2014, 1–7, Early Online
Identifying potential engaging leaders within medical education: The role of positive influence on peers BARRET MICHALEC1, J. JON VELOSKI2, MOHAMMADREZA HOJAT2 & MARK L. TYKOCINSKI2 1
University of Delaware, USA, 2Sidney Kimmel Medical College at Thomas Jefferson University, USA
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Abstract Background: Previous research has paid little to no attention towards exploring methods of identifying existing medical student leaders. Aim: Focusing on the role of influence and employing the tenets of the engaging leadership model, this study examines demographic and academic performance-related differences of positive influencers and if students who have been peer-identified as positive influencers also demonstrate high levels of genuine concern for others. Methods: Three separate fourth-year classes were asked to designate classmates that had significant positive influences on their professional and personal development. The top 10% of those students receiving positive influence nominations were compared with the other students on demographics, academic performance, and genuine concern for others. Results: Besides age, no demographic differences were found between positive influencers and other students. High positive influencers were not found to have higher standardized exam scores but did receive significantly higher clinical clerkship ratings. High positive influencers were found to possess a higher degree of genuine concern for others. Conclusion: The findings lend support to (a) utilizing the engaging model to explore leaders and leadership within medical education, (b) this particular method of identifying existing medical student leaders, and (c) return the focus of leadership research to the power of influence.
Introduction Previous research consistently highlights the value and necessity of cultivating leadership qualities among medical students (O’Connell & Pascoe 2004; Veronesi & Gunderman 2012). Emotional intelligence, confidence, creativity, practical knowledge and competence, interpersonal communication, motivation and encouragement of others, fostering a sense of community, social appraisal skills, and cognitive abilities among others are frequently offered as vital leadership skills and characteristics (Steinberg 2007; Crites et al. 2008; Goldstein et al. 2009; Varkey et al. 2009; McKimm & Swanwick 2011). The focus on this research has been almost exclusively on developing courses, strategies, programs, and seminars to ‘‘teach’’ medical students the traits, characteristics, and skills of leaders and leadership (Crites et al. 2008; Goldstein et al. 2009; Varkey et al. 2009; Long et al. 2011; Straus et al. 2013). Studies have shown, however, that attempts to foster positive attributes such as those related to professionalism (which are arguably akin to attributes related to leadership) are met with push-back from students, course scheduling dilemmas, and barriers related to the overarching organizational culture (West & Shanafelt 2007; Finn et al. 2010; Michalec & Hafferty 2013). Therefore, rather than constructing campus-wide courses and
Practice points
Research has neglected to focus on identificationbased approaches to understanding medical student leaders. Influence is the key construct of leadership, yet the ability to be influential appears to be absent from research on leadership in medical education. Previous research has focused on an individual-based, power-oriented model of leadership – given the emphasis on team-orientation, interprofessionalism, and collaboration, it is time to explore more otheroriented models such as the engaging leadership model. Findings show that students that were perceived as a high positive influence by their peers also had significant higher levels of other-orientation – lending support for the role of influence in leadership and employing the engaging leadership model. Findings also support the method of peer-nomination as an efficient means to identify existing leaders in medical school.
Correspondence: Barret Michalec, Department of Sociology, University of Delaware, 18 Amstel Ave, Smith Hall, Newark, DE 19716, USA. Tel: +302 831 1205; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–7 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.947933
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programs aimed at building leaders from the ground-up, faculty and administration could focus their energy and attention on students with existing key leadership qualities and attributes. An identification-based approach to understanding ‘‘leaders’’ within medical school, as compared with what appears to be an engrained cultivation-based approach, would concentrate efforts to encourage and further advance individuals that have already exhibited fundamental leadership qualities and capabilities. An identification-based approach would thereby eliminate, or at least minimize, the need of leadership ‘‘farming’’ that is proposed through grade cohortwide programs and classes, and lift some of the burden on already saturated curriculums. However, little to no research has proposed methods to identifying existing medical student leaders. Similarly, what appears to also be absent from the current state of the leadership-in-medical-education literature is an emphasis on constructing effective mechanisms to identify those with the ability to be influential with others (peers). At its core, leadership is about influence – as showcased in prominent conceptualizations of the term: (a) ‘‘. . . the process of influencing others to understand and agree about what needs to be done and how to do it . . .’’ (Yukl 2006), and (b) ‘‘. . . a process whereby an individual influences a group of individuals to achieve a common goal’’ (Northhouse 2007). Despite the essentiality of influence as it relates to leadership, studies in this specific arena have neglected to explore students’ ability to be influential (with their peers), and if/how this potential ability to be influential is related to leadership. Many of the leadership traits presented by previous literature can be considered other-oriented, further emphasizing that a crucial aspect of being perceived as a leader is the ability and willingness to connect and engage with others. The emphasis of other-orientation in regard to leadership qualities and capabilities is showcased in the engaging model of leadership proposed by Alimo-Metcalfe and Alban-Metcalfe (2005, 2006) and Alimo-Metcalfe et al. (2008) who argue that perhaps the most significant dimension to leadership can be classified as showing ‘‘genuine concern for others’’. Whereas traditional ‘‘heroic’’, charismatic, and ‘‘distant’’ models of leadership place the crux of power with the leader (individual-based), the engaging perspective of leadership emphasizes an individual’s other orientation and promotes the value of the individual’s accessibility, inspiration, support, and their ability to enable and encourage others to express their own influence and enterprise. Although a prominent model within the general leadership literature, including the discussion of effective leadership in the healthcare fields (McIntosh & Tolson 2008; Govier & Nash 2009), there has been minimal attention paid to employing the engaging model of leadership within the US medical education system to investigate leadership skills and attributes among medical students. Alimo-Metcalfe and colleagues argue that engaging leaders are perhaps most effective in facilitating high motivation and well-being among colleagues, positive organizational culture, and effective and efficient organizational performance. Given the changing culture of medicine 2
and care delivery, with a strong emphasis on team-based, collaborative, and interprofessional care, it is time to explore current and future leaders from a new, other-oriented perspective. This specific study examines the demographic- and academic performance-related characteristics of medical students designated by their peers as having a ‘‘significant positive influence’’ on their professional and personal development, and utilizing the tenets of the engaging leadership model investigates if peer-identified positive influencers also report high-score attributes related to showing a genuine concern for others. With this study, we attempt to redirect the current attention on leadership to the importance of the ability to be influential as well as investigate the association of positive influence on peers with genuine concern, which in turn, may lend support to the possibility of identifying existing medical student leaders through the method of peernomination. In doing so, we address the following research questions: (a) Differences between positive influencers and other medical students Are there demographic and/or academic achievement differences between those students identified as positive influencers and others? (b) Positive influencers as engaging leaders Regarding a genuine concern for others, the key element of the engaging leadership model, have those students identified as positive influencers reported higher empathy scores, and/or received higher scores on their simulated patient exams compared with other students? How do students conceptualize the ‘‘positive influence’’ they received/experienced from the students they selected? Do these reflect the tenets of the engaging leadership model?
Methods Study setting The Sidney Kimmel Medical College at Thomas Jefferson University is a large, private medical school located in an urban setting. This study was conducted between 2011 and 2013 as part of the Jefferson Longitudinal Study of Medical Education (Gonnella et al. 2011). The University’s Institutional Review Board determined that the study was exempt from full review for human subjects’ protection.
Sample A total of 630 (82%) of 766 students in three fourth-year classes (2011, 2012, and 2013) responded. These respondents were representative of the three classes with respect to age (p50.82), gender (p50.15), and ethnicity (p50.62). However, their mean scores on Step 1 (mean ¼ 225) and Step 2 (mean ¼ 237) of the United States Medical Licensing Examination (USMLE) were significantly higher (p50.001) than the non-respondents’ means on Step 1 (mean ¼ 217) and Step 2 (mean ¼ 231).
Results
Data for the Jefferson Longitudinal Study of Medical Education are collected annually in March at a class meeting when fourth-year students receive their results for the National Intern and Resident Matching Program (NIRMP). For the purposes of this specific project, a special instrument was added to the annual survey in 2011. Students were asked to think back to their medical school experiences to address the question ‘‘Which of your classmates had significant positive influences on your professional and personal development?’’ The instrument included the names of the entire graduating class listed alphabetically, and students were allowed to check as many names as they deemed necessary. We calculated the total number of times that each of the 766 students in the three classes was designated by a classmate as a positive influence. Students in the top 10% of this distribution for each class were designated as ‘‘high positive influence’’ and these 80 students were compared with 686 classmates. In order to explore differences between positive influencers and other medical students, we assessed demographic (sex, age, and race/ethnicity) and academic performance variables. Academic performance variables consisted of students’ MCAT, USMLE Step 1 and Step 2 scores, and faculty ratings of performance in clinical clerkships. Students’ level of ‘‘genuine concern for others’’ was assessed through two specific scores: (a) their scores on the Jefferson Scale of Empathy (JSE), and (b) the communication and interpersonal skills scores students earned during encounters with simulated patients in the third year. The JSE is a well-researched and validated measure of empathic engagement in the context of patient care (for an extensive discussion of the validity and reliability of the JSE see Hojat et al. 2002; Hojat 2007). Given the other-orientation of empathy and how communication and interpersonal skills also require understanding and perspective taking of another, the authors believe these measures to validly reflect students’ ‘‘genuine concern for others’’. Differences in categorical variables were evaluated using Chi-square and differences in means were evaluated using t-tests and analysis of variance. Multivariate associations were evaluated using logistic regression. To examine how medical students’ conceptualized the notion of the ‘‘positive influence’’ they experienced from those they selected, we added an open-ended item to the 2013 survey. Students were asked to think about who they selected as having a significant positive influence, and respond to the question, ‘‘In what way(s) have they [the student(s) they selected] had a positive influence?’’ Approximately one-half of the students provided words, phrases, or short sentences. These were read by one of the authors to identify the most frequently appearing concepts and categories. Four categories were identified: (a) support, (b) academic/organizational competence, (c) role model, and (d) fostering a positive/fun climate. Each phrase/term was then designated into a specific category, and a frequency analysis was conducted. The outcomes of these analyses are reported in the Results section.
Figure 1 shows the frequency distribution of the number of positive designations per student. The number of designations per student ranged from 2 to 82 with a median of 28. Ninety percent of the students were designated as being a positive influence by between 2 and 52 classmates. There were no significant differences found in the rates of being designated as a high positive influence for men and women as shown in Table 1. However, age was strongly associated with having a high positive influence. Only 3% of
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Number of Students 40 60
80
Measurements and procedure
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Identifying engaging medical student leaders
0
20 40 60 Number of Positive Designations per Student
80
Figure 1. Frequency distribution of number of positive designations per student.
Table 1. Personal characteristics of students designated by classmates as high positive influence compared to other students.
Designated by classmates
Gender Men Women Age at matriculation 18–21 22–26 27 and older Ethnicity African-American Asian Hispanic Indian/Pakistani White
a
High
Other
Total
Positive influence
Students
379 100% 387 100%
43 11% 37 10%
336 89% 349 90%
50.43
68 100% 615 100% 83 100%
2 3% 61 10% 17 20%
66 97% 554 90% 66 80%
50.001
25 100% 127 100% 39 100% 77 100% 494 100%
5 20% 10 8% 5 13% 6 8% 54 11%
20 80% 117 92% 34 87% 71 92% 440 89%
50.37
pa
p Values based on Chi-square analysis of frequencies.
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related to ‘‘fun’’, ‘‘enthusiasm’’, ‘‘great team member’’ and ‘‘positive attitude’’. The results of multiple logistic regression analysis (Table 3) indicated that only being older (p50.004) and having high ratings in clerkships (p50.009) were of unique value in explaining students’ designation in the high positive influence group.
those who entered medical school between the ages of 18 and 21 in the accelerated BS/MD program were designated as high positive influence, compared with the base rate of 10% for the vast majority of students. At the upper end of the age range, 20% of those who were 27 or older at matriculation were to be designated as high positive influence. The differences across ethnic groups were not found to be statistically significant (p50.37). High positive influencers were found to have a significantly higher (p50.01) mean empathy score (mean ¼ 117.1, SD ¼ 9) compared with that of other students (mean ¼ 113.5, SD ¼ 11). Furthermore, simulated patients assigned higher ratings on communication and interpersonal skills to students in the high positive influence group. As indicated in Table 2, no significant differences were found between the two groups on standardized tests of academic performance (MCAT and USMLE). However, students in the high positive influence group earned more honors grades from faculty ratings on students performance in core clinical clerkships. Regarding students’ conceptualization of the ‘‘positive influence’’, all the comments referred to types of prosocial behavior and academic/organizational understanding. The majority (58%) of terms were categorized as Support, as the comments related to substantive personal interactions such as being ‘‘helpful’’, ‘‘supportive’’, ‘‘encouraging’’, ‘‘listening’’, and ‘‘offering advice.’’ The second most occurring categories (15%) were Academic/Organizational Competence (e.g., ‘‘brilliant’’, ‘‘challenging’’, and ‘‘shared knowledge’’) and Role Model (e.g., ‘‘positive role model’’, ‘‘ability to balance work/life’’, and ‘‘exemplified commitment’’). Finally, 12% of the terms were categorized as Fostering a Positive/Fun Climate, as comments
Discussion With this study, we have attempted to turn the focus on the student-based leadership in medical school towards the key concept of influence by showcasing an effective and efficient mechanism (peer-selection) to identify existing ‘‘positive influencers’’ within the student body, and explored potential significant differences among high positive influencers and their peers. Furthermore, given the other-orientated nature of the prominent definitions of leadership as well as leadership attributes and traits highlighted by previous research, we employed the engaging leadership model discussed by AlimoMetcalfe and Alban-Metcalfe to investigate if (a) students that were designated as ‘‘high positive influencers’’ also presented characteristics related to the notion of showing a genuine concern for others, (b) ‘‘positive influence’’ was conceptualized by students in a similar manner to the notion of showing a genuine concern for others.
Demographics and academic performance differences Interestingly, there were no significant differences found in the rates of being designated as a positive influence between men
Table 2. Medical school performance of students designated as high positive influence compared to other students.
High positive influence
Other students
pa
10.5 10.2 223.8 235.4 2.8
10.6 10.0 223.8 235.8 1.9
50.34 50.40 50.94 50.78 50.001
82.3 81.2 86.4
82.4 81.4 85.1
50.89 50.65 50.02
Mean MCAT biological sciences Mean MCAT verbal reasoning Mean USMLE Step 1 Mean USMLE Step 2 Mean number of high ratings by faculty in 6 core clinical clerkships Mean on clinical skills assessment with simulated patients Data gathering skills Patient note documentation skills Communication and interpersonal skills a
p Values based on the independent t-test for means Chi-square analysis using frequencies. MCAT, Medical College Admission Test; USMLE, United States Medical Licensing Examination. Communication and interpersonal skills scored on 0–100 scale with mean of 85 and SD of 5.
Table 3. Logistic regression for students designated as high positive influence compared to other students.
Variable 27 and older at matriculation BS/MD program Communication and interpersonal skills Empathy score Ratings in clinical clerkships Constant
Odds ratio
Std. err.
z
p
95% conf. interval
2.50 0.99 1.04 1.34 1.93 0.07
0.79 0.01 0.27 0.34 0.49 0.018
2.91 1.57 0.13 1.14 2.59 10.26
0.004 0.12 0.89 0.25 0.009 0.000
1.35–4.63 0.97–1.00 0.62–1.72 0.81–2.19 1.17–3.19 0.043–0.19
Regression model used 692 observations and yielded a Chi-square of 23.38 with five degrees of freedom (p50.0003) and McFadden’s r-squared of 0.05.
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or women. Given that the crux of leadership is rooted in influence, this finding somewhat surprising as the literature consistently points to the glaring lack of females in leadership positions in professional and academic medicine (Morahan et al. 2011; Rosenthal et al. 2013; Valantine & Sandborg 2013; Bell et al. 2014). However, there could be differences between the men and the women in regard to which sex is more likely to serve in ‘‘official’’ (nominated and elected) positions within the classes, school, and University. Perhaps there continues to be an unconscious (and even at times conscious) bias towards women regarding leadership roles and positions. Fruitful next steps in this arena would include a comparative analysis of those students perceived as positive influence and those that are actually elected to official leadership positions, as well as assessing students’ perceptions of differences and similarities between being a positive influence (which may be more informal leadership) and formal leading in official positions. Similarly, no significant differences were found between the ethnicities of students either. It was found that older students, specifically those 27 and older, were significantly more likely to be designated as having a positive influence on their peers. Perhaps certain life experiences these older students gained (compared with the age-typical medical student) cultivated their willingness and ability to be supportive and helpful to their peers. It could also be suggested that because older students may be more likely to be married and/ or have children that these possible additional social relationships have cultivated their other-orientation, enhancing their attributes of encouragement of and engagement with others. Although there were no significant differences found between high influencers and all other students on the MCAT, Step 1, or Step 2, high influencers did earn significantly more honors grades on their faculty-rated clinical performance. Although high influencers did not out-perform their peers on the standardized tests, they were more likely to be the students recognized by medical school faculty as more capable and more knowledgeable in regard to their skills at doctoring and general organizational practice. Hence, it could be argued that high influencers exhibit a unique grasp of healthcare competence and capability as compared with their peers, and although ‘‘on paper’’ these students may not standout, they are indeed able to apply the knowledge and skills they learn to an impressive extent.
Genuine concern for others Students within the high positive influence group had a significantly higher average empathy score than all other students in the sample. This finding is consistent with that reported by Pohl et al. (2011) who found that medical students who were nominated by their peers on professionalism attributes obtained a significantly higher mean empathy scores than their other classmates. High influencers also received significantly higher scores from the ‘‘patients’’ during their simulated patient experiences. Similar findings are reported by Berg et al. (2011) who found that medical students with higher interpersonal skills (reflected in their scores on the JSE) received higher ratings of competence by simulated patients. It is important to note that whereas
empathy scores for this specific study were assessed at matriculation, the simulated patient assessments were conducted during the students’ third year. Therefore, this particular finding also offers a hint of consistency regarding these particular students’ degree of other-orientation. Furthermore, the terms and phrases offered by students regarding their own conceptualization of ‘‘positive influence’’ clearly echo the tenets of the engaging leadership model. Taken together these findings suggest that indeed students perceived by their peers as being a positive influence also reflect a genuine concern for others – the foundation of the engaging leadership model. In turn, this lends support the use of peer-nomination in this fashion to spotlight existing leaders in medical school. The data suggest that high positive influencers do show both a genuine concern for others and that students identified by their peers have the ability to be influential do indeed reflect the tenets of Alimo-Metcalfe and Alban-Metcalfe’s model of engaging leadership – and in this sense these influential students could in fact be agents of organizational change waiting to be tapped. By providing evidence that reinforces the notion that influence is at the crux of leadership it is hoped that future research on leadership in medical school and professional medicine will continue to focus on the role of influence and its various facets. The non-self-reported measures of achievement and capability (specifically the simulated patient assessment and the peer-identified positive influence designation) suggest that these students’ leadership traits are indeed visible to others, from peers to ‘‘patients’’. Perhaps on paper (standardized test scores) these high influencers are not obvious leaders, but rather it comes through in their actions and expression of attitudes and values toward and with others. Given these findings and the other-orientation of leadership, perhaps future work on medical student leadership should employ a more observation-based approach in tandem with the peeridentification instrument. A more subtle light could be shown on the lack of difference found among high influencers and other students on the standardized tests of medical knowledge. The predictive power of these tests (in regards to how ‘‘good’’ a medical student or doctor will be) has long been debated, but little attention has been paid to these tests’ role in spotlighting leadership potential or capability. A next step would be to examine the degree of influence perceived of those students that scored above average on these tests – to what extent are they perceived as a positive influence by their peers? Interestingly, previous research frequently highlights that medical students tend to ‘‘shed’’ their other-oriented attributes (i.e., empathy, compassion) during their years in medical school (Hojat et al. 2004, 2009; Michalec 2010). Yet, the findings presented from this study, specifically the multivariate tests that show that having higher faculty-delivered clerkship ratings were unique in explaining students designated in the high positive influence group, it would appear that these types of leaders can successfully engage in the tasks and responsibilities of their future profession as well as maintain their sense of empathy and supportive nature. Future work could explore the resiliency of engaging leaders in terms of preventative and
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protective factors and characteristics as they progress through their medical training. The findings featured in this specific study promote the role of influence as it relates leadership and that engaging leaders can be identified during their years in medical school. Although we are not suggesting that medical school admissions committees completely disregard applicants with stellar GPAs and MCAT scores, there is something to be said to possibly paying special attention to those students who may not stand-out test-wise but present letters of recommendation that speak of team-orientation, cooperation, peer-encouragement, and general supportive behavior. Furthermore, we argue that peer-assessment appears to be a worthwhile and reliable tool to identify leaders within medical education. This inference has also been reached in other studies that have also found peer-assessment/nomination to be a valid indicator of attributes related to professionalism and professional development (Holmboe & Hawkins 1998; Pohl et al. 2011). There are certain limitations to this study. Although students from three separate classes were included in the sample, students from only one medical school were studied. Students took the survey during a class meeting on the day they received the results of the NIRMP. Therefore, some students may have been of more positive affect towards others and perhaps more likely to view others as having a positive influence on their lives. The methods utilized do not provide insight regarding how far back (in years) students recalled to select positive influencing peers. Similarly, this study was cross-sectional, only a longitudinal approach would identify whether these high influencers/leaders possess these otheroriented and organizational knowledge-based attributes and characteristics when they arrive at medical school (or even before), and if/how these attributes are sustained. Research is currently underway (by this team and others) to utilize a social network analysis approach with these data to explore who students are actually choosing (one-way or reciprocal nomination), the ‘‘influence system’’ this creates, groups that cluster together, potential gender-based differences in selection of influencers, and who influences the influencers. Next steps should also include, however, utilizing the (Engaging) Transformational Leadership Questionnaire (TLQ) to further explore the engaging leadership model within medical education.
Conclusion This study emphasizes the role of influence as it relates to leadership by focusing on medical students that peers have identified as having a positive influence on their lives, explores demographic and academic performance-related differences between positive influencers and other students, and utilizes the engaging leadership model proposed by Alimo-Metcalfe and Alban-Metcalfe to explore whether positive influencers present/report the traits and capabilities related to genuine concern for others. There were no differences found between positive influencers and other medical students in relation to sex, race/ethnicity, MCAT, Step 1, or Step 2 scores. However, 6
high positive influencers were found to be older and more likely to receive high clinical clerkship ratings. Those students that were identified as high positive influencers were found to indeed possess a high degree of genuine concern for others as evidenced by higher levels of empathy and higher ratings on communication and interpersonal skills during encounters with simulated patient. The findings from this study lend support to the value and effectiveness of peer-nomination as a means to identifying leaders within medical education, and emphasize the essentiality of influence in regard to leadership. Engaging leaders possess unique potential to cultivate a positive and motivated work environment and culture, it is, therefore, invaluable, especially within this new era of teambased collaborative care, to identify these particular preprofessionals early and encourage them to take on ‘‘official’’ leadership roles as they progress through their training and practice.
Glossary Leadership: ‘‘. . . the process of influencing others to understand and agree about what needs to be done and how to do it . . .’’ Yukl G. 2006. Leadership in organizations, 6th ed. Upper Saddle River, NJ: Pearson-Prentice Hall
Notes on contributors BARRET MICHALEC, PhD, is an Assistant Professor, Department of Sociology, University of Delaware, Newark, Delaware. He is also an Adjunct Research Assistant Professor, Department of Family and Community Medicine of Thomas Jefferson University, Philadelphia, Pennsylvania. J. JON VELOSKI, MS, is a Director of Medical Education Research, and Instructor, Department of Psychiatry and Human Behavior, Sidney Kimmel Medical College, Office of the Dean, Center for Research in Medical Education and Health Care, Thomas Jefferson University, Philadelphia, Pennsylvania. MOHAMMADREZA HOJAT, PhD, is a Research Professor of psychiatry and human behavior, Department of Psychiatry and Human Behavior, and director, Jefferson Longitudinal Study of Medical Education, Center for Research in Medical Education and Health Care, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. MARK L. TYKOCINSKI, MD, is the Dean of the Sidney Kimmel Medical College at Thomas Jefferson University, as well as the Provost and Executive Vice President for Academic Affairs of Thomas Jefferson University, Philadelphia, Pennsylvania.
Declaration of interest: The authors declare that they have no interest to report.
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Identifying potential engaging leaders within medical education: The role of positive influence on peers BARRET MICHALEC1, J. JON VELOSKI2, MOHAMMADREZA HOJAT2 & MARK L. TYKOCINSKI2 1
University of Delaware, USA, 2Sidney Kimmel Medical College at Thomas Jefferson University, USA
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Abstract Background: Previous research has paid little to no attention towards exploring methods of identifying existing medical student leaders. Aim: Focusing on the role of influence and employing the tenets of the engaging leadership model, this study examines demographic and academic performance-related differences of positive influencers and if students who have been peer-identified as positive influencers also demonstrate high levels of genuine concern for others. Methods: Three separate fourth-year classes were asked to designate classmates that had significant positive influences on their professional and personal development. The top 10% of those students receiving positive influence nominations were compared with the other students on demographics, academic performance, and genuine concern for others. Results: Besides age, no demographic differences were found between positive influencers and other students. High positive influencers were not found to have higher standardized exam scores but did receive significantly higher clinical clerkship ratings. High positive influencers were found to possess a higher degree of genuine concern for others. Conclusion: The findings lend support to (a) utilizing the engaging model to explore leaders and leadership within medical education, (b) this particular method of identifying existing medical student leaders, and (c) return the focus of leadership research to the power of influence.
Introduction Previous research consistently highlights the value and necessity of cultivating leadership qualities among medical students (O’Connell & Pascoe 2004; Veronesi & Gunderman 2012). Emotional intelligence, confidence, creativity, practical knowledge and competence, interpersonal communication, motivation and encouragement of others, fostering a sense of community, social appraisal skills, and cognitive abilities among others are frequently offered as vital leadership skills and characteristics (Steinberg 2007; Crites et al. 2008; Goldstein et al. 2009; Varkey et al. 2009; McKimm & Swanwick 2011). The focus on this research has been almost exclusively on developing courses, strategies, programs, and seminars to ‘‘teach’’ medical students the traits, characteristics, and skills of leaders and leadership (Crites et al. 2008; Goldstein et al. 2009; Varkey et al. 2009; Long et al. 2011; Straus et al. 2013). Studies have shown, however, that attempts to foster positive attributes such as those related to professionalism (which are arguably akin to attributes related to leadership) are met with push-back from students, course scheduling dilemmas, and barriers related to the overarching organizational culture (West & Shanafelt 2007; Finn et al. 2010; Michalec & Hafferty 2013). Therefore, rather than constructing campus-wide courses and
Practice points
Research has neglected to focus on identificationbased approaches to understanding medical student leaders. Influence is the key construct of leadership, yet the ability to be influential appears to be absent from research on leadership in medical education. Previous research has focused on an individual-based, power-oriented model of leadership – given the emphasis on team-orientation, interprofessionalism, and collaboration, it is time to explore more otheroriented models such as the engaging leadership model. Findings show that students that were perceived as a high positive influence by their peers also had significant higher levels of other-orientation – lending support for the role of influence in leadership and employing the engaging leadership model. Findings also support the method of peer-nomination as an efficient means to identify existing leaders in medical school.
Correspondence: Barret Michalec, Department of Sociology, University of Delaware, 18 Amstel Ave, Smith Hall, Newark, DE 19716, USA. Tel: +302 831 1205; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–7 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.947933
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programs aimed at building leaders from the ground-up, faculty and administration could focus their energy and attention on students with existing key leadership qualities and attributes. An identification-based approach to understanding ‘‘leaders’’ within medical school, as compared with what appears to be an engrained cultivation-based approach, would concentrate efforts to encourage and further advance individuals that have already exhibited fundamental leadership qualities and capabilities. An identification-based approach would thereby eliminate, or at least minimize, the need of leadership ‘‘farming’’ that is proposed through grade cohortwide programs and classes, and lift some of the burden on already saturated curriculums. However, little to no research has proposed methods to identifying existing medical student leaders. Similarly, what appears to also be absent from the current state of the leadership-in-medical-education literature is an emphasis on constructing effective mechanisms to identify those with the ability to be influential with others (peers). At its core, leadership is about influence – as showcased in prominent conceptualizations of the term: (a) ‘‘. . . the process of influencing others to understand and agree about what needs to be done and how to do it . . .’’ (Yukl 2006), and (b) ‘‘. . . a process whereby an individual influences a group of individuals to achieve a common goal’’ (Northhouse 2007). Despite the essentiality of influence as it relates to leadership, studies in this specific arena have neglected to explore students’ ability to be influential (with their peers), and if/how this potential ability to be influential is related to leadership. Many of the leadership traits presented by previous literature can be considered other-oriented, further emphasizing that a crucial aspect of being perceived as a leader is the ability and willingness to connect and engage with others. The emphasis of other-orientation in regard to leadership qualities and capabilities is showcased in the engaging model of leadership proposed by Alimo-Metcalfe and Alban-Metcalfe (2005, 2006) and Alimo-Metcalfe et al. (2008) who argue that perhaps the most significant dimension to leadership can be classified as showing ‘‘genuine concern for others’’. Whereas traditional ‘‘heroic’’, charismatic, and ‘‘distant’’ models of leadership place the crux of power with the leader (individual-based), the engaging perspective of leadership emphasizes an individual’s other orientation and promotes the value of the individual’s accessibility, inspiration, support, and their ability to enable and encourage others to express their own influence and enterprise. Although a prominent model within the general leadership literature, including the discussion of effective leadership in the healthcare fields (McIntosh & Tolson 2008; Govier & Nash 2009), there has been minimal attention paid to employing the engaging model of leadership within the US medical education system to investigate leadership skills and attributes among medical students. Alimo-Metcalfe and colleagues argue that engaging leaders are perhaps most effective in facilitating high motivation and well-being among colleagues, positive organizational culture, and effective and efficient organizational performance. Given the changing culture of medicine 2
and care delivery, with a strong emphasis on team-based, collaborative, and interprofessional care, it is time to explore current and future leaders from a new, other-oriented perspective. This specific study examines the demographic- and academic performance-related characteristics of medical students designated by their peers as having a ‘‘significant positive influence’’ on their professional and personal development, and utilizing the tenets of the engaging leadership model investigates if peer-identified positive influencers also report high-score attributes related to showing a genuine concern for others. With this study, we attempt to redirect the current attention on leadership to the importance of the ability to be influential as well as investigate the association of positive influence on peers with genuine concern, which in turn, may lend support to the possibility of identifying existing medical student leaders through the method of peernomination. In doing so, we address the following research questions: (a) Differences between positive influencers and other medical students Are there demographic and/or academic achievement differences between those students identified as positive influencers and others? (b) Positive influencers as engaging leaders Regarding a genuine concern for others, the key element of the engaging leadership model, have those students identified as positive influencers reported higher empathy scores, and/or received higher scores on their simulated patient exams compared with other students? How do students conceptualize the ‘‘positive influence’’ they received/experienced from the students they selected? Do these reflect the tenets of the engaging leadership model?
Methods Study setting The Sidney Kimmel Medical College at Thomas Jefferson University is a large, private medical school located in an urban setting. This study was conducted between 2011 and 2013 as part of the Jefferson Longitudinal Study of Medical Education (Gonnella et al. 2011). The University’s Institutional Review Board determined that the study was exempt from full review for human subjects’ protection.
Sample A total of 630 (82%) of 766 students in three fourth-year classes (2011, 2012, and 2013) responded. These respondents were representative of the three classes with respect to age (p50.82), gender (p50.15), and ethnicity (p50.62). However, their mean scores on Step 1 (mean ¼ 225) and Step 2 (mean ¼ 237) of the United States Medical Licensing Examination (USMLE) were significantly higher (p50.001) than the non-respondents’ means on Step 1 (mean ¼ 217) and Step 2 (mean ¼ 231).
Results
Data for the Jefferson Longitudinal Study of Medical Education are collected annually in March at a class meeting when fourth-year students receive their results for the National Intern and Resident Matching Program (NIRMP). For the purposes of this specific project, a special instrument was added to the annual survey in 2011. Students were asked to think back to their medical school experiences to address the question ‘‘Which of your classmates had significant positive influences on your professional and personal development?’’ The instrument included the names of the entire graduating class listed alphabetically, and students were allowed to check as many names as they deemed necessary. We calculated the total number of times that each of the 766 students in the three classes was designated by a classmate as a positive influence. Students in the top 10% of this distribution for each class were designated as ‘‘high positive influence’’ and these 80 students were compared with 686 classmates. In order to explore differences between positive influencers and other medical students, we assessed demographic (sex, age, and race/ethnicity) and academic performance variables. Academic performance variables consisted of students’ MCAT, USMLE Step 1 and Step 2 scores, and faculty ratings of performance in clinical clerkships. Students’ level of ‘‘genuine concern for others’’ was assessed through two specific scores: (a) their scores on the Jefferson Scale of Empathy (JSE), and (b) the communication and interpersonal skills scores students earned during encounters with simulated patients in the third year. The JSE is a well-researched and validated measure of empathic engagement in the context of patient care (for an extensive discussion of the validity and reliability of the JSE see Hojat et al. 2002; Hojat 2007). Given the other-orientation of empathy and how communication and interpersonal skills also require understanding and perspective taking of another, the authors believe these measures to validly reflect students’ ‘‘genuine concern for others’’. Differences in categorical variables were evaluated using Chi-square and differences in means were evaluated using t-tests and analysis of variance. Multivariate associations were evaluated using logistic regression. To examine how medical students’ conceptualized the notion of the ‘‘positive influence’’ they experienced from those they selected, we added an open-ended item to the 2013 survey. Students were asked to think about who they selected as having a significant positive influence, and respond to the question, ‘‘In what way(s) have they [the student(s) they selected] had a positive influence?’’ Approximately one-half of the students provided words, phrases, or short sentences. These were read by one of the authors to identify the most frequently appearing concepts and categories. Four categories were identified: (a) support, (b) academic/organizational competence, (c) role model, and (d) fostering a positive/fun climate. Each phrase/term was then designated into a specific category, and a frequency analysis was conducted. The outcomes of these analyses are reported in the Results section.
Figure 1 shows the frequency distribution of the number of positive designations per student. The number of designations per student ranged from 2 to 82 with a median of 28. Ninety percent of the students were designated as being a positive influence by between 2 and 52 classmates. There were no significant differences found in the rates of being designated as a high positive influence for men and women as shown in Table 1. However, age was strongly associated with having a high positive influence. Only 3% of
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Number of Students 40 60
80
Measurements and procedure
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0
20 40 60 Number of Positive Designations per Student
80
Figure 1. Frequency distribution of number of positive designations per student.
Table 1. Personal characteristics of students designated by classmates as high positive influence compared to other students.
Designated by classmates
Gender Men Women Age at matriculation 18–21 22–26 27 and older Ethnicity African-American Asian Hispanic Indian/Pakistani White
a
High
Other
Total
Positive influence
Students
379 100% 387 100%
43 11% 37 10%
336 89% 349 90%
50.43
68 100% 615 100% 83 100%
2 3% 61 10% 17 20%
66 97% 554 90% 66 80%
50.001
25 100% 127 100% 39 100% 77 100% 494 100%
5 20% 10 8% 5 13% 6 8% 54 11%
20 80% 117 92% 34 87% 71 92% 440 89%
50.37
pa
p Values based on Chi-square analysis of frequencies.
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related to ‘‘fun’’, ‘‘enthusiasm’’, ‘‘great team member’’ and ‘‘positive attitude’’. The results of multiple logistic regression analysis (Table 3) indicated that only being older (p50.004) and having high ratings in clerkships (p50.009) were of unique value in explaining students’ designation in the high positive influence group.
those who entered medical school between the ages of 18 and 21 in the accelerated BS/MD program were designated as high positive influence, compared with the base rate of 10% for the vast majority of students. At the upper end of the age range, 20% of those who were 27 or older at matriculation were to be designated as high positive influence. The differences across ethnic groups were not found to be statistically significant (p50.37). High positive influencers were found to have a significantly higher (p50.01) mean empathy score (mean ¼ 117.1, SD ¼ 9) compared with that of other students (mean ¼ 113.5, SD ¼ 11). Furthermore, simulated patients assigned higher ratings on communication and interpersonal skills to students in the high positive influence group. As indicated in Table 2, no significant differences were found between the two groups on standardized tests of academic performance (MCAT and USMLE). However, students in the high positive influence group earned more honors grades from faculty ratings on students performance in core clinical clerkships. Regarding students’ conceptualization of the ‘‘positive influence’’, all the comments referred to types of prosocial behavior and academic/organizational understanding. The majority (58%) of terms were categorized as Support, as the comments related to substantive personal interactions such as being ‘‘helpful’’, ‘‘supportive’’, ‘‘encouraging’’, ‘‘listening’’, and ‘‘offering advice.’’ The second most occurring categories (15%) were Academic/Organizational Competence (e.g., ‘‘brilliant’’, ‘‘challenging’’, and ‘‘shared knowledge’’) and Role Model (e.g., ‘‘positive role model’’, ‘‘ability to balance work/life’’, and ‘‘exemplified commitment’’). Finally, 12% of the terms were categorized as Fostering a Positive/Fun Climate, as comments
Discussion With this study, we have attempted to turn the focus on the student-based leadership in medical school towards the key concept of influence by showcasing an effective and efficient mechanism (peer-selection) to identify existing ‘‘positive influencers’’ within the student body, and explored potential significant differences among high positive influencers and their peers. Furthermore, given the other-orientated nature of the prominent definitions of leadership as well as leadership attributes and traits highlighted by previous research, we employed the engaging leadership model discussed by AlimoMetcalfe and Alban-Metcalfe to investigate if (a) students that were designated as ‘‘high positive influencers’’ also presented characteristics related to the notion of showing a genuine concern for others, (b) ‘‘positive influence’’ was conceptualized by students in a similar manner to the notion of showing a genuine concern for others.
Demographics and academic performance differences Interestingly, there were no significant differences found in the rates of being designated as a positive influence between men
Table 2. Medical school performance of students designated as high positive influence compared to other students.
High positive influence
Other students
pa
10.5 10.2 223.8 235.4 2.8
10.6 10.0 223.8 235.8 1.9
50.34 50.40 50.94 50.78 50.001
82.3 81.2 86.4
82.4 81.4 85.1
50.89 50.65 50.02
Mean MCAT biological sciences Mean MCAT verbal reasoning Mean USMLE Step 1 Mean USMLE Step 2 Mean number of high ratings by faculty in 6 core clinical clerkships Mean on clinical skills assessment with simulated patients Data gathering skills Patient note documentation skills Communication and interpersonal skills a
p Values based on the independent t-test for means Chi-square analysis using frequencies. MCAT, Medical College Admission Test; USMLE, United States Medical Licensing Examination. Communication and interpersonal skills scored on 0–100 scale with mean of 85 and SD of 5.
Table 3. Logistic regression for students designated as high positive influence compared to other students.
Variable 27 and older at matriculation BS/MD program Communication and interpersonal skills Empathy score Ratings in clinical clerkships Constant
Odds ratio
Std. err.
z
p
95% conf. interval
2.50 0.99 1.04 1.34 1.93 0.07
0.79 0.01 0.27 0.34 0.49 0.018
2.91 1.57 0.13 1.14 2.59 10.26
0.004 0.12 0.89 0.25 0.009 0.000
1.35–4.63 0.97–1.00 0.62–1.72 0.81–2.19 1.17–3.19 0.043–0.19
Regression model used 692 observations and yielded a Chi-square of 23.38 with five degrees of freedom (p50.0003) and McFadden’s r-squared of 0.05.
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or women. Given that the crux of leadership is rooted in influence, this finding somewhat surprising as the literature consistently points to the glaring lack of females in leadership positions in professional and academic medicine (Morahan et al. 2011; Rosenthal et al. 2013; Valantine & Sandborg 2013; Bell et al. 2014). However, there could be differences between the men and the women in regard to which sex is more likely to serve in ‘‘official’’ (nominated and elected) positions within the classes, school, and University. Perhaps there continues to be an unconscious (and even at times conscious) bias towards women regarding leadership roles and positions. Fruitful next steps in this arena would include a comparative analysis of those students perceived as positive influence and those that are actually elected to official leadership positions, as well as assessing students’ perceptions of differences and similarities between being a positive influence (which may be more informal leadership) and formal leading in official positions. Similarly, no significant differences were found between the ethnicities of students either. It was found that older students, specifically those 27 and older, were significantly more likely to be designated as having a positive influence on their peers. Perhaps certain life experiences these older students gained (compared with the age-typical medical student) cultivated their willingness and ability to be supportive and helpful to their peers. It could also be suggested that because older students may be more likely to be married and/ or have children that these possible additional social relationships have cultivated their other-orientation, enhancing their attributes of encouragement of and engagement with others. Although there were no significant differences found between high influencers and all other students on the MCAT, Step 1, or Step 2, high influencers did earn significantly more honors grades on their faculty-rated clinical performance. Although high influencers did not out-perform their peers on the standardized tests, they were more likely to be the students recognized by medical school faculty as more capable and more knowledgeable in regard to their skills at doctoring and general organizational practice. Hence, it could be argued that high influencers exhibit a unique grasp of healthcare competence and capability as compared with their peers, and although ‘‘on paper’’ these students may not standout, they are indeed able to apply the knowledge and skills they learn to an impressive extent.
Genuine concern for others Students within the high positive influence group had a significantly higher average empathy score than all other students in the sample. This finding is consistent with that reported by Pohl et al. (2011) who found that medical students who were nominated by their peers on professionalism attributes obtained a significantly higher mean empathy scores than their other classmates. High influencers also received significantly higher scores from the ‘‘patients’’ during their simulated patient experiences. Similar findings are reported by Berg et al. (2011) who found that medical students with higher interpersonal skills (reflected in their scores on the JSE) received higher ratings of competence by simulated patients. It is important to note that whereas
empathy scores for this specific study were assessed at matriculation, the simulated patient assessments were conducted during the students’ third year. Therefore, this particular finding also offers a hint of consistency regarding these particular students’ degree of other-orientation. Furthermore, the terms and phrases offered by students regarding their own conceptualization of ‘‘positive influence’’ clearly echo the tenets of the engaging leadership model. Taken together these findings suggest that indeed students perceived by their peers as being a positive influence also reflect a genuine concern for others – the foundation of the engaging leadership model. In turn, this lends support the use of peer-nomination in this fashion to spotlight existing leaders in medical school. The data suggest that high positive influencers do show both a genuine concern for others and that students identified by their peers have the ability to be influential do indeed reflect the tenets of Alimo-Metcalfe and Alban-Metcalfe’s model of engaging leadership – and in this sense these influential students could in fact be agents of organizational change waiting to be tapped. By providing evidence that reinforces the notion that influence is at the crux of leadership it is hoped that future research on leadership in medical school and professional medicine will continue to focus on the role of influence and its various facets. The non-self-reported measures of achievement and capability (specifically the simulated patient assessment and the peer-identified positive influence designation) suggest that these students’ leadership traits are indeed visible to others, from peers to ‘‘patients’’. Perhaps on paper (standardized test scores) these high influencers are not obvious leaders, but rather it comes through in their actions and expression of attitudes and values toward and with others. Given these findings and the other-orientation of leadership, perhaps future work on medical student leadership should employ a more observation-based approach in tandem with the peeridentification instrument. A more subtle light could be shown on the lack of difference found among high influencers and other students on the standardized tests of medical knowledge. The predictive power of these tests (in regards to how ‘‘good’’ a medical student or doctor will be) has long been debated, but little attention has been paid to these tests’ role in spotlighting leadership potential or capability. A next step would be to examine the degree of influence perceived of those students that scored above average on these tests – to what extent are they perceived as a positive influence by their peers? Interestingly, previous research frequently highlights that medical students tend to ‘‘shed’’ their other-oriented attributes (i.e., empathy, compassion) during their years in medical school (Hojat et al. 2004, 2009; Michalec 2010). Yet, the findings presented from this study, specifically the multivariate tests that show that having higher faculty-delivered clerkship ratings were unique in explaining students designated in the high positive influence group, it would appear that these types of leaders can successfully engage in the tasks and responsibilities of their future profession as well as maintain their sense of empathy and supportive nature. Future work could explore the resiliency of engaging leaders in terms of preventative and
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protective factors and characteristics as they progress through their medical training. The findings featured in this specific study promote the role of influence as it relates leadership and that engaging leaders can be identified during their years in medical school. Although we are not suggesting that medical school admissions committees completely disregard applicants with stellar GPAs and MCAT scores, there is something to be said to possibly paying special attention to those students who may not stand-out test-wise but present letters of recommendation that speak of team-orientation, cooperation, peer-encouragement, and general supportive behavior. Furthermore, we argue that peer-assessment appears to be a worthwhile and reliable tool to identify leaders within medical education. This inference has also been reached in other studies that have also found peer-assessment/nomination to be a valid indicator of attributes related to professionalism and professional development (Holmboe & Hawkins 1998; Pohl et al. 2011). There are certain limitations to this study. Although students from three separate classes were included in the sample, students from only one medical school were studied. Students took the survey during a class meeting on the day they received the results of the NIRMP. Therefore, some students may have been of more positive affect towards others and perhaps more likely to view others as having a positive influence on their lives. The methods utilized do not provide insight regarding how far back (in years) students recalled to select positive influencing peers. Similarly, this study was cross-sectional, only a longitudinal approach would identify whether these high influencers/leaders possess these otheroriented and organizational knowledge-based attributes and characteristics when they arrive at medical school (or even before), and if/how these attributes are sustained. Research is currently underway (by this team and others) to utilize a social network analysis approach with these data to explore who students are actually choosing (one-way or reciprocal nomination), the ‘‘influence system’’ this creates, groups that cluster together, potential gender-based differences in selection of influencers, and who influences the influencers. Next steps should also include, however, utilizing the (Engaging) Transformational Leadership Questionnaire (TLQ) to further explore the engaging leadership model within medical education.
Conclusion This study emphasizes the role of influence as it relates to leadership by focusing on medical students that peers have identified as having a positive influence on their lives, explores demographic and academic performance-related differences between positive influencers and other students, and utilizes the engaging leadership model proposed by Alimo-Metcalfe and Alban-Metcalfe to explore whether positive influencers present/report the traits and capabilities related to genuine concern for others. There were no differences found between positive influencers and other medical students in relation to sex, race/ethnicity, MCAT, Step 1, or Step 2 scores. However, 6
high positive influencers were found to be older and more likely to receive high clinical clerkship ratings. Those students that were identified as high positive influencers were found to indeed possess a high degree of genuine concern for others as evidenced by higher levels of empathy and higher ratings on communication and interpersonal skills during encounters with simulated patient. The findings from this study lend support to the value and effectiveness of peer-nomination as a means to identifying leaders within medical education, and emphasize the essentiality of influence in regard to leadership. Engaging leaders possess unique potential to cultivate a positive and motivated work environment and culture, it is, therefore, invaluable, especially within this new era of teambased collaborative care, to identify these particular preprofessionals early and encourage them to take on ‘‘official’’ leadership roles as they progress through their training and practice.
Glossary Leadership: ‘‘. . . the process of influencing others to understand and agree about what needs to be done and how to do it . . .’’ Yukl G. 2006. Leadership in organizations, 6th ed. Upper Saddle River, NJ: Pearson-Prentice Hall
Notes on contributors BARRET MICHALEC, PhD, is an Assistant Professor, Department of Sociology, University of Delaware, Newark, Delaware. He is also an Adjunct Research Assistant Professor, Department of Family and Community Medicine of Thomas Jefferson University, Philadelphia, Pennsylvania. J. JON VELOSKI, MS, is a Director of Medical Education Research, and Instructor, Department of Psychiatry and Human Behavior, Sidney Kimmel Medical College, Office of the Dean, Center for Research in Medical Education and Health Care, Thomas Jefferson University, Philadelphia, Pennsylvania. MOHAMMADREZA HOJAT, PhD, is a Research Professor of psychiatry and human behavior, Department of Psychiatry and Human Behavior, and director, Jefferson Longitudinal Study of Medical Education, Center for Research in Medical Education and Health Care, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. MARK L. TYKOCINSKI, MD, is the Dean of the Sidney Kimmel Medical College at Thomas Jefferson University, as well as the Provost and Executive Vice President for Academic Affairs of Thomas Jefferson University, Philadelphia, Pennsylvania.
Declaration of interest: The authors declare that they have no interest to report.
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