Few Primary Care Physicians Lead Hospitals, Despite Their Immense Value: Systems Change and Delivery System Evolution Can Reverse This Trend

• Chief Executive Officer
• Culture Change
• Leadership
• Primary Care Physician
• Systems Change

In a revealing policy brief, Dr. Sullivan and her colleagues find that astonishingly few of America’s top hospitals are led by primary care physicians (PCPs).¹ This is concerning, given that primary care training and perspectives render these doctors able to adapt to and fulfill many roles, including as chief executive officers (CEOs) of health care organizations. During residency training, PCPs learn many skills that would serve them well in executive leadership positions, including the ability to

• build and work in interdisciplinary teams to collaboratively care for patients and solve problems;

• interpret, synthesize, and apply data from multiple sources to think strategically, homing in on the key question(s) that need to be asked and answered;

• communicate complex information to a wide variety of audiences;

• engage in continuous clinical learning, quality improvement efforts, and practice transformation initiatives;

• leverage longitudinal relationships and knowledge of health care delivery, including across different disciplines, care settings, regulatory environments, and resource levels, to navigate systems, advocate for patients, and effect systems change;

• partner with patients and families to make decisions that are aligned with their goals, values, and needs, mitigating conflict when necessary; and

• be comfortable with ambiguity when the path forward is not immediately clear.

Emerging evidence reveals that hospitals led by physician CEOs realize higher quality scores, greater patent safety, and increased patient satisfaction.² Physicians inherently understand the “core business” of patient care and, as a result, can bridge medicine and administration, understand the nuances of health care delivery from the clinic to the community, and motivate their peers as respected colleagues and leaders.³ They are frequently regarded as champions for their patients, relaying their stories to highlight needs and opportunities for change. Dr. Acey Albert articulates this well:

Physicians need a seat at the leadership table because they are uniquely qualified to keep the care in healthcare. Physicians are the ultimate advocates for patients, particularly in organizations and systems in which patients don’t have a formal voice. That’s hard to come by in a typical healthcare organization’s executive suite. Health system CFOs don’t see patients sacrifice heat in the winter because their bill for an admission went to collections. The medical group COO doesn’t see a patient show up to a clinic in florid heart failure because it took two weeks to get an appointment. The resource utilization director of a pharmacy benefit management company doesn’t see a diabetic patient lose a foot to infection because they couldn’t afford their insulin. Those experiences happen only where doctor and patient meet.⁴

Given the holistic, broad-based skill set PCPs offer spanning multiple settings and services, one could imagine their substantial impact on improving access and quality and lowering costs. More research is needed, however, to better understand PCPs’ unique contributions as CEOs of large health care organizations. As Dr. Sullivan and her team illustrate, with so few PCP leaders at the helm of hospitals, patients, families, and communities, as well as specialty colleagues, service line units, and board members are not realizing the benefits and perspectives of these types of leaders.

Why are so few PCPs leading larger hospitals and health systems? The underlying issue is multi-factorial. The COVID-19 pandemic rapidly accelerated a pre-existing trend of health system consolidation and acquisition of formerly independent PCP practices, leaving PCPs marginalized in the transition and increasingly employed.⁵ Front line PCPs are presently overburdened with clinical responsibilities, care coordination, and paperwork, with little bandwidth to dedicate to leadership roles.⁶ And in our predominantly fee-for-service system, specialists performing procedures are valued highly from a financial standpoint, resulting in greater visibility and likely more leadership opportunities as a result. Of note, and outside the scope of Dr. Sullivan’s study, small to midsize hospitals and health systems—especially those in rural and frontier areas—may be more likely to have PCPs in top posts.

To increase PCPs in top leadership roles, there are several strategies we can pursue, including

• introducing systems leadership and administration as meaningful career pathways as early as possible in undergraduate medical training;

• enhancing existing or creating new leadership development programs within residency and fellowship training that address strategic planning and communication; crisis management and conflict resolution; emotional intelligence and relationship building; and negotiation, decision-making, and critical thinking, among other skills⁷;

• providing mid-career transition assistance for PCPs interested in CEO positions, including peer support and skills-building courses, e.g., learning how health care is organized, financed, and delivered; how to partner with governance; and how to build teams and delegate to effectively implement strategies and goals⁸;

• establishing a formal PCP-to-CEO pipeline within large hospitals and health systems, including mentorship and experiential learning;

• examining current recruiting and hiring practices, identifying any process barriers or biases that may hinder PCPs from being considered for these roles;

• commending hospitals and health systems where PCPs serve as CEOs as exemplars among their peers; and

• promoting a change in culture around the idea that PCPs are highly qualified to serve as CEOs of large hospitals and health systems.

We are witnessing several simultaneous changes in our health care system that need and will benefit from physician leadership, including continued evolution from a volume- to a value-based system; greater emphasis on prevention, wellness, and population health; and in-person and virtual care delivery redesign in a number of settings.⁹ As our health system continues to evolve, more CEO opportunities may begin to emerge for PCPs.¹⁰ Stepping into leadership roles may give physicians a greater sense of autonomy, improve career satisfaction, and mitigate burnout. It will become increasingly valuable to have executives leading change who are skilled in team-based care, managing complexity of clinical care and care processes, and advocating for patients and families over time and across settings and circumstances. These skills, among others, are inherent in PCPs. Now, more than ever, visibility matters: both in elevating this issue—and potential solutions—and expanding our mindset of who is qualified to serve.