We are All Leaders: Introducing Self-Leadership Concepts Through the Lens of Improving Diversity in the Health Care Workforce

Educational Objectives

By the end of this activity, learners will be able to:

Introduction

The Institute of Medicine (IOM) proposed increasing the diversity of the health care workforce as a strategy to improve cultural competence and thus health outcomes for minorities.¹ To accomplish this, medical and other health fields must recruit more diverse trainees. The Sullivan Commission on diversity in the health care workforce was established in 2003 to address the IOM's recommendations on workforce diversity.² The commission emphasized the importance of minority faculty entering leadership positions, as leadership diversity leads to organizational cultural competence. However, the pipeline from student to resident to faculty to organizational leader is a long one, fraught with attrition. Medical students in groups underrepresented in medicine (URiM) face barriers to choosing a career in academic medicine³ and URiM physicians feel they must be more qualified than their white counterparts to move up in their health care organizations.⁴ The pipeline to improve diversity among health care leaders is leaky, therefore creative ways to influence medical schools and health care delivery organizations to embrace diversity and inclusion are needed.

Leaders improve the diversity and cultural competence of their organizations through their ability to influence. However, influence may occur at all levels of an organization. The concept of leadership, as defined by Gary Yukl⁵ is not tied to position on the organization chart, but one's ability to influence people and process in an organization to achieve goals. In this respect we can all be leaders if we are facile in our ability to positively influence others. There were more underrepresented racial and ethnic minority medical students (16%-18%) than faculty (8%) or department chairs in US medical schools in the 2018–2019 academic year.⁶ Engaging these medical students to be leaders (i.e., influencers) to improve cultural competence in medical schools may be one strategy for improvement until we reach increased diversity at higher organizational positions.

Self-leadership is the ability to influence oneself to perform effectively.⁷ Self-leadership is a concept related to self-efficacy, self-regulation, positive cognitive psychology, and others. Sahi⁸ and others have described strategies to improve self-leadership skills: behavior focused, natural rewards, and constructive thoughts. Empowering medical students and trainees with improved self-leadership skills may enhance their ability to influence others in medical schools and medical organizations to improve diversity and achieve cultural competence. Developing self-leadership skills and succeeding in influencing others can potentially increase trainees' self-efficacy towards serving as future leaders in academia.

“We Are All Leaders” complements and bridges two streams of scholarship represented in the MedEdPORTAL collection. Fernandez,⁹ Soto-Greene,¹⁰ Guilliames,¹¹ and Simpson-Mason¹² described educational interventions to raise awareness of academic career choice and offer strategies to clarify and pursue academic careers for URiM trainees. Our module built on that message, encouraging trainees to aspire to leadership positions in academic medicine as well. There are a number of contributions in MedEdPORTAL that described teaching leadership concepts and skills to trainees.^13,14 They predominantly offered resources to teach about leadership styles and theory, and offered skill-building on competencies such as communication, emotional intelligence, or teamwork. Our contribution was unique in offering a more empowering definition of leadership (as influence), that leadership can be exercised at all levels of an organization, and taught novices how to optimize their own personal effectiveness (self-leadership) as the first step for success. This workshop was developed by leaders of Building the Next Generation of Academic Physicians Inc. (BNGAP) as a part of a multiworkshop curriculum entitled “Engagement and Leadership in Academic Medicine.” This workshop was implemented at three medical schools. The three sites had reached out to BNGAP to serve as a site for implementation of the curriculum.

Our workshop was introductory in nature and was not intended to be a comprehensive leadership development program. It can be a stand-alone workshop, or may be enhanced by follow-up discussions that teach specific ways students may become involved as leaders in medical school.

Methods

We targeted this workshop to diverse trainees including medical students, residents, fellows, and other health care professionals. We recruited facilitators who were health care professionals with experience in leadership and facile in small group facilitation.

We designed and delivered the workshop in two components. The first was a short, 15-minute didactic PowerPoint presentation using active learning strategies such as think-pair-share and facilitated discussion (Appendix A). The accompanying facilitator's guide was Appendix B. The didactic component introduced the importance of diversity in the leadership of medical schools as described in the IOM report¹ and the Sullivan Commission² and included data from the AAMC on the lack of diversity in US medical school faculty, chairs, and deans. The concept of leadership as influence was introduced, with the message that since most medical schools lack diversity in leadership positions, we can all be leaders by influencing our organizations to embrace diversity, inclusion, and cultural competence.

In the second portion of the module, learners took the abbreviated self-leadership questionnaire (ASLQ), a validated self-leadership assessment tool¹⁵ (Appendix C), which may be completed before or during the workshop. During the workshop, 10 minutes were allotted for the trainees to complete the ASLQ. The facilitator guide (Appendix B) has information on interpreting the results. Drawn from concepts largely in the educational and social sciences literature, the questions in the ASLQ were aligned with literature-based strategies to improve self-leadership skills. This was followed by three case scenarios which we discussed as a large group, but could be assigned to smaller groups as class size and time would allow. The facilitator led a debrief on the cases after student-to-student discussion. Each case scenario and subsequent debrief took 10 minutes. The cases were designed to teach three strategies to improve self-leadership—behavior focused, natural rewards, and constructive thought. The facilitator guide contained suggested follow-up questions to encourage a rich discussion. The summary slide encouraged students to embrace the notion that we are all leaders, to optimize their self-leadership skills, and to become involved to influence their schools and medical organizations to embrace diversity and inclusion. The workshop took approximately 70 minutes to complete and was divided in the following manner:

The participants completed a pre- and postworkshop evaluation form (Appendix D). Both evaluation forms were administered as paper surveys the day of the workshop, the preworkshop prior to trainees participation in the workshop, and the postworkshop immediately after completion of the workshop. The coauthors created the evaluations forms to collect baseline information on learners' self-efficacy towards serving as a leader at a medical school, and their reaction (Kirkpatrick level 1 of evaluation) to the materials presented. The evaluation forms were aligned with the learning objectives and gave opportunity for free text comments on the module. A paired sample t test (p <.05) was used to assess for statistically significant changes in pre- and postworkshop survey responses.

Results

This workshop was implemented at three conference sites: Weill Cornell College of Medicine, University of Oklahoma College of Medicine, and McGovern Medical School at the University of Texas, Houston. A total of 87 trainees participated in the conferences and completed partial or full workshop evaluations. Sixty-six attendees submitted a matching pair of both the pre- and postworkshop surveys. The three workshops were facilitated by three individuals; two workshops were implemented by a single facilitator and one workshop by a pair of facilitators. All three facilitators were associate professors; one was also an associate dean for faculty and health affairs and another was an associate dean for diversity.

Of the 82 attendees who responded to the preconference survey, 65 (79%) identified as medical students, seven (9%) as residents, three (4%) as fellows, and seven (9%) as other health care related professions. This was a regional conference held at three medical schools. As such, the attendees hailed from medical schools in eight different states, as well as medical schools in Peru and the Dominican Republic.

Among these 82 respondents, three (4%) identified as Native American or Alaska Native, one (1%) as Native Hawaiian or other Pacific Islander, 15 (18%) as Asian, 26 (32%) as Black or African-American, 19 (23%) as Hispanic or Latino, 25 (31%) as white, and three (4%) as another race/ethnicity. Thirty-five (43%) identified as male, and 47 (57%) as female. Seventy (86%) identified as straight/heterosexual, five (10%) as gay or lesbian, and six (7%) as bisexual. Eighty-one (n = 65) agreed or strongly agreed their medical school did a good job fostering their development as a future physician while 51 (n = 41) agreed or strongly agreed their medical school did a good job of fostering their development as a future academic leader.

Among the 66 participants who answered the pre- and postsurveys there was a statistically significant increase in confidence regarding a trainee's ability to define self-leadership and assess their own self-leadership skills, identify a leadership role that aligned with their professional or personal interests, and effectively serve in a leadership position at their medical school given their gender, race/ethnicity, or sexual orientation. Results are exhibited in the Table.

Table. Pre- and Postworkshop Survey Responses on Learner Confidence

Over 95% of attendees either agreed or strongly agreed that each learning objective was met.

Postworkshop surveys gave the participants the opportunity to provide free text comments on positive experiences with the workshop and to suggest areas for improvement. Given the brief responses, a structured, qualitative analysis was not performed; however, comments were generally positive. Comments felt to be representative are presented below:

Discussion

This workshop was designed to provide medical students with an introduction to the concept of leadership and self-leadership. This was accomplished through a short didactic presentation, a self-assessment, and case study discussions. The module was created in the context of addressing the lack of diversity in the health care professional cohort, with a goal of encouraging trainees to become more involved in medical school as a vehicle of change. This workshop provided learners an empowering concept of leadership that was related to one's ability to influence, rather than one's position in an organization. Additionally, it taught strategies to improve one's self-leadership skills to be more effective in becoming influencers in their home organizations. Per the evaluations, this workshop accomplished its goals as over 95% of participants agreed that all learning objectives were met. Free text comments were positive and demonstrated that the concepts of leadership and self-leadership as presented were new to them and that they learned strategies for self-improvement. The case scenarios were highly rated by the learners and seem to have been an effective teaching strategy.

Based on comments, the diverse group of students appreciated learning about the lack of diversity among medical school leadership and agreed that the learning objective related to describing the importance of diversity in medical school leadership positions was met. However, comments suggested that the connection between this issue and the concept of leadership and self-leadership as influence was not appreciated for all participants. Based on this, slides were added to generate discussions to make this more explicit, with suggested corresponding guidance in the facilitator's guide. Additionally, the facilitator's guide for the summary slide was modified to include talking points encouraging students to use their newly gained appreciation of leadership and self-leadership to get involved in their home organization to influence it to become more diverse and inclusive.

Ideally the workshop facilitator should have leadership experience and, if not of a diverse background, should feel comfortable discussing issues of diversity and inclusion. The workshop worked well with up to 35 participants using large-group discussions for the case studies. The format allowed for breaking into smaller groups for the cases to allow more time for rich discussion and report out on each case. One of the coauthors (Raymond Lucas or John Paul Sánchez) cofacilitated at each of the three sites. The local cofacilitator was integrated easily and found both the facilitator's guide to be helpful and the PowerPoint presentation easy to use.

Although this workshop introduced learners to concepts of leadership and self-leadership, it was introductory in nature and should not be considered a complete leadership program. Leadership programs should be framed in a leadership competency model, use multiple approaches to learning, and provide opportunities to practice leadership skills and receive feedback.^16,17 Nevertheless, this module incorporated several approaches to teaching leadership described by Conger¹⁸ such as teaching leadership concepts, feedback through a self-assessment, and skill-building through the case studies.

Limitations to our workshop evaluation included a sample from a small number of medical schools where it has been presented. Our sample of learners, recruited through offices of diversity and inclusion, may be more interested or engaged in the topic than medical students in general. Additionally, our evaluation tool was not a validated instrument and only reported on reaction and not on learning, impact, or results.

This submission was unique in that it not only described the lack of diverse individuals in leadership positions in medical schools but defined a more empowering notion of leadership as influence. “We Are All Leaders” teaches that we can all lead (by influence) if we can improve our own self-leadership skills, become involved, and bring diverse perspectives to medical schools and health care organizations. Future research may focus on longer-term follow-up of participants to reassess their self-leadership skills and describe their level of involvement in their organizations.