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Interviewer: Developing leadership skills in future physicians—welcome to conversations between colleagues with The Scope Radio at AAMC Learn Serve Lead 2023. We're exploring the innovative ideas shaping the landscape of academic medicine.

In this episode, we get the opportunity to listen in on a conversation between Tom Hurtado, EdD, Senior Director of Student Affairs at Spencer Fox Eccles School of Medicine at the University of Utah, and Shira Kaplan, Director of Leadership Programs at AAMC. We're going to talk about why developing leadership in med students is so important and maybe some ideas on how to do that, especially if you don't have budget and space in the curriculum, which is a common problem.

So, let's start out with you, Tom. Explain the importance of this work in medical school. Why is it important to be doing this?

Dr. Hurtado: Well, I think it's important because it's something that's so necessary to being a physician. You are going to be a part of a healthcare team. You're going to hold a position on some level of leadership or the need to develop people and train people and work with patients. So, it's essential. And yet we don't have a ton of space for it, or money, or budget, or resources to do it. So, that's a big problem.

Shira: Yeah, I totally agree with everything you said, Tom. I would just add that I believe we share the belief that to be a competent doctor, you need all of the clinical skills, and yet we also want our doctors to be able to look us in the eye when they give us bad news, to be able to work on interprofessional teams, to be able to address conflict head-on, and be good communicators.

And so, for me, to be a competent doctor, you need all the clinical skills and you need the skills for your leadership, for your resilience, for your adaptability.

I also believe that if we can teach these skills as early as possible, it would serve their entire career as a physician. I don't want to wait until they're a department chair for them to go through some leadership training. I want to catch them when they're in their first or second year of medical school so they can apply those skills immediately in their medical school journey, and it would serve them for their entire career as a physician and just elevate the entire culture of medicine.

So, with that in mind, tell us more about what's going on at University of Utah School of Medicine.

Dr. Hurtado: I mean, I think we relate to a lot of schools, right? You have a desire to have leadership training, and yet there's not something that's baked in that's part of the curriculum. The money tree did not shake in that direction. So, what do you do? And I think, honestly, that's what a lot of people wonder. "I want to do it. I need to do it. We need to provide it. How do we do it?"

For us, we honestly just started with, "What is the fun size version of doing this?" And I'll break that down a little bit. But if you're not going to be given a platform in the curriculum, how can you get started?

We started by just holding leadership sessions, not as part of the curriculum, but just jumped in and offered them. Had two students show up and they never stopped showing up, and then they became part of helping us build it. We built it with students, and then from there it unfolded into a growing number of students that just started opting in to be a part of it. That's how RealMD started.

The name RealMD was developed in partnership with students. It's an acronym that stands for relationships, excellence, authenticity, and leadership.

And then from there, it built out over a three-year period into adding a faculty coaching component, and into the curriculum realizing, "Look, the students have spoken with their feet. They're showing up. Half of the student body cares about this on a pretty deep level." And then they started funding part of it. Student affairs along the way helped us.

You can incrementally move some things around in your budget, or you can do a lunch event here, or find a speaker who's very compelling who can speak to some of these important issues of resilience, or soft skill development, or team building. And you start to cultivate a culture that caress about it, even though they're not graded on it or even though they're not getting some immediate benefit from it.

And one of the questions that I want to ask you, Shira, is around . . . Your role is within leadership development at the AAMC. So, you have this national presence in providing leadership training for a lot of leadership, like existing faculty physicians who are leaders, right?

Shira: Right.

Dr. Hurtado: How did you even start to realize that students were an important part of what you could do as well?

Shira: Let me just say that this whole conversation is so meaningful to me because I reflect often back to us meeting at this exact meeting years ago. And the journey we've been on together is so special to me.

As you know, but I'll share with others, when I started at the AAMC about seven and a half years ago . . . We do have a very impressive portfolio of leadership development programs for anyone that works at or teaches at one of our medical schools or teaching hospitals. But it was very interesting to me that there were not any leadership development programs for our learners, for medical students, and residents, and grad students. And so. I wanted to change that.

I met you very early on, and I should just really say that your RealMD program and what you, and Tony, and your students together have created at Utah was a major inspiration to us at the AAMC and what we've created.

And so, back in 2019 with you, we created our first RISE seminar. We don't have the luxury of embedding in a curriculum. We don't have the luxury of creating an elective. We don't even have the ability to do monthly lunch and learns. So we did what we do best and we created a leadership development seminar, a two-and-a-half-day intensive leadership experience for medical students, and we opened up the opportunity to medical schools across the country.

We did not know what to expect, and we had almost 50 students that first year representing medical schools from across the country.

Taking a page out of your incredible playbook at RealMD, we of course focused on leadership development skills and spent time on skill development, but just as much time was spent on remembering your why, which is something that is a wonderful thing we copied, because imitation is the highest form of flattery, from Utah.

Helping people remember why they wanted to go into medicine. And as you have taught me, what's their meaning? What's their purpose? And really helping them have the tools that they need and the support that they need to continue on with their medical school journey, which is really quite hard.

And so, it was so successful that we got the funding. We did not want to charge medical students, and so the AAMC fully covered the expense of that. It was so successful that we decided to have two RISE seminars the following summer, but COVID hit and it was not. But we returned in full force last year.

And then what's also exciting is we've now added a second RISE seminar for fourth-year medical students.

We want to show up for our students when they need us most. We think that transition to medical school is such a hard transition. So, that's why we reached out to students between their first and second year of medical school with our initial RISE seminar, and now this additional part of the series for fourth-year medical students after Match to help them with the leadership and resilience skills that we know they're going to need in residency. And so, it's been an exciting journey.

I would also just end by saying the response we have received from our students has been so immense and so incredible, and there's just been this outpouring of gratitude and appreciation.

What I reflect on is I only had them at the AAMC for two and a half days, but if I were at a medical school and could have this continued involvement with them and be a part of their lives for all four years, how much greater would that impact be and what a difference I could make.

And so, that's really why I think that for me . . . or I know for me the most important thing is to get our medical schools more engaged and involved in joining us in this space.

I know that a lot of medical schools have reached out to you. What are you hearing from your colleagues? And what are you observing? What trends are you noticing?

Dr. Hurtado: I think I'm noticing the same sort of things that you're describing. How do you have things happening longitudinally where you can really work on and build students up and help them?

I'm so glad you brought up meaning and purpose. I think a lot of the work of leadership, like the pre-skill development work, is really around, "Why are you doing this, and what do you hope to offer the world with your training?"

And I think often we think that it's specialty-specific, and certainly there's a specialty in there as well, but as you really get into the work you're doing, it's much bigger than the particular specialty. It's, "What work are you really here to do?"

Then I think you build out the leader that you are on top of that, and I think that that's such an important thing.

But I do want to comment about RISE. Obviously, RealMD had influence on it, but I also noticed that you've provided for how many years? I mean, the RealMD has done this for decades in terms of training physician leaders on some of these skills. It really helped figure out how to scale it.

How do you do a two-and-a-half-day thing for medical students that's facing them? I understand the student, but you understand a format of two and a half days and making that extremely impactful and meaningful, and hearing students take that home in the surveys and say, "This has changed me and now I'm going back to my institution and I feel like I have some . . . I'm armed with a new set of perspectives and ideas." Obviously, the partnership is very mutual, so I wanted to throw that in there.

Shira: But you are right. We were able to leverage all of the adult learning principles, and all of the content that we had curated over the years for the leadership development that we had offered for faculty and professional staff. Much like I would assume someone that works in faculty development could leverage all of the professional and leadership development that goes on for faculty and staff at a school. We did absolutely leverage that.

And so, some of the principles you'll find, whether it's a leadership development program for a medical student or for a dean of a medical school, we want to make it interactive. We want to recognize that no one wants to sit and be talked at for days. And so, we want it to be highly participatory, highly interactive.

And it's really critical to us that we focus on skills that can be applied immediately. It's something that when you go back to work on Monday or go back to school on Monday, you can begin applying them immediately. So, we focus on practical, tangible skill development. And that's definitely a principle you would see throughout any of our AAMC programs.

But I think the message here is that someone that is creating a leadership development program for learners I don't believe is starting from ground zero.

Dr. Hurtado: Yes.

Shira: I think they also already have so much they can leverage. I don't know. Do you agree?

Dr. Hurtado: Totally. And we had that comment today during our presentation where someone said, "I came in thinking I wasn't that far along, but now that you've talked about this wider definition about what leadership development is, I'm starting to see that it is happening in pockets. And if I could just be more intentional and notice it, then maybe I can curate something that is partially built."

I think a lot of times people think that it's truly from scratch, and I don't know if that's the case, but because it's not intentional, it's not having maybe the impact that they were hoping.

So, I think there's even just work in identifying what you're doing and realizing that you're much more capable and, hopefully, much further along than you think.

Shira: The other thing I'm reflecting on from our session is . . . You were talking at our session earlier today that you got those early adopters right away. And so, maybe one of the things . . . These are my words, not yours. But maybe one of the things that's keeping you up at night is, "Well, how do I get the others? How do I get this incredible content and this meaningful, impactful self-reflection out to more and more students and not the ones that just show up so easily?" And I think that is a really big question for all of us to constantly be considering.

When we were creating our RISE seminars, we had to decide, "Well, where were we going to steer people to? What kinds of students should they send to us?" We started with, and continue still in our early phases, encouraging our medical schools to actually send us their leaders. Which you might say, "Well, they already have leadership skill development," which by the way is not necessarily true, but they might say, "Well, why are you starting with leaders?"

But also, I think if we're talking about this grassroots movement and culture change, it is the leaders that can be our allies and our ambassadors and help us in this space.

And so, when 80 leaders from medical schools across the country come to the AAMC and get this training and get this new way of thinking and get this sort of renewed sense of self and purpose, and then we send them all back to their medical schools, I think that's really how you begin to implement change.

It's a lot of times our students that are going to their dean or their Associate Dean of Student Affairs or whomever to say, "We need this added to our curriculum. We need this added to our everyday experience."

Dr. Hurtado: And I think that's a good point. We think that it needs to be structured and start from the top down. Medicine has a tendency to be pretty hierarchical, right? But when you're talking about creating leadership development, I think you should really consider co-creation.

You should say, "If I want buy-in from the students, then they need to help create what we're trying to do." That item, that set of skills or presentations or content that they're telling you they want is something they will also appreciate and participate in. I think there's a higher likelihood to have that happen.

And certainly, I think the AAMC has done a good job in identifying schools that could really benefit from some of these trainings and having the students then bring them back.

It's not just maybe a school that has a very established program. You're also reaching out to schools that maybe have identified leaders but aren't really providing very much for them yet. That's a good thing to start engaging and to hopefully have that happen.

Shira: Yeah, I couldn't agree more. And honestly, I just want schools to do something or anything. I don't need these full, blown-out programs. It's wonderful and I would encourage it, but I think that when you look at something so large, and so established, and pretty expensive, it's just so easy to be like, "No, we can't do that at our school."

And so, I just want them to do something or anything. It might just be a lunch, and it might just be a faculty hosting some people at their home. I mean, there are a million options.

And what's really important to me is we, at the double AMC, have been seeing so many wonderful models of providing leadership development in our medical schools. And so, there's absolutely just no one-size-fits-all, and there's just no one right way to do this. I think just moving the needle even a little bit is so important and impactful.

Dr. Hurtado: Yeah. I mean, the tragedy is if I can't do the king size version, I choose not to do it. And you really should start where you can. Absolutely start exactly where you are in an increment that you can do.

Interviewer: As a listener in this conversation, I've noticed a theme with a lot of initiatives that started at academic medical centers. Instead of getting permission or getting the big buy-in, just start doing something on some level. And I'm hearing that theme here. Tom, you called it the fun size version, right?

Dr. Hurtado: Mm-hmm.

Interviewer: What is the minimal you can do? You get a couple of students to show up, you would think that would be a failure, right? "Two people showed up. This was a big failure." But that snowballed into more students, and then that snowballed into a priority for the institution, and then that snowballed into more money. Am I hearing this correctly?

Dr. Hurtado: Yeah, that's right.

Interviewer: So then to get that first thing, to do that first thing, what would you recommend? If I get a couple students to show up now, what do I do?

Dr. Hurtado: I mean, content-wise, that's a great question. One of our students was here, who's one of the students that helps plan our programming, and when we were asked that question during our session today, he just said, "Teach me how to make connections with people, with physicians, with my mentors that I know I'm going to need. I'm going to need a village of mentors. How do I start creating those relationships?" Bring in somebody who can talk about their lived experience in finding a mentor.

And I think a lot of the content . . . Often, we think it needs to be this really polished PowerPoint-presented didactic information. We have to break the mold on that. It can't be delivered like the other curriculum is delivered.

You need to create a setting in which the hierarchy is flattened, where the physician is on-level talking about some lived experience that the student can relate to, and where what is possible for them in their mind about making, for example, connections with mentors becomes way more feasible in my mind.

All of a sudden, I feel like, "This is possible because you just told me, in a very real way, what it was like for you. And now I believe in myself to do that."

And I think a lot of these initial conversations are getting over the barriers that keep us from thinking that we're a leader, from thinking that we have the ability to connect with future mentors, from thinking that we have something to offer.

Yet as physicians, in the work that we're doing and the impact that you have on a community of people in a life's work, that is an absolute thing. That's going to happen. So, how do you give them more of a skillset earlier?

Shira, you've talked about these physician leaders saying, "Now, I'm Dean of Dean of Dean of Dean or something. I'm doing this big role and I really wish that I would've had this stuff earlier. I wish that I would've had these conversations, these opportunities much earlier in my training."

Interviewer: So, even just bringing somebody in to reflect upon that and talk about what they've learned would be a good session for the initial people that are showing up.

Dr. Hurtado: Yeah.

Interviewer: Shira, tell me what kind of curriculum do you think is effective? What are your thoughts on that?

Shira: Well, I agree with Tom that you need to listen to the students. And I think that we can, of course, use basic adult education principles and leadership development skills, but I think that the students are very willing and vocal to tell us what they want and what they need.

I also think that it's important to . . . We reached out to many different medical schools and also, really, UME and GME to say, "Talk to us about the students that are coming to you as residents. What skills do you wish that they had?" or, "Talk to us about the culture in your medical school. What's going on? How can we support it?"

I do think, going back to what you were saying, Tom, your version of, "It started with just a couple students," we were in the same boat. I mean, we built something and did not know who was going to show up and just crossed our fingers and wished and hoped.

And we got a really nice showing of 50 students that first year. The second year, we had 100 students registered. We doubled. We only had to cancel due to COVID.

But I do think it's a sense of . . . It's not "if you build it, they will come." But I think that you have to just take those first steps, and then that does create momentum.

You were trying to get justification for funding from Utah, I was trying to get justification for funding from the AAMC, but the success breeds excitement and momentum and energy all around you.

And so, I think that everybody really wants to help our students. Everyone knows that students are struggling. Everyone knows that there are financial burdens on our students. And so, I think there's just a lot of goodwill out there and really good intentions to help our students.

And so, the success of our programs just bred more opportunities and more funding. And I don't even think you need all that much funding if you can get the right faculty, right staff, and the right people to support you in this journey. I looked to a lot of colleagues at the AAMC who volunteered their time and came and spoke for free. I'm sure you do the same at Utah.

Dr. Hurtado: Yeah, we do. I think that's the part . . . I think once people are in a space where it's contributing to their meaning by paying it forward and helping, it's just this really great synergy of people realizing how valuable it is to make those connections and impart information about their authentic lived experience that, ultimately, could help somebody else.

Shira: Yeah. I know we're going to close soon, but I want to add that I think that just by taking the first steps at a medical school it not only helps change the culture, but it adds a vocabulary to use. It adds just a whole different sort of feeling and spirit to a school.

Medical students are whole human beings. Yes, they are study machines and need to memorize and learn a lot of data very quickly, in just a few years, but also they struggle. "It's grandma's birthday, but I have a big test tomorrow," or, "I haven't seen any of my friends and I'm not feeling like myself. How do I make time for that?" or, "I'm having this conflict with my study group and I don't even know how to handle it. And I know that that's going to happen more and more in my career."

I just want to end where I began, that I think competent doctors are excellent with their clinical skills, they know their specialty, but they also can operate in this world, know themselves, have resilience skills, be adaptable in times of change, which is a constant in our world and in medicine, and just can be good human beings and good teammates.

Dr. Hurtado: Yeah. And I think a lot of that is creating a space where people can reflect and remember sort of who they are and why they started doing this stuff in the first place. And I think that brings us all the way back.

I'll just share a quote as I close from one of my students, one of my students who's now well on his way in orthopedic surgery residency. I'm going to go eat dinner with him tonight. But he was one of those first two students that showed up to RealMD.

And when he came to the session, he said, "I'm not really sure what happened today, but you reminded me so much of things about myself that, as I go through the week, they're beaten out of me just because there's so much other stuff I'm trying to cram into my brain." He said, "If you gave the same message every week and I just showed up, it would still make such a huge difference."

Shira: I love that. And can I just add my favorite? There's a story about a little boy and an older man walking on a beach, and there were thousands of starfish that were being washed ashore. And the little boy was throwing starfish one by one back into the ocean, and most of them are washing back on the shore. I mean, everywhere you looked were starfish.

And so, the old man said to the young boy, "Why are you even wasting your time? I mean, you're not going to make a difference. There are just too many starfish. You're wasting your time." And the little boy picked up one starfish and he said, "Well, to this starfish, I'm going to make a difference," and he threw him back in the ocean.

I think that's really the message. If only two students had ever showed up, think about still what the tremendous impact you made on those two students' lives, who are then going to be such multipliers with everyone they come in contact with in their entire medical school journey and career as a physician.

So, if we make an impact or difference with one, that's still a win in my mind. But I know that that's not how it's going to be. I know that we're going to reach hundreds and thousands.

Interviewer: For those that are considering starting something at their own institution, I'm going to throw out my hot take here for you two, and I want to see if you confirm or deny this.

If you don't know what you're doing, but you know you want to do it, if you want to start some sort of leadership program, but you don't know what you want to teach, buy a couple of pizzas, put up a couple of posters, get some med students to show up and talk about it for an hour, and you'll probably have a lot of great ideas for the next few sessions.

Dr. Hurtado: Absolutely.

Shira: Yep. Agree. You're hired.

Interviewer: Well, I was mentored by the best. Tom Hurtado and Shira Kaplan, thank you very much for joining us, talking about how we can develop leadership skills in future physicians at our institutions when maybe we don't have the financial means or the curriculum resources that we need. We appreciate your insights.

Dr. Hurtado: Thanks for having us.

Shira: Thank you.