Development of a curriculum for community-based medical leadership education

Development of a curriculum for community-based medical leadership education | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development of a curriculum for community-based medical leadership education Koichi Hamabira, Marie Amitani, Hayato Sakiyama, Kimiko Mizuma, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8646770/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background Leadership is increasingly essential in community-based medicine, where physicians must collaborate with various stakeholders and address complex health needs with limited resources. Despite its importance, leadership education in Japan’s undergraduate medical curricula remains inconsistently implemented, lacking standardized competencies and practical training opportunities. This study aimed to identify essential leadership competencies in community-based medicine and develop a structured educational curriculum based on those competencies. Methods We adopted Kern’s six-step approach to curriculum development. A literature review was conducted to extract preliminary competencies. A two-round Delphi study was then implemented with 61 community-based physician leaders in rural and remote areas of Kagoshima Prefecture, Japan. In Round 1, 26 competencies were evaluated on necessity, difficulty of acquisition before graduation, and timing of acquisition using a four-point Likert-type scale. Items were refined using quantitative criteria including Cronbach’s a, McDonald’s w, and the content validity ratio (CVR). In Round 2, 14 revised competencies were confirmed using dichotomous agreement and the same values. Based on the results, a short elective course was designed with lectures and case-based group work for medical students. Results All 26 initial competencies were rated necessary, but only four met the criteria for both difficulty and timing. These, along with qualitative feedback, informed the creation of 14 revised competencies. In Round 2, internal consistency remained high (a = 0.97; w = 0.97), and all competencies surpassed the critical CVR threshold. The final curriculum emphasized attainable competencies and included practical scenarios aligned with Miller’s pyramid framework. Conclusions This study identified and validated leadership competencies specific to community-based medicine and developed a corresponding curriculum. The phased, evidence-informed approach addressed local needs and enabled structured educational implementation. While limited to one region, this framework may inform broader efforts to integrate leadership training into undergraduate medical education. Community-based medical education Leadership competencies Curriculum development Delphi method Undergraduate medical students Figures Figure 1 Figure 2 Background In recent years, the needs of community-based medicine have diversified. Amidst demographic shifts, a rising prevalence of chronic diseases, and limited medical resources, it has become increasingly crucial for health-care professionals to possess advanced clinical judgment and problem-solving skills. The practice of community-based medicine no longer solely involves the one-to-one relationship between a physician and a patient; it now necessitates effective collaboration with a wide range of stakeholders, including patients’ families, caregivers, community support networks, volunteers, interprofessional health-care teams, and even local governments, educational institutions, and nonprofit organizations. In addition, comprehensive team-based care has been shown to improve patient outcomes and reduce health-care costs [ 1 ]. Educational experiences designed to enhance interprofessional communication and collaboration have been reported to improve perceptions of patient care, communication skills, and teamwork. For a team to succeed, leadership is essential to guide its members [ 2 ]. Physicians, in particular, are expected to understand the social determinants of health within the community and contribute to not only the clinical improvement of individual patients, but also the health of the community as a whole [ 3 ]. Furthermore, in settings with scarce medical resources, such as remote islands and underserved rural areas, a single physician often assumes multiple roles, meaning that individual leadership can directly impact the health outcomes of the local population. International medical education frameworks also recognize leadership as a key physician competency. The CanMEDS framework in Canada identifies “Leader” as a core role, emphasizing the importance of physicians understanding their function within the health-care system and contributing to both medical practice and education [ 4 ]. Similarly, the UK’s Medical Leadership Competency Framework calls for all physicians to engage in leadership daily, identifying it as an indispensable capability for improving health-care quality, ensuring patient safety, and reforming the health-care system [ 5 ]. A recent systematic review [ 6 ] revealed that leadership training contributes to enhanced self-efficacy and problem-solving abilities among medical students. This suggests that early intervention is highly likely to translate into improved performance in future clinical practice, better preparing students to handle the complex challenges they will face in their careers. The COVID-19 pandemic accelerated the adoption of online learning and virtual environments in medical education. There have been reports of innovative programs that provided students with opportunities not only to acquire practical leadership skills from multiple mentor models across geographical boundaries, but also to contribute as members of international teams [ 7 ]. This indicates that strengthening leadership education remains a pressing priority, even as diverse educational strategies have become more accessible. Given this background, to ensure students are well-prepared for postgraduate practice, leadership in community-based medicine is a critical area that must be more robustly integrated into medical education. Existing issues While the need for leadership education in community-based medicine has been recognized, several issues exist within the current medical education curriculum. First, the specific content of leadership education is often left to the discretion of individual universities, and there are no standardized methods for its instruction [ 8 ]. Although the term “leadership” appears in Japan’s national Model Core Curriculum [ 9 ], significant variations in educational content among institutions prevent consistent outcomes. Consequently, leadership, which should be a universally required competency for medical students, is not being universally acquired. Competency-based curricula aim to set measurable learning objectives [ 10 ]; however, for a multifaceted competency such as leadership, which encompasses multiple concepts, these objectives have not yet been well-defined, thereby hindering their standardization. Second, it has been noted that even after receiving some education, residents lack experience in “leading a team,” “managing underperforming team members,” and “resolving interpersonal conflicts” [ 6 ]. Practical experience is essential for exercising leadership within a team, and current medical curricula are not considered able to provide sufficient experience-based learning. Previous educational studies have reported the utility of simulation scenarios [ 11 , 12 ] and peer-to-peer learning [ 13 ] in leadership development, emphasizing the need to incorporate practical experiences based on specific objectives. Third, students are already faced with an overcrowded curriculum, which has been identified as a barrier to learning leadership [ 14 ], posing a challenge of limited time. While a certain amount of time should be allocated for leadership development, given its experiential nature, it is desirable to establish realistic educational strategies that assess learner readiness and prioritize learning content to accommodate these time constraints. This necessitates a phased approach to curriculum development, implementation, and evaluation. Research question and study design To address these issues, we formulated the following research question: “What are the necessary competencies and educational content for leadership in community-based medicine for medical students?” Specifically, this study aimed to identify the competencies for leadership required in community-based medicine and develop a curriculum based on the competencies identified. The findings could be expected to contribute to the development of a leadership education curriculum focused on community-based medicine. Through the creation of validated competencies, this study could provide insights that would help future physicians become more effective leaders capable of responding to the increasingly diverse health needs of their communities. Methods This study adopted Kern’s six-step approach to curriculum development for a phased design and implementation process [15] (Figure 1). Step 1: Problem identification and general needs assessment To identify the competencies required for leadership in community-based medicine and perform a general needs assessment for the curriculum, we conducted a literature review of previously published articles [16–45] on PubMed. The review was conducted by two experts. One expert has over six years of experience as a community healthcare practitioner, and the other expert has over ten years of experience as a medical education specialist. Step 2: Targeted needs assessment Next, we considered a method to validate the identified competencies objectively. We employed the Delphi method [46] for the targeted needs assessment, as it allows for achieving expert consensus without the influence of anonymized individual opinions. Round 1 was conducted from September to October 2023, and Round 2 from March to April 2025. To gather opinions from active leaders in community-based medicine, we contacted 61 physicians serving as directors of medical institutions and public health centers in the remote islands and underserved rural areas of Kagoshima Prefecture (the location of our research group’s university). These physicians were invited to participate in two rounds of the Delphi survey. The response rate was 42.6% (26/61) for Round 1 and 61.5% (16/26) for Round 2 (Table 1). Responses were collected via Google Forms and handwritten sheets. Round 1 details In the first-round questionnaire, participants were asked to rate the competencies developed in Step 1 (Table 2) on a four-point Likert-type scale (Table 3) according to: (1) necessity, (2) difficulty of acquisition before graduation, and (3) timing of acquisition. To inform improvements for Round 2, we also included open-ended questions about situations where leadership was needed, what knowledge would have been beneficial, and what experiences or learning methods would facilitate acquisition, based on the participants’ experiences in community-based medicine. Finally, the participants were asked to add any other competencies they deemed necessary for leadership. Responses for each competency on the four-point Likert-type scale were scored accordingly. If multiple options were selected for items, the average of the selected values was used as the score (e.g., if 2, 3, and 4 were chosen, the score was (2 + 3 + 4) / 3 = 3). To assess the internal consistency of the responses, Cronbach’s a [47] and McDonald’s w [48] were calculated for (1) necessity, (2) difficulty of acquisition before graduation, and (3) timing, with a threshold of 0.7 set for acceptability. Furthermore, we evaluated the content validity of the response scores using Lawshe’s content validity ratio (CVR) [49]. The CVR was calculated using the following formula: CVR = ( N e − N /2) / ( N /2) where N is the number of respondents (26) and N e was determined as follows. With N = 26, the critical CVR value was set at 0.38 [50]. (1) Necessity N e = Number of respondents whose score for each item was ≥ 3 (corresponding to “Necessary” or “Very Necessary”). (2) Difficulty N e = Number of respondents whose score for each item was ≥ 3 (corresponding to “Possible” or “Easy”). (3) Timing N e = Number of respondents whose score for each item was ≤ 3 (corresponding to “By 1st year,” “By 4th year,” or “By graduation”). Round 2 details Based on the results of Round 1, the competencies were revised, and a second questionnaire was administered. Participants were asked to respond with “Agree” or “Disagree” regarding whether each item should be a competency for medical students to acquire before graduation. Similar to the first round, the responses were scored (Agree = 1, Disagree = 0), and Cronbach’s a, McDonald’s w, and the CVR ( N = 16 [total respondents], N e = number who answered “Agree,” critical CVR = 0.50 [50]) were calculated to evaluate internal consistency and content validity. All analyses were performed using Microsoft Excel for Microsoft 365 [51] and R version 4.5.1 [52]. Step 3: Goals and objectives Based on the results of the Delphi study, we initiated the development of an elective course, entitled “Community-Based Medical Leadership,” and established its learning goals and objectives. Step 4: Educational strategies We also designed educational strategies for medical students based on the established goals. Ethics approval This study was conducted in accordance with the Declaration of Helsinki. The research protocol was submitted to the Clinical Research Management Center at Kagoshima University Hospital. The committee within the Center determined that the study did not fall within the scope of the "Ethical Guidelines for Medical and Biological Research Involving Human Subjects" (Notice No. 1 of 2021 by the Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare; and Ministry of Economy, Trade and Industry, Japan). Consequently, the committee determined that ethical review was unnecessary (No. 230212). Informed consent Informed consent was obtained from all participants involved in the study. Participants received a written explanation of the study via mail and provided informed consent by explicitly selecting "Agree" on the Google Form or handwritten sheets prior to answering the survey. Results Step 1: General needs assessment Based on the literature review, 26 competencies were identified and categorized into four domains (Table 2). Step 2: Delphi study Round 1 results Regarding internal consistency, Cronbach’s a was 0.96 for (1) necessity, 0.89 for (2) difficulty, and 0.86 for (3) timing. McDonald’s w was 0.96 for (1) necessity, 0.91 for (2) difficulty, and 0.89 for (3) timing. As all values exceeded 0.7, the internal consistency was considered sufficient. Regarding the CVR (Table 4), all items in (1) necessity surpassed the critical value, indicating that all competencies were considered necessary for education. By contrast, the items in (2) difficulty and (3) timing showed varying results. Only four competencies—“A7 Communication,” “B3 Motivation,” “D1 Having an evidence base for action,” and “D4 Synthesizing opinions”—exceeded the critical CVR for both (2) and (3), and were thus identified as key elements for survey refinement (Figure 2). All other items fell below the critical CVR in either (2) or (3) and were therefore determined to require revision. Specifically, “A1 Defining one’s leadership style,” “A2 Self-management,” “A3 Critical thinking,” and “A4 Attitude of service” were eliminated as standalone items. Instead, these elements were consolidated into a comprehensive competency termed “Professionalism,” designed to be both learnable and desirable for medical students. The remaining items were synthesized, also taking into account the open-ended responses, and ultimately redesigned into 14 competencies (Table 5) to be presented in Round 2. Round 2 results Both Cronbach’s a and McDonald’s w were 0.97, indicating sufficient internal consistency. The CVR for all items (Table 6) also exceeded the critical value. Consequently, consensus was reached that the newly established 14 competencies were valid and appropriate for acquisition before graduation. Steps 3 and 4: Curriculum development Considering time constraints, we designed a half-day course and set the learning objectives as follows. To understand the nature of leadership required in community-based medicine. To be able to explain how to act as a future leader in community-based medicine, starting from before graduation. Considering that the target audience included students in the early stages of medical school, and with Miller’s pyramid [53] in mind, we designed an educational strategy (Table 7) combining a foundational lecture on leadership, an icebreaker activity (Work 1), and case-based group work. The curriculum focuses on competencies identified as easier to acquire. The content of each activity is as follows: Work 1: You have likely observed various forms of community-based medicine throughout your student life. In which situations did you encounter a leader in community-based medicine? What was that leader like? Please discuss it in your group. Work 2: Theme: “A Day in the Life of a Clinic Director.” A hypothetical scenario is presented. Assuming the role of a leader in community-based medicine, consider how to respond to a resident facing caregiving issues (Table 8). Discussion Process of leadership education development In this study, we developed a community-based medical leadership curriculum in a phased manner based on Kern’s six-step approach. This approach is widely recognized as a framework for curriculum development in medical education and offers the advantage of structurally guiding the process from needs assessment to post-implementation evaluation. A report on a clinical leadership curriculum developed for pediatric residents in the United States similarly followed a step-by-step development process. The results confirmed significant improvement in residents’ self-assessed confidence in their leadership skills after the program [54]. In our study, post-course reports also included statements about a deepened understanding of leadership. Although the target learners and leadership domains differ, these findings suggest that implementing Kern’s approach has the potential to yield positive effects on learners. For the needs assessment in Steps 1 and 2, we identified leadership competencies required in community-based medicine through a literature review and the Delphi method, confirming their validity by achieving expert consensus. Previous leadership education research has also employed the Delphi method in specialized fields such as diabetes patient management [55] and nursing [46]. For instance, in a needs assessment, a study investigating “Leadership Development for Postgraduate Internal Medicine Residents” selected panelists who had served as educational leaders in postgraduate medical education or held designated leadership credentials within a professional society [56]. This adheres to a key criterion for panelist selection in Delphi studies: “having knowledge and practical experience with the issue under investigation” [46]. While setting our panel as a homogeneous group of physicians serving as directors in the remote islands and underserved rural areas of Kagoshima Prefecture limits the generalizability of our findings, it enabled a deep and specific exploration of leadership needs within a particular health-care environment. Furthermore, the use of Cronbach’s a and McDonald’s w to assess internal consistency and the CVR to determine competency validity are established methods used in prior research. Employing these same techniques allowed us to conduct an objective and reliable needs assessment. In summary, our curriculum development process systematically and comprehensively covered the leadership competencies required for community-based medicine while considering the local context. Identified competencies In this study, 14 community-based medical leadership competencies were identified via the Delphi method. The literature on leadership education was used to create the initial items for the Round 1 survey. The high CVR for the identified competencies signifies a strong consensus among experts regarding their importance [50]. In particular, competencies related to communication, motivation, and evidence-based decision-making were deemed both feasible and desirable for introduction in pre-graduate education from Round 1, forming the core of the developed curriculum. A comparison with qualitative research on community-based medical leadership education revealed items that had already been identified as educationally important [57]. In one study, six categories and 20 subcategories were identified through semi-structured interviews. Compared with the final competencies in the present study, similar elements emerged, such as the “ability to convey one’s vision to others” and “gathering information on local social conditions, culture, and history.” However, elements such as “troubleshooting” and “opinion integration” are unique to our study. Given the homogeneous nature of our panelists, this difference may be attributed to the focus of our study on identifying competencies that are “easy for medical students to acquire before graduation.” Therefore, the identified competencies are significant in that, while building on existing knowledge, they specify more concrete and attainable leadership elements that medical students should learn before graduating. Student learning Based on reports of the effectiveness of incorporating practical experience into leadership development [11–13], we decided to include a hypothetical case based on real-world community medicine scenarios when designing the learning objectives (Step 3) and educational strategies (Step 4). A review of the literature suggested that the choice of a case-based approach was appropriate because it provided deep insights into the complex situations of actual community health-care settings, highlighted realistic leadership challenges by integrating multiple information sources and methods, and promoted dialogue, thereby facilitating practical understanding among learners [58]. Through this curriculum, students engage with a virtual case that simulates an actual community health-care setting. This experience is expected to go beyond mere knowledge acquisition, deepening their practical learning through proactive problem identification and solving, and laying the foundation for their growth as future health-care leaders. Limitations This study has some limitations. First, we conducted the Delphi survey and curriculum development within a single region (Kagoshima Prefecture). Therefore, the influence of circumstances specific to the target region on the resulting competencies and practical outcomes cannot be completely excluded, meaning that the same curriculum cannot be universally implemented in all educational settings. Additionally, as the course was conducted in a half-day format, it was difficult to assess the degree to which each individual competency was achieved. As we design longer courses spanning several days or weeks in the future, the educational strategies will need to be reconsidered. Conclusion This study identified valid community-based medical leadership competencies using the Delphi method. Through the curriculum developed based on Kern’s six-step approach, participants are expected to deepen their understanding of the role of leadership in community-based medicine and enhance their confidence in their own leadership abilities. While further time and research are needed to assess long-term impacts on community health care and changes in student behavior, the findings of the present study provide an opportunity for students to gain awareness and motivation for further learning. Future work should focus on validating educational effects with higher objectivity and universality and developing quantitative learner assessment methods. It is hoped that by applying the findings of this study to other professions and different stages of training, the number of health-care professionals who demonstrate leadership early in their careers will increase, leading to better outcomes for residents living in their respective communities. Abbreviations CanMEDS : Canadian Medical Education Directives for Specialists. CVR : Content Validity Ratio. Declarations Ethics approval This study was conducted in accordance with the Declaration of Helsinki. The research protocol was submitted to the Clinical Research Management Center at Kagoshima University Hospital. The committee within the Center determined that the study did not fall within the scope of the "Ethical Guidelines for Medical and Biological Research Involving Human Subjects" (Notice No. 1 of 2021 by the Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare; and Ministry of Economy, Trade and Industry, Japan). Consequently, the committee determined that ethical review was unnecessary (No. 230212). Informed consent Informed consent was obtained from all participants involved in the study. Participants received a written explanation of the study via mail and provided informed consent by explicitly selecting "Agree" on the Google Form or handwritten sheets prior to answering the survey. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors’ contributions KH and MA performed the data collection, analysis, literature searches, and manuscript drafting. MA, HS, KM, RI, and TO contributed to the study design, coordination, interpretation of the results, and critical review of the manuscript. 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Med Educ. 2018;52(5):480–7. doi:10.1111/medu.13469 Tables Table 1 Characteristics of Delphi survey participants Round 1 (N = 26) Facility type n (%) Hospital 18 69.2 Clinic 5 19.2 Public health center 3 11.5 Years of experience Average 31.4 Range 8–50 Specialty n (%) Internal medicine 11 42.3 Gastrointestinal surgery 6 23.1 Public health 3 11.5 General medicine 2 7.7 Pediatrics 1 3.8 Palliative care 1 3.8 Breast and thyroid surgery 1 3.8 Orthopedic surgery 1 3.8 Round 2 (N = 16) Facility type n (%) Hospital 13 81.3 Clinic 1 6.3 Public health center 2 12.5 Years of experience Average 35.2 Range 20–50 Specialty n (%) Internal medicine 6 37.5 Gastrointestinal surgery 5 31.3 Public health 2 12.5 General medicine 1 6.3 Breast and thyroid surgery 1 6.3 Orthopedic surgery 1 6.3 Note: Respondent attributes classified by facility type (hospital, clinic, public health center), years of physician experience, and specialty field. Due to rounding to the nearest tenth, the total percentage of people may not add up to 100%. Table 2 Proposed competencies for community-based medical leadership used in Round 1 Round 1 Domain Description of domain Competency Description of competency References A. Self-awareness The ability to understand one's own emotional state accurately and be fully aware of its influence on others. A1. Defining one's leadership style Can define what a leader in community-based medicine is for oneself. 16), 17), 18) A2. Self-management Can manage oneself to gain support from others as a leader in community-based medicine. 18), 19) A3. Critical thinking Can critically reflect on whether one's actions are contributing to community-based medicine. 20), 31) A4. Attitude of service Can proactively engage in activities that benefit residents' health, both within and outside of clinical practice. 21), 22), 39) A5. Knowledge acquisition Can identify and acquire the knowledge necessary for community-based medicine. 23), 24) A6. Lifelong learning Can continuously update one's knowledge while contributing to community-based medicine. 23), 24) A7. Communication Can communicate smoothly with colleagues. 11), 26), 27) A8. Interprofessional understanding Can understand the roles of other professionals involved in community-based medicine and perform one's own job accordingly. 27), 28), 29) B. Organizational management The ability to monitor and control one's own work and that of team members by checking progress and outcomes. B1. Team building Can assign roles to members and build cooperative relationships. 24), 29), 30) B2. Time management Can recognize the time required for tasks and manage schedules to prevent delays. 27), 30), 31) B3. Motivation Can act to support team members and improve team morale. 32), 33) B4. Giving feedback Can incorporate both positive and negative points regarding a member's actions for the benefit of the whole team. 24), 30), 34) B5. Adapting to change Can perceive environmental changes both inside and outside the team and respond collectively with all members. 35), 36) B6. Troubleshooting Can recognize and work toward resolving troubles both inside and outside the team. 35), 37) C. Strategic planning The ability to look to the future, envision a long-term vision, and construct a plan to achieve it. C1. Understanding the context Can understand the medical and cultural context of each specific region. 24), 31), 37) C2. Identifying issues Can identify the current issues facing community-based medicine in each specific region. 31), 37), 38) C3. Envisioning the future Can imagine the future state of medicine for each specific region. 37), 38) C4. Setting goals Can set goals to resolve the issues in community-based medicine. 30), 40) C5. Evaluating actions Can evaluate the progress toward the set goals. 30), 40), 41) C6. Proposing improvements Can propose areas for improvement to the team for better problem-solving. 33), 35), 42) D. Execution skills The ability to think with the team about how to execute a plan successfully and achieve results. D1. Having an evidence base for action Can act based on correct knowledge and evidence. 34), 43), 44) D2. Procuring resources Can gather necessary personnel and materials from the surroundings. 21), 27), 34) D3. Negotiating with others As a leader, can negotiate with others to ensure the plan's success. 27), 28) D4. Synthesizing opinions Can synthesize various opinions within the team. 28), 29) D5. Making decisions As a leader, can decide on the team's course of action. 28), 45) D6. Communicating appropriately As a leader, can use various media to communicate actions to others. 28), 45) Note: The lead author and one co-author selected candidate elements for leadership education necessary for community-based medicine, derived from the literature review, and created these 26 competencies, which were categorized into four domains for classification purposes and presented in Round 1 of the Delphi study. Table 3 Response options for Round 1 of the Delphi survey 1 2 3 4 ① Necessity Not necessary at all Somewhat unnecessary Somewhat necessary Very necessary ② Difficulty of acquisition before graduation Impossible Difficult Possible Easy ③ Timing of acquisition By the end of the 1st year By the end of the 4th year By graduation Post-graduation Note: In Round 1 of the Delphi study, responses were collected using a four-point Likert-type scale and open-ended questions. For the 26 presented competencies, participants were asked about ① necessity, ② difficulty of acquisition before graduation, and ③ timing of acquisition (within a 6-year curriculum). Table 4 Content validity ratio (CVR) results for Round 1 Round 1 ① Necessity Ne CVR ② Difficulty Ne CVR ③ Timing Ne CVR A1 26 1 * A1 12 -0.077 A1 9 -0.308 A2 25 0.9231 * A2 10 -0.231 A2 8 -0.385 A3 26 1 * A3 9 -0.308 A3 8 -0.385 A4 25 0.9231 * A4 15 0.1538 A4 12 -0.077 A5 26 1 * A5 16 0.2308 A5 16 0.2308 A6 26 1 * A6 13 0 A6 6 -0.538 A7 26 1 * A7 22 0.6923 * A7 23 0.7692 * A8 26 1 * A8 18 0.3846 * A8 14 0.0769 B1 26 1 * B1 13 0 B1 13 0 B2 26 1 * B2 16 0.2308 B2 15 0.1538 B3 26 1 * B3 21 0.6154 * B3 19 0.4615 * B4 26 1 * B4 17 0.3077 B4 17 0.3077 B5 26 1 * B5 15 0.1538 B5 16 0.2308 B6 26 1 * B6 13 0 B6 17 0.3077 C1 26 1 * C1 15 0.1538 C1 15 0.1538 C2 26 1 * C2 11 -0.154 C2 13 0 C3 25 0.9231 * C3 7 -0.462 C3 9 -0.308 C4 26 1 * C4 9 -0.308 C4 8 -0.385 C5 26 1 * C5 14 0.0769 C5 14 0.0769 C6 26 1 * C6 14 0.0769 C6 14 0.0769 D1 26 1 * D1 24 0.8462 * D1 22 0.6923 * D2 25 0.9231 * D2 9 -0.308 D2 10 -0.231 D3 26 1 * D3 15 0.1538 D3 12 -0.077 D4 26 1 * D4 20 0.5385 * D4 20 0.5385 * D5 26 1 * D5 16 0.2308 D5 12 -0.077 D6 26 1 * D6 15 0.1538 D6 13 0 Note: *Indicates items for which the CVR met or exceeded the critical value. Table 5 Revised competencies for community-based medical leadership used in Round 2 Round 2 Domain Description of domain Competency Description of competency Changes from Round 1 A' Professionalism The ability to demonstrate sensitivity to the contexts of rural medicine and cultivate an altruistic, patient-centered attitude. A1' Understanding others Can recognize diverse stakeholders in rural health care, empathize with their perspectives, and engage appropriately. A1–A4 are grouped under Professionalism. Attitudinal aspects from A7 and B3+A4→A1' Understanding others A2' Lifelong learning orientation Can remain aware that the knowledge required for rural practice constantly evolves and proactively acquire the latest information. A6→A2' Lifelong learning orientation B' Communication skills The ability to build and maintain positive relationships by considering each individual’s context and needs. B1' Application of communication skills Can apply team-based relational skills, respond effectively to challenges, and foster motivation among team members. D3+D6→B1' Application of communication skills B2' Collaboration with others Can establish collaborative systems through appropriate information sharing and trust-building. Technical aspects from A7 and B3 →B2' Collaboration with others C' Team management skills The ability to recognize the effectiveness of interprofessional collaboration and empowerment in rural teams and sustain coordination among members. C1' Interprofessional collaboration Can understand the roles and expertise of various professionals in rural settings and propose effective collaborative structures. A8→C1' Interprofessional collaboration C2' Troubleshooting Can address team-based challenges or changes and work proactively and flexibly toward solutions. Reclassified from B6' into C2' Troubleshooting C3' Consensus building Can integrate diverse opinions during decision-making and guide the team toward a unified conclusion. D4＋D5→C3' Consensus building C4' Empowerment Can provide guidance and support within the team to enhance others’ engagement and performance. B1-6, D4→C4' Empowerment D' Rural practice skills The ability to analyze issues based on the knowledge of rural health care and propose viable solutions. D1' Knowledge acquisition Can comprehend methods for acquiring essential knowledge specific to rural medicine. A5、D1→D1' Knowledge acquisition D2' Understanding social resources Can recognize the necessity of diverse resources—medical, human, economic—in rural health-care delivery. D2→D2' Understanding social resources D3' Local profile analysis & issue identification Can analyze the local characteristics of a rural area and extract key challenges for targeted interventions. C1+2→D3' Local profile analysis & issue identification D4' Strategy planning Can formulate targeted interventions designed to address and resolve identified challenges. C3+C4+C6→D4' Strategy planning D5' Presentation skills Can present the details of proposed measures in a clear, concrete, and accessible manner. D6→D5' Presentation skills D6' Strategy evaluation Can evaluate the effectiveness of implemented measures and develop evidence-based improvement strategies. C5→D6' Strategy evaluation Note: Based on the results of Round 1, we revised the framework with an emphasis on the elements judged most readily acquired by medical students before graduation. The specific modifications are detailed under “Changes from Round 1.” The framework has been restructured into 14 sub-elements organized under four major domains. Table 6 Content validity ratio (CVR) results for Round 2 Round 2 Ne CVR A1' 16 1 * A2' 16 1 * B1' 16 1 * B2' 16 1 * C1' 16 1 * C2' 16 1 * C3' 16 1 * C4' 16 1 * D1' 15 0.875 * D2' 15 0.875 * D3' 15 0.875 * D4' 14 0.75 * D5' 15 0.875 * D6' 14 0.75 * Note: Ne: Number of experts who responded “agree” to including the element. *Indicates items for which the CVR met or exceeded the critical value. Table 7 Educational strategies for curriculum implementation CanMEDs Framework Round 1 Round 2 Instructional strategy Preparation Miller’s Pyramid Assessment Estimated time Professional A1. Defining one's leadership style A' Professionalism Lecture; small-group learning Lecture slides (Comprehensive overview of leadership / Practical realities of mandatory service in remote island settings) Ice-breaking session / Group work 1 Knows Q&A during lectures; group learning outcomes Introductory lecture: 30 minutes Explanation of the exercise: 10 minutes Group work 1: 10 minutes Group work session 2: 70 minutes Debriefing and summary: 30 minutes C1. Understanding the context D3' Local profile analysis & issue identification Knows how Group learning outcomes C2. Identifying issues Communicator A7. Communication B2' Collaboration with others One-on-one instruction; small-group learning; problem-based learning (PBL); group presentations Group work 2 → Scenario development Knows how Shows how Feedback from facilitators Group learning outcomes Q&A during overall presentations A8. Interprofessional understanding C1' Interprofessional collaboration B3. Motivation B2' Collaboration with others C4' Empowerment B4. Giving feedback D2. Procuring resources D2' Understanding social resources D3. Negotiating with others B1' Application of communication skills D4. Synthesizing opinions C3' Consensus building Collaborator B1. Team building C2' Troubleshooting C4' Empowerment Small-group learning; PBL Group work 2 → Scenario development Knows how Feedback from facilitator Group learning outcomes B2. Time management B5. Adapting to change B6. Troubleshooting C6. Proposing improvements D4' Strategy planning Shows how Feedback from facilitators Q&A during overall presentation Leader A2. Self-management A' Professionalism One-on-one instruction Ice-breaking session / Group work 1 Knows how Shows how Feedback from facilitator A3. Critical thinking A4. Attitude of service C5. Evaluating actions D6' Strategy evaluation Small-group learning Group work 2 → Scenario development Feedback from facilitator Q&A during overall presentation Report evaluation D5. Making decisions C3' Consensus building Small-group learning; PBL Health advocate A4. Attitude of service A' Professionalism Small-group learning; PBL Setting of the report assignment Knows how Report evaluation A5. Knowledge acquisition D1' Knowledge acquisition Lecture Q&A during lectures D1. Having an evidence base for action Group work 2 → Scenario development Feedback from facilitators Q&A during overall presentation D6. Communicating appropriately D5' Presentation skills Scholar A6. Lifelong learning A2' Lifelong learning orientation PBL, group presentations Lecture / Setting of the report assignment Knows how Report evaluation C3. Envisioning the future D4' Strategy planning C4. Setting goals Note: Based on the results of the Delphi survey, we developed an educational strategy. For each element, we aligned it with the corresponding CanMEDS Framework roles and the competencies identified in Rounds 1 and 2. We then outlined concrete instructional approaches, including necessary preparatory steps and the corresponding level of Miller’s Pyramid. In addition, we planned and documented appropriate assessment methods and the estimated time required for implementation. Table 8 Simulated scenarios for group work 2 Part 1 A stepdaughter (Ms. A) came to the clinic looking troubled about her 101-year-old mother-in-law (Ms. X) who lives alone. Ms. A: “Doctor, my husband (Mr. B) and I had a fight about caring for Ms. X. I'm doing my best to take care of her, but my own children aren't interested. The other day, I asked my husband if it was okay to leave my mother-in-law as she is, but he just shrugged it off and said, ‘Things will work out.’ We ended up having a big fight.” →What kind of words of encouragement should we offer Ms. A? (5-10 minutes) Part 2 After talking with Ms. A for a while, I called Mr. B. Mr. B: “She doesn't seem to be in any worse condition, and my wife, Ms. A, is just making too much of a fuss. I don't really understand caregiving anyway.” “We can think about it when she can't get out of bed anymore, right?” →What kind of words of encouragement should we offer Mr. B? (5-10 minutes) Part 3 Ms. X has hypertension and insomnia and takes medication regularly. She used to manage her own medication, but since last year, she has been forgetting to take it more often. At her last outpatient visit, he said, “I'm still fine!” and was talking energetically at the clinic. A: “I haven't applied for care yet. But there are more and more things I can't do, so I can't take care of her by myself anymore.” →What should we say to A? (5-10 minutes) Part 4 There are no full-time doctors on the remote island where he lives. There is one nurse stationed there. A doctor visits twice a month to provide outpatient care. There is no ambulance, so when 119 is called, an emergency boat comes from the main island to pick up the patient at the port and transport them. It takes one hour to reach the main island. This clinic is a primary care provider. There are no hospital beds. There is only one facility in the town where hospitalization is possible. If intensive care is needed, a doctor's helicopter can be requested, arriving in 15 minutes, and a boat plus an ambulance can transport the patient to the central hospital in two hours. →Let's consider the issues Ms. X may face in the future. Part 5 The on-site nurse reported, "When I checked on her today, she looked thin and somewhat listless, and she didn't seem to remember eating. It might be better to have them examined at a facility where hospitalization is possible." Based on the information obtained at the time, it was determined that hospitalization was not urgent, but as the primary care physician, I feel that intervention for care is now necessary. After hearing both sides' opinions, I want to first mediate the argument between A and B. →I called A, B, and the on-site nurse to the clinic. How should I mediate? (10–15 minutes) Part 6 In community healthcare, it is common to see elderly people living alone, such as Ms. X, who have not applied for nursing care or whose families are in conflict over nursing care. As a doctor working in the field, I have always thought that measures are needed to reduce such nursing care-related conflicts in community care conferences. What should I do as a leader in community healthcare? Note: The scenario used in Group Work 2 is divided into six sections. Allocated discussion time for each section fosters student dialogue. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8646770","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":591628895,"identity":"ae39b1c4-3645-415f-b96c-be8f0c69ba0b","order_by":0,"name":"Koichi Hamabira","email":"","orcid":"","institution":"Kimotsuki Municipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Koichi","middleName":"","lastName":"Hamabira","suffix":""},{"id":591628896,"identity":"97c28822-39a2-4a28-bee9-96efc335ef38","order_by":1,"name":"Marie 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1","display":"","copyAsset":false,"role":"figure","size":84855,"visible":true,"origin":"","legend":"\u003cp\u003eFlow of the present study\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8646770/v1/533ccf10c50d25e363d091d2.jpg"},{"id":102862224,"identity":"66875fa1-08ec-4b04-a641-36b28315c9eb","added_by":"auto","created_at":"2026-02-17 16:16:13","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":85558,"visible":true,"origin":"","legend":"\u003cp\u003eScatterplot of content validity ratios (CVRs) for difficulty and timing in Round 1\u003c/p\u003e\n\u003cp\u003eNote: X-axis: ② Difficulty CVR, Y-axis: ③ Timing CVR\u003c/p\u003e\n\u003cp\u003eCritical CVR was set at 0.38 due to N=26.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8646770/v1/774bc4ae4863e43f31e0fb0e.jpg"},{"id":102965332,"identity":"aa560fee-82ae-4302-96ba-ba59d6925a11","added_by":"auto","created_at":"2026-02-19 04:31:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1324287,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8646770/v1/e830d26b-1dd6-4da3-b293-ab8ac87faefa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of a curriculum for community-based medical leadership education","fulltext":[{"header":"Background","content":"\u003cp\u003eIn recent years, the needs of community-based medicine have diversified. Amidst demographic shifts, a rising prevalence of chronic diseases, and limited medical resources, it has become increasingly crucial for health-care professionals to possess advanced clinical judgment and problem-solving skills. The practice of community-based medicine no longer solely involves the one-to-one relationship between a physician and a patient; it now necessitates effective collaboration with a wide range of stakeholders, including patients\u0026rsquo; families, caregivers, community support networks, volunteers, interprofessional health-care teams, and even local governments, educational institutions, and nonprofit organizations. In addition, comprehensive team-based care has been shown to improve patient outcomes and reduce health-care costs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEducational experiences designed to enhance interprofessional communication and collaboration have been reported to improve perceptions of patient care, communication skills, and teamwork. For a team to succeed, leadership is essential to guide its members [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Physicians, in particular, are expected to understand the social determinants of health within the community and contribute to not only the clinical improvement of individual patients, but also the health of the community as a whole [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, in settings with scarce medical resources, such as remote islands and underserved rural areas, a single physician often assumes multiple roles, meaning that individual leadership can directly impact the health outcomes of the local population.\u003c/p\u003e \u003cp\u003eInternational medical education frameworks also recognize leadership as a key physician competency. The CanMEDS framework in Canada identifies \u0026ldquo;Leader\u0026rdquo; as a core role, emphasizing the importance of physicians understanding their function within the health-care system and contributing to both medical practice and education [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Similarly, the UK\u0026rsquo;s Medical Leadership Competency Framework calls for all physicians to engage in leadership daily, identifying it as an indispensable capability for improving health-care quality, ensuring patient safety, and reforming the health-care system [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA recent systematic review [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] revealed that leadership training contributes to enhanced self-efficacy and problem-solving abilities among medical students. This suggests that early intervention is highly likely to translate into improved performance in future clinical practice, better preparing students to handle the complex challenges they will face in their careers.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic accelerated the adoption of online learning and virtual environments in medical education. There have been reports of innovative programs that provided students with opportunities not only to acquire practical leadership skills from multiple mentor models across geographical boundaries, but also to contribute as members of international teams [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This indicates that strengthening leadership education remains a pressing priority, even as diverse educational strategies have become more accessible.\u003c/p\u003e \u003cp\u003eGiven this background, to ensure students are well-prepared for postgraduate practice, leadership in community-based medicine is a critical area that must be more robustly integrated into medical education.\u003c/p\u003e\n\u003ch3\u003eExisting issues\u003c/h3\u003e\n\u003cp\u003eWhile the need for leadership education in community-based medicine has been recognized, several issues exist within the current medical education curriculum.\u003c/p\u003e \u003cp\u003eFirst, the specific content of leadership education is often left to the discretion of individual universities, and there are no standardized methods for its instruction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although the term \u0026ldquo;leadership\u0026rdquo; appears in Japan\u0026rsquo;s national Model Core Curriculum [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], significant variations in educational content among institutions prevent consistent outcomes. Consequently, leadership, which should be a universally required competency for medical students, is not being universally acquired. Competency-based curricula aim to set measurable learning objectives [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; however, for a multifaceted competency such as leadership, which encompasses multiple concepts, these objectives have not yet been well-defined, thereby hindering their standardization.\u003c/p\u003e \u003cp\u003eSecond, it has been noted that even after receiving some education, residents lack experience in \u0026ldquo;leading a team,\u0026rdquo; \u0026ldquo;managing underperforming team members,\u0026rdquo; and \u0026ldquo;resolving interpersonal conflicts\u0026rdquo; [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Practical experience is essential for exercising leadership within a team, and current medical curricula are not considered able to provide sufficient experience-based learning. Previous educational studies have reported the utility of simulation scenarios [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and peer-to-peer learning [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] in leadership development, emphasizing the need to incorporate practical experiences based on specific objectives.\u003c/p\u003e \u003cp\u003eThird, students are already faced with an overcrowded curriculum, which has been identified as a barrier to learning leadership [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], posing a challenge of limited time. While a certain amount of time should be allocated for leadership development, given its experiential nature, it is desirable to establish realistic educational strategies that assess learner readiness and prioritize learning content to accommodate these time constraints. This necessitates a phased approach to curriculum development, implementation, and evaluation.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch question and study design\u003c/h2\u003e \u003cp\u003eTo address these issues, we formulated the following research question: \u0026ldquo;What are the necessary competencies and educational content for leadership in community-based medicine for medical students?\u0026rdquo;\u003c/p\u003e \u003cp\u003eSpecifically, this study aimed to identify the competencies for leadership required in community-based medicine and develop a curriculum based on the competencies identified.\u003c/p\u003e \u003cp\u003eThe findings could be expected to contribute to the development of a leadership education curriculum focused on community-based medicine. Through the creation of validated competencies, this study could provide insights that would help future physicians become more effective leaders capable of responding to the increasingly diverse health needs of their communities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study adopted Kern\u0026rsquo;s six-step approach to curriculum development for a phased design and implementation process [15] (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 1: Problem identification and general needs assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo identify the competencies required for leadership in community-based medicine and perform a general needs assessment for the curriculum, we conducted a literature review of previously published articles [16\u0026ndash;45] on PubMed. The review was conducted by two experts. One expert has over six years of experience as a community healthcare practitioner, and the other expert has over ten years of experience as a medical education specialist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 2: Targeted needs assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNext, we considered a method to validate the identified competencies objectively. We employed the Delphi method [46] for the targeted needs assessment, as it allows for achieving expert consensus without the influence of anonymized individual opinions. Round 1 was conducted from September to October 2023, and Round 2 from March to April 2025.\u003c/p\u003e\n\u003cp\u003eTo gather opinions from active leaders in community-based medicine, we contacted 61 physicians serving as directors of medical institutions and public health centers in the remote islands and underserved rural areas of Kagoshima Prefecture (the location of our research group\u0026rsquo;s university). These physicians were invited to participate in two rounds of the Delphi survey. The response rate was 42.6% (26/61) for Round 1 and 61.5% (16/26) for Round 2 (Table 1). Responses were collected via Google Forms and handwritten sheets.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRound 1 details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the first-round questionnaire, participants were asked to rate the competencies developed in Step 1 (Table 2) on a four-point Likert-type scale (Table 3) according to: (1) necessity, (2) difficulty of acquisition before graduation, and (3) timing of acquisition. To inform improvements for Round 2, we also included open-ended questions about situations where leadership was needed, what knowledge would have been beneficial, and what experiences or learning methods would facilitate acquisition, based on the participants\u0026rsquo; experiences in community-based medicine. Finally, the participants were asked to add any other competencies they deemed necessary for leadership.\u003c/p\u003e\n\u003cp\u003eResponses for each competency on the four-point Likert-type scale were scored accordingly. If multiple options were selected for items, the average of the selected values was used as the score (e.g., if 2, 3, and 4 were chosen, the score was (2 + 3 + 4) / 3 = 3). To assess the internal consistency of the responses, Cronbach\u0026rsquo;s\u0026nbsp;a\u0026nbsp;[47] and McDonald\u0026rsquo;s\u0026nbsp;w\u0026nbsp;[48] were calculated for (1) necessity, (2) difficulty of acquisition before graduation, and (3) timing, with a threshold of 0.7 set for acceptability.\u003c/p\u003e\n\u003cp\u003eFurthermore, we evaluated the content validity of the response scores using Lawshe\u0026rsquo;s content validity ratio (CVR) [49]. The CVR was calculated using the following formula:\u003c/p\u003e\n\u003cp\u003eCVR = (\u003cem\u003eN\u003c/em\u003ee \u0026minus; \u003cem\u003eN\u003c/em\u003e/2) / (\u003cem\u003eN\u003c/em\u003e/2)\u003c/p\u003e\n\u003cp\u003ewhere \u003cem\u003eN\u003c/em\u003e is the number of respondents (26) and \u003cem\u003eN\u003c/em\u003ee was determined as follows. With \u003cem\u003eN\u003c/em\u003e = 26, the critical CVR value was set at 0.38 [50].\u003c/p\u003e\n\u003cp\u003e(1) Necessity\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003ee = Number of respondents whose score for each item was \u0026ge; 3 (corresponding to \u0026ldquo;Necessary\u0026rdquo; or \u0026ldquo;Very Necessary\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003e(2) Difficulty\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003ee = Number of respondents whose score for each item was \u0026ge; 3 (corresponding to \u0026ldquo;Possible\u0026rdquo; or \u0026ldquo;Easy\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003e(3) Timing\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003ee = Number of respondents whose score for each item was \u0026le; 3 (corresponding to \u0026ldquo;By 1st year,\u0026rdquo; \u0026ldquo;By 4th year,\u0026rdquo; or \u0026ldquo;By graduation\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRound 2 details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the results of Round 1, the competencies were revised, and a second questionnaire was administered. Participants were asked to respond with \u0026ldquo;Agree\u0026rdquo; or \u0026ldquo;Disagree\u0026rdquo; regarding whether each item should be a competency for medical students to acquire before graduation. Similar to the first round, the responses were scored (Agree = 1, Disagree = 0), and Cronbach\u0026rsquo;s\u0026nbsp;a, McDonald\u0026rsquo;s\u0026nbsp;w, and the CVR (\u003cem\u003eN\u003c/em\u003e = 16 [total respondents], \u003cem\u003eN\u003c/em\u003ee = number who answered \u0026ldquo;Agree,\u0026rdquo; critical CVR = 0.50 [50]) were calculated to evaluate internal consistency and content validity. All analyses were performed using Microsoft Excel for Microsoft 365 [51] and R version 4.5.1 [52].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 3: Goals and objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the results of the Delphi study, we initiated the development of an elective course, entitled \u0026ldquo;Community-Based Medical Leadership,\u0026rdquo; and established its learning goals and objectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 4: Educational strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe also designed educational strategies for medical students based on the established goals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. The research protocol was submitted to the Clinical Research Management Center at Kagoshima University Hospital. The committee within the Center determined that the study did not fall within the scope of the \u0026quot;Ethical Guidelines for Medical and Biological Research Involving Human Subjects\u0026quot; (Notice No. 1 of 2021 by the Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare; and Ministry of Economy, Trade and Industry, Japan). Consequently, the committee determined that ethical review was unnecessary (No. 230212).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants involved in the study. Participants received a written explanation of the study via mail and provided informed consent by explicitly selecting \u0026quot;Agree\u0026quot; on the Google Form or handwritten sheets prior to answering the survey.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eStep 1: General needs assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the literature review, 26 competencies were identified and categorized into four domains (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 2: Delphi study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRound 1 results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding internal consistency, Cronbach\u0026rsquo;s\u0026nbsp;a\u0026nbsp;was 0.96 for (1) necessity, 0.89 for (2) difficulty, and 0.86 for (3) timing. McDonald\u0026rsquo;s\u0026nbsp;w\u0026nbsp;was 0.96 for (1) necessity, 0.91 for (2) difficulty, and 0.89 for (3) timing. As all values exceeded 0.7, the internal consistency was considered sufficient.\u003c/p\u003e\n\u003cp\u003eRegarding the CVR (Table 4), all items in (1) necessity surpassed the critical value, indicating that all competencies were considered necessary for education. By contrast, the items in (2) difficulty and (3) timing showed varying results. Only four competencies\u0026mdash;\u0026ldquo;A7 Communication,\u0026rdquo; \u0026ldquo;B3 Motivation,\u0026rdquo; \u0026ldquo;D1 Having an evidence base for action,\u0026rdquo; and \u0026ldquo;D4 Synthesizing opinions\u0026rdquo;\u0026mdash;exceeded the critical CVR for both (2) and (3), and were thus identified as key elements for survey refinement (Figure 2). All other items fell below the critical CVR in either (2) or (3) and were therefore determined to require revision.\u003c/p\u003e\n\u003cp\u003eSpecifically, \u0026ldquo;A1 Defining one\u0026rsquo;s leadership style,\u0026rdquo; \u0026ldquo;A2 Self-management,\u0026rdquo; \u0026ldquo;A3 Critical thinking,\u0026rdquo; and \u0026ldquo;A4 Attitude of service\u0026rdquo; were eliminated as standalone items. Instead, these elements were consolidated into a comprehensive competency termed \u0026ldquo;Professionalism,\u0026rdquo; designed to be both learnable and desirable for medical students. The remaining items were synthesized, also taking into account the open-ended responses, and ultimately redesigned into 14 competencies (Table 5) to be presented in Round 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRound 2 results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth Cronbach\u0026rsquo;s a and McDonald\u0026rsquo;s w were 0.97, indicating sufficient internal consistency. The CVR for all items (Table 6) also exceeded the critical value. Consequently, consensus was reached that the newly established 14 competencies were valid and appropriate for acquisition before graduation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSteps 3 and 4: Curriculum development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsidering time constraints, we designed a half-day course and set the learning objectives as follows.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eTo understand the nature of leadership required in community-based medicine.\u003c/li\u003e\n \u003cli\u003eTo be able to explain how to act as a future leader in community-based medicine, starting from before graduation.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eConsidering that the target audience included students in the early stages of medical school, and with Miller\u0026rsquo;s pyramid [53] in mind, we designed an educational strategy (Table 7) combining a foundational lecture on leadership, an icebreaker activity (Work 1), and case-based group work. The curriculum focuses on competencies identified as easier to acquire. The content of each activity is as follows:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eWork 1:\u003c/strong\u003e You have likely observed various forms of community-based medicine throughout your student life. In which situations did you encounter a leader in community-based medicine? What was that leader like? Please discuss it in your group.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eWork 2:\u003c/strong\u003e Theme: \u0026ldquo;A Day in the Life of a Clinic Director.\u0026rdquo; A hypothetical scenario is presented. Assuming the role of a leader in community-based medicine, consider how to respond to a resident facing caregiving issues (Table 8).\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eProcess of leadership education development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, we developed a community-based medical leadership curriculum in a phased manner based on Kern’s six-step approach. This approach is widely recognized as a framework for curriculum development in medical education and offers the advantage of structurally guiding the process from needs assessment to post-implementation evaluation. A report on a clinical leadership curriculum developed for pediatric residents in the United States similarly followed a step-by-step development process. The results confirmed significant improvement in residents’ self-assessed confidence in their leadership skills after the program [54]. In our study, post-course reports also included statements about a deepened understanding of leadership. Although the target learners and leadership domains differ, these findings suggest that implementing Kern’s approach has the potential to yield positive effects on learners.\u003c/p\u003e\n\u003cp\u003eFor the needs assessment in Steps 1 and 2, we identified leadership competencies required in community-based medicine through a literature review and the Delphi method, confirming their validity by achieving expert consensus. Previous leadership education research has also employed the Delphi method in specialized fields such as diabetes patient management [55] and nursing [46]. For instance, in a needs assessment, a study investigating “Leadership Development for Postgraduate Internal Medicine Residents” selected panelists who had served as educational leaders in postgraduate medical education or held designated leadership credentials within a professional society [56]. This adheres to a key criterion for panelist selection in Delphi studies: “having knowledge and practical experience with the issue under investigation” [46]. While setting our panel as a homogeneous group of physicians serving as directors in the remote islands and underserved rural areas of Kagoshima Prefecture limits the generalizability of our findings, it enabled a deep and specific exploration of leadership needs within a particular health-care environment.\u003c/p\u003e\n\u003cp\u003eFurthermore, the use of Cronbach’s\u0026nbsp;a\u0026nbsp;and McDonald’s\u0026nbsp;w\u0026nbsp;to assess internal consistency and the CVR to determine competency validity are established methods used in prior research. Employing these same techniques allowed us to conduct an objective and reliable needs assessment. In summary, our curriculum development process systematically and comprehensively covered the leadership competencies required for community-based medicine while considering the local context.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentified competencies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, 14 community-based medical leadership competencies were identified via the Delphi method. The literature on leadership education was used to create the initial items for the Round 1 survey. The high CVR for the identified competencies signifies a strong consensus among experts regarding their importance [50]. In particular, competencies related to communication, motivation, and evidence-based decision-making were deemed both feasible and desirable for introduction in pre-graduate education from Round 1, forming the core of the developed curriculum.\u003c/p\u003e\n\u003cp\u003eA comparison with qualitative research on community-based medical leadership education revealed items that had already been identified as educationally important [57]. In one study, six categories and 20 subcategories were identified through semi-structured interviews. Compared with the final competencies in the present study, similar elements emerged, such as the “ability to convey one’s vision to others” and “gathering information on local social conditions, culture, and history.” However, elements such as “troubleshooting” and “opinion integration” are unique to our study. Given the homogeneous nature of our panelists, this difference may be attributed to the focus of our study on identifying competencies that are “easy for medical students to acquire before graduation.”\u003c/p\u003e\n\u003cp\u003eTherefore, the identified competencies are significant in that, while building on existing knowledge, they specify more concrete and attainable leadership elements that medical students should learn before graduating.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudent learning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on reports of the effectiveness of incorporating practical experience into leadership development [11–13], we decided to include a hypothetical case based on real-world community medicine scenarios when designing the learning objectives (Step 3) and educational strategies (Step 4). A review of the literature suggested that the choice of a case-based approach was appropriate because it provided deep insights into the complex situations of actual community health-care settings, highlighted realistic leadership challenges by integrating multiple information sources and methods, and promoted dialogue, thereby facilitating practical understanding among learners [58].\u003c/p\u003e\n\u003cp\u003eThrough this curriculum, students engage with a virtual case that simulates an actual community health-care setting. This experience is expected to go beyond mere knowledge acquisition, deepening their practical learning through proactive problem identification and solving, and laying the foundation for their growth as future health-care leaders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has some limitations. First, we conducted the Delphi survey and curriculum development within a single region (Kagoshima Prefecture). Therefore, the influence of circumstances specific to the target region on the resulting competencies and practical outcomes cannot be completely excluded, meaning that the same curriculum cannot be universally implemented in all educational settings. Additionally, as the course was conducted in a half-day format, it was difficult to assess the degree to which each individual competency was achieved. As we design longer courses spanning several days or weeks in the future, the educational strategies will need to be reconsidered.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identified valid community-based medical leadership competencies using the Delphi method. Through the curriculum developed based on Kern\u0026rsquo;s six-step approach, participants are expected to deepen their understanding of the role of leadership in community-based medicine and enhance their confidence in their own leadership abilities. While further time and research are needed to assess long-term impacts on community health care and changes in student behavior, the findings of the present study provide an opportunity for students to gain awareness and motivation for further learning.\u003c/p\u003e\n\u003cp\u003eFuture work should focus on validating educational effects with higher objectivity and universality and developing quantitative learner assessment methods. It is hoped that by applying the findings of this study to other professions and different stages of training, the number of health-care professionals who demonstrate leadership early in their careers will increase, leading to better outcomes for residents living in their respective communities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCanMEDS\u003c/strong\u003e: Canadian Medical Education Directives for Specialists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCVR\u003c/strong\u003e: Content Validity Ratio.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. The research protocol was submitted to the Clinical Research Management Center at Kagoshima University Hospital. The committee within the Center determined that the study did not fall within the scope of the \"Ethical Guidelines for Medical and Biological Research Involving Human Subjects\" (Notice No. 1 of 2021 by the Ministry of Education, Culture, Sports, Science and Technology; Ministry of Health, Labour and Welfare; and Ministry of Economy, Trade and Industry, Japan). Consequently, the committee determined that ethical review was unnecessary (No. 230212).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants involved in the study. Participants received a written explanation of the study via mail and provided informed consent by explicitly selecting \"Agree\" on the Google Form or handwritten sheets prior to answering the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKH and MA performed the data collection, analysis, literature searches, and manuscript drafting. MA, HS, KM, RI, and TO contributed to the study design, coordination, interpretation of the results, and critical review of the manuscript. All authors read and approved the final version of the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the staff members who performed and participated in the Delphi study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eReiss-Brennan B, Brunisholz KD, Dredge C, Briot P, Grazier K, Wilcox A, et al. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316(8):826\u0026ndash;34. doi:10.1001/jama.2016.11232\u003c/li\u003e\n\u003cli\u003eStoller JK. Developing physician-leaders: a call to action. J Gen Intern Med. 2009;24(7):876\u0026ndash;8. doi:10.1007/s11606-009-1007-8\u003c/li\u003e\n\u003cli\u003eDemir\u0026ouml;ren M, Atılgan B. 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Acad Med. 2020;95(2):293\u0026ndash;300. doi:10.1097/ACM.0000000000002900\u003c/li\u003e\n\u003cli\u003eLupi CS, Ownby AR, Jokela JA, Cutrer WB, Thompson-Busch AK, Catallozzi M, et al. Faculty development revisited: a systems-based view of stakeholder development to meet the demands of entrustable professional activity implementation. Acad Med. 2018;93(10):1472\u0026ndash;9. doi:10.1097/ACM.0000000000002297\u003c/li\u003e\n\u003cli\u003eThomas JV, Sanyal R, O\u0026apos;Malley JP, Singh SP, Morgan DE, Canon CL. A guide to writing academic portfolios for radiologists. Acad Radiol. 2016;23(12):1595\u0026ndash;1603. doi:10.1016/j.acra.2016.08.015\u003c/li\u003e\n\u003cli\u003eTsang VWL, Yu A, Haines MJ, Sagorin Z, Mitchell D, Ching G, et al. Transforming disruption into innovation: a partnership between the COVID-19 Medical Student Response Team and the University of British Columbia. 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Mahwah, NJ: Lawrence Erlbaum; 1999.\u003c/li\u003e\n\u003cli\u003eAyre C, Scally AJ. Critical values for Lawshe\u0026rsquo;s content validity ratio. Meas Eval Couns Dev. 2014;47:79\u0026ndash;86. doi:10.1177/0748175613513808\u003c/li\u003e\n\u003cli\u003eRomero-Jeldres M, D\u0026iacute;az E, Nadim T. A review of Lawshe\u0026rsquo;s method for calculating content validity in the social sciences. Front Educ. 2023;8:1271335. doi:10.3389/feduc.2023.1271335\u003c/li\u003e\n\u003cli\u003eMicrosoft Corporation. Microsoft Excel for Microsoft 365. Redmond (WA): Microsoft Corporation; 2025.\u003c/li\u003e\n\u003cli\u003eR Core Team. R: A language and environment for statistical computing. Version 4.5.1. Vienna: R Foundation for Statistical Computing; 2024. Available from: https://www.R-project.org/\u003c/li\u003e\n\u003cli\u003eMiller GE. The assessment of clinical skills/competence/performance. 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Med Educ. 2018;52(5):480\u0026ndash;7. doi:10.1111/medu.13469\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Characteristics of Delphi survey participants\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\" style=\"margin-right: calc(14%); width: 86%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59.911%;\"\u003e\n \u003cp\u003eRound 1 (N = 26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59.911%;\"\u003e\n \u003cp\u003eFacility type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e69.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Public health center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003eYears of experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e31.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e8\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59.911%;\"\u003e\n \u003cp\u003eSpecialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Internal medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e42.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Gastrointestinal surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e23.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Public health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; General medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Pediatrics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Palliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Breast and thyroid surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Orthopedic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59.911%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59.911%;\"\u003e\n \u003cp\u003eRound 2 (N = 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59.911%;\"\u003e\n \u003cp\u003eFacility type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e81.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Public health center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003eYears of experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e35.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e20\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 59.911%;\"\u003e\n \u003cp\u003eSpecialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Internal medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Gastrointestinal surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e31.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Public health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; General medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Breast and thyroid surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 59.911%;\"\u003e\n \u003cp\u003e\u0026nbsp; Orthopedic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8.2722%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 5.8908%;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 74.0741%;\"\u003e\n \u003cp\u003eNote: Respondent attributes classified by facility type (hospital, clinic, public health center), years of physician experience, and specialty field. Due to rounding to the nearest tenth, the total percentage of people may not add up to 100%.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Proposed competencies for community-based medical leadership used in Round 1\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" style=\"margin-right: calc(0%); width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRound 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDescription of domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCompetency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDescription of competency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\"\u003e\n \u003cp\u003eA. Self-awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"8\" valign=\"top\"\u003e\n \u003cp\u003eThe ability to understand one\u0026apos;s own emotional state accurately and be fully aware of its influence on others.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA1. Defining one\u0026apos;s leadership style\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan define what a leader in community-based medicine is for oneself.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e16), 17), 18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA2. Self-management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan manage oneself to gain support from others as a leader in community-based medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e18), 19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA3. Critical thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan critically reflect on whether one\u0026apos;s actions are contributing to community-based medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e20), 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA4. Attitude of service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan proactively engage in activities that benefit residents\u0026apos; health, both within and outside of clinical practice.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e21), 22), 39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA5. Knowledge acquisition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan identify and acquire the knowledge necessary for community-based medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e23), 24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA6. Lifelong learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan continuously update one\u0026apos;s knowledge while contributing to community-based medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e23), 24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA7. Communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan communicate smoothly with colleagues.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e11), 26), 27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA8. Interprofessional understanding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan understand the roles of other professionals involved in community-based medicine and perform one\u0026apos;s own job accordingly.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e27), 28), 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"84\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eB. Organizational management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eThe ability to monitor and control one\u0026apos;s own work and that of team members by checking progress and outcomes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB1. Team building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan assign roles to members and build cooperative relationships.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e24), 29), 30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB2. Time management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan recognize the time required for tasks and manage schedules to prevent delays.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e27), 30), 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB3. Motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan act to support team members and improve team morale.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e32), 33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB4. Giving feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan incorporate both positive and negative points regarding a member\u0026apos;s actions for the benefit of the whole team.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e24), 30), 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB5. Adapting to change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan perceive environmental changes both inside and outside the team and respond collectively with all members.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e35), 36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB6. Troubleshooting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan recognize and work toward resolving troubles both inside and outside the team.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e35), 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eC. Strategic planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eThe ability to look to the future, envision a long-term vision, and construct a plan to achieve it.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC1. Understanding the context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan understand the medical and cultural context of each specific region.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e24), 31), 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC2. Identifying issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan identify the current issues facing community-based medicine in each specific region.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e31), 37), 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC3. Envisioning the future\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan imagine the future state of medicine for each specific region.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e37), 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC4. Setting goals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan set goals to resolve the issues in community-based medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e30), 40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC5. Evaluating actions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan evaluate the progress toward the set goals.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e30), 40), 41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC6. Proposing improvements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan propose areas for improvement to the team for better problem-solving.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e33), 35), 42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eD. Execution skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eThe ability to think with the team about how to execute a plan successfully and achieve results.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD1. Having an evidence base for action\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan act based on correct knowledge and evidence.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e34), 43), 44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD2. Procuring resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan gather necessary personnel and materials from the surroundings.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e21), 27), 34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD3. Negotiating with others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAs a leader, can negotiate with others to ensure the plan\u0026apos;s success.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e27), 28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD4. Synthesizing opinions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCan synthesize various opinions within the team.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e28), 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD5. Making decisions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAs a leader, can decide on the team\u0026apos;s course of action.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e28), 45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD6. Communicating appropriately\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAs a leader, can use various media to communicate actions to others.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.0503%;\"\u003e\n \u003cp\u003e28), 45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 4.3166%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 95.5396%;\"\u003e\n \u003cp\u003eNote: The lead author and one co-author selected candidate elements for leadership education necessary for community-based medicine, derived from the literature review, and created these 26 competencies, which were categorized into four domains for classification purposes and presented in Round 1 of the Delphi study.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"72\" style=\"width: 4.3165%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Response options for Round 1 of the Delphi survey\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5563%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.8122%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5465%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6286%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.349%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5563%;\"\u003e\n \u003cp\u003e①\u0026nbsp;Necessity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.8122%;\"\u003e\n \u003cp\u003eNot necessary at all\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5465%;\"\u003e\n \u003cp\u003eSomewhat unnecessary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6286%;\"\u003e\n \u003cp\u003eSomewhat necessary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.349%;\"\u003e\n \u003cp\u003eVery necessary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5563%;\"\u003e\n \u003cp\u003e②\u0026nbsp;Difficulty of acquisition before graduation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.8122%;\"\u003e\n \u003cp\u003eImpossible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5465%;\"\u003e\n \u003cp\u003eDifficult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6286%;\"\u003e\n \u003cp\u003ePossible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.349%;\"\u003e\n \u003cp\u003eEasy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5563%;\"\u003e\n \u003cp\u003e③\u0026nbsp;Timing of acquisition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.8122%;\"\u003e\n \u003cp\u003eBy the end of the 1st year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5465%;\"\u003e\n \u003cp\u003eBy the end of the 4th year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.6286%;\"\u003e\n \u003cp\u003eBy graduation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.349%;\"\u003e\n \u003cp\u003ePost-graduation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 56.0859%;\"\u003e\n \u003cp\u003eNote: In Round 1 of the Delphi study, responses were collected using a four-point Likert-type scale and open-ended questions. For the 26 presented competencies, participants were asked about\u0026nbsp;①\u0026nbsp;necessity,\u0026nbsp;②\u0026nbsp;difficulty of acquisition before graduation, and\u0026nbsp;③\u0026nbsp;timing of acquisition (within a 6-year curriculum).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Content validity ratio (CVR) results for Round 1\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"617\" style=\"margin-right: calc(11%); width: 89%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eRound 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003e①\u0026nbsp;Necessity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003eNe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003eCVR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003e②\u0026nbsp;Difficulty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003eNe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003eCVR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003e③\u0026nbsp;Timing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003eNe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003eCVR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eA1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eA1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e-0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eA1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eA2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.9231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eA2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e-0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eA2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eA3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eA3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e-0.308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eA3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eA4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.9231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eA4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.1538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eA4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eA5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eA5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.2308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eA5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.2308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eA6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eA6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eA6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eA7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eA7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.6923\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eA7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.7692\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eA8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eA8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.3846\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eA8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.0769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eB1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eB1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eB1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.2308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.1538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.6154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.4615\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eB4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eB4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.3077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eB4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.3077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eB5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eB5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.1538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eB5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.2308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eB6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eB6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eB6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.3077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.1538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.1538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eC2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eC2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e-0.154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eC2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eC3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.9231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eC3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e-0.462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eC3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eC4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eC4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e-0.308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eC4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eC5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eC5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.0769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eC5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.0769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eC6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eC6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.0769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eC6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.0769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eD1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eD1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.8462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eD1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.6923\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eD2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.9231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eD2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e-0.308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eD2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.1538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eD3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eD4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eD4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.5385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eD4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0.5385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eD5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eD5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.2308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eD5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e-0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1977%;\"\u003e\n \u003cp\u003eD6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.518%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.9042%;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9402%;\"\u003e\n \u003cp\u003eD6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5.0824%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0031%;\"\u003e\n \u003cp\u003e0.1538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.759%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.7291%;\"\u003e\n \u003cp\u003eD6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.8249%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.5839%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\" style=\"width: 98.2229%;\"\u003e\n \u003cp\u003eNote: *Indicates items for which the CVR met or exceeded the critical value.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 1.4521%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e Revised competencies for community-based medical leadership used in Round 2\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"603\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eRound 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eDescription of domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCompetency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eDescription of competency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eChanges from Round 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eA\u0026apos; Professionalism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eThe ability to demonstrate sensitivity to the contexts of rural medicine and cultivate an altruistic, patient-centered attitude.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eA1\u0026apos; Understanding others\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan recognize diverse stakeholders in rural health care, empathize with their perspectives, and engage appropriately.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eA1\u0026ndash;A4 are grouped under Professionalism.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;Attitudinal aspects from A7 and B3+A4\u0026rarr;A1\u0026apos; Understanding others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"84\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eA2\u0026apos; Lifelong learning orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan remain aware that the knowledge required for rural practice constantly evolves and proactively acquire the latest information.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eA6\u0026rarr;A2\u0026apos; Lifelong learning orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"84\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eB\u0026apos; Communication skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eThe ability to build and maintain positive relationships by considering each individual\u0026rsquo;s context and needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eB1\u0026apos; Application of communication skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan apply team-based relational skills, respond effectively to challenges, and foster motivation among team members.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eD3+D6\u0026rarr;B1\u0026apos; Application of communication skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eB2\u0026apos; Collaboration with others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan establish collaborative systems through appropriate information sharing and trust-building.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eTechnical aspects from A7 and B3\u003cbr\u003e\u0026nbsp;\u0026rarr;B2\u0026apos; Collaboration with others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eC\u0026apos; Team management skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eThe ability to recognize the effectiveness of interprofessional collaboration and empowerment in rural teams and sustain coordination among members.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eC1\u0026apos; Interprofessional collaboration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan understand the roles and expertise of various professionals in rural settings and propose effective collaborative structures.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eA8\u0026rarr;C1\u0026apos; Interprofessional collaboration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"84\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eC2\u0026apos; Troubleshooting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan address team-based challenges or changes and work proactively and flexibly toward solutions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eReclassified from B6\u0026apos; into C2\u0026apos; Troubleshooting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eC3\u0026apos; Consensus building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan integrate diverse opinions during decision-making and guide the team toward a unified conclusion.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eD4＋D5\u0026rarr;C3\u0026apos; Consensus building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eC4\u0026apos; Empowerment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan provide guidance and support within the team to enhance others\u0026rsquo; engagement and performance.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eB1-6, D4\u0026rarr;C4\u0026apos; Empowerment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eD\u0026apos; Rural practice skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eThe ability to analyze issues based on the knowledge of rural health care and propose viable solutions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eD1\u0026apos; Knowledge acquisition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan comprehend methods for acquiring essential knowledge specific to rural medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eA5、D1\u0026rarr;D1\u0026apos; Knowledge acquisition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eD2\u0026apos; Understanding social resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan recognize the necessity of diverse resources\u0026mdash;medical, human, economic\u0026mdash;in rural health-care delivery.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eD2\u0026rarr;D2\u0026apos; Understanding social resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eD3\u0026apos; Local profile analysis \u0026amp; issue identification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan analyze the local characteristics of a rural area and extract key challenges for targeted interventions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eC1+2\u0026rarr;D3\u0026apos; Local profile analysis \u0026amp; issue identification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eD4\u0026apos; Strategy planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan formulate targeted interventions designed to address and resolve identified challenges.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eC3+C4+C6\u0026rarr;D4\u0026apos; Strategy planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eD5\u0026apos; Presentation skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan present the details of proposed measures in a clear, concrete, and accessible manner.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eD6\u0026rarr;D5\u0026apos; Presentation skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eD6\u0026apos; Strategy evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCan evaluate the effectiveness of implemented measures and develop evidence-based improvement strategies.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eC5\u0026rarr;D6\u0026apos; Strategy evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"53\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" rowspan=\"3\" valign=\"top\" style=\"width: 603px;\"\u003e\n \u003cp\u003eNote: Based on the results of Round 1, we revised the framework with an emphasis on the elements judged most readily acquired by medical students before graduation.\u003cbr\u003e\u0026nbsp;The specific modifications are detailed under \u0026ldquo;Changes from Round 1.\u0026rdquo; The framework has been restructured into 14 sub-elements organized under four major domains.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"72\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6\u003c/strong\u003e Content validity ratio (CVR) results for Round 2\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"159\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eRound 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eNe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003eCVR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eA1\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eA2\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eB1\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eB2\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eC1\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eC2\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eC3\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eC4\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eD1\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eD2\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eD3\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eD4\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eD5\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eD6\u0026apos;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Ne: Number of experts who responded \u0026ldquo;agree\u0026rdquo; to including the element. *Indicates items for which the CVR met or exceeded the critical value.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7\u003c/strong\u003e Educational strategies for curriculum implementation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCanMEDs Framework\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRound 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRound 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInstructional strategy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreparation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMiller\u0026rsquo;s Pyramid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAssessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEstimated time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eProfessional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA1. Defining one\u0026apos;s leadership style\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA\u0026apos; Professionalism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eLecture; small-group learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eLecture slides (Comprehensive overview of leadership / Practical realities of mandatory service in remote island settings)\u003cbr\u003e\u0026nbsp;Ice-breaking session / Group work 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKnows\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQ\u0026amp;A during lectures; group learning outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"27\" valign=\"top\"\u003e\n \u003cp\u003eIntroductory lecture: 30 minutes\u003cbr\u003e\u0026nbsp;Explanation of the exercise: 10 minutes\u003cbr\u003e\u0026nbsp;Group work 1: 10 minutes\u003cbr\u003e\u0026nbsp;Group work session 2: 70 minutes\u003cbr\u003e\u0026nbsp;Debriefing and summary: 30 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"69\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC1. Understanding the context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eD3\u0026apos; Local profile analysis \u0026amp; issue identification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eKnows how\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGroup learning outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"67\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eC2. Identifying issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"135\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eCommunicator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA7. Communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB2\u0026apos; Collaboration with others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eOne-on-one instruction; small-group learning; problem-based learning (PBL); group presentations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eGroup work 2 \u0026rarr; Scenario development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eKnows how\u003cbr\u003e\u0026nbsp;Shows how\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eFeedback from facilitators\u0026nbsp;\u003cbr\u003e\u0026nbsp;Group learning outcomes\u0026nbsp;\u003cbr\u003e\u0026nbsp;Q\u0026amp;A during overall presentations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"36\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA8. Interprofessional understanding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC1\u0026apos; Interprofessional collaboration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB3. Motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eB2\u0026apos; Collaboration with others\u003cbr\u003e\u0026nbsp;C4\u0026apos; Empowerment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"27\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eB4. Giving feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD2. Procuring resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD2\u0026apos; Understanding social resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"68\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD3. Negotiating with others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB1\u0026apos; Application of communication skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD4. Synthesizing opinions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC3\u0026apos; Consensus building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eCollaborator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB1. Team building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eC2\u0026apos; Troubleshooting\u003cbr\u003e\u0026nbsp;C4\u0026apos; Empowerment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eSmall-group learning;\u0026nbsp;\u003cbr\u003e\u0026nbsp;PBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eGroup work 2 \u0026rarr; Scenario development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eKnows how\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eFeedback from facilitator\u003cbr\u003e\u0026nbsp;Group learning outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"27\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eB2. Time management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eB5. Adapting to change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eB6. Troubleshooting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC6. Proposing improvements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD4\u0026apos; Strategy planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShows how\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFeedback from facilitators\u003cbr\u003e\u0026nbsp;Q\u0026amp;A during overall presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eLeader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA2. Self-management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eA\u0026apos; Professionalism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eOne-on-one instruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eIce-breaking session / Group work 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eKnows how\u003cbr\u003e\u0026nbsp;Shows how\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eFeedback from facilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eA3. Critical thinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eA4. Attitude of service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC5. Evaluating actions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD6\u0026apos; Strategy evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmall-group learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGroup work 2 \u0026rarr; Scenario development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFeedback from facilitator\u003cbr\u003e\u0026nbsp;Q\u0026amp;A during overall presentation\u003cbr\u003e\u0026nbsp;Report evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD5. Making decisions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC3\u0026apos; Consensus building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmall-group learning;\u0026nbsp;\u003cbr\u003e\u0026nbsp;PBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eHealth advocate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA4. Attitude of service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA\u0026apos; Professionalism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eSmall-group learning;\u0026nbsp;\u003cbr\u003e\u0026nbsp;PBL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSetting of the report assignment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eKnows how\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReport evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA5. Knowledge acquisition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eD1\u0026apos; Knowledge acquisition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLecture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQ\u0026amp;A during lectures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD1. Having an evidence base for action\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eGroup work 2 \u0026rarr; Scenario development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFeedback from facilitators\u003cbr\u003e\u0026nbsp;Q\u0026amp;A during overall presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD6. Communicating appropriately\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD5\u0026apos; Presentation skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"56\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eScholar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA6. Lifelong learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA2\u0026apos; Lifelong learning orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ePBL, group presentations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eLecture / Setting of the report assignment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eKnows how\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eReport evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC3. Envisioning the future\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eD4\u0026apos; Strategy planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003eC4. Setting goals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"28\" style=\"width: 0px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd height=\"28\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eNote: Based on the results of the Delphi survey, we developed an educational strategy. For each element, we aligned it with the corresponding CanMEDS Framework roles and the competencies identified in Rounds 1 and 2. We then outlined concrete instructional approaches, including necessary preparatory steps and the corresponding level of Miller\u0026rsquo;s Pyramid. In addition, we planned and documented appropriate assessment methods and the estimated time required for implementation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"72\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8\u003c/strong\u003e Simulated scenarios for group work 2\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003ePart 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003eA stepdaughter (Ms. A) came to the clinic looking troubled about her 101-year-old mother-in-law (Ms. X) who lives alone.\u003c/p\u003e\n \u003cp\u003eMs. A: \u0026ldquo;Doctor, my husband (Mr. B) and I had a fight about caring for Ms. X. I\u0026apos;m doing my best to take care of her, but my own children aren\u0026apos;t interested. The other day, I asked my husband if it was okay to leave my mother-in-law as she is, but he just shrugged it off and said, \u0026lsquo;Things will work out.\u0026rsquo; We ended up having a big fight.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026rarr;What kind of words of encouragement should we offer Ms. A? (5-10 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003ePart 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003eAfter talking with Ms. A for a while, I called Mr. B.\u003c/p\u003e\n \u003cp\u003eMr. B: \u0026ldquo;She doesn\u0026apos;t seem to be in any worse condition, and my wife, Ms. A, is just making too much of a fuss. I don\u0026apos;t really understand caregiving anyway.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;We can think about it when she can\u0026apos;t get out of bed anymore, right?\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026rarr;What kind of words of encouragement should we offer Mr. B? (5-10 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003ePart 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003eMs. X has hypertension and insomnia and takes medication regularly. She used to manage her own medication, but since last year, she has been forgetting to take it more often. At her last outpatient visit, he said, \u0026ldquo;I\u0026apos;m still fine!\u0026rdquo; and was talking energetically at the clinic.\u003c/p\u003e\n \u003cp\u003eA: \u0026ldquo;I haven\u0026apos;t applied for care yet. But there are more and more things I can\u0026apos;t do, so I can\u0026apos;t take care of her by myself anymore.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026rarr;What should we say to A? (5-10 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003ePart 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003eThere are no full-time doctors on the remote island where he lives. There is one nurse stationed there.\u003c/p\u003e\n \u003cp\u003eA doctor visits twice a month to provide outpatient care.\u003c/p\u003e\n \u003cp\u003eThere is no ambulance, so when 119 is called, an emergency boat comes from the main island to pick up the patient at the port and transport them. It takes one hour to reach the main island.\u003c/p\u003e\n \u003cp\u003eThis clinic is a primary care provider. There are no hospital beds. There is only one facility in the town where hospitalization is possible. If intensive care is needed, a doctor\u0026apos;s helicopter can be requested, arriving in 15 minutes, and a boat plus an ambulance can transport the patient to the central hospital in two hours. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026rarr;Let\u0026apos;s consider the issues Ms. X may face in the future.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003ePart 5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003eThe on-site nurse reported, \u0026quot;When I checked on her today, she looked thin and somewhat listless, and she didn\u0026apos;t seem to remember eating. It might be better to have them examined at a facility where hospitalization is possible.\u0026quot; Based on the information obtained at the time, it was determined that hospitalization was not urgent, but as the primary care physician, I feel that intervention for care is now necessary. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAfter hearing both sides\u0026apos; opinions, I want to first mediate the argument between A and B. \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026rarr;I called A, B, and the on-site nurse to the clinic. How should I mediate? (10\u0026ndash;15 minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003ePart 6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 697px;\"\u003e\n \u003cp\u003eIn community healthcare, it is common to see elderly people living alone, such as Ms. X, who have not applied for nursing care or whose families are in conflict over nursing care.\u003c/p\u003e\n \u003cp\u003eAs a doctor working in the field, I have always thought that measures are needed to reduce such nursing care-related conflicts in community care conferences. What should I do as a leader in community healthcare?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: The scenario used in Group Work 2 is divided into six sections. Allocated discussion time for each section fosters student dialogue.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"Community-based medical education, Leadership competencies, Curriculum development, Delphi method, Undergraduate medical students","lastPublishedDoi":"10.21203/rs.3.rs-8646770/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8646770/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeadership is increasingly essential in community-based medicine, where physicians must collaborate with various stakeholders and address complex health needs with limited resources. Despite its importance, leadership education in Japan’s undergraduate medical curricula remains inconsistently implemented, lacking standardized competencies and practical training opportunities. This study aimed to identify essential leadership competencies in community-based medicine and develop a structured educational curriculum based on those competencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe adopted Kern’s six-step approach to curriculum development. A literature review was conducted to extract preliminary competencies. A two-round Delphi study was then implemented with 61 community-based physician leaders in rural and remote areas of Kagoshima Prefecture, Japan. In Round 1, 26 competencies were evaluated on necessity, difficulty of acquisition before graduation, and timing of acquisition using a four-point Likert-type scale. Items were refined using quantitative criteria including Cronbach’s a, McDonald’s w, and the content validity ratio (CVR). In Round 2, 14 revised competencies were confirmed using dichotomous agreement and the same values. Based on the results, a short elective course was designed with lectures and case-based group work for medical students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 26 initial competencies were rated necessary, but only four met the criteria for both difficulty and timing. These, along with qualitative feedback, informed the creation of 14 revised competencies. In Round 2, internal consistency remained high (a = 0.97; w = 0.97), and all competencies surpassed the critical CVR threshold. The final curriculum emphasized attainable competencies and included practical scenarios aligned with Miller’s pyramid framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study identified and validated leadership competencies specific to community-based medicine and developed a corresponding curriculum. The phased, evidence-informed approach addressed local needs and enabled structured educational implementation. While limited to one region, this framework may inform broader efforts to integrate leadership training into undergraduate medical education.\u003c/p\u003e","manuscriptTitle":"Development of a curriculum for community-based medical leadership education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-17 16:16:09","doi":"10.21203/rs.3.rs-8646770/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-04T10:02:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T04:12:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-02T23:42:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331348272068982443632716104238103011090","date":"2026-02-12T05:28:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202570953145555737380517968046158623700","date":"2026-02-12T04:10:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-12T01:32:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-12T01:25:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-28T18:41:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-26T06:15:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-26T06:07:54+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":"947b4d26-59f8-4ad9-8a6f-cbf279284479","owner":[],"postedDate":"February 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T10:13:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-17 16:16:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8646770","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8646770","identity":"rs-8646770","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}