Am I allowed to be quiet? Looking through the lens of an introvert in medicine

Ever since my third-year clinical rotations in medical school, I can usually predict what will be written about me in my evaluations before seeing them.

The phrases “be more outspoken” and “try not to be so quiet” were copied and pasted in every form. There was usually nothing written about improvement in my knowledge or patient communication. When I started residency, I thought that I would never see those comments again, but they quickly came back to haunt me in my first evaluation as an intern. Under things to improve on, there were the words “be more outspoken.”

I became frustrated with these evaluations and would often not read them until I had my advisor meetings. How loud should I have been without overstepping the attending hierarchy? How much confidence is okay without coming across as arrogant? Does it matter that I had great communication with patients, got my discharges done in time and led my team as a senior resident without any problems? Unfortunately, the answers to these questions were never found in my evaluations. The only thing I knew was that I “need to stop being so quiet.”

I started to think that I should change my personality to become someone who always kept the conversation going and who was always seen in a group. I remember experimenting with this new persona during my rotation in the ICU. I answered the attending’s questions during rounds and would lead with my plans for patients loudly and proudly. Even with this new persona, there was no change with the care I showed to my patients, my efficiency to get tasks done and the number of patients we discharged from the ICU. The one change was the increase in the amount of silence I needed at the end of the day as my “social battery” had run dry.

As medical students, we are differentiated by knowledge and test scores. As residents, there are no more test scores, so the next ranking parameter is personality. Are you going to be the one who everyone knows and who attendings talk about? Or will you be the quieter one who is not well known by your voice but by your work? What about the ones who can camouflage and do both — the ambiverts? Everyone sees the person who is always talking, the one making jokes in the call room and the one who is challenging the attending. Their evaluations speak to how great of a physician they are because they can speak aloud. This makes me question my future in critical care. How dare I want to go into this specialty when the personalities are usually extroverted, and I do not fit in?

These thoughts are exemplified by two recent experiences I have had during residency. I was the senior resident with my intern, and the attending was clearly much more outspoken. Whenever we saw patients, his voice was the first and last to be heard. I would try to speak but I did not want to overstep in front of the patient, so I kept quiet. Even though I knew everything about every patient, I did minimal speaking during rounds and let my intern do most of the talking. The team ran smoothly all week except for one unstable patient, but I led the rapid response without any issues. All work was completed without any delays outside of our control. At the end of the week, my feedback was that I needed to be more outspoken and lead the team.

In contrast to this experience, I recall when I was on the oncology floor and there was a patient who came for persistent rectal bleeding due to his relapsed acute myeloid leukemia and thrombocytopenia. He would often be very sad in the mornings due to frequent transfusions and lack of sleep. He was one of my favorite patients, and I would always spend extra time in his room chatting with him and his son and explaining the plan for the day. One day he told me that he looked forward to seeing me every morning, and he would wait until 7.30 a.m. because he knew he would hear me knocking on his door. I was shocked because I was not the nurse who took care of him throughout the day or the oncologist who would see him and chat about further treatment options. When I asked him why he said it, he replied that it was because I always took time to speak with him and would listen to his worries and fears. Unfortunately, he passed during that hospitalization. I made sure to come into the hospital to say goodbye to him and his family because he made as much of an impact on me as I did on him. This interaction happened 2 years ago, and I still think about it to this day.

Although I cannot control how I am seen by my peers in medicine, I can try to bring awareness to this internalized bias toward extroversion. Ironically, when I look at some of my mentors around me, most of them are great at having deep conversations and help me to think through my career as a young physician. Even in critical care, where there is a bias toward extrovert personalities, the ones I seek advice from are those who do not make me feel inferior for not being the first voice in a conversation.

Some of the most powerful and smart leaders in history have described themselves as introverts — Eleanor Rosevelt, Albert Einstein and Gandhi. A third to a half of the population are introverts. This is one out of every two to three people who we interact with every day. The reason we may not notice is the fact that introverts are great at camouflaging to “fit in.” With the fear of being left out, we tend to portray a more social persona around our colleagues. I have been guilty of doing this in the hospital for fear of not being heard. A psychology study showed that when introverts portray extraversion, it can be energizing, but then they quickly have mental fatigue within an hour and require solitude. This is referred to as “our social battery” in today’s world.

There is a place for both extroverts and introverts in the world. While extroverts connect with their patients through humor and easy conversations, introverts also connect through active listening and empathizing. This is very different from being shy. The two terms are often confused for one another but are far from being synonymous. We gain energy from deep reflection, which also helps us to remember the past and plan for the future. This makes us great in positions of leadership when it is time to help a struggling colleague or propose ideas of improvement within an institution. Swiss psychiatrist and psychoanalyst Carl Jung believed that everyone has both an introverted and extroverted side, with one being dominant. Extroverts are energized by social stimulation with little need for downtime, whereas introverts may feel drained by too much social stimulation. However, many introverts, like me, love to socialize with a close group of friends. We just may need some time to be alone and recharge.

Introverts can make excellent leaders if given the chance to be themselves within society. Because of their contemplative nature, they are great at making difficult decisions with careful analysis, they are creative and they can think outside the box. They also have great attunement to the feelings of others, which makes it easy to form genuine connections.

Although we live in a world that prefers the person of action over the one of contemplation, we can attempt to provide the same support to those who like to be in the spotlight as well as to those who thrive behind the backdrop. I hope that one day I will not be able to predict the comments in my evaluations before I read them.

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