Leveraging physicians and nurses who care as much about the healthcare business as they do patients.

This article first appeared in the May 2017 issue of HealthLeaders magazine.

Healthcare leadership is evolving in a way that must merge the silos of clinical care and administration, resulting in a growing minority of C-suite positions occupied by physicians and nurses. There are numerous industry drivers of the clinician leadership trend, not the least of which includes mounting industry emphasis on value and quality. And amid various financial pressures and a need for clinicians to help facilitate change, it behooves organizations to close the gap between providers of care and executive leadership.

For some institutions, clinician executives are anything but novel. The Mayo Clinic, for example, boasts a 108-year tradition of physician leadership.

“I’m pleased to see the idea expanding,” says John Noseworthy, MD, president and CEO since 2009 of the Mayo Clinic in Rochester, Minnesota. “I suspect it means that these organizations are trying to find a way to provide more focus on the patients while keeping the tension between business and patients in balance,” he adds, noting that the Mayo model is one of dyad leadership, in which virtually every physician leader is paired with a nonclinical administrative partner.

A scientist at heart, Noseworthy aims to study any topic until he can communicate easily with the “true experts” on that topic, he says. “Once I do that, look out. I’m then the biggest champion of an empowered team, and I let that team run as fast and hard as it can go. Once the Mayo staff owns a solution, we are unstoppable,” he says.

Noseworthy came into his own leadership role by way of altering his original plans to become a neuroscientist and becoming a clinician-investigator instead. “This was plan B, and it not only suited me much better than plan A, but it helped me discover my gift for leadership, which is bringing really smart people together to accomplish what one could not do alone,” he says.

Link to quality

Many hospitals, as ranked annually by U.S. News & World Report (USNWR), are led by physicians. The publication’s 2016–17 Honor Roll was no exception, with physicians at the helm of the top five–ranking hospitals in the following order: Mayo Clinic, Cleveland Clinic, Massachusetts General Hospital, Johns Hopkins Hospital, and UCLA Medical Center.

What’s more, a 2011 study in Social Science & Medicine shows that hospital quality scores—now increasingly tied to reimbursement—are approximately 25% higher in physician-run hospitals than in manager-run hospitals.

In each of three specialty cases studied (cancer, digestive disorders, and heart and heart surgery), the mean Index of Hospital Quality score of hospitals where the CEO is a physician is greater than the mean score of the hospitals where the CEO is a professional manager. For example, the mean IHQ hospital-quality score of the cancer hospitals led by physicians is 31.63, while the mean quality score of cancer hospitals led by nonphysician managers is 23.61; for cancer, the mean of IHQ scores in the sample is 28.0.

Whether physician leadership boosts hospital performance or physician leaders are drawn to high-performing hospitals seems a circular argument, but the former explanation is plausible, says Noseworthy. “It wouldn’t surprise me at all if it’s true because of the way physicians are focused on service to the patient from the beginning of medical school. That’s not to say that administrators aren’t patient-focused, but that concern for patients is often why people become physicians and nurses.”

The paper’s authors also reached ambivalent conclusions. “The findings do not prove that doctors make more effective leaders than professional managers. Potentially, they may even reveal a form of the reverse—assortative matching—in that the top hospitals may be more likely to seek out MDs as leaders and vice versa,” writes Amanda H. Goodall, PhD. “Arguably, however, the better hospitals will have a wider pool of CEO candidates from which to choose, because of the extra status and wealth that they attract. This makes the fact established in this paper an interesting one. The study results show that hospitals positioned highest in the USNWR ranking have made judgments that differ from those hospitals lower down: On average they have chosen to hire physician-leaders as CEOs.”

Caring for the business

Despite the benefits of clinician leadership long appreciated by organizations such as Mayo Clinic, most hospitals remain run by professional managers. As of 2014, just 5% of hospitals were run by physicians, according to the American College of Physician Executives.

“There’s a lag in terms of known statistics,” says Peter Angood, MD, president and CEO of the American Association of Physician Leadership (AAPL) in Tampa, Florida. “What we do know is there’s a strong desire from hospitals and health systems to have clinicians become more involved in the C-suite and as CEOs.”

Allegheny Health Network (AHN), a Pittsburgh-based integrated health system with seven hospitals and numerous outpatient sites across Erie and western Pennsylvania, is a prime example of a system making distinct changes along these lines.

In mid-2016, AHN announced a leadership overhaul in which physicians Jeffrey Cohen, MD, and Mark Rubino, MD, MMM, were promoted to president of flagship Allegheny General Hospital in Pittsburgh and president of Forbes Hospital in Monroeville, respectively.

Later that year, Louise Urban, RN, took on expanded leadership opportunities as president and CEO of both Canonsburg and Jefferson Hospitals, overseeing operations in a large geographic region south of Pittsburgh. Around the same time, Marcee Radakovich, DNP, RN, continued her rise through AHN leadership ranks to become vice president of operations.

Claire Zangerle, MSN, MBA, RN, on the other hand, joined AHN as a newcomer to become the system’s first chief nurse executive. “We are excited about the impact she is already having in developing a global strategy for nursing at AHN, focused on recruitment and retention, and redesigning our care pathways,” says Cynthia Hundorfean, MBA, AHN president and CEO.

Throughout the system, a total of 12 physicians and nurses now hold executive roles, says Hundorfean, who joined AHN in February 2016, after an extensive tenure in administration at the Cleveland Clinic.

Hundorfean’s administrative experience at the Cleveland Clinic instilled in her an appreciation for clinician leadership, and she was clear about her intentions to replicate her former employer’s traditional governance model at the outset of her new presidency.

“The whole objective was to have the voice of the clinicians within the network at the table when we were making decisions,” she says.

On an even deeper level, she sought to incite a philosophical shift among the network’s caregivers. “I really wanted the physicians to care about the health and well-being of the organization as much as they did their patients,” she says. “At the end of the day, the patient is coming to see the clinician, not the administrators. So in order to make a quick change in a health system, you need to have the physicians on board. And when I arrived at [AHN] a year ago, I found that there weren’t enough clinicians with seats at the table.”

Executive ambitions

Meanwhile, executive recruiters report increased demand for (and upon) clinical leaders throughout the industry.

“There are so many organizations looking for these people,” says Linda Komnick, a senior partner and co-practice leader with executive search firm Witt/Kieffer’s Physician Integration and Leadership practice. “We used to have between eight and 10 candidates for these types of positions. Now I’d say we have three to five, and they’re each looking at several opportunities,” she says.

There are a number of reasons why the candidate pool is small, Komnick adds. “The demand for physician leaders has grown as organizations are looking for individuals to oversee initiatives aimed at clinical integration, population health, and alignment and engagement of both employed and independent physicians,” she says. “In the pipeline there is a dearth of physician leaders who have the tools to take on these roles. We’re starting to see that change as younger physicians become interested in administrative roles early in their careers, but it will take years to bridge the chasm between the number of physician leaders required and those prepared to take on these roles.”

What’s more, the job descriptions have become more rigorous, says Christine Mackey-Ross, RN, a senior partner and co-practice leader at Witt/Kieffer. “Clinicians are in the thick of strategic decisions. They’re expected to not only bring a clinical voice to deciding what’s best for patients and practitioners, but they are expected to have the same business acumen as any other member of the leadership team.”

Clinician interest in pursuing an administrative track, rather than being thrust into it, is also becoming more common, Komnick says.

For Susan Distefano, RN, MSN, CEO of Children’s Memorial Hermann Hospital in Houston since 2011, executive ambitions were born out of her desire to answer what she calls ‘“somewhat naïve’” clinical questions.

“One of my guiding principles has always been to push myself to the next level of knowledge in anything I’m doing,” she says. So as a nurse, she became motivated to better understand the processes, costs, complexities, regulations, and innovations behind various approaches to care. “Once I answered the clinical and physiologic-based questions, there was always another level to dive into while working in a large infrastructure in a large system.”

In her current role, Distefano’s oversight focuses around the 310-staffed-bed tertiary and quaternary women’s and children’s facility, part of the 14-hospital Memorial Hermann health system serving Houston and the Southeast Texas community.

Her past experience at the bedside influences her leadership on a daily basis, she says. “It allows me to discern and identify which programs to really invest in and get excited about,” Distefano says.

A recent investment that made the cut, for example, was the hire of a surgeon with special expertise in reducing spasticity in children. Historically, children stricken by this condition, sometimes from birth, receive physical therapy, occupational therapy, and eventual surgery upon reaching school age, which yields only slight functional improvements, she explains.

“This surgeon trained under an expert where they take kids into surgery around two years of age, and the children are walking quite a bit and hitting some of their milestones almost effortlessly when compared to the late-surgery group,” she says. “Because I’m a clinician and I’ve seen that first group of patients and families struggle with incremental improvement, it was an easy investment in that physician.”

Thinking strictly as a businessperson, however, Distefano suspects she may not have recognized how substantially a single surgery could change lives or help her hospital make an imprint on the health of children in the community.

In the long run, the decision had two primary drivers of cost savings: A new neurosurgery intermediate care unit with specialized nurses allows many patients to receive the same level of neurosurgical care at a fraction of the cost of an ICU stay, she notes. In addition, Children’s Memorial Hermann Hospital has created a one-stop-shop called the Texas Comprehensive Spasticity Center, where patients can see their entire care team in a coordinated visit, streamlining the process for managing a child’s movement disorder while reducing the cost of care. Since it opened in 2014, the clinic has seen more than 200 patients and counting. Calculating those precise cost savings is difficult, though.

“While it’s impossible to precisely quantify the impact this decision has made on overall healthcare costs and utilizations for pediatric patients diagnosed with spasticity, the outcomes have been remarkable on improving our patients’ mobility,” Distefano says. “Some who once required a wheelchair for any mobility have not only been able to take their first steps, they are able to run around like any other child. This kind of functional independence saves tens of thousands of dollars a year in durable equipment like canes, crutches, and wheelchairs, and hundreds of thousands of dollars over a patient’s lifetime in numerous follow-up surgeries and procedures.”

A clinical background can also make one a savvier negotiator with payers, says Frank J. Cracolici, RN, MHA, president and CEO since April 2016 of St. Vincent Medical Center, part of Verity Health System in Los Angeles.

“The reimbursement structure in California is particularly complex and heavily managed care. And when you’re talking about risk, you’re talking about how best to move patients through the system in a high-quality, cost-effective manner,” he says. “Having that clinical background—knowing what types of treatments and procedures, and understanding membership demographics, comorbid conditions, and the overall complexity of patient care needs is essential in strategic negotiations. Gaining a better understanding of what one can expect during the course of an acute hospitalization really prepares a leader for having a more thorough discussion not only with physicians but with payers.”

For these reasons and more, Hundorfean, a nonclinician running a healthcare system, sits firmly in the camp favorable to clinician leaders. “If you get clinicians involved in decision-making, you’ll make better decisions, you’ll invest money in the right places, you’ll make better use of your clinicians’ time, and it will be a better experience for your patients,” she says.

Select for success

Nonetheless, neither administrative ambition nor clinical excellence alone make for a successful clinician leader.

“Sometimes, unfortunately, it’s a bit of trial and error,” says Hundorfean. “But you have to be very good at selecting leaders who you think have the personalities, as well as the qualifications, to be able to lead efforts that are beyond their basic skill set.” Tasks such as making budget cuts, for example, can be difficult for physicians unaccustomed to making those type of decisions, she says.

AHN’s newly created leadership development program can offer individuals a chance to experience the realities of administrative roles in advance. “Our program seeks to provide clinicians with the opportunity to be an executive apprentice of sorts to make sure the role matches their expectations and capabilities.”

There is an art and science to selecting for success. “Every doctor is intelligent,” says Lynn Massingale, MD, cofounder and chairman of Knoxville-based TeamHealth, which offers outsourced clinical care across a variety of specialties to approximately 3,400 acute and postacute facilities and physician groups nationwide. “At the same time, they don’t all have the right personalities or interpersonal skills for leadership.”

At TeamHealth, clinicians identified for leadership positions undergo evaluations—such as DiSC profiling, a personality and behavior assessment tool—that help illuminate traits of one’s personality style.

“We actually use some tools for testing prospective physician and business leaders, but we look for high emotional IQ, empathy, ability to build consensus, etc., as starting points,” says Massingale. “Then we take those prospective physician leaders and help them understand what their strengths and weaknesses are, show them the areas they need to work on to be better leaders, and over a number of courses, augment their skills in conflict resolution and communication, to fill in the gaps.”

In other words, a candidate’s tendency toward analysis or emotion, for example, isn’t nearly as linked to success as his or her willingness to be self-aware, reflective, and coachable.

“To be a strong physician leader, you need to be a good physician. I also look for people with warmth and energy,” adds Hundorfean. “But most of all, I look for leaders who are direct. I like people who say what they mean, and don’t waste time. When you’re dealing with patients, physicians have to be direct with them, and I want our physician leaders to do the same when they are talking to me, or to employees.”

Engagement and alignment

With the right pieces in place, clinician leaders appear to be a tremendous organizational asset. “We are extremely pleased with the leadership team we have assembled at Allegheny Health,” says Hundorfean.

For instance, AHN’s new clinical access medical director, Elie Aoun, MD, has in a short time helped redesign the system’s call center infrastructure and processes to make same-day appointments a reality for primary care and specialty care, Hundorfean says. “It’s a huge lift for our organization from a technological and operational standpoint and in terms of

collaborating with our many clinicians to make it possible.”

Since activating same-day appointments for specialty care in January 2017, AHN has seen a great response from patients, she says, adding that thousands of patients have called and scheduled same-day appointments.

“The provider perspective plays a vital role because Dr. Aoun, as a physician, understands the operational hurdles that specialty clinicians and practices might have in adopting a new scheduling system. Different clinical areas might have different issues, but Dr. Aoun took time to synthesize those unique issues, and he knows how important workflow, scheduling, and capacity are to an individual practice—perhaps more so than a leader who had never worked in a clinical setting,” Hundorfean notes. “Having him act as a liaison between our administrative leadership and our doctors was key to getting our caregivers on board, and instrumental in getting same-day appointments up and running as quickly as we did.”

Meanwhile, one of Rubino’s personal goals in leading Forbes Hospital is to drive patient-centered care at an organizational level, through robust engagement of physicians, nurses, and support staff.

“If we’re going to move the organization forward, it comes down to the engagement of frontline staff,” Rubino says. “It can get a little overwhelming in regard to the amount of tasks that are necessary to perform this job, but I get very uncomfortable if part of my day isn’t spent walking those floors, interacting with the nurses, doctors, and other caregivers. I learn more from that than I do almost anything else.”

Making himself visible and accessible also helps foster a culture of mutual respect, Rubino notes, which he views as essential to engagement—and engagement as critical to managing change.

“As a physician leader, I am in the best possible position to understand the issues or challenges the clinical staff may face when trying to deal with the problems at hand,” he says. “Speaking directly with the staff or witnessing the issue firsthand with my senior team provides the information to best determine a root cause and problem solve. This behavior, based on mutual respect, has a direct impact on our culture and generates engagement.”

The advantages of advanced degrees

However, physicians and nurses traditionally do not receive business or management skills as part of their training. While offerings for master’s degrees in health administration (MHA), medical management (MMM), and business administration (MBA) have become more abundant and are sometimes combined with clinical programs, formal advanced business education isn’t necessarily essential.

The most important qualification, according to executive recruiters and current physician leaders, is experience related to the role for which an individual is applying. “Having an MBA will not get you the job, but it may tip the scales one way or the other,” says Mackey-Ross.

“If I were advising a young aspiring physician executive, I would say absolutely get an MBA, MMM, or MHA,” she adds. “You’ve got a career limit without it, especially if you aspire to being a system CEO.”

Advanced degrees and certifications can also influence physician leader compensation, which rose to a median of $350,000 in 2016, according to a survey published by Cejka Executive Search and the AAPL. As compared to physician leaders with no postgraduate degrees, an MBA earned respondents, on average, 13% more, and a certified physician executive (CPE), a credential offered by the AAPL, on average, earned 4% more, researchers found.

For Vivian Lee, MD, PhD, MBA, CEO of University of Utah Health in Salt Lake City and Dean of the University of Utah since 2011, going to business school in 2005 proved pivotal to her leadership success.

“For me, the MBA was an incredible opportunity to get that training after I had already been doing some administrative work and had increasing responsibility,” she says. “It was just so rewarding to be able to spend time with not only business school faculty but also my classmates who came from many other industries.”

Studying principles of the banking industry, for example, particularly about avoiding long queues, helped Lee get one of the system’s chronically behind-schedule clinics back on track.

For example, in the design of a branch bank, the modeling that simulates numbers of customers and their service needs can be used to design the bank—number of tellers, number of parking spaces, and the like, she explains. Similar software tools are useful in healthcare to model outpatient clinics, she says. 

“Additionally, we learned lessons from industry by taking groups of staff to stores like Apple and In-N-Out Burger to study customer satisfaction and customer-centered retail business,” Lee says. Those visits informed the organization’s “exceptional patient experience” initiatives, she adds. 

“Many other industries have tackled the problems we’re facing in healthcare,” she notes. In addition to insights gained for managing day-to-day operations, Lee says her MBA courses better prepared her for implementing Lean management, understanding financial incentives, and more.

Likewise, Rubino and Cracolici express similar appreciation for their business coursework.

“Looking back to being offered the CEO position, the foremost thing I wanted was to make sure I had the competence to fulfill those responsibilities, and I think the combination of experience with medical staff leadership, getting my master’s [in medical management], and serving as CMO gave me the confidence and skills to assume those responsibilities,” Rubino says.

Cracolici also took on increasingly challenging administrative roles after beginning his career as a critical care nurse, and received his MHA while working as a chief nursing officer for a small community hospital. He then went on to hold titles including vice president of nursing and chief operating officer at various organizations before becoming CEO of St. Vincent Medical Center, home to 366 licensed beds and several specialty clinics.

The business skills he had to learn along the way largely surrounded healthcare economics and the nuances of running a hospital, he says. “A lot of our education was centered around how to understand the mechanics of the financial and operational issues, in addition to leadership skills.”

Cracolici is also a Johnson & Johnson Fellow at the Wharton School of Business. “The one-month immersion fellowship training was invaluable in further developing my understanding of complex organizational dynamics and the strengthening of problem-resolution skills.”

A 2016 survey by AONE also found that nurse leaders as a whole (not limited to the C-suite) who hold master’s degrees have higher earning potential. According to the survey, half of responding nurse leaders’ salaries fall between $90,000 and $149,999, while 61% of nurse leaders who have a master’s degree earn between $100,000 and $179,999 per year.

Still, it’s possible for clinician leaders to learn business skills on the job, as did Massingale and Noseworthy.

“I really wish I’d gotten an MBA early,” says Massingale. “I never did, but [TeamHealth] would have been farther down the road sooner if I did. Just learning business vernacular, understanding income statements, and having formal business skills earlier, versus learning by reading and on-the-job training, would have facilitated our growth,” he says.

Noseworthy agrees that advanced degrees can be helpful but are not a must for clinician leaders, especially with a dyad model. Mayo, like a growing number of other large organizations, provides in-house leadership curriculum.

“We have a very rich toolbox of leadership development, for physicians and administrators, from onboarding, self-assessment, mentoring, to tailored programs, such as a Leadership Challenge for administrators, a six-month action-learning program attended in collaboration with the physician/scientist partner, Noseworthy says. “It is designed to strengthen leadership skills and deliver a project. Administrators can also attend a multi-rater assessment that provides feedback to you as a leader. It is aligned with the Mayo Leadership Capabilities Model.”

A program tailored to physicians and scientists becoming chairs of departments is Mayo’s Physician Leadership Business Academy, a key development experience at Mayo Clinic, designed to elevate physician leaders’ business, finance, and strategic acumen, strengthening the important and unique physician leader and administrator dyad. “The attendees can expect a powerful cohort and action learning-based program, in which department/division chairs and high potential leaders will be able to apply content learned in real-time Mayo Clinic business challenges, Noseworthy says.

Drawing from her similar experience at the Cleveland Clinic, one of Hundorfean’s first goals upon joining AHN was to launch a leadership development program of their own. Its purpose is twofold, she explains. While institutional leaders identify top clinical talent to participate in the program and create a pipeline of future leaders, it also gives prospective leaders a chance to determine whether they’d enjoy an administrative role.

“We are still building the leadership development program, but conceptually it will have a number of programs targeting different physicians based on experience levels,” she says. “Our physician leadership academy programs will pair classroom learning with exposure to various roles and experiences within the healthcare setting.”

The power of pairs

A less-universally adopted element of the Mayo leadership model, despite Noseworthy’s routine advice to industry colleagues, is the concept of paired leadership.

The keys to a successful dyad partnership are trust, respect, and complementary skill sets, he says. When these elements are present, physicians and administrators can share open and honest feedback with one another, which Noseworthy considers essential.

And Noseworthy has no lack of praise for his own administrative partner, Jeff Bolton, Mayo’s vice president of administration and chief administrative officer. “He comes from a background as a CFO, and prior to that he was in the social sciences. So he has a very deep understanding of humanity,” Noseworthy says. “He’s a caring, concerned humanist and a fabulous partner.”

As part of their working relationship, Noseworthy and Bolton spend half of every workday together, speak daily, and run meetings together. “But we do see things differently,” he notes. “A business-minded administrator is going to see a problem with a slightly different lens than a physician scientist.”

Those complementary points of view are part of what make the dyad work, Noseworthy says. And should the partners reach an impasse, the culture of Mayo is one of consensus building. “That doesn’t mean decisions are unanimous, but we do err on the side of getting more input rather than less,” he says, referring to the committee structure of the organization.

“I’m very fortunate that I have a really good partner to help me,” Noseworthy says, “especially when I don’t know what to do or I have a bad idea.”

In a way, Hundorfean’s appointment of clinician leaders at AHN hospitals achieves a similar objective. “When I joined the organization, I recognized early on that to be a truly clinician-led, patient-centered health system, we needed more clinically trained executive leaders in place across the network to help guide our strategy and mission. As a healthcare executive, I have found that having the insights of experienced clinicians in the C-suite is essential to ensuring that decisions are always made with the best interests of the patient in mind.”

For example, Aoun was appointed to his new position in June 2016, and AHN got same-day appointments fully up and running in six months. Same-day appointments for PCPs were in place by October, and the specialty side was ready to go by January.

“It took a big team rowing in the same direction to accomplish that—but certainly, his leadership was one of the reasons we were able to move as quickly as we did. It’s an incredible accomplishment for that team, and for Dr. Aoun,” Hundorfean says.

“We’re also moving faster in the area of patient experience,” she adds. “With Dr. Patrick DeMeo leading that process, leadership has greater credibility among the physicians to make the changes we need to make. It’s easier for doctors to talk to other doctors.”

‘Barriers and baggage’

But while some administrative and physician partners can be seen finishing each other’s sentences, not all organizations that try the dyad model experience the same level of success, says Angood.

He says that the best partners actively work to complement each other’s capabilities. “When they work nicely as a team, that tends to permeate down into the rest of the leadership and certainly down into the management,” Angood says.

The dyads that are less effective are characterized by partners who take more of a divide-and-conquer approach, he says. “Sometimes the nonphysician executive will say, ‘I know the administrative side and how to run an enterprise, so I’ll do that,’ and the physician half of the dyad will say, ‘I’m the expert in patient care, so I’ll look after that.’ That’s not an integrated dyad, and some organizations are falling into that trap.”

Individual clinicians can also be plagued by a host of “barriers and baggage” that can thwart their effectiveness, according to Massingale, whose company oversees more than 19,000 physicians. Qualities that can create challenges include resistance to change and a preference for autonomy over teamwork.

“Doctors are also used to being pretty autocratic,” he adds. “We write an order, and we expect someone to take that order off the chart and do it, whereas there’s a lot more consensus building in leadership roles.”

In addition, a widespread dilemma physician and nurse leaders face is forgoing some degree of one-on-one patient care to make time for administrative activities.

The right bedside-to-boardroom ratio varies by organizational policy and clinician preferences. Clinical leaders at AHN, for example, are almost all required to maintain some clinical practice, Hundorfean says.

Rubino says he has gradually reduced his clinical load over the years as his career encompassed greater and greater administrative responsibilities. As president of AHN’s  315-staffed-bed Forbes Hospital, he spends about 20% of his time seeing established patients of his 30-year-old OB-GYN practice and 80% on administrative responsibilities.

“I feel my level of clinical activity allows me to continue performing at the highest level. I impose a high standard on myself and would cease to operate or maintain clinical responsibilities if I or others witness anything less,” he says.

Moreover, the close relationship Rubino shares with his patients makes them comfortable sharing both good feedback and bad, he says. “They do not hesitate to tell me about their experiences at the hospital or their interactions with our caregivers.”

In addition, “I still operate, which I think gives me a certain level of credibility among my fellow caregivers because whatever clinical issues they’re facing, I’m facing as well,” Rubino says.

The Mayo Clinic espouses a similar philosophy, Noseworthy notes, which helps ensure clinical leaders are “walking the walk.”

Some leaders, on the other hand, eventually arrive at a difficult crossroads where they must choose one path, says Cracolici. “A very wise mentor of mine once warned, ‘You’re going to reach a point where you can’t work as a staff nurse on weekends and then work all week as an executive. To avoid burning out, you’re going to have to decide which one you’re going to give 150%.’ It was a challenging decision I think a lot of individuals face.”

Distefano no longer works as a nurse while serving as a hospital CEO, but has made peace with the transition. “You kind of move from being a steward or focusing on one patient or a small group of patients to affecting a larger group,” she says. “It’s admittedly a different approach. I’m not physically laying hands on patients, but I feel like I’m still improving patient care because I’m working on policy and decisions that have a broader impact. I still feel like I’m close to the patients.”

Handling discontent

A problem that could occur as clinicians’ ranks grow on executive teams is resistance from other members of the C-suite, including the CEO, says Angood. “There might be a sense of distrust, jealousy, or loss of territory and influence,” he says. “That needs to be addressed up front and people need to be aware of it. It’s all about interpersonal relationships.”

When it comes to wider industry opinion regarding clinicians in the C-suite, Massingale has encountered examples of both extremes, from traditional leaders who don’t trust a physician’s ability to read a P&L statement to physicians and nurses who believe nonclinicians aren’t equipped to make decisions affecting patient care.

Looking at executive turnover as evidence isn’t necessarily fair, he notes, considering that the average tenure for any hospital CEO is about three and a half years. “If a physician happened to get a CEO job and is out in 3 or 4 years, as far as I’m concerned, that’s just one more average statistic and not an indictment against the clinician leader.”

For the record, Massingale holds the moderate opinion that either a “lay” leader or clinician can run a healthcare organization successfully, provided he or she has the right preparation and mindset.

Rubino, for instance, acknowledges that the 24/7 demands of running a hospital were a lot to take on at this stage in his life and career. “I’m 30 years in. I’m a grandfather,” he says. “My wife looked at me and said, ‘Really? At this point you want this additional level of responsibility?’ But I see it as an honor and privilege that I’ve been given the opportunity as a physician to serve in one of the highest levels of the organization and to have my concerns, thoughts, and values appreciated when we’re in this transformation. It meant so much to me to have that opportunity, which is why I embraced it.”