The Problem of the Crown Physician Chief

The Crown Physician Chief

It’s a difficult task to wear both the pin of the monarch and the sash of the clans. No one seemed to be able to wear both and survive. The problem wasn’t the person. It was everyone around them. But one by one, the crown chiefs tried their best while the drums played. And one by one, they each died.

The Crown

Hundreds of years ago, the crown monarch was developing their empire and was navigating a difficult time in the journey. They had three problems: an outside competitor to the throne from across the sea, a growing famine across their territories, and they desperately needed money to both grow and solve the other two issues. The solution: they needed the engagement and support of the clans whom they had “acquired” throughout the nearby isles. The problem with the clans was that they still didn’t consider themselves subject to the crown. And no matter whom the crown sent, appointed, or elected to the job of engaging them, they all failed in the highland wild.

The Clans

Across the isles and highlands surrounding the crown, there ruled a dozen or so chiefs. They represented clans from different areas of the land, each with families and histories built on legacy and tradition. Those clans had much in common that they celebrated, and yet their proud differences were also engrained in their upbringing.

In times of danger or fear, the clans banded together. They faced invaders from the outside, rebellion from the inside, and countless plights the world brought to bear. In times of plenty and success, they shared some measure of the bounty and put the greater amount into their own clans, naturally by right.

If anything united the clans, above all else it was their distrust of the Crown. They needed the crown – for access to resources and defense against bigger threats from across the bigger waters – but they couldn’t respect or trust it. It was a necessary evil.

The Crown Chieftan

Vexed by the impossible task of engaging and enlisting the clan leaders with their own central delegates, the Crown finally thought it wise to turn the tables and ask the clans whom they would prefer represent them in the matters of the empire, whether domestic or otherwise. It was risky, but they’d run out of options, and pressures from the outside were steadily mounting. Perhaps the clans could unite themselves – for the Crown, anyway.

Upon hearing that the Crown wanted the Clans to elect their own representative “Chief of Chiefs,” the Clan Chiefs assembled by themselves in a cozy retreat across the wild, western bogs where the Crown rarely traveled. The fog and peat was perfect for both privacy and sharing the water of life, if you will. It was their moment to redefine their value and representation.

After hours of socializing and camaraderie, encouraged by the sound of familiar drums and dancing, it quickly became clear that the Chief with the longest heritage and roots across various marriages and county alliances was the best to represent them. They had shared blood, stories, and haunts. Everyone trusted this Chief as though they were their own sibling. It was decided!

Months later… after many trips to the Crown and back, nights and weekends spent in dinners and discussions with local Chiefs, and many sessions spent reviewing broader affairs of the empire with delegates of the other territories…the Chief of Chiefs was exhausted, and nothing had really changed.

Then one night, unexpectedly, the Chief of Chiefs died somewhere in the hills.

Shocked and disappointed upon hearing the news, and growing more distressed by the outlook of outside invasion and famine (along with a precarious financial statement), the Crown monarch personally went down to engage the Clans. They spent 1:1 time with each Chief, gathered them as a group, and even gave a very inspiring presentation to the broader community. Finally, they held another election for a replacement Chief of Chiefs.

This time, since the former Chief of Chiefs had apparently accomplished very little, they changed their selection strategy. They elected one of the Chiefs with the greatest, most measurable list of accomplishments and feats. Stories were told of their exploits and bravery. No one was confused about the commitment of this Chief to winning.

The drums beat on, the people danced, and life continued. And nothing really changed.

Suddenly one fateful night, the Clans received word that their Chief of Chiefs had died while visiting the Crown monarch. They were shocked and disappointed.

“What is this?” They asked one another. “How could this happen to them?”

When a representative of the Crown arrived the next morning, everyone beseeched them for the details.

“Well we’re not sure how they died,” the messenger said, “but I can say the Crown was not impressed with their performance.”

The other chiefs looked at one another as they processed this perspective. “Well weren’t they doing what the Crown wanted?” They asked.

“Well yes and no. They were, but you weren’t. Their job was to get you to do what the Crown wanted.”

The group stood perplexed. No one had thought of it that way before. They simply assumed the Chief of Chiefs was advocating for them the whole time. Not the opposite.

So once again, the Clan Chiefs assembled for a third time and discussed at length about who would be the right representative to take on the role that seemed so difficult to keep filled.

“Let’s choose someone who is truly both Clan and Crown,” one of the Chiefs proposed.

“Yes, that’s a suitable idea,” the rest agreed.

So they chose a younger, rising talent (though not yet a Chief) to represent them given that they were born of the Clans but raised in the more central towns and hallways of the Crown. The up-and-comer was delighted at the opportunity themselves, and they even put together their own presentation for how the Crown and Clans could be successful together. It was a fine shift in approach.

Sadly, it wasn’t but a few months before this new Chief also died – halfway on the road between the Clans and the Crown.

As the seasons changed, many inevitable changes came as well. A famine struck hard, and the Clans suffered as well as the rest of the Crown empire. Money was scarce. Then finally, the Clans were visited by a new ruler – from across the sea – who had taken over the former Crown and made it a part of their even larger empire. The Clans were given no more favorable terms but to submit. They were even given different clothing and rules about how they would live day to day, down to the minute.

The drums beat a little slower, the people danced a little less, and nothing at the end of the day really changed.

The Chief Physician and the Crown

I’ve experienced and worked with nearly every kind of physician organization that has existed in the United States. From independent to employed, community to academic, value-driven to profit-driven, physician-led and administrator-led. As these organizations of physicians in any form grow, the delicate manner in which they engage with leadership gets more complicated and less supported by trust.

Most often, there is a Chief Physician Executive whom the CEO has tasked with ‘aligning the physicians’ to the strategy and culture of the larger organization. Because they are a physician, grew up in the organization, came with an extensive curriculum vitae, or show great executive promise, the assumption is that they will be successful in doing so. Yet as soon as they wear the title of Physician Executive, CMO, etc, they become distrusted and powerless – by both sides.

The problem is rarely the person. It’s the role.

My team and I once took on the assignment of getting to the bottom of this with a growing health system where the medical group was notoriously skeptical of the system strategy and culture.

“The executives only care about money and growth,” the physicians would say.

“The physicians only care about money and autonomy,” the executive team would say.

Accordingly, said about the CMOs (past and present), we would hear “they don’t really seem to carry enough of a hammer to get things done.” Or, “They don’t really know how to practice anymore. They just work for the CEO.”

Hearing these familiar sayings, we asked the CEO and the physician executive each a question: “Have you asked the physicians what they think the strategy should be and how their priorities connect to the system priorities?”

“Not per se,” was the answer from each. “We got their input to inform the strategy, but it was more reactionary than authorship.”

So after some collective introspection, we did this: first, we asked all of the physicians some questions, such as what their top 10 priorities were for their practice, the medical group, and the system. We asked them where and how they thought they could drive or support the change that might be required. We asked them what was missing from the current state culture or structure to already be successful. We asked about their perceptions of quality, collaboration, and each other.

The results? The priorities were almost exactly the same as the system strategy was before. Everyone put patient outcomes and quality above other matters. The “us versus them” was actually about how any physician, being human, viewed any other physician, department, or part of the system. It wasn’t just a tension with the system – they didn’t trust anyone as much as their own team! And finally, they wanted to be involved as much as the system leaders thought they were asking for involvement. They were all simply using different languages and approaches to try and meet in the middle.

We finally all got together in a room and looked at their quality data, financials, cultural feedback, and most especially perceptions of reality on the table in a way that could be seen at once – the system view. We had honest conversation about truths, not just rumors. They added their perspectives to the strategy itself and gave expert advice on how to support it. And by the end of the day, after shifting from the proverbial ‘skeptical’ to ‘engaged,’ one of the physician specialty leaders stood up and asked, “Why haven’t we ever talked like this before?” Not about this – like this.

Hence the CEO and Chief Physician Executive got to sit together in the room and for once have a productive conversation with shared meaning and understanding across all parties. Though there would still be a very long journey ahead, they broke bread and moved forward together.



Many physician leaders have lived the trials of engaging two opposite sides in a journey that is meant to be walked side-by-side, together. Some survive to tell the tale, and some even thrive and build remarkable legacies. But if it all simply depends on a single “tie” or role expected to bind two sides, it will most likely break.

  • If you are a physician leader, do you feel like you are more often bringing something of value to clinical and non clinical colleagues alike, or is it more requests and delegations you need to “socialize?”
  • If trust is something that sometimes feels scarce or drying up, where is the dam stopping it? What’s getting in the way of honest dialogue?
  • If you are a CEO or administrative leader, what is your definition of “physician alignment?” If it is something along the lines of ‘ensuring the physicians are understanding of, agreed to, and performing to the expectations set for them,’ you will almost certainly fail.
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