A Holistic Approach of Personality Traits in Medical Students: An Integrative Review

Personality is one of the most crucial aspects of human life, since it influences all human behaviours in both personal and social life, and might also trigger important conflicts with a person’s surroundings in the setting of incompatible traits and characteristics. It is true that ‘one must be born’ for a certain medical specialty, but several components of personality might be educated with proper training. Increased levels of Conscientiousness, Agreeableness, and Openness associated with lower levels of Neuroticism might represent the key combination for achieving professional satisfaction in the medical profession. Medical students should receive proper interprofessional education, since effective interprofessional relationships among healthcare providers definitely improve patients’ safety. Empathy contributes to effective patient–physician communication, improving patient trust, compliance, and satisfaction, being positively correlated with Openness, Agreeableness, Conscientiousness and Extraversion. Emotional intelligence—the capacity to respond to one’s own and others’ emotions—was proven to contribute, in a synergistic way with empathy, to increasing empathic ability. Clinical communication skills represent a key component in medical students in order to achieve the best patient care, and they are certainly related and/or influenced by empathy, interprofessional collaboration skills, emotional intelligence and, especially, personality traits. Taking into account the complex interactions mentioned above, the implementation of effective courses based on these concepts in medical students, intending to promote the development of clinical communication skills, represents a real emergency, since it might result in a reduction in medical errors and subsequent related deaths. A thorough understanding of students’ personality is mandatory before designing these courses in order to provide a training tailored to their personality styles.


Introduction
The ways people think, feel, and behave impact their daily social interactions and should be properly assessed and trained whenever possible, especially in terms of professions that require interhuman interactions. The medical profession is by far the most peculiar of all in terms of communication, since it might act dichotomously resulting in either a strong doctor-patient partnership or, on the contrary, in a poor relationship defined by a lack of trust and respect, which will have a major negative impact on a patient's treatment outcome. However, the importance of medical communication is not always fully acknowledged and valued properly during medical education; once medical students graduate and begin to practice, they become aware of this crucial gap in their education. Moreover, this reflects on their medical actions and decreases their quality considerably. Medical communication should be based on empathy, defined as a complex social emotion consisting of the ability to identify and understand the feelings and thoughts of others and to respond with adequate emotions [1][2][3]. In terms of the medical profession, the concept of empathy was specified as being defined as a major cognitive attribute that implies the traits in the professional development of medical students. Each of the included articles was critically assessed according to the following: key results, quality of the results, interpretation of the results, suitability of the methods used to verify the hypothesis, limitations, and impact of conclusions to the field [9]. Moreover, we applied critical reading tools for scientific articles according to Jean-Baptist du Prel et al. [10], by analysing the study design of each article, the structure, the role of each section, as well as the potential sources of bias and limitations. Thus, analysis and inference were the most reliable critical reading tools used for the assessment of articles included in this review. We excluded articles that did not fit to the aforementioned criteria, as well as articles that were not written in English and those for which the full text was not available. We also identified additional references that fulfilled our criteria by a manual search of the reference list from the articles retrieved in the first round of search, for which we followed the same steps before including them in the review. We synthetized the findings from the remaining articles, highlighting both the similarities and inconsistencies between them in order to provide an objective narrative overview related to the impact of personality traits on a physician's work, academic satisfaction, and their patient's outcome. The methodological characteristics of the research-type studies included in this review are described in Table  1.   Empathy and big five personality model in medical students and its relationship to gender and specialty preference: a cross-sectional study.
To explore the relation-ship between empathy and personality Prospective cross-sectional study) Associations between medical student empathy and personality: a multi-institutional study.
To assess associations across institutions, looking for personality differences between students with high empathy and low empathy levels

Personality Traits in Medical Students-The Core of the Doctor-Patient Relationship
As mentioned above, each individual has their own way of thinking, behaving and expressing feelings or emotions, characteristics that define an individual's personality. Moreover, personality is known as one of the most crucial aspects of human life [11]. It is also known to influence all human behaviours in both personal and social life, but it might also trigger important conflicts with a person's surroundings in the setting of incompatible traits and characteristics [12]. Two famous personality theorists, Zweig and Webster, emphasise that the differences in an individual's personality represent probably the most important factor that influences a human's motivation in learning, performance, and behaviour, considering that all the controversies in areas such as thinking, intelligence, perception, emotions, learning, and motivation are based on this issue [11]. Taking into account that effective doctor-patient communication represents the cornerstone of patientand family-centred care, medical training should focus on improving personality traits that influence this communication. Nevertheless, this fact cannot be achieved without a proper assessment of personality traits.
One of the most frequently used tools for assessing personality is represented by the 'big-five model' and its derivatives, e.g., Personality Inventory NEO-PI-R [13]. The big-five model or the five-factor model has been used for assessing intercultural differences among different countries, defining the underlying qualities of personality traits [57,58]. Thus, the big-five model is based on the assessment of five dimensions of personality and its related facets, six for each dimension: Openness, facets-fantasy, aesthetics, feelings, actions, ideas, values; Extraversion, facets-warmth, gregariousness, assertiveness, activity, excitement-seeking, positive emotions; Conscientiousness, facets-competence, order, dutifulness, achievement striving, self-discipline, deliberation; Agreeability, facets-trust, straightforwardness, altruism, compliance, modesty, tender-mindedness; Neuroticism, facets-anxiety, angry hostility, depression, self-consciousness, impulsiveness, vulnerability [14,59]. Each of these dimensions is related to specific personality aspects and defines particular personality subdimensions. Thus, Openness is related to an individual's intellectual interests, culture and openness to experiences [15]. Extraversion is a reliable indicator of energy, enthusiasm, sociability, orientation towards others and task perseverance [60,61]. Conscientiousness is another personality dimension that implies prudence, responsibility, moral integrity, the need for structure and order, as well as perseverance in action [60]. Interpersonal relationships represent a fair reflection of agreeability, which is related to altruism, goodwill, gentleness, direct behaviour and trust in people [60]. Emotional Stability or Neuroticism is associated with depression, impulsivity, anxiety, vulnerability and the tendency to worry [60]. This model was assessed in multiple general studies, but unfortunately, its utility in medical students is far from being properly assessed. Taking into account the great impact of their personality on their professional skills and performance, a proper understanding of their personality would be of great benefit during medical school.
Professional satisfaction is a strong hallmark of wellbeing during adulthood. In terms of the medical profession, this is choosing a specialty that matches best with an individual's personality traits. Multiple factors were identified as essential contributors for medical specialty choice such as personality, gender, personal interest, economic status, clinical experience during clerkship, mentoring from professor, expected income, lifestyle, family or public media influence [16][17][18]. Thus, extrinsic factors display a greater influence on a student's decision when choosing their specialty. Nevertheless, personality remains a major determinant in specialty decision making. Taking into account the major impact of this choice on public medical services and policy on medical education, each career counsellor or professor that mentors medical students should focus more on finding an effective method to assess their personality [62]. Moreover, a proper assessment of personality traits might predict performance in carrying out tasks entailed by each medical specialty [6]. Thus, we are definitely entitled to say that 'one must be born' for a certain medical profession in order to achieve the desired performance. A recent study performed on medical students aimed to identify the relationship between specialty choice and personality traits, and concluded that students with more Agreeableness preferred clinical medicine instead of basic medicine [6]. The authors also underlined that students with an increased level of Openness intended to choose medical departments [6]. Openness was also proved to be directly related to satisfaction and personal interest when choosing the medical specialty [6]. Unsurprisingly, age was shown to influence certain personality traits such as Conscientiousness and Agreeableness, which seem to be higher in older students [6]. Another study that compared surgical residents with the general population in terms of personality traits pointed out that surgeons scored significantly higher for Extraversion, Conscientiousness and Openness [19]. According to the study of Hoffman et al., who compared the personalities of surgical residents, nonsurgical residents and medical students, surgical residents scored better for Conscientiousness and Extraversion, but worse for Openness than medical students [20]. Thus, previous studies emphasised the fact that surgeons possess a particular personality distinct from that of trainees in other medical specialties or the general population [19,63], suggesting there is an innate character of their personality that enables them to perform this specialty. Nevertheless, the question of whether surgeons are born or made is rather challenging. Thus, a recent study performed on surgical trainees and medical students who intend to pursue a surgical specialty proved that the two groups display multiple similarities regarding both personality traits and learning styles [21], indicating that most likely an innate personality is required for this profession and these traits are neither learnt or developed during surgical training. Both groups included in this study scored high for Conscientiousness, Agreeableness and Openness, and low for Neuroticism [21]. These findings suggest that trainees adjust their Neuroticism during residency programs and become more emotionally stable over the course of surgical training, experiencing lower anxiety and depression levels as compared to undergraduates that aim to pursue a surgical career. Moreover, the combination between increased levels of Conscientiousness, Agreeableness and Openness and lower levels of Neuroticism might represent the key attribute for enabling students to accept better and cope with the tasks and rigor of a stressful residency program such as surgical training. Thus, personality testing should be mandatory during medical education since it was clearly showed that personality profiling is an extremely useful tool for distinguishing between high-and low-performing residents [22]. Taking into account the crucial impact of the match between personality traits and medical career on the health care services and national economy, each university should implement a program designed for personality testing during the medical training in order to properly guide medical students in their specialty choice.
Interprofessional collaboration between healthcare providers is essential in order to achieve the best outcome for each patient and improve patient safety. Thus, the collaboration of different healthcare professionals in well-functioning teams by contributing with their specific knowledge related to each medical specialty, resulting in a holistic approach, will definitely impact both medical performance and patient satisfaction [22,64]. Interprofessional education is meant to provide students opportunities to develop, train, and learn collaboration skills and each medical university should implement this type of education as a regular training, since it is often challenging to achieve good interprofessional teamwork [64]. It is true that awareness regarding the need for interprofessional education during medical school has increased considerably during the last few years, but students' attitudes towards this type of training remain an issue since they seem to be influenced by multiple factors such as gender, learning styles or personality traits [8,[23][24][25][26][27]. Thus, once more, we emphasise that a thorough understanding of personality traits in medical students could considerably improve their attitudes towards interprofessional education and collaboration by providing teachers the opportunity to design proper teaching methods adjusted to medical students' personality traits and their preferences for different learning styles.
Medical empathy, defined as the ability to understand a patient's experiences, concerns, and perspectives and to express this understanding in their favour [24], is another essential concept that contributes to effective patient-physician communication, improving patient trust, compliance, and satisfaction in order to achieve the best outcome in clinical practice [28]. Thus, it was fairly stated that the physician's performance, clinical skills, and biomedical knowledge are strongly influenced by empathy and emotional abilities, which, in turn, are shaped by personality [29]. In terms of personality traits, Openness and Agreeableness were proven to be positively correlated with empathy [30]. Moreover, it seems that empathy is also positively correlated with two other personality dimensions, i.e., Conscientiousness and Extraversion [1]. Nevertheless, it is also true that increased empathy might result in emotional fatigue, increased risk of stress, and subsequent 'burn out' [65]. Self-assessment and understanding of personality traits could considerably decrease the previously mentioned risks by approaching suitable training strategies in order to improve unfavourable traits. The main daily goal for each physician is to provide the best of care for their patients and, therefore, the relationship between empathy, emotional intelligence, and personality was found to be the main factor that contributes to successful achievement of this goal. Multiple studies proved that emotional intelligence is associated with increased empathy, improved patient-physician relationship, teamwork, communication skills, stress management, and leadership resulting in higher academic performance [31,32,65]. The relationship between emotional intelligence and personality is further emphasised by the fact that the first one includes the ability to understand, perceive, and manage self-emotions, but also to perceive and understand the emotions of other humans [66]. In spite of their inherited and innate pattern, studies proved that emotional intelligence and empathy can be improved through proper education, implying an urgent need to implement communication training in medical students, since they seem to have a positive influence on both emotional intelligence and empathy [33,34,67]. Thus, an effective program designed for enhancing emotional intelligence and empathy in medical students should definitely take into account students' personality [35,67,68]. The implementation of such a program during medical school is crucial, since it was proved that empathy declines during academic medical school training [36]. In addition, the decreasing pattern of empathy continues after they begin to practice their profession, since a doctor's life is best characterised by resulting in an impairment of personality traits and devotion to patients. Therefore, programs for enhancing empathy would be of major benefit for improving professional experiences and performance.
A close interplay between personality traits, empathy, and interprofessional collaboration was emphasised by recent studies, which proved that empathy is positively associated with collaborative interprofessional work in postgraduates who are at the beginning of their specialisation [37], being well-documented that both empathy and interprofessional work are influenced by personality traits. Moreover, it was underlined that general empathy might be predicted by different personality styles, such as styles of protection, sensation, and accommodation [38]. In terms of interprofessional collaboration and communication skills, it was noticed that individuals that display a greater degree of empathy find it easier to accept failures in their life, being more optimistic regarding the future, motivated to satisfy others first, and trying to change their environment to fulfil their goals [38]. According to Zaki et al., empathy is a motivated phenomenon implying a close interaction between social desirability and intrinsic motivation [69]. Thus, a student's self-efficacy is moderated mainly by two motivational factors, i.e., value of the goal for which they work and the expectation to achieve that goal [39]. Nevertheless, intrinsic motivation and self-efficacy are not enough to achieve the goal in medicine if not supported by empathy. The complexity of practicing and understanding empathy in clinical situations requires a solid basis provided by intense training in terms of personal development, relationship and system maintenance, chance, and goal progress [40].
Emotional intelligence is another crucial ability for medical students, since it represents a measure of emotional awareness and the capacity to respond to one's own and others' emotions. Thus, Mayer and Salovey stated that emotional intelligence ability implies not only the ability to perceive and integrate emotion, but also to understand and regulate emotion in order to favour personal growth [29,70]. The Accreditation Council for Graduate Medical Education defined emotional intelligence competency as a set of assessment methods for interpersonal and communication skills, patient care, and professional behaviours in residents [71]. Thus, 12 abilities were related to emotional intelligence competency: emotional self-awareness, emotional self-control, achievement orientation, adaptability, empathy, positive outlook, coach and mentor, organisational awareness, influence, inspirational leadership, teamwork, and conflict management, which represent, along with empathy, the most important traits of 21 st century physicians [41]. An increased level of emotional intelligence was shown to positively influence doctor-patient relationship, teamwork, communication skills, level of empathy, organisation commitment, as well as stress management [31,32,65,72]. Emotional intelligence and empathy synergistically contribute to increasing empathic ability [29]. One of the most important deficiencies in medical students is a lack of confidence and resources to implement empathic behaviour, despite them fully acknowledging and understanding its value [29], emphasising once more the need for proper dedicated training during medical school. Therefore, medical education should focus not only on improving empathy and empathic behaviour in medical students, but also promoting and teaching methods for its effective implementation in residents and young physicians. Emotional intelligence is definitely influenced by personality. A recent study performed on US medical students, which focused on assessing emotional intelligence, revealed a strong positive association with Extraversion, a moderate positive one with Conscientiousness, Agreeability and Openness, as well as a weak negative association with Neuroticism [35]. Moreover, Conscientiousness and Openness were found to be reliable predictors for medical students' competencies in clinical contexts [42]; Openness and Agreeability promote the development of patient-physician relationships [43], as well as training proficiency [73]; and Conscientiousness was identified as the most important trait required for effective task completion [74]. Considering the complex aforementioned findings, emotional intelligence has an incontestable influence on patient-physician relationships, medical students' and physicians' communication skills, professional performance, and proficiency, creating important bridges with empathy and interprofessional collaboration skills under the close guidance of personality traits.
Clinical communication skills represent the key component in medical students in order to achieve the best patient care, and they are certainly related and/or influenced by empathy, interprofessional collaboration skills, emotional intelligence, and especially personality traits. Nevertheless, effective communication between physician and patient/caregivers represents the 'cornerstone' of care by improving the patient's outcome. Good communication skills improve not only the physical but also the mental health of patients, increasing their compliance and satisfaction regarding the provided care [44]. The physician's ability to communicate and their knowledge represent two major factors that equally contribute to the patient's outcome [45]. In addition, personality traits were proven to also affect attitudes regarding communication skills training, although these skills are currently considered a crucial attribute for all people working in primary health care systems [46]. Medical errors, a continuous cause of death displaying an increasing pattern worldwide, seem to be mainly related to a major lack of communication skills [47]. It is indeed a real fact that the current trends in medicine focus on the acquisition of proper communication skills in medical students and not only on enhancing the theoretical aspects of each medical field, underlining that these skills should be considered when determining physicians' competence [11]. Thus, medical educators should pay close attention and combine students' personality and the ability to learn the communication skills in order to develop effective communication skills training to reduce medical errors in the long run [45]. Based on these findings, we hypothesise that physicians' appropriate and effective ability to communicate might result in a considerable reduction in medical errors and subsequent deaths. Medical educators should also focus on increasing students' awareness regarding the importance of learning communication skills, since it was underlined that they find no merit in improving these skills because they do not acknowledge them as an important aspect of medical and practical education [11]. This fact is rather concerning considering the effectiveness of students' attitudes and satisfaction with learning in motivating and promoting knowledge quality [45]. Recent studies focusing on medical students' personality traits and their attitude towards learning communication skills concluded that anxiety was associated with a negative perspective regarding communication skills training during medical school [48,49], while students with increased sociability levels were found to have a positive attitude towards this training [45,48]. Moreover, Agreeableness, Extraversion, and Conscientiousness were positively correlated with medical students' attitudes regarding the interaction with patients, underlining that these personality dimensions might also be related to students' attitudes in terms of communication [50]. Contrariwise, aggression/hostility represents the main characteristic of antisocial and bold behaviours, and it was associated with a negative attitude towards learning communication skills, since individuals with this type of personality express no interest in communicating with others by lacking this desired attitude [45].
The importance of clinically focused skills and behaviours in medical education has been acknowledged by both the Association of American Medical Colleges and the European Board of Internal Medicine for over a decade [75,76]. The competencies related to clinical communication skills and to clinical practice include trust building; respect; compassion; altruism; empathy; understanding patient's spirituality, beliefs and meaning; professionalism; information sharing and mutual decision making; relationship building; cultural sensitivity; responsiveness to distress; appreciation of psychological factors; self-awareness; ethical issues; and acting with honesty [75,76]. These competencies were related to personality dimensions in several studies, but the results remain contradictory depending on the studied populations. Therefore, Sims et al. assessed the relationship between personality traits and communication skills in adults and showed that Agreeableness and Openness might predict assertiveness and empathic listening in communication [51]. Contrariwise, a study performed on psychology students revealed no significant correlation between the same neither before nor after communication training [52]. Studies performed on medical students remain scarce. Nevertheless, Agreeableness, Openness, and Extraversion were found to be the most important factors that positively influence students' attitude towards communication and learning, enhancing a better connection between the patient and physician [53]. Moreover, each of these dimensions were proven to have a major contribution to achieving the ultimate goal of improving students' attitudes towards communication in different ways: Agreeableness enables students to initiate a relationship with patients easier by providing the tendency to be friendly [54], Openness promotes the better acceptance of adversity and willingness to change [55], while Extraversion favours energy to social interaction better expressing the inner disposition [56]. Based on all these evidence-based statements, medical teachers should focus more on assessing students' personality traits and implement their teaching activities tailored accordingly or even support the development of personality dimensions that favour an effective doctor-patient communication.

Conclusions
The relationship between physician and patient represents the core of medicine and all efforts should focus on improving this relationship. A thorough assessment of medical students' personality traits is crucial for educators in order to acknowledge the main deficiencies in their students and to design effective tailored communication and clinical practice training for improving and educating these deficiencies. Professional satisfaction is definitely influenced by career choice, which should be properly guided after an individual assessment of personality traits. Interprofessional collaboration and teamwork are mandatory for patient safety and medical students should be made aware of its importance even before graduating. Emotional intelligence and empathy act as partners for improving em-pathic ability in order to reach the best doctor-patient relationship. Empathy is positively influenced by being positively correlated with Openness, Agreeableness, Conscientiousness, and Extraversion, and thus, training should focus on improving these components in medical students. The ultimate goal of the medical profession is to achieve the best outcome for each patient. Empathy, emotional intelligence, and clinical communication skills are essential for building an effective doctor-patient relationship, while interprofessional collaboration and teamwork are mandatory for assuring the best of care in practice, altogether being closely governed by personality traits and crucial for providing the best outcome for the patients. Taking into account students' personality traits, courses should aim to improve empathy, clinical communication skills, interprofessional collaboration, teamwork, and practical competencies for the patients' best outcomes. Thus, proper training should begin in medical students and should never end. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest:
The authors declare no conflict of interest.