O leader, where art thou?

What’s the role of a medical leader? What’s needed to head a college, medical association, or health service? Is it about supporting colleagues who experience unprecedented levels of abuse and violence from frustrated patients?1 Is it about charting a clear path to revive training affected by the pandemic, as Clara Munro and colleagues argue?2 Is it about tackling institutional discrimination, as the Royal College of Surgeons must now do,3 or protecting staff wellbeing,4 or solving access problems in primary care?56

Many good doctors aspire to being medical leaders7 but never quite reach the top. Some bad ones do. Reaching the pinnacle isn’t necessarily about your abilities. You arrive at the top, whatever your merits, only by playing a shrewd game of medical politics. But when you get there, in touching distance of awards and honours, and with the power to act, what path do you choose?

Covid-19 thrust medical leadership into the brightest light. Medicine is the new rock’n’roll, as one award winning magazine editor recently told me. Both public and profession grappled with the little known—from assessing personal covid-19 risk to managing acute respiratory failure, on both of which we offer updates.89 Whether it is the disputed value of prophylactic hydroxychloroquine or the controversial merits of delaying a second vaccine dose,1011 medical leadership was rarely more in demand.

But politically inconvenient voices are often sidelined, such as public health leaders who call for clarity in plans for public health,12 or concerns that some people drop their guard too quickly after a first vaccine dose,1314 or demands to regulate the freedom with personal data that the pandemic unleashed.15

Questioning official policy is dismissed as disloyal rhetoric on the part of the high priestesses and priests of hindsight. As self serving as Dominic Cummings might be,1617 enough people predicted the extent of the danger of covid-19 at the outset, a cost that the Health Foundation now estimates at 1.5 million years of life lost in the UK.18

Where were medical leaders in these debates, in the UK and worldwide? Yes, many did wonderful work reorganising services, maintaining staff morale, and arguing for personal protective equipment. But where were they in the public debate? When the crisis was on us, too many kept their heads down, avoiding confrontation.19 Leadership for too many amounted to not rocking the boat publicly. Perhaps they were rolling with the punches in private, winning arguments, saving thousands of lives?

But the fact that we don’t know what many stood for is indictment enough. Where was the public challenge to authority, where the open debate for services and patients, disadvantaged populations and minorities? Where are the commissions and inquiries into the pandemic response? How will history judge medical leaders of countries worst hit by the pandemic? When they were expected to lead, did too many fall back on medical politics and the prospect of future gongs? Staying in the room where it happens comes at a price, and that price is your perceived integrity.