The Need for a Leadership Curriculum for Residents

Physicians in training are observed, guided, and molded as part of their critical growth from fledgling trainee to junior faculty. They are coached on bedside manner, their clinical knowledge is tested and honed, and their surgical and procedural skills are refined. Their educational outcomes are measured to ensure that they meet the milestones deemed important by the larger specialty community. At the same time, a critical element of their education is not formally addressed. Daily patient care is carried out by a team of physicians, nurses, care coordinators, pharmacists, social workers, nutritionists, physical and occupational therapists, and other health care allies. Residents often lead these activities, yet their ability to effectively lead teams often is not explicitly addressed in their curriculum and is rarely assessed in a formal manner. Opportunities for growth in this area currently are not structured or coordinated, and they vary greatly.The goal of improving residents' leadership skills is not a new idea. Some programs and institutions have developed educational programs and experiences in this area and have published on this. Specialty organizations in pediatrics and dermatology have done much work in this area, and several groups with military affiliation have formalized training on leadership skills. But an individual resident's exposure to and opportunity for personal growth in leadership skills varies from extensive to none. Factors include program size, specialty, geographic area, and clinical environment. It is in this inherent disparity where we see an opportunity for growth.All of us have experienced situations in the context of hospital rounds or discharge planning where we find ourselves in a role that requires silent independence to ensure that a task is completed. Physicians-in-training recognize that the ultimate priority is to ensure the safe care of patients—and adjust accordingly, remain flexible, follow through on each task, and seek to prevent errors.Some of these challenges might be better approached with a distinct leadership skill set that integrates systems-based practice and inspires a clinical team to grow together. What if graduate medical education focused on honing residents' leadership skills to the same extent as their procedural or clinical skills? Unquestionably, residency training programs and society in general would benefit from investing in, promoting, and developing a cadre of physician leaders.The first step entails determining the approach best suited to producing future physician leaders. Best practices for developing young physician leaders, however, are only occasionally mentioned in the medical education literature. A brief literature search using Ovid, combining the key words “graduate medical education” and “leadership,” produced more than 4000 citations. This number rapidly dwindles when the focus is on content that could serve as a suitable curriculum or learning guide to the development of resident leadership skills. In fact, only a few articles discussed a formal leadership curriculum.A review published in 2013 evaluated the literature on leadership training in medical education to identify best practices.2 The authors found 8 studies that met the criteria and determined that the range of leadership training was broad and the time devoted to leadership training ranged from hours to years.2 In addition, while anecdotal responses from participants were positive, there were no outcomes associated with the interventions to provide a useful metric for identifying best practices.2A 2012 survey of dermatology residents revealed that more than 90% of respondents thought they had acquired their leadership skills via direct observation or modeled behavior.3 Two-thirds of the respondents agreed that a formalized leadership curriculum would help them become better supervisors and clinicians, yet only 13% reported that they had participated in formal leadership training. This suggests that residents are forced to rely on observational learning of leadership, which likely is inconsistent in quantity, quality, and timing.When compared with other health care professionals, such as nurses, pharmacists, and hospital administrators, there is a dearth of material relating to formal leadership training for physicians-in-training. Hospital administration as a profession devotes considerable resources to leadership training, including courses and seminars delivered in various formats and through its annual conference, the Congress on Healthcare Leadership.4 The American Association of Colleges of Nursing has started a leadership fellowship program for aspiring nurses who are seeking academic positions.5 The American Society of Health-System Pharmacists developed a Center for Health-System Pharmacy Leadership in 2006, which provides a diverse group of resources to teach leadership principles to pharmacy students, residents, and practicing pharmacists.6 The center consists of a Pharmacy Leadership Academy and Leadership Institute with a self-directed leadership development program that is also accessible online for asynchronous learning.7Military leadership and overall professional development may provide an added model outside the health care or business arena. The US Marine Corps, an exemplar of leadership training methodology, publishes an annual reading list that categorizes books and articles for every level of leadership and level of experience.8 The list is supported by a comprehensive website with discussion groups, books of the month, and easily accessible “discussion papers” designed to motivate troops in their home stations. Each Marine is encouraged to engage in dialogue regarding how leadership skills apply to their daily interactions.The lack of a dedicated national curriculum has caused some residents to turn to leadership “capstone courses” that are provided as a learning modality by some specialty and medical organizations. Anecdotal reports suggest that these courses may offer promise, but to date no data have been published on outcomes or best practices.What is known about leadership from the literature and real-world experiences is that leadership skills are developmental, and they need to be developed, nurtured, and assessed over time, as well as applied in the active practice of leadership. We believe it is time to start to identify best practices to develop the leadership skills of every physician-in-training. We envision that the starting point is a discussion about leadership development at national conferences and education meetings, to begin the development of a national leadership curriculum. This could result in increased physician leaders in the ranks of a given hospital and in the health care system overall. Including such a leadership curriculum and corresponding assessment within the existing physician competencies would provide an answer to residents across the country who are seeking leadership training.We also envision a sequenced, asynchronous, online curriculum that could be customized by the program. Learning content and online short modules would be supplemented by mentor and peer-group discussions at the home institution. Available leadership capstone courses for residents would be listed with dates and sign-up information. Annual education conferences would include leadership workshops and panels with experts who have implemented leadership curricula within and outside of medicine accompanied by an opportunity for active discussion and sharing of best practices. Residents in all programs would have exposure to leadership development from the time they arrive as interns. A mentor assigned to each resident would engage in discussions with the learner about the leadership challenges they encounter and would challenge them to use their own unique skill set to address these challenges. By the time trainees become senior or chief residents, they would be fine-tuning their leadership skills, having gained insight into the way they most effectively lead. Importantly, senior residents with leadership skills in turn will act as mentors for junior residents, effectively helping to bring along the next generation of physician leaders.In an effort to jump-start the development process at the local level, a “strawman” leadership curriculum with monthly goals and readings was developed by a leadership subcommittee of the Council of Review Committee Residents. The curriculum is available by contacting the corresponding author. As residents, we should seek the requisite leadership skills to navigate complex scenarios and, in doing so, would advance the clinical care team through improved patient care and physician autonomy. We hope this perspective begins a series of conversations focused on developing critically needed leadership skills in residents.