Training Young Pediatricians as Leaders for the 21st Century
Laurel K. Leslie, MD*; Mary Beth Miotto, MD‡; Gilbert C. Liu, MD§; Suzanne Ziemnik, MEd㛳; Antonio G. Cabrera, MD¶; Shellane Calma, BA*; Christina Huang, BA*; and Kenneth Slaw, PhD#
ABSTRACT. Objective. To conduct a needs assess-ment with young pediatricians who participate in a lead-ership training program and to evaluate the effectiveness of that program.
Methods. In concert with the Johnson & Johnson Pe-diatric Institute, LLC, the American Academy of Pediat-rics developed a 1-year strategy to train pediatricians who are<40 years old or<5 years in practice in leader-ship skills. Participants were nominated by American Academy of Pediatrics chapters and/or sections and were required to complete a detailed needs assessment, attend a 3-day training program, and commit to 1 leadership-related behavior change to be implemented within 6 months. A preanalytic/postanalytic design strategy was used.
Results. A total of 56 applicants representing 33 US states participated; 44.6% were male, and more than half (51.8%) were employed at a medical school/hospital. The needs assessment indicated that participants were confi-dent in many of their leadership qualities but desired increased training, particularly in areas of time and pri-ority management and leading “from the middle.” Post-survey instruments (n ⴝ 54, 96% response rate) deter-mined that participants positively evaluated the training program and improved in self-reported basic competen-cies; 87% also reported fully or partially achieving a leadership-related goal identified in a behavior change contract.
Conclusions. Results demonstrate that young phys-icians are eager for leadership training and that con-tinuing medical education in this area can be provided with positive results. Core competencies, curriculum, and evaluative tools need to be developed further and training opportunities need to be expanded to other sub-populations of pediatricians and pediatric health care providers.Pediatrics2005;115:765–773;pediatrics, leader-ship, leadership training, continuing medical education.
ABBREVIATIONS. IOM, Institute of Medicine; PLA, Pediatric Leadership Alliance; YPL, Young Pediatric Leaders for the 21st
Century Training Program; AAP, American Academy of Pediat-rics; JJPI, Johnson & Johnson Pediatric Institute.
T
he Institute of Medicine’s (IOM’s) 2001 report Crossing the Quality Chasm1opened by stating that, although the US health care system em-bodies the highest levels of medical expertise and technologically advanced care, it continues to fail at meeting the minimum needs of millions of Ameri-cans. The IOM report called for a restructuring of the health care organization to serve equitably its depen-dents, reduce system as well as individual errors, contain costs, and ensure quality. Central to the IOM agenda for redesigning the 21st-century health care system was the need for leadership in health care.1Most physicians are in positions of potential lead-ership. Reinertsen, in his article “Physicians as Lead-ers in the Improvement of Health Care Systems,”2 used a business-based definition of leadership, de-scribing it as the ability to coordinate processes that begin an organization or facilitate an organization’s adaptation to changing circumstances. Whether serv-ing in an academic medical center, workserv-ing as a physician executive in a health plan or public health program, functioning as a partner in a group prac-tice, collaborating on a community project, or advo-cating for effective health legislation, physicians have multiple opportunities to function as leaders in changing health care in the 21st century.
Despite these prospects, many physicians either have not taken on leadership roles or function inef-fectively in those roles. Some have argued that the majority of administrative, organizational, team-building, and self-assessment skills of quality leaders are not taught in medical training programs. In fact, much of traditional medical curricula have empha-sized autonomy in decision making, the individual physician-patient relationship, and hierarchical cul-tural processes that are counterproductive to effec-tive leadership.3,4 In addition, although leadership development programs have been implemented in many sectors of the economy and have been accom-panied by a rapid proliferation of both a scholarly evaluation and the popular inspirational literature, medicine has tended to act as though leadership were an innate characteristic and not a skill to be learned. Until recently, physicians who were inter-ested in acquiring leadership skills training have had to search for programs in industries outside medi-cine.
It is only in the past decade that the medical pro-fession has begun to recognize the need for system-From the *Child and Adolescent Services Research Center, Children’s
Hos-pital, San Diego, California; ‡Private Practice, Marlborough, Massachusetts; §Children’s Health Services Research, Indiana University School of Medi-cine, Indianapolis, Indiana; 㛳Division of Continuing Medical Education, American Academy of Pediatrics, Elk Grove Village, Illinois; ¶Department of Cardiology, Rainbow Babies and Children’s Hospital/Case Western Reserve University, Cleveland, Ohio; and #Membership, American Acad-emy of Pediatrics, Elk Grove Village, Illinois.
Accepted for publication Jul 22, 2004. doi:10.1542/peds.2004-1223 No conflict of interest declared.
Address correspondence to Laurel K. Leslie, MD, Child and Adolescent Services Research Center, Children’s Hospital, 3020 Children’s Way, MC 5033, San Diego, CA 92123-0282. E-mail: lleslie@casrc.org
atic training in leadership skills.3Programs and cur-riculum development have targeted specific types of physicians, for example, academicians,5–11 physi-cian executives (www.acpe.org),12–14 public health physicians,15,16 family physicians,17–20 and women physicians.21Modalities for leadership training have included one-on-one mentoring, workshops, extern-ships, seminars, community service experiences, and master’s degree programs. Issues such as cost, local-ity, use of the Internet, and content have been widely divergent. However, aside from the few programs that culminate in certificate programs or degrees from secondary educational institutions, the status of leadership training for physicians today remains sporadic and rudimentary. Evaluation of training opportunities has also been limited; the large major-ity of programs are briefly described in commentary form, and few programs have received formal eval-uation of specific interventions. To date, there are no formal evaluations either of the degree to which these programs encourage measurable behavior change or of the impact of these efforts on quality of care.
In this article, we describe the Pediatric Leadership Alliance’s (PLA’s) Young Pediatric Leaders for the 21st Century Training Program (YPL), a joint initia-tive sponsored by the American Academy of Pediat-rics (AAP) and the Johnson & Johnson Pediatric In-stitute, LLC (JJPI), to train recently graduated pediatricians as health care leaders for the 21st cen-tury. The YPL followed established approaches for significant leadership development by fostering con-ceptual frameworks regarding leadership and en-couraging self-assessment and personal growth, in-troducing topics related to systems management, and enhancing team leadership skills. We report the initial evaluative results of the program. Recognizing the need for longitudinal programs and develop-mental approaches for physician leadership training, we also discuss the future of the PLA and offer lessons learned that may be helpful for other orga-nizations/branches of medicine that plan to conduct similar training.
METHODS Overview: Development of the PLA
The AAP began addressing the need for formal pediatric lead-ership training in the mid 1990s. To generate a curriculum on leadership, the AAP sought out expertise external to the organi-zation. The AAP had already formed the PLA, a partnership with JJPI, a subsidiary of Johnson & Johnson; the PLA’s mission was to explore and deploy cutting-edge educational technologies to ad-vance the medical care provided to children. A proposal for for-mal leadership training was submitted by the AAP to the PLA, based on the premise that leadership excellence, coupled with clinical excellence, can contribute to improved quality of care and positive health system change. The concept was enthusiastically supported; not only did the PLA generate sufficient funds for the effort, but also representatives from the JJPI recruited experts from their Johnson & Johnson Consulting Group, a corporate executive leadership development program, as well as leaders in medicine and within the AAP, to create a leadership curriculum for pedia-tricians.
The first leadership program offered by the PLA was presented over a 12-month period from November 2000 through 2001. The program was designed for health care teams from communities, academic societies, and the AAP to come together and learn many
of the skills and tools of leadership, then apply those skills to a problem specific to their institution or community. The evaluation of this first leadership program suggested strongly that a subse-quent leadership program should be directed toward young pe-diatricians defined as those pepe-diatricians who are⬍40 years old or in practice for⬍5 years. Those results, along with the ideas of several young pediatricians who were members of the recently developed Young Physicians’ Section at the AAP, were used to form the basis of a new proposal to apply the same program design and principles to a training program for young pediatri-cians.
PLA YPL
Participant Selection
In January 2002, each of the 59 US chapters of the AAP as well as the 50 surgical, medical, and multidisciplinary sections of the AAP were offered an opportunity to nominate a young pediatri-cian to participate in the YPL. To solidify participation and com-mitment to the applicant, each sponsoring chapter or section was required to pay a nominal registration fee. In addition, nominees were required to sign an agreement that they would be willing to complete a prework packet and assignments during and after the program. By the cutoff date of March 15, 2002, 65 nominations had been received, and all nominees were approved for participation in the program. Over the course of the summer of 2002, 9 nomi-nees encountered scheduling conflicts with attending the training program, resulting in a total of 56 participants.
Curriculum Development
Curriculum development focused on 3 areas of physician or-ganizational, management, and leadership skills and competen-cies described in the literature: (1) self-management skills (self-awareness, personal leadership style development, career plan, role management, and time management), (2) systems manage-ment skills (assessmanage-ment of system needs and developmanage-ment of strategic plans), and (3) leadership competencies within the con-text of a team (development of a shared vision, communication of purpose, fostered collaboration, empowerment of others, and es-tablishment of trust).8The course curriculum drew heavily on
materials from the previous PLA leadership training (2000 –2001) and from the Johnson & Johnson Consulting Group. The curricu-lum also incorporated the perceived needs of the participants as measured by a needs assessment of participants conducted in the spring of 2002 (see “Measures” and “Results”) both as content (eg, curricular topics) and as process (eg, sample case studies).
The curriculum for the YPL was finalized in the spring of 2002. The 3-day training program began with an evening event that included an overview of the meeting’s philosophy and agenda and an introduction to pediatric leaders followed by 2 full 14-hour days of didactic and small-group programming centered on the core areas of curriculum (see Table 1 for specific details). Minimal didactic sessions were offered; other modalities, shown to enhance participant interaction and provide creative opportunities to prac-tice skills, were used, including role-playing, team projects, devel-opment of brief “infomercials,” small-group discussions and re-porting out, self-assessment surveys, case studies, and review of videotaped scenarios.22,23Participants of small groups were
re-shuffled for each topical area to encourage exposure to a variety of perspectives, highlight challenges in team formation, and serve as an introduction of the young physicians to colleagues from around the nation.
An additional critical component of the program that was refined from previous events was a hands-on workshop provided by leadership trainers from the Johnson & Johnson Consulting Group to introduce pediatricians to a collection of leadership and management tools that are used in business and were designed to define a project, define and direct a team, and prepare to roll out a project. Over the course of the training, participants worked in groups using appropriate tools applied to simulated health care scenarios.
of behavioral change contracts in influencing behavior change in drug/alcohol and smoking cessation and obesity intervention pro-grams.26–30Researchers in medical education similarly have found
that behavioral change (or “learning”) contracts reinforce the ed-ucational goals of a program once a physician returns to his or her clinical setting.23,31–36The YPL used reflective learning strategies
and asked participants to construct daily worksheets regarding possible behavioral changes that they would implement after the training program. On the last morning of the program, partici-pants contracted to make 1 specific leadership change off of their worksheets (see Table 2). Participants were advised that they would be required to report on the success, challenges, or modi-fications to their learning contract 6 months after completion of the program.
Evaluation Procedures
We chose to use a pre/post design as it was most feasible for the scope of the project. The program was conceived as having 4 time points: (1) before the training program (baseline), (2) at the on-site registration for the program (T1), (3) on-site immediately after the completion of the program (T2), and (4) 4 months after the program (T3). The prework packet including the needs assess-ment was distributed before the training program at baseline. Measures for T1 to T3 were in the form of survey instruments. T1 and T2 survey instruments were obtained on site at the program. T3 survey instruments were mailed, faxed, and/or e-mailed to respondents⬃6 months after the program. Faculty members con-tacted the participants to encourage return of the T3 instruments; 54 of the 56 respondents completed the T3 survey instrument for a response rate of 96%.
The proposed evaluation of the YPL targeted 3 of the 4 levels of evaluation described by Dixon37for continuing education
inter-ventions with health professionals. Level I included general eval-uation of participants’ satisfaction with program content and fac-ulty and used evaluation forms distributed at the end of each session and at the completion of the 3-day program (T2). Level II looked at self-reported change scores regarding 20 leadership competencies measured at T1, T2, and T3. Level III examined self-report of behavior changes made directly related to leader-ship. Given the limited resources of the program, level IV
evalu-ation data (direct outcomes measured at the level of the physi-cian’s environment) were not collected. The study was approved by the AAP Institutional Review Board.
Measures
This research effort used a dual-methods approach. Qualitative data were collected as part of the prework needs assessment conducted at baseline. Quantitative data, in the form of survey instruments, was collected at T1, T2, and T3. Survey question-naires are an accepted method for evaluating educational pro-grams and behavioral change and have been found to provide reliable information about respondents’ intentions.38Survey
ques-tions used in this study were based on existing instruments for some questions, including demographics of participants (ques-tions taken from the AAP periodic surveys of the Pediatric Re-search in Office Settings) and general program evaluation ques-tions (quesques-tions modified from existing AAP continuing medical education surveys). In addition, the PLA members developed a 20-question competency scale based on the learning objectives provided by faculty members. Scores on the competency scale were collected through the survey instruments at T1, T2, and T3, and change scores were created for T1 to T2 and for T1 to T3. Other outcomes measured included self-report of (1) use of the business tools presented, (2) presentation of material from training program to others in their community or medical setting, (3) pursuit of additional education in leadership training, (4) collab-oration with others regarding change, and (5) recruitment of a personal mentor to help address current leadership challenges. Last, self-reported completion of the goals specified in the learning contract was also examined as an outcome.
Analyses
Narratives from the prework packet were initially coded by research staff (C.H.) and then reviewed by PLA faculty members (L.K.L., M.B.M.) using an external coding schema based on a modified framework of organizational, management, and leader-ship skills and competencies necessary for physician leaderleader-ship described by Bogdewic et al.8Any discrepancies in categorization
were reviewed until consensus was reached. Quantitative data were analyzed using SPSS (version 9.0; SPSS, Inc, Chicago, IL). Statistical methods used includedttests and2tests.
RESULTS
Participant Sociodemographic Characteristics
Of the 56 participants, all were⬍40 years old and 44.6% were male. Thirty-six percent were residents or fellows in training; the remaining were in practice or academic medicine. Participants represented 33 different states. More than half (51.8%) of the partic-ipants were employed at a medical school/hospital, 33.9% were in either private or public group practice TABLE 1. Pediatric Leaders for the 21st Century Training Program Agenda
Day Agenda
Thursday
6:30–8:00pm Leading as a Pediatrician: Why? Friday
7:00–8:00am Identifying Characteristics of Pediatric Leaders 8:00–9:45am Conceptual Framework of Leadership; Assessment
of Leadership Style
10:00am–noon Assessment of Personality Style 1:00–3:00pm Teams
3:15–5:00pm Strategic Problem Solving in Complex Systems 7:30–9:00pm Leading in Pediatrics: How?
Saturday
8:00am–noon Business Management Tools 1:00–2:30pm Conflict Management
2:30–4:00pm Time and Priority Management Sunday
8:00–10:00am Mentoring, Coaching, Teaching, Evaluating, and Giving and Receiving Feedback
10:30–11:00am Leadership Requires Vision
TABLE 2. YPL Leadership Behavior Change Contract 1. What do you plan to change?
2. On a scale of 1 (not committed) to 5 (very committed), how committed are you to making this change?
3. What steps will you take to make this change?
4. What barriers do you anticipate as you try to implement this change?
5. What is your time frame for making this change? 6. How will you know you have made this change (eg, what
will be your measurable outcome)?
settings, 5.4% were employed at community/staff model hospitals, and 5.4% were with the Uniformed Armed Services. Close to two thirds (62.5%) of the participants participated in administrative work at their setting, 66.1% spent part of their time teaching, and 33.4% were involved in medical research. The majority (75.9%) named general pediatrics as their area of focus.
Needs Assessment
The baseline needs assessment asked questions regarding current leadership style and challenges as well as anticipated benefits from the program.
Current Leadership Style
When asked to describe their current leadership style, 75% of participants described themselves as fa-cilitative leaders. Key terms used included “demo-cratic,” “empowering,” “walking alongside,” “working together,” “being a team player,” and “leading a team by example.” As 1 pediatrician explained, “A facilitator empowers those around him or her to set individual goals and develop independent leadership. A facilita-tor listens and helps provide solutions without dictat-ing the answers.” Several commented that this style was essential in a medical environment with multiple strong leaders and personalities; as 1 person com-mented, “The people I was attempting to ‘lead’ were all strong leaders and achievers themselves.” Some com-mented on the potential downsides of this leadership style, for example, “I have a hard time delegating re-sponsibilities to others, and may bend too far back-wards to try to ‘make everyone happy.’ ” Another shared that her facilitative leadership style had been effective previously but needed to change: “My style is to assume the best of people and act accordingly. This strategy has been somewhat effective, especially in nonconfrontational situations. However, I feel I have now⬘outgrown’ my current leadership style. I would like to make more than an average impact in my pro-fessional and personal life.”
Current Leadership Challenges From Personal and/or Professional Life
Leadership challenges were categorized within a modified framework of competencies elucidated by Bogdewic et al8 as necessary for physician leader-ship, specifically, self-management skills, systems management skills, and team leadership competen-cies. The challenge named most often by respondents fell within the category of self-management and in-cluded time and priority management. As young physicians starting out in their careers, 44% of the respondents found it especially difficult to balance professional and personal obligations; 24% discussed difficulties in prioritizing different professional roles such as administrative committees, research, and practice. A second self-management challenge iden-tified involved having the personal skills to lead in several different types of situations that are salient to young physicians: (1) from a “powerless” position (one respondent described this as “learning the best, most tactile approach for presenting change in a well-established pediatric office of experienced
phy-sicians without offending anyone’s person or profes-sional style”), (2) in a new location (“as an outsider and a young physician entering an established chap-ter, it has been a challenge to establish myself”), or (3) with very little personal experience or training in leadership (“being 6 months into my first academic job, I feel I can barely take care of myself, much less assist other faculty members. I have never needed to manage a large group of people, deal with adminis-trative bureaucracies, as well as strategically plan for the future simultaneously”). A third area of concern among the applicants was inspiring a shared vision that would motivate all stakeholders to participate in change; respondents commented that they were of-ten troubled with issues of motivation, limited reve-nue funding, program priorities, fragmented pro-grams and departments, and cultural differences.
Anticipated Benefits
The most widely endorsed benefit was the oppor-tunity to meet and interact with other young leaders in pediatrics (44%). Most were nonspecific in their training goals, requesting general “leadership skills” training (35%) or “training to improve” their leader-ship skills (22%). Some pediatricians (19%) also re-quested training in the ability to advocate and pro-mote awareness of child health–related issues.
Overall Evaluation of the Program
Results from the immediate evaluation survey at T2 indicated high mean scores regarding satisfaction with the content of the course. Specifically, mean scores on 5-point Likert scales indicated that the program met attendees’ anticipated needs (x⫽4.59; SD ⫽ 0.53); provided an initial, intense entry into a long-term educational process in leadership (x ⫽ 4.65; SD⫽0.67); and led to solutions for leadership challenges experienced (x⫽4.05; SD⫽0.73). Attend-ees acknowledged a high likelihood of seeking out more information or speaking with colleagues about ideas presented during the program (x⫽4.47; SD⫽ 0.74) and a high likelihood of changes being made in the work setting as a result of information received at the program (x⫽ 4.29; SD⫽ 0.84). Last, interest in participating in other PLA leadership programs as a faculty member was high (x⫽4.16; SD⫽1.14). With regard to course content, participants endorsed the following topical areas as most helpful: (1) practical tools from the business literature (49.1%); (2) person-ality style introspective exercise and discussion of implications for working in teams (27.3%); and (3) primer in evaluation and feedback (20%).
Program Outcomes
Competency Scores and Changes Over Time
TABLE 3. Longitudinal Examination of Group Mean Scores and Individual Change Scores for Targeted YPL Competencies (n⫽54)
Competencies* Group Scores,
Mean (SD)
Individual Change in Scores, % (n)
Baseline (T1) Post (T2) Post (T3) T1–T2 T1–T3 Self-management
1. Using a defined conceptual model of leadership to examine the strengths and weaknesses of my particular leadership style
2.21 (0.91) 4.15 (0.66)† 3.53 (0.85)† Neg 1.8 (1) 5.6 (3) No 10.9 (6) 14.8 (8) Pos 87.3 (48) 79.6 (43) 2. Using the specific strengths and skills of my
leadership style
3.20 (0.75) 4.09 (0.67)† 3.94 (0.69)† Neg 5.4 (3) 5.6 (3) No 30.4 (17) 37.0 (20) Pos 64.3 (36) 57.4 (31) 3. Proactively working to improve the weaker areas
of my leadership style
2.88 (0.81) 4.14 (0.76)† 3.73 (0.79)† Neg 5.4 (3) 10.9 (6) No 19.6 (11) 23.6 (13) Pos 75.0 (42) 65.5 (36) 4. Periodically and proactively seeking out feedback
on my performance
3.27 (1.12) 4.00 (0.89)† 3.51 (0.72) Neg 10.9 (6) 29.1 (16) No 40.0 (22) 32.7 (18) Pos 49.1 (27) 38.2 (21) 5. Identifying personal and professional goals,
interests, and rewards
3.73 (0.80) 4.20 (0.76)‡ 4.33 (0.70)† Neg 10.7 (6) 10.9 (6) No 50.0 (28) 38.2 (21) Pos 39.3 (22) 50.9 (28) 6. Defining what tasks are urgent versus important
on a regular basis to determine my foci based on my personal and professional priorities
3.48 (0.85) 3.98 (0.65)‡ 4.05 (0.89)† Neg 14.3 (8) 9.1 (5) No 39.3 (22) 40.0 (22) Pos 46.4 (26) 50.9 (28) Systems management
7. Applying a systems perspective when making changes in my workplace or community
2.45 (1.11) 3.65 (0.83)† 3.64 (0.76)† Neg 7.3 (4) 3.6 (2) No 25.5 (14) 25.5 (14) Pos 67.3 (37) 70.9 (39) 8. Thinking “out of the box” to identify barriers and
to brainstorm solutions
3.34 (0.79) 4.00 (0.78)† 4.09 (0.76)† Neg 8.9 (5) 7.3 (4) No 32.1 (18) 29.1 (16) Pos 58.9 (33) 63.6 (35) 9. Applying management tools personally or in a
team process to define goals, identify barriers, and complete a task
2.73 (0.94) 3.91 (0.89)† 3.69 (0.75)† Neg 5.4 (3) 12.7 (7) No 28.6 (16) 18.2 (10) Pos 66.1 (37) 69.1 (38) Team leadership
10. Knowing what defines a team, when to use a team, and how to use a team
3.38 (0.90) 4.27 (0.67)† 4.13 (0.73)† Neg 10.9 (6) 5.5 (3) No 29.1 (16) 38.2 (21) Pos 60.0 (33) 56.4 (31) 11. Identifying the diverse styles and skills of my
co-workers on teams that I work with in my setting
3.34 (0.90) 4.11 (0.65)† 4.07 (0.75)† Neg 10.7 (6) 12.7 (7) No 33.9 (19) 29.1 (16) Pos 55.4 (31) 58.2 (32) 12. Building on the diversity of styles and skills in
team members to achieve a better product than possible working by myself
2.96 (0.83) 4.05 (0.67)† 3.91 (0.73)† Neg 5.4 (3) 5.5 (3) No 25.0 (14) 29.1 (16) Pos 69.6 (39) 65.5 (36) 13. Effectively using a team to accomplish tasks in my
professional setting
3.13 (0.81) 4.00 (0.67)† 3.67 (0.67)† Neg 5.4 (3) 12.7 (7) No 28.6 (16) 38.2 (21) Pos 66.1 (37) 49.1 (27) 14. Using my particular position on a team or in an
organization to influence the outcomes of a conflict, even if I am not the person “in charge”
3.29 (0.82) 3.66 (0.67)‡ 4.07 (0.75)† Neg 14.3 (8) 5.5 (3) No 48.2 (27) 36.4 (20) Pos 37.5 (21) 58.2 (32) 15. Quickly identifying when conflict is occurring and
what factors are triggering that situation
3.38 (0.91) 3.73 (0.70)‡ 3.93 (0.80)† Neg 19.6 (11) 12.7 (7) No 35.7 (20) 30.9 (17) Pos 44.6 (25) 56.4 (31) 16. Knowing my personal approach to managing
conflict and varying my approach as needed for a specific situation
3.20 (0.92) 3.75 (0.80)† 4.04 (0.85)† Neg 17.9 (10) 7.3 (4) No 30.4 (17) 32.7 (18) Pos 51.8 (29) 60.0 (33) 17. Managing people by delegating tasks where
possible, helping them to prioritize objectives, and monitoring their progress
3.09 (0.98) 3.68 (0.72)† 3.73 (0.83)† Neg 5.4 (3) 14.5 (8) No 50.0 (28) 34.5 (19) Pos 44.6 (25) 50.9 (28) 18. Giving feedback to co-workers in a constructive
and timely manner that includes their strengths as well as weaknesses
3.09 (0.84) 3.93 (0.80)† 3.73 (0.79)† Neg 10.9 (6) 16.4 (9) No 25.5 (14) 23.6 (13) Pos 63.6 (35) 60.0 (33) 19. Closely listening to all points of view (eg,
co-workers, community stakeholders) before communicating my perspective
3.46 (0.81) 4.13 (0.84)† 3.93 (0.88)‡ Neg 10.7 (6) 16.7 (9) No 30.4 (17) 38.9 (21) Pos 58.9 (33) 44.4 (24) 20. Engaging others in a task or project by speaking
with conviction about the higher purpose of our work
3.25 (0.92) 4.20 (0.80)† 4.02 (0.85)† Neg 5.4 (3) 9.3 (5) No 23.2 (13) 31.5 (17) Pos 71.4 (40) 59.3 (32) Neg indicates negative; Pos, positive.
* Competencies are rated on a 5-point Likert scale on which 1⫽weak and 5⫽strong. †P⬍.001.
The 3 lowest mean scores endorsed at T1 included a self-management skill (item 1, using a defined con-ceptual model of leadership to examine personal leadership style) and 2 systems management skills (item 10, applying a systems perspective when mak-ing change; and item 12, applymak-ing management tools). These findings closely paralleled themes gen-erated during the needs assessment as participants could set personal goals and lead by inclusion of others but were less sure of what it meant to be a leader and how to act to lead change in their setting. Table 3 also delineates the mean score for the participants as a group on each of these competen-cies at T2, immediately after the YPL, and at T3,⬃6 months after the program. All changes were noted at a significance level ofP⬍.05 except for the T1 to T3 mean scores for item 4, “periodically and proactively seeking out feedback on my performance.”
In addition to examining change scores in the ag-gregate, we examined individual change scores. Ta-ble 3 demonstrates whether an individual’s score on each item decreased (negative change), remained un-changed (no change), or increased (positive change). At T2, the majority of items were noted to have ⬎50% of respondents endorsing a positive change except for several self-management items (item 4, periodically and proactively seeking out feedback on performance; item 5, identifying personal goals; and item 6, defining urgent versus important for priori-tizing tasks) and several team leadership items (item 14, using particular position on team to influence change; item 15, identifying conflict occurrence; and item 17, managing people). At T3, items with⬍50% positive change included 1 self-management skill that had been marked low at T2 (item 4, periodically and proactively seeking out feedback on perfor-mance) and 2 team leadership skills (item 13, effec-tively using a team to accomplish a task; and item 19, closely listening to all points of view).
Additional Outcomes
Participants were also asked about changes that they had made since the YPL. First, participants rated on a 5-point scale 3 of the business tools pre-sented during the meeting with respect to their use-fulness to them as a leader in their particular setting; 71.7% endorsed the stakeholder analysis tool, 56.6% endorsed the threat/opportunity matrix tool, and 35.9% endorsed the force field analysis tool as useful to very useful. More than two thirds (72.7%) had shared the materials from the YPL with others, and 53.7% had pursued other educational opportunities with respect to leadership. One quarter (25.9%) had established collaborations as a result of networking that occurred at the YPL, and more than one third (35.8%) had found a mentor to work with them on a personal leadership challenge. Many had made per-sonal changes as a result of the program. One par-ticipant provided a salient example: “I found the PLA very helpful in helping me focus on changing my leadership style. It helped me tremendously, both personally and professionally. I am a much happier worker as a result as well. Without the con-ference I would not have pursued becoming chief of
the medical staff. Please continue to hold this confer-ence and mentor young physicians.” In addition, 3 participants planned ongoing training for their nom-inating bodies or institutions. One participant had returned to her chapter (Pennsylvania) and found sponsorship for a 2-day leadership training program for chapter members for fall 2003. A second planned a full day of leadership training for members of the Resident Section to be held at the 2005 AAP National Conference and Exhibition; a third had developed a series of workshops for the annual Robert Wood Johnson Faculty Scholars meeting. Last, members from the AAP Resident Section had begun a standing leadership training column to be included an all issues of its newsletter.
Participants next were asked about the accom-plishment of the goals that they had set in their learning contracts; it should be noted that several laid out⬎1 goal in their contract. The majority (74%) were in the area of team leadership; examples in-cluded using tools provided for team building or to delegating tasks. Another 37% fell in the area of self-management (eg, develop a 5-year career plan and present to mentor, use leadership self-assess-ment tool to reassess myself as a leader), and 13% were in the area of systems management (eg, utilize tools to facilitate progress for a new AAP chapter group, set up system for frequent meetings with nursing staff). The majority (87.0%) of respondents reported that they had achieved or partially achieved the leadership goal identified in their learning con-tract. It is interesting that 62.3% found that it had not been easy to implement their goal because of com-peting time demands (60.4%), dysfunctional teams at the workplace (30.2%), or that their goal required system-level changes (28.3%). Almost two thirds (62.7%) had found the learning contract helpful in prompting action on the specified goal.
Desired Topical Areas Not Covered in YPL
with their own careers and all the junior faculty who need them.” Participants also wanted more opportu-nities to discuss system-level changes. As 1 partici-pant summarized, “Excellent meeting, but periodic reinforcement is necessary to make changes perma-nent. Unfortunately, it’s too easy to let old habits set in. Also, when only one person alone changes, it is only minimally easier to change a larger system.”
DISCUSSION
Our study represents 1 of the first published eval-uations of the perceived needs of young pediatri-cians in the area of leadership skills. Although lead-ership training is well documented in the industrial literature, intensive leadership skills training pro-grams for physicians have not been documented ex-tensively in the medical literature. The area of train-ing needs for young pediatricians specifically has not been addressed.
Our results confirm that leadership training fills a critical need for young pediatricians. Young pedia-tricians found themselves in positions of leadership as chief residents, junior faculty, public health ad-ministrators, armed services physicians, and practi-tioners. Participants were often seen as “natural lead-ers” but wanted formal training in leadership to address better the leadership challenges that they faced. Many were making a transition into positions of leadership and clearly expressed their struggles as they found that strategies for leading used during medical school and residency, specifically facilitative leadership, continued to be useful in their new roles but that other mechanisms for leading teams were also required.
All of the participants actively supported attend-ing the program to acquire more leadership skills. Leadership skills have yet to become a part of med-ical school curricula, as evidenced in a recent review of educational programs in US medical schools in 2002–2003.39Very few opportunities for formal lead-ership training for young pediatricians exist, except for individual programs at academic institutions, chief residency training programs, or workshops available at the annual Pediatric Research Societies meeting. Participants in the YPL clearly demon-strated enthusiasm for the leadership training pro-gram, reported high levels of approval with the course content, and expressed interest in ongoing training.
Our results also suggest that the program resulted in overall self-reported improvement in leadership competencies and in activities related to leadership. Although some decreases in individual change scores between T1 and T2 were noted, this is not surprising given that T2 results were obtained im-mediately after the training, when respondents were most cognizant of skills that they wanted to develop further. In addition, a high percentage of participants reported achieving a leadership-related goal that was defined during the YPL. The learning contract was a tool that has been used in clinical education pro-grams but is new to the field of leadership training; our results suggest its continued use and
develop-ment as an educational tool in leadership education for physicians.
The results from this study also offer some ways that the program could be enhanced. Certain topic areas of specific relevance for this cohort of physi-cians were requested, including more directed dis-cussion of leading from the positions of relative powerlessness or in new settings, practical applica-tion of tools in systems analysis, and conflict man-agement/negotiation within the context of a facilita-tive leadership style. Clearly, ongoing follow-up and mentorship by faculty and additional contact with colleagues were important for the participants for emotional support, strategies, and implementation of their identified leadership behavior change.
Although many of the suggested mechanisms (list-serv, regional reunions) would have helped increase contact, these strategies do not address the need for a critical mass of individuals from an organization to support change. The results of the learning contract evaluation depict young pediatricians who face sig-nificant “real-world” obstacles against effective lead-ership. Demanding schedules, dysfunctional team dynamics, and system-level inertia emerged promi-nently in the reasons that YPL participants had dif-ficulty implementing leadership goals. In light of such impediments, it seems that in addition to the development and delivery of effective leadership training programs and mentorship, environment in-terventions that recognize and reward leadership, involve teams of health care providers in leadership training opportunities, and promote learning organi-zations are needed.40
The evaluation of the YPL also leaves many ques-tions unanswered regarding leadership training. First, if groups such as the IOM increasingly call for leadership from physicians, then core competencies will need to be delineated further. Other professional bodies, for example, the Public Health Practice Pro-gram Office of the Centers for Disease Control and Prevention,41 have begun the process of defining core leadership competencies in their field and could serve as models for pediatrics. Second, although the content of this program was elucidated carefully with input from experts in leadership training and was well received by participants, the core elements of leadership programs for physicians have not been researched. Only a handful of articles in the literature from the field of medicine present conceptual frame-works for leadership training for physicians, and none has been formally studied.40,42,43 Clearly, this area requires more thought. Third, this research sug-gests that physicians may have different types of leadership training needs, depending on their stage of career and environment.
literature from industrial psychology has examined the impact of leadership in fields such as mental health44; this type of research needs to be developed further within medicine. Unfortunately, educational research has many challenges: funding for educa-tional research is limited, trials of educaeduca-tional events are difficult to conduct, and results may not be gen-eralizable.45
At this point, the PLA is continuing to work with JJPI regarding leadership training for pediatricians. An interactive, Web-based module addressing lead-ership is being mounted through the PediaLink pro-gram. This tool provides an overview on leadership that can be accessed on-line at any time and allows for exchange among subscribers. The PLA also is participating in the development of a series of lead-ership programs that target various professional groups. For example, a 3-day training program was offered to the AAP Board of Directors, executive staff, incoming chapter vice presidents, and district vice chairpersons in the fall of 2004. Recognizing the importance of strong leadership in academic medical centers, the PLA is also partnering with the Associ-ation of Medical School Pediatric Department Chairs, Inc to develop a leadership curriculum for pediatric department chairs. Last, the PLA has reached outside the boundaries of pediatrics and has an ongoing collaboration in place with the American Association of Medical Society Executives and the Center for Association Leadership. The American Association of Medical Society Executives and the Center for Association Leadership had cohosted a summit in fall 2003 with ⬎40 nationally recognized medical leaders who ranked as their highest priority filling the leadership void in an environment of continued volatility. Ongoing leadership training activities will be forthcoming as a result of these and other collab-orative ventures. Additional training efforts, how-ever, will be needed and should be mounted within the context of academic medical centers, subspecialty areas, health plans, and practice networks. Determi-nation of a core curriculum and modification of available case studies from industries outside of medicine would make implementation of leadership programs throughout child health care settings more feasible.
The research presented here has several limita-tions. First, the research used a pre/postevaluation design to evaluate a leadership training program for young pediatricians. As such, it relied on self-re-ported behavior change and was unable to measure objectively more distal outcomes (eg, changes in the participant’s behavior in their setting of origin). A second limitation is that the study sample included pediatricians who were identified in their commu-nity as potential leaders; there is likely to be selection bias to include pediatricians who might seek out additional training experiences in leadership and work proactively to improve their leadership style. Last, we did not request that YPL participants spec-ify their race or ethnicity on any of the program materials and cannot formally present any results based on such distinctions. However, during the course of the meeting, it was noted that there was
limited black representation at the program, which sparked an impromptu on-site discussion among the participants and program planners. The basis for such racial and ethnic disparity is uncertain; how-ever, clearly effort needs to be undertaken to foster minority participation and eliminate any inadvertent discrimination in leadership training programs.
This study is the first to evaluate a leadership training program that targets young pediatricians. It demonstrates that leadership training programs are desirable, feasible, and effective in terms of helping early career pediatricians to achieve an identified leadership goal. Additional delineation of core lead-ership competencies that are specific to pediatrics, curriculum development and dissemination among pediatricians, and more in-depth evaluation will be necessary if we are to heed the IOM’s summons for leadership in health care for children and adolescents in the 21st century.
ACKNOWLEDGMENTS
We gratefully thank all the participants in the Pediatric Lead-ership Alliance Young Physicians LeadLead-ership Training Program, without whom this study could not have taken place. In addition, we thank all the members of the Pediatric Leadership Alliance Planning Committee and the faculty of the Pediatric Leadership Alliance Young Physicians Leadership Training Program, includ-ing (in alphabetical order): Errol R. Alden, MD; Antonio G. Ca-brera, MD; George M. Chewning, MA; Ralph Feigin, MD; Lewis First, MD; John Forbes; Aaron L. Friedman, MD; Mark Gelula, PhD; Andrea C. Kennedy; Carole Lannon, MD, MPH; Laurel K. Leslie, MD; Gilbert Liu, MD; Joy H. Marini, MS, PA-C; Mary Beth Miotto, MD; Kristin M. Outwater, MD; Robert Perelman, MD; Kenneth M. Slaw, PhD; Fernando Stein, MD; Sean Stevens, PhD; and Suzanne Ziemnik, MEd. Last, we thank Shelia Valadez from the American Academy of Pediatrics for unending commitment to the Pediatric Leadership Alliance project and organizational and coordinating work on this manuscript’s behalf.
REFERENCES
1. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001
2. Reinertsen JL. Physicians as leaders in the improvement of health care systems.Ann Intern Med.1998;128:833– 838
3. Schwartz RW, Pogge CR, Gillis SA, Holsinger JW. Programs for the development of physician leaders: a curricular process in its infancy. Acad Med.2000;75:133–140
4. Prather SE, Jones DN. Physician leadership: influence on practice-based learning and improvement.J Contin Educ Health Prof.2003;23(suppl 1):63–72
5. Wilson MP, McLaughlin CP. Leadership and Management in Academic Medicine. San Francisco, CA: Jossey-Bass; 1984
6. Irby DM. Faculty development and academic vitality.Acad Med.1993; 68:760 –763
7. Henley CE, Magelssen D. Faculty development and organizational sys-tems behavior.Acad Med.1990;65:406 – 409
8. Bogdewic SP, Baxley EG, Jamison PK. Leadership and organizational skills in academic medicine.Fam Med.1997;29:262–265
9. Fairchild DG, Benjamin EM, Gifford DR, Huot SJ. Physician leadership: enhancing the career development of academic physician administra-tors and leaders.Acad Med.2004;79:214 –218
10. Morahan PS, Kasperbauer D, McDade SA, et al. Training future leaders of academic medicine: internal programs at three academic health cen-ters.Acad Med.1998;73:1159 –1168
11. Schwartz RW, Pogge C. Physician leadership is essential to the survival of teaching hospitals.Am J Surg.2000;179:462– 468
12. Guthrie MB. Challenges in developing physician leadership and man-agement.Front Health Serv Manage.1999;15:3–26
14. Schwartz RW, Pogge C. Physician leadership: essential skills in a chang-ing environmentAm J Surg. 2000;180:187–192
15. Halverson PK, Mays G, Kaluzny AD, House RM. Developing leaders in public health: the role of executive training programs.J Health Admin Educ.1997;15:87–100
16. Woltring C, Constantine W, Schwarte L. Does leadership training make a difference? The CDC/UC Public Health Leadership Institute: 1991–1999.J Public Health Manage Pract.2003;9:103–122
17. McGaghie WC, Bogdewic S, Reid A, Arndt JE, Stritter FT, Frey JJ. Outcomes of a faculty development fellowship in family medicine.Fam Med.1990;22:196 –200
18. Bland CJ, Hitchcock MA, Anderson WA, Stritter FT. Faculty develop-ment fellowship programs in family medicine.J Med Educ. 1987;62: 632– 641
19. Bland CJ, Reineke RA, Welch WW, Shahady EJ. Effectiveness of faculty development workshops in family medicine.J Fam Pract. 1979;9: 453– 458
20. Saultz JW. Effective leadership in a reformed health care system: new skills for family physicians.Fam Med.1995;27:393–396
21. Association of American Medical Colleges. Professional Development Seminars. Available at: www.aamc.org/members/wim/meetings/ start.htm. Accessed April 29, 2004
22. Davis D, Thomson O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing edu-cation activities change physician behavior or health care outcomes? JAMA.1999;282:867– 874
23. Mazmanian PE, Davis DA. Continuing medical education and the phy-sician as a learner: guide to the evidence.JAMA.2002;288:1057–1060 24. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician
performance: a systematic review of the effect of continuing medical education strategies.JAMA.1995;274:700 –705
25. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.CMAJ.1995;153:1423–1431
26. Keane TM, Foy DW, Nunn B, Rychtarik RG. Spouse contracting to increase antabuse compliance in alcoholic veterans.J Clin Psychol.1984; 40:340 –344
27. Rodriguez L, Sandler J. The treatment of adult obesity through direct manipulation of specific eating behaviors.J Behav Ther Exp Psychiatry. 1981;12:159 –162
28. Ureda JR. The effect of contract witnessing on motivation and weight loss in a weight control program.Health Educ Q.1980;7:163–185
29. Neale AV, Singleton SP, Dupuis MH, Hess JW. The use of behavioral contracting to increase exercise activity.Am J Health Promot. 1990;4: 441– 447
30. Wilson DK, Wallston KA, King JE. Effects of contract framing, motiva-tion to quit, and self-efficacy on smoking reducmotiva-tion.J Appl Soc Psychol. 1990;20:531–547
31. Mazmanian PE, Daffron SR, Johnson RE, Davis DA, Kantrowitz MP. Information about barriers to planned change: a randomized controlled trial involving continuing medical education lectures and commitment to change.Acad Med.1998;73:882– 886
32. Purkis IE. Commitment for changes: an instrument for evaluating CME courses.J Med Educ.1982;57:61– 63
33. Curry L, Purkis IE. Validity of self-reports of behavior changes by participants after a CME course.J Med Educ.1986;61:579 –584 34. Parker FW, Mazmanian PE. Commitments, learning contracts, and
sem-inars in hospital-based CME: change in knowledge and behavior.J Cont Educ Health Prof.1992;12:49 – 63
35. Pereles L, Lockyer J, Hogan D, Gondocz T, Parboosingh J. Effectiveness of commitment contracts in continuing medical education.Acad Med. 1996;71:394
36. Campbell C, Parboosingh J, Gondocz T, Babitskaya G, Pham B. A study of the factors that influence physicians’ commitments to change their practices using learning diaries.Acad Med.1999;74(suppl):34 –36 37. Dixon J. Evaluation criteria in studies of continuing education in the
health professions: a critical review and a suggested strategy.Eval Health Prof.1978;1:47– 65
38. Martin K, Mazmanian PE. Anticipated and encountered barriers to change in CME: tools for planning and evaluation.J Cont Educ Health Prof.1991;14:301–318
39. Barzansky B, Etzel SI. Educational programs in US medical schools, 2002–2003.JAMA.2003;290:1190 –1196
40. Birleson P. Learning organisations: a suitable model for improving mental health services?Aust N Z J Psychiatry.1998;32:214 –222 41. Wright K, Rowitz L, Merkle A, et al. Competency development in
public health leadership.Am J Public Health.2000;90:1202–1207 42. Barker RA. How can we train leaders if we do not know what
leader-ship is?Hum Relat.1997;50:343–362
43. Corrigan PW, Lickey SE, Campion J, Rashid F. Mental health team leadership and consumers satisfaction and quality of life.Psychiatr Serv. 2000;51:781–785
44. Webster L, Hackett RK. Burnout and leadership in community mental health systems.Adm Policy Ment Health.1999;26:387–399
45. Cantillon P, Jones R. Does continuing medical education in general practice make a difference?BMJ.1999;318:1276 –1279
COLLEGE DEGREE STILL PAYS, BUT IT’S LEVELING OFF
“Ever so gradually, the big payoff in wages from a college education is losing its steam, which calls into question the emphasis that the White House, under both Bill Clinton and George W. Bush, has placed on a bachelor’s degree as a sure-fire avenue to constantly rising incomes. Men and women with 4 years of college earn nearly 45% more on average than those with only a high school diploma, according to the Bureau of Labor Statistics. The spread is as high as it has ever been, but it has been stuck in the 45% range since the late 1990’s, and through the 1990’s it rose much more slowly than in the 1980’s.”
Uchitelle L.New York Times. January 13, 2005
DOI: 10.1542/peds.2004-1223
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