#futureofmeded: governance as Leadership

By: Felix Ankel (@felixankel)

You are an associate dean for medical education at an academic health system. Residency directors have done an incredible job navigating their programs through the Covid-19 pandemic. You have helped lead successful institutional and residency accreditation reviews, residencies are able to recruit top candidates, and faculty and residents have met unprecedented challenges. Yet you see that program directors are struggling. It appears that the clinical learning environment is changing quicker than programs can adapt and program directors are asking for help.  The structures and processes that have been developed for the linear times of the past are no longer relevant for the exponential times of the present.  Where do you start? What mental models do you consider? What resources do you consult? You decide to look at the governance of the clinical learning environment to see if there are opportunities for growth.

Governance as leadership.

In their book Governance as Leadership”, Chait, Ryan, and Taylor discuss governance and leadership as integrated rather than two distinct disciplines.  They also outline three governance-as-leadership mental models (fiduciary, strategic, and generative) and suggest that healthy governance-as-leadership practices have a balance of all three models. The following is adapted from The Practitioner’s Guide to Governance and Leadership.

  1. Fiduciary governance (type I). Fiduciary responsibilities (from the Latin word “fidere” (to trust)) are often related to resources.  They involve maintaining a system of protection and order to the mission of the enterprise through policies, procedures, and precedents.  This involves fidelity to a budget, and compliance to local and national accreditation and certification bodies. Often this governance structure is hierarchical with standing committee meetings organized by staff that follow parliamentary procedures.  The predominant behavior is one of deference with limited group communication and education. A typical example of fiduciary governance is the graduate medical education committee (GMEC) meeting at sponsoring institutions accredited by the Accreditation Council of Graduate Medical Education (ACGME). This is a closed mental model.
  • Strategic governance (type II). Strategic work involves aligning the corpus of the internal work with outside threats and opportunities.  Rather than plans, ideas are the drivers of strategy, and the focus moves from stewardship to foresight.  Groups are often based on a theme rather than professional identity or organizational structure (e.g. finance, IT, planning, communication) and may consist of task forces and ad hoc groups rather than standing committees. Communication is often reciprocal, catalyzed by outsider experts, where divergent views are cultivated. A typical example is a strategic retreat focusing on a sponsoring institution’s approach to local and regional workforce needs that invites multiple stakeholders to participate. This is an open mental model.
  • Generative governance (type III). Generative governance is thinking about governance (e.g., meta-governance).  It digs deeper into sensemaking and how decision-making bodies analyze and synthesize data and information to make decisions.  Discussions center around environmental cues and frames that shape narratives.  They look at the methods of analysis and synthesis of data and information, interactions with environmental cues, and commonly used frames. Questioning an original frame is encouraged. An example is using scenario-based planning in organizational development work. This is a reflective model.

Why is this important?

We live in interesting times. Clinical learning environments are changing in multiple dimensions. Workplace assessments based on trust (EPAs) will become more important and shift to a development, formative, and criterion referenced focus. There will be more emphasis on mitigating distortion in the continuum of self-assessment, workplace assessments, and independent assessments by maximizing the fairness, reliability, and validity of assessments. All of this is fueled by trust: Trust in the individual, trust in the learning environment, and trust in the governance system.

Trust and the social contract

Caniano et al recently published “Transactional Competence, Reliability and Trustworthiness: Essential Attributes of the Successful Program Director” that discusses the social contract between learners, faculty, and the program director.  They outline the symbiotic roles of the program director and the learner and provide examples where the social contract between learner and program director was broken, and the program was put on probation.  Individual program director attributes are foundational to maintaining the social contract between learner and program director.  A balanced governance structure that incorporates Type I, Type II, and Type III governance allows it to flourish.

Questions to consider.

  1.  Have you identified the governing structure for your local clinical learning environment?  National accreditation organization? Hospital board? Graduate Medical Education Committee? Departmental or residency leadership structure?
  2. Is there a balance with fiduciary (type I), strategic (type II), and generative (type III) governance themes?  If not, how do you support governance structures and processes around less represented themes (e.g., generative) to co-exist with more dominant themes (e.g., fiduciary). 

Acknowledgement:  The author would like to thank Drs. Ezgi Tiryaki (@Neuro_Edu_ET) and Teresa Chan (@TChanMD) on their thoughtful review and helpful suggestions for this piece.


1.Chait RP, WP Ryan, BE Taylor. Governance as Leadership: Reframing the Work of Nonprofit Boards. 2004. Hoboken, New Jersey: John Wiley and Sons, Inc.

2. Trower, CA. The Practitioner’s Guide to Governance as Leadership: Building High-Performing Nonprofit Boards. 2013. San Franscisco, California: Jossey-Bass.

3. Caniano DA, CA Bernstein, W Carter, SR Mitchell, TJ Nasca. Transactional Competence, Reliability, and Trustworthiness: Essential Attributes of the Successful Program Director. J Grad Med Educ. 2023;15(1):134-139.

4. Potts S, GS Hoekzema, CK Cagno, E Anthony. Shaping GME Through Scenario-Based Strategic Planning: The Future of Family Medicine Residency Training. J Grad Med Educ. 2022;14(4):499-504

5. Ten Cate O, D Hart, F Ankel, J Busari, R Englander, N Glasgow, E Holmboe, W Iobst, E Lovell, LS Snell, C Touchie C, E Van Melle, K Wycliffe-Jones; International Competency-Based Medical Education Collaborators. Entrustment Decision Making in Clinical Training. Acad Med. 2016;91(2):191-8.

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