Medical leadership plays an increasing role in quality healthcare. Nearly all physicians hold leadership roles during their career. Therefore, the development of medical leadership competence should start during undergraduate education and continue to postgraduate training. Some medical schools offer specific leadership programs, but in many medical schools, students are just embedded in the clinical environment, observing leaders in action. The goal of our cohort study was to explore how undergraduate medical students assess their leadership competences at the beginning and at the end of the final year without participation in a leadership program.

Between November 2023 and June 2024, we conducted a cross-sectional cohort study with 112 students at the beginning (1^st trimester) and 117 students at the end (3^rd trimester) of their final year. All participants assessed their leadership competence with the Medical Leadership Competence Scale (MeLeCoS) on a 5-point Likert scale (1: ‘never’, 2: ‘rarely’, 3: ‘sometimes’, 4: ‘often’, 5: ‘always’). A t-test and Mann-Whitney-U-tests were calculated for the overall MeLeCoS score, for the six MeLeCoS factors, and the 37 items, respectively, to test for significant differences between both cohorts. Within both cohorts, factors were ordered according to their mean values. Wilcoxon-tests were calculated to look for significant differences between two adjacent factors.

No significant differences could be found between both cohorts for neither the overall MeLeCoS score nor for any of the factors or any item. In both cohorts, the factor 2 (‘Demonstrating responsible behaviour and shaping relations’) had the highest level in the self-assessment (1^st trimester; 4.32 ± 0.40 and 3^rd trimester; 4.31 ± 0.36). Factor 4 (‘Developing self-management and supporting management in healthcare’) and 6 (‘Introducing systemic perspectives into organizations’) were the only factors that showed no significant difference in their adjacent mean values.

Given that there were no significant differences between both cohorts, including teaching of medical leadership into the final year is recommended. As some medical leadership competences are highly developed at the beginning of the final year, a medical leadership curriculum should start before the final year. Individual development could be monitored and reflected by self-assessment using the MeLeCoS.

Since high-quality healthcare depends on formal and informal medical leadership, nearly all physicians hold a leadership role during their personal career [1, 2]. Hence, physicians need to acquire leadership competence to deal with complex decisions in their clinical, administrative, and management duties [2, 3, 4]. However, especially physicians in early career stages reported that they do not feel well prepared for their medical leadership roles [5, 6, 7]. These negative feelings are stronger, if only little feedback by colleagues or senior doctors is given to the junior doctor [8]. It was also reported that junior physicians feel stressed when changing role from student to young professional and that they find it challenging to deal with uncertainty, decision making and to work in multiprofessional teams [9]. These challenging tasks are all aspects of medical leadership according to the Medical Leadership Competence Framework (MLCF), which includes five medical leadership domains (‘Demonstrating personal qualities’, ‘Working with others’, ‘Managing services’, ‘Improving services’, and ‘Setting directions’) and covers examples on three different levels of experience (undergraduate, postgraduate training and continuing practice) [10].

To facilitate the advancement in leadership in the transition from undergraduate to postgraduate education leadership trainings in undergraduate medical education are being established [11, 12, 13]. Therefore, there is an increasing interest in including medical leadership into undergraduate medical education and many academic healthcare centres have leadership programs [14, 15]. A combination of theoretical sessions (in-person or online) and mentoring provided effective long-term development of leadership competences [16]. However, only 2% of the time of undergraduate medical education is spent on average on leadership topics [14]. Most of the undergraduate leadership programs are organized as longitudinal classroom lessons and vary between course durations of one to eight semesters [17]. At least three of the Medical Leadership Competence Framework (MLCF) dimensions of medical leadership are covered in most programs [17]. Based on the evaluation of many leadership courses a subjective positive effect on students’ development of leadership competences can be assumed, however, there is a lack of objectively measured leadership training effects, especially on system level [18]. As the development of medical leadership competences is an integral part of medical professional identity formation, medical students should be able to assess their leadership competences. For this purpose, we established the Medical Leadership Competence Scale (MeLeCoS) [19] which is based on content from all five MLCF dimensions for undergraduate medical students [10]. This instrument can be used by medical students to assess and self-reflect their development of medical leadership competences. Additionally, receiving feedback regarding their leadership competences can support students in their development of professional behaviour [20] and observing leaders in action was found to be a good learning experience of leadership behaviour [21].

In the six-year undergraduate medical curriculum in Germany no mandatory leadership program is established. However, during their final year medical students work full time in clinical and outpatient environments, which includes four months in internal medicine, four in surgery, and four months in a discipline of their choice. During this time, they are exposed to different aspects of leadership behaviour and to various role models. Therefore, we hypothesize that students’ leadership behaviour differs between their entry into and their exit out of the final year. In this cross-sectional cohort study, medical students at the beginning and medical students at the end of their final year self-assessed their medical leadership competence with the MeLeCoS [19] and their self-assessments were compared with respect to differences in the medical leadership competences.

Medical leadership competence was assessed in a cross-sectional cohort study at Hamburg University in final-year medical students between November 2023 and June 2024. Within this time period, all considered students were either at the beginning of their final year (1^st trimester, n = 461), or at the end of their final year (3^rd trimester, n = 499) of a six-year undergraduate curriculum. They were invited by e-mail to answer the Medical Leadership Competence Scale (MeLeCoS) online [19]. Participation was voluntary, anonymous, and students gave their written consent. The study was performed in accordance with the Declaration of Helsinki and the Ethics Committee of the Chamber of Physicians, Hamburg, approved this study and confirmed its innocuousness (PV3649).

The Medical Leadership Competence Scale (MeLeCoS) was designed and validated for medical students’ self-assessment of their medical leadership competence [19]. The scale is based on the MLCF examples for undergraduate medical students [10] and is in accordance with a previous scale development process for self-assessment of general medical competences [22]. The MeLeCoS includes 37 items and additional questions regarding demographic data at the end of the questionnaire. The answering scale is a five-point Likert scale (1: ‘never’, 2: ‘rarely’, 3: ‘sometimes’, 4: ‘often’, 5: ‘always’) [19]. It covers six factors of leadership: (1) Achieving learning and reflecting on performance (5 items); (2) Demonstrating responsible behaviour and shaping relations (9 items); (3) Fostering personal development and promoting quality improvement (6 items); (4) Developing self-management and supporting management in healthcare (8 items); (5) Promoting improvement and innovation in undergraduate medical education (5 items); (6) Introducing systemic perspectives into organizations (4 items) [19]. The internal consistency of the MeLeCoS is Cronbach’s α = 0.87. The questionnaire was offered online with Lime Survey Cloud version 6.3.9 (LimeSurvey GmbH, Hamburg, Germany). To facilitate responses, the items were categorized in three application areas of specific leadership behaviour (17 general leadership items, 12 hospital-related leadership items, and 16 study-related leadership items). The items were randomized within these three categories as well as the categories themselves were randomized. The factor structure of the MeLeCoS was covered to avoid influencing the response behaviour.

Data analysis was performed using IBM SPSS Statistics version 29.0.0.0 [23]. Descriptive statistics including mean and standard deviation were calculated for the overall MeLeCoS score, for the six MeLeCoS factors, and for all 37 MeLeCoS items separately for the two groups (1^st and 3^rd trimester). The following calculations were carried out to compare the two groups with each other. For the overall MeLeCoS score, the six factor-variables and for all 37 items normal distribution was tested computing a Kolmogorov-Smirnov test and similarity of variance was tested by Levene-test. Because all requirements have been met, a t-test for independent samples was used for comparison of the overall MeLeCoS score. The predefined α-level was set at 0.05. Across all six factor-variables and for all 37 individual items a Mann-Whitney-U test was calculated due to the lack of normal distribution and due to variance heterogeneity of one factor (factor 3) and of three individual items. The predefined α-level was corrected by Bonferroni and set to 0.008 because of multiple testing with 6 factors and set to 0.001 for multiple testing with 37 variables, respectively. To test for significant differences between the factors within each group, the factors were ordered according to their mean values and Wilcoxon-tests were calculated for differences between the means of two adjacent factors. The predefined α-level was corrected by Bonferroni and set to 0.01 because of multiple testing.

Of the 280 final-year students who started the MeLeCoS (return rate: 29.2% of the 960 invited students), 229 finished it completely (completion rate: 81.8%). Of these 229 students, 112 (48.9%) studied in their 1^st trimester (mean age 27.1 ± 3.1 years, 63% female, 36% male, 1% diverse) and 117 (51.1%) studied in their 3^rd trimester (mean age 28.2 ± 3.7, 70% female, 29% male, 1% diverse). Table 1 shows the mean values of all MeLeCoS factors comparing both groups. Overall, no significant differences between both groups were found. In both groups, factor 2 (‘Demonstrating responsible behaviour and shaping relations’) had the highest mean value (1^st trimester; 4.32 ± 0.40 and 3^rd trimester; 4.31 ± 0.36) followed by factor 1 (‘Achieving learning and reflecting on performance’) with 1^st trimester: 4.03 ± 0.6 and 3^rd trimester: 3.88 ± 0.53. Also, for both groups, factor 5 (‘Promoting improvement and innovation in undergraduate medical education’) had the lowest mean value (1^st trimester: 1.91 ± 0.94 and 3^rd trimester: 1.98 ± 0.90). When the factors were sorted by means and compared with the respective adjacent lower mean, significant differences (p < 0.001) were found for the 1^st trimester and the 3^rd trimester between factors 2 and 1, factors 1 and 3, factors 3 and 4, and factors 6 and 5. No significant difference was found in neither group between factors 4 (‘Developing self-management and supporting management in healthcare’) and 6 (‘Introducing systemic perspectives into organizations’) (p = 0.167 and p = 0.550, respectively).

The mean values and standard deviations for all 37 MeLeCoS items for both groups are shown in Table 2. For the overall MeLeCoS score no significant differences between the 1^st and the 3^rd trimester final year students could be found within the t-test (t (227) = 0.288, p = 0.774). The Mann-Whitney-U-test showed no significant differences for the six factors, shown in supplement 1. As displayed in supplement 2, the Mann-Whitney-U test showed no significant differences for the 37 items between the 1^st and the 3^rd trimester students.

Medical students need to develop medical leadership competences [2, 3, 4] because they will be engaged in different leadership roles in their daily work as physicians [24]. Observing physician leaders in action was described as a good learning experience of leadership behaviour and observing leaders in daily leadership behaviour was pointed out as very valuable for medical leadership development [21]. Therefore, we hypothesised that cohorts of medical students in their 1^st and 3^rd trimester of their final year of undergraduate studies, where they are fully embedded in clinical environments and observe physician leaders in action, will assess their leadership competences differently. To our surprise we did not find any significant differences in the level of medical leadership competences in students’ self-assessment with the MeLeCoS between students at the beginning and at the end of their final year, neither on factor nor on item level. Similar to the MeLeCoS development study [19], both cohorts showed the highest self-assessed expression for factor 2 (‘Demonstrating responsible behavior and shaping relations’).

The development of competence requires three necessary basic prerequisites: (1) acquiring a solid knowledge base, (2) acquiring clearly defined skills and abilities (i.e. qualifications), and (3) being familiar with values and norms [25]. The participating students in our study were embedded in the clinical environment and worked under supervision without specific leadership tasks. Additionally, they did not acquire specific medical leadership knowledge in courses or seminars during their final year as prerequisite for leadership competence. This could be a reason why we found no differences in the level of medical leadership competence between students in their 1^st and 3^rd trimester. Furthermore, the students were embedded in the clinical field and encountered many opportunities to observe medical leadership in role models to acquire skills and to familiarize themselves with values and norms. However, just watching the role models might not have taught them leadership aspects they wanted to adapt to, which was also seen in another study [26]. It has been shown that competence development is improved when role models of medical leaders were observed in daily action in combination with strategic learning-interactions focussing on special issues and with short mentoring relationships [21]. Our students had no structured leadership mentoring program or structured feedback on their leadership competences in their final year. This could be an additional reason why we found no differences between students in their 1^st and 3^rd trimester. Hence, we hypothesize that supporting students in the acquisition of the basic prerequisites for competence development could promote the evolution of their leadership competences.

‘Demonstrating responsible behavior and shaping relations’ (factor 2) shows the highest self-assessment in the 1^st and 3^rd trimester of the final year with no significant difference. These results could be attributed to longitudinal learning experiences up to year five of undergraduate medical training. During these years, students are longitudinally embedded in the clinical environment during rotations and clerkships where they not just observe leaders in action but are given clinical tasks with increasing responsibility and receive feedback. Longitudinal involvement in clinical tasks and receiving feedback was reported by medical students as being a valuable leadership experience [27]. A longitudinal learning format that many medical schools use as a regular curricular activity and that supports students to develop various leadership skills is problem based learning [28]. It has also been shown that particular leadership training can be integrated into a problem based learning program early in undergraduate training [29]. Many universities established specific longitudinal classroom leadership trainings [17]. For example, one school offered a four-year longitudinal program with different scholarly leadership activities, providing students with important knowledge and skills for becoming a medical leader [30]. Another longitudinal multi-didactical leadership program for undergraduate medical students includes core courses with relevant leadership topics like human capital, strategy and leadership challenges, a seminar series, and mentoring but no evaluation or assessment of developed leadership competences is provided [31]. Since we did not identify differences in leadership competences within the final year we hypothesize that longitudinal leadership training accompanied by self-assessment could better reflect medical students’ development of leadership competences throughout their undergraduate education than just in their final year.

The MeLeCoS factors 4 (‘Developing self-management and supporting management in healthcare’) and 6 (‘Introducing systemic perspectives into organizations’) showed no significant difference in their respective mean values for neither group. Additionally, the lowest self-assessed expression was found for factor 5 (‘Promoting improvement and innovation in undergraduate medical education’) with no group difference. In their final year, medical students concentrate primarily on improving their patient care in interprofessional interactions and, therefore, presumably score higher in leadership factors including such aspects. Hence, the MeLeCoS should be used based on its factor scores rather than on its overall score to focus on particular leadership competences of interest [19]. However, for the individual student it can still be interesting to assess whether leadership competences in innovation in undergraduate medical education were acquired longitudinally, i.e. before the final year, as they are included in the MLCF [10]. Personal development and self-management in medical education have also been shown to require longitudinal training [32, 33, 34]. This might be another reason why we did not find differences in scores between students in their 1^st and 3^rd trimester of the final year. With respect to these findings and based on the aspects discussed in the previous paragraph we suggest that learning objectives regarding leadership should be integrated longitudinally in the undergraduate medical curriculum including the final year. With a longitudinal teaching approach, all prerequisites for the development of leadership competences could be addressed and assessed with the MeLeCoS on factor level even though undergraduate students are not fully responsible for leadership. Longitudinal leadership training should continue into postgraduate training where residents take over full responsibility. Specific aspects for postgraduate leadership competences are also defined in the MLCF [10].

This study has some limitations. One limitation is the voluntary participation of medical students which could have attracted highly motivated students and students with a particular interest in leadership. Furthermore, students come with different background training and can also be influenced by the hidden curriculum which could have biased the results. The drop-out rate is also a limiting factor of this study as it reduced the originally larger sample by 18.2%. Another limitation is the cohort study design. A longitudinal study design would provide a better focus on the individual development of leadership competences and possible differences at the beginning and end of the final year. Since medical students in Germany are allowed to change medical school for their final year, a strength of our study is that our participants are not just from one medical school even though it is a weakness that the study was technically performed at one medical school. Therefore, despite the reduced completion rate a strength of our study is the high number of participating students in both cohorts. In addition, a strength of the MeLeCoS is the randomization of the categories and items in combination with the covered factor structure to reduce bias. Overall, the results of this study allow to suggest improving or establishing a longitudinal leadership curriculum in undergraduate medical education including the final year that could be accompanied with self-assessment with the MeLeCoS. Such an approach showed a successful increase in leadership competence during postgraduate medical education in a family medicine residency program [35]. Furthermore, multiple learning opportunities have been also recommended in other disciplines for the development of leadership [36] and self-reflection was identified as an important instrument for professional development [37]. In undergraduate medical education, the process of medical leadership development could start early in the curriculum and could be monitored using the MeLeCoS for self-assessment accompanied with a longitudinal research approach. Continuation of leadership training and assessment into postgraduate education would be desirable for successful transition.

i.e.:

id est

MeLeCoS:

Medical Leadership Competence Scale

MLCF:

Medical Leadership Competency Framework

NHS:

National Health Service

UK:

United Kingdom

US:

United States

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Both authors designed and performed the study. SH recruited the participants and BO coordinated the study, the data acquisition and performed the analyses. BO interpreted the results with SH. BO drafted the manuscript. All authors read and approved the final manuscript.

Correspondence to Sigrid Harendza.

The study was performed in accordance with the Declaration of Helsinki and the Ethics Committee of the Chamber of Physicians, Hamburg, approved this study and confirmed its innocuousness (PV3649). Participation was voluntary and all participants provided informed written consent for participation in this study. All data were anonymized.

Not applicable.

SH has a position as Senior Editorial Board Member to BMC Medical Education. BO has no competing interests.

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