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Harnessing Followership to Empower Graduate Medical Education Trainees

Followership is the leadership practiced by individuals who are in positions of responsibility without authority, whereby they exert their influence to help execute the vision of their leaders. The central principle of followership is a commitment to actively support leaders and organizations. Without effective followers, organizations flounder, decision-making lies only at the top echelons, and plans are either incompletely executed or not executed at all. In this perspective, we introduce the concept of followership as an important part of leadership development. We explore pedagogical methods for teaching graduate medical education (GME) trainees the followership tenets of service, assuming responsibility, and challenging leadership as necessary skills to achieve partnership with their leaders. We argue that developing followership skills, specifically partnering skills, can help trainees excel as leaders and attendings. GME trainees who practice effective followership take initiative by co-managing their patients with their attendings. By displaying both willingness to serve and challenge their leaders, they add to the success of the whole unit. Followership is a skill that can be learned. Learners should reflect on their own followership style and identify areas for flexibility and growth. Those seeking to become partners should solicit explicit feedback, observe their role models, and seek opportunities to role play situations that highlight the difficulties of followership. Partnership allows for development of a space between leaders and followers to experience empathy, reward ownership, and grow leaders.


Introduction
Followership is defined as "the ability or willingness to follow a leader," 1 but this definition minimizes the worth and power of effective followership and effective followers. Without effective followers, organizations flounder, decision-making lies only at the top echelons, and plans are either incompletely executed or not executed at all. General Martin E. Dempsey said "Because most who become leaders begin at some entry level, I contend that the best leaders learn to follow first." 2 A simple Pubmed search for the term "leadership" yields nearly 75 000 citations. A search for the term "followership," however, yields less than 500. This is problematic. Our trainees must learn to follow well before they can lead. They must understand that physicians at all levels (training or in practice) function in a follower and a leader role at any given time, depending on the context of a particular project or interaction. Learning the value of both roles, and practicing the flexibility to pivot between them, will set up our trainees for success. To better represent the relevance of the topic and its inextricable link to leadership, we define followership as the leadership practiced by individuals who are in positions of responsibility without authority, whereby they exert their influence to help execute the vision of their leaders. The purpose of this perspective is two-fold. First, we aim to briefly introduce the concept of followership as an important part of leadership training. Second, we aim to explore pedagogical methods through which we might teach trainees the followership tenets necessary to achieve partnership with their leaders: serving, assuming responsibility, and challenging leadership.

Followership
In his book, The Courageous Follower, Ira Chaleff describes 6 dimensions of followership in the context of the courage required to practice them 3 (See Table 1). We will focus on three that we believe are particularly germane to trainees in graduate medical education: the courage to assume responsibility, the courage to serve, and the courage to challenge. 3 Chaleff presents a two-by-two table that describes four possible followership styles. The table's x axis is increasing degrees of willingness to challenge leaders, and the y axis is increasing levels of support to leadership (See Figure 1). 3 The four styles are summarized below; it is important to note that while these styles sound distinct, one individual may be required to transition between them based on the situation at hand.

Resource
The "resource" provides low levels of support and is generally not willing to challenge authority. 3 An individual practicing this style of followership does their job, but does not offer any additional time or energy. They do their job, but are not committed to, or don't feel responsible for, the growth and success of the team. They care about their patients and are committed to serving and learning on their rotations.

Implementer
The "implementer" provides greater amounts of support but still is unwilling to challenge. 3 Implementers are dependable and team oriented. They respect their leaders and are considerate of their team members. They won't, however, challenge a treatment plan recommended by a superior physician or step in if they disagree with their leader's perspective. This style is prevalent early in medical training as trainees are learning the ropes but are not yet confident in their own skills.

Individualist
The "individualist" does not support the leader, but displays a great willingness to challenge authority. 3 Individualists may be perceived as overconfident, irreverent and confrontational.

Partner
The "partner" provides high levels of both support and willingness to challenge. 3 Partners focus on the success of the team. They dive in, take responsibility, and affect change. They may counter the perspective of the attending if they don't agree, but they will do so in a manner that is respectful and is meant for the growth and development of the team and is in the best interest of their patients. Partnering behaviors are valued not only by attendings, but also by accrediting bodies. The Accreditation Council for Graduate Medical Education (ACGME), for example, includes partnering skills within the Internal Medicine milestones. Milestones that reflect followership skills are "advocates for or leads systems change" within the systems based practice competency, "coaches others when their behavior fails to meet professional expectations within professionalism," and "creates strategies to enhance other's ability to efficiently complete…tasks," within the professionalism competency, and "facilitates conflict resolution" within the interpersonal and communication skills competency. 4 While the ACGME has these milestones in place, without the language of followership to ground them in, these impact of feedback within these milestones can be lost.
We argue that within the followership construct, residents and fellows should strive to be partners to their leaders, but

Journal of Medical Education and Curricular Development
we also recognize that this is not always possible. We will use the next section to describe followership skills that allow trainees to reach the partner level.

Assuming Responsibility
The first step that a resident or fellow must take to develop a partnership with the attending is to assume responsibility, both personal and professional. Assuming personal responsibility requires the trainee to know their own personal strengths and weaknesses. This requires both insight and dedication to reflection. They must know if they struggle with a specific procedure, topic, or leadership skill. They must develop an improvement plan and seek expertise and support as necessary. The selfregulated learning theory is an excellent model for developing these self-improvement habits. Through a cyclical process, trainees can learn to use their inherent motivation toward excellence to apply forethought (consider strengths and weaknesses and set goals ahead of time), perform the task (manage attention and behavior), and self-reflect (How did this go? Did I reach my goal? How might I do better next time?). 5 In addition to assuming personal responsibility, a partner on a medical team must assume professional responsibility. This requires assessment of the clinical work environment and the relationships in the unit. By understanding the processes and connections, trainees can identify problem areas, challenge the status quo, and develop performance improvement processes. For example, if a trainee notes conflict between their peers and nurses, they must be able to stand back, watch the interactions, and diagnose the stress points. Only then can they recommend processes that might improve professional relationships. As examples, a resident might meet with a pharmacist to determine medication-related risks or an infectious disease specialist to determine local infection control practices and risks. After developing an understanding of these high-risk areas, they can embark upon quality improvement projects to improve the clinical learning environment. A final important consideration in assuming professional responsibility is to follow through on all initiated projects and tasks. If trainees can assume professional responsibility for their clinical environment, this frees up the attending to advocate for patients and providers at higher levels.

Service
To become a partner to one's attending, a trainee must muster the willingness to serve. There are many ways in which residents serve not only the attending, but the entire medical team. Three specific questions may guide a resident in a followership role toward success in this realm: • How can I lighten the attending's burden today?
• How can I improve information flow to the attending?
• How can I ensure we present as a united front?
Lightening attending burdens can benefit both the leader and the follower. To do so, residents can engage in tasks like teaching, completing administrative tasks, or running family or team meetings to gain personal growth and experience while freeing the attending to manage the team as a whole. Taking on additional tasks while managing a busy clinical team, learning, and consolidating clinical skills seems daunting. Consider, however, the increasing levels of stress that develop when your leader is stretched too thin. The courage required to take initiative remains under-recognized and underappreciated, but it is essential for a follower to achieve partnership with a leader. Further, it allows attendings to "begin to view employees (residents and fellows) through the lens of exemplary followership," and "expand their expectations about what employees (trainees) can and should do." 6 Finally, service can be cyclical. Some followers will eventually rise into leadership positions. Having taken on the responsibility of service as a follower hones the future leadership skill not only of what to expect from followers once in a position of authority but also how to support them in their partnership pursuits.
Residents can also add great value by ensuring quality information flow to the attending. In an era of information overload, it is easy for any individual, no matter how seasoned, to become overwhelmed. Before rounds, residents can help guide the flow of information by reflecting on what information the attending needs to know each day. Getting this right is challenging. This challenge is multiplied by the number of attendings a trainee may work with since each attending may have personal preferences regarding how much they want to know and when they want to know it. A strategy that may enable this process is planning for a structured introductory meeting prior to working with each new attending. This can start with a trainee respectfully sharing their strengths, weakness, and preferences regarding supervision. Following this up with directly asking an attending's preferences regarding timeline, information flow, plan for new admissions, and oversight of the team can save a lot of time in the long run. This allows the attending to realize that the trainee intends to take ownership and primarily manage the team.
Undoubtedly, one of the hardest aspects of service is presenting a united front with each attending a trainee works with. Mistakes happens, bad outcomes occur despite best efforts, personality conflicts arise, and emotions flare in even the most measured of individuals. Attendings, like any leader, carry the burden of ultimate responsibility. Empathic followers recognize and aim to ameliorate the resulting stress. Supporting leaders' decisions, even if you disagree, can build strong bonds not only between a resident and an attending, but also between all team members. Efforts or statements made in support of a leader need not be grand. Often the best use of influence at the resident or fellow level is to state allegiance to the decisions that were made. It is important to highlight what the attending did right for the team instead of focusing on missteps or Bunin et al frustrations. Committing to service allows for personal leadership growth and helps optimize the function of a team.

Challenging Leaders
The ultimate characteristic of a partner is having a willingness to challenge. Presenting a united front with an attending should not be misinterpreted for acceptance of bad behavior or misguided clinical judgement. This type of alignment represents complacency and serves neither the trainee, the medical team, nor the attending. It is important to consider that challenges may have different levels of urgency and intensity. For most situations, a resident may be able to provide feedback to a leader that may help the leader discover a personal blind spot or help them plan for a better encounter in the future. Before embarking on providing feedback to a leader, however, a trainee should reflect on how they would like to receive feedback. It is important to remember that effective feedback requires observation and specific intent, but it is equally important to remember that feedback is best received when the source is a respected and trusted individual. Feedback is often about the relationship as much as about the content. As such, it is helpful for trainees to have authentic conversations with their faculty to develop trust. In addition, trainees should consider the timing and location of challenges. The trainee and attending can remain united if they discuss disagreements at a set upon time, preferably in private. Furthermore, a trainee should practice delivering feedback before a problem arises so that they consider the language to use when confronting an attending.
There may be times, however, that patient or provider safety, ethical concerns, or legal issues require a trainee to challenge beyond giving an attending routine constructive feedback. These events may require an immediate and direct challenge. These situations require moral courage. Residents should consider the values at stake, the dangers of challenging their leader, and their own willingness to endure any consequences. 7 After considering these factors, if a resident or fellow feels that they can successfully challenge, it is still important for them to set the stage for the feedback, present evidence, and plan the words they intend to use. If, after considering the factors, a trainee is unable to challenge the leader, they may want to establish allies or bring other authority figures to assist.

Teaching Strategies to Develop Followership Skills
Throughout our discussion of the courage required for a follower to become a partner, we spoke frequently of the importance of reflection and feedback. Some of the most important followership skills we can teach our trainees are to enhance their abilities in these areas. Reflection, giving feedback, and receiving feedback, in addition to being followership skills, are educational strategies we can use to grow our trainees. These, in conjunction with role modeling and role playing, should be considered as strategies in a followership curriculum.

Reflection and Self-Assessment
Reflection as defined by Sandars is "a metacognitive process that creates a greater understanding of both the self and the situation so that future actions can be informed by the understanding." 8 Encouraging trainees to engage in reflective practice regarding their relationships with colleagues in the hospital as well as their role as a follower may deepen their understanding of their own strengths, weaknesses, and contributions to the team. Additionally, reflection may allow trainees to form mental representations of their desired relationships and skills which may then guide their thoughts, actions, and interactions. 9 Sandars describes "reflection to develop a therapeutic relationship" as a main approach to reflection in medical education. 8 We argue that reflection is equally valuable in developing a partnering relationship between a trainee and an attending. A first step in developing an intentional habit of reflection may be requesting that trainees formally self-assess their interactions and later compare this assessment with feedback and evaluations. Alternatively, guided reflection may be encouraged by requesting a fellow write a response to an attending's prompt for later discussion, discuss the reflection regarding the prompt with a mentor outside of the relationship, or conduct a co-reflecting discussion in real time with the attending. This requires an environment with a high level of psychological safety but may result in significant insight and growth.

Feedback
Providing feedback is a key step to effective education and is a required ingredient in the model of deliberate practice, that is informed and purposeful practice designed to attain expert performance. 9 In medical education, we regularly provide our trainees feedback regarding their clinical skills, but we also provide feedback on their leadership skills such as their ability to run rounds. With deliberate attention, we can also provide them feedback on their followership skills by pointing out examples such as when they assumed responsibility for education, consistently reiterated the plan of care to the patient's family or stopped you from entering a patient's room before washing your hands. When we start paying attention, we realize that examples of outstanding (or toxic) followership are all around us. Our trainees need this feedback to reach their full potential. To ensure we optimize the value of the feedback we deliver, we must remain cognizant of the characteristics of effective feedback. Feedback ought be specific, learner-centered, private, timely, periodic, and goal-oriented. 10 While time is often cited as a barrier to delivery of effective feedback, feedback regarding followership is not an added requirement. On the contrary, it can be included in already scheduled feedback on clinical performance or delivered on the spot when appropriate. By partnering with our learners, we can deliver quality feedback that meets these criteria.

Role Play and Simulation
Role playing can be an outstanding strategy to practice both reflection and delivering feedback. By creating simulation scenarios that present followership challenges, we can give followers the opportunity to reflect on conflict, plan appropriate language, and troubleshoot potential conversations without the threat of inciting anger, escalating conflict, or risking the safety of others. There are challenges involved in role playing. Often, generating examples from which to develop scenarios may be the easy part. Ensuring that trainees clearly understand the scenarios, engage throughout the role portrayal, and receive effective feedback may be the more challenging steps.
An ideal use for role play might be creating scenarios in which trainees cannot reach the partner stage of followership. Residents will inevitably encounter attendings with whom they cannot partner. Toxic leaders in any setting wreak havoc on the team. Further, toxic leaders may inspire toxic followership. Providing scenarios that expose followers to toxic leaders may help them game plan these types of scenarios while stakes remain low. We can use these role plays to remind learners that the principles of effective followership are the same. Consistent behaviors of assuming responsibility, committing to service, and respectfully challenging leaders build the reputation of a resident. Trainees may not be able to challenge directly or challenges may go unheeded. It is vitally important that they recognize that this is okay and may even be expected within the course of their career. It is important to try to partner as much as possible but also recognize when you've hit the limitations of the attending. Role plays safely teach these principles.

Role Modeling
As with most skills in medicine and most skills in leadership, a highly effective way to teach followership skills is role modeling. Bandura's social learning theory describes a deliberate 4 step process: (1) focus the learner on the behavior being modeled, (2) help the learner create a mental representation, (3) observe the learner and provide feedback, and (4) motivate the learner to continue practicing the behavior. 5 Since any individual might be in a leader or follower role, attendings can demonstrate their own follower skills by including a trainee in interactions where they are not the primary leader. For example, in a mass casualty situation or an emergency exercise, an attending, who would generally play the leader role to the clinical care team, may be placed in a follower role. Encouraging the trainees to observe how the attending serves, challenges, or assumes responsibility, and emulate those follower behaviors, can be invaluable. Furthermore, many leadership skills double as followership skills. Practicing empathy for teammates, being authentic in difficult situations, being adaptable through challenges, practicing delegation, and improving communication are all skills that a leader may role model that may allow his trainees to excel as followers.

Conclusion
Developing followership skills, specifically partnering skills, during training can help trainees excel as leaders and attendings. Residents and fellows who practice effective followership take initiative by co-managing the medical team with their attendings. By displaying willingness to serve and challenge their leaders, they add to the success of the whole team. Followership, like leadership, is a skill that can be learned. Learners should reflect on their own followership style and identify which follower type speaks truest to their current behaviors. Those seeking to become partners should solicit feedback, observe their role models, and seek opportunities to role play difficult situations that highlight the difficulties of followership. Followership expands the roles of trainees beyond simply doing what they are told. Partnership allows for building of a space where empathy is experienced, ownership is rewarded, and leaders are grown.