Leadership Development in Graduate Medical Education: A Pilot Study of Implementation of a Validated Self-assessment Instrument

National organizations are calling for leadership training so that physicians can be better prepared to lead teams, affect change, and transform health care systems.^1-5 Calls for leadership development recommend training for all residents during early formative years. ^{6, 7} Graduate medical education programs need leadership assessments and curricula to engage residents and advance their leadership skills. ^{2, 8- 21}

Systematic reviews of physician leadership development programs show a gap in educational tools that address personal growth and self-awareness.^{8, 21, 22} Self-awareness is “both internal (the characteristics we ascribe to ourselves) and external (how we believe others see and react to us).”²³ Self-awareness is fundamental to leadership and requires self-assessment.^{8, 18, 22, 24, 25} As Andrade et al noted, “The purposes of self-assessment are to identify areas of strength and weakness in one’s work in order to make improvements and promote learning.” ²⁶ Based on the conceptual frameworks of self-directed learning²⁷ and reflective practice,²⁸ we theorize that physicians who commit to leadership self-assessment, self-directed study, and reflection will develop leadership self-awareness and engage in self-improvement of leadership skills.

In a previous publication²⁹ we shared our validation of a formative self-assessment instrument for early-career physicians, specifically residents, called the Foundational Healthcare Leadership Self-assessment (FHLS). The FHLS is a 21-item self-assessment that generates scores on 5 foundational leadership domains: accountability, collaboration, communication, team management, and self-management (Appendix 1). The FHLS promotes self-awareness and professional growth by identifying a learner’s self-assessed stronger and weaker leadership domains. The FHLS is the only validated instrument of its kind.

Leadership curricula based on the FHLS are lacking in the medical education literature. Our objective was to determine whether a leadership curriculum, using the FHLS as an educational tool to support self-assessment, self-directed learning, and reflective practice, promotes self-awareness and engagement in leadership development.

We conducted a qualitative pilot study in the University of Utah Family Medicine Residency Program (UUFMRP), integrating the FHLS into our residency’s longitudinal leadership curriculum.

UUFMRP is a 10-10-10 program that commits 8 weeks total to leadership rotations, spread throughout residency. The intent is to cultivate leadership early in residency and to advance those skills longitudinally as residents progress through residency. UUFMRP incorporated the FHLS into our residency’s longitudinal leadership curriculum from May 2019 to April 2020 using coaching, self-study, and reflection as key elements.^{27, 28, 30, 31} Residents completed the FHLS in the first half of the academic year and again at the end of the academic year.

During the pilot period, one faculty member (S.V.H.) met with every resident who was scheduled for any leadership rotation and conducted a one-on-one leadership skills coaching session. Using a coaching paradigm, faculty explored the resident’s prior leadership experience and self-assessed strengths and weaknesses that informed the FHLS results in each leadership domain (accountability, collaboration, communication, team management, self-management; Figure 1). Using the FHLS low-scoring domains, the faculty member and resident selected a leadership domain to target with self-study during the leadership rotation using resources from our curated leadership library. After completing the self-study, residents were asked to submit a written reflection responding to the following prompts: describe the resources you used, what you learned, and how you would apply that new knowledge. Written narratives provide qualitative data on the perspectives and ideas of participants’ learning. ³², ³³ Residents were not asked to comment about their enjoyment or the perceived value of the experience, and submitting a reflection was not compulsory.

We hypothesized that resident written reflections would demonstrate self-awareness and engagement in learning around the leadership domains of the FHLS. One author (S.V.H.) collected, collated, deidentified, and organized the reflections by the FHLS leadership domains at the conclusion of the pilot for post hoc analysis. We analyzed the reflection data using qualitative content analysis. ³⁴ Two authors (E.T., S.C.) independently reviewed the reflections to identify evidence of self-awareness and engagement in each leadership domain. Next, authors (E.T., S.C.) discussed the findings iteratively until agreement was achieved.

This study was deemed exempt by the University of Utah Institutional Review Board (IRB_00077940).

Residents completed 27 independent leadership rotations between May 2019 and April 2020 during the pilot study. During the study period, five residents completed rotations in both second and third year. The FHLS domains selected by residents for self-study were broadly distributed (team management 33%, self-management 26%, collaboration 22%, and communication 15%), with the exception of accountability, chosen by one resident (Table 1). Among senior residents, communication and self-management were selected most frequently (29%, 29%), while junior residents most commonly selected team management (40%). Following the leadership rotation, residents submitted 21 reflections. Of the 21 reflections, five residents completed two separate reflections (representing 10 total)—one reflection for each longitudinal leadership rotation. The remaining reflections (11) were single reflections. The reflections ranged from brief paragraphs to two pages in length and were generally received within days of completing the rotation.

Reflections showed evidence of impact on the residents’ self-awareness and engagement in leadership development. Most residents (21 of 27) elected to complete written reflections during their leadership rotation (Table 1). Several submitted long, thoughtful, and complex reflections. Reflections included vocabulary and concepts residents learned in their self-study, with descriptions of their desired behavior change for self-improvement, as evidence of leadership development. We identified exemplar quotes for each FHLS leadership domain that show self-awareness and engagement in learning (Table 2). Additionally, we compiled a list of the leadership library resources residents selected for self-study (Appendix 2).

Several reflections included unsolicited remarks on the curriculum design. A third-year resident wrote, “I really like how these papers prompted reflection on my own leadership skills and gave specific ways to improve and things to work on.” Another (second-year resident) stated, “I do really like the personalized leadership project. . . . This model of teaching leadership is very effective.”

Faculty coaching, self-study, and reflection, using the FHLS instrument as an educational tool, promoted exploration and growth of residents’ leadership skills, as demonstrated by concepts and application described in residents’ reflections.

A majority of residents completed a self-study and submitted a written reflection, thereby demonstrating engagement in personal leadership development. The reflections contained evidence of self-awareness as residents explored new perspectives, skills, thoughts, and behaviors. The most commonly selected leadership domain for self-study was team management, and this was predominantly among second-year residents, which corresponds with the progression into more senior roles on inpatient services. Because most residents had high scores in accountability, that domain was selected only once, which mirrors the overall high expectations of oneself common among individuals in health professions.

This study had several limitations. The FHLS instrument informed the educational focus of leadership self-study, which could miss other components of leadership not included in the assessment. This pilot was conducted at one institution among family medicine residents in one program. The curriculum used a faculty coaching paradigm, which may be difficult for other programs to reproduce. The FHLS lacks external validity. Further study of FHLS implementation is needed across diverse graduate medical education programs and within different structures of leadership curricula.

This qualitative pilot study supports the usefulness of the FHLS within a residency leadership curriculum to promote self-awareness and engagement in leadership development.

This work was supported in part by the Health Studies Fund, Department of Family and Preventive Medicine, University of Utah School of Medicine.