Kuo, Anda K. MD; Thyne, Shannon M. MD; Chen, H. Carrie MD, MSEd; West, Daniel C. MD; Kamei, Robert K. MD
In 2004, the University of California, San Francisco (UCSF) implemented a new pediatric residency training program with the express purpose of incorporating leadership development into standard clinical training. The aim of the program is to develop leaders committed to improving systematically the health of vulnerable populations. As health disparities widen in the United States, health care costs soar, and health indicators plummet, the need for physician–leaders is self-evident.1–10 The number of physicians serving in a formal leadership capacity has grown10,11 with over 12,000 members in the American College of Physician Executives. In addition, many other physicians are in leadership roles that may be unrecognized by either themselves or their colleagues.12–15 While many physician–leaders have been selected for their clinical or research skills,16,17 the skills demanded of today's physician–leaders require them to work with a diverse group of people in an environment of rapid change and global economic forces.7,10,14,16–22 As an example, department chairs report spending the majority of their time on administrative issues such as budgets, audits, and personnel management.23–25
Although some argue that leaders are “born and not bred,” there clearly are key acquired knowledge and skills possessed by successful leaders,7,17,22,26–28 and the most effective leaders have invested in developing further their personal leadership capacity.17,26,29,30 Similar to improving teaching skills or professionalism, leadership skills can be taught and developed.26,29,31 Medical education, however, has been slow to incorporate leadership training explicitly, usually assuming that this learning would occur “on the job” for the select few who naturally achieve key leadership positions.2,5,9,26,32,33 This has left a large gap between the relatively few physicians trained as leaders and the growing number of physician leadership positions.9
The majority of physicians who obtain leadership training attend workshops or intense short courses for midcareer professionals.26 However, this model has been criticized by some experts who have called for developing a network of physician–leaders with training that is longitudinal, local, experiential, and embedded in medical education.1,9,20,26 More recently, some medical school and residency curricula have begun to incorporate leadership components.34–38 In fact, undergraduate and graduate medical education, with their interdisciplinary and multilevel learner teams, are ripe with opportunities for trainees to develop explicit leadership practices. Key leadership skills, such as teamwork, consensus building, conflict resolution, and communication are everyday occurrences for trainees on the wards and in clinics and are not limited to those in executive positions. However, medical education, as a whole, has been missing existing opportunities to incorporate leadership development into clinical training and to improve the leadership practices of young physicians. Below, we share our program structure, early experiences, and lessons learned in the implementation of the UCSF Pediatric Leadership for the Underserved (PLUS) program.
The UCSF general pediatric residency program accepts 29 residents per year. The program has clinical rotations at five unique settings, including a university-based tertiary care teaching hospital, the public county hospital, and three community-based teaching hospitals and clinics. Four of the 29 UCSF residents are accepted into the PLUS program through a separate match each year.
The mission of the PLUS program is to train and inspire future leaders in pediatrics to identify and systematically address the varied issues that affect the health of underserved children. Our vision is that the program will provide a foundation of skills, knowledge, and mentorship from which its graduates will build careers in research, policy, and community engagement to lead and improve the health of underserved children.
Development and implementation
In 2003, a group of UCSF pediatric educators was asked to think creatively about ways in which medical education reform could begin to address current child health needs. A focus on physician leadership and underserved medicine emerged, and a planning committee which included community physician–leaders, pediatric faculty educators, and residents was formed. It was decided that the PLUS program should have a separate match number from the categorical program to allow for a separate selection process and because of the potential that the unique mission of PLUS might attract students who may not have otherwise applied to UCSF. For the first two years of the PLUS program, eight current UCSF residents were allowed to join the program as second- and third-year residents; thus, PLUS began in 2004 with a full complement of 12 residents.
The planning committee was responsible for developing the program and the curriculum. Because program participants were likely to either already have or want to pursue additional degrees, it was important that the program not require additional training time beyond the usual three years of pediatric residency training. The program was limited to only four residents per year to allow for protected time and clustering of PLUS residents into an annual PLUS block rotation and additional periodic half-day seminars for group learning (Figure 1). The educational program, faculty leadership, and resident continuity clinics were all based at the local public county hospital (San Francisco General Hospital) to allow residents exposure to a diverse patient population facing the greatest health disparities.
Curriculum and clinical training
The PLUS curriculum was developed around the themes of leadership, critical thinking, and community engagement. The leadership curriculum was based on the UCSF Center for Health Professions' leadership model with four major domains: Purpose, People, Process, and Personal.39 The PLUS leadership curriculum is taught using a framework that includes acquisition of key concepts, application of skills, and reflection on clinical relevance, with repetition and reinforcement of this process several times over three years of training (Figure 2). Critical-thinking skills are developed in small-group seminars with local experts, covering topics such as health disparities, social determinants of health and health policy, and economics. In general, curricula on special populations, such as immigrants and youth in foster care, include basic knowledge of relevant policies, visits with pertinent community-based organizations, and discussion with local experts. The community engagement curriculum was developed in partnership with community stakeholders. The first-year goal is to understand how the problems of individuals and the community interrelate and includes skills such as principles of campus–community partnerships, effective literature searches, and community asset mapping. The second-year goal is to understand how a community stakeholder approaches a problem and includes skills such as project management, grant writing, program evaluation, organizational structure, and budget development. The third year emphasizes the formation of partnerships and interventions and includes skills training in areas such as developing logic models, addressing sustainability, and communicating results.
Child health projects
A critical element of the PLUS curriculum is the completion of a collaborative child advocacy project that provides an opportunity for each resident to apply skills developed in the classroom to real-life situations. Residents are given one half-day a week to work on projects during nonseminar outpatient and elective rotations (Pr in Figure 1). Examples of PLUS resident projects are provided in Table 1.
The planning committee determined the need for a faculty champion of PLUS who would receive programmatic support to serve as the program director. In addition, PLUS residents are clustered into advising groups, which consist of one to two faculty advisors and one PLUS resident from each training year. These groups, called “pods,” are coordinated with longitudinal primary care clinic assignments in order to promote formal and informal advising within the pod. The eight faculty advisors, all of whom are active clinicians, have significant experience with vulnerable populations and community partnerships. Similar to faculty that serve as academic advisors to residents in the categorical program, PLUS advisors serve in an uncompensated, voluntary capacity. In addition to individual meetings with their advisees, each pod meets quarterly in an informal setting to discuss projects, professional goals, and clinical training. The pod advisors also meet quarterly for faculty development sessions focused on effective mentoring, leadership training, and curricular and programmatic updates. Communication is facilitated amongst the pods by an electronic learner's portfolio designed to enhance the ability of residents to capture the evolution of their child health projects and the development of their personal leadership skills. Residents also develop mentorships with physician–leaders at UCSF and in the community to guide their projects or careers; introductions to these mentors are usually facilitated by PLUS advisors or by guest lectureships for the PLUS curriculum.
Key Lessons Learned
The PLUS curriculum has evolved based on feedback from faculty and participants. Key lessons learned are described below.
Emphasize a skill-based instead of a topic-based curriculum.
PLUS was initially conceived as a topic-based curriculum in underserved medicine that would address the curricular pillars through each topic; residents would visit relevant community organizations, meet local leaders, and discuss policy developments on each given vulnerable population. While residents had varying interest in any particular topic, all shared a desire to develop their leadership skills. As a result, the curriculum continues to include underserved medicine but has a stronger emphasis on leadership skills and personal leadership development.
Cultivate an environment of reflection and multisource feedback.
There is evidence that improvement in leadership skills occurs through reflection, coaching, and personal investment.17,26,29,30 Residents' interactions with a complex health care team in a high-stress, educational setting provides an ideal environment to receive multisource feedback on leadership and professionalism. The PLUS program fosters peer feedback and a reflective culture by building these elements into seminars and by using exercises aimed at gaining insight into individual leadership styles and aspects of emotional intelligence. In addition, PLUS residents in each training year are now being grouped during some of their inpatient ward rotations and have weekly one-hour sessions to incorporate feedback and reflection on leadership styles and interactions.
Link the leadership curriculum explicitly to residents' current “everyday leadership” roles in the clinical arena.
Clinical training is rich with “critical incidents” in leadership (e.g., how to lead a resuscitation, interdisciplinary communication, managing a team, etc.). Residents may not recognize the daily leadership roles they assume on each clinical rotation and may incorrectly assume that leadership training is only meant for their future careers. Direct and explicit linkage of leadership skills to their current roles and behavior in the clinical arena enhances the active application and learning of leadership theory and skills.
Highlight role models and the various paths of physician–leaders.
Resident feedback consistently indicates that the opportunity to meet a diverse range of physician–leaders at various stages in their careers is critically important. Based on this feedback, PLUS training now includes a “leadership shadow experience” that allows each resident to accompany a high-profile, local leader for an afternoon. This activity includes attending meetings, strategy sessions, or negotiations that highlight that individual's leadership style. In addition, the PLUS curriculum includes a series called “Inspirational Individuals,” where, by junior and senior level, physician–leaders meet with the residents in a group to discuss the development of their careers and some lessons learned. These experiential sessions and discussions with the leaders provide concrete examples of leadership styles and career paths.
Incorporating specialized tracks, such as PLUS, within a larger training program requires balance.
PLUS began as a small program with a specific mission and protected curricular time within the context of our larger residency training program. The success of the PLUS program has highlighted the possibility and desire for other specific educational pathways and broader mentorship in the general residency program. However, the scheduling requirements of the PLUS curriculum put constraints on the general residency schedule that have raised the question of equity within the training program. Rather than compromising the PLUS model to try to gain parity, the residency program is working to develop and incorporate other specialized training models into the program.
Early Experiences and Outcomes
From 2004 to 2009, PLUS had a selective match of 24 residents, with 38% entering with additional relevant degrees (e.g., MPH, MPA, JD) and 25% identifying as underrepresented minorities. The program has attracted individuals from medical schools throughout the United States (only 2 of the 24 from UCSF). PLUS has an ongoing program evaluation that has been approved by our institutional review board. Entrance and exit evaluations of PLUS residents were instituted in 2005 and 2006, respectively, and analyzed through 2009. On a scale of 1 to 4 (1 = none; 2 = limited; 3 = moderate; 4 = significant), residents rated the influence of the following factors on their decision to apply to PLUS (mean [SD], n = 24): wish to influence population health/policy (3.95 [0.22]), to serve minority or underserved populations (3.90 [0.31]), to gain leadership skills (3.80 [0.41]), to interact with peer interest group during residency (3.68 [0.67]), desire to be at UCSF (3.15 [0.75]), desire to be in the San Francisco Bay Area (3.10 [0.72]), and understanding of market for professional opportunities (2.55 [0.89]). In subsequent years, entering residents were asked about their prior experiences; the response rate is 100%, but the number of residents who completed the survey differs depending on when each question was added to the evaluation. While PLUS attracts accomplished individuals who have demonstrated leadership capacity and a strong commitment to underserved, 8 of 20 had formal leadership training and 5 of 16 had formal training in community collaboration.
Fifteen of 16 residents who graduated from PLUS from 2006 to 2009 completed an exit survey. On a scale of 1 to 4 (1 = none; 2 = limited; 3 = moderate; 4 = significant), graduates reported on their experience in the PLUS program. All responses were in the moderate–significant range (mean [SD]): overall satisfaction with PLUS (3.73 [0.46]), impact on long-term career goals (3.55 [0.52], n = 11), positive impact on plans to influence population health and health policy (3.53 [0.64]), positive impact on plans to serve minority or underserved populations (3.47 [0.74]), improvement of competence as a leader (3.40 [0.74]), and positive impact on clinical education/skills (3.18 [0.75], n = 11). In addition, residents reported that PLUS had no-to-limited negative impact on clinical education/skills (1.27 [0.46]). All questions have an n value of 15 unless noted; questions with an n value of 11 were added in 2007.
The graduate exit survey also included open-ended questions about whether the reasons for applying to PLUS had been met by the program. Representative quotes provide insight into the potential educational gap the PLUS program fills for some residents. One resident wrote, “Had I trained at another program, I might not have kept the fire alive and just wanted a regular job with balanced hours. I feel more prepared to go after a really fulfilling career impacting child health and advocacy for underserved kids, while hopefully not burning out.” Another stated, “PLUS gave me some specific tools to build upon in my future career, and a desire to learn/refine those tools more after residency. It also gave me perspective, helped me stay focused on the bigger picture of becoming a child advocate while bogged down in some of the challenges of residency.”
Since its inception, nine PLUS residents have received 10 grants to support their child health projects and have received both local and national awards recognizing their leadership and commitment to the community (List 1). For example, from 2004 to 2009, PLUS residents received 13 of the 38 annual residency program awards even though they constituted only 13% of the total number of pediatric residents. Of the 20 graduates, five have pursued further training such as general academic pediatric and policy fellowships (List 1). An additional three graduates have pursued specialty training with a continued focus on public health and policy. Nine graduates are in positions of leadership such as medical directorships.
The experience with PLUS has led to steps to incorporate aspects of the curriculum into the general residency, particularly around leadership skills. Beyond developing a successful leadership training program, the PLUS program has illustrated the feasibility and utility of embedding a unique educational curriculum within the context of a general medical education program. In addition, while our program aims to create leaders in underserved medicine, the PLUS program demonstrates the potential of explicitly incorporating leadership skills into clinical training regardless of an individual's career goals.
In light of poor health indicators, the widening health disparities, and the uncertain health care delivery system in the United States, physician leadership is critical, yet most physicians receive no leadership training. The conception and implementation of the PLUS residency program demonstrates that leadership training can be incorporated successfully into the framework of a general clinical training program. Key lessons learned in the implementation include the importance of explicitly linking leadership training to clinical experiences to maximize relevance, using a skill-based (rather than topic-based) curriculum, and providing exposure to concrete examples of the many career paths of physician–leaders.
Matching into the PLUS program has been highly competitive, suggesting that an educational need is being met. Early outcomes suggest that leadership training does not detract—and may even enhance—clinical training. In addition, our experience suggests the possibility that special educational tracks during residency may help trainees to continue, and perhaps even accelerate, on a specific career trajectory. Long-term follow-up with PLUS graduates will provide important insight about the impact a program like PLUS may have on the career trajectories of its learners and their overall impact on the health of children.
The authors thank Patricia S. O'Sullivan, EdD, and the UCSF Office of Medical Education for their role in the development of the electronic portfolio and evaluation plan for PLUS. They also thank Joseph S.R. Park for his assistance with data analysis and with the figures and tables. Finally, the authors acknowledge the Dyson Initiative National Evaluation for sharing their evaluation tools.
The abstract of an earlier version of this article was presented at the Pediatric Academic Societies Meeting, Vancouver, 2010.
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