Leads Self: The Critical Roles of Self-Insight, Self-Awareness and Self-Direction

Special thanks to Glen Bandiera, MD, FRCPC, MEd, BASc(Engin), for developing this resource.

The ability to self-assess is one of the key fundamentals of the Leader Role, one that overlaps solidly with aspects of the Professional Role. The first component of the LEADS framework is “lead self,”’ which is conceptualized as incorporating four capabilities: self-motivated leaders are (1) self-aware, (2) manage themselves, (3) develop themselves and (4) demonstrate character.1 The importance of these competencies is also well recognized in the business literature, where there are numerous examples of how to develop an approach to self-management.2 Although not explicitly mentioned in the LEADS framework, the concept of self-assessment maps closely to capabilities 1 and 2: self-awareness and management of self. Self-awareness incorporates having both a strong sense of preferred leadership/interpersonal/collaborative style and personal values (often also called self-insight) as well as the ability to recognize when strengths and weaknesses are operative in addressing a given challenge. It also refers to one’s ability to recognize the impact that a given scenario or circumstance is having on one’s thoughts, feelings and actions; the interaction among these three things; and how the resulting behaviour in turn affects the scenario or circumstance. Capabilities 3 and 4, developing self and demonstrating character, are commonly enveloped in the term “self-direction,” which in general refers to one’s ability to assess one’s performance in light of the knowledge of self that is gained from effective self-awareness and to take steps to rectify deficiencies or mitigate their effects. As demonstrated in a systematic review, there is evidence that well-designed education around these concepts can be effective in resulting in “increased awareness of — and commitment to — their institution's vision and challenges, whereas others reported greater self-awareness of personal strengths and limitations, increased motivation, and confidence in their leadership roles.”3,4

Despite the impact of such formal educational interventions in increasing point-in-time knowledge and confidence, we know that the ability of physicians, including those in training, to conduct accurate self-assessment is limited. Accordingly, structured facilitative models embedded throughout the workplace-based education environment are probably required.5–8 One of the challenges for learners and front-line supervisors is to recognize opportunities for teaching and learning self-assessment leadership skills. A second challenge is to determine how to stimulate the reflective practice necessary to cultivate sound self-assessment skills (see the Reflection to Advance Leadership Development resource under KC3). The third is to work out how to capture this intervention and the resultant learning in a manner that supports confident decision-making when considering resident promotion or program completion. Table 1 from the section Implications for CBD within the CanMEDS Leader Resource helps to provide concrete examples of where these opportunities may arise, and the section on assessment strategies includes some recommendations for formal assessment and documentation. Accordingly, the remainder of this section will focus on the facilitation of reflective processes related to leadership in practice.

It is advisable to consider implementing some form of leadership-style or self-insight initiative early on in residency. Many formal instruments exist to do this, and some examples are included in the Teaching and Assessing the CanMEDS Leader Role section. Through the use of one or more of these instruments, residents can be introduced to the concept of leadership and collaboration styles and get a baseline assessment of their preferences and inclinations. The keys to success are to systematically choose a validated instrument that reflects the program’s priority skills (leadership vs. collaboration vs. problem-solving, for example); provide the resources, supports and time for residents to complete the work; make completion of the work and subsequent reflection a mandatory criterion for program (or level) completion; and provide residents with a resource to guide them in making sense of the results and developing an action plan. The latter may be a good role for a program mentor or leadership resource person in smaller programs. Most inventories embed some form of discussion around implications, benefits and drawbacks of various styles and how to optimize one’s strengths and mitigate one’s liabilities. This work can then form the basis for some of the facilitated reflections and feedback interventions discussed below.

In terms of leadership in action and at the most informal level, faculty should develop a low threshold for identifying leadership in action and stimulating discussions with learners. Asking how a learner felt about their role on a committee, in a group planning session or when trying to introduce an innovation can be a good starting point. Anchoring questions to the components of LEADS then provides a framework for discussion: (1) How did your preferred leadership style align with the task? What positive and negative emotions arose for you and can you identify any specific thoughts that might have driven those? (2) What adjustments did you need to make? How did you manage your thoughts and feelings to ensure that your actions remained appropriate? (3) What skills or knowledge items would have been helpful for you? (4) What plans or opportunities might be available to help? Some tips for teaching about reflection have been published.9 Specific models of feedback provision, such as the R2C2 model and the RX-OCR coaching process, can be helpful in equipping faculty members to establish the necessary foundations for sensitive discussions around the personal aspects of leadership.10

To ensure that the program acquires appropriate evidence of each learner’s competency in leadership, a simple strategy may be to introduce the requirement that residents complete a formal self-reflection exercise at a reasonable frequency throughout the program. This can take the form of a written summary of a situation, the resident’s role in it and their related thoughts, emotions and actions. Residents should be encouraged to undertake a personal analysis of the nature of these, the appropriateness of their resulting performance, any insights or surprises that arose, and some action plans to equip themselves for similar situations in the future. The reflection can then be assessed by faculty members or peers for content, impact and fidelity of a self-reflective loop. Soliciting a follow-up reflection on the feasibility and effectiveness of a proposed personal development plan is a good way to encourage iterative reflection and assessment of impact.

Another way to formally assess a resident’s performance as a leader is through a targeted multi-source feedback (MSF) process. The key elements of successful MSF interventions include a targeted instrument to solicit feedback, a robust process for selecting the informants including nominees by the learner, inclusion of a self-reflective component in advance, and formal review of the ensuing report with an expert debriefer who may or may not be in an evaluative capacity with the learner. While it can be hard to get at self-awareness competencies through the observations of others, including questions on the instrument that generally address ability to self-control, ability to adopt varying leadership approaches depending on the circumstances, and receptiveness to feedback can specifically target self-management competencies, and a documented follow-up action plan can be used as the basis for a future self-reflection on effectiveness. While we could find no widely used instruments targeted specifically to this purpose in residency education, two Canadian innovations, one a systematically developed instrument for a program director leadership MSF and the other an early development effort for resident as leader MSF, may provide guidance for those interested in developing a local product.11

Finally, programs that do not wish to pursue a formal MSF process may still solicit relevant data points by including the competencies of self-assessment in an observational assessment such as an EPA or an ITER. The former is preferrable because it is more intimately connected in time and context to an actual event, is meant to stimulate a formative developmental discussion rather than a summative retrospective discussion, and is meant to contribute to a multi-assessor, multi-context bank of data on the learner, not dissimilar to what a MSF does at a point in time. The design of the EPA should target specific self-assessment competencies and ideally frame a discussion with the assessor about the learner’s own reflections and learnings from the encounter.

In summary, cultivating the skills for effective self-assessment is a longitudinal journey. It should start with some form of baseline assessment to orient the learner to the concepts and their personal default predilections. Ideally there would be amenable faculty members who have the willingness and skill to identify leadership activities and provide direct feedback or coaching in a manner that stimulates ongoing reflection by the learner. Finally, there should be some manner that the program is aware of progress and demonstrated competency in this key area of leadership.

References

  1. LEADS Canada. Lead self. The root of the matter: what every health leader should know. Ottawa: LEADS Canada; 2010. https://leadscanada.net/document/2560/LeadSelf_ExecutiveSummary_EN_2019.pdf.
  2. Gavin, M. Leadership self-assessment. How effective are you? 2019. Harvard Business School Online. https://online.hbs.edu/blog/post/leadership-self-assessment.
  3. The Leadership Framework. Self assessment tool. Leeds (UK): NHS Leadership Academy; 2012. www.leadershipacademy.nhs.uk/wp-content/uploads/2012/11/NHSLeadership-Framework-LeadershipFrameworkSelfAssessmentTool.pdf
  4. Steinert Y, Naismith L, Mann K. Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME Guide No. 19. Med Teach. 2012;34:6, 483–503. DOI: 10.3109/0142159X.2012.680937
  5. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094–102. DOI: 10.1001/jama.296.9.1094
  6. Sargeant J, Mann K, van der Vleuten C, Metsemakers J. “Directed” self‐assessment: practice and feedback within a social context. J Contin Educ Health Prof. 2008;28(1):47–54. doi:10.1002/chp.155
  7. Eva K, Regehr G, Gruppen L. Blinded by “insight”: self-assessment and its role in performance improvement. In Hodges BD, Lingard L. The question of competence. Ithaca (NY): Cornell University Press; 2012. DOI: 10.7591/9780801465802
  8. Eva KW, Regehr G. “I’ll never play professional football” and other fallacies of self-assessment. J Contin Educ Health Prof. 2008;28(1):14–19. DOI: 10.1002/chp.150
  9. Aronson L. Twelve tips for teaching reflection at all levels of medical education. Med Teach. 2011;33:3, 200–5. DOI: 10.3109/0142159X.2010.507714
  10. Sargeant J, Armson H, Driessen E, Holmboe E, Könings K, Lockyer J, et al. Evidence-informed facilitated feedback: the R2C2 feedback model. MedEdPortal. 2016;12:10387. DOI: 10.15766/mep_2374-8265.10387
  11. Bharwani A, Swystun D, Oddone Paolucci E, Ball CG, Mack LA, Kassam A. Assessing leadership in junior resident physicians: using a new multisource feedback tool to measure Learning by Evaluation from All-inclusive 360 Degree Engagement of Residents (LEADER). BMJ Leader 2021;5:238–46.