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To the Editor:
We read with interest the article “Resident Leadership Roles and Selection” by Herzog and Holder (1), which brings attention to the diversity and ambiguity of resident leadership roles in family medicine programs, and the absence of standardized selection processes. As family medicine researchers in Spain, we believe the issues discussed are highly relevant beyond the US context. This humble contribution seeks to expand on several of the key points raised in the article; particularly the unclear definition of leadership roles, the lack of formal training in leadership during residency, disparities in selection, and the opportunity to develop transparent, and evidence-informed selection frameworks; by reflecting on their applicability in the Spanish primary care training landscape and by referencing existing literature.
In Spain, the structure of family medicine residency differs in significant ways from that of the US. While residents in Spain often take on informal leadership roles (such as coordinating rotations, organizing academic sessions, or acting as interlocutors between residents and supervising staff) there is no official or widespread system of resident leadership positions akin to the "chief resident" structure. The roles tend to emerge ad hoc, usually without formal recognition, defined responsibilities, or institutional support. Usually the more experienced older students help and supervise the younger ones. This informal nature may inhibit leadership development and limit the potential contributions of residents to the educational and organizational functioning of training units.
The absence of explicit leadership training within Spanish family medicine curricula is also noteworthy. While the National Specialty Training Program outlines general competencies in communication, teamwork, and professionalism (2), leadership is not systematically addressed as a learning objective. The limited availability of formal leadership training programs during residency is not unique to Spain (3). A scoping review by Godard and Ratnapalan (4) analyzed leadership training in family medicine residencies internationally and found that while some programs offer structured leadership development, these are often short-term and not universally implemented. The study emphasized the need for comprehensive, longitudinal leadership training integrated throughout residency to better prepare physicians for future leadership roles. This gap contrasts with calls in the international literature to integrate leadership development early in medical careers (5,6). Without intentional training and opportunities to apply these skills in structured roles, residents may complete their training with limited preparation for the managerial and coordination responsibilities expected in primary care practice.
The issue of equity in the selection of resident leaders, which Herzog and Holder rightly highlight, also warrants reflection in the Spanish context. While there is limited research on gender and racial disparities in resident leadership in Spain specifically, broader studies on gender equity in Spanish medicine show persistent inequalities. For example, Santucci et al. (7) found that women physicians were underrepresented in managerial and leadership positions despite being the majority among medical graduates. Although Spain’s residency programs are formally gender-neutral, cultural and institutional biases may still influence which residents are perceived as "natural" leaders and offered informal leadership opportunities. Moreover, Spain's increasing ethnic diversity calls for further investigation into whether residents of minority backgrounds face barriers to professional development and recognition.
In light of these considerations, the idea proposed in the article to develop clear, transparent, and equitable processes for selecting resident leaders, is both timely and transferable. Even if the roles are adapted to local needs and structures, such processes can help make leadership opportunities more inclusive and visible. A model similar to the four-step approach described in the pediatric residency program cited by the authors, including nomination, structured interviews, and holistic review, could be piloted in Spanish teaching units, ideally accompanied by formal role descriptions and mentoring support. Transparency in selection not only fosters trust among residents but also allows training units to align leadership responsibilities with educational goals.
Additionally, involving residents themselves in the co-design of these roles and processes could increase relevance and acceptability. Participatory approaches to curriculum and role development have been shown to enhance engagement and effectiveness in medical education (8). In our view, co-creating leadership pathways with residents could be a way to ground such initiatives in the lived realities of training in Spanish primary care centers, which often operate with limited resources but strong community ties.
We agree with Herzog and Holder that more empirical work is needed to understand and guide how resident leadership is developed and recognized. In the Spanish context, a starting point could be a national survey of teaching units to document existing practices, perceived needs, and barriers to formalizing leadership opportunities for residents. This would lay the groundwork for evidence-informed policy recommendations and potential integration into future revisions of the specialty training program.
In conclusion, we thank the authors for addressing a topic that has practical implications across diverse healthcare systems. We believe the core message of their article, that resident leadership roles should be clearly defined, equitably assigned, and adequately supported, is as relevant to Spain as it is to the United States. Adapting these insights to local contexts offers an opportunity to strengthen the educational experience of residents and enhance the functioning of primary care teams.
REFERENCES:
1. Herzog A, Holder S. Resident Leadership Roles and Selection. Ann Fam Med. 2025 Mar 1;23(2):177–177.
2. Ministerio de la Presidencia, Justicia y Relaciones con las Cortes. Orden PJC/798/2024, de 26 de julio, por la que se aprueba y publica el programa formativo de la especialidad de Medicina Familiar y Comunitaria, los criterios de evaluación de los especialistas en formación y los requisitos de acreditación de las Unidades Docentes Multiprofesionales de Atención Familiar y Comunitaria [Internet]. Sect. 3, Orden PJC/798/2024 Jul 30, 2024 p. 97152–210. Available from: https://www.boe.es/eli/es/o/2024/07/26/pjc798
3. Vu JV, Harbaugh CM, Dimick JB. The Need for Leadership Training in Surgical Residency. JAMA Surg. 2019 Jul 1;154(7):575–6.
4. Godard S, Ratnapalan S. Leadership training in family medicine residency: a scoping review. BMJ Lead [Internet]. 2020 Dec 1 [cited 2025 Apr 2];4(4). Available from: https://bmjleader.bmj.com/content/4/4/239
5. Frank JR, Snell L, Sherbino J, Boucher A. CanMEDS 2015. Physician Competency Framew Ser I. 2015;
6. Blumenthal DM, Bernard K, Bohnen J, Bohmer R. Addressing the leadership gap in medicine: residents’ need for systematic leadership development training. Acad Med. 2012;87(4):513–22.
7. Santucci C, López-Valcarcel BG, Avendaño-Solá C, Bautista MC, Pino CG, García LL, et al. Gender inequity in the medical profession: the women doctors in Spain (WOMEDS) study. Hum Resour Health. 2023 Sep 20;21(1):77.
8. Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. John Wiley & Sons; 2010. 320 p.