These results suggest that when primary care physicians see patients presenting with depression, personality traits are modestly but significantly associated with PCC patterns independent of patient presentation (symptom profile, request for medication) and physician demographics and training. Physicians more open to feelings tended to engage in correspondingly more communication exploring experiential aspects of patients’ “illness experiences”. Discussion of depression demands dialogue about the patient’s phenomenology, feelings, and emotions. Doctors disposed toward emotional acuity engender greater disclosure of patients’ ideas, feelings, expectations, and effects on function related to the depressive experience —yielding potentially clinically important information that allows the physician to discern the impact, pervasiveness and severity of the patient’s symptoms, as well as personalizing and humanizing the process of discussing depression during the office visit.
Physicians who were more dutiful engaged in communication patterns that were more liable to elicit psychosocial information about the patient’s family and social life, job, and hobbies. They were also less likely to find common ground and elicit patient preferences in the context of treatment planning (the latter result not hypothesized). These opposite effects on PCC likely reflect the tendencies comprising dutifulness: reliability, efficiency, and an adherence to internal and external standards for behavior (37
)—features similar to the perfectionism trait positively associated with communication skills in medical students (15
). When faced with a depressed patient, primary care physicians who are particularly dutiful may view exploration of patient’s psychosocial circumstances as a necessity to gain vital diagnostic, treatment, or referral information. At the same time, these physicians’ sense of obligation and responsibility may result in more directive approach to established treatment guidelines (39
), although this does not mean that are less collaborative in general. However, failure to fully solicit patient input, while well-intended, may undermine adherence (6
Physicians scoring higher on anxious vulnerability were also less likely to engage in communication patterns that elicited patient participation in treatment decisions. This trait indexes proneness to worry, insecurity, and doubts about one’s ability to handle life challenges (37
). Physicians with these tendencies may feel anxious, and/or less capable or comfortable with patient presentations of depression. As a result, they may be more likely to fall into an “expert” role that utilizes more directive and controlled communication about treatment. Future research might examine whether this tendency generalizes to other disease states.
In order to gain a sense of the magnitude of personality effects, they can be interpreted in the context of a more familiar factor also associated with PCC—years of practice experience. For instance, a 1 standard deviation increase in Openness to Feelings translated into a roughly .17 SD increase in component 1, whereas 10 years of practice experience decreased component 1 scores by .23 SD (indicating that physicians in this sample who more recently entered practice engaged in more PCC, possibly reflecting greater emphasis in medical training over recent years on PCC and/or a tendency to use less PCC with accumulating years of experience). So the personality effect is equivalent to (.17 / .23 =) a difference of .85 of a decade of practice, or roughly 8.5 years. Similarly, the effect of 1 standard deviation increase in Dutifulness on component 2 scores was equivalent to the difference of .73 of a decade of practice, or 7.3 years. For component 3, practice experience was not a significant predictor, but personality effects were roughly comparable to those for components 1 and 2.
These findings indicate that trainees with personality tendencies associated with poorer communication may require additional or alternative training approaches. For instance, physicians prone to anxiety may require training to manage their worry when involving depressed patients (and perhaps other patients who behave passively or display negative emotions) in treatment planning. Physicians less emotionally attuned might benefit from training emphasizing perspective-taking or empathy skills (e.g., (11
) ) when attempting to understand the personal impact of depression. Highly conscientious physicians, though likely to “cover their bases” with psychosocial history taking, might benefit from skill building around patient involvement in treatment planning. Of course, these same individuals may not self-identify as having poor PCC, reinforcing the importance of instructor, preceptor, and peer evaluations. Although personality can be expediently assessed by a variety of validated instruments (41
), traits can also be judged with reasonable accuracy by those familiar with the individual (42
). Interventions might best focus on honing PCC skills rather than altering personality itself however, given limited knowledge about how and to what extent personality changes during medical training (8
), and whether such changes can be shaped.
Tender mindedness did not influence exploration of the subjective “illness experience”. Tender mindedness reflects compassionate attitudes and behaviors (37
), and its lack of association with PCC was surprising and is difficult to explain substantively. Communication processes revolving around the patient’s psychosocial context may involve a great deal of mundane information that is not necessarily emotionally laden (i.e., non-affective small-talk about family and job), diluting any potential links between this component of PCC and physician openness to feelings. In addition, tender minded attitudes may not necessarily translate into patient-centered verbal behavior during office visits, or may do so only under certain circumstances (i.e., a patient in pain). Dutifulness also was not associated with component 1, perhaps because in the face of competing demands and time compression, more dutiful physicians strive to cover a wider range of biomedical information rather than explore patient phenomenology.
Conclusions must be tempered by the finding that while personality tended to explain as much variance in PCC as physician demographics, training, and patient presentation factors, both sets of influences accounted for modest amounts of variability in PCC. That is, physicians’ dispositional psychological and behavioral characteristics influence PCC to a small extent, as do other measured factors in the current study, but a large portion of variability in PCC remains unexplained. This probably reflects the complexity of PCC itself (1
), but allows for the possibility that PCC is largely a learned behavior rather than reflective of physician personality. Variance accounted for in behavioral research tends to be less in general than biomedical research due to such complexity (45
), and while our findings suggest that much remains to be understood about this important clinical skill, the present results provide a new increment in such understanding.
Study limitations include a sample of PCPs that—while reasonably sized for an SP study on practicing physicians’ personalities and PCC skills (e.g., (30
) )—is smaller than other areas of provider research for which large national databases can be used. Potentially, more modest associations were missed due to limited power. We were also underpowered to examine interactions between physician personality and patient presentation factors. It is also possible that personality characteristics of participating physicians differed from those who did not participate. We could not assess this. In some cases, ceiling effects may have precluded finding an association. It is also not clear to what extent these associations between personality and PCC within the context of office visits involving depressed patients generalize to other encounters, and research on other diseases and medical contexts is warranted. Clinical versus personal contexts may reveal different aspects of physician personality, another area for future investigation.
The use of SPs was both a limitation and a strength of the study. SP visits allow for rigorous and standardized presentation of cases closely approximating patients seen in real practice, for experimental control, and careful scrutiny of physician behavior through audio recordings (30
). But SPs are still actors, and may introduce unmeasured variance even though they maintained excellent fidelity and detection did not alter the associations observed here (cf. also (29
)). Future research may benefit from replicating these results in larger, more diverse PCP samples, using actual patients as well as SPs. .
These limitations not withstanding, we are unaware of prior work on personality traits and PCC among practicing physicians. Although the Institute of Medicine has identified patient-centered practice as an essential component of high-quality care and a process associated with important outcomes (46
), enhancing PCC in routine clinical interactions remains challenging. Understanding how personality traits affect doctors’ PCC can potentially inform efforts to identify medical trainees or practitioners who are apt to have difficulty with--or, alternatively, excel--at this skill, as well as guide tailored training efforts. Given the preliminary state of physician personality research, conclusions about broader policy would be premature. We also refrain from speculating about the implications of our findings for other aspects of physician decision making and clinical skills. However, the availability of brief assessment tools (41
) render formal personality measurement feasible and inexpensive, while other evidence suggests that personality judgments can be made reasonably accurately by those familiar with the individual (42
). Given interest in dispositional changes in cynicism and empathy during medical school (21
) proposals to counteract these (47
), efforts to assess the dispositional characteristics of medical school applicants (23
) in hopes of reducing direct and indirect costs stemming from dysfunctional trainee personality characteristics (24
), and the potential role of personality characteristics in subspecialty choice (51
), further research on the determinants and implications of physician personality is warranted.