A needs assessment of hospital management and leadership training among Indian medical undergraduates

Abstract

Background

Medical undergraduate students are often unaware of the managerial aspects of operating a healthcare facility. This leads to confusion and a sense of being lost when they assume administrative roles, highlighting the need for hospital management and leadership training. This prompted us to evaluate the needs of medical undergraduates concerning these crucial aspects.

Methods

An exploratory study was conducted on 240 medical undergraduate students to assess the medical undergraduates’ need to learn about hospital management and leadership training, their views about the importance and their self-perceived knowledge of the various elements of hospital management and leadership training. A meticulously validated questionnaire, comprising three essential parts, based on the Likert scale was effectively employed in the study. Part A asked students to evaluate the importance of 15 selected elements of hospital management and leadership training, ranging from not important to very important, in their role as a doctor. Part B required the students to assess their self-perceived knowledge levels on a scale from no knowledge to very adequate for the same 15 elements. Part C inquired about the students’ opinions on including these topics in their curriculum and, if so, the appropriate timing.

Results

Nearly 75% of the students felt that time management, stress management, and patient safety issues were very important for their role as doctor. Closely following these were communication/ public relation skills, hospital information system & record keeping, quality improvement/assurance, law, ethics & code of conduct. Only 25% of the students reported their self-perceived knowledge as very adequate for almost all the elements. For inclusion in the curriculum, the majority wanted to learn about these elements and throughout the course was the preferred timing.

Conclusion

The students felt that hospital management and leadership training were pivotal for their roles as doctors. They expressed a lack of sufficient knowledge in these areas and the need for these important aspects to be included in their curriculum as a longitudinal course.

Introduction

Medical graduates in a country like India are pillars of the public health service delivery system. However, these graduates often have minimal formal hospital management and leadership training, which are crucial for effectively managing the healthcare system. It is commonly assumed that a health degree like a Bachelor of Medicine and Bachelor of Surgery (MBBS) means that one can be a manager and a leader. As a result, fresh graduates without any knowledge or skills for healthcare management and leadership are given a wide range of managerial and supervisory responsibilities such as taking charge of healthcare delivery of an entire district including personnel and materials etc. Even as a postgraduate student or after joining a government/private/corporate hospital or running a practice, a doctor faces many issues that require a managerial approach e.g. working as a team manager or leader, record keeping, drug-related management and inventories, public communications, conflict resolution, recruiting, training and retaining staff of different levels, etc. Many young doctors often feel overwhelmed by the roles they have to perform. This indicates the need for knowledge, leadership skills, and a managerial approach in healthcare, in addition to clinical skills and knowledge. Kaur and Singh found that 70% of the medical students in their study agreed that including training in leadership and management skills should be part of medical education [1]. Realizing this need to train medical undergraduates, some countries have added these aspects to the curriculum. In the United Kingdom (UK), the National Health Service (NHS) Institute for Innovation and Improvement and the Academy of Medical Royal Colleges have developed the Medical Leadership Competency Framework (MLCF) [2]. In the United States as well as Canada many undergraduate medical curricula address these aspects.

In India, in the new competency-based medical education (CBME) curriculum, launched in 2019, by the Medical Council of India (MCI) now the National Medical Commission (NMC), being a team leader has been defined as a specific role for the Indian Medical Graduate (IMG) but actual teaching and learning for this is in a nascent stage [3]. A needs assessment of the medical undergraduate students would help gather information on their current knowledge, training, and attitudes toward these important aspects of healthcare delivery. The present study is one such important attempt to assess the felt need of medical undergraduate students for hospital management and leadership training as the existing status of these in the undergraduate medical curriculum in India remains largely obscure.

This study aimed to assess the perspectives of pre-final and final year medical undergraduate students trained under the new curriculum regarding the importance and self-perceived knowledge about hospital management and leadership training.

Materials & methods

A prospective, cross-sectional, exploratory study was conducted on 240 pre-final and final year medical undergraduate students of Kalpana Chawla Government Medical College, Karnal, Haryana, India after obtaining ethical approval from the Institutional Ethics Committee (KCGMC/IEC/2022/19). The sample size calculated was 208 with a 98% confidence interval and a ± 3% margin of error. A validated questionnaire with a Cronbach alpha value of 0.96, indicating a high degree of internal consistency was used. The questionnaire eliciting the students’ perception for various elements of hospital management and leadership training was adapted from Varkey et al. [4]. It included both, open and closed-ended questions. The 5-point Likert-type questionnaire included 15 elements of hospital management and leadership training. These elements were selected after searching from literature for the common topics included in research on the subject of teaching medical undergraduate students about hospital management and leadership training. The elements included were viz. human resource management, financial management, material management, conflict & risk management, time management, quality improvement/assurance, law, ethics & code of conduct, stress management, change management, disaster management, marketing of health services, medical audits, patient safety issues, hospital information system & record keeping, communication/ public relation skills. In part A of the questionnaire the students were asked to rate the elements from not important to very important in their role as a doctor. In part B, they graded their self-perceived knowledge about these elements from no knowledge to very adequate. In the end, two open-ended questions asked the students whether they thought these topics should be included in the MBBS curriculum. And if yes, what would be the appropriate timing for its inclusion. The questionnaire along with an invitation letter and information sheet was sent to all students via the Google platform through email. This letter informed them about the implied consent and their confidentiality. In case a student did not respond initially, two more attempts were made to obtain the response. The identity of the students was kept confidential.

The quantitative data collected was analyzed using Statistical Package for the Social Sciences (SPSS) software version 21.0. The responses of pre-final and final year students were compared as well as the level of importance for different elements was interrelated with the self-perceived knowledge by using the chi-square test. P < 0.05 was considered statistically significant. The open-ended questions were analyzed for the emerging themes.

Results

From the 15 listed elements, time management was rated as very important by 76.57% of the students, followed closely by stress management (75.73%) and patient safety issues (74.9%). The next three elements considered very important by the students were communication/public relation skills, quality improvement/assurance, law, ethics & code of conduct. The least number of students rated medical audits (51.88%), marketing of health services (47.28%) and change management (46.44%), as very important (Fig. 1).

Fig. 1

Rating of the importance of the elements in their role as a doctor

Figure 2 shows the self-perceived knowledge of the students about the elements included in the present study. Only 25% of the students reported their self-perceived knowledge as very adequate for almost all the elements except stress management (30.96%) and time management (28.03%), where it was marginally more. A higher number of students reported minimal or no knowledge of medical audits (31.4%) followed by marketing of health services (26.78%) (Fig. 2).

Fig. 2

Self-perceived knowledge of the students about the elements

The chi-square test was applied to evaluate a possible association between the importance rating and the self-perceived knowledge of the students. The p-values obtained for communication/public relation skills, marketing of health services, change management, law, ethics & code of conduct were highly significant (p-value < 0.001). The interrelation of importance and self-perceived knowledge for hospital information system & record keeping, medical audits, time management, human resource management and material management showed a statistical significance (p-value < 0.05). We found no major significant differences between responses by pre-final and final year students for most of the elements.

The medical undergraduates were asked about whether teaching pertaining to hospital management and leadership training should be included in the current curriculum or not. Out of 240 students, most (83.3%) of them felt the need to include these topics in the curriculum while 10% did not wish to include it or had no opinion (6.7%) about it. The students who responded yes were asked to express the appropriate timing for inclusion. 45% wished to have the course throughout the MBBS studies while 14% preferred internship and 41% mentioned other timings like 1st, 2nd year, etc.

Discussion

The present study was conducted to assess the needs of medical undergraduate students in the context of hospital management and leadership training. The students were asked to rate the level of importance and self-perceived knowledge of 15 elements of hospital management and leadership training. These 15 elements were selected after a review of the literature and adapted from the study of Varkey et al. [4].

In the present study, time management was rated as the most important by the medical undergraduates (76.57%) in their role as a doctor followed by stress management (75.73%) and patient safety issues (74.9%). The next closely followed elements were communication / public relation skills (72.38%), quality improvement/assurance (71.97%), law, ethics & code of conduct (71.97%) and hospital information system & record keeping (71.13%). A marginally lesser importance was given to financial management (67.36%), conflict & risk management (66.95%), disaster management (63.18%), human resource management (61.09%) and material management (60.67%). The least important ones were medical audits (51.88%), marketing of health services (47.28%) and change management (46.44%).

On comparing the elements covered in the present study with other studies, it was observed that financial management, conflict management, time management, law, ethics & code of conduct, communication/ public relations skills were the most frequently evaluated elements by other authors followed by quality improvement and change management [4,5,6,7]. The least frequently covered were human resource management, material management, stress management, medical audits, marketing of health services, patient safety issues, hospital information systems and record keeping [4,5,6, 8, 9]. Surprisingly, disaster management has not been included in any of the other studies, except the present one.

Time management

Medical undergraduate students’ crowded curriculum and schedules push them hard to manage their time well. It is not surprising to note that time management was rated as very important by 76.57% of the students in this study. Varkey et al. also reported that 85% of their students viewed time management as a very important skill [4]. The self-perceived knowledge of time management was reported as somewhat or very adequate by 60.25% of our students, which is similar to Varkey et al. (65%) and Rouhani et al. (67.5%) [4, 6] while Alzahrani et al. observed that 85% of their medical students rated themselves as satisfactory or more for this skill [7].

Stress management

Stress is an integral part of medical studies. 75.73% of the students in the present study considered stress management very important, and only 54.39% felt that they had somewhat or very adequate knowledge about stress management. In contrast, a higher percentage (75–85%) of the students were satisfied with their stress management skills as reported by Rouhani et al. and Alzahrani et al. [6, 7].

Patient safety issues

Patient safety has become an important component of healthcare. It is heartening to note that patient safety issues was rated as the third very important element by our students. However, only 58.53% of the students reported that they had somewhat or very adequate knowledge about these issues. Patient safety was frequently suggested as a topic for inclusion in the undergraduate curriculum in the qualitative study of students’ attitudes towards and opinions about leadership and management education by Quince et al. [9].

Communication/ public relation skills

Effective communication between doctor and patient as well as team members is an essential component of a doctor’s routine. 72.38% of our students rated it as a very important skill. Varkey et al. noted that 100% of their participants felt it was very important [4]. Considering the importance of good communication skills, Kakemam et al. included it in their framework of competencies for management and leadership [10]. In the present study, the self-perceived knowledge of communication/public relation skills was reported as somewhat or very adequate by 61.1% which is in remarkable contrast to the majority of the students in other studies stating satisfactory skills or competence in communication skills [4, 6, 7].

Quality improvement/assurance, law, ethics & code of conduct, hospital information system & record keeping

The self-perceived knowledge of quality improvement/assurance, law, ethics & code of conduct and hospital information system & record keeping was somewhat or very adequate (52.30-58.57%) among our students. Varkey et al. observed that 31% of their group felt competent for quality improvement but 90% felt competent for ethics [4]. Rekhter and Togunov reported that the course of highest interest was the healthcare legal system. The topic related to hospital information systems was rated lower than other topics for inclusion in the course content [5, 8].

Financial management, conflict & risk management, disaster management, human resource management and material management

Nearly two-thirds of the students in the present study rated financial management, conflict & risk management, disaster management, human resource management and material management as very important and about 50% of them reported that their self-perceived knowledge of these elements is somewhat and very adequate. The respondents of Martin et al. study placed financial management at the middle level whereas Varkey et al. found only 20% perceiving financial management as very important with very little reporting (15%) that they are competent [4, 8]. Rekhter and Togunov noted that the healthcare finance course was rated in fifth place in its usefulness [5].

Compared with the present study, Varkey et al. reported a marginally higher, 70%, of their participants felt competent for conflict management but the percentage decreased to 40% for risk management [4]. Resolving conflict was perceived as a satisfactory level of skill by participants of the study by Rouhani et al. (97.4%) and Alzahrani et al. (94%) [6, 7]. Managing people and team management was considered as of the highest importance by the participants of Martin et al. [8].

Respondents in our study considered disaster management and material management important but they had inadequate knowledge about these. Surprisingly these two elements have not been explored in any other study so far although, Kakemam et al. have included resource management as one of the important competencies in their new competency model for hospital managers [10].

Medical audits, marketing of health services and change management

The three elements with the least number of students reporting them as very important in descending order were medical audits (51.88%), marketing of health services (47.28%) and change management (46.44%). Similarly, change management was rated as the lowest by the respondents in the study of Martin et al. although Kakemam et al. have included it as a core leadership and management competency [8, 10]. Quince et al. also suggested the inclusion of evaluating change in the curriculum [9]. Similar to the present study, marketing and management was a course of low interest [5]. Audits are considered an important source of information for improving healthcare delivery. Nevertheless, Martin et al. noted that audits ranked at the middle level in the importance of inclusion in the curriculum [8].

An attempt was made to evaluate for any association between the level of importance and the self-perceived knowledge of the students for all the elements and it was found that when the self-perceived knowledge of an element was less then the level of importance was also lower.

Inclusion in the curriculum

The students were asked about whether teaching on hospital management and leadership training should be included in the curriculum. The majority (83.4%) wished to have teaching on hospital management and leadership training to be included in the undergraduate medical curriculum. Martin et al. in their exploratory study on students in the UK and Portuguese students noted that such a course was perceived as relevant [8]. Abbas et al. in a systematic review of curricular development reported the attitudes of medical students toward medical leadership and management. They concluded that the medical students perceived a need for this education but identified a lack of curriculum time and disinterest in some activities as potential barriers to implementation [11]. Their findings corroborate with Rouhani et al., further emphasizing the lack of medical management teaching [6]. Jalil et al. have also supported this lack of curriculum time being a key barrier to the incorporation of medical management teaching as at present in most of the institutions worldwide the timetables that are being followed allow for very little teaching time in addition to the current curricular aims [12].

Kaur and Singh reported that 81% of postgraduate students in their study agreed that they received little or no training for managing healthcare services and there was a need to understand the changing health scenario. The students were in favour of learning skills of leadership and management during medical training as 76% of them strongly felt that management is playing an increasingly important role in healthcare. Also, 57% responded that understanding healthcare management concepts will complement their learning during undergraduate training years [1].

A survey conducted by Maskell et al. on 644 medical students from 30 universities revealed that 88.3% of their students agreed that medical leadership and management skills are important for junior doctors and 87.4% felt that these skills are relevant to their education. However, only 17.1% felt that medical leadership and management are being taught effectively in their curriculum [13].

In Saudi Arabia, 52.1% of students in a study by Alzahrani et al. agreed that clinicians should influence management decisions in a healthcare setting and 49.7% of students felt that management/leadership skills are important for clinicians [7]. Muneeb et al. observed that the vast majority of their students believed that greater emphasis should be placed on medical leadership and management content within the core curriculum [14].

Till et al. gave twelve tips for integrating leadership development into undergraduate medical education. They further suggested that these broad areas can be woven into any type of curriculum, be this pre-clinical/clinical, problem or team-based, systems-based, or outcome/competence-based [15].

Hynes et al. recommended that leadership and management be recognized as one of a doctor’s core skills and be included in postgraduate and undergraduate curricula, with outcomes relevant to the stage of training. They also suggested that dedicated time for leadership and management is critical to developing skills and embedding these capabilities within the role of the doctor [16].

Timing of inclusion

In the present study, the students were asked for the appropriate timing of hospital management and leadership skills training in the curriculum. 45% wished to have a continuous course run throughout their undergraduate medical education while 14% wanted it during internship. In contrast, Kaur and Singh reported that almost 72% of their students felt that the best time for such training would be during the internship. Martin et al. have mentioned that most students in their study considered that a leadership/ management course should last one semester during the clinical years [8]. Alzahrani et al. reported that 43.2% of students desired to have more leadership training in medical school, and 38.4% of students agreed to seek additional leadership/management training in their postgraduate research studies [7]. Hsu et al. have further emphasized that the curriculum related to hospital management and leadership must start at the level of undergraduate medical education [17].

Methods of delivery

On being questioned about the method of delivery in a focus group discussion, the undergraduate students preferred experiential methods including observation, reflection, critical appraisal and mistake analysis at all levels while very little support was given to didactic sessions [9].

Kaur and Singh suggested that a module of 4–6 weeks duration on leadership and management skills with a component of the practical application can be developed especially as a part of the internship programme from a 2-day continuing medical education programme to a 1-or 2-week workshop activity [1]. Alzahrani et al. also recommended a 2-week leadership module using blended learning [7]. Hsu et al. have mentioned in their study that for successful adaptation of the healthcare business and management curriculum, this curriculum must possess the basic components of support, integration, practicality, application, and continuation [17].

Jalil et al. have suggested the incorporation of student-selected components in medical management teaching as it allows the students to pursue interests that often do not fall under the standard syllabus and also allows them to gain an insight into the management field [12]. Similarly, Muneeb et al. have also concluded in their study that a 4-week student-selected component comprising a small group, expert-led tutorials as well as opportunities to attend coroner’s courts and fitness to practice tribunals is an effective way of teaching medical leadership and management education at the undergraduate level [14]. Rekhter and Togunov have stated that overall the medical schools and continuing education departments were seen as the best choices for delivering healthcare management education [5].

Maskell et al. have reported that 57.5% of their students agreed that there should be a specific standard set for graduating medical students, but only 8.9% were aware of the MLCF. They commented that there are future challenges in matching students’ expectations towards developing leadership capabilities with formalized undergraduate curricula although the majority of the students recognize the importance of the topics [13].

Sethi et al. have also proposed a longitudinal curricular template/ framework utilizing a mixed/multi-modality approach for teaching and applying leadership competencies including team training, community and clinical experiences, student leadership opportunities, experiential learning, mentoring and networking [18].

In India, the new CBME launched in 2019 has included competencies for medical undergraduate students as a team leader but the core components of hospital management and leadership training are yet to be emphasized. On the other hand, many countries across the world have reworked their curricula to include the competencies related to hospital management and leadership [4, 6, 9, 10, 19]. To the best of our knowledge, the current study is the earliest evidence generated from India that documents the felt need of medical undergraduate students for hospital management and leadership training. However, this study was limited to medical undergraduate students from a single institution in Haryana state, India, so it does not represent the whole country’s medical student population.

Conclusion

The majority of our medical undergraduate students agreed that elements of hospital management and leadership training are very important although they expressed that their self-perceived knowledge for them is inadequate. Most believed that these elements should be included in their training at the undergraduate level as a longitudinal curriculum running throughout the MBBS years. It is, therefore, emphasized that in preparing IMG for their various roles as defined by the MCI/NMC, hospital management and leadership training holds great potential to improve the existing healthcare system. Undergraduate level/ MBBS is an ideal time for laying the foundation for not only future clinicians but also for their role as health care managers and leaders. Hence, it is recommended that hospital management and leadership training education should be included in the new CBME. It is suggested that suitable revisions are made to the existing curriculum so that these elements of hospital management and leadership skills can be applied longitudinally over the length of the undergraduate course with experiential learning and possible exposure during one of the electives. Furthermore, larger and multi-institutional studies should be done as they can provide a wider perspective and deeper insight regarding medical students’ opinions as well as their need for hospital management and leadership training which can aid in guiding future development of a curriculum addressing medical leadership and hospital management.