Scenario: It’s the start of a busy week and you’re the supervising physician working with a team of residents, interns, and medical students on a busy inpatient service. Despite extensive coaching by several members of the house staff, one of your clerkship students just doesn’t seem to be able to master the ability to develop and convey a differential diagnosis.
You’ve tried to be explicit, explaining that “the first step is to do this….the second is to do this…” but without any evidence of improvement. It’s not clear whether the student lacks knowledge, confidence, or both, or whether team dynamics are an issue. In any event, the rotation ends in less than two weeks and you’re both getting frustrated over the lack of progress. Could application of a different leadership paradigm improve the effectiveness of your teaching and help resolve the situation?
Introduction
While the literature is replete with papers addressing leadership theories and leadership training, little has been written about the application of leadership theories to teaching in the clinical environment, particularly with regard to the supervision of medical students, interns, or even junior residents. We attempt to fill this gap and highlight a variety of approaches that are most relevant to clinical teachers.
This is particularly important as individual learners develop at differing levels; bring a unique range of personal experiences, learning preferences, cultural and/or ethnic backgrounds to each situation and/or clinical task; and long-term, sustained relationships between teachers and learners may not always be possible in the clinical arena.
This is particularly true when clinical rotations are limited to short periods such as during a two-week ward rotation. This is why clinicians may find that their teaching could be enhanced by selective use of an appropriate leadership paradigm.(1) (We use the term “paradigm” to reference a model which can be applied. Many authors such as Northouse(2) refer to leadership concepts as “theories”.)
But first, a brief reminder of the etymology of the word education. Readers may recall that the word education derives from the Latin word “e-ducere,” meaning to lead out of (a state of dependence), just as “pedagogy” refers to the process of “leading out” from childhood to higher levels of knowledge and experience.
We performed a literature search focusing on key words such as “leadership” or “leadership theories” plus “clinical medicine,” “clinical teaching,” “medical student teaching,” or “clinical education.” We found a paucity of papers addressing the application of leadership paradigms to common challenges encountered in the clinical environment. A particularly salient work was exemplified by Saxena and colleagues(1) that highlighted the importance of an adaptive approach, where leadership styles can be modified based on the situation at hand. The authors also noted that in most situations, as individual leaders gain additional experience and expertise, they generally tend to become more adept at using multiple leadership styles.
What is less well-defined, however, is a description of how different leadership paradigms can be deliberately applied to common clinical teaching scenarios. In this article, we address that gap by defining and summarizing the key features of six prominent leadership paradigms (Trait, Situational, Leader-Member Exchange, Path-Goal, Transformational, and Critical Race Theory) and demonstrating how each could be applied to the situation described in the beginning (Table 1).
Other leadership paradigms can sometimes be applied, and while there are areas of overlap, Table 2 provides a brief description of some other contemporary paradigms.
Leadership theories involve two aspects: How relationships are managed and how results (such as learning or patient care) are achieved. They also vary in how these aspects are articulated and balanced. We will demonstrate how some of these leadership models exemplify the degree to which the teacher/leader is willing to negotiate with the learner, particularly with regard to how the desired educational outcome(s) will be achieved. Our overall goal is to enhance teacher flexibility by providing a range of models that can be applied in different situations.
Trait Theory
Consideration of trait theory is particularly important as many faculty members intuitively rely on the strength of their innate personality to guide their teaching. Northouse(2) describes trait theory as an approach in which successful leadership is derived from the personal characteristics (e.g., drive, motivation, and judgment) that are inherent in the leader.(3) This implies less personal flexibility and recognizes that those who are effective leaders in one situation may be less so in another.
Trait theory presumes that these traits are intrinsic in the teacher’s nature, so while faculty development can facilitate the cultivation of new and/or expanded skills, the underlying traits inherent in a given leader can be exceedingly difficult to change. This, in turn, can significantly influence the type of interactions among teachers, learners, peers, and patients.
When applied to a clinical scenario, such as the one portrayed at the beginning of this article, a trait-focused leader will seek to apply whatever “tried and true” approaches worked in the past. While many faculty members can play to their strengths, there are limits. Clinical teachers who rely on their innate ability to leverage their own particular leadership traits may sometimes find themselves “locked”(2) into a particular leadership style, with limited ability to adapt to the unique variables that a given learner may present.
The application of trait theory can be an effective means of role modeling, as it is a less directive and more explicit form of leadership. In the clinical arena, it is particularly important that teachers trust their students and that students perceive their teacher as being trustworthy. This reciprocal relationship involving the traits of trust and trustworthiness is essential to creating a positive learning climate, which in turn, allows for the provision of more effective and explicit guidance and/or correction.
Situational Leadership Theory
Popularized by Blanchard’s The One Minute Manager(4) series, situational leadership offers a second paradigm from which to consider teacher-learner interactions.
According to this model, teachers adjust their level of support (S) and direction (D) according to the situation at hand, or more specifically, based on the level of skill demonstrated by an individual learner. Or, as Bedford and Gehlert(5) note, the degree of explicit, task-oriented behavior (direction) versus relationship-oriented behavior (support) exhibited by a teacher varies depending on the degree of confidence and competence exhibited by the learner.
This translates into four leadership approaches that vary depending on the anticipated or observed needs of the learner: directing, coaching, supporting, and delegating. For example, interactions involving interns are more likely to be characterized by a more directive approach, whereas a second-year resident may respond well to coaching, with delegation being more typical for a senior resident.(2,6,7)
In general, the goal is for the leaders/teachers to align their degree of supervision with the developmental needs, degree of commitment, and level of competence exhibited by their followers/learners. From a teaching perspective, situational leadership provides more flexibility than trait theory, as it more readily adjusts to the needs of the learner, recognizing, for example, that a given learner may need different levels of support or supervision based on the task at hand.
On the other hand, a limitation of situational leadership is that it is primarily task-oriented and teachers typically select their leadership approach based on their learner’s overall level of training—in other words, they anticipate the learner’s needs. This is most evident in time-restricted settings, such as during a two-week ward rotation, where teachers may have limited time and/or ability to fully assess each individual learner’s specific developmental level.
Another potential limitation is that leaders/teachers can sometimes “misdiagnose” the situation(5) and select a degree of direction versus support that does not accurately match the specific circumstance. This, in turn, can be a source of angst for the learner and/or the teacher. In addition, situational leadership theory is typically viewed as being more teacher-centric, with the teacher choosing the style of interaction. Finally, the theory would suggest that learners and/or followers all have the same level of skill, which, depending on their prior experience and/or aptitude, may not always be accurate.
Leader-Member Exchange Theory
In contrast to the leader-centric focus of trait theory, the Leader-Member Exchange Theory (LMX) defines leadership as a flexible, dyadic relationship that emerges between a teacher and a learner.
Developing effective relationships takes time, however, and involves advancing through three distinct phases: Stranger (Phase 1), Acquaintance (Phase 2), and Partners (Phase 3).(2,9,10) It is in Phase 3 that these dyadic relationships are most mature, demonstrating high levels of mutual trust and reciprocal obligation.
Thus, from an educational perspective, the emphasis of the teacher should not be on how they “…discriminate among their people [learners], but rather on how they may work with each person [learner] on a one-on-one basis to develop a [meaningful] partnership with each of them.”(9)
Although application of the LMX theory can be time intensive, one of its greatest strengths is that it can reduce the perception of “in-groups” versus “out-groups,” as all members of the educational unit/team/organization should be equally able to benefit from the resources, trust, and support that emerge from LMX based partnerships.(8) This is particularly important in diverse educational environments, for when teachers cultivate environments characterized by a genuine sense of trust and belonging,(10) learners and teachers are much more likely to develop stronger and more advanced, LMX dyadic relationships.
On the other hand, one of the limitations of LMX theory is that there is the possibility that followers might be perceived as having differing (and possibly “better”) relationships with the leader, which can result in real or perceived inequities. Moreover, the amount of time a teacher and learner have together may not always allow for the dyadic relationship to advance beyond the “stranger” phase.
Nonetheless, the educational hand-offs that occur during teacher-teacher interactions can, if they happen to share a common set of expectations, facilitate the progression of future teacher-student relationships to a more advanced LMX phase.
Path-Goal Theory
The path-goal approach to leadership(11) builds upon the tenets described in Situational Leadership but suggests that the primary role of the leader (teacher) is to identify the path to success (i.e., the goal) and to remove obstacles that may be impairing the success of their individual followers (learners). As such, the role of the leader is to consider the nature of the task at hand along with the needs and/or motivations of their followers and use this assessment to select a leadership style that is predominantly directive, supportive, participative, or achievement oriented.(2)
For example, an experienced intern who has developed a strong sense of confidence and belonging may respond well to a supportive leadership style, whereas a medical student on their first clinical rotation will likely require a much more structured approach, with a directive leadership style.
If we assume that the learner in the opening scenario has already attained a fair amount of clinical experience and is motivated to excel, but views the task as both complex and ambiguous, the teacher might adopt an achievement-oriented leadership style that enhances the learner’s own ability to overcome perceived challenges and achieve their chosen goals (Table 1).
While application of the Path-Goal leadership approach can work well in many clinical situations, a potential limitation is that it assumes that learners/followers are already motivated to achieve a specified goal, and the teacher/leader is able to adapt their approach to match the instructional needs of learners.
Transformational Leadership Theory
The application of transformational leadership theory offers yet another approach to resolving the teaching dilemma described earlier in this article. This leadership strategy is defined as creating a relationship or connection that increases the motivation and capability of both follower (learner) and leader (teacher). It uses a combination of inspiration, motivation, intellectual stimulation, and individualized coaching(12) to help followers not only achieve, but also exceed identified goals, as they strive to achieve their full potential.
Moreover, this type of leadership is one in which the efforts of leaders and followers are inextricably connected. In addition to establishing a vision of what needs to be achieved, the leader (teacher) is also tasked with identifying and meeting the needs of individual followers (learners). By doing so, both leader and follower share in the achievement of aspirational goals, the results of which can be transformative on both individual and/or organizational levels.(2)
As Holmboe(13) noted, this approach is characterized by situations in which both teacher and learner actively engage in producing together, the desired educational outcome. In other words, “…making better use of each other’s assets, resources, and contributions to achieve [educational and clinical] outcomes or improve efficiency.” (13)
That said, despite its widespread appeal, Transformational Leadership theory has some limitations. One limitation is that it does not work well in clinical situations in which urgent or emergent intervention is needed, nor does it truly attend to cultural or social nuances.
Critical Race Theory
While not a leadership theory per se, Critical Race Theory (CRT) is an important consideration for leaders and teachers of all types and in all situations, as it incorporates the previously referenced elements of individualization and co-production of outcomes.
Although popularized by recent events, CRT is not new; it was first developed in the 1970s and is generally attributed to the work of two law professors: Harvard University Professor Derrick Bell and University of Buffalo Professor Alan David Freeman.(15,16,17) Moreover, CRT was actually designed to highlight and correct those structural and societal factors that often place people of color in situations in which inequities may persist and even flourish.
From an educational standpoint, CRT would expect teachers to actively identify, prevent, and/or deter microaggressions;(18, 19) to be sensitive to the potential effects of prior physical, psychological, or emotional trauma on their learners; and to avoid the often-misguided position of claiming that they “don’t see color.” Instead, educators should recognize that embracing individual learners’ cultural and ethnic heritage (to include their skin color) embraces a valued part of each learner’s unique identity.(20)
And, regardless of whether teachers share similar backgrounds, it is critically important that teachers not presume that they fully understand the impact of their individual learner’s lived experience when it comes to responding to a given patient and/or to their teacher’s feedback.
Finally, although a limitation of CRT is that it could be perceived as a paradigm that builds upon existing stereotypes, one of its strengths is that it urges teachers to try to recognize and understand the impact of individual learner’s lived experiences, considering factors of equity and equality.
The educational application of this paradigm adds social context to the consideration of learner stage, task difficulty and curricular setting for the teacher’s attention. The application of this paradigm along with the others are summarized in Table 2.
Conclusions and Key Points
A variety of leadership paradigms can be applied to teaching in the clinical setting. An additional focus involved demonstrating how these leadership approaches differ in the degree of negotiation that teachers and learners are encouraged to engage in negotiating either or both, the content of what is to be learned, how it is to be learned, and the teacher-learner relationship, all of which are accomplished while working toward desired educational outcomes.
There are five key “take-home” points for readers to consider:
Education and leadership are closely related; both strive to cultivate reliable, ethical, and independent action in their learners and/or followers.
Faculty development is essential, as it introduces teachers to a variety of leadership approaches. We suggest that this will, in turn, foster more confident, efficient, and impactful clinical teaching, particularly when teachers are able to more effectively combine their educational acumen with the strategic and selective application of an appropriate leadership paradigm.
Applying available alternative leadership approaches may facilitate more effective educational outcomes. This includes being able to adopt differing leadership styles based on the circumstances at hand as well as on the needs and/or experience of individual learners.
Leadership models typically offer varying degrees of flexibility as to how desired outcomes are identified and/or achieved. While Trait or Path-Goal leadership approaches are often well suited for use with early-stage learners, LMX or Transformational Leadership type benefits more advanced learners and could even be applied with those earlier in training. Of course, even senior residents might require a more directive approach, particularly when working with situations that are new to them.
Although not a leadership theory per se, Critical Race Theory highlights some significant leadership considerations for how educators can add social context when working with individuals.
Disclaimer: The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense or the United States Government.
References
Saxena A, Desanghere L, Stobart K, et al. Goleman’s Leadership Styles at Different Hierarchical Levels in Medical Education. BMC Medical Education. 2017; 17:169
Northouse PG. *Leadership: Theory and Practice, *8th edition. Thousand Oaks, CA:Sage Publications, Inc.;2018.
Best Practice Consulting. “What makes a successful leader?” Blog. https://www.bestpracticeconsulting.com.au/_blog/Articles/post/What_makes_a_successful_leader
Blanchard KH, Johnson S. The One Minute Manager. New York, NY:Morrow;1982.
Bedford, C, Gehlert, KM. Situational Supervision: Applying Situational Leadership to Clinical Supervision. The Clinical Supervisor. 2013;32(1):56–69.
Blanchard K, Zigarmi P, Zigarmi D. One Minute Manager: Increasing Effectiveness Through Situational Leadership II. New York, NY: William Morrow;2013.
Blanchard KH, Zigarmi D, Nelson RB. Situational Leadership® after 25 years: A Retrospective. Journal of Leadership & Organizational Studies. November 1993;1:21–36.
Bunin, JL, Meyer HS, Durning SJ. Could Application of a Leader-Member Exchange Theory Have Saved a Residency Mentorship Program? Perspectives on Medical Education. 2020; 9:264–267.
Graen GB, Uhl-Bien M. Relationship-Based Approach To Leadership: Development of Leader-Member Exchange (LMX) Theory of Leadership Over 25 Years: Applying a Multi-Level Multi-Domain Perspective. 1995. Management Department Faculty Publications. 57. https://digitalcommons.unl.edu/managementfacpub/57 .
Jackson EM, Johnson RE. When Opposites Do (And Do Not) Attract: Interplay of Leader and Follower Self-Identities and Its Consequences for Leader-Member Exchange. The Leadership Quarterly. 2012;23(3):488–501.
House, RJ. Path-Goal Theory of Leadership: Lessons, Legacy, and a Reformulated Theory. The Leadership Quarterly. 1996;7:323–352.
Campos A. Transformational Leadership Theory. Blog. https://sites.psu.edu/leadership/2020/11/05/transformational-leadership-theory .
Holmboe ES. The Transformational Path Ahead: Competency-Based Medical Education in Family Medicine. Family Medicine. 2021;53(7):583–589.
Braun L. Theorizing Race and Racism: Preliminary Reflections on the Medical Curriculum. American Journal of Law & Medicine. 2017;43:239–256.
Liou DD, Antrop-Gonzalez, R. Transformative Leadership and Creating Conditions to Empower Students Marginalized by Low Academic Expectations. In Marsh T, Croom N, eds. Envisioning Critical Race Praxis in K-12 Leadership Through Counter-Storytelling. Charlotte, NC: Information Age Publishing; 2016. pp.141–162.
Black Past. Critical Race Theory: A Brief History. Blog. https://www.blackpast.org/african-american-history/critical-race-theory-a-brief-history/
Ellingwood S. What Is Critical Race Theory and Why Is Everyone Talking About It? Columbia University News. July 1, 2021. https://news.columbia.edu/news/what-critical-race-theory-and-why-everyone-talking-about-it-0 .
Acheampong C, Davis C, Holder D, et al. An Exploratory Study of Stress Coping and Resiliency of Black Men at One Medical School: A Critical Race Theory Perspective. Journal of Racial and Ethnic Health Disparities. 2019;6(1):214–219.
Ackerman-Barger K, Boatright, D, Gonzalez-Colaso, R, et al. Seeking Inclusion Excellence: Understanding Racial Microaggressions as Experienced by Underrepresented Medical and Nursing Students. Academic Medicine. 2020;95(5):758–763.
Hall JM, Fields B. Race and Microaggression in Nursing Knowledge Development. Advances in Nursing Science. 2012;35(1):25–38.
Mind Tools. Blake and Mouton’s Leadership Grid—Leading People and Producing Results. https://www.mindtools.com/pages/article/newLDR_73.htm
Nikolić G, Grudic Kvasic S, Grbic L. The Development of Authentic Leadership Theory. 2020. https://www.researchgate.net/publication/343915712_The_Development_of_Authentic_Leadership_Theory .
Malila N, Lunkka N, Suhonen M. Authentic Leadership in Healthcare: A Scoping Review. Leadership Health Service. 2018 Feb 5;31(1):129–146. doi: 10.1108/LHS-02-2017-0007.
Ford J, Harding N. The Impossibility of the ‘True Self’ of Authentic Leadership. Leadership. 2011;7(4):463–479. doi:10.1177/1742715011416894 Accessed July 6, 2022.
11 Advantages and Disadvantages of Adaptive Leadership Styles. Future of Working: The Leadership and Career Blog. https://futureofworking.com/11-advantages-and-disadvantages-of-adaptive-leadership-styles/
Lindberg C. Adaptive Leadership Explained by a CEO. August 19, 2020. https://www.leadershipahoy.com/adaptive-leadership-what-is-it-pros-cons-examples/
Zaccaro SJ, Rittman AL, Marks MA. Team Leadership. The Leadership Quarterly. 2001;12(4):451–483, ISSN 1048-9843 https://doi.org/10.1016/S1048-9843(01)00093-5
The Eco Leadership Institute. Eco-Leadership in Organisations. https://ecoleadershipinstitute.org/ecoleadership-about
Western S. A Brief Guide to Eco-Leadership. Social Science Space. March 2020. https://www.socialsciencespace.com/2020/03/a-brief-guide-to-eco-leadership/
Lowe KB, Kroeck, KG, Sivasubramaniam N. Effectiveness Correlates of Transformational and Transactional Leadership: A Meta-Analytic Review of the Literature. The Leadership Quarterly. 1996; 7(3):385–425. https://doi.org/10.1016/S1048-9843(96)90027-2
STU Online. What Is Transactional Leadership? How Structure Leads to Results. November 25, 2014. https://online.stu.edu/degrees/education/what-is-transactional-leadership/
Robert E. Greenleaf Center for Servant Leadership. What Is Servant Leadership? https://www.greenleaf.org/what-is-servant-leadership .