Intended for healthcare professionals


Postgraduate leadership development: a cross specialty trainees’ perspective

BMJ 2016; 352 doi: (Published 25 January 2016) Cite this as: BMJ 2016;352:i374
  1. Alex Till, psychiatric core trainee, School of Psychiatry, Health Education North West Mersey, Liverpool,
  2. Archana Anandaram, general practice specialty trainee, Postgraduate School of General Practice, Health Education West Midlands, Birmingham,
  3. Andrew Dapaah, core surgical trainee, School of Surgery, Health Education North West (Mersey), Liverpool,
  4. Ramez Ibrahim, core anaesthetics trainee, School of Anaesthesia, Health Education North West, Manchester,
  5. Akshay Kansagra, emergency medicine specialty trainee, Postgraduate School of Anaesthesia, Critical Care and Emergency Medicine, Health Education West Midlands, Birmingham,
  6. Radhika Prasad, radiology specialty trainee, Mersey School of Radiology, Health Education North West Mersey, Liverpool,
  7. Ian Randall, psychiatric core trainee, School of Psychiatry, Health Education East Midlands (Leicester), Leicester,
  8. Clara Serrecchia, obstetrics and gynaecology specialty trainee, School of Obstetrics and Gynaecology, Health Education Thames Valley, Oxford,
  9. Philippa Thomas, paediatric specialty trainee, School of Paediatrics, Health Education Wessex, Winchester,
  10. Rachel Trickey, core medical trainee, School of Medicine, Wales Deanery, Cardiff,
  11. Judy McKimm, professor of medical education and director of Strategic Educational Development, College of Medicine, Swansea University, Swansea
  1. AlexTill54{at}


Alex Till and colleagues consider the development of leadership skills in basic specialty training

Being a good doctor means more than being a good clinician. A core quality is leadership, and this must be provided to our colleagues, organisation, and profession as a whole. Our ability to harness the leadership potential of doctors in training is concerning, and leadership is often considered an optional extra.

We have reviewed the development of leadership skills within basic specialty training (that is, core training and specialty training years 1-3), including the curriculum requirements and assessment methods used, and found that despite evidence that healthcare requires a new collective leadership style,1 “curriculum lag” at college level is hampering its development.

We looked at nine specialties covering 96% of core training year 1 and specialty training year 1 posts in the 2014 application round (anaesthetics, core medicine, emergency medicine, general practice, obstetrics and gynaecology, paediatrics and child health, psychiatry, radiology, and surgery). We examined all royal college publications produced between 2005 and 2015. Summaries of our findings are given below.

We found clear evidence that medical royal colleges are embracing leadership development. However, wide variations exist across training programmes, and systemic approaches to leadership development are not apparent within basic specialty training. Strategies range from specifically designed assessment tools, incorporation of competencies into exam structures, adaptation of pre-existing assessment tools, or no assessment process at all.

Royal colleges should develop and share innovative practice. Focused educational assessment tools, such as LEADER case based discussions developed in paediatrics, ELSEs in emergency medicine, and the NOTTS behavioural assessment tool, progress far beyond the adaptation of existing assessment tools. They make leadership a focus in itself with dedicated feedback and discussion. Alongside quality improvement, tools such as these should be integrated throughout training to show that even the most junior doctors can be exemplary leaders.23

Managing and leading within the NHS is now harder than ever, but it is a skill that can be taught and learnt.4 Leadership should not be considered an optional extra or skill distinct from day to day clinical practice; it is a core responsibility of being a good medical practitioner.5 It is no longer acceptable to assume leadership skills will be passively absorbed. Good leaders do not just emerge.

A comprehensive and systematic approach to leadership development and assessment must be formally adopted and implemented throughout every stage of postgraduate training, beginning early in doctors’ careers. Good leadership improves care, and trainees should be able to safely explore and develop their leadership skills within basic specialty training. Opportunities to identify, engage, motivate, and nurture potential leadership talent should be provided.6

Royal colleges and local organisations have an important part to play. Collectively, fresh strategies should be implemented across all postgraduate training schemes, with compulsory leadership education embedded into training. Curriculum lag is currently failing trainees, who are not developing the leadership skills required. This must be tackled by rapidly implementing the latest evidence into training programmes and clinical practice and be supported with protected time for experiential learning, formal assessment, and quality feedback opportunities.

This revised approach will be vital to ensure leadership is considered core to the skills, behaviours, and values embodied by all doctors and can mobilise a powerful and driven leadership resource that lies dormant within our NHS.


Anaesthetists often hold a unique leadership position at the head of multidisciplinary teams in acute, potentially life threatening situations. Alongside this clinical responsibility there is an expectation that at all stages a trainee must develop “an understanding of the management systems within which they work” and hold certain “professional attitudes and behaviours,” which feed into leadership skills.7 The college’s stance on leadership development is based largely on the Royal College of Physicians and Surgeons of Canada’s CanMEDs framework and the Medical Leadership Competency Framework (MLCF). The core features of these are largely considered to have been achieved if trainees engage in quality improvement, an activity that is being given increasing recognition.7 Supporting leadership development further, the college has introduced the Anaesthesia List Management Assessment Tool (ALMAT), a compulsory assessment for core trainees. The ALMAT assessment has limitations, because although it considers clinical leadership, this is not the assessment’s sole focus. As such, despite the above recognition of the importance of leadership within the specialty, there are no specific objective measures or competency level requirements, and a trainee’s leadership skills are largely assessed by the subjective reports of supervising consultants and completion of multisource feedback.7

Emergency medicine

Recognising that emergency departments “need and deserve good leadership” the Royal College of Emergency Medicine has prioritised the development of leadership skills at “every stage of a career in emergency medicine.”8 In the revised 2015 curriculum (strongly influenced by the MLCF), trainees are expected to show continuing development of leadership and management competences both clinically and within the department on the shop floor as they progress throughout their careers.9 As seen elsewhere, greater focus is given to higher trainees. For more junior doctors, expectations and assessments of leadership skills are outlined.

Leadership skills were previously assessed only in objective structured clinical examinations and workplace based assessments. They are now also assessed by a new situational judgment examination and for higher trainees, amongst others, through extended supervised learning experiences.10 These extended supervised learning experiences are a formative assessment of directly observed practice with extended narrative feedback, ratings using a validated instrument, and subsequent development plans. They are being piloted in core trainees and should be specifically extended to include leadership as is currently the case for higher trainees.9

General practice

The leadership skills required within general practice are increasing both in breadth and depth within the NHS. In recognition of this need and to ensure patients have access to highly trained general practitioners adhering to rigorous standards, leadership has been incorporated into the strategic plan of the Royal College of General Practitioners. It is one of the five key programmes of work in the strategic plan. There is a particular focus on developing the crucial leadership role of GPs and in supporting leadership and management training.11 The MLCF has been incorporated into the Royal College of General Practitioners curriculum, and shared leadership has appropriately been recognised as essential to coordinate and provide safe care. However, there is a lack of clear objective guidance on the level of leadership competency expected and how this will be assessed within the curriculum or membership exam to echo this philosophy.12 Formal enhancement and extension of training to develop leadership skills has been recommended.1314


Strongly advocating medical leadership, the Royal College of Physicians calls on doctors to commit to developing their leadership skills.15 The ethos of strong medical leadership is reflected in the core medical training curriculum produced by the Joint Royal Colleges of Physicians Training Board. The influence of the MLCF is clear. However, one could question whether a more vigorous approach is needed with respect to the assessment of leadership skills. Specific assessments through acute care assessment tools, whereby a trainee’s leadership skills are directly assessed by a senior clinician, are included. But for progression on to higher training only a level 2 (of 4) is required in each area.16 The acute care toolkit for medical registrars highlights leadership as a core responsibility.17

Obstetrics and gynaecology

The Royal College of Obstetricians and Gynaecologists aims to train doctors with leadership qualities to deliver high quality women’s healthcare. It recognises that various leadership skills and styles, including followership, are required.18 Leadership development is dealt with within the core curriculum, but it requires only basic development before progression on to higher training (specialty training year 3). It comprises mainly e-learning through e-learning for healthcare and the college’s tutorials and accompanying formal assessments.19 Leadership development opportunities are limited, but mandatory attainment of some departmental responsibility (that is, rota or teaching organisation) and attendance on a simulation course are required before starting the third year of specialty training. These simulation courses are a valuable leadership development opportunity through leading emergency scenarios and receiving behavioural feedback from both the team and trainer. Progressing the development of leadership skills further, the college has adapted and trialled the non-technical skills for surgeons tool, begun developing an integrated leadership module within the curriculum, and started collaborating with external organisations to develop bespoke leadership opportunities within their training programme.2021


The Royal College of Paediatrics and Child Health recognises that leadership entails multiple facets of clinical life and comprises a shared responsibility across the clinical team. The college acknowledges that insufficient time is dedicated towards leadership development within training and that there is a continued divide between doctors and managers within the NHS.22 Formally reflected in both the curriculum and the college’s Paediatrician’s Handbook, the MLCF is used to develop leadership as an integral part of a doctor’s training. Supporting this, the college has introduced LEADERs, a case based discussion structured specifically around the MLCF to provide a learning platform whereby trainees can demonstrate and receive feedback on their leadership skills.23 Within level 1 training (specialty training years 1-3), the expectation to complete LEADER assessments is optional and there is no formal assessment or expectation of attaining objective leadership competencies during this period.24 Outside the formal curriculum, the college promotes external leadership courses and offers a bespoke course, the Paediatric Clinical Leadership series, to promote leadership development.


With an official college committee and position statement on leadership and management in psychiatry, the development of leadership skills as a core attribute of psychiatrists is becoming increasingly important and is considered essential for high quality care.25 Reflecting this stance, the Royal College of Psychiatrists explores numerous strategies to embed leadership competencies into psychiatric practice, much of which draws on the MLCF and CanMEDs framework. Within training, expectations are held that trainees will take on appropriate leadership responsibilities for their given career grade, being assessed to varying degrees through core training. With only one case based discussion specifically dealing with leadership expected by completion of the third year of core training this is rarely considered at the annual review of competence progression.26 There is a specific leadership and management study guide for higher trainees, but a lack of focus on the development of leadership skills for core trainees.27 Among other activities which largely mesh with external organisations such as the Faculty of Medical Leadership and Management, the college has a well established and supported psychiatric trainees committee allowing elected trainees to develop leadership skills at both a local and national level.


Leadership development is viewed by the Royal College of Radiologists as paramount. It is part of three fundamental components of a learning culture and is seen as essential in providing an effective service.28 Developing this within the curriculum and in line with the MLCF, the college has incorporated the personal qualities and behaviours necessary for trainees not just to lead but also to follow. While assessing higher trainees’ assumption of a leadership role within multidisciplinary team meetings using their multidisciplinary team assessment tool, workplace based assessments are not leadership specific. Higher trainees are expected to incorporate leadership into their day to day practice, but core trainees are expected merely to hold an awareness as to the importance of medical leadership and management. The college recognises the value of quality improvement, a key mechanism for leadership development, outlining that at least one project must be completed in each training year.29 Outside the curriculum, leadership development is encouraged at a national level through the Junior Radiologists’ Forum, which holds representatives from each local education and training board and inputs directly into the royal college. Encouraging those excelling early in their career, the college recognises that leadership is skill based, rather than simply amassed over time through gains in professional knowledge or expertise.28 Opportunities for radiologists in training to develop these leadership skills are limited, and 58% of the 540 radiologists surveyed in 2012 by the royal college reported they had not had the opportunity to do so.30


Historically surgeons have focused almost exclusively on the technical skills of clinical practice. However, recognising the importance of leadership development within surgery, the Intercollegiate Surgical Curriculum Programme, which all core surgical trainees are assessed against, has been expanded to incorporate leadership via the MLCF.31 Whether or not surgeons hold formal leadership positions, there is now a strong recognition that leadership is a central aspect of quality and safety. As such, all trainees should develop their skills in this area through mastering small leadership tasks which, among other skills, should include leading the World Health Organization checklist and simulation training, for example.32 Aiding the development of leadership skills further, the Intercollegiate Surgical Curriculum Programme promotes and provides materials to help deliver training in the workplace, the most notable of which are the non-technical skills for surgeons guidelines. These guidelines provide a behavioural rating system for use in theatre assessing various competencies, including those explicitly stated relating to leadership.33 The qualities of the MLCF are gradually being disseminated into everyday clinical practice, but opportunities for leadership development are still limited and rarely targeted specifically for core trainees.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests