J. McKimm and S.J. Lieff

Introduction

Medical educators are involved in a wide range of activities including teaching, facilitating learning, curriculum design and development, assessment, evaluation and managing teams, departments and programmes. All these activities require some form of leadership, whether this is leading a team on a project, ensuring that you provide the right learning environment on a ward or in clinic or leading the development of a new programme or curriculum. We often think of ‘leadership’ as associated with senior management, with deans or principals or about people other than ourselves. However, Drucker (1996) suggests that effective leaders are people who have followers, who do the right things and achieve results, who set examples and are visible and who take responsibility. Leadership can therefore be found at all levels.

Evidence from all sectors of industry, public, private or third sector, shows that good leadership is vital in ensuring organizational success. And, conversely, that poor leadership and management have been shown to play a major part in failing organizations (Kotter 1990). From an educational standpoint, health professionals are increasingly required to engage in clinical leadership, and medical students and doctors are no exception. Internationally, doctors are being called upon to take more active engagement in the leadership and management of clinical services, which has led to an increased emphasis on ensuring that medical students ‘learn leadership’ in their undergraduate programmes. This requires medical educators to be much more aware not only of the practice of leadership as it relates to their educational work, but also of planning and delivering education that includes leadership concepts and examples. In this chapter we focus specifically on medical educational leadership, but many articles and books on general leadership (drawn mainly from industry) and educational leadership (particularly in the schools sector) and a growing literature on clinical leadership are all highly relevant to medical education, which straddles both education/training and health services.

A massive leadership literature has growing emphasis on whether (and if so, what) specific qualities, attributes, knowledge or skills are most effective in different organizational and professional contexts. Identifying specific issues, challenges and opportunities in medical education helps to strengthen capacity of organizations, improve individual leaders’ performance and enhance the experience for those who work within organizations and our clients or customers (i.e. students and the end users of medical education: patients).

Leadership and management

In this chapter, we have subsumed ‘management’ under the topic of leadership. Although many writers in the past have clearly differentiated between leadership and management, this approach tends to reinforce the difference between the two sets of activities, with management somehow being seen as secondary to leadership, thus promoting the idea that it is preferable to be a leader than a manager. Leadership theories in the 1950s and 1960s identified ‘transactional leadership’ as similar to a managerial approach in that the leader/manager engaged in transactions with subordinates. So a leader might motivate people by offering rewards for a job well done or imposing sanctions for non-compliance or failing to deliver. Contemporary theory emphasizes that effective leaders require managerial skills and vice versa. Whilst many of the (copious) lists of leadership qualities emphasize the importance of vision, strategic thinking, setting direction and communication, if the vision cannot be translated into activities that work on the ground and make a difference to improving the performance of an organization or learners’ experience, then the vision is illusory. The most effective leaders know their strengths and weaknesses and build a team who can deliver the shared vision.

Our current understanding of medical education leadership

Much has been written about leadership characteristics, behaviours, mind-sets and competencies in academic medical and education settings. In academic medicine, practising and aspiring leaders identify knowledge of academic role-related and health professional practice, interpersonal/social skills, vision and organizational orientation as desired abilities of academic physicians (Taylor et al 2008). Rich et al’s (2008) literature review of desirable qualities of medical school deans identifies a variety of management and leadership skills and attitudes as well as specific knowledge regarding academic medical governance, processes of medical education, legal issues and challenges and expectations of faculty. Leithwood et al (2009) found that successful school leaders engaged in four sets of core practices: setting directions, developing people, redesigning the organization and managing the teaching programme.

The literature surrounding medical education leadership is, however, still in its infancy. Bland et al (1999) were among the first to empirically study specific education leadership behaviours for successful university-community collaborations related to curricular change. In successful collaborative curriculum change projects, leaders most frequently used participative governance and cultural value-influencing behaviours: communicating vision, goals and values, creating structures to achieve goals, attending to members’ needs and development, and creating and articulating symbols and stories representing dominant values. Lieff and Albert (2011) extended these findings by studying the leadership practices (what they do and how they do it) of a diversity of medical education leaders in a faculty of medicine in their daily work.

This framework of practices aligns with the primarily relational and complex nature of leadership work in an ever-changing medical education system that must simultaneously attend to education and healthcare service needs. It also creates an opportunity for identifying enabling competencies for effectiveness in these multiple practices.

Bordage et al (2000) set out to identify the desirable competencies, skills and attributes of prospective educational programme directors in a variety of health professions as judged by potential employers. They identify being a competent practitioner as well as educational, decision-making, communication, interpersonal, teamwork and fiscal management skills. The top personal attributes were being visionary, flexible, open-minded, trustworthy and value-driven. McKimm’s (2004) study of health and social care education leaders in the UK describes similar skills and attributes, but adds self-awareness, self-management, strategic and analytic thinking skills, tolerance of ambiguity, being willing to take risks, professional judgement and contextual awareness.

Mintzberg’s ‘threads’ require deliberate attention in order to be effective. Effective leaders know how to think and make decisions in complex environments, which are dynamic and constantly evolving in response to internal processes as well as external demands that cannot be predicted. For complex issues, leaders are encouraged to act and learn at the same time by conducting small experiments with tight feedback loops that illuminate the path forward (Snowden & Boone 2007). Education leaders must realize that fragmentation is a natural tendency of a complex system; therefore, their role is to enable coherence making. They must keep their eye on the central focus of student learning and ideas that will further the thinking and vision of the school as a whole (Fullan 2002).

Lieff and Albert’s study (2010) of medical education leaders’ mind-sets shows that, while these leaders employed Bolman and Deal’s ‘four frames’ for understanding organizational work, they favour the human resource frame followed closely by the political and symbolic frames. From the political frame perspective, they recognize, understand and engage with stakeholders’ interests in order to be informed, advocate and cultivate support. They identify and leverage diverse sources of power and appreciate the complexity of resource and political issues as underpinning tensions in educational work. From a symbolic perspective, they work at ensuring a vision or direction that people can engage with in order to commit. They attend to the importance of credibility and modelling values and messages in behaviours, activities, structures and policies of programmes. They also appreciate that histories, traditions and belief systems can impede or enable change. Additionally, they deliberately appraised others’ interpersonal and work style in order to understand how to socially situate people in the organization so they can work to their strengths.

Leadership theory and practice

In this section, we describe theories and models that are most relevant to medical education leadership and give examples of how these might apply in practice for contemporary medical education leaders. Table 42.1 summarizes a wider range of leadership theories and key features (with different approaches, underpinning perspectives or discourses) found in the literature.

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