BMJ Open · education.[14] In the UK demonstration of competency in the MLCF’s domains is...
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Leadership and management in the undergraduate medical curriculum: A qualitative study of students’ attitudes and
opinions at one UK medical school.
Journal: BMJ Open
Manuscript ID: bmjopen-2014-005353
Article Type: Research
Date Submitted by the Author: 27-Mar-2014
Complete List of Authors: Quince, Thelma; University of Cambridge, Medical School Abbas, Mark; Queen Edith Medical Practice, Murugesu, Sughashini; Imperial College Healthcare NHS Trust,
Crawley, Francesca; West Suffolk Hospital NHS Trust, Hyde, Sarah; University of Cambridge, School of Clinical Medicine Wood, Diana; University of Cambridge, School of Clinical Medicine Benson, John; University of Cambridge, The Primary Care Unit
<b>Primary Subject Heading</b>:
Medical education and training
Secondary Subject Heading: Medical management
Keywords:
MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Change management < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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Title page
Leadership and management in the undergraduate medical curriculum: A qualitative study of
students’ attitudes and opinions at one UK medical school.
Thelma Quince (corresponding author)
The Primary Care Unit,
University of Cambridge
Forvie Site
Cambridge CB2 0SR
UK
01223 330364
Mark Abbas
GP Principal,
Queen Edith Medical Practice,
Cambridge
UK
Sughashini Murugesu
Foundation Year 1 Doctor
Imperial College Healthcare NHS Trust
London
UK
Francesca Crawley
Consultant Neurologist
West Suffolk Hospital NHS Trust
Bury St. Edmunds
UK
Sarah Hyde
Hinchingbrooke Health Care NHS Trust
Hinchingbrooke
Cambridgeshire
UK
Diana Wood
School of Clinical Medicine
University of Cambridge
UK
John Benson,
The Primary Care Unit,
University of Cambridge
UK
Word count 4878 (including quotes)
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ABSTRACT
Objective: To explore undergraduate medical students’ attitudes towards and opinions about
leadership and management education.
Design: Between 2009-2012 we conducted a qualitative study comprising 5 focus group
discussions, each devoted to one of the 5 domains in the Medical Leadership Competency
Framework, (Personal Qualities, Working with Others, Managing Services, Improving Services
and Setting Direction). Each discussion examined “what should be learnt”, “when” “by what
methods”, “how assessed” and “the barriers” to such education.
Participants: Twenty eight students from all three clinical years (4-6) of whom 10 were women.
Results: Broadening students’ perspectives to include those other stakeholders’ and to encompass the
organisational and societal context of health care provision, together with making such education
clinically relevant emerged as crucial prerequisites in fostering positive attitudes towards
leadership and management education. Topics suggested by students included structure of the
NHS, team working skills, decision making and negotiating skills. Patient safety was seen as
particularly important. Students preferred experiential learning, with placements seen as providing
teaching opportunities. Structured observation, reflection, critical appraisal, and analysis of
mistakes at all levels were mentioned as existing opportunities for integrating leadership and
management education and making it more explicit. Students’ views about assessment and timing
of such education were mixed. Student feedback figured prominently as both a method of delivery
and a means of assessment, whilst attitudes of medical professionals, students and of society in
general were seen as barriers.
Conclusions: Medical students may be more open to leadership and management education than
thought hitherto. These findings offer insights into how students view possible developments in
leadership and management education and stress the importance of developing breadth of
perspective and clinical relevance in this context.
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ARTICLE SUMMARY
Article focus:
• To explore undergraduate medical students’ attitudes towards and opinions about
leadership and management education.
Key messages:
• Medical students may be more open to leadership and management education than thought
hitherto
• Students’ perspectives which include those of other stakeholders’ and which encompass the
organisational and societal context of health care provision, together with clinical
relevance are important pre-requisites in fostering positive attitudes towards leadership
and management education.
• Students identified many opportunities for integrating leadership and management into the
existing curriculum.
Strengths and limitations of this study:
• Focus groups permitted students themselves to direct the flow and content of the
discussion, so delve deeper into their opinions, and producing in rich insights into their
attitudes towards and opinions about leadership and management education.
• The trustworthiness of the data was enhanced by the use of multiple coders.
• The research team are not aware of any other qualitative study addressing this topic with
UK undergraduate medical students.
• It was conducted in one UK medical school. Although drawn from all three clinical years
the number of participating students was small and inevitably self-selecting
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INTRODUCTION
Sustainability of health services is currently a topic of international discussion.[1] Leadership and
management skills are required to ensure provision of high quality patient care by the UK NHS
which faces unprecedented changes.[2-6] Engagement of clinicians in leadership and
management appears beneficial: positive associations have been found between doctors appointed
to hospital boards of directors and both clinical outcomes and overall performance.[7-10] Clinical
quality depends upon inter-professional team working hence leadership and management skills
are needed at all levels.[11,12] The UK NHS Institute for Innovation and Improvement and
Academy of Medical Royal Colleges developed the Medical Leadership Competency Framework
(MLCF) outlining the competencies expected of practicing clinicians in respect of five domains
(Figure 1).[13]
Leadership and management abilities are recognised as key areas in postgraduate medical
education.[14] In the UK demonstration of competency in the MLCF’s domains is fundamental
for career progression and necessary for satisfactory completion of the Annual Review of
Competence Progression (ARCP) required for gaining accreditation. Although the number of
programmes and fellowships aimed at engaging postgraduates doctors in leadership and
management has risen concern is expressed that to be effective, engagement needs to start earlier
in medical training.[15-17]
Medical schools are charged with the responsibility of training physicians not only to be
diagnosticians but also to understand resource management, financial considerations and multi-
professional team working.[18] Despite this, education in leadership and management is less well
developed at undergraduate level and there is limited literature on how to incorporate this into the
undergraduate curriculum.[19-20]
We conducted a qualitative study exploring medical students’ attitudes towards and opinions
about leadership and management education in the undergraduate curriculum: specifically, what
should be learnt and when; what methods should be used; how should learning be assessed; and
what barriers exist to such education?
We consider these questions essential for guiding curriculum development whilst recognising that
they are common to leadership and management education in many professions and
specialties.[21]
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METHODS
We adopted a qualitative approach using focus group discussions to explore issues relevant to
students and to generate acceptable, practical suggestions. An essentialist thematic analysis was
used, focusing on the ideas, experiences, opinions and meanings presented by the participants.
[22] Given its wide acceptance, we structured our enquiry around the Medical Leadership
Competency Framework.[13]
Figure 1 in here
The medical course in Cambridge comprises three core science years, with a small element of
clinical experience, followed by three clinical years. Each year between 2009 and 2012 in either
May or September all clinical students (n=135 in each cohort) were invited by email to participate
in the study. Two reminders were issued two weeks apart. Those willing to participate were
contacted and a time suitable for the discussion identified. Because clinical students were on
placements at these times only those with reasonable access to Cambridge were able to attend.
Five focus group discussions were held, one relating to each dimension of the Medical Leadership
Competency Framework (Figure 1). Participants received an outline of the MLCF’s
competencies for medical students for the dimension under consideration together with a topic
guide. This information was briefly repeated at the outset of the discussions.
We requested written consent to participate in the initial email correspondence and again, in
writing at the outset of each discussion. Discussions lasted between 90 and 120 minutes and with
participants’ permission, were recorded and transcribed verbatim. Transcribed data was
anonymised and entered into NVivo 9 software. (QSR International Pty Ltd, Melbourne,
Australia).
In total 28 clinical students took part, (10 women). The nature of participants and schedule of
discussions are given in Table 1.
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Table 1 Focus participants and schedule of discussions.
Dimension Number of students Date of focus group
discussion
Facilitator(s)
Working with Others 6 (2 women) July 2009 MA, TQ
Personal Qualities 7 (3 women) Oct 2009 MA
Managing Services 4 (1 woman) Oct 2010 MA
Improving Services 4 (2 women) Oct 2011 MA
Setting Direction 7 (2 women) Oct 2012 TQ, SM
Total 28 (10)
Stage of course Stage 1 (Year 4) Stage 2 ( Year 5) Stage 3 ( Year 6)
Number of Students 7 9 12
Using the “Setting Direction” discussion authors TQ and SM, working independently, derived
coding frameworks. Subsequent discussions generated a common framework which TQ extended
to the other transcripts. Authors, JB and FC, then independently considered the appropriateness of
the resulting framework to all dimensions and adjustments made following discussions. TQ, JB
and FC independently applied the agreed framework to a selection of transcribed data. A high
level of agreement of code application was found (> 90%). Following discussion between TQ, JB
and FC an overall coding framework was agreed (table 2) and applied by TQ to all transcribed
material.
Coded data was scrutinised and emerging themes initially identified by TQ using an inductive
semantic approach based on the extent to which the theme captured something important to the
overall research questions and the extent to which themes gave an accurate reflection of the entire
data set rather than discussion of one dimension alone. Themes were considered against the
transcribed and coded data independently by 3 other authors (JB, FC and SH) and following
discussion the final analytic structure agreed.
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Table 2: Broad categories of codes. (Detailed codes given in Appendix 1)
1. Awareness: Recognition of the need to understand leadership and management in general, its
relevance to future work and the levels at which it applies.
2. Timing and structure: When in the undergraduate curriculum should teaching about
leadership and management start and how should or could that be structured?
3. Methods of Delivery: How should leadership and management teaching be delivered and the
advantages and disadvantages of different methods.
4. Assessment: How should the leadership and management learning be assessed and the
advantages and disadvantages of different methods of assessment.
5. What should be taught?(Topics): What topics should be covered in leadership and
management teaching in the undergraduate curriculum?
6. Barriers The factors which may inhibit undergraduate medical students’ interest in and
learning about leadership and management.
The study received ethical approval from the University of Cambridge Psychology Ethics
Committee (the relevant body for all studies involving University of Cambridge students).
RESULTS
This paper reports generic results, potentially relevant to other medical schools. Specific opinions
and recommendations about the Cambridge Medical Course are not presented.
Figure 2 in here
Two strongly inter-related and mutually reinforcing themes emerged as pre-requisites for
curriculum development: breadth of perspectives and relevance in the clinical context. Figure 2
summarises the relationship between themes and codes and the organisation of the results.
Section 1: Breadth of Perspectives
Students’ felt that leadership and management education should take a broad perspective at three
levels:
• society as a whole,
• organisations in which they would work
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• individuals with whom they would interact.
These considerations influenced students’ suggested topics for incorporation into the
undergraduate curriculum.
1.1 Societal perspectives
Students appreciated the economic, political and social context within which UK health care
operates; recognising that taking account of that context had become ‘part of the job of a doctor’
with associated personal responsibilities.
External circumstances directly affect how we deliver care healthcare. ….. that makes the idea of
resource allocation and clinical judgement and the managerial aspect to that perhaps more
relevant for us now than for doctors previously, …. but I don’t think it is something that has quite
filtered down to medical students.F3
Some students linked issues of resource allocation and clinical judgement and acknowledged that
tomorrow’s doctors had to become more involved and engaged in leadership and management.
We don’t live in a vacuum, medical profession like any other cannot be isolated ….we have to live
in a world in which things cost money, where you know we have a credit crunch. M16
For some students awareness needed to start at the undergraduate level in order to avoid potential
“resentment” when confronted with management tasks as practicing clinicians.
even as an F1 Dr doing paperwork, making minor management decisions are an inevitable part of
junior doctor life……. So I think it important that students are made aware ……..in order to
remove the resentment,M4
Others were concerned that awareness of the economic and political context could potentially
disillusion medical students. Some students felt that some patients’ had developed more
“consumerist” type attitudes and demands, which in turn could result in conflict. The development
of such attitudes was seen as likely to inhibit medical students’ appreciation of the role of
leadership and management.
1.2 Organisational perspectives
All participating students had undertaken placements on wards and in GP practices. Their
comments reflected their appreciation of the organisational context of health care and the need to
take account of the perspectives of managers, other health care professionals and patients.
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….. in the hospital, there were no beds so all medical elective admissions have been cancelled …
consultants were told this morning …., I presume by a manager – do your estimated daily
discharge and try and discharge patients... So that’s not necessarily offering the best care you can
– the consultants may fight for it but at the end of the day there is a whole queues of patients
lining up to come into the hospital and we’ve got limited resources. M17
Students were particularly aware of the role of teams, potential conflicts within them and the
influence of management and leadership skills on team performance and thereby patient care.
I have seen some teams that work really well together and deliver excellent patient care, …..and
then some teams have such problems between doctors and nurses. F2
They saw an ability to manage teams as part of the doctor’s job, with the concomitant need to
develop such competence at undergraduate level. Some went further saying that the lack of such
education left them unable to evaluate or learn from the team dynamics they observed in clinical
practice.
We don’t necessarily have an organised framework in our heads to articulate to ourselves what
kind of organisational culture this is and to therefore to understand what we need to take from it
and ..what is worth practicing ourselves. M3
1.3 Individual perspectives
Students’ comments reflected their keen awareness of the patient’s perspective. They reflected on
how difficult it must be for patients confronted by so many different specialities, and receiving a
plethora of, sometimes conflicting, information. They saw the need to involve the patient in
his/her care and to be able to act as advocate for that care. But at the same time others commented
that taking the approach of “the patient” overlooked the diversity of patients and their individual
needs.
Both poor and exemplary doctor/patient relationships and their potential educational impact were
frequently reported, demonstrating students’ awareness of the importance of “the system” in
relation to patient care.
Students were also aware of pressures on individual doctors arising from changes in health care
provision: restrictions imposed by external bodies such as the then Primary Care Trusts and
patients’ more consumerist, and at times, hostile approach. Some students were surprised that not
only would their own performance be assessed, but also they would be expected to assess that of
their colleagues.
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I think the managing performance bit is something that struck me because you see it on the wards
when you see junior Drs filling out surveys and questionnaires on their colleagues and saying
how's their performance and things. I was quite taken a back as I didn’t know that it was that
formal and structured, it’s probably a good thing…..I think … making us aware that you will have
to judge our colleagues would be quite useful. M3
1.4 What topics should be learned?
The idea of broadening perspectives strongly influenced the topics suggested for inclusion in the
undergraduate curriculum. Topics relating to the societal perspective included the structure of the
NHS and developments affecting health care systems in other countries. Experience on wards and
involvement in coding exercises made them aware of the complicated nature of financial tariffs
and the need to understand some of this even at undergraduate level.
you are leading or being part of a team to maximise efficiency so whatever you do there’s an
opportunity cost so you can bring some management economics kind of into that ….to make an
informed decision also you have to think of the human aspects of medicine so it is very much like
a risk benefit sort of thing. That notion has to be put across slightly better in the medical
curriculum. M9
From the organisational perspective students were aware that junior doctors encounter potential
conflicts at various levels: at the individual level needing to prioritise the care of one patient over
that of another; at the team level between clinical colleagues; and at the organisational level
between doctors and managers. Some were also aware that conflict could be beneficial if handled
correctly.
Students identified effective communications as a factor which improved team working.
Communication skills were seen as often well developed and practiced in the doctor/patient
context but not always applied to team work. Extending communication skills teaching to team
working was suggested. Some students reported that interaction with others clinical team
members was well taught. Others indicated that this did not extend to interaction with managers or
“management”. Involving, accepting and valuing others were also seen as important to effective
team work.
Negotiating and conflict resolution skills were seen as important and proposed for inclusion in the
undergraduate curriculum, as were decision making and evaluation. Students who had experience
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of management studies highlighted this.
they had something called the negotiation workshop where you learnt how to talk to convince
other people and how to put your points across... I think that would be really helpful for doctors
and as we go on to interact with other professions as well. F9
And no way along the process, in my mind in medicine, is it defined as to how to make a decision.
M15
Understanding how patients’ experience “the system”, perceive their illness and care and how
they can be enabled to have greater understanding, and decision making in respect of that care
were topics students considered relevant. Whistle-blowing was raised frequently. Concerns were
expressed about maintaining team relationships when events occurred. Generally participants
appeared unsure of their position as medical students when confronting patient safety issues and
the routes for progressing problems
Audits were seen by the students as both a specific topic for inclusion in leadership and
management education, as well as a method by which organisational aspects could be taught.
Section 2: Relevance in the Clinical context.
Students strongly articulated the view that leadership and management education should be
relevant for, and relate closely to, the clinical context. Relevance was seen to foster greater
awareness of the social, economic and political context within which health care operated.
… you need to use examples ….. real life examples of hospitals that are failing or management
teams that have failed and try and look at why they failed, cause it kind of brings it to attention
that this kind of thing does happen and the fact that people die because of it…M18
The need for relevance predominantly influenced students’ views about methods of delivery,
assessment and feedback on their performance.
2.1 Methods of Delivery
Emphasising experiential methods, students saw many opportunities for using clinical experience,
including pre-set questions, observation and reflection, critical appraisal, greater involvement in
ward activities and learning from mistakes.
take an event that has happened in the clinical area that you are working in at the minute, and try
to go back over it and think why did this event happen, what were the risks that were involved and
then make a discussion about how you could improve them afterwards. F1
Reflecting on observations was regarded generally as a continual process but views were divided
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as to how to incorporate this into leadership and management learning. Some students supported
reflective essays. Others felt such exercises often became formulaic, preferring one to one or
small group discussions.
you can sit and think about them yourself but often you need somebody else and different people’s
views to actually understand the whole concept and to get someone else’s opinion because you
only have what you think.F2
Greater involvement on wards was seen as facilitating learning and audits as an extension to this.
However leadership and management aspects needed to be clearly highlighted otherwise audits
could become mere paper exercises. It was suggested frequently that considerable informal
teaching of leadership and management occurred on wards and that these could be better
formalised within the existing curriculum. Critical appraisal of how consultants and others
demonstrated leadership and management skills was suggested as a way of identifying such skills
in the ward context. .
we don’t really need an extensive course as a lot of the skills are already there, it’s just as we
talked about there are different ways of getting people to think about themselves in a different
way. All the skills about the patient we learnt in (communication skills teaching)- actually, we
need to think about them in the context of leadership and teamwork, and how I should relate to my
colleagues, the people I work for, the people I work with and the people that work for me. M12
Leadership and management topics could also be taught through examination, analysis and
reflection on actual mistakes at all levels. But there were issues about how to handle the
information generated particularly if this in turn raised questions about whistle-blowing. One
focus groups took place during the publicity surrounding the Francis Report on the failures at Mid
Staffs NHS Foundation Trust. Students in this group commented on how uninformed they were
about systemic failures on this scale.
While endorsing case-based or problem-based learning as a method of delivery, some students felt
that the leadership and management aspects had to be made explicit.
I think the structure where you go through the scenario and understand why it is important …. but
teaching on leadership and management would be quite alien to medical students as we haven’t
experienced this before. I think … to make the relevance quite apparent is really important. M3
Team-building and coding exercises were reported as beneficial for leadership and management
education, but only by those students who had undertaken them. Very few students mentioned
“role play” as a useful method. Another suggestion was for an innovation competition to
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encourage students to think about improvements.
There was little support for didactic teaching methods. A few students argued that some topics
could be introduced through lectures, but the material itself had to relate to clinical reality, draw
on practical experience rather than theory and be presented enthusiastically. Others saw lectures
as inappropriate.
Actually in xxx there’s a fantastic lecturer who teaches operations and management…. When
they’re enthusiastic about their subject – you just enjoy it so much more M14
I disagree about lectures – they’re very very tedious. No matter what they’re on – on the whole I
find them tedious.M16
2.2 Assessment
Assessment was seen as difficult and its value questioned. Some students felt that without
assessment there would be no measurable outcome for evaluating learning. Others considered that
given the pressure on the curriculum, learning not assessed would not be seen as important. By
contrast some students felt that assessment would reduce interest and constitute yet another
“hoop” they needed to jump. Similarly contentious was the issue of whether there should be
minimum standards that medical students had to achieve.
There should be some kind of defined minimum standard you should have for certain skills and
that basically the same with clinical skills for example with OSCEs you repeat the assessment
until you pass F7
I disagree with you totally. M11
There was no consensus as to whether assessment should be at the group or individual level.
Some felt that assessment through a group task or presentation would be less threatening. Group
tasks included case-based or problem based exercises around structured scenarios or real
examples of failing wards, audits, root -cause analysis exercises and role play team work
exercises. For many of these exercises assessment through group discussion or some form of
presentation was suggested. Direct observations of individual and/or group performance was also
suggested but these would need clear and detailed assessment criteria extending beyond simple
“pass and fail” and assessment undertaken by experienced personnel. Others felt that peers should
be involved in assessment.
. there could be a group task so four or five applicants are given a task and there would be like 2
assessors looking at the interaction of the people M7
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I think it would be good idea if it was peer assessed as well because you know part of the whole
leadership thing surely that is about being able to take positive criticism from the team that you
are working in to incorporate their ideas so perhaps it would be good in a way. F1
Suggestions for assessing individual student’s leadership and management learning included
written short reports of observed scenarios or specific examples, which for some could be
integrated into or built on other reflective writing exercises. Other suggestions included
assessment through OSCE type exercises, verbal assessments through viva type situations and
either written or verbally presented critical appraisal exercises, based on observations of real
practice. An interesting idea was that assessment would cover not only what had been observed
but also the analysis of that observation in terms of leadership and management performance.
…..demonstrated that you are aware of how to make a decision, you are aware of the problems in
the scenario if there was one and you know some techniques of how to improve it or if not then
who to refer to or who to speak to..M15
2.3 Feedback
Feedback figured strongly as a method of delivery and a method of assessment. Students
indicated that feedback was frequently asymmetrical: they were asked to give feedback but often
did not receive feedback or it was of limited value in terms of learning. This was seen by some as
discouraging. Views about feedback directly from patients and from peers were divided. Some
students felt that feedback from patients facilitated understanding of their perspectives, others saw
its value in the leadership and management context as limited. Similarly some considered that
feedback from peers would be questioned and not taken seriously. Other students saw it as a
precursor to 360 degree appraisal useful in encouraging team working.
Using the 360 thing as an example you realise that your colleagues, it encourages working well in
a team and the importance of it and if you are working well with you colleague you are going to
get OK feedback but if you just regard your colleagues within the team, ok they are not as good as
me, they’re not pulling their weight. It encourages teamwork I would say. M5
While emphasising the importance of feedback on placement, the difficulties of accomplishing
this because of numbers of students and consultants and senior doctors availability were
acknowledged. It was also felt that because of the on-going nature of leadership and management
learning, feedback could greatly enhance the learning effectiveness of reflection, and exercises
such as audits.
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In terms of the assessment of the course, if you are going to have things then it is much better,
especially in something like audit or management where it is a continual process, it is not
something that you do and then you forget about, you should get feedback about things and it is
not just a pass/fail something like that. F2
Section 3: Related to both perspectives and relevance
Both breadth of perspectives and clinical relevance influenced students’ views about timing and
structure and of leadership and management education and factors likely to inhibit such
development.
3.1 Timing and Structure of leadership and management education
There was support for the notion that developing societal and organisational perspectives to health
care provision should begin early. It was generally felt that students needed to have experienced
the clinical context in order to appreciate fully the importance of leadership and management to
patient care however, opinions were divided as to when to introduce some of the topics suggested
above and in particular the issue of whistle-blowing.
3.2 Barriers to leadership and management education
Students cited changing attitudes within society and the medical profession itself as factors both
necessitating greater leadership and management education and as potential barriers.
I think people are facing really big societal things about society attitudes and again things,
attitudes within the medical profession itself too like communication skills like the management
skills. And this will all have an impact on public health. F3
From an organisational perspective, the longstanding hierarchical nature of the medical
profession, together with medical students’ attitudes towards this hierarchy were cited as a
potential barriers. The view was also expressed that the existing career structure observed by
medical students did not facilitate the practice and exercise of management skills. This view of
hierarchy underscored students’ views of the complexities of whistle-blowing.
.I think that if the GMC wants to encourage people to have great management skills, imagination
and situational awareness then they need to empower people to be able to use those things and
make us feel a little bit less constrained as medical students climbing up the very narrow career
ladder. F7
Attitudes towards leadership and management education held by both existing clinicians and
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medical students were seen as potential inhibitors. Similarly some consultants were seen as
holding negative attitudes to teaching students in general. Developing awareness of the potential
beneficial impact of management decisions on the patient was seen as negating such attitudes.
these consultants are the consultants with a clinical background already you know... “in my day
when I was a lad you know”. Is it that or is it actually they feel we are actually not being
prepared adequately to be a member of a clinical team. Is it just “we never had that
communication skills malarkey in our day and we came out just fine”? M6
DISCUSSION
A recent systematic review identified leadership and management as one of the key competencies
for undergraduate community- based education for health professionals.[23] Our study suggests
medical students may be more open and accepting of the role of leadership and management
education in medical education than thought hitherto. Broadening students’ perspectives to
encompass those of other stakeholders and of the organisational and societal context with which
health care is delivered is a facet of this. The results also indicate the importance of making
leadership and management education relevant in the clinical context. These results closely
parallel findings from a study of medical education leaders, who cited “attending to the world
outside” as a key area of their work.[24]
Many viable topics were suggested in the study including: structure of the NHS, factors which
develop team working skills such as communication and conflict resolution skills, and decision
making and negotiating skills. Patient safety was particularly important.
In common with other studies our students expresses a preference for experiential learning.[24]
Placements were seen as providing leadership and management teaching opportunities. Structured
observations, reflection on these, critical appraisal and analysis of mistakes at individual and
organisational level were all mentioned. Mindful of the crowded nature of the curriculum
students identified opportunities for making both leadership and management education more
explicit and more integrated.
Students’ views about assessment were more diverse and its value questioned. Feedback figured
prominently: in terms of how to give feedback, as a method for delivering leadership and
management education and as a means of assessment. The importance of direct, timely and
appropriate feedback in self-regulated learning has long been recognised.[25]
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Some attitudes held by medical professionals and students and by society as a whole were seen as
barriers to leadership and management education in the undergraduate medical curriculum.
Changing attitudes is often slow and difficult.
Strengths and weaknesses of the paper
Using focus groups allowed for in-depth discussion and for articulation and exploration of
students’ opinions and attitudes. The size and number of the focus groups, together with the fact
that participants were drawn from all three years of the clinical course meant a wide range of
views were presented. The Management Leadership Competency Framework was derived from
consensus discussions and its adoption as the basis for the focus group discussions lends support
for the approach adopted.[12] The analysis of material focused on the experiences, opinions, and
meanings reported by the students.
A significant weakness of the study is that it was based in one medical school with a significant
“pre-clinical/clinical” divide in the curriculum. Although drawn from all three clinical years, it
was not possible to differentiate between levels of maturity and professional experience of
participants. Different views might be expressed by pre-clinical and post graduate students. As
with most qualitative studies, participants were volunteers and perhaps predisposed to leadership
and management education. With the exception of the focus group discussion considering
“Setting Direction” it was not possible to provide participant validation of the results. Finally,
although widely supported, the Management Leadership Competency Framework is not without
criticism. Some have suggested that competency frameworks lay responsibility on the individual
with little regard for the context and environment within which the individual operates.[26]
Studies in many sectors have highlighted generic obstacles to teaching leadership and
management: specifically applicable to the undergraduate medical curriculum include variability
of leadership practices and lack of a consistent and deliberate practice in the field. Medical
students witness a potentially confusing array of leadership styles and practices and without clear
guidance they may be unable to evaluate what they observe. Whereas clinical skills can be
practiced through simulation, providing such a practice field for leadership and management skills
is more complex. This, together with the crowded nature of the curriculum, means that there are
few opportunities for real time coaching.
Further work might usefully explore the views of students earlier in their medical studies and the
views of students engaged in different types of course design. However, there is a need to develop
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leadership and management education in some form at the present time. Perhaps the most
pragmatic approach would be to introduce small initial changes and modify them in the light of
their evaluation.
These findings offer insights into how students view possible developments in leadership and
management education. Although necessarily a partial view, it is relevant to the difficult choices
that face curriculum planners seeking to strengthen education in this area in the face of an already
overcrowded timetable. Perhaps, for them, students’ insights into the opportunities to develop
leadership and management learning within existing curricular experiences are most significant.
Contributorship Statement:
The study was conceived and designed jointly by Mark Abbas(MA) Thelma Quince(TQ), John Benson(JB)
and Diana Wood (DW).
Focus group discussions were conducted by Mark Abbas (MA), Thelma Quince (TQ) and Sughashini
Murugesu (SM).
Data analysis was undertaken by Thelma Quince (TQ) Sughashini Murugesu (SM) Sarah Hyde (SH)
Francesca Crawley (FC) and John Benson (JB).
Thelma Quince (TQ) wrote the first draft of the paper with significant inputs from Sarah Hyde (SH) and
Francesca Crawley (FC). All authors were involved in refining this into the final draft.
Competing Interests
None
Data Sharing Statement:
Anonymised coded data from the study available from Thelma Quince. ([email protected])
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References
1 World Economic Forum, Sustainable Health Systems: Visions, Strategies, Critical Uncertainties
and Scenarios. Geneva, Switzerland, World Economic Forum, 2013.
2 Darzi AV. Our NHS,Our future: NHS Next Stage Review (Interim Report). Department of
Health, 2007.
3 Darzi AV. High Quality Care for All: NHS Next Stage Review (Final Report). Department of
Health, 2008.
4 Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The
Stationary Office, 2013.
5 The King's Fund. Leadership and engagement for improvement in the NHS: Together we can :
The King's Fund Leadership Review, The King's Fund, 2012.
6 Tooke J. Aspiring to excellence: Final report of the independent inquiry into modernising
medical careers. Medical Schools Council, 2008.
7 Goodall AH. Physician-leaders and hospital performance: Is there an association? Soc Sci Med
2011;73:535-9.
8 Lega F, Prenestini A, Spurgeon P. Is management essential to improving the performance and
sustainability of health care systems and organizations? A systematic review and a roadmap for
future studies. Value Health 2013;16(1 SUPPL.):S46-S51.
9 Prybil LD. Size, composition, and culture of high-performing hospital boards. Am J Med Qual
2006;21:224-9.
10 Veronesi G, Kirkpatrick I, Vallascas F. Clinicians on the board: what difference does it make?
Soc Sci Med 2013;77:147-55.
11 Hewison A, Gale N, Yeats R, Shapiro J. An evaluation of staff engagement programmes in
four National Health Service Acute Trusts. J Health Organ Manag 2013;27:85-105.
12 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges:
Medical Leadership Competency Framework, Enhancing engagement in medical leadership.
Second edition. Coventry, 2009.
13 Health and Social Care Act 2012. The Stationery Office , 2013.
14 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges:
Medical Leadership Curriculum. Coventry 2009.
15 Royal College of Physicians. Learning to Make a Difference. http://www.rcplondon.ac.uk/
projects/learning-make-difference-ltmd.
16 Bethune R, Soo E, Woodhead P, Van Hamel C, Watson J. Engaging all doctors in continuous
quality improvement: A structured, supported programme for first-year doctors across a training
deanery in England. BMJ Qual Saf 2013:22:613-617.
17 Swanwick T, McKimm J, Clinical leadership requires system-wide interventions, not just
courses. Clin Teach 2012; 9: 89-93.
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18 General Medical Council. Tomorrow's doctors: Outcomes and standards for undergraduate
medical education. General Medical Council, 2009.
19 Dobson C, Cockson J, Allgar V, McKendree J. Leadership training in the undergraduate
medical curriculum. Educ Prim Care. 2008;19:526-9.
20 Reid AM. Developing innovative leaders through undergraduate medical education. Educ Prim
Care. 2013;24:61-4.
21 Allen SJ, Middlebrooks A. The Challenge of Educating Leadership Expertise. Journal of
Leadership Studies. 2013;6:84-9.
22 Braun V. Clarke V. Using thematic analysis in psychology. Qual Res Psychology, 2006; 3:77-
101.
23 Ladhani Z. Scherpbier AJ. Stevens FJ. Competencies for undergraduate community based
education for the health professions: A systematic review. Med Teach 2012;39:733-743
24 Lieff S. Albert M. What do we do? Practices and learning strategies of medical education
leaders. Med Teach 2012; 34:312-319.
25 Nicol D. Macfarlane-Dick D. Formative assessment and self-regulated learning: A model and
seven principles of good feedback practice. Stud High Educ 2006; 31:199-218.
26 Bolden, R and Gosling, J. Leadership competencies: time to change the tune? Leadership,
2006;2:147-163.
The research received no specific grant from any funding agency in the public, commercial or not-
for-profit sectors.
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Figure 1: NHS Institute for Innovation and Improvement Medical Leadership Competency
Framework (Graphic downloaded from and available at:
http://www.institute.nhs.uk/assessment_tool/general/medical_leadership_competency_frame
work_-_homepage.html)
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Figure 2: Relationship between themes and codes
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Appendix 1: Leadership and Management Codes.
1. Awareness
Recognition of the need for medical students to have an understanding of leadership and
management in general, of the relevance to their future work and of the levels at which this
applies. a] Awareness of and interest in leadership and management in relation to each of the 5 dimensions:
Working with others
Personal qualities
Managing services
Improving services
Setting direction
b] In the context of the dr/patient relationship
c] In the context of changing NHS
d] In relation to different levels of training
e] Conceptions of leadership and management
2. Timing and structure
At what point in the undergraduate medical curriculum should teaching about leadership and
management start and how should or could that be structured? a] When? At what point in the curriculum should teaching start?
b] Structure? The structure of the timing eg strands, components etc
c] Integration The extent to which L&M could be integrated into the existing course
3. Methods of Delivery
How should leadership and management teaching be delivered and the advantages and
disadvantages of different methods. a] Didactic methods (lectures)
b] Experiential learning
In the clinical context: audits, coding exercises, care pathways, observing and critiquing
behaviour
Team building exercises.
c] Analysis of and reflection on real events (mistakes etc)
d] Mentorship
4. Assessment
How should the leadership and management learning be assessed and the advantages and
disadvantages of different methods of assessment. a] Assessment of the group:
Assessment of output of groups ( posters, presentations)
Assessment of group in team exercise
b] Assessment of the individual
Written
Demonstration (OSCEs)/Oral
Feedback from others ( patients, doctors, peers)
c] Criteria ( minimum standards)
d] By whom? Peers or faculty
5. What should be taught? Topics
What topics should be covered in leadership and management teaching in the undergraduate
curriculum?
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a] Economic, political and organisational structure of the NHS
Changes in that
Other health care systems
b] Conflict
Conflicting demands faced by doctors, managers, members of teams
Arising out of changing context in NHS
Conflict resolution
c] Decision making
d] Patient safety issues
Progressing problems, whistle blowing
Root cause analysis
e] How to give feedback
f] How to reflect
6. Barriers to leadership and management education
The factors which may inhibit undergraduate medical students’ interest in and learning about
leadership and management. a] Relevance: the importance of
b] Time: problems of an overloaded curriculum
c] Attitudes; of medical students themselves, seniors and faculty
Importance of enthusiastic role models
Risk of disillusioning medical students
d] Challenge not hoops
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Leadership and management in the undergraduate medical curriculum: A qualitative study of students’ attitudes and
opinions at one UK medical school.
Journal: BMJ Open
Manuscript ID: bmjopen-2014-005353.R1
Article Type: Research
Date Submitted by the Author: 09-Jun-2014
Complete List of Authors: Quince, Thelma; University of Cambridge, Medical School Abbas, Mark; Queen Edith Medical Practice, Murugesu, Sughashini; Imperial College Healthcare NHS Trust,
Crawley, Francesca; West Suffolk Hospital NHS Trust, Hyde, Sarah; University of Cambridge, School of Clinical Medicine Wood, Diana; University of Cambridge, School of Clinical Medicine Benson, John; University of Cambridge, The Primary Care Unit
<b>Primary Subject Heading</b>:
Medical education and training
Secondary Subject Heading: Medical management
Keywords:
MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Change management < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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Title page
Leadership and management in the undergraduate medical curriculum: A qualitative study of
students’ attitudes and opinions at one UK medical school.
Thelma Quince (corresponding author)
Educational Research Associate
The Primary Care Unit
University of Cambridge
Forvie Site
Cambridge CB2 0SR
UK.
01223 330364
Mark Abbas
GP Principal
Queen Edith Medical Practice
Cambridge
UK.
Sughashini Murugesu
Foundation Year 1 Doctor
Imperial College Healthcare NHS Trust
London
UK.
Francesca Crawley
Consultant Neurologist
West Suffolk Hospital NHS Trust
Bury St. Edmunds
UK.
Sarah Hyde
Academic Clinical Fellow, Medicine
Hinchingbrooke Health Care NHS Trust
Hinchingbrooke
Cambridgeshire
UK.
Diana Wood
Clinical Dean
School of Clinical Medicine
University of Cambridge
UK.
John Benson
Senior Lecturer in General Practice
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Director, General Practice Education Group
The Primary Care Unit
University of Cambridge
UK.
Word count: 4563 including quotes.
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ABSTRACT
Objective: To explore undergraduate medical students’ attitudes towards and opinions about
leadership and management education.
Design: Between 2009-2012 we conducted a qualitative study comprising 5 focus group
discussions, each devoted to one of the 5 domains in the Medical Leadership Competency
Framework, (Personal Qualities, Working with Others, Managing Services, Improving Services
and Setting Direction). Each discussion examined, what should be learnt, when should this occur,
what methods should be used, how should learning be assessment what are the barriers to such
education.
Participants: Twenty eight students from all three clinical years (4-6) of whom 10 were women.
Results: Two inter-related themes emerged: understanding the broad perspective of patients and
other stakeholders involved in health care provision and the need to make leadership and
management education relevant in the clinical context. Topics suggested by students included
structure of the NHS, team working skills, decision making and negotiating skills. Patient safety
was seen as particularly important. Students preferred experiential learning, with placements seen
as providing teaching opportunities. Structured observation, reflection, critical appraisal, and
analysis of mistakes at all levels were mentioned as existing opportunities for integrating
leadership and management education. Students’ views about assessment and timing of such
education were mixed. Student feedback figured prominently as both a method of delivery and a
means of assessment, whilst attitudes of medical professionals, students and of society in general
were seen as barriers.
Conclusions: Medical students may be more open to leadership and management education than
thought hitherto. These findings offer insights into how students view possible developments in
leadership and management education and stress the importance of developing broad perspectives
and clinical relevance in this context.
ARTICLE SUMMARY
Article focus:
• To explore undergraduate medical students’ attitudes towards and opinions about
leadership and management education.
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Key messages:
• Medical students may be more open to leadership and management education than thought
hitherto.
• Undergraduate medical students need to be encouraged to appreciate the perspectives of
patients and other stakeholders, and the organisational and societal context within which
health care is delivered.
• Leadership and management education needs to be relevant in the clinical context.
• Students identified many opportunities for integrating leadership and management into the
existing curriculum.
Strengths and limitations of this study:
• Focus groups permitted students to direct the flow and content of the discussion, enabling
them to delve deeper into their views about leadership and management education.
• The trustworthiness of the data was enhanced by the use of multiple coders.
• The research team are not aware of any other qualitative study addressing this topic with
UK undergraduate medical students.
• It was conducted in one UK medical school. Although drawn from all three clinical years
the number of participating students was small and inevitably self-selecting.
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Leadership and management in the undergraduate medical curriculum: A
qualitative study of students’ attitudes and opinions.
Thelma Quince, John Benson, Francesca Crawley, Mark Abbas, Sarah Hyde, Sughashini Murugesu, Diana
Wood
INTRODUCTION
Leadership and management skills are required to ensure provision of high quality patient care.
[1-5] Active engagement of clinicians in leadership and management appears beneficial and
positive associations have been found between doctors appointed to hospital boards of directors
and both clinical outcomes and overall performance.[6-10] Clinical quality depends upon inter-
professional team working hence leadership and management skills are needed at all
levels.[11,12] Recently the UK NHS Institute for Innovation and Improvement and Academy of
Medical Royal Colleges developed the Medical Leadership Competency Framework (MLCF)
outlining the competencies expected of practicing clinicians.[13]
Leadership and management abilities are recognised as key areas in postgraduate medical
education. [14] In the UK demonstration of competency in the MLCF’s domains is fundamental
for career progression and necessary for satisfactory completion of the Annual Review of
Competence Progression (ARCP) required for gaining accreditation. However to be effective,
engagement needs to start earlier in medical training.[15-17]
Medical schools are charged with the responsibility of training physicians not only to be
diagnosticians but also to understand resource management, financial considerations and multi-
professional team working.[18] Despite this, and the publication in 2010 of guidance for
undergraduate medical education relating to the MLCF, (publication was after the start of this
study and included three authors of this paper as contributors), education in leadership and
management is less well developed at undergraduate level and there is limited literature on how to
incorporate this into the undergraduate curriculum.[19-21]
We conducted a qualitative study exploring medical students’ attitudes towards and opinions
about leadership and management education in the undergraduate curriculum .We asked the
following questions:
• What leadership and management content should be addressed?
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• At what point in the undergraduate curriculum should the teaching and learning occur?
• What methods should be used?
• How should learning be assessed?
• What are the barriers to such education
METHODS
We adopted a qualitative approach using focus group discussions to explore issues relevant to
students and to generate acceptable, practical suggestions. An essentialist thematic analysis was
used, focusing on the ideas, experiences, opinions and meanings presented by the participants.
[22]
The standard medical course in Cambridge comprises three core science years, with a small
element of clinical experience, followed by three clinical years, each comprising approximately
140 students. Between 2009 and 2012 clinical students from each of the years 4-6 were invited by
email to participate in the study. Two reminders were issued two weeks apart and those willing to
participate were contacted. Five focus group discussions were held, one relating to each
dimension of the MLCF (Figure 1).
Insert Figure 1 here.
Participants received an outline of the MLCF’s competencies for medical students for the
dimension under consideration together with a topic guide.[19] This information was briefly
repeated at the outset of the discussions.
Written consent to participate was requested in the initial email and again, at the outset of each
discussion. Discussions lasted between 90 and 120 minutes and, with participants’ permission,
were recorded and transcribed verbatim. Transcribed data was anonymised and entered into
NVivo 9 software. (QSR International Pty Ltd, Melbourne, Australia).
In total 28 clinical students took part, (10 women). The nature of participants and schedule of
discussions are given in Table 1. All Year 6 participants had received formal instruction in
leadership and management comprising a one day course, midway in their final year.
Table 1 Focus participants and schedule of discussions.
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Dimension Number of students Date of focus group
discussion
Facilitator(s)
Working with Others 6 (2 women) July 2009 MA, TQ
Personal Qualities 7 (3 women) Oct 2009 MA
Managing Services 4 (1 woman) Oct 2010 MA
Improving Services 4 (2 women) Oct 2011 MA
Setting Direction 7 (2 women) Oct 2012 TQ, SM
Total 28 (10 women)
Stage of course Year 4 Year 5 Year 6
Number of Students 7 9 12
Using the “Setting Direction” discussion TQ and SM independently derived coding frameworks.
Subsequent discussions generated a common framework which TQ extended to the other
transcripts. JB and FC independently considered the appropriateness of the resulting framework to
all dimensions and adjustments were made. TQ, JB and FC independently applied the agreed
framework to a selection of transcribed data. A high level of agreement of code application was
found (> 90%). Following discussion between TQ, JB and FC an overall coding framework was
agreed (table 2) and applied by TQ to all transcribed material.
Coded data was scrutinised and emerging themes initially identified by TQ using an inductive
semantic approach. These were based on the extent to which the theme captured something
important to the overall research questions and the extent to which the theme accurately reflected
the entire data set rather than one dimension alone. Themes were considered against the
transcribed and coded data independently by JB, FC and SH, and following discussion, the final
analytic structure agreed. Students participating in the “Setting direction” discussion were able to
comment on the results of their discussion which were presented as a poster.
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Table 2: Broad categories of codes. (Detailed codes given in Appendix 1)
1. Awareness: Recognition of the need to understand leadership and management in general, its
relevance to future work and the levels at which it applies.
2. Timing and structure: When in the undergraduate curriculum should teaching about
leadership and management start and how should or could that be structured?
3. Methods of Delivery: How should leadership and management teaching be delivered and the
advantages and disadvantages of different methods.
4. Assessment: How should the leadership and management learning be assessed and the
advantages and disadvantages of different methods of assessment.
5. What should be taught? What topics should be covered in leadership and management
teaching in the undergraduate curriculum?
6. Barriers: Factors that may inhibit undergraduate medical students’ interest in and learning
about leadership and management.
The study received ethical approval from the University of Cambridge Psychology Ethics
Committee (the relevant body for all studies involving University of Cambridge students).
This paper reports generic results, potentially relevant to other medical schools. Opinions and
recommendations specific to the Cambridge Medical Course are not presented.
RESULTS
Figure 2 in here
Two strongly inter-related themes were identified: understanding the broad perspective of patients
and other stakeholders involved in health care provision and the need to make leadership and
management education relevant in the clinical context. (Figure 2) The resulting students’
suggestions and opinions are presented in relation to each theme and in a third section relating to
both themes.
Understanding perspectives. [Section 1]
Figure 3 in here
Students believed that leadership and management education should encourage them to
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understand perspectives at three levels:
• society as a whole,
• organisations in which they would work
• individuals with whom they would interact.
These considerations influenced students’ suggested topics for incorporation into the
undergraduate curriculum.
Societal perspectives
The economic, political and social context within which UK health care operates was appreciated.
Clinical judgement and resource allocation were seen as linked and hence the need for tomorrow’s
doctors to become more involved and engaged in leadership and management.
External circumstances directly affect how we deliver care healthcare. ….. that makes the idea of
resource allocation and clinical judgement and the managerial aspect to that, perhaps more
relevant for us now than for doctors previously, …. but I don’t think it is something that has quite
filtered down to medical students.F3
Organisational perspectives
All participating students had undertaken placements in hospitals and general practice. Students
recognised the organisational context of health care and the need to take account of the
perspectives of managers, other health care professionals and patients.
….. in the hospital, there were no beds so all medical elective admissions have been cancelled …
consultants were told this morning …., I presume by a manager – do your estimated daily
discharge and try and discharge patients... So that’s not necessarily offering the best care you can
– the consultants may fight for it but at the end of the day there is a whole queues of patients
lining up to come into the hospital and we’ve got limited resources. M17
There was awareness of the role of teams, potential conflicts within teams and between clinicians
and managers and, more importantly, the influence of management and leadership skills on team
performance and thereby patient care.
I have seen some teams that work really well together and deliver excellent patient care, …..and
then some teams have such problems between doctors and nurses. F2
Ability to manage teams was seen as part of the doctor’s job and hence the need to develop these
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skill at undergraduate level was identified. Students lacking such education reported feeling
unable to evaluate or learn from the team dynamics they observed in clinical practice.
We don’t necessarily have an organised framework in our heads to articulate to ourselves what
kind of organisational culture this is and to therefore to understand what we need to take from it
and..what is worth practicing ourselves. M3
Individual perspectives
Involving the patient in his/her care and clinicians acting as advocate for that care were seen as
important, as were patients’ diversity and individual needs. Both poor and exemplary
doctor/patient relationships and their potential educational impact were reported frequently.
Pressures faced by individual doctors in all aspects of their daily practice were acknowledged.
Some students were surprised that not only would their own performance as doctors be assessed,
but also they would be expected to assess that of their colleagues.
I think the managing performance bit is something that struck me because you see it on the wards
when you see junior Drs filling out surveys and questionnaires on their colleagues and saying
how's their performance and things. I was quite taken a back as I didn’t know that it was that
formal and structured, it’s probably a good thing…..I think … making us aware that you will have
to judge our colleagues would be quite useful. M3
Suggested topics for inclusion in the undergraduate curriculum.
Topics relating to the societal perspective included the structure of the NHS, including financial
and resource constraints. Some students felt that comparisons with developments in health care
systems in other countries should be included.
Students’ clinical experience fostered awareness of the complicated nature of clinical coding and
its financial implications and there was a need to understand some of this, even at undergraduate
level.
you are leading or being part of a team to maximise efficiency so whatever you do there’s an
opportunity cost so you can bring some management economics kind of into that ….to make an
informed decision also you have to think of the human aspects of medicine so it is very much like
a risk benefit sort of thing. That notion has to be put across slightly better in the medical
curriculum. M9
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Effective communications was seen to improve team working. However this was not always
applied to team work and extending communication skills teaching to include this was suggested.
Greater interaction with manager and learning to involve, accept and value were also seen to
foster effective team work.
Negotiating, conflict resolution skills, decision making and evaluating change were proposed for
inclusion. Students who had experience of management studies highlighted this.
they had something called the negotiation workshop where you learnt how to talk to, convince
other people, and how to put your points across... I think that would be really helpful for doctors
and as we go on to interact with other professions as well. F9
And no way along the process, in my mind in medicine, is it defined as to how to make a decision.
M15
Understanding patients’ experience of their journey through the healthcare system and how they
might be enabled to take part in decision making in respect of that care was considered relevant.
Participants appeared unsure of both their position as medical students when confronting patient
safety issues and the routes for progressing problems. As a result patient safety and whistle-
blowing were suggested frequently as topics for inclusion.
Audit was seen as both a specific topic for inclusion in leadership and management education, as
well as a method by which organisational aspects could be taught.
Relevance in the clinical context. [Section 2]
Figure 4 in here
The view that leadership and management education should be relevant for, and relate closely to,
the clinical context was strongly expressed. Relevance was seen to foster greater awareness of the
social, economic and political context within which health care operated. In turn relevance
influenced students’ views about methods of delivery, assessment and feedback on their
performance.
… you need to use examples ….. real life examples of hospitals that are failing or management
teams that have failed and try and look at why they failed, cause it kind of brings it to attention
that this kind of thing does happen and the fact that people die because of it…M18
Methods of Delivery
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Experiential methods were preferred with many opportunities for using clinical experience given
as examples. These, including pre-set questions, observation and reflection, critical appraisal,
greater involvement in ward activities and learning from mistakes.
take an event that has happened in the clinical area that you are working in at the minute, and try
to go back over it and think why did this event happen? What were the risks that were involved
and then make a discussion about how you could improve them afterwards. F1
Reflecting on observations was regarded generally as a continual process but views were divided
as to how to incorporate this into leadership and management learning. Some students supported
reflective essays. Others felt such exercises often became formulaic, preferring one to one or
small group discussions.
Greater involvement on wards was seen to facilitate learning and audits as an extension to this.
However, leadership and management aspects needed to be clearly highlighted otherwise audits
could become mere paper exercises. A great deal of informal teaching of leadership and
management was seen on clinical attachments which could be formalised and incorporated within
the existing curriculum. Critical appraisal of how consultants and others demonstrated leadership
and management skills was suggested as a way of identifying such skills in the clinical context.
we don’t really need an extensive course as a lot of the skills are already there, it’s just as we
talked about there are different ways of getting people to think about themselves in a different
way. All the skills about the patient we learnt in (communication skills teaching)- actually, we
need to think about them in the context of leadership and teamwork, and how I should relate to my
colleagues, the people I work for, the people I work with and the people that work for me. M12
Leadership and management topics could also be taught by analysing and reflecting on actual
mistakes at all levels. But concerns were raised about the information generated could be handled,
particularly if it raised whistle-blowing issues. One focus groups took place during the publicity
surrounding the Francis Report on the failures at Mid Staffs NHS Foundation Trust. [3] Students
in this group commented on how uninformed they were about systemic failures on this scale.
While endorsing case-based or problem-based learning as a method of delivery, the leadership and
management aspects had to be made explicit.
I think the structure where you go through the scenario and understand why it is important …. but
teaching on leadership and management would be quite alien to medical students as we haven’t
experienced this before. I think … to make the relevance quite apparent is really important. M3
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Team-building and coding exercises were reported as beneficial for leadership and management
education by those students who had undertaken them. Very few students mentioned “role play”
as a useful method.
There was little support for didactic teaching methods. A few students argued that some topics
could be introduced through lectures, if the material was clinically relevant, drew on practical
experience and presented enthusiastically. Others saw lectures as inappropriate.
Assessment
Views about assessment were divided and its value questioned. Supporting assessment were
views that without assessment there would be no measurable outcomes to evaluate learning and
learning would not be seen as important. Contrasting views were that assessment would reduce
interest and constitute yet another “hoop” through which students needed “to jump”. Similarly
contentious was the issue of whether there should be minimum standards that medical students
had to achieve.
There should be some kind of defined minimum standard you should have for certain skills and
that basically the same with clinical skills for example with OSCEs you repeat the assessment
until you pass F7
I disagree with you totally. M11
There was also no consensus as to whether assessment should be at the group or individual level.
Some felt that assessment through a group task or presentation would be less threatening.
Suggested group tasks included case-based or problem based exercises using structured scenarios
or real examples of failing wards, audits, root-cause analysis exercises and role play team-work
exercises. Directly observing group performance was also suggested. These would need clear and
detailed assessment criteria extending beyond simple “pass and fail” and assessment undertaken
by experienced personnel. Others felt that peers should be involved in assessment.
.. there could be a group task so four or five applicants are given a task and there would be like 2
assessors looking at the interaction of the people M7
I think it would be good idea if it was peer assessed as well because you know part of the whole
leadership thing surely that is about being able to take positive criticism from the team that you
are working in to incorporate their ideas so perhaps it would be good in a way. F1
Similar suggestions about observing individual students’ leadership and management performance
were also made. Other suggestions included written short reports of observed scenarios or
specific real practice, critical appraisal exercises, OSCE type exercises, other verbal assessments
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through viva type situations.. One interesting suggestion was that assessment would cover not
only what had been observed but also the analysis of that observation in terms of leadership and
management performance.
…..demonstrated that you are aware of how to make a decision, you are aware of the problems in
the scenario if there was one and you know some techniques of how to improve it or if not then
who to refer to or who to speak to..M15
Feedback
Feedback figured strongly as both a method of delivery and a method of assessment. Students
indicated that feedback was frequently asymmetrical: they were asked to give feedback but often
did not receive feedback or received feedback of limited value in terms of learning. For some this
was discouraging. Views about feedback directly from patients and from peers were divided.
Some students felt that feedback from patients facilitated understanding of their perspectives,
others saw its value in the leadership and management context as limited. Similarly contentious
was feedback from peers: some participants felt it would be questioned and not regarded
seriously; others saw it as a precursor to 360 degree appraisal useful in encouraging team
working.
Using the 360 thing as an example you realise that your colleagues, it encourages working well in
a team and the importance of it and if you are working well with you colleague you are going to
get OK feedback but if you just regard your colleagues within the team, ok they are not as good as
me, they’re not pulling their weight. It encourages teamwork I would say. M5
It was also felt that feedback could greatly enhance the learning effectiveness of reflection, and
exercises such as audits.
In terms of the assessment of the course, if you are going to have things then it is much better,
especially in something like audit or management where it is a continual process, it is not
something that you do and then you forget about, you should get feedback about things and it is
not just a pass/fail something like that. F2
Understanding perspectives in their clinical context and relevance. [Section 3]
Figure 5 in here.
Students’ views about timing and structure and of leadership and management education in the
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undergraduate, curriculum, together with what they considered to be the barriers to such education
were shaped by both themes.
When should leadership and management education take place?
Conflicting views were expressed about when undergraduate students should be made aware of
the economic political and social context of health care provision. Some students felt that
awareness needed to start at the undergraduate level in order to avoid potential “resentment” when
confronted with management tasks as practicing clinicians. Others felt that awareness could
potentially disillusion medical students. “Consumerist” attitudes and demands expressed by some
patients were seen as possible sources of conflict and hence likely to inhibit medical students’
appreciation of the role of leadership and management.
even as an F1 Dr doing paperwork, making minor management decisions are an inevitable part of
junior doctor life……. So I think it important that students are made aware ……..in order to
remove the resentment,M4
However there was support for the notion that developing organisational perspectives to health
care provision should begin early. It was generally felt that to appreciate fully the importance of
leadership and management to patient care students had to have experienced the clinical context.
But opinions were divided as to when to introduce some of the suggested topics, and in particular
the issue of whistle-blowing. The overriding view was that leadership and management education
should be incorporated into the existing curriculum and hence be ongoing.
The barriers to leadership and management education
Changing attitudes within society and the medical profession itself were seen as both necessitating
greater leadership and management education and as potential barriers.
From an organisational perspective, the hierarchical nature of the medical profession and medical
students’ attitudes towards this hierarchy were cited as a potential barriers. The existing career
structure was seen not to facilitate or encourage the practice and exercise of management skills.
This view of hierarchy underscored students’ views of the complexities of whistle-blowing.
.I think that if the GMC wants to encourage people to have great management skills, imagination
and situational awareness then they need to empower people to be able to use those things and
make us feel a little bit less constrained as medical students climbing up the very narrow career
ladder. F7
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Attitudes towards leadership and management education held by both existing clinicians and
medical students were seen as potential inhibitors. Similarly some consultants were seen as
holding negative attitudes to teaching students in general. Developing awareness of the potential
beneficial impact of management decisions on the patient was seen as negating such attitudes.
these consultants are the consultants with a clinical background already you know... “in my day
when I was a lad you know”. Is it that or is it actually they feel we are actually not being
prepared adequately to be a member of a clinical team. Is it just “we never had that
communication skills malarkey in our day and we came out just fine”? M6
DISCUSSION
Clinician involvement in leadership and management has a beneficial effect on health care
delivery and concomitantly the quality of patient care. [8-10] If more of tomorrow’s doctors are to
engage in leadership and management there is a need to educate today’s medical students. Despite
the development of leadership and management education initiatives for first year doctors,
evidence of such developments at the undergraduate level are more limited. [16]
A recent systematic review identified leadership and management as one of the key competencies
for undergraduate community- based education for health professionals.[24] Our study suggests
medical students may be more open and accepting of the role of leadership and management
education in medical education than thought hitherto. Although we took as our starting points the
MLCF it was not our intention to compare in detail the suggestions made by our students with
suggestions for leadership and management education outlined in the guidance for undergraduate
medical education.[19] Nevertheless there are areas of commonality: encouraging students’
appreciation of the perspectives other stakeholders and of the organisational and societal context
within which health care is delivered is one. As is, the importance of making leadership and
management education relevant in the clinical context. [19] These results closely parallel findings
from a study of medical education leaders, who cited “attending to the world outside” as a key
area of their work.[25]
Many viable topics were suggested including: structure of the NHS, facilitators of team working
such as conflict resolution, negotiating and communication skills, and decision making. Patient
safety was particularly important.
In common with other studies experiential learning was preferred.[26] Placements were seen to
provide teaching opportunities. Structured observations, reflection on these, critical appraisal and
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analysis of mistakes at individual and organisational level were all mentioned. Mindful of the
crowded nature of the curriculum students identified opportunities for integrating leadership and
management education.
Students’ views about assessment were more diverse. Feedback figured prominently: in terms of
how to give feedback, as a method for delivering leadership and management education and as a
means of assessment. The importance of direct, timely and appropriate feedback in self-regulated
learning has long been recognised.[27]
Some attitudes held by medical professionals and students and by society as a whole were seen as
barriers to leadership and management education in the undergraduate medical curriculum.
Changing attitudes is often slow and difficult.
Strengths and weaknesses of the paper
Using focus groups allowed for in-depth discussion and exploration of students’ views. The size
and number of the focus groups, together with the fact that participants were drawn from all three
years of the clinical course meant a wide range of views were presented. The Management
Leadership Competency Framework was derived from consensus discussions and its adoption as
the basis for the focus group discussions lends support for the approach adopted.[11]
A significant weakness of the study is that it was based in one medical school with a significant
“pre-clinical/clinical” curricular divide. As with most qualitative studies, participants were
volunteers, potentially predisposed to leadership and management education. With the exception
of the focus group discussion considering “Setting Direction” it was not possible to provide
participant validation of the results. Finally, although widely supported, the Management
Leadership Competency Framework has been criticised for laying responsibility on the individual
with little regard for the context and environment within which they operate.[28]
Further Work
Studies in many sectors have highlighted generic obstacles to teaching leadership and
management: specifically applicable to the undergraduate medical curriculum include variability
of leadership practices and lack of a consistent and deliberate practice in the field. [29] Medical
students witness a potentially confusing array of leadership styles and practices and without clear
guidance they may be unable to evaluate what they observe. Whereas clinical skills can be
practiced through simulation, providing such a practice field for leadership and management skills
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is more complex. This, together with the crowded nature of the curriculum, means that there are
few opportunities for real time coaching.
Further work might usefully explore the views of students earlier in their medical studies and the
views of students engaged in different types of course design. However, there is a need to develop
leadership and management education in some form at the present time. Perhaps the most
pragmatic approach would be to introduce small initial changes and modify them in the light of
their evaluation.
Conclusions
These findings offer insights into how students view possible developments in leadership and
management education. Although necessarily a partial view, it is relevant to the difficult choices
that face curriculum planners seeking to strengthen education in this area in the face of an already
overcrowded timetable. Perhaps, for them, students’ insights into the opportunities to develop
leadership and management learning within existing curricular experiences are most significant.
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A] Contributorship statement:
The study was conceived and designed jointly by Mark Abbas(MA) Thelma Quince(TQ), John
Benson(JB) and Diana Wood (DW).
Focus group discussions were conducted by Mark Abbas (MA), Thelma Quince (TQ) and
Sughashini Murugesu (SM).
Data analysis was undertaken by Thelma Quince (TQ) Sughashini Murugesu (SM) Sarah Hyde
(SH) Francesca Crawley (FC) and John Benson (JB).
Thelma Quince (TQ) wrote the first draft of the paper with significant inputs from Sarah Hyde
(SH) and Francesca Crawley (FC). All authors were involved in refining this into the final
draft.B] Competing interests:
None of the authors have any competing interests.
C] Funding:
The research received no specific grant from any funding agency in the public, commercial or not-
for-profit sectors.
D] Data sharing:
Anonymised coded data from the study available from Thelma Quince.
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References
1 Darzi AV. Our NHS, Our future: NHS Next Stage Review (Interim Report). Department of
Health, 2007.
2 Darzi AV. High Quality Care for All: NHS Next Stage Review (Final Report). Department of
Health, 2008.
3 Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The
Stationary Office, 2013.
4 The King's Fund. Leadership and engagement for improvement in the NHS: Together we can:
The King's Fund Leadership Review, The King's Fund, 2012.
5 Tooke J. Aspiring to excellence: Final report of the independent inquiry into modernising
medical careers. Medical Schools Council, 2008.
6 Goodall AH. Physician-leaders and hospital performance: Is there an association? Soc Sci Med
2011;73:535-9.
7 Lega F, Prenestini A, Spurgeon P. Is management essential to improving the performance and
sustainability of health care systems and organizations? A systematic review and a roadmap for
future studies. Value Health 2013;16(1 SUPPL.):S46-S51.
8 Prybil LD. Size, composition, and culture of high-performing hospital boards. Am J Med Qual
2006;21:224-9.
9 Veronesi G, Kirkpatrick I, Vallascas F. Clinicians on the board: what difference does it make?
Soc Sci Med 2013;77:147-55.
10 Dorgan S, Layton D, Bloom N, et al. Management in healthcare: Why good practice really
matters. McKinsey and Co. and LSE (CEP). London, 2010.
11 Hewison A, Gale N, Yeats R, Shapiro J. An evaluation of staff engagement programmes in
four National Health Service Acute Trusts. J Health Organ Manag 2013;27:85-105.
12 The King’s Fund. The future of leadership and management in the NHS: No more heroes. The
King’s Fund, London, 2011.
13 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges:
Medical Leadership Competency Framework, Enhancing engagement in medical leadership.
Second edition. Coventry, 2009
14 NHS Institute for Innovation and Improvement. The Clinical Leadership Competency
Framework. Coventry 2011.
15 Royal College of Physicians. Learning to Make a Difference. http://www.rcplondon.ac.uk/
projects/learning-make-difference-ltmd.
16 Bethune R, Soo E, Woodhead P, et al. Engaging all doctors in continuous quality
improvement: A structured, supported programme for first-year doctors across a training deanery
in England. BMJ Qual Saf 2013:22:613-617.
17 Swanwick T, McKimm J, Clinical leadership requires system-wide interventions, not just
courses. Clin Teach 2012; 9: 89-93.
Page 20 of 55
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21
18 General Medical Council. Tomorrow's doctors: Outcomes and standards for undergraduate
medical education. General Medical Council, 2009.
19 Spurgeon P, Down I. Guidance for Undergraduate Medical Education: Integrating the Medical
Leadership Competency Framework, NHS Institute for Innovation and Improvement and the
Academy of Medical Royal Colleges 2010
20 Dobson C, Cockson J, Allgar V, et al. Leadership training in the undergraduate medical
curriculum. Educ Prim Care. 2008;19:526-9.
21 Reid AM. Developing innovative leaders through undergraduate medical education. Educ Prim
Care. 2013;24:61-4.
22 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychology, 2006; 3:77-
101.
23 Malterud K. Qualitative research: standards, challenges and guidelines. The Lancet,2001;
358:483-487.
24 Ladhani Z. Scherpbier AJ. Stevens FJ. Competencies for undergraduate community based
education for the health professions: A systematic review. Med Teach 2012;39:733-743
25 Lieff S, Albert M. What do we do? Practices and learning strategies of medical education
leaders. Med Teach 2012; 34:312-319.
26 Smith SE, Tallentire VR, Cameron HS, et al. The effect of contributing to patient care on
medical students’ workplace learning. Med Educ 2013;47:1184-1196.
27 Nicol D, Macfarlane-Dick D. Formative assessment and self-regulated learning: A model and
seven principles of good feedback practice. Stud High Educ 2006; 31:199-218.
28 Bolden R, Gosling, J. Leadership competencies: time to change the tune? Leadership,
2006;2:147-163.
29 Allen SJ, Middlebrooks A. The Challenge of Educating Leadership Expertise. Journal of
Leadership Studies. 2013;6:84-9.
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Figure legends
Figure 1. The Medical Leadership Competency Framework (NHS Institute for Innovation and
Improvement.)
Figure 2. Relationships between themes and codes.
Figure 3. Perspectives: Relationships between codes and student suggestions.
Figure 4. Relevance in the clinical context: Relationships between codes and student suggestions.
Figure 5 Perspectives and Relevance in the clinical context: Relationships between codes and
student suggestions.
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Title page
Leadership and management in the undergraduate medical curriculum: A qualitative study of
students’ attitudes and opinions at one UK medical school.
Thelma Quince (corresponding author)
Educational Research Associate
The Primary Care Unit,
University of Cambridge
Forvie Site
Cambridge CB2 0SR
UK
01223 330364
Mark Abbas
GP Principal,
Queen Edith Medical Practice,
Cambridge
UK
Sughashini Murugesu
Foundation Year 1 Doctor
Imperial College Healthcare NHS Trust
London
UK
Francesca Crawley
Consultant Neurologist
West Suffolk Hospital NHS Trust
Bury St. Edmunds
UK
Sarah Hyde
Academic Clinical Fellow, Medicine
Hinchingbrooke Health Care NHS Trust
Hinchingbrooke
Cambridgeshire
UK
Diana Wood
Clinical Dean
School of Clinical Medicine
University of Cambridge
UK
John Benson
Senior Lecturer in General Practice
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Director, General Practice Education Group
The Primary Care Unit,
University of Cambridge
UK
Word count: 4563 including quotes.
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ABSTRACT
Objective: To explore undergraduate medical students’ attitudes towards and opinions about
leadership and management education.
Design: Between 2009-2012 we conducted a qualitative study comprising 5 focus group
discussions, each devoted to one of the 5 domains in the Medical Leadership Competency
Framework, (Personal Qualities, Working with Others, Managing Services, Improving Services
and Setting Direction). Each discussion examined, what should be learnt, when should this occur,
what methods should be used, how should learning be assessment what are the barriers to such
education.
Participants: Twenty eight students from all three clinical years (4-6) of whom 10 were women.
Results: Two inter-related themes emerged: understanding the broad perspective of patients and
other stakeholders involved in health care provision and the need to make leadership and
management education relevant in the clinical context. Topics suggested by students included
structure of the NHS, team working skills, decision making and negotiating skills. Patient safety
was seen as particularly important. Students preferred experiential learning, with placements seen
as providing teaching opportunities. Structured observation, reflection, critical appraisal, and
analysis of mistakes at all levels were mentioned as existing opportunities for integrating
leadership and management education. Students’ views about assessment and timing of such
education were mixed. Student feedback figured prominently as both a method of delivery and a
means of assessment, whilst attitudes of medical professionals, students and of society in general
were seen as barriers.
Conclusions: Medical students may be more open to leadership and management education than
thought hitherto. These findings offer insights into how students view possible developments in
leadership and management education and stress the importance of developing broad perspectives
and clinical relevance in this context.
ARTICLE SUMMARY
Article focus:
• To explore undergraduate medical students’ attitudes towards and opinions about
leadership and management education.
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Key messages:
• Medical students may be more open to leadership and management education than thought
hitherto
• Undergraduate medical students need to be encouraged to appreciate the perspectives of
patients and other stakeholders, and the organisational and societal context within which
health care is delivered.
• Leadership and management education needs to be relevant in the clinical context.
• Students identified many opportunities for integrating leadership and management into the
existing curriculum.
Strengths and limitations of this study:
• Focus groups permitted students to direct the flow and content of the discussion, enabling
them to delve deeper into their views about leadership and management education.
• The trustworthiness of the data was enhanced by the use of multiple coders.
• The research team are not aware of any other qualitative study addressing this topic with
UK undergraduate medical students.
• It was conducted in one UK medical school. Although drawn from all three clinical years
the number of participating students was small and inevitably self-selecting.
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Leadership and management in the undergraduate medical curriculum: A
qualitative study of students’ attitudes and opinions.
Thelma Quince, John Benson, Francesca Crawley, Mark Abbas, Sarah Hyde, Sughashini Murugesu, Diana
Wood
INTRODUCTION
Sustainability of health services is currently a topic of international discussion.[1] Leadership and
management skills are required to ensure provision of high quality patient care. [1-5] by the UK
NHS which faces unprecedented changes.[2-6] Active Eengagement of clinicians in leadership
and management appears beneficial: and positive associations have been found between doctors
appointed to hospital boards of directors and both clinical outcomes and overall performance.[76-
10] Clinical quality depends upon inter-professional team working hence leadership and
management skills are needed at all levels.[11,12] Recently Tthe UK NHS Institute for
Innovation and Improvement and Academy of Medical Royal Colleges developed the Medical
Leadership Competency Framework (MLCF) outlining the competencies expected of practicing
clinicians. in respect of five domains (Figure 1).[13]
Leadership and management abilities are recognised as key areas in postgraduate medical
education. [14] In the UK demonstration of competency in the MLCF’s domains is fundamental
for career progression and necessary for satisfactory completion of the Annual Review of
Competence Progression (ARCP) required for gaining accreditation. Although the number of
programmes and fellowships aimed at engaging postgraduates doctors in leadership and
management has risen concern is expressed that However to be effective, engagement needs to
start earlier in medical training.[15-17]
Medical schools are charged with the responsibility of training physicians not only to be
diagnosticians but also to understand resource management, financial considerations and multi-
professional team working.[18] Despite this, and the publication in 2010 of guidance for
undergraduate medical education relating to the MLCF, (publication was after the start of this
study and included three authors of this paper as contributors), education in leadership and
management is less well developed at undergraduate level and there is limited literature on how to
incorporate this into the undergraduate curriculum.[19-2021]
We conducted a qualitative study exploring medical students’ attitudes towards and opinions
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about leadership and management education in the undergraduate curriculum .We asked the
following questions:
: specifically, what should be learnt and when; what methods should be used; how should learning
be assessed; and what barriers exist to such education?
• What leadership and management content should be addressed?
• At what point in the undergraduate curriculum should the teaching and learning occur?
• What methods should be used?
• How should learning be assessed?
• What are the barriers to such education
We consider these questions essential for guiding curriculum development whilst recognising that
they are common to leadership and management education in many professions and
specialties.[21]
METHODS
We adopted a qualitative approach using focus group discussions to explore issues relevant to
students and to generate acceptable, practical suggestions. An essentialist thematic analysis was
used, focusing on the ideas, experiences, opinions and meanings presented by the participants.
[22] Given its wide acceptance, we structured our enquiry around the Medical Leadership
Competency Framework.[13]
Figure 1 in here
The standard medical course in Cambridge comprises three core science years, with a small
element of clinical experience, followed by three clinical years, each comprising approximately
140 students.. Each year bBetween 2009 and 2012 in either May or September all clinical
students (n=135 in each cohort)from each of the years 4-6 were invited by email to participate in
the study. Two reminders were issued two weeks apart and .t Those willing to participate were
contacted. and a time suitable for the discussion identified. Because clinical students were on
placements at these times only those with reasonable access to Cambridge were able to attend.
Five focus group discussions were held, one relating to each dimension of the MLCF’sMedical
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Leadership Competency Framework (Figure 1).
Insert Figure 1 here.
Participants received an outline of the MLCF’s competencies for medical students for the
dimension under consideration together with a topic guide.[19] This information was briefly
repeated at the outset of the discussions.
Written consent to participate was requested in the initial email and again, at the outset of each
discussion. We requested written consent to participate in the initial email correspondence and
again, in writing at the outset of each discussion. Discussions lasted between 90 and 120 minutes
and with participants’ permission, were recorded and transcribed verbatim. Transcribed data was
anonymised and entered into NVivo 9 software. (QSR International Pty Ltd, Melbourne,
Australia).
In total 28 clinical students took part, (10 women). The nature of participants and schedule of
discussions are given in Table 1. All Year 6 participants had received formal instruction in
leadership and management comprising a one day course, midway in their final year.
Table 1 Focus participants and schedule of discussions.
Dimension Number of students Date of focus group
discussion
Facilitator(s)
Working with Others 6 (2 women) July 2009 MA, TQ
Personal Qualities 7 (3 women) Oct 2009 MA
Managing Services 4 (1 woman) Oct 2010 MA
Improving Services 4 (2 women) Oct 2011 MA
Setting Direction 7 (2 women) Oct 2012 TQ, SM
Total 28 (10 women)
Stage of course Stage 1 (Year 4) Stage 2 ( Year 5) Stage 3 ( Year 6)
Number of Students 7 9 12
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Using the “Setting Direction” discussion authors TQ and SM, working independently, derived
coding frameworks. Subsequent discussions generated a common framework which TQ extended
to the other transcripts. Authors, JB and FC, then independently considered the appropriateness
of the resulting framework to all dimensions and adjustments were made. following discussions.
TQ, JB and FC independently applied the agreed framework to a selection of transcribed data. A
high level of agreement of code application was found (> 90%). Following discussion between
TQ, JB and FC an overall coding framework was agreed (table 2) and applied by TQ to all
transcribed material.
Coded data was scrutinised and emerging themes initially identified by TQ using an inductive
semantic approach. These were based on the extent to which the theme captured something
important to the overall research questions and the extent to which the themes gave an accurately
reflection ofreflected the entire data set rather than discussion of one dimension alone. Themes
were considered against the transcribed and coded data independently by 3 other authors (JB, FC
and SH,) and following discussion, the final analytic structure agreed. Students participating in the
“Setting direction” discussion were able to comment on the results of their discussion which were
presented as a poster.
Table 2: Broad categories of codes. (Detailed codes given in Appendix 1)
1. Awareness: Recognition of the need to understand leadership and management in general, its
relevance to future work and the levels at which it applies.
2. Timing and structure: When in the undergraduate curriculum should teaching about
leadership and management start and how should or could that be structured?
3. Methods of Delivery: How should leadership and management teaching be delivered and the
advantages and disadvantages of different methods.
4. Assessment: How should the leadership and management learning be assessed and the
advantages and disadvantages of different methods of assessment.
5. What should be taught?(Topics): What topics should be covered in leadership and
management teaching in the undergraduate curriculum?
6. Barriers: The fFactors which that may inhibit undergraduate medical students’ interest in and
learning about leadership and management.
The study received ethical approval from the University of Cambridge Psychology Ethics
Formatted: Underline
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Committee (the relevant body for all studies involving University of Cambridge students).
This paper reports generic results, potentially relevant to other medical schools. Opinions and
recommendations specific to the Cambridge Medical Course are not presented.
RESULTS
This paper reports generic results, potentially relevant to other medical schools. Specific opinions
and recommendations about the Cambridge Medical Course are not presented.
Figure 2 in here
Two strongly inter-related and mutually reinforcing themes were identified: emerged as pre-
requisites for curriculum development: breadth of perspectives and relevance in the clinical
context. Figure 2 summarises the relationship between themes and codes and the organisation of
the results. understanding the broad perspective of patients and other stakeholders involved in
health care provision and the need to make leadership and management education relevant in the
clinical context. (Figure 2) The resulting students’ suggestions and opinions are presented in
relation to each theme and in a third section relating to both themes.
Section 1. Understanding Perspectives (Figure 3): Breadth of Perspectives
Students believed that leadership and management education should encourage them to
understand perspectives at three levels:
Students’ felt that leadership and management education should take a broad perspective at three
levels:
• society as a whole,
• organisations in which they would work
• individuals with whom they would interact.
These considerations influenced students’ suggested topics for incorporation into the
undergraduate curriculum.
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1.1 Societal perspectives
Students appreciated tThe economic, political and social context within which UK health care
operates was appreciated.; recognising that taking account of that context had become ‘part of the
job of a doctor’ with associated personal responsibilities. Clinical judgement and resource
allocation were seen as linked and hence the need for tomorrow’s doctors to become more
involved and engaged in leadership and management.
External circumstances directly affect how we deliver care healthcare. ….. that makes the idea of
resource allocation and clinical judgement and the managerial aspect to that, perhaps more
relevant for us now than for doctors previously, …. but I don’t think it is something that has quite
filtered down to medical students.F3
Some students linked issues of resource allocation and clinical judgement and acknowledged that
tomorrow’s doctors had to become more involved and engaged in leadership and management.
We don’t live in a vacuum, medical profession like any other cannot be isolated ….we have to live
in a world in which things cost money, where you know we have a credit crunch. M16
For some students awareness needed to start at the undergraduate level in order to avoid potential
“resentment” when confronted with management tasks as practicing clinicians.
even as an F1 Dr doing paperwork, making minor management decisions are an inevitable part of
junior doctor life……. So I think it important that students are made aware ……..in order to
remove the resentment,M4
Others were concerned that awareness of the economic and political context could potentially
disillusion medical students. Some students felt that some patients’ had developed more
“consumerist” type attitudes and demands, which in turn could result in conflict. The development
of such attitudes was seen as likely to inhibit medical students’ appreciation of the role of
leadership and management.
1.2 Organisational perspectives
All participating students had undertaken placements on wardsin hospitals and in GPgeneral
practice.s. Their comments reflected their appreciation ofStudents recognised the organisational
context of health care and the need to take account of the perspectives of managers, other health
care professionals and patients.
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….. in the hospital, there were no beds so all medical elective admissions have been cancelled …
consultants were told this morning …., I presume by a manager – do your estimated daily
discharge and try and discharge patients... So that’s not necessarily offering the best care you can
– the consultants may fight for it but at the end of the day there is a whole queues of patients
lining up to come into the hospital and we’ve got limited resources. M17
Students were particularlyThere was awareness of the role of teams, potential conflicts within
them teams and and between clinicians and managers and, more importantly, the influence of
management and leadership skills on team performance and thereby patient care.
I have seen some teams that work really well together and deliver excellent patient care, …..and
then some teams have such problems between doctors and nurses. F2
They saw an aAbility to manage teams was seen as part of the doctor’s job and hence , with the
concomitant need to develop such competencethese skill at undergraduate level was identified..
Some went further saying that theStudents lacking of such education reported feeling left them
unable to evaluate or learn from the team dynamics they observed in clinical practice.
We don’t necessarily have an organised framework in our heads to articulate to ourselves what
kind of organisational culture this is and to therefore to understand what we need to take from it
and ..what is worth practicing ourselves. M3
1.3 Individual perspectives
Students’ comments reflected their keen awareness of the patient’s perspective. They reflected on
how difficult it must be for patients confronted by so many different specialities, and receiving a
plethora of, sometimes conflicting, information. They saw the need to iInvolvinge the patient in
his/her care and clinicians to be able to acting as advocate for that care were seen as important, as
were . But at the same time others commented that taking the approach of “the patients’”
overlooked the diversity of patients and their individual needs.
Both poor and exemplary doctor/patient relationships and their potential educational impact were
frequently reported frequently., demonstrating students’ awareness of the importance of “the
system” in relation to patient care.
Students were also aware of pPressures faced by on individual doctors in all aspects of their
daily practice were acknowledged.arising from changes in health care provision: restrictions
imposed by external bodies such as the then Primary Care Trusts and patients’ more consumerist,
and at times, hostile approach. Some students were surprised that not only would their own
performance as doctors be assessed, but also they would be expected to assess that of their
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colleagues.
I think the managing performance bit is something that struck me because you see it on the wards
when you see junior Drs filling out surveys and questionnaires on their colleagues and saying
how's their performance and things. I was quite taken a back as I didn’t know that it was that
formal and structured, it’s probably a good thing…..I think … making us aware that you will have
to judge our colleagues would be quite useful. M3
1.4 Suggested What topics for inclusion in the undergraduate curriculum.should be
learned?
The idea of broadening perspectives strongly influenced the topics suggested for inclusion in the
undergraduate curriculum. Topics relating to the societal perspective included the structure of the
NHS, including financial and resource constraints. Some students felt that comparisons with and
developments affecting in health care systems in other countries should be included.
Students’ clinical . Eexperience on wards and involvement in coding exercises made them
fostered awareness of the complicated nature of financial tariffsclinical coding and its financial
implications and and there was a the need to understand some of this, even at undergraduate
level.
you are leading or being part of a team to maximise efficiency so whatever you do there’s an
opportunity cost so you can bring some management economics kind of into that ….to make an
informed decision also you have to think of the human aspects of medicine so it is very much like
a risk benefit sort of thing. That notion has to be put across slightly better in the medical
curriculum. M9
From the organisational perspective students were aware that junior doctors encounter potential
conflicts at various levels: at the individual level needing to prioritise the care of one patient over
that of another; at the team level between clinical colleagues; and at the organisational level
between doctors and managers. Some were also aware that conflict could be beneficial if handled
correctly.
Students identified eEffective communications as a factor whichwas seen to improved team
working. However this was not always applied to team work and Communication skills were
seen as often well developed and practiced in the doctor/patient context but not always applied to
team work. eExtending communication skills teaching to team workinginclude this was
suggested. Some students reported that interaction with others clinical team members was well
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taught. Others indicated that this did not extend to interaction with managers or “management”.
Greater interaction with manager and learning to Iinvolveing, accepting and valueing others were
also seen as important toto foster effective team work.
Negotiating, and conflict resolution skills, decision making and evaluating change were proposed
for inclusion. were seen as important and proposed for inclusion in the undergraduate curriculum,
as were decision making and evaluation. Students who had experience of management studies
highlighted this.
they had something called the negotiation workshop where you learnt how to talk to, convince
other people, and how to put your points across... I think that would be really helpful for doctors
and as we go on to interact with other professions as well. F9
And no way along the process, in my mind in medicine, is it defined as to how to make a decision.
M15
Understanding how patients’ experiences “the system”, perceive their illness and care andof their
journey throufgh the healthcare system and how they can they might be enabled to have greater
understanding, and take part in decision making in respect of that care were topics studentswas
considered relevant. Whistle-blowing was raised frequently. Concerns were expressed about
maintaining team relationships when events occurred. Generally pParticipants appeared unsure of
both their position as medical students when confronting patient safety issues and the routes for
progressing problems. As a result patient safety and whistle-blowing were suggested frequently as
topics for inclusion.
Audits was were seen by the students as both a specific topic for inclusion in leadership and
management education, as well as a method by which organisational aspects could be taught.
Section 2.: Relevance in the Clinical context. (Figure 4)
Students strongly articulated tThe view that leadership and management education should be
relevant for, and relate closely to, the clinical context was strongly expressed. Relevance was seen
to foster greater awareness of the social, economic and political context within which health care
operated. In turn relevance influenced students’ views about methods of delivery, assessment and
feedback on their performance.
… you need to use examples ….. real life examples of hospitals that are failing or management
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teams that have failed and try and look at why they failed, cause it kind of brings it to attention
that this kind of thing does happen and the fact that people die because of it…M18
The need for relevance predominantly influenced students’ views about methods of delivery,
assessment and feedback on their performance.
2.1 Methods of Delivery
Emphasising eExperiential methods were preferred with , students saw many opportunities for
using clinical experience given as examples. These, including pre-set questions, observation and
reflection, critical appraisal, greater involvement in ward activities and learning from mistakes.
take an event that has happened in the clinical area that you are working in at the minute, and try
to go back over it and think why did this event happen?, Wwhat were the risks that were involved
and then make a discussion about how you could improve them afterwards. F1
Reflecting on observations was regarded generally as a continual process but views were divided
as to how to incorporate this into leadership and management learning. Some students supported
reflective essays. Others felt such exercises often became formulaic, preferring one to one or
small group discussions.
you can sit and think about them yourself but often you need somebody else and different people’s
views to actually understand the whole concept and to get someone else’s opinion because you
only have what you think.F2
Greater involvement on wards was seen to as facilitating facilitate learning and audits as an
extension to this. However, leadership and management aspects needed to be clearly highlighted
otherwise audits could become mere paper exercises. It was suggested frequently thatA great deal
of considerable informal teaching of leadership and management occurred on wardswas seen on
clinical attachments which could be formalised and incorporated within the and that these could
be better formalised within the existing curriculum. Critical appraisal of how consultants and
others demonstrated leadership and management skills was suggested as a way of identifying such
skills in the ward clinical context. .
we don’t really need an extensive course as a lot of the skills are already there, it’s just as we
talked about there are different ways of getting people to think about themselves in a different
way. All the skills about the patient we learnt in (communication skills teaching)- actually, we
need to think about them in the context of leadership and teamwork, and how I should relate to my
colleagues, the people I work for, the people I work with and the people that work for me. M12
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Leadership and management topics could also be taught through examination, analysisby
analysing and reflection reflecting on actual mistakes at all levels. But concerns were raised there
were issues about how to handle the information generated could be handled, particularly if it this
in turn raised questions about whistle-blowing issues. One focus groups took place during the
publicity surrounding the Francis Report on the failures at Mid Staffs NHS Foundation Trust. [3]
Students in this group commented on how uninformed they were about systemic failures on this
scale.
While endorsing case-based or problem-based learning as a method of delivery, some students felt
that the leadership and management aspects had to be made explicit.
I think the structure where you go through the scenario and understand why it is important …. but
teaching on leadership and management would be quite alien to medical students as we haven’t
experienced this before. I think … to make the relevance quite apparent is really important. M3
Team-building and coding exercises were reported as beneficial for leadership and management
education, but only by those students who had undertaken them. Very few students mentioned
“role play” as a useful method. Another suggestion was for an innovation competition to
encourage students to think about improvements.
There was little support for didactic teaching methods. A few students argued that some topics
could be introduced through lectures, but theif the material itself had to relate to clinical
realitywas clinically relevant,, draw drew on practical experience rather than theory and be
presented enthusiastically. Others saw lectures as inappropriate.
Actually in xxx there’s a fantastic lecturer who teaches operations and management…. When
they’re enthusiastic about their subject – you just enjoy it so much more M14
I disagree about lectures – they’re very very tedious. No matter what they’re on – on the whole I
find them tedious.M16
2.2 Assessment
Assessment was seen as difficultViews about assessment were divided and its value questioned.
Supporting assessment were views that Some students felt that without assessment there would be
no measurable outcomes for to evaluateing learning. Others considered that given the pressure on
the curriculum, and learning not assessed would not be seen as important. By cContrasting views
were some students felt that assessment would reduce interest and constitute yet another “hoop”
through which students they needed “to jump”. Similarly contentious was the issue of whether
there should be minimum standards that medical students had to achieve.
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There should be some kind of defined minimum standard you should have for certain skills and
that basically the same with clinical skills for example with OSCEs you repeat the assessment
until you pass F7
I disagree with you totally. M11
There was also no consensus as to whether assessment should be at the group or individual level.
Some felt that assessment through a group task or presentation would be less threatening.
Suggested Ggroup tasks included case-based or problem based exercises around using structured
scenarios or real examples of failing wards, audits, root -cause analysis exercises and role play
team- work exercises. For many of these exercises assessment through group discussion or some
form of presentation was suggested. Directly observations ofobserving individual and/or group
performance was also suggested. but tThese would need clear and detailed assessment criteria
extending beyond simple “pass and fail” and assessment undertaken by experienced personnel.
Others felt that peers should be involved in assessment.
. there could be a group task so four or five applicants are given a task and there would be like 2
assessors looking at the interaction of the people M7
I think it would be good idea if it was peer assessed as well because you know part of the whole
leadership thing surely that is about being able to take positive criticism from the team that you
are working in to incorporate their ideas so perhaps it would be good in a way. F1
Suggestions for assessing individual student’s leadership and management learning included
written short reports of observed scenarios or specific examples, which for some could be
integrated into or built on other reflective writing exercises. Similar suggestions about observing
individual students’ leadership and management performance were also made. Other suggestions
included written short reports of observed scenarios or specific real practice, critical appraisal
exercises, assessment through OSCE type exercises, other verbal assessments through viva type
situations. and either written or verbally presented critical appraisal exercises, based on
observations of real practice. An One interesting idea suggestion was that assessment would cover
not only what had been observed but also the analysis of that observation in terms of leadership
and management performance.
…..demonstrated that you are aware of how to make a decision, you are aware of the problems in
the scenario if there was one and you know some techniques of how to improve it or if not then
who to refer to or who to speak to..M15
2.3 Feedback
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Feedback figured strongly as both a method of delivery and a method of assessment. Students
indicated that feedback was frequently asymmetrical: they were asked to give feedback but often
did not receive feedback or received feedback of it was of limited value in terms of learning. This
Ffor some this was was seen by some as discouraging discouraging.. Views about feedback
directly from patients and from peers were divided. Some students felt that feedback from patients
facilitated understanding of their perspectives, others saw its value in the leadership and
management context as limited. Similarly contentious some considered thatwas feedback from
peers: some participants felt it would be questioned and not taken regarded seriously; . Oothers
students saw it as a precursor to 360 degree appraisal useful in encouraging team working.
Using the 360 thing as an example you realise that your colleagues, it encourages working well in
a team and the importance of it and if you are working well with you colleague you are going to
get OK feedback but if you just regard your colleagues within the team, ok they are not as good as
me, they’re not pulling their weight. It encourages teamwork I would say. M5
While emphasising the importance of feedback on placement, the difficulties of accomplishing
this because of numbers of students and consultants and senior doctors availability were
acknowledged. It was also felt that because of the on-going nature of leadership and management
learning, feedback could greatly enhance the learning effectiveness of reflection, and exercises
such as audits.
In terms of the assessment of the course, if you are going to have things then it is much better,
especially in something like audit or management where it is a continual process, it is not
something that you do and then you forget about, you should get feedback about things and it is
not just a pass/fail something like that. F2
3. Understanding perspectives in their clinical context and relevance (Figure 5)Section
3: Related to both perspectives and relevance
Both breadth of perspectives and clinical relevance influenced sStudents’ views about timing and
structure and of leadership and management education in the undergraduate, curriculum,together
with what they considered to be the barriers to such education were shaped by both themes. and
factors likely to inhibit such development.
When should leadership and management education take place?
3.1 Timing and Structure of leadership and management education
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Conflicting views were expressed about when undergraduate students should be made aware of
For some students awareness needed to start at the undergraduate level in order to avoid potential
“resentment” when confronted with management tasks as practicing clinicians. the economic
political and social context of health care provision. Some students felt that awareness needed to
start at the undergraduate level in order to avoid potential “resentment” when confronted with
management tasks as practicing clinicians. Others felt that awareness could potentially disillusion
medical students. “Consumerist” attitudes and demands expressed by some patients were seen as
possible sources of conflict and hence likely to inhibit medical students’ appreciation of the role
of leadership and management.
even as an F1 Dr doing paperwork, making minor management decisions are an inevitable part of
junior doctor life……. So I think it important that students are made aware ……..in order to
remove the resentment,M4
Others were concerned that awareness of the economic and political context could potentially
disillusion medical students. Some students felt that some patients’ had developed more
“consumerist” type attitudes and demands, which in turn could result in conflict. The development
of such attitudes was seen as likely to inhibit medical students’ appreciation of the role of
leadership and management.
However Tthere was support for the notion that developing societal and organisational
perspectives to health care provision should begin early. It was generally felt that to appreciate
fully students needed to have experienced the clinical context in order to appreciate fully the
importance of leadership and management to patient care students had to have experienced the
clinical context. But however, opinions were divided as to when to introduce some of the
suggested topics, suggested above and in particular the issue of whistle-blowing. The overriding
view was that leadership and management education should be incorporated into the existing
curriculum and hence be ongoing.
3.2The Bbarriers to leadership and management education
Students cited cChanging attitudes within society and the medical profession itself were seen as
factors both necessitating greater leadership and management education and as potential barriers.
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I think people are facing really big societal things about society attitudes and again things,
attitudes within the medical profession itself too like communication skills like the management
skills. And this will all have an impact on public health. F3
From an organisational perspective, the longstanding hierarchical nature of the medical profession
and , together with medical students’ attitudes towards this hierarchy were cited as a potential
barriers. The view was also expressed that tThe existing career structure was seen not to facilitate
observed by medical students did not facilitate or encourage the practice and exercise of
management skills. This view of hierarchy underscored students’ views of the complexities of
whistle-blowing.
.I think that if the GMC wants to encourage people to have great management skills, imagination
and situational awareness then they need to empower people to be able to use those things and
make us feel a little bit less constrained as medical students climbing up the very narrow career
ladder. F7
Attitudes towards leadership and management education held by both existing clinicians and
medical students were seen as potential inhibitors. Similarly some consultants were seen as
holding negative attitudes to teaching students in general. Developing awareness of the potential
beneficial impact of management decisions on the patient was seen as negating such attitudes.
these consultants are the consultants with a clinical background already you know... “in my day
when I was a lad you know”. Is it that or is it actually they feel we are actually not being
prepared adequately to be a member of a clinical team. Is it just “we never had that
communication skills malarkey in our day and we came out just fine”? M6
DISCUSSION
Clinician involvement in leadership and management has a beneficial effect on health care
delivery and concomitantly the quality of patient care. [8-10] If more of tomorrow’s doctors are to
engage in leadership and management there is a need to educate today’s medical students. Despite
the development of leadership and management education initiatives for first year doctors,
evidence of such developments at the undergraduate level are more limited. [16]
A recent systematic review identified leadership and management as one of the key competencies
for undergraduate community- based education for health professionals.[2324] Our study suggests
medical students may be more open and accepting of the role of leadership and management
education in medical education than thought hitherto. Although we took as our starting points the
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MLCF it was not our intention to compare in detail the suggestions made by our students with
suggestions for leadership and management education outlined in the guidance for undergraduate
medical education.[19] Nevertheless there are areas of commonality: encouraging students’
appreciation of the perspectives other stakeholders Broadening students’ perspectives to
encompass those of other stakeholders and of the organisational and societal context within which
health care is delivered is a facet of thisone. The results also indicateAs is, the importance of
making leadership and management education relevant in the clinical context. [19] These results
closely parallel findings from a study of medical education leaders, who cited “attending to the
world outside” as a key area of their work.[2425]
Many viable topics were suggested in the study including: structure of the NHS, facilitators of
factors which develop team working skills such as communication and such as conflict resolution,
negotiating and communication skills, and decision making. and negotiating skills. Patient safety
was particularly important.
In common with other studies our students expresses a preference for experiential learning was
preferred.[2426] Placements were seen as providingto provide leadership and management
teaching opportunities. Structured observations, reflection on these, critical appraisal and analysis
of mistakes at individual and organisational level were all mentioned. Mindful of the crowded
nature of the curriculum students identified opportunities for making bothintegrating leadership
and management education. more explicit and more integrated.
Students’ views about assessment were more diverse. and its value questioned. Feedback
figured prominently: in terms of how to give feedback, as a method for delivering leadership and
management education and as a means of assessment. The importance of direct, timely and
appropriate feedback in self-regulated learning has long been recognised.[2527]
Some attitudes held by medical professionals and students and by society as a whole were seen as
barriers to leadership and management education in the undergraduate medical curriculum.
Changing attitudes is often slow and difficult.
Strengths and weaknesses of the paper
Using focus groups allowed for in-depth discussion and for articulation and exploration of
students’ opinions and attitudesviews. The size and number of the focus groups, together with the
fact that participants were drawn from all three years of the clinical course meant a wide range of
views were presented. The Management Leadership Competency Framework was derived from
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consensus discussions and its adoption as the basis for the focus group discussions lends support
for the approach adopted.[1211] The analysis of material focused on the experiences, opinions,
and meanings reported by the students.
A significant weakness of the study is that it was based in one medical school with a significant
“pre-clinical/clinical” divide in the curriculumcurricular divide. Although drawn from all three
clinical years, it was not possible to differentiate between levels of maturity and professional
experience of participants. Different views might be expressed by pre-clinical and post graduate
students. As with most qualitative studies, participants were volunteers, potentially and perhaps
predisposed to leadership and management education. With the exception of the focus group
discussion considering “Setting Direction” it was not possible to provide participant validation of
the results. Finally, although widely supported, the Management Leadership Competency
Framework has been criticised is not without criticism. Some have suggested that competency
frameworksfor laying responsibility on the individual with little regard for the context and
environment within which the individualthey operates.[2628]
Further Work
Studies in many sectors have highlighted generic obstacles to teaching leadership and
management: specifically applicable to the undergraduate medical curriculum include variability
of leadership practices and lack of a consistent and deliberate practice in the field. [29] Medical
students witness a potentially confusing array of leadership styles and practices and without clear
guidance they may be unable to evaluate what they observe. Whereas clinical skills can be
practiced through simulation, providing such a practice field for leadership and management skills
is more complex. This, together with the crowded nature of the curriculum, means that there are
few opportunities for real time coaching.
Further work might usefully explore the views of students earlier in their medical studies and the
views of students engaged in different types of course design. However, there is a need to develop
leadership and management education in some form at the present time. Perhaps the most
pragmatic approach would be to introduce small initial changes and modify them in the light of
their evaluation.
Conclusions
These findings offer insights into how students view possible developments in leadership and
management education. Although necessarily a partial view, it is relevant to the difficult choices
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that face curriculum planners seeking to strengthen education in this area in the face of an already
overcrowded timetable. Perhaps, for them, students’ insights into the opportunities to develop
leadership and management learning within existing curricular experiences are most significant.
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References
1 World Economic Forum, Sustainable Health Systems: Visions, Strategies, Critical Uncertainties
and Scenarios. Geneva, Switzerland, World Economic Forum, 2013.
21 Darzi AV. Our NHS,Our future: NHS Next Stage Review (Interim Report). Department of
Health, 2007.
32 Darzi AV. High Quality Care for All: NHS Next Stage Review (Final Report). Department of
Health, 2008.
43 Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The
Stationary Office, 2013.
45 The King's Fund. Leadership and engagement for improvement in the NHS: Together we can :
The King's Fund Leadership Review, The King's Fund, 2012.
56 Tooke J. Aspiring to excellence: Final report of the independent inquiry into modernising
medical careers. Medical Schools Council, 2008.
67 Goodall AH. Physician-leaders and hospital performance: Is there an association? Soc Sci Med
2011;73:535-9.
78 Lega F, Prenestini A, Spurgeon P. Is management essential to improving the performance and
sustainability of health care systems and organizations? A systematic review and a roadmap for
future studies. Value Health 2013;16(1 SUPPL.):S46-S51.
89 Prybil LD. Size, composition, and culture of high-performing hospital boards. Am J Med Qual
2006;21:224-9.
10 9 Veronesi G, Kirkpatrick I, Vallascas F. Clinicians on the board: what difference does it
make? Soc Sci Med 2013;77:147-55.
10 Dorgan S, LaytonD, Bloom N, Homkes R, Sadun R, Van Reenan J. Management in healthcare:
Why good practice really matters. McKinsey and Co. and LSE (CEP). London, 2010.
11 Hewison A, Gale N, Yeats R, Shapiro J. An evaluation of staff engagement programmes in
four National Health Service Acute Trusts. J Health Organ Manag 2013;27:85-105.
12 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges:
Medical Leadership Competency Framework, Enhancing engagement in medical leadership.
Second edition. Coventry, 2009.
13 Health and Social Care Act 2012. The Stationery Office , 2013.
14 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges:
Medical Leadership Curriculum. Coventry 2009.
12 The King’s Fund. The future of leadership and management in the NHS: No more heroes. The
King’s Fund, London, 2011.
13 NHS Institute for Innovation and Improvement and Academy of Medical Royal Colleges:
Medical Leadership Competency Framework, Enhancing engagement in medical leadership.
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Second edition. Coventry, 2009
14 NHS Institute for Innovation and Improvement. The Clinical Leadership Competency
Framework. Coventry 2011.
15 Royal College of Physicians. Learning to Make a Difference. http://www.rcplondon.ac.uk/
projects/learning-make-difference-ltmd.
16 Bethune R, Soo E, Woodhead P, Van Hamel C, Watson J. Engaging all doctors in continuous
quality improvement: A structured, supported programme for first-year doctors across a training
deanery in England. BMJ Qual Saf 2013:22:613-617.
17 Swanwick T, McKimm J, Clinical leadership requires system-wide interventions, not just
courses. Clin Teach 2012; 9: 89-93.
18 General Medical Council. Tomorrow's doctors: Outcomes and standards for undergraduate
medical education. General Medical Council, 2009.
19 Spurgeon P, Down I. Guidance for Undergraduate Medical Education: Integrating the Medical
Leadership Competency Framework, NHS Institute for Innovation and Improvement and the
Academy of Medical Royal Colleges 2010
19 20 Dobson C, Cockson J, Allgar V, McKendree J. Leadership training in the undergraduate
medical curriculum. Educ Prim Care. 2008;19:526-9.
20 21 Reid AM. Developing innovative leaders through undergraduate medical education. Educ
Prim Care. 2013;24:61-4.
21 Allen SJ, Middlebrooks A. The Challenge of Educating Leadership Expertise. Journal of
Leadership Studies. 2013;6:84-9.
22 Braun V. Clarke V. Using thematic analysis in psychology. Qual Res Psychology, 2006; 3:77-
101.
23 Malterud K. Qualitative research: standards, challenges and guidelines. The Lancet,2001;
358:483-487.
23 24 Ladhani Z. Scherpbier AJ. Stevens FJ. Competencies for undergraduate community based
education for the health professions: A systematic review. Med Teach 2012;39:733-743
24 25 Lieff S. Albert M. What do we do? Practices and learning strategies of medical education
leaders. Med Teach 2012; 34:312-319.
26 Smith SE, Tallentire VR, Cameron HS, Wood SM. The effect of contributing to patient care on
medical students’ workplace learning. Med Educ 2013;47:1184-1196.
2527 Nicol D. Macfarlane-Dick D. Formative assessment and self-regulated learning: A model
and seven principles of good feedback practice. Stud High Educ 2006; 31:199-218.
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26 28 Bolden, R and Gosling, J. Leadership competencies: time to change the tune? Leadership,
2006;2:147-163.
29 Allen SJ, Middlebrooks A. The Challenge of Educating Leadership Expertise. Journal of
Leadership Studies. 2013;6:84-9.
The research received no specific grant from any funding agency in the public, commercial or not-
for-profit sectors.
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Appendix 1: Leadership and Management Codes.
1. Awareness
Recognition of the need for medical students to have an understanding of leadership and
management in general, of the relevance to their future work and of the levels at which this
applies. a] Awareness of and interest in leadership and management in relation to each of the 5 dimensions:
Working with others
Personal qualities
Managing services
Improving services
Setting direction
b] In the context of the dr/patient relationship
c] In the context of changing NHS
d] In relation to different levels of training
e] Conceptions of leadership and management
2. Timing and structure
At what point in the undergraduate medical curriculum should teaching about leadership and
management start and how should or could that be structured? a] When? At what point in the curriculum should teaching start?
b] Structure? The structure of the timing eg strands, components etc
c] Integration The extent to which L&M could be integrated into the existing course
3. Methods of Delivery
How should leadership and management teaching be delivered and the advantages and
disadvantages of different methods. a] Didactic methods (lectures)
b] Experiential learning
In the clinical context: audits, coding exercises, care pathways, observing and critiquing
behaviour
Team building exercises.
c] Analysis of and reflection on real events (mistakes etc)
d] Mentorship
4. Assessment
How should the leadership and management learning be assessed and the advantages and
disadvantages of different methods of assessment. a] Assessment of the group:
Assessment of output of groups ( posters, presentations)
Assessment of group in team exercise
b] Assessment of the individual
Written
Demonstration (OSCEs)/Oral
Feedback from others ( patients, doctors, peers)
c] Criteria ( minimum standards)
d] By whom? Peers or faculty
5. What should be taught? Topics
What topics should be covered in leadership and management teaching in the undergraduate
curriculum?
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a] Economic, political and organisational structure of the NHS
Changes in that
Other health care systems
b] Conflict
Conflicting demands faced by doctors, managers, members of teams
Arising out of changing context in NHS
Conflict resolution
c] Decision making
d] Patient safety issues
Progressing problems, whistle blowing
Root cause analysis
e] How to give feedback
f] How to reflect
6. Barriers to leadership and management education
The factors which may inhibit undergraduate medical students’ interest in and learning about
leadership and management. a] Relevance: the importance of
b] Time: problems of an overloaded curriculum
c] Attitudes; of medical students themselves, seniors and faculty
Importance of enthusiastic role models
Risk of disillusioning medical students
d] Challenge not hoops
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