Targeted needs assessment for a leadership curriculum in a medical college of a developing country

Background: Leadership is an important competency expected of medical graduates. However, formal leadership curricula have been adopted sparingly and there is no reported curriculum specifically developed for resourceconstrained healthcare settings that face unique challenges. We conducted a targeted needs assessment to assess perspectives of students, faculty members and academic leaders regarding the leadership-related competencies required for an undergraduate medical curriculum at a private medical college in Karachi, Pakistan. Methods: A mixed method design was adopted. For the quantitative arm, a questionnaire was completed by 227 undergraduate medical students to assess leadership potential and perceptions regarding a leadership curriculum. For the qualitative arm, focus group discussions and semi-structured interviews were conducted with nineteen faculty members and two academic leaders for their perspective on required competencies and ideal teaching, learning and assessment methodology. Results: Faculty, academic leaders and students agreed on the definitions of leadership, perceived existing leadership qualities in students, and need for a formal integrated, longitudinal leadership curriculum. However, there were differences of opinion among stakeholders regarding preferred modes of learning that need to be reconciled for an effective curriculum. Conclusions: The study reported can inform the design of an innovative leadership curriculum in resourceconstrained context. Ghias K, Rehman R, Sabzwari S, Alam F, Abbas A, Ayoub Shaikh P, Siddiqui U MedEdPublish https://doi.org/10.15694/mep.2017.000074 Page | 2


Introduction
Medical graduates are expected to attain core competencies that are essential for effective healthcare practitioners. These include being a leader and manager, which requires self-awareness, teamwork, communication skills, empathy, and humility (Stoller, 2008;Varkey P, Peloquin J, Reed D, Lindor K, & Harris, 2009) and aligns with the role of physicians as medical experts entrusted with healthcare reform and improving patient care (Novack DH, Epstein RM, & Paulsen, 1999). Leadership has often been seen as an inherent quality defined by an individual's charisma and dynamism, discounting the possibility of developing leadership skills (Dass TK & Parks, 2006;Varkey P et al., 2009). While medical curricula have traditionally centered on knowledge of disease and principles of treatment, they are now evolving to ensure attainment of required competencies, including leadership (Stoller, 2009).
Several recommendations have been made regarding leadership training for medical students (Kohn, 2004), but formal leadership curricula have been adopted sparingly despite support from students, graduates, and physicians towards such a change (Abbas MR, Quince TA, Wood DF, & Benson, 2011). Among the pioneers of integrating leadership in medical school curricula in the developed world were 18 U.S medical schools participating in the Undergraduate Medical Education for the 21 st Century (UME-21) project (Rabinowitz HK et al., 2001). This project encompassed nine content areas, including Leadership and Teamwork -a previously neglected topic -to enable students to provide high-quality, accessible, and affordable care in the modern health care environment (O'Connell MT & Pascoe, 2004). In the UK, the Academy of Medical Royal Colleges and National Health Service Institute for Innovation have developed a Medical Leadership Competency Framework (MLCF), which has been recommended for integration into medical school curricula (Academy of Medical Royal Colleges & Improvement, 2010).
All existing leadership curricula described in the literature, however, focus on developed countries where better infrastructure and availability of resources are coupled with challenges of managed healthcare. These factors are very different from those in developing countries. In resource-constrained settings, physicians must deal with a unique set of circumstances that are different in each region, each country, and even each locality at times. In a country like Pakistan, lack of basic resources, poor infrastructure, absence of affordable insurance policies for the common man, language and cultural barriers significantly increase the magnitude of healthcare issues. In addition, generations-old beliefs and poor health literacy, and the widening disparity between public and private healthcare facilities pose further challenges (Kurji Z, Premani ZS, & Mithani, 2016). A unique approach therefore has to be taken to develop patient-doctor relationships, provide high-quality, affordable care and achieve positive outcomes. This requires a physician to continuously adapt, drive change and provide leadership in adverse circumstances.
At the Aga Khan University (AKU) Medical College in Karachi, Pakistan, one of the professional attributes expected of graduates after completion of a five-year Bachelor of Medicine, Bachelor of Surgery (MBBS) degree is 'leadership to address societal issues'. However, a formal leadership curriculum does not currently exist. In order to develop a structured leadership curriculum specific to a resource-constrained setting, we conducted a targeted needs assessment to assess perspectives of students, faculty members and academic leaders regarding the leadershiprelated competencies necessary in an undergraduate curriculum, aspects of leadership currently being delivered through formal or hidden curriculum, additional content necessary and preferred mode of learning and assessment.

Ethical considerations
The study was approved by the Ethical Review Committee of . Participants were provided with information regarding the study and informed consent was taken. Confidentiality of participants was ensured.

Study design
A mixed method design was adopted to meet the needs assessment objectives. Questionnaires, Focus Group Discussions (FGD) and semi-structured interviews were employed to collect data from the target population of the study.

Participants
Students: All students were invited to participate in the study. 227 out of the ~500 students that make up the undergraduate student body at AKU (there are approximately 100 students in each of the five undergraduate years) responded.
Faculty: All faculty members from the undergraduate medical education (UGME) programme were invited to participate in the study via email. Nineteen faculty members, including basic science and clinical faculty that interact routinely with students and/or are involved in administering the curriculum, responded and were included as participants.
Curriculum decision-makers and academic administrators/leadership: Through purposive sampling, two academic leaders who are directly responsible for the UGME programme in Karachi were interviewed.

Questionnaire: UGME students (Year 1 to 5)
A questionnaire was developed to assess student leadership potential and perceptions regarding a leadership curriculum. The questionnaire used had several sections. Section I addressed existing leadership qualities and was adapted from Academy of Medical Royal Colleges & NHS Institute for Innovation and Improvement Medical Leadership Competency Framework (MLCF) (Academy of Medical Royal Colleges & Improvement, 2009. Section II contained items assessing the required competencies of a leadership curriculum (Spurgeon P & Down, 2010;Stoller JK, Taylor CA, & Farver, 2013). Section III focused on the preferred mode of learning and assessment adapted from Varkey et. al. (Varkey P et al., 2009). The questionnaire was validated by a small group of content experts (5-10 members), curriculum developers and researchers who had understanding and experience of pedagogy and medical education research. Students being key stakeholders were also invited to review the tool. The group commented on the importance of each item within each subscale/domain, based on their understanding of the conceptual definition of each subscale/domain. Moreover, they provided feedback on the clarity of language and made suggestions for modifications of the tool.

Focus Group Discussions: UGME faculty
FGDs were conducted with teachers from basic science and clinical faculty for their perspective on required competencies and ideal teaching, learning and assessment methodology. Three FGDs were conducted with 19 faculty members involved in teaching in UGME. The duration of the interview was 45-60 minutes. The FGD was audio-recoded and transcribed with consent. To avoid bias, the FGDs were conducted by individuals with the requisite experience.

Semi-Structured interviews: Academic administrators/leadership
Semi structured interviews were conducted with two academic leaders to understand their expectations as well as any challenges associated with a leadership curriculum in the UGME program at AKU Karachi.

Data analysis
The data from the participants was analyzed for each individual according to study objectives/research questions using quantitative and qualitative techniques. Data was stored and analyzed using SPSS 16.0. The questionnaire was divided into three main sections. In section I, ninety questions were divided into five major themes (Demonstrating personal qualities, Working with others, Managing Services, Improving services and Setting directions), and these themes further explored on the basis of different variables/sub-themes given in Table 1. Agreement by participants with each questionnaire item was determined by merging 'Strongly agree' and 'Agree' responses; disagreement was determined by merging 'Strongly disagree' and 'Disagree' responses. Section II focused on the knowledge, skills and attitudes important for a leadership curriculum, and section III explored the most appropriate teaching/learning strategies.

Student questionnaire
The questionnaire was completed by 227 out of the total ~500 undergraduate medical students at AKU (response rate of 45%). Year 1 students made up 24% of the respondents, Year 2 students 29%, Year 3 students 14%, Year 4 students 16% and Year 5 students 17%. Fifty-five percent of the respondents were female. The pre-medical school educational background of majority of the students (87%) was the British system of GCE O and A levels.
Respondents were almost equally split between those who were from Karachi (44.68%) and those from other parts of Pakistan (48.40 %); 6.91% were from outside the country. Table 1 lists all the themes and sub-themes of medical leadership competency framework on which students were probed in the questionnaire. The items that had the greatest and least agreement in each sub-theme are provided. Detailed results and responses to all items are provided in the supplementary material. Students identified oral communication, time management, conflict resolution and negotiation skills, emotional intelligence, and knowledge of ethical principles as the most important competencies of leadership. On the other hand, billing, coding and compliance, and knowledge of investment principles were considered least important (Table 2). Problem-based learning and case studies were identified by students as the most effective whereas writing assignments and didactic lectures were the least effective ways of teaching/learning strategies for leadership training (Table 3). No significant difference in the perception of existing leadership qualities, required competencies of a leadership curriculum, and preferred mode of learning was found on the basis of students' demographics or year of study.

Focus Group Discussions
For the qualitative arm of the study, a total of 19 faculty members (8 men and 11 women) participated in the focus group discussions. Several themes emerged and there was largely consensus among faculty members, except on a few points, as evidenced by the representative remarks provided below.

Defining leadership
There was consensus among the faculty members that a physician-leader is someone who can take initiative, motivate self and others, be highly ethical and make a meaningful contribution to society. Team-work, communication skills, critical and innovative thinking, reliability, and credibility were also considered extremely important attributes of a good leader. -Faculty member C

Existing leadership qualities
Some faculty members felt that having had experiences of working as Team Captains and Student Council members are evidence of pre-existing leadership qualities. However, others thought that positions are more managerial positions and any leadership potential identified at the time of admission needs to be further developed.

Teaching and learning leadership
The majority of faculty felt that leadership can be learnt and developed, and therefore advocated for the integration

Semi Structured Interviews
Two academic leaders were interviewed using a semi-structured approach. They views were similar to faculty members and supported the implementation of a formal leadership curriculum, highlighting the importance of developing the practice of reflection as a key strategy.
'Reflective exercises will harness people who enter with leadership qualities and encourage those who do not have those qualities. They can learn how they can fight for the rights of people, how they can differentiate between right and wrong, and how they can initiate change.'

Discussion
This targeted needs-assessment study is the first of its kind reported from a developing country. The study was able to fulfill its objectives in gathering student and faculty perspectives on leadership in undergraduate medical education, its implementation and significance.
Leadership, both situational and organizational, can be taught (Parks, 2005) and is recognized as an important competency to be achieved by medical graduates. Majority of the faculty participants in the study reported here agreed that leadership can be nurtured, in alignment with student perception. The defining qualities of a leader highlighted by both groups were similar to those in previous studies that identified interpersonal and communication skills, professional ethics and responsibility, and continuous learning and improvement as key traits ( Our study showed no difference in student perception based on gender, city of origin, educational background and other demographics. While a recent study has ranked Pakistan as second-last in the world in gender equality (Khan, 2016), being female did not appear to negatively affect self-perception of existing leadership qualities in our cohort. Similarly, educational background or city of origin did not affect perceptions of existing leadership qualities, required competencies and preferred mode of learning. This can likely be attributed to the undergraduate medical admissions process at AKU through which highly motivated individuals of both genders are selected from urban and rural settings. The competitive selection process perhaps nullifies any differences that would have otherwise existed because of gender or educational background. From the perspective of curriculum design, a uniform baseline among students is advantageous, but it would be important to keep in mind that the literature reveals differences in the eventual leadership styles of women and men (Eagly AH & Johannesen-Schmidt, 2001).
Majority of students recognized that an understanding of billing, coding and investment principles were important aspects of leadership, identifying a common gap in the existing undergraduate medical curriculum. These results are similar to those reported by Varkey et al. in a study cohort from the developed world (Varkey P et al., 2009), although students in the current study emphasized the importance of knowledge of investment principles for leadership more than previously reported (96% vs. 55%). A previous study from Pakistan on financial wellness has also identified financial literacy, financial security and knowledge of budget plans as concepts deficient in medical students (Rehman R, Katpar S, Khan R, & Hussain, 2015). These findings could be indicative of a shift towards the relevance of finance in the practice of medicine.
Despite differences in educational backgrounds and circumstances, medical students from both developed and developing world ( (Agrawal JR et al., 2005). The current study revealed that our students acknowledge the importance of understanding health policy, but many are not aware of healthcare system data resources. Students from both the developed and the developing world identify this as a common area of deficient training.
Similarities were also observed in preferred learning methods for a leadership curriculum between the cohort in this study and those previously published from developed countries (Quince T et al., 2014;Varkey P et al., 2009). Students in the current study preferred problem-based learning, case studies and simulation/role-play the most. Students surveyed in the Varkey et al. study also preferably identified simulation and case studies, and additionally study groups as useful (Varkey P et al., 2009). Both cohorts rated readings, didactic lectures, reflective journaling and writing assignments as less preferential modes of learning leadership. An ideal theoretical framework for a leadership curriculum can be found in Kolb's theory of experiential learning (Kolb, 2014), which provides a holistic model of processes that influence learning. Student preference of active modes of learning aligns well with designing a leadership curriculum that allows students to progress through Kolb's learning cycle of concrete experience, abstract conceptualization, reflective observation and active experimentation (Kolb AY & Kolb, 2012).
Reflective practice, an important component of Kolb's learning cycle, has been shown to increase the moral conscience of leaders considerably, resulting in more effective leaders (Branson, 2007;Goleman D, Boyatzis RE, & McKee, 2002). While reflective practice was identified as a key teaching/learning tool for leadership by most faculty members in the current study, students did not perceive this as a key learning strategy for leadership. This discrepancy identifies a key deficiency that needs to be formally addressed in curriculum development. Given the importance of reflective practice for leadership documented in the literature, implementation of such a pedagogical approach will require justification and buy-in from students for effective execution.
Medical curricula has to keep pace with the evolving nature and demands of healthcare systems that require physician-leaders (Tibbitts, 1996). Our study and other similar studies from developed countries suggest that to keep up with the evolving responsibilities of a medical practitioner, leadership needs to be formally integrated into medical curricula. While models such as the UK's Medical Leadership Competency Framework provide a good starting point (Academy of Medical Royal Colleges & Improvement, 2010), they cannot be transplanted and adopted in totality since the needs of the developing world are different. For example, emphasis on managed care and insurance regulations may be important in other countries, but it is not a major issue in Pakistan, where most patients pay out-of-pocket. Instead, ethics of contradictions between medical and social realities and class disparities are of significant importance for health professionals in resource-constrained settings, such as Pakistan. Another aspect to consider when implementing a leadership curriculum is true integration with existing curricula rather an add-on feature, which is less likely to be successful because of curricular pressures and disinterest amongst students (Martins HMG, Detmer DE, & Rubery, 2005).
Some limitations of the study should be kept in mind. Primarily, the data is limited to one private medical college in Pakistan and generalizations when extrapolating findings to other, public universities in different cities and regions must be made with caution and contextually. Another limitation was that a bias was likely introduced in the study due to self-selection of participants. We were not able to include the perspectives of those stakeholders who are less inclined towards innovation in medical education and curriculum design. This may also have impacted the statistical analysis of the quantitative arm of the study.
While this study provides answers to a targeted needs-assessment and can inform development of a leadership Ghias K, Rehman R, Sabzwari S, Alam F, Abbas A, Ayoub Shaikh P, Siddiqui U MedEdPublish https://doi.org/10.15694/mep.2017.000074 Page | 12 curriculum, it does not guarantee success and impact of its implementation, which will be dependent on several factors such as student engagement, faculty willingness, and availability of time, among others.

Conclusion
There exists a need to incorporate a leadership curriculum in undergraduate medical education. Whereas challenges for implementation and variation of impact are both valid possibilities, this study can inform design of leadership curricula in resource-constrained settings and serves as a stepping stone to developing an innovative curriculum of leadership for the medical students of today.

Supplementary material SUPPLEMENTARY TABLES
Students were asked to indicate whether they strongly agree, agree, are neutral, disagree or strongly disagree with each of the statements pertaining to a medical leadership competency framework below. Percentage of participant responses are provided.
Key: A: Strongly agree and agree merged; N: neutral; D: strongly disagree and disagree merged

Take Home Messages
This is the first reported leadership curriculum for a resource-constrained setting, which has unique challenges for practice A participatory approach to curriculum design is important; therefore, a needs assessment should include all stakeholders, that is, students, faculty and academic leadership This study showed agreement between stakeholders on need for a formal integrated, longitudinal leadership curriculum that can capitalize on existing opportunities ALIZEH ABBAS is a fourth year medical student at the Aga Khan University Medical College. She has an interest in the fields of Surgery and Public Health and believes it is imperative to incorporate leadership in the undergraduate medical education curriculum.
PREET AYOUB SHAIKH is a final year medical student at the Aga Khan University Medical College. She is planning to pursue a career in General Surgery and is a strong proponent of student involvement in curricular development.
USMAN TARIQ SIDDIQUI is a graduate of the Aga Khan University Medical College and was working in the Department of Biological and Biomedical Sciences at the time this study was conceived and initiated. He is currently a general surgery resident at the University of Connecticut. He has strong interest in medical education and public health.