It is well recognized that physicians need leadership skills to coordinate teams and improve patient care. The Accreditation Council for Graduate Medical Education (ACGME) published an article in 2015 recommending physicians-in-training develop leadership skills and proposed a “strawman” curriculum for programs to adopt.(1) These ACGME competencies require residents to be proficient in areas such as interpersonal communication skills, teamwork, and quality improvement.(2)
Formal leadership training in internal medicine residencies, however, is lacking. About 65% of academic hospitals in the country have formal leadership training for residents, and such opportunities vary greatly among programs.(3) Of the few programs that have developed leadership curricula, the training is overall positively received by residents.(4) In addition, residents surveyed from programs that do not offer leadership curricula are eager to receive such training.(4) Thus, implementing standardized training for internal medicine residents can address these unmet needs.
When surveyed about their leadership skills, residents mention that they view themselves as “accidental leaders,” as they have developed these skills before residency either through jobs or extracurricular activities.(5,6) Many residents also noted that their leadership development during residency occurred informally, often through mentors or by learning through trial and error.(5,6) This lack of formal leadership training often results in residents adopting habits from their environment and evolving responsibilities: junior residents focus on managing students and tasks, mid-level residents prioritize providing feedback to peers, and senior residents attend to mentorship.(5,6)
The absence of structured leadership training not only affects individual professional growth, but also can affect healthcare teams and patient outcomes. As the healthcare system becomes increasingly complex, the need for proficient leaders who can navigate multidisciplinary teams and ultimately enhance patient care becomes even more critical.
Several medical specialties have established leadership curricula for their residents with great success, including otolaryngology, emergency medicine, obstetrics and gynecology, and general surgery. Most residents reported that the presence of leadership curricula strengthens their residency training, and the majority expressed that they would benefit from further training.(5–7)
Studies have correlated increased levels of self-awareness with improved leadership effectiveness and organization outcomes.(8) However, there has been no standardized leadership training involving DiSC for internal medicine residents, nor have there been data collected assessing personality traits and leadership styles of internal medicine residents at large.
Thus, our goal was to develop a curriculum to teach the intersection of personality and leadership styles to categorical internal medicine residents.
Methodology
The Mount Sinai Beth Israel Internal Medicine Residency Program included 79 categorical residents in the 2022–2023 academic year (31 PGY-1, 25 PGY-2, 23 PGY-3) who are on a 6 + 2 block rotation and spend two weeks out of every eight on ambulatory block. Tuesday mornings are allocated for instruction. We created a one-hour long workshop that one of us (MAW) led for resident groups every two weeks for four separate groups to encompass all residents.
The DiSC personality test, based on the theories by William Mouton Marston, is a tool to glean insight into various personality types. Marston discussed his ideas in his 1928 book Emotions of Normal People and postulated that the way individuals interact with their environment may be categorized into the following personality types: dominance (D), inducement (I), submission (S), and compliance (C). He then created a two-dimensional, two-axis model of emotional expression, which was further modified to create the modern DiSC personality tests with the following domains: dominance (D), influence (I), steadiness (S), and conscientiousness (C).(9)
Each personality type faces strengths and weaknesses when it comes to leadership and interpersonal communication. For instance, people who are D are generally assertive, focused on results, and quick to make decisions; however, they may struggle with impatience and stubbornness. People who are I are outgoing and people-oriented, but they may have difficulty being alone. People who are S are patient and prefer stability in situations, but they may also lack assertiveness. Finally, people who are C are generally problem-solvers and analytic, but they may be perfectionists in certain situations.(10)
These categories illustrate the tendencies people have in the workplace with regard to teamwork, communication, and collaboration, as well as the challenges they may face. In the healthcare setting, using the DiSC assessment has been shown to improve connection between nursing teams and patients and to help surgery residents better understand interpersonal characteristics.(10,11)
We asked residents to complete the free versions of the DiSC assessment from Open Psychometrics and Tony Robbins in advance of the session.(12,13) During the session, after some introductory remarks by the leader, residents were asked to separate into different areas of the room by personality types.
Each small group discussed two questions: 1) how does your personality type help you learn? and 2) what challenges of your personality type do you face? Residents then shared their responses with the larger group.
We facilitated a discussion of the various personality types: What resonated with them personally and as leaders, what are the preferred working styles of each personality type, and how to adapt when leading a team with learners from different styles. We also discussed how to best collaborate with other members of the medical team, such as social workers, surgical consults, and patients.
Outcomes
Not all of the residents attended a session and some residents had personality types split equally among two groups or preferred to sit with a group other than how they scored on the screener or did not complete the screener.
When residents separated into personality groups, the compositions were approximately 10% D, 9% I, 46% S, 35% C. This breakdown differed from the national breakdown (3% D, 11% I, 69% S, and 17% C), although there is no national subset for physicians.(14)
During the session, the author (MAW) who delivered the training, reported that the initial response to the sessions was positive. Residents seemed able to acknowledge their own personality types and how these types can be both helpful and a barrier in their daily tasks.
In a broad introduction to leadership, residents learned about their own skills and the opportunities and challenges of working with various personality types. Residents also discussed flexing leadership styles to better collaborate with different dispositions. For example, when delivering feedback, a D might need to hear feedback in a direct way, while an I might need to be engaged beforehand. Similarly, when a change in the plan occurs, an S might be best told what to do next, while a C might need an explanation as to why the change was necessary.
Participants in the sessions were noted to nod and gasp as they saw some of their behaviors reflected in the descriptions. This led to a discussion of leading teams in general and the role of the resident as both leader and manager. The groups also discussed how to respond to certain patient situations, such as a patient who has been waiting for a long time. A D patient might need to be offered choices (“You can wait here, you can reschedule, or you can go for a walk and I’ll text you when it’s your turn.”). An I patient might need to be sympathized with and engaged socially. An S or C patient might need to have an explanation for why the doctor is running late.
Based on our early results, the DiSC personality test was a useful tool for teaching leadership skills to internal medicine residents. In a survey (Figure 1) delivered to all 79 residents several months after the session, nine of the nine respondents (5 PGY-1, 3 PGY-2, 1 PGY-3) said they were very, quite, or somewhat prepared and confident to use these skills.
Discussion
The intent of this project was to improve leadership skills by promoting self-awareness of personality and, in turn, to help residents discover their individual strengths and areas of improvement both as individuals and as leaders. Lessons learned could be applied to interpersonal communication and leadership of the medical team when residents return to their clinical work.
The conversations in the workshops were robust and qualitatively led to thought-provoking discussions about individuals’ own skills, their leadership tendencies, and the way they relate to others.
Of course, there were many limitations in this project. First, data on personality types was incomplete as some residents did not complete the pre-work before the session, got different reports on the two tools, were equally split among two personality types, or chose to report something other than how they scored. Personality type data on physicians nationally is not available and would be helpful in this situation.
The response rate for the post-session survey was very low (and was sent out well after the session because of a concern from program leadership that they were being overwhelmed with surveys at the same time). Thus, although participants seemed engaged and satisfied in the sessions, it is hard to derive substantial conclusions from these data.
Next Steps
Standardized leadership training in internal medicine residency programs offers many benefits. We established a personality-based training course using the DiSC assessment to identify and develop residents’ leadership skills, which was met with a positive response. This approach could be implemented across more residency programs to improve self-awareness and interpersonal skills. Effects could be far-reaching, including strengthening the physician workforce and patient outcomes. Further evaluation of this program should be undertaken.
Future projects could include more quantitative surveys of skills before and after training and a more longitudinal curriculum to teach leadership skills throughout residency. Understanding the breakdown of DiSC personality types for physicians nationally in comparison with the general population would also be fruitful. For many of the programs that are not currently teaching leadership skills, using a DiSC-based workshop series can be a straightforward way to discuss personality and self-awareness topics with residents.
References
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