Physicians are increasingly asked to lead health care systems that are more complex and constrained than ever before. Clinical excellence remains essential, but it is no longer enough: the quality of care is shaped as much by the system around the bedside as by the decisions made at the bedside. Leading well requires an understanding of how the system works, including how systems function under pressure and where they break down.
This need has intensified as care has grown more complex. All physicians need a working understanding of how the care system functions in practice to provide effective care. But in this environment, physician leaders occupy a distinctive position: they combine clinical insight with day-to-day exposure to operational realities. They must pair clinical judgment with practical know-how about how care is organized, including workflows, handoffs, bottlenecks, and the organizational and policy dynamics that shape what is possible for patients and teams.
Emergency medicine makes this need visible, but the lesson is broader. Emergency departments have become the convergence point for public health and clinical care. Patients arrive not only with illness, but with the cumulative effects of housing instability, behavioral health crises, and gaps in access to primary and specialty care.
At the same time, EDs serve as the buffer for broader system failures. Research on ED crowding shows that preventable harm in time-sensitive treatment is often driven less by clinical error than by hospital-wide capacity mismatches. When patients are boarded in the ED, beds and staff are tied up, and teams deliver care in spaces not designed for inpatient management. Physician leaders must coordinate across hospital-wide constraints while providing life-saving patient care.
Meaningful innovation likewise depends on understanding how care is delivered. Breakthroughs in medical science remain essential, but many high-impact innovations in emergency medicine have come from physician leaders rethinking how care is delivered day to day. Innovations such as triage redesign, split-flow models and surge planning have reshaped ED performance. Split-flow models, in which lower-acuity patients move through parallel care pathways, are associated with improved throughput and reduced length of stay, even as volumes rise. ED-based critical care models have reported reductions in mortality and ICU admissions by delivering intensive care earlier in the patient journey. These are redesigns of care delivery rooted in clinical mastery. Innovation flourishes when physician leaders connect clinical insight to system design.
These lessons extend beyond the ED. Surgeons, cardiologists, and primary care clinicians all rely on transitions, capacity, and coordination. High-quality, patient-centered care depends on how work is designed, how information is shared, how staffing is allocated, and whether the hospital has capacity when patients need it. Physician leaders who understand these dynamics are better positioned to improve flow, redesign processes, and reduce risks before they compromise care.
A systems view is also essential to clinician well-being. When clinicians feel unable to deliver the care they know is needed, burnout and moral injury intensify. Roles that integrate clinical insight with operational influence can restore meaning and agency, but only when they are grounded in frontline realities and supported by institutions. Improving care delivery is also creative work—reimagining workflows, redesigning handoffs, and building better routines so teams can do the right thing for patients more reliably.
What follows for health systems and training programs? First, medical education must move beyond an exclusive focus on individual clinical competencies. Training should include management and policy, economics, operations, quality and safety, digital systems, and interprofessional collaboration. Second, health care organizations must support clinical and administrative roles with protected time and training. Without that support, we undermine physician effectiveness and well-being. Third, leadership development must engage community partnership: integrating social drivers of health into care models and collaborating with community organizations to address upstream causes of illness and utilization. Finally, as digital tools become more embedded in care delivery, physician leaders will need the expertise to evaluate these technologies for safety, appropriateness, and equity.
Health care’s challenges cannot be solved by clinical expertise or managerial acumen alone. They require physician leaders who understand both the science of medicine and how care is delivered in practice. Emergency medicine makes this dual requirement especially visible, but the lesson extends far beyond the ED: to lead health care well, physician leaders must learn how the system works, not just practice within it.
Authors: This work is a collaboration within Columbia University’s Department of Health Policy and Management and reflects perspectives from the Executive Healthcare Management Program. Yuna Lee, PhD, MPH, is Assistant Professor of Health Policy and Management and Faculty Director of the Executive program. Ben Rotter, MD, is the Dr. Lorna M. Breen EM Healthcare Administration Fellow in the Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons and a current Executive Masters of Health Administration student. Anupam Sharma is a Masters of Public Health student in the department.
References
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https://catalyst.nejm.org/doi/10.1056/CAT.22.0361
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