The Enneagram and its application in medical education

Abstract

Personality testing has become increasingly popular in healthcare with multiple modalities and implementations. Although personality testing has been utilized to inform various facets of graduate medical education, little is known about how the Enneagram can be utilized throughout postgraduate training. This narrative review explores the use of personality testing in graduate medical education, how personality testing has been used in the workplace, what research is available showing its use in medical residencies, and the need for additional studies on the Enneagram’s use in these areas. We conclude the Enneagram may serve as a valuable tool that can be used in postgraduate medical education to improve learning, interpersonal relationships, and teaming.

Personality, according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, “is the way of thinking, feeling and behaving that makes a person different from other people.”¹ The Myers-Briggs type indicator (MBTI) and the Enneagram can be used to separate the characteristics of people’s personalities and have been used to divide medical students into study groups, research groups, and other organizations.^2,3 Measuring personality attributes to predict performance has been popular in the business world, but the validity of this type of testing remains controversial.^4,5 Although personality information may be difficult to quantify, it may complement standardized testing, grade-point average, or class ranking when identifying factors that may facilitate stronger interpersonal communication and collaboration. In addition, personality is important in interdisciplinary relationships and patient interactions. Workplace interpersonal conflict is frequently cited as a cause of disruption in the healthcare system.⁶ This impact is often observed in high-risk areas where interprofessional communication and collaboration is key to patient outcomes, as described between surgeons and intensivists.⁷ Use of the Enneagram to analyze educational and motivational styles during residency training may provide additional data to facilitate teaming in settings where workplace interpersonal conflict may arise. This literature review describes how the Enneagram can be utilized during postgraduate training and in healthcare teams. First, we discuss the Enneagram as a personality test and explore research on personality testing within the workplace. We conclude by discussing research on personality testing in medical education and proposing how we want to study it further to inform graduate medical educators on the importance of team-based care.

THE ENNEAGRAM

The Enneagram, a term that in Greek refers to a nine-point symbol, is an ancient system of determining personality and personal growth.⁸ Used for more than a century, the Enneagram has been adapted to aid in education, motivation, and communication to help people comprehend themselves better and accept others more openly. Knowledge of the Enneagram provides individuals with a guide to understand others’ behaviors, perceptions, learning styles, and motivators.⁹ As an asset for both reflection and inner self-discovery, the Enneagram also allows individuals to discover the motivations, strengths, and limitations associated with their own personality type.

The nine types are outlined in Figure 1 and Table 1. Each classification is motivated by different experiences from one’s childhood.¹⁰ Individuals exhibit a primary type; however, in times of stress or security, they will move among different orientations.⁸ Each person also has wing points, the points adjacent on the circle to the primary type, which add dimensionality.⁸ Being aware of one’s stress points, security points, and wing points allows for “wholeness.” Due to the dynamic nature of the Enneagram, understanding one’s own type as well as that of others can be beneficial in multiple ways. It can improve postgraduate learning and collegial relationships and provide motivation during stressful patient care encounters.

Figure 1.

The traditional Enneagram symbol. Adapted from Oscar Ichazo’s original enneagon, the basis upon which the Enneagram was designed.³

Table 1.

Enneagram personality type descriptions^8–10

Type	Description
One	Reformer, Moralizer, Perfectionist Ethical, orderly, idealistic, fastidious, goal-oriented Likely raised in an environment where “making mistakes was not allowed” Needs instruction and well-communicated goals Challenges: Critical and perfectionistic At their best: Dependable, discerning, morally heroic
Two	Helper, Giver, Mentor Sincere, empathetic, generous, seeks the approval of others Grew up in a world in which being helpful was emphasized Challenges: Use of flattery and possessiveness as a defense mechanism in an unsupportive environment At their best: Unselfish, adaptable, optimistic
Three	Performer, Achiever, Producer Charming, poised, and leader Perseveres despite the odds, goal oriented Challenges: Status conscious, workaholic, has a poor quality of personal life At their best: Authentic, inspiring, efficient, hard-working
Four	Dreamer, Individualist, Romantic Artistic, innovative, self-aware, passionate about life Often raised in an environment where one should not be too functional or too happy Challenges: Feeling disdain toward others living ordinary lives, struggling with feelings of envy, being vulnerable and moody At their best: Creative, inspired
Five	Observer, Investigator, Thinker Insightful, curious, perceptive Childhood centered on autonomy, not personal comfort Challenges: Creating safety through distance, isolation, being intense At their best: Visionaries, see things in novel ways
Six	Loyalist, Guardian, Team Player Reliable, trustworthy, indecisive, fearful Grew up in an environment in which he or she questioned authority Challenges: Overly cautious, defensive, suspicious, rebellious At their best: Courageous, stable, can rely on self
Seven	Enthusiast, Dreamer, Visionary Fun-loving, impulsive, spontaneous Learned to depend on self for happiness Challenges: Struggles with commitment, being overextended, exhausted At their best: Joyful, appreciative, satisfied with life
Eight	Protector, Boss, Challenger Authoritative, assertive, resourceful, powerful Respected, taught to never be vulnerable Challenges: Becoming aggressive, confrontational, excessive, intimidating At their best: Strong, willing to take a stand for others
Nine	Peacemaker, Mediator, Peacekeeper Passive, inclusive, trusting, stable Dealt with conflict as a child and had difficulty coping with it Challenges: Oversimplifies problems, minimizes upsetting situations, procrastinates, struggles to make decisions At their best: Able to bring people together, embraces everyone

PERSONALITY-BASED LEARNING

Interest in personality-based learning has been increasing in an effort to meet the needs of individual learners. Traditional means of teaching students continue to evolve based on the concept that “one size does not fit all,” highlighting the need to move away from standardization.¹¹ Personality testing at different levels of training has found that modified learning styles can lead to improved performance.¹² Although research has shown that application of the MBTI in medical education can define Success Types, less attention has been given to exploring these relationships as it relates to medical and postgraduate education, and the small studies in existence have had inconsistent results.¹³ Currently the MBTI (Table 2) is one of the most broadly used personality testing modalities in the workplace,¹⁴ which was not its original intent for use.¹³ Unlike the Enneagram, the MBTI does not assess one’s weaknesses but rather opens the eyes to strengths on which to focus.¹³

Table 2.

Myers-Briggs type indicator²

Category	Dichotomies
Favorite world	(E) Extroversion	(I) Introversion
Information interpretation	(S) Sensing	(N) Intuition
Decision making	(T) Thinking	(F) Feeling
Structure/orientation	(J) Judging	(P) Perceiving

Several studies have assessed utilization of the MBTI in graduate training in healthcare disciplines. A study examining first-year medical school matriculants from the 1950s to the mid 1990s to the Louisiana State University School of Medicine at New Orleans showed that extroverts and introverts were equally represented, and a consistent increase in the judging type was observed over the decades.¹⁵ Individuals have behaviors defined by their personality that can be improved with learned skills.¹³ Healthcare is a team-focused discipline, and team-based learning (TBL) is increasingly being integrated into curricula. One of the more easily observed characteristics from group learning is distinguishing introverts from extroverts by discerning who is willing to lead the discussion to get the project started. However, extroversion is not an equivalent to intelligence.¹⁶ For example, a study of 159 first-year pharmacy students taking a pharmacokinetics course to determine students’ attitudes, course performance, and study skills toward TBL based on MBTI type found that while introverts may not prefer TBL, there was no negative impact on course performance and only a difference in attitudes toward TBL.¹⁶ While this may not directly affect a numerical grade for a small group project, lack of cooperation can lead to later conflict when the stakes are higher. When 82% of first- and second-year dental students completed the MBTI, the ISTJ (Introversion, Sensing, Thinking, Judging) was the most common personality type, comprising approximately 20% of the sample. Even though each person identifies with a particular MBTI type, everyone uses some part of all components of the MBTI routinely.¹⁷

Because each student has a particular personality type that lends itself toward a particular learning style, learning in both the classroom and for clinical application should be varied so that it is compatible with the learning styles of the entire student audience. Taking the time to understand personality types other than one’s own has implications beyond the classroom. The ultimate goal is to produce a well-rounded provider who can reach his or her patients beyond technical skills.¹⁷

PERSONALITY TESTING APPLIED TO THE WORKPLACE

While communicating effectively to educate healthcare learners is a critical step in molding future physicians, continuing strong communication skills in the healthcare workplace is equally important. This applies to the physician-patient relationship as well as interdisciplinary and interprofessional relationships, including hierarchical levels present within healthcare facilities.

The Enneagram typology provides a powerful tool for employee development. The main goal when understanding individuals based on their typology is to “distinguish groups of people who share similar intra-individual behaviors,” thus educating them on how to use these strengths, stressors, and security points in working as a team. A workplace study used the information drawn from the Enneagram of 416 individuals in both the education and healthcare sectors and concluded that the Enneagram’s ability to describe significant patterns of traits, values, and motives provided a useful tool for practitioners to apply management training and personal development in the workplace.¹⁸

One way that medical training challenges residents to develop interpersonal skills is through the position of chief resident. This role requires the ability to provide guidance in social situations, give other residents academic support, and often serve as a liaison to higher authorities. A personality inventory survey of 81 internal medicine chief residents found the majority (45.6%) were of the “feeling” type. Because different personality types are known to be stronger at certain tasks, such as organizational skills vs communication and liaison skills between residents and faculty, it is suggested to consider a selection process that balances personality types to cater to the different tasks demanded of such a role.¹⁹ This could be a mechanism for allowing leadership teams to thrive via deliberate and thoughtful delegation of responsibilities that plays to individual strengths, allowing all players to serve as leaders in their own right. Conversely, it could also be used as a tool for educating residents on how to better handle situations in which they are less comfortable, thus further preparing them for future leadership roles. An example could be public speaking; if this is not a strength of the trainee, development through understanding personality typology could be a mechanism to improve this skill. More research is needed to determine how the Enneagram can provide insight into selection and successes of chief residents and associated leadership teams.

Residents are held to the standards set forth by the Accreditation Council for Graduation Medical Education, such as maintaining a high degree of professionalism, managing workload while remaining within duty hour restrictions, and remaining focused on tasks at hand while not compromising bedside manner. A quality improvement project in a neurosurgery residency program analyzed 22 faculty and residents who took the MBTI to determine their personality type.¹⁴ Data collected from this analysis were then used as a group learning exercise to promote self-reflection as well as personal and professional improvement and revealed that no one single personality type was found within neurosurgery. This illustrates how the MBTI should not be used as a selection or screening tool due to the diversification of the residents within the field; instead, it could be used as a self-reflection exercise providing information on how certain personality types may misunderstand each other, resulting in team conflict.¹⁴ For future studies, the Enneagram may be a better tool for this type of self-reflection and professional development.

People who have similar components within their personality type are more likely to understand and get along with one another in comparison to those with almost no traits in common. However, simply understanding one another’s differences can prevent conflict that may arise, either individually or within groups. Playing to each group member’s personality strengths when assigning roles within a group as well as understanding weaknesses can be beneficial for the desired outcome, rather than making assignments randomly. Different personality types may find certain topics more or less intriguing, which can impact the quality of their work. It is important to note that while different personality types within a group can bring their own strengths to the table, they can also cause conflict and miscommunication. While each member of the team may ultimately be trying to reach the same goal, each personality type is likely to differ in what they believe is the best way to reach that goal. By understanding group dynamics, success can be achieved, and in the case of healthcare, patient safety will be maintained.^20,21

BUILDING EFFECTIVE RESIDENT TEAMS

To build teams within residency programs, the Enneagram could provide additional insight into the residency interview process. Criticisms of interview processes have been raised, stating the process “may not be as useful as perceived and may not predict subsequent performance as a physician” and that it is now a good time to ask how we might improve resident selection beyond objective measures. One solution may come in the form of the Enneagram, where the test may allow residency programs to see major character motivations and decide how the resident would function as an asset to the organization early in the process of training. Examples of character motivations can be found in Table 3.

Table 3.

Factors that motivate residents based on Enneagram type¹⁰

Type	Motivational factors
One	Goal-setting and an ethical environment
Two	Having an approving and encouraging environment
Three	Goal-setting and acknowledgment for work done
Four	Special recognition and support from one’s boss
Five	Extra vacation days, a private office, research opportunities to motivate and retain them
Six	Noncompetitive and organized environments
Seven	A fun workspace focused on new and interesting tasks
Eight	Traditional hierarchy in the workplace, competition, skill-based pay
Nine	Job involvement, recognition, and work/life benefits

Professionalism and interpersonal communication skills are two important traits needed in physicians today.²² Reliance on standardized examinations alone may overlook integral characteristics, and integration of tools such as the Enneagram may provide this additional information and assist with recruitment.²³ We suggest that implementation of a personality assessment tool may enhance the recruitment process by enabling programs to diversify their residency with focus on all Enneagram types, hence avoiding a residency composed of uniform personalities.

Once residents have joined a program, early identification of motivating factors (Table 3) will allow program directors and faculty to focus on strategies that are relatable to the learner. This will ultimately allow residency directors to ensure their residents are getting the most out of their residency and being trained to be the best in their fields of practice.

NEXT STEPS

Although the Enneagram has been used for over a century, its use in medical education is still in its infancy. The use of the Enneagram has led to improved communication and increased engagement among corporate entities; however, a paucity of literature exists for its application and utility in graduate and postgraduate medical education.²⁴ For it to be effective in medical education, the personality types of individuals must first be defined.

In postgraduate training, this information will allow further evaluation of residents’ strengths and weaknesses. The knowledge of personality types may also ameliorate conflict on teams by acknowledging communication and teaching styles, hence enhancing productivity in clinical work and didactics. This can be evaluated using scales focusing on conflict resolution and teamwork, such as those provided by the Agency for Healthcare Research and Quality TeamSTEPPS program.²⁵ An individual’s Enneagram type may also allow for improved interdisciplinary and interprofessional relationships by structuring committee selections with balanced personality types and delegation of tasks suited for those characteristics. Lastly, once the use of the Enneagram has been accepted among residents, the programs as a whole can use this tool to help brand their program toward recruitment of a diversified residency panel that cultivates the growth of all Enneagram types.

CONCLUSION

There continues to be a lack of research involving the use of the Enneagram in education, particularly the medical field, team building, and interpersonal growth. While other personality testing modalities, such as the MBTI, have gained more attention, the Enneagram has innate flexibility since it uniquely highlights how a particular personality type can move among its wing points and exhibit characteristics of the other types. This makes it especially valuable to apply to education styles, as it can challenge each individual to learn, even under times of stress. The same can be extrapolated for its use in the workplace, where knowledge of Enneagram types can be used to improve relationships by both preventing and resolving conflict. It will be interesting to see how the Enneagram can be used in the aforementioned areas to improve postgraduate medical education.