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ORIGINAL ARTICLE
Year : 2023 | Volume
: 9
| Issue : 2 | Page : 60-66
Sensitizing first-year medical undergraduate students to principles of leadership: A cross-sectional experience at a teaching hospital
Somanath Padhi1, Manish Taywade2, Sanjay Kumar Giri3, Gitanjali Batmanabane4
1 Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Burn and Plastic Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
4 Department of Pharmacology and Former Director, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
Correspondence Address:
Dr. Gitanjali Batmanabane
Former Director, All India Institute of Medical Sciences, Bhubaneswar, Odisha
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijam.ijam_65_22
Introduction: Literature on implementation leadership program in undergraduate (UG) medical education is lacking in the Asian continent. We aim to describe our experience in sensitizing the 1st year undergraduate medical students (UGMS) toward the principles of leadership in a medical institution.
Materials and Methods: Each year, one hundred 1st year UGMS were sensitized towards leadership principles and core domains through interactive sessions, focus group discussions, and short lectures. The students were asked to reflect on the sessions' activities as well as their follow-up usefulness in their day-to-day activities through a structured questionnaire shared through Google forms.
Results: A high proportion (75%) of students reported an improved perception or knowledge toward leadership principles and practices. Leadership attributes such as team building, decision making, confidence building, motivation, and managing crisis were reported to be very useful by 77.8%, 74.1%, 69.1%, 64.2%, and 61.7% of students, respectively. On follow-up, students described this sensitization exercise to be useful in their academic (16/52, 30.76%), organizational (10/52, 19.2%), sports (6/52, 11.53%), short-term research (4/52, 7.7%) activities, and editorial responsibilities (3/52, 5.7%).
Conclusion: The leadership sensitization workshop helps students adjust to the medical school's environment; and this may be incorporated in the UG curriculum to strengthen students' leadership potential.
The following core competencies are addressed in this article: Systems-based practice, Interpersonal and communication skills, Professionalism.
Keywords: Curriculum, domains, healthcare, leadership
The medical profession demands not only the acquisition of knowledge but also the necessary skills and attributes to enable students of medicine to become effective healthcare service providers for the nation at large. The students are expected to be self-directed learners; have the leadership attributes in day-to-day challenging situations; and demonstrate exemplary professional and humanistic qualities when required. Recognizing the fact that “naïve” 1st year undergraduate (UG) medical students are from diverse socioeconomic, ethnic, cultural, and premedical educational background, the then Medical Council of India in 2016 (now changed to National Medical Commission, NMC) felt the necessity of introducing a month long “foundation course (including leadership)” starting at the beginning of MBBS curriculum to serve as a bridge for a smooth transition and help UG medical students navigate the medical course with confidence.[1],[2] In accordance with the popular notion that leadership is not an inborn trait but an acquired skill, most health-care professionals tend to believe that leadership qualities can be developed automatically over a period of time and hence cannot be taught effectively.[3] Over the years, it has been increasingly recognized that leadership skills can be cultivated through both formal and informal education starting at an early level in UG medical curriculum.[4] While leadership program as a component of the medical curriculum already exists in many centers across the United States of America (USA), the United Kingdom (UK), and other countries across the globe, the same has not been the case in most of the medical institutions in India.[5],[6],[7],[8],[9],[10] Therefore, in accordance with NMC norms as well as a part of the institutional administrative policy, we introduced a leadership workshop as a part of the foundation course in an attempt to groom our students for their curricular and extracurricular development as well as become better health-care delivery providers. In this manuscript, we describe our experiences on UG leadership sessions at our center with a focus on its implementation with a brief comprehensive review of the existing practices across the globe.
Materials and MethodsStarting from August 2017, an annual 4-day sensitization workshop on “leadership” was conducted for the 1st year UG medical students (100/year) during August following their admission to the medical college. The students were divided into four subgroups of twenty-five each, who participated in a 3-h post lunch session in a lecture theatre. Before these sessions, three faculty members from various specialties who facilitated the sessions were assigned the tasks to formulate a comprehensive lesson plan after discussions with other faculty. The learning objectives, teaching–learning (T-L) media, educational content, group activities, time management, and tools for documentation were determined. During the session, the facilitators carefully observed the level of engagement by the students, their active participation, and sharing of their experiences/ideas. Feedback on the overall sessions as per the Kirkpatrick's four levels of training evaluation model (reaction, learning, behavior, and result) was collected from each batch of students at the end of the session every day. Subsequently, a structured questionnaire through Google forms was sent to individual batches through E-mail to collect the feedback on the utility of such sessions in the context of their professional activities. The schematic representation of the step-by-step methodology followed in the sessions is represented in [Figure 1]. The Institutional Review Board (IRB) of our institute approved the retrospective review study and waived the requirement for written informed consent (Ref. No: T/IM-NF/Pathol/20/164).
Figure 1: An algorithmic approach to our detailed lesson plan on leadership. Note the different steps of methodology, various leadership theories, and different leadership domains highlighted. The entire session was conducted over three hours for four consecutive days in lecture theaterGroup dynamics and team building
Each student and facilitator were asked to best describe himself/herself by a single word describing a personal characteristic which was then used consistently throughout the session as individual identity (not original names). Three students voluntarily came forward to lead; who then formed their own team (Group 1 [n = 8], Group 2 [n = 8], and Group 3 [n = 9]) by picking up the above said characters of their choice. The group leader shared his principles for choosing the team members.
Set induction
A short video clip (“Lead India-The Tree”) (5 min) was shown which described how a small school-going kid inspired adults to come out of their comfort zone to tackle a challenging situation. The students were asked to reflect on the video.
Learning objectives
The objectives of the session were to:
Sensitize the students regarding prevailing leadership theories.Identify the potential leadership attributes among them.Enable them to appreciate the fact that leadership skills are essential for a medical professional.Group activity 1
The objective was to engage the students in a discussion to highlight any two well-known personalities (with positive and negative attributes) from all fields, sharing their prior knowledge (recall) or experience obtained during premedical years. The positive and negative qualities of leaders were summarized by student volunteers.
Group activity 2 and 3 (leadership games)
The objective of this session was to subject a potential student-leader to different challenging scenarios; and sensitize them toward the necessary attributes required to tackle the situation for a successful result. In both the games, the leader received a prior briefing from the facilitator following which he/she was then asked to lead his/her team members to a successful outcome.
Tools and resource material
Focused group discussions, experience sharing, briefing and debriefing using blackboard and/or PowerPoint, sharing of quotes and literature from the web (Eagle's seven leadership principles, 5C models of Indra Nooyi, and different leadership models/styles), display of leadership in real life challenging situations, display of leadership through video clips.
Results and ObservationThe students' perception of existing knowledge, gain in knowledge during the session; and the importance of the session in medical profession is presented in [Figure 2]a and [Figure 2]b. The majority of students (70%) did not have the prior knowledge of the topic except for few (10%) who had some sort of nonformal experience obtained during their school and college days. On the other hand, majority (75%) of the students stated that they had a gain in knowledge on leadership after the session. Most (80%), if not all, appreciated the importance of the topic in future medical practice. When the activity of the students was graded on a 0–4 scale, 70% of students stated they participated actively to a large extent; 63% felt themselves engaged in different activities, and sharing of experiences/ideas was noted as fair (score 3) and to a large extent (score 4) by 30% and 43% of the students, respectively. Interestingly, the students perceived that leadership games (activities 2 and 3) helped them learn the leadership attributes effectively than activity 1. As a follow-up to the sensitization program, we could obtain eighty-one feedback responses from all batches (2017; n = 52, 2018; 21, and 2019; 08) while the remainder did not respond. The attributes of leadership which students learned during the sessions and those which they imbibed at present are presented in [Figure 3]a and [Figure 3]b, respectively. Five most common leadership attributes learned during sessions were as follows: team building (63/81, 77.8%), decision making (60/81, 74.1%), confidence building (56/81, 69.1%), motivation (52/81, 64.2%), and managing crisis (50/81, 61.7%). While more than 50% of students felt that they still imbibe those attributes at present, attributes like accountability (34.6% vs. 50.6%), risk-taking (51.9% vs. 59.3%), and conflict management (51.9% vs. 55.6%) saw some improvement.
Figure 2: Student's perception (knowledge) on leadership (a) and their level of participation during the entire sessions (b) (N = 100)
Figure 3: Leadership attributes learnt by students during the session (a). Five most common leadership attributes learnt were as follows: team building, decision making, confidence building, motivation, and managing crisis. Leadership attributes which students still imbibe today (at 1 year, 2 years, and 3 years) are presented in figure. Note that attributes like accountability, risk taking, and conflict management saw some improvement over the years (b) (N = 81 responses)We did obtain the feedback from 52 students (batch 2017) at the end of their third professional examination to have an idea regarding their change of perception on leadership attributes over the years; and asked them to rate themselves as “leader” on a five-point scale: score 1– no or minimal improvement, score 2 – improvement to some extent, score 3 – improvement to a moderate extent, score 4 – improvement to a large extent, and score 5 – excellent. While only four students (7.5%) felt to have developed leadership attributes to a large extent at the end of the first professional period; these numbers increased to 16 (29.6%); and 17 (32.1%) at the end of the second and final professional examination, respectively. Similarly, the number of students with excellent leadership attributes (score 5) improved from three (2.5%) in the first professional to nine (18.5%) at the end of the third professional exam [Table 1].
Table 1: Trend in perception of leadership qualities among final year MBBS students (Batch 2017) on follow up over a period of three years (2017-2019) (n=52/100)When asked about the utility of leadership sensitization workshop in their day-to-day educational and extracurricular activities in medical college, the students of the 2017 batch (n = 52) found this useful in different ways. Sixteen (30.76%) felt that leadership sessions helped them in routine classroom and out-of-the-classroom academic activities such as preparation and presentation at a student seminar, classroom presentations during integrated teaching sessions, leading the group academic group discussion both during anatomy dissections, practical laboratory postings as well as bed site case presentation/discussion, organizing and conducting quiz, and interaction with the community during their field trips. While another ten students (19.2%) found themselves in leadership roles while organizing intercollege students' meet; seven (13.46%) felt leadership sensitization workshop early in their career helped them better as a class representative; six (11.53%) used the principles in organizing intra- and inter-batch sports events; four (7.7%) got benefitted in doing short term student research projects; three (5.7%) carried out their responsibility as editor for student magazine; and remainder six (11.5%) used their leadership qualities in performing miscellaneous activities. As we received very few feedbacks from the other two batches (2018, 2019), we excluded them from our preview.
DiscussionWe aimed to sensitize the naïve 1st year MBBS students toward the concept of leadership and leadership roles immediately after they entered the medical college with a futuristic goal of preparing them for the upcoming educational and extracurricular activities during their 1st, 2nd, and 3rd professional period. We found a significant improvement in students' perception toward different leadership principles. We ensured active student participation through group discussions, interactive sessions, and sharing of personal ideas with faculty briefings. The initial group activity witnessed the emphasis on essential qualities of leaders from all spheres of life through role models (transformational leaders). During the group activities such as leadership games, the students got to know the various leadership roles in different situations (situational leadership) such as importance of meticulous planning, coordinated teamwork, higher-order thinking, effective communication with the team members, confidence building, adaptability, giving correct directions, courage of risk-taking, and the last but not the least the art of acceptance of failure. In addition, students found attributes such as accountability and conflict management very useful in their day-to-day curricular and extracurricular activities in the medical college career.
Nearly 50% of the students of the seniormost batch (2017) perceived an improvement in their leadership abilities over the years which they described as useful in carrying out academic/educational activities pertinent to initial formative years such as classroom presentations and student seminars, moderating a group discussion, leading the fellow group mates in demonstrating practical skills during cadaveric dissections, laboratory experiments in pre- and para-clinical subjects, bed site patient examinations, and carrying out IEC (information, education, and communication) activities during their community posting.
When we compared our leadership implementation exercise with different studies (both UG and graduate) published in the literature, we noted some similarities in our approach.[7],[8],[9],[11],[12],[13],[14],[15],[16],[17] Webb et al. presented a systematic review on the existence of 24 UG leadership curricula across the globe (the USA, the UK, Canada, Switzerland, Sweden, and Israel) over the last 34 years (1980–2014).[7] In most of the centers (17/24, 71%), the programs were conducted semester-wise (longitudinally) in both preclinical and clinical years in conventional classroom environment (50%) as workshops and/or lectures; in clinical care setting; or using simulation methods. While faculty from different medical specialties such as laboratory sciences, community and family medicine, clinics, as well as administrative heads participated in our center, many centers employed the involvement of community leaders as well as faculty from humanities, and education to supplement the medical faculty. The medical leadership competency framework domains, most commonly highlighted were as follows: working with others (88%), managing people and resources (79%), improving patient safety and quality (63%); personal integrity (54%), and setting the goal. On the evaluation of program effectiveness, 10/24 (42%) reported a change in learners' attitude; change in behavior as a result of learning (25%); and an observed change in organizational practice, quality, and efficiency was reported in 17%.[7] A group of faculty from diverse specialities and trainees (medical students and trainee physicians) at Duke University School of Medicine, Durham, USA developed an effective leadership in healthcare model (The Duke Healthcare Leadership Model) in 2017 that used leadership competencies such as personal integrity, effective communication, professional ethical values, pursuing excellence, building and maintaining relationships, and critical thinking. They developed a model based upon the core principle of patient centeredness and the core competencies such as integrity, teamwork, critical thinking, emotional intelligence, and selfless service.[18] Our leadership exercise was mostly in conformity with that of Clyne et al. who successfully introduced a structured leadership program (Leadership in Health Care) at the UG level as a part of 4-year integrated course starting early in their preclinical years.[11] This was based mainly on the leadership theories (transformational, situational, and servant) and fourteen core competencies which were delivered through classroom exercises on personal core values, guided discussions, and panel discussion; though outcome evaluation was not reported.[11] A 2017 nationwide web-based survey across the USA reported that formal longitudinal leadership curriculum does exist as an “educational priority” in more than half (54.5%, 45/88) of their institutions.[13] Nearly 35% of such curricula were “mandatory for all;” another 35% were “elective” (student participation ranging from 20% to 40%); and remainder 30% reported these as “both mandatory and elective.” The mode of content delivery was diverse across institutions in the form of the mentoring program (65%), dual degree program (58%), workshops (48.8%), seminar/lecture series (42%), course-based (41.9%), single seminars (18.6%), and other activities (32.6%).[13] Ginzburg et al. reported their assessment on ongoing problem based/case-based leadership program using leadership trait questionnaire. Medical students in their study demonstrated the development of several important leadership traits during the first 2 years of medical school, such as self-assurance, persistence, determination, and outgoing quality.[14] Another qualitative study from the UK reported the students' attitude and opinion toward leadership and management in UG curriculum in terms of team working skills, decision-making and negotiating skills, and patient safety.[8] Structured observation, reflection, critical appraisal, and analysis of mistakes at all levels were mentioned by students as existing opportunities for integrating leadership and management education. The University of Buckingham Medical School study also reported a significant improvement in students' perception toward leadership principles at the end of a week-long program delivered through lectures, focused groups, and short interview sessions highlighting their hospital values.[15] When compared with UG curricula, we also noted that graduate leadership programs across the USA (twelve prospective and three retrospectives) were more or less similar in terms of format, content, and duration; and the majority focused on conflict management, interpersonal skills, and stress management. Seven used pre- and post-test surveys, while seven used course evaluations. Only three curricula had follow-up evaluations after 6 months–1 year.[16] We did not find any published data pertaining to the implementation of leadership programs and/or their evaluation from most of the medical institutions across India. We could find leadership sessions are conducted only a few premier Indian institutions such as Jawahar Institute of Postgraduate Medical Education and Research, Pondicherry, and Christian Medical College, Vellore as a part of formal classroom sessions stretched over 1 h which mainly highlights team building, change management, and different leadership attributes (data unpublished).
Strength and limitation
From a faculty perspective, conducting such sessions were initially challenging in 2017 as these required rigorous and meticulous planning and practice, time management, and gathering of appropriate resource/teaching material for dissemination of ideas to naïve MBBS students in a simplified and practical manner to be useful in their medical college environment. However, once properly formulated, both faculty and students in each batch found that these sessions are highly enriching and useful. Moreover, these sessions were successfully conducted in the classroom environment of lecture theatres with minimal logistic requirements ensuring active participation and exchange of ideas. Although implementation has been successful over the years, the evaluation of such program's usefulness has not been properly standardized. Although we could obtain some students' feedback across batches, those were not representative of entire students. We also are of the opinion that conducting such workshops at different specified time intervals of UG curriculum (entry, midterm, and during exit) using varied T-L methods could be a better approach in sensitizing the students and evaluating the usefulness of the program.
ConclusionWe described our experiences in conducting the leadership sessions for the 1st year UG medical students at our center which, to the best of our knowledge, is possibly the first of such a kind in Eastern India. Students perceived that the leadership sensitization workshop helps them adjust the medical school's environment. Sensitizing MBBS students toward the principles of leadership is necessary; and this should be a part of UG as well as postgraduate medical curriculum which could perhaps lead to better health-care delivery outcomes since most of the time the doctor is the team leader for these teams. Development and validation of tools for leadership development among undergraduate and graduate students/trainees is the next way forward in our future endeavor.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Research quality and ethical statement
The IRB/Ethics Committee of the All India Institute of Medical Sciences, Bhubaneswar, approved the study and waived the requirement for written informed consent (T/IM-NF/Pathol/20/164). All ethical principles have been adhered to protect the dignity, rights, and welfare of research participants. The authors declare that they followed the applicable EQUATOR network (https://www.equator.network.org) research reporting guidelines.
References
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