Is postgraduate leadership education a match for the wicked problems of health systems leadership? A critical systematic review.

PURPOSE: There have been a growing number of leadership education programs for physicians. However, debates about the value and efficacy of leadership education in medicine persist, and there are calls for systematic and critical perspectives on medical leadership development. Here, we review evidence on postgraduate leadership education and discuss findings in relation to contemporary evidence on leadership education and practice. METHOD: We searched multiple databases for papers on postgraduate leadership development programs, published in English between 2007 and 2017. We identified 4,691 papers; 31 papers met the full inclusion criteria. Data regarding curricular content and design, learner demographics, instructional methods, and learning outcomes were abstracted and synthesized. RESULTS: There was modest evidence for effectiveness of programs in influencing knowledge and skills gains in select domains. However, the conceptual underpinnings of the 'leadership' training delivered were often unclear. Contemporary theory and evidence on leadership practice was not widely incorporated in program design. Programs were almost exclusively uni-professional, focused on discrete skill development, and did not address systems-level leadership issues. Broader leadership capacity building strategies were underutilized. A new wave of longitudinal, integrated clinical and leadership programming is observed. CONCLUSIONS: Our findings raise questions about persistent preparation-practice gaps in leadership education in medicine. Leadership education needs to evolve to incorporate broader collective capacity building, as well as evidence-informed strategies for leadership development. Barriers to educational reform need to be identified and addressed as educators work to re-orientate education programs to better prepare budding physician leaders for the challenges of health system leadership.

If You Build It They Will Come and Stay: A Community-Based Family Medicine Program.

INTRODUCTION: In response to a government request to address physician shortages in underserved communities, the University of Toronto (U of T) established the Family Medicine Residency Program (FMRP) at the Royal Victoria Regional Health Centre (RVH) in Barrie, Ontario, Canada. Prior to establishing the FMRP, approximately 21% of Barrie residents did not have a family physician. This study investigated residents' training experiences, strengths and opportunities for improvement of a community FMRP, reasons why graduates choose to work in Barrie after graduation, and graduates' practice setting and location. METHODS: RVH graduates from 2011-2016 (N=45) were invited to participate. Semistructured one-on-one interviews sought insight into graduates' experience in the program. We collected online survey data to gather demographic information. We determined current practice location using a government-funded data set and the public registry of the provincial licensing body. RESULTS: Analysis of qualitative data provided insights into an overwhelmingly positive educational experience that contributed to graduates choosing to stay and work in Barrie. Participants noted the wide range of hands-on training opportunities as a strength of the program. They perceived that the program added value to the local community by increasing capacity to provide care to an underserved patient population. Tracking data demonstrated that two-thirds of graduates continued to work in the RVH region after graduation. CONCLUSIONS: The successful establishment of a new university-affiliated FMRP in an underserved community provides a strong mechanism to recruit physicians. Training in this setting provided excellent educational experiences to residents, who felt prepared to enter independent practice upon completion of training.

The state-of-play in physician health systems leadership research.

PURPOSE: This paper aims to review a decade of evidence on physician participation in health system leadership with the view to better understand the current state of scholarship on physician leadership activity in health systems. This includes examining the available evidence on both physicians' experiences of health systems leadership (HSL) and the impact of physician leadership on health system reform. DESIGN/METHODOLOGY/APPROACH: A state-of-the-art review of studies (between 2007 and 2017); 51 papers were identified, analyzed thematically and synthesized narratively. FINDINGS: Six main themes were identified in the literature as follows: (De)motivation for leadership, leadership readiness and career development, work demands and rewards, identity matters: acceptance of self (and other) as leader, leadership processes and relationships across health systems and leadership in relation to health system outcomes. There were seemingly contradictory findings across some studies, pointing to the influence of regional and cultural contextual variation on leadership practices as well entrenched paradoxical tensions in health system organizations. RESEARCH LIMITATIONS/IMPLICATIONS: Future research should examine the influence of varying structural and psychological empowerment on physician leadership practices. Empirical attention to paradoxical tensions (e.g. between empowerment and control) in HSL is needed, with specific attention to questions on how such tensions influence leaders' decision-making about system reform. ORIGINALITY/VALUE: This review provides a broad synthesis of diverse papers about physician participation in health system leadership. Thus, it offers a comprehensive empirical synthesis of contemporary concerns and identifies important avenues for future research.