The Military Medicine Leadership Life Cycle: A Model for Longitudinal Leadership Development for Staff Physicians.

Leadership development is a challenge for all health care systems. Military Medicine has unique challenges with increased frequency of physician turnover and more junior leaders taking on positions of leadership earlier in their careers. Military medical corps officers are also challenged with leading in clinical, academic, and operational settings. Effective leadership within the Military Healthcare System requires an intentional and ongoing leadership development process across the careers of military medical corps officers. This article describes the leadership lifecycle of military medical corps officers, highlighting existing leadership development opportunities and providing an example of a leadership lifecycle from junior staff to senior executive for other organizations. The article concludes with specific recommendations that will allow military medicine to continue to strengthen the leadership skills of its officers to meet ever growing challenges.

The Military Medicine Leadership Life Cycle: A Model for Longitudinal Leadership Development in Medicine-Undergraduate and Graduate Medical Education.

Physicians must be leaders more than ever with innumerable challenges. Despite this need, there is a paucity of consistent leadership development (LD) from medical student to staff physician. Military medicine has additional challenges-working within a large health care organization, constant turnover, working in a variety of contexts-that make the need for LD even more pressing. The purpose of this paper is to describe the LD life cycle for military undergraduate and graduate medical education (UME and GME), providing examples for other organizations while identifying steps to meet the future needs in military medicine. The Health Professions Scholarship Program produces over 75% of graduates for military medicine each year. Yet, since learners are dispersed throughout civilian medical schools any LD results in a heterogeneous experience. Uniformed Services University has a 4-year LD program required for all students as well as other opportunities for leadership professional growth. Military GME programs are unique, requiring a military unique curriculum to prepare graduates for their initial assignments. Military unique curriculum vary, but include clinical topics relevant to military medicine as well as leadership. There is no Military Healthcare System-wide leadership curriculum used by everyone at this time. Based on these UME and GME approaches to LD, there have been multiple lessons learned formed on the authors experience and published literature: learners do not typically see themselves as leaders; learners want applicable curriculum with less lecturing and more application and discussion; programs are often siloed from one another and sharing curriculum content does not typically occur; no one-size-fits-all model. On the basis of the lessons learned and the current state of UME and GME leadership education, there are 5 recommendations to enhance UME and GME leadership programs: (1) develop a Health Professions Scholarship Program Leadership Curriculum; (2) develop a MHS GME Leadership Curriculum; (3) integrate UME and GME Leadership Curricula; (4) develop faculty to teach leadership; and (5) conduct research on UME and GME in military and share lessons learned. We suggest a roadmap for strengthening LD within military medicine and civilian institutions.

Leadership and Followership Dynamics in Interprofessional Health Care Teams: Attending Physician Perspectives.

PURPOSE: Effective interprofessional health care team (IHT) members collaborate to reduce medical errors, use resources effectively, and improve patient outcomes, making interprofessional collaboration imperative. Because physicians are often designated as the positional leaders of IHTs, understanding their perspectives on collaboration within IHTs could help to mitigate the disconnects between what is suggested in theory and what is happening in practice. This study aimed to explore leader-follower dynamics within medical teams that are commonly working in clinical care contexts. METHOD: Using a constructivist approach, the authors conducted 12 individual, semistructured interviews from November 2022 to September 2023 with attending physicians who have led IHTs in perioperative (i.e., preoperative clinic, operating room, postoperative and recovery unit) or emergency department settings. The transcripts were analyzed from December 2022 to December 2023 using inductive thematic analysis. RESULTS: Three themes explained the physician perceptions of IHT leadership-followership dynamics: (1) physicians are comfortable sharing leadership intraprofessionally, (2) the clinical culture and environment constrain interprofessional followership and shared leadership, and (3) hierarchical models hold true even while active followers are appreciated, when appropriate. CONCLUSIONS: The data in this study suggest that, in perioperative and emergency department settings, shared leadership largely may not occur interprofessionally but occurs intraprofessionally. Participants suggested that the clinical culture and environment (i.e., legal concerns, hierarchical assumption, patient care ownership responsibilities) constrained interprofessional followership and shared leadership. On the basis of the study's findings and how they align with previous research, future research into interprofessional collaboration and followership roles should focus on what factors enable and constrain active followership and shared leadership. Such collaboration can only be achieved when active followership and shared leadership are allowed and promoted. These findings and others suggest that not all contexts are enabling such types of interprofessional collaboration due to legal concerns, hierarchical traditions, and patient ownership considerations.

Emotionally intelligent themes in medical leaders' decision-making during COVID-19.

BACKGROUND: The COVID-19 pandemic presented unprecedented challenges for leaders in healthcare requiring decision-making and crisis response that can often be tricky without the right level of trust. Trust is fostered and facilitated with emotional intelligence (EI); thus, a critical examination of medical leaders' reflections was essential to understand how leaders perceived their leadership responses during the initial response to COVID-19. This exploratory study used an EI lens to investigate leaders' perceptions of their decision-making during COVID-19. METHODS: A purposeful sample of seven leaders in medicine who experienced leading during COVID were invited to participate in semi-structured interviews. RESULTS: Four themes around leadership response during the uncertain times of the COVID-19 were identified. The themes included communication, interprofessional collaboration including decision-making and strategic planning, internal and external awareness, and finally, trust and psychological safety. CONCLUSIONS: Incorporating EI competencies into crisis leadership education for healthcare professionals could enhance medical leaders' preparedness to adapt, collaborate and communicate effectively in a crisis.

Sport Psychology: Principles and Practices for Sports Medicine Physicians.

ABSTRACT: Sport psychology is the scientific study and application of psychological principles to enhance performance and well-being in sport, exercise, and physical activity. It has numerous applications to sports medicine, as psychological factors are associated with sport injury risk, recovery, successful return to play, and overall health. This article addresses how sport psychology is important to sports medicine and what applied sport psychologists do. We discuss several psychological principles and practices relevant to individual performance and well-being, including goal setting, communication, arousal and performance, imagery/mental rehearsal, attention management, managing psychological distress, and behavioral health. We also discuss principles and practices of sport psychology relevant to team performance, including stages of team development, goal setting, communication, arousal and performance, and behavioral health. Sport psychology and applied sport psychology practitioners can be valued assets to sports medicine teams in supporting individual and team performance and injury recovery.

Pilot study exploring the presence of leadership curricula in undergraduate medical education.

INTRODUCTION: The physician's role in the healthcare delivery system extends beyond patient care to include numerous critical leadership roles in healthcare. In addition to treating patients, physicians manage multidisciplinary teams and influence policies to optimise public health. Yet, leadership education is not currently emphasised as part of undergraduate medical education. The purpose of this pilot study was to survey US allopathic medical schools about their current leadership curricula for medical students, including aspects that promote or inhibit effective curricular implementation. METHODS: A survey was developed and administered to representatives at US allopathic medical schools regarding the presence and nature of leadership curricula for medical students currently in place, as well as barriers to effective implementation. RESULTS: A total of 41 of 144 medical schools (28%) responded to the survey. Of the schools that responded, 25 schools reported the presence of a leadership curriculum. Primary competencies and goals were similar among these institutions, but the structure of the curriculum and how it is being implemented varied. The study did not identify consistent methods of assessing student leadership competencies. Themes of improved communication and integration within the curriculum emerged as actions promoting successful implementation. Financial restraints and buy-in among stakeholder groups (eg, faculty, staff and students) were mentioned most frequently as barriers to the effective implementation of leadership curricula. CONCLUSIONS: Although leadership education within undergraduate medical education is emphasised by a variety of groups, including the Association of American Medical Colleges, medical schools do not appear to universally address this topic. The Liaison Committee on Medical Education, the primary accrediting body for medical schools, does not currently require leadership education as a core topic for accreditation. To provide effective education on leadership to medical students, administrative bodies could improve their support for this topic by considering the factors identified that both hinder and promote implementation.

Impact on Faculty's Own Development When Assessing Student Performance.

INTRODUCTION: Assessing learner performance is a primary focus within simulation-based education in order to prepare students with the knowledge and skills they will need going forward in their careers. In order to properly conduct these assessments of learner performance, faculty must be adequately trained on the scenario, expectations, assessment measures, and debriefing. During Operation Bushmaster, a five-day "deployment" for learners, faculty assess students as they rotate through different leadership roles. The faculty development includes online and in-person training that provides them with an understanding of the scenario; what learners know; the framework used at USU to guide curriculum, development, and assessment; how to assess learners; and how to provide feedback to learners. Research has examined the value of receiving assessment and feedback from a student perspective, but the impact of being the assessor and giving feedback has not been researched from the faculty point of view. The purpose of this study, therefore, was to examine the impact of assessing students in simulation scenarios on faculty's own development as an educator and leader. MATERIALS AND METHODS: Through a phenomenological qualitative study, we explored participants' lived experiences as faculty at Operation Bushmaster. Eighteen faculty from a variety of medical specialties and military ranks volunteered to participate. Participants were interviewed in-person using a semi-structured interview. Analyses included individually reading through each transcript; then individually coding and taking notes of terms and phrases used by participants; codes were compiled and organized into categories, which became the themes of our study. RESULTS: The interviews demonstrated the following themes in which providers who serve as faculty of Operation Bushmaster believe they gain from the experience: (1) The experience helps to reground their own thinking; (2) acting as faculty during simulation-based education helps them remain up-to-date on necessary skills; and (3) working with students helps faculty continually develop as an educator and a leader. CONCLUSIONS: This work describes how even when faculty are brought in for learner assessment, they are taking away lessons and experiences that aid in their own development as an educator as well as a leader. Acting as an assessing faculty for students may allow faculty to reground their own thinking, remain up-to-date on necessary skills, and continually develop their skills as an educator and leader. These findings suggest that some faculty involved in simulation events may also gain knowledge, skills, and experiences that can help with their own development even when the focus is on learners.

Followership in interprofessional healthcare teams: a state-of-the-art narrative review.

OBJECTIVE: A state-of-the-art (SotA) literature review-a type of narrative review- was conducted to answer: What historical developments led to current conceptualisations of followership in interprofessional healthcare teams (IHTs)? DESIGN: Working from a constructivist orientation, SotA literature reviews generate a chronological overview of how knowledge evolved and presents this summary in three parts: (1) this is where we are now, (2) this is how we got here and (3) this is where we should go next. Using the SotA six-stage methodology, a total of 48 articles focused on followership in IHTs were used in this study. RESULTS: Articles about followership within IHTs first appeared in 1993. Until 2011, followership was framed as leader-centric; leaders used their position to influence followers to uphold their dictums. This perspective was challenged when scholars outside of healthcare emphasised the importance of team members for achieving goals, rejecting a myopic focus on physicians as leaders. Today, followership is an important focus of IHT research but two contradictory views are present: (1) followers are described as active team members in IHTs where shared leadership models prevail and (2) conceptually and practically, old ways of thinking about followership (ie, followers are passive team members) still occur. This incongruity has generated a variable set of qualities associated with good followership. CONCLUSIONS: Leadership and followership are closely linked concepts. For leaders and followers in today's IHTs to flourish, the focus must be on followers being active members of the team instead of passive members. Since theories are increasingly encouraging distributed leadership, shared leadership and/or situational leadership, then we must understand the followership work that all team members need to harness. We need to be cognizant of team dynamics that work within different contexts and use leadership and followership conceptualisations that are congruent with those contexts.

Interprofessional Experiences of Family Nurse Practitioner Students During a Military Field Practicum.

INTRODUCTION: Team building is a real-world necessity in military and civilian health care settings. Interprofessional education (IPE) is therefore an essential component of health care education. At the Uniformed Services University, there are continued, deliberate attempts for IPE to occur to successfully prepare students to work together and adapt to ever-changing contexts. Although past quantitative research has analyzed interprofessional collaboration among military medical students, this study explores the interprofessional experiences of family nurse practitioner (FNP) students during a military medical field practicum. MATERIALS AND METHODS: This study was reviewed by the Uniformed Services University Human Research Protections Program Office (Protocol DBS.2021.257). We used the qualitative transcendental phenomenological approach to design our study. We analyzed the reflection papers of 20 family nurse practitioner students who participated in Operation Bushmaster in order to explore their interprofessional experiences. Our research team coded and categorized the data, developing textural and structural descriptions of these categories, which served as the results of our study. RESULTS: We present the study's three key findings that students expressed and include perspectives from their viewpoints to illustrate each theme. The three themes related to IPE are (1) quality of integration determines perception of experience, (2) challenges inspire continued growth, and (3) increased self-awareness of one's own strengths. CONCLUSIONS: It is important for educators and leaders to find ways to allow for positive team integration and cohesion so that students do not feel overwhelmed by their perceived lack of knowledge or experience. Educators can use that perception to motivate a growth mindset so that they can continually seek out ways to improve and grow. Additionally, educators can prepare students with adequate knowledge to ensure that each team member meets mission success. Finally, to continually develop, students need to have awareness of their own strengths as well as areas for growth to enhance their own performance as well as that of the military interprofessional health care teams.

Students' Leadership Development During a High-fidelity Military Medical Field Practicum.

INTRODUCTION: Leadership development is a cornerstone aspect of military medical education. Operation Bushmaster, a medical field practicum (MFP) conducted by the USU, tests fourth-year medical students' clinical skills and leadership acumen in an operational environment. No studies have examined students' perceptions of their own leadership development during this MFP. Therefore, this study explored leadership development from the students' perspectives. MATERIALS AND METHODS: Using a qualitative phenomenological design, we analyzed the reflection papers of 166 military medical students who participated in Operation Bushmaster during the fall of 2021. Our research team coded and categorized the data. Once defined, these categories served as the themes in this study. RESULTS: Three central themes were expressed: (1) the importance of direct and decisive communication, (2) unit cohesion and interpersonal relationships enhance the team's ability to adapt, and (3) followership quality determines leadership outcomes. The students' leadership ability was maximized by established relationships within their unit and well-practiced communication, and a decreased propensity for followership negatively affected leadership. Overall, Operation Bushmaster increased students' appreciation of the importance of leadership development and overall enhanced their leadership outlook as a future military medical officer. CONCLUSIONS: This study provided an introspective vantage from military medical students pertaining to their own leadership development, as participants described how the challenging environment of a military MFP challenged them to hone and develop their leadership skills. As a result, the participants gained a greater appreciation of continued leadership development and realization of their future roles and responsibilities within the military health care system.

Reflecting on LTCOS Scholarship and Implications for Educational Practice.

The Long Term Career Outcome Study is a central program of research in the Center for Health Professions Education at the Uniformed Services University. The overarching goal of Long Term Career Outcome Study is to perform evidence-based evaluations before, during, and after medical school, and as such, it represents a form of educational epidemiology. In this essay, we highlighted the findings of the investigations published in this special issue. These investigations span from "before" medical school matriculation to "during" medical school and "after" learners go on to graduate training and practice. Furthermore, we discuss how this scholarship might shed light on improving the educational practices at the Uniformed Services University and potentially elsewhere. We hope that this work demonstrates how research can enhance medical education processes and connect research, policy, and practice.

Well-being at a Military Medical School and Implications for Military Retention.

INTRODUCTION: Physical and psychological well-being play a critical role in the academic and professional development of medical students and can alter the trajectory of a student's quality of personal and professional life. Military medical students, given their dual role as officer and student, experience unique stressors and issues that may play a role in their future intentions to continue military service, as well as practice medicine. As such, this study explores well-being across the 4 years of medical school at Uniformed Services University (USU) and how well-being relates to a student's likelihood to continue serving in the military and practicing medicine. METHODS: In September 2019, 678 USU medical students were invited to complete a survey consisting of three sections-the Medical Student Well-being Index (MSWBI), a single-item burnout measure, and six questions regarding their likelihood of staying in the military and medical practice. Survey responses were analyzed using descriptive statistics, analysis of variance (ANOVA), and contingency table analysis. Additionally, thematic analysis was conducted on open-ended responses included as part of the likelihood questions. RESULTS: Our MSWBI and burnout scores suggest that the overall state of well-being among medical students at USU is comparable to other studies of the medical student population. ANOVA revealed class differences among the four cohorts, highlighted by improved well-being scores as students transitioned from clerkships to their fourth-year curriculum. Fewer clinical students (MS3s and MS4s), compared to pre-clerkship students, indicated a desire to stay in the military. In contrast, a higher percentage of clinical students seemed to "reconsider" their medical career choice compared to their pre-clerkship student counterparts. "Medicine-oriented" likelihood questions were associated with four unique MSWBI items, whereas "military-oriented" likelihood questions were associated with one unique MSWBI item. CONCLUSION: The present study found that the overall state of well-being in USU medical students is satisfactory, but opportunities for improvement exist. Medical student well-being seemed to have a stronger association with medicine-oriented likelihood items than with military-oriented likelihood items. To obtain and refine best practices for strengthening engagement and commitment, future research should examine if and how military and medical contexts converge and diverge throughout training. This may enhance the medical school and training experience and, ultimately, reinforce, or strengthen, the desire and commitment to practice and serve in military medicine.

Undergraduate Medical Education Leader Performance Predicts Postgraduate Military Leader Performance.

INTRODUCTION: Developing physicians as leaders has gained attention across the United States. Undergraduate medical education (UME) and graduate medical education (GME) leader development programs have increased. During postgraduate years (PGY), graduates bring their leadership education to the bedside; however, associations between leader performance in medical school and GME is largely unknown. It is important to find experiences that can assess leader performance that may be useful to predict future performance. The purpose of this study was to determine if (1) there is a correlation between leader performance during the fourth year of medical school versus leader performance in PGY1 and 3, and (2) leader performance during the fourth year of medical school is associated with military leadership performance in PGY1 and 3s while taking previous academic performance markers into account. METHODS: This study examined overall leader performance of learners (classes of 2016-2018) during the fourth year of medical school and their graduate leader performance post-medical school. Leader performance was assessed by faculty during a medical field practicum (UME leader performance) and graduate leader performance was assessed by program directors at the end of PGY1 (N = 297; 58.3%) and 3 (N = 142; 28.1%). Pearson correlation analysis examined relationships among UME leader performance and between the PGY leader performance items. In addition, stepwise multiple linear regression analyses were conducted to examine the relationship between leader performance at the end of medical school with military leadership performance in PGY1 and 3, while taking into account the academic performance markers. RESULTS: Pearson correlation analyses revealed that the UME leader performance was correlated with 3 of 10 variables at PGY1, and was correlated at PGY3 with 10 out of 10 variables. Results of the stepwise multiple linear regression analysis indicated that leader performance during the fourth year of medical school explained an additional 3.5% of the variance of PGY1 leader performance after controlling for the previous academic performance markers (MCAT total score, USMLE Step 1 score and Step 2 CK score). In contrast, leader performance during the fourth year of medical school alone accounted for an additional 10.9% of the variance of PGY3 leader performance above and beyond the set of academic performance markers. Overall, UME leader performance has more predictive power in PGY leader performance than the MCAT or USMLE Step exams. CONCLUSIONS: The findings of this study indicate that a positive relationship exists between leader performance at the end of medical school and leader performance in PGY1 and 3 years of residency. These correlations were stronger in PGY3 compared to PGY1. During PGY1, learners may be more focused on being a physician and an effective team member compared to PGY3 where they have a deeper understanding of their roles and responsibilities and can take on more leadership roles. Additionally, this study also found that MCAT and USMLE Step exams performance was not predictive of PGY1 or PGY3 leader performance. These findings provide evidence of the power of continued leader development in UME and beyond.

Assessment of Veterans Affairs Case Managers Using a Leadership Conceptual Framework.

PURPOSE/OBJECTIVES: Case management in Veterans Affairs (VA) depends on leadership skills such as effective communication, excellent resource management, self-governance, patient advocacy, and a distinctly professional attitude. VA registered nurses (RNs) and social workers (SWs) also provide case management services, a role and service, which is pivotal to veteran satisfaction and effective health care coordination.The leader-follower framework (LF2) was used to assess and compare the responses of RNs, SWs, and case managers (CMs) on the annual VA All Employee Survey (AES) to provide insight regarding VA case management performance, which has influenced veteran satisfaction. PRIMARY PRACTICE SETTING: VA CMs work in a variety of clinical settings, which, in recent years, includes the use of telehealth modalities because of COVID-19. VA CMs remain flexible working in environments where and when veterans require their services while promoting safe, effective, and equitable health care services. FINDINGS/CONCLUSIONS: RNs and SWs indicated greater agreement and satisfaction scores in 2019 compared with 2018 on questions related to the leadership element of character and questions regarding mutual respect between VA senior leaders and the respondents. In contrast, RNs and SWs indicated less agreement and satisfaction scores on questions related to the leadership elements of competence, context, communication, personal, interpersonal, team, organizational, and greater burnout in 2019 than in 2018. RN response scores in 2018 and 2019 were greater and burnout scores were less than SWs. Additionally, the one-way analysis of variance indicated no difference for RNs and SWs who were performing the duties of a CM. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The responses of RNs indicated greater satisfaction and less burnout than SWs and were consistent whether RNs and SWs were in case management roles or not. These are important findings and concerning trends warranting further discussion and research.

Leadership Elements in Veterans Affairs All Employee Survey.

PURPOSE/OBJECTIVES: Veterans Affairs (VA) case managers assist and advocate for veterans navigating VA and civilian health care systems. However, government reports indicate repeated dissatisfaction with veteran care coordination. Several case management publications suggest that VA case managers lead, as well as manage, but do not indicate exactly what this means. Few published articles address leadership, specifically, among VA case managers.The VA All Employee Survey (AES) is an annual survey of VA employees, including case managers, to gather information about their attitudes toward workplace characteristics, relationships, and leadership. The present study utilized a conceptual Leader-Follower Framework (LF2) to assess questions on the annual VA AES to determine which leadership elements are addressed, which leadership elements are not addressed, and whether there are any leadership elements that do not fit within the LF2. PRIMARY PRACTICE SETTING: Case managers work in a variety of clinical settings including more than1,400 facilities throughout the United States. VA case managers advocate for safe, effective, and equitable patient care according to their scope of practice. FINDINGS/CONCLUSIONS: All eight leadership elements from the LF2-Character, Competence, Context, Communication, Personal, Interpersonal, Team, and Organizational-were represented among the AES questions, and no leadership elements outside of the framework were identified. However, the leadership elements were unevenly represented within the AES questions, with communication and personal elements occurring frequently whereas context and team were underrepresented. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: These results indicate the LF2 can be used to evaluate the responses of VA employees, including those providing case management, and to address questions of interest related to leadership and may be considered in the development of future case management surveys.

Leading Change in Health Care.

Change leadership is essential for individuals, teams, and organizations. It focuses on leadership to initiate, support, and adapt to modifications, alterations, and new situations. Many perspectives, models, theories, and steps have been offered to optimize change. Some approaches emphasize organizational change, whereas others focus on responses of individuals to change. With regard to leading change in health care, it is important to enhance well-being among health-care professionals and patients and to improve organizational and system best practices. To achieve optimal health-care changes, this article draws from several business-focused approaches to change leadership, psychological models, and the authors' Leader-Follower Framework (LF2).

State-of-the-art literature review methodology: A six-step approach for knowledge synthesis.

INTRODUCTION: Researchers and practitioners rely on literature reviews to synthesize large bodies of knowledge. Many types of literature reviews have been developed, each targeting a specific purpose. However, these syntheses are hampered if the review type's paradigmatic roots, methods, and markers of rigor are only vaguely understood. One literature review type whose methodology has yet to be elucidated is the state-of-the-art (SotA) review. If medical educators are to harness SotA reviews to generate knowledge syntheses, we must understand and articulate the paradigmatic roots of, and methods for, conducting SotA reviews. METHODS: We reviewed 940 articles published between 2014-2021 labeled as SotA reviews. We (a) identified all SotA methods-related resources, (b) examined the foundational principles and techniques underpinning the reviews, and (c) combined our findings to inductively analyze and articulate the philosophical foundations, process steps, and markers of rigor. RESULTS: In the 940 articles reviewed, nearly all manuscripts (98%) lacked citations for how to conduct a SotA review. The term "state of the art" was used in 4 different ways. Analysis revealed that SotA articles are grounded in relativism and subjectivism. DISCUSSION: This article provides a 6-step approach for conducting SotA reviews. SotA reviews offer an interpretive synthesis that describes: This is where we are now. This is how we got here. This is where we could be going. This chronologically rooted narrative synthesis provides a methodology for reviewing large bodies of literature to explore why and how our current knowledge has developed and to offer new research directions.