February Faculty Article

Leadership Is No Longer Optional: Reframing the Surgeon’s Professional Obligation

Written By: 

Jason W. Smith, MD, PhD, MBA, FACS
Chief Executive Officer and Executive Vice President
UofL Health The Hiram C. Polk Jr., Department of Surgery University of Louisville

The contemporary healthcare landscape is unforgiving toward organizations that lack strong, adaptable leadership. The convergence of financial volatility, labor shortages, demographic change, and rising public expectations has exposed the limitations of conventional governance paradigms. Academic health systems now operate at the intersection of clinical intricacy, educational obligation, and research advancement, all while navigating increasingly constrained financial margins. In this environment, leadership is not an administrative indulgence; it is a critical imperative.

Surgeons occupy a unique and often underleveraged position within this leadership landscape, particularly at the level of enterprise decision-making. Their representation remains limited across senior executive roles, system-level operational leadership, and board governance, even though these forums increasingly shape clinical strategy, capital allocation, workforce policy, and quality infrastructure. Surgical training emphasizes accountability, decisiveness, situational awareness, and team coordination under pressure. These competencies are not incidental; they are forged through years of practice in environments where uncertainty is the norm and consequences are immediate. Yet, despite this alignment, surgeons remain underrepresented in the very leadership spaces where clinical insight is most needed.

This gap is not due to a lack of capability or ambition. Rather, it reflects a systemic failure to prepare surgeons for leadership beyond the operating room. Surgical education has historically—and appropriately—prioritized technical excellence and clinical judgment. What it has consistently failed to do is treat leadership as a professional competency requiring the same rigor, intentionality, and assessment as operative skill. As a result, leadership development is often left to chance, mentorship variability, or post hoc executive training rather than being integrated into the core professional identity of the surgeon.

The result is a predictable mismatch. Surgeons are frequently elevated into leadership roles based on clinical reputation or seniority and then expected to “learn leadership on the job.” While some succeed, many struggle—not because they lack aptitude, but because the role demands skills they were never trained to develop. Finance, strategy, workforce management, and organizational change are treated as ancillary rather than essential domains of surgical professionalism. This approach is no longer tenable. As healthcare systems grow more complex and interdependent, leadership competency can no longer be assumed to emerge organically from clinical excellence alone.

At the enterprise level, the consequences of this gap are not theoretical. Decisions regarding capital deployment, service-line growth, workforce stabilization, and academic investment increasingly occur in environments where clinical nuance matters. In my experience, these discussions rarely present clean choices. Determining whether limited capital should support trauma capacity expansion, workforce retention, deferred infrastructure replacement, or academic investment is not a purely financial exercise. Each option carries downstream implications for patient access, training pipelines, and community trust. Leaders who understand care delivery at the bedside are often best positioned to frame these tradeoffs honestly, even when the answers are imperfect or incomplete.

Recognizing this reality necessitates a clearer articulation of the competencies required for contemporary healthcare leadership. Effective leaders must be comfortable navigating ambiguity, accepting measured risk, and aligning diverse stakeholders around shared objectives. Surgeons possess many of the foundational skills for this work, provided their clinical instincts are intentionally recalibrated for enterprise environments. The ethical obligation to minimize harm—central to surgical practice—must be balanced against the necessity of innovation and transformation. Strategic leadership often requires acting with incomplete information and accepting short-term disruption in service of long-term sustainability. This shift is not intuitive, and it is not automatic.

Equally important is the transition from hierarchical authority to distributed leadership. Surgical culture has long relied on explicit hierarchies—an approach that serves patients well in acute, time-sensitive settings but can inhibit collaboration, innovation, and shared ownership within complex healthcare organizations. Effective surgeon leaders must learn to distinguish when command-and-control leadership is essential and when empowerment and collective problem-solving are more appropriate. Organizational success increasingly depends on shared intelligence rather than individual expertise, and leadership effectiveness is defined by the ability to cultivate that intelligence at scale. This is a learned skill, and it takes practice.

Any serious discussion of surgeon leadership must also acknowledge the practical barriers that complicate leadership development. Time constraints within clinical practice, compensation models that undervalue leadership work, and institutional resistance to redefining traditional roles all limit surgeons’ ability to pursue and sustain leadership growth. These barriers are not trivial, nor are they solely individual challenges. They reflect structural choices within healthcare organizations that often prioritize short-term productivity over long-term leadership capacity. In retrospect, some of these choices are understandable; many are no longer defensible.

For academic surgery, the implications are substantial. Leadership development must be reframed as a longitudinal responsibility rather than an episodic opportunity. Residency and fellowship programs should introduce leadership concepts early, normalize system-level thinking, and provide experiential exposure to organizational decision-making. Faculty development pathways must include progressive leadership responsibility, mentorship, and accountability for outcomes beyond the clinical domain. Institutions, in turn, must accept their role in cultivating leadership capacity. Elevating surgeons into nominal leadership positions without real authority or developmental support undermines both the individual and the organization. Authentic leadership pipelines—grounded in transparency, mentorship, and measurable responsibility—are essential to building a sustainable bench of future leaders.

The objective is not to dissuade surgeons from patient care nor to suggest that all surgeons should pursue executive leadership roles. Rather, it is to recognize that leadership competence strengthens the profession as a whole. Surgeons who understand system dynamics advocate more effectively for patients, trainees, and care teams. Organizations led by clinically grounded executives are better positioned to align mission and margin, quality and sustainability. From where I sit, leadership is not a departure from surgical professionalism; it is one of its natural extensions.

Leadership is no longer optional. In the decades ahead, the success of academic surgery will be measured not only by technical innovation, but by the ability of surgeons to lead organizations through complexity and change. Preparing surgeon leaders is an ethical, professional, and institutional imperative—and ultimately one that determines our ability to deliver safe, effective, and equitable care to the patients who depend on us.