Keywords:
Competency-based education - Leadership and governance capacity - Health facility
administration
Descritores:
Educação baseada em competências - Capacidade de liderança e governança - Administração
de unidades de saúde
INTRODUCTION
Over the centuries, leadership failure has been plaguing humanity's progress across
many areas, ranging from politics and geopolitics to business.[1]
[2] In the healthcare sector – one that has faced growing challenges because of rising
costs, competition and high rates of team burnout[3]
[4] – investing in leadership training has been a recent trend.[5]
[6] In the past, physicians rose to leadership positions because of seniority and hierarchy,
instead of training in the required skills; this phenomenon is still frequent in many
institutions and may have tragic consequences to the corporation and the physician
himself – as he is faced with the seemingly unavoidable reality of declining success
after a brilliant career as a clinician, researcher or educator.[7]
[8]
The basic concepts of leadership, including modern theories of leadership, required
skills and key leadership roles within the context of healthcare education have been
recently addressed by Van Diggele et al. (2020).[9] In a meta-analysis of trait and behavioural theories of leadership, Derue et al.
(2011)[10] concluded that much of the research evidence fails to provide an integrated framework
for understanding what constitutes leadership effectiveness. The authors did though
empirically identify some leader traits and behaviours that represent effective leadership.
Other leadership researchers aimed to distinguish between leadership, administration
and management, and concluded that leadership is synonymous with ‘change', while management
and administration are more in line with ‘maintenance'. Of note, all three dimensions
were identified as critical functions of organisational activity in a study reported
by Çitaku et al. (2012).[11] In a Japanese survey addressing leadership competencies in community medicine, six
set of competencies have emerged as critically important, namely 1) ‘Medical ability'
– which means being able to deal with a wide range of different problems;
2) ‘Long-term perspective' – which is the ability to develop a long-term, comprehensive
vision and to continuously work to achieve it; 3) ‘Team building' –
which is the ability to drive forward programs that include residents and local government
workers, to elucidate a vision, to communicate properly and to accept other medical
professionals; 4) ‘Ability to negotiate' – which ensures the smooth progress of the
programs and visions; 5) ‘Management ability' – which is the ability to run a clinic,
medical unit or association and 6) ‘Enjoying oneself' – which means that doctors need
to feel an attraction to community medicine, in terms of it being fun and challenging
for them. The authors felt that the study might contribute to the design of a personalised
curriculum to develop community medical leaders.[12] In short, leadership can be construed as a means of shaping the goals, motivations
and actions of others to initiate change or maintain stability.[13] Other researchers have adopted a social perspective to conceptualise leadership,
arguing that leadership activity is defined or constructed through the interaction
of leaders and followers during the execution of leadership tasks.[14]
According to some scholars, the teaching of leadership skills should start as early
as in medical school.[15] As predicted, formal education in leadership skills has been increasingly implemented
into the curricula of modern medical schools.[16] Several studies have also started to address the effectiveness of leadership training
programs in the medical education setting. In one study, for instance, a peer-led
structured academic mentoring program was proven a useful tool to improve leadership
skills of young mentors.[17] In another project, the development of an unique leadership training approach and
subsequent appraisals of the model eventually led to the development of an enterprise-wide
leadership institute dedicated to guide leadership development strategies in the healthcare
setting.[18] Of note, training in medical leadership skills has been increasingly available ‘on
demand' from many institutions across the globe – with a growing role of distance
learning, which is particularly important for physicians who are often unable to stay
away from their medical practices for long periods. Finally, as shown by the number
of publications in PubMed with the search terms ‘leadership' and ‘medical' (which
have increased from as few as 5-15 before the late 1960s to more than 2000 in 2019
alone), the scientific interest in the field of leadership development has risen sharply
in recent decades.[19]
In the early 2000s, Violato et al. (2009)[15] adapted from a business leadership questionnaire to address the required competencies
for academics involved with medical education. This survey was further developed by
Çitaku et al. (2012)[11] into a 63-item questionnaire, which was eventually applied to a sample of 229 healthcare
professionals who held academic positions in medical education. This survey disclosed
interesting findings about the participants' perceptions on the required leadership
skills in their field.
However, the valuation of specific leadership competencies is known to be highly dependent
on the cultural context, as previously demonstrated by findings of the GLOBE survey
performed in the corporative realm.[20] The Çitaku et al. (2012)[11] survey, though a multi-national and multi-institutional work, was restricted to
North-American (NA) and European (EU) (i.e. affluent) countries.[11] In 2018, we felt that similar data should be collected from other cultures and world
regions and set out to apply a slightly modified version of the survey to a sample
of 217 Latin-American (LA) physicians from oncology and related fields who held an
active leadership position at their institution.[21] The choice of a mainly ‘oncology setting' had to do with the specialty practiced
by the main author and most of the co-authors and their easier access to the contributing
medical societies/groups. This survey disclosed interesting findings, in a way confirming
the hypothesis that the valuation of the required leadership competencies would not
perfectly match the NA/EU study results.
Because of the large number of participants in this survey, several subgroup analyses
were performed.[21] Most of the participants were from Brazil (135; 63.0%), followed by Mexico (61;
28.5%). Subgroup analyses of the Brazilian participants versus those from other LA
nations disclosed significant differences in physician perceptions, especially in
terms of Brazilians placing a higher value on 4 of the 5 sets of competencies: task
management, social responsibility, self-management and leading others.[21] Among all subgroup analyses performed, country of medical practice showed the most
pronounced differences, which suggested the existence a significant level of cultural
heterogeneity in our sample.
Therefore, we decided to perform further analyses specifically focused on the Brazilian
subgroup of participants, with the aim to more efficiently analyze other variables
from the scope of a single selected nation.
OBJECTIVES
The objectives of the main study were as follows: 1) to offer the survey to a population
of LA physicians from the oncology community and related areas who held an active
leadership position; 2) to compare the results with those of the previous NA/EU survey;
and 3) to investigate potential interactions between LA physicians'
perceptions of leadership competencies and factors such as medical specialty, country,
sex, type of medical practice (private versus public), age, years of experience in
oncology and in a in leadership position.
The objectives of the current study were as follows: 1) to compare the results of
the Brazilian subgroup of participants with those of the previous NA/EU survey; and
2)
to investigate potential interactions between Brazilian physicians' perceptions of
leadership competencies and factors such as medical specialty, sex, type of medical
practice (private versus public) and seniority as defined by age, years of experience
in oncology and in a leadership position.
MATERIAL AND METHODS
The methodology of this study, as well as the full details of the study population,
have been published elsewhere.[21] Briefly, from November 13, 2018, to December 12, 2018, the survey was sent to close
to 8,000 physicians from LA countries who were members of one of the medical societies
or groups of specialists who agreed to participate, namely the Brazilian Society of
Clinical Oncology; 2) the Brazilian Society of Mastology; 3) the Mexican Society of
Mastology; 4) the Latin American Cooperative Oncology Group; 5) the Brazilian Society
of Pathology; and 6) the Mexican Society of Oncology. Of note, the distribution of
the survey had to comply with the internal regulations of each contributing institution.
For instance, some of the medical societies/groups allowed a single dispatch of the
e-mails, while other allowed two or an unlimited number. Furthermore, the Brazilian
Society of Radiation Oncology was unable to officially contribute with the project,
but the survey was circulated in a WhatsApp group held by the members so that radiation
oncologists were eventually properly represented. The survey was filled electronically
by the participants using the SurveyMonkey website. The invitation clearly stated
that only physicians who actively held a leadership position should take the questionnaire,
which probably accounts for the lower number of responses (n=217) eventually collected
in the original study.
As previously stated, for only three of the medical societies/groups (the Brazilian
and Mexican Societies of Mastology and the Brazilian Society of Pathology) cancer
care was not an exclusive activity. The unique characteristics of these medical societies/groups
have been previously described in detail.[21]
The survey contained 63 items, which were grouped into 5 major sets of competencies:
task management, social responsibility, self-management, leading others, and innovation.
The respondents rated questions from 1-5 (less important to most important) and we
considered a score of 4 or 5 as a ‘positive' response (i.e., the competence was ‘highly
valued').
The analyses were performed in terms of proportion of participants who responded with
4 or 5 (i.e., ‘this competence is important' or ‘this competence is very important',
respectively). Respondents' characteristics and the responses were summarized using
descriptive statistics. Differences between groups were analyzed using contingency
tables (χ2 test). Internal consistency reliability was computed (Cronbach's α = .830294). All
analyses were performed using the SAS statistical software (version 9.4; SAS Institute,
Cary, NC). A significance level of 5% was applied.
Both the published and current study were waived from obtaining informed consent forms
(ICF) by the institutional review board (IRB) of the Pontifícia Universidade Católica do Rio Grande do Sul – to whom the LACOG group reports to.
RESULTS
Characteristics of the Brazilian survey population are depicted in [Table 1]. A total of 135 responses were available for the analyses. An imbalance in gender
was evident in the current sample, with 84 (62.2%) males versus 51 (37.7%) females.
Overall, most of the respondents were younger than 45 years of age (71/52.5%), had
more than 10 years of experience in oncology (108/80%) and less than 10 years in a
leadership position (75/55.5%). Sixty-nine percent defined themselves as primarily
working in a private institution, and the majority were clinical oncologists (72/53,3%),
followed by surgical oncologists (31/22.9%) and other specialists (24/17.7%).
Table 1
Characteristics of the 135 participants from Brazil
|
Information of 135 participants
|
Total – n (%)
|
|
Gender
|
|
|
Male
|
84 (62.22)
|
|
Female
|
51 (37.78)
|
|
Age (Median = 44; Range =
25-72)
|
|
|
<45 years
|
71 (52.59)
|
|
≥45 years
|
64 (47.41)
|
|
Years of experience in oncology (Median = 16; Range = 0-43)
|
|
|
<10 years
|
27 (20.00)
|
|
≥10 years
|
108 (80.00)
|
|
Years of experience in leadership position (Median = 8; Range = 1-51)
|
|
|
<10 years
|
75 (55.56)
|
|
≥10 years
|
60 (44.44)
|
|
Type of institution that best defines your main leadership role
|
|
|
Private
|
94 (69.63)
|
|
Public
|
41 (30.37)
|
|
Main specialty
|
|
|
Clinical oncology
|
72 (53.33)
|
|
Radiation oncology
|
8 (5.93)
|
|
Surgical oncology
|
31 (22.96)
|
|
Other
|
24 (17.78)
|
When comparing the Brazilian versus NA/EU participants' responses, a higher proportion
of the former group placed a high value on task management competencies (93.3 versus
87.0%, p<0.0001) ([Table 2]). Social responsibility competencies were rated second in importance by Brazilian
physician-leaders, with no differences between the Brazilian and NA/EU participants'
scores for this category.
Table 2
Percentage of responses ≥4 for each group
|
Brazil - (%)
|
European/North American - (%)
|
|
|
Task management competencies
|
93.33
|
87.00
|
<0.0001
|
|
Social responsibility competencies
|
88.74
|
87.48
|
0.2178
|
|
Self-management competencies
|
88.72
|
87.55
|
0.2709
|
|
Leading others competencies
|
84.53
|
84.71
|
0.8358
|
|
Innovation competencies
|
87.39
|
85.31
|
0.0397
|
We performed subgroup analyses within the Brazilian respondents ([Table 3]). In the clinical oncology versus other specialties comparison, considering only
the analyses that achieved statistical significance, social responsibility competencies
were more highly valued by clinical oncologists as compared to others (90.5% versus
86.6%; p=0.0124), whilst leading others (81.2% versus 88.2%; p<0.0001) and innovation competencies (85.67% versus 89.34%; p=0.0166) were placed a lower value by clinical oncologists.
Table 3
Subgroup analyses of the Brazilian participants
|
% of respondents who scored competency as 4 (important) or 5 (very important)
|
|
Subgroup
|
Task Management
|
Social Responsibility
|
Self-Management
|
Leadin g Others
|
Innovation
|
|
Male (n=84, 62.22%) vs. Female (n=51, 37.78%)
|
92.69 vs. 94.38% (p=0.3119)
|
88.08 vs. 89.97% (p=0.2450)
|
88.52 vs. 89.07% (p=0.7447)
|
84.05 vs. 85.32% (p=0.3890)
|
86.55 vs. 88.76% (p=0.1609)
|
|
Age <45 (n=71, 52.59%) vs. Age ≥45
(n=64, 47.41%)
|
92.14 vs. 94.64% (p=0.1235)
|
88.12 vs. 89.27% (p=0.4703)
|
88.73 vs. 88.71% (p=0.9912)
|
84.10 vs. 84.51% (p=0.7771)
|
86.90 vs. 87.93% (p=0.4977)
|
|
Years of experience in oncology: <10 (n=27,
20%) vs. ≥10 (n=108, 80%)
|
92.06 vs. 93.64% (p=0.4367)
|
87.65 vs. 89.01% (p=0.4903)
|
90.91 vs. 88.18% (p=0.1830)
|
83.43 vs. 84.80% (p=0.4434)
|
85.71 vs. 87.81% (p=0.2732)
|
|
Years of experience in leadership: <10 (n=75,
55.56%) vs. ≥10 (n=60, 44,44%)
|
92.56 vs. 94.29% (p=0,2903)
|
88.00 vs. 89.66% (p=0,2930)
|
89.21 vs. 88.11% (p=0,5053)
|
83.76 vs. 85.49% (p=0,2285)
|
87.40 vs. 87.37% (p=0,9799)
|
|
Private (n=94, 69.63%) vs. Public
(n=41, 30.37%)
|
93.76 vs. 92.33% (p=0.4197)
|
88.26 vs. 89.84% (p=0.3548)
|
87.86 vs. 90.69% (p=0.1139)
|
84.01 vs. 85.71% (p=0.2721)
|
86.29 vs. 89.90% (p=0.0602)
|
|
Clinical Oncology (n=72, 53.33%) vs. Others (n=63, 46.67%)
|
92.05 vs. 94.78 (p=0.0928)
|
90.58 vs. 86.64% (p=0.0124)
|
87.69 vs. 89.90% (p=0.1800)
|
81.22 vs. 88.29% (p<0.0001)
|
85.67 vs. 89.34% (p=0.0166)
|
vs. = Versus.
No statistically significant differences in the responses were observed between physicians
working mainly in the private versus public sectors, in the male versus female comparison,
and in the analyses that addressed the effect of seniority based on age or years of
experience in oncology and in leadership positions ([Table 3]).
DISCUSSION
To the best of our knowledge, this LACOG/ALSS survey was the first to address leadership
competencies in LA physicians.[21] Our previous analyses disclosed significant differences in terms of how LA physicians
value specific leadership competencies as compared with their NA/EU counterparts (though
in the NA/EU survey, physicians represented only 40% of the participants).[11]
We performed this additional analysis focused specifically on the Brazilian population
because of the significant differences in the content of the responses observed in
most domains when Brazilians were compared with physicians from other LA countries
(mostly from Mexico).[21] As previously mentioned, significant cultural influence in the valuation of specific
leadership competencies has been documented in other domains,[20] and it could be the case that ‘being from LA' was not homogeneous enough for an
optimal evaluation of the other variables. Apart from language (Portuguese versus
Spanish), we found no other factors (such as age or years of experience) that could
justify the differences in the responses between the Brazilian and other LA participants
so that, most likely, they are attributable to cultural differences.[21]
Our hypothesis was that, by focusing only on participants from a specific country,
we would be able to more reliably interpret the other variables. Furthermore, Brazil
is the country with the largest population in LA (as of 2018, 209.469.323 –
representing 32.6% of the LA population),[22] so that a specific analysis of this culturally and languagesxhomogenous subgroup
is justifiable. Our large sample size, with a wide representation of Brazilian participants,
provides sufficient statistical power for the current analysis.
For the comparison between Brazilian versus NA/EU respondents, the results mirrored
those of the full population analysis, with a higher proportion of Brazilian participants
placing a high value on task management competencies as compared to NA/EU (93.33 versus
87,00%, p<0.0001). However, social responsibility rated second in the current analysis, as
compared to third in the primary study analysis. The potential reasons for the differences
between the LA versus NA/EU survey have been addressed elsewhere,[21] but might include the fact that physicians were underrepresented in the NA/EU survey,
in which they tended to place lower value on social responsibility competencies as
compared to non-physicians (we previously hypothesized that non-physicians might have
a deeper level of emotional involvement with patients and their families, potentially
making them more sensitive to the social hurdles associated with the course of their
illnesses).[21]
Results from this study show that women were slightly less underrepresented within
the Brazilian subgroup, though the differences were small. Of note, in Brazil, as
of 2017, 54.4% of the workforce were male, and since 2009, more female than male doctors
have been registered – which probably rule out an underrepresentation of female doctors
in the country as a whole as the cause for the female underrepresentation found in
this survey.[23] In the main study analysis, female physicians from LA placed a higher value on innovation
competencies as compared to males,[21] and we provided evidence that this had already been suggested by studies performed
in other domains.[24]
[25] In the current analysis, however, no such differences were observed. It could be
speculated that Brazilian female physician-leaders indeed differ from their LA (mainly
Mexican) counterparts in this aspect or, instead, this could be simply due to statistical
bias.
One of the most striking differences between the main and the current study analysis
was in terms of the effect of seniority on the results of the survey. In the full
study population, more senior leaders as assessed by age (≥45 years), years of experience
in oncology (≥10 years), or years of experience in a leadership position (≥10 years),
consistently placed a higher value on task management and leading others competencies,[21] which we believed could be due to the long time required to acquire these complex
skills. However, no such differences were observed in the current analysis, for any
of the definitions of seniority. The reasons for these differences between Brazilian
and other LA physician-leaders' responses should be further explored but could indeed
represent cultural differences reflected in their responses.
In terms of the clinical oncology versus other specialties comparison, the results
matched those of the primary analysis, with social responsibility competencies being
more highly valued by clinical oncologists as compared to others (90.58% versus 86.64%;
p=0.0124), and leading others (81.22% versus 88.29%;
p<0.0001), and innovation competencies (85.67% versus 89.34%; p=0.0166) being placed a lower value by clinical oncologists ([Table 3]). Also consistent with the main study findings, no differences were observed in
the responses placed by physicians working mainly in the private versus public sector.[21]
The limitations and strengths of our survey have been addressed elsewhere.[21] The current analysis included 135 participants, which represents 63% of the study
population. Although subgroup analyses should always be interpreted with caution,
because survey samples are often estimated on a convenience basis and few such studies
report on sample sizes larger than 100 participants, we assume the current sample
size is sufficient to provide statistical power for the analyses. One strength of
the current analysis is the fact that, by focusing on participants from a specific
country, we were able to eliminate a significant variable which was country of practice
(with the language and all the cultural differences expected between a Brazilian and
a [mainly] Mexican sample), potentially allowing for a more reliable analysis of the
other variables.
CONCLUSION
This analysis provides further evidence for the existence of significant cultural
differences within the LA participants, and that these cultural variations can significantly
affect the valuation of specific ML competencies. Because training physicians and
medical students in leadership skills is becoming a common practice, our data might
have implications in terms of helping make the content of these programs more suitable
to the region of the world in which they are applied. Finally, future studies addressing
ML competencies should consider the impact of culture on the results and enroll a
large sample of participants to allow for multiple subgroup analyses.
Bibliographical Record
Max Senna Mano, Rafaela Gomes Jesus, Carlos Henrique Escosteguy Barrios, Wanessa Cassemiro
Fernandes, Leandro Jonata de Carvalho Oliveira, Abna Faustina Sousa Vieira, Renan
Orsati Clara, Antônio Luiz Frasson, Gustavo Nader Marta, Sérgio Daniel Simon, Cynthia
Villarreal-Garza, Gustavo Werutsky, Fadil Çitaku. Subgroup analysis of Brazilian participants
of a medical leadership competencies instrument: a cross-sectional survey study of
the Latin American Cooperative Oncology Group (LACOG) and the Academy of Leadership
Sciences Switzerland (ALSS). Brazilian Journal of Oncology 2022; 18: e-20220375.
DOI: 10.5935/2526-8732.20220375
