2014, 1–8, Early Online
Defining the structure of undergraduate medical leadership and management teaching and assessment in the UK THOMAS D. STRINGFELLOW1, REBECCA M. ROHRER2, LOLA LOEWENTHAL3, CONNOR GORRARDSMITH4, IBRAHIM H. N. SHERIFF2, KIRSTEN ARMIT5, PETER D. LEES5 & PETER C. SPURGEON6 1
University of Nottingham, UK, 2University of London, UK, 3Epsom and St Helier University Hospitals NHS Trust, UK, Lewisham and Greenwich NHS Trust, UK, 5Faculty of Medical Leadership and Management, UK, 6Warwick University, UK
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Abstract Medical leadership and management (MLM) skills are essential in preventing failings of healthcare; it is unknown how these attitudes can be developed during undergraduate medical education. This paper aims to quantify interest in MLM and recommends preferred methods of teaching and assessment at UK medical schools. Two questionnaires were developed, one sent to all UK medical school faculties, to assess executed and planned curriculum changes, and the other sent to medical students nationally to assess their preferences for teaching and assessment. Forty-eight percent of UK medical schools and 260 individual student responses were recorded. Student responses represented 60% of UK medical schools. 65% of schools valued or highly valued the importance of teaching MLM topics, compared with 93.2% of students. Students’ favoured teaching methods were seminars or lectures (89.4%) and audit and quality improvement (QI) projects (77.8%). Medical schools preferred portfolio entries (55%) and presentations (35%) as assessment methods, whilst simulation exercises (76%) and audit reports (61%) were preferred by students. Preferred methods encompass experiential learning or simulation and a greater emphasis should be placed on encouraging student audit and QI projects. The curriculum changes necessary could be achieved via further integration into future editions of Tomorrow’s Doctors.
Introduction The evidence for the importance of effective medical leadership and management (MLM) is growing rapidly and is increasingly being linked to better patient outcomes. The recent publications of the Keogh Mortality Review (Keogh 2013) and the Francis Report into failings at Mid-Staffordshire hospitals (Francis 2013) have served to intensify the calls for wholesale changes in the attitudes of people working at every level within the NHS (Delamothe 2013; Pollock & Price 2013; Newdick & Danbury 2013; Roberts 2013). Whilst it has become evident that a change in ‘culture’ is needed (Delamothe 2013; Newdick & Danbury 2013), it is less clear how this cultural change can be effected (Davies & Mannion 2013). It is apparent that effective leadership and management of the NHS lies at the heart of changing the culture. Unfortunately, leadership and management are often poorly defined and this can cause confusion, especially among students (Edmonstone 2009; Swanwick & McKimm 2011). The development of the Leadership Framework (LF) (formerly the Medical Leadership Competency Framework, MLCF), (Figure 1) (NHS Leadership Academy 2014) has provided structure and necessary clarity about this subject. The LF is a diagram that separates out the various strands of medical leadership for all healthcare professionals
Practice points
Medical schools and medical students would like MLM further incorporated into the curriculum. Simulation exercises and small group teaching are the preferred teaching methods for leadership and NHS structure. Experiential assessment methods were preferred by schools and students. Students should be encouraged and supported to undertake audit and quality improvement projects, which can be assessed as part of the curriculum.
and students. In 2014; the LF was joined by a new approach, the Healthcare Leadership Model (NHS Leadership Academy 2013). The development of these frameworks and models shows that education of healthcare professionals is of paramount importance in ensuring that NHS leadership and management continuously evolves. It would therefore be advantageous for healthcare professionals to be introduced to these topics as early in their careers as possible. Appetite for learning more about MLM has been shown to exist amongst medical students (Abbas et al. 2011), thus creating a foundation for education.
Correspondence: Thomas D. Stringfellow, BMedSci, Medical School, University of Nottingham, Queen’s Medical Centre, Derby Road, Nottingham, Nottinghamshire NG7 2UH, UK. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–8 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.971723
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Figure 1. The Leadership Framework (LF) (NHS Leadership Academy 2014). Accessed via http://www.leadershipacademy. nhs.uk/discover/leadership-framework/ in February 2014. Despite this, teaching in MLM has only recently been incorporated into the undergraduate curricula (O’Connell & Pascoe 2004; Varkey et al. 2009). A study at Imperial College London showed curriculum compliance with leadership and management themes within Tomorrow’s Doctors 2009 and incorporated all elements of the MLCF (n ¼ 54) (Powell et al. 2012). This study provided evidence that at one medical school, course leads were designing the curriculum to include MLM and demonstrated a tool that could be used to map leadership teaching to outcomes outlined in Tomorrow’s Doctors 2009 (TD09) (Powell et al. 2012). Several teaching interventions have been offered to medical students with varying levels of success; including a series of lectures (Kaur & Singh 2009), a social network offering leadership-related internships for medical students (Sood et al. 2012) and small-group tutorials delivered by military officers (Clark et al. 2013). Fisher & Briel (2012) advocated the use of optional student-selected placements as a method to help some students gain these competencies (Fisher & Briel 2012), whilst Veronesi & Gunderman (2012) reported the potential of a student organisation in promoting medical leadership. Sriratanaban et al. (1999) highlighted the importance of taking on extra-curricular leadership responsibilities to enable students to mature as effective healthcare leaders (Sriratanaban et al. 1999). Finally, a recent UK study featuring group discussions with clinical medical students at the University of Cambridge (n ¼ 28) suggests that student opinion on preferred teaching methods can vary significantly (Quince et al. 2014). However, adoption of MLM at medical schools is inconsistent and requires rationalisation of teaching and assessment methods and a way of implementing it at all UK medical schools. Students’ views on which method they feel would be most effective is a logical approach to helping to address this gap and may help to inform tutors in how best to approach the task (Swanwick & McKimm 2012). Previous research on selected students with an interest in MLM concluded that US medical 2
students would prefer to learn leadership and management experientially (Varkey et al. 2009). A 2012 survey of 240 medical students at a single London medical school found that 84% of students felt that knowledge of medical leadership, management and NHS structure was important and 64% felt more was required from the curriculum (Butrous et al. 2012). The study supports MLM teaching nationally and highlights the startling reality that many students are unaware of basic NHS structure. The aims of this study are to: (I) Identify current attitudes towards and understanding of medical leadership and management via a survey of medical schools in the UK. (II) Determine the perceived importance of learning these topics as a medical student via a survey of medical students. (III) Ascertain students’ opinions of potential methods of teaching and assessment that might be effective to meet the knowledge gap. This study is the first to compare the views of medical students and medical schools across the UK. The aim is to identify appropriate and feasible medical leadership and management teaching interventions for undergraduate medical students.
Methods This study comprised of individual responses to a survey and did not require ethical approval but was carried out under the Declaration of Helsinki. Anonymity of all responses was preserved.
Medical schools’ survey There is evidence for the development of a survey tool based on the different domains of the MLCF which medical schools can use to map teaching of such topics (Powell et al. 2012).
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In 2012, the Faculty of Medical Leadership and Management (FMLM) revised a survey developed by the NHS institute and Academy of Medical Royal Colleges. In 2012 the survey was distributed to Deans and Directors of Curriculum at every UK medical school. Respondents could complete the survey via email attachment, post or as a telephone interview. The survey consisted of 29 questions, 17% were Likert psychometric scaling questions, 48% were simple multiplechoice questions and 35% were free text responses. It was broken down into sections on MLCF integration and usage of associated guidance, planned curriculum changes and teaching and assessment method preferences in line with the study aims. This allowed for both comparative quantitative data and collection of comments regarding curriculum integration. Of multiple responses from the same school, the latest was always recorded to reflect changes that may have taken place.
Medical students’ survey The second arm of the study surveyed UK medical students. The FMLM’s medical students’ group provided a national network of medical students at UK medical schools to publicise the project at a local level. All medical schools have student members of the FMLM, thus having the potential to be represented in the study. Seventy-five percent coverage of medical schools was possible using our contacts of students affiliated to the group and at 40% of schools an email was successfully sent to students. Information on location and year group was collected to analyse differences between students at various levels of training and university. A new questionnaire was designed by the FMLM Medical Students’ Group and uploaded to SurveyMonkeyß. The students’ survey was piloted within the FMLM Medical Students’ Group and refinements were made before opening the survey for data collection. Data was collected between October 2013 and January 2014 and analysed using Microsoft Excel ß (Microsoft Corporation, Redmond, WA). The student survey consisted of 24 questions, 54% of the questions used a Likert scale with an additional ‘not sure’ responses and the remainder were multiple-choice questions mainly to assess demographics. The survey included some of the same questions, especially regarding assessment methods, used in the medical schools survey to allow comparative analysis. The questionnaire was designed into three sections in line with the aims of the study; i.e. the current picture of MLM teaching, evaluation of current teaching and preferred teaching and assessment methods. Butrous et al. (2012) demonstrated the effective use of an online questionnaire using similar methods to gather students’ opinions regarding MLM topics at a single medical school only. The survey was distributed via several methods: FMLM medical student university representatives and medical student group committee members placed memos and emailed all year groups at their medical school. Medical leadership society presidents locally advertised the survey by the above methods. FMLM student members were invited to participate by email and publicity was placed on social media outlets.
Emails were worded in a way to minimise self-selection of those interested in leadership and management only, e.g. students were invited to ‘help shape the future of professional development in medical school’.
Results Medical schools’ survey The medical schools’ survey achieved a response rate of 48% of UK medical schools (n ¼ 16). Ninety-four percent of schools were aware of the MLCF and 88% were aware of curriculum integration guidance. 56% of schools report having made changes to their curriculum to integrate the MLCF (a minimum of a quarter of schools nationwide). 70% of those who made changes reported they now felt these successfully integrated the MLCF. Only 40% of schools in the sample currently assess MLM. Some of the barriers mentioned to integration of MLM topics in curricula included; lack of teaching time, lack of staff experience and lack of resources. However, 65% of medical schools either valued (60%) or highly valued (5%) the importance of teaching students MLM topics.
Medical students’ survey Two-hundred sixty-five visits to the survey were recorded online, 260 of which resulted in completion of the survey. These responses represented students from 70% of UK medical schools and with good geographical variation; 87% of responses were from medical schools outside of London and 24% of responses were from medical schools employing Problem-Based Learning (PBL) as part of their curricula. Uptake by question varied, with an average of 12.9% of respondents skipping each question. Students from 21 out of 35 surveyed medical schools responded (60%). Students from Leeds (19.8%), Nottingham (14.1%) and Sheffield (13.0%) were the highest responders (Figure 2). Of these students, the majority (67.6%) were in the clinical years (years 3–5) (Figure 3). A total of 93.2% of respondents felt that education in MLM topics (including patient safety, leadership and team management) is important for future doctors. 65.5% believed that specified standards in leadership and management should be created for medical students to achieve before becoming Foundation Year 1 (FY1) doctors, 77.4% of whom felt that standards in MLM would create a safer clinical environment. A total of 79.4% of respondents reported that they were unsure whether there was a medical leadership and management (MLM) society at their university. 30.9% of students reported that they knew that no such society existed at their university. 50% of students claimed that they would like to join an MLM society. A total of 40.9% of students stated they had received education about the structure of NHS and how it operates as part of medical school curriculum. 43.9% denied being taught this and 15.2% were unsure. However, only 38.2% felt that they had a good knowledge of NHS structure and management. 81.9% were not aware of the Medical Leadership Competency Framework (MLCF) and 23.1% unaware that basic leadership
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Percentage of Respondents From Each Medical School (n=262) 25%
% of Respondents
20%
15%
10%
UCL
Swansea
Sheffield
Southampton
Queen's, B…
Plymouth
Peninsula
Oxford
Nottingham
Newcastle
Leicester
Manchester
King's…
Leeds
Exeter
Edinburgh
Brighton
Birmingham
Barts, London
Figure 2. Breakdown of respondents’ answers to the question ‘‘Which medical school do you attend?’’ Perc centage of Repondents R in Each Yea ar of Medica al School (n= =262) 30% % of Respondents
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Aberdeen
0%
Imperial…
5%
25% 20% 15% 10% 5% 0% 1
2
3
4
5
Interccalation year
Figure 3. Breakdown of respondents’ answers to the question ‘‘Which year of medical school are you currently in?’’ Answers relate to academic year 2013–2014.
and management skills, knowledge of NHS structure and audit and quality improvement are criteria listed in Tomorrow’s Doctors’ 2009. Only 20.4% of students agreed that existing teaching of MLM is being delivered effectively with 12.7% stating that the MLCF is a good resource to support MLM teaching within medical school. Students reported variation in teaching of the sub-domains of MLM teaching as part of their medical education (Figure 4) with patient safety, team working and self-awareness the most widely taught and basic leadership, audit principles and resource management taught less widely. The majority of this existing teaching was delivered via lecture series or seminars (88.9%), reflective writing (68.3%) and logbook/ portfolio entries (47.6%). After the teaching by their medical school on MLM, 49.3% of students rated their knowledge of the subject as average, good or excellent on a 5-point Likert scale. 72.3% of respondents would like to see more MLM topics integrated into the curriculum. 66.3% of students agreed or strongly agreed with the statement ‘In light of The Francis Report and The Keogh Mortality Review, I feel that medical 4
leadership and management topics (e.g. patient safety, leadership and NHS structure) are under-taught at medical school’. In terms of possible teaching formats, 89.4% felt that it would be a good idea to have small group or lecture-based teaching on the basics of leadership and management and NHS structure in the first few years of the medical course. 77.8% wanted more quality improvement projects, audits and placements as part of student-selected components of their medical school curriculum. There was variation in how suitable students found different teaching methods for MLM (Figure 5). Effective assessment methods were perceived to be feedback from simulation exercises, written portfolio/logbook feedback, presentations and audit/project reports (Figure 6).
Best methods of teaching and assessing MLM to address the knowledge gap In this section, a comparative analysis was made between the medical schools’ planned changes of assessing MLM and medical students’ preferred assessment methods. Figure 7 represents assessment methods that schools were planning to
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Students' Responses: Current Teaching of MLM by Sub-Domain 100.
% of Responses
80. 60. 40. 20.
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Resource management
Basic leadership principles
Audit and quality improvement
Learning how to teach others
Self awareness and probity
Working well in a team
Patient safety
0.
Figure 4. Students’ responses to ‘Have you received any teaching in the following sub-domains of medical leadership and management (MLM) teaching as part of your medical education?’ This question was modeled on the MLCF sub-domains (n ¼ 208). Students' Res sponses: Wh hich are the e Most Usefu ul Teaching Methods? M 100 0%
75 5%
50 0%
25 5%
0 0% up Grou simulattion ses exercis
Lecture e series
Sma all group sem minars
Reflective R writing w
Not useful
Audit or quality Case based im mprovement discussions with projects clinical colleagues Som mewhat useful
Useful
y useful Very
Figure 5. Student responses for: ‘Please rate the suitability of the following teaching methods for leadership and management topics’. Options based on preliminary responses from the medical schools questionnaire (n ¼ 220). Students' Responses: Which are the Most Useful Assessment Methods? 100%
75%
50%
25%
0% Written Examinations
OSCEs
Feedback from Written portfolio simulation or logbook exercises feedback Not useful Somewhat useful Useful
Presentations
Audit or project reports
Very useful
Figure 6. Student responses for: ‘Please rate the suitability of the following assessment methods for leadership and management topics’. Options based on preliminary responses from the medical schools questionnaire (n ¼ 220).
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Preferred Methods of Assessing MLM: Schools vs. Students Opinions
100. Medical Schools
Medical Students
% of Respondents
80. 60. 40. 20. 0.
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Written / Online Examinations
OSCEs
Written portfolio Presentations Audit or project Feedback from or logbook reports simulation feedback exercises
Figure 7. This figure represents the analysis of questions from schools and students. Schools’ data represent planned changes to assess MLM. Students’ data represents those who thought each method was useful or very useful for assessing MLM. Note: ‘Simulation exercises’ was added as an option to the students’ survey following popular free-text response from the schools’ survey where it was omitted.
implement plotted side-by-side with the opinions of medical students on the usefulness of that method of assessment. It was clear from the schools’ survey free text that there is increasing demand for simulation exercises and this was therefore added as a further option in the survey sent to medical students.
Discussion This study achieved the aims set out previously to identify interest and support to develop MLM teaching at medical school with over 70% stating they would like more MLM in the curriculum. These topics were perceived as important by both staff and students and potential assessment methods to address the current knowledge gap have been suggested based on qualitative data.
Students’ perceptions of medical leadership and management Awareness among students of leadership frameworks such as the MLCF is disappointing, as low as 18%, whereas awareness among schools may be as high as 94%. The data reinforces previous evidence (Butrous et al. 2012; Quince et al. 2014), that students currently lack the knowledge of NHS structure and organisational culture with only 38.2% stating they had a good or excellent knowledge. Overall, the data presented show that students feel that the knowledge gap of NHS structure and MLM teaching would be best filled through specific, well-signposted teaching within the curriculum, an approach which would help to reduce the ‘hidden curriculum’ effect. These findings are in line with a single-centre qualitative study at a medical school from which we did not receive any responses (Quince et al. 2014).
Recommendations for teaching and assessment of MLM Patient safety, team working and self-awareness/probity were the most commonly taught elements of MLM. There is still a 6
long way to go to integrate audit, quality improvement, resource management and basic leadership principles into curricula. The fact that MLM is only being taught and assessed at less than half of UK medical schools may represent uncertainty and lack of guidance. Using evidence presented in this study, teaching in medical leadership and management would best incorporate: (i) Simulation exercises, to practice the skills required to lead teams that junior doctors might find themselves in, for example, as part of acute medical or surgical scenarios. (ii) Small group teaching or lectures on basic NHS structure to address the knowledge gap, ideally, before entering the clinical years. (iii) Reflective logbook or portfolio entries of leadership and management topics observed in the clinical setting to facilitate the experiential nature of these topics. (iv) An increased provision of audit and quality improvement projects, through support from medical schools or otherwise, which is needed to galvanize students’ enthusiasm to undertake such activities to improve patient care. These could be incorporated into the regular curriculum or as Student Selected Components (SSCs), as required by the General Medical Council. A particular example of best practice is a compulsory quality improvement project for all Imperial College students. Teaching and assessment should take place during the whole medical program, with a focus on experiential learning and simulation as part of a spiral curriculum, complementing the current research base (Varkey et al. 2009; Quince et al. 2014)
Barriers to MLM integration Using comments provided by medical schools, barriers to establishing MLM teaching programs were; a lack of staff experience, a lack of teaching time and a perceived lack of
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teaching resources to offer to students. It is likely that opposition to including these topics may be met from those who believe that biomedical sciences are increasingly undertaught. MLM teaching is likely to help prepare students to make the transition to the junior doctor and trainee years. The interim findings of the review of Tomorrow’s Doctors 2009; identified that management and leadership and protection of patient safety are identified as key issues that need addressing in future versions of Tomorrow’s Doctors (General Medical Council 2013). Most medical schools have personal and professional development themes and MLM teaching would fit very well into these requiring smaller scale changes. The Leadership Framework (formerly, the MLCF) is a useful tool to structure teaching and assessment of MLM. This has successfully been done at the University of Leeds Medical School, where each sub-theme of MLM is the focus of professional development each year. Integration of frameworks is unlikely to go the whole way to incorporating MLM and equipping graduates with these important skills, with a risk of ‘tick-box’ competence but a lack of real understanding and cultural change required in the doctors of tomorrow (McKimm & Swanwick 2011). Several undergraduate curricula have been developed including obstetrics and gynaecology, urology and musculoskeletal by respective Royal Colleges. However, these have not been evaluated before and after implementation so it is difficult to establish if national curricula are effective. A local musculoskeletal curriculum based on national guidance has shown mild improvements (6%) in student performance (Williams et al. 2010). At this level, an understanding of general leadership and management principles and NHS structure is important and hence a national curriculum is recommended. Alternatively, guidance from a cross-party group could enable universities to incorporate MLM topics into their existing curricula most suitably and more informally.
Study limitations The response rate for the medical schools survey (50%) was disappointingly small; this could represent uncertainly among schools about teaching these topics, waiting for others to successfully integrate MLM or a disinterested or time-pressured faculty. Measures such as persistent follow-up, multiple survey formats and telephone calls unfortunately did not successfully maximise the response rate. The survey to medical schools and medical students were not run in parallel over the same time period so this data may not accurately represent changes made by medical schools in the last year. For this reason comparison of student opinions of local teaching were not directly compared to reported changes from the schools survey. Tighter restrictions on emailing year groups and distributing survey instruments by some medical schools meant the average number of students per medical school was lower than expected. While selection bias of students with an interest in MLM was minimised by careful phrasing of standard emails and survey questions, inevitably this was present to a lesser extent due, in part, to the use of a network of students with an interest in MLM to distribute the survey.
Conclusion Knowledge of NHS structure remains a key area with a clear ‘knowledge-gap’ which needs addressing in undergraduates at the most basic level of MLM. Furthermore, fostering positive attitudes towards leadership and management among doctorsto-be is crucial in the rapidly changing NHS. Therefore doctors of tomorrow will be better equipped to rise to the challenge of improving services and outcomes for patients. Facilitating student involvement in audits to ameliorate patient safety and healthcare quality could help amass vast quantities of data on how to improve the NHS locally and nationally. A national curriculum in MLM for undergraduate medical schools could be designed by an inter-collegiate group which might include the FMLM, the GMC, the NHS Leadership Academy and leading academics at UK medical schools. This could be distributed nationally as competencies in the forthcoming review of Tomorrow’s Doctors. Case studies of best practice should be reported in the literature. Cross-party guidance on undergraduate MLM would also be useful either as a standalone document or in addition to a national curriculum. Care must be taken to avoid introducing a ‘tickbox’-based curriculum when programme-wide changes are required for students to develop skills and knowledge in MLM prior to starting work as doctors. Further research should examine the individual efficacy of each suggested teaching method, helping to make further recommendations as part of a national curriculum.
Notes on contributors THOMAS D. STRINGFELLOW, BMedSci, is a final year medical student at The University of Nottingham. REBECCA M. ROHRER, BSc MSc (Oxon), is a final year medical student at St. George’s, University of London. LOLA LOEWENTHAL, BSc MBBS MRCP (UK), is a Specialist Registrar in Respiratory Medicine at Epsom and St. Helier University Hospitals NHS Trust, London. CONNOR GORRARD-SMITH, BSc MB ChB, is an FY1 Doctor at Lewisham and Greenwich NHS Trust, London. IBRAHIM H. N. SHERIFF is an Intercalating Medical Student at Kings’ College, University of London. KIRSTEN ARMIT, BHSc, is the Chief Operating Officer at The Faculty of Medical Leadership and Management, London. PETER D. LEES, MB ChB MS FRCS FRCP, is the Chief Executive and Medical Director at The Faculty of Medical Leadership and Management, London. PETER C. SPURGEON, B.Soc.Sci PhD, is the Director of The Institute of Clinical Leadership and Professor in Clinical Healthcare Management at Warwick University.
Declaration of interest: All authors are members of the Faculty of Medical Leadership and Management (FMLM), PL is the medical director, and KA the manager of the FMLM. All funding was provided by the FMLM. Views expressed in this article are those of the co-authors and not those of the authors’ respective institutions.
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Defining the structure of undergraduate medical leadership and management teaching and assessment in the UK THOMAS D. STRINGFELLOW1, REBECCA M. ROHRER2, LOLA LOEWENTHAL3, CONNOR GORRARDSMITH4, IBRAHIM H. N. SHERIFF2, KIRSTEN ARMIT5, PETER D. LEES5 & PETER C. SPURGEON6 1
University of Nottingham, UK, 2University of London, UK, 3Epsom and St Helier University Hospitals NHS Trust, UK, Lewisham and Greenwich NHS Trust, UK, 5Faculty of Medical Leadership and Management, UK, 6Warwick University, UK
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Abstract Medical leadership and management (MLM) skills are essential in preventing failings of healthcare; it is unknown how these attitudes can be developed during undergraduate medical education. This paper aims to quantify interest in MLM and recommends preferred methods of teaching and assessment at UK medical schools. Two questionnaires were developed, one sent to all UK medical school faculties, to assess executed and planned curriculum changes, and the other sent to medical students nationally to assess their preferences for teaching and assessment. Forty-eight percent of UK medical schools and 260 individual student responses were recorded. Student responses represented 60% of UK medical schools. 65% of schools valued or highly valued the importance of teaching MLM topics, compared with 93.2% of students. Students’ favoured teaching methods were seminars or lectures (89.4%) and audit and quality improvement (QI) projects (77.8%). Medical schools preferred portfolio entries (55%) and presentations (35%) as assessment methods, whilst simulation exercises (76%) and audit reports (61%) were preferred by students. Preferred methods encompass experiential learning or simulation and a greater emphasis should be placed on encouraging student audit and QI projects. The curriculum changes necessary could be achieved via further integration into future editions of Tomorrow’s Doctors.
Introduction The evidence for the importance of effective medical leadership and management (MLM) is growing rapidly and is increasingly being linked to better patient outcomes. The recent publications of the Keogh Mortality Review (Keogh 2013) and the Francis Report into failings at Mid-Staffordshire hospitals (Francis 2013) have served to intensify the calls for wholesale changes in the attitudes of people working at every level within the NHS (Delamothe 2013; Pollock & Price 2013; Newdick & Danbury 2013; Roberts 2013). Whilst it has become evident that a change in ‘culture’ is needed (Delamothe 2013; Newdick & Danbury 2013), it is less clear how this cultural change can be effected (Davies & Mannion 2013). It is apparent that effective leadership and management of the NHS lies at the heart of changing the culture. Unfortunately, leadership and management are often poorly defined and this can cause confusion, especially among students (Edmonstone 2009; Swanwick & McKimm 2011). The development of the Leadership Framework (LF) (formerly the Medical Leadership Competency Framework, MLCF), (Figure 1) (NHS Leadership Academy 2014) has provided structure and necessary clarity about this subject. The LF is a diagram that separates out the various strands of medical leadership for all healthcare professionals
Practice points
Medical schools and medical students would like MLM further incorporated into the curriculum. Simulation exercises and small group teaching are the preferred teaching methods for leadership and NHS structure. Experiential assessment methods were preferred by schools and students. Students should be encouraged and supported to undertake audit and quality improvement projects, which can be assessed as part of the curriculum.
and students. In 2014; the LF was joined by a new approach, the Healthcare Leadership Model (NHS Leadership Academy 2013). The development of these frameworks and models shows that education of healthcare professionals is of paramount importance in ensuring that NHS leadership and management continuously evolves. It would therefore be advantageous for healthcare professionals to be introduced to these topics as early in their careers as possible. Appetite for learning more about MLM has been shown to exist amongst medical students (Abbas et al. 2011), thus creating a foundation for education.
Correspondence: Thomas D. Stringfellow, BMedSci, Medical School, University of Nottingham, Queen’s Medical Centre, Derby Road, Nottingham, Nottinghamshire NG7 2UH, UK. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–8 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.971723
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Figure 1. The Leadership Framework (LF) (NHS Leadership Academy 2014). Accessed via http://www.leadershipacademy. nhs.uk/discover/leadership-framework/ in February 2014. Despite this, teaching in MLM has only recently been incorporated into the undergraduate curricula (O’Connell & Pascoe 2004; Varkey et al. 2009). A study at Imperial College London showed curriculum compliance with leadership and management themes within Tomorrow’s Doctors 2009 and incorporated all elements of the MLCF (n ¼ 54) (Powell et al. 2012). This study provided evidence that at one medical school, course leads were designing the curriculum to include MLM and demonstrated a tool that could be used to map leadership teaching to outcomes outlined in Tomorrow’s Doctors 2009 (TD09) (Powell et al. 2012). Several teaching interventions have been offered to medical students with varying levels of success; including a series of lectures (Kaur & Singh 2009), a social network offering leadership-related internships for medical students (Sood et al. 2012) and small-group tutorials delivered by military officers (Clark et al. 2013). Fisher & Briel (2012) advocated the use of optional student-selected placements as a method to help some students gain these competencies (Fisher & Briel 2012), whilst Veronesi & Gunderman (2012) reported the potential of a student organisation in promoting medical leadership. Sriratanaban et al. (1999) highlighted the importance of taking on extra-curricular leadership responsibilities to enable students to mature as effective healthcare leaders (Sriratanaban et al. 1999). Finally, a recent UK study featuring group discussions with clinical medical students at the University of Cambridge (n ¼ 28) suggests that student opinion on preferred teaching methods can vary significantly (Quince et al. 2014). However, adoption of MLM at medical schools is inconsistent and requires rationalisation of teaching and assessment methods and a way of implementing it at all UK medical schools. Students’ views on which method they feel would be most effective is a logical approach to helping to address this gap and may help to inform tutors in how best to approach the task (Swanwick & McKimm 2012). Previous research on selected students with an interest in MLM concluded that US medical 2
students would prefer to learn leadership and management experientially (Varkey et al. 2009). A 2012 survey of 240 medical students at a single London medical school found that 84% of students felt that knowledge of medical leadership, management and NHS structure was important and 64% felt more was required from the curriculum (Butrous et al. 2012). The study supports MLM teaching nationally and highlights the startling reality that many students are unaware of basic NHS structure. The aims of this study are to: (I) Identify current attitudes towards and understanding of medical leadership and management via a survey of medical schools in the UK. (II) Determine the perceived importance of learning these topics as a medical student via a survey of medical students. (III) Ascertain students’ opinions of potential methods of teaching and assessment that might be effective to meet the knowledge gap. This study is the first to compare the views of medical students and medical schools across the UK. The aim is to identify appropriate and feasible medical leadership and management teaching interventions for undergraduate medical students.
Methods This study comprised of individual responses to a survey and did not require ethical approval but was carried out under the Declaration of Helsinki. Anonymity of all responses was preserved.
Medical schools’ survey There is evidence for the development of a survey tool based on the different domains of the MLCF which medical schools can use to map teaching of such topics (Powell et al. 2012).
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In 2012, the Faculty of Medical Leadership and Management (FMLM) revised a survey developed by the NHS institute and Academy of Medical Royal Colleges. In 2012 the survey was distributed to Deans and Directors of Curriculum at every UK medical school. Respondents could complete the survey via email attachment, post or as a telephone interview. The survey consisted of 29 questions, 17% were Likert psychometric scaling questions, 48% were simple multiplechoice questions and 35% were free text responses. It was broken down into sections on MLCF integration and usage of associated guidance, planned curriculum changes and teaching and assessment method preferences in line with the study aims. This allowed for both comparative quantitative data and collection of comments regarding curriculum integration. Of multiple responses from the same school, the latest was always recorded to reflect changes that may have taken place.
Medical students’ survey The second arm of the study surveyed UK medical students. The FMLM’s medical students’ group provided a national network of medical students at UK medical schools to publicise the project at a local level. All medical schools have student members of the FMLM, thus having the potential to be represented in the study. Seventy-five percent coverage of medical schools was possible using our contacts of students affiliated to the group and at 40% of schools an email was successfully sent to students. Information on location and year group was collected to analyse differences between students at various levels of training and university. A new questionnaire was designed by the FMLM Medical Students’ Group and uploaded to SurveyMonkeyß. The students’ survey was piloted within the FMLM Medical Students’ Group and refinements were made before opening the survey for data collection. Data was collected between October 2013 and January 2014 and analysed using Microsoft Excel ß (Microsoft Corporation, Redmond, WA). The student survey consisted of 24 questions, 54% of the questions used a Likert scale with an additional ‘not sure’ responses and the remainder were multiple-choice questions mainly to assess demographics. The survey included some of the same questions, especially regarding assessment methods, used in the medical schools survey to allow comparative analysis. The questionnaire was designed into three sections in line with the aims of the study; i.e. the current picture of MLM teaching, evaluation of current teaching and preferred teaching and assessment methods. Butrous et al. (2012) demonstrated the effective use of an online questionnaire using similar methods to gather students’ opinions regarding MLM topics at a single medical school only. The survey was distributed via several methods: FMLM medical student university representatives and medical student group committee members placed memos and emailed all year groups at their medical school. Medical leadership society presidents locally advertised the survey by the above methods. FMLM student members were invited to participate by email and publicity was placed on social media outlets.
Emails were worded in a way to minimise self-selection of those interested in leadership and management only, e.g. students were invited to ‘help shape the future of professional development in medical school’.
Results Medical schools’ survey The medical schools’ survey achieved a response rate of 48% of UK medical schools (n ¼ 16). Ninety-four percent of schools were aware of the MLCF and 88% were aware of curriculum integration guidance. 56% of schools report having made changes to their curriculum to integrate the MLCF (a minimum of a quarter of schools nationwide). 70% of those who made changes reported they now felt these successfully integrated the MLCF. Only 40% of schools in the sample currently assess MLM. Some of the barriers mentioned to integration of MLM topics in curricula included; lack of teaching time, lack of staff experience and lack of resources. However, 65% of medical schools either valued (60%) or highly valued (5%) the importance of teaching students MLM topics.
Medical students’ survey Two-hundred sixty-five visits to the survey were recorded online, 260 of which resulted in completion of the survey. These responses represented students from 70% of UK medical schools and with good geographical variation; 87% of responses were from medical schools outside of London and 24% of responses were from medical schools employing Problem-Based Learning (PBL) as part of their curricula. Uptake by question varied, with an average of 12.9% of respondents skipping each question. Students from 21 out of 35 surveyed medical schools responded (60%). Students from Leeds (19.8%), Nottingham (14.1%) and Sheffield (13.0%) were the highest responders (Figure 2). Of these students, the majority (67.6%) were in the clinical years (years 3–5) (Figure 3). A total of 93.2% of respondents felt that education in MLM topics (including patient safety, leadership and team management) is important for future doctors. 65.5% believed that specified standards in leadership and management should be created for medical students to achieve before becoming Foundation Year 1 (FY1) doctors, 77.4% of whom felt that standards in MLM would create a safer clinical environment. A total of 79.4% of respondents reported that they were unsure whether there was a medical leadership and management (MLM) society at their university. 30.9% of students reported that they knew that no such society existed at their university. 50% of students claimed that they would like to join an MLM society. A total of 40.9% of students stated they had received education about the structure of NHS and how it operates as part of medical school curriculum. 43.9% denied being taught this and 15.2% were unsure. However, only 38.2% felt that they had a good knowledge of NHS structure and management. 81.9% were not aware of the Medical Leadership Competency Framework (MLCF) and 23.1% unaware that basic leadership
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Percentage of Respondents From Each Medical School (n=262) 25%
% of Respondents
20%
15%
10%
UCL
Swansea
Sheffield
Southampton
Queen's, B…
Plymouth
Peninsula
Oxford
Nottingham
Newcastle
Leicester
Manchester
King's…
Leeds
Exeter
Edinburgh
Brighton
Birmingham
Barts, London
Figure 2. Breakdown of respondents’ answers to the question ‘‘Which medical school do you attend?’’ Perc centage of Repondents R in Each Yea ar of Medica al School (n= =262) 30% % of Respondents
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Aberdeen
0%
Imperial…
5%
25% 20% 15% 10% 5% 0% 1
2
3
4
5
Interccalation year
Figure 3. Breakdown of respondents’ answers to the question ‘‘Which year of medical school are you currently in?’’ Answers relate to academic year 2013–2014.
and management skills, knowledge of NHS structure and audit and quality improvement are criteria listed in Tomorrow’s Doctors’ 2009. Only 20.4% of students agreed that existing teaching of MLM is being delivered effectively with 12.7% stating that the MLCF is a good resource to support MLM teaching within medical school. Students reported variation in teaching of the sub-domains of MLM teaching as part of their medical education (Figure 4) with patient safety, team working and self-awareness the most widely taught and basic leadership, audit principles and resource management taught less widely. The majority of this existing teaching was delivered via lecture series or seminars (88.9%), reflective writing (68.3%) and logbook/ portfolio entries (47.6%). After the teaching by their medical school on MLM, 49.3% of students rated their knowledge of the subject as average, good or excellent on a 5-point Likert scale. 72.3% of respondents would like to see more MLM topics integrated into the curriculum. 66.3% of students agreed or strongly agreed with the statement ‘In light of The Francis Report and The Keogh Mortality Review, I feel that medical 4
leadership and management topics (e.g. patient safety, leadership and NHS structure) are under-taught at medical school’. In terms of possible teaching formats, 89.4% felt that it would be a good idea to have small group or lecture-based teaching on the basics of leadership and management and NHS structure in the first few years of the medical course. 77.8% wanted more quality improvement projects, audits and placements as part of student-selected components of their medical school curriculum. There was variation in how suitable students found different teaching methods for MLM (Figure 5). Effective assessment methods were perceived to be feedback from simulation exercises, written portfolio/logbook feedback, presentations and audit/project reports (Figure 6).
Best methods of teaching and assessing MLM to address the knowledge gap In this section, a comparative analysis was made between the medical schools’ planned changes of assessing MLM and medical students’ preferred assessment methods. Figure 7 represents assessment methods that schools were planning to
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Students' Responses: Current Teaching of MLM by Sub-Domain 100.
% of Responses
80. 60. 40. 20.
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Resource management
Basic leadership principles
Audit and quality improvement
Learning how to teach others
Self awareness and probity
Working well in a team
Patient safety
0.
Figure 4. Students’ responses to ‘Have you received any teaching in the following sub-domains of medical leadership and management (MLM) teaching as part of your medical education?’ This question was modeled on the MLCF sub-domains (n ¼ 208). Students' Res sponses: Wh hich are the e Most Usefu ul Teaching Methods? M 100 0%
75 5%
50 0%
25 5%
0 0% up Grou simulattion ses exercis
Lecture e series
Sma all group sem minars
Reflective R writing w
Not useful
Audit or quality Case based im mprovement discussions with projects clinical colleagues Som mewhat useful
Useful
y useful Very
Figure 5. Student responses for: ‘Please rate the suitability of the following teaching methods for leadership and management topics’. Options based on preliminary responses from the medical schools questionnaire (n ¼ 220). Students' Responses: Which are the Most Useful Assessment Methods? 100%
75%
50%
25%
0% Written Examinations
OSCEs
Feedback from Written portfolio simulation or logbook exercises feedback Not useful Somewhat useful Useful
Presentations
Audit or project reports
Very useful
Figure 6. Student responses for: ‘Please rate the suitability of the following assessment methods for leadership and management topics’. Options based on preliminary responses from the medical schools questionnaire (n ¼ 220).
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Preferred Methods of Assessing MLM: Schools vs. Students Opinions
100. Medical Schools
Medical Students
% of Respondents
80. 60. 40. 20. 0.
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Written / Online Examinations
OSCEs
Written portfolio Presentations Audit or project Feedback from or logbook reports simulation feedback exercises
Figure 7. This figure represents the analysis of questions from schools and students. Schools’ data represent planned changes to assess MLM. Students’ data represents those who thought each method was useful or very useful for assessing MLM. Note: ‘Simulation exercises’ was added as an option to the students’ survey following popular free-text response from the schools’ survey where it was omitted.
implement plotted side-by-side with the opinions of medical students on the usefulness of that method of assessment. It was clear from the schools’ survey free text that there is increasing demand for simulation exercises and this was therefore added as a further option in the survey sent to medical students.
Discussion This study achieved the aims set out previously to identify interest and support to develop MLM teaching at medical school with over 70% stating they would like more MLM in the curriculum. These topics were perceived as important by both staff and students and potential assessment methods to address the current knowledge gap have been suggested based on qualitative data.
Students’ perceptions of medical leadership and management Awareness among students of leadership frameworks such as the MLCF is disappointing, as low as 18%, whereas awareness among schools may be as high as 94%. The data reinforces previous evidence (Butrous et al. 2012; Quince et al. 2014), that students currently lack the knowledge of NHS structure and organisational culture with only 38.2% stating they had a good or excellent knowledge. Overall, the data presented show that students feel that the knowledge gap of NHS structure and MLM teaching would be best filled through specific, well-signposted teaching within the curriculum, an approach which would help to reduce the ‘hidden curriculum’ effect. These findings are in line with a single-centre qualitative study at a medical school from which we did not receive any responses (Quince et al. 2014).
Recommendations for teaching and assessment of MLM Patient safety, team working and self-awareness/probity were the most commonly taught elements of MLM. There is still a 6
long way to go to integrate audit, quality improvement, resource management and basic leadership principles into curricula. The fact that MLM is only being taught and assessed at less than half of UK medical schools may represent uncertainty and lack of guidance. Using evidence presented in this study, teaching in medical leadership and management would best incorporate: (i) Simulation exercises, to practice the skills required to lead teams that junior doctors might find themselves in, for example, as part of acute medical or surgical scenarios. (ii) Small group teaching or lectures on basic NHS structure to address the knowledge gap, ideally, before entering the clinical years. (iii) Reflective logbook or portfolio entries of leadership and management topics observed in the clinical setting to facilitate the experiential nature of these topics. (iv) An increased provision of audit and quality improvement projects, through support from medical schools or otherwise, which is needed to galvanize students’ enthusiasm to undertake such activities to improve patient care. These could be incorporated into the regular curriculum or as Student Selected Components (SSCs), as required by the General Medical Council. A particular example of best practice is a compulsory quality improvement project for all Imperial College students. Teaching and assessment should take place during the whole medical program, with a focus on experiential learning and simulation as part of a spiral curriculum, complementing the current research base (Varkey et al. 2009; Quince et al. 2014)
Barriers to MLM integration Using comments provided by medical schools, barriers to establishing MLM teaching programs were; a lack of staff experience, a lack of teaching time and a perceived lack of
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teaching resources to offer to students. It is likely that opposition to including these topics may be met from those who believe that biomedical sciences are increasingly undertaught. MLM teaching is likely to help prepare students to make the transition to the junior doctor and trainee years. The interim findings of the review of Tomorrow’s Doctors 2009; identified that management and leadership and protection of patient safety are identified as key issues that need addressing in future versions of Tomorrow’s Doctors (General Medical Council 2013). Most medical schools have personal and professional development themes and MLM teaching would fit very well into these requiring smaller scale changes. The Leadership Framework (formerly, the MLCF) is a useful tool to structure teaching and assessment of MLM. This has successfully been done at the University of Leeds Medical School, where each sub-theme of MLM is the focus of professional development each year. Integration of frameworks is unlikely to go the whole way to incorporating MLM and equipping graduates with these important skills, with a risk of ‘tick-box’ competence but a lack of real understanding and cultural change required in the doctors of tomorrow (McKimm & Swanwick 2011). Several undergraduate curricula have been developed including obstetrics and gynaecology, urology and musculoskeletal by respective Royal Colleges. However, these have not been evaluated before and after implementation so it is difficult to establish if national curricula are effective. A local musculoskeletal curriculum based on national guidance has shown mild improvements (6%) in student performance (Williams et al. 2010). At this level, an understanding of general leadership and management principles and NHS structure is important and hence a national curriculum is recommended. Alternatively, guidance from a cross-party group could enable universities to incorporate MLM topics into their existing curricula most suitably and more informally.
Study limitations The response rate for the medical schools survey (50%) was disappointingly small; this could represent uncertainly among schools about teaching these topics, waiting for others to successfully integrate MLM or a disinterested or time-pressured faculty. Measures such as persistent follow-up, multiple survey formats and telephone calls unfortunately did not successfully maximise the response rate. The survey to medical schools and medical students were not run in parallel over the same time period so this data may not accurately represent changes made by medical schools in the last year. For this reason comparison of student opinions of local teaching were not directly compared to reported changes from the schools survey. Tighter restrictions on emailing year groups and distributing survey instruments by some medical schools meant the average number of students per medical school was lower than expected. While selection bias of students with an interest in MLM was minimised by careful phrasing of standard emails and survey questions, inevitably this was present to a lesser extent due, in part, to the use of a network of students with an interest in MLM to distribute the survey.
Conclusion Knowledge of NHS structure remains a key area with a clear ‘knowledge-gap’ which needs addressing in undergraduates at the most basic level of MLM. Furthermore, fostering positive attitudes towards leadership and management among doctorsto-be is crucial in the rapidly changing NHS. Therefore doctors of tomorrow will be better equipped to rise to the challenge of improving services and outcomes for patients. Facilitating student involvement in audits to ameliorate patient safety and healthcare quality could help amass vast quantities of data on how to improve the NHS locally and nationally. A national curriculum in MLM for undergraduate medical schools could be designed by an inter-collegiate group which might include the FMLM, the GMC, the NHS Leadership Academy and leading academics at UK medical schools. This could be distributed nationally as competencies in the forthcoming review of Tomorrow’s Doctors. Case studies of best practice should be reported in the literature. Cross-party guidance on undergraduate MLM would also be useful either as a standalone document or in addition to a national curriculum. Care must be taken to avoid introducing a ‘tickbox’-based curriculum when programme-wide changes are required for students to develop skills and knowledge in MLM prior to starting work as doctors. Further research should examine the individual efficacy of each suggested teaching method, helping to make further recommendations as part of a national curriculum.
Notes on contributors THOMAS D. STRINGFELLOW, BMedSci, is a final year medical student at The University of Nottingham. REBECCA M. ROHRER, BSc MSc (Oxon), is a final year medical student at St. George’s, University of London. LOLA LOEWENTHAL, BSc MBBS MRCP (UK), is a Specialist Registrar in Respiratory Medicine at Epsom and St. Helier University Hospitals NHS Trust, London. CONNOR GORRARD-SMITH, BSc MB ChB, is an FY1 Doctor at Lewisham and Greenwich NHS Trust, London. IBRAHIM H. N. SHERIFF is an Intercalating Medical Student at Kings’ College, University of London. KIRSTEN ARMIT, BHSc, is the Chief Operating Officer at The Faculty of Medical Leadership and Management, London. PETER D. LEES, MB ChB MS FRCS FRCP, is the Chief Executive and Medical Director at The Faculty of Medical Leadership and Management, London. PETER C. SPURGEON, B.Soc.Sci PhD, is the Director of The Institute of Clinical Leadership and Professor in Clinical Healthcare Management at Warwick University.
Declaration of interest: All authors are members of the Faculty of Medical Leadership and Management (FMLM), PL is the medical director, and KA the manager of the FMLM. All funding was provided by the FMLM. Views expressed in this article are those of the co-authors and not those of the authors’ respective institutions.
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