Does Personality Matter? Perceptions of Introverts As General Surgeons

DOES PERSONALITY MATTER? PERCEPTIONS OF INTROVERTS AS GENERAL SURGEONS

Victoria M. Luong

Thesis submitted in partial fulfillment of the requirements for the Degree of Master of Education (Curriculum Studies for Health Interprofessionals)

Acadia University Spring Graduation 2019

This thesis by VICTORIA LUONG was defended successfully in an oral examination on

March 4, 2019.

The examining committee for the thesis was:

______Dr. Robert Seale, Chair

______Dr. J. Sargeant, External Examiner

______Dr. C. Shields, Internal Examiner

______Dr. A. Petrie, Supervisor

______Dr. Michael Corbett, Acting Director

This thesis is accepted in its present form by the Division of Research and Graduate Studies as satisfying the thesis requirements for the Degree of Master of Education in Curriculum Studies for Health Interprofessionals.

………………………………………………

I, VICTORIA LUONG, grant permission to the University Librarian at Acadia

University to archive, preserve, reproduce, loan or distribute copies of my thesis in microform, paper, or electronic formats on a non-profit basis. I undertake to submit my thesis, through my University, to Library and Archives Canada and to allow them to archive, preserve, reproduce, convert into any format, and to make available in print or online to the public for non-profit purposes. I, however, retain the copyright in my thesis.

______

Victoria Luong, Author

______

Allison Petrie, Supervisor

______

Date

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Table of Contents

List of Tables ...... vii

List of Figures ...... viii

Abstract ...... ix

List of Abbreviations ...... x

CHAPTER 1: INTRODUCTION ...... 1

1.1 Statement of the Problem ...... 3

1.2 Purpose and Research Questions ...... 3

1.3 Intellectual Goals ...... 4 Beyond the “variable” approach ...... 4 Situating “extravert culture” ...... 5 Introvert advocacy ...... 6

1.4 Practical Goals ...... 7 Specialty selection ...... 8 Adaptation ...... 8

1.5 Origins of the Study/My Role as a Researcher ...... 9

1.6 Theoretical Frameworks ...... 11 Personality ...... 12 The Big Five ...... 13 Introversion ...... 15 Distinctions ...... 17 Social skills ...... 17

Chapter Summary ...... 18

CHAPTER 2: LITERATURE REVIEW ...... 19

2.1 Personality and Medical Specialty Choice ...... 20 Selection bias ...... 21 Prototype matching ...... 22

2.2 Key Differences Between Introverts and Extraverts ...... 23 Knowledge ...... 24 Decision-making ...... 25 Leadership ...... 26 Working with patients ...... 27

Burnout ...... 29

2.3 Surgical Culture ...... 31 Expectations ...... 32 Surgical personality ...... 33 Identity dissonance ...... 34

2.4 Adapting to the Workplace ...... 34 The person-situation debate ...... 35 Personality development ...... 36 Protective factors ...... 36

Chapter Summary ...... 38

CHAPTER 3: METHOD ...... 39

3.1 Methodology ...... 39 Research paradigm ...... 39 Qualitative approach ...... 41 Grounded theory ...... 42 Design rationale ...... 44

3.2 Method ...... 46 Theoretical sampling ...... 46 Saturation ...... 48 Questionnaire ...... 50 Interviews ...... 51 Data analysis ...... 53

3.3 Rigour...... 56

3.4 Ethical Considerations ...... 59

Chapter Summary ...... 60

CHAPTER 4: RESULTS ...... 62

4.1 Participant Characteristics ...... 62

4.2 Group Distribution ...... 65

4.3 Context ...... 67 4.3.1 The nature of the job ...... 67 4.3.2 Essential qualities of a surgeon ...... 71 4.3.3 The surgical personality ...... 76

4.4 Perceptions of Introverts and Extraverts ...... 80

4.4.1 Definitions of introversion and extraversion ...... 80 4.4.2 Strengths of introverts ...... 81 4.4.3 Challenges for introverts ...... 82 Summary ...... 94

4.5 Outcome ...... 94 4.5.1 Effect on career choice ...... 95 4.5.2 Introverts adapt by acting more extraverted ...... 97 4.5.3 Consequences of acting extraverted ...... 100 4.5.4 Both personalities have to learn to adapt ...... 101

Chapter Summary ...... 101

CHAPTER 5: DISCUSSION ...... 103

5.1 Theoretical Implications ...... 104 5.1.1 Surgical context/expectations ...... 104 5.1.2 Perceptions of introverts and extraverts ...... 107 5.1.3 Consequences ...... 112

5.2 Practical Implications ...... 120

5.3 Limitations ...... 124

5.4 Recommendations for Future Research ...... 129

Conclusion ...... 136

REFERENCES ...... 137

Appendix A: Email Invitation to Participate in the Study ...... 156

Appendix B: Consent Form for Participation in a Research Study ...... 157

Appendix C: Preliminary Semi-Structured Interview Questions ...... 159

Appendix D: Questionnaire Results for All Participants ...... 163

Appendix E: Representative Quotes for Each Theme ...... 164

List of Tables

Table 1: Characteristics of participants from groups A and B p. 64

Table 2: Questionnaire Results for Groups A and B p. 64

vii

List of Figures

Figure i. Participant recruitment procedure. p. 48

Figure ii. Model for assessment of sample size: information power, items, and p. 49 dimensions.

Figure iii. Distribution of participants according to groups A and B. p. 63

Figure iv. Comparison of surgeon characteristics considered essential by groups A and B. p. 72

Figure v. Proportion of participants who believed there are more extraverts, more p. 78 introverts, or equal numbers in surgical careers.

Figure vi. Summary of results. p. 102

Figure vii. Explanatory model for the divergence in perspectives of the importance of p. 112 personality type (introvert or extravert) in surgical practice.

viii

Abstract

Few describe how medical trainees with different personalities succeed within the same specialties. Considering that surgeons are stereotypically dominant, aggressive, and extraverted, this study sought to explore how introverts experience, and are perceived in, surgical training and practice. Using constructivist grounded theory, we invited 16 general surgeons and residents to complete personality questionnaires and individual semi-structured interviews. An iterative coding process led to two patterns of responses.

One group saw few differences in how introverts and extraverts experience surgical training. However, another thought that introverts appeared less assertive, confident, and decisive than extraverts; unless these trainees forced themselves to act more extraverted, participants thought this would interfere with patient care. The existence of two contrasting perceptions of surgical culture refines our understanding of how trainees are socialized in medicine. Students could benefit from reflecting on the challenges that come from pursuing specialties in which they don’t initially seem to “fit.”

Keywords: introversion-extraversion, person-environment fit, surgical culture, socialization, grounded theory

List of Abbreviations i. PBL Problem-Based Learning ii. FFM Five Factor Model of Personality iii. TIPI Ten-Item Personality Inventory iv. BRS Brief Resilience Scale v. NEO-PI-R Revised Neuroticism-Extraversion-Openness Personality Inventory

Acknowledgements

I wish to thank my supervisors, Dr. Chris Shields and Dr. Allison Petrie, for their tireless effort during these past two years. I am truly grateful for your invaluable guidance, your expert feedback, and your openness to my ideas. I deeply felt that you were on my side every step of the way.

My sincerest thanks to Dr. Katerina Neumann for her help with participant recruitment and data review. I am also grateful to my defense committee–Dr. Robert

Seale, Dr. Joan Sargeant, and Dr. Michael Corbett–for taking the time to read my thesis and sharing their insightful questions and comments. Your scholarly expertise added a great deal to the robustness of this work.

A special thanks to the professors I had during this master’s program. To Dr.

Brenda Trofanenko, who was the first person to read my proposal: the care you have for your students is palpable, and I credit you for giving me the confidence to pursue this topic. Thank you to Dr. Anna MacLeod, who reviewed the first half of this paper. You have taught me so much, and I can only hope to be as brilliant as you are someday.

This work would not have been possible without the research participants who shared their personal thoughts and stories with me. I am grateful for both your honesty and your passion for surgery.

Finally, I am eternally thankful to my parents and friends for their love and support. To my wonderful fiancé, Mathieu Collette: thank you for listening to my endless thoughts about introverts, surgeons, and medical education–and for genuinely being as interested in them as I am. This work belongs to you as well.

Chapter 1: Introduction

When medical students choose to pursue a career in a surgery, they are not simply choosing a field upon which to develop knowledge and expertise. Rather, they are choosing to become participants in a distinct culture of practice; a culture that will influence how they think, feel, and behave on a day to day basis. As residents, trainees rapidly pick up on the behaviours, beliefs, and attitudes of their superiors, as well as the implicit social and cultural rules that govern the work environment (Gofton & Regehr,

2006). They learn what a successful surgeon looks like and are pressured to act in ways that signal their conformity with those values (Patel et al., 2018). In turn, those who feel unable to conform can be deterred from the specialty altogether (Coulston, Vollmer-

Conna, & Malhi, 2012; Hill, Bowman, Stalmeijer, Solomon, & Dornan, 2014).

Surgeons are thought to have one of the most distinctive personalities in medicine

(Borges & Osmon, 2001), having been described historically as bold, aggressive, and domineering (Coombs, Fawzy, & Daniels, 1993). In addition, key values within the field include quickness, decisiveness, and confidence (Jin, Martimianakis, Kitto, & Moulton,

2012). It is thus conceivable that one of the most consistent findings in the literature on personality and medical specialty choice is that surgeons tend to be extraverted rather than introverted (Borges & Sackivas, 2002; Coombs, Fawzy, & Daniels, 1993;

McGreevy & Wiebe, 2002; Warschkow et al., 2010). Extraverts are gregarious and dominant compared to introverts, who are quiet and reserved (McCrae & John, 1992).

Introverts tend to make more careful, considered decisions rather than more rapid intuitive ones (Sagiv, Amit, Ein-Gar, & Arieli, 2013), and are both less assertive (McCrae

& John, 1992) and socially inclined (Berry & Hansen, 2000) than are extraverts. What is

more, introverts sense that their quietness is often perceived as a lack of confidence

(Lawrence, 2015; Leung, 2015; Remus, 2005); Davidson, Gillies, and Pelletier (2015) found that introverted medical students frequently feel misunderstood and judged as underperformers, needing to act more extraverted in order to succeed in medicine. As one participant from another study put it: “If a person is timid, he probably won’t make it as a surgeon” (Coombs et al., 1993, p. 341).

While previous research on personality and medical specialty choice has focused on describing personality types for the various specialties using quantitative survey methods (Borges & Sackivas, 2002), to my knowledge, none have attempted to describe how those with different personalities succeed within the same specialties. Little research within medical education shows how individuals with certain personality-related preferences for thinking and behaving adapt to workplace cultures that may encourage opposing ones. Therefore, medical students who feel that their personality type does not

“fit” the typical characteristics of a particular specialist may lack meaningful resources for their self-reflections. It remains unclear if and how introverts–whose typical behaviours are often inconsistent with some of the values of surgical culture–can imagine themselves as surgeons and navigate this novel environment. If we are to ensure that the best candidates are applying into our surgical programs, we need to ensure that personality type is not an impeding factor in the career making process.

I will begin this proposal by outlining the research problem; the specific purpose along with the study’s research questions will follow. The next two sections name some of the practical and intellectual implications of this research. The last sections will cover some of the basic definitions and paradigms that form the study’s theoretical framework.

1.1 Statement of the Problem

In order to succeed in surgery, trainees need to navigate the culture of surgery and find their place within it. While we know from previous research that many of the defining characteristics of introverts (e.g., quietness, passivity, and careful reflection;

McCrae & John, 1992; Remus, 2005) are quite different from the characteristics most valued in surgery (e.g., confidence, decisiveness, and quickness; Jin et al., 2012), it remains unclear whether those in the surgical community perceive introverts to be fit for surgical practice. Furthermore, given that surgical residents feel pressure to conform to the values of the surgical community (Hill, Bowman, Stalmeijer, & Hart, 2014; Hill,

Bowman, Stalmeijer, Solomon, & Dornan, 2014; Patel et al., 2018), there is a need to understand how introverts fare in surgery and how they adapt to the surgical workplace.

1.2 Purpose and Research Questions

This thesis aims to explore how general surgeons and surgical residents perceive introverts as surgeons. I will describe their beliefs about what aspects of introverts’ personalities help or hinder surgical practice, and explore differences in how introverts and extraverts experience surgical training. The following questions frame this study:

1. What personality traits do general surgeons and surgical residents value, and how

well do they believe these traits align with the introverted personality (i.e., what

are the strengths and challenges of introverts in surgical training and practice)?

2. Do general surgeons and surgical residents perceive a need for introverts to adapt

their typical behaviours in order to fit the surgical workplace? If so, how?

1.3 Intellectual Goals

Three implications of this research are more theoretical in nature. This section will describe how the current study: i) contributes to the research literature on personality differences in medicine; ii) challenges commonly held assumptions about a “culture of extraversion” that have been growing in popularity since the mid-2000’s (Cain, 2012a;

Lawrence, 2015); and iii) advocates for the role of introverts in surgery and medicine in general.

Beyond the “variable” approach. An important body of research in psychology over the last four decades has focused on describing personality profiles for the various specialties (Borges & Osmon, 2001; Borges & Sackivas, 2002; Stilwell, Wallick, Thal, &

Burleson, 2000). Based on a thorough integration and literature review on personality and medical specialty choice, however, Borges and Sackivas (2002) recommend a shift in this research direction. One of the authors’ key findings was that all personality types can be found in each medical specialty; personality varies more within specialties than between them. For this reason, they recommend that future studies focus on the “person” rather than the “variable” perspective of personality research and that they demonstrate how personality interacts with different work environments. In other words, they call for studies showing how different personalities succeed within the same specialties.

Thus, rather than simply attempting to determine if introverts do or do not belong in surgery, the current research aims to describe how introverts and extraverts differentially interact with, shape, and adapt to the workplace. The “person” approach will be undertaken by recognizing the complexity of individual differences studied amid

multiple contextual factors. The qualitative nature of the study will aid in the representation of this complexity.

Situating “extravert culture”. A second intellectual goal of this research comes as a reaction to the growing recognition of a societal “culture of extraversion.” Recent authors (Cain, 2012b; Kahnweiler, 2009; Laney, 2002) trace the uprising of extraversion as a cultural ideal in North America from as early as the beginning of the twentieth century. This can be related to what Susman (2012) calls the movement from a culture of character that valued private behaviours such as citizenship, duty, and integrity, to a culture of personality that emphasizes the impression one makes on others. Within this culture, the admired are fascinating, magnetic, dominant, and forceful (Cain, 2012b).

Lawrence (2015) and Leung (2015) believe that a general preference for extraversion has created a modern education system catered towards them. In medical school, introverted students have described having felt like misfits, being frustrated with expectations to talk more and with less hesitation, and often feeling the need to change their identities to succeed in medical school (Davidson et al., 2015).

Proponents of this worldview demonstrate this extravert culture by referencing the fact that people who are more talkative are rated as smarter, more interesting, and more desirable as friends (Cain, 2012b; Swann & Rentfrow, 2001). In their study, Furham and

Henderson (1982) showed that extraversion is a more desirable personality trait: when participants were given a personality test and told to lie by faking either a “good impression” or a “bad impression” of themselves, the “good impression” group scored significantly higher on extraversion, and the “bad impression” group scored significantly lower on extraversion. In the research literature, introversion also tends to be associated

with a more negative tone of language. Personality researchers McCrae and John (1992) describe extraverts as venturesome, ascendant, and ambitious, while they describe introverts as lethargic, retiring, and withdrawn.

Within an atmosphere of growing advocacy for marginalized groups in medicine

(Hill & Vaughan, 2013; Manglitz, 2003), one could question whether personality differences should also be seen as a source of advantage or disadvantage. If introverts feel misunderstood and perceived as weak and inferior in general (Leung, 2015; Remus,

2005) and in the context of practicing medicine in particular (Davidson et al., 2015), one would expect that introverts in an extravert-dominant field such as surgery would feel the same. At the same time, cultural realities are highly context-dependent, contingent upon both time and place. With the ultimate goal of understanding how introverts experience surgery, this study will describe if and how those within the surgical workplace perceive these potential power differentials.

Introvert advocacy. The nature of surgical practice is in direct contrast with many introverted characteristics. For example, introverts’ tendency towards careful reflection is not always possible in busy clinical settings where quickness and decisiveness is considered necessary (Jin et al., 2012). However, introverts have their own set of strengths that may prove useful in the field. Research has shown that introverts tend to be less impulsive (Cooper & Taylor, 1999; Zumbo & Taylor, 1993) and susceptible to over-confidence (Schaefer, Williams, Goodie, & Campbell, 2004) than extraverts, while being more persistent on cognitively demanding tasks (Cooper &

Taylor, 1999), more resistant to sleep deprivation (Rupp, Killgore, & Balkin, 2010), and scoring higher on both general knowledge tests (Rolfhus & Ackerman, 1999) and pre-

clinical medical examinations (Haight, Chibnall, Schindler, & Slavin, 2012; Lievens,

Ones, & Dilchert, 2009). Introverted leaders make their team members feel heard and valued: as Grant, Gino, and Hofmann (2011) suggest, this is why they are more effective than extraverts at leading proactive teams. What is more, in a specialty inundated with negative physician stereotypes such as arrogant, domineering, uninhibited, and unempathic (Hojat et al., 2002; Warschkow et al., 2010), a more passive, unintimidating physician who listens more than he/she speaks may be exactly what their patients (and perhaps even their colleagues) need.

Thus, a final implication of this research is potentially transformative. If the research shows that there are, indeed, aspects of the introverted personality that benefit the clinical practice of surgeons, perhaps more introverts would be interested in pursuing this career. Consequently, having more introverts in the field of surgery may contribute to a cultural shift in accepted ways of thinking and behaving. Showing how introverted surgeons have successfully adapted to the demands of the workplace may give future medical students the courage to pursue clinical careers in which they don’t initially seem to “fit.”

1.4 Practical Goals

As a practical goal, it is my hope that this research will aid introverts (as well as students with all types of personalities) in their self-reflections throughout the process of becoming a surgeon. Providing a rich illustration of the culture of surgery and what that means for an introvert may help: i) medical students make more informed decisions about specialty selection, and ii) surgical trainees adapt to the specialty with more ease.

Specialty selection. Personality is a common consideration for educators who counsel students into different medical specialties, in part because it is thought that alignment between the two may lead to greater success and/or satisfaction within the chosen specialty (Borges & Sackivas, 2002; Lane & Gibbons, 2007). Thus, in order to make an informed decision about which specialty to pursue, introverted medical students need to be aware of the culture of surgery, what is valued in the workplace, and how their own personal characteristics may be perceived within it. They need to be able to imagine what becoming a surgeon may entail and then decide if it is the path they want to take.

Increasing individuals’ self-knowledge through self-exploration is an important component of the decision-making process. It is my hope that the findings of this study will provide a meaningful direction for students’ self-reflections.

Adaptation. While remaining open to conflicting findings, I anticipated at the beginning of this study that there would be differences between how introverts and extraverts experience surgical practice. Assuming that this were true, one could imagine that introverts may be faced with unique challenges in comparison with their extraverted colleagues. Introverts could thus benefit from being aware of potential challenges and finding ways to adapt to them.

While I recognize that this study could have come short of attaining this goal if we had found no differences between introverts’ and extraverts’ experiences in surgery, I believed that the possible benefits of the research outweighed the risks of an unfruitful research project. To my knowledge, this is the first study directly examining how introverted medical professionals adapt to the surgical workplace. The current research helps to identify what types of behaviours are most important to accommodate for in

accordance with the demands of the surgical workplace, and describes different ways they can arrive at achieving those goals. In other words, this research seeks to trace potential pathways introverted medical students may take towards a successful career in surgery.

1.5 Origins of the Study/My Role as a Researcher

Because I used a qualitative approach for this study, I must first provide a detailed description of my role as a researcher (VL) including the experiences that led to the development of this study. I am a recent graduate from the Université de Sherbrooke’s

Doctor of Medicine program. However, almost a year before completing my degree, I made the difficult decision to not pursue a residency program. Rather, my love for writing, as well as my need to understand how we learn, led me to a career in medical education. Currently, I am completing a Master’s of Education in Curriculum Design for

Health Interprofessionals.

I initially became interested in introversion because of a Ted Talk by Susan Cain

(Cain, 2012a). Subsequently, I read her book titled The Power of Introverts in a World

That Can’t Stop Talking (Cain, 2012b). Many of the author’s writings resonated with my own experience as an introvert. Throughout my education, I personally felt as if extraversion was considered the standard to which one was destined to comply. My peers and instructors encouraged group work and more social learning, and I often felt that they overlooked the value of quiet reflection.

In response to these ideas, I conducted a small study during a research methods course at my university. Using grounded theory, I analyzed five 30- to 60-minute-long interviews with three introverted and two extraverted medical students with the aim of

understanding the potential discord between introversion and the medical school environment. The results of this pilot study were powerful: all of the students, including the extraverted ones, believed that Problem-Based Learning (PBL) favoured extraverts.

PBL rewards those who enjoy speaking up in class. While the extraverted students spoke only positively of PBL, the introverted students expressed frustration with the expectation to talk as much as their classmates, required more time to reflect before answering, and found the act of cutting into conversations difficult. Introverts felt that their strengths were devalued in PBL. They felt the need to act more social, spontaneous, and assertive

(i.e., more extraverted) in order to succeed in their program. The incompatibility between introversion and PBL led to profound consequences: no matter how hard they tried to talk more, students were perpetually discouraged by constant negative feedback from their tutors. Some developed anxiety and difficulty concentrating in class because entire tutorials were spent desperately searching for opportunities to jump into conversation.

Some began to modify their learning strategies at home to study in terms of what they could say in the next day’s tutorial rather than in terms of what they needed to know to become a competent doctor.

Making sense of these results was difficult. On the one hand, I deeply saw myself in the laments of my fellow students and felt for their struggles. PBL was not enhancing these introverted students’ communication skills, and it seemed to me that the approach was doing more harm than good: it was teaching students to associate quietness with inferiority. At the same time, however, students need to demonstrate their ability to respond to adversity and adapt to situations that are uncomfortable for them. Introverts who tend to shy away from group discussions could benefit from becoming more

assertive and speaking up for themselves if they want to succeed in this demanding field.

As such, I began to inquire about how we can help introverted students adapt to situations in which they may need to “act more extraverted.”

Conversations with my master’s program cohort led me to the current inquiry of introverts in surgery. Surgery was felt to be one of the most stereotypically extraverted specialties to exist, and I wondered whether this preference towards extraversion could be found there as well. If this were true, I hoped that by describing its existence and demonstrating ways in which introverts have overcome these difficulties in the past, I would be able to improve how introverts experience medical training in the future.

Extraverts’ warmth, sociability, and assertiveness make them excellent surgeons.

However, I believe that introverts can make great surgeons as well. Introverts’ calm and inquisitive nature help them become skilled and knowledgeable. Their patience, sensitivity to others, and unintimidating nature help them build strong relationships with patients. The one comment I received in all of the clinical rotations I went through in medical school was the fact that I was deeply appreciated by my patients. It is my conviction that this was not in spite of my introverted nature, but because of it. In my opinion, having both introverts and extraverts in medicine is how we will succeed in providing optimal care to our patients.

1.6 Theoretical Frameworks

This section will define a number of key terms and contextual frameworks to facilitate understanding of the later chapters. I will define personality, the Big Five Factor

Model, as well as the terms “introversion” and “extraversion.” Because the introversion-

extraversion dimension of personality is closely linked to social skills (McCrae & John,

1992), I will briefly describe this construct.

Personality. In broad terms, personality constitutes the patterns of thought, emotion, and behaviour that characterize individuals (Funder, 2001). It describes differences between people and how these multiple factors combine to form a whole person (Matthews, 2004). This broad definition does not, of course, do justice to the complexity of studying personality. In their lexical study deriving trait terms from the

Webster’s English dictionary, Allport and Odbert (1936) identified 17,953 words describing some facet of personality. Hundreds of traits have, in fact, been argued throughout the years as being essential dimensions of personality (McCrae & John,

1992). Hence, interpreting human behaviour in any measurable way is an issue that has kept psychology researchers busy for decades (Jung, 1923).

Additional factors complicate the concept of personality even more. First of all, defining consistent dimensions of personality is problematic: two people may both define themselves as introverted, for example, but exhibit strikingly different patterns of behaviour (McCrae & John, 1992). Additionally, the way individuals behave changes constantly according to the context within which they are placed–sparking the debate about whether personality exists at all (Fleeson, 2004). Finally, the words we use to describe another’s personality may be understood by others quite differently than we originally intended, as language is always interpreted through our own unique patterns of thought (Allport & Odbert, 1936).

Personality researchers have used a variety of approaches–including the classic

(e.g., psychoanalytic, behaviourist, humanistic, and trait) and newer paradigms (e.g.,

social-cognitive, biological, and evolutionary approaches)–to study human behaviour

(Funder, 2001). While acknowledging the psychodynamic and biological contributions to the understanding of introversion, I have positioned this thesis at the level of trait theory; in particular, aligning with the Big Five Factor Model of personality.

The Big Five. The origins of the Five Factor Model of personality (McCrae &

John, 1992) date back to the 1930’s with Allport and Odbert’s (1936) lexical approach.

From a dictionary, these authors compiled key adjectives describing human behaviour called trait-names. This encompassed neutral descriptive adjectives (e.g., practical, talkative) as well as mood and emotion-related terms (astonished, reassured), and evaluative words (inferior, fair). The former (descriptive adjectives) were thought to be more useful for describing personality.

This lexicon was later restructured by Cattell (1945) and Tupes and Christal

(1961) among others leading to multiple iterations of factor analysis. These studies combined related traits to reduce the number of adjectives to 171 and 35, respectively.

Despite losing traction during the 1960’s, interest in the approach was revived with the help of researchers such as Goldberg (1990) and Costa and McCrae (1985), who helped bridge the gap between lexical and theoretical questionnaire traditions in personality research.

The FFM resulted from the finding that five fundamental dimensions of personality could consistently be found across different rating scales, traditions of inquiry

(e.g., lexical and theoretical), and languages (e.g., English, Japanese, Dutch, and German)

(McCrae & John, 1992). Its validity has been demonstrated with multiple types of instruments, as well as with participants of all ages and genders (McCrae & John, 1992).

The five dimensions of personality include: neuroticism, extraversion, agreeableness, conscientiousness, and openness to experience (McCrae & John, 1992). Neuroticism refers to the tendency towards negative emotionality; agreeableness to those who are nurturing and loving; conscientiousness to the organized and achievement-oriented; and openness to experience to an individual’s imagination, intellectual interests, and aesthetic sensitivity (McCrae & John, 1992).

Because it provides an integrated, comprehensive, efficient, and easily communicated framework for organizing the complex range of constructs that define personality (McCrae & John, 1992), researchers have applied the model to multiple fields of work. Several validated self-report questionnaires measure these dimensions, including the Revised Neuroticism-Extraversion-Openness Personality Inventory (NEO-PI-R;

McCrae & Costa, 2010) and the Ten-Item Personality Inventory (TIPI; Gosling,

Rentfrow, & Swann, 2003). The NEO-PI-R, developed by Costa and McCrae (2010), is a

240-item measure of the FFM of personality. On a five-point Likert scale from “strongly disagree” to “strongly agree”, participants describe the typical behaviours or reactions that characterize their personalities. Relative scores on these questionnaires have been used to predict factors such as workplace behaviours (Judge, Simon, Hurst, & Kelly,

2014), choice of medical specialty (Borges & Sackivas, 2002), and academic and clinical performance in medical school (Hojat et al., 2013).

This study specifically uses the TIPI in an initial participant questionnaire.

Gosling and his colleagues (2003) developed and validated the TIPI, which is a brief 10- item measure of the Five Factor Model of personality (i.e., extraversion, neuroticism, openness, agreeableness, and conscientiousness). Participants indicate the degree to

which they identified with 10 pairs of character traits on a 7-point Likert scale (from

“disagree strongly” to “agree strongly”). These character traits represent main components of each of the five factors. For instance, the two items measuring extraversion are “extraverted, enthusiastic” and “reserved, quiet.” The number indicated on the first item, and the number indicated on the second item (reversed) are averaged to produce a total score from 1 to 7.

Introversion. Although theorists have used the terms “introversion” and

“extraversion” to describe personality for centuries, over the years, various authors have provided slightly different definitions for the two terms (Matthews, 2004; McCrae &

John, 1992). In the 1920’s, Carl Jung was one of the first great thinkers to theorize about introversion. Jung considered introversion-extraversion to be the most distinct of the four major dimensions of psychological types (along with thinking-feeling, sensation- intuition, and rational-irrational; Jung, 1923). Jung called introversion the “inward- turning of libido” and extraversion the “outward-turning of libido”. In this manner, introverts are quiet and oriented towards the subjective inner world of their own minds; extraverts are sociable, outgoing, and oriented towards the objective outer world. Based on Jung’s psychodynamic theories of personality, Isabel Myers and Katherine Briggs developed a personality inventory that equated extraversion with high levels of sociability, impulsivity/non-planning, and liveliness/risk-taking/jocularity (Zumbo &

Taylor, 1993).

Following Jung’s theories, two major scientific discoveries also gave a biological basis to introversion and extraversion (Matthews, 2004). The first came from Eysenck

(1967) who studied the excitability of the reticulo-cortical circuit; the second came from

Kagan and Snigman (2004) who studied temperament and amygdala reactivity. Both the reticulo-cortical circuit and the amygdala are components of the central nervous system, are situated in the brain, and control levels of alertness. The general premise of these theories is that extraverts have a lower arousal level than do introverts. In order to raise their arousal to an optimal level, they seek out stimulation in the form of social activity.

Introverts, having a naturally higher level of arousal and thus being highly sensitive to the external environment, attempt to minimize this stimulation by seeking out solitary, quiet activities. Eysenck’s Personality Inventory is grounded in this theory (Sato, 2005). Like the Myers-Briggs Type Indicator, Eysenck emphasized the sociability and impulsivity components of extraversion (Sipps & Alexander, 1987). The inventory also distinguished the introversion-extraversion construct from anxiety, shyness, and emotional instability– which are related to neuroticism (Sato, 2005; Zelenski, Sobocko, & Whelan, 2014).

McCrae and Costa (1992) conceptualize extraversion as a combination of two axes: dominance and affiliation, with dominance being slightly more important. They also take into account positive emotionality as a defining characteristic of extraversion, arguing that people who are happy tend to be more warm, sociable, talkative, and dominant. To summarize, extraverts are described within the Five Factor Model as active, assertive, energetic, enthusiastic, outgoing, and talkative. They are warm, gregarious, seek excitement, experience more positive emotions, and are facially and gesturally expressive. It follows that introverts are calm, quiet, and subdued. The current research incorporates each of these viewpoints to arrive at the following definitions: introverts are silent, calm, reflective, passive types (McCrae & Costa, 1992) who are energized by solitary activities and avoid excessive social stimulation (Jung, 1923). Extraverts are

talkative, outwardly enthusiastic, impulsive, dominant types (McCrae & Costa, 1992) who are energized by being with other people and avoid spending excessive amounts of time alone (Jung, 1923).

Distinctions. The current study makes important distinctions between introversion, shyness (social anxiety), and withdrawal (social anhedonia). A person who suffers from social anxiety fears social situations in which he or she may be exposed to scrutiny by others (American Psychiatric Association, 2013). Social anhedonia characterizes those who do not draw pleasure from social situations (Martin, Cicero,

Bailey, Karcher, & Kerns, 2016). Many authors consider social anxiety and anhedonia conceptually distinct psychological constructs and not simply extremes of introversion

(Briggs, 1988; Martin et al., 2016; Zelenski et al., 2013). Introverts enjoy being with other people, but may need time to recharge alone afterwards and prefer smaller social groups (Zelenski, Santoro, & Whelan, 2012). Individuals who are shy or withdrawn would score high on introversion, but not all introverts are shy or withdrawn. If an introvert also suffered from social anxiety, he or she would score high on neuroticism; a calm introvert would not (Zelenski et al., 2013).

Social skills. The differences between introverts and extraverts can be explained, in large part, by differences in sociability. Extraverts are drawn to others and seek affiliation; introverts prefer to socialize in smaller groups. Hence, when speaking of the strengths and challenges of introverts engaging in professional activities, social skills and emotional intelligence are inevitably part of the discussion. Social skills are defined in this study as learned behaviours that involve an interaction with others, which enable individuals to function competently in social situations (Little, Swangler, & Akin-Little,

2017). These involve a range of behaviours, including emotional expressivity and sensitivity (sending and receiving nonverbal information), emotional and social control

(regulating self-presentation and displays of emotion), as well as social expressivity

(engaging others in conversation), manipulation (manipulating others in a social setting), and sensitivity (attention to others/observation skills) (Riggio, 1986).

Chapter Summary

In sum, there are distinct contrasts between the defining characteristics of introversion (e.g., quiet, passive, reflective) and the behaviours often seen in surgical specialties (e.g., boldness, quickness of action). Medical trainees who pursue surgery need to learn both the explicit and implicit demands of the workplace in order to become successful within it. The current study aims to explore how general surgeons and surgical residents perceive introverts in general surgery. In particular, this study will use grounded theory to hypothesize about what introverted characteristics are seen as beneficial in surgical practice, and what may be challenging for introverts. Developing a better understanding of how introverts adapt to surgery would help fulfill both the practical and intellectual aims of this study, including:

i) to go beyond the “variable” approach to personality research in medical

education;

ii) to explore the possibility of a culture of extraversion in surgery;

iii) to advocate for the role of introverts in surgical specialties;

iv) to inform specialty selection counselling practices; and

v) to demonstrate meaningful paradigmatic trajectories for introverts.

Chapter 2: Literature Review

There has been much debate over the years as to the pertinence of a literature review prior to data collection for grounded theory research (Urquhart, 2013). Indeed, the aim of grounded theory research is not to verify existing theories; theories should be developed from the data. While some warn that preconceived ideas (called theoretical baggage; Strauss & Corbin, 1990) may taint the research findings, most modern researchers (Urquhart, 2013; Watling & Lingard, 2012) agree that a preliminary literature review can be done as long as existing frameworks do not influence data collection and the researcher remains open to new or contradictory ideas. As Dey (1993) puts it, the researcher should have an ‘open mind, not an empty head’ (p. 63).

Hence, I present here a number of different research findings; however, these did not explicitly frame the research. Rather, the ideas and theories described in this section will have informed the final interpretation of the research results (see discussion section) in order to “expand existing theory or make use of extant theory to understand similar processes in different contexts” (Ng, Lingard, & Kennedy, 2013, p. 381).

The present literature review mostly includes articles and books published within the past 17 years (since 2000). Some older references (back to 1923) were included to provide a historical basis to certain theories and definitions. References were identified by using key words such as: surgery, surgical specialty, surgical culture, surgical personality, professional development, introversion, extraversion, ego depletion, sleep deprivation, affect, academic performance, sociability, social skills, emotional intelligence, leadership, medical specialty choice, role modeling, adaptation, personality change, and person-situation debate. The databases used include PsycInfo, Pubmed,

Educational Resources Information Center (ERIC), and Google Scholar. Credo Reference was used to provide pertinent definitions. The references cited by each article, as well as more recent articles that reference the original articles, provided additional sources for the literature review.

Of necessity, Chapter 2 repeats information already presented in the introduction.

In this section, these ideas will be contextualized according to the following subtopics.

Section 2.1 will review the relationship between personality and medical specialty choice, particularly as it relates to the relative dominance of extraverts in surgery. Section

2.2 describes the known differences between introverts and extraverts that could potentially influence their fitness for surgical practice. In section 2.3, I explore research related to the culture of surgery and its expectations. The last section (2.4) will give a theoretical background for how introverts may adapt to the demands of the surgical workplace; namely, by acting or becoming more extraverted.

2.1 Personality and Medical Specialty Choice

In their literature review, Borges and Sackivas (2002) integrated what is currently known on the topic of personality and medical speciality choice. Using the Five Factor

Model of personality as a framework for integrating multiple measures of personality

(e.g., California Psychological Inventory, Sixteen Personality Factor Questionnaire,

Myers-Briggs Indicator), they conducted a thorough evaluation of studies linking each of the personality dimensions to the medical specialties. Despite identifying a large number of studies on the topic, the authors found very little evidence that any specific personality profile could be linked to a particular medical specialty. However, one relatively strong

conclusion was that for the most part, surgeons can be considered extraverted (Coombs et al., 1993; Peel et al., 2018; Warschkow et al., 2010).

More recently, Peel et al. (2018) conducted a systematic review of the factors implicated in medical students’ decisions to pursue surgical careers more generally.

Analyzing 122 primary articles led them to three core themes: gender, exposure to surgery, and “fit” in the culture of surgery. The latter category included studies demonstrating the effects of role models and personality on specialty choice.

The authors found six studies relating personality type to medical students’ interest in surgery, and reported that those who are more extraverted, conscientious, less impulsive, and more motivated by prestige and financial reward appeared to be more likely to be interested in surgery. They even state that “students who are extroverted, ambitious and motivated by the prestige of surgical work may be good candidates for surgical training” (Peel et al., 2018, p. 64).

Hence, despite a number of authors suggesting that there may be more extraverted than introverted surgeons (Borges & Sackivas, 2002) and that there may be more extraverted than introverted students interested in surgery (Peel et al., 2018), very few have explicitly studied why this phenomenon exists. The following sections describe potential contributing factors.

Selection bias. First, it is possible that extraverts dominate surgical specialties simply because extraverts have dominated surgical specialties in the past. As Thomas

(1997) suggests, new generations of surgical residents may be chosen based on their similarity in personality to the generation that preceded them:

I am frequently astonished that after only a half-hour interview with a resident

applicant, I often hear, ‘This young man/woman will make a great surgeon, he/she

has all the tickets.’ Unstated by the interviewer, but perhaps understood by most

of the surgeons on the interview team, is that the interviewee is similar to, if not

‘just like us.’ (p. 573)

A prospective cohort study from the Penn State College of Medicine supports this assumption (Quintero, Segal, King, & Black, 2009). The authors asked 135 medical students interviewing for an orthopedic surgery residency position, as well as their 30 interviewers, to complete a personality questionnaire (the Myers-Briggs Type Indicator) prior to their interviews. They found that similarity between the interviewers and interviewees in certain dimensions of personality was related to significantly higher student rankings. In particular, medical students were rated more favorably when they shared one of the following pairs of characteristics with clinical faculty: extravert-sensing and sensing-thinking, extravert-sensing and sensing-judging, and sensing-feeling and sensing-judging. Of note, those who are extravert-sensing are orientated towards action and accomplishing practical tasks; those who are sensing-thinking are oriented towards methods and considering practicalities; those who are sensing-judging are oriented towards responsibility and hard work; and those who are sensing-feeling are oriented towards how their actions will impact on other people (Quintero et al., 2009). The authors concluded that there is an unconscious selection bias that influences clinical faculty interviewers to rank students according to their own personality.

Prototype matching. In the organizational psychology literature, the Person-

Environment Fit hypothesis proposes that individuals tend to match themselves to their

surrounding environment–preferring careers that align with their personal values and characteristics (Moss & Frieze, 1993). Moss and Frieze (1993) applied the concept of person-environment fit hypothesis to career decision-making. In their study, 86 MBA students completed mail surveys measuring their personal characteristics (such as being outgoing, creative, and independent) and the perceptions of the job opportunities they had been applying for. They were asked to describe the prototype of the typical person working in these jobs along a 25-item scale. Their analysis included a measure of similarity between self and prototype. They found a significant relationship between individuals’ self-ratings and their choice of career. Their study supports the theory that individuals tend to “match” themselves to jobs.

The self-to-prototype theory proposes individuals tend to make career decisions by organizing their perceptions around central “prototypes” (for example, the assertive, boisterous, male surgeon; the solitary, reflective pathologist) and searching for the option with greatest similarity to them. More recent studies have shown that the more individuals perceive they are similar to a dominant occupational identity, the more likely they are to enter the field–and exit it, if they perceive the opposite (Lane & Gibbons,

2007; Peters, Ryan, Haslam, & Fernandes, 2012).

2.2 Key Differences Between Introverts and Extraverts

Surgeons are asked to display competency in a number of areas. In order to be effective, they must be knowledgeable, make sound decisions, work well in groups, communicate effectively with their patients, and maintain their energy and concentration despite long hours of work (Canadian Medical Association, 2016). Section 2.2 will

discuss what is known about the differences between introverts and extraverts as they relate to each of these key areas.

Knowledge. Previous studies have associated introversion with higher academic performance in university (Entwistle & Entwistle, 1970; Furnham, Chamorro-Premuzic,

& McDougall, 2002; Lievens et al., 2009; Sanchez, Rejano, & Rodriguez, 2001).

Furnham et al. (2002), for instance, explored the relationship between the Big Five personality traits and academic performance by following 93 undergraduate students in

England over two years. They compared students’ overall exam averages to measures of their personality (using the NEO-PI-R), seminar performance, cognitive ability, and beliefs about intelligence. Among these latter variables, only personality was significantly correlated with academic performance. Extraversion (negatively), as well as conscientiousness (positively), were significantly associated with academic performance.

The authors conclude that introverts are more likely to excel in a university setting than are extraverts.

When applied to medical students, however, these performance differences between introverts and extraverts become less clear. Some studies have found no relationship between extraversion and early academic success (Haight et al., 2012).

Others, such as Lievens, Coetsier, De Fruyt, and De Maeseneer (2002), found an indirect relationship between the two. Lievens and his colleagues conducted a prospective longitudinal study that aimed to determine which personality traits predict pre-clinical performance in medical school. The authors examined a cohort of medical students for 3 years. Due to the high attrition rate (the original 607 students were reduced to 341 by

Year 3), they defined academic success as having passed the first 3 years of medical

school. The personality dimension of extraversion was only significantly related to academic success in Year 1. However, two extraversion facets seemed to be important: gregariousness and excitement seeking. Unsuccessful medical students scored higher on both of these dimensions. The authors suggest that low conscientiousness, combined with specific extraverted personality traits (high gregariousness and excitement seeking), may be detrimental to pre-clinical medical students’ academic success.

These studies suggest that introverts may be more likely to excel in the university setting than are extraverts. What these studies do not show, however, is how introverts fare in settings that are not purely academic. For instance, during the clinical years of medicine, group learning and communication skills become increasingly important.

Medical students begin to be evaluated based on their interactions with their patients, teachers, and colleagues. In these settings–when interpersonal competencies are part of the evaluation–it is the extraverts who tend to have the upper hand (Davidson et al., 2015;

Furnham et al., 2002; Lievens et al., 2009). As Haight et al. (2012) showed in their study exploring the associations between medical student personality and their performance across the curriculum, extraversion may be related to success on clinical evaluations for interpersonal behaviour. In particular, among their cohort of 152 medical students from the Saint Louis University School of Medicine, the extraverts tended to score higher on ratings for communication, patient rapport, team rapport, and patient care.

Decision-making. Introverts are reflective types who tend to consider possibilities and rationalize consequences in depth before making decisions. They tend to use more rule-based, systematic styles of decision-making (Sagiv et al., 2013).

Extraverts, on the other hand, tend to use more emotional, experiential-intuitive styles of

decision-making (Sagiv et al., 2013). Both styles of decision-making have their strengths and weaknesses; thoughtful decision-making may lead to more rational decision-making, but surgeons are often called upon to make rapid decisions in urgent situations (Ott et al.,

2018).

In the operating room, for instance, hesitation may be viewed as a lack of competence. Ott et al. (2018) sought to explore how hesitation related to surgical residents’ ability to develop their autonomy in the operating room. They interviewed nine pairs of surgical residents and their supervising surgeons, and observed them during a surgical procedure. Participants perceived hesitation as a disruption in the progress of the surgical procedure; these moments played a strong role in supervisors’ perceptions of their students’ competence.

Leadership. Extraverts are energized by working with others and shine when placed in social situations (Lievens et al., 2002; Lievens et al., 2009). Introverted medical students perceive that their extraverted counterparts tend to dominate more conversations, have less trouble interrupting others to contribute to a discussion, and respond more rapidly to their supervisors’ questions (Davidson et al., 2015). This sets up extraverts to be more powerful communicators, especially in a competitive and fast-paced setting like surgery. Both dominance and sociability, key components of extraversion (McCrae &

John, 2012), have been associated with leadership in qualitative (Mann, 1959) and quantitative studies (Bono & Judge, 2004; Judge, Bono, Ilies, & Geradt, 2002).

Using the Five Factor Model of personality as an organizing framework, Judge et al. (2002) conducted an exhaustive qualitative and quantitative review of the literature on the topic of personality and leadership. In their meta-analysis of 222 correlations from 73

samples (as well as well as a second meta-analysis of 384 correlations from 26 studies;

Bono & Judge, 2004), extraversion was the trait that most strongly and consistently correlated with leadership. The authors found significant relationships between extraversion and leadership emergence (i.e., being perceived as leaderlike), leadership effectiveness (leader’s performance in guiding the group towards its goals), as well as transformational leadership (leader’s moral conduct; ability to motivate, challenge, and recognize the needs of others).

Oher authors have argued that because introverts are good listeners and are less interested in dominating social relationships, they may be more likely to take their colleagues’ opinions into consideration when making decisions. For instance, in an experiment involving 163 college students led by either introverted or extraverted-acting team leaders in a t-shirt folding competition, Grant et al. (2011) found that when the team acted passively, the extraverted leaders outperformed the introverted leaders by being a strong directional voice for their concerted efforts. However, introverts outperformed extraverts when the group was proactive. The authors concluded that proactive team members perceived introverted leaders as more receptive and it is this that motivated them to invest more effort into the task. Studies such as these that demonstrate the potential benefits of introverted leaders have been limited. Considering the extensive evidence of extraverts outperforming introverts in leadership tasks, further research is needed to better understand the conditions under which introverts may make effective leaders.

Working with patients. A common concern for introverts in the clinical field is their social skills. Extraverts are, in fact, defined by their warmth, gregariousness, and

sociability. Many modern researchers (Davidson et al., 2015; Jerant, Fenton, & Franks,

2012; Lieberman & Rosenthal, 2001; Zelenski et al., 2014) challenge the idea that extraverts are inherently more skilled than introverts in all forms of social communication, especially in the doctor-patient relationship. Social and emotional skills are rather difficult to evaluate and are highly context-specific (Davies, Stankov, &

Roberts, 1998; Lopes et al., 2003). Studies related to nonverbal behaviour, in particular, have been conflicting; these have either not been able to show a relationship between extraversion and nonverbal decoding ability or, in fact, have shown that introverts are more skilled decoders (Berry & Hansen, 2000; Lieberman & Rosenthal, 2001).

For the most part, however, studies using various measurement tools have identified positive relationships between extraversion and social competence (Van der

Zee, Thijs, & Schakel, 2002), quality of social interactions (Berry & Hansen, 2000), rapport building (Barrick et al., 2011; Duffy & Chartrand, 2015), social skills (Riggio,

1986), and emotional intelligence (Ciarrochi, Chan, & Caputi, 2000). Extraverts spend more time in social situations, and are thus likely to have developed a better understanding of appropriate social behaviour over time (Festa, McNamara, Barry,

Sherman, & Grover, 2012; Martowska, 2014). They also seem happier (Smillie, Wilt,

Kabbani, Garratt, & Revelle, 2015) and more satisfied (Lopes et al., 2003) with their interpersonal relationships than are introverts.

Riggio (1986) found positive correlations between extraversion and all items of the Social Skills Inventory, which includes: emotional expressivity, emotional sensitivity, emotional control, social expressivity, social sensitivity, social control, and social manipulation. Martowska (2014) also related extraversion to intimate competence (e.g.,

physical contact with someone who needs consolation), social exposure competence (e.g., public speaking), and assertive competence (e.g., refusing a favor to a friend).

Burnout. A typical week as a surgeon may include several hours in the operating room, pre- and post-operative patients to check up on, patients to see at the clinic or in the emergency room, as well as paperwork to complete (Canadian Medical Association,

2016). This often leaves little time for rest. Multiple studies have shown that introverts are less affected by sleep deprivation than are extraverts. Experimentally, introverts have outperformed extraverts on sleep-deprived cognitive memory, logical reasoning, vigilance, and wakefulness tasks (Killgore, Richards, Killgore, Kamimori, & Balkin,

2007; Rupp et al., 2010; Smith & Maben, 1993; Taylor & McFatter, 2003).

At the same time, however, frequent social interaction may be psychologically and physiologically draining for introverts, who excel in solitary, slow-paced environments. Although it has not been studied in the surgical setting specifically, extraversion has been positively related to well-being (Rogers, Creed, & Searle, 2012) and indirectly, negatively related to stress (Tyssen et al., 2007) in medical students. In

Tyssen et al. (2007)’s six-year longitudinal study of Norwegian medical students at the beginning, middle, and end of their training, those who were labelled “brooders” (i.e., those who scored low on extraversion, high on neuroticism, and high on conscientiousness) were at an elevated risk of experiencing stress. In the general population, extraverts tend to experience more positive emotions than introverts (Smillie et al., 2015), likely due to a combination of factors: extraverts spend more time in social situations, have higher-quality social experiences (Smillie et al., 2015; Sun, Stevenson,

Kabbani, Richardson, & Smillie, 2017), and respond to reward cues with more intense

positive affect (Zelenski et al., 2012) than do introverts. This imbalance may be heightened by a feeling of isolation within a professional field where extraversion is so well regarded: introverted medical students have reported feeling like misfits, feeling judged as underperformers, and feeling a need to change their identities in order to succeed in a career in medicine (Davidson et al., 2015).

Career advancement. In a meta-analysis reviewing the factors predicting career success, Ng, Eby, Sorensen, and Feldman (2005) found that extraversion was related both to measures of objective (i.e., salary, number of promotions) and subjective (job satisfaction) career success. They argued that being outgoing, assertive, and energetic may help extraverts increase their visibility within an organization, making them more likely to be chosen for managerial positions. Turban, Moake, Wu, and Chung (2016) pursued this question further by examining the mediating effect of mentoring and organizational knowledge on career success. In their study, 333 business school alumni completed mailed surveys measuring personality (extraversion and proactivity), mediating variables such as the degree of mentoring received in their careers and their organizational knowledge, as well as objective and subjective career success. Proactivity was defined, in their study, as individuals’ tendencies to search for opportunities to act upon and influence their surroundings. Controlling for education, years since graduation, gender, tenure, and organization size, they used structural equation modeling to test their theory that extraversion and proactivity would have an indirect effect on career success.

Their results suggest that extraverts may be more likely to seek mentorship relationships that provide them with the learning and networking opportunities to succeed in their careers.

2.3 Surgical Culture

The previous section explored multiple ways in which personality may interact with the work environment. Both introverts and extraverts need to use their strengths and adapt their weaknesses in order to perform optimally as surgeons. The following section will shift from the more explicit to the more implicit demands of the workplace: surgical culture.

The way health professionals behave in the workplace depends not only on the specific tasks they need to accomplish, but also on the social context within which they operate. Placed in a hospital setting, medical students rapidly pick up on the behaviours, beliefs, and attitudes of their superiors, as well as the implicit social and cultural rules that govern the work environment. This is what researchers call the hidden curriculum.

As Gofton and Regehr (2006) explain:

…for pupils to succeed within the school system they must not only learn to

conform to the formal rules of the school, but also the informal rules, beliefs and

attitudes perpetuated through the socialization process.… The hidden curriculum

is a function not only of the institution’s implicitly held values, but perhaps more

so of the individuals by whom the trainee is surrounded personally.” (p. 21)

The concept of the hidden curriculum is in keeping with social learning theory

(Gluck, Mercado, & Myers, 2014): individuals learn how to behave by observing and evaluating the consequences of others’ behaviours. Relatedly, social conformity describes the natural tendency to adopt the behaviours of a group. Thus, part of understanding how introverts experience surgical training requires an understanding of the surgical culture.

The following sections will describe some of the expectations and stereotypes that may influence how trainees learn to behave.

Expectations. In their review of the psychology and social psychology literatures on identity construction, socialization, and image management, Jin et al. (2012) began constructing a conceptual framework for understanding the sociocultural influences on decision-making. Based on their review, the authors propose that the hidden curriculum dictates what behavior is accepted or not; those wishing to be accepted into the field of surgery are expected to act like those who came before them. Jin and colleagues describe how surgical culture values quickness, decisiveness, confidence, and boldness of action.

Motivated by the need to project a certain image of themselves, prospective surgeons

“dawn their cloaks” to appear competent; those unable to fulfill these expectations may experience identity dissonance.

Following this study, a number of the same authors (Patel, 2014; Patel et al.,

2018) published a qualitative study on the pressures surgical residents feel to engage in impression management. Using grounded theory, the authors analyzed 15 interviews with general surgery trainees in an urban Canadian academic health center. The authors found that residents sense the expectation to be all-knowing, quick, decisive, and confident:

You asked what the typical surgeon should be and I guess maybe I didn’t say it,

but implicit in that is that you should be invincible. Maybe that’s too strong of a

word but you should be not weak, not unsure, not unconfident. The pressure is

that you’re going to be the opposite of all those things. That you should always

know, that you should always be confident, that you should always have the

answer. And I don’t know where that comes from, but that’s definitely I think the

way you feel you should ultimately be. And I think when you aren’t all of those

things, or when people point out that you aren’t all of the things, or it’s brought to

your attention...then it’s a source of stress. (Patel, 2014, p. 66-67)

In order to project that image of competence, residents used multiple strategies

(e.g., fabricating stories, remaining silent, avoiding calling for help) that were, at times, harmful to their education. The authors demonstrated that participants’ anxieties about how others would perceive them impacted their ability to make sound decisions for their patients.

Surgical personality. Whether they are true or not, commonly held assumptions about what a “typical surgeon” looks like may have an influence on how trainees see the profession–and themselves as participants in it. Surgeon stereotypes are amongst the most well-known in medicine, having existed for a very long time (Otis & Weiss, 1973). In a small study of 50 non-surgeon health professionals by Thomas (1997), 90% of respondents agreed that a similar personality type exists among surgeons. Others have found that surgeons have the most distinctive personalities in medicine (Coombs et al.,

1993; Jin et al., 2012; McGreevy & Wiebe, 2002). This surgical type has been characterized as bold, authoritarian, and “thick-skinned” with fast-paced and take-charge mentalities (Borges & Osmon, 2001; Coombs et al., 1993; Thomas, 1997). Previous studies on surgeon stereotypes show that health professionals perceive surgeons as domineering, arrogant, aggressive, excitable, inpatient, uninhibited, frank, and lacking in social orientation (Bruhn & Parsons, 1964; Warschkow et al., 2010). Though most surgeons believe these perceptions to be largely inaccurate, personality tests do tend to

reveal higher levels of extraversion, openness to experience, and achievement orientation in surgeons (Borges & Sackivas, 2002; Warschkow et al., 2010).

Identity dissonance. Psychology researchers Ward and Chang (1997) propose that how well we adapt to our lives in a new social setting depends on the consistency between our personality and that of the group. Knowing that extraversion is much more common in Western countries than it is in Asian countries, they administered personality as well as psychosocial adjustment (depression) and adaption (social difficulty) questionnaires to 139 Americans who had recently moved to Singapore. Most of the participants (43%) were working, for the most part in education and management; a minority (4%) were students. The researchers defined the degree of “cultural fit” by measuring the absolute differences between participants’ extraversion scores and the host culture norms. They found that the greater the discrepancy between the average group level of extraversion and that of the individual, the more psychological distress that person developed over time. The age and location of the study, as well as its focus

(extraverts in an introverted group rather than the opposite) make the generalizability of its findings to surgery in a Canadian university difficult. However, when taken in the context of the literature on the hidden curriculum (Hill et al., 2014; Roberts, Caspi, &

Moffitt, 2003), it gives an interesting direction to the discussion of the challenges introverts may face in the extravert-dominant field of surgery.

2.4 Adapting to the Workplace

Becoming a surgeon requires students to interact with the culture of surgery and integrate into a novel work environment. Hill et al. (2014) used a constructivist grounded theory approach to explore how medical students navigate the hidden curriculum of

surgery and its relationship to career decisions. They began with an exploratory questionnaire completed by a purposive sample of 46 medical students; following these,

12 students underwent individual semi-structured interviews. Their analysis identified a distinct surgical culture. To be successful in the field, trainees needed to meet a number of requirements. They needed to build networks to “get ahead” (p. 887), and then portray themselves in a way that is consistent with what a typical surgeon is like. Hence, those who were capable of becoming surgeons were easily identified among their peers. The demands to conform to surgery’s hidden curriculum were seen as non-negotiable; those who were unable to “fit in” were excluded from the specialty.

The person-situation debate. The idea that individuals can “adapt” their behaviours to the workplace brings us back to the person-situation debate (Fleeson,

2004). If people constantly change the way they behave according to the situation at hand, one could question whether personalities exist in the first place. Researchers have long argued over what determines behavior more: personality or the environment.

Carl Jung (1923) originally theorized that natural introverts and extraverts do exist, but both tend to compensate their innate tendencies in order to maintain a “psychic equilibrium.” That is, introverts adapt to their natural environment by exhibiting opposing, more extraverted qualities: they become momentary extraverts. Accordingly, years of research generally support the ideas that: i) personality traits do exist that are characteristic of the individual and that predict behaviour over long stretches of time, ii) momentary behaviours (states) are extremely variable within individuals, and iii) both the average level and the variability of personality states are unique to the person and remain stable from one week to the next (Fleeson, 2004; Judge et al., 2014). In other words, the

answer to the person-situation question is both: individuals act very differently according to the situation they are placed in, but at the same time, people show stability in average behavior over long stretches of time.

Personality development. Another field of literature relevant to the idea of adapting to the workplace is personality development. Roberts and colleagues (2003) conducted a comprehensive longitudinal study aiming to describe the relationship between work experiences and personality development. Its 910 participants were members of the Dunedin study, a long-term study of a cohort of children beginning at the age of 3. Personality was measured at age 18 and 26 using a modified version of the

Multiple Personality Questionnaire (MPQ), and work experience was measured on a number of scales such as prestige, education level, and work satisfaction. The researchers found that: i) personality predicted future work experiences, ii) work experiences were related to personality change, and iii) the traits that lead individuals to choose particular work experiences were those that changed in response to those experiences. Thus,

Roberts et al. (2003) provide a theoretical and empirical background for personality development. In line with social learning theory, individuals change their behaviours as they become accustomed to the norms of the group; in many cases, this has been shown to lead to lasting personality changes (Roberts, 1997; Roberts et al., 2003).

Protective factors. A final consideration for this research is the influence of other factors on individuals’ ability and willingness to adapt. Previous studies, most notably in the field of sports psychology, have indicated passion (Vallerand et al., 2008) and mental toughness (Crust, 2007), but not any particular personality type, as indicators of achievement orientation and performance. Previous studies have demonstrated that

mental toughness is more common in surgeons (Borges & Osmon, 2001). The tough- minded are able to cope effectively with stress and adversity; they have an “unshakeable self-belief” and determination to succeed. They are less sensitive and more resilient, refusing to quit despite seemingly unsurmountable challenges. Hence, it is possible that factors such as these aid introverts to overcome the challenge of succeeding in extravert- dominant careers such as surgery. In the same way, it is possible that those who struggle to adapt the most in surgery are those who are less resilient.

Resilience may be a protective factor for both introverts and extraverts as they adapt to the ongoing demands of surgery. Resilience has been defined as one’s ability to bounce back from stress (Smith et al., 2008), to thrive, or function above the norm despite adversity (Tusaie & Dyer, 2004), and to effectively manage stress (Tafoya et al.,

2018). As such, the concept has been used in conjunction with concepts such as adaptability (Tafoya et al., 2018). Researchers in the health professions have broadly used resilience as a factor associated with patient outcomes (Tusaie & Dyer, 2004), as well as a predictor of medical student depression (Tafoya et al., 2018) and an intervention target for depressed healthcare professionals (Johnson, Emmons, Rivard, Griffin, &

Dusek, 2015).

One tool that has been used in medical education (Tafoya et al., 2018) is the Brief

Resilience scale (BRS) developed by Smith et al. (2008). The authors aimed to provide a brief measure of the construct of resilience in a semantically accurate manner. While most previous resilience scales have indirectly measured the construct by assessing such factors as protective mechanisms and coping styles, their measure directly evaluates participants’ perceptions of their ability to bounce back from stress. They demonstrated

that their tool was a reliable measure of resilience, correlating with related variables such as personal characteristics, social relationships, and negative affect.

The BRS asks participants to mark the degree to which they agree with 6 statements (e.g., “I tend to bounce back quickly after hard times”) on a 5-point scale. The average score for this test varies from 1 to 5, with higher numbers indicating a higher degree of resilience.

Chapter Summary

This literature review explored what is currently known about the relationship between personality and medical specialty choice, the key differences between introverts and extraverts, and the need to adapt to the workplace. While we know that the surgical workplace is dominated by extraverts as well as expectations of quickness and decisiveness, little is known about how introverts fare in that environment. A number of studies have described the differences between introverts’ and extraverts’ cognitive and interpersonal abilities, but few have inquired specifically about the surgical setting.

Finally, there is evidence that introverts act extraverted when they feel it is advantageous to them; a better understanding of this process in the surgical setting may be informative both for students hoping to succeed in surgery, and the medical educators hoping to advise those students.

Chapter 3: Method

Chapter 3 will present the methodology and method of this research. First, I will discuss the chosen research paradigm, as grounded theory can be used alongside various ontologies and epistemologies. The qualitative approach, followed by the use of grounded theory specifically, will then be explained and reasoned. Section 3.2 (Method) will detail the specific procedures used to collect and analyze data. Finally, I will discuss additional considerations such as rigour, the role of the researcher, scope and limitations, as well as ethics concerns and protocols.

This study used a constructivist grounded theory approach to explore the views of introverts in surgery. Ten general surgery residents and 6 general surgeons first completed a short, 16-item personality questionnaire, followed immediately by a 20- to

30-minute individual semi-structured interview. Data collection and analysis occurred iteratively; the latter was performed using open, selective, and thematic coding.

3.1 Methodology

Research paradigm. A common set of assumptions first needs to be established that orients both the researcher and the reader to the research. The three main philosophical positions in grounded theory research are positivist, constructivist, and critical (Urquart, 2013).

Positivism and post-positivism assume that ‘truth’ exists independently of the researcher and is waiting to be uncovered by objective data. Traditionally, positivist grounded theory was used as a way to make qualitative research appear more rigorous in the eyes of predominantly realist thinkers. Naturally, issues of validity (or credibility), reliability (or dependability), and triangulation were strongly emphasized in order to

demonstrate objectivity (Urquart, 2013). Generalization was also seen as a goal of qualitative research; however, instead of generalizing to a population, positivist grounded theorists aimed to generalize to a theory (Yin, 2009).

Constructivist (or interpretivist) grounded theorists disagree that there is an objective truth out there waiting to be discovered; meaning comes from the complex subjective experience of individuals (Ng, et al., 2013). The ontological standpoint is relativist; that is, there are multiple realities and interpretations of the world, each constructed by individuals’ past experiences and knowledge. Relatedly, the transactionalist epistemology posits that knowledge is co-constructed between the researcher and the participant. Constructivists use reflexivity to acknowledge the interpretive nature of the research process: data is inherently subjective and cannot be detached from human interpretation (Watling & Lingard, 2012). In other words, from a subjectivist viewpoint, the goal is to “construct an impression of the world as they see it, rather than to reveal truth” (Mann & MacLeod, 2015, p. 59).

Finally, critical theorists see knowledge as being grounded in social and historical practices. They are driven by a moral compass to change the conditions society has placed on marginalized groups, to uncover underlying forces of power and control, and to attempt to move from what is to what could be (Madison, 2005; see also Kincheloe &

McLaren, 1994).

Constructivism forms the backdrop of this paper. I conducted interviews as a means of gaining insight into how the process of becoming a surgeon may be experienced by introverts and extraverts (rather than to discover the undisputable “truth” about how introverts fare in this field). Further, I acknowledge that hearing participants’ stories

should not be understood as a gathering of facts; any meaning produced is the result of my interaction with them (Mann & MacLeod, 2015). At the same time, the theories produced by my findings could potentially be verified by future objectivist studies.

Further, I used several findings from the positivist research literature in personality and organizational psychology to inform the topics of my questionnaires.

Finally, although not the focus of the current thesis, this research has critical undertones. Power relationships can be drawn between surgical trainees and established surgeons, as well as between the quieter introverted types and the more dominant extraverts. The conclusions drawn could suggest changes in how we imagine introverts in surgery.

Qualitative approach. First originating from the social sciences and humanities, qualitative research in the health professions aims to explore social, rather than biomedical, phenomena (Sale et al., 2015). It focuses on creating meaning by interacting with people and experiences within natural environments. Unlike quantitative research, it does not aim to eliminate bias in order to determine precise causal relationships; instead, its rigour is demonstrated by rich representations of contextual phenomena embedded in all of its complexity (Ng et al., 2013). Qualitative research is not “generalizable” because that is not its purpose. The value in this research lies in its ability to provide a deeper understanding of processes that would not be possible with quantitative research, and to provide an authentic basis for theory generation (Watling & Lingard, 2012).

Despite the main approach of this study being qualitative, participants also completed a short, 16-item quantitative questionnaire. The TIPI was used to compare participants’ self-reported personalities to a validated scale; it was anticipated that the

two may sometimes differ, and this would add depth to the discussion of how different personalities experience the workplace. The BRS was added because we anticipated that resilience may be related to participants need (and ability) to adapt to the workplace. In both cases, these scales were added to help inform the researchers’ reflections on participants’ responses during the qualitative interviews, rather than to be an essential focus of the study itself. For this reason, I did not consider the current study mixed methods research.

Grounded theory. A popular approach to qualitative research in medical education is grounded theory. This methodology was born in the 1960’s with the groundbreaking book, The Discovery of Grounded Theory by Glaser and Strauss (1967).

At the time, recognition of qualitative research was reaching an all-time low (Strauss &

Corbin, 1994). Theory generation was reserved for a select number of chief academics; most researchers were simply meant to empirically test the theories of the “great men of sociology” (Urquart, 2013). Grounded theory was meant to overcome some of the pitfalls of structuralist and functionalist approaches (e.g. its speculative and deductive nature), to allow the average researcher to generate theory grounded in data, and to show that qualitative research could be rigorous too. They described systematic, codified procedures for data collection and analysis (Strauss & Corbin, 1994). Grounded theory provides “a chain of irrefutable evidence – for every concept produced, researchers can point to many instances of it” (Urquart, 2013, p. 73). Since its original release, the approach has slowly gained acceptance and has now spread across several research fields, including medical education (Watling & Lingard, 2012).

Grounded theory is “…the discovery of theory from data systematically obtained from social research” (Glaser & Strauss, 1967, p. 2). Strauss and Corbin (1990) defined grounded theories as the following:

A grounded theory is one that is inductively derived from the study of the

phenomenon that it represents. That is, it is discovered, developed, and

provisionally verified through systematic data collection and analysis of data

pertaining to that phenomenon…. One does not begin with a theory, then prove it.

Rather, one begins with an area of study and what is relevant to that area is

allowed to emerge. (p.23)

Thus, grounded theory as a qualitative research method uses systematic procedures to develop a set of theories inductively about a specific phenomenon. The resultant theoretical formulation provides insight into the concepts under study and has useful implications when considered in its research context (Strauss & Corbin, 1990).

Grounded theories are meant to be faithful to the complex and diverse daily realities of the group under study, and should thus be highly practical in dealing with their issues

(Strauss & Corbin, 1994).

Grounded theory’s growing popularity introduces the risk of researchers using this method inappropriately or with poorly defined procedures (Strauss & Corbin, 1994).

The current research plans to remain faithful to its intended design and purposes: data is obtained through the means of interviews, participant observation, or documents. An iterative process, theoretical sampling, and constant comparison mean there is a constant back-and-forth between data collection and elaboration of theories. A systematic coding process allows for the identification of categories and connections between them. The

final step to this process involves theoretical coding, leading to the generation of theories.

The process ends when theoretical saturation is reached. These terms will be defined in the following sections.

Design rationale. The differences between extraverts and introverts have been relatively well studied in the literature. We know that extraverts’ strengths lie in social activities while introverts have better focus, study skills, and resistance to sleep deprivation, for example. However, existing research does not tell us which of these aspects are relevant to the daily practice of surgeons, if there are other important differences that have yet to be discovered, and/or if some of these characteristics change during the course of a surgical students’ development. Previous authors describe how introverts may act out of character in pursuit of personal goals, but this has never been applied to a medical setting. To my knowledge, this is the first study to directly examine the experience of introverts working in an extravert-dominated medical field such as surgery.

Hence, grounded theory was chosen as the method of inquiry. Grounded theory is useful when studying a process, especially where no previous theories exist (Urquhart,

2013). It is exploratory in that new ideas and theories are uncovered from the data, providing potential explanations for the phenomenon at hand. Accordingly, this study explored the poorly described phenomenon of being an introverted medical professional in the extravert-dominant field of surgery. It aimed to reveal taken-for-granted assumptions about what characteristics of an introvert are considered strengths or challenges for clinical practice, as well as why, how and when introverts may act counter to their natural dispositions. This study may contribute to the development of survey

questions for future quantitative studies, in order to explore relevant theories and generalize findings.

An ethnographic or a phenomenological approach could also have been useful for this topic of research. Ethnography would have enabled a more in-depth understanding of the surgical culture and the social phenomena that result from an introvert being introduced to it (Watling & Lingard, 2012). Ethnographic studies typically require long- term engagement in a research setting as well as multiple methods of data collection, most often including direct observation, to provide a “holistic cultural portrait” of the social milieu (Watling & Lingard, 2012). A phenomenological approach would have enabled a richer description of the experience of an introvert becoming a surgeon.

Phenomenology focuses on deriving the essence of social phenomena by bracketing one’s own preconceptions and describing the lived experience of those having experienced it (Ng et al., 2013). I tend to agree with the suggestion of Varpio,

Martimiankis, and Mylopoulos (2015) that the divide between methodologies in qualitative research should be considered permeable. Using “methodological borrowing”

(p. 228), this research attempted to describe how introverts experience surgery. However, the use of the phenomenological methodology was minimal: important parts of the lived experience of introverts were described, but the focus remained on increased understanding of a process. I believe that grounded theory was the methodology most likely to meet the practical goals of this study. This approach provided pragmatic examples of how introverts succeed in surgery, more directly aiding introverts in their decision to pursue surgery and their adaptation to the specialty.

3.2 Method

Theoretical sampling. Theoretical sampling was the main recruitment strategy.

Broadly defined as “deciding on analytic grounds where to sample from next” (Urquart,

2013, p. 54), it is a responsive approach to data collection through which the researcher follows the analytic trail: subsequent participants are chosen based on how well they inform developing theories.

Theoretical sampling aims to maximize opportunities to develop concepts, identify variations, and to determine relationships between ideas (Corbin & Strauss,

2008). To do so, differences between participants can be maximized or minimized, generating theory that is either more broadly transferable or more focused on a particular group, respectively. Concepts can also be maximized or minimized, to build a theory in depth or to identify a diverse set of possible explanations. I chose to maximize differences in experiences by seeking both introverted and extraverted participants of diverse backgrounds. However, I limited the scope to general surgeons to provide an in- depth discussion of one particular sub-specialty rather than a superficial description of all of them. I chose general surgeons because they have often been the focus of studies on personality in medicine (Borges & Osman, 2001); however, many of the findings will likely be transferable to other specialties and sub-specialties.

Figure i illustrates the recruitment procedure. Participant recruitment occurred in two major phases, separated by approximately five months. I sent a direct email invitation (Appendix A) to all 14 faculty member general surgeons at one university hospital. The on-site supervisor (KN), a general surgeon, sent a general invitation to all current general surgery residents at the same university hospital; this reached

approximately 20 residents. As a result, five general surgeons and six residents agreed to participate. I met with most of the participants within the following two months; because of scheduling difficulties, one interview with a general surgeon was planned for five months later. The researchers used this this delay time to thoroughly review the data, discuss developing themes as a team, modify the interview questions, and plan for future data collection.

Because I had obtained a majority of extraverted participants during the first iteration of interviews, I asked the on-site supervisor (KN) to send a direct email invitation to an additional seven surgical residents who she believed, based on her experience working with them, may be introverted. I added to this email the following statement, in order to encourage only those who identify as introverted to respond: “At this point in time, we have received a sufficient number of extraverted participants and are now hoping to find some participants who identify as introverted to complete our dataset. If you consider yourself on the introverted side on the spectrum (i.e., more quiet, reserved, reflective, and prefer to work alone or in small groups) and are interested in participating, please let me know.” The final four residents were recruited in this manner.

Furthermore, because of the greater response rate for residents compared to surgeons, I invited two general surgeons from a second university hospital. One of these surgeons agreed to participate.

Figure i. Participant recruitment procedure.

Saturation. Research studies reach saturation when new categories or themes are no longer being identified in the data (Corbin & Strauss, 2008) and when the researchers have developed a comprehensive and convincing theory–one that makes sense and does not show any gaps. Morse (1995) defines saturated data as “rich, full and complete” (p.

149). The author also stresses that it is the quality and not the quantity of data that is important, since “richness of data is derived from detailed description, not the number of times something is stated” (p. 148).

The decision to end data collection was made along these lines; however, I recognized recent critiques of this problematic concept. Varpio et al. (2017) raised doubts about whether data can ever truly be saturated; new information can always add something new to the understanding of a phenomenon, no matter how small.

Unfortunately, saturation continues to be used loosely in the qualitative research literature

without fully detailing how these decisions were made (Malterud, Siersma, & Guassora,

2016).

Broad

Sparse Aim

None Larger Specificity Narrow Sample Size Weak Theory Dense Cross-case Dialogue Applied

Analysis Strong

Case Smaller Sample Size

Figure ii. Model for assessment of sample size: items and dimensions. (Malterud,

Siersma, & Guassora, 2015)

Hence, to render the methods more transparent, I used a model from Malterud et al. (2015) for assessing sample size in qualitative studies (see Figure ii). This follows from the concept of information power: the larger the power of the sample, the fewer participants are needed to complete the study. In this model, information power depends on: (a) the study’s aim, (b) sample specificity, (c) the use of established theory, (d) the quality of dialogue, and (e) the analysis strategy. The current study broadly sought to understand the experience of introverts in surgery. However, its well-defined research questions refined the goals of the study so that they would be achievable with a smaller sample size. In addition, the population was rather specific since only general surgeons were asked to participate, and I was able to capture a diversity of experiences and opinions within this target group after only a few interviews. Although an extensive

literature review was conducted prior to data collection, this study was not underpinned by existing theory; nonetheless, theory was used extensively during the discussion phase of the study.

Questionnaire. The questionnaire included both the TIPI to measure personality and the BRS to measure resilience. The goal of incorporating a measure of personality was to provide a secondary measure of participants’ personalities. In some instances, participants may self-identify with one personality type while their scores on the TIPI show different ones. These results gave us a richer context for understanding how participants saw themselves and their personalities. Further, resilience was included because I suspected that resilience may be a protective factor for introverts (as well as extraverts) who must meet the ongoing demands of surgery. It is possible, for instance, that those who struggle to adapt the most in surgery are those who are less resilient.

The TIPI was chosen because I wanted to compare individuals’ self-perceived personalities to a more formal scale, but recognized that surgeons and surgical residents would have limited time to participate in this study. The qualitative nature of this study meant that interview data were to be prioritized. The TIPI is less reliable and has less convergent validity than more lengthy questionnaires such as the NEO-PI-R, and cannot measure any of the individual facets of each personality type (Gosling et al., 2003). For instance, extraversion encompasses many personality constructs such as sociability and dominance (McCrae & John, 1992), but the TIPI does not provide separate measures of these dimensions. However, knowing this was not essential for the current study. The

TIPI has demonstrated convergence with common self, observer, and peer-reported measure of the Big Five, as well as acceptable test-retest reliability and predictive validity

(Gosling et al., 2003). Thus, the TIPI was sufficiently valid, yet brief to meet the needs of this study.

The participants first completed the questionnaire, and then were asked in the interview to self-identify themselves. I first asked participants to explain their personal definitions of introversion and extraversion, and then stated that in this study, “I define introverts as silent, calm, reflective, passive types who are energized by solitary activities and avoid excessive social stimulation. Extraverts are defined as talkative, outwardly enthusiastic, impulsive, dominant types who are energized by being with other people and avoid spending excessive amounts of time alone.” I then asked participants: “on the continuum between introversion and extraversion, where would you situate yourself? In terms of percentage, for example? Why?”. Participants responded with either a percentage or a number between 1 and 10. After the interviews were complete, I calculated participants’ scores on the TIPI. When the participant’s self-reported personality and their TIPI score differed, I indicated this by listing both separated by a slash (e.g., a self-reported introvert who received an extravert score on the TIPI would be labeled “self-introvert/TIPI-extravert”).

Interviews. Interviews were conducted in quiet rooms at the place of work of the participants (i.e., hospital library meeting rooms or physicians’ offices). Alone with the participants, I first provided explanations about (1) the general purpose of the questionnaire and interview; (2) the length and format of the questionnaire and interview;

(3) how the interview would be recorded; (4) the confidentiality of their participation; and (5) how to get in touch with me if they have further questions. I answered any

questions they may have had at this point, then had them sign a consent form (Appendix

B).

The interviews were semi-structured to allow for open discussion with flexible guidance, conducive to developing theories grounded in data (Watling & Lingard, 2012).

Appendix C presents a preliminary list of interview questions. These were mostly open questions that were not deliberately based on existing literature. The interviews began with general questions about the demands of surgery. After defining introversion and having participants describe their own personality, they were invited to think of some of the strengths and weaknesses of introverts in surgery. The final questions related to how participants may have adapted to the role of a surgeon.

A few changes were made between the original interview questions and the revised questions (see Appendix C). Firstly, the demographic questions were eliminated since the same information appeared on the written questionnaire. For the remainder of the questionnaire, the questions that were repetitive, unclear, and/or elicited a minimal response from the first group of participants were either eliminated or rephrased. An example for this is question 17 which was felt to be repetitive given questions 13 and 14.

Certain questions, particularly those related to the strengths and weaknesses of introverts and extraverts in surgery, became more specific. More refined questions inquired about participants’ perceptions of their own abilities and how they believe others view introverts in the workplace. Other questions were added based on developing theories; for example, I added more specific questions about leadership and confidence.

To ensure accuracy, I digitally-recorded and transcribed the interviews verbatim.

Although time-consuming, verbatim transcripts allow for a particular closeness with the

data that help with the in-depth grounded theory approach (Halcomb & Davidson, 2006).

Field notes and memos of my personal thoughts and interpretations during the entire process provided additional depth to the research (Halcomb & Davidson, 2006) and ensured a conceptual approach to interpretation (Watling & Lingard, 2012). When the participant was interested, I shared more information about my research and its preliminary findings after the interview was complete.

The data collection process was iterative; that is, data collection and analysis occurred simultaneously. While there were two major interview phases, the research questions were amended after each interview to accommodate new themes. Hence, each iteration could be understood as a method of triangulation: ideas and theories were corroborated by multiple sources. Subsequent data confirmed, disconfirmed, or re-shaped themes that resulted from the previous interviews in order to arrive at more complex understandings (Watling & Lingard, 2012).

Data analysis. I began to analyze the data as early as the first interview. I first read through each transcript, writing memos of my initial observations and ideas.

Following this, I began to qualitatively code the data. Qualitative coding refers to the practice of synthesizing, defining, and drawing meaning from data such as interviews, fieldnotes, and other documents derived from naturalistic settings (Charmaz, 2006).

Codes fragment the data into manageable parts that can be categorized and later used to make interpretations (Urquart, 2013). For the current study, I used a process of open, selective, and thematic coding as originally developed by Glaser and Strauss (1967) and later concretized by Urquart (2013). Though she uses a slightly different approach to

coding, I also consulted work by Charmaz (2006) during the course of this study to enhance my understanding of grounded theory more generally.

Beginning with open coding favored my openness to explore possibilities and maintain the authenticity of the data (Glaser, 1978). Line-by-line, the interview data were individually associated with open codes that labeled whatever phenomenon was happening. These codes answered the questions: “What is the data a study of?”, “What category does this incident indicate?”, and “What is actually happening in the data?”

(Glaser, 1978, p. 57). The open codes were then classified into selective codes. Selective coding focused the analysis on categories that were related to the developing core categories (Urquart, 2013). The selective codes synthesize and categorize data into themes at a more conceptual level (Glaser, 1978). This resulted in some categories being combined, while others were split.

Grounded theory dictates that data analysis move beyond the categorization level of coded themes: interpretation increasingly moves from the more specific to the more abstract (Watling & Lingard, 2012). Hence, theoretical coding involved comparing the different codes and interpreting their relationships to each other. These codes explored such factors as: causes and consequences; stages and transitions; types, styles, and classes; as well as strategies and mechanisms (Glaser, 1978; Urquart, 2013). To a lesser extent, I also considered the conceptual families of conflict, power relations, and personal narratives (Charmaz, 2006).

One important strategy used in this coding process was constant comparison. This is the manner in which instances of data in a given category are constantly compared with other instances in that same category (Watling & Lingard, 2012). For example,

participant A is an introverted surgeon and says she has difficulty connecting with her patients; participant B is also an introverted surgeon and says working with patients is her favorite part of the job, since it comes so naturally to her. How does instance A compare with instance B in the category of introverts’ relationship with patients? Both instances of similar and contrasting cases contribute to the richness of the research findings and are conducive to theory development (Watling & Lingard, 2012). In quantitative research,

“outliers” are considered sources of error; in qualitative research, these outliers are rich sources of information that contribute to the depth of a theory (Morse, 1995).

Selective and theoretical codes were reviewed throughout the analysis phase by the academic supervising researchers (AP, CS, KN). In-person meetings with VL, AP, and CS were organized: immediately after the first period of data collection and initial selective coding; after the second period of collection and initial theoretical coding; and after two more revisions of data analysis. Disagreement in the categorization of themes was resolved by consensus during email exchanges as well as group meetings. The supervisors suggested areas requiring further exploration or clarification: these were to be resolved by re-analysis of open codes or subsequent interviews. Some categories were re- organized during this process; for example, “confidence” and “need to be dominant and assertive” originally stood alone as unique categories, but were reconfigured to be components of “the essential qualities of a surgeon.” The iterative process of collecting, reading, coding, reflecting on the data, and deriving meaning through the interpretation of themes led to an increasingly rich description of the studied phenomenon (Ng et al.,

2013).

Theory. In this study, the term “theme” was defined as the essential categories– descriptive or conceptual–that synthesized and defined the ideas and experiences described by participants (Urquart, 2013). This definition must be distinguished from the term “theory.” Researchers from a positivist orientation define theories as explanations or predictions that relate concepts (called variables) to one another (Charmaz, 2006).

Positivist researchers seek parsimonious explanations that can be generalized to a population (Ng et al., 2013). In contrast, constructivists view the term “theory” as the development of “understanding rather than explanation” (Charmaz, 2006, p. 126).

Interpretivist theorists aim to elucidate patterns and illuminate differences. Their theories conceptualize complex phenomenon at higher levels of abstraction, rather than delineate generalizable conclusions (Watling & Lingard, 2012). Recognizing that theory generation should only be undertaken if and when the emerging data calls for it (Charmaz, 2006), the aim of this study was to provide an increased understanding of the phenomenon in a theoretical direction, acknowledging that a concrete theory may or may not emerge from the research process.

3.3 Rigour

Corbin and Strauss (2008) maintain that “quality” grounded theory research is both valid and innovative. They propose eight criteria for evaluation: i) Methodological consistency: how well the researcher systematically follows the

proposed methodology as planned. In this case, I followed through with constant

comparison, theoretical sampling until saturation, and coding. ii) Clarity of purpose: as described, the aim of the research was to provide a deeper

understanding of the phenomenon at hand.

iii) Self-awareness: the role of the researcher is made clear; I kept a journal of personal

thoughts and feelings, recognizing my influence on the research. iv) Training in qualitative research: qualifications and experience using this research

design. I have taken a course in qualitative research methods, and done a significant

amount of study about this method. In terms of experience, I had completed a

qualitative study in medical education as part of an undergraduate course in

psychology prior to this project. v) Sensitivity for the topic, participants, and research: ability to step into the shoes of

participants; to demonstrate empathy, respect, and honesty. I maintained an

awareness of these issues through journaling and memo writing. vi) Willingness to work and be creative: qualitative research can be time-consuming

and demanding. I recognized that it was important to think about things in new

ways. vii) Methodological awareness: being aware of the implications of each

methodological decision. I kept memos detailing these decisions, and was in

constant discussion with my supervising researchers concerning these decisions. viii) Research for its own sake: the research is done because of genuine interest in the

topic, and not because one feels obliged to do it. This was a topic I was particularly

interested in because of my experiences in the profession.

To summarize, rigour in qualitative research depends on trustworthiness, utility, and authenticity (Ng et al., 2013). Quality research has good truth value (is an accurate representation of participants’ perspectives), consistency (is replicable, provides an audit trail), confirmability (accounts for the researcher’s perspective), and applicability (is

useful in other contexts) (Nobel & Smith, 2015). Researchers should justify their choices of method and methodology, describe them in careful detail, and engage in ongoing reflection on their personal biases. They should seek cases of similarity and difference, accounting for multiple realities. Their thought processes should be transparent. The results of the research should provide rich, thick descriptions while being well written and easy for the reader to follow. Finally, the researcher should not work alone: engaging with other researchers, member checking, and triangulation are essential.

To the best of my ability, I incorporated these principles into this study. As the primary researcher, I kept a reflective journal and used memos to keep track of developing ideas and important decisions. Although only one responded, I also used member checking. All participants were sent their interview transcripts and were invited to comment on or clarify any of their ideas. I consulted regularly with the research team

(AP, CW, KN) in order to triangulate themes. The results provide rich verbatim extracts in order to allow the reader to form his/her own conclusion and to avoid “conceptual leaps” (Ng et al., 2013).

An important consideration during the process of analysis was utility. While constructing themes, I remained cognizant of their potential pragmatic and theoretical impact for medical education. Moreover, I constructed a diagram (p. 102) that not only helped organize these ideas, but that also clarifies the relationships between concepts and categories for the reader (Watling & Lingard, 2012).

The reader should note that for the most part, I avoid using the word “emerged” when writing about the thematic analysis. As Varpio, Ajjawi, Monrouxe, O’Brien, and

Rees (2017) explain, this term implies that themes and research findings conveniently

appear or make themselves visible during a study, rather than being developed collaboratively between the researcher and the research participants. Rather than attempting to appear more objective by using this type of language, I believe that recognizing and accounting for the inherent subjectivity of this qualitative research project is a more authentic way of carrying out its methods.

3.4 Ethical Considerations

Research Ethics Board (REB) approval was obtained from Acadia University as well as the Nova Scotia Health Authority (NSHA). Informed and voluntary consent were obtained by each participant prior to data collection (Appendix B). Consent is voluntary when it is without undue influence, manipulation, or coercion (Canadian Institutes of

Health Research, Natural Sciences and Engineering Research Council of Canada, and

Social Sciences and Humanities Research Council of Canada, 2014, p. 27). Incentives were not used for this study. Participants were free to withdraw at any time without consequence, whether they offered a reason to do so or not.

Participants were informed about the general purpose of the research, the researcher’s identity, the duration and nature of participation, the potential benefits and risks, their voluntary consent, the use and dissemination of findings, the contact information of myself and individuals to contact with ethical concerns, and their legal rights in case of research-related harm (Canadian Institutes of Health Research et al.,

2014, p. 29). Participants’ identities were held confidential by assigning numbers to each participant, and indicating only those numbers on questionnaires and transcripts. Only the researcher and supervisors had access to those transcripts. Appropriate measures were

taken to ensure the security of these documents. The collected data was only used in the manner described to participants.

As a final note, I will briefly mention the potential for conflicts of interest. As a graduate student, I have no authority over my participants, nor do I have a dependent relationship with any of them. One participant was a teaching staff surgeon from a previous clinical rotation in surgery. I had not previously met any of the other participants. It is unlikely that I will work with the research participants in the future; however, I am an employee at the targeted hospital in the radiology research department.

Chapter Summary

A constructivist research paradigm underpinned this research, with recognition of the potential for positivist and critical undertones. A qualitative approach was useful to understanding the complexities of the social phenomenon at hand. While borrowing from phenomenology, grounded theory allowed us to meet our research goals by increasing understanding of the phenomena at hand in the direction of theory production.

A purposive theoretical sample of 16 general surgeons and surgical residents was recruited via email to this study. Data collection and analysis occurred iteratively until theoretical sufficiency. Participants completed a short questionnaire (TIPI, BRS) followed by individual interviews of approximately 20-25 minutes. The primary researcher (VL) completed verbatim transcription followed by open, selective, and theoretical coding resulting in the categorization of main themes. Throughout this process, the supervising researchers (AP, CS, KN) were consulted to discuss areas of disagreement or need for improvement.

Rigour was demonstrated by its attention to trustworthiness, utility, and authenticity. I described my role as a researcher and the personal biases that result from my experiences with introversion in medicine. Scope and limitations of this study concern difficulties around sampling, understanding participants’ motives, and the difficulty of studying personality. Ethical considerations were also highlighted.

Chapter 4: Results

The participants in this study described the experience of being an introverted surgeon or surgical resident, as well as the perceptions they have of introverts in surgery.

The three main thematic categories were as follows: i) the surgical context, including the expectations surgeons and residents felt to act in specific ways; ii) the perceptions of introverts and extraverts in surgery; and iii) the consequences of a mismatch between surgical culture and personality. For each of these main themes, I will discuss the disparate views of two categories of participants.

4.1 Participant Characteristics

I divided the participants of this study into two main groups: “personality doesn’t matter” (group A) and “personality matters” (group B). I will describe the rationale and process for dividing the participants in the following section; however, I first present the demographics and questionnaire results of the participants in function of these groups.

Figure iii demonstrates the distribution of participants in both groups. The label

“non-introverts” refers to the fact that there were two participants (p9, p10) who were not clearly introverted, nor extraverted. I considered one participant an ambivert, being situated in the middle of the spectrum. This participant had difficulty identifying themselves as being either introverted or extraverted. On the TIPI, this individual scored

4.5/7 on the extraversion scale (with introverts scoring closer to 1, and extraverts scoring closer to 7). A second participant self-identified as introverted, but scored as an extravert on the TIPI (5.5/7).

All participants (n=16)

Group A: Group B: Personality Personality doesn't matter matters (n=8) (n=8)

Introverts Non-introverts Introverts Non-introverts (n=4) (n=4) (n=4) (n=4)

res: p15, p16 res: p5, p9, p10 res: p6, p7, p14 res: p3, p12 surg: p8, p13 surg: p2, p11 surg: p1 surg: p4

Figure iii. Distribution of participants according to groups A and B. The abbreviations p1-p16 refer to randomly-assigned participant numbers.

Table 1 compares the demographic factors of groups A and B. Both groups were similar on all factors except for gender. Most participant were between 28 and 50 years old, with one participant (categorized in group A) being over 50 years old. The mean age was 37.4 in group A and 35.5 in group B. There were more women than men in group A

(5:3), but more men than women in group B (6:2). Further, all of the surgeons in group B were male (n=3).

Table 1

Demographic Characteristics of Participants from Groups A and B

Group A Group B

Year of Year of Total N Gender Total N Gender residency residency

Residents 5 PGY1 = 0 M = 2 5 PGY1 = 1 M = 3 PGY2 = 2 .F = 3 PGY2 = 1 .F = 2 PGY3 = 3 PGY3 = 2 PGY4 = 0 PGY4 = 1 Years in Years in

practice practice Surgeons 3 ..1-9 = 0 M = 1 3 .1-9 = 0 M = 3 10-19 = 2.. .F = 2 10-19 = 3… .F = 0 .20+ = 1 20+ = 0

The second table (Table 2) lists the mean scores on the participant questionnaires.

Appendix D lists individual scores for all of the participants. Resilience was similar between groups A and B. On average, group B scored higher on extraversion than group

A. The reader should note that because the average age, the proportion of residents and surgeons, and the resilience scores were similar in both groups, we could not attribute any differences we found between groups A and B during the analysis to differences in age, years of experience, or resilience.

Table 2

Questionnaire Results for Groups A and B

Group A Group B

Mean Extraversion score 3.8 4.3 Mean BRS score 4.0 4.1

4.2 Group Distribution

While finding a consensus is a rare occurrence in constructivist studies such as these, the striking contrasts between responses from participants were a central theme throughout the research process. Descriptions of opposing–and seemingly incompatible– views appeared early on in my memo writing, and I continued to find these differences as

I engaged in constant comparison.

My initial impression of the interview data was that some participants did not believe that introverts possessed characteristics that disadvantaged them in surgical practice, while others believed that they may. In particular, this observation came from answers to such questions as: “How would your experience as a physician be different if you were an extravert?” and “What are some of the strengths and challenges of introverts in surgery?”. For some participants, these questions led to the discussion of how introverts may struggle in social situations where they are required to be an assertive, confident leader. For others, however, this led to the discussion of how introverts and extraverts do not differ in the core characteristics that make them effective surgeons.

After coding the data, constant comparison allowed me to further explore these initial impressions. Comparing individual instances of data pertaining to the same theme exposed key areas of disagreement. For instance, on the topic of the nature of the surgical job, one participant argued that “surgery is a solitary thing. It's you and your patients and your assistant. It's not a group thing” (p11), while others thought the “job completely occurs within a team environment…it's always a group type environment” (p18). In terms of challenges for introverts in surgery, some thought that “if you’re an introvert, things can be hard for you” (p12), while others stressed that “being more…quiet or reflective

doesn’t mean I can’t like go and speak to other people or get plans done” (p9). While some participants thought that introverts’ quiet and passive nature may disadvantage them in situations where they needed to be both heard and listened to, others argued that

“in the long run…I don’t think it matters if you’re an introvert or an extravert ‘cause people are gonna use their own criteria to judge whether or not they’ll listen to what you’re saying” (p5).

From this initial analysis, I observed that these disagreements were not random in nature; rather, the participants who agreed in one category tended to agree in the following categories, and vice versa. For this reason, after approximately the first 10 interviews, I divided the participants into two groups: “personality doesn’t matter” (group

A) and “personality matters” (group B). In general, group A included those who believed that there are generally little to no differences in how introverts and extraverts experience surgery, and that introverts should have no more difficulty succeeding in surgery than their extraverted counterparts. Group B believed that while both introverts and extraverts can succeed in the surgical profession, introverts may face challenges in this context that extraverts are less likely to be faced with. Appendix E shows these contrasts through representative quotes from groups A and B for each subtheme.

Recognizing that the boundaries between the two groups are not clear; that there was significant overlap between them; and that not one participant in each category perfectly matched the typical characteristics of the group, I believed that the description of these groups of responses would help us better understand the two general patterns of responses that were developing from the research process. The reader should conceptualize these two groups as two ends of a belief spectrum; presenting both sides of

the debate may provide a framework for better understanding how individuals perceive introverts in general surgery.

4.3 Context

This first section will cover the topic of context. Through the interviews, participants described the nature of the surgical workplace. They explained the types of activities surgeons are called to engage in and what the essential qualities are of a good surgeon. Participants also shared their perceptions of the surgical personality. Portions of participants’ quotes have been underlined in the text to facilitate understanding of key ideas.

4.3.1 The nature of the job

Surgeons have many responsibilities in their profession beyond performing surgery. Participants described how their time is divided between the operating room, seeing patients in clinic, the emergency department, and in-hospital, as well as more administrative and research-related work. Within each of those roles, surgeons need to be able to respond to a diversity of people and situations:

Because surgery is so multifaceted in terms of the work we do. We’re seeing patients in the emergency department, we’re seeing rounding patients on the ward. Some people are sick, some people aren’t, and we’re seeing all personalities. (p6, group B, introvert, resident)

4.3.1.1 Surgery as a social or solitary activity

Asking participants to describe the nature of their professional activities led to two competing discourses. Participants disagreed about whether surgery should be considered a social or a solitary activity. All those in group B saw surgery as a social activity due to its constant need for teamwork and collaboration:

It’s extremely, a very social job. So if we break the day down. We start at 6 in the morning. We round as a team. So we are with a team all day. So we deal with the team. Then you go round on the patients, you deal with the patients, right? Then you deal with the nurses who are looking after the patients. And then you deal with the other health care professionals who deal with the patients, and then you go to the operation room. You deal with other health care professionals like anes-, anesthesiologist, anesthesia technicians, nurses in the OR. After the cases you will see consults in the emergency departments and deal with other people. (p12, group B, extravert, resident)

…my job completely occurs within a team environment…perhaps how it's portrayed in certain TV shows or whatever where it's like this totally black environment with like just a single light on. An OR's not like that you know you have to work with the nurses, the anesthesiologist, the porters, um your surgical assist–I mean it is a big team environment. And then in the emergency department you know you're going into that environment you're working with the emergency nurses, the Emergency Physician–I mean it's, it's always a group type environment. (p8, group B, extravert, surgeon)

…any bigger decisions we work as a team to come up with a plan. And we all round together and then meet and come up with a plan of attack and divide. So general surgery is very much a team sport. (p3, group B, extravert, resident)

One participant even believed that those who do not enjoy the social aspect of surgery do not belong in the profession:

If you're someone that doesn't enjoy working with other people you're going to be uncomfortable in the operating room all the time you know...if you’re not a people person and you don’t want to be around people, then in general you shouldn’t be in a busy service dealing with patients every day. (p12, group B, extravert, resident)

Group A (personality doesn’t matter), however, tended to emphasize the social aspect of surgery significantly less. When asked to describe the daily activities of surgeons and surgical residents, these participants sometimes failed to mention group work:

I guess it would just involve like getting up and, like, going right to work. And then, taking care of patients and going to the operating room and then–coming home and then usually I would just grab something to eat and then go to bed to be honest. (p15, group A, introvert, resident)

One participant in group A even considered surgery a solitary activity because of its focus on the patient-doctor interaction:

Surgery is a solitary thing. It's you and your patients and your assistant. It's not a group thing. (p11, group A, introvert, surgeon)

Three participants in particular (two from group A and one from group B) made an important distinction between communication skills and sociability. They believed that communication was essential to working within team based environments, but that this skill was independent of one’s degree of sociability. The latter was related to how individuals interacted with each other on a more personal level. Being friends with one’s colleagues was not considered necessary to a surgeon’s competence:

I don’t know if it’s social, it’s- it involves teamwork…You’re interacting with them on a professional level. So...you know that doesn’t mean you have to be social with them…I don’t think you need to–you know ask people about their weekend necessarily in the OR and stuff like that to be a good surgeon. (p5, group A, extravert, resident)

…as long as you turn up and you do your work, I think that's probably all we ask for, for working with a team. (p1, group A, extravert, surgeon)

I invited him for a beer at some point, he said no I don’t really like beer. ___ didn’t say no. ‘Do you want to go for a coffee then?’ ‘Ok. We’ll talk here at work, we’ll talk about the cases. We’ll each go back home, we don’t eat together, we won’t’–That’s okay. (p13, group B, extravert, surgeon)

4.3.1.2 Relationships with patients: intimate, yet limited

In comparison, the views of those in groups A and B were more closely aligned when speaking to the relationships they had with their patients. Participants held two distinct discourses: they described these relationships as intimate, yet limited.

Across both groups, many participants considered these relationships to be intimate because of the need to develop trust:

…it's almost an intimate relationship. They are trusting you with their body. (p11, group A, introvert, surgeons)

Because of the trust we need with patients, we probably have to develop fairly close relationships with a number of your patients. (p2, group A, introvert, surgeon)

At the same time, however, most considered that the short-term, rapid nature of the patient interview limited their relationships. They believed that it was often difficult to develop a deep relationship with patients under these time pressures:

…in the current system we’re in, the time pressures of surgical practice, we’re not really forging very significant relationships with our patients…when we see patients, we have an agenda. Pieces of information we need to get. Um, we don’t put a lot of emphasis on making sure that they have a positive social experience from the interaction. I’m not saying that’s good, but that’s kind of the time pressures we’re working under. (p6, group B, introvert, resident)

…interaction with patients are often a bit more rushed than in, you know in a different specialty where you have more time to sit down with patients. (p7, group B, introvert, resident)

Surgeons’ priority was to manage their patients’ conditions appropriately; patients who lacked a connection with their physician were to seek reassurance elsewhere:

At the end of the day if you fix their pathol-, you know if you guide them through their illness according to the standard of care, it doesn’t really matter you know…at the end of the day, if someone’s being, has great bedside manners but is completely incompetent that’s not gonna help you either. (p5, group A, extravert, resident)

…you don't have to be a friend with your surgeon. The patients aren't always friends with surgeons. I might be warm and smiley and more outgoing than other people I work with, but they have just as good relationships or maybe the patients are less reliant on them for like you know, um, for reassurance? You know, you know but they have a good relationship but maybe less able to ask personal questions, right? (p1, group A, extravert, surgeon)

These alternative discourses (intimate and limited) may not be self-exclusive, however. Two extraverted participants believed that their patient interactions were generally rushed, but nonetheless thought it important to have trusting relationships:

…it's a different relationship in that you don't have a lot of time in most surgical practices to um, visit a lot with your patients. Most surgeons have a very high volume of work…on the other hand the relationship is, uh very intimate in terms of uh, you've actually used your hands to heal them and that creates a special relationship between a patient and a surgeon that other specialties would not have. (p5, group A, extravert, resident)

You will, when you do oncology you see those patients long-term but once a year. You know, it’s not really enough to get to know them. You know who they are and that’s all. Um, but otherwise, the problem is fixed, and you discharge them so it’s a relationship focused on a problem…it’s when there’s a problem or a complication, that they need to have confidence in you to come back to see you, or they’ll go see someone else. (p13, group B, extravert, surgeon)

4.3.2 Essential qualities of a surgeon

I specifically asked the first 12 participants to name what they considered important characteristics of an effective surgeon. By random occurrence, half of these participants happened to be categorized later in group A, and the other half in group B. In order to compare what groups A (personality doesn’t matter) and B (personality matters) considered important, I calculated the total number of participants in each group who spontaneously (i.e., not simply after I brought up the issue) mentioned each characteristic and divided that number by six (the number of participants from each group). Figure iv displays the proportions of responses per group.

As one could anticipate, participants believed that surgeons need to display a wide range of competencies. All those in group B–as well as most in group A–named communication, teamwork, and leadership skills as important qualities for a surgeon to master. Group B, however, tended to emphasize these points more prominently.

Decision-making and work ethic were equally important to both groups. Participants mentioned knowledge and compassion/care less frequently; most of these participants were from group A.

100% Group A (Personality doesn't matter) 80% Group B (Personality matters) 60% Overall

40%

Proportion of group 20%

Surgeon characteristics

Figure iv. Comparison of surgeon characteristics considered essential by groups A and B.

4.3.2.1 Leadership

Leadership was one of the most important themes in this research. Although both groups thought leadership was important, group B tended to emphasize this quality much more than group A. As demonstrated in Figure iv, all participants in group B brought up the issue spontaneously, without suggestion from the interviewer; in contrast, half of the participants in group A only spoke of leadership when directly asked about it.

Group B, in particular, believed that the absence of leadership skills was dangerous for surgical practice:

…you're in a leadership position so you know if you don't control it, no one else will and everything will go into chaos. So you know if you don't like being a leader, then you should not be a surgeon because very bad things will happen in the absence of leadership. So in the OR–you are the leader in the OR. In the trauma bay, you are the leader of that trauma. And so you must assume that role. (p8, group B, extravert, surgeon)

The theme of leadership was closely linked to four important sub-themes.

Participants described effective leaders as able to: make quick decisions under pressure;

work collaboratively with their teams rather than simply directing them; and maintain control of a group. Group B, much more than group A, thought that effective leaders need to be dominant and assertive.

Decision-making. Participants consistently described decision-making as one of the essential features of an effective leader. Both groups A and B felt that leaders need to have good clinical judgment, to think quickly, and to make firm decisions based on limited information:

…probably the overriding key is your ability to make a decision. Uh, particularly when there are high stakes involved. And be comfortable with your decisions knowing that they’re not always gonna be right. And…you learn from your mistakes when you make a decision that wasn’t maybe the best one. I guess that’s how you demonstrate your leadership. (p4, group B, introvert, surgeon)

So the ability to choose among all we know in the literature, to make a decision that’s often irreversible. (p13, group B, extravert, surgeon)

Leaders needed to not spend too much time deliberating on their options despite

(or because of) their often irreversible nature:

I think that worse than making a wrong decision is indecision. (p5, group A, extravert, resident)

We don’t ruminate. We tend to think, collect, and act. (p1, group A, extravert, surgeon)

Most participants also mentioned the importance of remaining calm and reflective through stressful situations, in order to make sound decisions:

…someone who can handle stressful situations and stay calm and think critically throughout them. (p9, group A, self-introvert/TIPI-extravert, resident)

Absolutely “sang-froid.” So the need to not panic in situations of crisis. (p13, group B, extravert, surgeon)

I think it’s someone who kind of like remains calm in the operating room. And if something’s not going the way that it should be going or if there’s any trouble.

That they’re not losing their cool, that they’re able to like proceed and continue to like manage the rest of the team. (p15, group A, introvert, resident)

Teamwork. While participants had different perceptions of the degree of group work involved in surgery–some considering surgery a social activity while others considered it a solitary activity–both groups also expected surgeons to be collaborate effectively with their teams when called to take on leadership positions. An effective leader works with his/her team even when directing them. Surgeons needed to be confident, firm, but also team players–not domineering or intimidating:

…you do have to be a good communicator and, because you’re constantly working with teams. Whether it’s taking care of patients or in the OR…you do need to communicate well with the rest of your team if you want to be effective. (p7, group B, introvert, resident)

…the [staff] shouldn't be intimidated by you. I think that’s what makes a good surgeon. That kind of…making it a…harmonious environment but they’re also the leader. (p10, group A, ambivert, resident)

I’m not sure about the word dominant, because dominant has a more like authority like control traits but here it’s like a team work. (p12, group B, extravert, resident)

Control. As seen in this previous example, participants believed that a good leader was able to maintain control of their team:

You need a doctor who’s capable of being the leader. He has to be able to respect obviously the other person, but still won’t let them take away the, take control of the medical management. (p13, group B, extravert, surgeon)

I guess that’s how you demonstrate your leadership. By your ability to, you know, take control of a chaotic situation. (p4, group B, introvert, surgeon)

And I think as a surgeon, you’re often put in a defacto leadership role when you’re in the OR… usually you have more of a say or more control of what’s going on than the anaesthesiologist. (p5, group A, extravert, resident)

Need to be dominant and assertive. For group B, one way to maintain that control

was by being dominant and assertive in one’s practice. Unlike group A, they thought it necessary for surgeons to be loud and dominant in these situations:

… you become more dominant in the operating room, just because you have to. (p6, group B, introvert, resident)

… you got to come in with a big voice, a big presence, you have to fill the room, you have to direct everyone and command attention…you have to be able to be the center of attention and feel comfortable in that role. (p8, group B, extravert, surgeon)

I’ll say assertive and leadership traits. So I’d say you have to have that in surgery because you have to make fast, quick, critical decisions in a short period of time…you have to be assertive. (p12, group B, extravert, resident)

...it can require you to be more assertive in situations than you may be used to. Like in trauma situations for example you have to be kind of loud and vocal. (p7, group B, introvert, resident)

Surgeons needed to be more aggressive in order for other staff members (who themselves were busy dealing with other responsibilities) to hear them.

…when you’re seeing consults and you’re trying to get other services to see your patient. You really have to be a little bit more–not convincing, but really get your point across that your patients sick and you need, they need this service to take a look at them to help you. So sometimes you have to be a little bit more aggressive, you know trying to get what you think is best for your patient, especially when resources are limited, everyone’s busy. So it’s really I guess…you become louder when you’re trying to advocate for your patient…not only do you have to be loud just so you’re heard, but you have to um–you know, it’s a team but somebody is always in charge. (p14, group B, introvert, resident)

This was in contrast with those in group B, who thought that being loud and aggressive was not necessary to being an effective leader:

If you're organized and you’re delegating tasks, you don't necessarily have to be loud and talking over others (p10, group A, ambivert, resident)

I don’t necessarily think that the person that is loudest in the room is being the most effective leader. (p15, group A, introvert, resident)

4.3.2.2 Confidence

For both groups, displaying confidence repeatedly appeared in the interviews as an essential part of being a surgeon. In particular, surgeons needed to show confidence in their decision-making:

…some degree of confidence in yourself and your decision-making. The ability to make decisions and you know like make them, firmly and competently and stick with your decisions. (p7, group B, introvert, resident)

Showing confidence was important for gaining respect from others and for oneself:

I would say displaying confidence…would help you in gaining respect from your patients, your co-workers, and would probably also help yourself. (p5, group A, extravert, resident)

The appearance of confidence may be more reassuring for patients and their families. One participant gave the example of a confident, enthusiastic surgeon who reassured a patient’s family with his smile:

Seeming confident gives the impression that we’re good. Whether we have the knowledge or not…when you go speak to the family, if you look sure of yourself, it’s probably reassuring…[the surgeon] was so happy about his case, when he came out he had this really big, big smile like this. Then he went to see the family…when they saw him, there was one that said ‘can I just tell you, the face that you have, it’s so reassuring’…compared to the one who says ‘I don’t know, I hope–I hope it’s going to go well. I don’t know.’ (p13, group B, extravert, surgeon)

4.3.3 The surgical personality

While the previous theme (The Nature of the Job) discussed which characteristics participants believed surgeons should have, this theme (The Surgical Personality) describes what characteristics surgeons do (or are believed to) have. In particular, this section explores perceptions of surgical stereotypes and the proportion of introverts and extraverts in surgery.

4.3.3.1 Surgeon stereotypes

Across the board, all participants were able to identify a number of stereotypes surrounding surgeons. For the most part, these stereotypes described surgeons as mean, arrogant, authoritarian, loud, and assertive; most character traits were pejorative.

Furthermore, participants in both groups often associated these traits with extraversion:

...I would say there definitely is a surgical type and in general that surgical type is loud, gregarious, self-confident, uh, an extravert. (p8, group B, extravert, surgeon)

I’d say the stereotype of a surgeon is extraverted. And I would say that stereotype probably exists for a reason. (p6, group B, introvert, resident)

I found that a lot of [medical students] have a pre-existing idea that you need to be extraverted to be in surgery. That there are all these crazy personalities and you need to be super intense all of the time and you need to be outgoing and that sort of thing. (p3, group B, extravert, resident)

Upon joining surgery, however, participants discovered that these stereotypes were mostly untrue:

I guess I just thought they were kind of more aggressive, outgoing, less thoughtful people. But that’s–I think that’s just a bit of a myth that–yeah, once I started meeting people in it I realized that that was–a myth. (p7, group B, introvert, resident)

I think it’s a bit of a high profile job which attracts extraverts and I think there was a bit of a misconception as to what it took to become a surgeon in the past and a lot of that was um–being sort of very strong, being loud, being noticed. Which would be associated with extraverts. (p5, group A, extravert, resident)

They attributed stereotypes to factors such as the traditional dominance of men in surgery, a paternalistic ideology, and historical factors such as glory-seeking surgeons in positions of power:

I think historically surgeons were, attracted more narcissists. Um, so not afraid to affirm themselves because they’re convinced they’re the best…so we’re perceived that way because that’s what we experienced. And the surgeons that weren’t like

that–well we don’t see them. Because they don’t speak up. (p13, group B, extravert, surgeon)

...there’s probably been some truth to it in the past. When I was a medical student, there were some surgeons who fit some of those stereotypes. Um, certainly had some of those characteristics. What’s portrayed in the media over time, that’s probably changed over time as well but…probably not a lot. But those are probably the reasons. I think there’s certainly people who fit those roles. (p4, group B, introvert, surgeon)

4.3.3.2 Dominance of extraverts

For the purposes of this research, I specifically asked participants about the relative proportions of introverts and extraverts in surgery. Figure v shows that most participants believed that there are more extraverts than introverts in surgery. Half as many participants believed that the proportions are relatively equal; only one believed that there are more introverts.

Equal numbers Group A (n=7) Personality doesn't matter Group B (n=6) More introverts Personality matters

More extraverts Beliefs about proportion of

introverts/extraverts in surgery 0 1 2 3 4 5 6 7 8 Number of participants

Figure v. Proportion of participants who believed there are more extraverted, more introverted, or equal numbers of extraverted and introverted surgeons. These proportions were based on the responses of seven participants from group A, and six participants from group B.

Among those who answered the question, all participants in group B believed that extraverts dominate the surgical profession, for the most part due to the nature of the job itself:

…the very nature of the job I say invites uh, extraverts… I think most surgeons sort of find somewhere in the spectrum towards being an extravert…90 percent or higher. (p8, group B, extravert, surgeon)

Extraverts. It’s more like a specialty that’s–that’s how it is, you know. If you’re an introvert, things can be hard for you. (p12, group B, extravert, resident)

In our group, introverts–there’s only one.... (p13, group B, extravert, surgeon)

Most in group A, however, thought that there were equal numbers of introverts and extraverts in surgery because pursuing the field is related to interest in the specialty more than personality:

I bet there's probably equal numbers…think it attracts people from both wal–both personality spectrums. And it has more to do with interest and uh, things like that rather than personality traits for why you end up choosing the specialty. (p2, group A, introvert, surgeon)

Many participants, from both groups, were initially under the impression that surgeons are mostly comprised of extraverts because you notice extraverts first.

However, they realized after joining surgery that it is probably closer to an equal mix:

…the first initial impression you get is that there’s only extraverts. But the more time you spend you meet more people and that’s when you get to meet the introverts? (p5, group A, extravert, resident)

I think people think that general surgery, so the extraverted ones kind of tend to go into it more. But just being around different staff surgeons, um, I've seen quite a few introverted ones as well. And–yeah I, it’s just makes based on experience I think that there’s half-and-half. (p10, group A, extravert, surgeon)

…initially I thought that surgery was you know, like dominated by extraverts. I think there are more introverts in surgery than I would have thought, as an…like now that I’m getting into it and I see more people that are like me. But I still, it’s probably dominated by extraverts, I would think. I think there’s more kind of outgoing types. (p7, group B, introvert, resident)

One even changed their answer to more introverts:

I would say that they're slightly more extraverts…you know, I will change that because when I think of participation in meetings, I think of–the extraverts are the people that are going to talk more…I'm going to say I think there was slightly more introverts. (p11, group A, introvert, surgeon)

Some participants, however, noted that there may be differences related to more specific specialties such as neurology (mostly introverted) and plastic surgery (mostly extraverted):

I would say that, you know, it may be different in Orthopedics. Then, may be different in neuro…neuro surgery maybe they may be more introverted, more like, but less risk-takers, private life. You know so, and then it might be different in plastic again. Plastics people tend to be more extraverted. (p1, group A, extravert, surgeon)

4.4 Perceptions of Introverts and Extraverts

The previous section described the culture of surgery and its values. I will now address how participants perceived introverts within that context. I will describe their perceived strengths and weaknesses in surgery, as well as other areas in which participants thought they perform equally to extraverts. In general, groups A and B agreed regarding introverts’ strengths in surgery, but disagreed about their challenges.

4.4.1 Definitions of introversion and extraversion

Participants described introversion and extraversion in similar ways. All participants defined them by their sociability:

I picture an extravert as someone who tends to, for lack of a better word, be more outgoing. Someone who tends to enjoy um, social activities and um, I guess puts themselves out there more. As opposed to someone who tends to enjoy more um, I don’t want to say solitary, but tends to enjoy you know self-directed activities, needs their alone-time, that kind of thing. (p3, group B, extravert, resident)

A notable difference between groups, however, was that several participants from group B specifically described introverts as “reserved”; not one from group A used this term:

Introvert would be someone more reserved, the extravert would be someone more comfortable with–expressing themselves more liberally. (p13, group B, extravert, surgeon)

[An introvert is] someone who, um, is a little bit more reserved, quiet… (p4, group B, introvert, surgeon)

4.4.2 Strengths of introverts

Almost all the participants in this study identified calm and reflexivity as introverts’ main strengths. They believed this to be useful in stressful situations:

I think um, being more introverted gives you more time to reflect on things. For example, when you’re learning to operate, there’s always like points in the procedure that you don’t understand or maybe you didn’t do a great job doing. And you know, sitting down and sort of reflecting on that and trying to think about how things can be different or better next time is a–an important aspect of training…staying calm and reflective in stressful situations. When people are sick or when traumas come in. (p9, group A, self-introvert/TIPI-extravert, resident)

I think they bring a lot of strengths to our team uh, as they’re often people who um seem to think through things a bit more even though it’s not necessarily true. They give that appearance that they’re more thoughtful in their decisions. (p3, group B, extravert, resident)

Their reasons for valuing calm included the importance of not becoming aggressive or excitable in situations where deliberate, quiet reflection leads to better decision-making. Their behaviour also reflected on their support team to create a more manageable work environment:

…rather than to kind of–getting angry or fly off the handle or–uh become very aggressive with people. Both in terms of working with patients and working with support staff in the operating rooms and places like that…anytime I’ve had difficulty in the OR, you know I’ve had bleeding and things like that I tend to approach it very calmly and rationally and I think that people generally appreciate that. (p2, group A, introvert, surgeon)

Uh, I think if someone’s easily excitable, that can very easily excite a room. And if you’re dealing with a trauma or someone who’s critically unwell, you don’t want an excited room. You want a calm room. You want a reflective room. Um, and I think uh, the person directing those particular scenarios, their personality has a lot of influence on the tone of that room and I think uh–I really do think a calm, reflective demeanour in those settings is more conducive to quality of patient care. (p6, group B, introvert, resident)

Introverts were also recognized for being thoughtful and intelligent whenever they speak:

The introverted person says nothing. When he says “I have an idea”–Good! It’s like we expect that they’re going to say something smart. (p13, group B, extravert, surgeon)

Well I think of some staff who sort of talk a lot in the operating room versus others who don’t. When someone who doesn’t talk much says something, people listen. Versus if someone’s talking all the time and they something, people might brush it off. (p5, group A, extravert, resident)

Being quiet and thoughtful also helped to counteract the negative stereotypes surrounding surgeons:

Um, you know I think, uh, sometimes surgeons have a, uh, stereotype of being brash. Uh, and I that, you know, like a bull in a china shop coming in and–uh, so you know I think being more thoughtful and considerate and empathetic to people around you are all, uh, all positive things. (p8, group B, extravert, surgeon)

4.4.3 Challenges for introverts

The differences in opinions between groups A and B were much more prominent when speaking of the challenges introverts face in surgery. Those in group A believed that introverts should not find the job of a surgeon any more challenging than an extravert would:

Because introversion extraversion doesn't affect learning. Doesn't really affect training. Doesn't affect your technical skills. So I'm not sure they should influence your surgical practice in any significant way. (p9, group A, self-introvert/TIPI- extravert, resident)

… in the long run…I don’t think it matters if you’re an introvert or an extravert

‘cause people are gonna use their own criteria to judge whether or not they’ll listen to what you’re saying. (p5, group A, extravert, resident)

However, the participants from group B viewed being an extravert as an overall advantage in the surgical setting:

…when I describe what an extravert is, I see them as all positive characteristics…maybe certain contexts, but to be honest, I always see those traits as being positive. (p8, group B, extravert, surgeon)

I think overall the communication skills, and if you’re able to kind of let people know where you are–I think that [being extraverted has] come out as an advantage overall. So no specific disadvantages um, that I can identify. (p3, group B, extravert, resident)

Group B named several areas as potentially challenging for introverts. I will describe these themes in the following sections.

4.4.3.1 Introverts’ leadership skills

Groups A and B disagreed significantly in their perceptions of introverts’ leadership skills. Group B believed that while both introverts and extraverts are capable of being effective leaders, extraverts possess certain personality traits that make them more prepared for the role.

Introverts were seen as less assertive. In particular, group B described extraverts as being more clear and assertive in their communication with staff. This allowed their co-workers to hear them over the noise of busy emergency situations:

…I think in the operating room, being extraverted is really good. So much of it relies on communication. Right? Uh, being clear, being assertive, being dominant, uh, ‘cause you really are directing that room. You need to make sure that individuals are listening to what you say when you’re operating. And you know, if you’re, you know, a more quiet type, it’s really easy to, you know, get drowned out in the noise. (p6, group B, introvert, resident)

Where I do see people having difficulty are in things like traumas. Where there needs to be someone who’s very vocal and directing a team, and I find that those instances can perhaps be difficult for those individuals…it’s a very loud, busy

environment and if there are too many people it can be tough to manage. And people can be talked over and that kind of thing. (p3, group B, extravert, resident)

If you’re an extravert, you’ll be more assertive. You’ll be more vocal about what you want in the OR when things are not going well. So you have to be the leader in the OR. (p12, group B, extravert, resident)

One extraverted participant had a particularly strong opinion of introverts’ communication skills. This individual believed that introverts tend to avoid interacting with their team, which negatively impacts patient care:

If you’re an introvert, things can be hard for you. Because if you’re not a people person and you don’t want to be around people, then in general you shouldn’t be in a busy service dealing with patients every day… [if I were an introvert], I would have hard time dealing with other physicians when I talk to them on the phone or even in person. I would be reluctant to go start conversation with like other health care professionals. So I think that would potentially affect patient care because you’re not doing what you’re supposed to do. (p12, group B, extravert, resident)

Other participants–including one from group A–believed that introverts may be more prone to having their power taken away from them:

…in a multidisciplinary meeting, in the relationships with your peers, there are other extraverted people who will say ok, I’m going to take your place now…he has to be able to respect obviously the other person, but still won’t let them take away the, take control of the medical management. (p13, group B, extravert, surgeon)

…if you’re too introverted then people are gonna walk over you. (p10, group A, ambivert, resident)

Decision-making. Group B thought that introverts may have more difficulty making rapid decisions based on limited information. They reasoned that introverts tend to consider all their options before making decisions. To these participants, introverts appeared more hesitant:

…you have to own those decisions and so I think those features and demands of the job attract a certain personality you know. Um, to be thoughtful and quiet and consider all the options...uh, you're going to miss the boat and the patient would

be dead. So you know I would think of stereotyping like an internist would be someone that would be more in that role they like to, you know, very carefully consider all the options and quietly think about things. Um, although there are times that you might do that as a surgeon. Particularly if you're doing emergency surgery or trauma surgery, then you do not have that luxury. You know, you have to make a decision and move forward. (p8, group B, extravert, surgeon)

I mean they tend to be…they tend to be more pensive when making decisions…it may seem like they take a bit longer to think about things. They don’t have a sort of off the cuff response to a lot of questions. (p3, group B, extravert, resident)

I wonder if an introverted person is less comfortable with making rapid decisions…you know, they seem to ruminate each decision because they care a lot about their patient, because they care more than I–I don’t know, but it’s the impression they give. But at the same time, they seem more hesitant. Less comfortable with difficult subjects. (p13, group B, extravert, surgeon)

The latter participant had experience with an introverted colleague who tends to ruminate over past decisions:

I wonder if an analytic person will suffer more. Um…because it’s as if…because I have some, some colleagues, friends, colleagues who are introverted and everything. They’re excellent in what they do. But–I have the impression he’ll take his retirement early. Even on vacation he can’t detach…an analytic person, living with the consequences afterwards. (p13, group B, extravert, surgeon)

Introverted participants also perceived these difficulties in themselves and in their introverted colleagues:

I think it’s something I learned to be more comfortable with, as I started surgery. Uh, just being confident in what you do. Like even in medical school I would always be like really hesitant about doing things. Um, whether that’s procedures or making decisions–like management plans for patients. (p14, group B, introvert, resident)

…we’ve had some pretty quiet residents over the years. Would be a small number. But yeah, they kind of hide. And those have certainly been some of the residents who probably haven’t finished the program–sometimes it’s um, you know. A lot of it comes down to [difficulty making] decisions. Um, be comfortable with them, um, accept that you’re going to make some mistakes along the way. (p4, group B, introvert, surgeon)

Introverts were seen as less natural-born leaders. In general, the extraverts in group B felt that their personalities made them more prepared to take the lead and command the attention of their groups. In fact, they saw taking on a leadership role as a natural extension of their personality:

[Being the leader is] a personality trait. It doesn’t stress me out, those types of things. (p13, group B, extravert, surgeon)

...you got to come in with a big voice, a big presence, you have to fill the room, you have to direct everyone and command attention. And that's all intro–I’m sorry extraverts. (p8, group B, extravert, surgeon)

The introverted residents (although, not the introverted surgeons) in group B saw leadership as a necessary skill to develop, but that was not innate:

It probably took me longer to uh, get to the point where I wasn’t feeling shy. You know where I felt like I had the skill set required to uh, direct the team. Uh and that’s a slow process. I think it’s probably a slow process for everybody. Perhaps introverts more so than extraverts. (p6, group B, introvert, resident)

…it’s unnatural for me but I kind of have to force myself just to talk louder and to be the person that’s kind of leading things and having everybody look at you and be the one directing the conversation and that’s kind of an unnatural and uncomfortable place for me to be in but it, once I know that I’m in that role, it sort of–I just get into that mindset and you can do that even though it’s not something you would do in your daily life. (p7, group B, introvert, resident)

In contrast, the extraverted residents did not mention any particular difficulties with leadership. They did not feel that it was an unnatural position for them to be in, and many felt that their previous experiences had sufficiently prepared them for the role:

The leadership in surgery has been…I guess, not minimal but lesser than it would as a senior resident? That being said, I held a few different leadership positions before, so I didn’t find it such…I haven’t found it’s been a big jump moving into a surgical residency. (p3, group B, extravert, resident)

Disagreement with group A. Group A had a different perspective than group B.

Group A (personality doesn’t matter) believed that introverts should have no more

trouble taking on the leadership role than extraverts, as long as they are willing to work with their peers:

So introverts tend to want to look up everything on their own. But there's also the um, academic collegiality…I think I was always willing to discuss, what would you do, how would you do it. That's patient care not introversion extraversion I suppose. But I don't think there are barriers as long as you're willing to communicate and talk and interact and keep up and–go to meetings and to the presentations. (p11, group A, introvert, surgeon)

…being more like quiet or reflective doesn’t mean I can’t like go and speak to other people or get plans done or things like that. (p9, group A, self- introvert/TIPI-etravert, resident)

For one participant, the benefits of being extraverted become insignificant over time, as trainees become more familiar with their co-workers:

I think an extraverted personality probably gets noticed faster, which if you’re working in an environment where people don’t know you, that may play in your favour. If you need to rapidly need to take control of a room in an acute situation, then an extraverted personality would benefit you. But in the long run I think…95% of the time when I’m talking to another staff person here I know them personally or I’ve worked with them. And um...so once you have a relationship established, I don’t think it matters if you’re an introvert or an extravert ‘cause people are gonna use their own criteria to judge whether or not they’ll listen to what you’re saying. (p5, group A, extravert, resident)

Some participants from groups A and B alike could agree that leadership is likely only an issue for introverts who fall on the extreme of the spectrum:

...if you don’t do well in group settings in the workplace then you would struggle to succeed in, in surgery I think. That being said a lot of people don’t enjoy social situations and are introverts but work very well in team settings. (p5, group A, extravert, resident)

I guess, when I think about introverted-extraverted, at the extreme the introverts never–are not gonna speak up and say what they need to say. I’m more than happy to speak up in a meeting or a group setting to say whatever I need to say which is why I wouldn’t put myself as a 1 on the introverted scale. (p4, group B, introvert, surgeon)

One introverted resident added, however, that taking on the role of leader is difficult for everyone, not only introverts:

[Being the leader is] not something I’m comfortable with but I think as you…as you progress it’s just being in that situation over and over again, you become more comfortable assuming that role. But I don’t think it comes natural–very easy to many people. (p14, group B, introvert, resident)

Furthermore, participants thought that both personality extremes could negatively affect leadership. Some associated extraversion with aggression, arrogance and impulsivity:

If you’re too extraverted I think you’ll get into fights I think and lose that respect. So both sides–but you need an appropriate degree of both. (p10, group A, ambivert, resident)

…often we associate maybe extravert with arrogance…we’re maybe less patient when we’re…often we place extravert with impulsive. I try to rid myself of my impulsivity. (p13, group B, extravert, surgeon)

Similarly, one participant described how being loud and aggressive may only be useful in very unique situations:

I don’t know if one personality type, outside of you know the very unique high- stress, high pressure operating room scenario is particularly beneficial. (p6, group B, introvert, resident)

Confidence. Although participants thought that both introverts and extraverts were capable of displaying confidence, they more commonly associated this trait with extraversion:

…I'm much more extraverted with patients because it's a one-on-one and because um, they're there seeking out information and I'm the source of that knowledge so it’s very easy to be confident and more talkative than usual because you're telling them stuff they need to know. (p11, group A, introvert, surgeon)

So an extravert is someone that enjoys other people that is social. Um, gregarious. Um, generally (not always) self-confident. (p8, group B, extravert, surgeon)

Not only did participants associate extraversion with being more self-confident, but they saw extraverts as more easily able to project confidence:

I think other people are better at kind of projecting, faking it kind of thing…if you’re more introverted, people potentially could be perceived as um–you know maybe having less confidence or being less confident and–you know if you have the skills and the knowledge to back up what you’re doing, then I think people see that. But, in more extraverted people they may just project that a little bit [more] clearly and just command a little bit more kind of espect- respect and–reassuring, be more reassuring when they come into the room. (p7, group B, introvert, resident)

…displaying confidence, which is probably more associated with extraverts… (p5, group A, extravert, resident)

Participants proposed other reasons for the perception of introverts as less confident. For example, being more quiet and analytical gave the impression of doubting oneself:

I am on the quieter um, end of things yeah, so I think, um, that can sometimes probably be perceived as being you know less–of me being less sure of myself or um, not as competent. (p7, group B, introvert, resident)

The more analytical person, gives the impression of doubt. Being too analytical sometimes gives the impression that it’s because…the person is doubting him or herself…we are under the impression that they’re more hesitant. Um, less sure of themselves. (p13, group B, extravert, surgeon)

Others perceived this quietness–and thus, perceived lack of confidence–as a lack of competence:

…often the person who stands out the most, you know who expresses himself the most, can pass on the short term as if he was better than the others…Extraverted personality stands out. It doesn’t mean he’s better; it’s just–sometimes the impression that it gives. (p13, group B, extravert, surgeon)

…when I have those introvert characteristics, so uh, probably initially maybe the staff surgeon or like the seniors might not think that I'm doing the job because I might not be as vocal…. (p10, group A, intro/extra, resident)

Surgical faculty and staff interpreted not speaking up as not knowing:

If you don't speak up, people are gonna assume it's because you don't know. And so you're uh, you need to take those opportunities to shine and so it definitely it would be a challenge for an introvert to get the recognition of what's going on inside. (p8, group B, extravert, surgeon)

It can be difficult for them, um, given the environment that we work in because if they don’t have an answer right away, they’re viewed as not knowing things. And in addition, with all the different nuances with relationships with nursing staff, and other health professionals. If there isn’t an answer right away, it can be viewed as they don’t know what they’re doing. (p3, group B, extravert, resident)

…it comes up every now and then in evaluations that you know, you should just make sure that you speak up more and like people know that, you know if you kind of volunteer more information, they’ll know that you know what you’re talking about and that kind of thing (p7, group B, introvert, resident)

They also misinterpreted being less vocal and proactive as a lack of interest:

…or if the staff, you know, if you’re not kind of more proactive in going and seeking them out and talking to them about things, they may think that you’re less interested. But that’s not necessarily the case. (p7, group B, introvert, resident)

Not all participants associated extraversion with confidence, however. A number of participants in group A did not believe introverts display less confidence:

I don't think, you know, being an introvert or extravert makes any difference to your confidence and how you, like, display yourself. (p1, group A, extravert, surgeon)

I don’t think that introverts display less confidence. They just display less. (p5, group A, extravert, resident)

4.4.3.2 Introverts’ lack of relationships with staff

One of the most consistent findings in this research was related to introverts’ lack of personal relationships with staff. This was seen as affecting introverts both personally and professionally.

One participant believed their introversion to be at the root of their lack of friendly relationships with staff. This had an impact on their sense of belonging:

I think people like to feel like you're part of the group and um... hail-fellow-well- met and that's not who I am so I don't think [introversion] benefits me, no… [VL: If you were more involved those social situations, what benefits would that bring you?] Um…just more social acceptance. More, um, feeling part of the group. (p11, group A, introvert, surgeon)

Introverts agreed that being more social may help them advance their careers:

...that I don’t wan’na go and spend time talking to a bunch of people after work too. And I don’t think it’s, it’s not necessarily in line with my career goals but potentially you know, if I were more involved in those kinds of things, making connections, that could potentially be of benefit. (p7, group B, introvert, resident)

…that’ll probably hold you back in terms of advancement because I think that, squeaky wheel gets the grease and stuff like that in terms of advancing through the academic ranks and stuff like that. (p2, group A, introvert, surgeon)

…there’s a very big social component that underlies everything we do in the hospital…I think that if I were more introverted it would’ve been a little bit more difficult for me to establish those types of relationships and by establishing them, I’ve been able to accomplish things though them. So, for example, the charge nurses on our ward. I would, you know, first name basis, we’re always you know talking and establishing a good work relationship. And I feel that you know, being a bit more extraverted helps with that. Being able to go and introduce yourself to someone and being upfront and honest all the time–not that people who are introverted are dishonest but being able to talk through what you’re thinking…. (p3, group B, extravert, resident)

Extraverts, on the other hand, spoke of how their sociability lead to positive relationships that helped further their careers:

If I’m known to be friendly with the people who organize the OR, I might get away with more than someone who–didn’t. (p5, group A, extravert, resident)

You know, you meet people better. I got my fellowship because I probably met people well and so that kind of thing…I think that probably helps you go further, career. Like who you know, not what you know right? (p12, group B, extravert, surgeon)

If you’re dynamic and sure of yourself, well I was chief resident, you know. Probably that’s why I got the job here. People remember you and call you. (p13, group B, extravert, surgeon)

4.4.3.3 Relationships with patients

Group A thought introverts handle social situations well, as long as they adapt themselves to their patients:

Well I think that how you approach somebody affects how they approach you back. Uh, if they get the impression that we’re not listening to them or we're trying to talk over them or push through them, they react negatively generally to the situation like that. On either hand, if you're not responding to them and giving them the response they need, they react negatively as well. I think that there has to be that interplay that people need. I think that different people act differently so. (p2, group A, introvert, surgeon)

One introverted participant from group A believed that introverts are equally capable of having positive relationships with their patients; however, she mentioned acting much more extraverted during these encounters:

I'm much more extraverted with patients because it's a one-on-one and because um, they're there seeking out information and I'm the source of that knowledge so it’s very easy to be confident and more talkative than usual because you're telling them stuff they need to know. You’re, you are trying to develop a trust relationship. (p11, group A, introvert, surgeon)

Participants from group B disagreed across the board on the quality of introverts’ relationships. Some thought introverts may have more difficulty forming bonds with their patients than extraverts:

‘Cause if you’re an introvert–let’s say you have a patient and two physicians. One introvert and one extravert. The introvert won’t stimulate conversation with the patient, may not engage much with the patient, and actually sometimes when you keep talking with the patient, they keep telling you about the condition and you can just probe and discover few things that they’re suffering from, just from talking to them. And I think if you’re talking to the patient that will have a good patient rapport. And patients will trust you and uh, try to be open with you and tell you the information you need. (p12, group B, extravert, resident)

…it’s harder to make a connection sometimes for somebody who's an introvert. (p1, group A, extravert, surgeon)

Others, still, believed that introverts have qualities that actually make their relationships stronger. Introverts were good listeners, and less likely to make their patients feel as if their physician were brushing off their concerns:

So when they're [extraverts] talking to patients, they’re not as…it feels like they're brushing off the patient if the patient brings up a concern because they have their own agenda just…brush off the patient concerns and the patient doesn’t feel like they’re being listened to…. Whereas an introvert person, they’ll probably listen to the patient’s concerns and try to address a, have a discussion. (p10, group A, ambivert, resident)

I think introverts can be, if they’re good at connecting with people quickly by kind of getting on their emotional level and reading what they need and that situation, then maybe they have a better interaction. Versus somebody that just comes off as a bit abrasive and–um, you know in a rushed interaction if the patient doesn’t feel like they connected with them at all…I find if you’re a bit, like calmer or quieter sometimes you get more out of the patient or they open up to you a little bit more. (p7, group B, introvert, resident)

…the doctor is supposed to listen. You don’t have to make a show. Um, so I probably had to learn to listen more–more than someone introverted and that would be easier for them. (p13, group B, extravert, surgeon)

4.4.3.3 Introverts have equal knowledge, but extraverts get noticed

All participants agreed that introversion probably has no effect on knowledge and/or surgical skill:

Because then if you think about it, it's like okay, an introvert may study alone, an extravert may study in a group, the bottom line is the knowledge you attain is going to be assessed by an exam purpose and they should not differ whether I trained this way or that way my knowledge base and ability should be similar if I'm getting assessed and passed. I should have attained the same knowledge. (p11, group A, introvert, surgeon)

One participant thought that while individuals with either personality are equally competent, extraverts may appear more competent because they “stand out” from the crowd. They found it important to be heard in order to be noticed:

…the one that gets the attention, you know the one who expresses themselves the most, can pass on the short term as if they’re better than the others. For the

attendings. You know they’ll remember you, they’ll say “Hey! He was good, that one!” If you’re not afraid to answer, if you’re sure of yourself, they’ll say “perfect, he’s good.”…The extraverted personality stands out. It doesn’t mean he’s better–it’s just. Sometimes the impression that it gives. (p13, group B, extravert, surgeon)

Summary

After first highlighting how participants defined the terms introversion and extraversion, this section described what participants perceived to be the strengths and challenges of introverts in surgery. There were areas in which all participants agreed, and other areas in which they disagreed. Generally, participants from both groups A and B believed that introverts’ main strengths in surgery were their calm and reflexivity. They thought that introverts likely had equal knowledge and technical skill to extraverts. They thought that a main challenge in surgery for introverts involved the relationships they had with staff, particularly as it related to career advancement.

In contrast, there were differing perspectives on the relationships introverts have with their patients even within each of the groups. Further, group B generally believed that introverts may have more difficulty than extraverts with leadership, because they tend to be less assertive, more hesitant, and less natural-born leaders. Group A tended to believe that their skills in this department were generally equal.

4.5 Outcome

Perceptions of the strengths and challenges of introverts had important implications for their experiences in surgery. In particular, participants (group B much more than group A) believed that personality could affect both career choice and residency training.

4.5.1 Effect on career choice

For those in group B, personality was an important factor for career choice. Being extraverted facilitated the choice of surgery as a career; the extraverts in this group saw themselves in the stereotypes of the “typical surgeon”, as well as in the surgeons they had previously encountered and admired. They identified with their peers and pursued surgery because of it:

I felt I clicked very well with the surgery group. The reason why, ‘cause I like–to be assertive. I like things to be done. (p12, group B, extravert, resident)

The following stories of how two extraverts chose to specialize in surgery illustrate this feeling of belonging:

…part of the career making process or career decision is as you rotate though different things you will do some rotations that you just don't feel like you belong. You know, and part of that is personality. Like I did not belong in Psychiatry. Like there's just a vibe there that, you know, I was very different than them. And then you go to surgery and you feel like you're just like oh you're one of the team! You know and you know it was very easy to slip into that role and feel like... you know. In some ways you know, surgery sort of feels like a frat house you know where, you know, you sort of belong to something and sort of boisterous like a frat house at times so sort of speaking to the extravert nature of that. So you know and you go on internal medicine, I think people that are in Internal Medicine you know when they rotate through surgery they sort of like, they roll their eyes and you know if you can imagine taking a member of the chess club and putting them with the football team they would sort of feel like oh god.... So I think you realize a little bit through your personality traits where you will shine. (p8, group B, extravert, surgeon)

…when I got into medicine, I saw myself as a surgeon because of these stereotypes…there’s a proverb that says ‘those who resemble each other, assemble’ [i.e., birds of a feather flock together]. I was pretty sure I wanted to be a surgeon when I got into medicine. The people I made fast friends with had personalities like mine, wanted to go into surgery too. They presented me to residents in surgery with whom they trained and stuff like that and I felt that it was my gang. When I started R1, I had the impression I was in my gang. It was, it was all extraverted people. I had the impression we resembled each other. (p13, group B, extravert, surgeon)

One extraverted participant even felt uncomfortable being with introverts, because this personality was so different from their own:

And when there was one that, that didn’t resemble that, I was less comfortable with them…. The extraverted surgeon, if you do something wrong, he’ll tell you right away. You know right away. The one that says nothing, you wonder maybe they’re, maybe they’re judging you, you make a mistake and they don’t say anything or they don’t like you and they don’t say anything. (p13, group B, extravert, surgeon)

The introverts, on the other hand, either did not think their personality wasn’t fit for surgery, or pursued surgery regardless because they loved the subject matter:

…initially I hadn’t thought about surgery until I did my rotation in 3rd year of medical school and I really liked it. And I had thought, kind of had some preconceptions leading into that that I, you know I thought, you know, I didn’t really fit in surgery, my personality didn’t fit. And even when I was going through the application process there were people that would say that to me. Like oh you, it doesn’t seem like–you know I’m surprised you would do that, or it doesn’t seem like that would fit you. But um, it didn’t. I kind of persisted despite that so. And now that I’m doing it I see all of these other elements of my personality that do fit perfectly with it so. (p7, group B, introvert, resident)

[Introversion/Extraversion] may affect your performance in surgery or your success in surgery but I think the interest is born more out of the disease processes that are involved and the interest in technical skill…I thought it was more engaging to be surrounded by the general surgery types who were generally a little more dominant, you know a little more uh talkative or sociable and um...so yeah. I think it definitely played a role. I liked the surgery personality more so than anything and I think that influenced my decision. (p6, group B, introvert, resident)

…it has more to do with interest and uh, things like that rather than personality traits for why you end up choosing the specialty. (p2, group A, introvert, surgeon)

Because many perceived that extraverts dominate surgery, one could question how introverts face living as the “minority” group. While extraverts chose surgery because they resembled their colleagues and wanted to be with other extraverts, the introverts had no problem being surrounded by the opposite personality. In fact, introverts actually enjoyed being with extraverts:

I think introverts and extraverts can both agree that extraverts are generally more fun. You know what I mean? The extraverted personality type is usually pretty engaging. (p6, group B, introvert, resident)

I guess, sometimes you know I feel like, maybe a little bit less heard but it’s okay with me because I feel, you know, a lot of my close friends are more extraverted types so I feel that that works for me because I feel that the burden on me is less to kind of be the person that drives all the conversations. So similarly I don’t feel uncomfortable being in a group of my colleagues because, I feel like our personalities work. (p7, group B, introvert, resident)

4.5.2 Introverts adapt by acting more extraverted

Need to conform. Participants from both groups described how, at the beginning of their training, students start off “undifferentiated,” ready for the training process to mold them into someone with the traits of a competent physician:

…you know, you come in as a first-year, you’re kind of undifferentiated. (p1, group A, extravert, surgeon)

…people that sort of come into the program a square peg, we in general–the surgical residency and the process, tries to fit them into a round hole. And unless you are able to conform and find your way, you're going to struggle a lot (p8, group B, extravert, surgeon)

Trainees learned how to behave by observing others. Some expected them to

“conform” to an accepted way of behaving, and to adopt the normative values of the surgical community:

And I think it’s something that you learn from association that, you know, imitate people. (p1, group A, extravert, surgeon)

I think we all try to mold ourselves during our training into you know, a reflection of our mentors in some respect? Um, and I’d say the majority of the mentors in my profession are fairly extraverted. (p6, group B, introvert, resident)

… I think a part of any training program is adopting certain normative values…part of the training program is this process of socialization (p8, group B, extravert, surgeon)

Acting extraverted. Group B felt that it was important for introverts to be able to act more loud and dominant while at work:

…you become louder when you’re trying to advocate for your patient…. Almost anyone you interact with–there’s certain points where you have to be a little bit more, um, not as quiet and passive. (p14, group B, introvert, resident)

…if you are an introvert and feel uncomfortable being the center of attention, then you aren't going to succeed as a surgeon. You know, one of the things we teach residents who may be, have tendencies to be more introverted, is that you gotta fake it to make it you know if you're running a trauma you got to come in with a big voice, a big presence, you have to fill the room, you have to direct everyone and command attention…if you are going to take it to level, to the next level and be mastering you have to suspend yourself and adopt this alternate persona. So whenever the trauma team leader or there's a crisis in the operating room, you have to make yourself larger than life. You have to become the person that is going to take charge and direct and so uh, that might not be completely within a person but it's part of the training process…so you would have to be one of these people that in the right contexts are able to switch it on you know and uh, step outside of themselves and you know it would be like, you would be this very calm, quiet person but when you need to like a big and loud and decisive…. (p8, group B, extravert, surgeon)

Introverts did so through an active process of forcing themselves out of their comfort zones:

So yes, in some respects it’s been an active process to try to learn, or become comfortable with uh...some of the more extraverted traits. You know, try to force myself to be uh, more talkative or more social or more–uh, dominant or authoritative. Because that’s what I see as the successful surgeon. (p6, group B, introvert, resident)

…mostly it’s just forcing yourself to do things that are uncomfortable. You know. To talk louder than you think you should and, just be, sometimes acting more confident than you actually feel. Um–yeah. Mostly just pushing yourself to do the uncomfortable things. (p7, group B, introvert, resident)

I think especially for…you know people who are more introverted. Acting out of your comfort zone and being more “extraverted”…personally, sometimes I’ve felt like that. You know, this isn’t really me, but I have to be like that at this point in time. (p14, group B, introvert, resident)

Trainees naturally developed confidence and more assertive traits over time:

…now I’m second year so I have more people kind of, under me so more as a second year, R1’s and more medical students so in terms of managing them, um, I’m find, I’m finding that so, I have to keep in mind about giving them tasks to do, making sure things are getting done. So I think in that sense I’m more commanding. (p10, group A, ambivert, resident)

…as people advance and get more comfortable in their training and their skills uh–and as they become more senior just through a maturity process than they're usually able to–sort of conform you know. (p8, group B, extravert, surgeon)

I’ve seen, from experience as a medical student seeing someone who is an R3 for example, who may have had difficulty with that, as they move toward an R4 or an R5, they’ve experienced it and they have strategies to manage that particular situation and they, and everything goes very well. (p3, group B, extravert, resident)

Acting versus becoming more extraverted. To some, it was unclear if surgery attracts certain personalities or if they become a certain way because of it:

…there’s always a bit of a debate you know is it you become that way on account of the training or you were like that in beginning and we just enhanced certain aspects that were already there. (p8, group B, extravert, surgeon)

Because the exposure you get in surgery, it’s quite long days of work, so you get exposed to different people, different personalities. So I think that would make your extravert characters like flourish and actually become more prominent. Even if you are an introvert, you can actually switch. (p12, group B, extravert, resident)

Despite acting more extraverted at work and forcing themselves to take on leadership roles, the introverted participants did not truly become extraverts:

[on becoming less introverted] Maybe a little bit less. Since I’m used to, you know, having to interact with people all day, it doesn’t, I don’t you know, worry about it at all. I’ve noticed that I have more confidence in certain things like public speaking (p7, group B, introvert, resident)

I wouldn’t say it’s something that I’ve ever become comfortable with, or something that I ever feel has truly been incorporated into my personality. (p6, group B, introvert, resident)

4.5.3 Consequences of acting extraverted

The introverted participants in Group B saw acting more extraverted as potentially tiring for introverts over time:

…in the moment it’s not, but I guess if I thought about it afterwards, it would be you know, being in that role all day would definitely kind of wear me out I think…. Just on the personal end of it, like the personal well-being end of it. If you’re more introverted, it potentially could be more draining and lead to like higher rates of burnout if you felt like you were drained at the end of the day from your interactions at work. Versus if you’re more extraverted, you potentially have more energy at the end of the day to kind of devote to other relationships in your life. (p7, group B, introvert, resident).

I think especially for…you know people who are more introverted. Acting out of your comfort zone and being more “extraverted”, it takes almost um–it just takes energy out of you. And I think people who are introverted need a bit more time to recover from that. So I think that in a certain way, you do–you are affected by acting out of your comfort zone. Um, obviously it gets easier and easier but I think at the same time, it’s not exactly who you are at some point. (p14, group B, introvert, resident)

The second participant expressed becoming more introverted at home as a consequence:

I’ve been forced to be more extraverted at work, but when I’m not here and I can revert to whatever I want, I think I’ve become more introverted than I was prior to surgical residency…it’s kind of been a weird dichotomy that way. I’ve become more extraverted in my professional sense, but probably more introverted than I want to be in my home life. (p6, group B, introvert, resident).

However, participants did not believe this behavior was, overall, destructive to their well-being:

I don’t feel like it’s been a huge struggle. (p7, group B, introvert, resident)

I’ve never thought to myself, oh God if only I could act myself, this would be so much easier. No. It’s just a part of the job. (p6, group B, introvert, resident)

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4.5.4 Both personalities have to learn to adapt

The need to adapt was not unique to introverts. Both introverts and extraverts should use their strengths to their advantage:

I think you can use what, you know your personality traits to your advantage. Knowing that there’s some weaknesses that you’ll have and you’ll have to make up for that in other ways…I don’t think it’s been a huge disadvantage to me. I think I’ve been able to work around the things I need to work around. (p7, group B, introvert, resident)

...everyone has their own sort of style. Um–but I think patients do too and what they expect from a physician. (p9, group A, self-introvert/TIPI-etravert, resident)

I just think you learn how to manage the person you are and what you want to be. (p12, group B, extravert, resident)

Personality preferences also depended on the patient/colleague. However, one participant held that in the end, adapting our personalities was not that important:

I find some patients enjoy um, a more extraverted person, especially someone who will talk to them a lot about things other than surgery. And others appreciate a very professional relationship that is strictly medical…. You have to adapt, for sure. Or you know if you don’t want to that’s fine. (p5, group A, extravert, resident)

Chapter Summary

The main results of this study are illustrated in Figure vi. Groups A and B displayed areas of disagreement and agreement in the three main categories of themes.

Contrary to group A, group B saw surgery as a social activity in which being loud and dominant is important, with the majority of surgeons being extraverted. In general, group

A felt that introverts had the same abilities as extraverts, while group B perceived introverts to be less confident, assertive, dominant, and more hesitant than extraverts.

They believed that introverts may experience more difficulty maintaining control of acute, busy emergency situations. Hence, group B (but not group A) felt that personality

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may have an effect on specialty choice, and that introverts need to act more extraverted in order to succeed in the specialty.

Figure vi. Summary of results

The results of this study showed that certain values are universal in surgery (e.g., being knowledgeable, a hard worker), while others can be debated (e.g., being loud, dominant; approaches to being a leader). These beliefs, combined with individuals’ sense of introverts’ and extraverts’ abilities, influence how they think different personalities can succeed in the surgical workplace.

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Chapter 5: Discussion

The goal of this research was to explore how general surgeons and surgical residents perceive introverts as surgeons. We sought to understand what behaviours and personality characteristics surgical specialists value and, within that context, what they perceive as the strengths and challenges for introverts who decide to pursue a surgical specialty. We also aimed to determine if and how those in the specialty believe that introverts should adapt to the surgical workplace. The results described two distinct groups of participants: those who believed that introverts and extraverts experience surgery in similar ways with neither being faced with more difficulties than the other

(group A); and those who believed that both introverts and extraverts can succeed in the surgical profession, but that introverts face challenges in surgical training that extraverts are less likely to be faced with (group B).

In this chapter, I will discuss the implications of the research findings. The theoretical implications (section 5.1) appear in a sequence similar to the results: context/expectations (5.1.1), perceptions of introverts and extraverts (5.1.2), and outcome/consequences (5.1.3). A central idea that links all the three themes together is the identification of two distinct cultures of surgery: equality and extraversion. Following this, I highlight practical implications (5.2) that may provide guidance to improve introverts’ and extraverts’ experiences in surgery. Section 5.3 provides direction for future research on the topic. Finally, I will review the limitations of this study.

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5.1 Theoretical Implications

5.1.1 Surgical context/expectations

All the participants in this study described the ideal surgeon as knowledgeable, technically skilled, and hard-working. Effective leaders were seen as respectful, collaborative, and able to make difficult decisions under stress. It makes sense that these values are common to all surgeons and residents, because each of these are embedded into medicine’s formal curriculum. In fact, most of these competencies can be found in the CanMEDS framework (Frank, Snell, & Sherbino, 2015) under the roles of medical expert, collaborator, and leader. Among these roles, some of these expectations were difficult for participants to meet; for instance, the relationships surgeons had with their patients were described as intimate, but limited by time constraints.

Other expectations originated more from the informal and hidden curriculum than from the formal curriculum. Participants described the need to be confident and to appear calm during stressful situations. They believed that effective leaders maintain control of their team by making decisions quickly, without hesitation. Ruminating over whether one has made the best decision was seen as counterproductive. These core values pressured trainees to act in ways that were sometimes counter to how they would normally behave.

The literature has described a number of implicit values and norms inherent to surgical culture, having characterized surgeons as bold and authoritarian with thick- skinned mentalities (Borges & Osmon, 2001; Coombs et al., 1993; Thomas, 1997). Hill et al. (2014) described surgical culture as being competitive, masculine, and requiring sacrifice; to succeed in surgery, residents need to “walk the talk” (p.888) by appearing confident, harsh, and assertive. Ott et al. (2018) showed that surgeons interpret hesitation

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as a lack of knowledge, confidence, and/or competence. Similarly, the surgical residents interviewed in a qualitative study by Patel et al. (2018) on impression management described the expectations they felt to act according to the profession’s normative values.

They felt social pressures to be “all-knowing”, “quick”,” decisive”, and “confident” (p.

770). The authors suggested that trainees learn implicit rules through surgery’s hidden curriculum, which influences them to behave in ways that are sometimes harmful to themselves and their patients. Hence, the current study demonstrated that these long- established expectations to appear calm, confident, and decisive remain pervasive in modern general surgical training.

Two distinct sub-cultures. This study diverges from previous research, however, for one important reason: in many instances, our participants profoundly disagreed with each other. In fact, we found two distinct narratives that represented two unique ways of perceiving the culture of surgery. The most prominent area of disagreement, related to the nature of the surgical workplace, concerned the importance of sociability.

On the one hand, when asked to describe the job of a surgeon, group A tended to emphasize the non-social aspects of the profession as much (if not more) than the social ones. One participant even saw surgery as a solitary profession. Further, when discussing the importance of communication skills for surgical practice, those in group A stressed the distinction between “professional” and “friendly” relationships surgeons had with patients and staff. For all those in group A, the surgeons’ role was, first and foremost, to care for their patients; they did not see developing personal bonds and engaging in small talk as particularly beneficial. What is more, in terms of leadership skills, group A thought that good leaders were not necessarily loud and dominant; introverted surgeons

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demonstrated their leadership by making sound decisions and communicating their needs in a respectful manner.

In contrast, the participants in group B saw surgical practice as highly social, and their descriptions of a “typical day” as a surgeon involved constant social interaction.

They placed teamwork at the core of their clinical practice. They believed that being outgoing and sociable helped surgeons be more effective in teams and with their patients.

To them, the absence of leadership skills was incongruent with being a surgeon, and being a leader required you to be more dominant and assertive. Contrary to group A, group B had the impression that the surgical profession was dominated by extraverts.

The development of these two opposing narratives makes describing the culture of surgery complex. Given that little consensus was found among participants, one may argue that there is simply no real culture related to sociability in surgery. I contend, however, that two (rather than no) cultures may exist simultaneously. Many participants believed that sociability is not an essential part of surgery and that there are equal numbers of introverted and extraverted surgeons; this demonstrates the presence of a culture of equality in surgery. At the same time, a significant number of participants believed that extraverts dominate surgery and that being loud and assertive is essential; this points towards a competing extravert culture–or a culture of hierarchy that favors extraversion–in surgery. Exploring where these two cultures overlap and diverge may reveal important nuances about the surgical workplace. The following sections will expand on this idea.

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5.1.2 Perceptions of introverts and extraverts

Despite there being many areas of disagreement in this study, there were areas for which we obtained a general consensus. Participants agreed on the basic competencies of a surgeon (i.e., being knowledgeable, technically skilled, with good communication and leadership skills) and the surgical stereotypes. Most initially perceived that surgery was dominated by extraverts, but began noticing the introverts after they joined the specialty.

All participants thought introverts were equally knowledgeable and technically skilled compared to extraverts. They saw introverts’ calm and reflexivity as their main strengths, and their lack of relationships with staff as one of their challenges.

Examining these areas of consensus provides insight into the essential differences between groups A and B. The research literature distinguishes introverts and extraverts primarily by their inward or outward orientation to the world (Jung, 1923) and their sociability (McCrae & John, 1992), and all the participants in this study had internalized these concepts. They defined extraverts as sociable and outgoing, and introverts as more solitary and reflective. However, there was one important way that the participants’ definitions differed: those in group B associated introversion with being less socially skilled, while those in group A did not.

Different definitions. These differing perceptions of introverts and extraverts can be better understood by relating them to work by Cantor and Mischel (1979). In order to make sense of the infinite differences between people and situations, individuals must simplify the complex external world into a coherent set of structures. Cantor and

Mischel’s program of research was concerned with the categorization of individuals into

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recognizable groups or types. For example, extraverted types, in our study, were viewed as outgoing, gregarious, and assertive.

The process of categorizing individuals as extraverts or introverts can be considered “fuzzy” (p. 10). This means that there is not a distinguishable set of characteristics shared by all members of the same group. Most extraverts are outgoing, but not being outgoing does not exclude someone from being considered extraverted.

Different extraverts can appear to have strikingly different personalities: some tend to be more dominating and aggressive, while others are more warm and friendly. There are introverts who are shy and reclusive, but there are also introverts who have excellent social skills. Therefore, when asked to define introverts and extraverts, different people will include, exclude, and stress different parts of their personalities.

Hence, the disagreement between group A and group B may be attributed, at least in part, to differences in definitions. Group A limited their distinction to where individuals derived their energy–from being alone or from being with others. Group B, on the other hand, also used the word “reserved” to describe introverts. While agreeing with group A’s definition, they also equated introversion with having difficulty being loud, dominant, and assertive. They associated introverts with a tendency to hesitate more when called to make difficult decisions.

In some sense, both groups A and B are correct. In the literature, introverts tend to score lower on leadership scales (Bono & Judge, 2004; Judge et al., 2002) and on medical school evaluations that include an interpersonal dimension (Lievens et al., 2002; Lievens et al., 2009), but not all introverts have poor leadership and interpersonal skills. Introverts tend to use more reflective, rule-based rather than intuitive styles of decision-making

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(Sagiv et al., 2013), but not all introverts shy away from making rapid, instinctive decisions.

These two ways of defining introversion and extraversion demonstrate two unique ways of thinking about personality. Group A’s definition focuses on what individuals are capable of doing if they are to realize their full potential. It conceptualizes the introversion-extraversion spectrum as a way of approaching the world, and not something that affects one’s abilities. In comparison, Group B’s definition does the exact opposite.

Abilities (i.e., communication and leadership skills) were seen as part of the categorization scheme of introverts and extraverts, rather than entirely separate concepts.

Their definition includes not only individuals’ orientation to the world, but also the consequences of that orientation. For instance, they may consider that introverts are oriented towards the inner world, which causes them to spend less time in social situations; this subsequently causes them to be less socially skilled than their extraverted counterparts.

The co-existence of both ways of thinking about introversion and extraversion may be important for surgical training and practice. Group A’s definition gives introverts the confidence to pursue any specialty they are passionate about, regardless of their personality. Group B’s definition reminds students to remain cognizant of their own strengths and limitations. It may be helpful for future medical students to use these alternative discourses as a catalyst for their self-reflections–especially when they are considering careers that are characterized by a specific culture.

Extravert culture. As described in the literature review, recent authors have written widely about a “culture of extraversion” in North America that idealizes

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extraverts–to the detriment of introverts (Cain, 2012b; Kahnweiler, 2009; Laney, 2002).

Quietness is often perceived as a lack of confidence or competence (Lawrence, 2015;

Leung, 2015; Remus, 2005). Introverted medical students have expressed feeling like misfits and needing to change the way they behave in order to succeed in the profession

(Davidson et al., 2015). In this study, we found evidence that many individuals consider extraverts to be better suited for surgery than introverts. Accordingly, the introverts in group B felt the need to adopt certain extravert-type behaviours in order to succeed in surgery. The extraverts did not feel the same for introvert-type behaviours. Taken together, these findings suggest that a culture of extraversion does, indeed, exist in surgery.

At the same time, it is important to consider that half of the participants disagreed with this sentiment. The introverts in group A did not feel marginalized by a culture promoting loud and dominant personalities, and felt no need to change who they were to succeed in surgery. The extraverts in group A saw little benefits to being extraverted compared to being introverted. In this manner, those in group A denied that a hierarchical culture related to personality exists in surgery. An important question to discuss, therefore, is how these two seemingly incompatible views can co-exist.

There are multiple ways to interpret these findings. First of all, it is possible that those in group A are correct, and there is no true extravert culture in surgery. However, approximately half of the participants in this study described a culture of surgery in which extraverts were advantaged compared to introverts. What is more, not one participant believed that introverts could be considered advantaged compared to

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extraverts. This suggests the existence of a culture of hierarchy, despite its not being universal.

Perhaps, then, those in group A were only exposed to informal and hidden curricula that were in line with the “culture of equality” and did not interact with individuals who believed that extraverts are more fit for surgery. This is also unlikely, since residents work with a number of physicians throughout their careers; they interact with most, if not all, of the surgeons in their department at some point during their training. An alternative explanation may be that individuals hold their personal opinions about what a surgeon should be like but, because these are never openly discussed, neither party is exposed to the opinions of the other. Again, this solution is questionable, since previous studies describe unwritten “rules” of surgery that are learned without having to be explicitly taught (Hill, Bowman, Stalmeijer, & Hart, 2014; Hill, Bowman,

Stalmeijer, & Solomon, 2014; Patel, 2018). Hence, a more likely explanation may be that residents are exposed to both ideas in the workplace, but only internalize those that are in line with their personal beliefs, experiences, and values.

In her critique of the concept of the hidden curriculum, MacLeod (2014) suggested that it may be more accurate to use the article “a” rather than “the” when using the term because there is not only one, but rather multiple hidden curricula. Similarly, a core theme of this research is that there is not one surgical culture that all those within it uniformly know to be “true.” Rather, surgical culture is composed of a number of contrasting–and sometimes conflicting–perceptions, beliefs, and values. All residents are exposed to informal and hidden curricula upon entering the surgical profession, but what they are taught will differ depending on who is teaching them at any given moment.

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Furthermore, this research suggests that what they will learn depends on how they interpret and accept those lessons. Learners’ backgrounds lead them to perceive the hidden curriculum in different ways. They compare any perceived expectations to their own beliefs and values, and then act according to what is truly important to them. Figure vii illustrates this explanation.

Figure vii. Explanatory model for the divergence in perspectives of the importance of personality type (introvert or extravert) in surgical practice.

5.1.3 Consequences

In this section, I discuss what participants perceived as consequences of introverts’ personalities for their experiences in surgical training and practice. The

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research findings add to the discussion on how trainees decide to pursue surgical specialties, as well as how they may adapt their behaviours to the surgical workplace.

The reader will note that for this section in particular, I discuss the views of group

B more than those of group A. However, rather than biasing the conclusions of the research, I argue that this approach is more appropriate to the qualitative method of inquiry. Instead of presenting the data proportionately to the number of individuals in each group, I chose to present the data proportionately to the ideas and themes derived from each group.

5.1.3.1 Medical specialty choice

This research demonstrated that for many in the medical profession, personality may play an important role in specialty choice. The extraverts in group B (“personality matters”) wanted to continue their careers in surgery because they felt that their personalities matched those of the surgeons they had encountered. They identified with the stereotype of surgeons being extraverted, and this confirmed their “goodness of fit” in the profession. The introverts in group B recognized that their personality did not line up with that of the typical surgeon, but decided to pursue the specialty regardless. This reflects Hill et al. (2014)’s description of the process of becoming a surgeon: residents need to fit the mold of the typical surgeon in order to be successful. As one participant in their study stated, “If you can be as much like the surgeons you know as possible, then you’re probably more likely to do well” (p. 888). Hence, this study expanded research concerning personality and medical specialty choice. Rather than quantifying which personality types typically choose which specialties, it provides a deeper understanding of why certain personality types may choose certain specialties.

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Prototype matching. A number of scientists have theorized about the tendency to choose careers that match with one’s own self-concepts. Much of this discussion originates from the Person-Environment fit theory (Moss & Frieze, 1993), which is modeled by the Person-Prototype concept (Cantor & Mischel, 1979). In this study, I used categorization to discuss introverts, extraverts, and surgeons. Participants demonstrated that they held prototypes of the typical behavior patterns of each of these prototypes: introverts are quiet, reserved, and solitary; extraverts are gregarious, assertive, and social; and surgeons are quick-thinkers and assertive leaders. These mental representations allowed participants to theorize about how introverts and extraverts would experience the surgical workplace.

Moss and Frieze (1993) showed that individuals tend to match their career decisions to their personal concepts of self. In this study, those who described the typical surgeon as extraverted believed that personality played a significant role in their choice of career. Extraverts noticed early on that they resembled those of their peers who were also interested in surgery; they felt that they had found their “gang” (p13). They described their identification to this group as being part of a “frat house” (p8) where being loud and boisterous was the norm. They compared surgery to the football team and internal medicine to the chess club (p8), and were deterred from specialties filled with personalities that were different from their own. The extraverts’ decision to pursue surgery was made easier by the fact that they matched this prototype. Some introverts, on the other hand, initially felt conflicted by their lack of “fit.” Some introverted medical students had the impression that they had to be extraverted in order to pursue surgery

(p3). Introverted students’ friends expressed surprise that they would pursue such a

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specialty (p7). There was one conflicting finding: an introverted participant pursued surgery because they wanted to be surrounded by more extraverted, engaging personality types (p6). However, for the most part, these findings are consistent with self-to- prototype theory. Medical students recognize the degree to which their personalities align with the image they have of the typical surgeon and this may play an important role in medical specialty choice.

5.1.3.2 Adapting to the specialty

The participants in this study described the process of socialization into surgical specialties. Medical students were seen as “undifferentiated” at the beginning of their training, and needed to conform to the cultural norms and expectations of surgical culture. Individuals were to be “molded” into the image of the typical surgeon. Because this typical surgeon was typically extraverted, introverts felt they needed to act more extraverted.

Acting extraverted. Thus, the introverted participants from group B acted more extraverted to succeed in surgery. This corresponds to Little’s (2008) social ecological model of human development. Little asserted that people often behave counter to their natural dispositions in order to accomplish personal goals. He suggests that individuals engage in socially acceptable behaviors (referred to by Little as behaviours of sociogenic origin), even when they are in direct opposition to their instinctive behaviors (referred to as behaviours of biogenic origin), if doing so will lead to the advancement of their core personal projects (i.e., their idiogenic aims). He calls these strategic enactments free traits. Thus, the way individuals behave in any situation depends not only on their personality, but also on their environment, external events, and internal processes. People

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exhibit both personality traits, which are stable over time, and personality states, which are precise moments where a person acts in a way that mirrors the affective, behavioural, and cognitive aspects of a personality trait (Judge et al., 2014). Hence, an introverted surgeon who enjoys spending most of his or her time alone (introvert trait) may purposefully act more aggressive, loud, and assertive (extravert state) when leading an operating room or trauma case.

Consequences. According to the theory of ego depletion (Baumeister, 2002), when an individual exerts effortful self-control to act in a way that is counter to their natural tendencies, they draw on limited mental resources that can become depleted. In turn, cognitive depletion may have important costs on an individual’s ability to make decisions, control their impulses, plan effectively, and persist on cognitively demanding tasks (Baumeister, 2002; Schmeichel, Vohs, & Baumeister, 2003; Van der Zee, Thijs, &

Schakel, 2002; Zelenski et al., 2012).

In the current study, acting extraverted was not something that came naturally to the introverted participants. They did so by “faking it” (p8), “acting” (p4) outside themselves, and “forcing” (p6) themselves out of their comfort zones. Consistent with the theory of ego depletion, the participants believed that acting more extraverted on a day- to-day basis may deplete introverts’ energy reserves, and eventually lead to burn-out. One participant explained that because they were forced to act more extraverted at work, they

“became more introverted” (p6) when at home; that is, they became even more solitary outside of work. In a similar manner, Little (2008) suggested that introverts may need restorative niches to recuperate from the fatigue of acting out of character. Restorative niches are techniques that introverts may use to restore energy after acting out of

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character for a certain period of time. For example, an introverted professor who acts extraverted during his 2-hour class lecture may retire afterwards to his office, locking the door behind him to spend some time alone. Introverts retreat to their “true selves” to restore the energy lost when enacting their free traits.

Apart from these short-term effects on energy depletion, this study did not find evidence that acting more extraverted was particularly harmful for individuals’ practice.

None of the introverted participants found acting extraverted harmful to their well-being.

As one participant stated:

I’ve never thought to myself, oh God if only I could act myself, this would be so

much easier. No. It’s just a part of the job. (p6)

This contradictory finding corresponds to work by Zelenski et al. (2012). In their study, they found that introverts who engaged in extraverted behaviour (talkative, bold, assertive) for 20 minutes did not show any immediate deficits in cognition. In fact, the introverts who acted extraverted showed increases in positive affect. As the authors conclude–and this research reflects–more research needs to be done to determine if acting extraverted on a daily basis may contribute to longer-term mental exhaustion.

Becoming more extraverted. Beyond simply displaying certain characteristics when it is of benefit to them, some researchers have proposed that learners may become more extraverted over time as a result of their experiences in surgical residency. Coombs et al. (1993) initially suggested this theory, which Borges and Sackivas (2002) later discussed. Because surgeons and surgical residents, but not medical students who later specialized in surgery, scored higher on their personality scale for extraversion, Coombs

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et al. (1993) proposed that differences between medical specialists may actually emerge or deepen during residency training.

Interestingly, our study did not provide support for this theory. Although the introverts in group B did knowingly act more extraverted at work, they did not feel that they had become much more extraverted. As mentioned, one introvert even expressed becoming more introverted at home as a compensating mechanism. In other words, the introverts in this study changed their behaviours at work in order to conform, but they did not change who they were in terms of personality (or at least, they did not think they did).

Furthermore, half of the introverts in this study (group A) felt no need to act more extraverted in the first place.

The corresponsive principle (Roberts et al., 2003) may help explain these contradictory findings. According to this principle, life experiences that are corresponsive are more likely to deepen the personality characteristics that we already have, rather than to switch our personality entirely. For example, a highly dominant person will seek work positions of high status, and their positive experiences in this role will further develop their dominance trait. On the other hand, when individuals enter social contexts that are in direct contrast to their own personality (i.e., introverts in an extravert-dominant field), they are prone to feeling “disaffected or alienated” and will “work to avoid or escape prolonged exposure to the experience” (p. 583). Hence, it is possible that the learners who already had extraverted tendencies became more extraverted during surgery because they actively sought the more team-based activities of their profession (i.e., discussing cases with their peers, working in groups, engaging in conversation during surgeries). On their end, perhaps the introverts who felt the need to act extraverted did so sufficiently to

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succeed in the profession, but sought out activities that were corresponsive to their own strengths (e.g., one-on-one interactions with patients, dividing cases with their peers so that they could work through problems alone). In this manner, the finding that surgical residents become more extraverted during their training may be explained by the extraverts becoming more deeply extraverted, rather than the introverts “becoming” extraverts.

Hence, this study advances our understanding of both the influence of personality on medical specialty choice and the influence of the medical specialty on personality development. However, future quantitative or mixed-methods studies would best be able to measure whether participants’ impressions about changes in their personalities reflect reality.

5.1.3.3 Group A

Compared to group B, the perspective of group A on the consequences of being introverted on individuals’ experiences in surgical training is much easier to describe.

Those in group A simply believed that there were no such consequences, because introverts and extraverts are equally competent and skilled in all relevant domains of practice. These participants did not feel that introverts and extraverts experience surgical training differently. They thought that personality has no effect on medical specialty choice, and that there is no need for introverts to “adapt” to the surgical workplace. Upon entering the surgical workplace, the introverts in group A continued to act as they normally would–at least in terms of their introverted characteristics.

At first glance, this seems to be in direct contrast with the literature discussed above. According to these theories, individuals should want to match their personalities

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to their careers (Moss & Frieze, 1993) and emulate the behaviours of the typical surgeon

(Gluck et al., 2014). However, the reader should recall that group A did not associate extraversion with the surgical professional in the first place, and this is likely why they saw no positive or negative consequences for introverts in the specialty. Thus, the discussion of the differences between the views of groups A and B regarding the theme of “consequences” relate back to the earlier discussion about the culture of equality and the culture of hierarchy. The following sections will explore the more practical implications of these findings.

5.2 Practical Implications

Source for reflections. The findings of this research–especially in terms of extravert culture, the cultures of equality and hierarchy, as well as the need to act more extraverted–are useful for medical students deciding between surgical and non-surgical careers in medicine. Awareness of these factors could help students in their self- reflections. Based on the results of the study, I recommend that students recognize and understand the fact that many surgeons view introverted qualities as sometimes counter to the values of surgical culture. Not all introverts are hesitant, reserved, and less able to display confidence; however, those who are will likely need to overcome those tendencies in order to succeed in the specialty. Many see “extreme” introvert-related behaviours, such as being very quiet and unable to speak up for oneself for instance, as inconsistent with being a surgeon. Individuals who feel unable to learn these important behaviours may be better suited for non-surgical careers.

At the same time, students may also benefit from the viewpoint of those promoting the “culture of equality.” In this study, many participants believed that

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introverts experience surgery in exactly the same way as extraverts, and that students should therefore not let personality play a significant role in their choice of medical specialty. Some of the introverts in this study adapted to surgery by acting more extraverted, but some of the introverts felt no need to do so. Introverts became competent leaders in their own quiet, reflective way. Ultimately, the decision to pursue surgery–and to “adapt” one’s personality to surgery, if it is chosen–belongs to the individual. As this study demonstrates, both those who adapt their personalities (group B) and those who do not (group A) may be capable of succeeding in surgery.

Self-improvement. In a similar light, this study highlighted the importance of self-improvement. The introverts in group B were motivated to act more extraverted not because they wanted to replicate cultural norms, but because they felt that acting in that manner would make them better surgeons. Group B argued that there is a legitimate reason the surgical profession values those who are loud, decisive, and confident: to them, these behaviours are conducive to good patient care. Participants’ beliefs about

“[becoming] comfortable with…extraverted traits” (p6), “pushing yourself to do uncomfortable things” (p7), “[stepping] outside of [yourself]” (p8), and “acting out of your comfort zone” (p14) all deeply illustrate their desire to become the most competent practitioners they can be.

As some participants mentioned, the need to adapt is not solely relevant to introverts. Both introverts and extraverts may benefit from adopting behaviours from the opposite side of the spectrum. As Jung (1923) proposed, it is only those who display extreme introverted or extraverted behaviours that have difficulty adapting to their social environment. Ambiverts (i.e., those who fall in the middle of the spectrum between

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introversion and extraversion) may be the most capable of using the strengths of both personalities. For instance, in one study, Grant (2013) found a curvilinear relationship between extraversion and sales performance. That is, among 340 call center employees who completed online personality and performance questionnaires, the ambiverts made more revenue over a 3-month period than the introverts and extraverts. The author attributed this to ambiverts’ ability to be assertive and enthusiastic with their clients

(extravert characteristics), while at the same time being inclined to listen to their clients’ needs and to not seem too excited or overconfident (introvert characteristics). Introverts benefit by becoming more comfortable with more extraverted behaviours, as do extraverts with more introverted behaviours.

Valuing introverts’ strengths. A majority of the participants in this study believed that extraverts currently dominate the surgical profession, and empirical studies tend to reflect this phenomenon (Borges & Sackivas, 2002; Warschkow et al., 2010).

Furthermore, nearly all the participants in this study believed that because introverts are less sociable, they are less likely to obtain leadership positions during their careers.

Hence, if we want to see more introverts become surgeons and to be promoted to leadership positions in the profession, there may be a need to highlight their strengths more prominently in the surgical community.

This study showed that surgeons value introverts’ ability to instill calm in others during stressful situations. Many felt that although they are less sociable, they tend to be better listeners and are less intimidating to patients who may have otherwise been too nervous to ask certain questions or volunteer sensitive information. They saw introverts’ reflexivity as essential in a domain that requires sound decision-making. Demonstrating

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to introverted students the value of their character traits in surgery may encourage more introverts to pursue the specialty. In turn, having more introverts in surgery may eventually shift surgical culture to a more introvert-friendly environment. In the same way, if educators teach new generations of medical students that being calm, thoughtful, and approachable is just as important as being loud, quick, and confident, it is possible that more introverts may find themselves in leadership positions.

Career advancement. Almost all of the participants identified relationships with staff as a significant barrier for introverts. Introverts preferred working alone when possible and limiting the social interactions they had with their peers. Although most participants accepted this as unavoidable fact due to their more reserved personalities, lack of friendly connections with colleagues was seen as a career disadvantage. As the participants illustrated, “it’s not what you know, it’s who you know” (p1). Prior research reflects this finding: extraverts may tend to seek relationships with their peers and teachers, which facilitates their career success (Ng et al., 2005; Turban et al., 2016). This study shows that the phenomenon does not uniquely exist in business culture; it is perceived to be an important part of surgical practice as well.

Belonging. Another way introverts’ relative lack of personal relationships with staff affects their experience in surgery is their lesser sense of belonging. As seen in the literature review, integrating into a new social setting may be easier when one’s personality matches the average personality of the new group (Hill, Bowman, Stalmeijer,

& Hart, 2014; Ward & Chang, 1997). Assuming that these results are transferable to this setting, it is possible that introverts who enter the typically extraverted social milieu of surgery may be prone to some of these same difficulties.

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Some of the introverted residents and surgeons had difficulty integrating into this more typically extravert-dominated specialty. Most held more professional than personal relationships with staff, and some simply felt that they didn’t belong. As the following quote from one of the participant interviews illustrates, being introverted affected how well they felt they belonged to the team:

I think people like to feel like you're part of the group and um... hail-fellow-well-

met and that's not who I am so I don't think [introversion] benefits me, no.… [I: If

you were more involved in those social situations, what benefits would that bring

you?] P: Um…just more social acceptance. More, um, feeling part of the group.

(p11, group A, introvert, surgeon)

Hence, beyond determining who will decide to enter the profession, personality may play an important role in how introverts experience the surgical workplace. If clinical teachers who mentor and counsel students are more aware of the personal factors that affect both medical students’ decisions to enter a specialty as well as how well they integrate into its new social milieu, they may be able to better facilitate their transition into the specialty.

5.3 Limitations

Complexity of the topic. The complexity of studying personality itself rendered this study difficult to undertake. As Carl Jung, one of the most important figures in personality psychology, wrote:

Since this is how matters stand in psychology today, we must bring ourselves to

admit that what is closest to us, the psyche, is the very thing we know least

about…. Because we ourselves are psyches, it is almost impossible to us to give

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free reign to psychic happenings without being dissolved in them and thus robbed

of our ability to recognize distinctions and make comparisons. (Jung, 1923, p.

526-527)

The participants interviewed were not, in fact, describing the differences between introverts and extraverts. Rather, they were describing their perceptions of introverts and extraverts according to their own personal definitions and experiences with both personality types. If people lie on a spectrum between introversion and extraversion and most people tend to compensate for their personalities by acting out of character, it can be difficult to conceptualize what character traits should be associated with each personality.

As discussed, it is likely that this complexity is what led to the broad diversity of opinions.

The introvert-extravert binary. As a researcher tackling the complex topic of personality, I recognized that the boundaries between introversion and extraversion could be considered fluid. Rather than identify themselves as one or the other, in this study, participants placed themselves on the spectrum between introversion and extraversion.

Specifically, they answered the question: “On a scale from 1 to 10, where would you situate yourself on the continuum between introversion and extraversion? Why?”.

Furthermore, I used the TIPI to measure, on a scale from 1 to 7, the degree to which participants identified with extraverted and introverted personality traits (i.e.,

“extraverted, enthusiastic” and “reserved, quiet”). The results on this scale could also be viewed on a spectrum: scores closer to 1 indicated a higher identification with the introverted personality, while scores closer to 7 indicated the same for the extraverted personality.

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Despite this, for the purposes of the current study, I divided participants into their primary orientation: introverted, extraverted, or ambiverted. Apart from one, all participants’ self-reported personalities matched their scores on the TIPI; thus, these participants were easily categorized into one of the three categories. The last participant, who self-identified as introverted but scored as extraverted on the TIPI, was not categorized: this person was referred to as “self-introvert/TIPI-extravert” throughout this work. Furthermore, I invited participants to comment on two distinct categories of people: those who were introverted, and those who were extraverted. I made this decision in order to have a structure within which I could explore specific patterns associated with individuals possessing similar personality traits. However, one may argue that analyzing the data according to these binaries may be, in itself, problematic. The approach is reductionist in the sense that it overlooks the complexities of the differences between people, and divides them into delusively complete and consistent entities. Future studies could focus on undoing these binary systems of inquiry, and give a more holistic account of the range of behaviours that characterize the surgical workplace.

False dichotomies. In addition to the false dichotomy between introverts and extraverts, it is important to note that there was a false dichotomy between groups A and

B. Participants could be placed on a spectrum between both beliefs. At both extremes, there were some participants who believed there were no differences at all between introverts and extraverts, and others who believed that introverts did not belong in surgery because their personalities were directly counter to the values of surgical culture.

In between those extremes, there were participants who felt that introverts were only disadvantaged in certain, specific situations, but were mostly equal to extraverts.

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Two participants, in particular, were difficult to categorize. Participant p10 (group

A) stated that there were large, noticeable differences between introverts and extraverts, but that extraverts faced equally important challenges compared to introverts. For instance, this individual thought introverts’ passivity was a disadvantage when they needed to accomplish a specific task, but that extraverts’ aggression was a disadvantage when they needed to work in cooperative teams. Furthermore, participant p4 (group B) felt that introverts and extraverts have equal abilities, but that individuals who lie on the extreme introvert side of the spectrum would be unable to succeed in surgery. While difficult to categorize, these participants’ views provided important insights into where the ideas of groups A and B may overlap.

Transferability. I chose to interview general surgeons at only two university hospitals. Whether the same findings are transferable to other health care settings is uncertain. Since I only interviewed individuals specializing in general surgery, it is unlikely they are invariably applicable to all the surgical specialties. However, a great degree of varying opinions was discussed, compared, and contrasted in this study. I therefore argue that the analysis, as well as the discussions that resulted from them, are broadly relevant to multiple surgical settings.

Authenticity. My constructivist positionality for this research meant that my own experiences and views of the world were not personal biases to be eliminated at all costs, but rather a rich contribution to the study itself. The directions the research took resulted both from an authentic desire to understand the perspectives of the interviewees and my own search for answers to specific questions. The conclusions drawn from the study

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reflect a co-construction of multiple realities, rather than the objective description of a single reality.

At the same time, there were a few biases that readers should consider. For instance, there is always a risk that I unintentionally formulated leading questions or that

I misinterpreted participants’ statements. I was aware of these risks during the study, and did my best to minimize them. There is also a need to acknowledge the participants’ motivations. During the interviews, I was often under the impression that the research participants had assumed my personal intentions for this study. Many in group A, in particular, seemed to think that I would be disappointed by the finding that introverts and extraverts are equally skilled.

For instance, participant p5 thought that being either introverted or extraverted was not important for succeeding in surgery; it was more important to stay true to oneself. The participant thought that this idea would not be helpful for my research:

Yeah you have to adapt, for sure. Or you know if you don’t want to that’s fine. If you wanna be true to whatever...you know If you’re a strong extravert and you wanna have that approach to patients and some patients don’t like it than so be it. And then the same way if you’re an introvert and some patients don’t like it, so be it. At the end of the day if you fix their pathol-, you know if you guide them through their illness according to the standard of care, it doesn’t really matter you know… So–again, I–I don’t think this is helping your research much but I feel it’s less about being an introvert and extravert but just being true to your personality.

After expressing the belief that both introverts and extraverts are equally suited for surgery, participant p10 feared that they may have not answered my questions as I wanted them to:

Participant: I don’t think one personality is better suited than the other. Because I’ve seen introverts who are very technically skilled, they get the job done and there’s like less complications. I think sometimes introverts are better because they’re better at focusing on like one thing. Extraverts also I think can be good in

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situations, in acute situations where there's like a lot of bleeding and they need to take control. I think in that sense extraversion would uh, be helpful in those situations. So I think it’s situation dependent.

Interviewer: Okay. But you think both would be equally able to…

Participant: Mhmm. Yeah. Am I answering your questions, like, the way you want me to?

Participant p1 apologized for saying that they did not believe personality makes any difference for surgeons’ interpersonal responsibilities:

Interviewer: So just talking about the strengths and weaknesses of introverts and extraverts in surgery. Do you think that personality would have an effect on teamwork skills or relationships with them between doctor and patient? Participant: So I think that…it’s harder to make a connection sometimes for somebody who's an introvert but you don't have to be a friend with your surgeon.… As long as everybody turns out to do their work, I don't think it really makes any difference? Sorry.

These extracts show that participants had pre-conceived ideas about what type of results I was hoping to find. However, what they also show is that participants answered honestly despite this. This makes sense, because it is unlikely that power hierarchies affected the results of this study. If anything, the interviewees (generally confident, assertive, established surgeons and surgical residents) were likely to have more authority than myself (a quiet, soft-spoken master’s student in medical education).

5.4 Recommendations for Future Research

Context: Changing “hidden curriculum” research. The research literature tends to paint the hidden curriculum as a somewhat uncontrollable influence that determines what learners will internalize as values, attitudes, and normal behaviours

(Martimianakis, et al., 2015). It depicts medical students as “blank slates” that will be molded into replicates of those that preceded them (Jin et al., 2012). As many participants also reflected “…as a first-year, you’re kind of undifferentiated” (p1), and as Hafferty

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and Franks (1994) describe, “medical training is a pathway by which lay persons are transformed into something other than lay persons” (p. 865). Medical school is a socialization process that intends to reproduce the existing surgical culture, rather than to create new ones.

Similar to–and inspired by–recent critiques from MacLeod (2014), my interpretation of this study shows a divergence from this way of thinking about the hidden curriculum. I propose that the previous view risks minimizing the influence of the individual learner on what is learned. The dichotomy between groups A and B demonstrated that there is not one surgical culture that all students uniformly learn through surgical culture’s hidden curriculum. My research suggests that medical students arrive to medicine with their own set of values, attitudes, and beliefs. When they are confronted with workplace cultures that are inconsistent with their own, they have to question whether they should adapt to those new values or retain their own at the risk of appearing less competent to others. Hence, future research should focus not only on what sociocultural influences comprise the hidden curriculum of surgery, but also on how individual students differentially respond to those influences.

Perceptions of introverts and extraverts: Self-assessment. Although there were equal numbers of introverts and extraverts in groups A and B, the average TIPI scores tended towards introversion for group A and extraversion for group B. In other words, the more extreme introverts tended to be in group A, and the more extreme extraverts tended to be in group B. Those in group A (especially the introverts) believed that introverts are just as competent as extraverts. Group B (especially the extraverts) felt that extraverts tend to be better leaders. Hence, it is possible to hypothesize that the introverted

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participants in group A, and the extraverted participants in group B, simply lacked the ability to perceive their own shortcomings.

This finding would make sense according to the literature on self-assessment: physicians do not tend to be particularly accurate self-assessors. In a systematic review of the literature comparing physician self-assessed and objective measures of competence by Davis et al. (2006), only 7 out of the 20 comparisons found a positive association between the two. In particular, the physicians who were the least skilled, and those who were the most confident about their abilities, were the least able to accurately self-assess

(Hodges, Regehr, & Martin, 2001). Hence, one may propose that the introverts in group

A who felt no need to learn more extraverted behaviours simply lacked insight into their own weaknesses. Alternatively, perhaps the extraverts in group B who believed that extraverted behaviours are ideal lacked insight into the disadvantages of this behavioural style. Answering this specific question was not a goal of this study. Quantitative or mixed methods studies would provide a more insightful answer to this question.

Perceptions of introverts and extraverts: Relationships with patients. The area of greatest variability in this study was related to the relationships introverts and extraverts have with their patients. Even participants within the same group disagreed on this topic. In general, the extraverts in group B thought that extraverts had better relationships with their patients because of their sociability, while others (three out of the four introverts from group B, and all but one in group A) thought that introverts and extraverts had equally intimate relationships. Introverts were seen as less intimidating, allowing patients to be more willing to open up to them. This finding reflects the research literature demonstrating introverts’ listening skills as conducive to effective salesmanship

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(Grant, 2013) and leadership in teams (Grant et al., 2011). The benefits of a more introverted approach to patient care would be an interesting avenue for future research.

Outcome: Paradigmatic trajectories. In section 5.1.3.1, I discussed self-to- prototype theory as an explanation for why more extraverts tend to pursue surgery than introverts. Another way of interpreting these findings is that compared to extraverts, introverts may lack the ability to imagine themselves as future surgeons. Hill and

Vaughan (2013) define paradigmatic trajectories as “visible career paths provided by a community that shape how individuals negotiate and find meaning in their own experiences” (p. 548). Through their interaction with others in the workplace, students begin to imagine their place within it. They learn about what is valued within that community of practice and then have to decide whether they are ready to meet those expectations. While these authors explore the idea of paradigmatic trajectories deterring female students from pursuing surgery, in this thesis, I advance the question of whether personality may play into how students imagine themselves in the role of a surgeon as well.

Hence, if extraverted behaviour styles dominate the culture of surgery (as suggested by group B), introverts may be deterred from surgical careers. It was not possible to explore this question further in this study since we interviewed only surgeons and surgical residents–not medical students considering different careers. Evidently, introverted medical students who decided not to pursue surgery because of this culture of hierarchy benefiting extraversion would not have been included in this study. However, the fact that some of the introverted residents in this study expressed initial conflict about

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pursuing surgery because of their personality suggests that this may be an important avenue for future research.

Gender differences. A striking finding from this research was related to the proportions of men and women in groups A and B. There were more women categorized in group A (5:3), and more men categorized in group B (6:2). Given that, historically, women have been marginalized in medicine and continue to be under-represented in surgical specialties (Hill & Vaughan, 2013), it makes intuitive sense that female surgeons would align with the culture of equality. One participant spoke to the need for women to prove that they are just as competent as men:

…you’re advocating for yourself and you're advocating for all the women coming

behind you, that there's absolutely nothing in here that I cannot do and I can't do

as well as or better than you. (group A, introvert, surgeon)

Another reason why there were more men than women in group B may be related to the tendency for men to exhibit (and perhaps, to value) more assertive and dominant personality traits than women, despite being less extraverted overall (Feingold, 1994).

However, exploring gender differences was not an objective of this study. Future research is needed to better understand this issue.

Other contexts. The introverted participants in this study were all general surgeons or general surgical residents. Another interesting avenue of research would be to explore how patients, as well as other health care workers such as nurses, respiratory therapists, and other types of physicians view introverted surgeons. This study examined what surgeons believe patients and staff think of introverts, but it is not clear whether their perceptions can be considered accurate.

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Furthermore, if we assume that many introverts are deterred from pursuing surgery because of their personality, it is possible that the introverts recruited in this study constitute a unique sub-population different from the average introverted medical student. Perhaps only the introverts who were particularly resilient or able to adopt extravert-typical behaviours, for example, were accepted into surgery. A comparison of introverts who pursue surgery and of those who do not may provide a more complete picture of how personality influences medical specialty choice. Future studies may also seek to understand how other personality types (e.g., openness to experience, conscientiousness, agreeableness, neuroticism) influence learners’ experience in a variety of medical fields.

Personality research in medical education. Finally, this study opens a broader conversation on the importance of studying personality in medical education in the first place. Identifying an entire group of participants who believed that “personality doesn’t matter” for surgical training (at least in terms of introversion and extraversion) seemingly implies that many believe research in this domain would prove unfruitful.

This finding reflects observations by social and personality psychologist David

Musson (2009). In a commentary published in Medical Education, Musson expressed his surprise that despite an extensive history of scholars studying the relationship between personality and job performance in fields dedicated to this very topic, few have attempted to advance our understanding of how personality impacts medical education and practice.

He suspects that this lack of motivation to study the topic comes from beliefs that personality research is either unscientific, or simply does not lead to any helpful or meaningful findings. Similarly, my literature review showed that studying the impact of

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personality on medical training obliges one to use, for the most part, research from other fields of work. Most often, researchers in medical education exploring the experiences of trainees do not factor personality into their analyses. Furthermore, while completing this project, many specialists in medical education encouraged me to choose a subject other than personality for my doctoral studies.

Better understanding these views and their legitimacy would be an interesting avenue of future research. The results of this study give preliminary insight into that phenomenon: approximately half of those interviewed believed personality to be unimportant to success in medical training. This study also demonstrated, however, that personality does matter for many others. To group B, personality deeply influenced their experiences throughout their training in surgery and beyond. This highlights the importance of conducting more research to better understand how personality influences, is shaped by, and interacts with medical training.

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Conclusion

This thesis aimed to broaden our understanding of the relationship between personality and medical training. To my knowledge, it is one of the first studies attempting to explore why, and not simply that, specific personality types are drawn to certain specialties. This adds an important nuance to the discussion of medical culture, the hidden curriculum, and socialization into the surgical environment. For many, personality influences who will decide to enter certain specialties and, in turn, the personalities of those who enter the specialties will dictate what is considered normal– and even essential–ways of practicing medicine.

The research identified two surgical cultures: hierarchy and equality. This dichotomy provides a more pragmatic way of understanding the vast differences in opinions between surgeons concerning the importance of personality in the workplace.

The co-existence of opposing perspectives has implications for medical students interested in surgery, as well as the educators mentoring those students. Although introverts may face challenges in surgery, many introverts consider themselves just as able and competent as their extraverted counterparts. Introverts who decide to become surgeons may need to adapt some of their typical behaviours in order to succeed; however, introverts bring a unique set of strengths to practice, and the surgical profession may benefit from having more of them.

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Appendix A

Email Invitation to Participate in the Study

Subject: Introverts as Surgeons: Invitation to a Study Body: Invitation to participate in a research study Study Title: Introverts as Surgeons: How They Adapt and What They Bring to the Workplace Principal Investigator: Victoria Luong, M.D. On-site supervisor: Dr. Katerina Neumann, MSc, MD/PhD, FRCSC Dear Colleague, For my master’s thesis in health professional education, I’m exploring the experience of introverted physicians working in surgical specialties and I am hoping that you would be interested in participating in this research. As I’m sure you know, surgeons have been branded with many stereotypes over the years. Words like dominant, uninhibited, excitable, arrogant, and aggressive most often permeate the field. Although most of these stereotypes do not reflect reality, we do know that extraverts–talkative, enthusiastic, dominant, impulsive, social types– currently describe the majority of surgeons. Whether you see yourself as an introvert or extravert, I am interested in hearing your perspective on how introverts may be able to succeed as surgeons. Participation in this study involves completing a brief (i.e., 3-minute) background and personality questionnaire (Ten-Item Personality Inventory, six-item Brief Resilience Scale) followed by an approximately 20-minute individual interview, according to your availability. Your valuable insights would be very much appreciated. Participation is completely voluntary and no identifying information is collected–all responses are confidential. If you would like to participate, or have any questions, please contact me directly at [email protected]. Thank you very much for your time. Sincerely, Victoria Luong Acadia University

For the purposes of establishing a baseline for our interview

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Appendix B

Consent Form for Participation in a Research Study

Acadia University

Primary researcher: Victoria Luong Study description: This study aims to explore the experience of introverted physicians working in surgical specialties. We will be exploring some of the strengths and weaknesses of introverts in surgery. Participation in this study will involve a 15-minute questionnaire, followed by approximately 45 minutes of interview time. Risks/benefits: There are minimal risks to completing this study. It is possible some questions may elicit strong emotions. The only benefit to participating in this study is your contribution to research in personality and medical specialty choice/development. Confidentiality: All of the information recorded today will be kept strictly confidential. A number will be attached to your name, and only this number will appear on your questionnaire and transcripts. The study reports will never reveal your identifying information. The only people who will see your questionnaires and transcripts will be the primary researcher, her supervisors, Acadia University’s research committee, and, if solicited, appropriate institutional review boards. Voluntary participation: Please remember that your participation in this study is completely voluntary. You have the right to withdraw from the study at any time, without consequence. You may refuse to answer any of the questions asked during the study and/or request to withdraw the data you provided. After the dissemination of results, however, it may no longer be possible to withdraw your data. Use and dissemination of data: This project is part of a thesis for a Master of Education in Curriculum Studies for Health Interprofessionals. Interviews will be tape-recorded, transcribed, and analyzed through qualitative coding procedures. Findings may be published through the university; however, your identity will remain confidential. There are no perceived conflicts of interest from the part of the researchers. For questions about the study: contact Victoria Luong, [email protected]. In case of problems or complaints about your participation in this study: contact the academic supervisor of this research (not yet identified). If this proves insufficient, please

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contact the chair of the ethics review board of Acadia University Research Ethics Board, Dr. Stephen Maitzen, [email protected]. Your consent does not waive any rights to legal recourse in case of research-related harm.

By signing this consent form, I show that I have understood the above information and consent to participate voluntarily, without undue influence or coercion, in this study.

______

Name (printed)

______

Signature Date

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Appendix C

Preliminary Semi-Structured Interview Questions

General questions We will begin with general questions about your background as a surgeon. 2. If a student: In what year of your residency are you? If an attending physician: How long have you been practicing? 3. How old are you? 4. What is your educational background? Defining introversion/extraversion My research talks about introverts and extraverts in medicine. 5. How would you define introversion? Extraversion? 6. In my research, I define introverts as silent, calm, reflective, passive types who are energized by solitary activities and avoid excessive social stimulation. Extraverts are defined as talkative, outwardly enthusiastic, impulsive, dominant types who are energized by being with other people and avoid spending excessive amounts of time alone. How does this definition compare to yours? 7. On the continuum between introversion and extraversion, where would you situate yourself? In terms of percentage, for example? Why? Introversion in general surgery We’re going to talk a bit about introversion in the field of general surgery. 8. Do you think that there are more extraverts in general surgery, more introverts, or there are equal numbers? Why do you think that is? If yes, more extraverts - 9. What is it like being an introvert in a field dominated by extraverts? - Would you say that it is easy, difficult, or it does not make any difference in your day-to-day work? - Do you behave differently at work than at home, when alone, in social situations, or in general? Would you say that you sometimes (or frequently) act out of character? 10. What was it like as an introverted student being part of a group with such differing personalities?

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11. Do you think that in general surgery, one personality is preferred over the other? By your fellow physicians? Other colleagues? Students? Patients? 12. How would your experience as a physician be different if you were an extravert? Strengths and weakness of introverts in general surgery We’re going to talk now about the strengths and weaknesses of introverts in surgery. 13. What do you think are some of the strengths of introverts as (general/other) surgeons? 14. What are some weaknesses of introverts as (general/other) surgeons? 15. What are your personal strengths as a surgeon? Weaknesses? 16. Describe to me what you think an ideal (general/other) surgeon looks like. 17. In what way do you think that introverts’ abilities in the following areas affect their practice: - Energy? - Sociability? - Teamwork and communication skills? - Doctor-patient relationships? - Emotions? - Knowledge? - Decision-making skills? - Commanding respect?

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Revised Semi-Structured Interview Questions

General questions

1. Could you describe a typical week as a [surgeon/surgical resident]? What sorts of tasks do you have to accomplish?

Defining introversion/extraversion

As you know, my research talks about introverts and extraverts in medicine.

2. Are you familiar with these terms? How would you define introversion and extraversion?

In my research, I define introverts as silent, calm, reflective, passive types who are energized by solitary activities and avoid excessive social stimulation. Extraverts are defined as talkative, outwardly enthusiastic, impulsive, dominant types who are energized by being with other people and avoid spending excessive amounts of time alone.

3. On a scale from 1 to 10, where would you situate yourself on the continuum between introversion and extraversion? Why?

Strengths and weakness of introverts in general surgery

We’re going to talk now about the strengths and weaknesses of introverts in surgery.

4. What makes a good leader in the operating room? What makes some people effective in team settings, and others not as much? What helps in doctor-patient relationships?

5. Describe a surgeon you know who seems very confident to you. What makes them appear confident? How did you develop this confidence personally?

6. Do you have any introverted colleagues or residents? Without revealing their identity, can you describe them to me? What makes them effective or less effective in their practice?

7. What [introverted/extraverted] qualities do you identify most with? How have these qualities benefited you during your training?

Were there any negative [introverted/extraverted] qualities that you’ve had to overcome? How did you overcome them?

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When at work, do you find yourself acting in ways that may seem a bit unnatural to you, but are required for the task at hand? (For example, do you make an effort to be more proactive, assertive, or talkative than you usually are? What else?)

8. [Optional]. Let’s say you’re a surgeon trying to give feedback to an introverted resident. This resident tends to be more quiet, prefers solitary activities, and sometimes needs a bit more time to think before acting than their peers do. Do you think these are qualities that work well in surgery, have little importance in surgery, or are they qualities that you would recommend they work on?

9. [Optional]. How do introverts, compared to extraverts, display confidence as surgeons?

Demands of the workplace

Now I’m going to ask you a few questions regarding your beliefs about surgery.

10. In your current practice, do you think that there are more introverts in general surgery, more extraverts, or there are generally equal numbers? Why do you think that is?

11. I’m sure you’re aware of some of the surgeon stereotypes around being more loud and dominant. What has it been like for you, as an [introvert/extravert], in a field with these stereotypes? Did they affect your initial decision to pursue surgery?

12. How do you think introverts are perceived within the general surgery community?

Adaptation to the workplace

13. Do you feel that your personality has changed during the course of your development as a surgeon?

[Was this deliberate, or it happened naturally with time?]

14. [As was probably discussed]. Often, to succeed in your career you have to act in ways that may feel less natural or comfortable to you. Do you think there are any consequences to this, positive or negative? On personal well-being, for example?

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Appendix D

Questionnaire Results for All Participants

Self-reported TIPI score Participant personality Personality Group (1-7, introvert BRS score label (1-10, introvert label to extravert) to extravert)

Group A p1 Extr. 5.5 Extravert 4.8 p2 3 1.5 Introvert 3.5 p5 9 6.5 Extravert 3.5 Self-intro- p9 4 5.5 vert/TIPI- 4.0 extravert p10 4 4.5 Ambivert 3.7 p11 3 2.5 Introvert 4.0 p15 3 2.5 Introvert 4.3 p16 3 2.0 Introvert 4.0

Mean: 3.8 Mean: 4.0

Group B p3 7 6.0 Extravert 4.7 p4 2.5... 2.0 Introvert 4.2 p6 3 3.0 Introvert 4.0 p7 2-3... 3.0 Introvert 3.7 p8 8 6.0 Extravert 4.3 p12 8 5.0 Extravert 4.0 p13 8 6.5 Extravert 4.5 p14 3 2.5 Introvert 3.7

Mean: 4.3 Mean: 4.1

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Appendix E

Representative Quotes for Each Theme

Group A Group B

4.2 CONTEXT Surgery is a solitary thing. It's 4.2.1 The nature of the job you and your patients and It’s extremely, a very social 4.2.1.1 Surgery as a social or your assistant. It's not a group job. (p12) solitary activity thing. (p11) …in the current system we’re Because of the trust we need in, the time pressures of with patients, we probably 4.2.1.2 Relationships with surgical practice, we’re not have to develop fairly close patients: intimate, yet limited really forging very significant relationships with a number of relationships with our your patients. (p2) patients. (p6) …you're in a leadership position so you know if you 4.2.2 Essential qualities of a don't control it, no one else surgeon I think that’s what makes a will and everything will go good surgeon. That kind of, into chaos. So you know if making it a, harmonious you don't like being a leader, environment but they’re also then you should not be a 4.2.2.1 Leadership the leader. (p10) surgeon because very bad

things will happen in the absence of leadership. (p8) I think that worse than making …probably the overriding Decision-making a wrong decision is key is your ability to make a indecision. (p5) decision. (p4) …as long as you turn up and …you do have to be a good you do your work, I think communicator and, because Teamwork that's probably all we ask for, you’re constantly working for working with a team. (p1) with teams. (p7) …you’re often put in a defacto leadership role when I guess that’s how you you’re in the OR…usually demonstrate your leadership. Control you have more of a say or By your ability to, you know, more control of what’s going take control of a chaotic on than the anaesthesiologist. situation. (p4) (p5) …if you're passive you will …you got to come in with a tend to react to situations than big voice, a big presence, you be in control of the have to fill the room, you Need to be dominant and situation…if I was on the have to direct everyone and assertive opposite scale and I was command attention (…) you aggressive and trying to get have to be able to be the things my way, I would center of attention and feel probably get into more fights comfortable in that role. (p8)

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with other people and not have more of a good multidisciplinary um, approach or cooperation with others. (p10) I would say displaying confidence…would help you Seeming confident gives the in gaining respect from your impression that we’re good. 4.2.2.2 Confidence patients, your co-workers, and Whether we have the would probably also help knowledge or not…(p13) yourself. (p5) I think there’s definitely sort 4.2.3 The surgical We had the impression we of a personality type that personality resembled each other. (p13) comes to surgery. (p9) I think it’s a bit of a high profile job which attracts extraverts and I think there ...I would say there definitely was a bit of a misconception is a surgical type and in as to what it took to become a general that surgical type is 4.2.3.1 Surgeon stereotypes surgeon...being sort of very loud, gregarious, self- strong, being loud, being confident, uh, an extravert. noticed. Which would be (p8) associated with extraverts. (p5) Extraverts. It’s more like a 4.2.3.2 Dominance of I bet there's probably equal specialty that’s–that’s how it extraverts numbers…. (p2) is, you know. (p12) 4.3 PERCEPTIONS OF INTROVERTS AND EXTRAVERTS …an introvert is someone Introvert would be someone who maybe doesn’t enjoy more reserved, the extravert socializing with people that would be someone more 4.3.1 Definitions they don’t know very well and comfortable they tend to like recharge with…expressing themselves when they’re alone. (p15) more liberally. (p13) I think if someone’s easily I think um, being more excitable, that can very easily introverted gives you more excite a room…the person time to reflect on things… directing those particular sitting down and sort of scenarios, their personality 4.3.2 Strengths of introverts reflecting on that and trying to has a lot of influence on the

think about how things can be tone of that room and I think different or better next time is uh, I really do think a calm, a...an important aspect of reflective demeanor in those training…. (p9) settings is more conducive to quality of patient care. (p6) … in the long run (…) I don’t …when I describe what an 4.3.3 Challenges for think it matters if you’re an extravert is, I see them as all introverts introvert or an extravert positive characteristics (…) ‘cause people are gonna use maybe certain contexts…but their own criteria to judge to be honest, I always see

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whether or not they’ll listen to those traits as being positive. what you’re saying. (p5) (p8) Where I do see people having difficulty are in things like traumas. Where there needs to be someone who’s very …being more like quiet or vocal and directing a team, 4.3.3.1 Leadership reflective doesn’t mean I can’t and I find that those instances Introverts were seen as less like go and speak to other can perhaps be difficult for assertive. people or get plans done or those individuals…it’s a very things like that.” (p9) loud, busy environment and if there are too many people it can be tough to manage. And people can be talked over and that kind of thing. (p3) …to be thoughtful and quiet and consider all the Decision-making options...uh, you're going to --- miss the boat and the patient would be dead. (p8) …it’s unnatural for me but I kind of have to force myself just to talk louder and to be the person that’s kind of

leading things and having Introverts were seen as less everybody look at you and be natural-born leaders the one directing the --- conversation and that’s kind of an unnatural and uncomfortable place for me to be in…(p7) I am on the quieter um, end of things yeah, so I think, um, I don’t think that introverts that can sometimes probably Appearing confident display less confidence. They be perceived as being you just display less. (p5) know less...of me being less sure of myself or um, not as competent. (p7) Extraverted personality stands out. It doesn’t mean he’s …when I have those introvert better; it’s just…sometimes characteristics, so uh, the impression that it gives. probably initially maybe the (p13) Appearing competent staff surgeon or like the

seniors might not think that If there isn’t an answer right I'm doing the job because I away, it can be viewed as might not be as vocal… (p10) they don’t know what they’re doing. (p3) I think people like to feel like I think that if I were more 4.3.3.2 Introverts’ lack of you're part of the group and introverted it would’ve been a relationships with staff um... hail-fellow-well-met and little bit more difficult for me

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that's not who I am so I don't to establish those types of think [introversion] benefits relationships and by me, no. (p11) establishing them, I’ve been able to accomplish things though them. (03) If I’m known to be friendly …squeaky wheel gets the with the people who organize grease and stuff like that in Career advantages the OR, I might get away with terms of advancing through more than someone the academic ranks and stuff who...didn’t. (p5) like that. (p2) So when they're [extraverts] talking to patients, they’re not as…it feels like they're brushing off the patient if the patient brings up a concern I think introverts can be, if because they have their own they’re good at connecting agenda just…brush off the 4.3.3.3 Relationships with with people quickly by kind patient concerns and the patients of getting on their emotional patient doesn’t feel like level and reading what they they’re being listened to. (…) need and that situation….(p7) Whereas an introvert person, they’ll probably listen to the patient’s concerns and try to address a, have a discussion. (p10) …bottom line is the …the one that gets the 4.3.3.4 Introverts have equal knowledge you attain is going attention, you know the one knowledge, but extraverts get to be assessed by an exam who expresses themselves the noticed purpose and they should not most, can pass on the short differ whether I trained this term as if they’re better than way or that…. (p11) the others. (p13) 4.4 OUTCOME …part of the career making process or career decision is 4.4.1 Effect on career as you rotate though different choice things you will do some …it has more to do with rotations that you just don't interest and uh, things like feel like you belong. You that rather than personality know, and part of that is traits for why you end up personality. (p8) Extraverts pursued surgery choosing the specialty. (p2) because of personality …when I got into medicine, I saw myself as a surgeon because of these stereotypes (p13) In most cases I don’t feel like I…had some preconceptions Introverts were initially my personality is, conflicts leading into that…I didn’t deterred from surgery with–in fact I, especially as a really fit in surgery, my because of personality junior resident, my personality didn’t fit. And personality kind of fits with even when I was going

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what’s expected of a junior through the application resident. (p16) process there were people that would say that to me. Like oh you, it doesn’t seem like...you know I’m surprised you would do that, or it doesn’t seem like that would fit you. (p7) …people that sort of come 4.4.2 Introverts adapt by into the program a square …you know, you come in as a acting more extraverted peg, we in general–the first-year, you’re kind of surgical residency and the undifferentiated. (p1) Need to conform process, tries to fit them into a round hole. (p8) I think especially for…you know people who are more introverted. Acting out of your comfort zone and being

more “extraverted” (…) Acting extraverted personally, sometimes I’ve --- felt like that. You know, this isn’t really me, but I have to be like that at this point in time. (p14) I wouldn’t say it’s something that I’ve ever become

Acting versus becoming more comfortable with, or

extraverted something that I ever feel has --- truly been incorporated into my personality. (p6) Acting out of your comfort zone and being more “extraverted”, it takes almost 4.4.3 Consequences of um…it just takes energy out acting extraverted of you…obviously it gets --- easier and easier but I think at the same time, it’s not exactly who you are at some point. (p14) I just think you learn how to 4.4.4 Both personalities …you have to adapt, for sure. manage the person you are have to learn to adapt Or you know if you don’t and what you want to be. want to that’s fine. (p5) (p12)

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