Background

Residency program directors have increasingly challenging roles, but they may not be receiving adequate leadership development.

Objective

To assess and facilitate program directors' leadership self-awareness and development at a workshop retreat.

Methods

At our annual program director retreat, program directors and associate program directors from a variety of specialties completed the Thomas-Kilmann Conflict Mode Instrument (TKI), which evaluates an individual's behavior in conflict situations, and the Hersey-Blanchard Situational Leadership (HBSL) model, which measures individuals' preferred leadership style in working with followers. Participants received their results during the retreat and discussed their leadership style results in the context of conflict situations experienced in the past. An online survey was distributed 3 weeks after the retreat to assess participant satisfaction and to determine whether participants would make changes to their leadership styles.

Results

Seventeen program directors attended the retreat and completed the tools. On the TKI, 47% preferred the Compromising mode for handling conflict, while 18% preferred either the Avoiding or Accommodating modes. On the HBSL, 71% of program directors preferred a Coaching leadership style. Ninety-one percent of postretreat-survey respondents found the leadership tools helpful and also thought they had a better awareness of their conflict mode and leadership style preferences. Eighty-two percent committed to a change in their leadership behaviors in the 6 months following the retreat.

Conclusions

Leadership tools may be beneficial for promoting the professional development of program directors. The TKI and HBSL can be used within a local retreat or workshop as we describe to facilitate positive leadership-behavior changes.

Residency program directors have increasingly challenging roles in the graduate medical education environment. Institutional financial pressures, generational differences among learners, and adherence to Accreditation Council for Graduate Medical Education program requirements are but a few of the many factors that make the job of the program director challenging. Program directors frequently are conflict managers, resolving issues among residents and faculty, and managing the changing group dynamics of each successive group of residents is a constant challenge. Given these formidable responsibilities, there is a fair degree of turnover among program directors, with an average length of 7 years for appointments.1 

Most program directors have little training in management and leadership skills prior to assuming this role. Those who have been associate program directors have learned of these skills on-the-job, and some may attend leadership training offered at annual program director association meetings (eg, annual meetings of the Association of Program Directors in Internal Medicine). However, economic pressures make it progressively more difficult to attend off-site development programs.

Several validated leadership development tools exist that can be used by medical educators to assess and develop leadership skills. The Thomas-Kilmann Conflict Mode Instrument (TKI) is designed to evaluate an individual's behavior in conflict situations.2 Behavior is described along 2 dimensions (figure 1): assertiveness (the extent to which individuals satisfy their own concerns) and cooperativeness (the extent to which individuals satisfy the concerns of others). Based on these 2 dimensions, 5 preferred methods of dealing with conflict emerge: Competing, Compromising, Collaborating, Avoiding, and Accommodating. Program directors aware of their preferred style for handling conflict may be able to more easily adapt to other styles as situations warrant. Use of the TKI has been described in the nursing literature,35 and the instrument also has been used to differentiate among residents who have problems adjusting versus those who succeed in an administrative role during residency.6 

The Hersey-Blanchard Situational Leadership (HBSL) model, developed in the late 1960s, focuses on leaders' assessment of their followers' needs and their adoption of the most appropriate leadership style.7 Followers may have variable degrees of competence and/or commitment (eg, a group of new interns may have little knowledge of systems-based practice tools and little motivation to learn them). Leaders can adopt a task-oriented, directive approach and/or focus more on supportive behavior. Along these 2 dimensions (figure 2), leaders can pursue a Directing, Coaching, Supporting, or Delegating leadership style, depending on the follower situation. In health care, several studies8,9 have used the HBSL to assess leadership in nurses.

At Maine Medical Center, we hold an annual 6-hour-long residency program director retreat at an off-site location each spring. Part of each retreat is focused on the leadership development of program directors. In this paper, we describe the use of the TKI and HBSL to assess conflict management and leadership style at one of these retreats.

Seventeen residency program and associate program directors attended the retreat (11 men, 6 women), representing a range of specialties and subspecialties. Participants completed the 30-question TKI and 12-question HBSL instruments. Completing the instruments took approximately 15 minutes. The authors scored each instrument during the retreat.

During the leadership portion of the retreat, program directors were asked to reflect on a recent conflict situation they had encountered in their program. A brief lecture followed on the background and concepts of the TKI and HBSL. The group discussed uses for each of the 5 conflict mode approaches with emphases on managing conflict for positive outcomes and the usefulness of knowing one's preference for handling conflicts, and that there are no right or wrong preferences. Selecting the appropriate conflict management mode was stressed. Reflective questions focused on situational leadership flexibility and included the following: Do you overuse or underuse directive versus supportive skills? Can you recognize the development level of the person with whom you are working? How do you improve your skills in one or more areas?

Program directors received their individual results, and in small groups of 4 to 5 they discussed the conflict situation each person had identified earlier and reflected on how the results of the tools changed their perception of the situation and might influence future strategy in conflict situations. The leadership portion of the retreat concluded with each individual writing down a commitment to change10 concerning his or her individual leadership behavior that the participants would pursue over the subsequent 6 months. The authors plan to distribute these individual responses to each program director 6 months after the retreat.

Three weeks after the retreat, program directors received an online survey regarding the leadership section of the retreat and other aspects. The survey used a 5-point Likert scale (1  =  strongly disagree, 5  =  strongly agree). The Institutional Review Board granted exemption status for these tools and survey.

The TKI survey showed that the majority of program directors fell into the Compromising category for dealing with conflict management, with 8 of 17 (47%) scoring in a high range. An equal number of program directors (18%) preferred the Avoiding or Accommodating conflict modes. Two of the program directors (12%) scored highly in the Collaborative category, and one program director preferred the use of a Competing style for conflict management.

On the HBSL, most of the program directors (71%) preferred a Coaching leadership style (ie, high on both task-oriented and supportive behaviors). Three program directors (18%) favored a Supporting approach (ie, high on supportive while low on directive behaviors), and only 2 program directors (12%) scored high in the Directing category (ie, high on task-oriented while low on supportive behaviors). No one favored a Delegating leadership style.

Eleven program directors completed the online survey after the retreat (65%). For the question regarding whether the leadership tools were helpful, the majority of respondents (91%) indicated either agree or strongly agree, and 91% thought they had a better sense of their “mode of handling conflict,” as well as “task- versus relationship-oriented behaviors.” When asked if they could commit to a change in their leadership style over the next 6 months, 82% indicated they would commit, and 18% reported they were not sure. Of those who indicated they would commit to a change, 73% thought they would be able to make those intended changes in their leadership style.

Program directors may not be receiving adequate leadership development. We highlight one retreat workshop format with the use of two user-friendly tools to assess and develop conflict management and leadership style. Our program directors found the tools useful in promoting self-awareness of their leadership styles and in facilitating changes in those behaviors.

While our results reflect a “snapshot” of one group of program directors at a single institution, we found it interesting that most prefer a Compromising mode for conflict management. This preference may be appropriate because program directors are often balancing the opposing needs of different stakeholders. For administratively successful residents, a Collaborative or Competing mode may be more productive.6 One possible concern was that a few program directors preferred the Avoiding or Accommodating modes. These 2 modes are clearly appropriate in specific contexts but may not be helpful if used predominantly to handle conflict. For example, use of the Avoidance mode may result in more resident dissatisfaction.

We were not surprised that the majority of program directors favored a Coaching leadership style. This inclination may reflect the self-selection of individuals who gravitate toward a program director's role, which demands great attention to detail and multiple tasks as well as relating interpersonally with many people on a supportive level. Delegating can be an important leadership behavior with specific groups of followers, and although no program director in our group preferred this style, we anticipate that program directors could shift to this style when the context is suitable (eg, working with a very competent and committed faculty team).

Limitations of this paper include the small number of participants from a single site, limiting generalizability. However, we hope other institutions can utilize this workshop format and/or the leadership tools. The workshop format can be modified to meet program-specific needs. Future research could focus on whether certain conflict management modes or leadership styles are better suited for the role of program director (eg, is there a relationship between preferred conflict mode and number of accreditation citations?), what differences may exist in the results of these tools between specialties or institutions, and how leadership development activities can improve program director job satisfaction and potentially decrease turnover.

1
Accreditation Council for Graduate Medical Education
Average length in years between program director appointment dates (based on turnover since 2001).
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Author notes

All authors are at Maine Medical Center, Department of Medical Education. Robert Bing-You, MD, MEd, MBA, is associate vice president for medical education; Whitney Wiltshire, PhD, is medical education specialist; and Jenny Skolfield, MS, is director of medical education.