I am still proud to be a doctor. This used to be because I looked up to inspirational mentors, tutors, and role models. I still do, although my inspiration is increasingly derived from younger doctors and medical students (a cohort effect). We have a young inspirational medical student working with us currently doing research in his elective period. He is asking a sample of medical leaders in the UK how appropriately we are training the next generation of medical leaders – to address the forthcoming challenges we face (to add to the plenty we already have). This presupposes that formal training in this area actually works. I suspect it does and we should certainly support Peter Lees and colleagues in establishing the Faculty of Medical and Management. It is what every profession and professional should do – although I wince every time I use the word professional – we should be training people for competence in tasks, not for memberships of professions. What’s your definition of a professional? I think mine is probably someone who is alert to the likelihood that they will one day be rumbled. If you sympathise, you’re probably fine. If it irritates you, you may want to ask yourself why.

Back to the medical student we are hosting. We are looking forward to the results of his research. In particular, we are intrigued to learn what medical leaders should be good at – i.e. over and above the day job. One angle might be the broader or “societal” dimension of health and healthcare: the extent to which doctors speak up, take action, and take personal risks on the health issues of our time, outside the immediate realm of day to day patient care: how we address smoking, nuclear weapons, cholera, assisted dying, or climate change. The last one is especially intriguing. The Climate and Health Council is led by some inspirational and deeply committed leaders. However, when we consider the strength of the basic science on health and climate change and the compelling evidence for change, and when we brag that medicine is a science based discipline, and we talk about getting science into practice and policy, is there some sort of dissonance about how genuinely engaged the medical profession is? Of course there are some inspiring and deeply committed medical leaders, but is there much evidence for most doctors to actively consider climate change as “greatest health threat of the 21st century” – in the same way as there was for cholera, or smoking, or HIV?  If not, then let me suggest 10 reasons.

• We’re too busy, with an important day [and night] job
• We’re not interested in health (just fascinated by illness)
• We’re not interested in the future (we love blue light emergencies, we hate slow burn emergencies)
• We’re not interested in prevention (where the absence of something is the sign of success)
• We over intellectualise it – and dance on the head of a needle over the strength of selective pieces of evidence
• We’re not trained to think in systems
• We already do good things: “I save patients, you want me to save the planet too?” (moral off-set)
• Our reward mechanism of recognition, respect, and reward is not aligned with taking risks and/or advocating action for the health of all
• Most of us are heavily trained to focus on the needs of the patient now, and not the needs (or risks to) the population in future
• Denial is a great coping mechanism: doctors are great at coping

They are all understandable and perhaps there are better ones. Perhaps we should have a poll on the BMJ website. We tend to think that health professionals in general and doctors in particular have a proud heritage of standing up and making a noise. If that’s really true, why aren’t more of us doing it now?  After all, if not us, then who? And if not now, then when?  Let’s be proud to make a noise about this “greatest health threat of the 21st century.”

David Pencheon is a UK trained public health doctor and is currently director of the NHS Sustainable Development Unit (England).