Leadership in Postgraduate
Family Medicine Training Programs:
A "Steps-Model" Implementation in
MBBS, ABFM, FFCM, MSc Med Edu (Cardiff-UK),
DTQM, Diploma/MSc PMHC (Nova-Lisbon)
Consultant Family and Community Medicine-Medical
Director, Postgradute Family Medicine Program
in Eastern Province-MOH
Chairman, Primary Mental Health Care Programs-MOH
CBAHI - Primary Care Surveyor
Vice-Chair, WONCA- Working Party on Mental Health-EMRO
Leadership in Family Medicine/ Primary
Health Care, including training of postgraduates
in this discipline, is essential to favorably
impact training, as well as patient related
health care outcomes.
In the Eastern
province of Saudi Arabia, a step model
leadership approach has been utilized
to achieve targets set for training of
postgraduates in Family Medicine training
program, in same time it also has been
utilized in the primary mental health
program in Eastern Province-MOH.
Step model leadership
initiative is a transformational leadership
that involves three steps.
Step one essentially is based on a managerial
role where tasks are assigned for the
team and desired outcomes agreed at the
start of the program. Step two is role
model stage that ensures progression of
the task. Step three is essentially an
evaluator type of leadership role that
tries to establish and mentain the continiuouty
of achieving the desired outcomes, it
utilizes advocacy as one of its main strategies.
It is important
that one in a leadership position in this
step model understands their role and
contributes effectively in line with the
expectations of the step model for leadership
This Step Model
for leadership has been successfully applied
in the training of postgraduates in Family
Medicine Program in Eastern province,
MOH of Saudi Arabia. It is proposed that
it should be applied throughout Saudi
Arabia and in other countries of the region.
Leadership, Step model, Family Medicine
Program, Post graduate training, Saudi
In one's role as Director of the postgraduates
in Family Medicine training program,MOH, effective
leadership is important to influence the performance
and postgraduate training related and patient
care outcomes(1). A new initiative called "Step
model" leadership could be considered as
a kind of transformational leadership for implantation
in Family Medicine programs/Primary Health Care.
Transformational leadership was introduced by
James McGregor Burns, in 1978. He defined transformational
leadership as a process where "leaders
and their followers raise one another to higher
levels of morality and motivation."(2)
Transformational leadership style demonstrates
as a positive contributor to safety environment(3),
and is effective in improving care staff's perception
of management support(4). Also, it contributes
positively to job satisfaction in healthcare
institutions, and in enhancing the empowerment
influences among work staff(5). Transformational
style generates greater commitment from followers
than other leadership styles(1).
Step-model is based on the the leader goal,
the nature of the task, and the age of the institution.
It has been applied in the Primary Mental Health
Program since 2003, and in the Saudi Postgraduate
Family Medicine Program in the Eastern Province,
MOH since 2010. It has proved to be very effective
in building a competent motivated team.
Step-model is based on transformation effectively
through 3 levels: manager, leader, and internal
evaluator. The person in charge should recognize
these levels when he/she transfers from one
step into another according to determined factors.
These factors are:
(1) The task nature and complexity
(2) Age of the task, is it new, in progression,
or already established?
(3) The maturity level of the team members.
(4) Ability of the person to modify his performance
according to each level.
(5) Assigned person's competencies in leadership,
motivation, and building a work-team.
For any new work or assigned task, the person
who is assigned as responsible for a team to
accomplish a task, should consider these three
steps. This person should be able to play these
roles correctly and transfer from one step to
the next in the correct time according to the
maturity of the team and the achievement level.
Step ONE "Manager":
When task is starting.
Manager's goal is "Coaching" to establish
an effective and efficient process for the work.
The manager is concerned with setting the rules
in order to accomplish a task. So, in this role,
the rules must be clear for every team member.
The manager is responsible for directing and
coaching his/her team within clear and defined
1. Establish the framework of the work and
2. Responsible for selection of the team
members who could work in a familiar and safe
3. Choice with the team an efficient
process to achieve the proposed outcomes
4. Create the ground rules for the work
in the view of the organization system
5. Assess team members' performance
6. Be sure the work is in the planned
7. Work is on progression
8. Motivate the team members
9. Select a appropriate task-leader and
members for a defined task
10. Work in solving the obstacles facing
the team work
11. Create proposed work leaders
Manager should assured that, everyone in his/her
team fully understand what they're responsible
for, and know how one will measure success.
Next, help the team to achieve the goal and
stay motivated. This type of management links
short-term achievement to the organization's
longer-term goals(6). In this step clear communication
and regular feedback are essential for the successful
passing of this step.
Step TWO "Leader": when task
is in progression.
Leader's goal "Model" is guiding work-team
for achieving the proposed outcomes.
The leader leads the team by redirecting them
toward the goal. The leader delegates the task
to the team members. However, he/she follows
the task progression as well as facilitates
the teamwork in order to achieve the set goals.
1. Guide the team for acheiving the task
2. Be a lived model for the team members
3. Support the team members to achieve
4. Work with team to modify the process,
as needed, according to the work needs
5. Share with his/her team the performance
6. Motivate his/her team members
7. Create and maintain a safe work environment
As cited in Bernard M. Bass's book, 1985, this
type of leader who is a model of integrity and
fairness; sets clear goals; has high expectations;
encourages others; provides support and recognition;
stirs the emotions of people; gets people to
look beyond their self-interest; inspires them
to achieve their goals(7).
This step may be the longest period till it
is sure that the proposed leaders become competent
enough to carry the responsibilities as effective
Step THREE "Internal Evaluator":
when task is almost or fully achieving the proposed
Evaluator's goal "Advocator" is to
maintain work in effective progression.
The internal evaluator supports team leaders
as well as the team members to accomplish the
task. Internal evaluator plays also the role
of the counsellor for the team.
Internal Evaluator's tasks:
1. Evaluate the leader's performance
2. Be sure the work outcomes are desirable
3. Work as an advocator and counsellor
for the team members
4. Work as mentor and adviser for the
team leaders and members.
5. Supervise the whole work and maintain
it in the desired process.
6. Interfere and correct any mistake
that can deviate the work.
7. Protect the work from outside distraction
The following Table shows Step-model and the
factors that influence transformation from one
step to another :
Designed by Dr. Nada Bounian
I am thanking Allah for all support, guidance,
and help for achieving a safe environment and
succeed through my career as a director of a
postgraduate family medicine (FM) program and
a primary mental health care (PMHC) program
in Eastern Province-MOH, Saudi Arabia.
My respect and thanks go to my colleagues in
both programs, PMHC and postgraduate FM for
their collabprations, contributations, and all
affection and care which they have provided
me during my work.
Deep thanks to my colleague and advisor Professor
Waris Qidwai for his advice and review.