Veronesi, Michael C. MD, PhD; Gunderman, Richard B. MD, PhD
The health of the profession of medicine and the quality of care provided to patients both depend, at least in part, on cultivating the leadership capabilities of future physicians.1,2 Many future physicians possess character traits necessary for leadership such as courage and compassion, but they may not have developed technical leadership competencies such as strategic planning and personnel management.3 If physicians do not understand the organizational and systemic dimensions of health care—an understanding that is intrinsic to leadership—their ability to serve as effective advocates for patients and communities will be compromised.4 Yet, in comparison with the molecular, cellular, and organ-system dimensions of health and disease, leadership tends to play, at most, a small role in the curricula of most U.S. medical schools. A search of the Association of American Medical Colleges (AAMC) CurMIT Curriculum Directory (March 20, 2011) revealed that of 131 U.S. Liaison Committee for Medical Education (LCME)-accredited medical schools, only about 10% explicitly articulate leadership development as an educational goal, objective, or competency.
The Potential of Student Organizations in Developing Leadership
One way to redress the neglect of leadership development in medical education would be to include more leadership education in the formal medical school curriculum.5,6 For a variety of reasons, not the least of which is intense competition among disciplines for students' time, we believe that a more feasible approach to cultivating leadership would be to make extracurricular opportunities available to students, allowing them to develop their understanding of how organizations work. In this article, we describe the important role that extracurricular student organizations can play in leadership development. We outline six specific leadership principles that we believe such experiences address: ownership, experience, efficacy, sense of community, service learning, and peer-to-peer mentoring. We also provide practical examples of each of these principles, drawing on the extracurricular activities at one institution, the Indiana University School of Medicine (IUSM). In addition, we use these examples, which may not be unique to IUSM, to illustrate that the medical school, its surrounding community, and our society stand to benefit in important ways from such efforts.
People are more likely to take pride in an organization and invest themselves in promoting its missions if they believe that they have a voice in charting its course.6,7 This principle is no more applicable to voters in a democratic society or shareholders in a corporation than to students in a medical school. Students who feel they have no opportunity to shape their educational experience will naturally tend to adopt a more passive attitude toward their education. The more deeply such habits of passivity become embedded, the more likely they are to persist well beyond medical school into both postgraduate training and medical practice.
IUSM has increased the role of students in its governance and operations. The Medical Student Council (MSC), in existence since the mid-1960s, has offered students the opportunity to participate in strategic planning, giving them a sense of genuine ownership and empowerment regarding their own education. The number of students who are able to participate in MSC activities is large, in part because it has helped to foster the development of nearly 40 additional student organizations and programs. These are not just “make work” initiatives or projects that exist merely to enhance the students' leadership experiences; they provide valuable services. A number of student-initiated and student-led programs are of vital importance to the school and its community.
Consider, for example, the role of the MSC in IUSM's LCME-mandated independent self-study. The student portion of this report is prepared under the leadership of students. Students develop questionnaires with Likert-like scales for rating the quality of various dimensions of their educational experience, including such diverse aspects as the physical plant, the curriculum, and the health and fitness programs. During the school's most recent self-study (2008), this student-led initiative culminated in the production of a 280+ page report that both the medical school and the LCME praised as extremely valuable in assessing current programs and formulating suggestions for improvement. Such opportunities help students approach their education with a greater sense of ownership.
To treat medical students as mere receptacles of information and skills is a mistake. Today's medical students will lead tomorrow's medical organizations, and medical education should provide students with experiences in collecting information, weighing alternatives, and implementing decisions. A recent assessment by Varkey and colleagues8 revealed a strong preference by medical students for experiential learning as a method of developing future leadership skills. This view is supported by other studies that specifically assessed the optimal development of leadership in medical students through small groups, administrative rotations, simulated exercises, and community service projects.9–11 Extracurricular activities, particularly those involving a mixture of self-governance and self-advocacy, can provide vital opportunities for students to begin developing their sense of individual and shared responsibility for how health care is organized and delivered.
Each year, through an entirely student-led interview and decision-making process, the members of the MSC fill roughly 100 student positions on important committees in the medical school community. About half of these positions carry full voting rights, including positions on, to name just a few, the Curriculum Council Committee, the Academic Standards Committee, the Teacher–Learner Advocacy Committee, the Student Promotions Committee, and the Admissions Committee. Large numbers of students are also appointed to extramural positions in organizations such as the AAMC's Organization of Student Representatives. Still others serve as chairs, coordinators, or decision makers in school organizations, such as the Evening of the Arts program (an art and talent show), the Peer Advisor Program, the student-run newspaper, the Volunteer Services program, and the Student Alumni Ambassadors, among others. These roles allow students to experience real leadership with all the responsibility, organizational skills, time management skills, and interpersonal skills it entails.
Another example of such leadership experience is the annual curriculum appraisal project that students conceived and implemented entirely on their own. Each year, the MSC sponsors a review of the entire first two years of the medical school curriculum. Relying on survey data and small-group discussions, students compose for each course a constructive critique that includes strengths and weaknesses and offers actionable suggestions for improvement. Students present these reports to both the course's teaching faculty and the Curriculum Council Steering Committee. Far from rejecting or resisting this process, faculty members have generally responded enthusiastically to it, even implementing numerous student-generated suggestions. This review helps students provide more substantive feedback to educators and gives students who participate a deeper appreciation for the challenges involved in providing high-quality medical education. These and other extracurricular activities provide students with real-world leadership exploration and development opportunities.
Efficacy is generally defined as the power or capacity to produce a desired effect. Efficacy pertains not just to individuals but also to groups, as in members' collective estimation of the probability that they can achieve a specific objective.12 In settings with a high level of group efficacy, groups members tend to exhibit a greater interest in continuing to work as a group, increased openness to learning from other group members, greater satisfaction with opportunities to lead the group, and increased desire to work independently within the group.13 By helping medical students find meaningful opportunities to collaborate in shaping their own and their successors' educational experiences, medical schools may enhance students' sense that they can successfully navigate and pilot their own professional destinies. When students are actively engaged in the educational process, they learn not only that they are capable of making valuable contributions to the medical school, the profession of medicine, and their communities but also that these contributions, in turn, help to transform the culture of medicine.
One example that highlights the potential of student-run activities to enhance students' sense of group efficacy is the institution of an honor code at IUSM. All students, residents, and faculty members now sign the code on matriculation. The purpose of the honor code is, above all, to cultivate a culture of honesty, integrity, and respect amongst the student body. The emphasis is not on detecting infractions or punishing violators but, instead, on character education—that is, cultivating each student's sense of personal integrity. The committee charged with promulgating the honor code is the Honor Code Student Advisory Committee (HCSAC). Students created the HCSAC in 1999, and its membership still consists entirely of students. In recent years, the HCSAC has drafted a constitution and rules of procedure for an Honor Council, which is now an official committee at the medical school. Developing the council and its constitution has involved the contributions of no fewer than 100 students over the past six years, each of whom can rightfully say that he or she has played a role in helping to shape the culture of the school. The wide visibility of these student-led changes contributes to a greater sense of efficacy for all students.
Sense of Community
Medical school can be a solitary experience. Again and again, we see some students become so immersed in their studies that they inadvertently withdraw from outside relationships and from one another. By fostering collaboration, participation in extracurricular activities such as student government can help to counteract this tendency. Instead of feeling isolated, students who participate in extracurricular activities may discover their common interests and develop a sense of community.
An example of such a collaborative endeavor is the aforementioned MSC, which serves as the collective voice of the 1,200-member student body in discussions with the faculty, administration, and community. The MSC comprises 25 voting members and 75 nonvoting members. The voting members include 5 executive officers, 4 regional center campus liaisons, and 16 class officers (4 from each of the first, second, third, and fourth-year classes). Because the MSC is a representative body whose members are elected by students, responsibility for its work ultimately rests with the student body. MSC meetings are held on a monthly basis during the academic year and are divided into three segments: (1) a community forum during which students (including nonmembers) may voice opinions or concerns, (2) the reports from officers, dean-appointed positions, and student organizations, and (3) a discussion of pertinent topics relating to the entire student body, including issues that require deliberation and resolution by the 25 voting members but that may include discussion by any attendee. All students are invited to attend, and many students who do not serve on the MSC do so.
In addition to regularly engaging the 100 MSC members in collaborative work on behalf of fellow students and the school, the MSC enhances student life by serving as a valuable forum for any student to raise concerns and discuss issues. The active participation of students in the MSC has engaged the school's administration to address student concerns more expeditiously and effectively. Such opportunities help students to feel that they are citizens and neighbors in—not just spectators of—the medical school community.
In the last 20 years, a movement in higher education to strengthen learning through service has occurred.14,15 Compared to traditional curricular learning, service-learning features a greater concentration of service (rather than learning) objectives, places a greater emphasis on reciprocal learning in which the traditional definitions of teacher and learner are intentionally blurred, consigns a greater stress on developing citizenship skills and achieving social change, and focuses more on reflective practice.15 The immediacy of service–learning experiences, where students have the opportunity to help patients and the public directly, tends to be personally meaningful to participants and to generate deeper and more enduring emotional responses.14
An important promoter of service–learning at IUSM has been the Office of Medical Service–Learning, which was created in 1998. This office and the programs it facilitates have spawned over a dozen service–learning projects led entirely by students. One example, a project called Rock for Riley, was initiated by two students in 2004 to raise funds for IUSM's freestanding children's hospital. Rock for Riley is an annual benefit musical concert, featuring a popular musical group that performs for a large local audience. The project is led and managed entirely by medical students. The goal of this service–learning project is to assist the hospital in its mission of providing the highest-quality medical care to children, regardless of their family's ability to pay. Since 2004, this service–learning project has been independently responsible for more than $560,000 in charitable contributions. In the course of providing valuable service to the community, the students who work each year on this project also learn valuable lessons about how to make a difference. Thanks to such opportunities, students gain the sense that their learning contributes directly to the lives of others.
Medical students have the capacity to serve as educators in their own right. Students can teach patients and the public, but they can also teach one another. Peer-to-peer mentoring can be a vital means for students to teach and learn leadership. At the beginning of each school year, the MSC hosts an annual, daylong leadership conference for medical students. A typical agenda for Leadership Day includes three presentations on leadership by faculty, students, and/or guest speakers, as well as small-group breakout sessions focusing on identifying and addressing opportunities to improve the medical school curriculum and culture. In the small-group sessions, a senior medical student acts as the group facilitator, leading more junior students through the discussion. Faculty members and administrators are not present during these discussions. Once students identify and prioritize issues, they work in partnership with administrators over the course of the school year to develop workable solutions.
The IUSM Peer Mentoring Program, which is also coordinated by students (who are appointed by the MSC), consists of students from the second-year class who volunteer to mentor to first-year students. Second-year students provide information and advice, including tangible resources such as books and practice tests, to their more junior advisees. This program has been run for students by students for over 30 years. These programs provide students with practical leadership opportunities through which they can teach and learn from one another.
What practical steps can medical schools take to help develop their students' leadership abilities and enable them to make greater contributions to the lives of their colleagues and to their communities? We believe that extracurricular student organizations, including a robust student government and affiliated groups, represent a key opportunity. They can serve as catalysts for the development of student leadership by helping students to work closely with one another, with the faculty and administration of the medical school, with the community, and with local, regional, and national professional organizations. Because these activities are not mandatory, students participate from their own desire to learn and contribute. Thus, these activities do not impinge on the formal curriculum. Extracurricular activities can move students from passive to active roles. They can foster the development of leadership interests and abilities that are important both to the future of individual medical trainees and to the medical profession. Finally, these activities can help to build a culture of responsibility, empowerment, community, service, and vitality throughout a medical school.
The authors wish to thank Ruth Patterson for her help with the manuscript and Mary Alice Bell, director of mentoring and student development, Indiana University School of Medicine, for her suggestions.