bmj open · education.[14] in the uk demonstration of competency in the mlcf’s domains is...

For peer review only

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

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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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

[email protected]

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


UK

John Benson,



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


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.


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


BMJ Open on D

ecember 2, 2020 by guest. P

rotected by copyright.http://bm

jopen.bmj.com

/B

MJ O

pen: first published as 10.1136/bmjopen-2014-005353 on 25 June 2014. D

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1

Title page




Educational Research Associate

The Primary Care Unit


Forvie Site

Cambridge CB2 0SR

UK.

01223 330364

[email protected]

Mark Abbas

GP Principal

Queen Edith Medical Practice

Cambridge

UK.

Sughashini Murugesu



London

UK.

Francesca Crawley



Bury St. Edmunds

UK.

Sarah Hyde

Academic Clinical Fellow, Medicine


Hinchingbrooke

Cambridgeshire

UK.

Diana Wood

Clinical Dean



UK.

John Benson

Senior Lecturer in General Practice

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Director, General Practice Education Group

The Primary Care Unit


UK.

Word count: 4563 including quotes.

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ABSTRACT






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.


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.



leadership and management education and stress the importance of developing broad perspectives

and clinical relevance in this context.

ARTICLE SUMMARY

Article focus:



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Key messages:


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.




• 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 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]


education. [14] In the UK demonstration of competency in the MLCF’s domains is fundamental


Competence Progression (ARCP) required for gaining accreditation. However to be effective,

engagement needs to start earlier in medical training.[15-17]



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]


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




[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).


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.


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discussion

Facilitator(s)






Total 28 (10 women)

Stage of course Year 4 Year 5 Year 6


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.


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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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.



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:






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.


resource allocation and clinical judgement and the managerial aspect to that, perhaps more



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.






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.



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.



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.






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.





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



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.




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.


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





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.






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.




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education by those students who had undertaken them. Very few students mentioned “role play”

as a useful method.


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.



until you pass F7


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





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.




Feedback

Feedback figured strongly as both a method of delivery and a method of assessment. Students


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.





It was also felt that feedback could greatly enhance the learning effectiveness of reflection, and

exercises such as audits.





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.




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.




ladder. F7

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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]




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]





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]


“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



of leadership practices and lack of a consistent and deliberate practice in the field. [29] Medical




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their evaluation.

Conclusions






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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:


for-profit sectors.

D] Data sharing:

Anonymised coded data from the study available from Thelma Quince.

([email protected])

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References

1 Darzi AV. Our NHS, Our future: NHS Next Stage Review (Interim Report). Department of

Health, 2007.


Health, 2008.



4 The King's Fund. Leadership and engagement for improvement in the NHS: Together we can:





2011;73:535-9.





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.



12 The King’s Fund. The future of leadership and management in the NHS: No more heroes. The

King’s Fund, London, 2011.



Second edition. Coventry, 2009

14 NHS Institute for Innovation and Improvement. The Clinical Leadership Competency

Framework. Coventry 2011.



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.



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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


25 Lieff S, Albert M. What do we do? Practices and learning strategies of medical education


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.



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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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1

Title page




Educational Research Associate



Forvie Site

Cambridge CB2 0SR

UK

01223 330364

[email protected]

Mark Abbas

GP Principal,

Queen Edith Medical Practice,

Cambridge

UK

Sughashini Murugesu



London

UK

Francesca Crawley



Bury St. Edmunds

UK

Sarah Hyde

Academic Clinical Fellow, Medicine


Hinchingbrooke

Cambridgeshire

UK

Diana Wood

Clinical Dean



UK

John Benson

Senior Lecturer in General Practice

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2

Director, General Practice Education Group



UK

Word count: 4563 including quotes.

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ABSTRACT






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.


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.



leadership and management education and stress the importance of developing broad perspectives

and clinical relevance in this context.

ARTICLE SUMMARY

Article focus:



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Key messages:


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.




• 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 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]


education. [14] In the UK demonstration of competency in the MLCF’s domains is fundamental


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]



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]


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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




[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).


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.



discussion

Facilitator(s)






Total 28 (10 women)

Stage of course Stage 1 (Year 4) Stage 2 ( Year 5) Stage 3 ( Year 6)


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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.


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.










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.


Formatted: Underline

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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:






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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.


resource allocation and clinical judgement and the managerial aspect to that, perhaps more



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


“resentment” when confronted with management tasks as practicing clinicians.









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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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.



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.



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.






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.





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



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.


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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.


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





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. .






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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.





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.


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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until you pass F7


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

teamwork 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





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.




2.3 Feedback

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Feedback figured strongly as both a method of delivery and a method of assessment. Students


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.





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.





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


“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.









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.




ladder. F7









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]




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]





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.


“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



of leadership practices and lack of a consistent and deliberate practice in the field. [29] Medical










their evaluation.

Conclusions



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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.


Health, 2008.



45 The King's Fund. Leadership and engagement for improvement in the NHS: Together we can :





2011;73:535-9.





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.





Second edition. Coventry, 2009.

13 Health and Social Care Act 2012. The Stationery Office , 2013.


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.



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Second edition. Coventry, 2009

14 NHS Institute for Innovation and Improvement. The Clinical Leadership Competency

Framework. Coventry 2011.



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.





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.



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


24 25 Lieff S. Albert M. What do we do? Practices and learning strategies of medical education


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.




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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2

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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