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Commissioning puts power with GPs

Research has shown GPs' personalities are a bigger cause of burnout and stress than conditions of work ­ Professor Elizabeth Paice asks whether medical school applicants should have their personalities tested as a condition of entry

Stress and depression among GPs is a major concerns to the profession. Levels run higher than in the rest of the population, and much higher than among professionals in other fields.

An American study some years ago looked at levels of burnout in 440 practising

doctors some 25

years after they had done a personality test before starting at medical school.

Higher burnout scores in middle age were significantly correlated with earlier evidence of low self-esteem, feelings of inadequacy, dysphoria and obsessive worry, passivity, social anxiety, and withdrawal from others.

In contrast, burnout scores exhibited no significant associations with demographic or practice characteristics, including sex, age, medical specialty, practice arrangements, hours worked per week, or percentage of work time spent in direct contact with patients1.

It seems that while skills, attitudes and appearance change over time, our personalities are hard-wired. An individual's responses to personality tests are remarkably constant over time from the late teens onward.

There are a number of personality tests around. One called the Big Five is particularly popular as being simple and reliable2. This uses just five dimensions: neuroticism, extraversion, openness to experience, agreeableness and conscientiousness. (

Together with colleagues at University College London, I looked in depth at the relationship between personality and satisfaction with a medical career. In this study 1,668 doctors currently working as senior house officers, specialist registrars or GP were asked about their approach to work, stress levels, satisfaction with medicine as a career, and their personality using the Big Five scale.

These doctors had previously answered similar questionnaires when they applied to medical school in 1990, upon leaving medical school, and during their pre-registration house officer year3. Not surprisingly, there was a strong correlation between having an agreeable personality and describing the climate at work as supportive and receptive to ideas.

Doctors who failed to plan ahead or do things in an orderly fashion, or who were careless about detail, tended to feel overwhelmed by work, finding it difficult to organise time effectively. They read work-related material without really understanding it and were unsure how to complete various tasks.

Those with high neuroticism also tended to feel overwhelmed at work, and in addition felt the climate at work was unsupportive and unreceptive. These were the doctors who were most likely to suffer from symptoms of stress.

In contrast, those with

high levels of extraversion and openness to experience tended to take a deep approach to work, relating the new ideas they read about with what they were doing day to day, and striving for a better way of doing the job. They felt in control of the way they were working, and did not feel stressed or burnt out at work.

Clearly, the personality traits of high conscientiousness, extraversion, agreeableness and openness to experience are desirable in a doctor, while high neuroticism is not. So why don't we select entrants to medical school on that basis, given a minimum threshold of academic achievement?

This is certainly an approach gaining ground in Australia, where a battery of psychometric tests is being assessed for its potential as part of the selection process.

Would medicine lose if we identified and excluded applicants to medical school who had high levels of neuroticism, thereby saving them from a life of worry, self-doubt and exhaustion? It is an interesting debate.

Would we want to lose that member of the team who can be guaranteed to worry about the detail and to anticipate disaster? Would the medical workplace become even more bruising as the threshold of tolerance to stress rose?

It may well be only because of the complaints and resistance of those with less resilience that the rest of the medical profession is not overwhelmed with demands.

And would some specialties lose out? We know that medical students who suffer from stress and self-doubt avoid specialties like surgery and acute medicine, and are over-represented in psychiatry and laboratory medicine ­ both areas of shortage.

The other personality type associated with stress and unhappiness in medicine is low conscientiousness ­ the disorganised person who cannot plan ahead or pay attention to detail.

It is hard to see what this personality brings to the medical team, until you consider that this trait is associated with vision, artistry and creativity.

Not everyone needs to be a completer-finisher, and while there is all too little scope for creativity and artistry in most doctors' daily grind, we would need to think hard before excluding those who had that spark.

A study of medical student career preferences suggests GPs and psychiatrists have a more artistic approach to medicine, seeing, interpreting and responding imaginatively to a range of medical, social, ethical and other problems4. It would be something of an own goal if efforts to reduce stress in doctors led to recruitment problems in these fields.

Diversity is increasingly being recognised as something to value. We don't need to define the attributes of the ideal doctor and try to select people with the full set.

Far better to select from as wide a pool as possible and ensure that medical students are a diverse lot with a wide range of talents and interests, who can show evidence of achievement and commitment in any of a variety of ways.

Any selection tools that can identify personality disorders and exclude the psychopaths and sociopaths should be welcomed with open arms. But we need to think hard before excluding applicants on the basis of their personality profile, even if the intention is to safeguard their future happiness.


1 McCranie EW, Brandsma JM. Personality antecedents of burnout among middle-aged physicians.

Behav Med. 1988;14:30-6

2 Matthews G, Deary IJ. Personality traits. Cambridge: Cambridge University Press, 1998

3 McManus IC et al. Stress, burnout and doctors' attitudes to work are determined by personality and learning style:

A 12-year longitudinal study of UK medical graduates. BMC Med. 2004; 2(1): 29.


4 Petrides KV, McManus IC. Mapping medical careers: Questionnaire assessment of career preferences in medical school applicants and f

inal-year students. BMC Med Educ. 2004; 4(1): 18.

Elisabeth Paice is dean director, London Deanery

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