We train physicians to practice, not to lead

Estimated reading time: 5 minutes

Welcome to AI-Rx 👋

This week is not about AI. It's about something I just published in Cureus with my co-authors, and a question the profession keeps avoiding: who is preparing physicians to lead the systems they work in?

A workforce under strain

Physicians are entering practice in an environment defined by consolidation, corporatization, and rising complexity. Independent practice keeps shrinking, and financial and administrative priorities increasingly shape clinical decisions.

The strain shows in the numbers: 39.5% of physicians meet criteria for burnout, against 24.6% of the general working population, with emotional exhaustion and depersonalization both running far higher.

These point to real questions about whether medical careers are sustainable as currently structured.

The leadership gap

Here is the mismatch. Physicians are expected to lead teams, steward resources, and sit in organizational decisions. Yet most graduate medical education offers little formal preparation for any of it.

Blumenthal and colleagues called this the "leadership gap in medicine." A systematic review by Sadowski and colleagues identified 52 leadership curricula across GME and found them feasible and well received, but often short and weakly evaluated.

Kumar and colleagues found the same: interest is growing, but training stays fragmented and optional rather than embedded in core training.

So we graduate excellent clinicians and underprepared leaders, then ask them to navigate some of the most complex organizations in the economy.

What I saw inside the C-suite

To understand that world, I stepped out of clinic during my fellowship for a hospital administration elective at a large nonprofit psychiatric health system. I spent dedicated time with the CEO, COO, CMO, CMIO, and service line leaders. Executive meetings, quality and safety committees, operational dashboards, strategic planning, EHR implementation.

Three things changed how I see clinical work.

First, there is a system behind every clinical encounter. The bed shortage, the long ED boarding, the agency that's hard to coordinate with.

As a clinician these feel like personal frustrations. Inside leadership meetings they reframe as problems of capacity, financing, staffing, and policy, most with identifiable upstream causes and real levers for change. Seeing that can ease the helplessness and moral injury that build up on the front line.

Second, the decisions that shape our work are made in rooms clinicians rarely enter.

Watching leaders balance safety, access, financial viability, and regulation demystified administration, and made obvious where clinician input is missing, like anticipating the clinical fallout of throughput decisions or designing workflows that protect the therapeutic relationship.

Third, leadership is part of professional identity, not a distant title you earn later.

That matters most in psychiatry, where we already lead multidisciplinary teams and advocate for under-resourced patients every day.

Why this matters most in psychiatry

Psychiatrists and child psychiatrists coordinate care across psychologists, social workers, educators, and community agencies. We are often the clinical anchor in fragmented systems.

We also work under hard financial constraints. Psychiatric visits are reimbursed at substantially lower rates than those in most other specialties, and fee-for-service billing disadvantages exactly the team-based models, like collaborative care, that work best for our patients.

On top of that, private equity-backed behavioral health and large-system employment have moved many psychiatrists into settings where staffing ratios and care models are set by non-clinician administrators.

Leadership training won't reverse those forces, but it changes how we engage them. When physicians are literate in finance, governance, and policy, they can advocate for patients from inside the room instead of reacting to decisions made without them.

Health systems are noticing too. Goodall found a positive association between top hospital quality rankings and having a physician CEO. The demand for physician leaders is rising. The training has not caught up.

A way forward

The answer isn't to turn every resident into an administrator. It's a tiered model: foundational exposure to leadership concepts for every trainee, deeper elective pathways like hospital administration rotations for those who want them, and these competencies embedded into milestones so they count as core skills rather than extracurriculars. Pair national standards with local, hands-on experience.

The barriers are real: dense schedules, limited protected time, a shortage of faculty with leadership training. Protected elective time, mentored projects, and partnerships with health system leaders are how programs work around them.

Here's my final thought

The professional experience of physicians is shaped not only by individual resilience, but by the systems we work in. We spend years learning to care for patients and almost no time learning how the systems around them function.

That gap is one reason so many capable physicians feel powerless against forces they never trained to understand.

We can keep producing clinicians who endure these systems. Or we can prepare physicians to shape them. I know which workforce I'd rather build.

Which one were you trained to be: a physician prepared to shape your health system, or one left to endure it?