By Justina Cheh Juan Tai
Medical educators, in recent years, have made it a priority to enable students from diverse backgrounds to flourish in medicine, doing so while embracing their strengths, rather than forcing them to conform to archaic, unfounded, standards. Yet, in its existing form, medical education disproportionately challenges introverts (1). I believe this is due to the ‘Extrovert Ideal’ and the way in which clinical evaluation largely relies on subjective – often verbal – measures of ‘engagement’ in class and on placements. The pedagogical implications persist beyond medical school, with even trainee surgeons describing the pressure to portray an outspoken and confident persona in order to be seen as competent (2, 3). If introversion and extraversion are merely personality traits, rather than defining aspects of character or ability, why do so many feel the need to project a false persona in order to be seen as equals to those for whom social prowess and charisma come naturally?
I have found this particularly interesting as an international student originally from Southeast Asia, a part of the world where quietness in the classroom is viewed as a desirable trait (4); it is classically interpreted to mean that the student is listening attentively, taking care to not interrupt the speaker, and being focused in class. This is in contrast to my experience in the United Kingdom, where the same level of quietness is, more often than not, interpreted as non-participation, lack of engagement, and in extreme cases, a manifestation of academic incompetence. The rapid escalation of the COVID-19 pandemic was a time of adversity that saw a scramble for teaching modalities compatible with the new era of physical distancing and intermittent state-mandated disruption. The result was a completely new approach to learning – synchronous and asynchronous online lectures, online small group tutorials, and interactive e-learning courses. From my experience, online learning has amazingly achieved some form of equity for introverts. Thus, I propose that it should remain an integral part of medical education even while the capacity for traditional in-person teaching returns.
Online learning levels the playing field for introverts in at least three key ways: (1) it removes logistical barriers of having to physically interrupt the speaker, (2) students can speak up anonymously without fear of judgement, (3) every voice is heard equally, not just those that are loud. Educators have been trying for years to get introverted students to speak up, but the ways through which they attempt to achieve this display a failure to understand the reasons introverts and extraverts behave the way they do. Many restrict the participation of extraverts in class, while picking on introverts to answer questions, resulting in an unpleasant and unnatural experience for all parties involved. This is in contrast to online learning, where extraverts and introverts have equal opportunity to speak up, yet each student enjoys the freedom of sharing as much as they are comfortable with. Extraverts have the option of contributing more to the discussion without being misunderstood as inconsiderate ‘discussion dominators’, while introverts have the option of expressing their opinions whenever they feel comfortable doing so. Online learning also eliminates ‘evaluation apprehension’, a proven flaw of groupwork where students express only views that will cause them to be perceived favourably among peers (5). The “there is no stupid question” cliché is, for once, a reality when the stakes of being judged for asking a question anonymously are, essentially, non-existent. Other advantages of online learning equally benefiting introverts and extraverts alike include the ability to label, draw on, or point at slides during live presentations, a tool that has been especially handy for radiology teaching. Polls have also been a popular feature as a refined version of in-person raising of hands, providing instant, quantitative feedback for students and educators alike.
As online learning is not without its flaws, my suggestion is not to abandon face-to- face learning in its entirety, but to recognise that both in-person and online approaches have value. As we usher in the post-pandemic age, it is vital that we carefully consider the various teaching adaptations that were conceived during this time of desperation, and take caution to not so quickly revert to the pre-pandemic status quo simply because there is no longer a perceived need for these adjustments. Clinical medical education, for far too long, has been biased towards outspoken individuals at the expense of the more reserved, but the pandemic has shown us that it need not be so. The ultimate hope is for a culture change, such that introverts may be encouraged to build on our own strengths rather than to foster an environment where individuals feel the need to appear to be something we are inherently not. Online learning is the perfect stepping stone to achieving this. Perhaps one day, the instinctive response towards quietness will not be to make presuppositions about ability or competence, but will instead be to remember that silence can, indeed, be golden.
References 1. Davidson B, Gillies RA, Pelletier AL. Introversion and medical student education: challenges for both students and educators. Teach Learn Med. 2015;27(1):99-104. 2. Patel P, Martimianakis MA, Zilbert NR, Mui C, Hammond Mobilio M, Kitto S, et al. Fake It 'Til You Make It: Pressures to Measure Up in Surgical Training. Acad Med. 2018;93(5):769-74. 3. Ott M, Schwartz A, Goldszmidt M, Bordage G, Lingard L. Resident hesitation in the operating room: does uncertainty equal incompetence? Med Educ. 2018;52(8):851-60. 4. Yamamoto Yk, Li J, editors. Quiet in the Eye of the Beholder: Teacher Perceptions of Asian Immigrant Children2012. 5. Geerts J, de Wit J, de Rooij A. Brainstorming With a Social Robot Facilitator: Better Than Human Facilitation Due to Reduced Evaluation Apprehension? Front Robot AI. 2021;8:657291.