Are medical students agreeable? An exploration of personality in relation to clinical skills training

Abstract

Background: Clinical competencies like trust, empathy, and cooperation are emphasized in medical school curricula. Agreeableness, a personality domain, reflects these competencies. It is unclear, however, whether medical student personality is intrinsically agreeable.

Aim: We explored whether medical student personality reflects Agreeableness, and compared student Agreeableness with that of police officer recruits, a group in which high Agreeableness is not preferred.

Methods: Students and recruits completed the Revised NEO Personality Inventory, which measures domains of the five-factor model: Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness.

Results: Medical student Agreeableness was at average levels. Students were high in Extraversion and Openness, reflecting personal growth, leadership, problem solving, and influencing. Relative to recruits, students had higher Neuroticism and Openness and lower Conscientiousness. Agreeableness and Extraversion did not differ. Using discriminant analysis, Neuroticism, Openness, and Conscientiousness accurately classified 77% of students and recruits.

Conclusion: Medical students were not inordinately agreeable. They were ambitious, intellectually-creative problem solvers with a preference to direct/influence. Clinical skills training that acknowledges this style may enhance clinical education processes. Model-based methods for clinical skills—including agenda-setting, conflict resolution, and alliance making – that require mastery of techniques and have evidence-based relevance to patient care may be useful adjuncts to conventional clinical training.

Introduction

The competencies that medical schools are expected to address in their curricula have evolved over recent years to include an array of clinically-focused skills and behaviors. This evolution is illustrated in the report of the Association of American Medical Colleges (AAMC) Project on the Clinical Education of Medical Students, which includes 41 core and advanced competencies related to clinical communication skills and 12 clinical practice competencies (AAMC 2005). These competencies refer to such skills and behaviors as professionalism; trust building; respect; empathy; altruism; compassion; relationship building; cultural sensitivity; understanding patient spirituality, beliefs, and meaning; cooperation, including information sharing and mutual decision-making; appreciation of psychosocial factors; responsiveness to distress; and self-awareness. Similarly, the European Board of Internal Medicine (EBIM) formed a working group in 2004 to define the competencies of the internist in order to, in part, ‘reform the education of internists across Europe’. The working group's model includes core competencies related to communication skills, professionalism, and ethical issues, competencies that include honoring the principles of altruism and social justice; acting with honesty, empathy, and sensitivity (including sensitivity to religion, culture, and socioeconomic status); providing careful explanations to patients; and involving patients in decision-making (Palsson et al. 2007). A lingering debate, however, reflects the question of whether students can be ‘taught’ such skills and behaviors (and, if so, how to reliably and validly evaluate whether students have ‘learned’ them) (Benbassat & Baumal 2004; Klitzman 2006). Another question – and one focus of the present study – is whether medical students are constitutionally prone toward such competencies by virtue of their personalities. The personality domain most relevant to the latter question is Agreeableness, one of the five primary domains of the five-factor model of personality (Goldberg 1993). Highly agreeable people are trusting, straightforward, altruistic, cooperative, modest, and empathic, traits that appear to define (or at least facilitate) many of the clinical competencies described above. In fact, research on the personality characteristics of ‘exemplary’ or ‘model’ physicians has identified such attributes as warmth, empathy, humanism, advocacy, honesty, cooperativeness, respectfulness, trustworthiness, and self-control (Magee and Hojat 1998; Hojat et al. 1999; Elzubeir and Rizk 2001; Bendapudi et al. 2006). Yet, it is unclear whether medical students are any more or less agreeable than other professional groups or the general population.

The present study investigated the latter question. We did this in two ways, by collecting norm-referenced descriptive data on Agreeableness (and other personality domains) for a third-year medical student class and by examining whether medical students could be differentiated from another type of professional trainee, police officer recruits, on Agreeableness (and other domains of personality). This comparison group was chosen since high levels of Agreeableness are actually not preferred in police officers. As Costa and McRrae (1992), two eminent researchers of the five-factor model of personality, have noted, ‘agreeableness is not a virtue on the battlefield’. Accordingly, with respect to Agreeableness traits, ‘model’ police officer recruits have been described by their field training officers as guarded regarding others’ motives (i.e. low in trust: cynical/skeptical regarding others’ motives/honesty) and tactical in social exchange (i.e. low in straightforwardness: calculating, crafty, and strategic in social interactions) (Detrick and Chibnall 2006). It is also desirable that other aspects of Agreeableness – altruism, cooperativeness, modesty, empathy – not be too high in recruits, but at average levels (Detrick and Chibnall 2006). We hypothesized that medical students would evince more Agreeableness than police recruits.

The first purpose of the study – to provide norm-referenced data on Agreeableness and other personality domains for medical students – was motivated in part by the diversity of the research literature on medical student personality. A vast array of personality inventories and personality trait scales have been used with medical students (e.g. the California Psychological Inventory, Tutton 1996; the Comrey Personality Scales, Shen and Comrey 1997; the Jefferson Scale of Physician Empathy, Hojat et al. 2002; the 16 Personality Factor Questionnaire, Manuel et al. 2005; the Myers–Briggs-Type Indicator, Davis and Banken 2005; the Hogan Development Survey, Knights and Kennedy 2006; and the Basic Character Inventory, Tyssen et al. 2007), generally in an attempt to predict medical school performance and/or adjustment. Such conceptual diversity (e.g. these measures vary considerably regarding the conceptual models of personality on which they are based and in the degree to which they are oriented toward psychopathology) restricts generalizability and inhibits uniform characterization of personality among medical trainees. Although largely ignored in the medical literature, the five-factor model of personality has gained widespread acceptance among personality theorists as the most parsimonious, yet robust and comprehensive, model of normal adult personality (Costa and McRae 1992; Yamagata et al. 2006). Its use with medical students has been minimal (Lievens et al. 2002), but its potential for providing a unifying model on which to base personality research in medical education is worthy of consideration. The Revised NEO Personality Inventory (NEO PI-R) is the foremost measure of the five-factor model (Costa and McRae 1992; Costa et al. 2000), and was used in the present study to assess personality. The NEO PI-R allowed us to generate norm-referenced Agreeableness scores for the medical student sample. We hypothesized that students would evince high levels of Agreeableness, relative to the NEO PI-R norms (which are based on a large normative sample selected to match US Census projections for age, gender, and race) (Costa and McRae 1992).

Table

Practice points

Examining medical student personality is relevant to the training of students toward competence in clinical skills like trust, sincerity, altruism, empathy, and cooperation, skills that are reflected in the personality domain of Agreeableness. We examined medical student Agreeableness using the Revised NEO Personality Inventory. Medical student personality was not distinguished by Agreeableness, but by tendencies toward personal growth/ambition, leadership, intellectual creativity, problem solving, and influencing/directing others; in fact, medical students were no more or less Agreeable than police officer recruits, a group in which high Agreeableness is not preferred. Since medical student personality is more inclined towards intellectual problem solving and influencing others, rather than Agreeableness, achieving competence in clinical skills like trust, empathy, and cooperation may be enhanced by incorporating specific, evidence-based methods of interaction (e.g. agenda-setting, conflict resolution, negotiation, and alliance making) into clinical education.

Methods

Participants

The medical student sample included 133 third-year students at Saint Louis University School of Medicine (89% of the class of 150). There were 78 men (58.6%) and 55 women (41.4%). The gender distribution in the class as a whole was 58.7% men and 41.3% women. Mean age was 25.5 years (SD = 1.7). The police officer recruit sample included 163 recruits from four police departments in the St. Louis, Missouri, metropolitan area. There were 130 men (79.8%) and 33 women (20.2%), with a mean age of 25.8 years (SD = 4.8). There were significantly more men among the recruits, relative to the students, χ²(1) = 15.2, p < 0.001. Mean age was not significantly different between the groups, t(294) = −0.7, p = 0.45.

Materials and procedure

All participants completed the NEO PI-R (Costa and McRae 1992; Costa et al. 2000). Scores were generated for the five major personality domains of Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness. Higher Neuroticism indicates more negative affect (e.g. worry, anger, sadness, shame), impulsiveness, and vulnerability under stress; lower Neuroticism indicates less negative affect, less impulsivity, and more emotional control under stress. Higher Extraversion indicates more friendliness, group affiliation, social assertiveness, energy, excitement seeking, and positivity; lower Extraversion indicates more social introversion, reservation, formality, and emotional composure. Higher Openness indicates more imagination, aesthetic sensitivity, attention to inner emotions, preference for variety, intellectual curiosity, and independence of judgment; lower Openness indicates more conventionality, narrower task orientation, blunted affect, traditional values, and acceptance of authority. Higher Agreeableness indicates more trust of others, straightforwardness, altruism, cooperation, humility, and empathy; lower Agreeableness indicates more skepticism, social strategizing, detachment, cynicism, competition, and egocentrism. Higher Conscientiousness indicates more capability, organization, reliability, adherence to principles, need to achieve, self-discipline, and circumspection; lower Conscientiousness indicates more incompetence, disorganization, unreliability, goal apathy, distractibility, and carelessness. NEO PI-R domain scores are norm-referenced T scores (M = 50, SD = 10) and are categorized as representing ‘very low’ (T < 35), ‘low’ (T = 35–44), ‘average’ (T = 45–55), ‘high’ (T = 56–65), and ‘very high’ (T > 65) levels of a domain.

After giving written informed consent to participate in the research (approved by the Saint Louis University institutional review board), medical students voluntarily completed the NEO PI-R in a small-group setting during their Psychiatry clerkship (2005–2006). Students were informed that NEO PI-R results would not be available to faculty or used in any way as a source of evaluation, and that NEO PI-R data would not be analyzed until after the clerkship was completed and a grade assigned. All police officer recruits had successfully completed a pre-employment evaluation, been hired by the police department, and were completing police academy training. They voluntarily completed the NEO PI-R as an exercise during a police academy class (2005–2007). All recruits who were asked to complete the NEO PI-R during this time did so. Recruits were assured anonymity and informed that NEO PI-R results would not be available to superiors or department personnel and would not be used for evaluation.

Statistical analysis

Descriptive data were generated on NEO PI-R domain scores for medical students and police officer recruits. Multivariate and univariate analysis of variance (MANOVA/ANOVA) were used to compare domain scores between groups. MANOVA was used initially because in the event of several variables being compared (here, five domain scores), it affords protection against the Type I error inflation associated with multiple univariate tests (Tabachnick and Fidell 1996). Stepwise multiple discriminant function analysis was used to classify students and recruits into their respective groups as a function of domain scores. The alpha level for statistical significance was set at p < 0.05 for all analyses.

Results

Domain score means appear in Figure 1. Among students, Extraversion (M = 55.9, SD = 11.2) and Openness (M = 55.6, SD = 12.2) were at high levels, while Neuroticism (M = 51.3, SD = 12.2), Agreeableness (M = 48.6, SD = 12.8), and Conscientiousness (M = 51.3, SD = 12.3) were within the average range. For recruits, Neuroticism (M = 43.3, SD = 8.7) was within the low range; Extraversion (M = 54.8, SD = 8.9) and Conscientiousness (M = 56.0, SD = 9.8) were at high levels; and Openness (M = 46.6, SD = 9.4) and Agreeableness (M = 46.6, SD = 8.5) were within the average range. A MANOVA comparing the five domain scores between groups was significant, F (5, 290) = 21.0, p < 0.001. Follow-up ANOVAs indicated significant differences for Neuroticism, F (1, 294) = 42.6, p < 0.001; Openness, F (1, 294) = 51.4, p < 0.001; and Conscientiousness, F (1, 294) = 13.2, p < 0.001. ANOVAs were not significant for Agreeableness, F (1, 294) = 2.6, p = 0.11, or Extraversion, F (1, 294) = 0.9, p = 0.35. A second MANOVA that included gender as an independent variable and age as a covariate yielded no significant effects associated with either gender or age.

Figure 1. Mean (95% CI) NEO PI-R domain scores for medical students and police recruits. The shaded area represents the ‘Average’ score range relative to NEO PI-R norms; the upper unshaded area represents the ‘High’ range and the lower unshaded area the ‘Low’ range. *p < 0.001.

The five domain scores were considered for inclusion in a discriminant function analysis in a stepwise fashion. Consistent with the ANOVA results, a significant discriminant function was obtained with the domain scores of Neuroticism, Openness, and Conscientiousness, F (3, 292) = 34.0, p < 0.001, with a corresponding canonical correlation of 0.51. Agreeableness and Extraversion did not contribute to discrimination. Discriminant loadings (structure correlations) were 0.71 for Openness, 0.64 for Neuroticism, and −0.36 for Conscientiousness. The function accurately classified 69% of students and 83% of recruits, for an overall classification accuracy of 77%. In a cross-validation analysis, each case (i.e. student or recruit) was re-classified, but based on a discriminant function derived from all cases except the case being re-classified. This is known as ‘leave-one-out classification’. This analysis accurately classified 68% of students and 83% of recruits, for an overall classification accuracy of 76%.

Discussion

Contrary to prediction, medical students were no more or less agreeable than police officer recruits and scored in the average range relative to NEO PI-R norms. Moreover, student personality was notable not for Agreeableness, but for high levels of Extraversion and Openness, a pattern consistent with personal growth and ambition, leadership, assertiveness, creativity, and adaptability (Digman 1997; Pauls & Stemmler 2003). People high in Extraversion and Openness may also be described as ‘creative interactors’, a style that values new challenges, making discoveries, interacting with others one-on-one, and influencing others through teaching and direction (Costa et al. 2000; Barrick et al. 2001; Judge et al. 2002).

There are potential implications of these results for medical school clinical skills training. To reiterate, the medical students in this sample were not inordinately agreeable. Rather, their personalities were more attuned to problem solving, mastery, intellectual flexibility, and directing/influencing others. Clinical skills training in medical school – directed at AAMC or EBIM clinical communication and practice competencies – might therefore be enhanced by recognizing and accommodating to these personality distinctions. Simply expecting or cajoling students to be agreeable (e.g. to be ‘empathic’) as part of their professional code of conduct is inadequate (not to mention difficult to evaluate), and students and practicing physicians (Stein et al. 2005) tend to file away this aspect of medical training under the heading ‘touchy-feely’. Certainly, the literature continues to bemoan the insensitivity of the medical encounter (Kleinman 2008). Adjunctive methods of clinical skills training that play to the personality-based strengths of medical students are worthy of consideration, and might be described as ‘interpersonal procedures’. The literature includes a number of such approaches – although generally not applied at the medical student level – for acquiring clinical skills in model-based, practical ways, including agenda-setting, negotiation, conflict resolution, alliance making, empathy demonstration, and counseling (Stein and Kwan 1999; Markakis et al. 2000; Stein et al. 2005; Krupat et al. 2006; Rodriguez et al. 2008). Incorporation of such methods into medical student education, however, would require the training of faculty regarding both implementation and evaluation. Nevertheless, such approaches may garner additional legitimacy among medical students through their links to important practice outcomes – including patient adherence, satisfaction, loyalty, change maintenance, healthcare use, psychological well-being, and legal/regulatory actions (Levinson et al. 1997; Stewart et al. 2000; Williams et al. 2000; Federman et al. 2001; Tamblyn et al. 2007) – and their enhanced amenability to reliable/valid assessment for evaluation purposes (Krupat et al. 2006). By contrast, clinical skills ‘training’ currently falls primarily within the province of the clerkships, where students are expected to develop their clinical skills with actual patients under the supervision of an attending physician or senior resident. Unfortunately, the literature is consistent in describing both the quantity (i.e. the amount of direct observation of student clinical skills) and quality (e.g. role modeling) of bedside teaching (clinical teaching in the presence of a patient) of trainees by attending physicians as inadequate (Markakis et al. 2000; Holmboe 2004; Williams et al. 2008), a situation that in turn negatively impacts validity of clinical skills evaluations (Chibnall and Blaskiewicz 2008).

The primary limitation of this descriptive study is generalizability. Results are based on data from one class of medical students at one university, and on police officer recruits in the St. Louis metropolitan area. The extent to which these results apply to other samples must be examined in future studies.

Conclusions

The present results are suggestive that clinical skills training with regard to aspects of Agreeableness (trust, straightforwardness, altruism, cooperativeness, modesty, and empathy) may benefit from attention to the personality style of medical students, which appears strongly oriented toward problem solving, intellectual creativity, directing/controlling/influencing, and personal growth. Adjunctive, specific, directed, and evaluable approaches to clinical skills in the medical school curriculum may be needed, rather than relying on traditional ‘modeling’ approaches in the clerkships. In general, Agreeableness is not the strong suit of the medical student; the learning and application of clinical strategies and techniques that promote a clinical environment of Agreeableness may be.

Acknowledgment

The authors thank Robin Park, MD, for her assistance.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Additional information

Notes on contributors

John T. Chibnall

JOHN T. CHIBNALL, PhD, is a Research Psychologist and Professor of Neurology & Psychiatry at Saint Louis University School of Medicine in St. Louis, Missouri, USA. He is also Co-Director of Medical Student Education for the Division of Psychiatry.

Robert J. Blaskiewicz

ROBERT J. BLASKIEWICZ, MD, is an Obstetrician/Gynecologist and Professor in the Department of Obstetrics, Gynecology, and Women's Health at Saint Louis University School of Medicine in St. Louis, Missouri, USA. He is also Director of Medical Student Education for his department.

Paul Detrick

PAUL DETRICK, PhD, is a Clinical Psychologist, Personnel Selection Specialist, and owner of Florissant Psychological Services in Florissant, Missouri, USA. He is consultant to several law enforcement agencies in the St. Louis, Missouri, metropolitan area.