In this study we found that HEMS physician’s leadership skills were overall well developed, irrespective of physician characteristics. Attention for- and training of these skills, by the organization, during recruitment and after induction into the service contributed to higher levels of proficiency. Although this study was carried out amongst HEMS physicians, our findings can likely be extrapolated to a wider cohort of critical care physicians, as leadership skills are of similar importance when leading in-hospital multidisciplinary critical care teams, such as resuscitation- and trauma teams.

As this is the first study to systematically assess leadership skills in a large international cohort of HEMS physicians using a validated questionnaire, it is difficult to value absolute scores for the various subdomains as reported. Although any comparison with historical data is likely hampered by substantive differences between professions, zeitgeist and self-reporting bias, the scores found in our cohort did align with those observed in other high-performance professions such as military personnel and aircraft operators [17, 21]. HEMS physicians scored highest on the specific leadership behavior “consideration”, which is regarded as one of the principal indicators of effective leadership [3, 22]. The lowest scores were reported for the “production emphasis” and “superior orientation” subdomains. This may be explained by the specific context of HEMS operations: crews typically function as small, well-established teams that inherently maintain a collective, outcome-oriented focus. In such settings, the responsibility for initiating and maintaining this focus may fall less on the leading physician and more on cohesive team dynamics. Also, physicians in these teams are generally self-proficient on scene, prioritizing adaptive leadership and teamwork over superior orientation.

Health care organizations, and in particular HEMS services seem to be aware of the importance of leadership skills, as they often mention these skills as required- or desired attributes when they recruit [23]. In this study we found that physicians recruited into organizations where specific attention was given to leadership skills during the recruitment process on average scored higher on four specific leadership subdomains (“persuasiveness”, “reconciliation”, “tolerance of uncertainty” and “initiation of structure”). Hence, our findings indicate that services are able to evaluate leadership skills early during the recruitment process for their organizations, and are able to select the best suited candidates possessing the desired skills.

After commencing employment, training- and organization characteristics play a pivotal role in the further development of leadership skills: Specific attention to leadership skills during service induction contributed to higher scores on 6 of the 12 leadership subdomains. Organization-specific attributes such as systematic mission debriefs (previously mentioned as a means to improve patient outcomes [24]) and on-base scenario training were associated with higher leadership scores. Both processes may have a direct impact on leadership skills by reinforcing a shared mental model that emphasizes the importance of leadership as a component of effective teamwork. These results highlight the significance of training as a crucial factor for predicting and improving leadership skills and are in line with previous literature [4, 8, 12, 22, 25]. Of note, the observed positive effect of leadership skills training was independent of team composition, team size, base specialty, patient exposure or years of experience, as none of these factors were related to any of the 12 leadership subdomain scores. Thus, ongoing training in leadership skills may be beneficial, irrespective of level of experience. Interestingly, while most training characteristics were positively correlated to leadership behavior, physicians who attended formal NTS/CRM training scored lower on “tolerance of freedom”. In the context of HEMS, this may be explained by an emphasis on structured, directive leadership, adherence to protocols, and reduced individual autonomy in specific leadership-oriented NTS/CRM training. This finding aligns with previous research which suggests that high-acuity settings often require a more directive leadership style [26].

Our findings not only emphasize the importance of (facilitating) training, they also demonstrate that targeted training, tailored down to an individual level, may be possible. As the reported association between various LBDQ subdomain scores and self-reported potential areas of improvement suggests that individual HEMS physicians are aware of potential areas for improvement in their own leadership skills. Training can be directed specifically aimed at these area’s.

Despite the large, international and heterogenous study population, our study had several limitations. First, self-scoring (even when using a validated questionnaire) risks social-desirability bias. Therefore, our findings may have overestimated HEMS physician leadership skills. However, given the context of this study, where peer-rating is difficult, we believe this is largely unavoidable. Second, most associations between the various physician, service, and training characteristics and the various leadership subdomains were weak, each explaining less then 10% of observed variance. In this respect, it is worth recognizing that quantitative assessment of soft skills, like leadership, inherently involves complexities and nuances not fully captured by traditional statistical measures. Further, concerns regarding multiple hypothesis testing may arise due to the substantial number of correlation tests performed. However, this was largely unavoidable as a priori all twelve subdomains were deemed equally important. Lastly, it is difficult to state to which extent the reported variance in leadership scores as reported in relation to the variables explored translates into clinically relevant differences, especially as subdomain scores were high for the group as a whole.