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Abstract
Objectives The General Medical Council has stipulated that greater importance must be placed on undergraduate students developing their ability to lead and work effectively as part of a team. Wales Universities’ Officer Training Corps have attempted to meet this requirement through a third year interactive tutorial which aims to encourage students to recognise their strengths and limitations in the six outcomes of leadership, teamwork, accountability, management, feedback and communication.
Methods 16 tutorial groups of 10–15 students were each led by one officer who divided the tutorial group into three teams. The teams worked on complex planning exercises with an intrateam constructive feedback discussion to raise students’ awareness of their strengths and limitations as individuals during the task, as perceived by others.
Results The student perception was that all six learning outcomes were achieved by the session. 163 students returned feedback questionnaires and learning outcomes 1–4 were felt to have been addressed effectively or very effectively by 90%, 91%, 90% and 86% respondents, respectively. The fifth and sixth outcomes were less well achieved with only 66% and 64% respondents agreeing that the outcomes were achieved effectively or very effectively.
Conclusions Students commended the instructor's demonstration of leadership and the novel teaching method but improvements could be made in reinforcing why these skills are important.
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Key messages
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The General Medical Council guidance highlights that leadership and management are an essential part of the undergraduate curriculum.
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Although perceived as important, medical students must have the importance of these skills impressed upon them for teaching sessions to be effective.
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Planning exercises completed as a team provide a challenging task where leaders and team members are forced into using these skills in the classroom to explore in themselves where development is needed.
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Medical students regarded highly the Wales Universities’ Officer Training Corps officers and officer cadets in supervising the leadership and management sessions, admiring their ability and relevance to the sessions.
Introduction
Both the General Medical Council (GMC) guidance1 and the Tooke report2 have identified that greater attention needs to be paid to leadership, communication and resource management in the undergraduate medical curriculum. Effective leaders positively impact achievement in goal orientated tasks,3 but physicians often lack leadership skills compared with other health professionals.4 Communication and leadership are identified as the two most important qualities for management in medicine.5
Cardiff University School of Medicine responded to the GMC guidance by constructing a leadership and service improvement curriculum centred on three important documents in 2011.6–8 It was recognised at an internal annual curriculum meeting that Army officers were well trained in some of the areas of leadership to be taught, and might additionally benefit the teaching programme by stimulating student interest in the subject.
Wales Universities’ Officer Training Corps (WUOTC) were approached and agreed to provide staff and design the lessons. The University Officer Training Corps are Army organisations spread across the UK that develop the leadership potential of interested university students after a selection process, while raising awareness of the ethos, values and career opportunities of the Army.9 The University Officer Training Corps are a Territorial Army group B unit. The curriculum meeting concluded that the young WUOTC officers and officer cadets would relate well to the students, and as all the instructors were students themselves, it also concluded that small group teaching would allow the students to recognise their individual attributes of leadership, teamwork and communication in a comfortable environment10 and hence didactic teaching was not used. WUOTC was asked to arrange teaching sessions to cover the six learning outcomes (Box 1).
The six learning outcomes targeted by the Wales Universities’ Officer Training Corps tutorial package and assessed by the end-of-course questionnaire
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Communicate effectively in various roles, for example, as patient advocate, teacher, manager or improvement leader.
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Demonstrate the ability to build team capacity and positive working relationships.
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Undertake various team roles including leadership and the ability to accept leadership by others.
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Link availability of resources to the need to use resources efficiently, safely and fairly across the diversity of needs.
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Function effectively as a mentor and teacher by contributing to appraisal, assessment and review of colleagues, giving effective feedback, and taking advantage of opportunities to develop these skills.
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Hold yourself and other team members accountable for outcomes.
The teaching sessions aimed to provide intellectually stimulating leadership and teamwork training using team-based planning exercises (PLANEX) as used by the Army Officer Selection Board, Westbury.11 A PLANEX is a theoretical written exercise which aims to test candidates’ ability to address a complex problem, extracting information from a narrative text and map. There are generally several ways of completing a PLANEX, but with each having different needs, including manning, resources and timeframes. The candidate's analytical skills are tested, prioritising certain tasks over others while keeping the outcome in mind. The advantages include that they require no prior knowledge of medicine or leadership theory and that they have multiple components. A PLANEX based on humanitarian aid, without a military focus was deemed appropriate for medical students by WUOTC and the author of the leadership and service improvement curriculum.
Method
All instructors were Territorial Army commissioned officers in WUOTC who had undertaken a defence instructors’ course, had an active teaching role within the WUOTC and were volunteers with an interest in delivering leadership skills to an audience beyond WUOTC. Preparation for the teaching sessions began over 2 months before the tutorials were delivered. A presentation on leadership and the required documents for the session were written and reviewed with input from Cardiff Medical School and WUOTC. Instructor packs were issued prior to the leadership sessions. All instructors were given pretutorial guidance on the importance of achieving the learning outcomes, and to highlight how leadership skills could benefit medical students’ careers using a PowerPoint presentation citing appropriate evidence.12 ,13 In order to provide sessions for the entire third year of Cardiff Medical School, the sessions were run four times over a period of 12 days with a maximum of eight tutorials provided at one time. The teaching sessions lasted 1 h.
Third year medical students were taught in tutorial groups of 10–15, each instructed by one officer cadet or officer from WUOTC. The instructor further divided the group into two or three roughly equal teams to complete the PLANEX.
The classroom-based exercise began with an explanation of why doctors needed to be good leaders and how PLANEX can be a useful tool to build leadership and teamwork with reference to inspirational medical leaders such as Professor Archie Cochrane, a Cardiff medical graduate himself.
The four or five person groups were given a written scenario, which is summarised in Box 2 and available in full as online supplementary Box 1. They were given 30 min in which to plan their response, after which the group were required to give a constructive, verbal feedback of their group and individual performances and to discuss with a neutral observer who had been present throughout.
Planning Exercise (PLANEX) Summary
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The planning exercise describes a humanitarian aid mission in a fictitious war-torn African country with limited infrastructure in which the students are given the role as an aid relief driver. A scenario is described, where supplies of food and water must be delivered to a town, and given a fixed scheduled time in which to do this. A map is provided, illustrating six towns with roads of varying distances linking them.
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The truck provided does not contain enough fuel to complete this journey and a refuelling stop must be considered, there being two villages in which to refuel.
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To make the matter more complicated, the truck is carrying families travelling to refugee camps en-route as well as two surgeons, who need to arrive in another town by a fixed time in order to save the life of a child with congenital heart disease. The truck is also transporting a transplantable liver, which must be kept cool through a small cooler powered by the truck's electrical system.
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To compound any possible problems that the original scenario may have brought about, the truck begins leaking fuel after setting off, losing thirty litres of fuel which is followed by a message over the radio stating that the truck's engine will overheat four hours from starting the journey. A mechanic is desperately needed.
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A mechanic can be found in several of the towns, not all of them directly on the route to the original destination. The mechanics in each location have differing abilities and resources, some of which will be able to repair the engine and provide a fridge for the transplantable liver during this, whilst others lack electricity. The security risks in each location also differ allowing for different lengths of stay whilst one location has some movement restrictions due to the visit of the country's president.
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A plan must be devised by the students, prioritising and addressing each problem. Time, speed, fuel and resources must be considered carefully to achieve all goals.
Following the session, feedback forms asked the students to rate the session according to its six learning outcomes as completely ineffective, not very effective, fairly effective, effective or very effective. The questionnaire also asked two open questions about what the students particularly enjoyed and how they thought the sessions could be improved to look for any patterns that may have been missed by the directed questions. This style of questionnaire is regularly used within Cardiff Medical School to assess student perceptions of teaching. Completed questionnaires were counted as registration for the session.
Results
The WUOTC tutorial sessions were attended by 211/289 third year medical students, and 163 completed questionnaires were collected (77% response rate). The first four outcomes were generally felt to have been very well addressed (Figure 1). The two free text questions (Table 1) identified the WUOTC tutors who ran the session as ‘confident’, ‘helpful’, ‘excellent tutorial leaders’ and ‘demonstrating maturity beyond their years’. Two participants questioned the suitability of military personnel being involved in civilian medical training.
Summary table of positive and negative feedback
Outcomes of the student feedback questionnaire regarding the effectiveness of the tutorial in addressing the individual learning objectives.
Almost all of the responses made comment on the sessions being particularly enjoyable with the practical aspect of doing a task as a group far more stimulating than being lectured about leadership skills. Further praise was given to the scenario being non-medical based, enabling all to participate fully without discrimination regarding the individual's knowledge of the subject. Some comments were made regarding the scenario not being clinical.
The most common suggestions as to how the session could be improved were related to having more sessions, rotating roles within a group and having larger groups to allow for more group discussion and variety of opinions. Much of this suggests that the sessions were successful in leadership development and were engaging for those who participated.
The sensitivity of the quantitative data to a conservative assumption that non-responders were indifferent or held negative views was assessed. If non-responders were considered as believing all learning outcomes as ‘fairly effective’, ‘not very effective’ or ‘completely ineffective,’ then 70% would still consider the best addressed outcome (outcome 2) as ‘very effective’ or ‘effective.’ Nearly half (48%) of respondents would have rated the least well addressed learning outcome (outcome 6), as ‘very effective’ or ‘effective’ at accomplishing what was required.
Discussion
The GMC have reviewed their guidelines on leadership and management, recognising the key points of working with others to maintain and improve performance as well as leadership accountability in practice and identifying or solving problems as a team.14 It was felt that focusing on this latter point was of utmost importance, as much of the medical course experience to date focused on the diagnosis and management of patients and there were few circumstances in which medical students would have to make difficult decisions within a team environment, taking on different leadership and team roles.
Medical leadership, teamwork and resource management are undertaught skills12 ,15–18 but a large amount of literature reinforces the importance of these skills, especially the importance of teamwork and communication in medicine.19 ,20 Abbas et al19 echoed our views that most students considered the skills relevant, but might be uninterested in a ‘non-medical’ subject.
Of importance to clinical practice, Pawlina et al12 demonstrated that basic anatomy course grades of first year medical students were positively correlated with strength of leadership. Institutions where clinicians play an active role in leadership or management have higher quality care.13 Indeed, it has been argued that the attributes and values of a professional doctor and a leader are the same.21 No evidence was found of similar efforts to use military personnel to teach undergraduates in leadership and teamwork.
The concept of being taught by non-healthcare professionals and being asked to work as a group with no prior reading or knowledge would be new to most medical students used to learning and applying facts and concepts. There was some concern from the WUOTC teaching team that participants would regard being instructed by military instructors in skills of leadership, teamwork and communication unnecessary in the medical profession, despite the GMC guidance on the importance of leadership. In addition evidence identified early on in the programme, demonstrating that core leadership skills improve academic attainment12 and health outcomes,13 was highlighted in the sessions. However, the results showed the students held positive views of the sessions and accepted being taught by officers in leadership and teamwork. This positive response was augmented by the relevance of seeing these confident students possessing such qualities.
It is not known why questionnaires were not returned for registration at the sessions, as this was made clear by the instructor and in the PowerPoint teaching presentation. Overall, the tutorials were received well by the year. However, it was identified that some students may have known their instructor and this may lead to bias of their feedback. Due to anonymity of feedback, it is impossible to detect differences in the 77% students who responded compared with the 23% who did not. Learning outcomes 1–4 remained as outcomes which were well achieved after the assumptions made that non-responders did so for negative reasons or were indifferent. However, outcomes 5 and 6 did not. Learning outcomes 1–4 were predominantly based on recognising and using qualities of leadership, communication, teamwork and resource management. The final two entailed taking responsibility for decisions and being able to mentor, teach and give honest feedback to colleagues, which are abilities not commonly addressed throughout medical education, but of fundamental importance for doctors.1 ,2 With no evidence provided in the feedback as to why these outcomes were addressed poorly, it is thought that students felt that these learning outcomes were not achieved as effectively for two reasons. Courage is required to criticise and hold peers accountable, and an interactive tutorial might not encourage such discourse. Second, while these tutorials aimed to exhibit an individual student's ability in feedback, criticism and personal accountability, a short tutorial may not be long enough to enforce the importance of these skills. In future it will be more realistic to introduce these concepts in the teaching sessions, discussing in some depth the difficulties involved in holding oneself and colleagues accountable and the skills needed to teach and mentor peers. The development stage could then take place later, being integrated into clinical placements. This would make it relevant to clinical medicine and allow proper development over a longer time span.
Issues with the questionnaire were addressed. Ambiguous wording and multiple question foci in question 5 and unfamiliar terminology in question 6 were believed to limit the survey's effectiveness.22 Furthermore, only the ‘team observer’ could comment on question 5 and so it limits the relevance of the question to the remainder of the cohort.
Conclusions
The leadership and management qualities recognised by the new GMC guidance were taught to students by Officers from WUOTC. The PLANEX-based tutorial sessions were well received by students despite founded fears that leadership might not be perceived as an important subject. Feedback was encouraging but more effort could be made in explaining why these skills are required and further refinement of complex question wording may minimise the disparity between what was taught and how this was documented in the feedback questionnaire.
Acknowledgments
The authors wish to thank Lt Col H Evans TD RA(V), Commanding Officer Wales Universities Officer Training Corps (2009–2012), for providing the instructors.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online supplement
- Data supplement 2 - Online Box
Footnotes
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.
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Data sharing Additional methodology, planning materials, introductory presentation, raw data and the planning exercise model answer are available on request.