Leadership in Undergraduate Medical Education: A Study of Pakistani Medical Students' Perceptions, Attitudes, and Interest

Background: Despite calls for the much-needed involvement of physicians in leadership, very few medical colleges in Pakistan provide explicit training on the knowledge, skills, and attitudes necessary to be an effective physician leader. Objective: To explore Pakistani medical students' perceptions, attitudes, and interests regarding Leadership training in medical education. Methods: Participants were asked about their perceptions and attitudes towards medical leadership on a 5-point Likert scale. Students also self-rated their leadership competencies noted as per Medical Leadership Competency Framework. Survey also assessed the perceived need and topics for a leadership curriculum for physician leaders, the teaching format, and barriers to leadership training in medical schools. Data were analyzed using SPSS 26. Results: About 60.6% of the total 1204 respondents rated their leadership training in medical college as “very poor” or “poor” and 80.3% of them endorsed their interest and need for it. 77.4% of the participants agreed that clinicians should influence leadership decisions in a clinical setting. Only 25% of respondents were aware of the demands of a leadership rank in medicine. Leadership competencies endorsed for training included problem-solving, leading a team, confronting problematic employees, and communication skills with a multimodal teaching approach, including teaching methods like small group discussions. The main barriers to leadership training were identified as time constraints (66.1%), lack of available curriculum (69.0%), and disinterest by faculty (67.0%). Conclusion: Our study suggests that medical students in Pakistan appreciate the importance of leadership training in undergraduate education. There is a need for dedicated leadership teaching and study data to specify the possible content and delivery methods to serve as goals for an undergraduate leadership curriculum in Pakistan.


Introduction
eadership is the potential of an individual or a Lgroup to influence and guide others towards achieving a common goal and solving problems thoughtfully and effectively.A leader should be able to foresee the circumstances and utilize resources to improve things.He /She should motivate and inspire others and be empathetic.Some are born with leadership qualities, but they can be instilled in a person by teaching behaviors that can be learned and skills that can be nurtured.
Although leaders are often thought to belong to professions like politics and business in which they lead organizations or countries, being an effective leader is 1 equally important for a doctor and any other profession.
A doctor has to treat the patient but to perform this duty efficiently, physician has to be an effective leader in the hospital working in a team to guide patients accurately, lead people towards a healthy community, resolve  1) Table 2 shows the self-perception of leadership qualities [as per medical students' medical leadership competency framework (MCLF)].The highest-ranked qualities were "acting with integrity", "organization" and "motivating others", with 56.3%, 49.7% and 49.4% of respondents grading themselves as "very good" or "good".(Table 2) More than half the respondents (60.6%) described their leadership training in medical college as "very poor" or "poor".(Figure 1)

Discussion
Studies on leadership skill acquisition within a healthcare setting in Pakistan are few.To our knowledge, this is the first multi-institutional study that evaluated the attitudes and views of medical students towards medical leadership following recommendations of leadership being one of the competency which should be acquired at undergraduate level.Although there is ample evidence of the need for leadership amongst physicians, given the nature of their profession, it appears that there is a lack

Leadership Training Competencies
Leadership Training Competencies institutions.Not only in times of unprecedented social upheaval, such as natural disasters and pandemics but everyday situations, physicians face life and death decisions.The expectation placed on doctors and healthcare workers to govern situations steadfastly leads to quick It is also notable that there were no demographic biases within the results; most participants identify as women and agree with a pressing need to acquire leadership skills, whereas developing countries often do not have women in visible leadership positions.This study indicates a changing trend within medical colleges, with women wanting to take up leadership positions, as highlighted by the fact that a majority of respondents in our study wanted to take up leadership roles in the future and would like any leadership positions available to be highlighted.
While the differences in the training and social circumstances of students from the developed and developing world are vast, medical students across the board have similar perceptions of what constitutes leadership skills 15 necessary for physicians.These include communication skills, conflict resolution, and ethical considerations such as acting with integrity and self-reflection.Those mentioned above were all areas students identified as deficient in their learning, with a majority self-identifying as 'satisfactory'.
However, it is still not understood how best to approach the integration of leadership skills into physician training during medical college.With the demands of the medical curriculum, it seems unlikely that further adding on lectures and tests around leadership would be effective.This idea was furthered by the fact that only 10% of respondents within this study found this method to be significantly effective.A study at the University of Michigan corroborates this idea and argues that while students recognize a need for leadership skill acquisition, mandatory curriculum changes have limited effective-16 ness.
The students surveyed appeared to prefer more interactive and hands-on methods of acquiring leadership skills consistent with previous studies,17 with 42.1% of students agreeing that small group exercises would be 'significantly effective'.In contrast, 37.1% of students also agreed that role play would be 'significantly effective'.This appears to be an idea shared across the board, with a survey of residents at Massachusetts General Hospital corroborating that hands-on leadership training 18 is a preference of trainee physicians.
The study has several limitations.Although our study includes medical students from both public and private medical colleges, the results may not be generalized to all the medical colleges in the country, especially those in smaller cities of Pakistan with different social and economic statuses.Further, data was collected by the means of a self-administered questionnaire.There is a possibility that respondents who answered together may have caused each other to give similar responses or there may have been selection bias with students interested in leadership responding more.

Conclusion
Our study suggests that medical students in Pakistan appreciate the importance of leadership training in undergraduate education.Despite the limitations, this study accurately identifies the deficiencies perceived by medical students concerning leadership training within their studies in Pakistan.However, a plan for implementing adequate training depends on various factors which were not surveyed within this study.

P r o b l e m S o l v i n
Table1describes the students' perceptions and attitudes, and interests regarding medical leadership.Only one-fourth of respondents agreed with the statement, when asked if they were well-informed about the demands of leadership position in medicine.77.4% of respondents were in agreement that clinicians ought to influence leadership decisions in a clinical setting.In contrast, 86% felt it is crucial for clinicians to have leadership tasks.A significant proportion (80.3%) of medical students would like to have more focus on leadership training during medical college, and almost 60% would prefer to seek additional training in this domain in residency training.Questions about whether undergraduate medical students would be attracted towards embracing leadership duties in their future careers and need for such opportunities to be emphasized to them led to majority's agreement at 56% and 81.5%, respectively.(Table 4important role in controlling the pandemic.Doctors, nurses and paramedic staff were the frontline warriors.On the one hand, they treated the patients and, on the other hand, addressed the issue expeditiously to the government and masses about the ongoing situation and how to prevent it from worsening.That explains how important learning leadership skills and acquiring management skills are.The medical profession demands excellent clinical knowledge, training, leadership qualities, and effective 5 management skills to provide good services to patients.For doctors to be effective leaders of the future, a basic training program for medical students should be started 3 earlier in the medical curriculum.Many medical schools and residency programs all over the world, lack this kind 6,7 of curriculum and Pakistan is not an exception.Studies have shown that medical ethics, time management, and communication skills are not incorporated into the MBBS (Bachelor of Medicine, Bachelor of Surgery) curriculum taught in Pakistan, resulting in communi-8% (250) , Year 3 students 16.4% (197) ,Year 4 students 23.0% (277) and Year 5 students 15.7% (189).Almost 95.9% (1153) students reported no prior leadership training, and 87.5% (1051) reported no previous April -June 2023 | Volume 29 | Issue 02 | Page 106 leadership experience.

Table 1 :
Perceptions, attitudes, and interest toward medical leadership using a 5-point Likert scale (strongly agree to strongly disagree)

Table 2 :
Self-perception of leadership skills highlighted by the MLCF, using a 5-point Likert scale (very good to very poor)

10,11 of
concentration on curricula that focus on this need.Physicians are constantly put in situations where they have to act quickly and maturely under immense amounts of pressure, both in healthcare and medical education April -June 2023 | Volume 29 | Issue 02 | Page 108

Table 3 :
Preference of leadership training methods desired by the medical students.
The numbers may vary because of missing data.