¹Department of Intensive Care and Physiotherapy Department, Sir Charles Gairdner Hospital, Perth, Western Australia; Curtin University, Faculty of Health Sciences, Perth, Western Australia
²Department of Intensive Care, Bendigo Health, Bendigo, Victoria, Australia; Monash Rural Health Bendigo, Monash University, Victoria, Australia; Rural Clinical School, University of Melbourne, Victoria, Australia; Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
³Phoenix Australia, Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia; Division of Mental Health, Austin Health, Heidelberg, Victoria, Australia
⁴Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel

^*Address for Correspondence: Dennis D, Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, Australia; Senior Lecturer, Curtin University, Perth, Australia; E-mail: Diane.Dennis@health.wa.gov.au

Submission: 10 June 2022
Accepted: 16 July 2022
Published: 23 July 2022

Copyright: © 2022 Dennis D, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Intensive care professionals work together within a high-acuity high-stress environment and develop unique clinical and human skill sets within the specialty. The manner in which medical leadership acts, responds, and is understood by those around them is an important component of optimising healthcare. The aim of this study was to explore, qualify and define the self-perceived attributes of senior doctors working in intensive care (Intensivists), and construct ‘Intensivist personas’ that might provide useful insight for the entire healthcare team.

Methods: Using a prospective qualitative design, this study involved face-to-face interviews with 19 Intensivists who each had more than four year’s clinical experience. Participants were asked their perceptions of the typical personality traits of a ‘flourishing’ Intensivist; and how they felt they were viewed by others outside their specialty. Interviews were audio recorded, transcribed and attributes were coded using a thematic framework analysis of each transcript using NVivo software. Personas that might represent the contemporary Intensivist were then constructed based on the themes that emerged.

Results: More than 700 pages of coded data were extracted from the transcripts. Six personas were built according to how Intensivists saw themselves: the Fixer; the Retriever; the Diplomat; the Negotiator; the Pragmatist; and the Duck. An additional three personas were created relating to how they perceived they were viewed by others’: the Superhero; the Naysayer; and the Dictator.

Conclusion: This study describes the self-perceived personality traits of modern-day Intensivists and in doing so, adds to the scarce qualitative literature available. Understanding these attributes is important for all who work in intensive care, including nurses who are an integral part of healthcare service delivery.

Intensive care medicine; Doctors; Thematic framework analysis; Personality traits; Interview

The practice of medicine goes back to ancient times and was historically a broad-based science. In modern medicine, there is increasing specialisation of practice in line with the massive expansion of knowledge, and the advanced skill set required to deal with new technology. As a result, our human understanding of ‘what it is to be a doctor in the 21^st Century (Common Era) is rapidly evolving, with over 1.5 million new medical-related studies indexed annually on search engines such as Pubmed [1].

Intensive care is a field of medicine devoted to managing complex life-threatening illness. It has its origins in the mid-nineteenth century Crimean War, when Florence Nightingale tended to those soldiers worst injured in an area geographically closest to her nursing station. These patients were closely monitored and attended to quickly in the event of clinical deterioration [2]. This ‘collective’ model of acute care (cohorting the sickest patients to where most of the resources are) was further established in the 1950s in response to the global poliomyelitis epidemic. Medical centres throughout the world established respiratory ‘intensive care units’ (ICUs) to monitor and manage patients requiring positive and negative pressure ventilation. Anaesthetists were frequently involved in the development of these services as they were seen to be the experts in airway intubation [2], ventilation and resuscitation. In the years that followed, these respiratory or ‘general’ ICUs devolved into the distinct sub-specialties seen today in some countries, based on the nature and case-mix of the hospital. For example, separate ICUs for surgical, burns, cardiac, paediatric and neonatal patients.

As the discipline of Intensive Care matured, specialist doctors from other, often diverse, backgrounds also sub-specialised in intensive care medicine. Part of this involved the establishment, development and maturation of professional societies which defined the role of the ‘Intensivist’, including the core competencies and training required. In Australia and Aotearoa New Zealand, the ‘newness’ of intensive care medicine as a speciality is reflected by the fact that the Australian and New Zealand Intensive Care Society (ANZICS) first met in 1975 [3], formalising training of Intensivists in 1976 with a specialist College becoming operational in December 2010 [4,5].

The key service elements of a modern general ICU are centred on the delivery of a number of highly invasive supportive therapies such as mechanical ventilation; renal replacement therapy; extracorporeal membrane oxygenation and monitoring [6], which are implemented through the coordination of a broad interprofessional team of doctors, nurses, allied health professionals and others. Modern-day Intensivists are correspondingly directly responsible for patients under their care in a relatively closed clinical system, with input from other specialties as required [4], the so-called “closed” model of intensive care.

Although present-day doctors represent a similar cohort in terms of the entrance criteria for medical school, and receive broadly similar pre-licensure training, there is an abundance of literature dating back to the 1960s suggesting that personality stereotypes exist for some medical specialties [7,8]. Anaesthesia, for example, has been reported to attract people who are more self-sufficient and extroverted compared to doctors in general practice [9]; Psychiatrists have been characterised as possessing greater frustration tolerance, emotional maturity and stability than seen in other fields [10]; Surgeons have been found to be more tough-minded, resolute and unempathic compared to both anaesthetists and doctors in general practice [11]. These data are important, as the synergy of personality type with working environments has been shown to be significantly related to workplace resilience [12].

A persona describes a particular type of character that a person seems to have, often different from the real or private character that person has [13]. It is a fictional individual whose characteristics may be derived as a composite of a number of different real people [14]. As the field of intensive care medicine is relatively new, there is little published data related to the self-perceived personality traits of doctors working in the domain. Creating a shared understanding of these frames would be useful to all who work within the intensive care healthcare service delivery. Based on the personal reflections of a sample of Intensivists, the aim of this study was to explore, qualify and define the attributes of doctors working in intensive care in order to construct the persona or personas of the contemporary Intensivist.

This study used a prospective qualitative design to explore the research question of what characteristics define the attributes of doctors working in intensive care. To answer this, the primary objectives were to

1. Interview a group of experienced Intensivists
2. Analyse their responses and construct a persona or personas of the ‘typical’ Intensivist.

A once-off face-to-face interview was conducted on-site at each participant’s respective hospital during non-clinical time in a quiet location adjacent to the ICU. Ethical approval was granted by Sir Charles Gairdner Hospital HREC (Lead site: RGS0794); the Austin Hospital/HREC/18/OTHER/14); Hadassah University Hospital (0313-18HMO). All participants provided informed written consent prior to participating in the study.

An example of the specific interview questions relating to Intensivists’ perception of the characteristics of the modern-day Intensivist was:

“Can you describe what you think are the attributes and typical personality traits of a ‘flourishing’ Intensivist?”

and “How do you think those professionals outside of intensive care view the stereotype of the contemporary Intensivist?”

Intensivists from two countries (Australia and Israel) who had worked in the ICU specialty for more than four years were considered for inclusion in the study cohort. They were approached in-person by the site investigator and provided informed written consent prior to participating.

Data collection was undertaken by three researchers (Intensivists [CK and PVvH], and non-Intensivist [DD]) who all had experience in qualitative research methods. Interview data was audio-recorded and transcribed. Transcripts were edited by participants for accuracy, and then returned to one investigator (DD) who entered them into the dataset as de-identifiable data. Data saturation was reached after approximately 60% of the population of Intensivists had been interviewed at the first site (in Israel), suggesting that approximately 15-18 participants would provide thematic sufficiency.

NVivo software (Version 12, 2018 software; QRS Pty Ltd., Victoria, Australia) was used to undertake a thematic framework analysis. Codes were initially generated by two investigators (DD and RK) who reviewed two random transcripts independently. One of these researchers (RK) had not undertaken any interviews and was not an Intensivist, which ensured the reflexivity of the analysis. The final code-book was built with the consensus of all investigators who subsequently coded all manuscripts. Personas were created from the themes and subthemes that emerged from coding; literal quotations were selected to support these constructs.

During 2018, 19 hour-long interviews were carried out at an Israeli institution (n=6) and two Australian institutions (n= 6 and 7 respectively), with one Australian Intensivist declining to participate. Six personas were constructed around the self-perceived attributes that defined the Intensivist.

The Fixer (Table 1): Described as one who applied technical competence to make patients better; someone confident who worked well under pressure.

The Retriever (Table 2) : Described as one who was able to take the sickest of patients and restore them to better health.

The Diplomat (Table 3): Described as one who was able to navigate interpersonal relationships successfully in order to facilitate best patient care.

The Negotiator (Table 4): Described as one who was a steadfast patient advocate in order to facilitate best patient care.

The Pragmatist (Table 5): Described as one who was realistic and practical in the face of difficult conversations and uncertainty.

The Duck (Table 6): Described as one who appeared consistently calm in a crisis whilst perhaps figuratively paddling furiously beneath the water to achieve a good outcome.

A further 3 personas were constructed around reported attributes which the Intensivists considered were the external perception of that outside of the Intensive Care Medicine specialty (Table 7). These were the Super-hero; the Naysayer; and the Dictator.

When asked to describe the attributes and typical personality traits of a ‘flourishing’ Intensivist, one respondent began by saying, “I think it takes all sorts” and this statement summarises the data that emerged. We built nine personas from the attributes that Intensivists’ identified, either within themselves or in their intensive care colleagues. Six of these were constructed according to how they viewed themselves; three were assembled in line with how they imagined their specialty projected themselves outside of intensive care.

Intensive care doctors deal in high levels of patient illness acuity, and each persona perhaps reflects a unique facet of their daily life, including the responsibility of directing the provision of care. Intensivists are often leading a team as the last in a long line of defence trying to enhance survival and recovery for a patient. Working with their team, they may bring people back from the certainty of death to the possibility of survival (the Retriever persona). We can conjure up visions of care and consultation outside of the ICU, such as their attendance at Medical Emergency Team calls, their involvement in the triage of patients’ enroute from places external to hospital emergency departments; or from within the hospital, like operating theatres. Being both curious and sceptical of other’s decision making fits the uncertainty of being faced with an unknown patient in an unfamiliar non-ICU environment. It also allows for the avoidance of cognitive biases in one’s own decision-making which is needed in order to function as this last line of defence [15]. Being adaptable and flexible in response to unexpected circumstances, in fact thriving in that atmosphere, like an ‘adrenaline junkie’, were key components of this persona.

Perhaps more optimistically, Intensivists also possess the expertise and technological arsenal to lead new solutions in the high acuity environment (the Fixer persona) to enhance patient survival or improve prognosis. This persona comprised sound clinical competence, strong technical skills with confidence and ability to undertake multiple tasks and make quick decisions under high levels of pressure.

Acknowledgment that the Intensivist does not function in isolation was a key attribute of the Fixer, whereby teamwork, and the ability to share in the celebration of success, were qualities identified.

The Intensivists recognized that they bring others along with them on the patient’s journey, sometimes willingly (the Diplomat persona) and sometimes under duress (the Negotiator persona). The features of the Diplomat included an ability to ‘read the room’ in difficult circumstances and remain grounded and compassionate. The Diplomat is happy to seek the advice of others, and able to laugh at their own idiosyncrasies. The most distinctive attribute of the Negotiator is the skill of communicating, and the ability to navigate and overcome interpersonal conflict and diffuse tension. This extended from interactions with co-workers in the ICU to interactions with patients, and family, and the other specialties with whom they worked.

Respondents commonly acknowledged that no matter how much quality care they provide, patients can still unpredictably live or die without rationalisation. The Pragmatist persona comprised those attributes of honesty, diligence and realism, which aligned with an ability to have a degree of detachment from emotional involvement and a poor memory for bad events.

Finally, at their best, Intensivists bestow both their care and training of others in a calm and consistent manner (the Duck). This persona represented more the manner in which they approached their craft rather than the craft itself. The analogy was that during crises, the Intensivist delivered coordinated care effortlessly as they glided across the water, and yet beneath the water, they were actually furiously paddling away. There is perhaps a piece of the Duck persona in each of the other personas.

At face value, the projected perceptions of others looking in at the specialty were somewhat at odds to the perceptions Intensivists had of themselves. On closer examination however, each of the three external personas could be seen as being equal and opposite to the other six self-perceived constructs, albeit viewed in somewhat of a negative light. For example, the ‘Super-hero’ Intensivist is seen to swoop in when a patient or colleague is in peril to save the day with super-human knowledge, calmness and strength of character that belies authority. These features might be equally represented as positive attributes in the characterisations of the Retriever and the Duck - although the weight of responsibility that the Super-hero persona conjures up perhaps matches the burden of the unreasonable expectations placed upon them by others.

Likewise, characteristics of the Pragmatist in taking a realistic negative appraisal of the long-term outlook of patient care, and relaying these views honestly with a level of personal detachment and resilience, might be interpreted as reflecting a Naysayer persona - the interpretation of what is pessimistic versus what is realistic defining the difference between the perspectives. The wide-angle lens of the Fixer affords a longitudinal view and broad oversight and understanding that might be viewed as arrogance in the ‘Dictator’ persona. Likewise, the emotional intelligence and skill in communicating, seen in the Diplomat and Negotiator respectively, might be represented in the Dictator with negative connotation as being aloof and controlling.

It remains unclear as to whether these described perceptions were derived from the responses Intensivists encountered in their present-day practice, or whether they were anecdotally derived from their years-in-training. No data was collected from people outside of the specialty to support or refute the perceptions held, including the nurses they worked with, as this was beyond the scope of the study.

With emerging literature related to the high rate of burnout within the intensive care domain [16-18], our findings have important implications in terms of the selection of, and entry into, the specialty by medical trainees. Before choosing the intensive care pathway, junior doctors should reflect deeply around their personal attributes as to whether they fit some of the personae described. Equally as important, during the selection of their trainees, training programmes should screen applicants for attributes accordingly. It should be acknowledged that some of these attributes, though not directly teachable, can nonetheless be deliberately cultivated so may have relevance even for current trainees/Intensivists. By having awareness of the cultural traits in senior Intensivists, it may also be desirable to select trainees differently for the creation of different or diverse future personae for Intensivists who continue to adapt to the ever-evolving sociotechnical field of intensive care medicine.

A strength of this study was that it sampled doctors from 3 sites in 2 countries who had been working in the field of Intensive care for a substantial length of time. Although some of those interviewed serviced rural areas as ‘retrievalists’, a limitation was that the study cohort was predominantly from urban adult intensive care centres within well-developed healthcare service delivery teams. We acknowledge that other personas and attributes may have surfaced from a sample that included both rural and paediatric Intensivists. There were also no interviews of people external to the specialty to substantiate the perceptions had by those outside the discipline as to the personas of the Intensivists, and this is both a limitation and a path for further study.

This study adds to the relatively scarce qualitative literature on the personality traits of doctors in modern-day medicine, providing specific self-reported insight into the intensive care specialty. Nine personas were constructed, and no one of these stood alone as the ultimate definitive identity; neither was one specific persona necessarily mutually exclusive of another. The contemporary view of the Intensivist is perhaps better represented as a combination of all of the nine described. The perception of others working in the field related to these personas is a future direction of this work.