amenable to change. Therefore, there is
no point to assess those personal traits or implement programs to enhance those
personality features that have already been formed based on genetic
predisposition and early life experiences.
Fifth, some believe that items of personality tests are
often transparent, and can thus be “faked” or answered in a way that is recognized as socially desirable. According to this belief, results of
self-reported personality tests are not valid because respondents can
manipulate their answers to intentionally produce a socially desirable image of
themselves.
Purpose
Selected personality instruments frequently used in medical education
(1) Measurement of the five factors of personality
A review of the literature on personality and its measurement indicates
that a great volume of published research in recent years examined specific
personality attributes under a rubric of the five-factor model (FFM) of
personality. These factors are often referred to as Openness,
Conscientiousness, Extraversion, Agreeableness and Neuroticism (or emotional
stability which is the opposite of neuroticism). The acronym OCEAN was used by Hoffman and colleagues (2010) to represent these big-five
factors of personality, respectively.
The five factors were originally extracted based on an extensive psycho-lexical analysis of thousands of English
words describing personality, supported subsequently by empirical
findings resulting from factor analytic
research (Goldberg 1990, 1992; Costa & McCrae 1992). The FFM is based not only
on theories of personality but is also grounded on a variety of biological, psychological and social perspectives, and an integration of both nature and nurture underpinnings of
personality development (McCrae & Costa 1989, 1997; Goldberg 1993; De Raad
& Perugini 2002). Evidence suggests that at least some components of the five factors are inherited (e.g. excitability component of the Neuroticism factor) which supports the
view on biological roots of some personality attributes (Jang et al. 1996).
The FFM, or some variant of it, currently a popular model of personality
among psychologists, has been studied extensively and used by many personality
researchers (Musson 2009). Each of the five factors includes a number of facets
or components.
l
For example, the Openness factor includes
facets such as fantasy, aesthetics, feelings, ideas, actions, imagination,
preference for variety, curiosity and intellectual qualities (Costa &
McCrae 1992).
l
The Conscientiousness (C) factor includes
components such as competence, dutifulness, achievement striving,
self-disciplined, deliberation and order.
l
The Extraversion (E) factor includes facets such as sociability, warmth,
activity, positive emotions, assertiveness, gregariousness and excitement-
seeking.
l
The Agreeableness (A) factor encompasses
facets such as trust, compliance, straightforwardness, altruism,
tender-mindedness and modesty; and
l
the Neuroticism (N) factor includes components such as anxiety, anger,
depression, hostility, self-consciousness, impulsiveness and vulnerability
(Costa & McCrae 1992).
The NEO-PI-R, which has been widely used in
personality studies and in medical education research, is one of the
instruments available for the assessment of the big five factors. This
instrument, developed by Costa and McCrae (1992) is the first published
instrument designed specifically to measure the big five
factors of personality (De Raad & Perugini 2002). The
original inventory was developed to measure the three factors of Neuroticism, Extraversion and Openness, hence named NEO
Personality Inventory (PI) which was revised (NEO-PI-R) to include two additional factors of
the FFM (Agreeableness and Conscientiousness).
The revised self-report form of this instrument consists of 240 items answered on a
five-point scale, measuring not only the big five personality factors (48 items
per factor) but also six personality
facets within each factor (eight items per facet). A shorter version of this instrument (NEO-FFI, 60-item) is
also available for measuring the big five factors without detailed measurement
of the facets within each factor (Costa & McCrae 1992). Other personality
instruments, such as the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ,
Zuckerman 2002), were also developed to measure the big five factors or some
variant of the FFM.
Performance
The associations
between the five personality factors and academic performance have been
addressed in a number of studies. For example, in their cross-sectional and
longitudinal studies, Lievens and colleagues (2002) administered the Flemish
translation of the NEO-PI-R to 785 students in five Flemish universities and
found that the chance of success in the pre-clinical years of medical school was
better for students who scored high on the Conscientiousness factor. High scores on the Openness factor significantly
predicted the final scores in the third year of medical school
(Lievens et al. 2002).
It was also found
that more
l
proactive facets of the Conscientiousness factor such as
“self-discipline” and “achievement striving” could predict medical students’
academic achievement better than more
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regulatory facets of the Conscientiousness factor such as “order,”
“deliberation” and “dutifulness.” (Lievens et al. 2002).
The Extraversion factor was the only factor
that negatively correlated with examination results in the first year of medical
school, suggesting
a restricting effect of this factor at the beginning of the academic career
(Lievens et al. 2002). These investigators concluded that significant variation exists among medical students in terms of
personality, reflected in the FFM, which is linked to academic success. In
particular, they placed an emphasis on the findings that scores on the Conscientiousness factor could strongly predict students’ success in preclinical years of medical school (Lievens et al. 2002).
In a study by Helle
and colleagues (2010), the five factors of personality inventory and a test of
visual perceptual skills, designed to assess an individual's visual perception (Martin 2006) was
administered to 150 second-year medical
students at the University of Turku in Finland. Results showed that the Conscientiousness factor and one element of visual perceptual ability (spatial relationship
awareness) predicted performance on the diagnostic
classification in microscopic
observation in an undergraduate course in pathology at the beginning of
the course. In a study of 176 students attending the Nottingham Medical School
in the UK, Ferguson and colleagues (2003) found that the Conscientiousness factor was the best predictor of academic performance in the pre-clinical phase of medical education.
In a meta-analytic review, the Conscientiousness
factor was found to be a significant predictor
of job performance in other occupations as well (Tett et al. 1991).
In a longitudinal
study, Lievens and colleagues (2009) followed up on students who participated
in their original study (Lievens et al. 2002). It was found that grade point averages in the first year rather than personality factors were the most important predictors of attrition in preclinical years. However, as the students progressed
through medical school, the Openness,
Conscientiousness and Extraversion factors became
increasingly important predictors of academic success in the clinical phase of
medical education. Consistent with these findings, McManus and his colleagues
(2004) in a 12-year longitudinal study of medical students who attended five
medical schools in the UK reported that perception of
stress and burnout were predicted by scoring high on the Neuroticism, low on the Extraversion factor, and low on
the Conscientiousness factor.
The Conscientiousness factor has long been
recognized as a crucial predictor of job performance in medicine as well as in other professions (Barrick & Mount
1991; Behling 1998; Hurtz & Donovan 2000). Also, research findings suggest
that sociability, a prominent feature
of the Extraversion factor, is an important mediating variable in the clinical performance of medical students
(Ferguson et al. 2003; McManus et al. 2004; Hojat et al. 2004a; Knights &
Kennedy 2007; Tyssen et al. 2007; Lievens et al. 2009). However, their results
on the Extraversion factor are less consistent in the preclinical than clinical phases of medical education
(Piedmont et al. 1991; Lievens et al. 2002).
Lievens and
colleagues (2009) used the expressions of “getting along” as a reflection of the Extraversion and Openness factors, and “getting ahead” as a reflection of
the Conscientiousness factor. Extraversion and Openness to experiences are
two personality attributes that facilitate physician-patient
interpersonal relationships, and thus can contribute to optimal clinical
outcomes. The importance of the Extraversion and Openness factors in clinical
performance has also been confirmed in a study by Piedmont and colleagues
(1991).
In a study by Haight
and colleagues (2012), the relationships between personality measures and
medical student preclinical and clinical performances in 175 students at the
Saint Louis University School of Medicine were examined. It was found that
scores of the MCAT correlated with academic examinations, whereas scores on the Conscientiousness and Extraversion factors correlated
with indicators of clinical
performance and humanism nominations. More specifically,
the Conscientiousness factor could predict clinical skills, but the Extraversion factor was a significant predictor of indicators of clinical skills that relied heavily on interpersonal interactions. In a review
article, Doherty and Nugent (2011) examined the relationships between
personality and academic performance in medical school. They concluded that the
Conscientiousness factor can predict long-term success in medical education, and the Extraversion factor is an important mediating factor in clinical performance.
In a longitudinal
study to examine changes in the validity coefficients of personality in
predicting academic performance of an entire 1997 cohort of medical students in
six Flemish universities in Belgium, Lievens and colleagues (2009) reported
that the Openness, Conscientiousness and Extraversion factors (and most of
their facets) showed an increase in the magnitude of the their validity
coefficients as students progressed through medical school. For example, the
validity coefficient for the
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Extraversion factors shifted from
a negative correlation of −0.11 in the first year of medical school to
a positive correlation of 0.31 in the
last year of medical school.
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The changes in the validity coefficients from the first to the last year
of medical school were from 0.18 to 0.45
for the Conscientiousness,
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0.02 to 0.30 for the Openness,
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−0.01 to 0.17 for the Agreeableness and
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0.03 to −0.07 for the Neuroticism factors (Lievens et
al. 2009).
The significant
change in the validity coefficient of the Openness factor from the preclinical to the clinical years of medical school
deserves some explanations. Openness has been linked to academic ability and
divergent thinking (Goff & Ackerman 1992; McCrae 1996). However, the
magnitude of its validity coefficients in predicting academic achievement has
not been impressive (Hough 1992; Barrick et al. 2001). Openness is a
personality factor that facilitates acceptance and adequate adjustment to the
wide variation of changes (LePine et al. 2000) that is encountered during the
clinical phase of medical education. Lievens and colleagues (2009) suggested
that although there may be no advantages
to being open to new experiences in the preclinical years of medical school,
this personality attribute increasingly
becomes relevant in clinical
education and in applied settings. Therefore, openness to experiences seems to be more
beneficial in the clinical phase of medical education,
which requires interpersonal interaction with patients.
With regard to the
findings on variation in the magnitude and direction of validity coefficient
for the Extraversion factor, Lievens and
colleagues (2009) speculated that while it might not be beneficial for medical students
to be extraverted during the preclinical
years, this
quality becomes important later in the clinical years when human interaction is required for achieving optimal
outcomes. Consistent with this notion, Rolfhus and Ackerman (1999) found that extraverts, compared to introverts, obtained lower
scores on knowledge tests. Thus, the negative correlation between extraversion
and performance in the preclinical phase of medical education could be due to
the fact that extraverted students are likely to spend more time socializing (Chamorro-Premuzic & Furnham 2003) and be involved in
nonacademic activities such as sports and social events. Instead, introverted students may spend more time
reading the high volume of course materials in the preclinical years. In addition, it has been reported that extraverts are
more likely than introverts to be easily distracted, while introverts are more likely to
focus on cognitively demanding
tasks (Entwistle & Entwistle 1970), which help them to obtain better grades
on tests of acquisition of factual information; a key feature of examinations
in the preclinical years (Sanchez et al. 2001).
Conversely, it has
been reported that extraverts are more likely to
obtain better assessment marks in the activities performed in group settings, clerkships, practicums
or seminar classes (Furnham & Medhurst 1995). Thus, extraverts seem to
have the personality attributes needed to perform better in educational
environments that require interpersonal
interactions (Ferguson et al. 2000). Therefore, one can expect that those who score
high on the Extraversion factor would not
perform as well as their introverted counterparts in the preclinical phase of
medical education. This can explain the change of the validity coefficient of
the Extraversion factor from negative in preclinical to
positive in the clinical years of medical school.
The lack of
predictive validity for the Neuroticism factor in medical
school found in the Lievens and colleagues study (2009) is not surprising.
Those high in Neuroticism are prone to anxiety; thus, less likely to perform well on
academic tests that require concentration
and recall of factual information. In addition, high scorers on Neuroticism are more
vulnerable to test-taking anxiety and evaluation apprehension during examinations
of recalling factual information early in medical school. Some studies on emotional stability, the opposite of neuroticism, have shown positive relations between emotional
stability and performance in
college students (e.g. Cattell & Kline 1977; Lathey 1991; Sanchez et al. 2001) and in medical students (Barratt & White
1969).
The facets of the Agreeableness factor such as trust,
altruism, modesty and tender-mindedness (Costa & McCrae 1992) can facilitate physician-patient relationships, thus it is expected
that scores on the Agreeableness factor predict the clinical competence of
medical students. The facets of the Agreeableness factor are positively
associated with clinical performance in medical students
(Gough et al. 1991; Shen & Comrey 1997). However, findings on relationships
between this factor and performance in medical school are not consistent.
Among the big five
factors, the Conscientiousness factor has been found
most consistently to predict academic
achievement in both preclinical and
clinical phases of medical education (Costa & McCrae 1992; Goff & Ackerman 1992;
Blickle 1996; De Raad 1996; De Raad & Schouwenburg 1996; Busato et al.
2000) and performance in the work environment (Barrick & Mount 1991;
Salgado 1998; Dudley et al. 2006; Burch & Anderson 2008). Obviously, facets
of this factor such as achievement
striving, competence, dutifulness, self-discipline, order and deliberation (Costa & McCrae
1992) can provide a plausible explanation as to why the Conscientiousness factor
is the best predictor of academic success in undergraduate college students
(Wolfe & Johnson 1995), as well as graduate college students (Wiggins et
al. 1969), and in medical school (Lievens et al. 2009).
Tyssen and colleagues
(2007), in a six-year longitudinal study of 421 students who were accepted into
four medical schools in Norway reported that low levels of Conscientiousness combined with high levels of Neuroticism and low levels of Extraversion could increase susceptibility to stress in medical school,
thus negatively affecting academic performance.
Career interest
Personality
attributes contribute to an individual's behavior, preferences and interests
including career choices. Empirical studies provide support for the notion that
personality is linked to specialty interests in medical students and
physicians.
l
For example, Borges and Savickas (2002) found that scores on extraversion and openness to new experiences
could distinguish surgeons from other
physicians.
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It was also reported (Borges & Savickas 2002) that physicians in nonsurgical specialties were less adaptive to
change (e.g. low on the Openness factor).
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Myers and Davis (1976) found that pathologists were less
extraverted, and experienced more negative effects in their career due to lower
levels of sociability and less dominating personalities.
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Psychiatrists were described as
being imaginative, curious, looking
for variety and experiencing deep feelings which are among features of the Openness and Agreeable factors (Borges &
Savickas 2002).
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Anesthesiologists,
surgeons and psychiatrists, compared to
obstetricians/gynecologists, showed a common feature by sharing a higher mean
score on the Openness factor.
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Family
physicians were found to be mixed in this factor (Borges & Savickas 2002).
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Lower scores
on the Extraversion factor were shared by anesthesiologists and surgeons, but family physicians and psychiatrists were more Agreeable than
obstetricians/gynecologists and surgeons (Borges & Savickas 2002).
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Family
physicians, who were characterized as sympathetic, trusting, cooperative and
altruistic, showed higher scores on the Agreeableness and Conscientiousness factors, but varied
regarding the Openness factor (Borges & Savickas 2002).
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Hoffman and colleagues (2010) studied a group of 204 residents (in
surgery, medicine, pediatrics and anesthesiology), and another group of 207
medical students, and compared their scores on the big five factors with norms
for the general population. They found that surgery residents scored higher on the Conscientiousness, and Extraversion factors but lower on Openness.
l
Medical
students scored on average high on Extraversion which placed them in
the same group as students who studied law, economics, psychology, education,
and political and social sciences. Conversely, medical students' extraversion
scores were significantly higher than students of other academic majors such as
sciences and applied sciences (Lievens et al 2002). In a study by Magee and
Hojat (1998), using the NEO PI-R, it was found that male and female physicians
who were nominated as positive role models in medicine, compared to the general
population, scored significantly higher on the Conscientiousness Factor, and on
personality facets such as achievement striving, activity, competence,
dutifulness, trust, assertiveness and altruism. They scores lower than the
general population on the vulnerability facet of personality.
l
In another study, internal
medicine residents, compared to the general population, scored higher on the Openness Factor, and on the
idea, achievement striving, excitement seeking, fantasy, feelings and
deliberation facets (Hojat et al. 1999c).
Chibnall et al.
(2009) compared 133 third-year
medical students at Saint Louis University School of Medicine with 163 police officer recruits. Discriminant
function analysis showed that the factors of Conscientiousness, Neuroticism and Openness could accurately
classify 77% of medical students and police recruits. Medical students scored
higher on Openness and Neuroticism but lower on the Conscientiousness factor than police
recruits. This pattern of findings, according to study investigators can be
explained by the fact that Openness and Neuroticism, in contrast to
Conscientiousness, do not seem to be virtues for police and security personnel. A high level of Conscientiousness in police recruits
can be expected, considering facets of this personality factor such as order,
dutifulness and self-discipline which are desirable characteristic for police recruits (Chibnall et al.
2009).
l
Barrick and Mount (1991) examined the relationship between the five
personality factors and indicators of job performance in five occupational groups which included
professionals (physician were in this occupational group), police, managers,
sales persons and skilled/semi-skilled workers). Results showed that the Conscientiousness factor consistently predicted performance in all occupational groups.
l
Extraversion predicted performance
in two occupational groups that required social interaction, such as managers
and sales persons and training
proficiency in all occupations was linked to the Openness and Extraversion factors (Barrick
& Mount 1991).
l
Medical
students, compared to students in philosophy, languages and history scored
significantly higher on the Consciousness and Extraversion factors (Lievens et
al. 2002). Medical students compared to humanities students scored lower on the
Extraversion and Openness factors (Bunevicius et al. 2008).
The FFM of
personality has received attention among personality researchers, and is
recognized as the most parsimonious and comprehensive model of normal adult
personality (Costa & McRae 1992; Yamagata et al. 2006). Although its use in
medical education research is not yet widespread, its potential for providing useful
information for personality research in medical education is worthy of
consideration (Chibnall et al. 2009).
Overall, the results of the FFM in medical education research generally
suggest that among all big five factors, the Conscientiousness factor seems to be a more consistent predictor of
academic performance in medical school, and the Extraversion factor appears to be linked to preferences in some “people-oriented” specialties that require more
intense patient-physician interaction.
l
The NEO-PI-R is a widely used instrument in personality research for the
assessment of the big five personality factors: Openness, Conscientiousness,
Extraversion, Agreeableness and Neuroticism.
l
The Conscientiousness factor and its facets (achievement striving,
deliberation, dutifulness, order, and self-discipline) are conceptually more
relevant to performance of physicians-in-training and in-practice.
l
Empirical data support the link between scores on the Conscientiousness
factor and performance measures in the preclinical and clinical phases of
medical education.
(2) The 16 Personality Factor Questionnaire
The 16 Personality Factor Questionnaire (16PF) is a
well-known instrument developed by Cattell (1943, 1946, 1947, 1948), Cattel
& Kline (1977) and Cattell et al. (1993). It is one of the oldest
personality instruments, first published in 1949, revised several times with the
most recent version
released in 1993. It contains 185 items which provide scores for the 16 primary
personality factors.
The 16 personality factors were determined and based on
an extensive factor analytic study of a large number of personality attributes
derived from a psycho-lexical hypothesis suggested by Allport and Odbert
(1936), based on the assumption that if a word exists for a personality
attribute then that attribute must be real. The primary 16 factors are
1.
Warmth,
2.
Reasoning,
3.
Emotional Stability,
4.
Dominance,
5.
Liveliness,
6.
Rule-Consciousness,
7.
Social Boldness,
8.
Sensitivity,
9.
Vigilance,
10.
Abstractedness,
11.
Privateness,
12.
Apprehension,
13.
Openness to Change,
14.
Self-reliance,
15.
Perfectionism and
16.
Tension.
Higher order factor analysis of the primary 16 personality factors
resulted in the five global personality traits which resemble the FFM of
personality. These five global personality traits are:
l
Openness-Tough
Mindedness (analogous to the Openness factor in the FFM),
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Self-Control (analogous to the Conscientiousness factor in the FFM),
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Extraversion (similar to the Extraversion factor in the FFM),
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Independence-Accommodation (analogous to the Agreeableness factor in the FFM),
and
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Anxiety (analogous to the Neuroticism factor in the FFM)
(Conn & Rieke 1994; Hofer & Eber 2002).
The 16PF Questionnaire enjoys strong psychometric support (Cattell et al. 1970). It is one of the
most frequently used instruments in a large volume of personality studies, and has also been
used in medical education research.
Performance:
In a study by Manuel
et al. (2005), 206 medical students at the University of Cincinnati, School of
Medicine completed the 16PF Questionnaire. The scores on the Warmth factor were positively
correlated with indicators of clinical data
gathering skills. However, scores on the Abstractedness and Privateness factors were negatively correlated with the assessment
of clinical skills. In addition, measures of communication
skills correlated positively with Warmth, Emotional Stability and Perfectionism factors and
negatively with the Privateness factor. The
investigators concluded that some personality factors from the 16PF
questionnaire can predict medical students’ clinical skills (Manuel et al.
2005).
In explaining their
findings, Manuel and colleagues (2005) speculated that
l
high scorers on the Warmth factor are likely to
have the following features: attentive to
others, easy-going and likeable;
l
high scores on the Emotional Stability factor are likely to
be adaptive, mature and in control; and
l
high scorers on the Perfectionism factor are likely to
be self-disciplined,
socially precise and organized.
All of the
aforementioned personality attributes contribute positively to clinical skill assessments. In addition, those
investigators suggest that high scorers on the Abstractness factor of the 16PF Questionnaire are likely to be impractical, and high scorers on the Privateness factor are likely to
be discreet and shrewd. Thus, these
personality attributes were expected to be negatively related to assessments of
clinical competence (Manuel et al. 2005).
In another study by
Green et al. (1991), the 16PF Questionnaire was administered to 129 medical
students at the University of Wales, College of Medicine. No relationship was
found between personality scores, performance in medical school, and subsequent
academic success. It was concluded that the 16PF questionnaire would be unlikely to help in the
assessment of applicants and medical students (Green et al. 1991).
Similar findings were obtained in another study of 146 students at the
University of Wales, College of Medicine by the same investigators (Green et
al. 1993).
Contrary to findings
reported by Green and colleagues (1991), a study in Malaysia by Peng and
colleagues (1995) showed that the 16PF
Questionnaire could make a distinction between students who were at risk of academic failure and their
counterparts who were not. In their study, 101 students completed the Bahasa Malaysian
translation of the 16PF Questionnaire at the beginning of medical school. The
relationships between personality scores and academic success at the end of the second year of preclinical training in medical school
were examined.
l
Personality attributes such as being enthusiastic (a feature of the Liveliness factor), venturesome (a feature of the Social Boldness factor), imaginative (a feature of the Abstractedness factor) and experimenting (a feature of the Openness to Change factor) correlated positively with indicators of success.
l
A personality attribute such as being self-assured (a feature of the Apprehension factor) was negatively correlated with performance measures (Peng et al. 1995). Students who were
academically in trouble were more likely to be reserved, less emotionally
stable, and more apprehensive than others.
The authors concluded
that the 16PF Questionnaire is a useful
instrument for identifying the personality profile of students who are likely
to have academic problems (Peng et al. 1995).
Huxham et al. (1985)
administered the 16PF questionnaire and the EPI (Eysenck & Eysenck 1964,
1975) to a cohort of 142 medical students in Australia in the second and sixth
years of medical school. These investigators were interested in examining changes in personality during medical school. They concluded that
during the study period, medical students became brighter, more mature, more venturesome, more tough-minded, more trusting, more self-assured, more self-controlled and more extraverted (Huxham et al. 1985).
Career interest:
The 16PF
Questionnaire has also been used to examine specialty differences.
l
For example, Reeve (1980) used the 16PF to compare anesthesiologists and general practitioners. It was found that
the former group was more likely to be self-sufficient (a feature of the Self-Reliant factor), dominant (a feature of the
Dominance factor), tense (a feature of the
Tension factor) and introverted.
l
In another study, Borges and Osmon (2001) used the 16PF questionnaire to
investigate personality differences among anesthesiologists compared to family physicians and general surgeons.
Anesthesiologists seemed to have a different level of suspiciousness and skepticism (features of the
Vigilance factor) than the other two groups of physicians.
l
Family
physicians differed significantly from general surgeons and anesthesiologists with
regard to Rule-Consciousness and Abstractedness factors which
indicate that family physicians were more rule bound and imaginative, which is
somewhat consistent with Taylor (1993), and the Taylor et al. (1990)
description of family practitioners.
l
By using the 16PF questionnaire, Chowdhury and colleagues (1987) showed
that internal medicine residents had a tendency to be skeptical and aloof.
l
Residents in
psychiatry were characterized by greater tolerance for
frustration, emotional maturity, and stability. Psychiatry residents were also found to
be more tender-minded, compared to
internal medicine residents who were more realistic and practical. Psychiatry
residents showed a high-level capacity for abstract thinking, faster
learning and a quicker grasp of
ideas (Borges & Savickas 2002).
Findings on the 16PF Questionnaire generally suggest that the instrument
has limited success in
predicting academic performance in medical school or in predicting specialty interest of
medical students.
l
The 16PF Questionnaire which provides scores for 16 primary personality
factors is one of the oldest personality instruments used in medical education
research.
l
Although this instrument generally enjoys strong psychometric support in
personality research, its success in predicting specialty interest and performance
of physicians-in-training and in-practice is limited.
(3) The California Psychological Inventory
The California Psychological Inventory (CPI) is a frequently used
self-report personality instrument, originally developed by Harrison Gough, which
has been revised three times. It is a lengthy instrument, and its current form
includes 434 items measuring
20 folk scales:
1.
Dominance,
2.
Capacity for Status,
3.
Sociability,
4.
Social Presence,
5.
Self-acceptance,
6.
Independence,
7.
Empathy,
8.
Responsibility,
9.
Socialization,
10.
Self-control,
11.
Good Impression,
12.
Communality,
13.
Well-being,
14.
Tolerance,
15.
Achievement via
Conformance,
16.
Achievement via
Independence,
17.
Intellectual
Efficiency,
18.
Psychological
Mindedness,
19.
Flexibility and
20.
Femininity-Masculinity
(Gough 1987).
The scales were not developed based on factor analytic
research; however, a factor analytic study of the CPI suggests that the big five
factors of personality can also be measured by the CPI (Soto & John 2009).
The CPI has been used in a number of medical education studies in
predicting academic performance and specialty interest. In a review article, Ferguson et al. (2002) claimed that the CPI was the most commonly used personality
instrument in medical education.
Performance:
Gough and colleagues
reported several studies using the CPI with medical students and residents to
predict their performances (Gough et al. 1963, 1964, 1991). Gough and Hall
(1967) reported that the CPI could differentiate cognitive performance of successful from unsuccessful students in medical
school. Reich et al. (1999) demonstrated that certain scales of the CPI were
associated with poor clinical
performance among residents.
In a study with all
applicants to the School of Medicine at Ben-Gurion University, statistically
significant correlations (albeit low in magnitude), were found between interview ratings and scores of the
following scales of the CPI: Dominance,
Self-acceptance, Well-being, Tolerance, Responsibility and Achievement via
Conformance (Hobfoll et al. 1982). Interview ratings were based on a global judgment
of overall assessment of attributes such as empathy, responsibility, personal
integrity, intellectual flexibility and tolerance of ambiguity.
In a discriminant
analyses, it was also found that scores of the CPI scales of Achievement via Independence,
Self-acceptance, Dominance and Achievement via Conformance were the best overall
predictors of cognitive performance and teaching staff ratings (Hobfoll et al.
1982). Teaching staff ratings were based on the judgment of five teaching staff
on whether a student fits an idealized model with regard to personality
attributes such as self-initiative, interpersonal sensitivity and intellectual
flexibility. No significant correlation was found between scores of the CPI and
ratings of clinical competence (Hobfoll et al. 1982).
Ferguson and
colleagues (2002) in their review article reported that the following eight
scales of the CPI had more consistently emerged as significant predictors of success in medical education: Dominance, Tolerance, Sociability,
Self-acceptance, Well-being, Responsibility, Achievement via Conformance and
Achievement via Independence. Their summarized review findings indicate that scores
on the Dominance scale correlated negatively with undergraduate multiple choice
examination grades (r = −0.26); Tolerance
correlated negatively with the ability to use numerical information (r = −0.25); and
Well-being and Achievement via Conformance correlated positively with success
in oral examinations (0.22 and 0.32, respectively) (Ferguson, et al. 2002).
In a study by Hodgson
and colleagues (2007), it was found that physicians who demonstrated unprofessional behavior during medical
school, compared to those who did not, scored significantly lower on four CPI
scales. Results were in agreement with findings in which indicators of
unprofessional behavior of medical students, extracted from the excerpts of
negative comments in medical students’ academic records, could be grouped into
domains of irresponsibility,
lack of self-improvement and poor initiative (Papadakis et al. 2005).
The level of professionalism in medicine was found
to be significantly associated with scores of the CPI scales of Responsibility (r = 0.53), Communality (r = 0.50) and Well-being (r = 0.46) (Hodgson et al. 2007). Significant
differences were observed on scores on the CPI scales of Responsibility, Sociability, Self-control,
Communality and Well-being between those who had a record of unprofessional behavior and their
counterparts without such a behavior (Hodgson et al. 2007). These findings
suggest that the CPI, administered at matriculation to medical school, could
predict unprofessional behavior
during medical school (Hodgson et al. 2007).
Career interest:
l
Gough et al. (1991) administered the CPI to first-year anesthesiology residents and
reported that they were self-confident, had superior interpersonal skills, and
were goal seeking as indicated by their high scores on the CPI scales of
Dominance, Social Presence and Achievement via Independence, respectively.
l
Coombs et al. (1993) compared surgical and
nonsurgical specialists who graduated from the University of California, School
of Medicine. They administered the CPI and other personality scales at the
beginning and at the end of medical school, and found no pronounced difference
between the two groups on any of the CPI scale scores (Coombs et al. 1993).
Overall, regarding the above-mentioned findings on the use of the CPI in
medical education research, we agree with the concluding remarks by Hobfoll and
colleagues (1982) that this personality
instrument has a limited value
in predicting students’ performance in medical
school and the specialty interest of physicians in training.
l
The California Psychological Inventory (CPI) is a lengthy instrument and
one of the most commonly used personality inventory in medical education
research.
l
Despite a large volume of research, the CPI seems to have a limited value
in predicting specialty interest and performance of medical students and
physicians.
(4) The Myers-Briggs Type Indicator
The Myers-Briggs Type Indicator (MBTI) is a widely used
personality instrument developed in the 1950s by Isabel Briggs Myers and her mother Katherine Cook Briggs based on Carl G. Jung's psychological typology (Jung 1933, 1971;
Myers 1962; Myers & Caully 1985). The test includes 144 forced-choice items (in a longer Form Q
and 93 items in a shorter Form M) designed to measure four bipolar personality
types and their combinations:
l
Introversion-Extraversion (I or E type),
l
Sensing-Intuition (S or N type),
l
Thinking-Feeling (T or F type) and
l
Judging-Perceiving (J or P type).
Based on the scores on the aforementioned personality
types, the test taker can be further classified into one of the 16 combined personality types. For example, higher
scores on Introversion (as opposed to Extraersion), Intuition (as opposed to
Sensing), Thinking (as opposed to Feeling), Judging (as opposed to Perceiving)
will classify individual's combined personality type in the
Introversion-Intuition-Thinking-Judging category, or the INTJ type.
The MBTI has been widely used in educational counseling, human resource
management and in medical education research. In an early large-scale study,
Myers and Davis (1965) used data from the MBTI collected in the 1950s from 45
medical schools on 5355 students. It was found that there were approximately
equal numbers of medical students in all of the personality types; thus, it was
concluded that medicine is a diverse field that can benefit from a variety of
personality types; each can match a desirable personality constellation for a
particular specialty. In another large-scale study, a total of 7190 medical
students completed the MBTI and it was reported that there were more Intuitive,
Feeling and Judging types among medical students compared to the general
population (McCaulley 1977, 1981).
Performance:
Some studies using
the MBTI reported a link between personality types and academic performance in
medical students. For example, in one study medical students who were
classified as the Sensing-Thinking
(ST) type obtained the highest scores in a neurochemistry course (Wild & Skipper 1991). In another study with 114
students at the University of New Mexico, School of Medicine, the failure rate
was highest in the medical
licensing examination (National Board of Medical Examiners, Part 1) among those
who were classified as the Intuitive-Feeling
(NF) type (O’Donnell 1982). In a study by Tharp (2009), the highest grades in an
undergraduate physiology course were achieved by students with a Sensing preference. Kim (1999)
reported that medical students with a Thinking preference performed better in medical school than their counterparts with
a Feeling preference.
The MBTI was
administered to 263 osteopathic medical students at Midwestern
University/Chicago College of Osteopathic Medicine to examine the relationship
between personality types and performance on the MCAT (Sefcik et al. 2009). No
significant correlation was obtained between personality types and performance on the MCAT. However, the NF personality type students were more likely to score
lower on the Comprehensive Osteopathic Medical Licensing Examination-USA
(COMLEX-USA, Level 1) (Sefcik et al. 2009).
In a study by
Ornstein and colleagues (1987), the association between personality types, and
residents’ laboratory test ordering behavior was examined. Participants
included 39 family medicine
residents at the University of South Carolina Medical Center in Charleston who
treated 1326 hypertensive patients in 14 006 visits, and ordered 7361
laboratory tests. Results indicate that the Introvert and Intuitive types were likely to order more tests than the Extravert
and Sensing types; however, the findings did not reach the traditional level of
statistical significance (Ornstein et al. 1987). McNulty and colleagues (2006)
examined the relationships between personality types and learning style.
Findings showed that although the use of computer-aided instruction was
positively correlated with the Sensing rather than Intuitive personality types,
higher use of discussion forums (as opposed to lecture and tutorial) was
associated with Perceiving-Judging type. From their study with 137 medical
students, Wild and Skipper (1991) concluded that the relationships between
personality types and academic performance may be more complicated than had
been discussed in the literature.
Career interest
Twelve schools
expressed their willingness to share data. Findings on the available data
linking personality types with specialty choice showed that the Thinking type
students were likely to choose primary and non-primary care specialties at
about the same rate; however,
l
the Feeling type students were
significantly more likely to select
primary care specialties. Similarly, the Extravert type students chose primary
and non-primary care specialties at about the same rates.
l
Those who pursued family
medicine were more likely to be the Feeling rather than Thinking
type (Stilwell et al. 2000).
l
Also, the Feeling types chose surgical
specialties at a significantly lower rate than did the Thinking types. Finally, the Introvert types pursued surgical specialties at a
significantly lower rate than did the Extravert types (Stilwell et al. 2000).
l
These investigators further divided those who chose non-primary care
specialties into two groups of surgical and nonsurgical specialties. Their
findings suggest that gender, E–I and T–F types could predict
interest in surgical specialties (e.g. being male, extraverted and thinking
types) (Stilwell et al. 2000).
l
The personality types of applicants to an otolaryngology residency program were compared to
those of the general population and physicians in other medical specialties
(Zardouz et al. 2011). It was found that otolaryngology applicants were likely
to have an Extravert-ST-Judging personality profile.
These investigators also reported that Thinking (T) and Judging (J) types were
more common than Feeling (F) and Perceiving (P) types among the otolaryngology
residency applicants (Zardouz et al. 2011).
l
A study by McCaulley (1978) showed that those who were attracted to
ophthalmology and otolaryngology had similar personality types. However, those
choosing ophthalmology were more people-oriented and those choosing otolaryngology were more technology-oriented. The proportion of
Extravert-ST-Perceiving type was significantly higher in otolaryngology
residency applicants (8%) than the general population (3%) (Zardouz et al.
2011).
l
In different studies, personality types of physiatrists (Sliwa & Shade-Zeldow 1994), pediatric residents (Lacorte
& Risucci 1993) and emergency department staff have
been compared (Boyd & Brown 2005), and no pronounced differences in their
personality types have emerged.
Harris and Ebbert
(1985) used the MBTI to examine differences in personality types between
first-year family medicine
residents and rural primary care
physicians. Results showed that the residents were significantly more Intuitive (as opposed to
Sensing) and more Feeling (as opposed to
Thinking) types. The authors concluded that family medicine residents differed
from rural primary care physicians in how they gather information. Family
medicine physicians also tend to rely on their intuition (N) rather than
sensing (S) perception when gathering information (Myers & Davis 1976;
Harris & Ebbert 1985; Friedman & Slatt 1988; Taylor et al. 1990).
l
Obstetricians
and gynecologists have been described by Myers and Davis (1976) as being
more likely to be Extravert and Sensing types.
l
Findings of a longitudinal study using the MBTI (McCaulley 1978) showed
that the obstetrics-gynecology specialty attracted individuals with a Sensing
type, whereas Friedman and Slatt (1988) found that medical students who entered
obstetrics-gynecology tended to score high on ST-Judging dimensions.
l
Myers and Davis (1976) reported that pediatricians showed a large proportion of the Extraversion-Sensing-Feeling-Judging type, as well as Introverted-Sensing-Feeling-Judging types.
l
However, Friedman and Slatt (1988) found that medical students interested
in pediatrics yielded less distinctive MBTI profiles. They also found that
medical students who were interested in psychiatry were more likely to display
an Introverted-Feeling-Perceiving personality type (Friedman & Slatt 1988).
l
Myers and Davis (1976) found that surgeons were more likely to display the Extraverted and Sensing (S) type, whereas
Friedman and Slatt (1988) found that students interested in surgery yielded less
distinctive MBTI types.
l
Findings of a longitudinal study (McCaulley 1978) showed that the surgical subspecialties of general,
orthopedic and obstetrics/gynecology, which deal with straightforward problems
requiring technical skill, attracted individuals with a Sensing (S)-type
personality.
l
The Sensing type has often been reported to be common among obstetricians (Myers & Davis
1976; McCaulley 1978), general surgeons and orthopedic surgeons (McCaulley
1978).
l
Neurological,
plastic and thoracic surgeons (McCaulley 1978) often score high on the Intuitive
dimension and thus could be characterized as imaginative, curious and having a
need for variety (Borges & Savickas 2002).
l
Although hospital-based and support specialties, such as pathology and radiology have not received as
much attention in MBTI studies, some researchers have addressed personality
types in these specialties. For example, Myers and Davis (1976) reported that
pathologists tended to be the Introvert, Intuitive and Thinking type; and Friedman
and Slatt (1988) reported that students interested in pathology did not display
a distinct personality type in the MBTI. Using the MBTI,
l
Myers and Davis (1976) showed that anesthesiologists were characterized as both Introverted-ST-Perceiving and
Introverted-Sensing-Feeling-Perceiving types.
It has been reported
that compared with data from the 1950s, the type distribution of physicians has remained relatively unchanged, with the exception of
a trend toward more Judging types. It is also reported that women in medicine,
today as compared to those in the 1950s when medicine was
more male-dominated, are more
representative of the general population in the Feeling personality type
(Stilwell et al. 2000). From the published studies, it seems that Feeling type
students and women were more likely to choose primary care specialties.
l
Although research findings on the link between personality types from the
MBTI and specialty interest do not provide a consistent and clear picture, a
more frequently reported conclusion that can be drawn from the MBTI studies is
that surgeons are more likely to be
the E type (extraverted) (Myers & Davis
1976; McCaulley 1978; Stilwell et al. 2000), suggesting that they tend to be
sociable and active.
l
Another frequently reported finding from MBTI studies of medical
specialists is that family
physicians are likely to have a Feeling
personality type (Harris & Ebbert 1985; Friedman & Slatt 1988; Taylor et al. 1990;
Stilwell et al. 2000; Borges & Savickas 2002), which can be helpful at least
in medical students’ career counseling.
Despite the large
volume of medical education research in which the MBTI has been used, one cannot determine with confidence
which personality type performs better in medical school, and which personality
type predicts interest in a specific specialty and subspecialty. In
addition, some of the findings on personality types and specialty choice seem
counter-intuitive such as family physician's Introvert and surgeons Extravert
personality types because intuitively, family physicians require more social
skills than surgeons to maintain long-term relationships with their patients.
Overall, the MBTI does not
seem to be a useful instrument in predicting academic performance in medical
school. Although the MBTI has been widely used in medical education research and
in career counseling, this instrument has little credibility among research
psychologists (APA 2007, pp. 604–605).
l
The MBTI probably is the most widely used personality instrument in
medical education research on career counseling and specialty choices.
l
Despite the large volume of research, this instrument does not have high
credibility among psychologists and personality researchers.
(5) The Jefferson Scale of Empathy
The Jefferson
Scale of Empathy (JSE) (20 items) was specifically
developed for measuring empathy in the context of medical education and patient
care, relying on the conceptualization of empathy
as a predominantly cognitive (as opposed to affective or emotional)
attribute that involves an understanding
(as opposed to feeling) of patients’ pain, experiences, concerns and
perspectives, combined with a capacity to communicate this understanding, and
an intention to help (Hojat 2007, 2009; Hojat et al. 2009). This
conceptualization makes a distinction between empathy (predominantly a cognitive attribute) and sympathy (predominantly an
effective attribute). The two concepts have different consequences in patient
care (Hojat 2007; Hojat et al. 2011b). For example, empathy in abundance is
always beneficial in patient care, while sympathy in excess can be detrimental, causing
emotional dependency in patients and leading to emotional exhaustion, burnout
and compassion fatigue in physicians (Hojat 2007, Hojat et al. 2011b). This
distinction was recognized by Nightingale et al. (1991) in their empirical
study in which they observed that physicians’ empathy had a different
measurable effect than sympathy on their clinical decision making behavior.
Three versions of the JSE are available:
l
One for administration to medical
students (S-Version),
l
one for administration to physicians
and other health professionals (HP-Version) and
l
one for administration to students
in any health profession fields other than medicine (HPS-Version).
These versions are similar in content with slight changes in wording
to reflect students’ orientation toward empathy in medical education
(S-Version), other health profession education (HPS-Version), and behavioral
tendencies toward empathic engagement in patient care (HP-Version) in
physicians and other health professionals. For example, an item in the
S-Version that reads “It is difficult for a physician to view things from
patients’ perspectives” reads as “It is difficult for me to view things from my
patients’ perspective” in the HP-Version, and reads as “It is difficult
for a health care provider to view things from patients’ perspectives” in
the HPS-Version.
In exploratory factor analytic studies, three factors of
l “perspective taking,”
l
“compassionate
care” and
l “walking in patients’ shoes”
have emerged in samples of medical students and physicians in the United
States (Hojat et al. 2001a, 2002c) and abroad (Alcorta-Gaza et al. 2005; Di
Lillo et al 2009; Kataoka et al. 2009; Rahimi-Madiseh et al. 2010; Roh et al.
2010; Shariat et al. 2010).
The three-factor model was also reproduced in confirmatory factor analytic
studies with medical students in England (Tavakol et al. 2011) and in medical
students in Iran (Shariat & Habibi 2013). Ample evidence has been reported
in support of the validity and reliability of the JSE in medical and other
health profession students, physicians, and other practicing health
professionals. The JSE has enjoyed broad international attention by medical
education researchers, has been translated into 43 languages thus far, and used in over 60
countries. It has been described as one of the most researched and widely used
instruments in medical education (Colliver et al. 2010). Information about the JSE is posted at: www.tju.edu/jmc/crmehc/medu/oempathy.cfm).
To our knowledge, before the development of the JSE, no
psychometrically sound instrument was available to measure empathy specifically
among medical students, residents and physicians. There was a need for such an instrument,
and in response the JSE was developed to measure empathy in the context of
patient care. A few instruments exist for measuring empathy in the general
population (for a review, see Hojat 2007, pp. 63–74). However, none of those instruments is
content-specific and context-relevant to medical education and patient care.
다른 instrument들
The following four of these instruments have been frequently used in
medical education research.
l
The Interpersonal
Reactivity Index (IRI, Davis 1983) includes 28 items tapping both cognitive
and emotional empathy, and contains four scales: perspective-taking, empathic
concern, fantasy and personal distress. A sample item (from the
perspective-taking scale) is “I sometimes try to understand my friends better
by imagining how things look from their perspective.”
l
Another instrument is the Empathy Scale
(Hogan 1969) which includes 64 items. A sample item is “I have seen some things so sad
that I almost felt crying.”
l
The third instrument is the Emotional
Empathy Scale (Mehrabian & Epstein 1972) which includes 33
items intended to measure “emotional empathy” (synonymous to sympathy). A
sample item is “It makes me sad to see a lonely stranger in a group.”
l
There is another instrument, the Balanced Emotional Empathy Scale (BEES, Mehrabian 1996), which includes 30
items, and according to its author intended to measure “vicarious emotional
empathy.” A sample item is “Unhappy movie endings haunt me for hours afterward.”
As indicated before, and reflected in the content of the sample items, none of
these instruments seem to have “face” and “content” validity specific to
medical education and patient care. With the exception of the BEES, extensive
psychometric data have been published for the other three instruments in the
general population (Hojat 2007, pp. 66–69, 72–73). Thus, the JSE is
the only instrument featuring “face” and “content” validities in the context of
medical education and patient care.
Performance:
l
A significant association has been reported between medical students’ scores on the JSE and medical school
faculty's global ratings of students’
clinical competence in core clinical clerkships in the third year of medical
school (Hojat et al. 2002a). This association can be explained by the fact that
the ability to communicate with patients and understand their concerns (key features in the
conceptualization of empathy) is often taken into consideration in the
assessments of students’ global clinical competence.
l
No significant
association was observed between scores of the JSE and grades on objective (multiple-choice) examinations of medical knowledge (Hojat et al. 2002a),
which was consistent with findings reported by other researchers (Hornblow et
al. 1977; Kupfer et al. 1978; Diseker & Michielutte 1981; Austin et al.
2005).
l
In a group of Mexican medical students, significant associations were
found between scores of the JSE and academic performance in medical school
(Alcorta-Garza et al. 2005).
Significant
associations have been found between JSE scores on the one hand, and simulated patients’ evaluations of
students’ empathic engagement in objective
structured clinical exam stations (OSCE, Berg et al. 2011a, 2011b), peer nominations on professionalism attributes (Pohl et al. 2011),
and scores of attitudes
toward interprofessional
collaboration (Hojat et al., 2012c; Ward et al. 2009), on the other hand.
Career interest:
Scores of the JSE
have been associated with specialty choice. For example, several studies
reported that physicians in “people-oriented” specialties (e.g. general
internal medicine, family medicine, pediatrics and psychiatry) scored higher on the JSE than others who were
practicing “technology-oriented” or
“procedure-oriented” specialties (e.g. pathology, radiology anesthesiology,
surgery) (Hojat et al. 2002b, 2002c).
This pattern of
finding was observed not only among practicing physicians (Hojat et al. 2002b,
2002c), but also among first year
medical students who completed the JSE on the first day of medical school (orientation day)
before being exposed to medical training (Hojat et al. 2005). In addition to
completing the JSE, these students were asked about the specialty they were
planning to pursue after graduation from medical school. Students planning a “people-oriented specialty (e.g. family
medicine, general internal medicine, general pediatrics, psychiatry) scored higher on the JSE than their peers who
chose “technology/procedure-oriented” specialties (e.g. pathology,
anesthesiology, radiology, surgery) (Hojat et al. 2005).
The significant
differences in the mean scores of the JSE observed among physicians in
“people-oriented” and “technology/procedure-oriented” specialties can be
partially explained by the fact that physicians with different degrees of interpersonal skills are naturally
inclined to pursue specialties that demand certain degrees of interpersonal
skills (Harsch 1989). The differences might also be a function of medical
training by the amount of emphasis that is placed on interpersonal skills
training in different specialties. Obviously, the “people-oriented”
specialties, such as general internal medicine, require a higher degree of
interpersonal skills than “technology/procedure-oriented” specialties, such as
pathology, diagnostic radiology or anesthesiology. However, our findings that entering medical students with higher scores on the JSE, before being
exposed to formal medical education, are interested in pursuing
“people-oriented” specialties suggest that interpersonal skills training in
medical school may not be the only factor that prompts students to pursue
specialties that require such skills.
In addition, among
consistent findings was the gender difference in mean scores of the JSE in the favor of female medical students (Hojat et al. 2001a,
2002a, 2002b) and in practicing physicians (Hojat et al. 2002c) in the United
States and abroad (Hsiao et al. in press; Alcorta-Garza et al. 2005; Kataoka et
al. 2009; Shariat et al. 2010; Suh et al. 2012; Zenasni et al. 2012). This
pattern of finding for women's higher
empathy is consistent with those reported in the general population. Several
explanations can be offered for a gender difference in empathy.
l
For example, it has been suggested that women are more
receptive to emotional signals (Trivers 1972), a quality that can contribute to
a better understanding and hence to a greater empathic engagement.
l
Also, on the basis of the evolutionary theory of parental
investment (Trivers 1972), women are inclined to invest more than men in the
caring for their children and develop more caring attitudes toward their
offspring which is also reflected in their social relationships.
l
The findings on gender differences in empathy are also in agreement with
the reports on the practice style of female physicians who are likely to spend
more time with their patients (Bertakis et al. 1995), and render more
preventive and patient-oriented care (Maheux et al. 1990; Hojat et al.
1995a). All of these factors can lead to forming an empathic engagement in
patient care.
Other correlates:
l
Significant associations have been reported between scores of the JSE and
some personality measures. For example, in a study with medical students (Hojat
et al. 2005b), we found that the scores of the JSE were significantly and
positively correlated with Sociability
scores (measured by
the Zuckerman-Kuhlman Personality Questionnaire [ZKPQ], Zuckerman 2002).
l
In addition, a significant but negative
correlation was observed between the JSE and Aggressive-Hostility scores from the ZKPQ.
l
Furthermore, higher scores on the JSE were significantly associated with
higher levels of students’ self-reported
satisfaction with their early
relationships with their
mothers (Hojat et al. 2005b), which provides support for the notion that empathy
is nurtured by the quality of the early mother-child attachment relationship
(Hojat 1998, 2007).
A statistically
significant correlation has been observed between scores of the JSE and a
measure of patients’ perceptions
of physician empathy among physicians in a family medicine residency program (Glaser et al. 2007).
Clinical outcomes:
Clinical outcome is a
complex notion because it depends not only on physician performance, but also
non-physician factors, such as insurance regulations, governmental policies,
patients’ social-cultural background and beliefs, environmental, technical and human
resources that contribute to the quality of patient outcomes (Gonnella et al.
1993). Perhaps because of this complexity, there is a scarcity of empirical
evidence on the clinical outcomes of personality measures in medical education
research. However, there are studies that report some indicators of empathy in
the context of patient care to be associated with patient outcomes. For
example, it was shown that specific features of empathic engagement in patient care, marked by understanding, communication, positive language, appropriate touching,
eye contact and bodily posture, can lead to
l
patient
satisfaction (Hall et al. 1988; DiMatteo et al. 1993; Zachariae et al. 2003; Kim et al.
2004),
l
greater
compliance (DiMatteo et al. 1986; Falvo & Tippy 1988; Squier 1990),
l
patients’
feelings of being important (Colliver et al. 1998),
l
accuracy of
diagnosis (Barsky 1981),
l
accuracy of
prognosis, (Dubnicki 1977) and
l
lower rates of
malpractice litigation (Beckman et al. 1994; Levinson et al. 1997).
l
It has been reported that physicians’ understanding of their patients’ perspective, a key feature in the conceptualization
of physician empathy (Hojat 2007), enhances patients’ perceptions of being helped (Eisenthal et al.
1979), improves patients’ empowerment (Street et al. 2009),
and increases patients’ perception of
a social support network (Eisenthal et al. 1979; Hojat 2007; Street et al. 2009).
l
In a study with diabetic patients, dietitians’ empathy was found to be predictive of patient
satisfaction and successful
consultations (Goodchild et al. 2005). Physicians’ understanding of their diabetic
patients’ beliefs about their illness was associated with better self-care
outcomes such as improved diet
and increased blood glucose self-testing (Sultan et al. 2011).
l
In a study with internal medicine residents, a lower level of empathy was associated with a higher rate of incidents of medical errors (West et al. 2009).
l
To our knowledge, there are only two empirical studies in which a direct
link between scores of a validated measure of empathy developed in the context
of patient care (JSE) and tangible clinical outcomes has been reported. In one
study with 29 family medicine
physicians and their 891 patients with diagnoses of diabetes mellitus, it was found
that physicians’ scores on the JSE were predictive of optimal clinical outcomes
in the patients (indicated by medical
test results of hemoglobin A1c <7.0% and LDL-C<100) (Hojat et al.
2011a).
l
In another large scale study with 242 primary care physicians and their 20 961 patients diagnosed with diabetes
mellitus in Italy, it was found that physicians’ higher scores on the JSE were
significantly associated with lower rates
of metabolic complications (coma, diabetic ketoacidosis, hyperosmolar state) that
required hospitalization of their patients (Del Canale et al. 2012).
In a recent
editorial, we indicated that empathic engagement in patient care revolves
around reciprocity and mutual understanding that evokes “psycho-socio-bio-neurological” responses in both
physicians and patients (Hojat et al. 2013). These mechanisms provide plausible
explanations for the observed associations between physician empathy and
clinical outcomes.
l
For example, at the psychosocial level, empathic
engagement lays the foundation for a trusting relationship. Constraints in
communication will diminish when a trusting relationship is formed. In the
secure space of a trusting relationship, the patient begins to tell the tale of
his/her illness without concealment. This in turn leads to a more accurate
diagnosis and greater compliance, which ultimately will result in a better
quality of care.
l
At the bio-neurological level, empathic engagement is analogous
to a synchronized dance between involved parties, which is orchestrated by
bio-neurological markers. For example, the interpersonal attunement in empathic
engagement can activate some pro-social endogenous neuropeptides or hormonal
changes (e.g. oxytocin, vasopressin) (Heinrichs & Domes 2008). In addition,
a set of neurons, known as the mirror neuron system (MNS) is discharged when
observing another person performing a goal-directed act, as if the observer is
performing the act (Rizzolatti et al. 1996; Gallese 2001). In other words, the
same set of neuron cells that is discharged in the acting person, will be
implicated in the person who observes the act, without actually performing it.
The MNS is believed to play an important role in understanding the experiences
of others, which is the key ingredient of empathic communication. Of course,
more research will further clarify the associations between physician empathy
and clinical outcomes in a variety of diseases and settings and the underlying
mechanisms.
Overall, findings of studies in which the JSE was used showed that empathy
scores were significantly associated with indicators of clinical competence and were predictors
of tangible patient
outcomes. Furthermore, it was found that scores on the JSE were associated with career interest and specialty choices. Also, research
findings confirmed that empathy can be
enhanced and sustained by targeted
educational programs (Hojat et al. 2012a; Van Winkle et al. 2012). The
psychometric support and empirical findings suggest that the JSE is a promising
instrument for measuring a personality attribute that is conceptually relevant
to patient care, and empirically linked to clinical performance in medical
school, career interest and patient outcomes.
l
The JSE was specifically developed to measure empathy in the context of
medical education and patient care.
l
The JSE is supported by strong evidence in support of its validity and
reliability in medical students, physicians and other health professions
students and practitioners.
l
Empirical data support the associations between scores of the JSE and
indicators of clinical performance in medical school, and interest in broad
areas of “people-oriented” and “technology/procedure-oriented” specialties.
l
Empirical evidence is available in support of a link between physicians’
scores on the JSE and tangible clinical outcomes.
(6) The Eysenck Personality Inventory
The Eysenck Personality Inventory (EPI) (Eysenck & Eysenck 1964) and
its successor The Eysenck Personality Questionnaire (EPQ) (Eysenck &
Eysenck 1975) have been used in a number of medical education studies. The EPQ
includes three scales of Extraversion,
Neuroticism, and Psychoticism. It also contains a “Lie” scale to detect a “faking good” tendency.
l
In a study with students at Jefferson Medical College (Fenderson et al.
1999), it was found that students in the top 20% of the class who declined an
invitation to participate in an honors
program in pathology scored higher on the Neuroticism scale of the EPQ.
l
In another study, we found that medical students who received lower marks
on clinical competence were more likely to
score lower on the Extraversion scale of the EPQ
(Hojat et al. 2004a).
l
It was also found that those who were in the top half of their class in clinical competence evaluations scored
significantly lower on the Neuroticism scale of the EPQ
(Hojat et al. 1996a).
In a study by Ashton and Kamali (1995), second year medical students at
the University of Newcastle in the UK completed the EPQ and a questionnaire
about their alcohol, tobacco, cannabis and other illicit drug consumption, and
their physical fitness. Compared to a previous study conducted about a decade
earlier, no significant change was observed in students’ personality,
prevalence of cigarette smoking, levels of caffeine consumption and
participation in sports. However, students’ use of cannabis and other illicit
drugs increased two-fold (Ashton & Kamali 1995). Golding and colleagues
(1983) and Golding and Cornish (1987) reported significant correlations between
personality factors and drug abuse in students. Specifically,
tobacco and alcohol consumption and experience with cannabis and illicit drugs,
which is detrimental to academic attainment, correlated with scores of the
Psychoticism scale of the EPQ.
(7) The Minnesota Multiphasic Personality Inventory
The Minnesota
Multiphasic Personality Inventory (MMPI) is a widely used personality instrument,
primarily for the assessment of
mental health (Tellegen & Ben-Porath 2008).
l
It has also been used in medical education research. For example, John et
al. (1976) reported that poor academic
performance in medical students was predicted by MMPI scores.
l
In their study of medical students, Schonfield and Donner (1972) observed
a link between higher scores of the masculine pole of the masculinity-femininity scale of the MMPI and
interest in the technology-oriented
specialties.
l
In their comparisons of medical and law students, Solkoff and Markowitz
(1967) used the MMPI and found that medical students were more introspective and idealistic and more sensitive to the needs of others, whereas law students were more likely to
be extroverted and masculine oriented.
l
It has also been reported that scores on the MMPI could predict physician
burnout (McCranie & Brandsma 1988).
The MMPI was used in a study comparing accelerated and traditional
students at three points in time: matriculation, after ten weeks, and after 62
weeks of medical school (Nathan et al. 1989). No significant difference was
observed between the two groups of students. These investigators concluded that
concerns about the relative immaturity of younger accelerated students and a
corresponding inability to cope with the stressful environment of medical
school might be unfounded (Nathan et al. 1989).
(8) The Profile of Mood States
The Profile of Mood States
(POMS; McNair et al. 1981) measures six mood-related dimensions:
l
“Tension-Anxiety,”
l
“Depression-Dejection,”
l
“Anger-Hostility,”
l
“Vigor-Activity,”
l
“Fatigue-Inertia” and
l
“Confusion-Bewilderment.”
The POMS also assesses an overall personality attribute of mood
disturbance by adding the scores of the six mood-related scales. A consistent
pattern of findings that emotions vary
throughout the school years was observed in eight studies (Mitchell et al. 2005). In
two studies (Ford & Wentz 1984; Uliana et al. 1984), it was found that “Anger-Hostility” scores rose during
the first year of residency training. Another study reported that scores on an
additional scale such as Fatigue-Inertia worsened throughout
the year (Gordon et al. 1986). In yet another study, Bellini and colleagues
(2002) found that scores on Anger-Hostility, Fatigue-Inertia and Depression-Dejection all rose by the fifth
month of internship.
These
attributes are amenable to change by targeted programs. For example, in one
of our studies, we noticed that a course in “mindfulness-based stress
reduction” could reduce any psychological stress of students reflected in their
significantly lower mean posttest scores on Tension-Anxiety and Confusion-Bewilderment, and higher mean
scores on Vigor-Activity (Rosenzweig et al.
2003). In a similar study with primary care physicians who participated in a
mindfulness meditation and self-awareness course, improvements in the POMS
scores were observed (Krasner et al. 2009).
(9) The Temperament and Character Inventory
The Temperament
and Character Inventory (TCI), developed by Cloninger (1986, 1987) is a self-report
instrument that measures four
temperament and three character
dimensions of Cloninger's personality model (Cloninger 1986, 1987; Cloninger et al.
1991, 1993).
The four independent temperament dimensions are
l
“Novelty Seeking,”
l
“Harm Avoidance,”
l
“Reward Dependence”
and
l
“Persistence.”
The three character dimensions are
l
“Self-Directedness,”
l
“Cooperativeness” and
l
“Self-Transcendence.”
In one study in Japan, the TCI was administered to 119 second year medical students at Osaka City University Graduate School of
Medicine (Tanaka et al. 2009). It was found that scores on Persistence, Self-Directedness,
Cooperativeness and Self-Transcendence were positively
associated with a measure of intrinsic
academic motivation. In a multiple regression analysis when adjustments were made for age and
gender, it was found that scores on Persistence, Self-Directedness and
Self-Transcendence were positively associated with intrinsic academic
motivation that can lead to better academic performance in medical school
(Tanaka et al. 2009).
In another study by Jiang and colleagues (2003), associations between the
TCI scores, anxiety and fatigue were examined in 162 first-year and 89
fifth-year students from Saga Medical School in Japan.
l
Significant and positive correlations were found in the TCI scores on the Harm Avoidance and scores on
measures of anxiety and fatigue (general fatigue,
psychological fatigue and physical fatigue).
l
In addition, scores on Self-Directedness were negatively
correlated with scores on trait anxiety and
fatigue (Jiang et al. 2003).
The TCI scores on Harm Avoidance and Self-Directedness, as predictors for
fatigue-related disorders in medical students (Jiang et al. 2003), can
influence academic performance in medical school. The associations between TCI
scores and anxiety and depression have been addressed in other studies
(Cloninger 1986; Crowley et al. 1993; Joffe et al. 1993; Tanaka et al. 1997,
1998; Hansenne et al. 1999).
(10) The Personal Qualities Assessment
The Personal
qualities Assessment (PQA) was developed in Australia, designed to assess
personal qualities considered important for the study and practice of medicine
and other health professions. The PQA questions are grouped into three scales.
l
The first is a measure of individual differences in cognitive skills;
l
the second is a measure of being involved
or detached (empathy,
self-confidence, narcissism and aloofness); and
l
the third is a measure of ethical or
moral orientation (Munro et al. 2005; Powis et al. 2005; James et al.
2009).
In their study with Scottish medical students, Lumsden and colleagues
(2005) found that students’ cognitive
ability was similar in men and
women, but women were more empathic
and had better communication
orientation.
Also, no significant differences were observed on any of the PQA measures
between those who attended the state-funded or independent schools. Those with a deprived family background tended to score lower on the scale of cognitive skills. The study investigators concluded that
fairness in the medical school admissions process might be improved by using
personality instruments to objectively identify desirable qualities in future
doctors (Lumsden et al. 2005).
(11) The Maslach Burnout Inventory
The Maslach
Burnout Inventory (MBI) is a 22-item self-administered instrument that measures
three components of burnout:
l
“Emotional
Exhaustion,”
l
“Depersonalization”
and
l
“Personal
Accomplishment” (Maslach et al. 1996).
Three studies used the same data collected from family medicine residents
to analyze different aspects of burnout (Rafferty et al. 1986; Purdy et al.
1987; Lemkau et al. 1988).
l
Findings indicate that family
medicine residents, regardless of gender, exhibited moderate to high levels of burnout, especially on Emotional Exhaustion and Depersonalization scales.
l
In another study, it was reported that 76% of internal medicine residents met criteria for burnout (Shanafelt et al. 2002).
l
These studies suggest that burnout in different specialties is an
important factor that must be taken into consideration to improve patient
outcomes. It has been reported that burnout not only negatively
can influence performance in medical school, but also can exert adverse
impact on professionalism in medicine (Bellini
et al. 2002; Shanafelt et al. 2002; Thomas 2004).
This instrument has been used for the assessment of educational programs
to reduce psychological distress. For example, in a study with primary care physicians, it was found that a
course in mindful meditation and self-awareness could cause a
significant decrease in Emotional Exhaustion and Depersonalization, and an
increase in the Personal Accomplishment component (Krasner et al. 2009).
(12) The Medical Specialty Preference Inventory
The Medical
Specialty Preference Inventory (MSPI): Career preference in medical specialty and career indecision have been studied in medical education by using the MSPI
(Zimny 1979, 1980, Sodano & Richard 2009). The revised version of the MSPI (150 items, revised in 2002) calculates interest
scores for six major specialties (family medicine, internal medicine,
obstetrics/gynecology, pediatrics, psychiatry and surgery). Borges and
colleagues (2005) reported that physicians whose specialty interest (measured
by the MSPI) was congruent with their actual area of practice were more
satisfied with their job than those with incongruent match between specialty of
interest and of practice.
Career
indecision can also be determined by the pattern of
scores on this inventory (Richard 2005). For example, Walters (1982) examined the
relationship between career indecision and academic performance. It was found
that
l
students who were classified as “low-interest undecided” obtained significantly lower medical school grades
compared to “decided” students;
l
whereas “high-interest
undecided” students did not differ from the “decided” students.
Another study examined the association between career indecision and
personality.
l
Students classified as “low-interest
undecided” showed less personal integration compared with “decided” students (Walters 1982).
Furthermore, as suggested by Walters (1982), a lack of commitment to a
career in medicine (reflected in the low interest category) could negatively
influence academic performance in medical school. Some reported that
vocationally undecided students were more likely to perform poorly in medical
school than their vocationally decided counterparts (Rose & Elton 1971;
Lunneborg 1975, 1976).
Students in the “low-interest
undecided” group obtained significantly higher scores on measures of the impulse
expression scale of the Omnibus Personality Inventory (OPI, Heist & Yonge
1968) and obtained significantly lower scores on measures of personal
integration, personal bias and altruism, measured by the OPI compared to
students in the “high-interest
undecided” students (Walters 1982). In a longitudinal study of predictive validity,
Glavin et al. (2009) reported that the MSPI scorers could correctly predict
medical students’ future specialty choice 58.1% of the time.
(13) The Jefferson Scale of Attitudes Toward
Physician-Nurse Collaboration
This 15-item
scale was developed to measure orientation toward collaboration and teamwork
between physicians and nurses (Hojat & Herman 1985; Hojat et al. 1997a,
1999a). The scale was developed in response to a need for a validated
instrument to measure an important
aspect of professionalism in medicine, namely teamwork and interprofessional collaboration (Veloski & Hojat
2006).
Psychometric
evidence in support of this scale has been reported among American (Hojat et al. 1997a,
1999a; Ward et al. 2008), Mexican (Hojat et al. 2001b), Italian and Israeli
samples (Hojat et al. 2003b). This scale has been translated into several languages (e.g. Spanish,
Hebrew, Persian/Farsi, Turkish, Japanese, and Chinese) and used by medical and
nursing education researchers in different countries (Yildirim et al. 2005;
Ardahan et al. 2010; Hansson et al. 2010; El Sayed & Sleem 2011; Onishi et
al. 2012). In a review article, this scale was listed among the recommended
instruments for measuring physician-nurse collaborative relationships
(Daugherty & Larson 2005). Three underlying factors of
l “shared education and teamwork,”
l “caring as opposed to curing” and
l “physician authority”
emerged in factor analytic studies of this scale (Hojat et al. 1999a).
A significant
correlation has been found between scores on this scale and the JSE (Ward et al. 2009).
Also, scores of this scale was significantly correlated with scores of a
validated measure of attitudes toward physician-pharmacist collaboration (Hojat
et al. 2012c).
(14) The Jefferson Scale of Physician Lifelong Learning
This is a
16-item instrument developed to measure another element of professionalism in medicine,
namely, lifelong learning (Veloski & Hojat
2006). Data are available in support of the psychometrics of this instrument
(Hojat et al. 2009, 2010, 2012b). Factor analytic studies show three reliable
factors in this instrument:
l “learning beliefs and motivation,”
l “attention to learning opportunities” and
l
“skills in
seeking information.” (Hojat et al. 2006, 2009, 2010, 2012b).
These factors correspond to the key features of lifelong learning often
described in the literature, were empirically supported in a study with medical
students (Brahmi 2007).
In a large-scale study of 3195 physicians who graduated from Jefferson
Medical College, we collected survey data from physicians who were classified
into three groups: Full-time clinicians (n = 1127), academic clinicians (n = 1612) and others (n = 456). The reliability coefficients
(coefficient alpha and test-retest) of the instrument ranged from 0.72 to 0.86
in these groups of physicians.
l
We found that the academic
clinicians scored significantly higher on the lifelong learning scale
than the full-time clinicians (Hojat et al. 2009,
2010, 2012b).
l
A Significant association was observed between scores of the lifelong learning scale and medical school class rank in both groups of
academic clinicians and full-time clinicians (Hojat et al. 2009, 2010, 2012b).
Also, significant correlations were found between scores on this
instrument and the criterion measures of
l
reported commitment
to lifelong learning,
l
learning motivation,
l
information seeking
skills,
l
professional
accomplishments,
l
career satisfaction and
l
academic performance
in both full-time clinicians and academic clinicians (Hojat et al. 2009,
2010, 2012b).
Professional
accomplishments such as publishing in a professional journal, research presentation at
national professional meetings, and receiving professional awards and honors
were significantly associated with scores of the Jefferson Scale of Physician Lifelong Learning in both groups of
physicians (Hojat et al. 2009, 2010, 2012b).
l
No
significant gender difference was observed on the
scores of lifelong learning.
l
However, we noticed that physicians in internal medicine scored higher than others, and
l
those with combined MD-PhD degrees had higher scores on this scale (Hojat
et al. 2009, 2010, 2012b).
The Jefferson Scale of Physician Lifelong Learning has also been adapted
for administration to medical students with satisfactory psychometric support
(Wetzel et al. 2010).
l
Although the EPI, MMPI, POMS, TCI, PQA, MBI, MSPI, Physician-Nurse
Collaboration and Physician Lifelong Learning are all useful exploratory
instruments in medical education research, the last four are more specific than
others for physicians-in-training and in-practice.
l
The last two instruments (Physician-Nurse Collaboration and Physician
Lifelong Learning), plus the JSE which was previously described, are
particularly important as measures of oft mentioned elements of professionalism
in medicine.
Discussion
However, we noticed that the literature on the link between personality
and specialty interest is somewhat sketchy with no consistent results.
Because common personality attributes are found in
physicians in different specialties, it seems that no specific personality attribute uniquely
fits any specific specialty (Borges & Savickas 2002). Empathy though may be an exception when broader
specialty areas are taken into consideration (e.g. “people-oriented” and
“technology/procedure-oriented”).
Validity concerns
One noticeable finding on the link between personality and performance is
that the reported predictive validity coefficients are often modest in
magnitude. Perhaps this is one of the reasons that some have questioned the
utility of personality measures in medical education. The modest validity of
personality measures in medical education research, though, should not be
surprising, given the conceptual and methodological issues involved in studying
the relationships between personality measures on the one hand, and criterion
measures on the other hand.
(1) Multidimensionality of personality
Personality is not unidimensional. Different personality researchers have
devised different sets of personality constructs, as by its very nature the
field requires.
(2) Construct dissimilarity
Construct similarities and dissimilarities between personality attributes
and criterion measures can contribute to the magnitude of correlations among
them. Obviously, a correlation of a larger magnitude is expected between two
conceptually relevant variables, such as scores on empathy and ratings of interpersonal
skills,
(3) Changes in predictor-criterion
matching
Poor predictor-criterion matching in medical education research (Hough et
al. 1990; Hough 1992) can contribute to the underestimation of validity of
personality measures (Lievens et al. 2009). An important issue related to the
observed variation in the predictive validity of personality measures during
the course of medical education is that the nature of the criterion measures (performance indicators) changes from preclinical to clinical phases of medical education.
The conventional medical school curriculum has been divided into
preclinical and clinical phases.
l
Early in medical school, during the preclinical phase, students take courses related to the sciences that are
basic to medicine (e.g. anatomy, physiology, biochemistry). These courses are
typically assessed by examinations of recalling factual information and declarative
knowledge.
l
Later in medical school, the curriculum shifts to the clinical phase, and medical students rotate across various
clerkships that often require
patient contact. Students’ performance is usually assessed by faculty's ratings of clinical competence, or by standardized
or simulated patients in
OSCE stations, oral examinations or other methods.
Different sets of ability or skills are often involved in
the performance of medical students during preclinical and clinical phases of
medical education.
l
For example, the ability to recall, compartmentalize and organize factual
information, as well as test-taking skills, under the rubric of “cognitive” abilities, often contribute to
success in the preclinical phase.
l
However, communication and interpersonal skills, bedside manner,
attitudes, personal qualities or characteristic (referred to as “noncognitive” attributes), often contribute
to the assessments of competence in the clinical phase (Haight et al. 2012).
l
In our own research, we noticed that measures of cognitive abilities contributed more than
those of the noncognitive attributes to the prediction of performance in the preclinical phase of medical education.
l
However, a shift toward a higher validity coefficient was observed when personality measures were included to
predict clinical competence in the clinical phase of medical education
(Hojat et al. 1993).
The oft-reported findings of the increase in the predictive validity of
personality measures from the preclinical to clinical phase of medical education
can be explained by the trait-activation
theory (Lievens et al. 2009). In other words, personality traits
that are important for clinical performance manifest themselves during the
clinical phase of medical training. This notion is consistent with the view in
organizational psychology about different components required for performance
in various jobs (Borman & Motowidlo 1993). The theory of trait-activation
provides a plausible explanation as to why measures of academic abilities prior
to medical school (e.g. grades on examinations of declarative knowledge, scores
on entrance examinations such as the MCAT) have shown a declining predictive
validity as students progress from preclinical to clinical phases in medical
school; while the predictive validity of personality measures increases in the
clinical phase of medical school training (Humphreys & Taber 1973; Lin
& Humphreys 1977; Lievens et al. 2009).
(4) Proximal and distal
criterion measures
Based on the aforementioned discussion, one can reasonably expect that personality measures are more likely to
predict the “distal” performance
(in clinical phase) rather than “proximal” criterion measures (in the
preclinical phase) in medical school. Accordingly, the predictive validity
and utility of personality measures would be underestimated when using the
“proximal” criterion measures, which leads us to another issue; the time
interval between recording of predictors and criterion measures.
Personality measures are often
administered early in medical
school sometimes during the admission process. Measures of performance in the
clinical phase of medical education in North America are recorded usually after
completion of the second year of medical school. This is a relatively long time interval to examine predictive validity. Specific
experiences or events occur during this time period that can confound the
predictive validity. The time interval between administering the personality
test and recording criterion measures in the personality research reported in
the psychological literature is usually a few months and rarely exceeds a year
or two (Lievens et al. 2009). However, in this particular situation, distal
performance (measures of clinical competence) is more relevant to personality
attributes than proximal performance (grades on sciences basic to medicine).
Therefore, the confounding effects of the time interval between testing and the criterion measure, subsequent to
gaining new experiences, could suppress the true relationships between
personality measures and distal performance, adding to the complexity of
validity research on personality testing in medical education.
(5) Restriction of range
Another reason for the modest validity coefficient of personality measures
in medical school is that a correlation coefficient is highly dependent upon
the range and variability of the measures. Restriction of range, due to selection and attrition, can shrink validity
coefficients. Therefore, inferences drawn from correlation coefficients may be
misleading; because all things being equal, the more restricted the range of
scores, the lower the validity coefficient. The true relationships between
correlated measures cannot be captured when only those who successfully
completed their medical training are included in the final statistical
analyses; thus, eliminating those in the bottom tail of the score
distribution who could not successfully completer medical school. The resulting
“ceiling effect” would lead to a lower
validity coefficient (Gough et al. 1963).
(6) Nonlinear relationships
A nonlinear relationship between some measures of personality and some
indicators of academic attainment can lead to a decrease in predictive
validity. When the nature of a relationship is nonlinear, the magnitude of the
Pearson correlation coefficient will become negligible. A curvilinear relationship (i.e.
inverted U shape) has been reported between anxiety and performance in
medical school (Shen & Comrey 1997; Ferguson et al. 2002), which is consistent with
the arousal theory (Yerkes & Dodson 1908) suggesting that individuals
perform better at their optimal
arousal level, below and above which performance is likely to fall. In almost all
validity studies on personality measures in medical education research, the
linearity assumption has not been tested (Shen & Comrey 1997).
(7) Multicollinearity
The genuine relationship between predictors (personality measures) and
criterion measures (performance indicators) cannot be captured when predictors are themselves highly
correlated. This phenomenon, known as multicollinearity, contributes to
underestimating the predictive validity of personality attributes. The modest
contribution of some personality measures in multiple regression analyses could
be an artifact of multicollinearity, which must be taken into consideration
when assessing the validity of personality measures.
(8) Volunteer bias
Volunteer bias in research can also confound validity coefficients. Medical students’ willingness to voluntarily participate in medical education research varies by gender, ethnicity and academic
achievement (Callahan et al. 2007). We have shown that research volunteers in medical
school, on average, perform better during and after medical school, compared to
their unwilling classmates (Callahan et al. 2007). This finding suggests that volunteer
participants in medical education research cannot fairly represent the entire
population of medical students. This leads to the self-section bias and raises
question about the validity of research in medical education when participation
is voluntary. This issue is exacerbated by the requirement of voluntary
participation in human subject research for granting approval by most
universities’ research ethics committees (e.g. the institutional review
board, IRB). Nevertheless, high participation rates and evidence of the
representativeness of the volunteer sample in relation to the population being
studied can provide support for the validity.
(9) Variation in methods of
assessment
Variation in methods of assessment is another factor that can contribute
to the modest validity coefficients between personality and criterion measures
in medical school. Self-report personality
measures rely mostly on Likert-type
scales. Criterion
measures of cognitive performance in
medical school are often assessed by multiple
choice or true-false formats (in the preclinical
phase) and by observational methods, ratings of clinical competence by the
faculty or assessments by simulated patients in the clinical phase of medical
education.
(10) Gender effects
Gender is another variable that can confound predictive validity
assessments (Hojat et al. 1999b). Gender was not an important factor in
early studies of medical education when medical students and physicians were
predominantly male (Zeldow & Daugherty 1991). The influx of women to
medicine in the later part of the past century and gender differences observed
in personality, performance, career motivation, and specialty preference suggest
that gender must be considered as a contributing variable in validity studies
in medical education research.
It has been reported that women on average fall behind
their male counterparts during the preclinical phase of medical education, but
they usually catch up to or sometimes surpass men on some measures of clinical
competence during the clinical phase of medical education (Hojat et al. 1997b;
Halpern et al. 1998; Ferguson et al. 2002).
In addition, female
physicians are rated higher on personal qualities such as
l
helpfulness,
l
human relationships,
l
expressiveness,
l
intrinsic career
motivation,
l
family responsibility
and
l
job security;
while men obtained higher marks
on personality features such as
l
independence,
l
decisiveness,
l
self-confidence,
l
extrinsic career
motivation and
l
orientation toward
income and prestige (Buddedberg-Fischer et al. 2003).
Gender
differences have also been observed in career choices (Hojat et al. 1999b).
For example,
l
historically women have been more likely
to choose “people-oriented” specialties that
require intensive patient contact,
l
while men have been more likely
to prefer “technology-oriented” specialties that
require performing complicated procedures (Buddedberg-Fischer et al. 2003;
Hojat 2007).
A detailed discussion of whether the underlying reasons for gender
differences are the results of social learning (Bandura 1986), or hard-wired
gender specific inclination (Halpern 1992, 1997; Valian 1999) is beyond the
intended scope of this Guide. Regardless of the reasons for gender differences,
it is important to examine and control gender effects for a fair assessment of
predictive validity of personality measures in medical education research.
(11) Race and ethnicity
effects
In addition to gender, race and ethnicity can contribute to the validity
of personality measures. Given the changing demographic and ethnic composition
of medical students and physicians, particularly in the United States, and the
emphasis placed on ethnic diversity in the medical workforce (AAMC 2004;
Nickens et al. 1994), it is important to control for ethnic status as a
possible intervening variable in the validity studies. Our research findings
suggest that ethnicity contributes
significantly to the assessment of cognitive (Rosenfeld et al.
1992; Veloski et al. 2000) and noncognitive
measures (Berg et al. 2011a) in medical education research.
A number of studies also confirm the role of ethnicity in medical school admissions and academic attainment (Rosenfeld
et al. 1992; Esmail et al. 1995; McManus et al. 1995; Ready 1995; Crump et al.
1999; Tekian 1997; Girotti 1999; Hardy 1999; Lumb & Vail 2000; Giordani et
al. 2001; Ferguson et al. 2002).
Reasons for optimism
Despite all of the aforementioned conceptual and methodological
limitations, the findings of the modest predictive validity of personality
measures in medical education and practice are still encouraging
Social desirability response bias
In addition to the issue of modest validity, another reason for hesitation
to use personality instruments in the assessment of physicians-in-training and
in-practice is the issue of social desirability response bias that can also be
relevant to the validity of personality tests.
The degree to which socially desirable responses have a
confounding effect on test scores can be a function of the test taker's
perception of the purpose of personality testing.
There are very few studies on the effects of “faking” in personality test
outcomes (Hough et al. 1990). We conducted an empirical study to examine the
possible effect of socially desirable responses (Hojat et al. 2005b) in which
we administered the JSE and other personality tests, including the ZKPQ to 422
first-year medical students. The ZKPQ includes
an “Infrequency” subscale that was developed to
detect intentionally false responses by identifying respondents with an invalid pattern of responses (Zuckerman 2002).
Scores on this subscale can be regarded as indicators of social desirability
response bias. Attempts to give socially desirable responses were determined by
a cutoff score of 3, which the test's authors suggested would identify
respondents whose patterns of responses were of questionable validity. An
examination of the distribution of scores on this subscale indicated that 4.9%
of the respondents attempted to give false “good impression responses” or to
respond carelessly without regard for the truth (Hojat et al. 2005b).
Second, we used the analysis of covariance (ANCOVA) method to control the
effect of giving false responses on the research outcomes by using the
“infrequency” score as a covariate. Again, we noted no substantial change in the general pattern of results. These findings
suggest that social desirability response bias did not distort the validity of
the JSP score.
Our findings were consistent with the results of an earlier study by
Matthews and colleagues (1981), who reported that their derived index of empathy was not affected by social desirability response
bias or by scores on a
“good impression” scale.
One approach that may minimize the effect of social
desirability response bias is reminding the respondents to reply truthfully,
since their intentionally false responses can be detected by a scale embedded
in the test which will invalidate the test results. One of the available
measures (e.g. Infrequency subscale from the ZKPQ) could be used for that
purpose. For example, pattern of endorsement of items such as “I never met a person
I did not like” or “I have always told the truth” (from ZKPQ) can give a clue
as to whether a respondent is honest in completing the test.
Are personality attributes amenable to change?
l
Proponents of
nature over nurture
place great emphasis on the notion that genetic predisposition has an
undeniable role in the development of human behavior. Some developments in the Human Genome Project have provided more
fuel in support for that argument (Collins 1999).
l
However, proponents of nurture over nature use Watsonian classical conditioning (Watson 1924), Skinnerian operant conditioning (Skinner 1938) and Bandura's (1986) social learning theory as evidence that
personality can be molded by principles of behavior modification, personal
experiences, social learning and educational interventions; thus, they conclude
that environment and learning could have a prominent role in the development of
personality.
However, most scholars today are of the opinion that it
is the interaction of nature and nurture that contributes to the development of
personality. Human beings are born with some potential for “engageability,” which is triggered
and developed to a certain degree by environmental, social, experiential, and
educational factors (Neubauer & Neubauer 1990). Abundant research evidence
has been accumulated in support of the proposition that social and educational environments play an important
role in the development of personality including the shaping of interpersonal
skills and caring attitudes (Hojat 2007). There are empirical studies showing
that some personality attributes can be changed as a result of positive or
negative educational experiences in medical school. This notion is supported by
the findings on the erosion and enhancement of empathy during medical school.
Erosion of
empathy during medical education
A number of studies
have shown that during the course of health professions education, a person's
capacity for empathy can undergo positive, negative, or no change (see Hojat
2007, pp. 181–184 for a review).
l
Some studies have reported a significant
decline in the scores of the JSE during the clinical phase of medical education
(Hojat et al. 2004b, 2009, Chen et al. 2007; Hojat 2007, Newton et al. 2008).
l
In our more recent longitudinal study of four classes of medical students
at Jefferson Medical College (Hojat et al. 2009), a significant decline in scores of the
JSE was observed
in third-year medical
students when the curriculum shifts to clinical training and patient care, and the
decline did not rebound during the rest of
medical school training.
Such a decline on the scores of the JSE was also noticed in
another study with internal
medicine residents as they progressed through residency training (Mangione
et al. 2002). However, the decline in empathy in this study did not reach the
conventional level of statistical significance. The findings of erosion of
empathy during medical education are consistent with those reported by
Whittemore and colleagues (1985), Bellini and colleagues (2002) and Bellini and
Shea (2005). A similar decline in empathy scores also was observed among
nursing students who had more exposure to patient care than others (Ward et al.
2012).
Consistent with the
above-mentioned findings, an early study by Becker and Geer (1958) reported
that medical students become somewhat cynical during the course of
medical education.
l
By the third year of medical school, according to Becker and Geer (1958),
the students realized that they were no longer motivated by an idealized view of medicine, leading to a hedonistic shift, shown also by Whittemore and colleagues (1985), and by Feudtner and
colleagues (1994).
l
In a study by Zeldow and colleagues (1987), a modest but “unmistakable” shift (according to the
study authors) toward hedonism between the freshman and junior year of medical
school was observed in two cohorts of students. According to the investigators,
these changes perhaps reflect a less
idealized view of the self and a less
sentimental view of the medical profession (Zeldow et al. 1987).
In explaining changes
in empathy, medical students reported
l
a lack of positive
role models,
l
lack of time to form
an empathic relationship with patients,
l
excessive workloads,
l
disrespectful and
overly demanding patients,
l
over-reliance on
computer-based diagnostic and therapeutic technology, and
l
a market-driven
health care system
as factors that
contribute to erosion of empathy (Hojat et al. 2009) and the escalation of
cynicism (Hojat 2007).
Despite the
overwhelming evidence of the erosion of
empathy during medical education, skeptics have raised concern about the significance of
these findings in undergraduate
and graduate medical education (Colliver et al. 2010), but such critics have not been
left unchallenged by our team (Hojat et al. 2010) and other empathy researchers
in medical and dental education (Newton 2010; Sherman & Cramer 2010).
Findings of erosion
of empathy in undergraduate (Hojat et al. 2004b, 2009; Chen et al. 2007) and
graduate medical education (Bellini et al. 2002; Bellini & Shea 2005;
Mangione et al. 2002) suggest that if a personality attribute, such as empathy,
can decline by negative educational experiences, it can also be enhanced by
positive educational experiences and targeted interventions.
Enhancement
of empathy in medical education
The link between
empathy, clinical competence and patient outcomes (Hojat et al. 2011a; Del
Canale et al. 2012) makes it critical that we nurture empathy in
physicians-in-training and physicians-in-practice. The cultivation of
empathy in undergraduate medical education has been listed among learning
objectives endorsed by the Association of American Medical Colleges (AAMC
2008). Also, the ABIM recommended that humanistic qualities such as empathy be
instilled and assessed as an essential part of graduate medical education (ABIM
1983).
The reported decline
in empathy during undergraduate and graduate medical education coupled with the
findings that empathy should be viewed as a component of physician competence
that has implications for patient outcomes, beg for the development of targeted
educational programs
to sustain and enhance empathy among physicians-in-training and physicians-in-practice.
Research has shown that empathy must
be considered as an important component of a health care
provider's overall competence and is a significant factor in optimal patient
outcomes (Hojat et al. 2009; Del Canale et al. 2012).
These findings
suggest that leaders and faculty at all levels of health profession education
(e.g. undergraduate, graduate and continuing education) must implement targeted
educational remedies to enhance and sustain empathy in all students and
trainees, and assess the educational outcomes. Research shows that empathy can be enhanced with targeted educational programs. For example, the
following 10 approaches have been described (Hojat 2009) for improving empathy
among health professions students and practitioners:
1.
Improving interpersonal
skills;
2.
analyzing audio or
video taped encounters with patients;
3.
being exposed to role
models;
4.
role-playing (e.g.
aging games);
5.
shadowing a patient
(e.g. patient navigator);
6.
experiencing
hospitalization (e.g. getting admitted to a hospital by presenting fabricated
symptoms);
7.
studying literature and
the arts;
8.
improving narrative
skills;
9.
watching theatrical
performances and
10.
engaging in small group
discussion about difficult patients, e.g. Balint (1957) method.
l
In a study with pharmacy
students, Chen et al. (2008) reported enhancement in the JSE scores among students
who participated in an empathy training program.
l
Also, Fernandez-Olano and colleagues (2008) reported a significant
increase in the JSE among Spanish
medical students and residents who participated in a communication skills training program.
l
However, Cataldo and colleagues (2005) found no significant increase in
the JSE scores as a result of Balint training among residents in a family medicine residency program.
l
In a qualitative and quantitative study with 40 staff physicians at the
Cleveland Clinic, it was found that a faculty development program using guided
narrative writing could influence, to a limited extent, the empathy of practicing physicians (Misra-Herbert et al.
2012).
l
In one study, it was found that watching a short theatrical play (depicting problems
facing elderly patients) could significantly increase scores of the JSE in medical and pharmacy students (Van Winkle et al.
2012). The increase in empathy
scores, however, did not last for a long time.
l
In another study, it was reported that shadowing patients by first-year emergency medicine residents in the
emergency room for a short period of time prevented decline in empathy. The empathy scores of the control group who followed
their routine training schedules declined during the study period (Forstater et
al. 2011).
l
In a study with primary care physicians, it was found that participation
in a course of mindful
meditation and self-awareness could significantly increase scores of the JSE (Krasner
et al. 2009).
In our latest study
to examine if enhanced empathy can be sustained, we showed medical students video clips of patient encounters selected from three
movies. Students were encouraged to present their views on positive and
negative episodes of the encounters in the video clips, and discussed the
feedback. Enhanced empathy was observed among
all students who watched and discussed the video clips of patient encounters
(as compared to a control group who did not). A few weeks later, those who
watched and discussed the video
clips were divided into two groups. One group participated in a lecture and
discussion session on the importance of empathy in medical education and
patient care. The other group watched a documentary movie. Enhanced empathy
could be sustained in the first group, but not in the second group. It was
concluded that the enhanced
empathy could be sustainable when reinforced by additional intervention, but will dissipate without such reinforcement (Hojat et al. in
press). We are exploring approaches not only to enhance but also sustain
empathy by additional reinforcement during the course of medical education.
The aforementioned
findings suggest that targeted educational programs can significantly
improve empathy in the context of medical education and patient care. In
all of our experiments, we noticed significant variation in the magnitude of
changes among participants. Not everyone could equally be influenced by
negative experiences (Hojat et al. 2003a, 2009) or equally benefit from the
educational programs (Van Winke et al. 2012), which may suggest that
constitutional factors provide a window of opportunity for changes, but the
size of that window varies among participants. Personality attributes are
indeed unevenly distributed in the population. Some people possess some of
the personality attributes (positive or negative) in abundance; some in meager
amounts, depending upon many factors including genetic predisposition, early
relationships experiences, family and social environment, and of course
learning and educational factors. Some people seem to have a larger window
than others for personality changes; not all seeds sowed in a garden bed grow
at the same rate.
Based on the
aforementioned findings, we propose that some personality attributes are
amenable to change by targeted educational programs, but the degree of change
depends on constitutional factors, early attachment experiences, exposure to
positive role models and social and educational factors.
Conclusions
Conceptual relevancy and empirical evidence
The crucial question raised by many is how can we identify the pertinent
personality attributes for medical training and practice? We believe that at
least two factors could be considered.
l
First, the selected attribute must be conceptually
relevant to components of physician performance, and theoretically linked to optimal patient
outcomes. A lack of clear conceptual relevancy between a selected
personality attribute and a defined outcome measure will undermine the
potential value of personality measures in medical education and make it
totally unacceptable to society.
l
Second, in addition to conceptual or theoretical relevancy, selection of
desirable personality attributes must
be evidence-based, meaning that convincing empirical support must be available
to back the significant associations between selected personality measures and
indicators of performance.
Therefore, our first task is to choose a manageable number of personality
measures that meet the conceptual relevancy, and empirical support
requirements. Ease of administration,
time needed to complete, and cost-benefit factors can also be taken into
consideration.
Selected personality measures
The conscientiousness
factor
At the conceptual
level, it seems reasonable to concur that personal qualities such as responsibility, competence, dutifulness,
achievement striving, self-discipline, deliberation and order are
relevant to a physician performing his or her roles as a clinician, educator
and manager (Figure 1). These are all among the facets of the Conscientiousness
factor of the big FFM of
personality (Costa & McCrae 1992).
In addition to the
findings, we previously reported in describing the FFM of personality, the Conscientiousness factor was found to
be a significant predictor of
professional success not only in medicine, but also in a variety of other
occupational settings (Tett et al. 1991). The Conscientiousness factor is not
only a positive predictor of competence in the clinical phase of medical training, but also a significant predictor of
performance in the preclinical
phase of medical education, even when statistical control was made for previous
academic performance (Ferguson et al. 2002). In their meta-analytic research,
Barrick and Mount (1991) concluded that conscientiousness is a universal predictor of job performance. The universality of
the Conscientiousness factor in academic and professional success has been
confirmed in a variety of disciplines and in different academic settings (Hurtz
& Donovan 2000; Noftle & Robins 2007; Poropat 2009; Haight et al.
2012), and in predicting healthy behavior (Bogg & Roberts 2004). Thus,
conscientiousness is the first personality attribute we selected as being
relevant to medical education and the practice of medicine. The scores of the Conscientiousness factor of the NEO
PR-I (Costa & McCrae 1992) can well serve as a psychometrically sound
measure of this personality attribute.
Empathy in patient care
There is another set
of personal qualities such as communication
skills, understanding, ethnic and cultural sensitivity, perspective taking
ability, teamwork, collaboration and personal and professional ethics
that seem desirable for the practice of medicine and in improving clinical
outcomes. These are all
ingredients of empathy as we conceptualize
it (Hojat 2007, 2009; Hojat et al. 2009). We have shown that medical students’
empathy is significantly linked to global
ratings of clinical competence (Hojat et al. 2002a). We also showed that medical
students’ self-report empathy scores (measured by the JSE) were predictive of
ratings of empathic behavior and interpersonal
skills (given by the directors of postgraduate medical education programs) about
three years later (Hojat et al. 2005a).
Furthermore, and more
importantly, we have shown that scores on physician empathy (measured by the
JSE) were significantly associated with tangible clinical outcomes in diabetic patients (Hojat et al. 2011a;
Del Canale et al. 2012). These findings provide convincing evidence to confirm
that empathy is an important component of overall competence for medical
students and physicians, and a significant factor in optimal patient outcomes, suggesting that
empathy must be placed in the realm of evidence-based medicine. Therefore, we selected empathy as the second
personality attribute relevant to the clinical performance of medical students
and physicians as well as optimal patient outcomes. The JSE can serve as a
psychometrically sound instrument for measuring this attribute.
Other personality
attributes
We are not fully
satisfied with the two-attribute personality profile. There may be other
pertinent personal characteristics that deserve more attention.
l
As an example, in our own research, we noticed that students’ retrospective report of their perception of
early relationships with their parents, especially the mother, was a significant
predictor of ratings of clinical competence and interpersonal skills given by
the directors of postgraduate medical education programs to physician residents
(Hojat et al. 1996a).
l
We also found that such positive perceptions of the early relationships with the mother were associated with
a positive personality profile (e.g. lower loneliness, lower depression, lower
anxiety, higher self-esteem) (Hojat 1998) and also with more positive
appraisals of stressful life events, as well as success in medical school
(Hojat et al. 2003a).
l
Medical students’ reports of maternal
unavailability in childhood were associated with higher scores on the intensity and
chronicity of loneliness experiences, more depression, lower self-esteem and
more negative appraisal of stressful life events (Hojat 1998; Hojat et al.
2005b).
These findings are in
agreement with some human
social-emotional development theories, including John Bowlby's attachment
theory (Bowlby 1969). Of course more empirical evidence
(preferably in longitudinal studies) to show that the quality of early
relationships with a primary caregiver can significantly predict clinical
performance of physicians-in-training and in-practice would add to our
confidence to consider the early relationship information as an important attribute
in the personality assessments. Considering the available evidence, however, at
the present time, we suggest that the two selected personality attributes be
used as potential indicators of success in medical education and the practice
of medicine until further research suggests additional measures.
There are other
personal qualities that seem conceptually relevant to performance in the
context of medical education and patient care. For example, indicators of emotional intelligence, tolerance of ambiguity and emotional regulations seem desirable for
optimal clinical performance and patient care, but more convincing empirical
evidence is needed to connect these features of personality directly to
measures of success in medical school and in the practice of medicine.
Empirical confirmation of these links should be placed on the agenda of future
research.
It is also
interesting to contemplate the idea that similar to the “g” factor in intellectual abilities, there might be a
general, or a “g” factor in
the personality of competent medical students and
physicians. It would be a break-through in personality research in medical
education if such a “g” factor was discovered for predicting success among
physicians-in-training and in-practice. The possibility of the existence of
such a general factor should be examined in future medical education research.
Implications
Identifying applicants who are likely to become competent
physicians is a crucial responsibility of academic medical centers (Haslam
2007; Gonnella & Hojat 2012). The assessment of personality is one step toward
achieving this goal. Based on our discussion of the reported findings in this
Guide, we suggest that attention be given to applicants’ scores on measures of
conscientiousness and empathy at undergraduate and graduate medical education
levels to identify those applicants with a more “suitable” personality profile
for medical practice. At the least, these measures could be used as
potential “tie breakers” in the admission decisions for those applicants with
relatively similar profiles on other admission requirements.
However, in the admission process, serious legal and
socio-political concern exists as to whether society is prepared to accept the
use of personality assessments for excluding an applicant from medical
education and denying the opportunity to become a physician.
Lingering doubts and hesitation to take bold action in
utilizing personality assessments in the selection and professional development
of trainees in medicine, result in a futile and never-ending search for additional evidence which would be counterproductive for medical
education and the practice of medicine; because, waiting to certainty is waiting for eternity.
Final remarks
First, in response to the importance of personality in the process and
outcomes of medical education, we have shown in this Guide that personality
plays a significant role in the performance of physicians-in-training, and
in-practice. While we may not be as certain about the role of personality
in specialty choice and selection, a large volume of empirical studies provides
convincing evidence, which adds to our confidence, on the importance of
personality attributes in predicting performance in medical school and the
practice of medicine.
Second, in response to identifying a manageable number of personality
attributes most relevant to medical education outcomes, after our review of the
literature we have selected the two personality attributes of
“conscientiousness” and “empathy” because of their conceptual relevance to
physician competence as well as support from a number of empirical studies.
Of course, there might be as well additional personality attributes that can
serve a similar purpose. Further research is needed to provide convincing and
consistent evidence about the validity and utility of such additional
personality measures.
Third, in response to the notion of redundancy or
overlapping cognitive and noncognitive aspects of performance, we have shown
that the two constructs of academic
aptitudes and personality are
separate entities (Hojat et al. 1988) that uniquely contribute to prediction of
performance in undergraduate (Hojat et al. 1988) and graduate (Hojat et al.
1996a) medical education outcomes. In other words, they are complementary, not redundant.
Fourth, in response to the idea of the amenability of personality
attributes to change, as an example we have described approaches that enhance
empathy in undergraduate and graduate medical education. We reported that even
short workshops can influence empathy of trainees in undergraduate (Hojat et
al. 2012a) and graduate medical education levels (Forstater et al. 2011), and
that the enhanced empathy can be sustained by additional educational
reinforcements (Hojat et al. 2012a).
Fifth, in response to the issue of the possibility of “faking” in
personality testing, we reported some studies that suggest social
desirability response bias may not substantially distort the results when the
test is administered in a “non-penalizing” situation. However, the
production of an intentional “good impression” in responses is always a
possibility; proper instructions and examinations of response pattern on
specific items to detect socially desirable responses can be helpful in
minimizing “faking” and to identify those with invalid responses.
Because of the contribution of personality to all aspects – personal and professional – of human behavior, we strongly believe
that medical education and medicine can profoundly benefit from seriously
considering the potential of pertinent personality attributes in the selection
and education of intellectually qualified applicants to undergraduate and
graduate medical education as well as in professional development of physicians
to better perform their roles as clinicians, educators and resource managers.
Medicine which was considered by the public as one of the
most highly respected professions of all, is losing ground (Thomas 1985) partly
because of the failure of some physicians to preserve their altruistic image
(Schlesinger 2002). At the turn of 20th century, George Bernard Shaw equated
the image of the medical profession to the faith in God by declaring that “We
have not lost faith, but we have transferred if from God to the medical
profession.”
However, in the past few decades, profound changes in
medical education and the health care services,
l
an imbalance in
teaching the science and the art of medicine,
l
unduly monetary
considerations to contain cost,
l
increasing
commercialization of medical care,
l
health insurance policies
formulated by nonmedical administrators,
l
the emergence of
“defensive” medicine, and
l
loss of the human
presence in caring for the patients by its replacement with computerized
diagnostic and therapeutic technology
have transformed the image of physicians, and eroded the
public's trust in medicine (Schlesinger 2002).
Perhaps medicine can regain some of its well-deserved
reputation, and physicians can reclaim their altruistic image by greater
attention to the role of personality in the selection, education, practice and
professional development of physicians.
Med Teach. 2013 Jul;35(7):e1267-301. doi: 10.3109/0142159X.2013.785654. Epub 2013 Apr 25.
Personality assessments and outcomes in medical education and the practice of medicine: AMEE Guide No. 79.
- 1Center for Research in Medical Education and Health Care, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA. mohammadreza hojat@jefferson.edu
Abstract
In a paradigm of physician performance we propose that both "cognitive" and "noncognitive" components contribute to the performance of physicians-in-training and in-practice. Our review of the relevant literature indicates that personality, as an important factor of the "noncognitive" component, plays a significant role in academic and professional performances. We describe findings on 14 selected personality instruments in predicting academic and professional performances. We question the contention that personality can be validly and reliably assessed from admission interviews, letters of recommendation, essays, and personal statements. Based on conceptual relevance and currently available empirical evidence, we propose that personality attributes such as conscientiousness and empathy should be considered among the measures of choice for the assessment of pertinent aspects of personality in academic and professional performance. Further exploration is needed to search for additionalpersonality attributes pertinent to medical education and patient care. Implications for career counseling, assessments of professional development and medical education outcomes, and potential use as supplementary information for admission decisions are discussed.
- PMID:
- 23614402
- [PubMed - indexed for MEDLINE]
Scholarship-of-Teaching-and-Learning.pdf
