Abstract
If leadership skills can be developed during post-medical school training, physicians will be better prepared to influence positive change for their patients and communities. Based on both LEADS and CanMEDS Leader competencies, a mixed methods approach was used to identify the most valued leadership constructs and which of these should be prioritized for development in an enhanced family medicine curriculum. The interpersonal skills were identified most often and included: self-awareness/leads self, effective communications, leading change and building teams. While some opportunities to achieve competence in leadership skills already exist in family medicine residency programs, increased attention to providing development opportunities as well as assessment methods and faculty development is necessary in order to support new doctors as leaders. This study identifies over-arching goals to guide curriculum change in order to achieve this.
Introduction
Evidence shows that improved leadership skills in physicians can yield superior outcomes for patients and healthcare organizations. 1 Kouzes and Posner identify leadership as a skill that can be deliberately learned with proper guidance and exposure to valued learning experiences. 2 If leadership skills are developed during post-medical school training (hereafter called residency), physicians will be better prepared to influence positive change for their patients and communities.
The imperative for post-graduate trainees (hereafter called residents) to acquire leadership skills has been endorsed globally by Canadian residency accrediting bodies within their CanMEDS competency framework. 1,3 The healthcare system has changed considerably with most physicians working in interdisciplinary teams rather than solo clinics. Physicians are often regarded as leaders; cultivating leadership skills is beneficial for them, their patients, and their teams. This is reflected in a recent change to the CanMEDS framework from the manager role to that of leader. However, most physicians learn about leadership on the job and rarely have time to devote to the topic and can be reluctant to identify themselves as leaders. 4
Sonnin suggests that possessing “business and administrative acumen” represents a concept foreign to most physicians. Now, clinical leaders are critically important and it behooves medical schools to invest in developing residents’ leadership capacity. 5 Two recent Canadian studies indicate that leadership development for family medicine residents is important, but formal leadership curricula among postgraduate programs is scarce. A survey of family medicine residents indicates that enhancing both personal and system-level leadership skills is desirable and family medicine post-graduate program directors agree that leadership training should be included in curriculum. 6,7 There is no consensus, however, on which skills to prioritize or how to implement changes to curriculum.
Leadership frameworks and theories are plentiful, although the construct is ill-defined. Leadership models come from the business world, others from the military or healthcare in general. Of significant importance in this study was to understand leadership as it applies to family physicians and identify which of the skills associated with leadership are deemed critical enough to be included in medical training. Concepts from the CanMEDS leader role and domains from LEADS in a Caring Environment framework (hereafter referred to as LEADS) were used in this study and considered to be the most familiar to physicians. 8,9
The purpose of this study was to identify leadership learning objectives to guide curriculum change, to understand the most important areas of knowledge to acquire during residency, and to begin to understand what demonstration of that knowledge would look like. 8
Methods
A mixed-methods concurrent design was used. Quantitative methods were used to identify the frequency of most valued leadership constructs over the course of a medical career; qualitative methods were used to explore these constructs and identify which should be prioritized during residency. The Health Sciences Research Ethics Board of Queen’s University approved the study.
Participants and setting
Two groups of participants contributed data to this study through either a workshop or a focus group. Physician leaders from all areas of medicine attending a national conference workshop contributed to the study through a participatory exercise.
10
Using a list of 15 leadership skills from CanMEDS leader role and LEADS framework (Table 1), participants identified which of five points in time was optimal for developing each skill. Focus group participants, all family physicians, were identified using purposive sampling. Focus groups were used to prioritize leadership skills for development during family medicine residency and to understand what demonstration of those skills would look like.
List of skills/leadership concepts by framework.
Data collection and analysis
Data were collected between April and July 2017. One researcher led two 90-minute conference workshops. Data were transferred from flip charts to Microsoft Excel for storage and comparison.
Two other research team members moderated the two 70-minute focus groups that were digitally recorded and transcribed verbatim. The focus group protocol was developed by the entire team.
Descriptive statistical analysis was used with workshop data. Frequency counts and proportions were calculated for each time point and leadership construct.
Inductive analysis was used with focus group data. Two members independently coded each transcript, compared codebooks, and resolved any discrepancies. Quotes illustrative of key themes were identified. The team reviewed data and thematic analysis and identified key findings.
Findings
Fifty-seven physician leaders from various specialities participated in workshops and nine academic and community-based family physicians participated in focus groups. All focus group participants teach residents and had a formal leadership role.
Most important skills to learn and when
When asked to prioritize the skills needed by a physician leader, participants chose interpersonal skills most often, although all were strongly endorsed (the lowest being 79%). Workshop participants ranked self-awareness/leads self and effective communications (92%, 84%, respectively) as the most important skills that medical students should demonstrate when they begin residency (Table 2).
Leadership skills/concepts acquisition during medical career; workshop exercise.
Focus group participants identified effective communications, leading change, building teams, and self-awareness/leads self as the most valued capabilities of a physician leader to be acquired during residency training. To know your own strengths and weaknesses. That is the hardest job for anybody right. If you can’t lead yourself how are you going to lead others?
Learning leadership in residency
Focus group participants emphasized the ambiguity associated with the term “leadership.” Physicians can be both leaders and followers, clinical or community leaders, and work in flat or hierarchical structures. The leader role was viewed as overlapping with other roles such as advocate and professional. It was noted that physicians would be an asset to their profession if they were able to increase their knowledge of leadership during residency. Their ability to see value in physicians who lead would increase and they would have a higher level of confidence when asked to act in a leadership capacity. Any physician, regardless, they’re seen as a leader and they should feel comfortable coming out and being in that role. I had zero leadership training, as many. And I actually had no concept when I started medicine that physicians even were leaders. So you can either lead badly or you can actually be thoughtful and reflect on what you’re leading. It’s not about you. It’s not about your ego. It is about all of us reaching a common goal together. There’s probably some benefit even knowing if you’re not going to lead that you can have an appreciation for what’s going on when someone’s actually trying to lead.
Existing opportunities to achieve competence
Researchers wanted to know which of the CanMEDS leader skills were already a focus in the curriculum to understand where gaps lie. Focus group participants emphasized that, while resources are dedicated to development of some skills, demonstration of knowledge in practice differs, for example, a focus on quality improvement techniques increases resident knowledge of that skill but the ability to apply it in practice without “cues” was questioned. Participants indicated that residents were also given the opportunity to develop patient safety skills and stewardship of healthcare resources. In terms of remaining skills, there was consensus that residents had little exposure to change management, practice improvement, managing work-life balance, and demonstrating leadership in professional practice.
Demonstration of competence
Focus group participants identified behaviours that demonstrate actual leadership competency for a family medicine resident. Being able to deal with a challenging patient encounter, for example, would demonstrate effectiveness in communications. Self-awareness would be evident through reflective practice, by developing their own learning plan and by seeking opportunities to offset their weaker areas. Demonstrating initiative and working on their own call schedule would be an indication that they can lead change and/or prioritize work-life balance. All of these could be assessed. Participants stressed the importance of providing developmental opportunities for residents, while also acknowledging that identifying leadership behaviours is just as important to capture associated learning. Assigning them to committees, having them run meetings, I mean all these things that make you uncomfortable, but that’s how you develop the leadership right? Ok, so this is a phase of leadership that you’re doing. If we articulate it then people start thinking about it differently as well. And that’s partially our responsibility.
Discussion
Although the initial purpose of this study was to define learning objectives to inform a leadership curriculum for family medicine, the results turned out to be more overarching, leading to the articulation of broader program goals. A learning objective describes what the learner should be able to do after completing instruction, whereas a goal states the intended overall outcome of a period of learning.
11
Goals are valuable in their ability to guide the development of curriculum and can guide program philosophy, approach, and intended outcomes. This study generated three program goals: A resident will understand why physician leadership is important. A resident will understand the breadth of leadership and roles family physicians may have as leader. A resident will increase self-awareness and gain capacity to see themselves as leader.
The articulation of these goals is significant because each highlights an area to be addressed in developing physician leaders and the collection represents an apt philosophy that can impact whether graduating doctors are prepared to act as the clinical leaders that they are seen to be. When residents are given the opportunity to learn leadership theories and constructs, they are more likely to see how patient care can be affected with their influence as physician. If residents are exposed to leadership roles that a family physician may have, leadership will be demystified and more relatable. Increasing self-awareness, advancing communication, change management, and teamwork skills will allow them to see themselves as leaders and be more effective as part of an interdisciplinary team. Some ideas for a leadership curriculum may be having residents lead team meetings and then assessing this through a 360° feedback process, building leadership assessment into quality improvement projects 12 and providing more opportunities to work in teams.
The essence of the identified goals adds to what is known about physician leadership development programs. In a systematic review of 45 studies of leadership development programs for physicians, it was noted that most were focused on the capacity of the individual. 13 This study highlights the need to address leadership differently to be effective for family medicine residents, endorsing the need for leadership self-awareness while also emphasizing the need to understand how leadership relates to changes within organizations or at the system level. An enhanced knowledge of the importance of and the breadth and depth of leadership that is directly related to practice, as is outlined in the identified goals, could be pivotal in terms of the influence that new physicians can have.
Limitations
A limitation of this study is that the quantitative method of data collection used a longer time span (entry to medical school to several years in practice) than the qualitative component (2 years of residency), which could lead to misinterpretation of results. Additionally, the workshop method precluded the opportunity for further exploration of leadership constructs and assessment strategies.
Future directions for research
Implementing changes to curriculum will require further study related to state of readiness of faculty who will deliver leadership training, teaching methods, program evaluation strategies, and assessing competency of residents as leader. Future studies could also explore the role of physician leaders from the perspective of the interdisciplinary team.
Conclusion
Influencing the next generation of physician leaders through changes to curriculum can be accomplished and goals identified can affect that shift. The department will still need to articulate curriculum to support the achievement of these goals, ideally in a workplace-based environment, and delineate assessment strategies to capture competency development. Leadership skills identified as being more appropriate to develop and refine once out in practice could inform the College of Family Physicians of Canada’s support of new graduates.