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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

doi: 10.1097/ACM.0000000000000502
RIME
Free
SDC

Purpose To characterize leadership curricula in undergraduate medical education as a first step toward understanding best practices in leadership education.

Method The authors systematically searched the PubMed, Education Resources Information Center, Academic Search Complete, and Education Full Text databases for peer-reviewed English-language articles published 1980–2014 describing curricula with interventions to teach medical students leadership skills. They characterized educational settings, curricular format, and learner and instructor types. They assessed effectiveness and quality of evidence using five-point scales adapted from Kirkpatrick’s four-level training evaluation model (scale: 0–4) and a Best Evidence Medical Education guide (scale: 1–5), respectively. They classified leadership skills taught into the five Medical Leadership Competency Framework (MLCF) domains.

Results Twenty articles describing 24 curricula met inclusion criteria. The majority of curricula (17; 71%) were longitudinal, delivered over periods of one semester to four years. The most common setting was the classroom (12; 50%). Curricula were frequently provided to both preclinical and clinical students (11; 46%); many (9; 28%) employed clinical faculty as instructors. The majority (19; 79%) addressed at least three MLCF domains; most common were working with others (21; 88%) and managing services (18; 75%). The median effectiveness score was 1.5, and the median quality of evidence score was 2.

Conclusions Most studies did not demonstrate changes in student behavior or quantifiable results. Aligning leadership curricula with competency models, such as the MLCF, would create opportunities to standardize evaluation of outcomes, leading to better measurement of student competency and a better understanding of best practices.

Ms. Webb is a fourth-year medical student, Duke University School of Medicine, Durham, North Carolina.

Mr. Tsipis is a fourth-year medical student, Duke University School of Medicine, Durham, North Carolina.

Mr. McClellan is a fourth-year medical student, Duke University School of Medicine, Durham, North Carolina.

Mr. McNeil is a fourth-year medical student, Duke University School of Medicine, Durham, North Carolina.

Ms. Xu is a fourth-year MD–PhD student, Duke University School of Medicine, Durham, North Carolina.

Dr. Doty is chief of staff, Feagin Leadership Program, Duke University School of Medicine, Durham, North Carolina.

Dr. Taylor is professor, Department of Orthopedic Surgery, director, Duke Sports Medicine Fellowship Program, and chair, Feagin Leadership Program, Duke University School of Medicine, Durham, North Carolina.

Funding/Support: None reported.

Other disclosures: Four of the authors (A.W., N.T., T.M., M.X.) are graduates of the Duke University School of Medicine’s John A. Feagin Jr., MD, Leadership Program, which trains medical students in leadership. Two authors (J.D., D.T.) hold leadership positions in the Feagin Leadership Program.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Ms. Webb c/o Dr. Taylor, Box 3615, Duke University Medical Center, Durham, NC 27710; e-mail: allison.webb@duke.edu.

The health care system in the United States is a rapidly changing enterprise that faces many challenges, such as funding constraints, demand for greater accountability, changes in patient populations, and increasing regulation.1 This reality led the Institute of Medicine to conclude that academic health centers must “develop leaders at all levels who can manage the organizational and systems changes necessary to improve health.”2 These leaders need to help “define the future, align people with a vision, and remove obstacles to allow people to see this vision.”2 There is also evidence that medical students perceive a need for management and leadership education.3,4 For example, in one survey, 85% of responding medical students indicated that leadership, communication, teamwork, and quality improvement skills should be taught in medical school.4 The combination of students’ perceived need and the challenges facing the U.S. health care system supports the concept that the medical education system must identify effective ways to train future physician leaders.

Many medical schools provide formal leadership training through combined MD/MBA programs. In 2001, there were 33 MD/MBA programs in U.S. medical schools,5 and as of July 2014, there were 57 national and international programs listed by the Association of MD/MBA Programs.6 Although these combined programs have been growing in number, they are resource intensive and usually require medical students to extend their time in training. A number of U.S. medical schools are developing alternative forms of leadership training. For example, at the Duke University School of Medicine, the Duke Leadership and Education and Development (LEAD) program—a student-initiated, four-year longitudinal leadership curriculum—was introduced for all first-year medical students during the 2013–2014 academic year. Students will progress through the LEAD curriculum, which is a requirement for graduation, as they advance through the four years of medical school. During the curriculum’s pilot year, the course directors and student course leaders from Duke’s Feagin Leadership Program, including the authors of this article, identified a need to better understand best practices for developing undergraduate medical education (UME) leadership curricula. We recognized the importance of identifying clear leadership competencies that would serve as a basis for creating course objectives and guiding our curriculum.

Although there is little published information about best practices, competency-based leadership models and frameworks to guide leadership training and curricular development are emerging.7 A compelling example is the Medical Leadership Competency Framework (MLCF)8 developed by the National Health Service (NHS) to direct leadership training for physicians and medical students in the United Kingdom. Components of the MLCF include setting direction, demonstrating personal qualities, working with others, managing services, and improving services.

Our long-term goal is to understand how best to incorporate leadership training into an already-crowded UME curriculum. As a first step toward achieving this goal, we conducted a systematic review of the literature on leadership training in UME, specifically focusing on published descriptions of formal leadership curricula. Our aim was to determine (1) the characteristics of leadership curricula, including the qualities, skills, and competencies taught, and (2) the extent to which these curricula were aligned with a known model of leadership in medicine. We use this information as a framework to present recommendations regarding best practices to inform the development of UME leadership curricula. We hope this work will serve as a foundation upon which to build targeted and collaborative research in leadership education in medicine.

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Method

Review protocols

This study was guided by the following literature review protocols: (1) the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement,9 the PRISMA checklist,9 and the PRISMA explanation and elaboration document10; and (2) the Best Evidence Medical Education (BEME) Guide No. 13, “Conducting a Best Evidence Systematic Review.”11 Ethical approval was not required for this study as it was a systematic review of published literature.

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Search strategy and data sources

The initial literature search was completed on December 19, 2013, by one of the authors (A.W.) and a Duke University medical librarian (Megan von Isenberg). Four databases were searched: PubMed, Education Resources Information Center (ERIC), Academic Search Complete, and Education Full Text. The following subject headings and key word variants were used:

  • PubMed: “Students, Medical”[MeSH] AND (“leadership”[MeSH Terms] OR “leadership”[All Fields]) AND Curriculum
  • ERIC: “leadership” AND “medical students”
  • Academic Search Complete and Education Full Text: “leadership” AND “medical students” AND “curriculum”

The searches were limited to peer-reviewed English-language articles focusing on UME published since 1980. We included curricula at global UME programs and MD- and DO-granting U.S. medical schools. An updated search was completed on January 22, 2014. All reference lists of articles selected for full-text review were hand searched for additional articles not discovered in the initial database search.

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Inclusion and exclusion criteria

We considered articles that included medical students at any point in their UME program. To be included, the article had to describe or evaluate a leadership curriculum, which we defined as a curriculum that included one or more interventions in which developing new leadership skills, attributes, or competencies was the primary goal. Studies that evaluated students’ perceived leadership abilities without an intervention, for example, were excluded. Because the focus of this review was learning how leadership is explicitly taught in UME programs, studies analyzing students’ opinions and understanding of the importance of leadership or students’ existing knowledge, skills, or attitudes about leadership were excluded because they lacked an intervention.

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Title and abstract review

After duplicates were excluded, two authors (A.W. and N.T.) independently reviewed the titles and abstracts of all articles. They selected articles for full-text review if they met inclusion criteria and placed them on a shared Microsoft Excel spreadsheet (version 14.1.0; Microsoft, Redmond, Washington). If there was a discrepancy, the abstract was discussed and a consensus was reached. All abstracts without consensus on initial eligibility were independently reviewed by two other authors (M.X. and T.M.) to determine if they met inclusion criteria.

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Full-text review and data extraction

A data extraction tool was created using the BEME guidelines.11 Each article was read independently by two reviewers, who used the data extraction tool. If discrepancies arose in the data they extracted, a third reviewer read the full-text article, and the three individuals came to a consensus.

Extracted data were placed in an online, shared Google Spreadsheet (Google Inc., Mountain View, California). Fields included description of leadership program; leadership skills taught; curricular format; learner level; instructor type; educational setting; data collection methods and evaluation tools; and significance/implications.

We stratified curricular format as either longitudinal or isolated. Longitudinal was defined as a curriculum lasting at least one semester with time between interventions. Isolated was defined as a curriculum in which the intervention(s) occurred in a single session or over concurrent sessions for a defined period. For example, a weeklong retreat or a one-time simulation session would be classified as isolated.

We classified educational settings as clinical, classroom, simulation, online, project based, or mixed. Workshops and seminars were considered to be part of the classroom setting. Curricula taught in clinical settings took place in patient care environments, whereas curricula in project-based settings were conducted in the context of community activities or other initiatives outside of classroom or clinical settings. Curricula with mixed settings were those that used multiple settings, such as didactic education delivered in a classroom combined with project-based learning that occurred outside the classroom.

We categorized learner levels as preclinical, clinical, both (preclinical and clinical), or not specified. Preclinical was defined as medical school years 1 and 2 in the traditional U.S. UME structure; years 3 and 4 were considered clinical. We also categorized “senior” or “final year” students as clinical. International studies typically defined their learners as preclinical or clinical, and we classified them as they were described. We defined instructor type as clinical faculty, nonclinical faculty, student educators, not specified, and other. Clinical faculty were defined as clinical instructors within the institution. Nonclinical faculty were defined as small-group leaders, basic science faculty, or other faculty within the institution. Other was defined as online programs, guest speakers from outside the institution, and instructors from the institution who were not faculty (e.g., hospital administrators).

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Data synthesis and analysis

We assessed each curriculum’s evaluation strategy using Kirkpatrick’s12 four-level training evaluation model and scored the effectiveness of each intervention according to the model shown in Table 1. Kirkpatrick’s hierarchy ranges from changes in learners’ attitudes (level 1) to evidence of tangible results (level 4); we added a level of “0” for articles that did not evaluate outcomes. To score the quality of evidence, we assessed each curriculum using the sample classification scale included in BEME Guide No. 13.11 This quality of evidence hierarchy ranges from results being not clear/not significant (1) to results being unequivocal (5).

Table 1

Table 1

As a research team, we discussed each hierarchy, with examples of each level, before arriving at a consensus on how to use it to score curricula. Any discrepancies in effectiveness or quality of evidence scores were discussed by A.W. and N.T. until a consensus score was reached. Basic statistical analyses of these values were performed using Microsoft Excel.

We used the MLCF8 to characterize the leadership skills taught in each curriculum. We chose this UK framework because it is the most comprehensive and detailed model for leadership education in medicine that we found in the literature. In addition, the NHS has published guidance for use of the model in UME,13 making the framework particularly applicable to this review. The MLCF includes the following five domains of competence as well as four subcompetencies in each domain: (1) demonstrating personal qualities, (2) working with others, (3) managing services, (4) improving services, and (5) setting direction.8 The full-text articles were split up, and the leadership skills taught were independently characterized by one researcher (M.M. or T.M.) according to the MLCF domains. These skills were then independently reviewed and characterized by another researcher (A.W. or N.T.). The researchers reviewed these data together, discussed discrepancies, and came to a consensus.

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Results

Our database searches and hand searching of reference lists identified 485 articles. After duplicates were excluded, 457 articles were included in the abstract and title review. Of these, 45 articles met the full-text review inclusion criterion of describing a curriculum with one or more interventions to teach leadership to medical students. Twenty-five articles were excluded after full-text review, resulting in a final count of 20 articles (4.4% of the initial 485).14–33 All but 1 of the 20 articles described a single curriculum. The one exception described 8 curricula from institutions that had participated in the Undergraduate Medical Education 21 project.27 Three of those 8 curricula were excluded because they did not include an explicit leadership intervention. Thus, in our review, we evaluated a total of 24 curricula (see Figure 1 and Appendix 1).

Figure 1

Figure 1

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Educational settings and curricular formats

The 24 curricula took place across the globe: 17 (71%) in the United States, 3 (13%) in the United Kingdom, and 1 (4%) each in Canada, Switzerland, Sweden, and Israel.

Varied medical educational settings were represented. Some leadership curricula and interventions were delivered in classrooms or during simulation exercises; others were integrated into service learning projects or clinical environments. Of the 24 curricula, 12 (50%) were implemented in a classroom setting. Seven (29%) employed mixed approaches in which multiple environments and curricular formats were used to teach and apply leadership skills: 5 (71%) of these 7 were taught in a classroom or online with an associated application project.14,22,23,25,31 In addition, 2 (8%) were project based,26,28 1 (4%) was strictly simulation based,24 1 (4%) was a lecture series that occurred over dinner with faculty,32 and 1 (4%) was an eight-week student elective on management and leadership.20

The majority of curricula (n = 17; 71%) approached leadership training in a longitudinal manner across periods ranging from one semester to all four years of medical school and included breaks of at least one week between sessions. The isolated interventions (n = 7; 29%) included a leadership statement made during a simulation,24 a three-day workshop,15 and a weeklong retreat.17

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Learner levels

Leadership curricula were available to medical students at many levels of their education. They were most commonly provided during both preclinical and clinical years (n = 11; 46%); those that occurred only during the preclinical years (n = 4; 17%) or clinical years (n = 7; 29%) were less common. Of note, one program15 delivered leadership training for MD–PhD students during their research training and before their clinical training; we classified this program as a preclinical curriculum. Learner level was not specified for 2 (8%) of the curricula.

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Types of instructors

Leadership curricula were taught by a variety of instructors. The most common instructor type was clinical faculty (n = 9; 38%); these faculty represented a range of clinical specialties. Several (n = 4; 17%) employed nonclinical faculty within their institution; for example, one included a physiology small-group leader,33 and another used faculty from the institution’s School of Management and College of Education and Human Development.15 Four (17%) studies described the involvement of other types of instructors: Valani et al31 described a curriculum in which members of nongovernmental organizations and hospital administrators helped facilitate the instruction; Jobe et al32 emphasized the use of community leaders, including bankers, ministers, and elected officials, to supplement the clinical faculty; Fisher and Briel20 described working with the chief operating officer of a local hospital; and Gonsenhauser et al23 reported on a curriculum that consisted solely of online material and did not have an official instructor. Five studies (21%) involved student educators. Eleven (46%) articles did not specify the type of instructor facilitating the interventions. It is important to note that some curricula (n = 7; 29%) used multiple instructor types. None used patients or patients’ family members as instructors.

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Leadership competencies

The curricula established by the various institutions emphasized a variety of leadership skills and competencies. The most common MLCF domain emphasized was working with others (n = 21; 88%), followed by managing services (e.g., managing people and resources; n = 19; 79%). Fifteen curricula (63%) focused on improving services, with an emphasis on patient safety and quality improvement. Thirteen curricula (54%) taught the leadership competencies of demonstrating personal qualities, and 13 (54%) addressed setting direction.

Of the 24 curricula, 19 (79%) addressed at least three MLCF domains. Two curricula (8%) emphasized four domains, and 7 (29%) addressed all five domains. Only 5 curricula (21%) addressed two or fewer domains; just 2 (8%) taught one domain. It is important to note that one of the curricula that addressed only one domain had a specific goal of determining gender differences within groups33; therefore, the only domain it focused on was developing personal qualities.

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Outcome measures

The curricula had a median effectiveness score of 1.5. The median score for quality of evidence was 2. The mode for effectiveness scores was 1. There were two modes for quality of evidence scores: 1 and 2. No curriculum received the highest quality of evidence score (5). Only three curricula scored a 4 on both scales; these had the highest levels of effectiveness and quality of evidence in this review.14,23,24 The scores of each scale were strongly correlated (r = 0.76). See Table 1 and Appendix 1, respectively, for overall and curriculum-specific scores.

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Discussion

In this review, we endeavored to establish a baseline understanding of leadership education in UME by characterizing published curricula aimed at teaching medical students leadership skills. Our review provides insight into the types of leadership skills being taught, the framework in which they are taught, and the quality of outcomes being measured. This information provides a framework for our recommendations regarding best practices and future directions in research and curricular development in leadership education.

Overall, our evaluation of effectiveness and quality of evidence showed that most curricula did not demonstrate changes in student behavior or quantifiable results. It is not surprising that outcomes of many leadership interventions are difficult to measure, particularly if the curricula are limited in scale. Two studies, however, showed how leadership education could affect patient outcomes. Hunziker et al24 demonstrated that focused leadership training significantly improved the cardiopulmonary resuscitation skills of students as measured by quicker hands-on time in preparing for CPR, faster initiation of CPR, and more appropriate chest compression rate. Similarly, Gonsenhauser et al23 showed that leadership and teamwork training led to improved use of World Health Organization Surgical Safety Checklists, an important quality improvement benchmark, across four different surgical services. Two other studies demonstrated improved quality of student teaching17 and improved community engagement projects14 as tangible results of longitudinal leadership curricula. Certainly, the specifics of evaluation depend on the aims of the curriculum; however, using objective measures of important outcomes is critical to advancing understanding of best practices in leadership training in medicine. Increasing the rigor of outcome measurement is an opportunity for improvement in the development of future leadership curricula.

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Leadership models or frameworks

Just as leadership curricula vary widely in their methods of delivery, the leadership competencies and skills on which they focus also differ. For example, one curriculum included in this review emphasized quality improvement,23 while another emphasized developing community leaders.25 In Crossing the Quality Chasm, the Institute of Medicine34 recommended that leadership training focus on communication, teamwork and interprofessionalism, group development and dynamics, and patient safety and quality improvement. To properly assess physicians’ development of these and other leadership competencies and skills, a standardized assessment tool must be established. One such competency framework, the MLCF,8 clearly outlines the skills necessary for physician leadership, which is why we used it to characterize leadership skills in this review.

We found that only three of the articles included in this review described aligning the leadership curriculum with existing competency models. Bergman et al16 isolated two of the six Accreditation Council for Graduate Medical Education core competencies—interpersonal and communication skills and systems-based practice—to guide their curriculum. Valani et al31 used the CanMEDS framework to guide the development of their curriculum. Finally, Fisher and Briel20 chose to focus on three of the five domains within the MLCF framework (managing services, improving services, and setting direction) to create a leadership rotation in which medical students shadowed and worked with a hospital administrator. Of course, it is possible for schools to set their own leadership curriculum and define the skills and competencies on which they will focus. For example, an MD–PhD program identified motivating others, giving feedback, understanding conflict, and coaching as the competencies to feature in its leadership curriculum.15 Although defining or creating program-specific leadership competencies allows educators to tailor the curriculum to the needs of their students, anchoring the skills and competencies that are taught to a framework allows for standardized evaluation of programs across schools. For this reason, we recommend that educators work to align leadership curricula with known leadership models.

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Curricular format and delivery

It is clear that leadership curricula and interventions are delivered in a wide variety of formats. Although the lack of standardization makes it difficult to evaluate them and their outcomes side-by-side, we discerned some trends that may help guide the development of a successful leadership curriculum. Most of the classroom interventions were well received by the students (when evaluated) but did not provide opportunities for students to practice leadership skills. Simulation encourages direct application of leadership skills to patient outcomes, but it can require significant resources (e.g., simulation center, staffing). One study we reviewed showed that a 10-minute lecture on leadership prior to a simulation exercise positively affected patient outcomes in a simulated code immediately and four months later.24 This study demonstrated not only the utility of simulation but also that a brief and isolated leadership intervention can have lasting effects on student behavior.

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Longitudinal integration

A significant concern in developing a leadership curriculum is the challenge presented by competing educational requirements in the already-crowded UME curriculum. One potential way to balance these conflicting demands is to integrate leadership training into longitudinal elements of the medical school curriculum. However, although many (71%) of the interventions in this review were longitudinal, there was little mention of integrating leadership training into existing curricula. We think this is a considerable missed opportunity in leadership education. Medical schools teach skills such as communication and teamwork, and explicitly branding these skills as leadership competencies would frame a common leadership language that could be reinforced throughout a longitudinal curriculum. In addition, longitudinal interventions would allow for more project-based learning and application of leadership skills. Employing a longitudinal and integrated approach to leadership training in the high-stakes, time-limited UME environment would permit students to develop and apply the leadership skills that are appropriate at different stages of their professional development and would place these skills into a meaningful context. We believe that integration of leadership training into longitudinal curricula represents an opportunity for innovation and further study.

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Implications for health care delivery

We found that none of the curricula we reviewed explicitly included discussion of health care reform efforts. Only 4 (17%) of the 24 curricula we analyzed discussed a health systems approach; these included a focus on “systems thinking,”25 “systems-based practice,”16 and the functioning of health care systems.27 As the implications of health care reform become clearer, medical schools may choose to incorporate a discussion of systems-level processes into their standard UME curriculum. This could present opportunities to integrate principles of leadership development into discussions of health care system functions.

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Limitations

We acknowledge that a literature review has limited utility in understanding the state of existing leadership curricula. We took great care to ensure that we cast a wide net in our initial literature search for leadership curricula; however, it is possible that relevant articles were missed. This may be a particular problem in reviews of the medical education literature as many curricular interventions are described in online repositories such as MedEdPORTAL Publications (contains peer-reviewed resources; www.mededportal.org) and iCollaborative (contains non-peer-reviewed resources; www.mededportal.org/icollaborative). Thus, it may be the case that an institution or group has developed an effective curriculum for leadership education but has not sought publication in traditional venues. In addition, we made decisions regarding classification of each curriculum’s data (e.g., format, learner level, instructor type) according to the evidence provided in each article, and, as such, our characterizations may not fully reflect the entire scope of the respective curriculum. Similarly, our MLCF-based classification of the leadership skills addressed by each curriculum was based on the statements made in the article and followed thorough review by multiple researchers. Occasionally, articles included vague statements about teaching “leadership skills” that, if not elucidated by context, were left out of our MLCF classifications. This review represents a first step in what we hope will be more targeted efforts to explore and characterize UME leadership curricula.

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Conclusions

Health care is changing rapidly, and it is critical that physicians develop leadership skills to help guide this change. To meet this need, well-designed and well-evaluated leadership curricula are necessary. In this systematic review of the literature, we found that leadership curricula at the UME level focused on a wide range of competencies but usually were not purposefully aligned with established leadership competency frameworks. Aligning leadership curricula with competency models, such as the MLCF, would create opportunities to standardize evaluation of outcomes, leading to better measurement of student competency and a better understanding of best practices. Looking forward, we believe there are both tremendous opportunities and a need to focus on outcomes at high levels of effectiveness on the Kirkpatrick training evaluation scale and on higher-quality evidence. Although this will be challenging, three studies included in this review demonstrated that it is possible, and two of those showed a possible impact on patient outcomes. Finally, any effort to expand leadership training at the UME level needs to acknowledge that there is little room to add content to the medical school curriculum. To address this issue, we urge medical schools to integrate leadership training into longitudinal curricula by taking advantage of areas in which such training overlaps with existing curricular content. In the changing environment of health care, it is imperative that we develop the leadership skills of the next generation of physicians. This need presents an exciting chance for institutions to collaborate to uncover the best practices in leadership training in medical education.

Acknowledgments: The authors would like to thank Dr. Colleen Grochowski, Dr. Saumil Chudgar, Dr. Kathryn Andolsek, and medical librarians Megan von Isenberg and Virginia Carden for their significant guidance and contributions to this project.

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Appendix 1

Appendix 1

© 2014 by the Association of American Medical Colleges