Identifying informal leaders among medical residents as a basis for educational interventions

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Hence, identifying the manifestations of residents’ informal leadership can guide educational interventions. It is unclear how theories of formal leadership can support the identification of informal leaders. Purpose To propose an approach for identifying the manifestations of informal leadership among medical residents, using this information for proposing interventions. Methods We conducted a social network analysis survey including 68 physicians (22 preceptors and 46 residents) from an internal medicine service of a university hospital using data on advice-seeking relationships, self-assessments of four leadership styles (transformational, relational, adaptive, resilient), and preceptors’ evaluations of the styles’ importance. For each respondent, a Leadership Score was calculated by integrating four network metrics (in-degree, betweenness, in-closeness, and out-closeness) logically associated to the leadership styles. This score was a proxy of “leadership-as-done” (LAD). The average of responses to the self-assessment questions was a proxy of “leadership-as-imagined” (LAI). The scores for both LAD and LAI were weighted by the importance of leadership styles. A scatterplot placed each participant by LAI and LAD scores, partitioned into four groups: established, brittle, and aspirational leaders, and non-leaders. Results Among the residents, 15.2% were established leaders, 23.9% were brittle leaders, 21.7% were aspirational leaders, and 39.1% were non-leaders. Established and brittle leaders stand out as informal leaders. The former regard their skills well developed and play central roles in the network; the latter do not consider their skills well developed, while still being central. Conclusions Educational interventions should focus on enhancing the leadership skills of brittle leaders that match their real demand for advice, giving opportunities for increasing the network centrality of aspirational leaders, providing supervised leadership experiences for non-leaders, and offering advanced training for established leaders. informal leadership medical residents training social network analysis internal medicine Figures Figure 1 Figure 2 1. Introduction Leadership in medical residency programs plays a crucial role in shaping professional identity, team dynamics, and patient safety [1-3]. However, a large portion of leadership in clinical environments emerges informally, especially among medical residents (MRs) who undertake critical responsibilities in the absence of senior physicians and lead junior staff [4-6]. Even though these informal leadership roles are important, residency programs often leave leadership-related skills (e.g., communication, conflict resolution, and decision-making) to the “hidden curriculum”, which is not explicitly taught, labeled, or assessed within the formal syllabus [5, 7-8]. This problem is compounded by the inconsistent supervision MRs receive from preceptors [5, 9]. Theories of formal leadership offer a point of departure for understanding informal leadership, as both types usually coexist in the same environment and address similar healthcare challenges [10]. However, previous studies do not clarify how these theories can be applied to identify informal leaders [11, 12]. This gap is important since recognizing informal leaders among MRs enables targeted interventions to enhance leadership skills. Such skills are valuable for all MRs, as they may be required to lead at various points in their daily clinical work, regardless of whether they are considered informal leaders. Leadership will also be needed in their professional careers beyond residency [13-15]. Moreover, previous studies of MR leadership, either formal or informal, do not account for the gap between self-perceived leadership and leadership displayed in practice. This misalignment resembles the gap between work-as-imagined and work-as-done. Work-as-Imagined (WAI) refers to how tasks, roles and responsibilities are prescribed in guidelines and plans, whereas Work-as-Done (WAD) captures the adaptations and interpersonal dynamics that occur under real-world constraints and uncertainty [16-18]. Building upon this lens, leadership in medical residency can be understood as a dual construct comprising Leadership-as-Imagined (LAI) and Leadership-as-Done (LAD). In line with leadership identity [12], LAI is an indicator of leadership “claims”, whereas LAD reflects the extent to which these claims are “granted” by colleagues through their advice-seeking ties. LAI in residency training is conceptualized as a set of competencies and behaviors that physicians are expected to demonstrate such as clear communication, conflict management, team coordination and the ability to motivate colleagues [19, 20]. This normative view is formalized through competency frameworks, leadership curricula and assessment tools, and it also manifests when residents rate themselves on leadership scales derived from formal leadership theories [5, 13]. Therefore, it is also necessary to investigate the actual influence patterns (LAD) in the daily network of professional relationships. To this end, this study uses Social Network Analysis (SNA), which reveals the influence that shapes collective work in practice [21]. SNA enables the visualization and examination of connections within different types of networks, from information science to human resources, and is extensively applied in healthcare to improve patient care [21-24]. Grounded in graph and network theory, SNA examines behavioral patterns, social influence, and teamwork by analyzing relationships between network individuals [25, 26]. It is typically implemented through questionnaire surveys in which respondents indicate individuals they rely on for information or advice [27, 28]. These surveys may also include questions about the respondent’s profile (e.g., alignment with certain leadership styles), which can be analyzed alongside responses related to the peer-consultation relationships [28]. Building on this approach, this article focuses on internal medicine residents, for whom leadership skills are crucial to supervising junior staff, coordinating patient care, and engaging in quality improvement initiatives [29-31]. This investigation draws on the core ideas of transformational, relational, adaptive, and resilient leadership theories, which align with the highly complex internal medicine context [32-35]. Transformational leadership highlights a leader’s ability to inspire and motivate members toward a shared vision, fostering innovation and continuous improvement [32, 33]. These are essential abilities for internal medicine residents who guide clinical teams, promote open discussions, and build collective consensus [20]. Relational leadership focuses on collaboration and engagement among team members, making it well suited to the multidisciplinary care teams often led by internal medicine residents [34]. Resilient leadership emphasizes emotional stability in the face of challenging or unexpected clinical scenarios, which are part of residents’ daily work [36, 37]. Adaptive leadership addresses coping with ambiguity and uncertainty when no single standardized solution exists, a situation frequently encountered in internal medicine [38]. Both LAI and LAD in internal medicine residency might be regarded as emergent properties of the interactions between these four leadership styles. A leadership style corresponds to the manifestation of the core ideas of a leadership theory in practice. Considering this background, the research question addressed by this study is stated as follows: how can formal leadership theories be used for the identification of informal leaders among medical residents, supporting targeted educational interventions? The research question was empirically examined in a large university hospital, allowing the development of a novel SNA-based approach for identifying informal leaders among MRs. Internal medicine MRs and their preceptors were surveyed about their advice-seeking relationships and their self-perceptions regarding the adoption of the aforementioned leadership styles. For each actor in the network, leadership style data and network metrics were used to generate two scores, respectively representing LAI and LAD. The results gave rise to a four-quadrant model that allows to identify different manifestations of informal leadership, setting out a basis for targeted educational interventions. 2. Background 2.1. Leadership theories considered in this study As previously mentioned, four leadership theories are particularly relevant to medical residents: transformational, relational, adaptive, and resilient [ 33 – 36 ]. Collectively, these theories provide a comprehensive perspective on how residents exercise leadership in hospital settings under varying conditions. Transformational and relational leadership address the routine leader–follower dynamics of residency, emphasizing trust-building, goal alignment, and sustained motivation across rotations and shifts [ 33 , 34 ]. In contrast, adaptive and resilient leadership highlight the capacity of residents to guide teams through complexity, uncertainty, and acute disruptions in care [ 35 , 36 ]. Table 1 presents a summary of these four theories. Table 1 Main characteristics of leadership theories in this study Leadership Theory Transformational Relational Adaptive Resilient Unit of analysis Leader-follower relationship Team dynamics Team dynamics Leader-follower relationship Leader's approach Visionary and inspiring, creating an environment of innovation and commitment (Judge & Piccolo, 2004). Encourages open communication, empathy, and participative decision-making (Brower et al., 2000). Challenges followers, encouraging continuous learning and experimentation (Heifetz et al., 2009). Focus on emotional intelligence and stress management to cope with crises (Coutu, 2002). Definition Inspires followers to achieve significant changes through charisma, vision, and intellectual stimulation (Bass & Riggio, 2006). Emphasizes building strong, trust-based relationships with followers to enhance collaboration and mutual growth (Uhl-Bien, 2006). Mobilizes teams to face challenges and find innovative solutions through adaptation (Heifetz, 1994). Sustains effectiveness in crisis by managing stress and fostering team cohesion (Coutu, 2002). Focus Transforms followers and aligns individual and organizational goals (Bass & Riggio, 2006). Focuses on interpersonal connections, emotional intelligence, and shared goals (Carifio, 2010). Solves problems that require learning and cultural changes (Heifetz et al., 2009). Maintains morale, safety, and productivity during adversity (Lombardi et al., 2021). Objective rives long-term organizational and personal change (Bass & Riggio, 2006). Fosters a culture of inclusivity, trust, and teamwork to achieve sustainable outcomes (Brower et al., 2000). Empowers teams to face and solve unknown challenges (Heifetz et al., 2009). Restores and sustains organizational performance and cohesion during crises (Lombardi et al., 2021). Table 1 - Main characteristics of leadership theories considered in this study 2.2. Social Network Analysis Metrics SNA applies core concepts such as nodes (individuals), ties (relationships), and quantitative metrics to interpret social structures [ 39 , 40 ]. For nodes, these metrics include degree, closeness, and betweenness centrality. Degree centrality reflects direct connections and popularity [ 41 , 42 ]. Closeness centrality indicates accessibility within the network [ 41 , 43 ]. Betweenness centrality highlights roles in mediating interactions and controlling information flow [ 41 , 44 ]. At the network level, density measures overall connectivity among all nodes [ 41 ]. Specialized software, such as UCINET, calculates these metrics, while the NetDraw extension provides visual representations [ 45 , 46 ]. These metrics and their variations can be interpreted in the context of informal leadership. For instance, in-degree centrality counts the number of ties directed towards a node, while in-closeness centrality measures the average shortest path from other nodes that seek support to that node. Both are reasonable proxies for informal leadership, as such individuals are often sought out by peers and are easily accessible [ 11 ]. In turn, out-closeness centrality, defined as the average shortest path length from a node to all others it supports, relates to the capacity to disseminate information across the network [ 47 ]. Fast and effective communication, reflected in high out-closeness centrality, is a characteristic of informal leadership in dynamic environments such as hospitals [ 1 , 21 ]. 3. Methods 3.1. Overview of the Hospital’s Internal Medicine Service The Internal Medicine Service (IMS) is situated within a large university hospital in Brazil. The hospital provides an average of 400,000 in-person consultations, 40,000 teleconsultations, 40,000 surgical procedures, 300 transplants, and 2,800 births annually. The institution employs 6,215 staff members, including 518 faculty, and supports 2,195 undergraduate students, 553 medical residents, and 108 multi-professional residents across all departments. The IMS is staffed by 25 attending physicians (preceptors), seven of whom also hold university faculty positions. The residency program comprises 25 first-year residents (R1), 26 second-year residents (R2), and one third-year resident (R3), in addition to 21 rotating residents who complete one-month rotations at the IMS. Each month, 12–14 second-semester students and 15 final year interns participate in clinical activities within the service. The IM residency program has a mandatory duration of two years, with an optional third year available through a separate selection process. In terms of infrastructure, the IMS has a reception area, separate rooms with computers for residents and preceptors, and meeting rooms, equipped with computers, televisions, and whiteboards, used for rounds. Residents also use equipment from other departments and hospital wards depending on their care activities. The work is organized into teams of up to eight members: one preceptor, one R2, two R1s, two interns, and 1 or 2 5th-semester students. Residents work on internal medicine teams and rotate through different areas of the hospital (e.g., emergency room, intensive care unit, outpatient clinic, and wards), using the IMS space for computer access, meetings, and theoretical activities. The internal medicine teams conduct daily rounds to review and discuss patient cases, both within the IMS facilities and at the point of care. The IMS also interacts with various specialties and multidisciplinary teams, including nursing, pharmacy, and nutrition. Seasonal variations affect patient flow and the types of illnesses encountered (e.g., increased respiratory cases during winter), requiring efficient resource management. The service manages a highly diverse patient population, often presenting multiple decompensated conditions. These contextual factors, such as high resident turnover and limited time spent in the IMS office, may influence interpersonal and professional interactions within the service. 3.2. Data Collection Before accessing the questionnaire, participants were provided with the project title, average time for fulfilling the form, the anonymity statement and a link containing more details on the project, ethics and project responsible contacts in case of doubts. Then, they were provided with electronic informed consent in Qualtrics by selecting “Yes” or “No” to the question “Do you agree to participate in this research?”. The questionnaire was only available for those who marked “Yes” in this question and blocked for those who marked “No”. The survey comprised four main sections: (i) demographic information about respondents, (ii) advice-seeking interactions, (iii) respondents’ perceptions on how they identify with the four leadership styles, and (iv) perceptions of the relative importance of these styles in training future IMS leaders. The complete survey is in Supplementary file 1. The survey was pilot tested with two of the 77 IMS members and then refined for final use. Two main groups were targeted: preceptors (P), and residents, from first, second, and third year (R1, R2, R3). Residents from other specialties rotating through the IMS were excluded due to high turnover. The survey was administered via Qualtrics, a platform commonly used in SNA, and participants were contacted primarily through institutional e-mail. The survey was sent to all 77 IMS members, yielding 68 valid responses (response rate of 88.3%). This exceeds the rate of 75% recommended by Borgatti, Carley, and Krackhardt for ensuring valid and reliable SNA metrics results [ 48 ]. Also, Brass and Borgatti [ 49 ] point out that a response rate of 80% suffices to capture the most important network characteristics. The questions in section (iv), which addressed the perceived importance of leadership styles for training future IMS leaders, were administered exclusively to the 25 preceptors. Nineteen valid responses were received, corresponding to a 76% response rate. 3.3. Data Analysis All respondents who marked “Yes” to the question “Do you agree to participate in this research?” provided a complete form fulfilled. No respondent answered “No” to this question. The questionnaire was then downloaded, checked and treated to be inserted into UCINET software for analysis. Also, a spreadsheet was used to support the analysis of the data – e.g. calculation of LAI, LAD and the graphics generation. LAI was operationalized using questions 8 to 15 representing respondents’ self-assessed development across the four leadership styles and question 16 (leadership styles weighted by preceptors). Questions 8 to 15 comprised eight statements capturing the core aspects of the four leadership styles - two statements per style, with agreement rated on a 5-point Likert scale. For each participant, we calculated an LAI score by summing the means for each leadership style - comprising 4 different means per individual - and multiplied each one of them by the corresponding weights assigned by the preceptors. The LAI score was the sum of these four weighted means per individual. LAD was operationalized using the advice-seeking network data derived from question 7, and question 16. SNA metrics were generated by UCINET software, and the network graphic (i.e., sociogram) was obtained by the use of the NetDraw extension. Responses to question 7 were used to build an adjacency matrix in which each cell \(\:{x}_{jk}\) represented how frequently respondent \(\:j\) sought advice from person \(\:k\) . For each individual, we computed four centrality metrics that captured complementary dimensions of network influence: in-degree, betweenness, out-closeness, and in-closeness. All centrality metrics were normalized to allow comparison and to enable their combination into a novel composite score denoted as the Leadership Score ( \(\:{LS}_{k}\) ). \(\:{LS}_{k}\) is defined as follows: let \(\:{w}_{i}\) denote the importance weight assigned to leadership style \(\:i\) , computed as the sum of the reciprocals of rank positions attributed to each style \(\:i\:(i=1,\dots\:,4)\) by the 19 preceptors who responded section (iv) of the survey. Let \(\:{n}_{ik}\) denote the network metric of individual \(\:k\) associated with leadership style \(\:i\) (see Table 3 ). The Leadership Score is then given by: Table 3 Leadership styles, associated network metrics, and importance weights Leadership style Description Associated network metric Importance weight Relational Their role in promoting collaboration reflects the core of relational leadership, which values social integration, cross-disciplinary interaction, and collective learning (Dempwolf & Lyles, 2012; Uhl-Bien, 2006). Concise descriptor: information broker. Betweenness centrality : quantifies how often a node lies on the shortest paths between other nodes, highlighting control over information flow. 0.29 Transformational These individuals are consistently sought out for their knowledge, vision, and ability to guide others. Their influence is built on trust, expertise, and a commitment to developing team members as mentors (Bass & Riggio, 2006; Wasserman & Faust, 1994; Bono & Anderson, 2005).Concise descriptor: trusted advisor. In-degree centrality : measures the number of incoming connections, directly indicating who is sought after. 0.28 Adaptive The ability to quickly disseminate information and tailor messages during times of uncertainty and crisis is central to adaptive leadership (Isba et al., 2017; McKimm et al., 2023; Uhl-Bien & Arena, 2018). Concise descriptor: rapid information disseminator. Out-closeness centrality : measures how quickly a node can reach all other nodes in the network. 0.23 Resilient The ability to quickly capture and process relevant information under pressure is a key trait of resilient leadership, enabling effective decision-making in high-stress situations (Bertoni et al., 2022; Förster & Duchek, 2017; Lombardi et al., 2021). Concise descriptor: efficient information receiver. In-closeness centrality : measures how quickly a node can be reached by information originating from others. 0.20 $$\:{LS}_{k}={\sum\:}_{i=1}^{4}\left({w}_{i}{\times\:n}_{ik}\right),\:k=1,\dots\:,68$$ 1 The weights were normalized such that \(\:{\sum\:}_{i=1}^{4}{w}_{i}=1\) . Eq. ( 1 ) thus represents a weighted aggregation of selected network metrics derived from the advice-seeking relationships [section (ii) of the survey], scaled by the relative importance of each leadership style elicited in section (iv). After calculating the LAI and LAD proxy scores for each participant, we plotted all individuals in a two-dimensional graph with LAI scores on the horizontal axis and LAD scores on the vertical axis. To differentiate “low” and “high” score values, we used the sample averages as the cut-off. As such, it was possible to delineate four quadrants, named as follows: high LAI and high LAD (established leaders); low LAI and high LAD (brittle leaders); high LAI and low LAD (aspirational leaders); and low LAI and low LAD (non-leaders). Residents positioned in the brittle and established leaders´ quadrants were regarded as informal leaders. In the last step, we linked each LAI-LAD quadrant to a set of targeted educational interventions. These intervention proposals were based on logical reasoning related to each quadrant characteristics (e.g., respondents with low LAI and low LAD scores should require more extensive training) as well as on insights from the literature. 4. Results 4.1. Characteristics of respondents Table 2 presents the main characteristics of the 68 respondents. Forty-two of them were male (61.8%) and 26 females (38.2%). They were evenly split between preceptors (22; 32.4%) and first-year residents (22; 32.4%), with a similar proportion of second-year residents (23; 33.8%), and a single third-year resident (1; 1.5%). Regarding clinical experience, 11 participants (16.2%) had less than one year as a doctor, 21 (30.9%) had 1–2 years, and 19 (27.9%) had more than 10 years, indicating a mix of junior and senior physicians. Experience in internal medicine was shorter, with 29 respondents (42.6%) reporting less than one year and 21 (30.9%) between 1–2 years, while only 9 (13.2%) had more than 10 years in the specialty. Table 2 – Main characteristics of the survey respondents Gender n (%) Female 26 (38.2) Male 42 (61.8) Staff n (%) Preceptors (P) 22 (32.4) First-year residents (R1) 22 (32.4) Second-year residents (R2) 23 (33.8) Third-year residents (R3) 1 (1.5) Years of experience as a doctor n (%) Less than 1 11 (16.2) 1–2 21 (30.9) 2–3 7 (10.3) 3–5 5 (7.4) 6–10 5 (7.4) More than 10 19 (27.9) Years of experience in Internal Medicine n (%) Less than 1 29 (42.6) 1–2 21 (30.9) 2–3 1 (1.5) 3–5 3 (4.4) 6–10 5 (7.4) More than 10 9 (13.2) Total 68 (100.0) Table 2 - Main characteristics of the survey respondents 4.2. The relative importance of the leadership styles Before computing LAI and LAD, we estimated the relative importance of the four leadership styles from preceptors’ rankings, converting them into normalized weights that were applied both to the self-perception items (LAI) and to the network metrics in the Leadership Score (LAD). Table 3 presents the network metrics that reflect the leadership styles and their importance weights. Although the four styles were clearly important, relational and transformational styles ranked slightly higher than adaptive and resilient styles. These results can be due to the multidisciplinary and technically complex nature of internal medicine, which requires teamwork and technical expertise, attributes respectively valued by relational and transformational styles. Table 3 - Leadership styles, associated network metrics, and importance weights 4.3. Leadership-as-imagined (LAI) Scores for LAI related to the self-perception questions ranged from 3.07 to 5.00, with an average of 4.20 for the whole sample. Seventeen out of the 46 residents, representing 25% of the whole sample, presented LAI values higher than the overall mean, indicating that they perceived themselves as displaying significant leadership skills. Table 4 shows the ten highest LAI scores, which included six preceptors, two first-year residents and two second-year residents. These residents feel highly confident about their ability to mobilize colleagues, communicate clearly, and manage difficult situations, even at relatively early stages of residency. It is noteworthy that the youngest resident (R2.23) in the top scorers is a 24-year-old who self-assessed almost as well as the oldest preceptor in this group, a 66-year-old. Table 4 The ten highest self-perception averages (LAI) ID Leadership self-perception average (LAI) Gender Age (years) Experience in Medicine (years) P1 5.00 Female 51 28.0 P18 5.00 Male 66 43.0 P22 5.00 Male 49 25.0 R1.15 4.89 Male 29 1.0 P17 4.80 Male 45 20.0 R2.5 4.80 Female 25 2.0 P5 4.79 Male 42 18.0 P10 4.79 Male 31 7.0 R2.20 4.79 Male 26 1.5 R2.23 4.79 Female 24 1.5 On the other hand, 27 out of 46 residents (58.7% of the residents) presented LAI scores lower than the overall mean, indicating that they did not see themselves as leaders. However, that does not necessarily imply an absence of leadership potential but can rather suggest an acute awareness of their position as learners or followers. Table 4 - The ten highest self-perception averages (LAI) 4.4. Leadership-as-done (LAD) LAD was assessed using the composite Leadership Score ( \(\:{LS}_{k}\) ) derived from the advice-seeking network and the importance weights provided by preceptors. \(\:{LS}_{k}\) values ranged from 1.45 to 3.97, with an average of 2.22, which was also used as the cut-off between low and high LAD. Table 5 presents the ten highest LAD scores, including their respective network metrics rescaled to a 5-point Likert scale. In this group, there were five preceptors, two first-year residents, and three second-year residents. There was only one actor (R2.5) who appeared as a top scorer for both LAI and LAD, suggesting a significant gap between these two dimensions. This point can also be further exemplified by R2.23 who obtained the 10th highest LAI score and ranked 34th for LAD, with a LS = 2.06. Table 5 The ten highest Leadership Scores (LAD) ID Network attributes Non-network attributes Demographics In- Degree Betweenness Out- Closeness In- Closeness Leadership Score Gender Age (years) Experience in Medicine (years) P9 3.31 5.00 4.26 3.06 3.97 Male 49 20 P12 4.02 4.05 4.56 2.59 3.87 Female 49 25 R2.14 2.42 4.86 3.27 5.00 3.84 Male 27 2 P4 4.56 3.34 4.78 2.28 3.80 Male 39 15 P21 4.73 2.18 4.83 1.94 3.46 Male 46 23 P7 5.00 1.46 5.00 1.65 3.31 Male 39 14 R2.5 2.07 3.50 3.63 3.63 3.16 Female 25 2 R2.3 2.78 2.21 3.50 2.99 2.82 Female 27 2 R1.6 1.62 2.30 3.06 4.54 2.74 Male 25 0 R1.8 1.98 2.50 3.50 3.13 2.71 Male 26 2 Preceptor P9 had the highest score (LS = 3.97), followed closely by P12 (3.87), R2.14 (3.84), P4 (3.80), and P21 (3.46). These actors combine high in-degree (for example, P7 with 46 incoming advice nominations, P4 with 41, and P21 with 43) with high betweenness and closeness values, acting as bridges between different parts of the service and as accessible sources of information for colleagues. By contrast, individuals presenting the lower LS scores had few incoming ties (for example, R1.15 with no incoming ties, R1.2 with one, and R2.2 with four), remaining at the edges of the network. Although these participants contribute to patient care and team functioning, they are not widely recognized as advice sources. Table 5 - The ten highest Leadership Scores (LAD) Responses to the advice-seeking question also informed the development of the sociogram in Fig. 1, which shows a highly connected network. Although advice flows in multiple directions and across hierarchical levels, the sociogram shows a clear centralization around a subset of highly connected actors, while others remain in more peripheral positions. Such positions are occupied by both residents and preceptors as indicated in Fig. 1. Figure 1 - Sociogram of the network. Note: blue squares represent preceptors and red circles represent residents. 4.5. Characterization of leadership groups Figure 2 plots all individuals according to their LAI and LAD scores. Quadrants are partitioned based on the average values of LAI and LAD, and their rationale is described in Table 6 . Table 6 The four quadrants of leaders Quadrant LAI LAD Definition Established leaders (high LAI, high LAD) ≥ 4.20 ≥ 2.22 These individuals strongly perceive themselves as leaders and occupy central positions in the advice-seeking network. Brittle leaders (low LAI, high LAD) < 4.20 ≥ 2.22 These individuals are central in the advice-seeking network, but do not regard themselves as skilled leaders. Aspirational leaders (high LAI, low LAD) ≥ 4.20 < 2.22 These individuals strongly perceive themselves as leaders yet occupy relatively peripheral positions in the network. They express leadership aspirations, which have not yet been fully exploited by their peers. Non-leaders (low LAI, low LAD) < 4.20 < 2.22 These individuals neither tend to see themselves as leaders nor occupy central positions in the advice-seeking network. Table 6 - The four quadrants of leaders Figure 2 - Positioning of respondents according to their LAI and LAD scores Table 7 presents the distribution of participants according to the quadrants. Among the 46 residents, 7 (15.2%) were classified as established leaders, 11 (23.9%) as brittle leaders, 10 (21.7%) as aspirational leaders, and 18 (39.1%) as non-leaders. These mixed profiles further reinforce the argument of this paper regarding the need for targeted, and to some extent customized, educational interventions. Table 7 Distribution of respondents according to the four quadrants Group - Preceptors Residents R1 R2 R3 Established leaders Quantity 8 3 3 1 % 53.3% 27.3% 27.3% 9.1% 46.7% Brittle leaders Quantity 1 5 6 0 % 8.3% 41.7% 50.0% 0.0% 91.7% Aspirational leader Quantity 11 2 8 0 % 52.4% 9.5% 38.1% 0.0% 47.6% Non-leaders Quantity 2 12 6 0 % 10.0% 60.0% 30.0% 0.0% 90.0% Regarding the professional role, established leaders included 8 preceptors and 7 residents (3 R1s, 3 R2s, and 1 R3). These residents stand out as the main informal leaders, and their average experience time in internal medicine residency was 1.5 years. Brittle leaders included 1 preceptor and 11 residents (5 R1s and 6 R2s); residents’ average experience time in internal medicine residence was 1.1 years. While brittle residents are also informal leaders, their lower experience and lower LAI scores allow to hypothesize that their leadership effectiveness is lower in comparison to the established leaders. Aspirational leaders included 11 preceptors and 10 residents (2 R1s and 8 R2s). Possible hypotheses for the high incidence of preceptors in this group are that their leadership effectiveness is low and that they are experts in highly specialized fields, rather than being generalists with a wider potential for the provision of advice. Among residents, most aspirational leaders were R2s, suggesting that some junior physicians feel ready to lead but are still building their network influence within the service. Non-leaders comprised 2 preceptors and 18 residents (12 R1s and 6 R2s), with two-thirds of them in the first year. This may reflect limited involvement in leadership roles during their current stage of clinical training. It is noteworthy that there were two preceptors in this group, suggesting that their formal responsibility for supervision is not translating into influence within the advice-seeking network. Table 7 - Distribution of respondents according to the four quadrants 5. Discussion 5.1. On the alignments and misalignments between LAI and LAD The joint analysis of LAI and LAD allows to discuss how these two dimensions are aligned or not. Alignment between LAI and LAD occurs for established leaders and non-leaders. In the established leaders’ quadrant there were 8 preceptors and 17 residents. Even though residents and preceptors may be established leaders, they might experience this role very differently in terms of workload, emotional strain, and risk of burnout [ 10 , 50 ]. Furthermore, the notion of established leaders resembles the concept of key players in social network analysis. According to Borgatti et al [ 48 ], key players are optimally positioned to quickly diffuse information, attitudes, behaviors or goods and/or to quickly receive the same. As a drawback, an over reliance on a few key players can make the network performance vulnerable when they are unavailable [ 1 ]. Alignment between LAI and LAD also occurred for non-leaders. This quadrant contained a large proportion of first-year residents (54.5% of the entire group of residents), which is consistent with the steep learning curve in early residency and with studies showing that the new resident often feels unprepared to lead teams or manage crises [ 5 , 51 ]. From an educational perspective, this group should not be labelled as “weak”, but rather as individuals whose leadership identity and network role are still emerging and developing. Recognizing non-leaders as being at an early stage of residents’ identity construction reframes them from “followers” to prospective leaders in formation [ 7 , 19 ]. Misalignment between LAI and LAD appears among aspirational leaders, who see themselves as leaders yet are not frequently sought by peers for advice. This group included 11 of 22 preceptors (50.0%) and 10 of 46 residents (21.7%), of whom 8 were in their second year of residency. LAI not translated into LAD can be due to structural barriers related to rotation patterns, shift schedules, task assignment, or hierarchies [ 52 , 53 ]. The predominance of preceptors and R2s in this quadrant suggests that experience, by itself, is not enough to ensure network legitimization. Moreover, aspirational leaders reflect findings of past studies indicating that physicians tend to overestimate their non-technical performance [ 11 , 54 , 55 ]. Misalignment between LAI and LAD also occurs among brittle leaders. They comprised 4.5% of all preceptors (1/22) and 23.9% of the residents (11/46), indicating that they are central points of reference in the advice-seeking network despite not feeling skilled leaders. Studies of leadership identity point out that influence can be attributed to individuals before they feel fully competent in that role [ 12 ]. This mismatch can be a source of stress and frustration for these individuals. 5.2 Targeted interventions by leadership groups The four-quadrant framework allows to consider suitable directions for leadership development for each group. This idea aligns with the need for context-sensitive and data-driven approaches to leadership development in health education [ 13 , 19 , 56 ]. Leadership initiatives tend to be more effective when they are aligned with participants’ baseline experience, identity stage, and contextual constraints [ 12 , 19 , 57 ]. The quadrants provide a diagnostic starting point to discuss how existing educational strategies such as mentoring, feedback, and team training could be prioritized or tailored for established leaders, brittle leaders, aspirational leaders, and non-leaders. For established leaders, interventions should focus on advanced training. Established leaders are natural candidates to play central roles in educational and quality-improvement activities, given that they are both self-identified and network-recognized as key sources of advice. Engaging such residents in roles that combine formal learning with practical responsibilities – for example, co-facilitating debriefings, mentoring junior residents, or contributing to curricular refinements - is associated with gains in leadership competences and organizational outcomes [ 19 , 57 , 58 ]. At the same time, these professionals may become overwhelmed by these responsibilities, requiring initiatives that support personal resilience, wellbeing, and sustainable engagement in leadership roles [ 50 , 59 ]. For the non-leaders group, interventions may focus on providing supervised leadership experiences as they are at early stages of leadership identity construction. For this group, the literature highlights the importance of progressive participation in clinical work, explicit role-modelling of everyday leadership behaviors, and psychologically safe environments for speaking up such as by creating reflexive spaces [ 4 , 5 , 60 ]. These mechanisms support leadership maturing over time. Interventions for aspirational leaders may provide opportunities for increasing the network centrality of these individuals. From an educational perspective, misalignment in this quadrant should not be interpreted necessarily as “overconfidence”, but rather as a sign that these individuals are actively engaging in leadership identity construction without being recognized by their team as informal leaders [ 12 , 61 ]. For this group, structured mentoring relationships should be combined with opportunities for taking leadership roles such as co-leading ward rounds, leading case discussions, or taking responsibility for small quality-improvement projects and team meetings. These experiences can increase their chances of being legitimized by the network, progressing toward the established-leaders quadrant [ 6 , 19 , 62 ]. Interventions for brittle leaders may focus on enhancing leadership skills and confidence so that their self-perceptions more closely match the high demand for advice they receive within the network. This group was composed mainly of first- and second-year residents, which raises concerns about the concentration of coordination demands in some inexperienced individuals who are not confident in their skills. For this group, the literature points to the importance of combining strategies to promote self-confidence, reduce distress, recognition and feedback that makes it clear their central network role and how to cope with it [ 59 , 63 , 64 ]. Finally, there is an implication that applies to all quadrants and connects to the way LAI and LAD were combined in this study. Sharing aggregated and (where appropriate) individualized results of LAI and LAD with residents through feedback sessions or facilitated debriefings may help participants to reflect on how they see themselves as leaders, and how they are seen by others in the advice network. This type of feedback is consistent with indications that structured reflection can calibrate physicians’ self-perceptions and stimulate more realistic assessments of their non-technical competences [ 29 , 54 , 55 ]. By making the patterns of alignment and misalignment visible, network-based feedback may serve as a low-cost intervention that supports leadership identity development in all quadrants. 6. Conclusions This research study addressed the knowledge gap regarding how formal leadership theories can inform the identification of informal leaders in medical residency, with the aim of supporting educational interventions. A novel approach based on a social network analysis survey is proposed, combining traditional advice-seeking relationship questions with tailored items on the adoption and importance of four leadership styles. We translated transformational, relational, adaptive, and resilient leadership concepts into survey questions that were used to construct the LAI scores and to weigh the network centrality metrics that compose the LAD score. By comparing LAI and LAD scores in the internal medicine study, this work demonstrates how expectations about leadership and actual influence patterns may either converge or diverge in a medical residency program. The LAI-LAD framework provides not only a new descriptive taxonomy of leadership configurations but also a diagnostic tool to identify informal leaders and where educational interventions are most needed. This study has some limitations. First, the survey instrument was tested only in the internal medicine context. However, its structure and underlying logic are not context-specific and could be applied to other medical residency programs. A key adaptation for other contexts would be the selection of relevant leadership styles to be assessed. Second, this was a cross-sectional study and thus did not capture how networks and associated leadership profiles change over time. Future longitudinal research could monitor how residents’ LAI and LAD scores evolve throughout the entire residency, enabling interventions at different stages. Third, social network analysis alone provides limited insight into why a network assumes a particular configuration. Further research could incorporate qualitative data (e.g., from interviews) to explore underlying factors such as personal attributes of leaders and followers, leadership influence processes, and organizational context. Abbreviations MRs — medical residents WAI — Work-as-imagined WAD — Work-as-done LAI — Leadership-as-imagined LAD — Leadership-as-done SNA — Social Network Analysis UCINET — UCINET software (used to calculate SNA metrics) IMS — Internal Medicine Service R1 — first-year residents R2 — second-year residents R3 — third-year resident IM — Internal Medicine P — preceptors (applied to all preceptors – e.g. P1, P2, P3) LS — Leadership Score Declarations Ethical approval and consent to participate Ethical approval was granted by the Ethics Committee of Hospital de Clinicas de Porto Alegre by the number 81596524.8.0000.5327 (internal project number 2024/0185). We also declare that this study adhered to the Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Participants. Participation was voluntary and consent was obtained from all participants. Consent for Publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the corresponding author, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the corresponding author upon reasonable request and with permission of the Ethics Committee of Hospital de Clinicas de Porto Alegre. Competing interests The authors declare that they do not have any competing financial interests or personal relationships that could induce bias in the results reported in this study. Funding The first author received a scholarship granted by the National Council for Scientific and Technological Development – Brazil (CNPq) during the research period. Grant number 140719/2023-7 . Author’s contributions PFS conceived and designed the study, conducted the literature search, data collection, quality appraisal, and analysis, wrote and revised the manuscript; TAS contributed to the study design, analysis, wrote, served as second reviewer, supervised the study, and critically read and revised the manuscript; FSF contributed to the study design, analysis, wrote, and served as a third reviewer, critically read and revised the manuscript. JMD and DRVR supported data collection, data analysis, read and revised the manuscript, contributing to its adequacy and adherence to the medical area and also to the manuscript writing. All authors interpreted the data, discussed the findings, and read and approved the final manuscript version. Acknowledgments The research team would like to thank Hospital de Clinicas de Porto Alegre for their support throughout this project. References Lawson D, Fleshman JW. Informal leadership in health care. 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07:56:42","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14842,"visible":true,"origin":"","legend":"","description":"","filename":"Table6.docx","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/5c7f6ec784e89086011611c3.docx"},{"id":100367295,"identity":"2ef88c86-8985-4007-bfbe-2a7da3b94a0a","added_by":"auto","created_at":"2026-01-16 07:56:56","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15905,"visible":true,"origin":"","legend":"","description":"","filename":"Table7.docx","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/c298bdbfc6a0f2dfb6e0045f.docx"},{"id":100366282,"identity":"358d69cb-3609-49e5-8fa8-61d4c90b8391","added_by":"auto","created_at":"2026-01-16 07:56:11","extension":"json","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8185,"visible":true,"origin":"","legend":"","description":"","filename":"f236a93809da4de7a8ac552f3a40ab11.json","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/3385a4e4610b5cad10cfaf5f.json"},{"id":100126986,"identity":"6ab1285c-5802-4f9c-94d4-c155bc53ae06","added_by":"auto","created_at":"2026-01-13 09:26:26","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":17842,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/104ca3b73387c3d505f4ea59.docx"},{"id":100367292,"identity":"110dc3b7-062f-4cbb-b97a-af3771fcd205","added_by":"auto","created_at":"2026-01-16 07:56:56","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":169683,"visible":true,"origin":"","legend":"","description":"","filename":"f236a93809da4de7a8ac552f3a40ab111enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/da7883f554a6d4c90b1821c9.xml"},{"id":100126991,"identity":"05e2f829-8ab6-49af-8460-b880bc4a3158","added_by":"auto","created_at":"2026-01-13 09:26:27","extension":"jpg","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":363212,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/5dfed702eb6fcc125e575b8f.jpg"},{"id":100366116,"identity":"62333e31-4e9a-40b7-8d83-9c462837bcc5","added_by":"auto","created_at":"2026-01-16 07:55:59","extension":"jpg","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":302828,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/58317f4b4846971e2fa4a3cf.jpg"},{"id":100126996,"identity":"ddd033bb-45b3-414a-ac8e-a93fac671e85","added_by":"auto","created_at":"2026-01-13 09:26:27","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":108363,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/1960d01c8690ceb1322c4e71.png"},{"id":100126993,"identity":"1380984a-2394-4e8b-9742-af7b50de5123","added_by":"auto","created_at":"2026-01-13 09:26:27","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116305,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/237a3ad8dceab6b371bcf119.png"},{"id":100126998,"identity":"c6a99d38-6e5f-464e-86b3-3278a778d6d2","added_by":"auto","created_at":"2026-01-13 09:26:27","extension":"xml","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165765,"visible":true,"origin":"","legend":"","description":"","filename":"f236a93809da4de7a8ac552f3a40ab111structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/83566308ac2bbd8d12c60bbd.xml"},{"id":100367770,"identity":"ff516f3d-9332-4a52-bee4-7cb5bf009ae3","added_by":"auto","created_at":"2026-01-16 07:57:16","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":182052,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/275e7d381d733324add387a4.html"},{"id":100126980,"identity":"21c81b7b-2cec-466f-8479-29e44eeecaec","added_by":"auto","created_at":"2026-01-13 09:26:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":363212,"visible":true,"origin":"","legend":"\u003cp\u003eSociogram of the network. Note: blue squares represent preceptors and red circles represent residents.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/97a20a0f7b11a65e5f815976.jpg"},{"id":100126978,"identity":"77b7a227-1b6c-468d-9d63-46eeb75bc0a2","added_by":"auto","created_at":"2026-01-13 09:26:26","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":302828,"visible":true,"origin":"","legend":"\u003cp\u003ePositioning of respondents according to their LAI and LAD scores\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/db25ffd6b863b38987f289af.jpg"},{"id":103765819,"identity":"6d07c133-e30c-40c4-bb6d-190330faafa6","added_by":"auto","created_at":"2026-03-02 16:09:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2056107,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/79df31f4-9713-41c3-bd15-2ceb545ef748.pdf"},{"id":100366361,"identity":"11803f61-5227-4ff1-95f3-f115ddf50885","added_by":"auto","created_at":"2026-01-16 07:56:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17842,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8418016/v1/005c1d20dfff3606b7a667e0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Identifying informal leaders among medical residents as a basis for educational interventions","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eLeadership in medical residency programs plays a crucial role in shaping professional identity, team dynamics, and patient safety [1-3]. However, a large portion of leadership in clinical environments emerges informally, especially among medical residents (MRs) who undertake critical responsibilities in the absence of senior physicians and lead junior staff [4-6]. Even though these informal leadership roles are important, residency programs often leave leadership-related skills (e.g., communication, conflict resolution, and decision-making) to the \u0026ldquo;hidden curriculum\u0026rdquo;, which is not explicitly taught, labeled, or assessed within the formal syllabus [5, 7-8]. This problem is compounded by the inconsistent supervision MRs receive from preceptors [5, 9]. Theories of formal leadership offer a point of departure for understanding informal leadership, as both types usually coexist in the same environment and address similar healthcare challenges [10]. However, previous studies do not clarify how these theories can be applied to identify informal leaders [11, 12]. This gap is important since recognizing informal leaders among MRs enables targeted interventions to enhance leadership skills. Such skills are valuable for all MRs, as they may be required to lead at various points in their daily clinical work, regardless of whether they are considered informal leaders. Leadership will also be needed in their professional careers beyond residency [13-15].\u003c/p\u003e\n\u003cp\u003eMoreover, previous studies of MR leadership, either formal or informal, do not account for the gap between self-perceived leadership and leadership displayed in practice. This misalignment resembles the gap between work-as-imagined and work-as-done. Work-as-Imagined (WAI) refers to how tasks, roles and responsibilities are prescribed in guidelines and plans, whereas Work-as-Done (WAD) captures the adaptations and interpersonal dynamics that occur under real-world constraints and uncertainty [16-18]. Building upon this lens, leadership in medical residency can be understood as a dual construct comprising Leadership-as-Imagined (LAI) and Leadership-as-Done (LAD). In line with leadership identity [12], LAI is an indicator of leadership \u0026ldquo;claims\u0026rdquo;, whereas LAD reflects the extent to which these claims are \u0026ldquo;granted\u0026rdquo; by colleagues through their advice-seeking ties.\u003c/p\u003e\n\u003cp\u003eLAI in residency training is conceptualized as a set of competencies and behaviors that physicians are expected to demonstrate such as clear communication, conflict management, team coordination and the ability to motivate colleagues [19, 20]. This normative view is formalized through competency frameworks, leadership curricula and assessment tools, and it also manifests when residents rate themselves on leadership scales derived from formal leadership theories [5, 13].\u003c/p\u003e\n\u003cp\u003eTherefore, it is also necessary to investigate the actual influence patterns (LAD) in the daily network of professional relationships. To this end, this study uses Social Network Analysis (SNA), which reveals the influence that shapes collective work in practice [21]. SNA enables the visualization and examination of connections within different types of networks, from information science to human resources, and is extensively applied in healthcare to improve patient care [21-24]. Grounded in graph and network theory, SNA examines behavioral patterns, social influence, and teamwork by analyzing relationships between network individuals [25, 26]. It is typically implemented through questionnaire surveys in which respondents indicate individuals they rely on for information or advice [27, 28]. These surveys may also include questions about the respondent\u0026rsquo;s profile (e.g., alignment with certain leadership styles), which can be analyzed alongside responses related to the peer-consultation relationships [28].\u003c/p\u003e\n\u003cp\u003eBuilding on this approach, this article focuses on internal medicine residents, for whom leadership skills are crucial to supervising junior staff, coordinating patient care, and engaging in quality improvement initiatives [29-31]. This investigation draws on the core ideas of transformational, relational, adaptive, and resilient leadership theories, which align with the highly complex internal medicine context [32-35]. Transformational leadership highlights a leader\u0026rsquo;s ability to inspire and motivate members toward a shared vision, fostering innovation and continuous improvement [32, 33]. These are essential abilities for internal medicine residents who guide clinical teams, promote open discussions, and build collective consensus [20]. Relational leadership focuses on collaboration and engagement among team members, making it well suited to the multidisciplinary care teams often led by internal medicine residents [34]. Resilient leadership emphasizes emotional stability in the face of challenging or unexpected clinical scenarios, which are part of residents\u0026rsquo; daily work [36, 37]. Adaptive leadership addresses coping with ambiguity and uncertainty when no single standardized solution exists, a situation frequently encountered in internal medicine [38]. Both LAI and LAD in internal medicine residency might be regarded as emergent properties of the interactions between these four leadership styles. A leadership style corresponds to the manifestation of the core ideas of a leadership theory in practice.\u003c/p\u003e\n\u003cp\u003eConsidering this background, the research question addressed by this study is stated as follows: how can formal leadership theories be used for the identification of informal leaders among medical residents, supporting targeted educational interventions? The research question was empirically examined in a large university hospital, allowing the development of a novel SNA-based approach for identifying informal leaders among MRs. Internal medicine MRs and their preceptors were surveyed about their advice-seeking relationships and their self-perceptions regarding the adoption of the aforementioned leadership styles. For each actor in the network, leadership style data and network metrics were used to generate two scores, respectively representing LAI and LAD. The results gave rise to a four-quadrant model that allows to identify different manifestations of informal leadership, setting out a basis for targeted educational interventions.\u003c/p\u003e"},{"header":"2. Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Leadership theories considered in this study\u003c/h2\u003e \u003cp\u003eAs previously mentioned, four leadership theories are particularly relevant to medical residents: transformational, relational, adaptive, and resilient [\u003cspan additionalcitationids=\"CR34 CR35\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Collectively, these theories provide a comprehensive perspective on how residents exercise leadership in hospital settings under varying conditions. Transformational and relational leadership address the routine leader\u0026ndash;follower dynamics of residency, emphasizing trust-building, goal alignment, and sustained motivation across rotations and shifts [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In contrast, adaptive and resilient leadership highlight the capacity of residents to guide teams through complexity, uncertainty, and acute disruptions in care [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents a summary of these four theories.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMain characteristics of leadership theories in this study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeadership Theory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransformational\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRelational\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdaptive\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResilient\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnit of analysis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeader-follower relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTeam dynamics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTeam dynamics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeader-follower relationship\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeader's approach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisionary and inspiring, creating an environment of innovation and commitment (Judge \u0026amp; Piccolo, 2004).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEncourages open communication, empathy, and participative decision-making (Brower et al., 2000).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChallenges followers, encouraging continuous learning and experimentation (Heifetz et al., 2009).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFocus on emotional intelligence and stress management to cope with crises (Coutu, 2002).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDefinition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInspires followers to achieve significant changes through charisma, vision, and intellectual stimulation (Bass \u0026amp; Riggio, 2006).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmphasizes building strong, trust-based relationships with followers to enhance collaboration and mutual growth (Uhl-Bien, 2006).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMobilizes teams to face challenges and find innovative solutions through adaptation (Heifetz, 1994).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSustains effectiveness in crisis by managing stress and fostering team cohesion (Coutu, 2002).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFocus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransforms followers and aligns individual and organizational goals (Bass \u0026amp; Riggio, 2006).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFocuses on interpersonal connections, emotional intelligence, and shared goals (Carifio, 2010).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSolves problems that require learning and cultural changes (Heifetz et al., 2009).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaintains morale, safety, and productivity during adversity (Lombardi et al., 2021).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003erives long-term organizational and personal change (Bass \u0026amp; Riggio, 2006).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFosters a culture of inclusivity, trust, and teamwork to achieve sustainable outcomes (Brower et al., 2000).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEmpowers teams to face and solve unknown challenges (Heifetz et al., 2009).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRestores and sustains organizational performance and cohesion during crises (Lombardi et al., 2021).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e - Main characteristics of leadership theories considered in this study\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Social Network Analysis Metrics\u003c/h2\u003e \u003cp\u003eSNA applies core concepts such as nodes (individuals), ties (relationships), and quantitative metrics to interpret social structures [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. For nodes, these metrics include degree, closeness, and betweenness centrality. Degree centrality reflects direct connections and popularity [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Closeness centrality indicates accessibility within the network [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Betweenness centrality highlights roles in mediating interactions and controlling information flow [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. At the network level, density measures overall connectivity among all nodes [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Specialized software, such as UCINET, calculates these metrics, while the NetDraw extension provides visual representations [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. These metrics and their variations can be interpreted in the context of informal leadership. For instance, in-degree centrality counts the number of ties directed towards a node, while in-closeness centrality measures the average shortest path from other nodes that seek support to that node. Both are reasonable proxies for informal leadership, as such individuals are often sought out by peers and are easily accessible [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In turn, out-closeness centrality, defined as the average shortest path length from a node to all others it supports, relates to the capacity to disseminate information across the network [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Fast and effective communication, reflected in high out-closeness centrality, is a characteristic of informal leadership in dynamic environments such as hospitals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Overview of the Hospital\u0026rsquo;s Internal Medicine Service\u003c/h2\u003e \u003cp\u003eThe Internal Medicine Service (IMS) is situated within a large university hospital in Brazil. The hospital provides an average of 400,000 in-person consultations, 40,000 teleconsultations, 40,000 surgical procedures, 300 transplants, and 2,800 births annually. The institution employs 6,215 staff members, including 518 faculty, and supports 2,195 undergraduate students, 553 medical residents, and 108 multi-professional residents across all departments.\u003c/p\u003e \u003cp\u003eThe IMS is staffed by 25 attending physicians (preceptors), seven of whom also hold university faculty positions. The residency program comprises 25 first-year residents (R1), 26 second-year residents (R2), and one third-year resident (R3), in addition to 21 rotating residents who complete one-month rotations at the IMS. Each month, 12\u0026ndash;14 second-semester students and 15 final year interns participate in clinical activities within the service. The IM residency program has a mandatory duration of two years, with an optional third year available through a separate selection process.\u003c/p\u003e \u003cp\u003eIn terms of infrastructure, the IMS has a reception area, separate rooms with computers for residents and preceptors, and meeting rooms, equipped with computers, televisions, and whiteboards, used for rounds. Residents also use equipment from other departments and hospital wards depending on their care activities. The work is organized into teams of up to eight members: one preceptor, one R2, two R1s, two interns, and 1 or 2 5th-semester students. Residents work on internal medicine teams and rotate through different areas of the hospital (e.g., emergency room, intensive care unit, outpatient clinic, and wards), using the IMS space for computer access, meetings, and theoretical activities.\u003c/p\u003e \u003cp\u003eThe internal medicine teams conduct daily rounds to review and discuss patient cases, both within the IMS facilities and at the point of care. The IMS also interacts with various specialties and multidisciplinary teams, including nursing, pharmacy, and nutrition. Seasonal variations affect patient flow and the types of illnesses encountered (e.g., increased respiratory cases during winter), requiring efficient resource management. The service manages a highly diverse patient population, often presenting multiple decompensated conditions. These contextual factors, such as high resident turnover and limited time spent in the IMS office, may influence interpersonal and professional interactions within the service.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Data Collection\u003c/h2\u003e \u003cp\u003eBefore accessing the questionnaire, participants were provided with the project title, average time for fulfilling the form, the anonymity statement and a link containing more details on the project, ethics and project responsible contacts in case of doubts. Then, they were provided with electronic informed consent in Qualtrics by selecting \u0026ldquo;Yes\u0026rdquo; or \u0026ldquo;No\u0026rdquo; to the question \u0026ldquo;Do you agree to participate in this research?\u0026rdquo;. The questionnaire was only available for those who marked \u0026ldquo;Yes\u0026rdquo; in this question and blocked for those who marked \u0026ldquo;No\u0026rdquo;. The survey comprised four main sections: (i) demographic information about respondents, (ii) advice-seeking interactions, (iii) respondents\u0026rsquo; perceptions on how they identify with the four leadership styles, and (iv) perceptions of the relative importance of these styles in training future IMS leaders. The complete survey is in Supplementary file 1.\u003c/p\u003e \u003cp\u003eThe survey was pilot tested with two of the 77 IMS members and then refined for final use. Two main groups were targeted: preceptors (P), and residents, from first, second, and third year (R1, R2, R3). Residents from other specialties rotating through the IMS were excluded due to high turnover. The survey was administered via Qualtrics, a platform commonly used in SNA, and participants were contacted primarily through institutional e-mail. The survey was sent to all 77 IMS members, yielding 68 valid responses (response rate of 88.3%). This exceeds the rate of 75% recommended by Borgatti, Carley, and Krackhardt for ensuring valid and reliable SNA metrics results [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Also, Brass and Borgatti [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] point out that a response rate of 80% suffices to capture the most important network characteristics. The questions in section (iv), which addressed the perceived importance of leadership styles for training future IMS leaders, were administered exclusively to the 25 preceptors. Nineteen valid responses were received, corresponding to a 76% response rate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Data Analysis\u003c/h2\u003e \u003cp\u003eAll respondents who marked \u0026ldquo;Yes\u0026rdquo; to the question \u0026ldquo;Do you agree to participate in this research?\u0026rdquo; provided a complete form fulfilled. No respondent answered \u0026ldquo;No\u0026rdquo; to this question. The questionnaire was then downloaded, checked and treated to be inserted into UCINET software for analysis. Also, a spreadsheet was used to support the analysis of the data \u0026ndash; e.g. calculation of LAI, LAD and the graphics generation.\u003c/p\u003e \u003cp\u003eLAI was operationalized using questions 8 to 15 representing respondents\u0026rsquo; self-assessed development across the four leadership styles and question 16 (leadership styles weighted by preceptors). Questions 8 to 15 comprised eight statements capturing the core aspects of the four leadership styles - two statements per style, with agreement rated on a 5-point Likert scale. For each participant, we calculated an LAI score by summing the means for each leadership style - comprising 4 different means per individual - and multiplied each one of them by the corresponding weights assigned by the preceptors. The LAI score was the sum of these four weighted means per individual.\u003c/p\u003e \u003cp\u003eLAD was operationalized using the advice-seeking network data derived from question 7, and question 16. SNA metrics were generated by UCINET software, and the network graphic (i.e., sociogram) was obtained by the use of the NetDraw extension. Responses to question 7 were used to build an adjacency matrix in which each cell \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{x}_{jk}\\)\u003c/span\u003e\u003c/span\u003e represented how frequently respondent \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:j\\)\u003c/span\u003e\u003c/span\u003e sought advice from person \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:k\\)\u003c/span\u003e\u003c/span\u003e. For each individual, we computed four centrality metrics that captured complementary dimensions of network influence: in-degree, betweenness, out-closeness, and in-closeness. All centrality metrics were normalized to allow comparison and to enable their combination into a novel composite score denoted as the Leadership Score (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{LS}_{k}\\)\u003c/span\u003e\u003c/span\u003e). \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{LS}_{k}\\)\u003c/span\u003e\u003c/span\u003e is defined as follows: let \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{w}_{i}\\)\u003c/span\u003e\u003c/span\u003e denote the importance weight assigned to leadership style \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:i\\)\u003c/span\u003e\u003c/span\u003e, computed as the sum of the reciprocals of rank positions attributed to each style \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:i\\:(i=1,\\dots\\:,4)\\)\u003c/span\u003e\u003c/span\u003e by the 19 preceptors who responded section (iv) of the survey. Let \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{n}_{ik}\\)\u003c/span\u003e\u003c/span\u003e denote the network metric of individual \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:k\\)\u003c/span\u003e\u003c/span\u003e associated with leadership style \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:i\\)\u003c/span\u003e\u003c/span\u003e (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The Leadership Score is then given by:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLeadership styles, associated network metrics, and importance weights\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeadership style\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssociated network metric\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImportance weight\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheir role in promoting collaboration reflects the core of relational leadership, which values social integration, cross-disciplinary interaction, and collective learning (Dempwolf \u0026amp; Lyles, 2012; Uhl-Bien, 2006).\u003c/p\u003e \u003cp\u003eConcise descriptor: information broker.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eBetweenness centrality\u003c/em\u003e: quantifies how often a node lies on the shortest paths between other nodes, highlighting control over information flow.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransformational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThese individuals are consistently sought out for their knowledge, vision, and ability to guide others. Their influence is built on trust, expertise, and a commitment to developing team members as mentors (Bass \u0026amp; Riggio, 2006; Wasserman \u0026amp; Faust, 1994; Bono \u0026amp; Anderson, 2005).Concise descriptor: trusted advisor.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eIn-degree centrality\u003c/em\u003e: measures the number of incoming connections, directly indicating who is sought after.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdaptive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe ability to quickly disseminate information and tailor messages during times of uncertainty and crisis is central to adaptive leadership (Isba et al., 2017; McKimm et al., 2023; Uhl-Bien \u0026amp; Arena, 2018).\u003c/p\u003e \u003cp\u003eConcise descriptor: rapid information disseminator.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eOut-closeness centrality\u003c/em\u003e: measures how quickly a node can reach all other nodes in the network.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResilient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe ability to quickly capture and process relevant information under pressure is a key trait of resilient leadership, enabling effective decision-making in high-stress situations (Bertoni et al., 2022; F\u0026ouml;rster \u0026amp; Duchek, 2017; Lombardi et al., 2021).\u003c/p\u003e \u003cp\u003eConcise descriptor: efficient information receiver.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eIn-closeness centrality\u003c/em\u003e: measures how quickly a node can be reached by information originating from others.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cdiv id=\"Equ1\" class=\"Equation\"\u003e \u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equ1\" name=\"EquationSource\"\u003e\n$$\\:{LS}_{k}={\\sum\\:}_{i=1}^{4}\\left({w}_{i}{\\times\\:n}_{ik}\\right),\\:k=1,\\dots\\:,68$$\u003c/div\u003e \u003cdiv class=\"EquationNumber\"\u003e1\u003c/div\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe weights were normalized such that \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\sum\\:}_{i=1}^{4}{w}_{i}=1\\)\u003c/span\u003e\u003c/span\u003e. Eq.\u0026nbsp;(\u003cspan refid=\"Equ1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) thus represents a weighted aggregation of selected network metrics derived from the advice-seeking relationships [section (ii) of the survey], scaled by the relative importance of each leadership style elicited in section (iv).\u003c/p\u003e \u003cp\u003eAfter calculating the LAI and LAD proxy scores for each participant, we plotted all individuals in a two-dimensional graph with LAI scores on the horizontal axis and LAD scores on the vertical axis. To differentiate \u0026ldquo;low\u0026rdquo; and \u0026ldquo;high\u0026rdquo; score values, we used the sample averages as the cut-off. As such, it was possible to delineate four quadrants, named as follows: high LAI and high LAD (established leaders); low LAI and high LAD (brittle leaders); high LAI and low LAD (aspirational leaders); and low LAI and low LAD (non-leaders). Residents positioned in the brittle and established leaders\u0026acute; quadrants were regarded as informal leaders.\u003c/p\u003e \u003cp\u003eIn the last step, we linked each LAI-LAD quadrant to a set of targeted educational interventions. These intervention proposals were based on logical reasoning related to each quadrant characteristics (e.g., respondents with low LAI and low LAD scores should require more extensive training) as well as on insights from the literature.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Characteristics of respondents\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the main characteristics of the 68 respondents. Forty-two of them were male (61.8%) and 26 females (38.2%). They were evenly split between preceptors (22; 32.4%) and first-year residents (22; 32.4%), with a similar proportion of second-year residents (23; 33.8%), and a single third-year resident (1; 1.5%). Regarding clinical experience, 11 participants (16.2%) had less than one year as a doctor, 21 (30.9%) had 1\u0026ndash;2 years, and 19 (27.9%) had more than 10 years, indicating a mix of junior and senior physicians. Experience in internal medicine was shorter, with 29 respondents (42.6%) reporting less than one year and 21 (30.9%) between 1\u0026ndash;2 years, while only 9 (13.2%) had more than 10 years in the specialty.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Main characteristics of the survey respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (38.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (61.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStaff\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreceptors (P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (32.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst-year residents (R1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (32.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond-year residents (R2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (33.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThird-year residents (R3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of experience as a doctor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (16.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (30.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (10.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (27.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears of experience in Internal Medicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (42.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (30.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e68 (100.0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e - Main characteristics of the survey respondents\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.2. The relative importance of the leadership styles\u003c/h2\u003e \u003cp\u003eBefore computing LAI and LAD, we estimated the relative importance of the four leadership styles from preceptors\u0026rsquo; rankings, converting them into normalized weights that were applied both to the self-perception items (LAI) and to the network metrics in the Leadership Score (LAD). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the network metrics that reflect the leadership styles and their importance weights. Although the four styles were clearly important, relational and transformational styles ranked slightly higher than adaptive and resilient styles. These results can be due to the multidisciplinary and technically complex nature of internal medicine, which requires teamwork and technical expertise, attributes respectively valued by relational and transformational styles.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e - Leadership styles, associated network metrics, and importance weights\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Leadership-as-imagined (LAI)\u003c/h2\u003e \u003cp\u003eScores for LAI related to the self-perception questions ranged from 3.07 to 5.00, with an average of 4.20 for the whole sample. Seventeen out of the 46 residents, representing 25% of the whole sample, presented LAI values higher than the overall mean, indicating that they perceived themselves as displaying significant leadership skills. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the ten highest LAI scores, which included six preceptors, two first-year residents and two second-year residents. These residents feel highly confident about their ability to mobilize colleagues, communicate clearly, and manage difficult situations, even at relatively early stages of residency. It is noteworthy that the youngest resident (R2.23) in the top scorers is a 24-year-old who self-assessed almost as well as the oldest preceptor in this group, a 66-year-old.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe ten highest self-perception averages (LAI)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeadership\u003c/p\u003e \u003cp\u003eself-perception average \u003c/p\u003e \u003cp\u003e(LAI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperience in Medicine\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn the other hand, 27 out of 46 residents (58.7% of the residents) presented LAI scores lower than the overall mean, indicating that they did not see themselves as leaders. However, that does not necessarily imply an absence of leadership potential but can rather suggest an acute awareness of their position as learners or followers.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e - The ten highest self-perception averages (LAI)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Leadership-as-done (LAD)\u003c/h2\u003e \u003cp\u003eLAD was assessed using the composite Leadership Score (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{LS}_{k}\\)\u003c/span\u003e\u003c/span\u003e) derived from the advice-seeking network and the importance weights provided by preceptors. \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{LS}_{k}\\)\u003c/span\u003e\u003c/span\u003e values ranged from 1.45 to 3.97, with an average of 2.22, which was also used as the cut-off between low and high LAD. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents the ten highest LAD scores, including their respective network metrics rescaled to a 5-point Likert scale. In this group, there were five preceptors, two first-year residents, and three second-year residents. There was only one actor (R2.5) who appeared as a top scorer for both LAI and LAD, suggesting a significant gap between these two dimensions. This point can also be further exemplified by R2.23 who obtained the 10th highest LAI score and ranked 34th for LAD, with a LS\u0026thinsp;=\u0026thinsp;2.06.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe ten highest Leadership Scores (LAD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eNetwork attributes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNon-network attributes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn-\u003c/p\u003e \u003cp\u003eDegree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBetweenness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOut-\u003c/p\u003e \u003cp\u003eCloseness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIn-\u003c/p\u003e \u003cp\u003eCloseness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLeadership Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eExperience in Medicine\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePreceptor P9 had the highest score (LS\u0026thinsp;=\u0026thinsp;3.97), followed closely by P12 (3.87), R2.14 (3.84), P4 (3.80), and P21 (3.46). These actors combine high in-degree (for example, P7 with 46 incoming advice nominations, P4 with 41, and P21 with 43) with high betweenness and closeness values, acting as bridges between different parts of the service and as accessible sources of information for colleagues. By contrast, individuals presenting the lower LS scores had few incoming ties (for example, R1.15 with no incoming ties, R1.2 with one, and R2.2 with four), remaining at the edges of the network. Although these participants contribute to patient care and team functioning, they are not widely recognized as advice sources.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e - The ten highest Leadership Scores (LAD)\u003c/p\u003e \u003cp\u003eResponses to the advice-seeking question also informed the development of the sociogram in Fig.\u0026nbsp;1, which shows a highly connected network. Although advice flows in multiple directions and across hierarchical levels, the sociogram shows a clear centralization around a subset of highly connected actors, while others remain in more peripheral positions. Such positions are occupied by both residents and preceptors as indicated in Fig.\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eFigure 1 - Sociogram of the network. Note: blue squares represent preceptors and red circles represent residents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.5. Characterization of leadership groups\u003c/h2\u003e \u003cp\u003eFigure 2 plots all individuals according to their LAI and LAD scores. Quadrants are partitioned based on the average values of LAI and LAD, and their rationale is described in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe four quadrants of leaders\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuadrant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLAI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLAD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEstablished leaders\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(high LAI, high LAD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThese individuals strongly perceive themselves as leaders and occupy central positions in the advice-seeking network.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBrittle leaders\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(low LAI, high LAD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThese individuals are central in the advice-seeking network, but do not regard themselves as skilled leaders.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAspirational leaders\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(high LAI, low LAD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThese individuals strongly perceive themselves as leaders yet occupy relatively peripheral positions in the network. They express leadership aspirations, which have not yet been fully exploited by their peers.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon-leaders\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(low LAI, low LAD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThese individuals neither tend to see themselves as leaders nor occupy central positions in the advice-seeking network.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e - The four quadrants of leaders\u003c/p\u003e \u003cp\u003eFigure 2 - Positioning of respondents according to their LAI and LAD scores\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e presents the distribution of participants according to the quadrants. Among the 46 residents, 7 (15.2%) were classified as established leaders, 11 (23.9%) as brittle leaders, 10 (21.7%) as aspirational leaders, and 18 (39.1%) as non-leaders. These mixed profiles further reinforce the argument of this paper regarding the need for targeted, and to some extent customized, educational interventions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of respondents according to the four quadrants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePreceptors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eResidents\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eR1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eR2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eR3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEstablished leaders\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuantity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e53.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e46.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBrittle leaders\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuantity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e8.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e91.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAspirational leader\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuantity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e52.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e47.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNon-leaders\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuantity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e10.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e90.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the professional role, established leaders included 8 preceptors and 7 residents (3 R1s, 3 R2s, and 1 R3). These residents stand out as the main informal leaders, and their average experience time in internal medicine residency was 1.5 years. Brittle leaders included 1 preceptor and 11 residents (5 R1s and 6 R2s); residents\u0026rsquo; average experience time in internal medicine residence was 1.1 years. While brittle residents are also informal leaders, their lower experience and lower LAI scores allow to hypothesize that their leadership effectiveness is lower in comparison to the established leaders. Aspirational leaders included 11 preceptors and 10 residents (2 R1s and 8 R2s). Possible hypotheses for the high incidence of preceptors in this group are that their leadership effectiveness is low and that they are experts in highly specialized fields, rather than being generalists with a wider potential for the provision of advice. Among residents, most aspirational leaders were R2s, suggesting that some junior physicians feel ready to lead but are still building their network influence within the service. Non-leaders comprised 2 preceptors and 18 residents (12 R1s and 6 R2s), with two-thirds of them in the first year. This may reflect limited involvement in leadership roles during their current stage of clinical training. It is noteworthy that there were two preceptors in this group, suggesting that their formal responsibility for supervision is not translating into influence within the advice-seeking network.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e - Distribution of respondents according to the four quadrants\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e5.1. On the alignments and misalignments between LAI and LAD\u003c/h2\u003e \u003cp\u003eThe joint analysis of LAI and LAD allows to discuss how these two dimensions are aligned or not. Alignment between LAI and LAD occurs for established leaders and non-leaders. In the established leaders\u0026rsquo; quadrant there were 8 preceptors and 17 residents. Even though residents and preceptors may be established leaders, they might experience this role very differently in terms of workload, emotional strain, and risk of burnout [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Furthermore, the notion of established leaders resembles the concept of key players in social network analysis. According to Borgatti et al [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], key players are optimally positioned to quickly diffuse information, attitudes, behaviors or goods and/or to quickly receive the same. As a drawback, an over reliance on a few key players can make the network performance vulnerable when they are unavailable [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlignment between LAI and LAD also occurred for non-leaders. This quadrant contained a large proportion of first-year residents (54.5% of the entire group of residents), which is consistent with the steep learning curve in early residency and with studies showing that the new resident often feels unprepared to lead teams or manage crises [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. From an educational perspective, this group should not be labelled as \u0026ldquo;weak\u0026rdquo;, but rather as individuals whose leadership identity and network role are still emerging and developing. Recognizing non-leaders as being at an early stage of residents\u0026rsquo; identity construction reframes them from \u0026ldquo;followers\u0026rdquo; to prospective leaders in formation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMisalignment between LAI and LAD appears among aspirational leaders, who see themselves as leaders yet are not frequently sought by peers for advice. This group included 11 of 22 preceptors (50.0%) and 10 of 46 residents (21.7%), of whom 8 were in their second year of residency. LAI not translated into LAD can be due to structural barriers related to rotation patterns, shift schedules, task assignment, or hierarchies [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The predominance of preceptors and R2s in this quadrant suggests that experience, by itself, is not enough to ensure network legitimization. Moreover, aspirational leaders reflect findings of past studies indicating that physicians tend to overestimate their non-technical performance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMisalignment between LAI and LAD also occurs among brittle leaders. They comprised 4.5% of all preceptors (1/22) and 23.9% of the residents (11/46), indicating that they are central points of reference in the advice-seeking network despite not feeling skilled leaders. Studies of leadership identity point out that influence can be attributed to individuals before they feel fully competent in that role [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This mismatch can be a source of stress and frustration for these individuals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Targeted interventions by leadership groups\u003c/h2\u003e \u003cp\u003eThe four-quadrant framework allows to consider suitable directions for leadership development for each group. This idea aligns with the need for context-sensitive and data-driven approaches to leadership development in health education [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Leadership initiatives tend to be more effective when they are aligned with participants\u0026rsquo; baseline experience, identity stage, and contextual constraints [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. The quadrants provide a diagnostic starting point to discuss how existing educational strategies such as mentoring, feedback, and team training could be prioritized or tailored for established leaders, brittle leaders, aspirational leaders, and non-leaders.\u003c/p\u003e \u003cp\u003eFor established leaders, interventions should focus on advanced training. Established leaders are natural candidates to play central roles in educational and quality-improvement activities, given that they are both self-identified and network-recognized as key sources of advice. Engaging such residents in roles that combine formal learning with practical responsibilities \u0026ndash; for example, co-facilitating debriefings, mentoring junior residents, or contributing to curricular refinements - is associated with gains in leadership competences and organizational outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. At the same time, these professionals may become overwhelmed by these responsibilities, requiring initiatives that support personal resilience, wellbeing, and sustainable engagement in leadership roles [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the non-leaders group, interventions may focus on providing supervised leadership experiences as they are at early stages of leadership identity construction. For this group, the literature highlights the importance of progressive participation in clinical work, explicit role-modelling of everyday leadership behaviors, and psychologically safe environments for speaking up such as by creating reflexive spaces [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. These mechanisms support leadership maturing over time.\u003c/p\u003e \u003cp\u003eInterventions for aspirational leaders may provide opportunities for increasing the network centrality of these individuals. From an educational perspective, misalignment in this quadrant should not be interpreted necessarily as \u0026ldquo;overconfidence\u0026rdquo;, but rather as a sign that these individuals are actively engaging in leadership identity construction without being recognized by their team as informal leaders [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. For this group, structured mentoring relationships should be combined with opportunities for taking leadership roles such as co-leading ward rounds, leading case discussions, or taking responsibility for small quality-improvement projects and team meetings. These experiences can increase their chances of being legitimized by the network, progressing toward the established-leaders quadrant [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterventions for brittle leaders may focus on enhancing leadership skills and confidence so that their self-perceptions more closely match the high demand for advice they receive within the network. This group was composed mainly of first- and second-year residents, which raises concerns about the concentration of coordination demands in some inexperienced individuals who are not confident in their skills. For this group, the literature points to the importance of combining strategies to promote self-confidence, reduce distress, recognition and feedback that makes it clear their central network role and how to cope with it [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, there is an implication that applies to all quadrants and connects to the way LAI and LAD were combined in this study. Sharing aggregated and (where appropriate) individualized results of LAI and LAD with residents through feedback sessions or facilitated debriefings may help participants to reflect on how they see themselves as leaders, and how they are seen by others in the advice network. This type of feedback is consistent with indications that structured reflection can calibrate physicians\u0026rsquo; self-perceptions and stimulate more realistic assessments of their non-technical competences [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. By making the patterns of alignment and misalignment visible, network-based feedback may serve as a low-cost intervention that supports leadership identity development in all quadrants.\u003c/p\u003e \u003c/div\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eThis research study addressed the knowledge gap regarding how formal leadership theories can inform the identification of informal leaders in medical residency, with the aim of supporting educational interventions. A novel approach based on a social network analysis survey is proposed, combining traditional advice-seeking relationship questions with tailored items on the adoption and importance of four leadership styles. We translated transformational, relational, adaptive, and resilient leadership concepts into survey questions that were used to construct the LAI scores and to weigh the network centrality metrics that compose the LAD score.\u003c/p\u003e \u003cp\u003eBy comparing LAI and LAD scores in the internal medicine study, this work demonstrates how expectations about leadership and actual influence patterns may either converge or diverge in a medical residency program. The LAI-LAD framework provides not only a new descriptive taxonomy of leadership configurations but also a diagnostic tool to identify informal leaders and where educational interventions are most needed.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, the survey instrument was tested only in the internal medicine context. However, its structure and underlying logic are not context-specific and could be applied to other medical residency programs. A key adaptation for other contexts would be the selection of relevant leadership styles to be assessed. Second, this was a cross-sectional study and thus did not capture how networks and associated leadership profiles change over time. Future longitudinal research could monitor how residents\u0026rsquo; LAI and LAD scores evolve throughout the entire residency, enabling interventions at different stages. Third, social network analysis alone provides limited insight into why a network assumes a particular configuration. Further research could incorporate qualitative data (e.g., from interviews) to explore underlying factors such as personal attributes of leaders and followers, leadership influence processes, and organizational context.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eMRs\u003c/strong\u003e \u0026mdash; medical residents\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWAI\u003c/strong\u003e \u0026mdash; Work-as-imagined\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWAD\u003c/strong\u003e \u0026mdash; Work-as-done\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLAI\u003c/strong\u003e \u0026mdash; Leadership-as-imagined\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLAD\u003c/strong\u003e \u0026mdash; Leadership-as-done\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSNA\u003c/strong\u003e \u0026mdash; Social Network Analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUCINET\u003c/strong\u003e \u0026mdash; UCINET software (used to calculate SNA metrics)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIMS\u003c/strong\u003e \u0026mdash; Internal Medicine Service\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR1\u003c/strong\u003e \u0026mdash; first-year residents\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR2\u003c/strong\u003e \u0026mdash; second-year residents\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR3\u003c/strong\u003e \u0026mdash; third-year resident\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIM\u003c/strong\u003e \u0026mdash; Internal Medicine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e \u0026mdash; preceptors (applied to all preceptors \u0026ndash; e.g. P1, P2, P3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLS\u003c/strong\u003e \u0026mdash; Leadership Score\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Ethics Committee of Hospital de Clinicas de Porto Alegre by the number 81596524.8.0000.5327 (internal project number 2024/0185). We also declare that this study adhered to the Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Participants. Participation was voluntary and consent was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the corresponding author upon reasonable request and with permission of the Ethics Committee of Hospital de Clinicas de Porto Alegre.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they do not have any competing financial interests or personal relationships that could induce bias in the results reported in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe first author received a scholarship granted by the National Council for Scientific and Technological Development \u0026ndash; Brazil (CNPq) during the research period. Grant number\u0026nbsp;\u003c/strong\u003e140719/2023-7\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePFS\u003c/em\u003e conceived and designed the study, conducted the literature search, data collection, quality appraisal, and analysis, wrote and revised the manuscript; \u003cem\u003eTAS\u003c/em\u003e contributed to the study design, analysis, wrote, served as second reviewer, supervised the study, and critically read and revised the manuscript; \u003cem\u003eFSF\u003c/em\u003e contributed to the study design, analysis, wrote, and served as a third reviewer, critically read and revised the manuscript. \u003cem\u003eJMD\u003c/em\u003e and \u003cem\u003eDRVR\u003c/em\u003e supported data collection, data analysis, read and revised the manuscript, contributing to its adequacy and adherence to the medical area and also to the manuscript writing. All authors interpreted the data, discussed the findings, and read and approved the final manuscript version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team would like to thank Hospital de Clinicas de Porto Alegre for their support throughout this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLawson D, Fleshman JW. Informal leadership in health care. Clin Colon Rectal Surg. 2020;33(4):225\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe VF, von Krogh G, Sir\u0026eacute;n C. Expertise diversity, informal leadership hierarchy, and team knowledge creation: a study of pharmaceutical research collaborations. Organ Stud. 2022;43(6):907\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimard J, Shea C, Cho V, Perrier L, Prokopy M, Moshirzadeh E, et al. 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Acad Med. 2020;95(9):1428\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med. 2007;35(7):1668\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelrhiti Z, Giralt AN, Marchal B. Complex leadership in healthcare: a scoping review. Int J Health Policy Manag. 2018;7(12):1073\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHofmann R, Sayer A, Nurse J, et al. Patterns in clinical leadership learning: understanding the quality of learning about leadership to support sustainable transformation in healthcare education. Sustainability. 2024;16(10):4165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePattni C, Scaffidi M, Li J, et al. Video-based interventions to improve self-assessment accuracy among physicians: a systematic review. PLoS ONE. 2023;18(7):e0288474.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCook DA, Hauer KE, Teherani A, Hunderfund ANL, Durning SJ, Colbert-Getz JM. Curriculum research solutions: shifting from did it work locally? to contributing to a scholarly conversation. Acad Med. 2025;100(8):896\u0026ndash;908.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeerts JM, Goodall AH, Agius S. Evidence-based leadership development for physicians: a systematic literature review. Soc Sci Med. 2020;246:112709.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilmartin H, Goyal A, Hamati MC, Mann J, Saint S, Chopra V. Brief mindfulness practices for healthcare providers: a systematic literature review. Am J Med. 2017;130(10):1219.e1-1219.e17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWest CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinez W, Etchegaray JM, Thomas EJ, Hickson GB, Lehmann LS, Schleyer AM, et al. Speaking up about patient safety concerns and unprofessional behaviour among residents: validation of two scales. BMJ Qual Saf. 2015;24(11):671\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMastalerz KA, Jordan SR, Townsley N. Moving targets: medical resident professional identity formation in interprofessional teams. J Interprof Educ Pract. 2021;24:100422.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSambunjak D, Straus SE, Marušić A. Mentoring in academic medicine: a systematic review. JAMA. 2006;296(9):1103\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinchek M, Bird A, Pincavage AT. Building team resilience and debriefing after difficult clinical events: a resilience curriculum for team leaders. MedEdPORTAL. 2017;13:10601.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClarke S, Horeczko T, Cotton D, Bair A. Heart rate, anxiety and performance of residents during a simulated critical clinical encounter: a pilot study. BMC Med Educ. 2014;14:153.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"informal leadership, medical residents, training, social network analysis, internal medicine","lastPublishedDoi":"10.21203/rs.3.rs-8418016/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8418016/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eleadership skills are not usually integrated into the curriculum of medical residents, contributing to variation in skills development. Hence, identifying the manifestations of residents\u0026rsquo; informal leadership can guide educational interventions. It is unclear how theories of formal leadership can support the identification of informal leaders.\u003c/p\u003e\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo propose an approach for identifying the manifestations of informal leadership among medical residents, using this information for proposing interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a social network analysis survey including 68 physicians (22 preceptors and 46 residents) from an internal medicine service of a university hospital using data on advice-seeking relationships, self-assessments of four leadership styles (transformational, relational, adaptive, resilient), and preceptors\u0026rsquo; evaluations of the styles\u0026rsquo; importance. For each respondent, a Leadership Score was calculated by integrating four network metrics (in-degree, betweenness, in-closeness, and out-closeness) logically associated to the leadership styles. This score was a proxy of \u0026ldquo;leadership-as-done\u0026rdquo; (LAD). The average of responses to the self-assessment questions was a proxy of \u0026ldquo;leadership-as-imagined\u0026rdquo; (LAI). The scores for both LAD and LAI were weighted by the importance of leadership styles. A scatterplot placed each participant by LAI and LAD scores, partitioned into four groups: established, brittle, and aspirational leaders, and non-leaders.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the residents, 15.2% were established leaders, 23.9% were brittle leaders, 21.7% were aspirational leaders, and 39.1% were non-leaders. Established and brittle leaders stand out as informal leaders. The former regard their skills well developed and play central roles in the network; the latter do not consider their skills well developed, while still being central.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEducational interventions should focus on enhancing the leadership skills of brittle leaders that match their real demand for advice, giving opportunities for increasing the network centrality of aspirational leaders, providing supervised leadership experiences for non-leaders, and offering advanced training for established leaders.\u003c/p\u003e","manuscriptTitle":"Identifying informal leaders among medical residents as a basis for educational interventions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-13 09:26:21","doi":"10.21203/rs.3.rs-8418016/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-19T06:04:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-15T16:02:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-14T19:10:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-12T14:56:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254513999513579186460649437654152645792","date":"2026-01-11T03:09:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325299218530170921584766454428180227052","date":"2026-01-10T18:04:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161768763676880534447548473469600065940","date":"2026-01-09T16:46:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99006052719545142481176868030720548820","date":"2026-01-08T15:37:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163616954500840585764612453902208200940","date":"2026-01-08T14:59:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-08T14:35:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-08T14:00:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-29T06:33:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-26T14:29:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-12-26T14:19:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"216530b5-331d-4d9a-8c26-fa324fab6910","owner":[],"postedDate":"January 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T16:06:56+00:00","versionOfRecord":{"articleIdentity":"rs-8418016","link":"https://doi.org/10.1186/s12909-026-08918-0","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-02-28 15:59:52","publishedOnDateReadable":"February 28th, 2026"},"versionCreatedAt":"2026-01-13 09:26:21","video":"","vorDoi":"10.1186/s12909-026-08918-0","vorDoiUrl":"https://doi.org/10.1186/s12909-026-08918-0","workflowStages":[]},"version":"v1","identity":"rs-8418016","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8418016","identity":"rs-8418016","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}