Somewhere in your organization is a physician who was, in Dr. Kristin Mascotti's word, voluntold.

"Transitioning physician executives may find themselves thinking, 'you’re a highly clinically competent physician, you’re well regarded, people look up to you, you may have broad influence' — and sometimes you’re sort of voluntold about a leadership position,” said Mascotti, market chief medical officer for CommonSpirit Health Mountain Region, during a July 2026 presentation with Jackson Physician Search. “There’s a whole other significant workload here that I may or may not be prepared for.”

That gap — between the workload and the preparation — was addressed by Mascotti along with Jackson Physician Search’s Andrew Walker, senior director of executive business development, and Tom Rossi, vice president of executive search. Their argument, in short: organizations keep recruiting for a job that no longer exists.

From clinical advisor to clinical operator

“If you looked at this 15 years ago, the physician leadership scope and role looked very, very different,” Walker said. “As more pressures are placed upon healthcare delivery organizations, a lot of those pressures are pushed down to that physician leadership level.”

Mascotti was blunt about how narrow the old role was. “Historically, physicians had oversight of quality — although quality directors and nursing primarily ran that — and then medical staff governance.”

What replaced it is an enterprise job. Care migrated from inpatient to outpatient and the physician leader was expected to offer more than just clinical crediblity. Boards and CEOs want the physician executive to show “a measurable ROI” through improved documentation, length of stay, readmissions, access, growth, and operating performance. “And this one's really tough,” Mascotti noted, “because how do we prove the impact for the organization?"

The problem begins before a search opens: clinical excellence is treated as leadership readiness; the scope grows without matching authority or resources; compensation stays attached to the old job; and onboarding is expected to happen by osmosis. A strong physician can still fail inside a poorly designed role.

Define the authority before the job posting

Too many organizations can describe the title but not the decisions behind it. In a matrixed medical group or health system, that omission misses the entire job.

Rossi located the problem structurally. “The nuance comes in that so many of these organizations are so matrixed,” he said. “You have what seems like a direct responsibility, but then you have to be aware of — we've got the physician group here, but we've also got the rest of the system, and we’ve got the academic piece there.” Even the unicorn candidate cannot outrun that ambiguity, and it gets worse amid consolidation and physician groups become part of something bigger while still operating as themselves.

“They still need to have a true scope of authority that allows them to get things done,” Rossi said, along with enough clarity to know where they lead, where they influence and where someone else decides.

Mascotti hears the practical version from candidates: “What can I actually influence and decide? Or who has the right to decide within the team?” The organization should be able to answer that question across strategic, operational, financial and quality responsibilities before the offer letter goes out.

Those four domains also expose the development gaps. Quality is usually the most familiar territory, though many physicians still lack formal quality training. Strategic thinking may feel closer to the work clinicians already do. Operations and finance are more likely to require deliberate preparation.

Those less familiar areas can also make the leader's value visible. Mascotti described partnering with her CFO on service-line decisions that produced “some pretty big pickups in cleaning up efficiencies and rev cycle.” The physician voice helped explain why documentation, billing and workflow changes mattered to clinicians — and helped move the work.

Her takeaway was simple: “If you can become a clinical operator, it’s a highly marketable skill.”

What separates the dyads that work

Asked in the chat whether they ran dyad or triad models, attendees split roughly evenly. Mascotti has worked in both dyad and triad structures. One attendee volunteered “dysfunctional dyad,” which got a laugh and got at the question Mascotti says follows her every time she discusses this topic: If I think I’m in a bad one, how do I reset?

Her definition of a good one is deliberately unbusinesslike. “The best way to define a successful dyad is that ultimate trust and psychological safety,” she said. “It's solid when it’s the person you’d go to with the biggest problem, close the door, and talk authentically.”

That trust requires physicians to flatten the hierarchy. Mascotti has heard administrators say, “We have a say, but we know who’s really driving the decisions,” meaning the doctors. Her message to physician leaders is direct: treat the CNO or administrator as an equal who brings expertise the physician does not have.

In Mascotti’s current structure — CEO, CMO and CNO, with no COO — the triad reflects where the work lives. “When you really look at the workforce of a hospital, acute care, it’s primarily nursing,” she said. “If we can get the nursing and the physicians aligned, that is where the power, or the magic, comes in.”

Two mechanics keep that partnership from becoming three people attending the same meetings. First, they name who is primary and who is secondary for major priorities: one person moves the work, while the other supports and stays informed. Second, they learn each other’s strengths well enough to know when to hand off, lean in or challenge an assumption.

The strongest organizations recruit for that complementarity. “If they’re recruiting for one, they specifically look for complementary competencies,” Mascotti said. “It's actually brilliant.”

Rossi made the same point from the search side. Strategic thinking, change leadership, data literacy, influence and dyad effectiveness are not an all-you-can-eat menu. “No one has them all,” he said. The hiring team has to decide which capabilities the role needs most — and which strengths already exist in the surrounding team.

Scope creep is a compensation event

Walker’s extensive time working in physician compensation points to a common complaint about benchmark use: too many organizations enter a dataset, pull one number and leave.

“There’s not a one-size-fits-all approach,” Walker said, “but you have a lot of tools inside of this dataset.” For physician executives, that may mean looking beyond the flagship provider compensation data to medical directorship compensation, management and staff benchmarks for fully administrative roles, and academic views for faculty-ranked positions.

Then comes the mechanism nobody budgets for. “The more effective you are as a physician leader, the more you acquire,” Mascotti said. “The more change you make, the more you're given.” One hospital becomes two. A service line becomes several ambulatory sites. A quality role picks up operations, budget responsibility or enterprise projects.

Walker named it scope creep. When it arrives, the organization should revisit the whole package: authority, protected nonclinical time, performance measures, title, development support and compensation. An annual review is the floor, not the only trigger; a material change in the work should start the conversation sooner.

Rossi pushed organizations to think in terms of total rewards — base, incentive, benefits and development — and noted that smaller groups can sometimes compete creatively with coaching, education or other benefits. Creativity helps, but it cannot compensate for a role that keeps growing while the time and authority stay fixed.

Mascotti said physician leaders strengthen their case when they can show what changed because of their work — from growth and added revenue to more efficient operations.

Physicians want to talk to physicians

Rossi also made the case that a physician executive is a recruitment asset many organizations underuse.

“As a recruiter, we can paint the picture. As an operations leader, we can explain the history of the practice, where the practice is going,” he said. “But so many times, the key conversation is the one with the other physicians.” Candidates use that conversation to test the culture, the credibility of the administrative partnership and whether physicians can influence change.

The moment he keeps seeing is small: a physician leader hands the candidate a card and offers to answer questions later. “It’s such a selling point,” Rossi said, “because that's the voice that really resonates the most, physician to physician.”

The same credibility makes a bad role design more expensive. “There's a lot of direct costs in terms of what it takes in time and effort to recruit a physician,” Mascotti said. “The indirect costs, I would say, are even bigger” — including disengagement, missed strategic priorities and consequences for quality and patient safety.

When the partnership works, the effects spread. “The dyads and triads that have that with a physician leader — you just watch them run, and you try to support them,” Mascotti said. “They drive teams, they drive outcomes, and the finances follow, essentially.”

One free lever remains: celebrate the work publicly. “Thank them when they do a great job,” Mascotti said. “Physicians don’t do that very often to one another, but a little goes a long way.”

Answers to questions your leadership team will have

If you've never had a physician executive, where do you start? Map the work before naming the role. Document the strategic, operational, financial and quality responsibilities; define what the leader owns, shares, recommends and escalates; identify the executive sponsor and leadership partners; then write the job description.

What’s the biggest mistake in creating a new CMO or medical director role? Role misrepresentation — the position described during recruitment is not the position that exists — followed closely by authority gaps. Mascotti’s version was plain: “They don’t have the voice that they thought they would have.”

How should clinical and administrative time be divided? Start with the actual leadership workload: recurring meetings, span of responsibility, major projects, expected availability and ongoing clinical duties. Put the clinical full-time-equivalent (cFTE) split and protected leadership time in writing, then revisit both when the scope changes.

How often should you revisit compensation? At least annually, and whenever sites, service lines, reporting relationships, budget responsibility, clinical effort or performance expectations materially change. Scope creep is the trigger; the calendar is only a backstop.

We don’t have a leadership development program; what can we do immediately? Borrow a mentor. Rossi described smaller groups reaching out to an experienced physician leader in the community who is willing to meet regularly. Mascotti suggested using some existing continuing education support for targeted leadership learning in finance, operations, quality, strategy or difficult conversations.

Are organizations hiring for potential over prior executive experience? The better question is whether the selection process tests the competencies the job requires. Prior experience can shorten the learning curve, but complementary strengths, self-awareness and the ability to work with the future dyad or triad may matter just as much.

Additional resources

• Watch the on-demand webinar: “Rethinking the Physician Executive: How Role Design, Compensation, and Development Drive Recruitment and Retention”
• “Developing the Next Generation of Physician Executives” (Jackson Physician Search and MGMA, 2024)
• “Stronger Together: Leveraging Triad Leadership for Healthcare's Biggest Challenges” (Jackson Physician Search, 2026)
• “Create and Sustain a Successful Leadership Development Institute” (MGMA, 2023)