VIRGINIA REED: Thank you. It's a pleasure to be here. I'm seeing a lot of familiar faces because a lot of you-all had input into this project. I've met many of you over the course of the past six months or so, at a variety of meetings where we've talked about the project, at some of the focus groups were we gathered information that went into it. There is a copy of the project that may have got e-mailed to you. It certainly is available on the Website. And what we're going to do today is talk about some of the highlights of that. When we sent out to look at this project, we decided rather than starting with the huge literature that we heard alluded to this morning that we would start with asking all of you who lived the experience of being involved in MCH Interdisciplinary Programs. Given the context-dependent nature of leadership, that was where we decided to focus. And we decided to come at it from two, um, points of view. But starting with some very key questions, about what contributes to leadership, how does it develop, how do we know when we see it, can we think about ways of measuring that with the goal of finding ways to track that development and provide feedback so that we can intervene in that development along the way.

We decided to work with two pieces of information that we could relatively easily get access to. One was the annual progress reports that program directors send into the Bureau, and that have some narrative components to them. As a part of those progress reports, program directors are asked to indicate the percentage of their graduates five years out who are engaged in a variety of leadership acts, experiences and activities. And they're also asked to write some narratives describing some exemplary postgraduates and some faculty in terms of the leadership abilities. So one of things that we did was take those narratives and do some analysis of those. We also decided that that was great for getting information about what people are doing five years out, that programs are very good at saying, these are people who are finished with our programs now, they're out there in the field, they're doing a variety of things. But if what we want to be able to do is impact what goes on during training, we really have to step backwards. And we have to look and say, "What's going on during training that is developing leadership or potential leadership that we can get a handle on at that point?" Think a little bit about trying to turn a submarine. If you're trying to turn a submarine, from the time you turn-and I know they don't call it a wheel-but from the time you turn whatever is the equivalent of the wheel, if you wait for the ship to actually move, you're going to keep turning and turning because it takes a long time that feedback loop to happen. What we really need in terms of thinking about looking at the leadership development in our trainees is a way to say, "Can we get some feedback that's going on during training subtly can make small incremental steps rather than either having no information until the end and finding we're way off the mark, or overcorrecting and finding we're off the mark the other way. So those were the two pieces of information that we decided to use in this process. Now, inherent in a process like this is that you have to have some decisions and some rules for how you're going to think about this information.

Coding is an inherently subjective task. And I will tell you that at the very beginning. So both in terms of looking at the leadership narratives and in terms of looking at the focus groups, other people could look at the same data and could come up with different decisions about how to group it. They could perhaps make some different conclusions. So, this it is a subjective task. It's a snapshot task. When we look at those leadership reports that are sent in as part of the annual progress reports, that reflects what directors describe happening at one point in time. And we know that, that they probably used some different decision-making rules for thinking about how they were going to do that. Particularly in terms of describing outstanding faculty. Sometimes as a notion that should be distributed and spread around and if somebody got described last year, somebody else should get described this year. So we don't always know what was in the heads of people who were making these decisions. We also had to make some decisions about how literal we were going to be, or how much we were going to infer from what people said. For example, if someone lists that a former trainee is now a journal editor, you could probably infer that at some point, that person had been a reviewer for a journal. You don't usually get to be an editor without going through some steps. But you didn't know that all the time because, because again, these were written with very wide guidelines. We decided to err on the side of being very literal in terms of, of looking at those leadership analyses. So there are some limitations to this. We have to be very careful about not generalizing, over-generalizing, because again, what we have is a one-year snapshot. But what we found was that this was very rich information that let us think a lot about how program directors see and count leadership activities.

There were, as you can see, a variety of programs who described trainees, programs who described faculty, all in all, we had narrative information about a wealth of individuals. A hundred and fifty-seven trainees, and 129 faculties. So a lot of opportunity to look for patterns in the information. One of the things that we found which would be no surprise to you, it was that, this is hugely interdisciplinary. You talk about these programs being interdisciplinary, but when you look at the disciplines, represented, they really cover the whole waterfront in terms of different kinds of experiences. We also looked at when there was information available about when trainees had completed so we could get a sense of is there, are there differences by the amount of time that people are out of programs, understanding also that people take interdisciplinary training at a variety of points in their careers. Some of them are, are very new, just out of undergraduate, some of them are much further on mid-career. And again, we run into the issue that was alluded to this morning of, how much can the program actually take credit for and how much did these people, bring with them, when they came in?  But what we saw was of the vast majority of people who were written about in, in this one year had completed their training in the last eight years. What we did then was to go through a process where we tried to take these narratives and identify some activities and behaviors that were alike and group them, and look at what it was people were engaged in. Some questions that obviously lend themselves to thinking about, are questions such as, is leadership better if it's broad? If a person covers a variety of these, or is it better if it's deep, if a person really sort of homes in and really specializes in their one area?  That's a question to think about.

Some other things that became relatively apparent to us to was that as we looked at the fact that these are all academic programs in which this information was being collected, it was clear that describing academic activities was language that was very familiar to program directors. The performance measures that come out from the Bureau list four areas. Academics, clinical, public health, and public policy, and advocacy. And particularly in the area of academics, that was very three language, and we found that program directors describing activities of recent graduates used almost exactly the same language. As is, appearing in, uh, the performance measures. So, publications, funding, those kinds of things were very frequently seen terms. Similarly, with clinical leadership, again, it was a, it's familiar language. It's familiar territory in which most of you are engaged. Things like developing guidelines, being on an advisory board, being a chair of a department, those, are familiar.

It got a little trickier when it got to public health, public policy and advocacy, and this was interesting. I went to the public policy advocacy group this afternoon, because I was curious to hear how they describe leadership. It's much harder to get from the leadership narratives ways of actually describing this. That terms being and, a leader in advocacy were used a lot. But when you start to think about the specific skills that are actually involved in that, it was less familiar language. We hypothesized that that was for probably two reasons. One, and one is that these tend to be longer-term type activities as opposed to single kinds of activities. And that it's a longer-term or a pattern of activities that results in success that you tend to see. The other was, and this was alluded to too, in our group, that particularly people who are going to be into academic careers, the reward systems are often not completely compatible. And particularly early in their careers, when we were seeing the results for most of those graduates, they're focused on doing what they need to do in terms of their investment and promotion. And it may be that for many of those folks, advocacy and involvement in public policy are activities that tended to come later in their activity, when they have established some credibility where they are. So, one additional finding there was the notion of collaboration being talked about a lot. And collaboration was something that did not fit particularly into the performance measures, but we saw it raised over and over again in terms of activities that recent graduates were engaged in. This led us to some conversation and the notion of where does collaboration fit within this?  Certainly, it seems to be valued within MCH  interdisciplinary programs, but that collaboration probably in and of itself probably is insufficient to be a leadership trait. It's a necessary but insufficient, that you can be a collaborator without taking a leadership role. So, that was pretty much the findings from the leadership narratives.

 We held five focus groups at three meetings, we ended up with 61 participants ranging from program directors or other leaders, training directors, trainees, and the notion here was to try and cover the waterfront as much as we could to get a variety of perspectives from people. And a question that was asked at each of these focus groups was, if you believe that your program is successful in producing leaders, how do you know it?  And there was very little other direction besides that. And the groups were very free flowing. Each of these groups was about an hour and a half long. When we came back and took this material, it went through several iterations of then summarizing and pulling out different statements to look at what were the activities and behaviors that people listed that were indicative of leadership. And there were 175, more than 175 separate statements. So what do you do with 175 separate statements?  You have to think about ways of grouping that. And we tried a variety of approaches.

One of the ways we thought about doing it was grouping it with the four performance measure domains. Academics, clinical, public health and policy, and advocacy. And we found that most of these statements crossed boundaries. There were a few that were specific, but that in terms of dealing with the whole range, that was not the most useful indicator at that point. We also tried grouping them with the ACGME competencies. We heard from some folks that they're dealing with this new set of mandates, and if we could find a way to tie into that, to sort kill two birds with one stone, that that would be good. It was obvious that they were a fair number of statements that fit in particularly with communication skills and professionalism. But beyond that, there were many, many statements that didn't map specifically to one or the other of those competencies. Both of those are, are approaches that could certainly be gone back to again, and thought about again as if that was useful. What we ended up doing was saying, what we really thought we found were five separate domains of kinds of statements with some subheadings under them.

First off, who are trainees, who are people who come into the program?  These people come with a past in terms of both, their personalities, but as well as in terms of their academic accomplishments, they're training, their experience, that they have had. Some of whom have had a lot of leadership experience before they ever get to the programs. So, who are the folks there? And what are the characteristics that they bring?  Then there was a set of statements that we categorized as workplace skills, things that we thought were organizational skills or statements about initiative. There were statements about knowledge. And those really came out into, into two separate pieces. One of which was, what is it that we see trainees doing during training, when they're actively participating in the learning experience, when they're here with us. And a second piece being, what are some demonstrations of applied learning that we could see them doing, which is moving beyond the classroom to their fieldwork, and beyond. And problem solving being a subset of that. Interpersonal skills was a big piece.

Thinking a lot about interaction, a lot about communication, and a lot about collaboration. And that's where those, those notions of, of collaboration really seem to fit. And then there was a fifth section that, that we really didn't know what to do with, except that those statements really came together under the notion of, these were pieces that are family center care. And we heard this over and over, not surprisingly from focus group participants, that family center there is, is something that you value and that you can list the components of that, and you can, you can tell what that looks like. So once we did the conceptual clusters, then we went to the literature to say, "Okay, how do these things fit with what the literature tells us about leadership?  And our scan of the literature, and I would call it a scan rather than a review, was very broad, rather than exhaustive. And what we did was read and look for evidence that the kinds of statements we were hearing in the focus groups mapped to something that had been written about. And one of the things that was very obvious was that our notions about what leadership is evolve and change over time. We heard this morning about the, the stacks at Borders or Barnes & Noble, if you go to an electronic database and look, Medline has over 16,000 citations if you use leadership as a keyword. Pro Quest, which is a business database has over 48,000. Okay?  So, it's a huge literature out there to think about. But it's also had its own evolution. And these are just dissertations. This comes from dissertation abstracts. And if you see that looking prior to 1940, it wasn't even a blip. I think we're, we're in the less than, than 50 dissertations a year written at that point. And once we really hit the '70s, and particularly the '80s, we hit an inflexion point where leadership became very trendy. And people started thinking a lot about leadership and what it entailed. And what we know is that how we think about that has changed over time.

The work in the '40s looked at leadership as, as power and control issues. It was very authoritarian. Shortly after that, it focused a lot of traits, with the notion that if we could just identify the traits that people had as leaders, we could predict who would be leaders. And, while they found they were very good identifying those traits, they found that those were insufficient to predict leadership, that it's more than just traits that it takes. The notion of groups and association being part of this, that you have to have followers and you have to leaders was another piece of the evolution of this, as well as then other, disciplines getting involved in this. Anthropologists, sociologists, business consultants, all kinds of people as we've moved along through the '60s, started to get involved in thinking about leadership. The notion of leadership as management, went through. And the notion of, of transformational leadership. Lots and lots of trends and looking at leadership and, and how we should think about that have come along the path. What I think we've found is-oh, and interestingly enough, many, many, most of the documents written about leadership failed to define it. That there's a notion out there that we know leadership when we see it, and we don't have to define it.

There are lots of definitions out there. We've heard lots of good ones today. And I think the issue is to, to find, what are the components that make sense to you in your context?  Because it does vary. There are things but it really in business or corporations that, that may be very important to them that may not be important to you in your context. But coming to a shared understanding of what leadership is in your context is important. Another guiding principle that we decided was that leadership consists of an interaction of traits and behaviors. Certainly, the traits are out there, and, and you-all identified many of them in your working groups. Some of the things that we heard were that honesty, integrity, flexibility, self-confidence, self-control, self-awareness, openness, able to take another's perspective. Those are things that we heard from focus group participants. Certainly there's a lot of literature out there. But it's the interaction of those traits with behaviors in a particular context that will probably really be important in determining who was a leader and who's not. Something else that seemed quite important was the notion that leadership is developmental in nature. Leaders probably don't come fully hatched. And you don't pick up a rock and, and find them. They all had the start somewhere. And there's some fascinating literature looking at the development of leadership following through by tracking children and adolescents, and looking at the behaviors that we now identify in adults as leadership behaviors. And, can we go back and can we see some evidence of those things in kids, and even more interesting, can we train for it? 

So, there is a leadership trajectory. Once we can identify a trajectory, that's important because it means there's an opportunity to intervene on that trajectory. It also means if were working backwards, that that should leave evidence or a trace somewhere of what developing leadership looks like. And that's the piece that were really trying to get our arms around here, which is what does potential leadership look like? Now once we open the world that big, we're going to identify some things that are probably not going to end up being associated with leadership, because we're looking for potential here. And not all potential becomes actualized. But if we close off the world and say we're only going to look at what we know about developed leadership, we'll miss a lot of what goes on during the developmental nature of that. So we struggled a lot with the notion of competence versus leadership. And we heard today, and I've heard others of you say before, competence is assumed at the end of your programs. That's a fact that you require. And I think we can say that all leaders are competent, but we can't say that all who are competent are leaders. So again, what we're trying to get our arms around is, where is this tipping point between competence and leadership. And some of the things we heard from people in focus groups is that early competence could be a good marker of potential leadership.

So you're looking for people who are ahead of the curve, who do more before you expect them to do it, who do it better than you expect them to do it at, at a particular point. So, early competence would fit under that notion of active participation and learning. Some of the kinds of statements we heard from people were coming to class prepared, doing more than the basic expectations. Questioning information, seeking mentors, excelling academically, knowing what they know and what they don't know, keeping up with the workload, and being able to articulate what's been learned, gain from and learning experience. That those might be some markers of that early competence. We also heard people say that in that notion of demonstrating applications of learning, that this is another place you can look for that notion of early competence. So you're looking for people who can utilize their knowledge by conceptualizing, by being able to see beyond clinical perspective by using strategies seeking out and using feedback for growth, people who can view ideas through multiple lenses. So these were, were notions of thinking about, how can we think about what early competence looks like. One of the other notions that seemed particularly important was that leadership can certainly be assigned or elected, or it can emerge spontaneously. And our thought was that particularly in dealing with groups of trainees, there are many, many opportunities for leadership to emerge spontaneously than there are to have it assigned. And the notion of emergent leadership is one that really builds on that notion of credibility. You have, it's a democratic process.

Basically a group has to have a shared task, and they, the group has to let someone take that leadership position, and they're not going to let that happen if they don't feel that the person's credible. If they don't feel that person has the skills to do it. So, there are some skills involved in there of both being able to take charge-we heard from focus group participants-and at the same time, not having to be in charge all the time, of understanding that there is a going back and forth of sharing roles, and that sometimes one's a leader and sometimes a follower, and that that's a mark of a good leader who knows when to step back, and when to step up. Other skills that we heard from people in the focus group was that someone who is likely to be an emergent leader can articulate the goals and objectives of the group. They can listen to what they hear. They can synthesize and restate those back to the group in a way that makes sense. They're good at reading nonverbal cues, so they know what's going on in a meeting. They can build consensus. So those are some of the skills that we heard. We also know that leadership is contextual in nature. And that there are some cultural dimensions to this notion. This is difficult. In, in a way, we talked about cultural competence here, and we know that programs are dedicated to having diverse faculty and diverse trainees. And that most of what we know about leadership, we know based on what we hear from Western culture. And if we are going to think about leadership and valuing leadership in diverse populations, we need to think about what that means, and how we deal with that.

The center for creative leadership, in the handbook, lists several notions that we tend to think up as Western notions. Everyone can develop leadership capacity. Leadership can be learned. It's good to face challenges. Ambiguity and uncertainty are natural. Leading is learning by doing. What we need to realize is that not all cultures look at leadership through the same lens, and that we need to both be sensitive to that, and think about the challenges that that provides for us as we think about these goals that could sometimes be seen as difficult goals. Leadership and management aren't necessarily the same. They can be in the same person. But they aren't, and we heard, we heard from the group, who talked about leadership and management, that there's a particular set of management skills. We can have leaders who don't manage, we can have managers who don't lead. And again, we just need to be clear about where those skills go. What are some management skills?  We covered some of them earlier. But some of the things that focus groups have talked about are that managers can run a meeting. They value others in a discussion, the term was used, they play well with others. They show respect for others, they display cultural competence. And that those are, those are useful skills for management. They're also useful skills in terms of leadership.

There are some issues of leaders and followers, in that, we've touched a little bit on this, particularly in the notion of emerging leadership that leadership is often granted to the leader by the followers in the group. The notion of the fluid role that leaders play is important here. There some things particularly in the popular literature that says, everybody at whatever level they are in an organization is a leader. That may be a decision that a group makes. But most organizations find that even if everyone is seen as a leader, there are levels of leaders within groups, and are levels of, of leadership, um, activities. We've talked some today about the notion of leadership as an inherently ethical concept. And this is a, this is an interesting one, because we can certainly look both at ancient history and recent history and see lots of examples of leadership that we don't think is, is particularly moral or ethical. A nice distinction that I've seen made is looking at the opportunities to be ethical in leadership as process issues and as content issues. And process issues mean that we have, we have an opportunity to think about, if we involve other people in decisions, or are we authoritarian, do we think about the fact that the means justify the ends?  Ends justify the means?  Ends justify the means. But there are, there are some inherently sort of ethical ways of behaving, as well as thinking about, the content of decisions that leaders make.

So another, another principle to think about. Basically, we get to this point, and we say, okay, what comes next?  We started out with four key questions, saying, what contributes to leadership, how does it develop?  How can we think about measuring it, and what are the best ways to provide feedback?  This project to this point was aimed at basically answering the first two of those questions. Getting a handle on what introduced a leadership and its development from the point of view of the people here who are engaged in it. The program directors, the program participants, the program trainees. The next step that we've proposed is to start to think about the measurement of this by looking at what exists out there in terms of existing measures, where are there gaps compared to the domains that you believe are important. Where do we need to create new measures, and then thinking about what are ways to put this in a system that makes it inherently useful in terms of tracking leadership and providing feedback. This is what you all are really involved in doing here. This project was aimed at wrapping this piece up to dovetail with your meeting here. It seems to me a really nice opportunity that we have multiple perspectives coming together thinking about leadership at the same time. Our opportunity here is to capitalize on all of that, viewpoint and synergy and create next steps for the future. So thank you very much.