A Case-Based Approach to Medical Leadership Education Is Effective and Reproducible in Diverse Graduate Medical Education Settings

Leadership is the process of influencing individuals and teams to accomplish their shared objectives.(1) Although leadership is increasingly recognized as an important skill for physicians, graduate medical education programs around the world generally lack consistent and effective approaches that help physicians learn how to reason systematically through leadership challenges and take strategic action.(2,3) The failure of physicians to skillfully negotiate the interpersonal and organizational dynamics in their work environment often produces frustration, conflict, and even threats to patient safety.(4-6 )Leadership challenges are magnified in limited-resource settings such as Sub-Sahara Africa due to a multitude of factors, such as the more absolute delegation of decision-making authority to physicians by patients and the scarcity of resources that significantly and unpredictably limit the practice of evidence-based medicine.(7-10)

Graduate medical education is predominantly an apprenticeship model in which trainees observe explicit clinical problem-solving by role models. However, for leadership decisions, the role model’s processing of information and translation of internal calculations into concrete action usually is implied rather than explained outright. Several frameworks for formal medical leadership education have emerged in recent years.(11-13) In a systemic review of 35 medical leadership education interventions, most reported improvements in areas such as performance of organizational roles in academic medical settings, self-awareness, and strategic planning.(14) Programs that were considered the most effective included experiential rather than didactic methods, use of reflective practice, and peer support. Most interventions targeted practicing physicians or faculty and were stand-alone events (e.g., workshops, short courses) detached from other program components. Since 1996, we have developed and successfully implemented an approach to medical leadership education that is case-based and integrated in graduate medical education programs across specialties at Baylor College of Medicine (BCM) in Houston, Texas. That method, Reflective Practice & Leadership (RP&L), addresses a number of leadership capabilities articulated in the American College of Graduate Medical Education Core Competencies.(15)

The concept of reflective practice in education stretches back to Socrates and includes influential thinkers such as John Dewey and Donald Schön.(16-18) The RP&L design was based on the premise that physicians rely on hypothetic-deductive reasoning as a fundamental analytic and decision-making tool when faced with novel, complex, or ambiguous problems.(17,19,20) Frugé et al.(21) have provided detailed information on the RP&L method and examples of applications. The method has reliably demonstrated effectiveness across a variety of specialties, stages of professional development, learning targets, and institutions in the United States.(15,22,23) We recently integrated the RP&L method in a new two-year pediatric hematology-oncology (PHO) clinical fellowship in sub-Sahara Africa based at Makerere University College of Health Sciences (MakCHS) in Kampala, Uganda. We report the effectiveness and reproducibility of the RP&L approach to medical leadership education in this graduate medical education environment.

Implementation of the RP&L Method in Africa

Setting

The MakCHS PHO fellowship program was created in 2016 in collaboration with the BCM/Texas Children’s Hospital Global HOPE Program.(24) The Program is a training hub for the PHO subspecialty workforce in the region and currently has trainees from Democratic Republic of Congo, Kenya, Malawi, Nigeria, Tanzania, and Uganda. The development of leaders for PHO in Africa is a primary objective of the Global HOPE fellowship, and we incorporated RP&L sessions as a core component of the curriculum to achieve this goal.

Fellows were provided protected time to attend monthly 60-minute sessions throughout the academic year. Sessions were confidential, led by a designated moderator and staffed by medical faculty who were well versed in the RP&L method (an average of two on-site in Kampala and two by video conference from Baylor College of Medicine in Houston). The sessions followed the standard RP&L six-step approach:

1. Case presentation and framing a question: A Fellow volunteered to describe a recent, ongoing or recurrent challenge and framed a concise question to the group.

2. Reflection (systematic analysis): Participants—both Fellows and faculty—described comparable circumstances.

3. Formulation of a working hypothesis: Based on the analysis of the Fellow’s case and comparable cases, the team identified factors that might have caused, perpetuated, or complicated the situation.

4. Planning for strategic action: Based on the working hypothesis, the team presented and weighed the pros and cons of potential strategies.

5. Summary and evaluation: The trainee who presented the case was then given an opportunity to evaluate how the session did or did not address their personal or organizational challenge.

6. Faculty review: Following the session, the faculty reviewed the process and content of the session via email and searched for lessons that could be learned to improve future sessions.

Evaluation of the Effectiveness of RP&L at MakCHS and Comparison with BCM Counterparts

Fellows at both MakCHS and BCM participated in RP&L sessions as part of their core curriculum. The same moderator and some physician faculty participated in RP&L sessions at MakCHS and BCM, but Fellows at the two sites never interacted during training, including in RP&L sessions. Fellows at both sites were asked to complete the same anonymized retrospective pre- and post evaluation of their leadership capabilities annually, shortly after completing their first year of fellowship. A self-reported estimate of competency was used because we are not aware of validated observational tools to measure broad leadership competency. The questionnaire employed a simple Likert scale to assess change in perceived competency in six domains of leadership and awareness of self, patient/family, team, and organizational dynamics(25):

1. Psychological and social effects of illness and treatment on child, family, medical professionals, and teams;

2. Tragedy, communication, and the physician’s role;

3. Patient care;

4. Practice-based learning and improvement;

5. Interpersonal communication skills; and

6. Professionalism.

Data were normally distributed and therefore were suitable for parametric statistical testing. Pre- and post-RP&L means were compared using a paired Student t-test to establish statistical significance of any difference in self-rated competency before and after the RP&L; differences were considered statistically significantly at p <.05. To establish the reproducibility of the RP&L, we compared aggregate components scores for each of six domains of leadership and self-awareness for PHO Fellows from MakCHS and BCM using the two-sample t-test. Data were graphically summarized as box plots. Differences and statistical precision between mean domain scores were tested using 95% confidence intervals and considered statistically significantly different at p <.05. The Baylor College of Medicine Internal Review Board reviewed and exempted the study.

Results

Between September 2016 and June 2019, all 14 MakCHS Fellows in three cohorts of the program participated in nine monthly RP&L sessions during their first year. These Fellows reported that the RP&L sessions gave them a sense of clarity with regard to understanding of personal implications and organizational facets of the field of pediatric hematology and oncology. Examples of leadership challenges presented by the Fellows included the following questions:

• How do you provide leadership in a clinical team when you are personally struggling to cope emotionally with the high mortality in the clinical unit?

• How do you deal with the stress that arises from knowing the best care you should provide to your patients when your institution’s priorities do not support provision of that care?

Effect of RP&L on Leadership Capabilities Among Pediatric Hematology/Oncology Fellows at MakCHS

Trainees at MakCHS reported significant improvement in all domains of medical leadership and self-awareness that were evaluated. The breakdown of pre- and post-RP&L competency ratings by component within each domain are summarized in Table 1. All ratings are on a Likert scale, from 1 to 10. The lowest rating of pre-RP&L competency was in the domain Tragedy, Communication, and the Physician’s Role (mean = 4.3, SD = 1.5), particularly for the component “ability to understand my own and my colleagues’ personal responses to tragic medical situations” (mean = 3.9, SD = 1.61). The Fellows improved to a post-RP&L rating of 7.8 (SD = 1.5; p <.001) in this domain and to 7.5 (SD = 1.61; p <.001) in this component, respectively. The MakCHS Fellows’ pre-RP&L ratings were highest in the domain Professionalism (mean = 6.8, SD = 1.4). Although post-RP&L ratings in Professionalism improved to 8.8 (SD = 1.1; p <.001), this domain appeared to be the least affected by the RP&L sessions. The largest self-rated improvement was in the area of “understanding psychosocial factors in ways that will enhance my ability to effectively lead teams and institutions” with a pre- and post-RP&L mean improvement of 3.9 points (p <.001).

Comparing Reproducibility of RP&L Between MakCHS and BCM Fellows

We compared the PHO Fellows at MakCHS with a cohort of the 40 most recent PHO Fellows at BCM (MakCHS:BCM ratio close to 1:3; Figure 1). The MakCHS trainees rated their pre-RP&L capabilities significantly lower than their BCM counterparts in all but one of the assessed domains of leadership and self-awareness. However, post-RP&L, MakCHS Fellows rated themselves significantly higher than their BCM counterparts did in five of six domains. In the domain of Tragedy, Communication, and the Physician’s Role, where the MakCHS Fellows had much lower rating from their BCM counterparts pre-RP&L, they improved to be at par post-RP&L (MakCHS = 31.0, 95% CI [27.7, 34.3]; BCM = 30.4, 95% CI [29.0, 31.7], p = .351). This is the only domain in which the MakCHS Fellows’ ratings did not exceed the BCM counterparts post-RP&L. In the domain of Professionalism, the only one where the two groups started off at par prior to RP&L, MakCHS trainees rated themselves significantly higher than their U.S. counterparts after RP&L (MakCHS = 35.1, 95% CI [32.8, 37.5]; BCM = 32.1, 95% CI [30.1, 33.5], p = .013). The post-RP&L difference between the two groups was most marked in the domain of Practice-based Learning (MakCHS = 24.2, 95% CI [22.5, 26.0]; BCM = 20.5, 95% CI [19.2, 21.7], respectively; p <.001).

Figure 1. Comparison of pre- and post-RP&L self-rated competency of Fellows at Baylor College of Medicine versus those at Makerere University College of Health Sciences. BCM, Baylor College of Medicine; MakCHS, Makerere University College of Health Sciences; RP&L, Reflective Practice and Leadership.

Next Steps and Operational Implications

The results indicate that the RP&L method can be successfully integrated into graduate medical education programs in diverse medical settings, including in low- and middle-income countries. This adaptability of the RP&L method can be attributed to the underlying design of the approach for the following reasons:

• It is case-based, experiential and reflective rather than didactic; and

• It uses a hypothetic-deductive approach to problem-​solving that is familiar and foundational in clinical medical education and practice worldwide.

Although this leadership education model resulted in improved self-rated leadership skills, we found an intriguing pattern of more improvement (lower pre-RP&L and higher post-RP&L self-ratings) among MakCHS Fellows compared with BCM Fellows. This difference may be explained by the fact that MakCHS Fellows often had substantial experience in medical leadership roles (e.g., as chiefs of clinical services, or medical school faculty or research team leaders) before entering fellowship. We hypothesize that learning leadership skills using this reflective and problem-solving approach is enhanced by prior exposure to real-life leadership roles and the involved challenges. We propose adoption, integration, and continual evaluation and improvement of the RP&L method for leadership in graduate medical education curricula.

Acknowledgments: The authors wish to acknowledge the Global HOPE Program of Texas Children’s Hospital for logistical support that enabled conducting RP&L training at MakCHS in East Africa.

References

1. Yukl GA. Leadership in Organizations. 5th ed. Upper Saddle River: Prentice-Hall; 2002.

2. Warren OJ, Carnall R. Medical leadership: why it’s important, what is required, and how we develop it. Postgrad Med J. 2011;87(1023):27-32.

3. Quince T, Abbas M, Murugesu S, et al. Leadership and management in the undergraduate medical curriculum: a qualitative study of students’ attitudes and opinions at one UK medical school. BMJ Open. 2014;4(6):e005353.

4. Bochatay N, Bajwa NM, Cullati S, et al. A multilevel analysis of professional conflicts in health care teams: insight for future training. Acad Med. 2017;92(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 56th Annual Research in Medical Education Sessions):S84-S92. doi: 10.1097/ACM.0000000000001912

5. Forbat L, Sayer C, McNamee P, Menson E, Barclay S. Conflict in a paediatric hospital: a prospective mixed-method study. Arch Dis Child. 2016;101(1):23-27.

6. Pishgooie AH, Barkhordari-Sharifabad M, Atashzadeh-Shoorideh F, Falco-Pegueroles A. Ethical conflict among nurses working in the intensive care units. Nurs Ethics. 2019;26:2225-2238.

7. Wilkinson JP, Lyerly AD, Masenga G, Hayat SK, Prabhu M. Ethical dilemmas in women’s health in under-resourced settings. Int J Gynaecol Obstet. 2011;113(1):25-27.

8. Ghose S, Radhakrishnan V, Bhattacharya S. Ethics of cancer care: beyond biology and medicine. Ecancermedicalscience. 2019;13:911.

9. Cobos Munoz D, Merino Amador P, Monzon Llamas L, Martinez Hernandez D, Santos Sancho JM. Decentralization of health systems in low and middle income countries: a systematic review. Int J Public Health. 2017;62(2):219-229.

10. Masten M, Sommerfeldt S, Gordan S, et al. Evaluating Teamwork in the Neonatal Intensive Care Unit: A Survey of Providers and Parents. Adv Neonatal Care. 2019;19(4):285-293.

11. Crawford SB, Monks SM, Mendez M, Quest D, Mulla ZD, Plavsic SK. A Simulation-Based Workshop to Improve Residents’ Collaborative Clinical Practice. J Grad Med Educ. 2019;11(1):66-71.

12. Frich JC, Brewster AL, Cherlin EJ, Bradley EH. Leadership development programs for physicians: a systematic review. J Gen Intern Med. 2015;30(5):656-674.

13. Nakanjako D, Namagala E, Semeere A, et al. Global health leadership training in resource-limited settings: a collaborative approach by academic institutions and local health care programs in Uganda. Hum Resour Health. 2015;13:87.

14. Turner S, Chan MK, McKimm J, Dickson G, Shaw T. Discipline-specific competency-based curricula for leadership learning in medical specialty training. Leadersh Health Serv (Bradf Engl). 2018;31(2):152-166.

15. Frugé E, Lee D, et al. Reflective practice and leadership: an effective approach to education for the “new” core competencies. American Society of Pediatric Hematology/Oncology; 2007; Toronto, Canada.

16. Dewey J. How we Think. Boston: DC Health; 1910.

17. Schön D. The Reflective Practitioner: How Professionals Think in Action. New York: Basic Books; 1983.

18. Bolton G. Reflective Practice: Writing and Professional Development. 3rd ed. Los Angeles: Sage Publications; 2001.

19. The Doctor, His Patient and the Illness. London: Churchill Livingstone; 1957.

20. The Reflective Practitioner: How Professionals Think in Action. New York: Basic Books; 1983.

21. Frugé E, Drutz J, Horowitz M. Reflective practice & leadership in medicine & medical education. 2019. www.texaschildrens.org/health-professionals/continuing-medical-education-courses/reflective-practice-and-leadership-medicine-and-medical-education .

22. Drutz JE, Horowitz. M., Frugé E. Reflective Practice and Leadership in primary care pediatrics: from systematic needs assessment to CME to faculty development. American Association of Medical Colleges Annual Meeting; 2009; Boston, Massachusetts.

23. Frugé E, Mahoney DH, Poplack DG, Horowitz ME. Leadership: “They never taught me this in medical school.” J Pediatr Hematol Oncol. 2010;32(4):304-308.

24. Lubega J, Airewele G, Frugé E, et al. Capacity building: a novel pediatric hematology-oncology fellowship program in sub-Saharan Africa. Blood Adv. 2018;2(Suppl 1):11-13.

25. Accreditation Council for Graduate Medical Education. The Milestones Guidebook. 2016. www.acgme.org/Portals/0/MilestonesGuidebook.pdf . Accessed February 10, 2020.