Primary Care Physician Leadership in Top Ranked US Hospitals

• Hospitals
• Leadership
• Physicians
• Primary Health Care

Estimates about physician leadership suggest that 5% of hospital CEOs are physicians,¹ though they are disproportionally found to run some of the best performing hospitals in the US² Primary care practice consolidation accelerated throughout the COVID-19 pandemic, despite the potential adverse implications of this trend.³ Primary care physician (PCP) leadership in large systems is critical to counter potential negative impacts on access, quality, and costs emerging from consolidation. PCP leadership is associated with having a generalist, holistic perspective of the health system, yet they make up a small proportion of all hospital CEOs.^4⇓–6 Our objective was to characterize hospital leadership by PCP versus other specialties across the US top ranked hospitals.

We identified top ranked hospitals from 4 popular lists: Becker 100 Great Hospitals in America 2020, LeapFrog 2021 Top Hospitals, Lown Index Honor Roll 2021, and US News and World Reports (USNWR) 2021 Best Hospitals Honor Roll. Each list was built using a different methodology, although quality of care was a driving metric for all.⁷ We collected CEO biographical information provided by each hospital between March 20-May 9, 2022, including gender, education, and training in a primary care specialty (defined as internal medicine, family medicine, geriatrics, pediatrics, med/peds, or preventive care). Leadership across the 4 lists was compared using frequency data and cross tabulations.

The USNWR list had the highest proportion of total physicians (65.0%) (Table 1, Figure 1). The Becker list had the highest proportion of PCPs (6.9%), which is significantly lower than the proportion of PCPs in the total physician workforce (30%).⁸ When examining physician leaders (bottom Table 1), internal medicine was the primary care specialty with the most PCP leaders across all 4 lists. Medical subspecialists made up the highest proportion of physicians on the Becker (23.7%) and USNWR (38.5%) lists; surgical subspecialists made up the highest proportion on the Leapfrog list (18.2%). The proportion of medical and surgical subspecialists in leadership roles alone far exceeded the proportion of primary care specialties in all cases. The extreme rarity of women physician CEOs is noteworthy.

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Figure 1.

Overall proportion of leadership representation on top hospital lists. Abbreviations: PCP, Primary care physician; USNWR, US news and world reports.

This study was limited to hospitals on 4 rankings lists; midsize or smaller hospitals may have more representation of PCPs. However, although evidence indicates the broad benefits of clinician leadership,^1,2,9 there are fewer physicians in CEO roles in top ranking entities than nonphysicians, and total PCP representation remains low in leading hospitals across all lists. This has critical implications for primary care’s role in the US health system as most consolidated health systems are led by specialty trained MD-CEOs or non-MD CEOs. Integrating leadership development throughout the medical training process, and intentionally promoting a PCP leadership pipeline⁴ could ensure that the US health system reaps the benefits of primary care leadership.

• Received for publication October 30, 2022.
• Revision received December 16, 2022.
• Accepted for publication December 21, 2022.