A landscape analysis of leadership training in postgraduate medical education training programs at the University of Ottawa.

BACKGROUND
There is growing recognition of the importance of physician leadership in healthcare. At the same time, becoming an effective leader requires significant training. While educational opportunities for practicing physicians exist to develop their leadership skills, there is a paucity of leadership opportunities for post graduate trainees. In response to this gap, both the Royal College of Physicians and Surgeons of Canada and the Association of Faculties of Medicine of Canada have recommended that leadership training be considered a focus in Post Graduate Medical Education (PGME). However, post-graduate leadership curricula and opportunities in PGME training programs in Canada are not well described. The goal of this study was to determine the motivation for PGME leadership training, the opportunities available, and educational barriers experienced by PGME programs at the University of Ottawa.


METHODS
An electronic survey was distributed to all 70 PGME Program Directors (PDs) at the University of Ottawa. Two PDs were selected, based on strong leadership programs, for individual interviews.


RESULTS
The survey response rate was 55.7%. Seventy-seven percent of responding PDs reported resident participation in leadership training as being "important," while only 37.8% of programs incorporated assessment of resident leadership knowledge and/or skills into their PGME program. Similarly, only 29.7% of responding residency programs offered chief resident leadership training.


CONCLUSIONS
While there is strong recognition of the importance of training future physician leaders, the nature and design of PGME leadership training is highly variable. These data can be used to potentially inform future PGME leadership training curricula.


Introduction
The current practice of medicine necessitates a diversity of leadership skills in order to comprehensively and efficiently respond to the complex needs and demands of the current and ever-evolving healthcare system. Although there are growing opportunities for leadership development for practicing physicians, many believe that leadership training should begin long before licensure occurs. In fact, the Association of Faculties of Medicine of Canada (AFMC), in their documents titled "The Future of Medical Education in Canada (Undergraduate Medical Education and Postgraduate Medical Education)" recommended that leadership development be included in the curricula at both the Postgraduate Medical Education (PGME) and Undergraduate Medical Education (UME) levels. 1,2 In particular, the development of leadership at the PGME level is included in the AFMC's collective vision for graduate medical education as one of its 10 core recommendations, highlighting the need to develop a national core leadership curriculum to focus on "professional responsibilities, self-awareness, providing and receiving feedback, conflict resolution, change management, and working as part of a team as a leader, facilitator, or team member." 3 Similarly, the Royal College of Physicians and Surgeons of Canada (RCPSC) recently modified the former CanMEDS role of "manager" with the role of "leader", highlighting the importance of strong leadership as a fundamental role in training future physicians. As part of the leadership role, the RCPSC describes four key competencies (Table 1). 4

Table 1. Royal College of Physicians and Surgeons of Canada leadership role competencies Key competencies:
Physicians are able to:

Enabling competencies:
Physicians are able to: 1. Contribute to the improvement of healthcare delivery in teams, organizations and systems. While the mandate to train leaders is clear, there has been little research to date exploring leadership training and/or curricula in PGME. Of the research studies to examine innovative leadership programs for postgraduate medical trainees, only a few have rigorously evaluated the interventions using quantitative measures. 5 In addition to the paucity of research in the area of leadership interventions in PGME, little is known about the landscape of leadership opportunities and curricula at the individual program level.
Interviewing program directors to assess current practices in leadership training would be the first critical step towards developing best practices in leadership curricula. The goal of this study was to determine the motivation for PGME leadership training, the opportunities available, and educational barriers experienced by PGME programs at the University of Ottawa. Perhaps by better e34 understanding the current milieu of PGME leadership training at one institution, we can replicate this study at other sites and, in the future, develop better curricula.

Methods
The study protocol was reviewed by the Ottawa Health Sciences Research Ethics Board and granted exemption. Analytic approaches. With respect to the online survey, quantitative data were analyzed for descriptive statistics using Fluid Surveys© and qualitative free-text responses were reviewed for themes. With respect to the semi-structured interviews, field notes were analyzed for themes and innovative ideas.

Quantitative: online questionnaire analysis
The survey response rate was 55.7% (n=39). Programs identified by the responding PDs, (n=32), e35 are shown in Table 2 alongside the total number of trainees per program. The majority of PDs (77.1%, 27/35) reported resident participation in leadership training as being "important" on a three level Likert scale, ranging from "unimportant" to "important" (Figure 1).  Program preparedness for CanMEDS 2015 leadership role key competencies varied significantly between competencies. Competencies that PDs reported being "not prepared for" included: "Design and organize elements of healthcare delivery" (30.8%, 12/39), "Facilitate change in healthcare to enhance services and outcomes" (41.0%, 16/39), and "Manage health human resources in a practice" (30.8%, 12/39) ( Table 2). Alternatively, the competency that PDs reported most consistently being "prepared" to address was, "Manage career planning" (61.5%, 24/) ( Table 3).
The delivery of residency leadership programs varied greatly between programs. The majority of programs offered optional activities as part of their leadership program. The leadership activity that was most often made a mandatory component of leadership programs was participation in (a) multisource feedback (MSF) exercise(s) (mandatory in 86.8% of programs, 33/38, Table 4). MSF is considered part of leadership development as it attempts to address the self-awareness pillar of effective leadership.
e36 e37 Assessment of resident leadership was only undertaken by 37.8% (14/37) of responding programs. Of those programs that incorporated some mode of assessment, the most commonly used means of assessment was "direct observation", the details of that encounter not further elucidated. With respect to leadership training, the majority of programs did not incorporate training that addressed self-reflection, self-management, or selfawareness themes (Table 5). Only 29.7% (n=11) of programs offered training for chief residents, while 54.1% (n=20) responded that they did not currently offer any training for chief residents, and 16.2% (n=6) of programs were uncertain as to whether any chief resident training was offered (Total response rate 37). Only 12 programs of 37 responding programs (32.4 %) reported conducting some form of formal assessment of chief residents activities, not necessarily specific to leadership qualities.  (Table 6).
Alternatively, the following factors were considered to be "Not a Barrier" to implementing leadership training by a large percentage of PDs: lack of buy-in by residents (56.8%, 21/37), lack of evidence to support leadership training (57.1%, 20/35), and lack of buy-in by faculty (40.5%, 15/37) ( Table 6). e38 PDs found the majority of listed supports to be "very helpful." In particular, the specific supports of "Information about other implemented leadership training curricula" (70.3%, 26/37) and "Infrastructure to support leadership training" (74.3%, 26/35) were most consistently reported by PDs as being "very helpful." Alternatively, further research was found to be the least helpful according to PDs; only 13.5% (5/37) of PDS reported it to be "very helpful," 54.1% (20/37) reported it to be "somewhat helpful." and 32.4% (12/37) reported it to be "not helpful" (Table  7).

Evaluation and Feedback
Step 1 has been fulfilled by the AFMC, RCPSC and others in that they have identified physician leadership development as a need in Canadian medical training and fortunately, PDs have bought into this concept. At the same time, it is difficult to know if PGME trainees exhibit the same sense of buy-in. Although programs, such as the Residents as Leaders course (RALS), are highly sought after and regarded at the University of Ottawa, only a small portion of residents participate. 8 The second step in Kern's process is a targeted needs assessment. 7 It is suggested that leadership training will require some variability across programs to best address their trainees' needs, which is congruent with our findings that highlight the variability of opportunities across programs. However, it is uncertain from this study whether PGME trainees have played an active role in helping to design their leadership training. Including PGME trainees in curricula development may be paramount to ensure applicability and buy-in from PGME trainees.
Creating tangible and clear goals and objectives is the third step in Kern's process. 7 Although the overarching goal of any leadership training is to develop an effective leader, the concrete description of what makes an effective leader is more elusive. In our study, PDs reported unclear curricular guidelines for leadership training as being significant barriers to leadership training. Currently, the Canadian Medical Association and other societies are utilizing the "LEADS in a Caring Environment"© framework. This framework "defines the knowledge, skills and attitudes a leaders needs to have successfully contribute to an effective, efficient Canadian healthcare system" 9 and includes five pillars: leading self, engaging others, achieving results, developing coalitions, and transforming systems. Perhaps encouraging programs to utilize this LEADS framework would provide consistency for the trainee throughout his/her career and could encourage him/her to consistently build their skills into an established framework and underscore the need for continued professional development.
Similarly, using an established framework will ideally prevent multiple programs and institutions from reinventing goals and objectives, but rather allow them to devote time to creation of resources to develop knowledge and skills in a concerted way.
The development of educational strategies is necessary in curriculum development in medical education and constitutes the fourth steps of Kern's cycle. 7 In our study, PDs identified several challenges in this regard, importantly a lack of content expertise and lack of knowledge of other successful PGME leadership programs. Suggestions to overcome these barriers included: sharing and dissemination of educational strategies, support from specialty societies, and a centralization of expertise (and potentially delivery) at the faculty, provincial and/or national levels.
The fifth step of Kern's six-step approach to curriculum development for medical education is implementation. Implementation of leadership training has been reported as difficult for many PDs. 7 Scarcity of time and lack of infrastructure have been reported as significant challenges. One PD suggests that perhaps a solution to this barrier is to redefine traditional "service" work as an "opportunity for leadership development". By providing the PGME trainee with the necessary support, mentorship and resources and investing in residents as leaders during their service roles, the PGME program has the two-fold potential of addressing hospital and patient needs, while at the same time meaningfully e40 equipping residents with the opportunity to apply their skills and knowledge, which will be essential to them as independent practitioners.
Kern's sixth step in medical education curriculum development focuses on evaluation and feedback, not solely of the trainee but more importantly of the program. 8 Although the RALS course at the University of Ottawa has been well evaluated and may serve as an example for other programs, there was little to suggest that individual programs' leadership training elements were evaluated. Similarly, PDs report difficulty in adequately evaluating the PGME trainee in terms of her/his leadership effectiveness. 8 As further evaluation tools are created, it is paramount that these be disseminated.

Study limitations
The limited response rate of 55.7% may allow for the results of the study to have been shaped by a nonresponse bias, thereby undermining the reliability and validity of the survey. Responders were given the option of identifying their program or responding anonymously. As a result, it is impossible to identify any specific trends with respect to the programs that did not respond. Included in the combined group of "non-responders" and "anonymous responders" were the programs of Anesthesia, General Surgery, Obstetrics and Gynecology, which all of have large numbers of trainees. The survey also focuses on PGME leadership training at a single institution and thus does not completely represent the depth and breadth of PGME leadership training in Canada. However, it is likely that most PDs may have knowledge and/or access to PGME leadership strategies through their individual specialty societies. Furthermore, only two semi-structured interviews were conducted. Additionally, qualitative analysis of the interviews was limited to informal assessment for innovative ideas and themes. Notwithstanding these limitations, the findings of this study reflect a gap between the established benchmark for resident leadership and existing training opportunities.

Conclusions
While there is widespread recognition of the importance of training resident leaders, the nature and design of residency leadership training is highly variable. Our data suggest that stakeholders consider leadership training in PGME valuable; however, there is a scarcity of time and a lack of expertise, resources, and infrastructure to meet the training needs. Similarly, they often do not know how to assess leadership capacity in their trainees. Description of successful leadership training models is a step in addressing this gap and providing PDs with the knowledge they clearly need.
This study presses the need for further research into leadership training for PGME trainees, assessment of the trainees, and also evaluation of leadership curricula. Future strategies may include greater centralization, PGME leadership networks, and clinically oriented leadership curricula.
Conflicts of interest: There are no conflicts of interestfor any of the authors.

Appendix 1 A Landscape Analysis of Leadership training in Postgraduate Medical Education Training Programs at the University of Ottawa
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Backgr ound
The imp ortance of strong leadership is underscored b y the Royal College's decision to include the "leader" role in the newest iteration of CanMEDs 2015, rep lacing the former role of "manager." The Royal College of Physicians and Surgeons of Canada (RCPSC) p rovides the following definition on leadership , "As Leaders, physicians develop a vision of a high-quality health care system and, in collaboration with other health care leaders, take responsibility for effecting change to move the system toward the achievement of that vision." The RCPSC further describ es leadership stating: "Society has exp licitly identified leadership and management ab ilities as core requirement s for the p ractice of medicine. Physicians and others exercise collab orative leadership within the comp lex health care systems that form their sp ecific work environment s. At a system level, p hysicians contrib ute to t he develop ment and delivery of continuously imp roving health care and engage others to work with t hem toward this vision. Physicians must b alance their p ersonal lives with their resp onsib ilities as leaders and managers in their everyday clinical, administrative, research, and teaching activities. They function as individual care p roviders, as memb ers of teams or group s, and as p articip ant s and leaders in the health care system locally, regionally, nationally, and glob ally. The CanMEDS Leader Role describ es the active engagement of all p hysicians as leaders and managers in decision making in the op eration and ongoing evolution of the health care system." While, the mandate t o t rain p hysician leaders is clear, the concrete descrip t ion of p ost-graduate leadership curricula and opportunities in p ostgraduate medical education (PGME) training p rograms in Canada is not well describ ed and may b e challenging for PGME to satisfy. In this survey, which has b een distrib uted to all Program Directors at the University of Ottawa, we are trying to elucidate the current b readth of leadership t raining/curricula availab le and the b arriers to imp lementation. The ultimate goal of this p roject is to p rovide p rogram directors with resources, curriculum element s and concrete examp les of leadership t raining opportu nities so that they may imp lement t hem as they see necessary in their own p rogram. e44 The current draft of CanMeds 2015 suggests that to achieve resident leadership develop ment involves develop ment of "activities and educational p rograms that develop self-awareness, self-reflect ion, and selfmanagement as a leader and a follower in health care organizations." Please indicate what typ e of leadership training opportunities are offered as p art of your p rogram according to aforementioned comp etencies.

Topic Mandatory Optional Not Presently Offered
Self awareness: conscious knowledge of one's own character, feelings, motives, and desires. ○ ○ ○

How is resident leadership t raining funded within your dep artment?
Please select all that apply: Another program outlined how residents are incorporated into academic and hospital committees. Making residents a part of the hospital leadership culture, as noted by this PD, has been instrumental in convincing faculty to support resident attendance in formal leadership development activities.
5. PDs would like their University to centralize some PGME Leadership Training for access by all programs.
 Some PDs encouraged resident participation in local leadership programs and had history of strong resident attendance in such programs.  PDs overwhelmingly support the "Resident as Leaders Program" (RALs) course, a five-day face-to-face course followed by a longitudinal leadership practical experience offered to residents at the University of Ottawa (9). Interested residents must be supported by their residency program and in turn be accepted to the program.
6. PDs would like to redefine SERVICE to LEADERSHIP as a means of highlighting and developing practical application of leadership knowledge and skills and provide the support and mentorship needed to do so  An important theme that emerged in interviews with PDs was the relationship between resident service and leadership opportunities.  Resident service, namely the clinical responsibilities required during residency, can be skilfully integrated with resident leadership opportunities, as described by one PD. When coupled with mentorship and teaching, investing in residents as leaders during their service roles has the two fold potential of addressing hospital and patient needs, while at the same time meaningfully equipping residents with skills and experience which will be essential to them as independent practitioners. One prominent success story of information sharing is the RALs leadership program, which is open to all residency programs at the University of Ottawa.  PDs voiced a need for further clarity from the Royal College with respect to specific benchmarks for leadership competencies (Table  6).

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8. PDs feel there should be Recognition Trainees for Leadership successes  PDs recognize resident involvement in leadership training has been a critical driving force of department and hospital improvements.  One PD shared, "Leadership in a safety initiative by a previous resident has tangibly improved patient care and provided a career path for that resident."  Another PD noted, "…residents who took the faculty leadership course have become important drivers of positive change in our department." In addition to the impact on the department/division and hospital, resident involvement in leadership has also been essential for professional development.  One PD noted, "A former resident that underwent training became the Quality and Safety lead in the Division, and shows potential to be [a future] Division chief."