The big five personality traits of medical students who choose community medicine career

Abstract

Background

Personality traits may play a role in the likelihood of success in training and careers. If the characteristics of community medicine-oriented personalities can be identified, mismatches in the Regional Quota Program (RQP) on admission to medical school can be reduced.

Methods

This study analyzed the personality tendencies of community medicine-oriented students. All medical students (n = 750 of a medical school in Japan, who were selected into the RQP, RQP Without Loan [RQPWL], or standard program) were asked to complete the validated psychometric questionnaire to investigate the five major personality traits: neuroticism, extraversion, openness, conscientiousness, and agreeableness. A multivariable logistic regression was performed to assess the association between personality traits and willingness to engage in community healthcare. We also assessed the association between personality traits and admissions programs.

Results

In total, 601 students completed the questionnaire. The RQPWL was associated with year (odds ratio [OR] 0.77), gender (OR 2.94), and extraversion (OR 0.91). The RQP was associated with gender (OR 1.76), extraversion (OR 0.91), and conscientiousness (OR 1.05). There were differences in the willingness to engage in community healthcare with respect to gender (OR 1.35), admission programs (OR 15.19 for the RQPWL, OR 31.85 for the RQP), extraversion (OR 0.90), openness to experience (OR 1.06), and agreeableness (OR 1.08).

Conclusion

Female students tended to be willing to engage in community medicine, and gender diversity can improve medical staff recruitment in rural areas. Fundamental differences were observed between the RQP and community medicine-oriented groups, demonstrating that the RQP may not adequately select students who want to engage in community medicine. A solution can be found by adjusting admissions to accept applicants with lower extraversion scores and enhancing openness to experience and agreeableness by providing cooperative learning education in medical schools.

Introduction

The shortage of health professionals working in medically unpopulated areas is a global problem [1, 2]. The rural medical workforce shortage results from various causes, including inadequate workforce policies guiding the number of doctors in training, changing patterns of employment of doctors as new graduates seek better work-life balance, and so on. Several attempts have been made, including the introduction of financial incentives and employment limited to working in rural areas, but not much depends on academic performance, nor have definitive measures been established so far. In particular, Japan is facing the most aged population in recorded world history, and the number of physicians per 1,000 in Japan is 2.67 (as of 2020) [3], which is insufficient compared to the OECD average of 3.6 (as of 2019) [4]. Although the number of physicians is increasing, the maldistribution of the region has not improved [5]. Similarly, in the United States, where the number of physicians per 1,000 people is 2.77 (as of 2019) [3], the shortage of physicians in rural areas is well recognized, and it has been found that only 9% of physicians are responsible for medical care in rural areas where 20% of the population lives [4]. However, no reliable method has not been established for selecting medical professionals who want to work in rural areas. The main recruitement strategy to attract and keep more physicians in rural and remote regions has been the financial and economic incentives, althouth there is little evidence about the effectiveness [6]. Any recruitment method other than economic incentives needs to be established.

In other fields than rural medicine, several investigations have demonstrated a correlation between personality traits and the determination of employment, as well as career accomplishments within the medical field. [7–11]. Several attempts have been made to link personal characteristics and work fitness, and the usefulness of personality assessments has been recognized in various domains and professions [12]. Certain personality traits are associated with success in the careers of people with traits, such as law enforcement agencies or aviation services. Several studies have demonstrated that medical students’ personality tendencies can predict their future choice of specialty, especially in medicine [13–165]. However, little is known about the personality tendencies of medical students and their willingness to engage in medically underserved activities.

Although previous studies have examined medical students’ personality tendencies and willingness to engage in community healthcare [17, 18], few studies have assessed them using a validated personality model. Insufficient evidence supported by well validated models have prevented the implementation of policies that link personality and community health care. If more robust evidence on community health care-oriented personalities is identified, it would not only advance research on personalities as the competence of the health professions, but would also provide a more reliable supply of human resources for areas with physician shortages. This study, therefore, aimed to identify the personality attributes of medical students who aspire to community medicine.

Methods

Participants and Procedures

This study was conducted at Shinshu University, Japan, a national university located in central Japan with fewer physicians than Japan’s national average. There are three admission pathways available at the Shinshu University School of Medicine, consistent with the majority of medical schools in Japan. The General Admission Program (GAP) does not impose any requirements for admission to post-graduate career paths. The Regional Quota Program (RQP) requires applicants to be engaged in medical practice in medically underpopulated areas for at least nine years after graduation in exchange for a six-year non-refundable scholarship [19]. All participants of RQP must avail themselves of the scholarship. The efficacy of augmenting the quantity of rural physicians through the implementation of scholarship programs has been substantiated [6]. The Regional Quota Program Without Loan (RQPWL) requires applicants to have lived in the area where the medical school is located for a certain period, but participants are not obliged to practice in medically underpopulated area and not required to utilize this schlarship. None of the three programs included personality assessment examinations in any manner, and no selection was made based on gender. 

The respondents were students at Shinshu University School of Medicine in Japan. A self-administered questionnaire was distributed to all the students between October and November 2022. All questionnaires were distributed by staff not involved in the teaching or assessment of the students. Questionnaires were distributed after the end of lectures at the university for first-through fourth-year students, after the end of the all-in-one event for fifth-year students, and after the regular examinations for sixth-year students. 

Questionnaire

The questionnaire consists of two parts. The first part consists of sociodemographic questions, asking about gender, grade, admission method (Quota), and willingness to engage in community health care (“will do,” “won’t do,” “I do not know”). The second part consists of personality questions. Personality characteristics were measured using the shortened Japanese version of the Big Five Inventory [20]. This questionnaire is a validated measure of the five-factor model (FFM) [21], and each item is scored on a five-point Likert scale ranging from “completely disagree” (1) to “completely agree” (5). 

Statistical Analysis

Descriptive statistics for the variables in the first part were calculated for all the respondents. Next, the scale scores for each factor of the FFM were calculated from the second part of the questionnaire. Cronbach’s alpha was calculated to assess the internal consistency of responses, and Spearman’s correlation coefficient was calculated for each factor. Respondents were divided into three groups based on their willingness to engage in community health care: RQP, RQPWL, and GAP. Comparisons between groups were made using Welch’s test, the Kruskal-Wallis test, Fisher’s exact test, or Pearson’s chi-square test, depending on the basic index and distribution of the dependent variable. Next, to evaluate the relationship between the admission method and personality, we conducted four multiple logistic regressions. The dependent variable was whether the admission method was RQP/RQPWL and the control group was GAP. The independent variables were either (1) each factor of the FFM or (2) each question item in the second part. Finally, we conducted multivariate logistic regressions on (1) each factor of the FFM or (2) each question item in the second part, as well as on gender and grade. Finally, a multivariate logistic regression was conducted to evaluate the association between willingness to engage in community healthcare and personality. The dependent variable was the willingness to engage in community health care. The independent variables were gender, grade, admission method, and either (1) each factor of the FFM or (2) each item of the second part of the questionnaire. 

Upon examination of (2) each item of the second part of the questionnaire, a univariate logistic regression was initially employed to identify items with a p-value less than 0.25. Subsequently, variables were forcedly chosen based on the Akaike Information Criterion (AIC) [22].  The results are summarized as odds ratios (ORs) and 95% confidence intervals (CIs), and model fitness was checked using the Hosmer-Lemeshow test. All statistical tests were performed at a significance level of 0.05. Statistical analyses were performed in R version 4.2.1 with the MASS package [23] (version 7.3-58.1; stepAIC function) and the bootStepAIC package [24] (version 1.3-0; boot.stepAIC function).

Ethical statement

Students received a written informed consent form, and all the participants were informed that the survey was not mandatory and was not used for other purposes such as their grading or their future career mentorings. Those who understood the purpose of the research and agreed to participate received the questionnaires. Those who understood the purpose of the research and agreed to participate returned the completed questionnaire form as consent to the participation. Since they were adults over the age of 18, minors were not included. The entire project was approved by the Institutional Review Board of Shinshu University School of Medicine (#5626).

Results

Of the 750 students, 601 (80.1%) responded from the first to the sixth year (37.2% female). In the analysis, six responses were excluded due to the presence of missing values. Additionally, four students who did not identified their gender specifically were also omitted from the analysis, ensuring a more coherent and accurate evaluation. The breakdown of the respndents is presented in Table 1.

[Table 1 should appear near here]

Five factors were calculated from the second section of the questionnaire: extraversion (E), openness to experience (O), agreeableness (A), conscientiousness (C), and neuroticism (N). The total Cronbach’s alpha value for the second part of the questionnaire was 0.84, indicating a good level of internal consistency. Cronbach’s alpha values for the five factors were as follows: (E), 0.81 (O), 0.78 (A), 0.83 (C), and 0.82 (N), respectively. The correlations among FFM values are illustrated in Table 2.

[Table 2 should appear near here]

Regarding sociodemographic questions, a significant difference was found in admission methods between the genders (Fisher’s exact test, p =0.002). There were no differences in four of the five factors of the FFI questionnaire when comparing the group based on their gender with Welch’s t-test: extroversion (p =0.63), agreeableness (p = 0.56), conscientiousness (p = 0.87), and neuroticism (p = 0.46). A significant difference was found in openness to experience (p < 0.001). The mean level of openness to experience (O) was 18.29 (SD=4.54) for women and 16.93 (SD=4.72) for women.

Next, the responses to the “willingness to engage in community health care” question were divided into three groups: “I will,” “I will not,” and “I do not know.” The results are presented in Table 3. 

[Table 3 should appear near here]

When comparing the two groups that indicated positive and negative willingness (i.e. “I will” and “I will not”), there was a significant difference in the willingness to engage in community health care (Fisher’s exact test, p = 0.016) between the genders. There was a significant difference in the willingness to engage in community health care (Fisher’s exact test, P<0.001) between the admission methods (Quota).

By comparing the There were no differences in three of the five factors of the FFM questionnaire when comparing the groups based on their willingness to engage in community healthcare: openness to experience (Kruskal-Wallis Test, p =0.64), conscientiousness (Kruskal-Wallis Test, p =0.25), and neuroticism (Kruskal-Wallis Test, p =0.29). Significant differences were found for extraversion (Kruskal-Wallis Test, p =0.002) and agreeableness (Kruskal-Wallis Test, p =0.010).

Logistic Regression Analysis on Admission method(s)

The multivariate logistic regression analyses for the admission method are illustrated in Tables 4–9.

Regional Quota Without Loan

Tables 4–5 illustrate the analysis of the RQPWL (N=514) with the GAP as a control. The p-values of the Hosmer-Lemeshow test were 0.626 (Table 4) and 0.396 (Table 5), respectively, indicating a good fit. Regarding personality (Table 4), extraversion (E), openness to experience (O), grade, and gender were significant. In relation to the question items (Table 5), Q14 and Q18 were significant. 

[Tables 4 and 5 should appear near here]

Regional Quota Program

Tables 6–7 illustrate the analysis of RQP(N=552) in contrast to GAP. The p-values of the Hosmer-Lemeshow test were 0.645 (Table 6) and 0.891 (Table 7), respectively, indicating a good fit. Extraversion (E), conscientiousness (C), and gender were significantly associated with personality (Table 6). Regarding the questionnaire items (Table 7), Q6 was significant.

[Tables 6 and 7 should appear near here]

Logistic Regression Analysis on Willingness to Engage in Community Health Care

The results of the multivariate logistic regression analysis of the FFM factors are illustrated in Table 8. The p-value of the Hosmer-Lemeshow test was 0.230, indicating a good fit. 

There was a strong association between willingness to engage in community health care for students enrolled in the RQP (OR 31.85, 95% CI 11.31–133.51) and those enrolled in the RQPWL (OR 15.19, 95% CI 4.16–98.46].

Regarding personality, there was A; OR significant association between willingness to engage in community healthcare for openness to experience (OR 1.06, 95% CI 1.00–1.12) and agreeableness A; (OR 1.08, 95% CI 1.02–1.14). There was also a significant but negative association with extraversion ( OR 0.90, 95% CI 0.84–0.97). However, neither grade nor gender was associated with willingness to engage in community healthcare.

[Table 8 should appear near here]

The results of the multivariate logistic regression for each question in the second part are illustrated in Table 9. The p-value of the Hosmer-Lemeshow test was 0.593, indicating a good fit. There was also a strong association between willingness to engage in community health care for students enrolled in the RQP (OR 35.97, 95% CI 12.44–130.81) and those enrolled in the RQPWL (OR 20.06, 95% CI 5.51–150.81).

Concerning each item, there was a significant association between willingness to engage in community healthcare for Q18 and Q21.

[Table 9 should appear near here]

Discussion

In this study, the personality profiles of students oriented toward community medicine and those not oriented toward community medicine were compared using a logistic regression when examining orientation toward community medicine. In addition, each RQP and RQPWL was investigated using a logistic regression and compared to the GAP. This study is groundbreaking because it uses a commonly used five-factor model to clarify personality tendencies and willingness to engage in community medicine among medical students.

The results of our study indicate that women are more likely to enter medical school through the RQPWL or RQP quotas. These results suggest that, in Japan, women living in rural areas are more likely to behave in ways that remain within the prefecture. According to the research by Kono et al., female physicians exhibit lower academic accomplishments in Japan [25]. Pursuing the academic career in the medical field is frequently regarded as difficult for women in Japan. The academic trajectories of physicians in Japan are frequently influenced by their associations with university hospitals as specialists, with a distinct delineation between community medicine and scholarly pursuits. As a result, a career in community medicine might be more attractive to women than seeking an academic role. Promoting gender equality in academic careers may correct the difference between genders recognized in this study. On the other hand, considering the fact that the number of female physicians remains low in Japan [26], increasing the number of female physicians may be another strategy that does not depend on financial incentives to increase the number of physicians who dedicate their career to community medicine. 

Our results demonstrated that the personality characteristics between the RQP and community medicine-oriented groups clearly differed in the correlations between the Big Five elements and several questions, and this indicated that the two cohorts were different. In general, it seems that students who entered medical school through RQP did not intend to practice community medicine but rather to benefit from the financial incentive to receive a scholarship loan that does not have to be repaid. It is possible that the attempt to increase the number of medical personnel engaged in community medicine by providing financial incentives may be a cause of the mismatch and that the most appropriate personnel may not be selected. 

According to these data, we can infer that the current selection of medical students by the RQP may not adequately pick up on the students who want to engage in community medicine. However, it was set up to increase the number of doctors involved in community medicine. Therefore, it is necessary to further optimize the entrance examination format to increase students’ interest in engaging in community medicine.

The results illustrated that the community medicine-oriented group demonstrated a positive correlation between (O) and (A) and a negative correlation between (E). Regarding the high score of (A), we interpreted that those who have the ability to get along with others well are oriented toward community medicine because it is essential in community medicine to conduct medical care tailored to the community while keeping oneself in harmony with others. 

Furthermore, in the group oriented toward community medicine, there was a positive correlation with (O), which can also be interpreted as intelligence [27]. In community medicine, the aging population is ahead of that of Japan’s metropolitan areas and thus anticipates various future problems in Japan. They may be considered a group willing to work on solving such issues. 

Finally, there was a negative correlation with (E) in the group oriented toward community medicine. We hypothesized that this was due to the location of the rural areas relative to the metropolitan area. Metro areas attract people from rural areas, but those willing to resist the flow and settle in rural areas tend to be more introverted. There was a positive correlation   between (O) and (E), similar to that found in the previous large-scale survey in Japan [28]. Nevertheless, in the present study, the surprising result was that a population oriented toward community health care has high (O) and introversion, which is an exciting finding. 

We believe it is crucial to admit students with these personality traits to increase the number of medical professionals engaged in community medicine. For example, applicants with high extraversion scores may be mismatched with regard to the provision of community healthcare, and adjustments may be necessary to prevent this from occurring. For selective admission of students with these personality traits, it may be effective, for instance, to conduct a multiple mini-interview (MMI) during the admission interview and to provide a task that looks at these personality traits. One study demonstrated the usefulness of MMI in selecting PA programs in the United States [29].

Additionally, it is suggested that education that develops such tendencies after admission to medical schools may increase the number of students oriented toward community medicine. Although personality tendencies have traditionally been viewed as fixed [30], they can change with growth, development [31], and life events [32]. In particular, the personality traits of young adults may be changeable [33, 34]. There have been cases in which interventions changed the personality tendencies of primary care physicians [35]. For example, it is possible to propose the introduction of collaborative learning in medical education to develop a tendency toward (A). This educational method will enable medical students to not only learn medicine but also develop their interactive communication and cooperation, and as a result, may increase the number of students who want to practice medicine in the community [36].

This study had several limitations. First, data were collected cross-sectionally. Therefore, it is unknown whether students who indicated their intention to engage in community healthcare chose to pursue a career in community healthcare. A follow-up study is needed to confirm the students’ actual choices. Second, all data were obtained through self-report questionnaires, which may have introduced response bias. Third, this study was conducted at a single facility in a single region; therefore, the generalizability of the results should be carefully considered. It has been reported that in Japan, there are regional differences in personality traits [37]. Therefore, studies on institutions in other regions are desirable. Fourth, we must acknowledge that the effects on willingness to engage in community healthcare for our study subjects’ five main personality traits were small, which may limit the practical application of our results to a certain extent.

Conclusion

Implementing measures to rectify gender diversity and carefully choosing medical students with a demonstrated interest in rural practice can provide a highly efficacious solution. In addition, incorporating coordination education into the medical school curriculum has the potential to significantly bolster the number of medical graduates dedicated to providing care in underserved rural areas.

Abbreviations

FFM: Five Factor Model; GAP: General Admission Program; RQP: Regional Quota Program; RQPWL: Regional Quota Program Without Loan; (A): Agreeableness; (C): Conscientiousness;(E): Extraversion; (N): Neuroticism; (O): Openness to Experience

Declarations

Ethics approval and consent to participate 

Participants provided a written informed consent form, and those who understood the purpose of the research and agreed to participate in the study.

All the participants were informed that the participation was not mandatory and was not related to their grading. 

 All methods were carried out in accordance with relevant guidelines and regulations.

This study was approved by the Institutional Review Board of Shinshu University (#5626).

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available due to the participants’ data and anonymity but are available from the corresponding author per written request.

Competing interests

The authors have no competing interests.

Funding

Not Applicable.

Authors’ contributions 

HK made substantial contributions to: conception and design, acquisition of data, analysis and interpretation of data as well as drafting the document the manuscript. 

TY made substantial contributions to: analysis and interpretation of data as well as critically revising the manuscript.

IS made substantial contributions to: conception and design, analysis and drafting and critically revising the manuscript.

All the authors approved the final version of the manuscript to be submitted. Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the content and each has agreed to be accountable for all aspects of the work.

Acknowledgments

We thank the students who participated in the research and the faculty members who supported this research. We would also like to thank Editage (www.editage.com) for the English language editing.

Authors’ information 

Hirofumi Kanazawa, MD, is a resident at The University of Texas Health Science Center at Tyler School of Medicine, the United States.

Tomonari Yoshizawa, MD, is a senior resident in the Department of Psychiatry at Shinshu University Hospital, Japan.

Ikuo Shimizu, MD, MHPE, is a project professor at Department of Medical Education, Chiba University, Japan. 

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Tables

Table 1 The number of respondents from the three programs.

Table 2 Correlation among the FFM values.

Notes: Spearman’s correlation coefficients. Bold font indicates statistical significance.

Table 3 Characteristics broken down by willingness to community health care

Notes: The personality items in the table represent means, and those in parentheses represent standard deviations.

Table 4 Logistic regression analysis between RQPWL and FFM factors (N=514)

Notes: Bold font indicates statistical significance.

Table 5 Logistic regression analysis between RQPWL and question items of the second part (N=514)

Notes: Bold font indicates statistical significance.

Table 6 Logistic regression analysis between RQP and FFM factors (N=552)

Notes: Bold font indicates statistical significance.

Table 7 Logistic regression analysis between RQP and question items of the second part (N=552)

Notes: Bold font indicates statistical significance. 

Table 8 Logistic regression analysis between FFM factors and willingness to engage in community health care (N=377)

Notes: Bold font indicates statistical significance.

Table 9 Logistic regression analysis between question items of the second part and willingness to engage in community health care (N=377)

Notes: Bold font indicates statistical significance.