Goldstein, Adam O. MD, MPH; Calleson, Diane PhD; Bearman, Rachel MA; Steiner, Beat D. MD, MPH; Frasier, Pamela Y. PhD; Slatt, Lisa MEd
Although the U.S. health care system embodies high medical expertise and advanced technology, it fails to meet the minimum needs of millions of Americans.1 Inadequate access to health care, lack of health insurance, and significant health disparities reflect crises in health care.2,3 To help solve these crises, health care organizations need outstanding leadership. Excellent leadership creates environments that influence people to follow chosen directions, thereby influencing the actions of individuals, groups, and organizations.4 For instance, physician leadership across professional, social, and regulatory agencies has contributed significantly to the reduction of tobacco use in the U.S. during the last five decades.5
Physicians remain uniquely situated to lead on issues adversely affecting health care because of their knowledge, their experience, and the respect of the physician's role in society.6 To effectively lead, physicians must possess not only excellent clinical skills but also excellent leadership skills.7
Calls for increasing the number of trained physician leaders have come from many places.1,8,9 The Institute of Medicine, for one, has stated that increased physician leadership and opportunities for leadership training would help redesign the health care system for the 21st century.1 As a result of these calls, the creation of leadership training programs for physicians has occurred across many settings, including those affiliated with major universities (e.g., Yale University, University of Tennessee), private companies (e.g., Center for Creative Leadership, Advisory Board Academies), and professional organizations (e.g., American Medical Association, American Academy of Family Physicians).10,11 Most of these programs enroll physicians posttraining and vary from weekend courses to two-year degree programs that may lead to certificates of medical management or master degrees in business administration or health administration.11 Although the creation of physician leadership programs has begun to extend to a few residency programs, the number of physicians graduating with skills necessary to take on leadership roles in practice remains insufficient given the large challenges facing health care.6,11–13
To ensure that physician leaders continue to emerge, one option is to integrate leadership training in community service into the undergraduate medical school curricula. Medical students understand that their training forms the core of what they need to know as future physicians. Exposing medical students to leadership training in community service during medical school may validate leadership concepts and help mitigate the tendency of students as they progress through training to feel less idealistic about medicine and more negative toward the underserved.14–18
Currently, medical students receive little exposure to leadership concepts while in training. Research from the Association of American Medical Colleges (AAMC) shows that whereas two thirds of graduating medical students report delivering clinical care to underserved populations, only one third report field experiences in service, only one fifth report working directly with diverse community groups, and up to one half report inadequate instruction in health care systems, medical economics, community medicine, and public health.19 The AAMC curriculum directory lists only three medical schools as offering leadership courses, and few published data exist about the outcomes of these courses.20
Leadership competencies in community service include not just knowledge and attitudes but also a broad set of skills such as coalition building, policy advocacy, fundraising, program planning, motivation, and facilitation—skills not taught in the medical curriculum. The most successful learning environments combine content knowledge with practical application, but few models exist for how to combine needed leadership competencies with actual service opportunities in the medical curriculum.21
Two medical schools have reported ways of offering leadership training to medical students. One program involves an integrated leadership and medical degree curricula, but this program requires an additional year of training, something most medical schools and medical students are not likely to choose.22 Another medical school, the University of Wisconsin School of Medicine, has a program called LOCUS (Leadership Opportunities with Communities, the Underserved, and Special Populations) that seeks to improve medical students' leadership, knowledge, and skills through community service, but the program is not a curricular offering but, instead, a longitudinal, extracurricular activity.23 Finally, the American Medical Student Association conducts an annual Primary Care Leadership Training Program that focuses on primary care, leadership skills, curricular reforms, and health policy issues,24 but only a limited number of medical and dental students may attend.
The “Advanced Leadership Skills in Community Service” (ALSCS) offers a new model for training undergraduate medical students in leadership skills. The course is available annually to second-year medical students at the University of North Carolina at Chapel Hill School of Medicine (UNC SOM). It is 1 of 13 semester-long selectives that students can choose in a required humanities and social sciences course. Between 12 and 14 students have enrolled in ALSCS for each of the last five years. This article describes the development, philosophical framework, curriculum and assessment, and initial outcomes of the ALSCS course.
The ALSCS came about as part of a three-year Bureau of Health Professions Title VII grant to the University of North Carolina Department of Family Medicine, for a new curricular program called Education for Lifelong Service (ELS). The ELS program was designed to introduce curricular reforms in medical education centered on community service and care to underserved populations. Several efforts evolved from this grant, including the ALSCS course. The ALCSCS course built on, but substantially changed, a preexisting elective for one or two fourth-year students on medical activism taught by one of the ELS faculty (A.O.G.).
Leadership Skills Framework
Several leadership theories guided the curriculum framework for the ALSCS. Bass's25 transformative theory of leadership acknowledges that although leadership involves personality traits and unique events, most people choose to become leaders and learn leadership skills. Transformative leadership emphasizes leadership skills that individuals must acquire to transform their environments and not simply lead. We used transformational leadership theories to ensure that medical students would develop a strong vision and apply newly developed competencies toward leadership opportunities. Bolman and Deal's26 leadership framework emphasizes how effective leadership must simultaneously understand and manage structures, human resources, politics, and symbols. This leadership framework teaches emerging leaders how to learn from different leadership styles (e.g., internal versus external) and to learn the competencies that deal with the processes of leadership in addition to the outcomes. From this leadership theory, we ensured that students had sufficient curricular time exploring different leadership styles to make groups more effective, and to learn skills such as facilitating discussions, building coalitions, and running effective meetings.
A final leadership framework acknowledges leadership in its service to underserved populations. Originating in part from Robert Greenleaf's work on servant leadership, this framework emphasizes the transformation that occurs from the bottom up rather than the top down. Leadership of this type is often based in communities.27,28 We used this theory to help guide community projects, select guest speakers, and develop classroom activities exemplifying leadership.
The course instructors for the selective come from an interdisciplinary background, including health behavior, education, and medicine. Course faculty, all from UNC, had prior experience in teaching about leadership, and several had also taught in the UNC School of Public Health's leadership program.
From these theories, frameworks, and experiences, the instructors selected the following curriculum strategies:
* Understanding the importance of developing a transforming vision to guide leadership goals;
* Understanding the value of different leadership styles;
* Using self-reflection to identify personal strengths, weaknesses, values, and ethics;
* Identifying and connecting with appropriate role models and mentors and practicing networking skills;
* Focusing on team-building skills (i.e., facilitation, giving and receiving constructive feedback, conflict resolution);
* Learning and applying media and policy advocacy skills necessary for structural change (i.e., preparing and giving presentations, organizing community activism, using the media);
* Demonstrating collaboration and fundraising skills needed for successful leadership; and
* Demonstrating commitments to community-based leadership by applying learned skill sets to service projects rooted in the community.
Classes and teaching methods
The ALSCS curriculum comprises 11 class sessions that occur across a four-month period. Each two-hour class has specific course objectives, readings, class activities, and follow-up. Table 1 provides an overview of the curriculum, and List 1 provides an overview of the objectives and activities for one class. Most classes start with a short leadership exercise, icebreaker, or quote. The faculty and students also check in with one another, reporting anything new in their lives as a way to inspire one another, build trust, and strengthen teamwork necessary for successful leadership. Students then share any examples of leadership—germane to any previous class sessions—that they have witnessed or experienced. For example, one student discussed witnessing a bus hit a pedestrian and his opportunity to practice several leadership competencies. The class subsequently sent a condolence note to the family of the injured pedestrian and examined the issue of pedestrian walkways around campus (see below). As expected, some of the examples the students share are of poor leadership (e.g., a meeting run without an agenda or time limits and with little facilitation), and some are of excellent leadership (e.g., a student using inspiring techniques to recruit a fellow classmate to join a community service project).
The principal portion of each class is devoted to active learning, whereby students discuss, practice, and reflect on a new leadership skill. All class sessions emphasize interaction and discussion rather than lecture. After a brief (five- to eight-minute) summary of a topic pulled from preassigned class readings and an opportunity for any clarifying questions, students break into smaller groups to discuss cases, examples, and scenarios that apply to the selected leadership competency. For instance, when discussing soliciting funds from an individual—whether family, friend, or stranger—students practice asking each other for money, knowing how and when to be silent, countering objections, and providing appropriate follow-up after the conversation. When discussing facilitation, students monitor and comment on class dynamics, or they may teach one part of the class, noting when class instructors or fellow students perform a facilitation skill well or when facilitation skills need improvement. To practice the leadership skill of giving feedback, students critique one another using scenarios developed for the course as well as examples relevant to their current experiences with peers. At the end of each small-group exercise, the whole class debriefs, sharing what they have learned and/or experienced.
The remaining class time starts with a discussion of a reading from the course textbook as it applies to the examples discussed in class until that point in time. The required course text, Mountains Beyond Mountains by Tracy Kidder, features the life and mission of Dr. Paul Farmer and his colleagues to alleviate poverty, HIV, and tuberculosis among the poor in the United States and internationally. Usually, students read 30 to 40 pages between class sessions, and both they and the instructors select quotes to bring into class for discussion. The book inspires students, giving real examples that relate to classroom exercises.
Two or three faculty guests come to the class each year, spaced out over the course. Guests are selected by the group, based on student or faculty suggestions, and represent alignment with students' service and leadership interests. Faculty guests receive extensive previsit preparation to ensure that they know the overall course objectives and that the content and process of their visit reinforce the class objectives for the day. Faculty ensure that guests selected represent diversity of opinions, gender, and ethnicity, are recognized leaders in health care, and have strong records of community service. To ensure interaction between guests and students, guests are asked to talk for only 10 minutes at the start, and students come to class with prepared questions to ask guests, based on their knowledge of the guest's professional work, class readings, and objectives.
Classes end with a review of the day's objectives and accomplishments, followed by a brief overview of the next class and any upcoming written assignments. Instructors post readings for each class, as well as written assignments, on a Web-based instructional system that allows for varied teaching interactions between faculty and students (Blackboard Learning System 6.1.0, 2005). Instructors try to finish class early to allow students time to meet in small groups to discuss their community projects.
In addition to attending classes, students must complete written assignments that relate to the topics, allowing them to practice leadership skills and to reflect further on in-class concepts. Students have a total of seven written assignments over the entire course, and they always have at least two weeks to finish each assignment. The seven assignments (all require writing the requested work to turn in to faculty for feedback) consist of
* creating a personal vision statement;
* reaching out to three new mentors;
* providing written feedback to colleagues and actively facilitating some portion of a group meeting;
* motivating colleagues to participate in a service project;
* developing and executing a focused advocacy project;
* submitting an op-ed piece or letter to the editor regarding a policy outcome; and
* writing a small grant or individual solicitation for funds.
Each assignment has very focused and practical tasks. List 2 provides an overview of an assignment associated with one class. The typical time commitment for an assignment, although varying by student effort, is approximately two to four hours. Students receive written feedback on every assignment, and because the quality of the students' written work is quite high, instructors frequently ask several students to read aloud portions of their assignments to the group at the start of a class session to illustrate unusual or important points of the assignments.
Some students also choose to participate in an additional out-of-class written activity, an e-mail list serve. Although not a mandatory part of the class, this list serve allows the students and instructors to communicate with one another throughout the course on several topics that are not part of the formal curriculum but that often help students acquire a deeper and stronger leadership perspective. For instance, list serve participants discuss selected quotes or experiences dealing with spirituality; with balancing leadership, community service, work, and family; and with ethics. On average, most students participate in at least one of the list serve discussions, and several participate in all of the discussions.
Community service projects
Students must also participate in a community service learning project, which they themselves choose. Together, during the first few class sessions, students brainstorm about multiple possibilities—some that the faculty suggest and some that the students know about from their prior service experiences. The class researches projects, discusses how each would fit class criteria, and ultimately votes as a group to carry out three or four projects, dividing evenly into groups based on interests. The faculty design the service learning project to enable the students to simultaneously (1) integrate multiple leadership skills learned in the course, (2) practice collaboration, team building, and trust through interactions with classmates, (3) contribute to addressing a community need, especially related to underserved populations, and, if possible (4) address a one-time community need, or build a more sustainable bridge with a community partner. Students should be able to complete the service projects with approximately 15 hours of out-of-class time for both preparation and conduct.
Groups for the service projects usually comprise three to five students, must receive permission before embarking on their projects, and must define their project ideas by the beginning of the fifth class. Instructors ask students to make sure their projects are “SMART,” or specific, measurable, achievable, realistic, and time sensitive. At the same time, group projects must address multiple class concepts, such that the students can demonstrate their mastery of certain competencies, such as networking in the community, using media appropriately, and conducting policy advocacy. For instance, successful student projects on improving access for patients with disabilities have resulted in enabling stroke patients to have greater access to care, disabled patients to have access to community gardens, and adult patients with mental handicaps to have greater access to nutritional resources. In each situation, students not only performed a service for the community but also implemented a plan that utilized and accessed community resources (e.g., when working with seniors, the students also worked with the county department on aging), that involved local media (the students wrote an opinion editorial to a local newspaper), and that required successful policy advocacy (encouraging adoption of legislation that promotes senior health).
A focus of the community service projects is to ensure that each meets a community need and is rooted in community desires. To preclude students from imposing their vision on those in need, the course instructors try to link students with existing service organizations or existing needs when possible. The case studies used, the selection of guest speakers, and class discussions of the ethics of collaboration also reflect a concern for a community-based approach to leadership.
At the final class session, the groups present their projects (e.g., obesity prevention among adolescent girls, nutrition and exercise among low-income youth; List 3) to the entire class, allowing the students to practice giving oral presentations in addition to allowing each group to share its outcomes. Most of the students have received very high grades on these projects for their attention to and integration of class concepts. For instance, one group project involved improving the design, visibility, and safety of local crosswalks. Concerned about many potential avoidable injuries (such as the car that had hit the student going through a crosswalk), students advocated for improvements at a crosswalk with insufficient safety parameters near the UNC SOM. The students' research and advocacy demonstrated both the extent of the problem and how citizen leaders could make changes. The media advocacy component of their project resulted in a little publicity. Two weeks after the student presentation, a transit bus tragically killed a visiting law student who was jogging at that intersection. The local press quoted student leaders associated with the project, and the students' ideas received much more attention. Ultimately, several changes occurred to increase pedestrian safety on campus.
A few service learning projects have been less successful, in large part because the students ultimately chose issues with more of an educational focus and did not link them sufficiently with policy outcomes.
Students receive several forms of evaluation, including written comments, individual feedback, and grades. Written comments about their work in the class model the appropriate feedback discussed throughout the course as a leadership competency. Faculty review their substantive comments regarding written assignments with the students. Faculty also let students know halfway through the course in general if the students' work to date in the course is outstanding, solid, or in need of increased attention. Final grades reflect classroom participation (35%), the completion of the seven assignments (45%), and the outcome of the service project (20%).
Course evaluations consist of quantitative and qualitative measures. An end-of-course student survey assesses the amount and value of faculty teaching, assigned readings, class discussions, written assignments, student presentations, and any guest lecturers. This evaluation also asks students whether the course achieved the five principal objectives. During the first five years, students have consistently rated the faculty teaching, class discussions, and guest lecturers very highly. Some students also gave qualitative feedback in years one and two. Some felt that the assigned readings and written assignments were too much work, particularly compared with what their colleagues reported doing in other second-year selectives. Other students suggested in their written comments that the course should emphasize certain competencies more than others. Almost all students reported that the course objectives were achieved. List 4 shows sample written comments from students. Over time, the course readings and written assignments have changed as a result of student feedback, and students spend more time on cases and scenarios in small-group settings, with less time spent in large-group discussions.
The first two cohorts of students participating in the selective completed 13 item pre- and postcourse voluntary surveys, approved by the internal review board at the UNC SOM. The surveys assessed student confidence in communicating their leadership vision, effectively networking with diverse groups, working collaboratively, developing a coalition, organizing and facilitating meetings, negotiating and resolving conflict, advocating for a cause, raising money, motivating people, delivering effective presentations, writing grants, transferring organizational leadership, and using an understanding of leadership styles to lead an organization. We compared differences between students in their mean answers before and after course assessments (based on a five-point Likert scale) using t tests (Table 2). Students rated their confidence in their ability to effectively conduct media and policy advocacy in precourse evaluations lowest among skill sets and their ability to work collaboratively among groups highest among skill sets. Postcourse results showed that significant changes occurred in students' assessment of their skill levels across almost all listed leadership skills. In many cases, students reported increases of at least one full point.
The effect of the leadership course on student attitudes is shown in Table 3. Medical students responded that most leadership skills were important to them before taking the course, with mean scores generally ranging from 3.9 to 4.5. Before taking the course, students gave the lowest scores (least important) to the skills involved in political and media advocacy. Students gave the highest scores (most important) to the skills of working collaboratively with diverse groups. At the end of the course, postevaluation showed little change across survey questions about the importance of various skills to students. In 2004–05, most mean attitude scores increased, but only one (knowledge of leadership styles) increased significantly.
After five years, the ALSCS selective demonstrates many positive outcomes, including an increase in students' reported self-efficacy regarding dimensions of leadership, student evaluations of the course, instructor evaluations of student performance, and the completion of more than 15 community service projects. The selective offers an innovative model of a leadership-skills-based course that seems to have a positive impact on leadership skill development among medical school students. The ALSCS course also seems to have successfully integrated into the medical school curriculum.
The inclusion of a leadership course in the medical school curriculum is unique compared with the ways in which medical students usually receive exposure to leadership roles. Most often, medical students assume leadership roles through their work in student service organizations and receive little training other than through these direct experiences. As part of the curriculum, the content of the ALSCS course provides sanctioned time and concentrated focus to develop specific leadership skills, thus legitimizing the content in the students' eyes. Further, the course enables students to practice blending various leadership skills and styles in collaboration with others, and to conduct an abbreviated service project with strong mentoring and support.
The course also supports and is consistent with the broader mission of UNC SOM. The ALSCS selective emanated from a predoctoral training grant awarded to UNC SOM in 2001, a grant designed to introduce innovations into the medical curricula that focused on service and leadership. Outcomes associated with that grant, in addition to the ALSCS selective, included the formation of an office of community service in the UNC SOM, a vice president of community service in the medical student governance structure, an advanced medical Spanish course, and a certificate program in health disparities. Further, in its 2006 strategic planning document, the UNC SOM recognized the need to provide “leadership training skills to new chiefs and chairs and individuals” in senior leadership positions. The SOM offers new faculty in leadership positions lectures, workshops, and a leadership coach to serve as ongoing resources for issues unique to the culture of leadership at UNC and in the region.
The ALSCS selective incorporates the values of professionalism as well as hands-on skills that complement students' clinical training. Students make contributions to community service at the same time they are learning and practicing the skills necessary for long-term leadership success. Combining leadership skill training with community service offers students an invaluable experience to better prepare them for the medical environment in which they will eventually practice. Situating the ALSCS experience earlier in medical education may also help maintain and bolster students' enthusiasm for altruistic work and for the medical profession in general.17
The ALSCS selective challenges medical students to explore novel or uncomfortable ideas and to not only learn but also to practice new skill sets with which they may not previously have had experience. The learning and practice take place in an environment that builds trust and collaboration between students, with a goal of transferring these new competencies across other situations. One medical student reported in the postcourse evaluation, “As we learn skills, we apply and practice them in hands-on ways that allow me to put them to immediate use. I daily catch myself directly applying what we learn in class to a student organization I run, and more importantly, I have the tools to be a successful leader in the future.”
We have learned several lessons from teaching the ALSCS selective that will prove useful for other medical schools or educators seeking to develop their own leadership courses. For teaching methods, we learned that teaching through whole-class or small-group discussions depends on desired outcomes. Holding mostly large-group discussions in a small class is easy, but to best meet the objective of using self-reflection to identify personal leadership strengths and weaknesses, smaller-group exercises with case examples and role plays are more effective. Whereas small-group discussions allow students to more actively engage their classmates and the topic, larger-group exercises allow students to hear more varied classmate opinions, to debrief between exercises, and to see and practice the skills of facilitating discussions.
We have learned how to refine the teaching of certain leadership skills. For instance, most students best learn advocacy and collaboration skills by working collaboratively on their own learning service projects over the course of the 11-week selective, which provides a longitudinal learning atmosphere for these constructs. Learning about lobbying occurs best through a meeting with a lobbyist and through an assignment that requires students to call an elected politician or legislator in order to advocate for a particular policy or piece of legislation.
Group cohesiveness, through which students learn to trust and share with one another, has proved essential for the course. This cohesiveness has come about in part through discussing, at the start of each class, personal experiences—both positive and negative—that relate to class topics in the previous weeks. The list serve, although not universally utilized, offers many students an additional avenue to discuss with one another feelings about issues outside of the class setting.
We learned through student feedback that, for most students, the group projects are the highlight of the course. Many students, in saying why they enjoy these projects, comment that they “gave us a chance to apply skills” and “taught us the importance of teamwork and facilitation.” These projects take time to develop because the students must be able to discuss possibilities, choose projects, and form groups. Letting this process evolve requires patience, but having the students take ownership is essential.
Finally, we learned that our initial expectations (for the first two years) regarding written assignments and class readings were too extensive. Originally, we had too many class readings and assignments, detracting from, rather than adding to, in-class experiences. When we reduced such readings and assignments, course evaluations rarely mentioned those issues. The course text, Mountains Beyond Mountains, with its numerous examples of all class concepts available for discussion, has proved universally positive. Most students, even those who have read it previously, say it is “stimulating, challenging and enjoyable to read.” Pointing out where the experiences discussed in the book result in positive change and where they do not is important, as is eliciting students' reactions to the reported experiences.
This description of the ALSCS selective has several limitations. One limitation is that most of the data on medical student change in skill acquisition were self-reported; students reflected on and reported their own perceived progress in skill development. Although students may overestimate their skill acquisition, the fact that levels of perceived skill increased, rather than changes in the perceived importance of the topics, lends salience to the idea that skill levels actually increased. We did document more limited skill acquisition through the completion of assignments and the group project, all of which are experiential. To actually measure student skill levels, particularly over time, would take resources beyond the scope of this project and would be a good area for future research.
Nor could we measure the impact of this selective on long-term outcomes, such as career choice or competency in leadership positions. We know that the leadership skills may not hold throughout the duration of medical school, much less into residency and practice. Anecdotally, we have received spontaneous e-mails from students, months after the selective has ended, indicating how the course has positively impacted a recent student leadership experience. One student, when asking a course faculty member (A.O.G.) to write a letter of recommendation for residency, sent a follow-up personal note of thanks, saying, “I have not forgotten how important it is to thank people for what they do for me.” Although we do not know whether the second year is the best time to incorporate a substantive leadership experience for medical students, and our selective lasts only for several months, the course is in a time slot that is now available at the UNC SOM. The impact of a more longitudinal experience could come at the expense of ease of replication at other institutions. Alternatively, the addition of leadership training in residency would bolster any leadership training that occurs in medical school.12,13
Finally, we cannot compare the ALSCS selective with other selectives, because each selective has a unique evaluation tailored to its objectives. Although only 12 to 14 students—rather than the whole class—take the ALSCS selective each year, this constitutes 10% of the class, a substantial amount given competition for curricular space.
Undergraduates and young professionals seek programs, like ALSCS, that serve to improve their leadership skills. Teaching leadership skills to medical students, along with successful attempts to integrate leadership training beyond medical school and into residency training, provide new opportunities to improve health care and end health disparities in the United States.
This study received funding from grant #D16HP0013901, Department of Health and Human Services, HRSA, Bureau of Health Professions.