A new European survey of psychiatric trainees, published in March, lands a finding that should not surprise anyone and yet keeps surprising the system: 63% had no leadership training in their programme, every single respondent said there should be, and those who did receive some were, on average, dissatisfied with it.

The diagnosis is correct. The treatment being prescribed worries but does not surprise me.

Look at how the survey — and the institutions responding to the same gap — define “leadership.” It is a list of competencies to be acquired: communication, teamwork, public speaking, professionalism, networking, media interaction. The EPA’s new Leadership Academy, launched last year and a genuinely welcome initiative, describes its aims in almost identical terms: enhancing communication skills, team management, presentation and public speaking technique. Even the UEMS mandate, which I’m glad exists, asks trainees to “acquire and continuously maintain” leadership skills.

Acquire and maintain. Those are horizontal verbs. They describe the addition of capabilities to a person whose way of making sense of the world is treated as fixed.

But notice what the survey authors keep tripping over without the language to name it. They report that the transition from trainee to consultant — the increase in responsibility, and crucially the increase in “awareness about limitations” — changes which skills people value, and they cite this as a driver of leadership development. That is not skill acquisition. That is a shift in how a person constructs meaning, authority and their own role. In the language of adult constructive-developmental theory, and what we recognise in Harthill as movement between Action Logics — the kind of vertical growth that no competency checklist can deliver, because the checklist assumes the meaning-maker stays the same while only the toolkit grows.

This matters beyond psychiatry. The paper itself notes that the COVID pandemic was what “firmly established” leadership as central to medical identity. Yet what that period actually exposed in healthcare leaders was rarely a deficit of communication technique. It was the struggle to hold complexity, ambiguity and competing legitimate demands without collapsing into false certainty or paralysis. That is a capacity of mind, not a line on a syllabus. You can be an extraordinarily skilled communicator and still be overwhelmed by a problem that exceeds your current way of organising reality.

So here is the risk. Europe has correctly diagnosed that medical leadership training is absent. The instinct now is to fill the vacuum quickly, and the fastest thing to reach for is a competency framework — definable, teachable, assessable. We will end up training the what of leadership while leaving untouched the who that determines whether any of it transfers under pressure.

None of this is an argument against the EPA Academy or against teaching skills. Skills matter. The point is sequencing and depth: horizontal capability sits on a vertical foundation, and a leader’s stage of development shapes whether they can even use the skills we give them. The same conflict-resolution training lands entirely differently on an Expert-stage clinician defending technical correctness and an Achiever-stage one balancing outcomes across a team — and differently again on someone beginning to question the systems they operate inside.

The opportunity for the medical leadership community is to build the vertical dimension in from the start, rather than discovering in ten years that the competency programmes plateaued. The evidence is already pointing there. The survey’s own most-favoured modality — a blend of theory and lived practice, reflected on over time — is exactly the experiential, inquiry-based structure that supports developmental growth, and exactly what most current provision lacks.

Diagnose the gap as horizontal, and you fill it horizontally. Recognise that what complexity demands is bigger minds, not just fuller toolkits, and you build something that lasts.

Santos et al., “Leadership skills training needs of early career doctors: a European survey,” Academia Mental Health and Well-Being, 2026.