Special thanks to Jamiu O. Busari, MB ChB, MD, PhD, MHPE, and Ivy F Oandasan, MD, MHSc, for developing the Teaching content and to Anne Matlow, M. Sc., MD, FRCPC, for developing the Assessment content.
Assessment in medical education has two fundamental objectives: to ensure the quality of the training and to ensure learning outcomes are met.1 In residency programs, both learning opportunities in clinical settings and structured learning opportunities outside of clinical settings (e.g., didactic, online, problem-based, small-group and project-based learning) can be used in competency-based medical education (CBME).2
The teaching and assessment of “being a leader” is not a perfect science, and it can be challenging. As Warren Bennis, a leadership expert, has said, “Leadership is like the abominable snowman, whose footprints are everywhere, but is nowhere to be seen.”3 Although the building blocks of leadership include acquiring the necessary knowledge, building character, enhancing emotional intelligence and cultural sensitivity, setting direction and achieving results, the practice of leadership is primarily based in the workplace. The challenge for medical educators is to define the requisite leadership competencies, employ valid and reproducible methods for identifying where they are being demonstrated, and find ways to assess learners, ideally by observing the competencies in action or by measuring knowledge and skill acquisition through standardized testing such as multiple choice examinations and simulated oral examinations, projects or essays.
According to the LEADS in a Caring Environment Framework, leadership is “the collective capacity of an individual or group to influence people to work together to achieve a common constructive purpose: the health and wellness of the population we serve.”4 Leaders must have the necessary knowledge and skills and exercise the appropriate attitudes and behaviours to achieve this goal. The CanMEDS 2015 Physician Competency Framework sets out the enabling competencies and milestones that form the key competencies of the Leader Role. The milestones established by the Royal College of Physicians and Surgeons of Canada, which reflect the progression of training, are adapted by each specialty. Along with the specialty-specific entrustable professional activities (EPAs), they form the foundation upon which assessment is based.
The College of Family Physicians of Canada (CFPC) has characterized leadership as one of the four primary responsibilities of family physicians.5 Family physicians are expected to demonstrate leadership at all levels to enable the provision of “accessible, high-quality, comprehensive, and continuous first-contact health care that responds to local conditions” and “research that advances an understanding of this care”.5 The CFPC’s training statement for leadership describes the college’s expectations of graduates as follows: “All graduates demonstrate personal accountability and trustworthiness in the most responsible physician role, and they can provide direction in medical emergencies and other challenging clinical situations. They function as collaborative clinical team leaders and often serve as community leaders. They have foundational abilities that prepare them for more advanced leadership roles in practice.”6 The CanMEDS-FM Manager Role has evolved into the Leader Role, similar to the evolution of this role in CanMEDS.7
A possibility to consider is asking supervisors to inform their resident that the competency focus on a particular day will be on the Leader Role. On this day, the learner can be asked to jot down the times when they were involved in an activity that required leadership skills, including empathy. The supervisor should consider the times when observation can happen, such as during team meeting and discharge rounds, and plan to be present. If there was a challenging interaction with a patient, family or team member, the supervisor can ask the resident how they felt during the interaction (self-awareness) and whether on reflection they were satisfied with how they managed the situation. Would they do it any differently the next time? These are all elements of emotional intelligence. A team member can be asked to observe the learner and offer feedback on the resident’s leadership skills as a fieldnote.
Visit the following resources for tips on providing “Coaching in the Moment” (post workplace-based observation):
Although learning in the clinical context is both experiential and aligns with adult learning principles, it can also be helpful to offer structured learning opportunities to residents at various points in their residency. A multitude of online resources, videos, courses and conferences are available that can help residents to develop their leadership skills. Curriculum planners need to determine which competencies learners are expected to demonstrate at each stage of their training and then match these to relevant resources or experiences. As part of this resource, self-reflection tools are offered that can be coupled with the clinical learning opportunities discussed above. Using guided self-assessment with a supervisor, recommended learning tools can be suggested to the resident to enhance their learning. The learner can document in their learning portfolio the work they do in this area; again, this aligns with a more progressive approach to leadership.
Giving residents opportunities to enhance their personal awareness of self and to gain critical consciousness skills can help them to delve into and reflect upon times they will need to demonstrate leadership qualities, particularly when they are faced with challenges related to equity, diversity and inclusion.
Visit the following resources for more on self-reflection, self-assessment, longitudinal coaching of residents, and developing critical consciousness skills:
Leadership during residency training is demonstrated primarily in the workplace. It is important for supervisors to identify when residents are engaging in leadership activities, so that they can provide teaching and coaching in the moment. Over time, documented formative feedback can be used to render a judgement as part of a summative assessment offered by the residency competence committee.
Learners routinely act as leaders and practise leadership skills in their day-to-day activities. The challenge is to help them to identify when leadership skills are, or can be, put into action, to highlight how their preceptors can observe and document them, and to explain how other team members can offer multi-source feedback to help them improve their leadership skills.
Strategies for assessing leadership competencies in the workplace include the following:
Many elements of leadership are amenable to didactic teaching, personalized study, small group activities and facilitated reflection. It is helpful for residency curricula to supplement the workplace learning offered to residents in leadership by including specific learning in the following areas:
The following scenario, a typical day in the life of a resident, is annotated with the KC3 competencies as an example of how this might be done. 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.
Leadership skills are inherent in other CanMEDS Roles. For example, residents will demonstrate leadership skills in communicating with patients about a patient safety incident event and collaborating with colleagues to escalate patient care in an emergency situation (see “Analyze Patient Safety Incidents to Enhance Systems of Care” in KC1 in the Physician Leader Resource).
Leadership skill competencies can be integrated into existing entrustable professional activities (EPAs) and assessment strategies. An example from pediatrics can be used to illustrate this point. At the Foundations of Discipline level of training, EPA #5 for pediatric residents is “assessing, diagnosing, and managing patients with common pediatric problems.”11 The milestones associated with this EPA include considering costs when choosing care options. Milestones related to competency 3.1 of the Leader Role, demonstrating leadership in professional practice, which focus on self-management and leadership style in the patient encounter, can also be integrated in the assessment strategy for EPA #5, such as through observation or guided reflection, for a broader look at a resident’s leadership capability in the workplace.
Assessment tip: Multi-source feedback from members of the team on the resident’s performance has included some comments about the resident’s control-and-command leadership style. With this in mind, the supervisor offers the resident some resources on leadership styles7 and emotional intelligence8 (see the Additional Resources at the end of this section) and suggests that at their next meeting they have a further discussion about what the resident has learned and the changes they have made.
See Leadership Skills in the CanMEDS Leader Role (CanMEDS Teaching and Assessment Tools Guide) for an example of multi-source feedback.
Dickson G, Tholl B, editors. Bringing leadership to life in health: LEADS in a Caring Environment. Putting LEADS to work. 2nd ed. Berlin: Springer Nature; 2020.
The importance of physician leadership
Bohmer RM. Leading clinicians and clinicians leading. N Engl J Med. 2013;368(16):1468-1470. doi:10.1056/NEJMp1301814
Souba W. Health care transformation begins with you. Acad Med. 2015;90(2):139-142. doi:10.1097/ACM.0000000000000534
Bushe G. Generative leadership. Can J Physician Leadersh 2019;5(3):141–7.
Leadership development for physicians
Geerts JM, Goodall AH, Agius S. Evidence-based leadership development for physicians; a systematic literature review. Soc Sci Med 2020;246:112709. doi:10.1016/j.socscimed.2019.112709
Sultan N, Torti J, Haddara W, Inayat A, Inayat H, Lingard L. Leadership Development in Postgraduate Medical Education: A Systematic Review of the Literature. Acad Med. 2019;94(3):440-449. doi:10.1097/ACM.0000000000002503
Blumenthal DM, Bernard K, Fraser TN, Bohnen J, Zeidman J, Stone VE. Implementing a pilot leadership course for internal medicine residents: design considerations, participant impressions, and lessons learned. BMC Med Educ. 2014;14:257. Published 2014 Nov 30. doi:10.1186/s12909-014-0257-2
Frich JC, Brewster AL, Cherlin EJ, et al. Leadership development programs for physicians: a systematic review. J Gen Intern Med. 2015;30(5):656–74. doi:10.1007/s11606-014-3141-1
Sadowski B, Cantrell S, Barelski A, O'Malley PG, Hartzell JD. Leadership Training in Graduate Medical Education: A Systematic Review. J Grad Med Educ. 2018;10(2):134-148. doi:10.4300/JGME-D-17-00194.1
Lerman C, Jameson JL. Leadership development in medicine. N Engl J Med. 2018;378(20):1862–3. doi:10.1056/NEJMp1801610
Dickson G, Van Aerde J. Enabling physicians to lead: Canada's LEADS framework. Leadersh Health Serv (Bradf Engl). 2018;31(2):183–94. doi:10.1108/LHS-12-2017-0077
Oza SK, Boscardin CK, Pierce R, Pierece R, Miao E, Lockspeiser T, et al. Leadership observation and feedback tool: a novel instrument for assessment of clinical leadership skills. J Grad Med Educ. 2018;10(5):573–82. doi:10.4300/JGME-D-18-00113.1
Emotional intelligence
Bracket M. Emotional intelligence as a superpower [YouTube video]. 13 Jul. 2017. https://www.youtube.com/watch?v=JcFefehMpZ0
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
Character-based leadership
Seijts G, Crossan M, Carleton E. Embedding leader character into HR practices to achieve sustained excellence. Organ. Dyn. 2017;46:30–9.
Byrne A, Crossan M, TSeijts G. The development of leader character through crucible moments. J Manage. Educ. 2018;42(2):265–93.
Leadership styles
Goleman D. What makes a leader? Harv Bus Rev. 1998;76(6):93–102.
Conflict management and negotiation
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
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
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
Fisher R, Ury W, Patton B. Getting to YES: negotiating agreement without giving in. 3rd ed. New York (NY): Penguin Books; 2011.