Introduction

Involving physicians in the leadership process of healthcare significantly impacts performance, quality, and safety of care. These impacts can be measured by various process and outcome indicators [1–3]. Consequently, leadership competence is expected to become an essential skill for all physicians in both medical education and healthcare settings in the future [4].

Healthcare is undergoing rapid changes, making it crucial for physicians to develop leadership skills to effectively guide these transformations. The importance of leadership development at every hierarchical level in the medical profession is recognized by medical regulators worldwide [5–10]. Additionally, integrating applied interdisciplinary leadership education into curricula for medical and other health professions could strengthen students’ confidence in their ability to effect change in healthcare and assume future leadership roles [11].

While not all physicians will become formal leaders in health organizations, most will serve as informal leaders within their communities or practices [12]. According to the Finnish Medical Association’s recent study of physicians (n = 4 885) conducted every fifth year, 20% of working age respondents’ (under the age of 65) work includes formal front-line leadership work. The majority of the respondents considered leadership education for physicians insufficient. Even though 28% of all respondents were quite interested or very interested in formal leadership positions, interest has decreased since 2018, when 34% of physicians were very interested or quite interested in formal leadership positions [13]. Thus, introducing leadership skills to all undergraduate medical students early and throughout their education could be beneficial. These skills are no different from other skills taught to medical students. This approach also provides a solid foundation for continuing professional leadership education after medical school and pursuing formal physician leadership positions as career choices [12].

Moreover, the COVID-19 crisis heightened the need for leadership and management competencies. This situation has required physician leaders and physicians at all levels in the healthcare system to act as managers—establishing processes and structures—and as leaders capable of creating new visions and inspiring action [14]. In daily healthcare practice, physicians at all levels are expected to exhibit various leadership skills as part of their daily responsibilities. Additionally, since medical students in Finland are permitted to temporarily work as doctors in formal doctor vacancies under certain circumstances, this partially applies to them as well [15].

Previous studies have posited that physicians need both management and leadership skills [16]. However, a recent systematic review revealed that medical students and new graduates struggle to define leadership, even though they understand its role in current practice, and recognize the importance of leadership and management, despite their acknowledged significance [17]. This confusion may stem from a lack of leadership education in formal medical curricula, an insufficient understanding of theoretical leadership models, or the belief that leadership skills are innate. Additionally, there are concerns that gender biases may influence perceptions of leadership, potentially complicating future workplace dynamics [18]. Furthermore, it has been argued that formal leadership education probably does not lead to changes in leadership understanding but can refine these perceptions. Thus, there is a call for workplace-based learning that integrates theoretical knowledge with practical insights into workplace contexts, relationships, and organizational structures [19].

New graduates often view leadership as individualistic and hierarchical and feel only partially prepared for leadership roles. This preparedness is linked to increasing responsibility, experience, and tenure. Furthermore, the leadership communication skills of senior colleagues are rarely questioned [17]. Hence, medical students typically have a traditional view of leadership, seeing followers as adherents to the leader’s vision and goals [17, 19]. Similarly, second-year resident physicians in hospitals often distinguish sharply between management and leadership, deeming the former inferior [20]. According to a recent Canadian study of medical students, a character, a competence, and a commitment were appreciated in physician leadership; thus, more possibilities to participate in leadership work as well as reflection exercises were suggested for inclusion in leadership education [21], which aligns with the perspectives of more experienced physicians and physician leaders [22, 23].

All in all, while physicians’ leadership competence is crucial [4], the current undergraduate medical education does not provide sufficient leadership training [16, 24]. The challenge lies in integrating more leadership education into an already dense medical curriculum. Thus, research-based knowledge is needed to understand when and how to incorporate leadership studies into the medical curriculum effectively. However, studies in this context are scarce. One approach to expand our understanding is to investigate the stability of medical students’ perceptions on leadership during medical school. Therefore, we have begun addressing this issue by comparing the perceptions of the first-year and the final (sixth)-year medical students on how physicians should be led. To our knowledge, no such previous studies exist.

Since perceptions can influence actions, motivation, and behavior [3]—both presently and in the future—it is crucial to research and value these perceptions. Addressing this need and fostering a comprehensive understanding of physician leadership across all stages of a medical profession including medical students as physicians and physician leaders of tomorrow, is both timely and relevant. Hence, we believe that the findings of this study can be universally beneficial in planning leadership education for medical students.

Materials and methods

Results

The qualitative analysis of our study yielded three main thematic categories common to both first- and final-year medical student groups: (1) traits, (2) a leadership approach, and (3) the culture of healthcare. The theme of a leadership approach was further divided into two subcategories: science-oriented leadership based on a practice approach and goal-oriented leadership with support as needed. Similarly, the traits were divided into seven subcategories: education, role model, communication, empowerment, ethics, autonomy, and collegiality. Upon comparing the results between the two groups, consistent findings emerged (Table 1).

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Table 1. The results of the first- and the final-year medical students’ perceptions regarding how physicians should be led.

https://doi.org/10.1371/journal.pone.0314082.t001

Discussion

According to the findings of our study, consistent results were observed across both groups. Given that final-year medical students in Finland are permitted to temporarily work as doctors in formal doctor vacancies under certain circumstances but the first-year students are not [15], we expected the results of the groups to differ from each other. However, the perceptions of both groups closely align with those of experienced physicians and physician leaders reported in the literature [22, 23]. The lack of differences in perceptions between the two medical student groups in our study, as well as in previous literature [22, 23], suggests that leadership may also be influenced by universal principles. Moreover, medical students may share a similar vision of their future professional identity, which could be another confounding factor. Furthermore, identities seem to shape behaviors and experiences [38], which in turn influence identity development within a social context [39]. Additionally, a sense of collective belonging to a professional group [39] may also have impacted the results. Nonetheless, the desire for humane treatment and respect transcends prior experience.

The greater a leader’s medical knowledge is, the more authority he or she commands. Therefore, successful physician leadership is actualized through the leader’s own medical experience and understanding of the realities of clinical work at various career stages. Being a peer and a role model on the front line, while exhibiting collegial manners, expertise, and competence, is vital. If the leader is not a physician, a medically knowledgeable physician as a working partner is necessary. Furthermore, in the light of the results of this study, effective physician leadership is characterized by a science-oriented approach grounded in practical experience. This reflects the need for a leadership approach grounded in broader, evidence-based scientific knowledge, including, for example, economic knowledge, as well as an understanding of physicians’ lives in a broader context, such as family situations, research commitments, and personal health issues. However, leaders are expected to display altruistic behavior, where financial gain is not the primary driver. Hence, understanding all levels of the healthcare environment, with their challenges and pain points, is essential. Additionally, the leadership approach should be goal-oriented, providing clear instructions and support from higher authorities, especially in challenging work situations. Collegiality is essential, and common-sense behavior is wise, while micromanagement or top-down management is ineffective in the long term. Leaders are expected to prioritize occupational well-being and serve as role models in promoting a positive workplace atmosphere and collegiality. These findings align with the previous studies addressing that physicians need both management and leadership skills [16].

Subordinates desire to be heard and engaged in open discussions to align and agree on common rules and practices. Effective communication is key to successful leadership. Mutual communication is necessary to address challenging issues and can be facilitated by minimizing hierarchical barriers. Conversely, effective communication across the profession can help lower these hierarchical barriers. Openness, honesty, and transparency are highly valued, with good leaders providing constructive feedback and proactively addressing problems. Leaders’ decision-making should be independent yet interactive, utilizing group intelligence and respecting physicians’ autonomy, as their work involves significant independent decision-making and responsibility. Furthermore, respecting the autonomy of physicians being led includes listening to their points of view. However, this necessary autonomy does not diminish the importance of effective communication in successful physician leadership. In the light of these findings, medical students appear capable of defining leadership work comprehensively, which differs from but also partially aligns with previous literature. Students understand the leadership role in current practice and recognize the importance of leadership and management [17].

According to previous literature, medical students traditionally view leadership as a relationship in which followers are seen as adherents to the leader’s vision and goals [17, 19]. This perspective contrasts with the findings of our study. Our research identifies a generational shift in attitudes toward this leader-follower relationship compared to previous literature. Instead of favoring top-down leadership, our findings suggest that an approach rooted in mutual respect and valuing egalitarianism and interpersonal connections is more preferred. Based on the results of this study, subordinates want responsibilities, and their professional development should be enabled. Ideal physician leadership resembles coaching, where individuals’ potentials are maximized through support, encouragement, and attentive listening without overburdening anyone. While workplace rules should be uniform, individuals may require different types of support to perform their duties. Despite the growing call for flexible working conditions and a people-oriented, respectful, and cooperative approach, the rational supervision of healthcare economics must not be neglected.

Conclusions

As new graduates have reported feeling only partially prepared for leadership roles [17], and physicians have expressed that leadership education for physicians is insufficient, [13] there is a clear need to expand leadership education in medical curricula. Understanding medical students’ perceptions of physician leadership is a step toward best identifying practices for leadership education in undergraduate medical education programs.

Our findings reveal no substantial differences in perceptions of physician leadership between first-year medical students and final-year medical students. Furthermore, their perceptions align with those observed in recent studies of Canadian medical students [21], as well as among residents, more experienced physicians, and physician leaders [22, 23]. However, our study identifies a generational shift in the leader-follower relationship compared to previous literature. The medical students in this study do not adhere to the traditional view of leadership, which sees followers as mere adherents to the leader’s vision and goals [17, 19]. Instead, they favor a leadership approach rooted in mutual respect, which suggests a paradigm that values egalitarianism and interpersonal connections over top-down leadership.

Since leadership skills are no different from other skills taught to medical students, introducing leadership training to all undergraduate medical students early and throughout their education can be beneficial [12]. Furthermore, given that the stage of medical education does not appear to influence students’ perceptions of physician leadership, our findings suggest that leadership education need not be postponed; it can commence in the first year and continue throughout the medical education.

The long-term objective is to determine the type of leadership training needed and how it can be effectively incorporated into an already crowded medical curriculum without overburdening students. As the medical curriculum already includes fundamental leadership competencies such as communication and teamwork [40], one possible solution could be to integrate broader leadership education into the existing time-limited longitudinal elements of the medical curriculum [40]. Implemented in this way, it could provide a meaningful context for students to practice and develop leadership skills and leader identity at various stages of their professional development, offer a time- and cost-effective approach [41].

Strengths, limitations, and future research

This study benefits from sufficiently large sample sizes and excellent response rates. However, several limitations must be considered when interpreting the findings. The study was restricted to first-year and final (sixth)-year medical students from a single university, and many outcomes of leadership interventions are challenging to measure. Additionally, qualitative research inherently has limited generalizability, though similarities may be drawn in comparable research contexts. A survey methodology was employed for its effectiveness in efficiently collecting data from large samples within a limited timeframe [31]. While in-depth interviews could have provided richer interpretations and a more nuanced understanding of the research topic, they also have limitations, such as the potential for individuals to feel marginalized, intimidated, or reluctant to speak openly in individual or group settings [33]. Moreover, the study was conducted during the COVID-19 pandemic, a period when extensive face-to-face interactions were generally discouraged. Future research could examine the evolving perceptions of the same cohort of medical students regarding leadership throughout their medical education and assess whether these perceptions change after completing a leadership course. Additionally, it may be valuable to compare medical students’ perceptions with established theoretical models of leadership.

Supporting information

Acknowledgments

The authors wish to thank the medical students at the University of Oulu for their participation in the study.