Who truly understands the healthcare system well enough to lead it toward something better?

Some Arab tribes in Arabia and Iraq had an unusual habit: when listing the qualities of a good tribal leader, they included “good fortune” on the list. Not just wisdom or experience — but luck. At first, it sounds naive. But think about how many leaders you’ve seen succeed mainly because the timing was right, or they knew the right people. The elders weren’t being superstitious. They were being honest.

That honesty is a good place to start when asking who should lead our hospitals — because the answer is often less about merit than we’d like to admit.

The Double Standard

The common argument goes: doctors belong in clinics, not in management. Yet universities are led by academics, sports teams by former athletes, and tech companies by engineers. Why should medicine be different? Why do we assume someone who has never stood in an operating room or delivered difficult news to a family is better placed to run a hospital, as long as they can read a budget?

What the Data Shows

Researcher Amanda Goodall looked at the top 100 US hospitals across cancer, heart disease, and digestive disorders and asked: Are better hospitals more likely to be run by doctors or managers? The answer was consistent — physician-led hospitals scored around 25 percent higher on quality measures. The most elite institutions were almost all led by physicians, and the pattern held year after year.

She found the same logic elsewhere: universities improve when great scholars lead them, NBA teams win more when coaches were great players, and Formula 1 teams perform better when led by former drivers. The common thread is leaders who have deeply lived the core work of their organisation.

“The best hospitals in America are disproportionately led by physicians. This is not a coincidence.”

Administrators Still Matter

This isn’t a case for handing hospitals entirely to clinicians. Hospitals are complex organisations that need budgets, logistics, strategy, and workforce management — and many brilliant doctors would be miserable and ineffective running one. Administrators bring real and necessary skills. The question is about who holds the top job, not whether operational expertise matters.

The Real Problem: How We Choose

Here’s where the tribal elders’ honesty about luck stops being quaint and starts being uncomfortable. In many healthcare organisations, leadership appointments have less to do with demonstrated ability than with familiarity, timing, and connections. A junior doctor gets promoted before they’ve matured clinically. An administrator rises on a good impression. Someone gets the CEO role because no one better was available.

The debate about doctors versus administrators often skips over this. It only has a real answer if leaders were actually chosen on merit in the first place. If luck and relationships are driving appointments, neither group gets a fair test — and patients pay the price.

“The problem isn’t always who leads. It’s how we decide who leads.”

The Better Question

The research favours physicians in complex clinical environments — their credibility with staff, their instinctive grasp of what good care looks like, and their ability to attract talented colleagues. But a medical degree alone guarantees nothing. What matters is the quality of the person and the integrity of the process that put them there.

The Arab tribal elders who listed luck among leadership qualities were making a quiet confession: that the best person doesn’t always end up in charge. The real question for healthcare isn’t “doctor or administrator?” It’s whether we have the honesty and the processes to actually find the right person — or whether we’re still, more often than we admit, just leaving it to chance.

References:

Goodall, A.H. (2011). “Physician-leaders and Hospital Performance.” Social Science and Medicine, 73(4).

Goodall, A.H. (2013). “Should Doctors Run Hospitals?” CESifo DICE Report.

Goodall, Kahn & Oswald (2011). “Why Do Leaders Matter?” Journal of Economic Behaviour and Organization, 77.

Falcone & Satiani (2008). “Physician as Hospital CEO.” Vascular and Endovascular Surgery, 42.