Development of a Framework of Leadership in Academic Medicine (FLAM)

Abstract

OBJECTIVES

Leadership within medical academic institutions often adheres to hierarchical structures, relying on factors like seniority and context, with limited focus on leadership development. This study aims to develop a structured framework by examining the traits, aspirations, and pre-requisites of academic leaders within medical school faculties.

METHODS

A cross-sectional study collected input from regular medical faculty and those in leadership roles through an online questionnaire, followed by quantitative and qualitative analyses. Data was curated, analyzed, and triangulated to establish subdomains, domains, and themes for the framework.

RESULTS

Among 229 respondents, 121 held formal academic leadership roles, the remaining 108 were regular medical faculty. And 92% of regular faculty cited lack of experience and training as significant barriers to effective leadership. Both groups agreed on the need for intensive leadership training, as 85% of leaders and 66% of regular faculty lacked formal academic leadership training. The concept of affiliative leadership was favored by 45% of leaders. Qualitative analysis and subtheme triangulation led to the development of the 6 Es Framework for Leadership in Academic Medicine (FLAM). This framework encompasses: ethics (accountability and role modeling), education (structured curriculum and training), envision (clear path and talent identification), engagement (structural foundation and attainable goals), empowerment (fostering passion), and encouragement (financial incentives).

CONCLUSION

This research reinforces the necessity of structured leadership development in academic medicine. The unique attributes of the 6Es FLAM have the potential to enhance leadership in this field.

Introduction

Leadership, with its diverse definitions, involves inspiring a group toward a shared goal, emphasizing collaboration and accountability. It's depicted in literature as multifaceted, influenced by traits, influence, virtue, behavior, context, and opportunity.^1,2 In medicine, it's divided into physician leadership in healthcare settings and academic leadership in educational institutions. Clinical leadership enhances healthcare quality and adapts services to meet evolving needs, while academic leadership is essential for education quality, research facilitation, and clinical excellence.^3,4 Medical schools globally have traditionally prioritized clinical and scientific training, frequently overlooking the importance of leadership development and training. In the regular academic landscape, leaders within educational institutions have predominantly relied on formal positions of authority, such as professors, chairpersons, heads of departments, and deans. Instead of receiving formal leadership and management training, most of these leaders have typically depended on their professional expertise to fulfill their roles. ⁵

Accredited programs and courses in academic leadership are presently offered by a select group of universities in North America, such as Stanford, Harvard, Michigan, UCLA, and Penn State. These programs offer diverse avenues for leadership development, including courses, workshops, and mentorship, but they often have high costs and limited openings for external candidates. ⁶ Their focus is primarily on cultivating leadership skills tailored to internal contexts. A prime example of such a program is an internal faculty leadership development initiative at University of California San Francisco. ⁷ Outside North America, academic leadership programs in medical schools are sporadic. Initiatives like Canada's LEADS framework, the UK Faculty of Medical Leadership and Management (FMLM), and the International Hospital Federation (IHF) concentrate on physician leadership in healthcare, with less emphasis on academic leadership. Their objectives include improving patient outcomes and addressing the ever-evolving landscape of healthcare, but these initiatives typically lack a specific emphasis on academic leadership. ⁸ Beyond these flagship frameworks, there is a lack of literature presenting alternative frameworks for upskilling or training medical academic leadership. This highlights a unique gap in leading a specialized group of healthcare professionals within the medical field. Literature underscores the compromised performance of academic institutions due to the lack of formal training and certification in academic leadership. Implementing such training not only improves the approach and performance of leaders but also contributes significantly to the attainment of organizational goals and desired outcomes.^9,10 To equip academic faculty members with valuable leadership skills and attributes, it is advisable to establish internal leadership programs within medical schools. ¹¹ We believe, this can be achieved through a systematic approach: assessing existing challenges, gathering insights from leaders and faculty to design the training framework, and implementing the leadership development program with an effective evaluation process.

The aim of this study was to adopt the systematic approach and analyze both quantitative and qualitative insights from academic leaders and regular faculty at UOS and its affiliated hospitals. This process aimed to create a Framework of Leadership in Academic Medicine (FLAM), encompassing essential characteristics of academic leadership, leader readiness, perceived challenges, and willingness for professional training. Findings from FLAM will reinforce a structured training program, aiding medical educators with leadership roles and enhancing organizational performance.

Materials and methods

Study setting

The UoS medical cluster in the UAE encompasses four colleges: the College of Medicine (CoM), the College of Dental Medicine (CDM), the College of Pharmacy (CoP), and the College of Health Sciences (CHS). These colleges employ about 252 faculty members in various roles, including senior lecturers, assistants, associates, and full professors. The hierarchical leadership structure includes the dean, vice/assistant deans, heads of departments, and program directors. Additionally, UoS is affiliated with six tertiary care hospitals in the UAE, crucial for clinical training and evaluating undergraduate medical students. Approximately 270 physicians serve as adjunct faculty members in these hospitals, with some holding leadership positions such as CEO, CMO, Heads of Departments, and Program Directors. The only exclusion criteria used was if a physician does not hold an official title of adjunct faculty with UoS affiliated hospitals.

Study methodology

In this prospective cross-sectional study conducted between March and September 2022. Our main aim was to develop a leadership framework in academic medicine, gathering both quantitative and qualitative data. A self-administered questionnaire with 28 statements was distributed via SurveyMonkey^® to all UoS medical cluster faculty and adjunct faculty from affiliated hospitals. Participants were categorized as leaders if they held positions such as deans, vice/assistant deans, department heads, program directors, CMO, or CEO. Others were classified as regular faculty. All participants received a research overview and instructions, maintenance of anonymity and confidentiality of the participants and their informed consent was obtained before questionnaire completion. The research was conducted following the receipt of ethics approval from the Research Ethics Committee (REC) of the University of Sharjah (REC-19-05-26-01).

Development of questionnaire

Following a literature review, we developed a questionnaire for our study.^12–14 Two subject-matter experts evaluated it, clarifying any ambiguities and enhancing content. Following revisions, we pretested the questionnaire with six volunteers to ensure validity, reliability, and appropriateness. ¹⁵ The 28-item questionnaire comprised 6 segments (labeled A to F). Segment A gathered demographic data, B focused on training and experience, C explored barriers and facilitators to leadership, D delved into leadership awareness and implementation, E investigated leadership experiences, and F included an open-ended question for suggestions. Respondents used a five-point Likert scale for responses (Appendix I). Regular faculty completed all segments except E, while faculty in leadership roles omitted segment D. The development of the questionnaire was a transparent process, with the caveat that one of the researchers holds an academic leadership position, which brought a wealth of experience and perspective to the framing of the research questions. However, the research team worked collaboratively, actively questioning assumptions and decisions throughout the process.

Data analysis

For quantitative analysis, we utilized SPSS version 29.0, generating frequency distributions and presenting descriptive data with grouped bar charts. Inferential statistics were applied to Likert scale statements using tests. When the normality test was significant, we employed the Mann-Whitney U test to compare responses between leaders and regular faculty, with a significance level set at a P value of 5%.

For qualitative analysis, we followed Braun and Clarke's six-step thematic analysis approach. This involved familiarizing with the data, developing codes, generating themes, revising themes, labeling themes, and establishing a final report. ¹⁶ All quoted excerpts were de-identified before transcription. Initial coding of these extracts built a coding tree using inductive coding and clustering to categorize primary findings into descriptors, categories, and subthemes. This process organized qualitative findings into subthemes and themes, creating a comprehensive framework. We periodically analyzed the responses to see if new themes or significant new information are emerging. After analyzing 200 responses, we observed that no new themes or significant insights were emerging from the data. The consistency in responses indicated that data saturation had been reached, suggesting that additional responses were unlikely to provide further information relevant to our study objectives. To ensure the relevance of the qualitative analysis in our research, best practices were rigorously followed to avoid potential bias, maintain objectivity, and achieve intersubjective knowledge. ¹⁷ By being reflexive, we were able to question our preconceptions and remain open to unexpected findings, ultimately enriching the quality and depth of the thematic analysis.

Results

Segment A—demographics

Out of the 522 individuals invited to participate, a total of 229 provided complete responses, resulting in a response rate of 43.87%. Among the 229 respondents, 121 were categorized as leaders, and 108 were classified as regular faculty. Within the regular faculty, there were 53 (49.1%) women and 55 (50.9%) men, with the majority, comprising 79% (85 of 108), falling below the age of 50. Similarly, among the leaders, there were 33 (27%) women and 88 (73%) men. In this leaders’ group, 33% (40 of 121) were under the age of 50.

Segment B—leadership training

Regarding their response to formal leadership training and certification, the survey results revealed that 66% (71 of 108) of the regular faculty and 85% (102 of 121) of leaders had not received prior formal leadership training.

Segment C—barriers and facilitators in effective leadership

Table 1 presents a comparison of responses from both leaders and regular faculty for common statements, utilizing mean rank scores obtained from the nonparametric Mann Whitney U test. Statements that exhibited a significant mean rank score difference between the two cohorts are highlighted in bold. The findings showed that the leaders had stronger agreement than the regular faculty for three statements; (1) “having leadership training programs can enhance institutional performance” with mean ranks of 136.82 for leaders versus 89.70 for nonleaders (P value <.05); (2) “leaders in health care education need to establish credibility with different stakeholders in order to produce competent health care practitioners” with a higher mean rank of 129.17 for leaders versus 99.12 for the regular faculty (P value <.05); and (3) “having overly stagnant and bureaucratic structure as an institutional barrier to effective leadership” with mean ranks of 122.85 for leaders versus 104.07 for the regular faculty (P value <.05).

Table 1.

A comparison of responses of leaders and the regular faculty to common statements about academic leadership in medicine using the Mann-Whitney U test (n = 229).

STATEMENTS	LEADERS	REGULAR FACULTY	MANN-WHITNEY U	Z-VALUE	P VALUE
Formal structured training is essential for academic leadership positions	97.18	132.54	4424	−4.78	<.01
Having leadership training programs can enhance institutional performance	136.82	89.70	3802	−5.76	<.01
I am open to any training and certification to develop my leadership skills	78.50	155.89	2118	−9.26	<.01
Leadership programs are cost-effective in terms of their benefits	88.79	144.83	3362	−6.89	<.01
Academic leadership training can be easily implemented in academia	108.23	122.59	5715	−1.79	<.01
In today's world, academic leaders face more challenges than ever	99.57	132.29	4667	−4.16	<.01
Leaders in healthcare education need to establish credibility with different stakeholders to produce competent healthcare practitioners	129.17	99.12	4820	−3.72	<.01
Having overly stagnant and bureaucratic structure as an institutional barrier to effective leadership	122.85	104.07	5358	−2.31	.02*
I consider lack of training and experience as a personal barrier to effective leadership	115.68	113.19	6338	−0.32	.75
Having a strong team around me as an institutional facilitator for effective leadership	118.31	109.25	5914	−1.17	.24
Showing authentic leadership (being honest and progressive) as a personal facilitator to effective leadership	119.14	109.32	5912	−1.28	.20

On the other hand, the degree of preferences of regular faculty were more pronounced than leaders for agreeing with some statements. Of particular interest, the regular faculty mean rank score of 132.54 versus 97.18 by leaders “formal structured training is essential for academic leadership positions” (P value <.05). Similarly, other statements with their results are displayed in Table 1.

In our findings, when leaders were questioned about academic leadership in medicine, the most prevalent response was, “I am open to any training and feedback to develop my leadership skills,” with the highest agreement from 73 out of 121 respondents. Conversely, the statement “academic leadership training can be easily implemented in academia” received the least support, with 30 out of 121 respondents strongly agreeing (Figure 1A). Similarly, when assessing the responses of regular faculty, it was evident that the statement “showing authentic leadership (embodying honesty, transparency, and progressiveness in actions and interactions) ¹⁸ is regarded as a facilitator to effective leadership” was the most frequently cited, with agreement from 63 out of 108 individuals (Figure 1B).

Figure 1.

Responses to statements regarding leadership in the field of medicine from (A) leaders (n = 121) and (B) regular individuals (n = 108).

Segment D—leadership awareness, implementation, and assessment

A thorough examination of regular faculty responses to statements related to leadership awareness, implementation, and assessment can be found in Supplemental Table 1. Responding to the specific functions and responsibilities carried out by their leaders, 22 of 108 (20.4%) acknowledged planning skills and 21 of 108 (19.4%) recognized problem-solving skills as the most significant. Conversely, the least common functions identified were sustainability and problem definition. Regarding their responses to the statement concerning the most suitable approach for their leaders in handling complex situations, the majority (42.6%), exhibited agreement with “leaders redesign from within by focusing on internal processes.” In contrast, only 9 of 108 (8.3%) respondents opted for the alternative, “leaders describe what might be emerging, and people may listen.” In terms of the regular faculty's perspectives on the strategies employed by their leaders to achieve their objectives, “controlling meetings” was the most frequently chosen strategy, selected by 25 of 108 (23.1%) respondents, while ‘displacement’ was the least popular strategy, chosen by only 4 (3.7%) participants. Interestingly, when it came to decision-making approaches and essential leadership behaviors demonstrated by their leaders, the majority of respondents, specifically 75 of 108 (69.4%), observed that their leaders employed a combination of essential leadership behaviors. These included open communication, efficient resource allocation, and the cultivation of shared knowledge and goals (Supplemental Table 1).

Segment E—leadership experiences

Among the 121 respondents occupying academic leadership positions, 75% (91 out of 121) had prior experience in leadership roles for an average duration of 6 to 10 years. When assessing leadership styles within the medical field, a majority of 54 (44.6%) leaders displayed a preference for the “affiliative” leadership style, followed by the “authoritative” style, which received favor from 23 (19%) of the respondents. Conversely, the “coercive” leadership style was the least favored, chosen by a mere 2 (1.6%) leaders. Regarding the perceived sources of power in academic leadership, “expertise” emerged as the most prevalent strategy, acknowledged by 50 (41.3%) respondents. In contrast, “opportunity” was the least frequently selected source of power, chosen by only 5 (4.1%) leaders (Supplemental Table 2).

Qualitative analysis

Following our study methodology, we utilized a sequential approach to establish descriptors, categories, and subthemes. Our analysis highlighted the importance of justice and equity, professional development, rewards and recognition, and leadership succession plans. These subthemes were derived from key areas such as education, training, envisioning, involvement, and empowerment. Each category was linked by a unique descriptor, refined for clarity and relevance. Further qualitative analysis allowed cohesive generation and collation of subthemes. Quotes from respondents regarding academic medicine leadership were organized under major themes (see Supplemental Appendix II).

Framework development

At the final stage of our study, we mapped the key findings from quantitative and qualitative arms and performed data source and methodological triangulation. This process of integration of main concepts allowed us to generate themes that were tagged with specific contents. Finally, the 6Es FLAM was developed (Figure 2). The 6 Es included ethics (accountability, role model, and respect), education and training (training courses and structured curriculum), envision (clear path, talent hunting, and team man), engagement (structural foundation and achievable targets), empowerment (employees and create passion), and encouragement (financial rewards). As evident from the FLAM monogram, the overarching features of each theme had certain overlapping characteristics with other themes. This unique nature of FLAM sheds light on the reinforcing and consolidating nature of this framework.

Figure 2.

Main themes and their contents in the 6Es Framework for Leadership in Academic Medicine (FLAM).

A brief account of notable and overarching excerpts linked with their specific themes is provided hereunder.

Ethics

Ethics and morality have been considered to be integral to training and developing future doctors in leadership positions. ¹⁹ Regrettably, standardized medical leadership programs with integrated ethical components are currently lacking.

“Don't use age, religion, nationality, or race as criteria when choosing a leader.”

“Administer the department in a proper honest way. Build trust and respect with all staff. Everyone should take responsibility.”

“Honesty and directness are requirements for leaders. It takes a lot of confidence to do this. Remember to always hear the employee's side of the story before you come to a decision and act because it is not simple to point out a problem or terminate someone.”

“Leaders should lead by example. Their actions and behaviors should inspire, motivate, and teach students. when a leader sets good example, doctors and students will work harder to get their job done.”

Education and training

The need for formal training of academic faculty, physicians, graduate medical students, and undergraduates is evident.^4,9 However, structured academic leadership programs remain scarce and limited in availability.

“Begin with teaching leadership styles and give medical students the chance to be leaders and make decisions for the team, one at a time, and start giving them more confidence in themselves.”

“As part of training leaders, make it that we can put potential leader in situations and challenges that he/she will encounter someday, as a training method.”

“I believe that many international courses are available, and leaders should be directed to learn about them and do their best to implement them in their work.”

“Leadership training should begin during university.”

“Start looking for talented people to be leaders starting in the clinical years of medical schools. Some students have the talent that can be nurtured.”

“There is a lot of leadership styles, leaders should be open to learn and try new leadership styles as this can improve the productivity and quality of the services given by the doctors and students.”

Envision

A notable distinction between managers and leaders is that leaders provide their employees with a clear vision and a well-defined timeline, whereas managers focus on the day-to-day oversight of tasks without a deep understanding of their overall purpose. ²⁰ Leaders collaborate with their teams and establish the framework for accomplishing objectives.

“A good leader should influence, energize, and motivate other people.”

“Being a leader implies being a member of a team, and as a leader, you should be able to encourage and motivate your team members to work together as effectively as possible. Encourage or mentor a team member when they require it. At times, all someone needs are someone to listen to them and show empathy.”

“You need to set a goal for your team to work towards and overcome obstacles to attain in order to be a great leader.”

“Leader should know the personality of the people around them, trigger positive attitude and encouragement, and create harmony among the team.”

Engagement

Leadership involves motivating others to undertake tasks that leaders firmly believe should be accomplished. ²¹ This motivation is fostered through inspiration, providing professional support, and instilling confidence in teams and employees.

“A leader should round on all departments to see how they lead to get a better idea.”

“Engage your team. Find out from them how they support one another. Motivate them to get better.”

“There should be fair participation from all stakeholders. There should be a strong structural foundation. There should be a support system for leaders.”

“A true leader should forget the single lettered word “I” and replace it with “WE”. Should lead from the front and at the time of recognition, should push others to the front.”

Empowerment

Leader-empowering behavior exerts a significant influence on employee performance and satisfaction. ²² Simultaneously, empowering employees enhances confidence and self-motivation within teams, resulting in increased industrial productivity.

“Academic leadership needs a competent support staff (non-academic) team. Academic leaders do not work alone, and they do not work with their academic peers only. It's the support staff team that makes the most of the this to happen and achievable.”

“Empower staff and hold them accountable.”

“Leaders should empower their students and colleagues. they should set high standards to get the best out of their team.”

“Leaders should be changed every few years (4-5 years). Same (leader) for 20 + years reduces chances for development and innovation.”

Encouragement

One distinctive leadership style involves motivating teams and employees by celebrating minor accomplishments and establishing attainable objectives. ²³ Nevertheless, this leadership approach necessitates specific training and skills that can be cultivated through dedicated courses and personality development programs.

“Leaders need privileges to act. Clear career path for the leader from the start. Financial rewards.”

“Invest in developing junior staff.”

“Active 1:1 engagement with team members. Dialogue and effective communication.”

“Encourage fresh ideas from staff members and follow their progress. You may instill confidence in them by encouraging them to move outside of their comfort zone and by believing in them.”

Discussion

Our study investigates the essential qualities of academic leadership in medicine, leader preparedness, and perceived challenges in leadership training. A significant finding is the scarcity of dedicated training programs for academic medicine leadership within medical schools, prompting the development of the 6 Es FLAM as a proactive strategy. Quantitative analysis showed high mean rankings for the statement “Formal structured training is essential for academic leadership positions” from both leaders and regular faculty (P value .05), scoring 132.54 and 97.18, respectively. This underscores the widespread recognition of the need for formal leadership education in medicine, consistent with global trends. Despite our findings aligning with or exceeding existing literature, the inadequacy of formalized leadership training alone to sustain medical leadership globally is evident. ²⁴ While some may argue that nonformal education, like self-directed learning through abundant resources such as books, podcasts, and YouTube videos on leadership and its various styles, can be beneficial for those who are in leadership positions, or aspire to leadership positions, and it often does not require significant financial or human resources. ²⁵ However, nonformal education cannot be a replacement but can be aligned with formal education and training.

There is an urgent need for integrated academic leadership development programs in medical curricula. Implementing faculty development programs explicitly designed to enhance leadership skills could offer a swift solution. ²⁶ Additionally, leaders’ strong agreement with the statement “having leadership training programs can enhance institutional performance” reinforces the importance of such programs, with mean scores of 136.82 for leaders and 89.70 for regular faculty (P value .05).

Participants identified various challenges in effective leadership, including rapid educational evolution and diversity considerations. The evolving educational landscape driven by technological advancements and shifting paradigms necessitates rapid adaptability. In this dynamic and demanding context, academic leadership calls for innovative solutions and an unwavering commitment to educational excellence. ²⁷ Similarly, stagnant bureaucratic structures were also seen as hindrances, obstructing the free flow of ideas and initiatives, ²⁸ emphasizing the need for flexibility and innovation in leadership approaches. ²⁹

Leadership styles encompass diverse approaches used by leaders to influence their team members. ¹ While various styles exist, their effectiveness remains debated among scholars. ³⁰ In our study, most leaders favored the affiliative style, emphasizing relationship-building and collaboration. ³¹ Although this style fosters trust and creativity, it may not suit all situations, necessitating flexibility in leadership approaches. ³² Effective leaders often employ a mix of leadership styles to address different circumstances and challenges. Interestingly, regular faculty identified the authoritative style as the most employed approach by their leaders. This divergence highlights the importance of blending leadership styles for broader acceptance. ³³ Additionally, field of expertise and access to information emerged as a power source in our study, emphasizing the fusion of charisma and subject knowledge for effective leadership influence. ³⁴

Gender representation in leadership roles revealed a predominant male presence 73% (88 of 121) echoing global trends.^35,36 The gender disparity may have several potential explanations, including greater opportunities for men, less recognition for women, and certain incentives that favor one gender over the other. However, the prevalence of men does not correlate with superior leadership skills, as evidenced by research indicating women's outperformance in leadership abilities.^37,38

Our qualitative data reveals the depth of scientific knowledge enhancing leadership in academic medicine. It underscores the need for a leadership development program in medical curricula to enhance leadership abilities. Role modeling is essential for ethical leadership, while attention to emotional intelligence is crucial for improved performance. Emotional intelligence is often associated with transformational and affiliative leadership styles.^39,40 Additionally, our study highlights accountability, respectfulness, and talent acquisition as key leadership traits. ⁴¹

The 6 Es FLAM outlined in our study possesses distinct characteristics crucial for leadership in academic medicine, including ethics, education, and training. ⁴² It serves as a framework for developing training programs and curricula tailored for academic leaders. Envisioning institutional strategy is a cornerstone trait, complemented by empowering, engaging, and encouraging employees.^43,44 These strategies involve acknowledging achievements, offering rewards and recognition, and providing support services. The 6 Es FLAM holds promise in cultivating leadership skills in academic medicine, aiming to enhance institutional performance and outcomes in the long term.

Limitations

Generalizing our study findings may be challenging due to the limited sample size. We did not perform a sample size calculation for this study because our intention was to distribute the questionnaire to the entire UoS medical cluster faculty and adjunct faculty from affiliated hospitals. Additionally, we did not specify the definition of “formal leadership training” in the questionnaire, which may have led to assumptions regarding its nature, duration, and the emphasis on self-education in leadership development. For instance, interpretations could vary widely—from considering it akin to pursuing a master's degree to viewing it as attending a brief workshop or a single-hour lecture. Finally, considering the questionnaire's impact on the open-ended question, participants’ responses may be influenced by earlier sections, despite seeming independent traditionally. ⁴⁵

Conclusion

Our study carefully identifies key features of academic leadership in the field of medicine. Planning and problem-solving skills are the most impactful leadership attributes, and the affiliative leadership style proves to be the most effective. The thoughtfully constructed FLAM, characterized by its components of ethics, education and training, envisioning, engagement, empowerment, and encouragement, has the potential to significantly influence the restructuring of leadership training programs in medical schools.

Supplemental Material

sj-docx-1-mde-10.1177_23821205241296976 - Supplemental material for Development of a Framework of Leadership in Academic Medicine (FLAM)

Supplemental material, sj-docx-1-mde-10.1177_23821205241296976 for Development of a Framework of Leadership in Academic Medicine (FLAM) by Nihar Ranjan Dash, Rim Koutaich, Heba Awad Al Khalaf, Mohammad Jasem Hani, Rayan Koutaich and Salman Yousuf Guraya in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-2-mde-10.1177_23821205241296976 - Supplemental material for Development of a Framework of Leadership in Academic Medicine (FLAM)

Supplemental material, sj-docx-2-mde-10.1177_23821205241296976 for Development of a Framework of Leadership in Academic Medicine (FLAM) by Nihar Ranjan Dash, Rim Koutaich, Heba Awad Al Khalaf, Mohammad Jasem Hani, Rayan Koutaich and Salman Yousuf Guraya in Journal of Medical Education and Curricular Development