Curriculum Implementation for Leadership and Teamwork: Medical Students

Objective: Today’s health care system requires the need for primary care physicians to develop leadership competencies. In this study we aimed to describe a medical leadership and teamwork course in undergraduate medical curricula and to share the feedbacks of students. Methods: This descriptive study was performed at a medical faculty. An elective medical leadership course was developed for the fifth academic year. The curricular format as well as learner and instructor types were presented. A quantitative and qualitative analyses of the data were performed between 2012 and 2015. Results: Total 537 students (62.9%) selected the medical leadership course. The quantitative analyses comprised students’ feedback for the course, while the qualitative part comprised their opinions. Many students provided open-ended responses regarding their opinions about the medical leadership course. Conclusion: There is necessity of leadership courses in undergraduate medical curricula. Students recognized the need to develop leadership competencies. We believe that this multifaceted approach can also be implemented using more innovative designs by involving other stakeholders and relevant professional resources to ensure high-quality outcomes on course completion with long-term assessment after graduation. voluntary selection and of by indicates regarding the of in the medical recognized to develop competences. Traditional medical school curricula and doctor models do fulfil the requirements of today’s medical system. The present findings will help future development of leadership training programs in medical education curricula. In addition, undergraduate education provides an ideal setting for postgraduate medical programs and for laying the foundation for leadership competencies.


INTRODUCTION
There is growing evidence acknowledging the need for doctors to develop leadership and teamwork competencies for high-quality care and they have a significant importance to today's healthcare organizations (1). Medical leadership is the ability to motivate and direct fellow healthcare professionals to work toward best patient outcome and community healthcare (2). While few people are 'natural' leaders, some leadership skills can be taught, and many skills develop with experience, reflection, and guidance. Although some methods are developed for specific conditions, pilot trials followed by fine-tuning are required for developing and establishing general leadership guidelines (2). Healthcare organizations experience leadership and teamwork challenges because of several reasons. These include the following:  Healthcare organizations are complex and involve a random collection of several professional establishments and financial institutions.  A new organizational change is needed to create and effective teamwork among multi discipliner team member.  The learning and mastering of technical skills are prioritized over the development of leadership skill for physicians.  Issues involving access, affordability, and high-quality care appear more important than focusing on healthcare leadership (3). As mentioned previously, the physicians working within this system must be knowledgeable and skilled with respect to team and leadership dynamics and be aware of the culture and functions of the healthcare organization. A physician's professional education should include the basic concepts of team structure and function as well as the concepts of effective leadership (4,5). Medical schools are entrusted with the responsibility of training physicians to be diagnosticians and understand resource management, financial considerations, and multiprofessional team working (1). Academic health centres or medical schools' hospitals are expected to "develop leaders at all levels who can manage the organizational and systems changes necessary to improve health through innovation in the health education of healthcare professionals, patient care, and research'' (6). Although the faculty and students recognize the importance of leadership training (7,8), the specific values, resources, and practices required for making leadership training a part of the curricula of undergraduate medical education are not defined (6). In 2008, the School of Medicine in Leeds developed a new curriculum that included leadership training, which was structured as a "spiral curriculum" (9). In 2004, the Wright State University Boonshoft School of Medicine (BSOM) initiated a separate leadership curriculum that was integrated with business management or public health education at an early stage of clinical education (10). At the Duke University School of Medicine, the Duke Leadership and Education and Development (LEAD) program, a student-initiated, four-year longitudinal leadership curriculum was introduced for all first-year medical students during the 2013-2014 academic year (11). Queen's University in Canada conducted a study in order to determine the family medicine residents' opinion on leadership according to CanMeds roles (12). However, to the best of our knowledge, there is no formal leadership program in the curriculum of the medical education in Turkey. Further, only one survey conducted on a limited number of students has emphasized the need for leadership training (13). Our aim and conceptual framework is based on the assumption that leadership in healthcare can be developed and taught. Therefore, this program is the first clerkship programme named, 'Leadership in Medicine' in Turkey since 2012. The purpose of this study was to describe the formal curricular content of medical leadership and teamwork course and to obtain student feedback regarding the initial implementation of this course.

SUBJECTS and METHODS
We used a mixed methodology, combining the quantitative and qualitative techniques for evaluating the survey. A quantitative as well as qualitative analyses of the data regarding students' feedback were performed between 2012 and 2015. Our institution, the -X-University Faculty of Medicine, offers a 6year educational programme. During the fifth year, there are compulsory and elective clerkships.
An elective medical leadership course was developed for the fifth academic year of medical school. The curricular format as well as learner and instructor types were presented.In compliance with the needs of the leadership course, 4 faculty members from different departments of the medical school (Medical Education, Obstetrics & Gynaecology, and Nuclear Medicine) initiated this elective clerkship within the existing medical school curriculum. Moreover, as part of the curriculum, guest lecturers from the Turkish Medical Association (TMA), representatives of the World Health Organization (WHO) country office for Turkey, and a physician Parliamentarian/Representative (who were not formal faculty members) were invited as speakers. The faculty for this clerkship formulated the directives and accepted the responsibility of implementing the clerkship program during the fifth academic year.

Clerkship syllabus
The duration of this elective course was 5 business days, and each group comprised 15-20 students. The syllabus of the course is presented in Table 1. The aim and the learning objectives of the course were as follows: Aim: To ensure that on completion of the course, grade 5 students are able to recognize the value of leadership and its components while practicing medicine.

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Learning Objectives: On completion of this elective course, the term 5 students should be able to: • Categorize the differences between a leader and an administrator • Analyse the relationship between leadership and medicine • Explain the importance of teamwork in healthcare services • Criticise the components and characteristics of a team and teamwork • Analyse crisis management • Use the steps involved in problem solving • Realize the concept of health management • Realize the initiative and components of personal leadership • Make a presentation We provided the clerkship files to students on the first day of the training. The final grades of the students were calculated by averaging the scores of the written examination and the presentation skills demonstrated in explaining a leadership topic on the last day of training. The data regarding the number of fifth-year students, students who selected the course, and those who completed the feedback form, according to each year of the study have been presented in Table 2. The participants gave their feedback on the last day of the training program after the written exam. The form included questions regarding all the theoretical and practical components of the course. The participants were asked to respond to the questions using a 5-point Likert scale. As we presented the educational programme of leadership clerkship and feedbacks about it Ethics Committee approval did not require. Oral informed consent was obtained from all the study participants. SPSS v.20.0 for Windows (Chicago, IL, USA) was used for the statistical measurements. The data was expressed as percentages and mean scores.

Quantitative results
At the end of each training session, feedback was collected and 275 (51.2%) of them were men. Total 62.9% of the subjects selected the training clerkship as an elective from among all the offered clerkships (Table 2). With respect to the learning method, the students gave the highest score of 4.4 to "managing yourself", 4.3 to "teamwork", crisis management and TMA (Turkish Medical Association). In terms of contribution to the profession, they gave the highest score of 4.6 to the Ministry of Health (MOH) and 4.5 to the deputies. Expectation had the highest score in terms of satisfaction with 4.4 taking managing selflessons ( Figure 1).

Qualitative data (open-ended opinions)
Many students conveyed their opinions about the medical leadership course via open-ended responses. For example, one student stated: "I think that the practical foot of this clerkship is very useful and very preliminary in terms of our professional life. At the same time, I was very pleased to express ourselves and make it possible for us to direct the lessons. This clerkship contributed greatly to expanding my horizon in terms of productivity for me. "(Female, 22age.) Confidence and modest attire were cited as an important quality in a physician for leadership. As one student commented: "This was a particularly nice elective. I received more than I initially expected. May be I will never find the same opportunity of this reflection again. It was a good experience to discuss our problems with the professional medical people in person. The elective was a very productive term. Thank you. I also did not have an intention on leadership at the beginning, but now I really think I can improve myself in that direction. Thank you for your contributions to this awareness." (Male, 23age.) "Ability to work with others in a team" is an important leadership skill. As outlined by one of the participants: "This elective was very/quite? different from our other clerkships. I always thought that one person would be designated to be the leader. Now I believe that I can be the leader in any venue if when I need to. I also noticed how important the concept of leadership and teamwork is in medicine …. With this clerkship, I made a journey within myself and left positive effects on me. I think it would be beneficial for the clerkship to be offered in earlier years of medical education." (Female, 23age.) Another student reported more active participation as follows: "It would be more beneficial to get technical information and to learn how to function rather than just sitting in the places where they are going. The Ministry of Health and Ministry of Development may be also included ? the .evaluation of the procedural bureaucracy in health system. Apart from that, I was very satisfied with this clerkship.
Thank you." (Female, 22 age). An opinion that led to awareness of leadership was as follows: "I did not know that the concept of leadership was so important and effective for our profession.

DISCUSSION
There are very limited studies on leadership curricula and interventions are delivered in a wide variety of formats, and these have lack of standardization (5)(6)(7)(9)(10)(11). As per the current medical curricula in Turkey, not all medical schools offer leadership as an elective course. However, all the students who chose this elective benefitted from the course in one way or another. Several medical education programs focus solely on the education of management principles and practices (16)(17)(18). Although management is a basic component of leadership education, certain other skills are also considered important, such as motivating others, human resource management, budgeting, communication, relationship building, teamwork, and negotiation (19)(20)(21)(22). As Sen (23) stated, "Human development is defended as a goal in itself; it directly enhances the capability of people to lead worthwhile lives, so there are immediate gains in what is ultimately important, while safeguarding similar opportunities in the future. There is hardly any example in the world of the expansion of education and health being anything other than monotone: good education and good health seem to generate powerful demand for these opportunities (and more) for our children".
During the last decade, the importance of leadership training for medical students has been increasingly recognized (4,(24)(25)(26)(27)(28)(29). In the United Kingdom (UK), the National Health Service (NHS) has contributed to the development of a competency framework for undergraduate medical education (24,25). A curricular project in the area of leadership and teamwork has been developed in the United States of America (USA) in partnership with 8 medical schools (4).
In this short report, we have described a systematic, qualitative inquiry regarding a short clerkship program at our institution, a multifaceted leadership education curriculum in integration with undergraduate medical school, business administration, and public health. Although detailed descriptions of medical courses and skills for medical education are available in the literature, there are limited resources that can provide guidance for developing a comprehensive leadership curriculum for medical students.
Three of the 4 students selected the program voluntarily. This indicates the high level of awareness regarding leadership among the students. A study on the awareness of junior medical students regarding leadership revealed that such training may be more valuable if provided along with clinical training (30). Our medical students had maximum benefit points regarding MOH and house parliament members meetings. Another study that reviewed undergraduate medical education in relation to leadership programs indicated that the participation of community leaders such as bankers, ministers, and elected officers facilitated the leadership education in practice (11).
Different leadership education programs are offered in different settings (24,25,31). In our institutional program, we used different educational techniques such as discussion, game-based learning, and case discussions. Students reported the best understanding during the discussion based on Steven Covey's "The 8 th habit: From Effectiveness to Greatness" (15).
Martins H (7) reported that for most people, leadership is associated with grand posts, high-responsibility positions, and sometimes, charismatic personalities. However, educating a group of medical students requires leading them, in a transformational leadership sense. The results of the inquiry yielded program theory development, program delivery design, a competency based curriculum model design, and a review of existing programs as the basis for a new leadership curriculum.  We believe that this multifaceted approach can also be implemented using more innovative designs by involving other stakeholders and relevant professional resources to ensure high-quality outcomes on course completion with long-term assessment after graduation.

CONCLUSION
The voluntary selection and demand of leadership courses by medial students indicates the awareness regarding the requirement of leadership in the medical profession. Students recognized the need to develop leadership competences. Traditional medical school curricula and doctor models do not fulfil the requirements of today's medical system. The present findings will help future development of leadership training programs in medical education curricula. In addition, undergraduate medical education provides an ideal setting for postgraduate medical programs and for laying the foundation for leadership competencies.