Teaching Leadership to Practicing Psychiatrists

All physicians are expected to be leaders regardless whether they have an administrative title.(1,2) As healthcare is delivered by teams rather than by individual providers, the practice of medicine increasingly requires a skill set that includes leading other professionals, often from a variety of disciplines, in a coordinated effort toward healing an ever-growing and ever-more-complicated population of patients in need of care.

Psychiatrists are not excepted from this trend.(3) Delivery of optimal psychiatric care, once thought to be achievable from a psychiatrist’s or psychologist’s private office, now routinely relies on the input of primary care providers, nurses, social workers, care coordinators, occupational therapists, nutritionists, depression specialists, health coaches, and others. Psychiatrists must be skilled leaders in order to be most effective in modern healthcare settings.

Despite recognition that leadership skills are important to physicians, medical education curricula rarely teach these skills.(3-6) Several programs that integrate the teaching of leadership concepts into the training of medical students and residents have proven successful,(4,5,7,8) but it is difficult for physicians who have already completed their training and may even already hold formal leadership positions to access this type of program.

Physicians typically assume leadership positions without deliberately having sought leadership and thus often do not have an opportunity to formally prepare for these roles.(6) Although the American Association for Physician Leadership offers a variety of training programs for this purpose, many physician leaders continue to learn non-systematically or wait for skills to emerge out of a crisis.(9)

We sought to develop a leadership curriculum for practicing psychiatrists that could be delivered through a relatively compact educational module in the context of an existing continuing medical education (CME) course. We expected this format to be more accessible to practicing psychiatrists than either a trainee curriculum or an independent conference. We hypothesized that learning in this module would increase participants’ comfort level with the core skills needed to lead interdisciplinary teams.

Although measurement of other potential downstream benefits of the curriculum, such as participants’ mastery of the material, application of the material to their practices, and long-term impact on their clinical programs (i.e., the Kirkpatrick model), would have been a more robust assessment of the course’s impact, we did not think such measurements would be feasible to collect in this study. Moreover, the wide variability among individual participants’ motivation, resources, and baseline knowledge and skill levels would have weakened the validity of such an assessment.(10)

Course Curriculum

We designed a four-hour curriculum to cover basic elements of multidisciplinary team leadership for psychiatrists. Multiple topics are considered essential to leadership in psychiatry, including mentorship,(11) faculty development,(6,11) quality improvement,(11,12) quality measurement,(11) maintaining accreditation,(12) budgeting,(12) marketing,(11,12) risk management,(6) optimizing the use of information technology,(12) emotional intelligence,(7,13) supporting women and minority faculty,(14–16) engaging stakeholders,(6) formulating a strategy,(6) and communicating a vision.(6,9) We considered covering all of these topics to be insurmountable within the framework of a half-day course. Therefore, we chose to frame the curriculum more specifically on program development as a platform for introducing foundational lectures on communication strategies, metric selection and interpretation, and financial management.

Table 1 describes the presentations and objectives included in the session; material was developed by the authors and incorporated pre-survey feedback from enrolled participants before the course. Multiple approaches to delivering educational material are considered appropriate for this content, including didactic learning,(1,5) experiential learning,(1,5) and mentoring.(1,14) A combination of methods would have been ideal.

Because the frame of a four-hour CME module did not allow for real-time experiential learning or mentorship, we relied primarily on didactics and case examples. Each talk ended with an interactive component inviting questions and feedback on participants’ own projects. Handouts were used to guide participants in developing projects alongside presented talks.

Speakers included two psychiatrists with administrative roles in academic medicine, a consultation-liaison psychologist, and a nurse practitioner with experience as a nurse manager. The session was presented as a paid pre-conference course at the national meeting of the Academy of Consultation-Liaison Psychiatry in November 2018; accordingly, material was tailored to consultation-liaison psychiatry practice.

Evaluation Study

An evaluation study was conducted to assess the quality and effectiveness of this curriculum. Prior to the course, early registrants were invited to complete an online electronic pre-survey describing their clinical roles, leadership experience, and familiarity with existing management and quality improvement models. The 17-question pre-survey also asked about goals for this course in order to guide curriculum development. Prior registration was not required for attendance, however, and participants who could not complete the pre-survey before the course were invited to complete a paper version the morning of the course.

After the course was completed, all attendees were invited to complete an online post-survey on the quality of the course. The post-survey had 15 questions including a five-question multiple-choice knowledge assessment and open-ended response questions for respondents to describe what they liked most and least. Comments were reviewed for content but not thematically analyzed.

The primary outcome was the change in self-reported comfort and competency in effecting change in the participants’ clinical practices. Three secondary measures pertained to the participants’ self-reported comfort and competence in other core multidisciplinary leadership skills: planning new projects, executing projects, and translating a clinical project into an academic product. These questions asked participants to rate their agreement with a statement on a five-point Likert Scale (“strongly disagree” to “strongly agree”).

We also collected attendees’ assessments of course quality and performance on the knowledge assessment. Analyses were conducted according to a published algorithm.(17) Sub-analyses were performed to assess correlates with outcomes, and no a priori confounders were identified and adjusted for. Missing data were excluded from relevant analyses, and pre-surveys from participants who did not complete a post-survey were excluded from pre-/post-comparisons.

Electronic surveys were collected using REDCap, a secure online electronic database designed for research.(18) Paper pre-surveys were entered into REDCap by the senior author, and these entries were checked for accuracy by the first author. Statistical analyses were conducted in Stata (StataCorp, College Station, TX). All statistical tests were two-sided. Attendees’ participation in the evaluation study was optional, and the evaluation study was approved as an evaluation activity by the Denver Health Quality Improvement Review Committee, which has been endorsed by the Colorado Multiple Institutional Review Board to grant such approval.

Course Outcomes

Participants

Twenty-two people attended the course. All completed a pre-survey online or on paper. Pre-surveys were completed a mean of 19 days (SD±16) before the course. Most attendees (19/22, 86 percent) completed a post-survey; post-surveys were completed a mean of seven days (SD±5) after the course.

Participants were a mean age of 44 years (SD±7) and 64 percent male. One was a fellow but otherwise 95 percent were physicians out of training. Accordingly, most (20/22, 91 percent) had at least one board certification, most commonly in general adult psychiatry (20/22, 91 percent) and consultation-liaison psychiatry (12/22, 55 percent), befitting this course’s presentation at a consultation-liaison psychiatry conference.

Attendees were largely clinical providers with some administrative obligation: the mean portion of full-time equivalent (FTE) committed to clinical care was 70 percent (SD±21 percent) and to administrative time was 22 percent (SD±21 percent). Dedicated FTE for teaching was less common (mean of 9 percent, SD ± 9 percent).

Most participants (20/22, 91 percent) said that they were currently leading or planning to lead or design a clinical program or team. Participants were largely unfamiliar with common program development and QI models including Kotter’s change model (16/22, 73 percent, were not at all or only somewhat familiar), Lean management (91 percent), plan-do-study-act cycle (77 percent), Ishikawa diagrams (91 percent), or logic models (91 percent).

Survey Results

Participants reported statistically significant increases in their comfort and confidence in effecting change in their clinical practices (61 percent agreed more strongly in the post-survey than in the pre-survey). They additionally reported increased comfort and confidence in other core aspects of multidisciplinary team leadership, including planning (53 percent) and executing (47 percent) new clinical projects and translating their projects into academic products (42 percent). These results as well as Wilcoxon signed-rank testing for pre-post comparisons are included in Figure 1. A clear majority of post-survey respondents (16/19, 84 percent) reported improvement in at least one of the four primary outcome questions.

Figure 1. Participants reported greater comfort and confidence in leadership domains after attending the course (n=19)

To assess the value of this course among participants with varying leadership experience, analyses were stratified by years of experience since finishing training, percent full-time equivalent (FTE) dedicated to administrative time, and familiarity with quality improvement (QI) models. Strata for the first two continuously defined categories were defined by being below the mean versus at or above the mean. For the last category, participants describing themselves as “very familiar” with any one presented QI model constituted one stratum and were compared to all other participants.

Although analyses were limited by small sample sizes, the value of this curriculum generally appeared more pronounced among participants with greater experience, administrative time, and familiarity with QI models. For example, greater administrative experience was associated with gains in comfort executing a project (p = .03) and translating projects into academic deliverables (p = .03). Self-reported ability to effect change in the practice environment improved more among those with greater administrative experience (p = .01) but remained significant regardless of prior clinical experience or familiarity with QI models. In no instance was less experience correlated with a negative impact of the course. Supplemental Table 1 illustrates the impact of stratification on primary and secondary outcomes.

Participants suggested that the course was meaningful and helpful. Most somewhat or strongly agreed that the course taught them new things (18/19, 95 percent), was well-organized and clearly presented (100 percent), relevant to their professional goals (100 percent), and will help them achieve those goals (18/19, 95 percent). No sub-analyses suggested that approval of the course was associated with participants’ prior leadership experience.

The mean score on the knowledge assessment was 69 percent (SD±14 percent) among 18 respondents (18/22, 82 percent). Less experience was associated with a higher score on the knowledge assessment.

Qualitative Feedback

Participants reported what they liked most about the course: “I learned new things about leadership” including on “change management and metrics discussion,” and “administrative aspects of the work we do.” Several respondents noted that the “content was excellent” and “presented with great clarity.” The use of “case-based presentations” and “open discussion” was particularly appreciated.

Opportunities for improvement included the use of “small groups activity” and “more participation” to incorporate “more specifics from the audience.” Some talks used too much “jargon.” “Consider making [the financial talk] simpler…,” advised one participant.

Discussion

Practicing psychiatrists commonly are expected to lead teams regardless whether they have received formal training in leadership skills at any stage in their career development. Despite these expectations, many psychiatrists — including those attending this course — lack familiarity with many core concepts of team leadership.

Participants reported significant benefit from this curriculum regardless of their previous administrative experience. However, this course’s value may have been more pronounced among learners with greater experience. It is possible that the course may have been more effective in building upon existing skills among experienced learners than in teaching new skills to novice learners. The short course duration may have been insufficient to provide deep practical instructions for novices whereas more senior administrators could draw on their own experiences to apply teaching. Admittedly, the small sample size limits the strength of conclusions based on these subanalyses.

Subjective feedback from learners indicated that better use of group discussion and audience participation could have added value to the course. This feedback is consistent with knowledge that teaching modules that incorporate multi-modal approaches, including experiential learning, is often more effective than didactic learning alone.(1,5) Although this format did not permit real experiential learning, small-group discussions and role playing can be used effectively as proxies for experiential learning in a classroom setting.(1)

Future iterations of this course will incorporate more frequent small group discussions and role playing. This format may also enhance the value of this course among attendees with less administrative experience.

Limitations of this study include its small sample size and a focus on consultation-liaison practice potentially at the exclusion of other psychiatric sub-specialties. Consultation-liaison psychiatrists work exclusively in collaboration with primary medical and surgical teams, whereas some other psychiatrists work in different team configurations. That attendees actively sought this training and paid for it may introduce some bias that exaggerates these results; however, this population does reflect the population and circumstances of physicians who are most likely to participate in this curriculum again.

Participants’ course feedback and self-assessments reflect how successfully the course taught core leadership concepts, but they cannot be used to measure leadership success downstream. Our analysis is limited by having information only on attendees’ feelings about what they learned rather than direct evidence of improved leadership skill. Therefore, we cannot conclude that participants practiced what they learned or became more effective leaders as a result of this course.

This study boasts several strengths, including a high participation rate and the use of an objective assessment to ascertain knowledge acquisition. This study also demonstrates a clear need for and benefit of leadership training among practicing psychiatrists. At least some core concepts that are essential to successful leadership can be delivered through a brief CME course. This format may be a practical solution to ensuring that practicing psychiatrists have access to leadership training even when leadership training was not included in their medical educations.

Conclusions

Physician learners can become more comfortable with core concepts of successful leadership through a four-hour CME course. Physician leaders require accessible and effective teaching to maximize their ability to lead teams in complex, multidisciplinary healthcare settings.

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