Resources for the Leader KC3 Competency

Key Competency 3

Demonstrate leadership in professional practice

Enabling Competencies

3.1 Demonstrate leadership skills to enhance health care
3.2 Facilitate change in health care to enhance services and outcomes

Teaching Key Competency 3 of the Leader Role

Key Competency 3 is largely about leadership in action. It defines the competencies residents, as future independent practitioners, must exhibit to be, and be seen as, leaders who can achieve the best outcomes for individual patients and populations and drive essential changes in the system.

There is a discrete body of knowledge and skills relating to various aspects of leadership in action.

In contemplating a guiding model, we agreed that the LEADS in a Caring Environmentleadership capabilities framework, advanced by the Canadian College of Health Leaders, supported by the Canadian Medical Association and adopted by many health care institutions across Canada and beyond, is useful in helping to situate the skills relevant to Key Competency 3.^1,2 Furthermore, our experiences suggest that several perspectives remain underdeveloped in medical leadership curricula; these have been given specific emphasis in this resource: leadership as a means to advancing social justice, leadership as rooted in self-insight and self-direction, key elements of emotional intelligence, and leadership development as a necessary reflective activity.

While many elements can be highlighted in considering how to demonstrate leadership in practice, the CanMEDS Leader Role description formally maps the following key concepts to Key Competency 3:

3.1 Demonstrate leadership skills to enhance health care

Negotiation
Personal leadership skills

3.2 Facilitate change in health care to enhance services and outcomes

Effective committee participation
Leading change
Physician roles and responsibilities in the health care system
Physicians as active participant-architects within the health care system
Priority-setting
Quality improvement

One competency, implicit in many of the above but not explicitly stated, is that of emotional intelligence, defined as “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them, and to use this information to guide one’s thinking and action”³. Being aware of our own emotions enables us to manage them and to be empathic and sensitive to the emotions of others. Integration of these many elements then allows us to function and manage relationships, so important for example in teamwork.

As previously mentioned in the Leader Resource, in CBME the mapping of potential learning opportunities in clinical workplace settings can be done by program directors, site directors and the residents themselves. Table 1 provides an example of how this may be done using Enabling Competency 3.1 and its associated key concepts as an example.

Table 1: Opportunities for learners to develop and demonstrate KC3 enabling competency 3.1 (Demonstrate leadership skills to enhance health care)
Key concept	Work-based context	Work-based examples
Negotiation	Within intra- or inter-disciplinary clinical team of physicians	Assigns patients; arranges for patient tests during off-hours
	Within clinical interprofessional team	Engages the social work department in a patient’s care
	With patient	Engages in shared decision making
	For patient	Requests off-label drugs
	With committee	Assigns tasks within committee; voices opinion; is respected by the other members of the committee
	Nonclinical	Changes call schedule
Personal leadership skills	Discharge planning rounds	Communicates clear expectations
	Running a cardiac arrest code	Effectively assumes clinical challenges commensurate with leadership skills
	Situations during which emotions may be heightened, such as while receiving feedback, when recognizing that a medical error has occurred or when sleep-deprived	Demonstrates awareness of personal emotions and manages these emotions effectively (emotional intelligence); demonstrates awareness of patient safety risks when lacking sleep
	Committee	Seeks leadership opportunities by volunteering for committee roles
	Discussions with patients and families	Demonstrates empathy while discussing poor clinical outcomes; teaches younger trainees how to be empathetic
	Interactions with members of team	Enables psychological safety; lets other team members speak first; gives encouragement

In the descriptions of the leadership activities associated with Enabling Competency 3.1 of the Leader Role (Table 1), it is clear that residents are enacting leadership skills in their day-to-day work. The trick is for both learners and supervisors to remind themselves that these activities are already happening and to use them as opportunities for self-reflection, coaching and feedback.

The following scenario, a typical day in the life of a resident, is annotated with the KC3 competencies. It illustrates how the supervisor might leverage a clinical encounter as a learning and assessment opportunity for leadership competencies. The leadership skills a resident demonstrates in a “routine” day at work can also be captured in a narrative and reflective piece to be included in the learner’s portfolio.

Dr. Z is a PGY2 resident in Internal Medicine. At midnight, while Dr. Z is on call, a 73-year-old female in-patient with diabetes mellitus has a massive ischemic stroke resulting in a right-sided hemiplegia and aphasia. Dr Z. works with the diagnostic imaging department to expedite a computed tomographic (CT) scan (Competency 3.1 of the Leader Role: Demonstrate leadership skills to enhance health care) and initiates treatment with alteplase when the results are in. Dr. Z attends the morning huddle with the Internal Medicine team and supervisor in attendance. While Dr. Z. is providing the history of the patient, the supervisor asks how Dr. Z was able to expedite the CT scan. Dr. Z responds that he had to be persistent because the diagnostic imaging technician did not respond quickly to his first call; Dr. Z needed to call the resident on call to ensure that the CT scan would be done.

Dr. Z continues to report on the progress of the patient. The nurse reports that she received a call from the patient’s daughter, who was critical of the communication with her family about her mother’s condition overnight and concerned that her mother’s care would suffer because she cannot communicate her needs. Dr. Z shares with the team that he put in a consult request to both the physical therapist and the occupational therapist on the ward to assess the patient. The resident, hearing of the daughter’s concern, suggests initiating an interprofessional team meeting with the physical therapist, occupational therapist and a family member and asks his supervisor to be in attendance to observe and offer feedback (Competency 3.2 of the Leader Role: Analyze patient feedback to help improve patient experiences and clinical outcome). The supervisor agrees. During the rest of the morning huddle, the supervisor notes that Dr. Z’s attention to detail has slipped. The supervisor asks Dr. Z to stay behind and asks him how much sleep he got the previous night. Dr. Z responds that he got only two hours of sleep. The supervisor then asks how Dr. Z thinks his lack of sleep will affect his ability to complete his duties for the rest of the day. Dr. Z. admits that he is quite tired and is worried that there may be an impact to his performance. He asks if he can take the rest of the day off and transfer care of his patients to a colleague (Competency 3.1 of the Leader Role: Describe how self-awareness, self-reflection, and self-management are important to developing leadership skills and are considered key elements of emotional intelligence). The supervisor agrees and provides positive feedback to Dr. Z about his self-awareness and his choice to put patient safety first.

Resources

Goldberg C, Tanabe T, Plato M. Can we talk? Case studies in communication challenges and conflict management for clinicians. MedEdPORTAL. 2011 Jun. 19. https://doi.org/10.15766/mep_2374-8265.7957 (Enabling Competency 3.1)
Saltman DC, O’Dea NA, Kidd MR. Conflict management: a primer for doctors in training. Postgrad Med J. 2006;82(963):9–12. doi:10.1136/pgmj.2005.034306 (Enabling Competency 3.1)
Chan T, Bakewell F, Orlich D, Sherbino J. Conflict prevention, conflict mitigation, and manifestations of conflict during emergency department consultations. Acad Emerg Med. 2014;21(3):308-313. doi:10.1111/acem.12325 (Enabling Competency 3.1)
Fisher R, Ury W, Patton B. Getting to YES: negotiating agreement without giving in. 3rd ed. New York (NY): Penguin Books; 2011. (Enabling Competency 3.1)
Reflection to Advance Resident Leadership Development (Enabling Competency 3.1)
Leads Self: The Critical Roles of Self-Insight, Self-Awareness and Self-Direction(Enabling Competency 3.1)
Developing Critically Conscious Leadership in Postgraduate Trainees for Greater Social Justice in Health Care: Teaching Module (Enabling Competency 3.1)
- Cases for Social Justice in Health Care
Bracket M. Emotional intelligence as a superpower [YouTube video]. 13 Jul. 2017. https://www.youtube.com/watch?v=JcFefehMpZ0 (Enabling Competency 3.1)
Mintz LJ, Stoller JK. A systematic review of physician leadership and emotional intelligence. J Grad Med Educ. 2014;6(1):21–31. doi:10.4300/JGME-D-13-00012.1 (Enabling Competency 3.1)
Lead the Change (online module adapted by KC1 working group) (Enabling Competency 3.2)
How to Create a QI Curriculum for Residents (online module adapted by KC1 working group) (Enabling Competency 3.2)
Essential guidance for quality improvement (Enabling Competency 3.2)

Key features of the Royal College CBD residency model

Special thanks to Anne Matlow, M. Sc., MD, FRCPC, for developing this content.

Specialty-specific EPAs will evolve over time as new knowledge, novel technologies, artificial intelligence and future innovations affect specialty practice and as societal issues such as social justice continue to have an impact on how physicians work. However EPAs may change in the future, enactment of most of them will always require exercising the leadership capabilities embodied in Key Competency 3 of the Leader Role.

The core components of the CBD initiative for residency education were constructed to align with the core components of competency-based medical education outlined by Elaine Van Melle in 2016.⁴ These components have been adapted in Table 2 to include Key Competency 3 of the Leader Role.

Table 2. The core components of competency-based medical education and considerations for Key Competency 3 of the CanMEDS Leader Role
Core component	Summary	Features of the Competence by Design initiative	Considerations for Key Competency 3 of the Leader Role
Framework	Competencies are clearly articulated.	Social accountability: Competencies and outcomes are aligned with societal needs. Every discipline will have Royal College entrustable professional activities (EPAs) and associated milestones that will provide discrete markers of competence. Learners will be required to demonstrate CanMEDS 2015 and discipline-specific competencies.	Specialty-specific competencies, milestones and EPAs enable trainees to demonstrate their personal, intraprofessional and interprofessional leadership skills. They use these skills to enhance the delivery of timely, safe, equitable, effective and relationship-centred health care for all patients.
Progression	Competencies are sequenced progressively.	CBD competence continuum: Specific, distinct, integrated stages of training are employed to mark trainees’ progression on a continuum of competence (stages of increasing competence and independence in practice). Competencies are sequenced progressively: milestones and EPAs are categorized within each stage of progression.	Trainees are given leadership tasks (e.g., doing a procedure, running a family meeting) commensurate with their increasing capabilities and skills. Trainees are also given the opportunity to take on more leadership roles (e.g., being on a committee) as they demonstrate the desire to expand their leadership repertoire.
Tailored experiences	Learning experiences facilitate progression.	Trainees are provided with authentic, work-based environments for learning that match the settings of future practice. Learning experiences are organized to enable trainees to acquire competencies and demonstrate EPAs. A hybrid model of competency-based, timed rotations is employed with a mix of time-free and time-dependent approaches. Time is de-emphasized to ensure that learning experiences are organized to immerse the learner in authentic practice conditions.	Trainees have an opportunity to grow their personal, intraprofessional and interprofessional leadership skills, commensurate with their abilities and experience, in various workplace settings and learning environments that include patient populations representative of those they will encounter in practice. Trainees may rotate through a given environment more than once and will be given more opportunities to enact leadership over time.
Competency-focused instruction	Teaching practices promote progression.	Learning is guided by real-time, high-quality feedback from multiple observations. EPAs are used to structure learning and focus instruction (in contrast to extemporaneous approaches).	High-quality feedback must target individual leadership skills. Feedback from multiple sources is paramount, particularly given the fact that leadership is enacted in teams. Patients and families should be considered part of the team for the purpose of feedback on leadership.
Programmatic assessment	Assessment practices support and document progression.	Assessment for learning: Competency-based assessment is focused on EPA observations in the workplace. Assessment for progression: Promotion and certification are achieved upon successful completion of EPAs and progression through stages of training as determined by a competence committee, which is responsible for regularly reviewing learner progress using highly integrative data from multiple EPA and milestone observations and feedback in clinical practice. Changes to the certification examination: Entry to the Royal College examinations is aligned with promotion decisions entrusted to the competence committees. Examinations are maintained, but their timing and emphasis will shift to occur earlier in training to promote a smoother transition to practice. An electronic portfolio is used to demonstrate and record progression in competence and independence.	Physicians are leaders because of the nature of the medical profession, which aims to improve the health and well-being of the population(s) we serve. Most EPAs probably have an inherent element of leadership, whether this is stated or not. Observations or documentation that speaks to the “leaderliness” displayed by the trainee whenever it is apparent will underscore the importance of the Leader Role and emphasize that trainees are being leaders all the time, even when they don't specifically think of it.

References

Dickson G, Tholl B. Bringing Leadership to Life in Health: Leads in a Caring Environment. Springer London Ltd; 2016.
Canadian College of Health Leaders website: https://www.cchl-ccls.ca/site/pd_leads. Last accessed February 2021.
Salovoy P et al. Emotional intelligence. Imagination, cognition and Personality 1990; 9: 185-211.
International Competency-based Medical Education Collaborators. Five core components of CBME. Ottawa: Royal College of Physicians and Surgeons of Canada; 2018. https://gocbme.org/icbme-site/five-core.html