Challenges in Translation: Lessons from Using Business Pedagogy to Teach Leadership in Undergraduate Medicine

World Psychiatric Association-Asian Journal of Psychiatry Commission on Psychiatric Education in the 21st century

Psychiatric practice faces many challenges in the first quarter of 21st century. Society has transformed, as have training requirements and patient expectations, underlining an urgent need to look at educational programmes. Meanwhile, awareness has grown around psychiatric disorders and there are evolving workforce trends, with more women going to medical school and specialising in psychiatry. Trainee psychiatrists carry different expectations for work-life balance and are increasingly becoming conscious of their own mental health. A tendency to see health as a commodity and the litigious nature of society has elicited additional pressures for healthcare professionals. Cartesian mind-body dualism has created further complexity and this can often be frustrating for patients and care-partners alike. In many cultures across Asia and beyond, patients can present with physical symptoms to express underlying psychological distress with increasing physical investigations. Simultaneously, in various countries, a shift from asylums to community-based interventions and then home treatments have changed psychiatric care in remarkable ways. These changes have added to pressures faced by mental healthcare professionals. However, trainees and other mental healthcare professionals continue to receive similar training as they did a generation ago. The tensions and differences in ideology/orientation between different branches of psychiatry have made responses to patient needs challenging. Recognising that it is difficult to predict the future, this World Psychiatric Association-Asian Journal of Psychiatry Commission makes recommendations that could help institutions and individuals enhance psychiatric education. This Commission draws from existing resources and recent developments to propose a training framework for future psychiatrists.

Leadership Training in Undergraduate Medical Education: A Systematic Review

Background: This review seeks to characterize existing curricular interventions implemented to develop leadership skills in undergraduate medical students at LCME-accredited medical schools and elucidate best practices for leadership curriculum development. Methods: PRISMA guidelines were used to guide the review. Comprehensive literature searches of five databases retrieved peer-reviewed journal articles with empirical data published in English. Two phases of screening were conducted to identify studies describing leadership development curricular interventions, followed by data extraction and synthesis. Results: Comprehensive literature searching and hand searching identified 977 articles potentially eligible for inclusion, with a final set of 16 articles selected for the review. A majority of the leadership development programs targeted preclinical students, while others spanned the entire curriculum. "Mixed settings," including both classroom and clinical and community components were common. There was a wide range of cohort sizes spanning from over 100 students to fewer than 10. Using the competencies defined by Mangrulkar et al, we determined that all of the programs described leadership skills development, including conflict management and emotional intelligence. Out of the 16 selected studies, curricula that emphasized the development of skills were evidence-based medicine and practice, and 6 curricula targeted interprofessionalism. Conclusions: Leadership development needs to be standardized in undergraduate medical education, ideally using a competency-based framework to develop these standards. Longitudinal programs that had a didactic and project-based component received consistently high quality and effectiveness scores, as did programs with smaller cohort sizes that received more consistent mentorship and monetary investment from institutions.

Professional Identity Formation, Professionalism, Leadership and Resilience (PILLAR) in Medical Students: Methodology and Early Results

Objectives

The fundamental role of medical education is the transformation of students to doctors, through a process of education and professional identity formation (PIF), which can be informed by several educational, behavioural and emotional factors. PIF has been deemed to be of equal importance to the acquisition of clinical knowledge and skills and includes constructs such as professionalism, leadership and resilience. We aimed to assess professional identity formation, professionalism, leadership and resilience (PILLAR) in the junior years of medical school in the 2020/2021 academic year and illustrate the potential role of quantitative assessment to demonstrate progression in these areas. In this research, we provide the methods and baseline results for the PILLAR study.

Methods

We implemented a compulsory assessment in pre-clinical years of graduate entry and direct entry medicine at the Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland. Validated scales were used to assess students' PILLAR. Descriptive and univariable statistical techniques were used to compare student scores between respective years.

Results

A total of 1311 students (92% response rate) provided their consent for research. For the psychometric scales, there were no evident trends among the years on these assessment measures. Results indicated significant differences in all measures, however, these did not correspond to ascending years of seniority.

Conclusion

The PILLAR methodology provides important information on the challenges of quantitatively assessing medical students in the four key areas of PIF, professionalism, leadership, and resilience. Our cross-sectional results point to cohort effects, without the expected progression per year in the cross-sectional data, or suggest that the chosen quantitative measures may be problematic for these constructs in pre-clinical students. Therefore, while we believe that PILLAR has potential as a progress test for these constructs, this will only truly be elucidated by repeated measures of each cohort over time.

When theory joins practice: A design-based research approach for leader identity development

INTRODUCTION

Inclusive educational leaders promote teacher team functioning. To support leader inclusiveness, we designed and implemented a faculty development programme focusing on leader identity formation. We investigated (1) how participants' leader identity developed throughout the programme and (2) how the design principles contributed to this process, according to participants.

METHODS

A design-based research approach was followed. Participants were 7 course coordinators, leading an interdisciplinary teacher team. To study leader identity development, participants repeatedly filled out a validated questionnaire. To investigate how design principles contributed, observational field notes, facilitator debriefings, a programme evaluation questionnaire and a semi-structured focus group were used. Thematic analysis was applied for qualitative data.

RESULTS

Participants gained broader views on leadership, moving from individual dominance towards engaging team members. Most participants initially experienced a deconstruction of their former leader identity and became motivated to improve leadership qualities. Competence-building, reflecting and receiving feedback on workplace experiences, and practicing in a safe environment were perceived to be key for identity development.

CONCLUSIONS

We developed and evaluated a leader identity programme which can convert teachers' classic leadership views towards views incorporating social interactions and relationships. We demonstrated how social interactions provide opportunities to learn from pe.ers in the work environment.

Enhancing Team Learning through Leader Inclusiveness: A One-Year Ethnographic Case Study of an Interdisciplinary Teacher Team

PHENOMENON

Developing modern medical curricula requires collaboration between different scientific and clinical disciplines. Consequently, institutions face the daunting task to engage colleagues from different disciplines in effective team collaboration. Two aspects that are vital to the success of such teamwork are "team learning behavior" by all team members and "leader inclusiveness behavior" by the team leader. Team members display team learning behavior when they share information, build upon and integrate each other's viewpoints. The team leader can promote such team learning by exhibiting inclusiveness behavior, which aims to encourage diversity and preserve individual differences for an inclusive workplace, nurturing engagement in teamwork. There is a paucity of in-depth research on leader inclusiveness behavior in the field of medical education. This case study aimed to offer unique insight into how leader inclusiveness behavior manifests itself in a successful interdisciplinary teacher team, demonstrating team learning behavior in undergraduate medical education.

APPROACH

We conducted a qualitative, ethnographic case study using different but complementary methods, including observations, interviews and a documentary analysis of email communication. By means of purposive sampling, we selected an existing interdisciplinary teacher team that was responsible for an undergraduate medical course at Maastricht University, the Netherlands, and that was known to be successful. Chaired by a physician, the team included planning group members and tutors with medical, biomedical, and social sciences backgrounds as well as student-representatives. In the course of one academic year, 23 meetings were observed and recorded, informal interviews were conducted, and over 100 email conversations were collected. All data were submitted to a directed content analysis based on team learning and leader inclusiveness concepts.

FINDINGS

Leader inclusiveness behavior became evident from verbal and non-verbal interactions between the team leader and team members. Leader inclusiveness behavior that facilitated team learning behavior manifested itself in five actions undertaken by the team leader: coordinating, explicating, inviting, connecting, and reflecting. Similarly, team members facilitated team learning behavior by participating actively, speaking up behavior, and mimicking leader inclusiveness behavior. These behaviors demonstrated engagement and feelings of inclusion, and reinforced leader inclusiveness behavior by creating additional opportunities for the leader to exhibit such behavior.

INSIGHTS

This case study responds to the need for inclusive leadership approaches in medical education. Our findings build upon theoretical knowledge on team learning and leader inclusiveness concepts. By studying behaviors, interactions and documents we obtained in-depth information on leader inclusiveness. Our findings are unique in that they demonstrate how leader inclusiveness behavior manifests itself when leaders interact with their team members. This study provides health professionals who are active in education with practical suggestions on how to act as a successful and inclusive leader. Finally, the behaviors identified open up avenues for future professional development initiatives and future research on team leadership.

Supplemental data for this article is available online at here.

Interventions to improve the well-being of medical learners in Canada: a scoping review

BACKGROUND

Medical education affects learner well-being. We explored the breadth and depth of interventions to improve the well-being of medical learners in Canada.

METHODS

We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to July 11, 2020, using the Arksey-O'Malley, 5-stage, scoping review method. We included interventions to improve well-being across 5 wellness domains (i.e., social, mental, physical, intellectual, occupational) for medical learners in Canada, grouped as undergraduate or graduate nonmedical (i.e., health sciences) students, undergraduate medical students or postgraduate medical students (i.e., residents). We categorized interventions as targeting the individual (learner), program (i.e., in which learners are enrolled) or system (i.e., higher education or health care) levels.

RESULTS

Of 1753 studies identified, we included 65 interventions that aimed to improve well-being in 10 202 medical learners, published from 1972 through 2020; 52 (80%) were uncontrolled trials. The median year for intervention implementation was 2010 (range 1971-2018) and the median length was 3 months (range 1 h-48 mo). Most (n = 34, 52%) interventions were implemented with undergraduate medical students. Two interventions included only undergraduate, nonmedical students; none included graduate nonmedical students. Most studies (n = 51, 78%) targeted intellectual well-being, followed by occupational (n = 32, 49%) and social (n = 17, 26%) well-being. Among 19 interventions implemented for individuals, 14 (74%) were for medical students; of the 27 program-level interventions, 17 (63%) were for resident physicians. Most (n = 58, 89%) interventions reported positive well-being outcomes.

INTERPRETATION

Many Canadian medical schools address intellectual, occupational and social well-being by targeting interventions at medical learners. Important emphasis on the mental and physical well-being of medical learners in Canada warrants further exploration.

An e-leadership training academy for practicing clinicians in primary care and public health settings

Leadership is an essential competency for clinicians; however, these skills are not a standard part of health professionals' education and training. Access to resources (time, money) is frequently cited as a barrier for clinicians to participate in leadership development programs. We aimed to tackle this barrier within postgraduate health professions education and training through establishing an online e-Leadership Academy. The e-Leadership Academy was developed as a community-academic partnership between Clinical Directors Network, Inc. (CDN) and the Harvard Medical School Center for Primary Care to train clinicians and healthcare staff in the fundamental concepts and skills for leading within a clinical practice. For this article, the primary outcome analysis examined participants' responses to both formative and summative evaluations that took place throughout and at the end of the course. Results were used to assess course quality, participant satisfaction, participant engagement, and provide recommendations about future course offerings for a similar audience. The authors propose that future training programs could measure the changes in team behavior and clinical outcomes using expanded evaluations. Proposed plans for expansion of the e-Leadership Academy include developing additional modules, virtual coaching and mentoring, and the potential integration of an in-person component.

"You are in Some Sort of Occupational Adolescence": An Exploratory Study to Understand Knowledge, Skills, and Experiences of CanMEDS Leader Role in Psychiatry

OBJECTIVE

The study explored knowledge, attitude, and practices of Canadian Medical Education Directions for Specialists (CanMEDS) "'Leader" role in faculty psychiatrists in a university setting.

METHODS

This is a qualitative study using a thematic analysis approach. Participants were identified by purposive, convenience, and snowball sampling. Telephone interviews were conducted to explore participants' perceptions of leadership. Qualitative analysis was carried out using a constant comparative analysis approach to identify themes across the interview data. Data was transcribed and coded into themes and categories to form an analysis of physicians' knowledge, attitude, and practices of the CanMEDS "Leader" role.

RESULTS

Twenty-eight faculty psychiatrists participated in the study. The following themes and subthemes emerged from analysis: (a) characteristics of leadership and lack of clarity regarding CanMEDS "Leader" role (subthemes: differences between manager and leader, lack of specificity and practicality, relevance to practice) and (b) the meaning of leadership (subthemes: "positional leadership" and "everyday leadership," physician as team leader, developing leadership skills, getting beyond "occupational adolescence").

CONCLUSION

Participants perceived CanMEDS "Leader" role description as a high-level vision, which needs practice-oriented guidance. Participants conceptualized the dual nature of physician leadership at an individual level and at an organizational level. Leadership training is important both in residency as well as lifelong learning.

The Importance of Leadership Development in Medical Curricula: A UK Perspective (Stars are Aligning)

"Medical leadership and management" describes the engagement of doctors in the leadership and management of both individual patient care and of the departments, organizations and systems within which they work. Around the world, doctors are generally accepted as the leaders of clinical teams, holding ultimate accountability for individual patient care. However, the role of doctors as organizational and system leaders within healthcare, despite evidence of benefit, shows considerable variation. In this article, we briefly explore the history of leadership development for doctors, and then, taking a UK perspective on recent developments in undergraduate education and postgraduate training, consider the opportunities and challenges for medical schools, educators and doctors in implementing these. The future of medical leadership and management development is promising although there is still a lack of evidence on the longer-term outcomes and impact on patients of current interventions. It is clear, however, that faculty need to be skilled in holding effective developmental conversations and structuring formative experiences for those they educate, and that leadership development must be integrated longitudinally throughout a doctor's career, with undergraduate development being a critical stage for helping medical students recognize and understand their wider responsibility to the system, as well as the patient in front of them.

Twelve tips for a successful student-led conference in health professional education

Student-led initiatives provide an authentic context for students to shape their own learning experiences and to develop skills in complex interpersonal behaviors, communication, teamwork, and leadership. A student-led conference is an example of a student-led initiative that integrates skill development across these professional domains that are necessary for contemporary health practice with conceptual understanding of basic and clinical sciences. Importantly, by participating in the student-led conference, students can form advanced views about knowledge, such as that scientific knowledge is complex and uncertain or even start to see themselves as capable contributors to the profession's knowledge. Drawn from literature as well as our experiences in implementing student-led conferences in dentistry courses, these 12 tips provide practical guidance to academics and curriculum designers on how to introduce and implement a student-led conference in health professional education. These 12 tips will help educators to consider aspects associated with design, implementation, and evaluation of a student-led conference, as well as surfacing aspects pertaining to relationships and culture. In doing so, we also aim to prompt academics to think more deeply about issues that arise when students partner with their academic advisors and the opportunities that the academics involved have for their own professional development.

Why we need to teach leadership skills to medical students: a call to action

Health system reform models since the early 1990s have recommended leadership training for medical students, graduates and health workers. Clinicians often have leadership roles thrust on them early in their postgraduate career. Those who are not well trained in leadership and the knowledge that comes with leadership skills may struggle with the role, which can impact patient safety and create unhealthy working environments. While there is some literature published in this area, there appears to be little formal evaluation of the teaching of leadership, with scarcely any discussion about the need to do so in the future. There are clear gaps in the research evidence of how to teach and assess medical leadership teaching. In this paper, three leadership frameworks from Australia, Canada and the UK are compared in terms of leadership capabilities for a global view of medical leadership training opportunities. A literature review of the teaching, assessment and evaluation of leadership education in medical schools in Australia, the UK and America is also discussed and gaps are identified. This paper calls for an education shift to consider practical health system challenges, citing the mounting evidence that health system reform will require the teaching and rigorous evaluation of leadership methods. Opportunities for teaching leadership in the curricula are identified, as well as how to transform leadership education to include knowledge and practice so that students have leadership skills they can use from the time they graduate.

Assessment of medical students' leadership traits in a problem/case-based learning program

BACKGROUND

Healthcare delivery is shifting to team-based care and physicians are increasingly relied upon to lead and participate in healthcare teams. Educational programs to foster the development of leadership qualities in medical students are needed to prepare future physicians for these roles.

OBJECTIVE

Evaluate the development of leadership attributes in medical students during their first 2 years of medical school while participating in leadership training integrated into a problem/case-based learning program utilizing the Leadership Traits Questionnaire assessment tool.

DESIGN

Ninety-eight students enrolled at Zucker School of Medicine participated in Patient-Centered Explorations in Active Reasoning, Learning and Synthesis (PEARLS), a hybrid problem/case-based learning program, during the first and second years of medical school. The Leadership Traits Questionnaire, designed to measure 14 distinct leadership traits, was utilized. It was administered to students, peers in students' PEARLS groups and their faculty facilitators. Participants completed questionnaires at three-time points during the study. Likert scale data obtained from the questionnaire was analyzed using a two-level Hierarchal Linear Model.

RESULTS

Complete data sets were available for 84 students. Four traits, including self-assured, persistent, determined, and outgoing, significantly increased over time by measurements of both peer and facilitator-rated assessments. Six additional traits significantly increased over time by measurement of facilitator-rated assessment. By contrast, a majority of student self-rated assessments trended downward during the study.

CONCLUSIONS

Medical students demonstrated development of several important leadership traits during the first 2 years of medical school. This was accomplished while participating in the PEARLS program and without the addition of curricular time. Future work will examine the impact of third year clerkships on leadership traits.

Preparing health professions students to lead change

PURPOSE

Health care systems increasingly demand health professionals who can lead interdisciplinary teams. While physicians recognize the importance of leadership skills, few receive formal instruction in this area. This paper aims to describe how the Student Leadership Committee (SLC) at the Harvard Medical School Center for Primary Care responded to this need by creating a leadership curriculum for health professions students.

DESIGN/METHODOLOGY/APPROACH

The SLC designed an applied longitudinal leadership curriculum and taught it to medical, dentistry, nursing, public health and business students during monthly meetings over two academic years. The perceptions of the curriculum were assessed via a retrospective survey and an assessment of team functioning.

FINDINGS

Most teams met their project goals and students felt that their teams were effective. The participants reported increased confidence that they could create change in healthcare and an enhanced desire to hold leadership positions. The sessions that focused on operational skills were especially valued by the students.

PRACTICAL IMPLICATIONS

This case study presents an effective approach to delivering leadership training to health professions students, which can be replicated by other institutions.

SOCIAL IMPLICATIONS

Applied leadership training empowers health professions students to improve the health-care system and prepares them to be more effective leaders of the future health-care teams. The potential benefits of improved health-care leadership are numerous, including better patient care and improved job satisfaction among health-care workers.

ORIGINALITY/VALUE

Leadership skills are often taught as abstract didactics. In contrast, the approach described here is applied to ongoing projects in an interdisciplinary setting, thereby preparing students for real-world leadership positions.

Competencies necessary for becoming a leader in the field of community medicine: a Japanese qualitative interview study

OBJECTIVES

To clarify competencies for inclusion in our curriculum that focuses on developing leaders in community medicine.

DESIGN

Qualitative interview study.

SETTING

All six regions of Japan, including urban and rural areas.

PARTICIPANTS

Nineteen doctors (male: 18, female: 1) who play an important leadership role in their communities participated in semistructured interviews (mean age 48.3 years, range 34-59; mean years of clinical experience 23.1 years, range 9-31).

METHOD

Semistructured interviews were held and transcripts were independently analysed and coded by the first two authors. The third and fourth authors discussed and agreed or disagreed with the results to give a consensus agreement. Doctors were recruited by maximum variation sampling until thematic saturation was achieved.

RESULTS

Six themes emerged: (1)'Medical ability': includes psychological issues and difficult cases in addition to basic medical problems. High medical ability gives confidence to other medical professionals. (2)'Long term perspective': the ability to develop a long-term, comprehensive vision and to continuously work to achieve the vision. Cultivation of future generations of doctors is included. (3) 'Team building':the ability to drive forward programmes that include residents and local government workers, to elucidate a vision, to communicate and to accept other medical professionals. (4)'Ability to negotiate': the ability to negotiate with others to ensure that programmes and visions progress smoothly (5) 'Management ability': the ability to run a clinic, medical unit or medical association. (6) 'Enjoying oneself': doctors need to feel an attraction to community medicine, that it be fun and challenging for them.

CONCLUSIONS

We found six competencies that are needed by leaders in the field of community medicine. The results of this study will contribute to designing a curriculum that develops such leaders.

Leadership and Academic Medicine: Preparing Medical Students and Residents to Be Effective Leaders for the 21st Century

Introduction

Physician leadership positions have evolved from autonomous roles in clinical medicine to those of leaders in interdisciplinary teams managing population-based care in a value-based care-delivery system, to C-suite administrative roles in hospitals and other health care systems. Unfortunately, many practicing physicians are ill prepared to take on these new roles.

Methods

In response to the evolution of the role of the physician leader in the 21st century, an educational workshop consisting of didactics and interactive case discussion was developed to introduce medical students and residents to the concepts and practices of physician leadership. During the workshop, trainees were: (1) introduced to leadership terms and theories, (2) provided examples of leadership opportunities during medical training and upon entering medical practice, and (3) given instruction and resources on how to become more effective leaders.

Results

Results of a paired-sample t test of learner responses (pre- and postworkshop) showed a statistically significant increase in participants' perception that a career in academic medicine would allow them to serve in a leadership role at their medical school or community of interest. Over 90% of participants agreed that the workshop gave them a greater appreciation of leadership terms and theories, leadership opportunities, and ways to become a more effective leader.

Discussion

Participants gained specific knowledge regarding leadership styles and the scope of leadership roles available to physicians. They also recognized their lack of knowledge regarding physician leadership roles and opportunities, and expressed their interest in pursuing leadership opportunities in their current educational programs.

How should medical schools prepare medical students for leading the NHS?

The NHS is an evolving landscape. While the level of clinical knowledge conferred to medical students remains constant, their competence in other skills, such as leadership, needs to be enhanced in order for them to successfully work within the health-care system. The importance of leadership is considered at the start and end of a medical degree – when applying to medical school with various examples of leading a team, and upon balancing scenarios of leadership when sitting the situational judgement test in final year. In the interim, however, more teaching needs to be delivered to ensure that medical students are prepared for leading the NHS. Through enabling students to engage, identify and align with being a leader, they become increasingly aware of their future role and will improve service delivery.