**2. Personality traits of students and residents**

There are numerous studies which examined the traits of students who enter the various medical specialties. This section will compare traits of students who desire to enter an OB/GYN residency with those who prefer another primary care residency, or a surgical residency. Specialties which are primary care are typified by a continuity of patient care and include OB/GYN, Family Medicine (FM; also known as Family Practice), Internal Medicine (IM), and Pediatrics (PED). Surgery (SURG) is not a primary care specialty, but along with FM, IM, PED and OB/GYN, SURG is considered a specialty that has a non-controllable lifestyle. 

Obstetrics and gynecology, FM, IM, PED, and SURG can be contrasted with those specialties which are considered as having a controllable lifestyle, e.g., radiology, ophthalmology, pathology, and anesthesiology. A controllable lifestyle specialty is characterized by the physician controlling the number of hours spent on professional duties, leaving more time for personal activities. Increasingly, students are selecting residencies with a controllable lifestyle (Dorsey et al., 2005; Schwartz et al., 1990, 1989).

#### **2.1 Medical students**

In the 1970s, McGrath and Zimet (1977) studied the personality traits of male and female students vs. their specialty choice. Women were found to be more self-confident,

Who Selects Obstetrics and Gynecology as a Career and Why, and What Traits Do They Possess? 3

10% of their class who entered FM increased from 8% to 40%. Fortunately, for students entering OB/GYN, the trend was reversed with the number of top students increasing from 5% to 11% during the 1964-1979 to 1980-1991 timeframes. Conversely, the bottom 10% of

Myles & Henderson, II (2002) found that students who failed Step I of the United States Medical Licensing Examination (USMLE; given at the end of the two basic science years of US medical education) were likely to fail the National Board of Medical Examiners (NBME) OB/GYN comprehensive exam given at the end of an OB/GYN clerkship. Thus, students who score at or below the 25th percentile on the USMLE Step I should be identified as in need of increased observation and training in the OB/GYN clerkship. This will help ensure a successful outcome and increase the potential number of students who may select an OB/GYN residency (Myles & Henderson, II, 2002). For students who had already indicated a prior interest in OB/GYN, it seems likely that earning a poor score on the NBME OB/GYN exam would discourage them from selecting an OB/GYN

One undesirable trait, Machiavellianism (i.e., someone who avoids identifying with another's point of view, settles for less than the ideal, and isn't concerned for conventional morality), was found in 15% of students from four U.S. medical schools. (Merrill et al., 1993). Students who express this trait are authoritarian, shift blame to others when they have failed a patient, view the medical record and laboratory profile as more important than seeing the patient as a person, and find undiagnosable illnesses and unpredictable patient outcomes as offensive. Thankfully, students who select primary care specialties like OB/GYN (characterized by high patient-contact), exhibited the fewest Machiavellian traits; whereas, the low patient-contact specialties, e.g., anesthesiology, radiology and SURG exhibited the most Machiavellian traits. However, when the decreasing amount of empathy being expressed by students (cf. section 5) is combined with the emotional detachment characteristic of a Machiavellian, OB/GYN residents and faculty must always maintain highly professional, competent, patient/physician interactions (Konrath et al.,

Female OB/GYNs from 1950 to 1989 were surveyed and their traits contrasted against female physicians in all other specialties (Frank et al., 1999). Like other female physicians, female OB/GYNs had equivalent amounts of home stress, and the same marital status and numbers of children. In contrast to other female physicians, women OB/GYNs spent less time on childcare, cooking and housework. They were more likely to be in a group practice and worked more clinical hours. Female OB/GYNs also had more on-call nights where they slept less, and were more likely to report they worked too much and had increased amounts of work-related stress. Female OB/GYNs counseled and screened more patients than most other female physicians because of their increasing role of having to act as a primary care physician. Their counseling and screening role was especially true for topics concerning breast cancer, hormone replacement therapy, HIV prevention, and the need for PAP smears and colonoscopies. It was revealing that traditional residency training inadequately prepared the residents for the realities of providing a substantial amount of non-OB/GYN

students entering OB/GYN residencies fell from 10% to 5%, respectively.

residency.

2011).

**2.2 Practicing OB/GYNs** 

primary care for many of their patients (Frank et al, 1999).

autonomous and aggressive than men; whereas men displayed more nurturance than the normal population. Because females were the minority of medical students before and during the 1990s, it was postulated they had to be self-confident and aggressive in order to compete with their male peers.

In the 1980s, students entering medical school and considering OB/GYN were least depressed, highly motivated and exhibited feminine vs. masculine traits. They also exhibited large degrees of neuroticism, social anxiety, and public self-consciousness (Zedlow & Daugherty, 1991). By the 2000s, neuroticism, conscientiousness, openness, and agreeableness were prominent in students entering OB/GYN (Markert et al., 2008). Other studies in the 2000s, using various survey instruments, examined other medical student traits which influenced residency selection. Women who desired to enter an OB/GYN residency had the following traits in significantly greater amounts than men; sociability, a fondness for demanding and difficult work, agreeableness, conscientiousness, extraversion, openness, persistence, cooperativeness, and being reward-dependent. In contrast, men were significantly more aggressive/hostile, impulsive and sensation-seeking (Hojat & Zuckerman, 2008; Maron et al., 2007; Vaidya et al., 2004). Females exhibited slightly more neuroticism/anxiety than males when compared with other primary care specialties and SURG. On a positive note, male or female students entering into OB/GYN had the lowest neuroticism/anxiety tendencies (Hojat & Zuckerman, 2008; Maron et al., 2007).

In 2002, Borges and Savickas wrote a seminal paper reviewing studies, using the Myers-Briggs Type Indicator or the Five-Factor Model of Personality, on the personalities of students selecting the various medical specialties. Students entering an OB/GYN residency were extroverted, sensing-thinking-judging, highly conscientious, and achievement oriented. These students were less open to new experiences and less agreeable. When compared to students entering FM, OB/GYN students were less sympathetic, trusting, cooperative, and altruistic. However when compared to students entering IM or PED, the OB/GYN students were not as stiff, skeptical, extroverted, or neurotic, but were more conscientious and empathetic. Students entering SURG were much more open to new experiences and were more extroverted than those in primary care specialties.

The same trends were seen when the study by Doherty and Nugent (2011) found success in medical school was best predicted by a student who was conscientious and sociable. A survey of Swiss students affirmed the above and showed female students were more helpful, conscientious, and had greater intrinsic motivation than the males who expressed greater degrees of independence, decisiveness, and a desire for income and prestige. These personality differences showed females preferred specialties with a high degree of patient contact (e.g., OB/GYN), vs. males who were more interested in high-tech, instrumentdriven specialties such as SURG (Buddeberg-Fischer et al., 2003).

Student academic achievement is another trait that influences residency selection. Jarecky and colleagues (1993) found that between 1964 and 1991 students who were elected into Alpha Omega Alpha (A US-based medical school honorary that includes only the very top students.) increasingly selected controllable lifestyle residencies, thereby reducing opportunities for students in the bottom 10% of their class from entering those residencies. Comparing data from 1964-1979 to 1980-1991, the number of top students who entered controllable lifestyle residencies increased from 21% to 36%, whereas students in the bottom 10% of their class who entered FM increased from 8% to 40%. Fortunately, for students entering OB/GYN, the trend was reversed with the number of top students increasing from 5% to 11% during the 1964-1979 to 1980-1991 timeframes. Conversely, the bottom 10% of students entering OB/GYN residencies fell from 10% to 5%, respectively.

Myles & Henderson, II (2002) found that students who failed Step I of the United States Medical Licensing Examination (USMLE; given at the end of the two basic science years of US medical education) were likely to fail the National Board of Medical Examiners (NBME) OB/GYN comprehensive exam given at the end of an OB/GYN clerkship. Thus, students who score at or below the 25th percentile on the USMLE Step I should be identified as in need of increased observation and training in the OB/GYN clerkship. This will help ensure a successful outcome and increase the potential number of students who may select an OB/GYN residency (Myles & Henderson, II, 2002). For students who had already indicated a prior interest in OB/GYN, it seems likely that earning a poor score on the NBME OB/GYN exam would discourage them from selecting an OB/GYN residency.

One undesirable trait, Machiavellianism (i.e., someone who avoids identifying with another's point of view, settles for less than the ideal, and isn't concerned for conventional morality), was found in 15% of students from four U.S. medical schools. (Merrill et al., 1993). Students who express this trait are authoritarian, shift blame to others when they have failed a patient, view the medical record and laboratory profile as more important than seeing the patient as a person, and find undiagnosable illnesses and unpredictable patient outcomes as offensive. Thankfully, students who select primary care specialties like OB/GYN (characterized by high patient-contact), exhibited the fewest Machiavellian traits; whereas, the low patient-contact specialties, e.g., anesthesiology, radiology and SURG exhibited the most Machiavellian traits. However, when the decreasing amount of empathy being expressed by students (cf. section 5) is combined with the emotional detachment characteristic of a Machiavellian, OB/GYN residents and faculty must always maintain highly professional, competent, patient/physician interactions (Konrath et al., 2011). United most

## **2.2 Practicing OB/GYNs**

2 From Preconception to Postpartum

autonomous and aggressive than men; whereas men displayed more nurturance than the normal population. Because females were the minority of medical students before and during the 1990s, it was postulated they had to be self-confident and aggressive in order to

In the 1980s, students entering medical school and considering OB/GYN were least depressed, highly motivated and exhibited feminine vs. masculine traits. They also exhibited large degrees of neuroticism, social anxiety, and public self-consciousness (Zedlow & Daugherty, 1991). By the 2000s, neuroticism, conscientiousness, openness, and agreeableness were prominent in students entering OB/GYN (Markert et al., 2008). Other studies in the 2000s, using various survey instruments, examined other medical student traits which influenced residency selection. Women who desired to enter an OB/GYN residency had the following traits in significantly greater amounts than men; sociability, a fondness for demanding and difficult work, agreeableness, conscientiousness, extraversion, openness, persistence, cooperativeness, and being reward-dependent. In contrast, men were significantly more aggressive/hostile, impulsive and sensation-seeking (Hojat & Zuckerman, 2008; Maron et al., 2007; Vaidya et al., 2004). Females exhibited slightly more neuroticism/anxiety than males when compared with other primary care specialties and SURG. On a positive note, male or female students entering into OB/GYN had the lowest

neuroticism/anxiety tendencies (Hojat & Zuckerman, 2008; Maron et al., 2007).

experiences and were more extroverted than those in primary care specialties.

driven specialties such as SURG (Buddeberg-Fischer et al., 2003).

In 2002, Borges and Savickas wrote a seminal paper reviewing studies, using the Myers-Briggs Type Indicator or the Five-Factor Model of Personality, on the personalities of students selecting the various medical specialties. Students entering an OB/GYN residency were extroverted, sensing-thinking-judging, highly conscientious, and achievement oriented. These students were less open to new experiences and less agreeable. When compared to students entering FM, OB/GYN students were less sympathetic, trusting, cooperative, and altruistic. However when compared to students entering IM or PED, the OB/GYN students were not as stiff, skeptical, extroverted, or neurotic, but were more conscientious and empathetic. Students entering SURG were much more open to new

The same trends were seen when the study by Doherty and Nugent (2011) found success in medical school was best predicted by a student who was conscientious and sociable. A survey of Swiss students affirmed the above and showed female students were more helpful, conscientious, and had greater intrinsic motivation than the males who expressed greater degrees of independence, decisiveness, and a desire for income and prestige. These personality differences showed females preferred specialties with a high degree of patient contact (e.g., OB/GYN), vs. males who were more interested in high-tech, instrument-

Student academic achievement is another trait that influences residency selection. Jarecky and colleagues (1993) found that between 1964 and 1991 students who were elected into Alpha Omega Alpha (A US-based medical school honorary that includes only the very top students.) increasingly selected controllable lifestyle residencies, thereby reducing opportunities for students in the bottom 10% of their class from entering those residencies. Comparing data from 1964-1979 to 1980-1991, the number of top students who entered controllable lifestyle residencies increased from 21% to 36%, whereas students in the bottom

compete with their male peers.

Female OB/GYNs from 1950 to 1989 were surveyed and their traits contrasted against female physicians in all other specialties (Frank et al., 1999). Like other female physicians, female OB/GYNs had equivalent amounts of home stress, and the same marital status and numbers of children. In contrast to other female physicians, women OB/GYNs spent less time on childcare, cooking and housework. They were more likely to be in a group practice and worked more clinical hours. Female OB/GYNs also had more on-call nights where they slept less, and were more likely to report they worked too much and had increased amounts of work-related stress. Female OB/GYNs counseled and screened more patients than most other female physicians because of their increasing role of having to act as a primary care physician. Their counseling and screening role was especially true for topics concerning breast cancer, hormone replacement therapy, HIV prevention, and the need for PAP smears and colonoscopies. It was revealing that traditional residency training inadequately prepared the residents for the realities of providing a substantial amount of non-OB/GYN primary care for many of their patients (Frank et al, 1999).

Who Selects Obstetrics and Gynecology as a Career and Why, and What Traits Do They Possess? 5

than 27. When asked what OB/GYN traits the patients wanted, the top five ranked selections all dealt with interpersonal communication; the OB/GYN is respectful, listens to me, explains things clearly, is easy to talk to, and is caring. These traits were considered more important than clinical expertise. Zuckerman et al. (2002) found striking gender preferences associated with patient religious practices in Brooklyn, New York. Female OB/GYNs were preferred by 56% of Protestants, 58% of Catholics and Jews, 74% of Hindus and 89% of Muslims. Yet patients indicated no gender difference in the quality of the care. Johnson and colleagues (2005) found that in thirteen different sites in Connecticut, twothirds of the patients had no gender preference for their OB/GYN, 6.7% preferred a male, and 27.6% preferred a female. Furthermore, the gender or age of the OB/GYN had no impact on the quality of care they received. The most important OB/GYN characteristics the women desired were an OB/GYN who was; attentive to their needs (69%), experienced (68%), knowledgeable (62%), had good technical skills (56%), and was accessible (53%). It is interesting to note that attributes dealing with communication skills and bedside manner

In Ontario, Canada, Fischer and colleagues (2002) found that 75% of patients had no gender preference, and only 21% strongly felt they desired a female OB/GYN, while 4% wanted a male OB/GYN. Various patient characteristics had no bearing on gender preference, e.g., single, pregnant, those with a history of abortion, STDs or sexual dysfunction. In Israel, Piper and colleagues (2008) found that 60.3% of patients expressed no gender preference for their OB/GYN. Women who had children had a predilection to prefer female OB/GYNs. The important factors for Israeli OB/GYN selection were; professional demeanor (98.9%),

Studies performed in Iraq and the United Arab Emirates (UAE; Lafta, 2006; Rizk et al., 2005), showed that a high percentage of patients, 79% and 86%, respectively, preferred a female OB/GYN. Only 8% of Iraqi and 1.6% of UAE women preferred their OB/GYN to be a male. In either country, the preference for a female OB/GYN significantly increased as the educational level fell. Very few women in either country had no gender preference. It was clear that socio-cultural and religious traditions played a very significant role in preferring a female OB/GYN. In the UAE study, Muslim women did not accept a male OB/GYN, even in the presence of a female chaperone, and especially during Ramadan (Rizk et al., 2005). Another prominent barrier to accepting a male OB/GYN was feeling greatly embarrassed if they had to be examined by a male. Many patients (69%) felt that female OB/GYNs had a greater awareness of female reproductive issues, were more compassionate, and better listeners than male OB/GYNs. Younger women had a stronger preference for female OB/GYNs than older women. It seems clear that younger, less educated Muslim women

Additional data from the UAE study reveals that women look for the same positive traits in an OB/GYN of either sex, as the other aforementioned studies. They want their OB/GYN to show professionalism by being responsive to their needs, caring, empathetic, displaying a good bedside manner, and being a skilled communicator. Secondarily, they want their OB/GYN to be knowledgeable, experienced, and technically competent (Rizk et al., 2005).

reveals for

were not expressly mentioned by patients in the Connecticut study.

showing courtesy (96.6%), and being board certified (92%).

view OB/GYN gender as a gateway requirement to care.

**3.1 Gender preferences outside the US** 

#### **3. What do patients prefer in their OB/GYN?**

There has always been a controversy over male physicians treating gynecologic and obstetric issues (Balayla, 2010). Even today there are considerable differences in the OB/GYN gender preference in patients within different age ranges. The shifting patient demographics, especially the increasing number of post-menopausal women, combined with the recent large influx of female OB/GYNs, has resulted in preference changes over the decades. In 1970, only 9% of medical students were female. This had increased to 45.7% by 2001 (as cited in Table 1; Johnson et al., 2005). From 1980 to 2000, the number of practicing female OB/GYNs increased from 12% to 32%. Between 1989 to 2002, the number of female OB/GYN residents rose from 44% to 74% (cf. refs. in Gerber & Lo Sasso, 2006). Projections indicate an expanding population of female OB/GYNs in the 2010s and beyond. For example, in 1980, females constituted 27.8% of the OB/GYN residents, and 12% of the physicians in practice. By 2001 those numbers increased to 71.8% and 39%, respectively (as cited in Table 1; Johnson et al., 2005).

It is clear from the studies cited below, that good bedside manner and professionalism are extremely important to patients. Plunkett and Midland (2000) found that "well-educated" Caucasians (from Chicago, Michigan, US) placed an emphasis on communication skills when selecting an obstetrician. In contrast, patients who were to undergo surgery decided the surgical reputation of the OB/GYN was more important than bedside manner. Over 90% of either set of patients wanted the OB/GYN to be responsive to their needs, exhibit professional behavior, and to be confident and knowledgeable. Only 38% of the patients thought that OB/GYN gender was an issue, and even fewer (15%) took the age of the OB/GYN into consideration. Of the 38% of patients who considered OB/GYN gender as important, 96% wanted a female obstetrician and 84% wanted a female gynecologist.

Plunkett et al. (2002) performed another study in Chicago, and included African-Americans, Hispanics, and individuals with varied levels of education. Less than one-half of the women (42%) considered OB/GYN gender as important. When seeing an obstetrician, bedside manner, office location, referral by another physician, and recommendations from friends and family were the four factors considered most important at 57%, 45%, 40% and 35%, respectively. When selecting a gynecologist, office location, recommendations from family and friends, bedside manner, and referrals by other physicians were the top four ranked attributes at 55%, 48%, 47% and 43%, respectively. When specifically asked if they preferred a male or female OB/GYN, 52.8% wanted a female, 9.6% wanted a male, and 37.6% had no preference.

There were similar findings in New York City, where 58% of patients preferred a female OB/GYN, while 7% wanted a male and 34% had no preference (Howell et al., 2002). Only 10% of patients thought the gender of their OB/GYN impacted their care. These patients thought female physicians would naturally understand more about "female issues" than would males. When asked to rank order important attributes patients desired in an OB/GYN, bedside manner, communication skills, and technical expertise were the dominant factors for selecting an OB/GYN — or leaving if they lacked any of these skills (Howell et al., 2002).

In a large study in Michigan, Mavis et al. (2005) found that OB/GYN gender mattered most to patients who were; underrepresented minorities, unmarried, less educated, and younger than 27. When asked what OB/GYN traits the patients wanted, the top five ranked selections all dealt with interpersonal communication; the OB/GYN is respectful, listens to me, explains things clearly, is easy to talk to, and is caring. These traits were considered more important than clinical expertise. Zuckerman et al. (2002) found striking gender preferences associated with patient religious practices in Brooklyn, New York. Female OB/GYNs were preferred by 56% of Protestants, 58% of Catholics and Jews, 74% of Hindus and 89% of Muslims. Yet patients indicated no gender difference in the quality of the care.

Johnson and colleagues (2005) found that in thirteen different sites in Connecticut, twothirds of the patients had no gender preference for their OB/GYN, 6.7% preferred a male, and 27.6% preferred a female. Furthermore, the gender or age of the OB/GYN had no impact on the quality of care they received. The most important OB/GYN characteristics the women desired were an OB/GYN who was; attentive to their needs (69%), experienced (68%), knowledgeable (62%), had good technical skills (56%), and was accessible (53%). It is interesting to note that attributes dealing with communication skills and bedside manner were not expressly mentioned by patients in the Connecticut study.
