Leadership in Medical Education: A Review

Dr. Fariha Altaf^*, Dr Amra Farrukh¹, Dr Yakub Kasam Sayyad²

1. FCPS, MRCS, Specialist Paediatric surgery.

2. Affiliated with Shifa Clinic.
 

Corresponding Author: Dr. Fariha Altaf, MBBS, MCPS, FCPS, MRCOG, MRCPI, Senior specialist Ob Gyn, Arrayan Hospital, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia.

Copy Right: © 2022 Dr. Fariha Altaf. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: February 01, 2022

Published Date: March 03, 2022
DOI: 10.1027/margy.2022.0124

 

Abstract

To meet the challenges of our modern health care system, there have been increasing calls for physicians to develop the capabilities to lead health care transformation. The key to building high-quality healthcare is inculcating good medical leadership amongst residents and future healthcare professionals. As compared to technical and academic skills, leadership skills are not given that much importance in medical education. To meet the current transformation of health care leadership skills are needed to be incorporated in the medical curriculum as leadership skills help develop better physicians. Besides, it also seems to be imperative to begin leadership education in the earlier years of medical training so that they can lead as physicians with better skills in the health care system. Along with lecture and lecture-based programs, practical experiences are also important. There are several activities carried out in the medical profession that requires proper management. But due to a lack of leadership skills physicians fail to manage it properly. So, they need to be appropriately trained during their medical schooling.  

Leadership has been shown to increase thinking power, skills, and actions, which delivers good quality healthcare services and enhances our healthcare system and in turn, patient care. These skills can be obtained through enough experience in teamwork under the supervision of teaching staff. Hence medical leadership skill plays an important role in medical education. In this review, the goal is to throw some light on the importance of incorporation of leadership in Medical Education.

Keywords: Leadership, medical education, physicians, Healthcare, clinicians, medical doctors.                                      

Introduction

Modern healthcare structures are facing lots of challenges in recent times, which have raised a concern about imposing management talents on clinical educators. [1] There have been numerous calls to extend leadership development to the training of physicians. [2-3] Over the years, healthcare has been experiencing a profound transformation in terms of all of its sectors, thus implying a definite change is the crux of the healthcare system, which is health education. Leadership forms one of the integral components in cultivating better physicians of tomorrow.

Observational data have suggested that patient outcomes are improved with physician leadership. [4] Clinical schooling encompasses a wide range of activities such as coaching, learning, assessment, managing teams, and programs. [5] All these activities require some form of management. Internationally, medical doctors are being called upon to require greater active engagement in the management and control of clinical services. This caused a greater emphasis on ensuring that clinical college students can comprehend and be a part of such leadership programs. [5] Leadership has been shown to increase thinking power, skills, and actions, ultimately leading to the delivery of quality healthcare services and enhancing our healthcare systems and patient care. [6]

It is crucial to realize that leadership has to be equally shared among medical, clinical, and managerial professionals who add partnerships to deliver high-quality care. But at the international level, there is a considerable variation. Doctors are considered the leaders of the clinical teams. [7]

To construct the best healthcare leadership is important to fulfill the desires of healthcare in the twenty-first century. Competent leaders are vital across all health professions, including allied health, nursing, pharmacy, dentistry, and medicine. [8] Consequently, the incorporation of leadership training and development should be a neighborhood of all healthcare provider curricula. [8] Nearly all physicians tackle huge management obligations throughout their careers. However, in contrast to other careers in which control talents are crucial, physicians are neither taught to lead nor are they normally rewarded for correct management. [9] Even though clinical establishments have designated a middle clinical competency, management talents are not often taught and strengthened throughout the continuum of medical training. [9]

More evidence suggests that leadership skills and control practices have a significant impact on both patient and healthcare enterprise outcomes. [9] 

Thus, it becomes clear that leadership schooling must be officially incorporated into medical and residency schooling curricula. [9]

Likewise, research on academic leadership, especially that from outside of Europe, emphasizes the importance of getting institutional leaders closely concerned with superior academic programming. [10] Excellent leadership skills are required to ensure the availability of high-quality patient care. [10] Incorporating leadership skills into students while they pursue their courses will enhance team functioning, improve the learning environment, and will ultimately improve the health provision system. [11]

Practice-based learning and improvement of interpersonal and communication skills, and systems-based practice are leadership skills that should be incorporated into medical schooling or in training programs. [12]

In this review, the goal is to throw some light on the importance of the incorporation of leadership in Medical Education.

 

Methodology

The literature review for this work was conducted after a comprehensive investigation in reputable databases such as PubMed, Research gate, PMC Articles and Google Scholar. Key index words used for this literature review were Leadership, medical education, physicians, Healthcare, clinicians, postgraduate, medical doctors.

Inclusion criteria: The date of publishing until September 2021 was chosen as an inclusion criterion. In order to collect data, only English-language sites were used. Case reports and research articles from reliable sources were included in the studies, and their credibility was determined by their publisher.

Exclusion Criteria: Studies published in other languages were not included. Only credible research papers were included. As a result, any research papers that were not published in peer-reviewed journals were not examined. Articles that did not clearly address the application of leadership in medical education were eliminated, and only relevant articles that matched the inclusion criteria were utilized as references. Ultimately, the major goal was to acquire high-quality data.

 

Leadership Education in Healthcare Sector

The healthcare system is continually evolving, and it is confronted with numerous issues such as funding restrictions, increased accountability, changes in patient populations, and increased regulations. [13] This has led to the conclusion that, in order to improve health, academic health centers must create leaders at all levels of organization and systems. [13]

Incorporation of leadership coaching in medical schooling can turn out to be a very important method for achieving respective goals, fostering resilience among future healthcare professionals, and benefit not only the workers in the health sector but also their families, patients and broader communities. [14] In addition, there has been a renewed push to develop leadership skills in medical students, beginning early in their careers and continuing throughout their careers, so that they can take on more important leadership responsibilities within the healthcare system in the near future. [15]

To be an effective leader, leadership abilities should be cultivated earlier in medical training. [16] Medical schooling at the undergraduate level focuses on the diagnosis & management of diseases with very little emphasis on the systemic issues surrounding the provisions and the outcomes as well as the teamwork required to deliver safe and prime quality healthcare to the community. [16]

Leadership skills are not well developed at the undergraduate level and currently, there is limited literature available supporting the same so as to incorporate them into the curricula. [17] One survey showed that an outstanding 85% of medical students thought that they must be taught leadership and teamwork skills in their grad school. [17] A specific leadership curriculum including role play, team training, community experiences, student leadership opportunities, participation in quality improvement projects, and mentored leadership development plans are potential ways to spice up under the current education system thus leading to future healthcare professionals becoming adept physicians through the medical education leadership training. [18]

The Accreditation Council for Graduate Medical Education (ACGME) recognized practice-based learning and improvement, interpersonal and communication skills, and systems-based practice as core competencies, all of which contain elements of leadership qualities. [19] The Can MEDS agenda hired by the Royal College of Physicians and Surgeons of Canada renamed the role of “manager” to “leader”, thus paving the way for the incorporation of leadership training under the realm of medical education. [20] The Academy of Medical Royal Colleges started a Medical Leadership Competency Framework (MLCF) composed of 5 categories: demonstrating personal qualities, working with others, managing services, improving services, and setting direction. [21] These examples show the support of graduate medical education (GME) accrediting bodies for inculcating leadership training for residents. [21]

Mostly, our teaching system in healthcare is predicated on certain guidelines, in other words, we are taught to form guideline-based decisions and hence it becomes a tad bit difficult in managing medical situations that tend to fall outside of the linear guidelines. [22] Experiences say that teaching method that affords medical students limited responsibilities in clinical higher operation, which are then vetted by senior clinicians greatly improve confidence. [22] An illustration for this idea would be a general practitioner setting where they are encouraged to determine their own patients, make a well-informed diagnosis and complete a management plan pending approval from a senior MD. [22] This approach might be translated to medical management, where students are given limited responsibilities for deciding under tutelage from those within the sphere. [22] In order to attain this, implementation, and encouragement of leadership in medical education is crucial. [22]

 

Discussion

A physician’s involvement in leadership and management has a beneficial effect on the health delivery system and concomitantly the quality of patient care. [23] If today’s medical students are well educated regarding leadership skills, tomorrow's doctors will become well equipped with the skills essential to delivering quality healthcare services and also might pique interest amongst these young inquisitive minds to get more engaged in leadership and management systems. [24]

In spite of the development of leadership education initiatives for first-year doctors, evidence of such developments at the undergraduate level are even more limited. [24] A recent study identified leadership as one of the key skills for undergraduate community-based education for health professionals. [25] On the contrary, some studies reflect obstacles to teaching leadership, specifically to the undergraduate medical syllabus, including variability of leadership practices and lack of consistent and deliberate practice in the field. [26]

The problem in undergraduate medical education is the compromise between adding more content into an already content condensed education. [27] In one of the studies from the University of Michigan, it was found that there was limited success in an experimental required curriculum for all students which may signal those integrated efforts may not produce the most robust response to the training that is usually expected. However, it is important to consider the fact that despite poor performances, students were still wanting to receive this type of education and training on the whole. [28]

A study reported from Ghana searched the importance of role modeling on the event of leadership skills, and the way role models impact students’ perception of important leadership skills. [29] Finally, a survey of US grad school deans revealed various leadership development opportunities, including dual degree programs, workshops, lectures, seminars, and non-curricular options like committee work, student organizations, service projects, and volunteer and teaching opportunities. [30]

An article published in 2011 identified areas of essential medical leadership and management skills for undergraduate medical education, including quality improvement, managed care, use of resources and healthcare cost, doctor’s role, patient safety, and general leadership and management. [31] To implement the above qualities, medical students want increased training but lack the time to effectively participate and reap benefits from them. Some of them also tend to show disinterest in certain areas. [32] The solution to resolve this can be to utilize a module-based system in which the learning is more self-paced throughout undergraduate medical education. This method was implemented by the University of Newfoundland. [33] But the study concludes by calling for more research on the topic and more investigations into the best approaches to leadership development for medical students. [34]

In another, a more recent review of 11 studies from 2018, the authors again concluded that there is limited evidence of effectiveness in the studies they examined ranging from the years 2000–to 2014. [35] This review also summarized a lack of objective and long-term outcomes, as well as a standard framework for the evaluation of these problems.

Besides, it is crucial to understand the fact indicated by the workforce data is that several experienced clinicians and healthcare educators will retire over the following ten years. [36] This means that the need for effective succession planning and leadership training is well recognized with a current shortage of emerging leaders entering into leadership roles being highlighted. [37,38,39] Effective leaders must be nurtured and supported by the organizations from which they are being educated, trained as well as in the institutes they work in. [40] So it is of utmost importance to introduce the subject of leadership as a key curriculum area. [41] Leadership development, assessment and feedback are necessary throughout the education and training of health professionals. [41] Aspiring and current leaders are often identified, trained, and assessed through formal leadership development programs, and through supportive organizational cultures. [41] It needs embedding leadership training programs, opportunities for leadership practice, and promotion of professional networks within and beyond the organization. [41] The significance of mentorship within healthcare education is well recognized, offering a method to further enhance leadership and engagement within the workforce. [42] 

There is a lack of focused attention toward the development of leadership capabilities in trainees. Proof suggests that leadership quality affects patients, healthcare system outcomes, and finances alike. [43] As an example, hospitals with higher-rated management practices and more highly rated boards of directors are shown to deliver higher quality care and have better clinical outcomes, including lower mortality rates. [43] Enhanced management practices have also been related to higher patient satisfaction and better financial performance by not only the clinicians but the whole healthcare staff. [43] Success in leadership additionally affects physician well-being, with stronger leadership qualities indirectly related to less physician burnout and better satisfaction. [43]

These advantages are crucial in a healthcare landscape that is increasingly focused on measuring and achieving high care quality, which is characterized by high rates of burnout across clinical personnel, and that is asking physicians to steer larger, multidisciplinary teams of nurses, social workers, physician assistants, and other health professionals towards a positive direction. [43]

There are so many opportunities for medical students to get involved in activities that may help in developing their leadership skills, from quality improvement [44] to structured programs; these may be achieved either within an educational program or through specific day trips of coaching. [45] However, as per the expectation of all the members of our community to own critical reading skills and to grasp research, with some taking additional opportunities to achieve a far greater understanding of research, it is plausible that with the leadership we want to and can effectively form the opportunities for all the students and trainees to be told a way to manage themselves and lead a team with some trainees helping them acquire those extra skills required for being successful under corporate leadership. [46]

Despite these advantages, leadership and management are viewed cynically by some clinicians; inappropriate and careless remarks, like moving to the dark side, are sometimes made about trainees assuming who are willing to or actually developing leadership skills. [46] Comments like these are reminiscent of the hierarchy of specialties within the profession and are frequently fueled by the lack of proper understanding. [46] The power to assimilate the data to succeed in a working diagnosis and agree upon a treatment plan and measures of improvement is comparable to the power to spot and assess issues creating a management problem and agree on an action plan and measures of change. [46] Furthermore, the skill set needed to influence others to vary behavior whether or not they are patients or team members – are the same: active listening, negotiation and influencing. [46] An alternative approach that is unlike the usual one, towards leadership and management is at the best unhelpful and, if left unchecked, most definitely creates a rift between the healthcare professionals as well as the health service managers. [46]

At the international level, to be specific, across the United Kingdom, most local Health Education England offices and deaneries have created local opportunities to have interaction in leadership activities. [46] Additionally, there are national programs like the Faculty of Medical Leadership and Management (FMLM) Clinical Fellows Program and the chief registrar project at the Royal College of Physicians. [46] These offer medical students the opportunities to dabble themselves in national organizations, contributing towards projects focused on developing leadership skills. There are other opportunities that can be highlighted here as well: many trusts offer leadership development to all or any new consultants; the FMLM offers development for General Physicians usurping leadership roles and much of parts of the United Kingdom offer learning sets and specific leadership programs. There also are national programs like those offered by the Leadership Academy and King's Fund. [46]

In medical, leadership is best learned through practical experiences. Classroom lectures and lecture-based programs will only provide theoretical knowledge. [46] For several trainees and students, the important aspect of leadership development will still be the abilities and behaviors necessary to figure effectively with others. These include the facility to delegate, negotiate, support, and motivate, additionally to the talents necessary to acknowledge error as well as the act to correct it. [46]

Various skills are needed to become a leader. A comparative analysis of grad school leadership job postings from 2000-2004 and 2010-2014 showed that there was a difference within the posting language with an increased concentrate on collaboration, clarity, community-controlled, accountability, and teamwork, highlighting the changing skills needed in medical education. [47] Further, for girls in leadership positions, tenured faculty cited individual skills and actions to facilitate development, including mentorship and institutional support for diversity and inclusion because the key factors in becoming successful leaders. [48] There are remarkable impacts for medical students on their acquisition of leadership skills or lack thereof. [49] In a paper, while discussing the sort of leadership development skills, medicine residency directors are attempting to specifically find a variety of various leadership development tools as a necessary component of a hopeful medicine resident. [49] Different methods like serving on the school of medication committees, student grouping involvement, involvement in organized medicine, and dealing on, and completing, projects were a variety of the examples listed as beneficial for leadership growth. [49] Yet, those gaps still persist into residency. During an inspection of medicine residents at Massachusetts General Hospital, resident physicians reported needing more experience in “leading a team”, “confronting problem employees”, and “resolving interpersonal conflict. [50] The foremost frequent ways they hoped to attain those skills were through interactive methods like case discussions, small discussions, simulation, and lectures. [50]

The Healthcare system is dynamic and changing in tremendous ways. Hence, it is critical for the physicians to develop leadership skills to assist as well as receive appropriate guidance in this transformation. For this, there is a need for well-designed and well-evaluated leadership curricula. Healthcare education leaders are required to figure effectively and collaboratively across various disciplines and organizational boundaries, where titles do not seem to be always linked to leadership roles but may occur in everyday work. Good leadership also means knowing when, and about the proper way to support others in their endeavors. Leadership curriculum at the medical education level focuses on a large range of abilities but is often not intended to be per the existing leadership competency framework. 

Future physician leaders have to be trained throughout the sphere of education and in lifelong learning. Medical education provides a perfect environment for laying the inspiration for leadership competencies, like system thinking training, team collaboration, communication skills, quality improvement, and insurance systems. In the long run, it is imperative for healthcare education leaders to demonstrate excellence in teamwork, clinical skills, patient-centered care, and responsibly balance accountability with autonomy.

 

Conclusion

With this review, it is also important to highlight the fact that further research is critical to review optimal teaching and assessment methods in medical education leadership curricula. There is also a need for in-depth qualitative and quantitative studies to characterize the prime appropriate leadership competencies on an annual basis of medical schooling and also the impact of such a curriculum on future leadership outcomes. With more thorough research supporting this ideology, leadership education can definitely pave a way for healthcare professionals to become more equipped with the skills that they can use to dispense top-notch health services.

 

References

1.McKimm J, Lieff SJ. Medical education leadership. A practical guide for medical teachers. Ch.42. In: Dent J, Harden RM, Hunt D, editors. London: Churchill Livingstone-Elsevier; 2013. pp. 343–51. [Google Scholar] [Ref list]

2.Addressing the leadership gap in medicine: residents' need for systematic leadership development training. Blumenthal DM, Bernard K, Bohnen J, Bohmer R Acad Med. 2012 Apr; 87(4):513-22.[PubMed] [Ref list]

3.Physician leadership in changing times. Cochran J, Kaplan GS, Nesse RE Healthc (Amst). 2014 Mar; 2(1):19-21.[PubMed] [Ref list]

4.Physician-leaders and hospital performance: is there an association? Goodall AH Soc Sci Med. 2011 Aug; 73(4):535-539. [PubMed] [Ref list]

5.https://www.researchgate.net/publication/242357002_Medical_education_leadership

6.Adjei DI. 2013. Leadership management. Int J ICT Manage. 1:103–106. [Google Scholar]

7Dorgan S, Layton D, Bloom N, Homkes R, Sadun R, Van Reenen J. Management in Healthcare: Why Good Practice Really Matters. London: McKinsey and co. and LSE; 2010

8.Leadership in healthcare education Christie van Diggele, ,Annette Burgess, Chris Roberts & Craig Mellis  BMC Medical Education volume 20, Article number: 456 (2020)

9.Why Doctors Need Leadership Training by Lisa S. Rotenstein,,Raffaella Sadun,and Anupam B. Jena October 17, 2018

10.Effective leadership in higher education: A literature review. Studies in Higher Education, 32, 693–710.Christensen, C. M., & Eyring, H. J. (2011).

11. AAMC organization. Core entrustable professional activities for entering residency: curriculum developer’s guide. Washington (DC): The Association of American Medical Colleges; 2014. https://members.aamc.org/eweb/upload/core%20EPA%20Curriculum%20Dev%20Guide.pdf ?. [Google Scholar] [Ref list]

12. Accreditation Council for Graduate Medical Education. Milestones. http://www.acgme.org/What-We-Do/Accreditation/Milestones/Overview. Accessed February 22, 2018. [Ref list]

13. A First Step Toward Understanding Best Practices in Leadership Training in Undergraduate Medical Education   a Systematic Review, Webb, Allison M.B. MAT; Tsipis, Nicholas E. MPH; McClellan, Taylor R.; McNeil, Michael J.; Xu, MengMeng; Doty, Joseph P. PhD; Taylor, Dean C. MD

14.The impact of leadership coaching in an Australian healthcare setting Anthony M Grant ¹, Ingrid Studholme ¹, Raj Verma ², Lea Kirkwood ², Bronwyn Paton ², Sean O'Connor 

15.Medical leadership: a significant and required competency for medical students T sung-Ying Chena, b*

16.Leadership curriculum in undergraduate medical education: a study of student and faculty perspectives. Varkey P, Peloquin J, Reed D, Lindor K, Harris I Med Teach. 2009 Mar; 31(3):244-50. [PubMed] [Ref list]

17.Leadership and management in the undergraduate medical curriculum: a qualitative study of students' attitudes and opinions at one UK medical school. Quince T, Abbas M, Murugesu S, Crawley F, Hyde S, Wood D, Benson J BMJ Open. 2014 Jun 25; 4(6): e005353. [PubMed] [Ref list]

18.Leadership curriculum in undergraduate medical education: a study of student and faculty perspectives. Varkey P, Peloquin J, Reed D, Lindor K, Harris I Med Teach. 2009 Mar; 31(3):244-50. [PubMed] [Ref list]

19.Accreditation Council for Graduate Medical Education Milestones http://www.acgme.org/What-We-Do/Accreditation/Milestones/Overview. Accessed February 22, 2018

20.Dath D. Chan MK. Abbott C. CanMEDS 2015: from manager to leader 2015. http://www.royalcollege.ca/rcsite/documents/cbd/canmeds-2015-manager-to-leader-e.pdf. Accessed February 22 2018

21. NHS Institute for Innovation and Improvement; Academy of Medical Royal Colleges. Medical leadership competency framework: enhancing engagement in medical leadership 3rd edition 2010. https://www.leadershipacademy.nhs.uk/wpcontent/uploads/2012/11/NHSLeadership-Leadership-Framework-Medical-Leadership-Competency-Framework-3rd-ed.pdf. Accessed March 19, 2018

22.Reference: Incorporation of management teaching into medical school curricula: a medical student’s perspective Harun Abdul Jalil1 Amin Habib2 Ali Shah2 1 School of Medicine, Keele University, Keele, Newcastle ST5 5BG, UK; 2 School of Medical Education, King’s College London, London, UK

23.Size, composition, and culture of high-performing hospital boards. Prybil LD Am J Med Qual. 2006 Jul-Aug; 21(4):224-9. [PubMed] [Ref list]

24.Engaging all doctors in continuous quality improvement: a structured, supported programme for first-year doctors across a training deanery in England. Bethune R, Soo E, Woodhead P, Van Hamel C, Watson J BMJ Qual Saf. 2013 Aug; 22(8):613-7. [PubMed] [Ref list]

25.Review Competencies for undergraduate community-based education for the health professions--a systematic review. Ladhani Z, Scherpbier AJ, Stevens FC Med Teach. 2012; 34(9):733-43. [PubMed] [Ref list]

26.Allen SJ, Middlebrooks A. The challenge of educating leadership expertise. J Leadersh Stud 2013;6:84–9 [Google Scholar] [Ref list]

27.Abbas MR, Quince TA, Wood DF, Benson JA. Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development. BMC Med Educ [Internet]. BioMed Central Ltd; 2011; 11:93. Available from: http:// www.biomedcentral.com/1472-6920/11/93.

28.Wagenschutz H, McKean EL, Mangrulkar R, Zurales K, Santen S. A frst?year leadership programme for medical students. Clin Teach [Internet]. 2019; 16:623–9. Available from: https://onlinelibrary. wiley.com/doi/abs/https://doi.org/10.1111/tct.13005.

29.Community-based education: The influence of role modeling on career choice and practice location. Amalba A, Abantanga FA, Scherpbier AJ, van Mook WN Med Teach. 2017 Feb; 39(2):174-180. [PubMed] [Ref list]

30.The state of leadership education in US medical schools: results of a national survey. Neeley SM, Clyne B, Resnick-Ault D Med Educ Online. 2017; 22(1):1301697. [PubMed] [Ref list]

 

31.Abbas MR, Quince TA, Wood DF, Benson JA. Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development. BMC Med Educ [Internet]. BioMed Central Ltd; 2011; 11:93. Available from: http://www.biomedcentral.com/1472-6920/11/93. [PMC free article] [PubMed]

32.Review Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development. Abbas MR, Quince TA, Wood DF, Benson JA BMC Med Educ. 2011 Nov 14; 11():93. [PubMed] [Ref list].

33.Leadership training for undergraduate medical students. Maddalena VLeadersh Health Serv (Bradf Engl). 2016 Jul 4; 29(3):348-51. [PubMed] [Ref list]

34.Review Attitudes of medical students to medical leadership and management: a systematic review to inform curriculum development. Abbas MR, Quince TA, Wood DF, Benson JA BMC Med Educ. 2011 Nov 14; 11():93.[PubMed] [Ref list]

35.Review A systematic review of leadership training for medical students. Lyons O, Su'a B, Locke M, Hill A N Z Med J. 2018 Jan 19; 131(1468):75-84.[PubMed] [Ref list]

36.Norcini JJ, Banda SS. The global health workforce shortage: role of surgeons and other providers. Adv Surg. 2008;42:63–85.Return to ref 24 in article.

37.Kim T. Succession planning in hospitals and association with organizational performance. Nurs Econ. 2012;30(1):14–20. Google Scholar

38. Swanwick T, McKimm J. Clinical leadership development requires system-wide interventions, not just courses. Clin Teach. 2012; 9:89–93. Article Google Scholar

39.Matthews JH, Morley GL, Crossley E, Bhanderi S. Teaching leadership: the medical student society model. Clin Teach. 2017;15:2. Google Scholar 

40.Swanwick T, McKimm J. What is clinical leadership and why is it important. Clin Teach. 2011;8:22–6.Return to ref 6 in article

41.Leadership in healthcare education Christie van Diggele, Annette Burgess, Chris Roberts & Craig Mellis.

42.Burgess A, van Diggele C, Mellis C. Mentorship in the health professions: a review. Clin Teach. 2018;14:1–6.Return to ref 28 in article Google Scholar 

43. Why Doctors Need Leadership Training by Lisa S. Rotenstein,Sadun, and Anupam B. Jena October 17, 2018

44.Ahmed M Arora S, Tiew S, et al. Building a safer foundation: the Lessons Learnt patient safety training programme. BMJ Qual Saf 2014; 23:78–86.Abstract/FREE Full TextGoogle Scholar

45.Agius S, Brockbank A, Baron R, Farook S, Hayden J. The impact of an integrated Medical Leadership Program. J Health Organ Manag 2015;29:39–54.Google Scholar

46.Tomorrow's leaders – the role of leadership in medical education and training. Jacky Hayden

47. Gorsky D, MacLeod A. Shifting norms and expectations for medical school leaders: a textual analysis of career advertisements 2000–2004 cf. 2010–2014. J High Educ Policy Manag [Internet]. 2016; 38:5–18. Available from: http://www.tandfonline.com/doi/full/10.1080/1360080X.2015.1126893. [Ref list]

48. Silent Bias: Challenges, Obstacles, and Strategies for Leadership Development in Academic Medicine-Lessons from Oral Histories of Women Professors at the University of Kansas. Pingleton SK, Jones EV, Rosolowski TA, Zimmerman MK Acad Med. 2016 Aug; 91(8):1151-7.[PubMed] [Ref list]

49.Shanahan R, Rosen B, Schofer J, Fisher AS, Wald D, Weiner S, et al. medical student leadership in emergency medicine. J Emerg Med [Internet]. Elsevier Inc; 2020;1–3. Available from: 10.1016/j.jemermed.2020.02.023. [Ref list]

50.Assessment of leadership training needs of internal medicine residents at the Massachusetts General Hospital. Fraser TN, Blumenthal DM, Bernard K, Iyasere C Proc (Bayl Univ Med Cent). 2015 Jul; 28(3):317-20. [PubMed] [Ref list]