2013 Radcliffe Publishing Limited Teaching exchange 61

Developing innovative leaders

through undergraduate medical
education
Anne-Marie Reid EdD BDS MEd Cert Ed FHEA
Senior Lecturer, School of Medicine, University
of Leeds. Lead for TEMPUS project on
Modernising Medical Education in Eastern
European Neighbouring Areas (MUMEENA)
Keywords: leadership skills, team work,
undergraduate curriculum
INTRODUCTION
The requirements of Tomorrows Doctors
1
to be
Practitioners, Professionals and Partners includes
the demonstration of effective leadership skills to
deal with the increasing complexity of working
effectively in the NHS. This is in response to the
Darzi Next Stage Review
2
which sets out clearly
the links between leadership, organisational
performance and patient outcomes. In addition to
a focus on outcomes for medical graduates, policy
drivers and guidance in Good Medical Practice,
3

Leadership and Management for all Doctors
4
and
the NHS Framework for Leadership
5
have echoed
the need for development of effective teamworking
and leadership. In primary care, practice-
based commissioning and the move to clinical
commissioning groups (driven by the NHS and Social
Care Act, 2012)
6
requires practitioners to develop
greater understanding of, and expertise in, a range
of leadership and management skills. This includes
managing resources, both human and financial,
understanding leadership in multiprofessional teams
and developing negotiation skills in a more business-
orientated environment. Irrespective of the extent to
which primary care practitioners feel enthusiastic
about these requirements on either a personal or
political level, it is incumbent upon medical schools
to prepare undergraduates to face these demands,
rather than assuming that there will be plenty of
time following graduation. This early preparation
needs to support undergraduates in developing
an understanding of the demands of leadership
within a current practice context, but also needs to
encourage them to become the innovative leaders
of tomorrow, who not only respond to policy and
practice demands, but actively contribute to policy
making and empowering others, not least, patients.
THE LEADERSHIP CURRICULUM
Mindful of these changing demands, and as part
of a curriculum review which began in 2008, the
School of Medicine in Leeds has developed a new
Innovation, Development, Enterprise And Leadership
& Safety (IDEALS) curriculum strand which spirals
through the five years of the MBChB programme. A
core working group was established to develop the
IDEALS strand, which incorporates six key themes:
Leadership and management
Professionalism
NHS Business Understanding the Service
Patient safety
Learning and teaching skills
Personal and professional development (including
careers).
Having agreed the main themes, smaller subgroups
of the core group were formed to develop these
individually, with the larger working group being
convened on a regular basis to ensure synergy
between the themes. The starting point for
elaboration of the teaching on leadership and
management was in developing a curriculum to meet
the outcomes set by Tomorrows Doctors
1
(Box 1).
Box 1 Outcomes set by Tommorrows Doctors
Outcome 15 Communicate effectively with
patients and colleagues in a medical context
(h) Communicate effectively in various
roles, for example, as patient advocate,
teacher, manager or improvement leader.
Outcome 22 Learn and work effectively within
a multi-professional team
(a) Understand and respect the roles and
expertise of health and social care
professionals in the context of working
and learning as a multi-professional
team.
(d) Demonstrate ability to build team capacity
and positive working relationships and
undertake various team roles.
Tomorrows Doctors (GMC 2009)
THE SPIRAL CURRICULUM: THE
EARLY YEARS
The IDEALS curriculum is structured in accordance
with the nature of a spiral curriculum
7
where
students are iteratively exposed to increasingly
complex concepts and structures which require
higher-level skills and application in response
to them. The early teaching is concentrated on
exploring the differences between groups and
teams and developing understanding of effective
teamworking through engaging with problem-solving
tasks. Students normally work in small groups and
then each group provides feedback on both the task
itself and the contribution made by individuals to the
62 Teaching exchange
team. The discussion is placed within the context
of theoretical models of teamwork, with students
being encouraged to critique the evidence base to
support teamwork theory (or generally the lack of a
sound evidence base!) and the generalisability of the
models. All students come with some experience of
teamworking, so that they can appreciate that the
ideal formula for a sports team, for example, may
not resemble that of a team in a critical care unit.
Although models of teamworking and role theory are
widely used in business and increasingly in health
care, there is little research evidence to support their
value when applied in different contexts. Discussion
of this helps students to develop critical thinking skills
which are essential in effective leadership. Towards
the end of year 1 the emphasis moves towards
working in interprofessional and multiprofessional
teams with consideration of professional roles and
appropriate leadership responsibility according
to patient need and healthcare setting. Students
take part in a day of interprofessional learning with
nursing and healthcare students which is focused
on patient safety, a topic particularly appropriate for
interprofessional learning groups.
The next phase of the curriculum debates
leadership and management as contested concepts,
terms often used interchangeably, and subject to
different understandings through time and history.
Key lectures provide an overview of the theoretical
framework which outlines the move away from trait
theories
8
of leadership which have an emphasis on the
powerful charismatic personality of the individual, to
the concept of contingency leadership
9
where there
is recognition of a more dynamic relationship between
the leader, followers and the context. Working on
small group tasks allows students to explore the
differences between leadership and management,
and the value of different approaches to leadership
within the policy and practice context of the NHS. The
policy context is outlined and debated in the theme
of Understanding the Business of the NHS which is
delivered alongside the leadership and management
curriculum. This supports an appreciation that
effective leaders also need to have an understanding
of management principles and practices, particularly
in the area of primary care.
10

Early exposure to clinical placements offers the
opportunity for reflection on practice experience
to reinforce the concepts and understanding of
leadership. This is enabled by dedicating one half
day per week to placements in Year 1, and one day
per week in Year 2, with time spent in both primary
and secondary care. Students are attached to the
same GP practice over this period which allows them
to form good relationships with the practice team
and to observe teamwork and leadership in action.
THE SPIRAL CURRICULUM: THE
LATER YEARS
In the later years, contemporary theories of
leadership which emphasise the links between
leadership and emotional intelligence
11
are explored,
with an emphasis on developing understanding
of the quality of the relationship between the
leader, individuals and the team as a whole. An
emphasis is placed on empowering others through
an appreciation of distributed leadership and
recognising the role of non-medical staff members
as team leaders where appropriate. A focus on the
links between leadership, teamworking and patient
safety allows exploration of real practice scenarios
where patient safety has been compromised. This
leads naturally to an appreciation of the negative
impact of hierarchies on effective communication,
and the relationship between organisational culture,
team culture and communication.
The process of change management is introduced
through a presentation on the Kotter model
10
and
groupwork tasks, where students apply the model
to specific case scenarios involving changes in
healthcare practices. This is linked to the current
policy context, with consideration of the barriers
to change, and the ways in which the outcomes of
change are often far from those intended. This leads
on to the concept of transformational leadership
8

and the need for transformational leaders in both
primary and secondary care who can support others
in embracing change and direct this in the interest
of patients. Alimo-Metcalfe and Alban-Metcalfe
12

describe a transformational leader as someone
who encourages and enables the development of an
organisation that is characterised by a culture based
on integrity, openness and transparency (p. 4).
Their extensive research on leadership in complex
health and social care environments concludes that
transformational leadership has a notable positive
impact on staff motivation, commitment and
organisational effectiveness. This evidence base, in
support of a transformational model of leadership
which takes account of contextual factors, is
contrasted with the current emphasis on leadership
competencies encompassed within the NHS
Leadership framework, which has been critiqued as
being rather mechanistic, behaviourally focused and
tending to fragment the leadership role.
13
THE TEACHING TEAM AND
APPROACH TO LEARNING
A clinical academic with a background in managing
palliative care services leads the IDEALS strand,
with a core team of clinical academics who have
responsibility for each of the themes. The core group
is supported by a team of facilitators with a range
of backgrounds in health and social care including
GPs, dental practitioners, nurses, a pharmacist,
a physiotherapist, a paramedic, a retired chief
executive of an NHS Trust, a community worker and
a management consultant. The commitment to an
understanding of leadership within the context of
interprofessional and multiprofessional teamworking
is modelled through utilising the experience and
Teaching exchange 63
expertise of this range of staff to develop and deliver
the curriculum. Each facilitator teaches the same
group of approximately 12 students for one half day
each week throughout year 1 and year 2 with less
concentrated campus-based teaching in later years.
Regular training days are held for the whole team to
enable new materials to be discussed and different
perspectives to be considered, a process which
enriches the curriculum. Students greatly appreciate
the knowledge of current developments and the
wide range of expertise brought by this diverse and
experienced team.
I initially develop the teaching materials as I have
responsibility for the leadership and management
theme. The materials are reviewed with the
teaching team and amendments made before and
after teaching in the light of feedback from both
facilitators and students. Learning and teaching
methods include a few lecture presentations which
are supported by audiovisual material and further
reading on the virtual learning environment (VLE).
Most teaching is centred on groupwork tasks using
case scenarios, storytelling through digital media
and short videos and podcasts. Video clips and
podcasts have been produced with the support of
a range of junior and senior medical and healthcare
staff who reflect on their experiences of teamworking
and leadership in different capacities, with a strong
focus on primary care. Some of the materials have
been developed by senior students as part of their
Special Studies projects, which has been of benefit
to all parties. Reflection on performance is an integral
part of teaching and this is used not only to enhance
learning and consolidate understanding of teamwork
and leadership, but also to explore the principles of
professionalism. Relating campus-based teaching
to real examples from practice requires students
to consider issues of confidentiality, consent and
appropriate disclosure carefully, and allows the
tutor to intervene at an early stage to challenge
and discourage inappropriate behaviour. Exploring
attitudes and professional boundaries in a relatively
safe environment allows students to modify their
own behaviour at an early stage in the course.
Assessment of learning is on-going through group
presentations and projects, as well as through
completion of tasks and reflective exercises which
are entered into an e-portfolio. Students are also
required to complete 360-degree feedback to
encourage self-awareness and the ability to provide
constructive feedback to others which are essential
ingredients of effective leadership. Regular feedback
on e-portfolio exercises is given by the facilitator to
support the personal development of students and
to facilitate change as appropriate.
WHAT HAVE WE LEARNED?
The curriculum is now in the third year of delivery
and a number of changes have been made as a
result of student performance as well as feedback
from facilitators and students. Initially the concept of
leadership and organisational culture was introduced
in Year 1 and we found that this was too early in the
programme. The majority of students arrive straight
from school or college which limits the extent to
which they are able to reflect on experience of
leadership and management and appreciate these
concepts. Exploring these ideas at a later stage
allows students to bring their own placement
experience of leadership and management in action,
albeit predominantly from an observer perspective.
We have also found that having an emphasis on
leadership in the healthcare context engages
students more readily than using a wider range of
examples from other fields. It appears that students
come to medical school very keen to develop their
identity as trainee doctors and using materials
which support this are more likely to stimulate their
imagination. In addition, it enables facilitators to
identify more readily with the cases and supplement
them with examples from their own practice.
CONCLUSION
The integration of teaching on leadership and
management into the undergraduate curriculum
is essential but it is challenging in the light of the
maturity of students at this stage, and their relative
lack of experience of the world of work. Meeting
this challenge requires an interactive and engaging
approach to learning and teaching which centres
on experiential learning of teamworking initially,
with a later focus on leadership and management.
The spiral curriculum at Leeds allows this with the
integration of teaching on professionalism and
patient safety, alongside placement experience,
strengthening the self-awareness and efficacy of
students so that they develop an appreciation of
the words of Lao Tzu
14
Mastering others is strength,
mastering yourself is true power.
References
1 General Medical Council (2009) Tomorrows Doctors.
GMC: London. Available at: www.gmc-uk.org/publications
(accessed 16/10/12).
2 Darzi A (2008) High Quality of Care for All, NHS Next
Stage Review Final Report. Department of Health:
London.
3 General Medical Council (2006) Good Medical Practice.
GMC: London. Available at: www.gmc-uk.org/guidance
(accessed 16/10/12).
4 General Medical Council (2012) Leadership and
Management for all Doctors. GMC: London. Available at:
www.gmc-uk.org/publications (accessed 16/10/12).
5 NHS Institute for Innovation and Improvement (2010)
Medical Leadership Competency Framework. Available
online at: www.institute.nhs.uk/medicalleadership
6 Department of Health (2012) NHS and Social Care Act.
DH: London.
7 Bruner J (1977) The Process of Education. Harvard
University Press: Massachusetts.
64 Teaching exchange
8 Bass BM and Rigio RE (2006) Transformational Leadership
(2e). Erlbaum: Mahwah, New Jersey.
9 Hersey P and Blanchard KH (1993) Management of
Organisational Behaviour: utilising human resources.
Prentice Hall: New Jersey.
10 McKim J and Philips K (2010) (eds) Leadership and
Management in Integrated Services. Learning Matters Ltd:
Exeter.
11 Goleman D, Boatzis R and McKee A (2001) Primal
Leadership, The Hidden Driver of Great Performance.
Harvard Business Review online at: www.hbr.org.
(accessed 16/10/12).
12 Alimo-Metcalfe B and Alban-Metcalfe J (2008) Research
Insight. Engaging Leadership: creating organisations that
maximise the potential of their people. Chartered Institute
of Personnel and Development: London.
13 Brockbank B, Farook S and Aegius S (2011) NHS
Leadership Framework: introduction, critique and
recommendations for practice. In: The Consultant, Issue
7 December 2011. Available at: www.theconsultantjournal.
co.uk (accessed 16/10/12).
14 Tzu Lao (1995) The Tao Te Ching of Lao Tzu. St Martins
Press: New York.
Correspondence to: Dr Anne-Marie Reid, Leeds
Institute of Medical Education, School of Medicine,
Worsley Building, University of Leeds, Leeds LS2
9NL, UK. Tel: +44 (0)113 343 1754; email: a.m.reid@
leeds.ac.uk