DOI: https://doi.org/10.21203/rs.2.14044/v1
Background : With the increasing recognition that leadership skills can be acquired, there is a heightened focus on incorporating leadership training as a part of graduate medical education. However, there is considerable lack of agreement regarding how to facilitate acquisition of these skills to resident, chief resident, and fellow physicians.
Methods : Articles were identified through a search of Ovid MEDLINE, EMBASE, CINAHL, ERIC, PsycNet, Cochrane Systemic Reviews, and Cochrane Central Register of Controlled Trials from 1948 to 2019. Additional sources were identified through contacting authors and scanning references. We included articles that described and evaluated leadership training programs in the United States and Canada. Methodological quality was assessed via the MERSQI (Medical Education Research Study Quality Instrument).
Results : 15 studies, which collectively included 639 residents, chief residents, and fellows, met the eligibility criteria. The format, content, and duration of these programs varied considerably. The majority focused on conflict management, interpersonal skills, and stress management. Twelve were prospective case series and three were retrospective. Seven used pre- and post-test surveys, while seven used course evaluations. Only three had follow-up evaluations after six months to one year. MERSQI scores ranged from 6 to 9.
Conclusions : Despite interest in incorporating structured leadership training into graduate medical education curricula, there is a lack of evidence evaluating its effectiveness. High-quality well-designed studies are required in order to determine if these programs have a lasting effect on the acquisition of leadership skills.
The American healthcare system is in a state of tremendous flux, with the role of physicians and other healthcare providers rapidly changing to keep up with technological advances, financial restructuring, and the adoption of new societal and technological standards. Leadership training has been proposed as a means of managing these changes and ensuring that physicians are able to retain their central roles as health providers.1 This follows the example of the business community, where leadership development is considered a high priority among managers.
Leadership is a term that is used to describe the ability of an individual to guide an organization or group of individuals.2 In contrast to managers, leaders tend to exert authority through words and actions to convince followers towards a fulfillment of a vision, rather than through reward or punishment to induce control over subordinates. While considerable controversy exists over what styles and skills are necessary for effective leadership, this has become a burgeoning field of study. Sitkin and colleagues have identified six interrelated domains of leadership, namely personal, relational, contextual, inspirational, supportive, and responsible.3 Each domain of leadership has an associated conceptual basis, group of behaviors, and set of skills. While an in-depth discussion of these domains and their application to medical education is beyond the scope of this article, acknowledgement of the importance of leadership and the heterogeneity of leadership styles is essential towards understandings the role of leadership development in graduate medical education.
With regards to medicine, it has been noted by several authors that there is a lack of leadership training for physicians in academic medical centers.4 There has been a tendency to believe that leadership skills are acquired on the job and cannot be taught effectively, leaving a deficit of highly qualified physician leaders.5 However, it is being increasingly recognized at least some leadership skills can be cultivated through formal and informal education, and that effective leaders cultivate their leadership capacity through diligent practice.6–8 Despite these calls for leadership training, the Accreditation Council on Graduate Medical Education (ACGME) has not yet articulated a specific position on leadership training. Currently, leadership skills constitute sub-competencies in two of the six competencies promoted by the Outcome Project of the ACGME, namely (1) professionalism and interpersonal skills, and (2) communication skills.9 New program requirements proposed by the ACGME have focused on the medical team, which is intimately linked to team leadership. Further, some of the members of the Council of Review Committee Residents Leadership Subcommittee of the ACGME have supported the need for leadership training, although they state that their opinions are not necessarily the official position of the ACGME.10
There are scarce data about how leadership training programs are implemented in the framework of graduate medical education, i.e. residency and fellowship programs. Even less is known about the impact of these programs. Two systematic reviews have been performed regarding physician leadership training programs, but these did not specifically focus on resident and fellow physicians in North America, who operate in a very distinct environment and face unique challenges compared to physician executives, faculty members, and trainees in other geographic settings.11,12 In order to document and characterize these programs, we have conducted a systematic review of literature.
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to guide our literature search and report (Appendix 1).
Two authors (B. K. and M. L. S.) searched MEDLINE (from 1948 to January 31th, 2019), EMBASE (from 1988 to January 31th, 2019), CINAHL (from 1994 to January 31th, 2019), Cochrane Central Register of Controlled Trials (from 1996 to January 31th, 2019), Cochrane Systematic Reviews (from 1993 to June 30th, 2017), ERIC (from 1965 to January 31th, 2019) and PsycNet (1970 to January 31th, 2019), for potentially relevant studies. These searches were limited to articles written in English. A Boolean search strategy using a series of three terms was employed in order to obtain these articles. Search terms included (“medical education,” OR “residency,” OR “fellowship,” OR “medical training”) AND (“leadership” OR “management” OR “advocacy”) AND (“development” OR “skills” OR “training” OR “workshop” OR “session” OR “curriculum” OR “activities” OR “syllabus” OR “modules”).
Additionally, we supplemented this search by scanning the references of identified studies, as well as the related three systematic reviews.11,12,13 In order to address publication bias, we also attempted to contact the authors of studies that were ultimately included in our review. The contact information of six authors was obtained, but only one had replied back with four articles, but none of these were new, previously unidentified studies.
All qualitative and quantitative studies written in the English language that contained data regarding the implementation and evaluation of leadership training programs during graduate medical education were eligible. These graduate medical education programs consisted of residency and fellowship programs in either Canada or the United States.
We excluded studies that did not specifically deal with leadership training in graduate medical education, such as studies solely describing practice management or quality improvement. Similarly, we excluded studies that were not designed towards trainees in graduate medical education.
The two authors independently screened titles and abstracts compiled during the literature search. Full text of relevant articles was obtained based on the eligibility criteria noted above. Abstracts without concomitant full studies were excluded as they would be unlikely to provide enough detailed information for the systematic review. Conflicts were resolved by discussion and an apparatus was set up for a third author (M. S.) to resolve any discrepancies, although no conflicts occurred. The kappa statistic was calculated as 0.92.
The two authors jointly developed criteria for data abstraction. These included study design, physician characteristics, and outcomes. We discussed any studies that were subject to conflict, and calculated the kappa statistic. The MERSQI (Medical Education Research Study Quality Instrument) criteria were used to appraise the methodological quality of included studies (Table 2).
A narrative review was drafted based on the included studies. While the original intent was to perform a meta-analysis, this could not be performed due to the heterogeneity of study designs and outcomes.
15,159 citations were obtained through the literature search strategy, of which 46 articles were deemed potentially relevant. 30 of these did not include data on either evaluation or implementation, resulting in 16 unique studies.14–32 Among these, four were excluded since they were descriptive of new leadership curricula but lacked information on how effectiveness was assessed.14,15, 17,27 The kappa statistic was calculated and was 0.92 for the twelve included studies.
Of the 15 unique studies identified, twelve were prospective case series and three were retrospective case series. Fourteen were quantitative in nature and one had a qualitative component. Surveys were used to determine the effect of the intervention in twelve studies while another looked at outcomes in terms of awards, grants, and projects either won or executed by participants after completion. Among those evaluated by survey instruments, eight used self-assessment surveys and seven used course evaluations. Seven used pre- and post-test surveys while an eighth used a post-test and retrospective pre-test. Geographically, Fourteen studies were conducted in the United Statesand one was conducted in Canada. Two of these involved participants from multiple institutions.16,26
Altogether, there were 639 residents or fellows participating in the thirteen studies. All participants were graduate medical education trainees, but these varied among different residency and fellowship training programs. Three were designed specifically for chief residents and three for senior residents, while the rest of the nine were open to residents of all different training years. Only one explicitly included fellow physicians in addition to resident physicians. Details regarding age and gender were not available for thirteen of the fifteen studies.
There was considerable variety in content, methods of instruction and the duration of intervention. Four studies did not enumerate the specific topics beyond development of “leadership skills.” The most common topics listed included teamwork and communication, which was seen in seven of the studies. A full list of topics covered is noted in Table 1. The methods of instruction also varied: nine were workshops, four were didactic sessions, one was a series of small-group discussions, and one was an entire three-year residency program. Even among these, there was considerable heterogeneity in the length of time of each workshop/seminar, with some sessions as short as 30 minutes and others lasting for over 90 minutes. Additionally, the duration of training ranged considerably from a one-day workshop to a three-year residency program.
Only two of the 15 studies included details on the age or gender of the participants, and so the representativeness of these studies compared to the general population of GME trainees is unclear. The twelve prospective case series did not detail specifically about how participants were selected, aside from being members of the residency or fellowship program. Similarly, no exclusion criteria were elaborated.
Self-reported questionnaires were utilized in fourteen of the fifteen of the studies. However, only one was noted to be validated by authors. Also, none described blinding of outcomes assessment. One study reported follow-up after six months; two additional studies reported follow-up after twelve months. The remaining twelve did not have follow-up. One study looked at the outcomes in terms of awards and grants six years after graduation of the first set of cohorts.
MERSQI scores were calculated for each of the included studies, and varied from 6 to 9 (Table 2).
Among the seven studies that used pre- and post- self-assessment surveys, all showed improvement in the perceptions and attitudes of knowledge and leadership skills, although measured in different ways. In the six surveys evaluating the programs themselves, there was broad satisfaction at the quality and content of the program.
To our knowledge, this systematic review is the first to characterize and appraise leadership development programs specifically among graduate medical education trainees. Of note, one prior systematic review had appraised the strength of conclusions using the Best Evidence in Medical Education (BEME) Index, but did not appraise the methodology, framework, and results in total. However, the information that we collected has several important limitations.
First, because leadership encompasses several overlapping concepts, the foci of these studies were slightly different. Some articles did not break down what types of leadership skills were emphasized in these training programs, while others provided significantly more detail. Among these, conflict resolution was the commonly encountered topic covered, seen in 7 studies, followed by stress management in 4 studies. Ancillary topics in advocacy, personal finance, quality improvement, public health, and business management were also seen in several studies.
Second, the outcomes reported were largely self-reported through non-validated questionnaires. Except for Kuo’s report of the establishment of a three-year residency program, all of the included studies used either pre- and post-test knowledge-based assessments, or self-assessments. Six of the studies that evaluated the course content and composition demonstrated that participants were satisfied, according to the authors’ conclusions. Additionally, 6 studies demonstrated there was a positive impact on their own perception that they had learned about leadership skills. While these are helpful in determining what was learned and how learners viewed their experiences, it does not necessarily provide information about how leadership training impacts behaviors or institutional culture. The absence of follow-up beyond the initial training course in all but three studies also makes it difficult to determine what lasting impact these training programs had on participants.
Thirdly, inclusion and exclusion criteria were not clearly elucidated in the included studies. In the absence of this information, it is difficult to ascertain selection bias or drop-out between training sessions. Similarly, demographic information regarding age and gender were missing in all but one study. These findings preclude generalization of any particular conclusion about leadership training in graduate medical education.
Our systematic review does have certain methodological shortcomings. We limited our search to articles focusing on leadership, but due to the ambiguities regarding the precise definition of leadership, we may have missed articles related to “team leaders,” “managers,” “self-management” or other topics within the realms of leadership training.
Strengths of our systematic review include the use of multiple databases and the solicitation of other references by both searching the reference lists and by attempting to contact authors of the published material. The methodological rigor of the review was upheld through strict adherence to the PRISMA statement, and each study was evaluated by the MERSQI, a validated instrument to appraise the methodological quality of studies.
This systematic analysis has identified a significant absence in the publication of leadership training programs. What has been published suggests that leadership training is a worthwhile endeavor, and that participants do learn more about leadership and are favorably disposed to workshops and seminars. We recommend that further high quality research be undertaken in order to better understand how leadership skills can best be imparted for trainees in graduate medical education, and how formal training programs influence more long-term and objective measures of leadership and management.
Ethics approval and consent to participate: Not applicable
Consent for publication: Not applicable
Availability of data and materials: Not applicable
Competing interests: MS is an Associate Editor of BMC Medical Education
Funding: This study was funded through the Arnold P. Gold Research Institute’s “Mapping the Landscape, Journeying Together” Grant
Authors’ contributions: BK: literature review concept design, analysis and interpretation of data, drafting of manuscript. MLS: analysis and interpretation of data, drafting of manuscript. MS: analysis and interpretation of data, drafting of manuscript. All authors read and approved the final manuscript.
Acknowledgements: The authors wish to thank Jeffrey Pettit, PhD MA and Hanna Mawad, MD
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