Leader and Leadership Education and Development in Medical Education across the Professional Life- Cycle

Problem: Leader and Leadership Education and Development (LEAD) is of growing interest in medical education and is a critical element for success. Several programs world-wide in undergraduate medical education (UME) and graduate medical education (GME) include their own versions of LEAD, but these programs remain relatively unique to university and institution missions. Creating and using a common language across the life-cycle (spanning pre-UME, UME, GME, and beyond) and delivering appropriate curricula and assessments for each stage of the professional life-cycle is essential. Approach: The purpose of the 2019 LEAD Summit and Working Group meeting was to share opinions, experiences, and current practices across the medical professional life-cycle. Attendees offered diverse perspectives relevant to leadership programs before, during, and after medical school. Outcomes: Three themes emerged from the meeting: the importance of common language; relevant and effective curriculum; and meaningful assessment across the life-cycle. Additionally, integration should occur within each step of the life-cycle and across the life-cycle to enhance the learning experience. To achieve these goals requires the development of learners and faculty. Next Steps: Leadership is valuable in medicine. If medical education programs do not value LEAD, then these programs will fail to equip graduates to be effective 21 Century medical professionals. The development of a common language, clear expectations within and among training programs, and accreditation from appropriate organizations would provide some quality control and encourage institutions to provide resources and buy-in from learners and faculty. Barry E, Hudepohl N, Kleber H, McManigle J, Weistroffer J, Grunberg N MedEdPublish https://doi.org/10.15694/mep.2019.000218.1 Page | 2


Table 2. List of questions focused around undergraduate medical education for facilitators to guide working group discussion
• Does your admissions process consider undergraduate leadership experiences and/or education? • Should medical schools consider (or require) previous leadership experiences/education? • Should undergraduate institutions provide these opportunities for pre-med students? • How should leadership experiences/education be assessed and weighted? • What are your institution's philosophy, conceptual framework, curriculum, requirements, and assessment approaches for UME leader and leadership education and development? • Is your program required, recommended, optional? • Is your program across all four years, one year, a single course or elective, etc.? • How does your program address needs of a heterogeneous student population with regard to leadership background and life experiences? • Should leadership programs be integrated with other aspects of UME? If so, how? Barry E, Hudepohl N, Kleber H, McManigle J, Weistroffer J, Grunberg N MedEdPublish https://doi.org/10.15694/mep.2019.000218.1 Page | 4 Table 3. List of questions focused around undergraduate medical education for facilitators to guide working group discussion • What leadership knowledge, skills, and attitudes (KSAs) should be required of medical school graduates? • Does your institution's UME community partner/coordinate with GME programs regarding leadership education and development? • Does your GME program partner with the faculty development program at your institution to develop and implement leadership programs at the GME level? • Should GME include (as requirements or options) leadership education and development?
• If so, what should the programs entail?
• If so, how should the programs be delivered, integrated, and assessed?

Outcomes
Three themes emerged from the 2019 LEAD Summit and Working Group meeting. These were: importance of common language, relevant and effective curriculum, and meaningful assessments across the life-cycle (medical school admissions to UME to GME and beyond). Additionally, integration should occur within each step of the lifecycle and across the life-cycle to enhance the learning experience. To achieve these goals requires the development of learners and faculty (see Table 4 for themes).

Table 4. Leadership themes throughout leader and leadership education and development within and between the life-cycle of medical education
Integration (within each and between) with the use of reflection and feedback

Medical School Admissions
Development of learners and faculty -Common language -Curriculum -Assessment Undergraduate Medical Education -Common language -Curriculum -Assessment

Graduate Medical Education and Beyond
-Common language -Curriculum -Assessment

Medical School Admissions
Common language. It is important to develop ways to assess leadership and followership experiences and potential within the medical school application and admissions process. To accomplish this goal, a common language regarding leadership and followership terms and elements is needed within and between programs and institutions. This common language also could be used during medical school admissions processes.
Curriculum. There currently is no particular pre-UME curriculum addressing leadership, followership, and team work. Experiences with these topics are varied and it is important to recognize that some applicant may not have had opportunities for formal leadership activities. With regard to leadership and followership potential, it is valuable to consider traits such as humility, awareness of self, ability to reflect on experiences, vision, empathy, ethics, and professionalism. Multiple mini interviews/problem-based interviews might improve the assessment of leadership and followership potential of medical school applicants. This approach would allow interviewers to gain a deeper sense of the applicant's ability to reflect on past experiences and provide a sense of how the applicant used those experiences to improve and express their vision for the future. Event team-based interviews also would provide a way to consider how individual applicants perform with others and possibly allow for the assessment of humility and team attitudes. Some schools have used behavioral event interviews, but these seem to focus on leadership competency and not the applicant's potential. Further studies would be required to confirm these thoughts.

Undergraduate Medical Education
Common language. The development of a common framework and language for use with learners and faculty is extremely important. Common language could be extended to other institutions as well as to post-graduate education programs to help learners transition between medical school and graduate medical education. Common language should use words that are consistent with the learners' views as well as within the curriculum. For example, words such as "wellness" and "resilience" are related to leadership and followership and are important in the learner's development.

Curriculum.
It is important to develop emotional intelligence, build empathy, encourage team building, and improve well-being of self and others. Near-peers and peer-peer support/coaching should be used. Additionally, regular, individual and team coaching/mentoring could improve each learner's experience by providing more specific guidance.
The lessons, examples, and experiences provided for learners should be relevant to their stage of education and development. Faculty need to find ways to make the lessons more intentional with the use of specific and applicable examples to help the learners integrate the material to all settings and experiences. UME curricula are already packed with required material and LEAD curricula should include all learners whenever possible. Finding ways to use every opportunity to create team-based activities and provide opportunities for feedback and reflection are extremely important. For instance, team-based learning occurs within the anatomy lab and skills such as team building, effective communication, and problem solving can be emphasized in these settings to underscore how these skills are relevant to situations outside of "leadership sessions." Integration within multiple aspects of UME provides opportunities for learners to practice and have their leadership skills assessed, while concurrently learning clinical skills (e.g., effectively communicating with a patient; running a code; performing a "time out" prior to surgery). The use of common language would help to underscore the value of leadership topics.

Assessment.
Assessments must align with program goals. Use of self-and peer-assessments is an important way to build self and social awareness as well as develop appropriate feedback skills that can be used to lead up, down, and sideways on teams. Additionally, more research needs to be done regarding programmatic assessment of leader and leadership programs within medical education to determine the program's effectiveness. The focus throughout medical school in the United States is based on the learner's numerical performance coming into medical school (GPA and MCAT) and the first two steps of the United States Medical Licensing Examinations which are used to determine the learner's potential for success and residency matches. Leadership training initiatives may be graduates. For example, is the program's goal for graduates to focus on and emphasize professional work or for graduates to be able to balance life, family, and work? This type of question can guide the program and allow faculty to model the goal behaviors and attitudes for the learners. As learners develop, it is important that the experiences provided match their level of development. Programs should train medical students (teaching them the knowledge and skills to prepare for the "known"), educate them (i.e., prepare for the "unknown"), and transition to coach physicians (by working on ways to improve through comparisons of their performance to norms).
Leadership is valuable in medicine and relevant to all. If medical education programs do not value LEAD, then these programs will fail to equip graduates to be effective 21 st Century medical professionals. The development of a common language, expectations within and among training programs, and involvement of professional organization and accrediting bodies are essential. LEAD accreditation would provide a degree of quality control and pressure on institutions to provide resources and buy-in from learners and faculty.

Future LEAD Summit and Working Group Meetings
Future LEAD Summit and Working Group meetings will address how to: (1) improve the admissions processes to UME; (2) integrate curricula, faculty development, and create a common language; and (3) develop effective leader/follower/team assessments to be used in UME and GME.

Take Home Messages
It is important to create a common language to use across the lifecycle, to develop and deliver relevant and effective curricula and meaningful assessments for each stage of the professional lifecycle. Development of learners and faculty at all stages of the professional lifecycle is important. Integration should occur within each step of the lifecycle as well as across the life-cycle to enhance the learning experience.