The “high-performance physician” course, originally designed by Dr. Cal Botterill and colleagues for a research study with multiple stakeholder support,16 has evolved into a longitudinal program. This program supports leadership development by providing skill building and personal growth opportunities learned from performance psychology with “strategies to increase focus at work, improve recovery from stress, and sustain personal and professional performance.”17 Workshops have been designed and contextualized for different audiences and time-frames, including those given at Doctors Manitoba and in various university departments. Leadership-building competencies have been focused primarily at the postgraduate level, such as regular integration into the emergency residency curriculum,18 but many faculty have also participated, with positive feedback.

Physician leadership development: University of Manitoba’s landscape across the educational continuum

Ming-Ka Chan, MD, Debrah Wirtzfeld, MD, Aaron Chiu, MD, Shaundra Popowich, MD

The need for professional leadership development in health care is growing. Such development must start early in training and continue throughout the life cycle. In this case study, we review the numerous physician leadership education opportunities at the University of Manitoba, highlighting some exemplars and discussing enablers and challenges. Local, regional, national, and international opportunities exist for core development for all students and residents as well as enhanced leadership education. Although faculty have rich opportunities for leadership development, there is no mandated curriculum. Interprofessional learning opportunities are desirable and need further development. The diversity and breadth of leadership education for medical students, residents, and faculty are encouraging and the academic culture is supportive. Continued momentum to harness engaged learners and faculty is needed with priority on enhancing formal curricula, training the trainers, and developing widespread opportunities for experiential learning and application. Processes and outcomes need to be reviewed to understand the return on investment and allow for ongoing support and sustainability.

KEY WORDS: leadership development, education, curriculum, LEADS, medical students, residents, faculty

Leadership development for physicians and health care professionals has been identified as a growing need and part of the educational mandate around the world.1 The Future of Medical Education in Canada (FMEC) reports for both undergraduate2 and postgraduate3 learners specify that leadership development must start early and continue throughout professional life.

At the Max Rady College of Medicine, University of Manitoba, the medical leadership development program is based on the premise that the acquisition of competencies and capabilities occurs along a continuum from undergraduate to postgraduate to faculty level. Curriculum planning centres, in part, around the debate about the need for “leadership education for all” versus “leadership education for some,” and examples of both sides of the debate are apparent at our institution. The need for collaborative leadership, highlighted by both FMEC reports,2,3 leads to the idea of developing leadership among multiple health care professionals and learner groups. We are in the early stages of such development, collaborating with other health care professionals by sharing resources and/or teachers and providing a small sampling of interprofessional leadership learning opportunities.

In this paper, we highlight the formal curricular opportunities offered to medical students, residents, and faculty at the University of Manitoba. Opportunities may be episodic or longitudinal and, although most are face to face, online sessions are also available. Although not explicitly discussed, we recognize that experiential learning and application along with feedback and mentorship are also important facets of lifelong leadership development.

The undergraduate medicine leadership landscape

The undergraduate program begins in the first year with mandatory sessions for all medical students, which carry through to the third year of the four-year program. This graduated curriculum supports students as they develop capabilities in the first two components of the LEADS framework: Lead self and Engage others.4 The curriculum focuses on the intersection between the LEADS framework4 and a model5 that suggests that leadership behaviours arise from a combination of mental models of leadership, leadership skills, and leadership style (Figure 1). To build on this core curriculum, a limited number of students also have an opportunity to participate in an intense fourth-year leadership selective (see Appendix) emphasizing the Developing coalitions and Systems transformation parts of the LEADS framework.4 Other formal and informal opportunities arise through student engagement in initiatives in and outside the university. Some local opportunities include medical student governance, leading student interest groups, and curriculum renewal endeavours.

National initiatives include Students and Trainees Advocating for Resource Stewardship (STARS) in collaboration with Choosing Wisely Canada,6 as well as the collaborative efforts of the Canadian Federation of Medical Students and the Fédération médicale étudiante du Québec to develop a policy paper on advocacy and leadership in Canadian medical school curricula.7 Although all of these opportunities provide informal mentoring and experiential learning opportunities, some, such as the STARS initiative, incorporate formal leadership training through their annual one-day summit.

In the international arena, opportunities exist through resources and work with groups, such as the International Federation of Medical Students’ Associations, which recently launched a Social Accountability in Medical Schools campaign.8

Undergraduate core curriculum

The core curriculum is based on the premise that all medical students should be aware that they are perceived as future leaders. An introduction to leadership in the medical profession, self-awareness, engaging others, and conflict management are essential to this mandatory part of the longitudinal leadership curriculum. There is an emphasis on leadership behaviours in physicians, being the culmination of a distributed leadership mental model on which individual styles and strengths are layered.

An important aspect of this curriculum is that leadership behaviours must be modeled by every physician, not just those who assume a named leadership position. It is based on the “five levels of leadership” model, proposed by John B. Maxell, which emphasizes that “positional leadership is the lowest level of leadership.”9 Teaching faculty come from a variety of medical disciplines as well as from the business school.

Undergraduate selective opportunities

Students with an interest in increasing their focus on leadership development are invited to participate in activities that will broaden their exposure to medical leaders in the health care system and the development and implementation of a business plan focused on health care transformation. Each year, three to six fourth-year (final year) medical students are invited to participate.

The objectives for the three-week selective are to identify important attributes of successful modern day medical leaders; to describe one historical medical leader and his or her contributions to the medical field; to gain greater personal insight into emotional intelligence and areas for leadership improvement through the EQi-2.0 leadership scale; and to gain familiarity with the leadership literature (Appendix).

Most important, each group of students comes together as a team to identify a critical issue in health care and develop a business plan (including requests for funding and identification of relevant positive and negative stakeholders). The business plan is presented to the Board of Doctors Manitoba (Manitoba’s medical association), who must be convinced that the plan can be appropriately implemented and outcomes successfully measured before releasing the necessary funds.

The postgraduate medicine leadership landscape

Through the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada (CFPC), all Canadian residency programs use the CanMEDS10 (Canadian Medical Education Directions for Specialists) physician competency framework, which defines seven physician roles. This framework highlights leadership in a number of ways including a role name change from Manager to Leader in 2015.11 Leadership and management competencies are key components of the Leader role, along with those for patient safety/quality improvement and resource stewardship. As a result, leadership education is seen as a core requirement for residency education and there is momentum to continue to build and expand existing curricula. Top

Most formal postgraduate leadership development activities are offered primarily within a discipline or specialty, although some are designed for interdisciplinary learning. Most activities are implemented at a local level and, as for the medical student examples, there are formal and informal opportunities for additional experiential learning. Regional, national, and international opportunities are also made available through participation in the core or task specific work in specialty organizations, professional societies, medical associations, education associations (e.g., RCPSC, CFPC, the Canadian Association for Medical Education, the Association of the Faculties of Medicine of Canada, or the Medical Council of Canada), or conferences, such as the International Conference on Residency Education (ICRE). The latter offers a variety of opportunities, such as ICRE chief resident roles, participation in planning committees, as well as a specific stream of formal sessions for resident leadership development.

Core curriculum and discipline-specific opportunities

Interdisciplinary opportunities exist within the core curriculum for all residents and include online and/or face-to-face sessions covering a variety of topics within the LEADS4 domains, such as feedback, conflict negotiation, and practice management. These sessions are offered through the central postgraduate office. Additional opportunities to build on learning at these core events are encouraged within the individual residency programs.

Within a discipline, one model of formal leadership education for all residents includes the “transition to senior” workshops, such as those offered in pediatrics.12 These workshops focus on the development of leadership (specifically Leading self and Engaging others),4 management and teaching skills of all residents transitioning to a senior role on call and as team lead on the wards. This annual one-day event is part of a longitudinal graduated experiential curriculum that prepares residents (from the lens of different CanMEDS roles10) to become a “senior.” The formal longitudinal components include monthly mock resuscitations or codes, “buddied” call, where new seniors are paired with a more senior resident, as well as two weeks as “acting senior” during their final ward month. Ongoing peer and faculty mentorship also provide some of the needed support to develop as good team leaders and followers (as appropriate to the context).

A strategy to develop leadership in the Achieve results and Develop coalitions domains4 is through a group advocacy project that has been completed by each third year (of four years) pediatric resident cohort since 2009. Through this endeavor, the residents collaboratively lead an initiative to advocate around a health issue for pediatric patients and their families.

Since 2014, faculty and learners from the university have also collaborated internationally to develop open-access online leadership education modules, which integrate the CanMEDS10 competencies with the LEADS4 leadership framework (available at www.sanokondu.com). Each case-based module can be adapted for local contexts and can be used for single or multidisciplinary teaching/learning. Five of these modules have been modified for local general surgery residents and delivery started in fall 2017.

Enhanced leadership education for some residents

Chief resident development has been a long-standing commitment at the University of Manitoba. Pediatrics has over 16 years of experience at the national level, which includes an annual 2.5-day conference in Winnipeg. The surgery department had also provided a conjoint surgical specialties chief resident development program for over five years with various models, ranging from a half-day session to a 1.5-day event. Other programs, such as internal medicine and psychiatry, send their chief residents to development programs that are run in Canada or the United States.

The Physician Leadership Institute (PLI) sessions offered through Joule/Canadian Medical Association (CMA) have been used by residents to continue to enhance their skill sets, with some online courses developed specifically for residents. Others have taken advantage of the diverse opportunities available to faculty, which are described below. Certainly, the development of the clinician investigator program at the university has offered additional salary support to residents and provided opportunities to those who wish to pursue formal master’s or PhD-level training in leadership education or other programs. Top

The faculty leadership education landscape

The process of lifelong learning and continuing professional development is complex for faculty. Designed to use reflection, self-assessment, and feedback, ongoing faculty development is typically self-identified and designed. Although there are currently no mandated educational activities for faculty (including specifically for leadership and management development) at this university, a range of leadership/management education opportunities are championed and promoted at the departmental and other levels.

Significant improvements have been made in more formalized longitudinal leadership development opportunities for faculty at the University of Manitoba through the George and Fay Yee Centre for Healthcare Innovation (CHI),13 originally formed in 2008. In 2011, further evolution of the centre in partnership with the Winnipeg Regional Health Authority, University of Manitoba, and Government of Manitoba led to the launch of an Academic Health Sciences Leadership Program which began its seventh iteration in fall 2017. This programming was a critical advancement to the leadership development milieu, given further evidence suggesting that “when physicians actively and effectively participate in leadership roles, they can improve health care system quality outcomes.”14 Attendees include current and aspiring leaders in medicine and the other health care professions. The faculty are also interprofessional by design.

In addition, CHI has facilitated several targeted leadership education sessions annually including Crucial Conversations15 and in-house versions of PLI courses (a longstanding professional development resource that provides a longitudinal curriculum built on LEADS4) since 2013. Doctors Manitoba (through the endeavors of the Health and Wellness committee) offers an additional PLI session each year. Through these various initiatives, the CHI and Doctors Manitoba have helped create critical networking exposure to further shape the evolution of a multidisciplinary/multiprofessional collaborative culture for a group of health care professionals, who tend to be siloed by the intensity and nature of their work.

The “high-performance physician” course, originally designed by Dr. Cal Botterill and colleagues for a research study with multiple stakeholder support,16 has evolved into a longitudinal program. This program supports leadership development by providing skill building and personal growth opportunities learned from performance psychology with “strategies to increase focus at work, improve recovery from stress, and sustain personal and professional performance.”17 Workshops have been designed and contextualized for different audiences and time-frames, including those given at Doctors Manitoba and in various university departments. Leadership-building competencies have been focused primarily at the postgraduate level, such as regular integration into the emergency residency curriculum,18 but many faculty have also participated, with positive feedback.

Longitudinal development through graduate programming, such as the master’s in leadership degree at Royal Roads University or master’s in business administration offered at the University of Manitoba as well as attendance at annual education conferences or Canadian Society of Physician Leaders meetings, also round out opportunities for faculty (and learners). Indirect leadership education through other masters’ programs, such as master’s in education, also occur. Top

Other Canadian opportunities to develop core leadership competencies include the University of Toronto’s Newly Emerging Academic Leaders longitudinal program and the Canadian Leadership Institute for Medical Education, an annual four-day event offered in English or French by the Canadian Association for Medical Education. Numerous international offerings, at a discipline specific or interdisciplinary/interprofessional level, are also available; these can be offered by field-specific organizations, e.g., Canadian Blood and Marrow Transplant Group, or through medical education conferences, e.g., ICRE, where CanMEDS Leader Role sessions are always part of the programming.

Enablers and challenges

Facilitating factors at an institutional level include a College of Medicine wide mandate for leadership development, as well as supports at the department or section level. The physician leadership development curriculum committee, chaired by one of us, brings together a cross-disciplinary membership of physicians passionate about advancing leadership development, many of whom are engaged on a broader scale, such as through the provincial medical association’s health and wellness committee. The mandate is multifaceted, but includes efforts to consolidate, communicate, and assist implementation of leadership education opportunities that provide a more strategic alignment of curriculum across the spectrum of learners from undergraduate to faculty.

The crucial partnerships formed between the university and such stakeholders as Doctors Manitoba and the CHI represents a transformative commitment to advance interdisciplinary opportunities for leadership development, including subsidization of participant fees for annual leadership education events. There are also learners and faculty who are highly engaged in leadership education and its scholarship on local, national, and international platforms.

Coaching and mentorship form a strong facet of our medical community at all levels from undergraduate through to faculty. Opportunities exist at an individual and group level and include formal programming to support mentor and mentee development at the university and through Doctors Manitoba. Peer and more senior mentor support are both valued and encouraged within and outside the discipline or geographic site. Because much of the curricula for undergraduate, postgraduate, through to faculty level are based on the LEADS4 model, this alignment is beneficial as faculty and learners can prepare themselves as leaders and for the teaching of leadership to learners at all levels.

Challenges include the need to tailor to an individual’s or cohort’s learning needs as well as ensuring that workplace-based leadership teaching is supported and developed, given the pivotal role these experiences play in leadership development.19 Reframing some of the innumerable challenges physicians address daily as opportunities for professional growth continues to provide development consistent with goals in the local context, while integration of these experiences can remain difficult for individual learners. The fragmented nature of such experiential learning as well as variation in opportunities across disciplines, coupled with additional barriers, may partly explain why health care leadership development continues to stagnate behind societal changes including “the transition from leadership based on the power and role of iconic individuals to leadership residing in networks of people.”20

Specific funding to support leadership education for both learners and teachers is also a precious and limited resource. Collaborations between the health care disciplines and professions must be developed further with greater momentum.

Finally, comprehensive program evaluation strategies to measure the return on investment and look at our processes and outcomes have just started with, for example, development of a national pediatric chief resident feedback tool. This program evaluation needs to expand to ensure the effectiveness and sustainability of our leadership education programming. Top

Conclusions and next steps

Leadership education is an ever-changing but rich landscape for undergraduate, postgraduate, and faculty learners. Widespread support is a key factor in the success of leadership education at the university and includes engaged learners and teachers. Broader collaboration between disciplines and professions locally, nationally, and internationally is the aspiration. Ensuring equal opportunities tailored to meet individual learning trajectories in a landscape of competency-based education remains to be navigated.

Furthermore, we recognize that leadership education will need to continue to acclimate as more undergraduate leadership education programs develop both within Canada and beyond, thus influencing the postgraduate milieu. Faculty development will have to evolve further to ensure better alignment with advancements in both the undergraduate and postgraduate curriculum, without which we will be unable to ensure the transition of these theoretical frameworks into an empirical skillset that is applicable to all in the health care context. Integration of contextual leadership development opportunities along the educational spectrum using a robust leadership framework remains an aspiration.

In addition, the need to implement more rigorous methods for evaluation along the educational spectrum remains a challenge shared with other institutions19 that must be addressed to support the return on investment required for further advancements in the future. Top

Appendix: Components of the core curriculum and opportunities for selected medical students

Year 1 core curriculum: what is leadership – framework development, self-awareness, and building diverse, successful teams

Goals

• Define leadership and discuss the importance of physician leadership to the health care system
• Develop a framework for results-oriented leadership that incorporates LEADS
• Gain familiarity with the LEADS framework for medical leadership
• Recognize what it means to Lead self through the administration of a personality inventory
• Engage others/Achieve results through a focus on using the personality inventory to gain self-awareness, appreciate differences between individuals, and build successful, diverse teams

Components

• Introduction to leadership using LEADS framework – 1 hour
• Myers-Briggs type indicator: Introduction to leading self through increasing self-awareness of type and recognizing that differences between individuals adds to the diversity and strength of the group – 2 hours
• Myers-Briggs type indicator: Emphasis on building successful teams and fostering the development of others (Engage others and Achieve results) through an appreciation of differences between team members – 2 hours
• Team-based assessment: Completion of a team-based evaluation of preparation, participation, and cohesion following each of 20 sessions of self-directed clinical reasoning sessions over 2 years in a team with stable membership

Year 2 core curriculum: how to lead – appropriate leadership styles and leading by influence

Goals

• Define leadership styles and appropriateness in different settings
• Understand what it means to lead from a position of influence rather than a named leadership position

Components

• Leading by influence and leadership styles: Collaboration with the Asper School of Business, University of Manitoba, to define leadership styles, important roles in a team, and how to lead from a place of influence – 3 hours

Year 3 core curriculum: leadership in difficult times – conflict management

Goals

• Define conflict
• Identify conflict within a group or team
• Understand the importance of early identification of conflict
• Communicate effectively during conflict
• Identify resources available to medical students to continue to develop leadership

Components

• Conflict resolution lecture and panel discussion with faculty and residents who have a preference for different conflict-resolution styles – 3 hours with leadership psychologist

Year 3 selective leadership project

Target students: Third-year medical students who self-identify as future leaders and who are interested in health system transformation

Goals

• To identify important attributes of successful modern day medical leaders (LEADS)
• To detail one historical medical leader and his/her contribution to the medical field (LEADS)
• To gain greater personal insight into emotional intelligence (EI) and personal leadership strengths and areas for improvement through use of the EQi-2.0
• To develop a team-based business plan for a critical issue in health care, including presentation of the proposed approach to the Executive Board of Doctors Manitoba for their approval and potential funding (Develop coalitions, Systems transformation)
• To gain familiarity with the leadership literature through a journal club format (LEADS)

Components

• Review session on leadership – definitions, theories, importance of physician leadership
• Introduction to community medical leaders who will speak about their individual leadership journey, including strengths/weaknesses and the importance of influence and team-based leadership
• Each participant will choose a historical medical leader and present a 20-minute talk on attributes that lead to potential successes and failures based on LEADS format
• Use of the EQi-2.0 to assess areas for further self-development as leaders
• Working as a group, students will develop a business plan around the topic “How to get medical students more involved in the functions of Doctors Manitoba” (this business plan will be presented to a representative Board of Doctors Manitoba for discussion and potential funding)
• Participation in three journal clubs on physician leadership Top

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Acknowledgements

The authors acknowledge Ms. Margaret Shiels for her work in administering the Leadership Development Curriculum Committee at the Max Rady College of Medicine, University of Manitoba.

Author attestation

No funding or sponsorship was provided for the development of this paper. There are no conflicts of interest.

Ming-Ka Chan took the lead in organizing and developing the overall concept of the paper with emphasis on content development of the section on postgraduate leadership education. She also worked on the section on enablers/challenges and overall integration of the paper. Debrah Wirtzfeld took the lead in the description of the undergraduate leadership development program and overall review of draft and final versions of the manuscript. Aaron Chiu helped to develop the concept of the paper and reviewed draft and final versions of the manuscript. Shaundra Popowich took the lead in developing the continuing professional development section and helped develop the enablers/challenges section. She also provided an overall review of draft and final versions of the manuscript. All authors approved the final version of the article.

Authors

Ming-Ka Chan, MD, MHPE, FRCPC, is a clinical educator and associate professor (pediatrics) and director of education and faculty development, Department of Pediatrics and Child Health, and assistant director, International Medical Graduate Program, Max Rady College of Medicine, University of Manitoba.

Debrah Wirtzfeld, MD, MSc, FRCSC, FACS, CCPL, CEC, ICD.D, is a professor (surgery) and regional lead, general surgery, University of Manitoba and Winnipeg Regional Health Authority, and director, Leadership Development, Max Rady College of Medicine, University of Manitoba.

Aaron Chiu, MD, FRCPC, FAAP, MBA, ICD.D, is an associate professor (neonatology), associate dean, Quality Improvement and Accreditation, and director, Manitoba RSV Prophylaxis Program, Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba.

Shaundra Popowich, MD, FRCSC, MBA, is an ssistant professor and program director (gynecologic oncology), Department of Obstetrics and Gynecology, Max Rady College of Medicine, University of Manitoba. Top

Correspondence to:

Ming-Ka.Chan@umanitoba.ca

This article has been peer reviewed.