This is the first study on the association between physician personality traits and the in-hospital delay for stroke thrombolysis treatment in China. In this study, we demonstrated that certain personality traits among physicians are associated with door-to-needle time for thrombolytic therapy in acute ischemic stroke. The extraversion trait shortened the door-to-needle time. However, the trait of conscientiousness, to some extent, postponed the time of procedure for thrombolysis treatment.
“Time is Brain, Every Minute Counts” has been widely acknowledged, with every minute the thrombolytic treatment for stroke is started earlier, the higher the odds of a good outcome[14–15]. The importance of constant improvement of in-hospital treatment routines cannot be overemphasized. In addition, the door-to-needle time is a critical factor in achieving prospective outcomes after an ischemic stroke. Nevertheless, there is a wide chasm in access to essential and emergency treatment between high and low/middle income countries[4, 16–17].
In China, the government instituted ambitious strategies for the prevention and treatment of stroke ten years ago. Owing to the support of the Stroke Prevention Project Committee (founded in 2011), affiliated to the National Health Commission, the Stroke Center of Huzhou Central Hospital was officially established in Jan 2017. Moreover, the Acute Stroke Care Map was implemented in Oct 2018 in Huzhou district (Zhejiang Province, East China). With this, the improvement in the Stroke Center of Huzhou Central Hospital is noticeable, with the percentage of stroke patients with acute ischemic stroke (within 6hrs) receiving intravenous thrombolysis improving from less than 1% in 2013 to up to 8% in 2019, and the median door-to-needle time shortened from 85.1 min in 2013 to 47.2 min in 2019 for stroke thrombolysis treatment. It is obvious that there is improvement in the rapid administration of intravenous thrombolysis and the reduction of door-to-needle time in China[1, 18],The results of this study demonstrated that the prolonged DTI, DTL, and FTN accounted for the in-hospital delay. Our results are consistent with the findings of a previous study, which documented that FTN contributed significantly to in-hospital delay. FTN constitutes the time involved in the process of decision-making for IVT. The decision-making process is composed of the decision of the family of the patient and the advice of the physician. Moreover, considering the tense between the doctor–patient relationships in China, the simple decision making process becomes extremely challenging.
In our study, we found that higher levels of extraversion were associated with a lower proportion of in-hospital delay. Physicians during an emergency may require more enthusiasm, activeness, and energy in dealing with critical situations. Our results are consistent with the findings of a previous study conducted in Germany, which demonstrated that the “resilient crisis manager” personality characteristics as suitable for emergency medical personnel. Our subgroup analysis with respect to gender indicated that the personality traits of extraversion in male neurologists were associated with a lower likelihood of in-hospital delay. However, the advantage of extraversion was not reported in female physicians. This could be because Chinese female physicians are more reserved, introverted, fond of tranquility, overly considerate, and habituated to self-restraint.
Moreover, our study showed that conscientiousness was associated with moderate in-hospital delay, especially in female physicians and the correlation decreased in male physicians. The personality traits of conscientiousness include organization, planning, reliable, responsible, and thorough. High levels of conscientiousness have been reported as desirable traits in a previous study among neurologists and neurosurgeons. This medical professionalism among physicians may transform into a weakness in the surrounding when racing against time. Some physicians may take time performing head magnetic resonance imaging for accurate diagnosis in patients with a minor stroke. In addition, they take time weighing each patient in the emergency department, while others consider that it should be done only when patients do not know their weight. Of note, it takes 3–5 minutes to take the weight on a self-made weighing scale (Fig. 5).
We also found that the agreeableness personality decreased the in-hospital delay for stroke thrombolysis. The appreciative, forgiving, kind, and sympathetic traits were shown to play a positive role in communicating with patients and their family members. Successful communication forms the basis of the final decision-making process for thrombolytic therapy. This could be attributed to empathy, which is an essential element in medical practice. Previously, agreeableness has been demonstrated to be relatively associated with empathy in both Chinese and Japanese medical students[24–25].
In this study, we established that neuroticism and openness personality traits have paradoxical effects on in-hospital delay. In the rough correlation analysis, the higher the scores of neuroticism, the more likely the in-hospital delay, especially among female physicians. However, after multivariate regression analysis, corrected factors, such as clinical neurology experience, age, etc., indicated that neuroticism could be an effective protective factor for effective treatment. Previous studies have suggested an important link between perfectionism and neuroticism, and that neuroticism is correlated with the extent of anxiety, which might be more conducive to emergencies to a certain extent. Nevertheless, it should also be noted that neuroticism is prone to burnout syndrome. On the other hand, we showed that the openness scores were lower among female physicians than male physicians. Therefore, the traits of curiosity could help improve work efficiency in the process of thrombolysis among the female physicians. With regards to the male physicians, because of the artistic, original and wide interest traits concerning openness, they are more flexible in the real-world thrombolysis treatment for stroke. For instance, when the patient and his/her family decline to receive thrombolysis therapy due to financial limitations, the physician with more openness would recommend the alternative medicine of urokinase. Urokinase is one-tenth the price of Alteplase in China. Although this medical behavior may increase the DNT of thrombolysis, they would increase the percentage of thrombolysis treatments, and attain reperfusion opportunity for patients.
Moreover, we established a negative correlation between the acquired clinical neurology experiences and the in-hospital delay, regardless of the big five personality traits. With the accumulation of clinical experience, some of the personality disadvantages might get weak, consistent with the findings of previous studies conducted in France. A better outcome is attributed to the shortened door-to-needle time created by more experienced neurologists. A previous study showed that the mobile thrombolysis team with more experienced physicians but not personnel could shorten door-to-needle time. In China, although there are clinical guidelines and stroke protocols, the fear of the risk of complications of thrombolysis, education level, and working years constitute the factors contributing to the in-hospital delay and low rate of thrombolysis for AIS.
In addition, since the big five personality traits were important for thrombolysis therapy for acute stroke among Chinese neurologists in this study, the big five personality traits should be applied to post-graduation education, such as standardized training which has been validated in other countries, for neurologists residents, which also will meet the new medicine curriculum requirements in China. It might be necessary to provide individualized education program for resident during the post-graduation education according to their personality traits, and more subsequent studies are recommended to investigate how the unique constellation of personality traits impinge upon their medical practice, promote positive physician-patient interaction and relationship.