This article was originally published in Student BMJ, a magazine produced by the British Medical Journal for medical students. An online version can be found here.

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When Susan Cain wrote Quiet: the Power of Introverts in a World that Can’t Stop Talking, she had no idea how successful it would become. The book, which has sold over two million copies in thirty different languages, argues that our societal attitudes undervalue, and effectively discriminate against, the traits of an introverted personality. Her accompanying TED talk on the subject has been viewed more than eighteen million times, propelling Cain to a cult status even higher than that expected of a New York Times best-selling author.

She defines introversion – separable from social anxiety or shyness – as a preference for “quiet concentration, listening rather than talking and thinking before speaking”. More likely to enjoy in-depth, one-on-one conversation than small-talk, introverts are at ease when spending time alone. Generally, she claims, they exhibit a more contemplative, independent and empathetic character. Extroverts, on the other hand, draw energy from social situations and group settings, enjoy thinking aloud and are more likely to thrive when at the centre of attention.

Today Cain runs a project called Quiet Revolution, which aims to rebalance how we think of quiet personalities. The website’s testimonies make clear that Cain’s repositioning of introversion as a strength rather than a weakness has resonated across a number of different professions. There is the criminal psychologist who credits her acute observations to her introversion, the lawyer who began to take pride in her quietness and the corporate manager who earnt promotion after her boss took a gamble on her calm, thoughtful approach to leadership.

However, Cain’s quiet revolution appears to have had little impact in medicine. When considering the portrayal of doctors in media (think of the average episode of ER or Grey’s Anatomy), medicine is often presented as a career at the preserve of the extrovert. At best clinicians are presented as effervescent, gregarious social butterflies, and at their worst as twisted entertainers plagued by arrogance and narcissism. Whether eager to embarrass medical students to bolster the spectacle of their ward round or adept with polished, jovial small talk, both the positive and negative portrayals of doctors fit well into the extrovert stereotype.

Medicine: an extroverted career?

So why do we tend not to think of doctors as introverts; is it just that extroverted personalities are more suited to medicine? Helen Salisbury, a general practitioner who runs the communications skills course for medical students at the University of Oxford, thinks not. She meets “a variety of personality types making successful careers in medicine” and asserts that there is not “one ideal” personality for a doctor. Although introversion “could be seen as a disadvantage if taken to an extreme,” Salisbury argues that introverted students are likely to be “thoughtful and reflective about their role and relationships with patients,” a trait decidedly positive in a clinical career.

Megan Riddle graduated from medical school in 2014. Now a junior doctor, she describes her introverted personality as “invaluable” to her clinical life. Her introverted traits posed challenges throughout medical school, particularly her preference to “develop proficiency in something before being asked to move to the next thing” and “not speaking up unless [having] something to contribute”. Working as a psychiatrist, she now believes there are “many niches for introverts” in medicine, describing how the struggle for a medical student to “be out in front, showing what you can do” is largely replaced by the need for consistency, conscientiousness and an independent work ethic as a practising doctor.

Riddle regards her quiet persona as instrumental in gradually building trust within a team. Sil-Jun Lau, a final-year student at Barts and The London School of Medicine, similarly credits his introversion for much of the positive feedback he’s received on communication skills. “Being reserved translates well into being a patient listener, which can get praise,” he summarises.

The idea that introversion can be advantageous to team-work and leadership has been gaining traction in social science research. Although introversion has never been analysed in the context of medicine, a 2011 paper identified that teams led by extroverts often performed less well than teams led by introverts, an effect that was most pronounced when employees were proactive. Although it is unclear whether this trend applies to clinical settings, it is an area which social scientists will likely be keen to investigate soon.

Despite these potential benefits of introversion, Riddle remembers medical school being “stacked in favour of the extrovert,” with rapid-fire questioning during ward rounds, endless group activities and an emphasis on networking to find research opportunities. Nathaniel Fleming, a second year medical student at Stanford School of Medicine, raises similar concerns when discussing the attitudes embodied by the famous medical school adage of “see one, do one, teach one”. Such an approach comes naturally to extrovert personalities, he suggests, but is “jarring for [students] who like to take time for deliberation and reflection”.

Social challenges

Fleming also suggests that medical school can pose social challenges for quieter students. The “expectation for medical students to be constantly engaged in a conversational way, and to get to know everybody else, rewards the ability to network” he argues, which sees other attributes go undervalued. “It starts to feel like it’s just all small talk, all the time; an introvert’s worst nightmare”. Amy, another student, told Student BMJ that she had “found medicine to be quite cliquey”. “Most of the organised events are geared towards more social students, and there’s an assumption that everyone falls into the binge-drinking, or work-hard play-hard, stereotype”.

Amy describes how not being in the right friendship group can cause students to be left “out of the loop and miss out on key resources”. This is especially apparent in the run up to exams, where revision resources are passed down by students in the years above.

The challenges introverts face at medical school can also undermine their confidence in their ability to practice medicine. Johnny, a fifth year medical student at Manchester University, told Student BMJ that he had questioned if he could excel as a quiet doctor. “I found myself less willing to put myself forward for things than my extroverted colleagues and wondering whether I could face being the centre of attention for the rest of my career”. These kind of experiences are probably common, especially as longitudinal studies have found that, throughout medical school, introverted students are at higher risk of stress and burnout than their extroverted colleagues.

Recommendations for medical schools

Given this, are medical schools doing enough to support their quieter students? Research published in the journal Teaching and Learning in Medicine suggests not. The authors of a 2015 paper lamented “an increasingly negative tone of language associated with introversion,” a problem they believed to be “particularly salient” because of the recent proliferation of interactive and problem-based learning techniques in medical schools. The paper recommends “simple strategies to foster the learning of introverts,” such as offering students time to reflect on their answers instead of rapid-fire questioning, and organising discussion-based teaching in a way that encourages all group members to participate.

The authors also note a “potential bias” in the evaluation of medical students’ abilities. According to the paper, introverted students may be disadvantaged by evaluation metrics that disproportionately value extroverted behaviours, such as “willingness to initiate discussion, taking the lead in a group and participation in a session”. Instead, the authors suggest giving more weight to behaviours such as “thinking before speaking, offering a synthesis of information and listening to peers before engaging”. Not only would this assess medical school performance more fairly, they argue, but it would benefit extroverted students by identifying clinically important areas to improve on.

The paper also cautions medical educators to be mindful of the difference between introversion and social anxiety. While “interventions such as increased exposure are useful for anxious individuals, these same interventions can be counterproductive for non-anxious introverts”. The authors conclude that encouraging introverted students to change their personality risks invalidating their perspectives of the world.

It is unclear how these recommendations in the academic literature will be received by medical educators. When responding to the suggestion that medical schools could better cater for their introverted students, Oxford’s Helen Salisbury acknowledged that some activities, such as group work and role plays, are “much harder for some students than others.” Recognising that “the medical consultation is usually a one-to-one interaction,” she sympathises with those who question why medical students are taught in groups. But she argues that the resources for individual tuition are limited, and that peer-to-peer feedback can be a useful teaching tool. Activities like role playing are a “necessary skill whatever your personality” Salisbury concludes, as they form the method of examination in “every medical school and higher professional exam.”

Planning for the future

Although Salisbury’s arguments do not contradict the suggestions made in the literature, the lack of discussion about the specific learning needs of introverted students means that any substantial changes are unlikely in the short-term. Given this, it may be tempting for introverted students to look at what steps they can take to improve their own experience of medicine.

Many online tools offer this very service, by recommending medical specialties based on personality tests such as the Myers-Briggs Type Indicator. The test classifies students into four dichotomies, one of which is introversion-extroversion. However, the test’s accuracy is questionable. A 2016 study showed that for psychiatry – a specialty which the tool recommends for introverted personalities – the Myers-Briggs Type Indicator had no predictive value of a student’s choice of specialty. Caroline Elton, a chartered psychologist who runs a career planning service for doctors, also recommends a nuanced reading of the evidence behind these tests. “Personality is more about how you do your specialty, rather than what specialty you do,” she summarised.

At least for now, it seems that many of the immediate challenges facing introverts in medicine are unavoidable. However, it is clear is that the cardinal signs of introversion – thoughtfulness, an analytical mind and adept listening skills among others – can equip students with a strong basis for a clinical career. Although these traits may feel under-appreciated at medical school, the lessons learnt from junior doctors, researchers and medical educators suggest that many of today’s introverted students will come to view their personality as “a strength rather than a weakness” as their clinical lives progress.

Some of the students in this article have chosen to be identified using a pseudonym.

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