Introduction
Throughout history, people with different personalities and characteristics have embarked on careers in medicine. Given the diversity within the medical profession, it can be difficult to label specialties according to the behaviour and temperament of the individuals within it. However, it is postulated that certain specialties may attract individuals with particular traits.Reference Guthrie, Tattan, Williams, Black and Bacliocotti 1 – Reference Borges and Savickas 3
We have all heard the stereotypic remark ‘that is just like a surgeon’, and have felt a transient surge of pride tempered by the knowledge that negative connotations are sometimes implied by this statement.Reference Thomas 4 Evidence of a ‘surgical personality’ has been provided by studies that have confirmed traits such as aggressiveness, tough-mindedness and competitiveness.Reference Zeldow and Daugherty 5 These research findings corroborate the traditional or popular view of surgeons as highly strung and motivated individuals who can be prone to irascible behaviour.
A cross-sectional study performed on 342 surgeons throughout the UK in 2012 suggested that surgeons' character profiles significantly predicted burnout.Reference Upton, Mason, Doran, Solowiej, Shiralkar and Shiralkar 2 The authors raised concerns that UK surgeons show high levels of stress, cynicism and burnout, irrespective of their subspecialty, grade or hours worked per week. Not surprisingly, high levels of exhaustion have been linked to psychiatric morbidity and substance abuse.Reference Ramirez, Graham, Richards, Cull, Gregory and Leaning 6
To date, only a handful of studies have investigated the characteristics of doctors within particular specialties, and none have focused on ENT. Hence, we conducted a survey to identify whether ENT surgeons have a particular personality type. We aimed to determine whether ENT surgeons' personalities predisposed them to clinical, psychiatric or psychosocial morbidities. To this end, ENT specialty trainees were selected as a representation of the new generation of surgeons. This group were subsequently compared with foundation doctors.
Materials and methods
A validated personality questionnaire, taken from the Department for Work and Pensions, 7 was incorporated into a survey (Figure 1) that was distributed to all otolaryngology specialty trainees within the East of England Multi-Professional Deanery between October 2013 and November 2015. The survey contained two sections: personality characteristics and demographics. The personality characteristics section consisted of 13 questions with responses based on an 11-point Likert scale. This section was scored as per the scoring system shown in Figure 2, to determine the respective personality type. The demographics section comprised three questions: (1) ‘What grade are you?’; (2) ‘What is your gender?’; and (3) ‘What is your subspecialty of choice?’. Trainees were also asked why they had selected ENT as their specialty.
Two-page survey distributed to ENT specialty trainees, SHO = senior house officer; SAS = staff grade and associate specialist; ST = specialty trainee.
Scoring system for personality characteristics.
A similar questionnaire (Figure 3) was distributed to two cohorts of foundation doctors within a district general hospital in the East of England Multi-Professional Deanery between October 2013 and November 2015. Although the personality characteristics section remained the same, the demographics section was altered to comprise the following questions: (1) ‘What level are you at?’; (2) ‘What is your gender?’; and (3) ‘What are your career intentions?’.
Two-page survey distributed to foundation doctors, FY = foundation year.
All scores were calculated and the subjects were categorised as having personality types A or B based on the scoring system shown in Figure 2.
Ethical consideration
Ethical approval was not required as this was a cross-sectional study in which a survey was distributed to volunteering National Health Service staff.
Statistical analysis
Chi-square analyses were performed to compare the baseline characteristics and personality types of ENT specialty trainees and foundation doctors. A combination of chi-square analyses and Fisher's exact tests were utilised to compare the personality types associated with gender, grade and subspecialty interest, for both groups. Statistical significance was set at p < 0.05.
Results
We received 26 completed questionnaires from a total of 29 ENT specialty trainees throughout the deanery (90 per cent response rate) and 79 completed questionnaires from 104 foundation doctors (76 per cent response rate). The responding ENT specialty trainees included those with locum appointment for training (‘LAT’) and fellowship posts, and all had gone through a competitive selection process to attain their training jobs.
For ease of analysis, all personality types were grouped into type A or type B, incorporating the subdivisions of extreme type A and extreme type B.
ENT specialty trainees
There were 20 male and 6 female responders, of varying grades (Table I). Regarding subspecialties, 5 trainees were interested in head and neck, 6 in otology, 2 in rhinology, 1 in skull base surgery, and 1 each in facial plastics and paediatrics, while 10 were still undecided (Table I).
Baseline characteristics of responding ENT specialty trainees and foundation doctors
Statistical analysis was performed using the chi-square test; significance was set at p < 0.05. *Total n = 26; †total n = 79. ‡Categorical comparisons made between surgery and non-surgery specialties. FY = foundation year; LAT = locum appointment for training; ST = specialty trainee
Of the 26 specialty trainees, 18 had type A personalities while 8 exhibited type B personalities. There were no associations between personality type and grade, gender or subspecialty of interest (Table II).
Comparison between personality type and gender, grade and subspecialty interest of ENT specialty trainees and foundation doctors
*Total n = 26; †total n = 79. ‡Statistical analysis performed using Fisher's exact test; **statistical analysis performed using chi-square test. FY = foundation year; LAT = locum appointment for training; ST = specialty trainee
The main reasons quoted for selecting ENT as a specialty included the diversity of the specialty (both from a clinical and operative perspective), good work–life balance, and enjoyment of ENT placements during their time as a medical student or foundation doctor. Trainees also enjoyed the academic side of the specialty.
Foundation doctors
Of the 44 foundation year 1 and 35 foundation year 2 doctors who completed the survey, 47 were females and 32 were males (Table I). When asked about their career intentions, 17 were keen on general practice, 13 on general medicine, 8 on surgery, 6 each on obstetrics and gynaecology, paediatrics, and anaesthetics, 4 on psychiatry, 3 on radiology, and 1 each on microbiology, histopathology, emergency medicine, and a managerial career. Twelve foundation doctors who were all foundation year one doctors were still undecided about their career choice.
Thirty-two doctors exhibited type A personality traits, while the remaining 47 exhibited type B personality traits. There were no major associations between personality type and grade, gender or career intentions (Table II). However, interestingly, all 12 doctors who were still uncertain about their career choices had type B personalities.
Personality analysis
The proportion of type A personalities was significantly higher in the ENT specialty trainees compared to the foundation doctors (p = 0.01, chi-square = 6.4708; Table III).
Comparison of personality types between ENT specialty trainees and foundation doctors*
*p = 0.01, chi-square = 6.4708
Discussion
Our results indicate that ENT specialty trainees are more likely to be of type A personality in comparison to our control group of foundation doctors. This either suggests that individuals who pursue a career in ENT may have shared personality characteristics that draw them to the specialty, or that the selection process for the specialty tends to favour individuals with these characteristics. Our concerns were that these characteristics might predispose them to various health hazards.
A literature review published in 2002 revealed a possible loose association between certain personality factors of doctors and their medical specialties.Reference Borges and Savickas 3 The authors employed the five-factor model of personality, a commonly used model in psychology that divides the human personality into five broad domains (openness, conscientiousness, extraversion, agreeableness and neuroticism), and described surgeons as extroverts who could be open to experiences.Reference Borges and Savickas 3 , Reference Matthews, Deary and Whiteman 8 Further research suggested that certain personality profiles of doctors may predict their interest in person-oriented versus technical-oriented specialties.Reference Borges and Gibson 9
These links formed the basis of our study and our hypothesis regarding the personality characteristics of ENT surgeons. The nature of such a surgical career, which requires the delivery of an immediate or dramatic outcome, while maintaining a quick turnover at high standards, would certainly appeal to an individual with type A characteristics as outlined in Table IV. We chose ENT specialty trainees as our study group to reflect the current generation of ENT surgeons who have all gone through a rigorous, competitive and unbiased selection process prior to enrolment into the specialty. Foundation doctors were the ideal control group because of their diverse spread of specialty interests.
Characteristics of type A and type B personality profiles 7
All ENT specialty trainees and foundation doctors were categorised as having either a type A or type B personality (Table IV). Cardiologists Meyer Friedman and Ray Rosenman originally developed these personality types during their studies of individuals with coronary heart disease in America in the mid-1950s. 7 Their research findings, which would later be corroborated by further evidence, demonstrated that individuals with type A personalities were at higher risk of suffering from such diseases. 7
The factor linking type A personality and heart disease is postulated to be stress. Individuals with type A personality characteristics often find themselves in high-pressure and high-demand settings that may not always produce the outcome they seek. This can result in impatience, agitation and possibly aggression. Their continual rush for time triggers the chronic and abnormal discharge of adrenaline and cortisol. This in turn is theorised to increase bloodstream levels of cholesterol and fat, leading to blockages of the coronary arteries. However, there are uncertainties concerning the possible causal associations of type A behaviour to coronary heart disease given the complexities of measuring the adverse behaviours and the physiological disease together. 7
The highly strung nature of an individual with type A personality suggests a constant challenge may be required at work to promote and maintain job satisfaction. A lack of this, alongside rising stress levels, has been cited as a major cause of burnout.Reference LaPorta 10 Untreated, excessive stress and burnout can spiral towards psychiatric illnesses and substance abuse.Reference Guthrie, Tattan, Williams, Black and Bacliocotti 1 , Reference Upton, Mason, Doran, Solowiej, Shiralkar and Shiralkar 2 , Reference Ramirez, Graham, Richards, Cull, Gregory and Leaning 6 , Reference Taylor, Graham, Potts, Richards and Ramirez 11 Given the risks of physical and psychosomatic disorders amongst individuals with type A personalities, a few specific exercises have been developed for them to help manage their behaviour (Table V). 7 This list is not exhaustive, and, certainly, other behavioural management techniques or a psychologist's input may be of paramount importance.
Suggested exercises to help reduce stress in individuals with type a personality 7
Like all highly driven professionals, ENT surgeons have a set of traits that may make them more vulnerable to stress and ultimately burnout syndrome.Reference LaPorta 10 From studies conducted amongst maxillofacial surgeons, we found that specialties like ENT surgery may attract individuals who are highly compulsive, with unrealistic expectations and high standards of performance. All these traits are considered to be a part of type A personality. These individuals are often impatient and aggressive, and the more of these traits they display, the less they are able to cope with occupational stress.Reference LaPorta 10 , Reference Freeman, Main and Burke 12 Traits such as compassion and dedication, often thought to be highly desirable, tend to increase their susceptibility to stress.Reference Pride 13
To date, no studies have examined levels of stress, burnout or psychiatric morbidity amongst ENT surgeons in the UK. Our results merely represent a stepping-stone within the field, and further targeted research is required before a concrete link to the high incidence of type A personalities, as seen within the ENT specialty trainees in our study, can be established.
Type B individuals are, in contrast, often characterised as ‘uncompetitive’ and ‘without a worry in the world’ (Table IV). It is thus unsurprising that the 12 foundation doctors still uncertain of their career choices had type B personalities.
Limitations
We are aware of the existence of various personality questionnaires within the literature. Commonly used validated scoring systems include the five-factor model of personality mentioned above, the Minnesota Multiphasic Personality Inventory, the Jenkins Activity Survey and the Temperament and Character Inventory. Selection of a particular questionnaire may vary according to indication. For example, the Myers–Briggs Type Indicator, which contains 93 questions, was originally designed to measure psychological preferences in how people perceive the world and make decisions.Reference Briggs and Myers 14 Based on guidance from the senior authors, who are from departments of occupational health, psychiatry and clinical psychology, and who have a wealth of experience in the subject, we felt that the length and limited relevance of such questionnaires may not be appropriate for our study.
The considerations factored into the selection of our questionnaire, shown in Figure 1 and Figure 3, included the length and ease of completion, in order to increase responder compliance. Although there is controversy and bias surrounding the funding of the tobacco industry in the original study that linked type A personalities to coronary heart disease,Reference Petticrew, Lee and McKee 15 which might be considered to affect the relevance and validity of the questionnaire itself, we were reassured by its use by the Department of Work and Pensions in 2000 to guide effective stress management. 7 We also accept that our chosen questionnaire merely serves as a guide, as the complexities of human personality cannot simply be divided into two broad categories.
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• Careers in medicine are embarked on by people with various personalities
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• The proportion of type A personalities was significantly higher in ENT specialty trainees compared to foundation doctors
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• These characteristics may help explain their decision to embark on a surgical career or may reflect the specialty's selection process
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• There are links between type A personality and coronary heart disease, stress, burnout and psychosocial morbidities
Another limitation of our study is the actual number of ENT specialty trainees sampled, despite a 90 per cent response rate from the region. This is most likely a reflection of the size of ENT as a specialty and the small numbers of specialty trainees recruited annually. Nonetheless, we were satisfied with the significant difference seen between the groups, which we postulate would be strengthened by a larger study with increased statistical power.
