Physician leadership development through the lens of LEADS and competency-based education
Manitoba pediatric residents’ experience
Ming-Ka Chan, MD, Celia Rodd, MD, Elisabete Doyle, MD, Eleanor MacDougall, MD, Jenette Hayward, MD, and Karen Gripp, MD
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Leadership development for health care professionals has received increasing emphasis globally, with a focus on starting training early and continuing throughout the career life cycle. In this case study, we review the current milieu of physician leadership education opportunities in pediatrics at the University of Manitoba, showcase some exemplars, and discuss enablers and challenges. Our leadership development programs are incremental; use formal and informal teaching, role modeling, and mentor support; and provide abundant opportunities for application. Local initiatives are further enriched by regional, national, and international opportunities to engage in interdisciplinary and interprofessional learning. Our program is robust and supported by a culture that values such development. Increasing momentum is needed to enhance the formal curriculum, further integrate it into a competency-based education model, train the trainers, and increase opportunities for experiential application. Processes and outcomes must be measured and evaluated to understand the return on investment and make the case for ongoing support and sustainability.
KEY WORDS: leadership training, leadership development, resident education, mentorship, CanMEDS, LEADS, pediatrics
The need for leadership development for health care professionals has been steadily growing, and it is recognized as integral to the global educational mandate.1 The Future of Medical Education in Canada (FMEC) reports for both undergraduate2 and postgraduate3 learners recommend that leadership development start early and continue throughout the professional life cycle. The University of Manitoba, and particularly the Department of Pediatrics and Child Health, wholeheartedly embrace this philosophy. Our curriculum centres around the need for “leadership education for all physicians” with additional “leadership education for some,” such as chief residents. Although the FMEC reports2,3 specify the need for collaborative leadership, our current offerings are largely concentrated within our discipline, with some joint resident and faculty opportunities.
The objective of this article is to describe the curricular opportunities provided to our pediatric residents with respect to leadership training. These include both targeted episodic and longitudinal offerings, which are predominantly direct and in person. In addition, we discuss facets of experiential learning and application, along with the feedback and mentorship so critical to lifelong leadership development.
The evolution of residents as leaders begins with the acquisition of skills, followed by opportunities to practise leadership and receive coaching feedback, which is provided and enhanced by senior resident and faculty role models. Graded supervision allows advancement to increased levels of autonomy. The LEADS framework4 (lead self, engage others, achieve results, develop coalitions, systems transformation), integrated with CanMEDS competencies,5 provides a useful organizational scaffold on which to base our curriculum.
Transition to discipline
In the first few months of residency, leadership development begins with a focus on leading self and engaging others,4 with some targeted sessions on achieving results.4 Residents reflect on personal strengths, goals, and barriers; practise communication skills; and learn and practise feedback skills, supported by online modules. This stage is further buoyed by the assignment of experienced core-of-discipline (second- and third-year) resident mentors, who provide fundamental support at this early stage, as new residents require not only orientation to residency, but often also adaptation to a new environment. Top
Early in the first year, all residents participate in and reflect on a nurse-shadowing experience to engage and better appreciate the perspective of others. Fundamental skills in team leadership are developed through formal courses in neonatal resuscitation and pediatric advanced life support, as residents accept explicit responsibility as a team leader to assign roles and facilitate team communication. During ward rotations, participation in monthly mock code scenarios reinforces the key learning points of respectful and effective communication and collaboration.
Since 2016, all first-year residents participate in a four-week rotation titled “academic skills and knowledge” (ASK), building on the experience of other successful pediatric programs.6-8 Using adult-learning strategies, sessions are mostly interactive in a small-group setting.9 Residents prepare ahead of time and lead sessions; didactic information is applied immediately in a practical manner; and opportunities abound for residents to share existing knowledge as well as reflections. For a small
(< 5%) portion of the curriculum, residents use online tools, such as the Tri-Council Policy Statement ethics tutorial10 and the Institute for Health Improvement Open School on Quality Improvement.11
The overarching goal of ASK is development of lifelong learning skills by engaging the residents around questions relevant to best care practices (achieve results), as well as enhancing their ability to appraise literature critically. By doing this, we aim to improve their ability to understand and apply pediatric literature and support their mandatory scholarly projects as they develop into clinicians and leaders.
As part of the leadership focus, all preceptors introduce themselves and highlight individual career trajectories and their roles in and outside the department apart from clinical duties. Many faculty have additional credentials, such as specialized graduate degrees, in addition to Royal College training. Moreover, the residents learn to see preceptors as role models and leaders, locally, nationally, and internationally. Such extended introductions enable residents to forge links with the hospital; past residents have commented on increased comfort with approaching faculty and seeking leadership, advocacy, and scholarship opportunities. Top
Using deliberate initiatives, residents are asked to see the hospital, patient care, and leadership as shared activities. Inclusiveness is explicitly fostered by residents alternating groups and roles, such as leader and follower. Through informal mingling, teamwork, and the creation of a trusting environment, residents develop a remarkable cohesiveness that enables increasingly mature feedback on small-group presentations. Residents also have opportunities to contribute to improvements in health care, engage in stewardship, demonstrate leadership, and discuss career planning — all key competencies of a leader. These opportunities often involve simulated or self-designed plan-do-study-act cycles.
The ASK curriculum serves as a finale to the “transition to discipline” period. With the benefit of role modeling and direct application, residents evolve from passive observer and “complainer” (as one resident described it) to feeling empowered and self-motivated. Residents achieve their goals of learning how to engage others4 to create a healthy organization, in part by using their skills in critiquing medical literature to implement these goals and achieve results.4 Through cooperation with others and a better understanding of the many roles that preceptors play, residents see themselves evolving into truly multi-dimensional pediatricians. In formal course feedback, one learner expressed the view that the rotation had helped integrate leadership skills for residents, teaching them that they were part of the effort to improve pediatric care practices locally and globally.
Foundation of discipline
During the latter two-thirds of the first year of residency, the “foundation” stage, the leadership curriculum continues to build on previously integrated materials with more emphasis on engaging others and achieving results.4
Central to all apprentice-style training, role modeling by more senior residents and faculty, combined with exposure to training experiences, is a rich and productive method by which learners develop as leaders. Such role modeling occurs during clinical training, formal sessions such as journal club, and committee participation. All residents are required to participate in committees where representatives for each year of training liaise with other residents and faculty, learning to facilitate successful bidirectional exchange by transmitting concerns and suggestions between their own cohort and the committee.
Later in the first year, residents begin looking for supports for other training requirements, for which faculty mentorship is coordinated. Faculty mentors assist with guidance on topics including scholarly pursuits, work–life integration, and career decisions, with potential additional areas of interest, such as ethics, global health, education, or leadership. With the addition of a third mentor for the resident’s scholarly project as well as individual guidance from program directors, the mentorship support provided to residents throughout their training is both intentional and complementary.
In the clinical setting, the evolution of foundation residents as leaders is well illustrated by their three one-month blocks on the inpatient wards. For the first two blocks, they are managers of care for up to 6–8 patients on weekdays. During overnight and weekend call, residents admit patients and also provide cross-coverage for up to 20–25 patients, which requires quick assimilation of skills in time management, communication, and knowledge-gathering. Foundation residents use teaching and feedback skills in their new position as role models, taking on partial responsibility for supporting more junior learners in patient care, such as acting as a buddy for medical students on their first call night. Assisting medical students and early management of their own patients, with support from senior physicians, are the main leadership goals of these first two ward experiences.
In the final months of the foundation stage, the third ward block shifts the focus from leading an individual student and one’s own patients to leading a team. Just before this block, an annual preparatory one-day case- and simulation-based “transition to senior” workshop facilitates development of skills for those moving to a senior role as ward team lead and overnight senior on-call resident. For the first half of this third block, the resident continues as a foundation resident, but closely observes the “core” resident’s management skills and interactions with others. In the latter half, the roles are reversed. The foundation resident takes on the role of team leader, while the core resident takes on the duties of the foundation resident, but provides support through coaching feedback and as a resource. The transitioning resident is further supported by faculty.
On-call leadership consists of a two-week “night float” block during which the foundation resident screens patients in the Emergency Department, reviews cases with junior learners, and manages the three teams caring for up to 75 patients. During the first three overnight shifts, the foundation resident is buddied with a core senior resident who provides graded supervision. As reflected by a recent graduate: “This style of leadership training is very effective as we [residents] are able to develop our skills very early on, and have the benefit of one-on-one mentorship from senior residents who have already gone through the process.”
At the end of these two transition rotations, a comprehensive assessment of each resident’s readiness to move to the core stage determines further progress. Top
Core of discipline
As residents transition from their junior role into the senior (core) period in years two and three of the four-year program, responsibilities evolve to more independent practice with continued faculty support. Residents refine existing skills to achieve results4 and begin to evaluate system transformation. Pediatric residents rotate as ward team leaders for four months and develop skills across many domains, including guidance of junior learners (including those in difficulty), prioritization and triage of responsibilities, and professional communication, while solidifying skills needed to provide comprehensive care to pediatric inpatients.
Scheduling of these rotations is intentionally spread over two years with the first ward senior rotation often coordinated with a fourth-year transition-to-practice junior attending, who provides additional guidance and role modeling, along with the faculty. The fourth and final ward rotation, at the end of third year, is deliberately arranged with a first-year resident, so that the core resident can provide high-level mentorship with faculty guidance.
During these core years, residents receive dedicated and structured learning opportunities to advance clinical leadership through courses such as “Advanced trauma life support,” “Pediatric advanced life support renewal,” and “Trauma resuscitation in kids,” the latter facilitating exposure to intense, high-fidelity simulation along with debriefing experience and further training in team dynamics.
Monthly mock codes occur, with leadership by one of the three ward senior residents and collaboration with other health care professionals. Each mock code scenario is written by the current Pediatric Intensive Care Unit (PICU) residents and reviewed by PICU and pediatric emergency preceptors. Real-time review, assessment, and debriefing are carried out by both nursing and physician evaluators, including the resident authors. A second monthly simulation opportunity is organized by a resident-led simulation committee and facilitated by faculty.
As in the first year of training, residents continue to participate in at least two committees. Junior–senior resident pairing on these committees allows for continuity in skill development as well as peer mentorship and coaching. On a monthly basis, residents lead colleagues in reviewing articles during journal club sessions. Deliberate engagement of faculty and residents around mentorship occurs informally and formally, including annual retreats as well as twice-yearly mentoring sessions hosted in a faculty home to discuss career planning and provide guidance.
An annual group advocacy project engages all third-year residents to directly impact an important pediatric health issue. This project allows for a higher level of collaboration, both within the resident cohort and the community, with a timeline designed for residents to advance from idea to completion within one year. By stepping into the wider public, each resident begins a journey in community leadership. One recent participant remarked how this initiative provides “real growing experience to move outside of the hospital and meet with community groups, government and the media.”
Transition to practice
The final year of residency brings together accumulated skills with an emphasis on critical thinking and knowledge synthesis vital to successful independent practice. Thinking outside the hospital environment, residents explore developing coalitions4 and how to transform4 the health care system. The university’s office of postgraduate medical education supports an annual seminar in practice management, sponsored by the Canadian Medical Association/Joule. Numerous opportunities for leadership include collaborative organization of an independent study curriculum for the Royal College certifying examination. Top
All final-year residents rotate through the ward as a junior attending (JA) for two weeks, during which they oversee the ward team and are responsible for attending-level tasks. The JA takes 24-hour home call for 10 of the 14 days on rotation and receives the first call for all existing and new patients, with faculty providing continual support as well as retaining ultimate responsibility for patient care. JAs are coached and assessed on their ability to fulfill the expected role at the level of a consultant pediatrician.
To further foster leadership development, Continuity Clinic occurs as a 12-month longitudinal experience from the end of third year to the end of fourth year. For one half-day a week, residents attend a general pediatrics outpatient clinic, with a designated preceptor. Goals of Continuity Clinic include gaining proficiency in all responsibilities associated with carrying out a community pediatric practice. Real-world experiences require balancing clinic flow and patient satisfaction with increased efficiency and judicious management of resources and consultants. Exposure to administrative tasks incorporates the complexity and leadership challenges of office practice management.
Leadership development of selected residents
In addition to this exposure for all residents, two residents are selected each year to function as chief residents for one year starting toward the end of their core training. Chief residents play a vital role in hospital functioning and the administration of the pediatric postgraduate program, in part by active participation on many hospital committees and regular meetings with residents, program directors, and the department head. Administrative tasks include organizing various teaching, managerial, and leadership responsibilities. With the support of the program directors, chief residents problem-solve on a daily basis. During this year, each chief resident is also expected to take on a project to advance pediatric resident education.
These longitudinal experiences are further enhanced through the annual 2.5-day Canadian Pediatric Resident Leadership Conference, which focuses on collaboration and leadership skills. Past attendees have primarily included chief residents in core programs across Canada, but recent and current conferences also involve subspecialty residents. The upcoming 2018 conference will co-locate with the annual International Conference on Residency Education, which has a resident-specific stream for leadership development.
Enablers and challenges
The Department of Pediatrics strongly promotes leadership in many ways, including provision of protected time for residents, dedicated time for faculty endeavours, funding for administrative costs for the ASK rotation and the health advocacy project, and financial support for additional leadership programs, such as the annual Canadian Pediatric Resident Leadership Conference. The program directors and faculty have a culture of valuing leadership education and mentorship; a monthly Pediatric Medical Education Interest Group was established to develop faculty (and residents) as teachers and leaders.
As a key theme of the department, mentorship integrates resident and faculty programming. An annual departmental fund of $10,000 supports broader activities through a competitive application process, and the university dean’s office provides prioritized funds for faculty toward educational and leadership development.
As described above, all residents benefit from active coaching in their process of becoming leaders. Residents are given feedback midway and at the end of each rotation on their leadership ability, including suggestions for advancement. Leadership is also reviewed and promoted at semi-annual meetings with one of the program directors.
Although our culture is supportive of leadership development, there are still areas requiring further work, such as interdisciplinary and interprofessional learning and teaching opportunities. The upcoming implementation of competency-based medical education (CBME) will require integration with national standards. However, our longitudinal competency-based and integrated leadership curricula should be easily adapted to this new model. We expect further enhancement of expected outcomes and processes will occur during adoption of CBME, where leading teams is a defined activity and expectation. Measurement of our processes and outcomes is still in early development.
Conclusions and next steps
The topography of pediatric postgraduate leadership education at the University of Manitoba is both robust and effective, with widespread support by engaged learners and teachers a key factor in its success. The integrated use of CanMEDS competencies5 with the LEADS framework4 provides a scaffold for curriculum development and design. Implementation of ongoing collaborative approaches with other disciplines and health care professions continues.
Ensuring leadership training and opportunities for application to all residents, while adapting programming to meet individual learning trajectories in a CBME environment, requires further refinement. As the landscape of leadership education continues to shift with development of more undergraduate leadership education programs around Canada and the world, these changes will influence the postgraduate (and faculty) milieu. Training the teachers as well as conducting program evaluation of our processes and outcomes must be a priority to ensure ongoing support and sustainability.
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No funding was provided for this paper. There are no conflicts of interest.
The authors attest that they all approved the final version of the article. Ming-Ka Chan took the lead in organizing and developing the overall concept of the paper, developed the section on enablers and challenges, and provided overall edits. Celia Rodd wrote the section on the ASK curriculum and provided overall edits. Elisabete Doyle wrote the sections on transition to discipline and foundation (PGY1) residents and provided an overall review. Eleanor MacDougall wrote the mentorship program section and provided an overall review. Jenette Hayward contributed the resident (recent graduate) perspective on leadership teaching in the residency program and provided an overall review. Karen Gripp wrote the sections on core (PGY2-3) and transition to practice (PGY4) residents and provided overall edits.
All six authors are with the Department of Pediatrics and Child Health, Max Rady College of Medicine, at the University of Manitoba.
Ming-Ka Chan, BSc (Psych), MD, MHPE, FRCPC, is director of education/faculty development. Her interests include leadership development in health care, feedback/assessment, competency-based medical education, transitions in the education continuum, and program evaluation.
Celia Rodd, MD, MSc, FRCPC, is an associate professor in pediatric endocrinology at the University of Manitoba and a researcher at the Children’s Hospital Research Institute of Manitoba.
Elisabete Doyle, BSc, MD, FRCPC, FAAP, is director of pediatric postgraduate medical education and assistant professor in the section of pediatric emergency medicine.
Eleanor MacDougall, MD, FRCPC, is assistant professor in the section of community pediatrics.
Jenette Hayward, BSc, MD, FRCPC, is lecturer in the section of rehabilitation and complex care.
Karen Gripp, BSc, MD, FAAP, FRCPC, is director of pediatric postgraduate medical education, chair of Canadian Pediatric Program Directors, and an assistant professor in the sections of pediatric emergency and pediatric hospital medicine.
This article has been peer reviewed. Top