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Back ground: Few stud ies have ex am ined the pre dic tors of psy chia trists' per ceived suc cess and per sonal sat is fac tion with their ca reers. The pres ent ...
ORIGINAL RESEARCH

Predictors of Success and Satisfaction in the Practice of Psychiatry: A Preliminary Follow-up Study Paul E Garfinkel, MD1, R Michael Bagby, PhD2, Deborah R Schuller, MD3, Charmaine C Williams, MSW4, Susan E Dickens, MA5, Barbara Dorian, MD6

Background: Few studies have examined the predictors of psychiatrists’ perceived success and personal satisfaction with their careers. The present study examines self-reported success and personal satisfaction with their careers in a cohort of psychiatrists followed for more than 20 years. Methods: A total of 29 psychiatrists, all of whom had participated in a study during their residency 21 to 24 years earlier, completed a self-report questionnaire. The first set of questions addressed the type and characteristics of their professional practice; the second set assessed aspects of their nonprofessional practice; and the third set assessed aspects of their nonprofessional, personal lifestyles. The personality traits of neuroticism and extraversion were assessed during the residency years and were used as predictors. Composite measures of self-perceived external success and personal satisfaction were computed. Regression models were constructed to determine the best predictors of these composite measures. Results: Neuroticism proved to be a significant predictor of external success but not of personal satisfaction, with higher scores predicting a lower rating of perceived external success. There were 2 practice characteristics—involvement with research and practising from an orientation other than psychoanalytic—that predicted perception of success. One personal lifestyle characteristic—the perception that one’s nonprofessional life sustained professional life—also predicted perception of success. The best predictor of personal satisfaction was overall satisfaction with nonprofessional aspects of life. Conclusions: Personality, nonprofessional social support, and engaging in research are associated with greater perceived success and personal satisfaction with a career in psychiatry. (Can J Psychiatry 2001;835–840) Key Words: job satisfaction, psychiatrist, personality, lifestyle, work characteristics

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sychiatrists are known to have high rates of mental disorders (1–4), and a higher frequency of both emotional disorders and suicide has been reported more among practising psychiatrists than among other medical practitioners (5,6). One explanation for these high rates is that medical students who are attracted to psychiatry may be prone to mental illness early in life. Thus, it is this vulnerability that contributes to their selecting psychiatry as a career, thereby accounting for the high rates of emotional disturbance. For example, Walton (7) reported that high levels of neuroticism were associated with a positive attitude to psychiatry as a career choice among medical students, although it is an empirically established vulnerability factor for emotional disturbance (8). Another explanation is that the specific stressors associated with psy-

chiatric practice, combined with personality vulnerability, lead to emotional dysfunction. Evidence supports this latter interpretation. In a relatively recent study, Deary and others (3) compared a sample of randomly selected consulting psychiatrists (n = 39), who worked within the National Health Service in Scotland, with a group of 149 physicians and surgeons. Several variables related to the stress process, including personality traits, coping strategies, psychological distress, burnout, job stress, and work demand. Compared with the other physicians and surgeons, psychiatrists reported fewer clinical work demands and, as a group, did not report more work-related stress than did the other physicians and surgeons. There were, however, significant differences in the personality characteristics, with psy chia trists scor ing sig nifi cantly higher than the other physicians on the personality dimensions of neuroticism, openness-to-experience, and agreeableness and lower in conscientiousness. Given that work demands were less and reported work-related stress was lower, psychiatrists reported higher work-related emotional exhaustion and depression.

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The Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto Address for correspondence: Dr P Garfinkel, President and CEO, Centre for Addiction and Mental Health, 33 Russell Street, Toronto, ON M5S 2S1 e-mail: [email protected]

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This may attribute to a general disposition that experiences negative emotion (neuroticism, including job-related stress), heightened sensitivity to emotional states (openness-toexperience), a need to please others (agreeableness), and an admittedly less self-disciplined, achievement-oriented style. These results suggest that the personality characteristics that might dispose some individuals toward a successful career in psychiatry might be the same factors that make them vulnerable to emotional problems. The current study aims to examine the relation between personality and job satisfaction in a sample of psychiatrists in Ontario. We extended the scope of previous investigations by exploring the role of personal lifestyle patterns and how these variables connect to job satisfaction for psychiatrists in Ontario. More specifically, we explore the correlates of selfreported success and personal satisfaction in a cohort of psychiatric residents, who have been followed for more than 20 years (9,10). First, we sought to examine the relation between professional-practice characteristics and nonprofessional, personal lifestyle patterns as predictors of professional success and personal satisfaction. Because previous investigations indicated that personality traits measured during residency predicted professional behaviour and misconduct in the years following training (9,10), a second goal was to examine whether personality characteristics—in particular, the stable and replicable traits of neuroticism and extraversion (11), assessed during residency—contributed to the prediction of perceived success and personal satisfaction. The current investigation represents an ongoing examination of a cohort of psychiatrists who entered 2 Canadian residency programs in the mid-1970s (9). Method Subjects and Procedures As part of this ongoing follow-up study of the practice and career patterns of psychiatrists, we solicited the same cohort of psychiatrists who participated in the first phase of this research program, which was performed during their residency (21 to 24 years ago) (9). The original cohort comprised 70 psychiatric residents from 2 Canadian universities (University of Toronto and University of Western Ontario), who were entering first-year residency training between 1974 and 1978. All potential participants were informed that to take part in the study they must a) complete a series of psychologic tests, of which they would not be given the results; b) allow the investigators to access their personal files held by the Department of Psychiatry; and c) agree to be contacted for follow-up investigations after completing their training. Those who agreed to participate signed an informed consent document that stipulated each of these conditions. The group of participants in this study included psychiatrists from the original sample of participants (n = 70). In the original study, 120 residents were invited to participate for an

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overall response rate of 58%. We were unable to locate or learn the status of 22 of the original 70 psychiatrists (31%) who had completed the original research protocol. Of the remaining 48, 2 were deceased, and an additional 7 were not currently practising psychiatry. Of the remaining 39 (56% of the original sample), 32 were men and 7 were women. In the fall of 1998, we mailed a questionnaire package to the sample of 39 psychiatrists. This package included a cover letter explaining the purpose of the study, a consent to participate and reply letter, and a 10-page self-report questionnaire. In addition, we provided 2 stamped return envelopes to ensure confidentiality of questionnaire responses: 1 for the return of the consent and reply letter and the other for the confidential return of the completed questionnaire. For psychiatrists who did not respond, 2 additional reminder mailings followed the initial mailing. Six months after the first mailing, 29 (70%) of the 39 (or 41% of the sample that participated 21 to 24 years earlier) that were included in the mailing returned completed questionnaires. Independent sample t-tests and chi-square analyses indicated no significant differences between the psychiatrists included in this study (n = 29) and those who were not (n = 41) on the following variables assessed during their residency training: age, sex, and marital status. Measures In the original study, residents completed several questionnaires, which included the Eysenck Personality Inventory (EPI) (11). At the time of the original study, the EPI was the best known self-report instrument, measuring 2 robust and replicable dimensions of personality—neuroticism and extraversion. Although several other models of personality have been developed since then (for example, the Five-Factor Model) (12), the dimensions of neuroticism and extraversion are still represented in almost every model. Neuroticism is best defined as the propensity to experience a wide range of negative affects and a general susceptibility to psychological stress. High scorers in normal samples tend to be prone to anxiety and dysphoric mood and are relatively incapable of regulating emotional responses to stressful life events. Low scorers are more emotionally stable, calm in the face of stress, even-tempered, and relaxed. Extraversion, in the broadest sense, represents sociability but also represents the capacity to experience positive emotions. High scorers on extraversion are assertive, outgoing, active, gregarious, and cheerful in disposition. Low scorers, on the other hand, do not manifest such exuberances; they are shy, socially retiring, and reserved (12). Recent studies indicate that these 2 personality traits have high heritability coefficients (13) and display remarkable stability across the lifespan (14). At follow up, participants completed a questionnaire, which consisted of several items that inquired about their personal and professional lives, with a particular focus on their sense of professional and personal satisfaction with their career

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choice of psychiatry. For example, there were questions concerning the degree of professional isolation and emotional burden associated with their work, the extent of fulfillment and internal impact of current major life events, and the presence of any re grets about choos ing psy chia try as a profession. Criterion Variables We created 2 outcome (criterion) variables to measure 1) perception of external success and 2) personal satisfaction, using sets of items from the questionnaire. To assess external success, we summarized participants’ responses to the following questions: expectations about a career in psychiatry that had been met, personal satisfaction with their individual careers, and regrets about choosing psychiatry as a career. Each of these questions used in the composites was rated using a 5point Likert scale, ranging from ratings 1 (very low) to 5 (very high). The composite scale measuring external success ranged in scores from 5 to 25, and the composite scale for the personal satisfaction ranged in scores from 3 to 15. The internal reliability of these composite scores was excellent, with Cronbach’s α = 0.81 and 0.78, respectively. Predictor Variables We also created 2 sets of predictor variables, which were used to predict the 2 criterion variables outlined above. These variables were also extracted from items on the questionnaire. One set of variables focused on personal aspects of the psychiatrist’s professional life and included responses to the following 2 questions: degree of emotional burden experienced in clinical work and perceived professional isolation. The second set of variables focused on the psychiatrist’s work or practice characteristics and included responses to the following questions: psychoanalytic or nonpsychoanalytic orientation; actively or nonactively involved in research. Because we were primarily interested in the predictive capacity of personality traits and the influence of nonprofessional aspects of psychiatrists’ ratings of external success and personal satisfaction with their careers in psychiatry, the personality traits of neuroticism and extraversion and the question regarding the degree to which nonprofessional aspects of their life sustained professional life were included in both sets of predictor variables. Statistical Analyses We used means, standard deviation, and percentages to de scribe the demographic and professional characteristics of this cohort of psychiatrists. Stepwise regression analyses were performed to identify the predictors of external success and personal satisfaction. Overall, 4 different regression models were constructed: 2 models sought to determine what were the best predictors of personal satisfaction. To assess the potential and independent contributions of practice characteristics and personal aspects of professional life that are relative to personality and social support, we regressed these sets

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of predictor variables against the composites in separate analyses. Results Demographic and Professional Characteristics The mean age of the sample was 50 years (SD 2.8). Of these, 97% (n = 28) were currently married or cohabiting and had been for an average of 19.2 years (SD 6.2). Further, 90% had children ranging from age 3 to 28 years, with a mode of 18 years. The entire sample completed specialty training in psychiatry between the years 1977 and 1983. The average age at the start of the training was 31.3 years (SD 3.3), and 31% had obtained subspecialty training in psychiatry. Of the 29 par ticipants, 14 (48%) received additional formal training. In fact, 1 participant received an advanced degree in another field, 5 obtained additional fellowship qualification training, and 4 received formal psychoanalytic training. The remaining participants indicated that they had received further training in cognitive behavioural therapy (n = 2), interpersonal therapy (n = 1), and brief psychodynamic therapy (n = 1) that led to special certification. Similarly, 65% (n = 19) of the sample reported teaching on a regular basis, including the instruction of psychiatry residents and medical students. And 38% (n = 11) reported being currently active in research. There were 24% (7 of 29) who indicated that they had published a paper in a scholarly journal, and 13% (4 of 29) indicated that they had been first author on 1 or more of these publications. Nearly all the sample (97%) (n = 28) indicated that they had professional colleagues available to them to share concerns about patients. Likewise, a large percentage of the respondents indicated that they had nonprofessional significant others with whom they could share professional concerns. (88%) (n = 26). Regression Analyses In the first regression model, we sought to examine which of the variables associated with the personal aspects of the psychiatrists’ professional lives were predictive of self-reported external success. The composite rating of external success served as the criterion variable, and the following questions served as the predictor variables: degree of emotional burden experienced in clinical work, perceived professional isolation, degree to which nonprofessional aspects sustained their professional life, and the personality traits of neuroticism and extraversion. In this model, neuroticism only proved to be a significant predictor, with a higher score on neuroticism predicting a lower rating of perceived external success, (r2 = 0.20; F1,26 = 6.45; P = 0.02; [β = –0.45]). In the second regression model, we sought to determine which of the variables related to the psychiatrists’ practice characteristics were predictive of self-reported external success. The following questions served as the predictor variables: 1) psychoanalytic or nonpsychoanalytic orientation, 2)

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actively or nonactively involved in research, 3) degree to which nonprofessional aspects of life sustained their professional life, and 4) the personality traits of neuroticism and extraversion. In this model, the following 3 variables were found to be predictive of self-perceived external success: 1.

active involvement in research r2chg = 0.25; Fchg 1,26 = 8.71; P < 0.001; (β = 0.34)

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practising from an orientation other than psychoanalytic r2chg = 0.16; Fchg 2,25 = 6.92; P < 0.01; (β = 0.44)

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personal aspects of life sustaining professional life r2chg = 0.18; Fchg 3,24 = 10.66; P < 0.001; (β = 0.44)

The next 2 regression models examined the best predictors of personal satisfaction with psychiatric careers. These models were identical to the first 2 models, except that personal satisfaction replaced external success as the criterion variable. In these 2 regressions—which included the 2 sets of predictor variables in each regression model—the best predictor of personal satisfaction was the variable assessing the degree to which personal aspects sustained professional aspects of their life: r2 = 0.40; F1,26 = 17.33; P < 0.0001; (β = 0.63) Discussion This study’s results suggest that a personality trait measured some 20 years earlier—in this instance neuroticism—was the best predictor of a subjective evaluation of psychiatrists’ experience of external success, but not personal satisfaction, in the practice of psychiatry, relative to several personal and professional characteristics. This finding is not unlike that of a previous study with this same cohort, wherein we found that 2 psychiatrists, who were identified as having psychopathic personality characteristics as measured by the Minnesota Multiphasic Personality Inventory (MMPI) at the time of their residency, subsequently lost their licence to practise years later as a consequence of sexual contacts with their patients (10). It is striking that in both studies, the personality traits in the early stages of training had an enduring influence on the course of the quality of a career in psychiatry. In the current study, neuroticism accounted for 20% of the variance in the external measure of success, thus indicating that the more neurotic the resident, the more negatively, 20 years later, he or she evaluated career success, as defined by degree of financial success, professional peer recognition, academic achievement, community recognition, and appreciation by patients. In the second regression model, we examined practice characteristics in relation to external success in the career of psychiatry. The factors predictive of external success were

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personal life and professional practice characteristics and included involvement in research (25% of the variance), an orientation other than psychoanalytic (16% of the variance), and the role of one’s personal life in sustaining one’s professional world (18% of the variance). Personal satisfaction measured one’s sense of professional and personal satisfaction, along with psychiatry as a career choice. It considered issues such as degree of professional isolation and emotional burden, extent of fulfillment and internal satisfaction with psychiatric practice, balance achieved between personal and professional lives, impact of current major life events, and presence of any regrets with the choice of psychiatry as a profession. There was one strong association—the extent to which personal aspects of life sustained professional life predicted the degree of internal satisfaction in this sample, which explained 40% of the variance. While of value due to its prospective nature and the use of well-validated measures, a study such as this one that was completed more than 20 years previously, is not without caveats. The sample size is modest, including only 41% of the participants from the original study. Clearly, from the high number of subjects who are involved in full- or part-time academic practice and are working primarily in urban settings, this is a unique sample of practising psychiatrists. Despite these limitations, this project does highlight, in a preliminary manner, some of the factors that are critical to success and satisfaction within the profession of psychiatry. Most personality theorists conceptualize neuroticism and extraversion as 2 dominant dimensions of emotional experience: nega tive af fec tiv ity and posi tive af fec tiv ity, respectively. They consider negative emotion and positive emotion to be largely independent of one another, rather than opposing poles of a single dimension of personality (12). Neurotic individuals are quickly aroused physiologically by all types of stimuli and have a tendency to experience the nega tive af fects of anxi ety, de pres sion, and selfconsciousness (that is, shame and embarrassment), while introverts are also typically thoughtful and introspective of their emotions. That the more neurotic individuals rated their perception of external success negatively may reflect that a propensity to negative affect skews one’s view of relative achievement. Or, perhaps, it indicates the impact of neuroticism in inhibiting the active pursuit of one’s goal. Curiously, from this perspective, neuroticism was not predictive of internal dissatisfaction with the practice of psychiatry. One might hypothesize that the proclivity to arousal with stressful situations and the tendency to experience negative affects, particularly in introspective individuals, would create the potential for a sense of extreme burden or disillusionment in the practice of psychiatry, due to constant immersion in the emotional pain and suffering of human beings. This sample, how ever, is strik ing in the de gree of par tici pants’

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involvement in the academic enterprise and in the amount of sustaining social support available to them. As noted previously, the internal sense of satisfaction and fulfillment in a psychiatric career was predicted by the extent to which the nonprofessional aspects of the subjects’ lives sustained their professional activities. Social support is a critical determinant in various health outcomes (15), and social support by women may be more effective in this regard (16). Although the mechanisms underlying the beneficial effects of social support are uncertain, it has been hypothesized that such may occur through in flu ences on neu ro bio logi cal regu la tory systems. This has been demonstrated in maternal-infant attachment paradigms (17,18). In this study, most of the psy chiatrists were men, and most were married or in long-term relationships. The enduring and sustaining pattern of relationships that are seen in these individuals may provide not only the instrumental support essential to a productive and satisfying career, but may also enhance psychiatrists’ resilience to affective dysregulation. Such a formulation is reinforced by the other 2 unexpected findings relative to the external measure of success (that is, being actively involved in research and not practising psychiatry with a psychoanalytic orientation). Over one-third of this sample conducted research—a rate much higher than the Canadian national average for psychiatrists (19). This high degree of involvement may reflect the inherent satisfaction of combining scholarly enquiry with clinical life (20). In addition, the activity, diversity of takes, and ongoing interaction with colleagues that one experiences through academic involvement may enhance the expression of positive emotion and provide a regulatory function with respect to negative emotion. Research, through its objective measures of success—such as numbers of grants, publications, and research dollars—may provide an objective barometer of achievement that is missing from the more tangible day-to-day clinical world, particularly if one is dealing with persistent mental illness or severe character pathology. A psychoanalytic orientation to practise implies greater time spent in intense, one-on-one interactions with patients in a relatively isolating environment, with little respite from negative affectivity and the stressful nature of transference projections. That a psychoanalytic orientation was associated with rela tive regret and dissatisfaction with psychiatry as a career choice may also relate to the current role of psychoanalysis within contemporary psychiatry and the presence of external threats by third-party funders, criticism, and dissension regarding the indications for and efficacy of psychoanalytic treatments. The experience of diminished status, along with enhanced demands for accountability in providing costeffective treatments, may interact with the inherent difficulties of the clinical work itself, thus leading to a sense of frustration, disillusionment, and isolation.

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Clinical Implications • For Canadian psychiatrists, personal life satisfaction is highly correlated with professional career satisfaction.

• Integration of research with clinical work is correlated with great job satisfaction for Canadian psychiatrists.

Limitations • The sample size was small. • The study was biased toward academic psychiatrists. • Large sample attrition occurred.

In summary, although limited by a small sample size and a bias toward academic physicians, this study does nevertheless highlight, in a preliminary fashion, the critical importance of a strong support base with the nonprofessional aspects of life. As a result, psychiatrists maintain a sense of personal satisfaction in their careers. This finding may relate to the frequently isolating nature of the work and the known importance of social supports in many other areas of life, including health and illness. The association of a high degree of personal career satisfaction with participation in research and practising from an orientation other than the psychoanalytic were unexpected findings. In fact, a follow up of the larger cohort of psychiatrists who used detailed interview techniques, such as those used in qualitative research designs, would enhance these findings. We are presently planning such a study. References 1. Looney JG, Harding RK, Blotcky AR, Barnhardt MJ. Psychiatrists’ transition from training to career: stress and mastery. Am J Psychiatry 1980;137:32–6. 2. Naisberg-Fennig S, Fennig S, Keinan G, Elizur A. Personality characteristics and proneness to burnout: a study among psychiatrists. Stress Med 1991;7:201–5. 3. Deary IJ, Agius RM, Sadler A. Personality and stress in consultant psychiatrists. Int J Soc Psychiatry 1996;42:112–23. 4. Prosser D, Johnson S, Kuipers E, Szmukler G. Mental health, “burnout” and job satisfaction among hospital and community-based mental health staff. Br J Psychiatry 1996; 169:334 –7. 5. Bourgeois M, Peyre F, Delile JM, Pommereau X. Suicide among medical doctors, psychiatrists, medical and psychiatry students, and doctors’ wives/Le suicide des medecins, des psychiatres, des etudiants en medecine et en psychiatrie et des femmes de medecins. Psychologie Medicale 1987;19:631–3. 6. Rich CL, Pitts FN. Suicide by psychiatrists: a study of medical specialists among 18,730 consecutive physician deaths during a five-year period, 1967-72. J Clin Psychiatry 1980;41:261–3. 7. Walton HJ. Personality correlates of a career interest in psychiatry. Br J Psychiatry 1969;115:211–9. 8. Costa PE, McCrae RR. Influence of extraversion and neuroticism on subjective well-being: happy and unhappy people. J Pers 1980;38:669–78. 9. Garfinkel PE, Waring EM. Personality interests, and emotional disturbance in psychiatric residents. Am J Psychiatry 1981;138:51–5. 10. Garfinkel PE, Bagby RM, Waring EM, Dorian BJ. Boundary violations and personality traits among psychiatrists. Can J Psychiatry 1997;42:758–63. 11. Eysenck H, Eysenck S. Eysenck Personality Inventory. San Diego (CA): Educational and Industrial Testing Service; 1968. 12. Costa PT, McCrae RR. Professional manual for revised NEO personality inventory. Odessa (FL): Psychological Assessment Resources; 1992. 13. Eysenck H. Genetic and environmental contributions to individual differences: three major dimensions of personality. J Pers 1990;58:245–61. 14. Costa PT, McCrae RR. Set like plaster? Evidence for stability of adult personality. In: Heatherton TF, Weinberger JL. Can Personality Change? Washington (DC): American Psychological Association Press; 1994. 15. House JS, Landis KR, Umberson D. Social relationships and health. Science 1988;41:540–5.

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16. Glynn LM, Christenfeld N, Gerin W. Gender, social support, and cardiovascular response to stress. Psychosomatic Medicine 1999;61:234–42. 17. Hofer MA. Relationships as regulators: a psychobiologic perspective on bereavement. Psychosomatic Medicine 1984;46:183–97.

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18. Hofer MA. Early social relationships: a psychobiologist’s view. Child Dev 1987;58:633–47. 19. Woodside B, Lin B. Personal communication. 1999. 20. Garfinkel PE, Goldbloom DS, Kaplan AS, Kennedy S. The clinician investigator interface in psychiatry I: problems and values. Can J Psychiatry 1989;34:361–3.

Résumé : Prédicteurs de succès et satisfaction dans la pratique de la psychiatrie : une étude de suivi préliminaire Contexte : Peu d’études ont examiné les prédicteurs du succès perçu des psychiatres et la satisfaction personnelle quant à leur carrière. La présente étude examine le succès et la satisfaction personnelle auto-déclarés par une cohorte de psychiatres suivis pendant plus de 20 ans. Méthodes : Un total de 29 psychiatres, ayant tous participé à une étude durant leur résidence, 21 à 24 ans auparavant, ont rempli un questionnaire d’auto-évaluation. La première série de questions abordait le type et les caractéristiques de leur pratique professionnelle, la deuxième série évaluait les aspects de leur pratique non professionnelle et la troisième évaluait les aspects de leur mode de vie personnel. Les traits de personnalité que sont le névrosisme et l’extraversion ont été évalués durant la résidence et ont servi de prédicteurs. Les mesures composées du succès extérieur perçu et de la satisfaction personnelle ont été calculées. Des modèles de régression ont été construits pour déterminer les meilleurs prédicteurs de ces mesures composées. Résultats : Le névrosisme s’est révélé un prédicteur significatif du succès extérieur mais pas de la satisfaction personnelle, les notes élevées prédisant une cote faible du succès extérieur perçu. Il y avait 2 caractéristiques de la pratique — la participation à la recherche et la pratique d’orientation autre que psychanalytique — qui prédisaient la perception du succès. Une caractéristique du mode de vie personnel — la perception selon laquelle la vie non professionnelle soutient la vie professionnelle — prédisait également la perception du succès. Le meilleur prédicteur de la satisfaction personnelle était la satisfaction générale à l’égard de tous les aspects non professionnels de la vie. Conclusions : La personnalité, le soutien social non professionnel et la recherche sont associés à un plus grand succès perçu et à une satisfaction personnelle accrue quant à la carrière en psychiatrie.