Surgeons’ personalities and surgical outcomes
Publication: The Bulletin of the Royal College of Surgeons of England
Volume 100, Number 6
Abstract
Previous studies have found links between personality and exam scores, job satisfaction and burnout. Now, for the first time, we are able to investigate the relationship between surgeon personality and outcomes.
The relationship between personality and surgical outcomes has never been investigated. If there is an optimal surgeon’s personality, it is likely to have evolved with the dramatic changes in surgery since its establishment as a scientific discipline in the 18th century. Early studies provide no consensus on the existence of a distinct ‘surgical personality’ or what traits may define it,1 but this may reflect the heterogeneity of the methods used. More recent studies suggest that surgeons form a distinct and homogenous group but there are varying reports about which traits differ.2–4
The five factor model (FFM) enables personality to be studied more objectively using self-report questionnaires such as the Big Five Inventory and NEO inventories. It has been used widely in personality research. The five traits measured (conscientiousness, agreeableness, neuroticism, openness and extraversion) have been shown to predict a number of important life outcomes in the general population, such as health5 and job performance across a wide range of fields.6
Studies investigating correlation between personality traits and clinical performance have looked at examination scores,7–10 assessment by senior clinicians8,10,11 and simulation,4 as well as correlation with non-technical aspects of performance, including stress tolerance and burnout,12–15 job satisfaction16 and risk tolerance.17 High conscientiousness, high neuroticism and low extraversion correlate with stress, burnout and reduced job satisfaction. The relation of FFM personality traits to risk tolerance and technical performance, however, is unclear. Studies have shown that, together with patient risk factors, the surgeon has a significant impact on outcomes while different anaesthetists do not.18,19
To our knowledge, this study is the first to investigate the relationship between personality and actual surgical outcomes, which are determined by both technical and non-technical performance. Following the widespread implementation of the EuroSCORE (European System for Cardiac Operative Risk Evaluation), risk-adjusted outcomes for cardiac surgeons in the UK are now in the public domain, which enables the study of the relationship between clinical performance and personality. The present study also measured the personality of cardiac surgeons and compared the findings with the general population.
Methods
Emails were sent to all 261 UK consultant cardiac surgeons asking them to complete a 50-item self-reported International Personality Item Pool (IPIP) FFM questionnaire (based on the NEO inventories) between June 2016 and August 2016. The FFM is recognised as ‘the most parsimonious and comprehensive model of normal adult personality’,20 and the NEO inventories are one of the best validated FFM measures.21 The Myers–Briggs Type Indicator also measures personality and overlap with the FFM has been described,22 but its use in personality research is less validated.
Studies have shown that, together with patient risk factors, the surgeon has a significant impact on outcomes while different anaesthetists do not
This study used the smallest well validated version of the IPIP23 to optimise the response rate. There were ten questions for each of the five personality domains, resulting in scores from 1 to 5 in conscientiousness, agreeableness, neuroticism, openness and extraversion. Where a question was not answered by a respondent, the remaining nine questions were scaled up appropriately to impute a score for that domain.
Data on surgical outcomes made were sourced from the website of the Society for Cardiothoracic Surgery (SCTS)24 for operations undertaken between April 2012 and March 2015. The risk-adjusted mortality ratios (RAMRs) of the surgeons participating in the study were calculated by dividing the actual mortality rate by the expected mortality rate based on operation risk (determined by the SCTS modified EuroSCORE).
Comparison with the general population
Surgeons’ personality traits were compared with those of a large working age (21–60 years) sample of 71,867 members of the general population.25 Equal variance was assumed, and an unpaired t-test was used to produce two-tailed p-values based on the mean and standard deviation of both samples.
Comparison of surgical outcomes
Participants were ranked by score for each of the five personality domains and divided into even-sized tertiles for each, depending on whether they were in the top, middle or bottom third for that particular trait. Oneway analysis of variance (ANOVA) was used to compare the mean RAMR scores for the tertiles of each personality trait and post hoc analysis was performed with Tukey’s range test in cases of statistical significance.
Results
The questionnaire was returned by 96 of the 261 surgeons to whom the survey was sent (response rate 36.8%). Eighty-five participants gave sufficient information for identification (the full sample). Surgical outcomes and RAMRs were available for 53 of these identifiable respondents (the outcomes sample). Reasons for outcomes information not being available included insufficient numbers of operations performed by a particular surgeon during the relevant period (a RAMR is only reliable if at least 100 operations have been performed), surgeons undertaking operations for which a RAMR is not applicable such as paediatric and thoracic procedures (as the EuroSCORE is specific to adult cardiac surgery), and missing results from particular institutions.
Nine respondents did not complete the personality questionnaire fully; these surgeons left between 1 and 3 of the 50 questions unanswered. In these cases, the full score was imputed from the answers to the other completed questions.
The demographic characteristics of the participants are shown in Table 1. There were no significant differences between the full sample and the outcomes sample; in both, the ages followed a normal distribution, the median age was within 45–54 years and there was a strong male preponderance.
| Age | sex | ||||||
|---|---|---|---|---|---|---|---|
| 25–34 years | 35–44 years | 45–54 years | 55–64 years | 65–74 years | Male | Female | |
| Full sample (n=85) | 1 | 15 | 46 | 21 | 2 | 79 | 6 |
| Outcomes sample (n=53) | 1 | 4 | 31 | 15 | 2 | 51 | 2 |
Personality scores compared with the general population
The mean scores and standard deviations for all five personality domains of the full sample, outcomes sample and general population are shown in Table 2. Surgeons had higher conscientiousness (p<0.001), higher agreeableness (p=0.016) and lower neuroticism (p<0.001) than the general population, and similar openness and extraversion.
| Conscientiousness | Agreeableness | Neuroticism | Openness | Extraversion | |
|---|---|---|---|---|---|
| Surgeons (n=85) | 4.10 (SD: 0.47) | 3.91 (SD: 0.60) | 2.51 (SD: 0.69) | 3.86 (SD: 0.49) | 3.17 (SD: 0.76) |
| General population (n=71,867) | 3.63 (SD: 0.71) | 3.73 (SD: 0.69) | 3.22 (SD: 0.84) | 3.92 (SD: 0.67) | 3.27 (SD: 0.90) |
Personality scores and outcomes
The overall mean RAMR of the outcomes sample was 1.03 (standard deviation: 0.37, range: 0.46–2.04). The mean RAMRs for the three tertiles of each personality trait are depicted in Figure 1. A one-way ANOVA indicated that the lowest extraversion tertile tended to be associated with better outcomes (F(2,50)=2.50, p=0.093), with a Tukey’s honest significant difference (HSD) of 0.090 between the lowest and middle tertiles. Conversely, the highest openness tertile was significantly associated with worse outcomes (F(2,50)=3.46, p=0.039), with a Tukey’s HSD of 0.046 between the highest and middle tertiles. There was no significant correlation between conscientiousness, agreeableness or neuroticism and the RAMR.
Discussion
Personality of surgeons and the general population
Findings from previous studies most consistently suggest that surgeons have lower neuroticism as well as higher conscientiousness, openness and, especially, extraversion scores than the general population.2–4,26–30 The increased conscientiousness and agreeableness and decreased neuroticism in our cohort may reflect a distinctive pattern of personality traits in cardiac surgeons.
Our data showed no significant difference in extraversion or openness between surgeons and the general population. A number of authors have reported higher extraversion in surgeons than in non-surgeon physicians26,27,29,30 and in the general population.2,28 In one study, qualified American surgeons were predominantly extraverted while surgical trainees were predominantly introverted.3 It was suggested that this reflects recent changes in the selection and training of surgeons, with the replacement of the apprenticeship model of residency. Contemporary surgeons have been described as tending to ‘avoid introspection, deny emotional needs and shun emotional support’.31 One study noted higher openness in surgeons than in the general population,2 but a review of multiple studies concluded that this was the case only for fully graduated surgeons and not for those in training.26 This indicates that higher openness may be ‘acquired’ by training and experience.
Several authors have found surgeons to have raised conscientiousness, both compared with the general population2,4 (as in our study) and compared with non-surgeon physicians,30 while one paper reported no statistically significant difference.29 There have also been conflicting results for agreeableness, with one study demonstrating a lower score for surgeons than for non-surgeons,30 others not finding a difference,2,29 and our data showing that agreeableness in surgeons was increased compared with the general population.
Neuroticism appeared to be lower in surgeons than in the general population in two studies,2,4 although one observed this result only in men.2 Our sample had a male predominance and exhibited lower neuroticism, which lends support to these findings. Other studies have reported lower neuroticism in surgical trainees than in medical students,32 and lower neuroticism in surgeons than in non-surgical physicians.27
Personality of surgeons and surgical outcomes
Our study is the first to look at correlations between personality traits and surgical outcomes, which can be affected by both technical and non-technical performance. A growing body of evidence supports the idea that personality profile can influence non-technical performance such as stress tolerance and burnout, risk tolerance and job satisfaction.12,13,15–17 Non-technical performance has been shown to play a role in surgical outcomes33,34 and has also been seen to correlate with technical skills in surgery.35–37
In our study, surgeons with low extraversion (ie introverted surgeons) tended to have better outcomes
High conscientiousness and neuroticism and low extraversion have been found to correlate with burnout and stress12,13,15 as well as reduced job satisfaction,16 and personality has also been linked to risk tolerance.17
The predominant surgical personality traits, as reported in the literature, may therefore have a mixed effect on non-technical aspects of performance. The lower neuroticism and higher extraversion reported suggests a reduced susceptibility to stress/burnout and increased job satisfaction, while higher conscientiousness suggests the opposite. The net and relative contributions of these factors are unclear.
To our knowledge, only one study has looked at the effects of personality traits on technical performance (using a virtual reality laparoscopy simulator).4 The authors found no correlation between technical performance and personality.
Extraversion
In our study, surgeons with low extraversion (ie introverted surgeons) tended to have better outcomes. This is particularly interesting given the consistent reports of higher extraversion in surgeons compared with the general population. Consequently, the trend that surgeons recently chosen for training are more introverted than in the past3 could reflect a selection process for trainees that will produce better outcomes. The mechanisms by which extraversion may affect surgical outcomes are unclear.
Openness
Our data suggest that surgeons with higher openness have worse outcomes. This was the strongest association observed in our study. Interestingly, openness has not been found to correlate with any non-technical factors of performance so its impact may be through technical performance or unexplored non-technical factors.
Conscientiousness, agreeableness and neuroticism
Study limitations
This study looked only at cardiac surgeons and may not apply to other specialities. There were few women in the study, reflecting the current surgical demographics, and this may affect our interpretation of the difference between surgeons and the general population. Our response rate was low, increasing risk of selection bias. While this would affect the personality scores of the participants in our sample (and therefore comparisons with the general population), it would not affect the investigation of correlation with RAMRs. ‘Faking’ answers to personality profile questions is an inherent limitation in all studies relying on our methodology, although there is no reason to assume that there is any benefit to be gained from such behaviour in our study. Despite being the most reliable and consistently used psychometric measure, the FFM has limitations such as minor fluctuations for the same individual over time38 and potential distortion by self-deceptive biases.39
Conclusions
Surgeons differ from other people in terms of personality. These differences have an impact on performance and patient outcomes. Our findings have potential implications in the selection and training of future surgeons.
Acknowledgements
The authors would like to thank all participants for their time and support as well as the SCTS for help in the dissemination of the questionnaire.
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Published In
The Bulletin of the Royal College of Surgeons of England
Volume 100 • Number 6 • September 2018
Pages: 259 - 263
Copyright
Copyright © 2018 Royal College of Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Published in print: September 2018
Published online: 3 September 2018
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