A Whitepaper by Dr. Nancy J Stark
Relationship building is an integral part of the successful implementation of any clinical trial. You need good relationships with investigators, study staff, your project team, your colleagues, your boss, and your subordinates in order to successfully implement any project. One thing is for certain: they are not going to change. If you want a good relationship you will have to adapt to them.
Myers and Briggs are great heroines and role models to me. Imagine two women psychologists during World War II. Katherine Cook Briggs and her daughter Isabel Briggs Myers had plenty of obstacles stacked against them. They had only master's degrees, they were women, they were playing in a man's world, yet they developed a personality tool that is still used seventy years later. These two did original research extending Carl Jung's theories to practical applications in the workforce.
Why did it matter? Women were entering the workforce en masse without a clue as to what they would be good at: office work (quiet and peaceful), factory work (noisy and lots of yelling), data work (numbers and logic), design work (color, texture, image, spacial relationships), or whatever.
In this whitepaper I will attempt to adapt the work of Myers and Briggs to the critical task of relationship building in clinical trials. I use layman's language because I am not a psychologist. If you are, feel free to add your comments, corrections, contributions, and rebuttals below.
The theory of personality type originates from the work of Carl Jung, who proposed that people perceive the world through two different functions: 1) the 'rational' (judging) functions of thinking and feeling, and 2) the 'irrational' (perceiving) functions of sensing and intuition. Jung went on to propose that these functions are expressed in either an introverted or extraverted form. From Jung's original concepts, Myers and Briggs developed their own theory of personality types. [1. Myers-Briggs Type Indicator]
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Understanding Personality Types
Myers and Briggs saw that there are four essential steps in how people relate to the world: 1) we focus on the world of our choice, 2) we perceive information, 3) we judge the information, and 4) we present the information to the outer world with a characteristic attitude. We do each of these four steps as either introverts or extroverts for a total of sixteen possibilities. For the sensors among us, I've tried to represent the concept in a simple, colorful visual image. [2. Gifts Differing]
As children we learn how to survive in the world that we know first: family and parents. And those survival skills are our default personality throughout life. As we gain experience and mature we learn to move out of our preferred personality type and become skilled at all possibilities, allowing us to act appropriately in different situations. But when under stress we tend to revert to the survival skills of our childhood. If we understand our own personality types, and become adept at discerning the personality types of others, we can adjust our behavior to build the best possible relationships with our colleagues.
 Focusing on the World: Introversion or Extroversion
People prefer to focus on either the inner world of thoughts and ideas (introversion) or the outer world of people and things (extroversion). Introverts do their best work in their heads in reflection; extroverts do their best work in the outside world, in action. Our focus on the world effects dramatically how we live in the world. Only an introvert would sit alone in their office and write this whitepaper. An extrovert will be impatiently waiting to get to the practical applications.
Introverts organize the facts and principles related to a situation and are good at researching material, writing protocols, or designing investigations; extroverts organize the situation itself, including any idle bystanders, to get things rolling. Extroverts are good at implementing clinical investigations.
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Introverts work out their insights slowly and carefully, searching for eternal truths. Extroverts have an urge to communicate and put their inspirations into practice. Can you imagine the annoyance of an introverted study nurse when an extroverted monitor bombards her with emails to give her the latest study updates; or the annoyance of an extroverted (and eager) investigator when an introverted monitor is slow to communicate the start date?
 Perception, Taking in Information by Sensing or Intuition
Perception refers to how you get information from the outside world into your head. People take in information either by sensing or by intuition. Sensing means to become aware of information by our five senses: touch, smell, sight, sound, and taste. Intuition means to become aware of information through the unconscious. With intuition we incorporate our ideas or associations to what we sense with lightning speed and seemingly without logic.
Discuss a new device with a sensing person and they may tell you it is too lightweight, it is smaller than the current model, the materials aren't sturdy enough, but the display panel is clear and easy to read—all the information taken in by their senses. Sensing people are well suited for the demands of clinical trial monitoring. Practical and matter-of-fact, they see the world as it is rather than as it should be. They are often good project managers, following the project with Gantt charts, spreadsheets, drawings, flowcharts, and data. If both you and the investigator are sensors you may focus too closely on the details and lose sight of overall progress.
Hand an intuitive person the same device and they may answer, "This reminds me of my grandmother. She used this kind of device every day when I was a kid, we'd check in on her to make sure it was functioning properly and then play a game of checkers." Instead of focusing on the device, your intuitive colleague focused on her associations with it. [3 Tieger]
Intuitive people often have inspired product ideas, clever solutions to problems, or make associations that no one else would see. Intuitive people are good at picking up undercurrents, they know when a situation is 'off' even if they can't exactly tell you why. If both you and your investigator are intuitives, you may have imaginative conversations but not notice some study problems.
I had an extroverted, sensing boss who had a rule that we could present no more than three possibilities to him. If he asked you what went wrong, you had better not give him a list of five things. If he asked you for a recommendation, you had better not have more than three. His intuitive, data-loving subordinates were terrified.
“Readers who are sensors will tend to confine their attention to what is said here on the page... readers who are intuitive are likely to read between and beyond the lines to the possibilities that come to mind.”
 Judging, Processing Information by Thinking or Feeling
Judging refers to how you process the information you take in. Thinkers use a logical process aimed at reaching an impersonal finding. Feelers use an emotional process of viewing information in a personal, subjective manner.
The thinking protocol writer may make a list of all the data elements they think are necessary to meet the purpose of the new clinical trial. As they develop the protocol they use their list of data elements as an absolute guide. They are not swayed by pleas from marketing to include questions they have already dismissed as unessential or exclude questions because "it is knowledge we would rather not have." Thinking writers may try to collect too much data in a clinical trial—oblivious to the impracticality.
If, as a member of the project team, you want additional data elements included in the study you should listen closely to the thinking writer's rationale for omitting them, be respectful of their reasoning, and use facts and data that relate back to the trial's purpose to persuade them to make the change. Thinking people objectify situations—dealing in facts, figures and data; they do not respond well to insincere flattery. (My husband is even suspicious of sincere flattery, I only tell him he has done a good thing when I know he already thinks so himself.)
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A feeling person may make a list of data elements but it will have little influence on the final protocol design—the decision to collect data is made because it “feels” right. The decision is made first, and a rationale is developed later. A thinking monitor who is ill-at-ease with the site's data collection should be delicate with a feeling investigator who is confident the device works, but they should not back down. They should challenge the data with facts while being thoughtfully respectful of the investigator's mode of processing information.
Another consequence of thinking and feeling personalities is how they relate to each other. Feeling people subjectify situations—anticipating how facts, figures and data will affect the people involved. A feeling monitor (such as myself) might have difficulty enforcing an important requirement, say, for dating an informed consent, because it causes too much inconvenience to the investigator. The feeling person’s prime motivation is harmonious relationships, not regulatory compliance. A sensing boss has no difficulty pointing out the monitor's deficiencies.
“A reader who first considers whether an idea is consistent and logical is using a thinking process. A reader who first considers whether an idea is pleasing or displeasing, supporting or threatening, is using a feeling process.”
 Attitude to the World: Perception or Judgment
Our attitude in presenting information to the world is a reflection of which personality type is more strongly developed, perception or judgment. Attitude or "face" refers to how you present information back to the outside world. For extroverts, attitude is a reflection of the personality type that is dominant. For introverts, attitude is a reflection of the personality type that is subordinate because they reserve their favored, dominant preference for the more highly prized, inner world. In other words we know exactly what extroverts think and we never know what introverts think.
People with perceptive attitudes maintain an open mind regarding situations, continuing to seek additional information that can broaden and deepen their understanding. If pressed, they will disclose the facts, but they will refrain from telling you what it means or predicting the outcome. Perceptive people make others feel safe and accepted, and are valued members of any project team because they keep an open mind. Project managers with perception attitudes may be reluctant to move the action forward. They are more likely to delay conclusions or fail to act at all. They can be positively frustrating to bosses who who are at a critical decision-point.
Persons with judging attitudes shut off their perception (at least for the moment) and make a judgment. They may not have all the facts, but they can certainly tell you what they mean. Monitors or project managers with judging attitudes will have strong opinions about the value of a project, work product, piece of data, or whitepaper; and will freely share that opinion with listeners. They are more likely to come to wrong conclusions, a positively frustrating behavior to bosses who want to be sure before acting on a recommendation. But judgers are an essential component of a well-functioning project team; they bring issues to closure and move the project to the next step.
The Queen of Hearts in Lewis Carroll’s classic novel Alice in Wonderland had a typical judgment attitude (as well as being an impatient extrovert). “Off with her head, we’ll have the execution now and the trial later!” she said.
“Readers who are still following this explanation with an open mind are using perception, readers who have decided by now that they agree or disagree with me are using judgment.”
Putting It to Practice
The most important step in building relationships is the first one: know thyself. To help you get over the embarrassment of digging so deep into your psyche, I'll tell you that I am an introverted, sensing, feeling, judger (an ISFJ.) I live in my head, which is far more fascinating to me than anything going on outside; furthermore you will never know what I really think. I take in information by my senses: are there data-gaps, are the facts consistent, do I trust the source, do I need more information? I am a feeler, use the wrong word (mismanagement versus bad economy) and your conversation with me is over. And I am a judger, I have an opinion about almost everything, a quality essential for writing whitepapers or editorials.
Happily we are not stuck on home base. With time and experience I have learned to behave like an extrovert, make a rare intuitive leap of logic, be objective in my assessment of a situation, and withhold judgment until the facts are in—at the cost of a great deal of psychological energy. The hallmark of maturity isn't balance, but being able to move freely from one extreme to the other as the situation demands.
The next step is understanding your colleagues. Changing them is not your goal or your business, and anyway it won't work. The goal is to build relationships that will facilitate the successful completion of your trial. If you're working with an introvert be respectful of their privacy; if you're working with a extrovert enjoy the excitement. If your working with a sensor be prepared with facts and details, if with an intuitive go for the big picture. If your working with a thinker be logical in your presentation, if with a feeler never, never, never say "you". If your working with a perceptive be patient while they work through information on their own, if with a judger you may want to slow them down. The best project teams have someone of every personality type.
Relationships are complicated by supervisor/subordinate, client/consultant, parent/child, wife/husband, boyfriend/girlfriend, addiction, religion, politics, culture, heritage, wealth, and so much more; there is no one simple answer to building good relationships. But understanding personality types and adjusting our own behavior to meet the needs of our colleagues in order to meet the goal, is something we can all do.
 Myers-Briggs Type Indicator, Wikipedia, the free encyclopedia.
 Isabel Briggs Myers with Peter B Myers, Gifts Differing, Understand Personality Type, Davies-Black Publishing, Palo Alto, CA, (1980).
 Teiger PD, Barron-Teiger B, The Art of SpeedReading People, Little, Brown & Company, New York (1998).
Questions or Comments?
Please post your questions, comments, contributions, and rebuttals below.
Nancy J Stark, PhD
President, Clinical Device Group Inc