A Roadmap to Leadership During the Postgraduate Residency in India

Postgraduate residents of today are the healthcare leaders of tomorrow. However, leadership training for doctors, especially during the medical training, has not received adequate attention. Doctors learn much of their medicine by following their teachers (mentors and role models) in clinical rounds and are trained to spend most of their physical and mental resources during their training toward achieving the organizational objectives. This natural process of evolution of a doctor, often imparted through the “hidden curriculum,” ¹ invariably demands the transition from being a follower to a leader. After graduating from medical college, doctors in India either choose to pursue post-graduation or enter voluntary/obligatory government service, where, irrespective of their ability to lead, many of them are expected to embrace the roles of leaders in hospital administration and policymaking in the health centers they are allotted.^2,3 This transition involves adapting to the challenges of new roles and responsibilities that demand a skill set that extends the brief of clinical medicine. This presents a unique predicament to early-career doctors who are not well equipped to handle such exigencies as they are stuck in the student zone. Thus, the roles, demands, and responsibilities entrusted on the physicians and other healthcare professionals are varied, ranging from the delivery of healthcare to maintenance and improvement of the healthcare system as a whole. This mandates the residents to acquire relevant leadership competencies during their training and practice to tackle the expectations better. ⁴ Additionally, improved leadership translates to higher satisfaction and lesser burnout. ⁵ However, while the need for leadership development among healthcare professionals in training and practice is widely acknowledged, the actions taken toward bridging the gap in leadership development for healthcare professionals remain an open question.

This article provides a critical appraisal of leadership training during residency in India.

Need for Leadership Training Among Medical Residents in India

A leader is defined as one who selects, equips, trains, and influences one or more followers who have diverse gifts, abilities, and skills. The followers willingly and enthusiastically expend emotional and physical energy in a concerted, coordinated effort to achieve the organizational mission and objectives. ⁶ Although, to an extent, doctors are trained to be leaders, a paradoxical void exists in leadership in medical residents. There are several challenges to leadership development during the residency in India that are summarized below.

Challenges Within

1. Attitudinal barriers: Pressurizing all residents toward leadership is imprudent as every resident may not want to become leaders beyond the call of clinical practice. Although clinical problem solving is traditionally taught as hypothetico-deductive reasoning that is inculcated while dealing with patients suffering from various ailments, ⁷ the same cannot be said about the ability of residents for problem-solving skills across the rubric of personal and professional challenges. This process of complex problem solving has many factors influencing it. This includes trait factors such as an individual’s cognitive abilities and personality and state characteristics, such as knowledge, social judgment, experience, and skill. ⁸ Investing time and resources in leadership is not an implicit process.

2. Reductionist view of residency: Although the residency program is meant to facilitate the residents to obtain a professional degree at the end of their training, a reductionist view of residency as just a means to obtain a degree limits the opportunity for leadership and growth.

3. Overzealous focus on clinical and academic skills: The lack of short-term rewards for leadership development translates to academic and clinical skills being the prime and only target of residents. Faring well in an exam or an assessment, mastering a new surgical technique, accurately diagnosing a complex clinical presentation or achieving a university gold medal, all of which are desirable virtues, are powerful immediate and short-term motivators that demand time, energy, and resources that are likely to nudge out leadership development in terms of felt need.

4. Genuine lack of protected time: Due to the lack of affordability of private healthcare, a significant proportion of Indian patients depend upon public healthcare systems and medical colleges for their healthcare needs. This translates to increased patient loads on these systems, where residents are often the front-line providers of health care. Additionally, residents face challenges in finding time to meet deadlines for other clinical and academic demands, such as dissertation, seminars, journal club presentations, and case-conferences. This leads to a lack of protected time for residents for introspection and leadership development.

5. Stress and burnout: Burn out among residents is an increasingly recognized reality, with prevalence rates up to 50%. ⁹ Inherent vulnerabilities such as neuroticism or poor coping skills, coupled with stressors of residency and personal life, can often lead to significant burn out that often demotivates a resident from focusing on higher-order needs such as leadership.

Challenges Around

1. Fractured medical curriculum: Medical curriculum across the world focuses on enhancing the academic and clinical abilities, often superseding the other essential “non-technical” skills such as professionalism, working with a team, and effective communication. Most often, the bigger picture is sacrificed for the hassles and joys of daily work—assignments, examinations, clinical responsibilities, etc., which can be termed as a fractured learning environment. ¹⁰ This microsystem-based learning may lead to acquisition of knowledge and clinical skill at the cost of leadership and professional skills.

2. Lack of incentives: Leadership training received by the resident doctor usually does not figure in the list of essential attributes on the curriculum vitae (CV) alongside academic credentials and research publications. In a CV, clinical experience is a substantially more desirable virtue over leadership experience.

3. Lack of timely and robust feedback: Residents do not get timely positive and constructive feedback as they perform micro-leadership roles such as organizing workshops, symposia, audits, and undergraduate teaching. Another major constraint would be the required time needed for such feedback in the existing curricula of the medical students or clinic hours of healthcare professionals. ¹¹

4. Rotatory structure of training: The constant rotations during postgraduate residency hinder aspiration for leadership development in residents due to continually changing short-term and medium-term roles and objectives.

5. The nomadic doctor: Residents may not choose to continue working in the institute of their postgraduation for various reasons, and, therefore, the institute and its faculty may not be naturally inclined to invest in the leadership development of a resident doctor.

Challenges from Above

1. Institutional work cultures: The priorities of most healthcare organizations are inherently patient-, policy-, service-, and economy-centric. Leadership development for residents seldom figures in the organization’s list of objectives. The channels of communication are most often unidirectional in the top-down direction. Additionally, a silent resident who does not disturb the institutional homeostasis is preferred over residents who may be willing to act as genuine agents of change in leadership roles. Therefore, organizations are unlikely to take the initiative toward developing a policy decision on leadership unless mandated by professional bodies such as national and state medical councils. ¹²

2. The centralized power system in healthcare organizations: Most of the vital leadership and administrative decisions are centered around a select administration committee that relies heavily on the hierarchical model of power, and, therefore, the culture of developing future leaders in healthcare, including residents, is not a natural process.

3. Role model system of leadership development: The development of next-generation leaders in Indian milieu is predominantly modeled on an apprenticeship system wherein a mid-level faculty is trained for the job that he/she is the successor designate. This invariably breeds a followership model of next-generation leaders and is not conducive to early-career leadership development.

4. Lack of dedicated funding: Resident leadership training initiatives require periodic training programs and symposia that, in turn, require funding. This puts additional strain on the already burdened economic resources of the institute.

Leadership Perspective in Modern Medicine

The perspective of leadership is evolving rapidly in the context of modern medicine. Learning and expertise in several of the below key components have become increasingly relevant in healthcare delivery. It is, therefore, prudent to sensitize residents to some of these challenges and opportunities during the residency itself.

Health Economics

In modern medicine, across different countries at various stages of development, strained economic resources have necessitated all critical decision making to factor in maximizing efficiency despite the constraints of budget or resource allocation. The threat faced by the National Health Service (NHS) in the United Kingdom is a prime example that highlights the importance of health economics in modern medicine. ¹³ There is an enhanced need for better awareness and competence in this area, and it is seldom addressed in the medical or postgraduate curriculum. ¹⁴

Procedures for Quality Assurance and Accreditation

The practice of medicine is increasingly structured around nationally and locally defined quality control policies and accreditation standards. The knowledge and proficiency about these standards, coupled with the competency to imbibe the same in the prevalent work environment, are a necessary leadership skill when heading small teams or hospital subcommittees. ¹⁵

Ethics and Law

Modern healthcare leadership needs to always side itself on the right side of law and ethics. Ethically sound and legally correct systems practice needs a favorable institutional work culture fostered through individual and organizational leadership. Such skills are a prerequisite to run healthcare systems and subsystems within the confines of the regulatory and legal framework. ¹⁶

Expertise in Crosstalk Between Different Systems

A successful leader at any level of healthcare organization will have to interact with multiple systems such as hospital administration, patients, employee associations, academic boards, national and local medical councils, community leadership, non-government agencies, media, and, occasionally, political leadership. This involves fostering collaborative power-sharing over competitive power-sharing, a negotiated order across different teams, and ensuring effective, innovative healthcare delivery relevant to the community.

Innovation and Marketing

This unique leadership skill involves the process of choosing simpler, affordable solutions over complicated or expensive solutions, and finding the correct business model solutions in healthcare delivery. Also, a reasonable degree of marketing healthcare services is required within the regulatory framework to ensure that the bridge between need and supply is established. ¹⁷

As the need for leadership among healthcare professionals is widely felt these days, several modern healthcare organizations and academic and teaching centers have established leadership programs for faculty and trainees.^18,19 These programs provide the materials and training for the faculty and trainees to develop and refine their leadership skills such as communication, collaboration, mentoring, and managerial skills. However, such leadership programs are not universal and are being provided in only a few institutions.

Leadership During Postgraduation: Focus on India

Although the medical training system in India is geared to impart the clinical knowledge and skills to the trainees and residents, it is not systematically equipped to deliver the leadership skills needed to the residents. The Medical Council of India does not recognize the need for leadership training to medical graduates as an essential skill and rather views it as a quality to be built by oneself beyond the confines of the clinic by the end of residency. ²⁰ Moreover, some of the challenges outlined above hinder the development of leadership qualities in the residents. This calls for an effort to build a nurturing environment in institutions offering residency programs that will further increase desire and aptitude in residents to explore leadership in various avenues during residency. This brings the essential questions of who should be responsible for the development of the leadership skills in the residents and how to build a systematic program in the medical curriculum to impart this vital skill. The onus lies with the administrative body involved in the development of the medical education curriculum in India and the medical institutions imparting education. Medical Council of India, in consultation with the field experts and medical institution representatives, could explore the specific leadership needs of the young doctors in the society, develop curriculum for the same, and taking into consideration the existing infrastructure available in the medical institutions to deliver these leadership skills. This needs coordinated efforts in developing the structured curriculum, training the clinicians/teachers working in medical institutions on leadership skills, ways of imparting them to students, and building appropriate infrastructure in the medical institutions to deliver these skills.

Till such a broad framework is available, a team of a senior faculty and a junior faculty member can be nominated from each department to facilitate near-peer learning to develop guidelines around which leadership needs can be met during residency. These guidelines need to be tailored, keeping in mind the residency and the leadership at the local and national levels.

The Stepwise Initiation to Different Components of Leadership

Although we acknowledge that the process of building leadership skills extends beyond residency and continues throughout one’s career, we highlight the broad framework toward forging essential leadership skills during residency.

Core Competency

Broadly defined as the set of knowledge and skills that are mandated by the curriculum, core competency development is akin to the concept of micro-gains where the resident tries to achieve excellence in each responsibility allotted (academic and non-academic). The Medical Council of India has laid down specialty-specific competency curricula and mandated periodic appraisal.^21,22

Time Management

Time management and prioritization are also vital skills that a resident needs to manage the increased workload and maintain optimum efficiency and simultaneously to avoid stress and burnout during residency. ²³ Time management techniques include effective planning of short-term goals, recognition of physical, technological, and psychological barriers in achieving the objectives within the allocated timeframe, and a constant self-mastery over time that needs to start early during the period of residency.

The Role of Mentorship

Most successful doctors attribute their success, at least in part, to guidance received from mentors.^24,25 Finding THE mentor (different from finding a mentor) is vital for personal and career growth, and the following tips can help a resident in the same:

Observe and shortlist the list of potential mentors, preferably from the same department.

Preferably choose mid-career faculty—Senior-level faculty members are often the most sought-after mentors and guides in professional training. However, owing to the many roles and responsibilities they are assigned at work, they may not be in a position to take in one more mentees under their wing. It is, therefore, more pragmatic to choose a mid-career faculty member as a mentor.

Choosing a primary mentor from a list of mentors—Finding the right mentor is akin to forming a new professional relationship. The initial hunches about a mentor can often be wrong. Hence, it is vital to spend time collaborating with or working under each potential mentor before finally choosing the primary mentor.

The career trajectory of previous mentees—One can look at the number of co-authored publications, collaborative research grants, leadership roles, and career growth of previous mentees. This is often a surrogate marker of the mentor’s skills.

Compatible personality profiles—It is crucial that broadly, the mentor and mentee should be able to meet the eye on essential aspects of the working relationship, goals, and deadlines.

3 As—Approachability, Accessibility, and Availability—The mentor must be approachable. It is logistically tricky if the mentee finds it very difficult to approach the mentor despite the significance of the challenges at hand. The mentor should also be accessible in-person and available at times of need to ensure timely guidance of the mentee.

Lean on, but do not sit on the mentor—Once a resident gets a mentor who fulfills all criteria mentioned above, there is an inherent temptation to check with the mentor about all queries that may arise in the mentee’s mind. However, a mentee must be mindful of the potential time limitations of the mentor and use their guidance judiciously.

Professionalism

A professional is not an embodiment of professionalism by default (Often, obtaining a professional degree and practicing is equated with professionalism). However, professionalism is neither an autochthonous skill that will appear by itself by the end of the residency, nor is it just a term to describe the regular clinical practice. The following determinants of professionalism, given by the American Academy of Pediatrics, ²⁶ are to be learned and taught during residency:

Honesty and integrity—The foundations of integrity are based on the four principles of ethics—respect for autonomy, nonmaleficence, beneficence, and justice. Several everyday situations can be learning opportunities toward honesty and integrity—covering for a colleague who called in sick, being forthcoming about any mistakes committed, dealing with ethical challenges in patient care, among many others. ²⁷

Compassion and empathy—Residents are likely to face many challenges in dealing with patients and their families—patients who have suffered trauma, those on the verge of death, breaking bad news, among many others. Residency is an opportunity to learn and develop empathy and compassion, which ensures that a clinician is also a healer. ²⁸

To be self-aware of one’s strengths and limitations in everyday practice.

Altruism and advocacy—Residency provides an opportunity to recognize the under-served areas of health care, encourages community participation, and provides residents with a first-hand perspective of the patient’s medicolegal rights and potential for empowerment. Residency thus provides a platform to work on altruism and assertiveness on behalf of the patients and enhances resourcefulness in challenging circumstances to promote advocacy in healthcare. ²⁹

Networking

A resident may have come up in life, plodding his/her way up through years of hard work, without the help of others. However, in scientific careers, social networking is the current day cryptocurrency that opens possibilities and a likely determinant of success. This social capital must be earned through an investment, mainly involving time and energy, and is bound to fetch reward in the longer run. This is becoming increasingly relevant even in the area of scientific research, wherein analytical metrics are based on social media influence (Altmetric) in addition to citations and impact. ³⁰

Recognizing their sphere of social influence, one can work on expanding the same through opportunities sequentially:

Engaging with colleagues from across departments and various timelines of training in the parent institute—interdisciplinary networking forges meaningful exchange of ideas, resources, and information.

Collaborating with the scientific community during national and international conferences—to engage in discussions with student forums, make use of volunteering opportunities, and meet “key colleagues” who are likely to provide the gateway introduction to many others. It will help if one has a brief idea about introducing oneself in front of others in 30 s or less, to ensure awkward silence or gaps in the first part of the conversation with new contacts.

Creating opportunities for interaction with experts in the field while attending talks, lectures, or keynote addresses, to create genuine encounters.

Using social media such as WhatsApp, Facebook, Twitter, and email groups effectively and responsibly to stay connected with persons in the network in the longer run.

One important principle to keep in mind is that social relationships are based on reciprocity, and hence, an exclusive “what is in it for me” attitude will not be beneficial, especially when networking. It is also essential to understand that the process of networking is akin to gardening, with every node of network requiring time, energy, and resources that will produce a harvest of an elaborate network in the longer run.

Role of Organizations and Professional Bodies

For the residents, another space that is a fertile ground to learn the leadership skills within the hospital setup is to be involved in the organizational activities. Medical residents need exposure to various administrative and organizational activities involved in the everyday functioning of the system. Two essential aspects of systems literacy and the role of professional bodies are highlighted as follows:

System literacy—All medical professionals are expected to understand the system that they work in and the role their organization plays in the broader framework of health goals in the community. This expertise is not intuitive and needs to be inculcated in the curriculum beyond the framework of learning about health and disease. This needs additional exposure to medical leadership, including process-mapping of patients receiving healthcare, vital insights from observing healthcare managers in health economics, and troubleshooting. These dialogues can be initiated by periodic non-clinical rounds akin to clinical rounds. These non-clinical rounds can provide an atmosphere for facilitating discussion on administrative, ethical, and legal issues in healthcare. Additionally, shared administrative responsibilities beyond the call of duty can be continuously encouraged in the curriculum, preferably involving observership and interaction with governmental and nodal agencies dealing with healthcare regulations.

Increasing participation in professional bodies and organizations—Professional associations and licensing bodies have always had it in their charter that they serve to protect the interests of its members and simultaneously cater to the needs of the society. Psychiatry organizations worldwide have had pivotal roles in framing legislation on issues of public health importance such as euthanasia, regulation of substances, gender inequality, rights of the minorities, and gun control.^31–34 These organizations should provide templates for ethical practice, teamwork, leadership, and social responsibilities. Further down the line, just as the Medical Council of India recommends the research methodology course before the second semester for residents, ³⁵ leadership courses can be inculcated in the curriculum as a mandatory requirement. Alternatively, well-designed distance learning courses on hospital administration and leadership can serve to bridge the gap in leadership development.

Conclusion

Postgraduation can serve as a unique opportunity to start learning the basics of leadership through the conscious application of some principles outlined above, coupled with the development of a unique professional identity. This article serves as a template to learn the nuts and bolts of leadership during residency. Moreover, leadership skills in medical training and research can be acquired and enhanced by suitable interactive and pragmatic training programs. Medical education, both at undergraduate and postgraduate levels, should consider providing leadership training regularly and consistently across different stages of specialization and possibly beyond. To conclude, postgraduate trainees of today are the leaders of tomorrow. Emphasis on leadership training during postgraduation may potentially have a cascading positive influence on the healthcare delivery of the future.