There seems to be an increasing demand for clinical, and in particular medical, leadership. Lord Darzi's next stage review recommendations and the reviews of healthcare being conducted across strategic health authorities will not work without it.

In addition, there are a number of other challenges that will occupy medical leaders in the coming months and years, including the European working time directive, further reform of postgraduate medical training (always a popular topic), rationalising services and implementing the new General Medical Council requirements for revalidation.

Who then is providing medical leadership? We expect that the chief medical officer, the NHS medical director and the various Royal Colleges will. Medical and clinical directors will obviously have a key role in local implementation of reform.

The problem is that doctors may not necessarily see these people as leaders. At every junior doctors' induction day, I ask the new doctors if they know what my job as medical director involves. This is nearly always greeted by silence or a very occasional "political stooge" heckle. Either we have an unusually reticent bunch of doctors (statistically unlikely) or we are failing to teach them anything about how the NHS works and is managed. The problem starts at medical school and then persists, usually until the end of training, at which time a management course is perceived as a useful CV adjunct just before the consultant interview. So who do junior doctors turn to?

Negative attitude

Often they will look to their consultant for leadership, and here we have a problem. Clearly, not all consultants behave badly, but there is a vociferous minority whose constant (I hope unintentional) belittling of junior doctors makes an unhelpful impression.

Juniors are being told from the first moment they step on the wards that they are not as knowledgeable or experienced as previous generations. This is a pernicious version of "aren't the policemen looking young these days", and reflects more on the speaker than the recipient.

In addition, consultants often tell junior doctors that their training will be inferior and that they will not develop into consultants like them (to which my response is "thank goodness"). This arises out of a belief that "in the old days" training was better, and that a combination of Modernising Medical Careers and the European working time directive will finally put paid to any hope of decent training.

The atmosphere is not helped by the senior medical response to much reform. This is usually along the lines of "patients will suffer or die", "training will be worse", "this is a dumbing down of doctors" and so on.

Herding cats

The King's Fund and the Royal College of Physicians have recently published a document entitled Understanding Doctors: harnessing professionalism, to which I hope to return at a later date. This examines in detail the responses to a series of consultation events run across the country.

Some doctors who took part in the event felt medical leadership was conspicuous by its absence. One contributor is quoted as saying: "The profession is unleadable - like herding cats." Another said: "The GMC, BMA and royal colleges are progressing the agendas that seem most important to them but there are conflicts between them." Many felt there was too much political interference, despite the fact that all the reforms I have quoted were initiated and led by doctors.

So do we have too many leaders? Are there too few? Is the profession really unleadable? Is it true that where there are two doctors there are three opinions?

I remain optimistic that we can overcome these difficulties, but it will not be easy. One of the most telling observations was that doctors demand clinical leadership and then attack it at every opportunity.