This is the third in a series of posts about my concern with the students that we are bringing into medical school. I am constantly reminded that not everyone believes that there is a problem. Some think that we are getting the right students into medical school. My question. The burning question for this series of posts is: if we are getting the right students in, why is the end product not meeting the needs of America? Or the needs of our individual states? There was a recent op-ed in the New England Journal of Medicine by Stephen R. Smith, MD, MPH from the Warren Alpert Medical School at Brown University.(1) Dr Smith said "medical schools must recognize the current factors that discourage medical students from pursuing primary care careers and then devise ways to overcome these barriers."
My first post in this series, Why do we put so much import on the MCAT? was about the MCAT and why (in my opinion) we need to de-emphasize the MCAT as a criterion for entry into medical school. I am not the only one saying this. Dr. Smith said, "The first test of this commitment will come in the way in which admissions are handled. The little evidence that is available on factors predicting career choice indicates that students who express a desire to serve underserved populations, who demonstrate altruism, and who are committed to social responsibility are more likely to go into primary care." Dr. Smith went on to say that "admissions criteria need to be broadened beyond scores on the Medical College Admission Test (MCAT) to include these personal attributes. The school should adopt an “MCAT-blind” admissions policy, dictating that students whose MCAT scores are at or above a predefined minimum that predicts a likelihood of success in medical school should then be considered further for admission without the reporting of their MCAT scores to the admissions committee."
In my last post, Characteristics of Future Physicians, I blogged about characteristics that I believe that we should want in graduates of our medical schools. There are several factors that medical school faculty have rated as extremely important but very hard to teach. My argument is that we should select students who already have those traits prior to matriculation. Some of the traits listed are obvious: (1) is emotionally stable; (2) is a person of unquestionable integrity; (5) is unusually intelligent; and (6) has sustained genuine concern for patients during their illness. Some are less obvious but seem really important: (9) is motivated primarily by idealism, compassion, and service; (14) is able and willing to learn from others; (17) is observant; and (18) is adaptable.
So the question for today is: are there personalities that do better in a medical curriculum and those that do worse? If you read the article by Dr Sade (2) I am sure that it is no surprise that there are some personalities that do better in medical school and some that seem to struggle more. Medical school is an extremely stressful environment. Many of the students that come to medical school, have never struggled academically in their lives. I have heard folks say, medical school is a pressure cooker.
The pressure cooker brings out all of the problems. It stresses them. It pushes them in ways that many of these students have never been pushed. 28 percent of physicians report that they have stress that affects their ability to provide clinical care.(3) A recent systematic review found that medical students perceive similar levels of stress to physicians.(4)
I see students struggle because they have never been in this kind of situation. Students are young, they are often coming straight from undergraduate school. Students that come to medical school have often not had any real life experiences. They have not had a job, or had extensive life experiences. Then we put them into an academically stressful environment that is extremely competitive and at some schools even cutthroat. The good news is that some personalities may be better at handling the stress of medical school, and then potentially life as a physician. McManus (5) studied stress in UK students over a period of 12 years. The authors found that stress could exacerbated or even caused by personality factors, specifically by high levels of neuroticism, low levels of extraversion and low levels of conscientiousness. These traits are dimensions that are part of the Five Factor model of personality. This model is well accepted and validated. The model is used by many of the studies of personality contributing to success in academic settings.
Another study from the UK (6) looked at Goldberg's "Big Five dimensions of personality" to study 176 medical students at the Nottingham Medical School. The authors compared the students' personality scores and academic assessments in Years 1 through 5. The conscientiousness dimension was a significant predictor of academic performance in the pre-clinical years but interestingly in the clinical years (Years 4 and 5) it correlated with poorer performance.
So, there are personalities that may be more suited for medical school. And even more importantly, these personality traits can affect success as physicians. The Aussies looked at this a few years ago. In this study, Knight, et al (8) studied whether personality characteristics, measured by the Hogan Developmental Survey (HDS), were associated with academic performance in 139 medical students. They found that borderline/schizoid and narcissistic/antisocial characteristics were negatively correlated with academic success. That one seems pretty obvious. One of the subsections of the HDS, the ‘Diligent syndrome’, were found to be positively correlated to higher exam scores. The Diligent syndrome is students who have a tendency to be attentive and good with details, orderly, rational, careful and well organized.
What about here in the US? The folks at Jefferson Medical College are the only ones who have studied this. Hojat, et al(8) studied six personality measures. They also asked about the students' relationships with their parents and their general health. They compared these assessments with global faculty ratings of competence in the clinical clerkships (family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery). The ratings used a 4-point scale (‘high honours’, ‘excellent’, ‘good’, ‘marginal competence’). The students in the lowest group had significantly lower levels of self-esteem and sociability, they were lonelier, and had less satisfactory relationships with their parents.
So, what should we do? Conscientiousness seems to be an important predictor of success in the preclinical years, but it may also lead to vulnerability to stress. And it is related to worse performance in the clinical years. Extraversion, self-esteem, and sociability seem to be more important in the clinical years. Maybe we should do like the Australians did and have every applicant fill out a personality profile. I am not sure how this was used, but it does not seem that it was used to choose students. Next time, I will write about some of the ways to screen incoming students.
(1) Smith S. A Recipe for Medical Schools to Produce Primary Care Physicians. New Eng J Med 2010; 364(6).
(2) Sade M, et al. Criteria for selection of future physicians. Ann Surg. 1985 February; 201(2): 225–230.
(3) Firth-Cozens J. Doctors, their well-being, and their stress. BMJ 2003;326:670–1.
(4) Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med 2006;81 (4):354–73.
(5) McManus IC, et al. Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: a 12-year longitudinal study of UK medical graduates. BMC Med 2004;2:29.
(6) Ferguson E, et al. Pilot study of the roles of personality, references, and personal statements in relation to performance over the five years of a medical degree. BMJ 2003;326 (7386):429–32.
(7) Knights JA, Kennedy BJ. Medical school selection: impact of dysfunctional tendencies on academic performance. Med Educ 2007;41 (4):362–8.
(8) Hojat M, Callahan CA, Gonnella JS. Students’ personality and ratings of clinical competence in medical school clerkships: a longitudinal study. Psychol Health Med 2004;9 (2):247–52.