Medical Leadership Development (MLD): the need of change and the way to approach it

Dear Editor, 
There are multiple challenges embedded in the health care system which put medical organizations and schools at a crossroad. These challenges are not limited but they can be related to the substantial increases of costs in health care, the pressing need of changing the education of health professionals, poverty and socio-economic disparities, to name a few (1).  These obstacles make the practice of medicine difficult and put the community at a greater risk if appropriate actions for an improvement in the competencies of medical students as well as medical teachers towards leadership are not called upon. Such instances have been emphasized by experts and relevant bodies in which effective leadership can be a panacea (2). Therefore, our health care delivery system is in direct need for transitions and rearrangement as well as necessary transformative changes in terms of medical leadership to efficiently improve and achieve excellent outcomes. “Leadership is the process through which an individual attempts to intentionally influence another individual or group in order to accomplish a predetermined set of goals”; thus leadership is a process and a performing art (3).
 
It is highly important to mention that physicians are the driving force in health care organizations not only in Primary Health Care (PHC) endeavors, but also in directing services and acting as the focal points of health care services. They work as managers, hospital administrators, trainers and researchers. Thus, they are at the frontline of healthcare and they play a pivotal role in leadership and management of others. Consequently, there is a need to make them competent concerning leadership skills. In this regard, if we educate and train medical doctors concerning leadership issues while they are in undergraduate, postgraduate or continuing practice, the resultant would have long-term implications in the delivery of health care services due to the their inspiration, wisdom and charisma, to name a few. Conversely, negligence and circumventing leadership training can negatively impact the health care system.
When it comes to a matter of change concerning the MLD, there should be contemplation on some important questions. These questions are:
1) Are the current physicians with responsibilities within the health care organizations well prepared for their leadership duties?
2) What have the responsible entities done so far to implement a curricular medical leadership for medical students and clinical teachers in practice?
3) How can changes be integrated in the organizational structure?
4) What educational models/frameworks are available that encourage and guide leadership development in medical education?
 
Thinking over such questions and finding answers to these questions put us on the right path for a change concerning MLD. In order to address the challenges and the changing needs of health care systems in the 21^st century, there is a need to provide formal leadership training to our medical teachers and medical students in different stages of their professional development. Taking into account that leadership can be developed and taught, there are some leadership programs to be utilized to bridge the gap of formal training for future Leaders. We should bear in mind that many schools lack formal curricular; however, there are some schools that offer leadership trainings. These leadership programs have been accentuated by different universities and medical centers (4,5), for instance, the Scott and White Executive Educational Program (SWEEP). This program aims to provide the fundamental principles of leadership to health care staff at the University of Texas (6). Also, a leadership curriculum has been developed by O’Connell and Pascoe in which the curriculum was implemented in 8 medical schools to cover leadership and teamwork skills necessary for leadership activities (7). Such programs should start in medical schools as early as possible to inculcate the ideas of leadership in junior and senior students as well as their teachers to equip them with necessary competencies to work as leaders in running health care organizations.
 
One of the frameworks which can be used in the development of a curriculum in leadership and management is the Medical Leadership Competency Framework (MLCF). This framework has been developed jointly by the Academy of Medical Royal Colleges and the National Health Service (NHS) institute in conjunction with a wide range of stakeholders in 2010. The MLCF depicts the leadership competencies that physicians need to be actively involved in the planning, delivery, and transformation of health services (8). This framework revolves around the theme of Delivering Services which is at the heart of the MLCF. There are five domains in MLCF which are shown below. Each domain in this framework is essential for physicians to gain a mastery over them in order to deliver appropriate, safe and effective services. Within each domain there are four elements and each of these elements is further divided into four competency outcomes. They include:
1. Demonstrating Personal Qualities
1.1 Developing self-awareness
1.2 Managing yourself
1.3 Continuing personal development
1.4 Acting with integrity
2. Working with Others
2.1 Developing networks
2.2 Building and maintaining relationships
2.3 Encouraging contribution
2.4 Working within teams
3. Managing Services
3.1 Planning
3.2 Managing resources
3.3 Managing people
3.4 Managing performance
4. Improving Services
4.1 Ensuring patient safety
4.2 Critically evaluating
4.3 Encouraging improvement and innovation
4.4 Facilitating transformation
5. Setting Direction
5.1 Identifying the contexts for change
5.2 Applying knowledge and evidence
5.3 Making decisions
5.4 Evaluating impact
 
This framework can be used in healthcare organizations in designing leadership programs and their evaluations. By the same token, clinical faculty members and medical students can be assisted in their professional development and career progression as medical leaders through using this framework.
 

Figure 1. The UK Medical Leadership Competency Framework (8)

There are also other frameworks which can be adopted for the same purposes. These include a framework developed by the Health Care Leaders Association of British Columbia (9) and the framework developed by the National Center for Healthcare Leadership (10).
 Concerning the implementation of a leadership change, research suggests that leadership training ought to begin during the years when students are nurturing as physicians in order to be developed as future physician-leaders (11). An appropriate approach to formal leadership training in medical schools is the adaptation of a “horizontal” program to teach the qualities, knowledge and skills to the targeted groups. A study undertaken to elicit the perspectives of faculty physicians and students concerning a leadership curriculum showed that confidence, creativity, humility, and emotional intelligence were considered as required qualities of leaders. Also, communication, teamwork, quality improvement, and management were identified as necessary skills and knowledge (12). The importance of acquiring leadership competencies has been highlighted in different studies by medical students and clinical faculty members in their roles as physician leaders (11,13). We assume that in order to implement a leadership initiative into our health care system, there should be a matter of change in the organizational structures of our health care delivery system. This change can be “vertically” tailored at institutional leaders who are decision makers and should accept the notion of change, set appropriate goals and cast a clear vision of how the change can be obtained and how it can improve the targeted goals. In addition, these leaders should work collaboratively to implement the change, provide motivation and act as the policy leaders for this change. Evidence shows that the main function of a leader is to produce change (14). Paving the path towards changes by a leader is a fundamental function of leadership.
 
In conclusion, driving the force to make the necessary changes in the organizational structure of health care organizations is the first most important action. In addition, the need to implement a formal medical leadership training program is crucial in the setting of prevalent changes in the 21^st century. Such derivatives like the MLCF and others can help sustain the major changes in the health care system and make physicians accountable for the community health by the cultivation of this idea that no room is given to individualistic culture of care (physician autonomy) but a harmonious environment in which care is managed by cooperation (interdisciplinary and inter-professional care). Besides, there is no doubt that the above-mentioned frameworks in this paper can be used to train doctors as leaders in health care systems.
We recommend further investigation on the ideal leadership curriculum, its format and content as well as its delivery and evaluation. Furthermore, the best practices of leadership training should be known to direct policy makers and medical educationalists towards evidence-based practices.
 
Ethical considerations  
Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.
Conflict of Interest: None to be declared.