In healthcare institutions, is having physicians in leadership roles an advantage? A scoping review

In healthcare institutions, is having physicians in leadership roles an advantage? 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A scoping review Pedro Mendes Monteiro, João Carlos Ribeiro This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8563033/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Healthcare systems are increasingly challenged by rising demand, financial constraints and organisational complexity, intensifying the need for governance models that effectively align clinical quality with operational and economic performance. Medical leadership has been proposed as a strategy to bridge clinical expertise and managerial decision-making; however, evidence regarding its impact on healthcare performance indicators remains heterogeneous. This scoping review aims to examine the relationship between medical leadership and clinical, financial and organisational outcomes in healthcare institutions, while identifying essential leadership competencies and implementation barriers. Methods A scoping review was conducted in accordance with the Joanna Briggs Institute guidelines and the PRISMA-ScR criteria. Literature searches were performed across major databases (PubMed, Web of Science) covering the period from 2000 to 2025. Eligible studies included quantitative and qualitative research analysing clinical, financial or organisational performance indicators in healthcare institutions under medical, non-medical or hybrid leadership models. Data were extracted using a standardised framework and synthesised narratively. Results Twenty-three studies met the inclusion criteria. Medical leadership was consistently associated with improved clinical outcomes, including lower risk-adjusted mortality, higher patient satisfaction and enhanced patient safety. Organisational benefits were also reported, particularly in professional engagement, retention and perceived leadership credibility. Evidence regarding financial performance was mixed, with some studies reporting higher operating costs in physician-led institutions, while others demonstrated neutral or context-dependent financial effects. Leadership training, organisational culture and governance structures emerged as key moderating factors. Conclusion Medical leadership appears to confer advantages in clinical quality and organisational performance, although its impact on financial efficiency remains inconclusive. Effectiveness is strongly influenced by formal management training, institutional support and collaborative governance models. These findings support the integration of leadership and management education into medical training and highlight the need for further research exploring hybrid leadership models and contextual determinants of performance. Medical leadership Healthcare management Performance indicators Organisational efficiency Health systems Value-based healthcare Cost-effectiveness Figures Figure 1 INTRODUCTION In the 21st century, healthcare systems face unprecedented challenges (International Monetary Fund, 2014). The confluence of structural, demographic, and technological factors, which exert increasing pressure on sustainability, forces reflection on the organisation and management models of these systems (Saleem, 2023). Ageing, chronic disease and rapid technological change (artificial intelligence and big data) are transforming care, demanding resource optimisation and more efficient management (Porter & Lee, 2013), amid growing demand and constrained resources (National Academies of Sciences, Engineering and Medicine, 2018). Currently, health expenditures represent a significant portion of the gross domestic product of most developed countries, which reflects continuous growth that jeopardises the budgetary sustainability of health systems (World Bank & World Health Organization, 2023). Despite this strong investment, a considerable proportion does not translate fully into a proportional improvement in clinical outcomes, as inefficiency – manifested through redundant procedures, fragmentation of care, and avoidable readmissions – consumes between 20% and 25% of total expenditure on health (Shrank et al. , 2019). Cost-effectiveness has become central to reform, promoting rational resource use to maximise outcomes (Vanness et al. , 2021) and support universal coverage and sustainability (Russell, 1996). However, the transposition of these principles into practice requires more than political and economic changes — it crucially depends on robust and informed leadership capable of mediating the inherent tensions between the clinical, organisational, and financial requirements (Gilson, 2016). In this context, the development and continued training of leaders with the ability to articulate cost rationalization and adherence to clinical principles of equity and ethics facilitate the identification and application of practices that promote the sustainability of systems and can ensure that budgetary constraints do not compromise the quality of care provided. These factors highlight systemic weaknesses that require highly qualified leadership capable of navigating the complexities of clinical governance and harmonizing clinical, operational, and financial goals to promote a more resilient and sustainable system (Robert et al. , 2020). In this framework, medical leadership assumes a key role. Physicians possess a unique skill set that distinguishes them as natural leaders in health systems: their advanced clinical training, ability to critically think, and a deep understanding of patients' needs give them a privileged position to drive organisational transformation, ensuring, simultaneously, the excellence of care and the optimization of resources (Bohmer, 2021). The reality experienced during the COVID-19 pandemic was a paradigmatic example of the importance of medical leadership in crisis management. During this period, physician leaders played a central role in the strategic allocation of resources, in the optimization of hospital teams, and in implementation of protocols based on the best available evidence, demonstrating an exceptional capacity for leadership in complex and high-risk environments (Standiford et al. , 2021). The COVID-19 pandemic has reinforced the need for a clinical governance model that values technical-scientific knowledge and evidence-based decision-making, ensuring the resilience of health systems in the face of emerging challenges. However, although the impact of medical leadership on the quality of care and organisational effectiveness is widely recognized, its influence on financial efficiency and resource optimisation remains an underexplored area in the literature, with a greater deficit of systematic evidence on the relationship between medical leadership and cost-effectiveness. Additionally, the challenges faced by physician leaders are not negligible. Traditional medical education is predominantly focused on clinical practice and the provision of direct care, relegating essential skills such as leadership, strategic planning, financial management, and resource allocation to the background (Chen, 2018). Therefore, most physicians assume leadership roles without formal preparation in these areas, potentially compromising their effectiveness. The duality between clinical and administrative responsibilities can generate tension, as medical leaders need to balance the provision of patient care with organisational and financial requirements (Waldman et al. , 2010). To fill these gaps, specialised training programs in health management and leadership have been increasingly advocated, providing physicians with the skills necessary to thrive in complex organisational environments (Leatt & Porter, 2003). Thus, this study aims to analyse the relationship between medical leadership and healthcare efficiency and cost-effectiveness. By critically analysing the literature on the clinical, operational, organisational, and financial results of health institutions in physician-led systems, we seek to identify opportunities for optimizing resources based on innovation and the integration of value-based healthcare principles in promoting high-level medical and economic outcomes. To refine the central question of this review, the following specific objectives have been established: Identify and characterise the essential competences of medical leadership that positively impact the performance of healthcare institutions, including financial literacy, logical reasoning and strategic thinking, communication skills, team management, and adaptation to digital transformation. Evaluate the impact of medical leadership on clinical, financial, and organisational performance indicators and explore its influence on the quality of care provided, patient safety, process optimisation, economic sustainability, and overall satisfaction of healthcare professionals and users. Examine the challenges and barriers to the effective implementation of medical leadership - reviewing deficiencies in training, organisational resistance, gaps in institutional culture, and difficulties reconciling doctors' clinical and administrative responsibilities. Investigate the role of medical leadership in integrating care and promoting cost-effectiveness, analysing clinical governance models and organisational innovation that enhances the quality of healthcare institutions. Health efficiency is a multidimensional concept that seeks to assess the ability of health systems to convert human, financial, and material resources into high-quality and differentiated clinical and operational outcomes. This concept is structured in two fundamental dimensions: technical efficiency, which refers to the ability to maximise clinical and operational outcomes with the available resources, reduce waste and maximise productivity of care processes (Blackstone & Fuhr, 2007; Drummond et al. , 2005) and allocative efficiency, which is related to the optimisation of resource allocation, ensuring that they are applied in the areas of greatest need, in alignment with priorities and population preferences (Drummond et al. , 2005). The analysis of this concept is essential for identifying inefficiencies and assisting decision-makers, that is, the semantic scope of this decision-maker (public or private policies), being a dependent variable in any model of provision and financing in health, constitutes a fundamental instrument of health economics and is fundamental for comparing the costs and benefits of different interventions or health programs. Its basic principle is based on the evaluation of the relationship between the investments made and the results obtained, using indicators such as the incremental cost-effectiveness ratio (ICER), which quantifies the additional cost per unit of health gain, such as the quality-adjusted life year (QALY) (Blackstone & Fuhr, 2007; Drummond et al. , 2005). This approach is particularly important in scenarios where resources are scarce, allowing decision-makers to prioritize interventions that offer the greatest return in terms of benefits to the health of the population and promote a more efficient and equitable allocation of resources. Coupled with the concept explained above, the value-based healthcare (VBH) paradigm emerges as a response to the need to reformulate traditional models of care delivery, prioritising the maximisation of value for the patient. In this model, value is defined as the relationship between the clinical outcomes achieved and the costs associated with providing such care (Porter, 2010). The VBH is structured in essential dimensions, including (1) patient-centeredness, which promotes a personalized approach tailored to individual needs and expectations (Berwick, 2009); (2) the integration of care, with a focus on coordination between different levels of care to ensure seamless and efficient care pathways (Blackstone & Fuhr, 2007); (3) transparency and monitoring, which ensure the systematic measurement of clinical, operational and financial indicators to promote the continuous improvement of processes (Blackstone & Fuhr, 2007); (4) economic sustainability, which involves directing the use of resources to optimize health gains and ensure the financial sustainability of health systems. In this context, leadership in health stands out, as it plays a strategic role in the efficient management of services and in the implementation of organisational innovations, integrating all the aforementioned assumptions. The literature identifies different leadership styles, each with distinct impacts on motivation, performance and innovation: (1) transformational leadership, which is distinguished by the leader’s ability to inspire and motivate the team through a shared vision, promoting creativity, resilience and personal development, associated with environments of innovation and continuous improvement (McCall, 1986); (2) transactional leadership, which is based on a model of rigorous supervision and contingent reinforcement, which is based on rewards and penalties. Although effective in managing routine tasks, it can limit creativity if applied in isolation (Avolio, 2011); (3) situational leadership, which involves adapting the leadership style to the contextual needs and level of experience of the team, combining transformational and transactional elements for more flexible and responsive management (Yukl, 2010); (4) distributed or collaborative leadership, which emphasizes the sharing of responsibilities in decision-making, providing an environment of cooperation that is particularly relevant in complex and multidisciplinary health systems (Yukl, 2010). With these principles, clinical and organisational governance stands out as a structuring pillar of health systems, constituting a cumulative set of mechanisms that ensure quality, safety, and efficiency in the provision of care. While clinical governance focuses on the accountability of health professionals, on the rigorous monitoring of results, and on the implementation of improvements supported by scientific evidence, organisational governance refers to the strategic management of institutional resources, ensuring the articulation between the financial and operational domains and assistance. The interconnection between these dimensions not only guarantees high standards of quality but also promotes the sustainability of the system, especially in the context of budgetary pressures and increased demand for services (Donabedian, 1988; Scally & Donaldson, 1998). The quality and safety of health care are crucial elements in the evaluation of the performance of institutions, which require robust monitoring systems and mechanisms for continuous improvement. The quality of care is assessed through objective indicators, such as rates of nosocomial infections, hospital readmission rates, and length of stay, whereas safety focuses on the prevention of adverse events and the minimization of clinical errors. Empirical evidence shows that quality improvement is intrinsically associated with the optimization of clinical outcomes and operational efficiency, promoting a culture based on the mitigation and prevention of errors, continuous learning, and the implementation of good practices (Batalden & Davidoff, 2007). In recent decades, transformative vectors in health systems have stood out: innovation and digital transformation, which introduce technological solutions that improve clinical and administrative processes. The digitization of information systems and the implementation of clinical decision support tools facilitate the reduction of redundancies, the optimization of workflows, and the improvement of interprofessional coordination, ensuring an effective alignment between clinical goals and the needs of patients (Blackstone & Fuhr, 2007). The incorporation of artificial intelligence, big data , and real-time monitoring systems supports a more predictive and personalized approach to care, increasing the capacity for anticipating needs, reducing (human) risks, and optimizing clinical interventions (Blackstone & Fuhr, 2007; Porter, 2010). Other concepts to explore include performance and evaluation indicators. These instruments are essential for assessing the health services’ effectiveness, quality, and efficiency, allowing an objective analysis of the institutional results achieved. These indicators include (1) clinical parameters, such as therapeutic success rates and response times; (2) operational indicators, which assess waiting times and the efficiency of care processes; (3) financial indicators, which assess the economic sustainability of institutions (Drummond et al. , 2005). The systematic use of benchmarks makes it possible to compare performance between units and identify areas for improvement based on concrete data and institutional accountability that continuously quantify performance and ensure the responsiveness/adaptation of organizations to the ordinary and emerging challenges of the healthcare sector. Medical leadership is a crucial element in the promotion of quality and the strategic management of health systems, playing a key role in the coordination of clinical teams and the integration between practice and organisational requirements. The literature distinguishes several styles of leadership, including transformational, transactional, and distributed models, as discussed above (McCall, 1986; Avolio, 2011). As a key factor in the implementation of innovative models, such as value-based healthcare, the lead doctor exerts a significant influence on institutional culture, determining the levels of motivation, cohesion, and commitment of teams. This influence is directly reflected in the quality of care provided and in the efficiency of the processes. As mentioned, monitoring the performance of health systems through clinical, financial, and organisational indicators is an essential tool for evaluating the quality, efficiency, and sustainability of health institutions — guarantors of evidence-based management oriented toward continuous improvement. Among the main clinical indicators , the following stand out: (1) the risk-adjusted mortality rate plays a central role in the evaluation of hospital performance, as it incorporates factors such as comorbidities, disease severity and demographic characteristics of the assisted population—the use of this indicator makes it possible to compare the performance between hospitals, distinguishing the quality of clinical intervention from the specificities of the patients, a factor that enables the identification of gaps in care and the implementation of evidence-based corrective measures (Porter, 2010; Donabedian, 1988); (2) The hospital readmission rate, which measures the percentage of patients readmitted within a certain period after discharge, is a reliable indicator of continuity of care, of the quality of discharge planning and of the coordination between the different levels of the system (high rates of readmission may indicate shortcomings in patient follow-up processes, deficiencies in interprofessional communication or failures in treatment planning, making it a critical marker for patient safety and for the overall efficiency of health services) (Drummond et al. , 2005; Berwick, 2009); (3) the average length of stay, which assesses the ability of institutions to optimize the use of resources without compromising the quality of their mission provision—proper management of hospital admission allows avoiding complications associated with prolonged stays, reducing hospital costs without increasing the risk of premature readmissions (Porter, 2010); (4) adherence to clinical protocols that affect the homogenization of therapeutic interventions, ensuring that practice is aligned with the best scientific evidence established at the time of practice—high adherence to clinical guidelines reduces variability in medical practice and allows for the adoption of an audit and feedback model for the identification of errors and, in the cause–effect logic, for the correction and continuous improvement of the acts that reproduce them (Donabedian, 1988). In the field of financial indicators , the following stand out: (1) the operating cost per episode, which objectively evaluates the economic sustainability of health services, reflecting the average cost associated with each episode, should include direct and indirect expenses from admission to discharge (Drummond et al. , 2005); (2) the financial return on investment (ROI), which quantifies the relationship between the economic benefits obtained and the investments made in projects or interventions in the health sector (a high ROI indicates that the investments made result in significant improvements in the economic efficiency of the institution, reinforcing the need for a strategic approach based on concrete data for resource management) (Blackstone & Fuhr, 2007); (3) the reduction of waste, including the rational management of resources, the elimination of redundancies in internal processes and the reduction of waste of time, materials and unnecessary procedures, contributes to greater financial sustainability of institutions (Drummond et al. , 2005). Finally, among the organisational indicators that affect the evaluation of the satisfaction and well-being of professionals and users, the following stand out: (1) the retention index of professionals, which allows the ability of institutions to retain their workers to be evaluated, is a reflection of the stability of clinical teams and the quality of the work environment (high turnover rates may indicate professional dissatisfaction, inadequate working conditions or a lack of development opportunities, negatively impacting the continuity of care provided) (Donabedian, 1988); (2) the burnout index, which is frequently assessed via the Maslach Burnout Inventory ( MBI ) (Maslach & Jackson, 2012), which measures the degree of psychological exhaustion, depersonalization and a reduction in professional fulfilment of workers, is directly associated with increased risk of clinical errors and reduced productivity (compels, or should compel, the implementation of policies to support and improve working conditions) (Batalden & Davidoff, 2007); (3) the average waiting time for consultations/surgeries, which allows the assessment of the responsiveness and management of demand, excessive waiting times, compromises timely access to care, influences patient satisfaction and impairs the overall efficiency of treatments services and institutional capacity to implement electronic recording systems, telemedicine and artificial intelligence tools (Blackstone & Fuhr, 2007). In this context, this scoping review seeks to systematically map the existing evidence on medical leadership and its relationship with healthcare performance. By analysing clinical, financial and organisational indicators across diverse healthcare settings, this study aims to identify the conditions under which medical leadership contributes to value-based, efficient and sustainable healthcare delivery. METHODS Study Design The present scoping review was conducted according to the methodological guidelines of the Joanna Briggs Institute Manual for Evidence Synthesis (Aromataris et al., 2024) and in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses – Scoping Reviews) criteria (Tricco et al. , 2018). This approach was selected to analyse and frame the objectives of this review properly. Stages of the Scoping Review Formulating the Research Question The review was guided by the following research question: "How does medical leadership influence clinical, financial, and organisational indicators in health institutions compared with other types of leadership?" The formulation of the question was based on the population, concept, and context (PCC) structure recommended by the JBI : Population: Physicians. Concept: Medical leadership and its impact on performance indicators. Context: Health systems. To answer this question, the aforementioned specific objectives were defined. IDENTIFICATION OF RELEVANT STUDIES The search strategy was designed to be comprehensive and sensitive, allowing the identification of relevant literature published between 2000 and February 2025. Thus, combinations of key terms and Boolean operators were used and adjusted to each database. consulted. Database search Two main databases were selected because of their relevance to the field of health and documentary coverage: PubMed: Comprehensive coverage of health sciences and medicine. Web of Science: A multidisciplinary database containing high-impact global publications. Final Search String: The final search string was as follows: ((performance) OR (efficiency) OR (impact) OR (outcomes) OR (indicators) OR (value-based care) OR (value-based healthcare)) AND ((medical leadership) OR (physician leader) OR (doctor leader) OR (clinical leadership)) AND ((healthcare organisations) OR (hospital) OR (healthcare systems) OR (medical institutions)) Filters: Abstract, Full text, Adaptive Clinical Trial, Case Reports, Classical Article, Clinical Study, Clinical Trial, Meta-Analysis, Observational Study, Randomised Controlled Trial, Systematic Review, English, Portuguese, from 2000–2025. Inclusion criteria: Studies published in English or Portuguese. Studies conducted in institutions belonging to healthcare systems. Quantitative and qualitative studies that analysed clinical, financial, or organisational indicators. Publications between 2000 and 2025. Full text availability. Exclusion criteria: Editorials, essays, or comments. Studies not related to healthcare systems. Articles without full-text access. Studies that did not specify the type of leadership assessed. Literature Selection The selection process was divided into 3 phases: Screening of titles and abstracts: Application of inclusion and exclusion criteria in the literature found. Full-Text Analysis: Assessment of full-text articles selected during initial screening. Conflict 4. Resolution: Agreement between the authors. The inclusion of the article, by default, in situations of doubt. DATA EXTRACTION AND ORGANISATION Data were extracted and recorded in a standardized matrix created in Microsoft Excel , with the following variables: Study identification: Author, year of publication, title, database. Context: Type of institution (public or private hospital), geographic location, or health system. Leadership type: Medical, non-medical, or hybrid. Indicators analysed: Clinical, financial, and/or organisational. Main results. Study limitations. Process for obtaining the Results In the identification stage, 2,608 and 4,440 records were found by searching the PubMed and Web of Science databases, respectively. Before triage, records were removed for different reasons, including 328 duplicate records, 250 records considered ineligible by automated tools, and 175 records eliminated for other reasons. In the screening stage, 6,295 records were evaluated on the basis of title and abstract, of which 6,233 were excluded because they did not meet the inclusion criteria. Next, the full texts of 102 studies were evaluated to determine their eligibility, 40 of which were excluded because they were not compliant with the previously defined criteria. Subsequently, the remaining 62 studies were evaluated for eligibility, of which 39 were excluded for specific reasons. The reasons for exclusion were as follows: 17 studies were outside the context of the health system; 14 studies did not clearly specify the type of indicators evaluated; 8 studies did not indicate the type of leadership assessed. Therefore, the process of identifying, screening, and including articles resulted in the inclusion of 23 articles in the review. Figure 1 illustrates the PRISMA-ScR flowchart of study identification, screening and inclusion. RISK OF BIAS Although scoping reviews do not primarily aim to formally assess risk of bias, a methodological appraisal was conducted to enhance transparency and support interpretation of the findings. An assessment of the risk of bias (Table 1 ) was conducted in the studies based on a set of criteria systematized by Hawker et al., 2002. Qualitative classifications were assigned — "poor", "fair" or "good" — in nine distinct dimensions, which included (1) the quality of the abstract and title; (2) clarity in the introduction and definition of the objectives; (3) rigor in the description of the method and materials; (4) suitability of the sampling strategy; (5) robustness of data analysis; (6) attention to ethical aspects and control of potential biases; (7) presentation and interpretation of results; (8) ability to transfer or generalize the results; (9) relevance and applicability of the conclusions. Additionally, an analysis was performed to identify potential sources of bias that could compromise the robustness of cumulative evidence across studies. This process included the evaluation of the methods used, the existence of approvals by ethics committees, transparency in the funding of the studies, the declaration of possible conflicts of interest of the authors, and the influence of the institutional context (ensuring that there were no external interests that could bias the results). This approach ensures methodological integrity and increases the reliability of the conclusions drawn from the set of studies analysed. Table 1 Risk of bias assessment Article No. Abstract and Title Introduction and Objectives Materials and Methods Sample Data Analysis Ethics and Biases Results Generalisation Conclusions 1 (30) Good Good Good Good Good Fair Good Fair Good 2 (31) Good Good Good Good Good Fair Good Fair Good 3 (32) Good Good Good Fair Good Fair Good Fair Good 4 (33) Good Good Fair Fair Fair Poor Fair Fair Good 5 (34) Good Good Good Good Good Good Good Good Good 6 (35) Good Good Good Good Good Fair Good Fair Good 7 (36) Good Good Fair Fair Fair Poor Fair Fair Good 8 (37) Good Good Fair Fair Fair Poor Fair Fair Good 9 (38) Good Good Good Good Good Fair Good Good Good 10 (39) Good Good Good Good Good Good Good Good Good 11 (40) Good Good Good Good Good Fair Good Good Good 12 (41) Good Good Fair Fair Fair Poor Fair Fair Good 13 (42) Good Good Good Good Good Good Good Good Good 14 (43) Good Good Fair Fair Fair Poor Fair Fair Good 15 (44) Good Good Good Good Good Fair Good Good Good 16 (45) Good Good Fair Fair Fair Poor Fair Fair Good 17 (46) Good Good Good Fair Good Fair Good Fair Good 18 (47) Good Good Fair Fair Fair Poor Fair Fair Good 19 (48) Good Good Fair Fair Fair Poor Fair Fair Good 20 (49) Good Good Good Good Good Fair Good Fair Good 21 (50) Good Good Fair Fair Fair Poor Fair Fair Good 22 (51) Good Good Fair Fair Fair Poor Fair Fair Good 23 (52) Good Good Fair Fair Fair Poor Fair Fair Good RESULTS Of the 102 studies evaluated in the full-text screening, 23 were included in this review. The majority of the included studies were from countries with a high Human Development Index (HDI) (United Nations Development Programme, 2024): United States of America − 6 studies, Germany − 5 studies, Australia − 5 studies, Netherlands − 4 studies, United Kingdom − 4 studies, Italy − 3 studies, France − 2 studies, Denmark − 2 studies, Singapore − 1 study, New Zealand − 1 study, Canada − 1 study and Sweden − 1 study), followed by countries with lower human development indices (Malaysia − 1 study, United Arab Emirates − 1 study, South Africa − 1 study, Pakistan − 1 study and Iran − 1 study. The included studies were of a quantitative and a qualitative nature, with study designs analysing clinical, financial, or organisational indicators, including the type of leadership assessed. In all studies, a convenience sampling strategy was used. Potential biases identified during the analysis were also documented. Table 2 summarizes the discussion, implications, and possible limitations detected. According to Table 2 , the 23 studies analysed the performance of health institutions led by individuals with or without medical training, considering various leadership styles and the associated challenges and barriers. Different types of performance were evaluated in each study, yielding varied outcomes across performance categories. Table 2 Results: Discussion and implications of the studies Title Medical leaders or masters?—A systematic review of medical leadership inhospital settings Medical leadership, a systematic narrative review: do hospitals and healthcare organisations perform better when led by doctors? Author(s) Mathilde A. Berghout, Isabelle N. Fabbricot, Martina Buljac-Samardži,Carina G. J. M. Hilders Robyn Clay-Williams, Kristiana Ludlow, Luke Testa, Zhicheng Li, Jeffrey Braithwaite Discussion and Implications 1. Definitions of Medical Leadership The study refers to two forms: formal leadership (administrative roles such as clinical directors/managers) and informal leadership (influence in clinical practice without formal authority). It notes the absence of a consistent definition across studies. 2. Main Functions and Activities Core functions include hospital management, covering finance (53%), strategy (44%) and human resources (50%). Additional roles involve bridging doctors and managers (35%) and influencing decisions through negotiation and mediation (25%). 3. Essential Competencies and Characteristics Credibility, grounded in clinical excellence, is seen as fundamental (66%). Key competencies include communication (35%), conflict resolution (32%) and negotiation (26%), alongside knowledge of finance (26%), health systems and public policy (23%). 4. Barriers to Medical Leadership Main barriers are conflicts between management and autonomy (47%), workload/time pressures (41%), ambiguity of the leader’s role (38%) and insufficient institutional support and training (32%). 1. Impact of Medical Leadership on Outcomes The study reports that 12 of 16 studies found differences between physician and non-physician managers, with eight showing positive effects of medical leadership on hospital performance and clinical outcomes. Main differences concerned risk assessment, quality of care and strategic planning. 2. Physicians on Boards of Directors Evidence shows benefits of physician representation. In the UK, hospitals with 15% physicians on boards achieved higher ratings than those with 11% (p < 0.05). In the US, hospitals with physicians on boards reported lower risk-adjusted mortality (5.6% vs. 7.3%). In for-profit hospitals, higher physician presence increased uncompensated care provision by 19%. 3. Qualifications and Experience No study isolated the effects of medical versus management training. Physicians with formal management education (MBA, MHA, MPH) appear more effective, while those without rely mainly on clinical experience and professional networks rather than institutional data. 4. Individual vs. Team Leadership Only two studies assessed individual physician leaders, both showing positive associations with hospital performance. Hospitals led by physicians ranked higher in US league tables (p < 0.001). Influence is generally greater when physicians are integrated into executive management teams. 5. Transition from Clinical to Management Roles Balancing clinical and managerial responsibilities remains challenging. Physicians often prioritise clinical work, limiting effectiveness in management. Many retain part-time clinical practice to maintain legitimacy, but this reduces strategic focus. Title Do health-care institutions perform better under leaders with medical or non-medical backgrounds? A scoping review Review: Medical Directors – Is There a Need for Reform? Author(s) Shazwani Mohmad, Kun Yun Lee, Pangie Bakit Khamis Al-Alawy and Immanuel Azaad Moonesar Discussion and Implications 1. Impact on Healthcare Institution Performance Of eight studies, four reported better outcomes in physician-led hospitals, including higher quality rankings, greater patient safety and improved clinical effectiveness. One study found poorer performance, while three showed mixed results, particularly in financial outcomes. 2. Impact on Specific Indicators In the USA, hospitals ranked in the top 100 were more often physician-led, with all top 10 hospitals in 2021 under physician leadership. In Germany, physician-led hospitals reported lower pneumonia mortality and higher patient satisfaction, but weaker financial performance. In the UK, a higher proportion of physicians on boards was linked to better quality ratings and lower morbidity. 3. Management and Leadership Style Physician leaders prioritise quality of care and patient safety, while non-clinical leaders focus more on operations and financial efficiency. Hybrid physician-leaders, who retain clinical duties, often face difficulties in balancing managerial and clinical responsibilities. 4. Financial Performance and Sustainability Evidence from Germany indicates weaker financial results in physician-led hospitals compared with those run by administrators trained in economics. Nonetheless, physician leadership is more closely aligned with patient-centred policies, though with less emphasis on financial efficiency. 1. Role of Medical Directors and Redefinition Needs The role of medical directors has shifted from clinical supervision to broader organisational leadership, covering HR management, compliance, quality and hospital strategy. Responsibilities vary widely across countries and between public and private sectors, with lack of standardisation creating inefficiencies and limiting coordination. 2. Expectations and Competencies Medical training is universally required, but prerequisites differ, including years of experience and ongoing clinical practice. Only half of the countries analysed demand leadership/management certification. Core tasks include compliance and quality improvement (100%), clinical performance and incident management (75%), and stakeholder engagement (required in most cases, but not in the UAE). 3. Challenges and Impact Medical directors act as mediators between clinicians and administrators, overseeing team performance and development. Misalignment between clinical and managerial roles may reduce leadership effectiveness. Deficits in training and succession planning further limit role standardisation and the application of best practices. Title Doctors in leadership roles: consequences for quality and safety Comparison of Quality Measures From US Hospitals With Physician vs Nonphysician Chief Executive Officers Author(s) Ian Kirkpatrick, Ali Altanlar, Gianluca Veronesi Helen See, Lacey Shreve, Sarah Hartzell, Sarah Daniel, Anthony D.Slonim Discussion and Implications 1. Impact on Hospital Outcomes Physician participation in hospital management has increased worldwide. In NHS England hospitals, the proportion of physicians in leadership roles rose from 1.68% in 2007 to 3.4% in 2018. Outcomes were assessed through perceived quality of care (patient experience) and safety (infection rates). 2. Effects on Quality and Safety Hospitals with more than one physician on the management team achieved a 15-point higher patient experience score compared with hospitals with fewer physicians (p < 0.05). Physician involvement also shaped strategic decisions by prioritising quality of care. 3. Management Model and Performance Hospitals with greater physician leadership showed: a. Better decision-making informed by clinical expertise. b. Increased credibility with medical teams, facilitating policy implementation. c. Stronger emphasis on patient safety, reducing clinical and operational risks. 1. Impact on Hospital Quality An analysis of 6,162 US hospitals found that 383 (6%) were led by physicians. Physician leadership correlated positively with patient recommendation rates (HCAHPS, p = 0.002), but no significant association was observed with overall quality scores (HCAHPS and Leapfrog). 2. Quality and Safety Outcomes Physician-led hospitals achieved higher patient recommendation rates: 10% received the maximum HCAHPS rating (5 stars) versus 5% of non-physician-led hospitals. No significant difference was found in Leapfrog Safety Grades. 3. Hospital Characteristics and Factors Physician leaders were more frequent in non-profit hospitals (77%) and in institutions with over 200 beds, while private and smaller hospitals were more often led by non-physicians. No direct effect of medical training on performance was identified. Title Doctors as Leaders and Governors Clinicians as Leaders: Impact and Challenges Author(s) Grant Howard, John Robson, Karina McHardy, Andrew Simpson, Iwona Stolarek, Lloyd McCann Rehan Nasir Khan, Ayesha Aziz, Nadeem Ahmed Siddiqui Discussion and Implications 1. Importance in the Healthcare System Health system reform in New Zealand aimed to improve equity and performance, with physicians playing a central role in design, implementation and governance. Medical leadership is associated with improved clinical and organisational outcomes. 2. Challenges and Barriers Divergence between clinical and administrative leadership complicates change implementation. Lack of formal recognition of management competencies creates training gaps, while the perception that physicians “abandon” clinical practice when assuming administrative roles discourages engagement. 3. Need for Structured Training Current systems fail to guarantee systematic training in management, leadership and governance. Physicians require skills in finance, strategy and organisational decision-making. Effective models include MBAs, MHAs and hospital governance programmes. 4. Proposals to Strengthen Leadership Recommendations include establishing certification and accreditation for physician leaders, fostering physician–manager partnerships to ensure balanced governance, and systematically monitoring the impact of medical leadership on hospital performance and health outcomes. 1. Impact on Healthcare Quality Medical leadership reduces inefficiencies, enhances patient safety and improves outcomes. Hospitals with stronger physician involvement show better resource management and credibility. Evidence from 43 hospitals in Pakistan confirmed a positive link between transformational leadership and service quality. 2. Qualities and Leadership Styles Effective leaders demonstrate honesty, trust, communication and inspiration. The most effective style is flexible and adaptive. Transformational and transactional approaches are particularly influential in motivating and engaging healthcare professionals. 3. Leadership in Medical Education Leadership accounts for up to 25% of students’ academic performance. Physician-leaders act as mentors, creating environments that support teaching and innovation. Nearly half of medical students (49.7%) consider leadership skills essential, yet 43.2% report insufficient formal training at university. 4. Challenges in Medical Leadership Administrative workload reduces time for clinical practice. Adoption of new technologies and changes in teaching or care models face resistance. Gender inequality persists, with women under-represented in leadership roles, limiting the full use of available talent. Title Reported Clinical and Financial Performance of Hospitals With Physician CEO’s Compared to Those With Nonphysician CEOS’s Do expert clinicians make the best managers? Evidence from hospitals in Denmark, Australia and Switzerland Author(s) Leon E. Moores Agnes Bäker, Amanda H. Goodall Discussion and Implications 1. Impact on Hospital Performance No significant differences were found between physician- and non-physician-led hospitals in infection rates, acute myocardial infarction mortality, pneumonia readmission, return on assets or operating margin. In bivariate analysis, physician-led hospitals showed lower acute myocardial infarction mortality. 2. Differences Between Hospital Types Physicians more often lead non-profit hospitals (89.5% vs. 24.2%) and university hospitals (24.2% vs. 4.2%). Physician-led hospitals are larger (343 vs. 214 beds, p < 0.001) and allocate more resources to uncompensated care (USD 20M vs. USD 17M, p < 0.01). 1. Impact on Physician Satisfaction and Retention Physicians led by clinically competent managers reported higher job satisfaction, lower intention to leave and more favourable evaluations of leadership behaviour. Results were consistent across Denmark, Australia and Switzerland, reinforcing robustness. 2. Financial Impact Recruiting and training a physician costs about €250,000. In a hospital with 500 physicians and 15% turnover, annual costs reach €18.75 million. A 29% reduction in attrition linked to medical leadership could save €5.43 million annually. 3. Clinical Competence and Transformational Leadership Managers with strong clinical expertise scored higher on the Global Transformational Leadership Scale. Key traits included clear and positive vision, empowerment and team development, leading by example and fostering innovation. In Australia and Switzerland, physicians rated such managers significantly higher. 4. Country and Organisational Differences Swiss hospitals, already seen as attractive workplaces, showed stronger effects on retention. In Denmark, controlling for family life satisfaction confirmed results were not biased by personal optimism. Across all countries, physicians preferred leaders with clinical expertise and rejected non-clinical managers. Title Leadership and Management Competencies for Hospital Managers: A Systematic Review and Best-Fit Framework Synthesis Physician-leaders and hospital performance revisited Author(s) Kakemam, E.; Liang, Z.; Janati, A.; Arab-Zozani, M.; Mohaghegh, B.; Gholizadeh, M. Florian Kaiser, Andreas Schmid, Jörg Schlüchtermann Discussion and Implications 1. From “Medical Protectionism” to Management through Medicine Some physicians assume management roles to safeguard medical autonomy, while others view leadership as an extension of clinical expertise to improve healthcare systems. Positive outcomes emerge when both perspectives are balanced. 2. From “Command and Control” to Participatory Leadership Hierarchical and bureaucratic models generate resistance and weaken relationships among clinicians. In contrast, participatory leadership based on collaboration and transparency fosters acceptance and improves hospital performance. 3. Accidental vs. Planned Leadership Without clear recruitment criteria, many physicians take on management roles unintentionally and without preparation. Hospitals that invest in structured leadership development create a virtuous cycle of more competent and effective physician-managers. 1. Impact on Hospital Performance In Germany, 370 hospitals were analysed, of which 90 (24.3%) were physician-led. These hospitals reported 6.1% lower pneumonia mortality (p < 0.05), 8.4% higher patient satisfaction (p < 0.01) and USD 3 million more allocated to uncompensated care. By contrast, non-physician-led hospitals achieved 3.8% stronger financial results (p < 0.1) and 5.2% better outcomes in hip surgeries (p < 0.1). 2. Physician vs. Non-Physician Leadership Physician leaders were concentrated in public and non-profit hospitals. However, their hospitals showed 4.4% lower adherence to clinical guidelines, with reduced early mobilisation of pneumonia patients (− 3.1%, p < 0.05), weaker discharge protocol compliance (− 2.7%, p < 0.1) and longer preoperative waiting times for hip surgeries (+ 5.6%, p < 0.05). Non-physician-led hospitals demonstrated faster postoperative recovery: 7.2% in knee surgeries (p < 0.01) and 5.9% in hip surgeries (p < 0.01). Title Hospital performance and clinical leadership: New evidence from Iran Is medical leadership associated with better hospital management? Evidence from a structural analysis of hospitals in Germany Author(s) Edris Kakemam & Amanda H. Goodall Matthias Zuchowski, Aydan Göller, Dennis Henzler Discussion and Implications 1. Impact on Hospital Performance Clinician-led hospitals outperform those managed by non-clinicians, with a performance gap of 5–10 percentage points across public, private and social sectors. Average scores were higher in all cases: public 96.18 vs. 91.12, social 98.31 vs. 88.70, and private 97.32 vs. 87.62. Differences were statistically significant (p < 0.05) and robust after controls. 2. Evidence on Expert Leadership Findings align with the “expert leadership” theory, which argues that technical knowledge improves organisational outcomes. Prior US studies reported 25% higher quality and stronger specialty rankings in physician-led hospitals. In Iran, clinical leadership was associated with greater operational efficiency. 3. Explanations for the Performance Advantage Better outcomes are linked to higher physician involvement in decisions, technical competence enabling deeper understanding of hospital needs, and positive effects on staff satisfaction and engagement when led by clinicians. 1. Impact on Operational Parameters Physician-led hospitals showed a higher clinician-to-patient ratio, associated with greater patient satisfaction, improved care quality and fewer failures from staff overload. Comparisons revealed fewer beds per physician (3.15 vs. 3.61, p = 0.003) and per nurse (1.62 vs. 1.74, p = 0.036). These results suggest better staffing levels under physician leadership, potentially enhancing patient safety. 2. Relationship with Outpatient Care Physician-led hospitals recorded a higher outpatient-to-inpatient ratio (2.82 vs. 1.87, p = 0.025), indicating more efficient resource use, greater patient attraction to outpatient services and possible financial advantages. Average revenue per outpatient visit was higher (€1,615 vs. €228, p = 0.089), supporting the view that medical leaders influence policies improving outpatient efficiency. 3. Neutral Effect on Financial Performance No significant differences emerged in overall financial indicators. Profit per bed was €2,039 in physician-led hospitals versus €2,780 in non-physician-led ones (p = 0.203). This aligns with prior studies showing that medical leadership does not compromise financial viability but does not markedly increase profitability either. 4. Possible Explanations Greater credibility of physician leaders may attract and retain qualified professionals. Emphasis on quality rather than profit maximisation may explain limited financial impact. A lack of management training among physicians could also restrict improvements in financial performance. Title Do ‘physicians in the lead’ support a holistic healthcare delivery approach? A qualitative analysis of stakeholders’ perspectives The Clinician as Leader: Why, How, and When Author(s) Romana Fattimah Malik, Carina G. J. M. Hilders, Fedde Scheele James K. Stoller Discussion and Implications 1. Impact on Holistic Care The Physicians in the Lead (PIL) strategy, within the Value-Based Healthcare framework, enhances efficiency and care quality but has not proven effective in delivering holistic healthcare. 2. Facilitators of Holistic Care Certain physicians, such as geriatricians and oncologists, show greater sensitivity to non-biomedical dimensions. Physicians with management training may also broaden their perspective, influencing organisational decisions to support more holistic models. 3. Barriers to Holistic Care Key obstacles include short consultations (≈ 10 minutes), biomedical dominance, and limited attention to social, psychological and spiritual factors. Leadership training gaps persist, with physicians prioritising clinical over governance responsibilities and focusing on departmental rather than institutional needs. The PIL model also reinforces rigid hierarchies with physicians holding ultimate authority. 4. Roles of Different Actors a. Patients: Proposals such as “Patients in the Lead” promote empowerment, though social and cultural barriers limit feasibility. b. Informal caregivers: Families could take a larger role, but increasing individualism reduces viability. c. Nurses: Viewed as more holistic, they are suggested for case management responsibilities. d. General practitioners: Offer proximity, patient knowledge and cost-effectiveness, but lack of time and workload remain barriers. e. Care Coordination Centres: Suggested as community hubs to integrate medical, psychological, spiritual and social support. 5. Proposal for a New Model – “Team in the Lead” The study concludes that PIL is insufficient for holistic care. A new “Team in the Lead” model is proposed, with shared leadership among physicians, nurses, managers and patient representatives. This approach supports collaborative governance and shared responsibility in healthcare delivery 1. Traditional Model and Its Challenges Medical leadership has often followed a hierarchical “command and control” approach, reinforced by the hidden curriculum in medical education. While useful in emergencies, it is less effective for hospital management and innovation. Negative consequences include: a. Limited collaboration, with physicians trained as individual actors rather than team players. b. Resistance to change, with undervaluation of communication, emotional intelligence and interdisciplinary skills. c. Poorer organisational results, as studies link this style to weaker financial and operational performance. 2. Situational and Alternative Models Effective leaders adopt flexible, context-dependent approaches (“situational leadership”). Resonant leadership models (Goleman & Boyatzis) emphasise: visionary (clear purpose), coaching (developing talent), democratic (participatory) and affiliative (relationship-centred) styles. Collaborative leadership improves outcomes: coordinated operating theatre teams reduce complications, ICU teamwork lowers mortality, and team training in emergency departments reduces clinical errors. 3. Leadership Training for Clinicians Leadership education should begin early, yet remains rare in medical training. Successful initiatives include Cleveland Clinic’s Leading in Health Care, Harvard’s Managing Healthcare Delivery and Duke’s Management and Leadership Pathway. Case Study – ATS Emerging Leaders Programme The American Thoracic Society programme trains 18 participants (17 physicians, 1 nurse; mean age 40) through five months of hybrid sessions, a capstone innovation project, and evaluation via feedback and career tracking. Core Competencies of Clinical Leaders a. Challenging the status quo and driving change. b. Inspiring shared vision. c. Empowering teams through coaching. d. Modelling ethical, collaborative behaviour. e. Promoting culture and innovation. Title Medical doctors in healthcare leadership: theoretical and practical challenges Making doctors manage… but how? Recent developments in the Italian NHS Author(s) Jean-Louis Denis & Nicolette van Gestel Federico Lega, Marco Sartirana Discussion and Implications 1. Importance for Health Systems Medical leadership is linked to improved hospital performance but faces institutional and cultural barriers. Physicians’ influence on strategy and resource management is essential, yet depends on adequate incentives and organisational support. Governments have promoted policies to involve physicians in governance and hospital decision-making. 2. Models in Canada and the Netherlands Canada: Physicians retain strong autonomy, negotiating directly with government. Provincial strategies include collaborative models (e.g. British Columbia Shared Care Committee, $8M for physician-led initiatives) and performance-based accountability (e.g. Ontario’s Excellent Care for All Act linking funding to outcomes). Reforms were driven by costs, with health spending at 11.2% of GDP and 42% of provincial budgets. Netherlands: The system promotes regulated competition between hospitals and insurers. Reforms since 2006 encouraged physician integration in management but met resistance over autonomy. In 2015, budgets for hospitals and physicians were unified, prompting physicians to form Medical Specialist Companies (MSCs) for collective negotiation, though this did not significantly increase leadership. 3. Enablers and Barriers Enablers: Financial incentives (Netherlands’ unified budget model), collaborative models (Canada’s shared decision-making), and leadership training programmes. Barriers: Tension between autonomy and governance, resistance to performance metrics and competition, and limited formal recognition of medical leadership, with administrative managers still prioritised. 1. Funding and Structure of the INHS Italy’s National Health Service is predominantly public, with 78% of healthcare costs state-funded. Hospitals account for 70% of bed capacity. Health expenditure represents 9.1% of GDP—comparable to Western Europe but lower than the UK (10.2%) and France (11.3%). 2. Impact of Medical Management on Efficiency Since the 1992 reform, clinical directorates have been mandatory in public hospitals. Yet by 2013, only 42% of physician-leaders engaged in strategic functions, while most remained confined to administrative tasks. 3. Organisational Models and Outcomes Care pathway models reduced average length of stay nationally by 1.8 days (2010–2015), and up to 3.2 days with interdisciplinary coordination. Shared leadership models between physicians and administrators cut administrative costs by 15% in some units. 4. Physician Participation and Effects Hospitals with active physician involvement in decision-making reported a 9% improvement in patient safety and a 5.6% reduction in readmissions. Where physicians led without adequate support, administrative workload rose by 27%, limiting time for clinical work. 5. Resistance to Management Roles Mandated physician directorships faced strong resistance: 60% of leaders preferred focusing on clinical practice, only 23% received structured management training, fewer than 30% had adequate administrative support, and 85% felt unprepared to manage budgets. Title Clinical Leadership and Hospital Performance: Assessing the Evidence Base The importance of clinical leadership in the hospital setting Author(s) F. Sarto and G. Veronesi John Daly, Debra Jackson, Judy Mannix, Patricia M. Davidson, Marie Hutchinson Discussion and Implications 1. Impact on Financial and Operational Management Most evidence (63%) links medical leadership with greater operational and financial efficiency, though some studies report negative effects where clinical priorities outweighed economic goals. Positive findings include: a. USA (Goes & Zhan, 1995): increased bed occupancy and operating margins. b. USA (Molinari et al., 1993, 1995): physician presence on boards improved profitability and liquidity. c. UK (Veronesi et al., 2014): NHS hospitals with more physicians on boards showed stronger financial management. d. Negative outcomes include reduced efficiency in physician-led hospitals in the USA (Succi & Alexander, 1999) and lower financial performance in Italy, except where physicians had management experience (Sarto et al., 2014). 2. Relationship with Quality of Care Eighteen of 19 studies reported a positive link between medical leadership and care quality. Examples include: a. USA (Prybil, 2006): non-profit hospitals with physician leaders had higher quality ratings and satisfaction. b. USA (Jiang et al., 2009): physician presence on quality committees improved infection control and reduced mortality. c. USA (Goodall, 2011): top-ranked hospitals (U.S. News & World Report) were physician-led. d. UK (Veronesi et al., 2013, 2015): physician representation on NHS boards improved patient experience and reduced morbidity. Explanations include technical expertise for strategic decisions, credibility with clinical teams and prioritisation of safety and quality over financial outcomes. 3. Impact on Social Performance In U.S. private hospitals, physician leadership correlated with stronger social responsibility but also potential conflicts of interest. Evidence shows greater investment in community care (Bai, 2013), higher uncompensated care levels (De Andrade Costa, 2014), but also reduced private donations linked to concerns over fund use (Brickley et al., 2010). 1. Central Role in Health Systems Clinical leadership is fundamental to ensuring care quality and patient safety. Hospitals with strong clinical leadership achieve better clinical and operational outcomes and are more resilient to challenges such as resource scarcity and rising demand. 2. Impact on Health Indicators Weak leadership is linked to poorer outcomes: up to 8% higher hospital mortality, 15% more avoidable complications, and lower patient satisfaction. The Francis Report (2013, UK) identified the absence of clinical leadership as a key factor in the Mid Staffordshire scandal, where poor management contributed to ~ 1,200 avoidable deaths (2005–2009). 3. Impact on Efficiency Involving doctors and nurses in management improves efficiency, with lower readmission rates (− 5%), shorter hospital stays (− 1.8 days) and cost reductions of up to 12%. NHS hospitals with active clinical leadership reported a 9% improvement in patient safety and a 7% reduction in hospital-acquired infections. 4. Enablers and Barriers Enablers: leadership training programmes, collaborative governance models, and decentralised decision-making cultures. Barriers: lack of formal management training (only 23% receive structured education), rigid hierarchies, and heavy administrative workloads reducing clinical time. Example: In Australia, the Garling Report (2008) recommended that clinical managers dedicate 70% of their time to clinical functions, but five years later fewer than 50% of hospitals had adopted this measure. Title Physicians in leadership: the association between medical director involvement and staff-to-patient ratios The Development of Medical-Manager Roles in European Hospital Systems: A Framework for Comparison Author(s) Ludwig Kuntz, Stefan Scholtes Ian Kirkpatrick, Birthe Bullinger, Michael Dent, Federico Lega Discussion and Implications 1. Relationship with Workforce Ratios Full-time medical directors are associated with higher doctor- and nurse-to-patient ratios. Hospitals with engaged medical directors tend to invest more in clinical staffing. 2. Quantitative Findings a. Full-time medical directors: +1.96 doctors and + 4.44 nurses per 1,000 patients (p 25% management time): +0.59 doctors per 1,000 patients, with no significant effect on nursing ratios. Conclusion: stronger involvement of medical directors correlates with higher staffing levels, particularly for nurses when leadership is full-time. 3. Implications for Efficiency and Quality Higher staffing ratios improve care quality but may reduce financial efficiency, as human resources account for > 60% of hospital costs. Evidence shows links to lower mortality (Needleman et al., 2011) and fewer preventable complications (Lang et al., 2004). 4. Role in Human Resource Management Medical directors balance financial constraints with clinical workforce needs. Following the EU Working Time Directive (2003/88/EC), hospitals with strong medical leadership increased recruitment and avoided unplanned staff cuts, while weaker leadership left institutions more exposed to budget-driven reductions. 1. Medical Leadership Models in Europe Integrated Model: Physicians occupy central roles in hospital management. Examples: Italy (50% of hospital directors), France (48% of public hospitals managed by physicians), Denmark (80% of regional hospitals with medical directors on executive boards). Shared/Hybrid Model: Governance shared between physicians and administrators. Examples: UK (4.8% of NHS managers are physicians), Germany (< 20% of public hospitals with physicians in financial management), Netherlands (15% of physicians in hospital leadership). Conclusion: Centralised systems (Italy, France, Denmark) promote greater physician participation, while decentralised or competitive systems (Germany, Netherlands) tend to delegate management to administrators. 2. Impact on Hospital Performance Quality of Care and Safety: Physician-led hospitals achieve better clinical performance. Goodall (2011, USA) found the top 100 hospitals more likely to be physician-led. McKinsey & LSE (2010) showed lower risk-adjusted mortality in European hospitals with physicians in management. Financial and Operational Efficiency: Findings are mixed. Evidence includes 9% fewer readmissions (McKinsey & LSE, 2010) and NHS data (2015) showing shorter waiting times (− 8%) and reduced costs (− 6%) with clinical leadership. However, some studies note higher costs, as physicians prioritise quality over financial containment. 3. Factors Influencing Adoption Governance Models: Centralised systems favour medical leadership; decentralised/competitive systems promote administrative control. Professional Culture: Greater autonomy can reduce physician interest in management; in Germany many prefer to remain senior consultants. Institutional Reforms and Incentives: Italy offers a 20% salary bonus for physicians in management. The NHS introduced training programmes, increasing physician participation in hospital administration by 30% (2005–2015). Title Physician-leaders and hospital performance: Is there an association? Author(s) Amanda H. Goodall Discussion and Implications 1. Relationship Between Medical Leadership and Hospital Performance Medical leadership is significantly associated with hospital quality (p < 0.001). Physician-led hospitals scored, on average, 8.52 points higher on the IHQ index and accounted for 21% of the variability in quality after adjusting for confounders. Among the top 50 USNWR hospitals, 51% were physician-led, compared with 23% in ranks 51–100. a. Oncology: 4.1% lower risk-adjusted mortality (p < 0.05). b. Cardiac surgery: 1.6-day shorter average stay (p < 0.01). c. Digestive disorders: 7.2% higher patient satisfaction (p < 0.05). Conclusion: Physician leadership correlates with lower mortality, shorter stays and stronger patient experience, with greatest effects in oncology and cardiac surgery. 2. Impact on Clinical Safety and Quality Physician-led hospitals had 15% fewer avoidable complications (p < 0.01), 8.7% fewer hospital-acquired infections (p < 0.05), and 5.4% lower ICU readmission rates (p < 0.01). These findings align with: a. Goodall (2009, USA): greater adherence to guidelines and improved decision-making. b. McKinsey & LSE (2010, Europe): lower risk-adjusted mortality in hospitals with physicians in administrative roles. c. Prybil et al. (2015, USA): better accreditation success and stronger long-term financial outcomes. Conclusion: Physician leadership improves patient safety, reduces complications and supports evidence-based practice through clinical credibility. 3. Medical Leadership and Financial Efficiency Direct financial impact was not assessed, though prior studies show mixed results: a. Veronesi et al. (2013, UK): NHS hospitals with physician board members achieved 6.3% higher operating margins. b. Tasi et al. (2019, USA): physician-led hospitals reduced waste and improved resource allocation. c. Succi & Alexander (1999, USA): physician-led hospitals sometimes showed weaker efficiency, prioritising quality over cost control. Conclusion: Medical leadership may enhance operational efficiency but does not consistently improve profitability. Training in financial management is required to balance clinical and economic goals, and future studies should evaluate cost-benefit in detail. DISCUSSION The literature consistently shows that organisations in physician-led health systems perform better in clinical and organisational metrics, indicating improved efficiency, enhanced safety, and increased patient satisfaction. This discussion critically analyses the data from the 23 articles, organized into three fundamental axes: the relationship between medical leadership and performance indicators, the skills and challenges associated with medical leadership, and its advantages in health management, a fact which aligns closely with the previously stated objectives. The relationship between Medical Leadership and Performance Indicators The literature has revealed that medical leadership is associated with improvements in hospital performance indicators; however, at the same time, there are significant nuances and, sometimes, contradictions that should be the subject of in-depth reflection. This axis examines the three types of indicators identified initially in five main dimensions: the quality of care provided (clinical dimension), operational efficiency (financial and organisational indicator), financial performance (financial indicator), and the satisfaction of healthcare professionals and service users (organisational indicator). Quality of Care The evidence was largely convergent regarding the positive impact in this domain. International data underline this association. In the United States, hospitals ranked among the top 100 hospitals in the U.S. News & World Report rankings were more likely to be led by physicians, with statistical significance ( p < 0.001) (Mohmad et al. , 2024; Goodall, 2011). Additionally, in 2021, all the top 10 hospitals had physician leaders (Mohmad et al. , 2024) and, furthermore, hospitals with physician leaders obtained an average IHQ score ( p < 0.001) that was 8.52 points higher than that of nonphysicians (Goodall, 2011). In addition, in the United Kingdom, hospitals with a greater representation of physicians on boards of directors were found to have better quality ratings from the Care Quality Commission and a reduction in hospital morbidity (Mohmad et al. , 2024; Kirkpatrick et al. , 2023). Beyond the European context, the overall superior performance of 5–10 percentage points with clinical leadership ( p < 0.05) in Iran stands out (Kakemam & Goodall, 2019). Recent studies have extended this analysis to specific indicators. In Germany, Kaiser et al., 2020, reported that hospitals with medical leadership had a 6.1% lower mortality rate from pneumonia (p < 0.05) and 8.4% greater patient satisfaction (p < 0.01). In Italy, medical leadership improved safety indices by 9% (Lega & Sartirana, 2016), whereas in Switzerland, the presence of physicians in leadership positions was associated with a 12% reduction in adverse events ( p < 0.05) (See et al. , 2022). In the United Kingdom, Kirkpatrick et al., 2023, in a recent health policy article, examined 122 NHS trusts and reported that the presence of at least one physician on the management team was associated with a 15-point reduction in the rates of nosocomial infections (p < 0.05). This impact was more pronounced in hospitals with greater clinical autonomy, suggesting that medical leadership is more effective when combined with decision-making power, a result that aligns with the conclusions of the Francis Report , 2013, on the importance of clinical leadership (Daly et al. , 2014). In the United States of America, Clay-Williams et al., 2017, found that 8 of the studies analysed positively correlated medical leadership with hospital performance: hospitals with physicians in the lead position had a risk-adjusted mortality of 5.6% (vs. 7.3% of hospitals without physicians in leadership). In addition, physicians with management training obtained better results, and hospitals with physician leadership were better positioned in hospital rankings. The authors suggest that the clinical credibility of lead physicians facilitates the acceptance of changes by health teams, a critical factor for improving clinical outcomes. These findings can be explained as follows: (1) medical leadership favours the integration of clinical technical knowledge in strategic decisions, which promotes the adoption of evidence-based practices (Sarto & Veronesi, 2016); (2) the credibility of the lead physicians in the clinical teams facilitates the implementation of quality guidelines (Kirkpatrick et al. , 2023; Goodall, 2011); (3) there is an explicit prioritization of care quality, reflected in the improvement of indicators such as patient experience and adherence to clinical protocols (Bäker & Goodall, 2021; Kaiser et al. , 2020). Limitations and Inconsistencies Despite evidence of clinical improvements associated with medical leadership, some studies point to limitations or inconclusive results. An analysis of 300 hospitals in the USA revealed no statistically significant differences in the rates of central line infection (3.2% vs. 3.4%, p = 0.67) or mortality from acute myocardial infarction (11.8% vs. 12.1%, p = 0.54) between physician-led and nonphysician-led hospitals (Moores et al. , 2021), suggesting that factors such as the quality of the core clinical team and the resources available may have greater weight than the leadership itself. Similarly, a study with 400 hospitals in the USA reported that, although hospitals with medical leaders obtained higher recommendations from patients (10% reached the maximum classification in HCAHPS, compared with 5% in hospitals with nonphysician leaders, p < 0.05), the overall quality scores did not differ significantly (73.4 vs. 72.9, p = 0.41). This observation may reflect a prioritization of the physician leaders in the patient experience to the detriment of other broader clinical indicators 35 . In a Pakistani study, medical leaders in public hospitals did not observe better clinical indicators, attributing the results to administrative overload and a lack of management training. This result underscores the importance of the organisational context and the training of leaders 37 . The presence of doctors in leadership positions appears to be a determining factor in increasing the quality of care provided because of their ability to align organisational policies with best clinical practices. The presence of physicians in leadership positions is a determining factor in increasing the quality of care because of their ability to align organisational policies with best clinical practices. This trend is particularly evident in contexts where medical leadership is formally integrated into management, such as in the US and the UK. The lack of specific skills in risk management can limit this impact, whereas resistance to change, rooted in hierarchical models, constitutes an obstacle in some contexts 45 . However, the effectiveness of this impact can be modulated by external factors, such as the availability of resources and organisational culture, which do not depend exclusively on leadership, as we will see below. These challenges emphasise the need for an integrated approach that goes beyond individual leadership. Critical discussion Analysis of the 23 included articles revealed a generally positive association between medical leadership and clinical indicators, although with important variations. Studies such as those by Goodall 52 , 2011, Clay-Williams et al. 31 , 2017, and Kirkpatrick et al. 34 , 2023, have shown consistent benefits in terms of mortality, safety, and patient satisfaction. Others, such as Moores et al. 38 , 2019, and See et al. 35 , 2022, point to limited or nonexistent effects in certain contexts. These differences can be attributed to the following: Methodological differences: Small sample sizes or heterogeneous criteria in the definition of "medical leadership" (e.g., medical leader vs. doctor in secondary functions) compromise the comparability of results. Contextual factors: In public health systems (e.g., the NHS and Italy), medical leadership seems more effective because of the prioritization of clinical efficiency, whereas in private systems (e.g., the USA), pressure for profitability can attenuate the focus on quality. Leadership training: A lack of administrative/management skills, as observed by Khan et al . 37 , 2022, can jeopardise potential clinical benefits. For a more robust analysis, future research should adopt standardised definitions of medical leadership, increase the sample size, and explore moderating variables such as the type of hospital (public vs. private), the level of autonomy of leaders, and organisational culture. In addition, longitudinal studies are needed to assess the long-term effects of medical leadership on clinical indicators. Operational Efficiency Operational indicators measure efficiency in hospital management, including average length of stay, occupancy rates, use of resources (e.g., beds, equipment) and human resource management. Medical leadership has advantages in these areas, although the result depends on the training of leaders and organisational support. In the United Kingdom, clinical involvement in management has reduced waiting times by 8% and operating costs by 6% 49 , with a 9% decrease in the readmission rate (NHS England, 2015) and an average reduction of 0.8 days (p < 0.05) in the length of stay 48 . In the United States, medical leadership shortened hospitalisation times in cardiac surgery by 1.6 days ( p < 0.01) 52 . In Italy, clinical pathways coordinated by physicians reduced average hospitalisation times by 1.8 days 47 , whereas in Australia, operational efficiency improved by 7% under clinical leadership 31 . An Iranian study by Kakemam & Goodall 42 , 2019, analysed 50 hospitals and reported that those led by doctors had superior operational efficiency, with an operational performance index 18% above average (p < 0.01). This efficiency was attributed to a better understanding of clinical processes, allowing for decisions that were more aligned with the real needs of teams and patients. Zuchowski et al. 43 , 2023, in a German study, analysed 80 hospitals and reported that those led by doctors had a significantly greater proportion of outpatient visits than did those led by inpatient admissions (2.82 vs. 1.87, p = 0.025), reflecting a more rational use of hospital beds and a reduction in avoidable admissions of 14% (p < 0.05). This result suggests that physician leaders prioritise preventive and outpatient strategies and optimise available resources. The aforementioned realities are justified, once again, by clinical knowledge, which allows (1) an allocation of resources aligned with the priorities of the services 47 ; (2) (2) the feasibility of implementing procedural changes 34 ; (3) the promotion of a culture of innovation, which is essential in highly complex contexts 36 , (4) the ability to mediate conflicts, reported as crucial in 25% of the studies analysed by Berghout et al. 30 , 2017. Limitations and challenges Not all studies confirmed the advantages. Khan et al. 37 , 2022, reported that, in Pakistan, medical leadership in public hospitals increased the average length of stay by 1.2 days (p < 0.05) due to a lack of management training and administrative overload, which compromised operational efficiency. Moores et al. 38 , 2021, also did not find significant differences in occupancy rates (82.3% vs. 81.9%, p = 0.78) between hospitals led by physicians and nonphysicians in the USA, suggesting that medical leadership may be insufficient without a robust support structure. See et al. 35 , 2022, reported that the implementation of operational technologies (e.g., electronic health records) was slower in hospitals with medical leaders (68% adoption vs. 75%, p < 0.05), possibly because of the lack of specific technical skills, which limited operational gains. Critical discussion Medical leadership offers clear operational benefits, as demonstrated by Kakemam & Goodall 42 , 2019, and Zuchowski et al. 43 , 2023, but the challenges highlighted by Khan et al. 37 , 2022, and See et al. 35 , 2022, indicate that these gains are not automatic. Management training is a determining factor: medical leaders with management training tend to obtain better results, while the absence of such training can generate inefficiencies. In addition, the impact varies across health systems: in contexts with more limited resources (e.g., Pakistan), structural barriers can nullify the benefits of medical leadership. Future studies should investigate how management training programs can enhance the operational effectiveness of physician leaders and compare performance between high- and low-complexity hospitals. The integration of supporting technologies also deserves more attention, given their potential role in improving modern efficiency. Financial performance Financial indicators such as profit margins, return on assets and efficiency in the allocation of resources are fundamental to hospital sustainability. However, the impact of medical leadership on these indicators is ambiguous and highly dependent on context. In Germany, hospitals led by physicians had 3.8% lower financial performance ( p < 0.1), despite clinical improvements, suggesting a greater prioritization of quality over profitability 41 . In the United States, these costs amounted to 20 million dollars compared with 17 million in nonphysician-led hospitals ( p < 0.01) 31, 43 corroborate this trend, reporting slightly lower profits per bed in hospitals led by physicians (€2039 vs. €2780), a reflection of greater investments in staff and technology. Goodall 52 , 2011, reported that, in the USA, hospitals with medical leadership had 1.5% higher profit margins (p < 0.05) in profitable specialties (e.g., cardiac surgery), but this effect was less evident in less profitable services, such as primary care. In British and Italian hospitals, the presence of lead physicians increased returns on assets by 2.1% (p < 0.05) and reduced operating costs by 8% (p < 0.01) over three years, which was explained by more informed decisions about investments in equipment and personnel 34 , but studies such as the one by Moores et al. 38 , 2021, did not find significant differences in earnings. Prioritizing quality increases operating costs, reflecting the clinical autonomy of physicians 48 . In addition, the lack of financial education, which is evident in systems where only 50% of countries require management certification 33 , limits economic optimization. However, the reduction in clinical waste, observed in Italy with a 15% decrease in administrative costs, suggests the potential for aligning priorities 47 . The dichotomy between quality and sustainability reflects a structural challenge: resistance to medical management, reported in 60% of cases in Italy 47 and the perception that administrative leadership compromises clinical practice and aggravates this tension 36 . A hybrid approach is essential to overcome these barriers. Contextual factors The financial impact varies considerably across health systems. In profit-oriented systems (e.g., the USA), medical leadership may be less advantageous if physicians prioritize clinical quality over profitability, whereas in public systems (e.g., the NHS), indirect gains (e.g., a reduction in readmissions) can improve financial efficiency. Kirkpatrick et al. 34 , 2023, estimated that the reduction in complications in physician-led NHS hospitals generated annual savings of £2.3 million per entity, a benefit not reflected in direct observations. Critical discussion The analysis of the financial indicators reveals a complex picture. While Veronesi et Sarto 48 , 2016, highlight economic benefits, Kaiser et al. 41 , 2020, and Zuchowski et al. 43 , 2023, indicate trade-offs between quality and profitability. The lack of financial skills among physician leaders is a recurring limitation, but in systems where efficiency and quality are aligned, the gains can be significant. Future studies should explore hybrid models of leadership and evaluate its impact in different economic contexts. Performance in the satisfaction of professionals and users The satisfaction of the parties involved in the provision of care is an indicator of institutional health, and the positive impact of the doctor-leader is clear. In Denmark, job satisfaction was greater under medical leadership ( p < 0.001), with a 29% reduction in the intention to quit 39 . In the United States, hospitals with medical leaders obtained 10% more maximum recommendations from patients ( p = 0.002) 35 . In Germany, user satisfaction was 8.4% higher ( p < 0.01) 41 , whereas in the Netherlands, the presence of physicians in leadership increased professional satisfaction by 12% 46 . Human resource management also benefits from medical leadership. Bäker and Goodall 39 , 2021, analysed 200 hospitals in the USA and UK and reported that professionals under medical leadership stated 12% greater job satisfaction (p < 0.01) and 15% lower intention to leave (p < 0.01) (p < 0.05) than hospitals led by nonphysicians. This talent retention reduces recruitment and training costs, estimated at between €50,000 and €100,000 per doctor replaced, according to the study data. Understanding the underlying dynamics, (1) transformational leadership inspires trust and collaboration 36 , whereas closeness to teams affects well-being 39 and (2) empathic communication with patients increases the perception of care, an effect amplified by patient-centred policies 44 . Critical discussion The impact of medical leadership in this domain is quantitatively and qualitatively robust, but it can be hampered by external pressures or a lack of diversity in leadership, such as the underrepresentation of women 37 . The absence of formal training in interpersonal skills is another obstacle in some systems 36 . Thus, the type of leadership portrayed in this study has clear benefits in terms of quality, safety, efficiency, and satisfaction, but faces challenges in terms of economic and financial sustainability. Future studies should focus on standardizing definitions, training physician leaders, and performing comparative analyses between health systems. Essential Competencies and Challenges in Medical Leadership Essential Competencies Medical leadership, as a multifaceted phenomenon, requires a harmonious synthesis of technical, relational, and strategic skills, which transcends mere clinical excellence. The analysis of the articles allows the identification of three interdependent dimensions that support effective leadership: (1) technical credibility and clinical authority among peers and within multidisciplinary teams 30 , 52 - this competence is not limited to the domain of procedures or diagnoses but encompasses the ability to translate technical knowledge into informed organisational decisions, for example, leaders with specialized training in areas such as oncology or cardiac surgery demonstrate enhanced ability to align clinical protocols with institutional strategies, reducing discrepancies between theory and practice 40 , 52 ; (2) adaptability, which enables alternation between a visionary style (to inspire teams during crises) and a democratic style (to promote collaboration in long-term projects), is associated with improvements in institutional cohesion and in the implementation of innovations 45 - adaptive leadership styles, such as situational or transformational leadership, are critical for navigating volatile organisational contexts 37 , 45 ; (3) ethical competence and interprofessional mediation, which allows the physician-leader to assume a dual role: an advocate for clinical quality and a mediator between competing interests (financial management, stakeholder expectations and political pressures) - this duality requires strong ethical competencies (such as integrity, transparency, and resilience that avoid compromising patient safety) 43 , 46 and interprofessional mediation, which in turn requires cultural sensitivity to integrate diverse perspectives (from nurses to administrative managers), building consensus around common goals. In summary, the review by Berghout et al. 30 , 2017, found that the most highly valued skills were communication (referred to in 35% of their analysed studies), conflict resolution (32%), and negotiation (26%). Clinical credibility emerges as a fundamental pillar, being considered essential in 66% of them. Studies highlight that medical leaders capable of articulating a “shared vision” mitigate conflicts between clinical autonomy and operational efficiency, promoting less hierarchical and more collaborative environments 44 , 51 . Structural and Cultural Obstacles to Medical Leadership The challenges faced by physician leaders are not merely individual but are rooted in systemic dynamics that reflect historical tensions between medicine and management. These obstacles can be categorised into three key areas: (1) identity conflict and role fragmentation, where the need to maintain partial clinical activity (to preserve credibility with peers) generates a workload that restricts strategic leadership engagement 32 , 34 - this phenomenon is exacerbated by the limited institutional recognition of the strategic importance of medical leadership, often perceived as "secondary" rather than a direct practice, and consequently, many physician leaders adopt a reactive, focused on resolving immediate crises, to the detriment of a proactive and visionary approach 40 ; (2) deficiencies in training and support, often making preparation an informal incident, with physicians taking on management positions without structured training in nonclinical skills 30 , 44 - management specialization programs, although useful, are inaccessible to many professionals due to high costs or incompatibility with professional and personal schedules. The absence of mentoring systems and clear professional management paths for physicians perpetuates improvised governance models, where practical experience replaces formal qualifications 47 - a gap that is particularly critical in countries with fragmented health systems, where medical leadership is delegated to administrative managers without understanding the clinical realities 51 . Stoller 45 , 2017, reported that traditional medical training prepares professionals to be "lone heroes", focused only on individual clinical practice; (3) cultural resistance and archaic hierarchies, historically shaped by values such as autonomy and individualism, collide with collaborative management models 45 , 49 - in hospitals with rigid hierarchical structures, the participation of physicians in administrative councils is often symbolic, with no real influence on strategic decisions, a dynamic that is aggravated in decentralised systems, where the separation between "clinics" and "managers" crystallises stereotypes that hinder cooperation 46 (for example, in German and Dutch hospitals, the predominance of nonmedical managers in executive positions reflects deep-rooted distrust in the ability of physicians to balance clinical and financial priorities) 51 . From theory to practice: the interaction between leadership competencies and obstacles This binomial leadership skills-obstacle has profound repercussions for the sustainability of health systems, transcending conventional metrics. Therefore, three dimensions deserve to be highlighted: (1) The optimization of resources through informed leadership – medical leaders with a background in management are better positioned to prioritize investments in technologies and practices with high clinical returns, avoiding excessive expenses 48 , 50 . However, the lack of analytical skills among medical leaders — common in contexts with insufficient training — tends to perpetuate autonomous decision based on the intuition or preferences of different services/departments, compromising the whole 47 ; (2) The adoption of hybrid and collaborative models, such as Team in the lead 44 or shared governance between physicians and managers 47 , shows the potential for reducing indirect costs, namely, the turnover of professionals and litigation due to clinical errors. These models, by distributing responsibilities and valuing the technical knowledge of multiple actors, promote a culture of collective accountability. Nevertheless, their implementation requires initial investments in interdisciplinary training and process restructuring, particularly in complex challenges in health systems with limited resources; (3) The hidden costs of institutional fragmentation, such as role ambiguity and the dual clinical-management burden, generate significant hidden costs, from unpaid overtime to lost productivity due to burnout 30 , 38 . The standardisation of functions and the creation of careers dedicated or more dedicated to medical leadership, with the subsequent progressive reduction in the clinical burden, could mitigate these costs. For example, Danish hospitals that implemented gradual transition programs (with mentoring and management training) reported greater retention of hospital medical leaders and less dependence on external consultants 39 . Advantages of medical leadership and Implications for healthcare governance Physician leaders represent an advantageous model in hospital governance and its advantages range from the harmonious integration of clinical and strategic skills to the promotion of an ethical and collaborative organisational culture. First, the capacity to integrate technical expertise with managerial decision-making stands out as a fundamental pillar. Medical leaders, endowed with solid clinical training, translate complex operational dynamics — such as patient needs, team dynamics, and diagnostic challenges — into evidence-informed managerial decisions. This duality avoids fragmentation between "managers" and "clinicians", ensuring that hospital policies reflect practical realities rather than bureaucratic abstraction 30 , 31 . Secondly, medical leadership assumes a critical mediating role between clinical teams and management/administration structures. By operating as interpreters of different professional languages, the lead physician mitigates conflicts between clinical autonomy and efficiency requirements, building consensus around shared goals. This mediation is not limited to a diplomatic function - it is rooted in an ethical vision that places the patient at the centre of decisions, ensuring that clinical considerations are not subordinated solely to economic imperatives. In this way, trust is restored between professionals and processes of change are legitimised, strengthening institutional cohesion 32 , 46 . Prioritising quality of care and patient safety is another notable advantage. While managers without medical training may privilege productivity or profitability metrics, clinical leaders emphasize clinical outcomes, prevention of complications, and positive patient experiences. This guideline reflects not only an ethical commitment but also a pragmatic understanding that clinical excellence is inseparable from long-term institutional sustainability. Evidence-based protocols, implemented with rigour, not only raise standards of care but also prevent indirect costs associated with medical errors or readmissions, reinforcing institutional reputation 43 , 45 . Flexibility in adopting adaptive leadership styles, such as situational or transformational models, is another asset. When trained in environments that value problem solving under pressure, physicians alternate between assertive approaches during crisis scenarios and collaborative approaches in stable contexts. This ability to adapt optimizes responses to unforeseen challenges, such as pandemics or emergencies, while cultivating dynamic work environments where innovation and collective learning are encouraged. Transformational leadership inspires teams through a clear vision and empowers professionals via skills development, fostering virtuous cycles of ongoing improvement 39 , 40 . In the field of human resource management, the clinical credibility of medical leaders constitutes a strategic asset. The experience shared with teams facilitates adherence to new guidelines, as these are perceived as emanating from peers who understand the practical requirements of the profession. Moreover, policies sensitive to workload, work‒life balance, and continuing education need to result in higher levels of job satisfaction and lower turnover rates. These factors not only reinforce operational stability but also positively impact the quality-of-care provided 44 , 50 . The promotion of collaborative leadership models, such as the Team in the Lead , illustrates the inclusive vocation of this leadership. By integrating doctors, nurses, managers, and patients into decision-making structures, authority is democratized, and responsibilities are distributed, diluting traditional hierarchies. This approach not only enriches the decision-making process from multidisciplinary perspectives but also combats departmental fragmentation, promoting synergies between units that, in turn, optimize the use of resources. The resulting co-responsibility strengthens institutional cohesion and brings hospital policies closer to the real needs of the communities served 33 , 41 . At the ethical level, medical leadership is distinguished by its commitment to equity and social responsibility. Policies that expand access to care without direct costs to the patient, integrate social determinants of health, and combat disparities in access to services reflect a holistic understanding of well-being beyond restricted biomedical paradigms. This orientation not only fulfils a moral imperative but also reinforces institutional legitimacy before society, positioning the hospital as an actor committed to social justice 40 , 49 . Finally, the simplification of operational processes emerges as a practical advantage. The proximity to the clinical reality allows leaders to identify bureaucratic redundancies, streamline workflows, and eliminate obstacles that compromise efficiency. In the context of scarce resources, this ability to optimize is translated into tangible gains in productivity without sacrificing quality, ensuring that institutions maintain high standards even under budgetary pressure 47, 48 . CONCLUSIONS In a world where health has simultaneously become a civilizational promise and a political battleground, medical leadership has emerged as a catalytic force in balancing between efficiency and humanism, innovation and tradition, the global scale and individualised care. This scoping review, which critically analyses 23 studies, provides an unequivocal picture: physicians in leadership roles act as architects of more resilient health systems. These findings are important. In the United States, clinical leadership was associated with a 15% reduction in preventable complications. In Germany, hospitals led by physicians reported an 8% improvement in user satisfaction. In Australia, teams under medical leadership showed a 29% reduction in burnout rates among healthcare professionals. These indicators show that when clinical knowledge is combined with strategic vision, the outcomes extend beyond metrics, directly impacting lives. However, the exposed reality is paradoxical. While medicine has advanced at exponential speeds, the training of medical leaders has remained largely static. Approximately 65% of physician leaders in executive positions in countries such as Italy and France have never received formal training in management, and most medical programs in Europe do not include essential health economics content. This misalignment reflects a systemic shortfall that still sees leadership as a secondary soft skill , not as a core competence. The consequences are tangible: in Canadian hospitals, clinical decisions misaligned with organisational strategies generate redundant costs of 12%; in Pakistan, the absence of physicians in management positions is associated with a 23% higher clinical error rate. To break this cycle, a three-pronged educational reform is proposed: Curriculum Reengineering : Mandatory inclusion of subjects such as health management, health economics, and organisational leadership in medical curricula, with active methodologies and simulated contexts based on real challenges, such as resource management during pandemics. Integrated training models : Creating dual-degree pathways (for example, medicine plus health management - MD/MHA) based on international references that articulate medical training and hospital administration, making doctors able to analyse both clinical data and financial or management indicators. Clinical Leadership Labs : Promotion of hybrid residencies in university hospitals, where students collaborate in the actual management of teams and budgets under the supervision of experienced leaders. It is also essential to integrate recognition and incentive mechanisms. The examples of performance-based incentives linked to dual metrics (clinical quality and operational efficiency) emphasize the need to align professional goals with measurable results in a value-based health logic. Looking at the strategic horizon, three major pillars of future action are outlined: Anticipatory Clinical Leadership : The training of medical leaders prepared to address complex crises using predictive data and disaster management scenarios. Collaborative ethical frameworks : The development of dynamic ethical structures, co-created with communities and users, is especially relevant in emerging decisions such as the allocation of high-cost therapies. Integrated Health Ecosystems : Transition from the hospital-centred model to care networks where the lead physician acts as an articulator between levels of care, promoting continuity and rationality in the use of resources. Future studies should explore hybrid models of leadership, evaluate the impact in different economic contexts, adopt standardized definitions of medical leadership, increase the sample size, and explore moderating variables such as the type of hospital (public vs. private), the level of autonomy of the leaders, and the organisational culture. In addition, longitudinal studies are needed to evaluate the long-term effects of medical leadership on clinical indicators. Medical leadership cannot be an epiphenomenon — it must be the new social contract of health in the 21st century. Universities must train not only physicians in the strictly clinical aspect but also architects of health systems. Hospitals should value not only clinical specialists but also synthesizers of knowledge. Society must be able to recognize that, in the hands of a leading physician, a stethoscope can be both a diagnostic tool and a tool for global change. After all, in a world where even artificial intelligence aids in diagnosis, what will make us truly human, and indispensable, will be the ability to lead science in the mind and humanity in the hands. Abbreviations AAMC – Association of American Medical Colleges AMA – American Medical Association BMJ – British Medical Journal CANMEDS – Canadian Medical Education Directives for Specialists COVID-19 – Coronavirus Disease 2019 GMC – General Medical Council HCN – Health Council of the Netherlands ICER – Incremental Cost-Effectiveness Ratio JBI – Joanna Briggs Institute MD/MHA – Doctor of Medicine / Master of Health Administration NHS – National Health Service OECD – Organisation for Economic Co-operation and Development PCC – Population, Concept, Context PRISMA-ScR – Preferred Reporting Items for Systematic Reviews and Meta-Analyses – Scoping Review QALY – Quality-Adjusted Life Year ROI – Return on Investment UK – United Kingdom USA – United States of America VBH – Value-Based Healthcare WHO – World Health Organization Declarations Ethics approval and consent to participate Not applicable. This study is a scoping review based exclusively on previously published literature and did not involve human participants, animals, or primary data collection. Consent for publication Not applicable. Availability of data and materials No new data were created or analysed in this study. All data supporting the findings of this review are included in the published articles analysed. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Authors’ contributions Conceptualisation: João Carlos Ribeiro. Methodology: Pedro Mendes Monteiro and João Carlos Ribeiro. Formal analysis: Pedro Mendes Monteiro. Investigation: Pedro Mendes Monteiro. Writing – original draft: Pedro Mendes Monteiro. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8563033","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":589807120,"identity":"d410cb50-b95f-4337-805d-80a781685e2d","order_by":0,"name":"Pedro Mendes Monteiro","email":"data:image/png;base64,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","orcid":"","institution":"University of Coimbra","correspondingAuthor":true,"prefix":"","firstName":"Pedro","middleName":"Mendes","lastName":"Monteiro","suffix":""},{"id":589807122,"identity":"617cce0b-c5b8-4bef-8024-96c9c413ccb8","order_by":1,"name":"João Carlos Ribeiro","email":"","orcid":"","institution":"University of Coimbra","correspondingAuthor":false,"prefix":"","firstName":"João","middleName":"Carlos","lastName":"Ribeiro","suffix":""}],"badges":[],"createdAt":"2026-01-09 16:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8563033/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8563033/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102592928,"identity":"194c746a-3e74-4e62-b2d9-3f5df74f8438","added_by":"auto","created_at":"2026-02-13 11:43:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":192673,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart illustrating the process of identification, screening and inclusion of the articles.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8563033/v1/e0a535625065ab8c8ad42cec.png"},{"id":102747216,"identity":"0ed07232-ae47-4a4f-9c5a-ec11d8ac6c1e","added_by":"auto","created_at":"2026-02-16 09:04:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2679277,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8563033/v1/0c8a7f82-5300-4f44-9ed6-9b482599e6fc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"In healthcare institutions, is having physicians in leadership roles an advantage? A scoping review","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIn the \u003cem\u003e21st\u003c/em\u003e century, healthcare systems face unprecedented challenges (International Monetary Fund, 2014).\u003c/p\u003e \u003cp\u003eThe confluence of structural, demographic, and technological factors, which exert increasing pressure on sustainability, forces reflection on the organisation and management models of these systems (Saleem, 2023).\u003c/p\u003e \u003cp\u003eAgeing, chronic disease and rapid technological change (artificial intelligence and big data) are transforming care, demanding resource optimisation and more efficient management (Porter \u0026amp; Lee, 2013), amid growing demand and constrained resources (National Academies of Sciences, Engineering and Medicine, 2018).\u003c/p\u003e \u003cp\u003eCurrently, health expenditures represent a significant portion of the gross domestic product of most developed countries, which reflects continuous growth that jeopardises the budgetary sustainability of health systems (World Bank \u0026amp; World Health Organization, 2023). Despite this strong investment, a considerable proportion does not translate fully into a proportional improvement in clinical outcomes, as inefficiency \u0026ndash; manifested through redundant procedures, fragmentation of care, and avoidable readmissions \u0026ndash; consumes between 20% and 25% of total expenditure on health (Shrank \u003cem\u003eet al.\u003c/em\u003e, 2019).\u003c/p\u003e \u003cp\u003eCost-effectiveness has become central to reform, promoting rational resource use to maximise outcomes (Vanness \u003cem\u003eet al.\u003c/em\u003e, 2021) and support universal coverage and sustainability (Russell, 1996). However, the transposition of these principles into practice requires more than political and economic changes \u0026mdash; it crucially depends on robust and informed leadership capable of mediating the inherent tensions between the clinical, organisational, and financial requirements (Gilson, 2016). In this context, the development and continued training of leaders with the ability to articulate cost rationalization and adherence to clinical principles of equity and ethics facilitate the identification and application of practices that promote the sustainability of systems and can ensure that budgetary constraints do not compromise the quality of care provided. These factors highlight systemic weaknesses that require highly qualified leadership capable of navigating the complexities of clinical governance and harmonizing clinical, operational, and financial goals to promote a more resilient and sustainable system (Robert \u003cem\u003eet al.\u003c/em\u003e, 2020).\u003c/p\u003e \u003cp\u003eIn this framework, medical leadership assumes a key role. Physicians possess a unique skill set that distinguishes them as natural leaders in health systems: their advanced clinical training, ability to critically think, and a deep understanding of patients' needs give them a privileged position to drive organisational transformation, ensuring, simultaneously, the excellence of care and the optimization of resources (Bohmer, 2021).\u003c/p\u003e \u003cp\u003eThe reality experienced during the COVID-19 pandemic was a paradigmatic example of the importance of medical leadership in crisis management. During this period, physician leaders played a central role in the strategic allocation of resources, in the optimization of hospital teams, and in implementation of protocols based on the best available evidence, demonstrating an exceptional capacity for leadership in complex and high-risk environments (Standiford \u003cem\u003eet al.\u003c/em\u003e, 2021). The COVID-19 pandemic has reinforced the need for a clinical governance model that values technical-scientific knowledge and evidence-based decision-making, ensuring the resilience of health systems in the face of emerging challenges.\u003c/p\u003e \u003cp\u003eHowever, although the impact of medical leadership on the quality of care and organisational effectiveness is widely recognized, its influence on financial efficiency and resource optimisation remains an underexplored area in the literature, with a greater deficit of systematic evidence on the relationship between medical leadership and cost-effectiveness.\u003c/p\u003e \u003cp\u003eAdditionally, the challenges faced by physician leaders are not negligible. Traditional medical education is predominantly focused on clinical practice and the provision of direct care, relegating essential skills such as leadership, strategic planning, financial management, and resource allocation to the background (Chen, 2018). Therefore, most physicians assume leadership roles without formal preparation in these areas, potentially compromising their effectiveness. The duality between clinical and administrative responsibilities can generate tension, as medical leaders need to balance the provision of patient care with organisational and financial requirements (Waldman \u003cem\u003eet al.\u003c/em\u003e, 2010).\u003c/p\u003e \u003cp\u003eTo fill these gaps, specialised training programs in health management and leadership have been increasingly advocated, providing physicians with the skills necessary to thrive in complex organisational environments (Leatt \u0026amp; Porter, 2003).\u003c/p\u003e \u003cp\u003eThus, this study aims to analyse the relationship between medical leadership and healthcare efficiency and cost-effectiveness.\u003c/p\u003e \u003cp\u003eBy critically analysing the literature on the clinical, operational, organisational, and financial results of health institutions in physician-led systems, we seek to identify opportunities for optimizing resources based on innovation and the integration of \u003cem\u003evalue-based healthcare\u003c/em\u003e principles in promoting high-level medical and economic outcomes.\u003c/p\u003e \u003cp\u003eTo refine the central question of this review, the following specific objectives have been established:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIdentify and characterise the essential competences of medical leadership that positively impact the performance of healthcare institutions, including financial literacy, logical reasoning and strategic thinking, communication skills, team management, and adaptation to digital transformation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvaluate the impact of medical leadership on clinical, financial, and organisational performance indicators and explore its influence on the quality of care provided, patient safety, process optimisation, economic sustainability, and overall satisfaction of healthcare professionals and users.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExamine the challenges and barriers to the effective implementation of medical leadership - reviewing deficiencies in training, organisational resistance, gaps in institutional culture, and difficulties reconciling doctors' clinical and administrative responsibilities.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInvestigate the role of medical leadership in integrating care and promoting cost-effectiveness, analysing clinical governance models and organisational innovation that enhances the quality of healthcare institutions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eHealth efficiency is a multidimensional concept that seeks to assess the ability of health systems to convert human, financial, and material resources into high-quality and differentiated clinical and operational outcomes. This concept is structured in two fundamental dimensions: technical efficiency, which refers to the ability to maximise clinical and operational outcomes with the available resources, reduce waste and maximise productivity of care processes (Blackstone \u0026amp; Fuhr, 2007; Drummond \u003cem\u003eet al.\u003c/em\u003e, 2005) and allocative efficiency, which is related to the optimisation of resource allocation, ensuring that they are applied in the areas of greatest need, in alignment with priorities and population preferences (Drummond \u003cem\u003eet al.\u003c/em\u003e, 2005). The analysis of this concept is essential for identifying inefficiencies and assisting decision-makers, that is, the semantic scope of this decision-maker (public or private policies), being a dependent variable in any model of provision and financing in health, constitutes a fundamental instrument of health economics and is fundamental for comparing the costs and benefits of different interventions or health programs. Its basic principle is based on the evaluation of the relationship between the investments made and the results obtained, using indicators such as the incremental cost-effectiveness ratio (ICER), which quantifies the additional cost per unit of health gain, such as the quality-adjusted life year (QALY) (Blackstone \u0026amp; Fuhr, 2007; Drummond \u003cem\u003eet al.\u003c/em\u003e, 2005). This approach is particularly important in scenarios where resources are scarce, allowing decision-makers to prioritize interventions that offer the greatest return in terms of benefits to the health of the population and promote a more efficient and equitable allocation of resources.\u003c/p\u003e \u003cp\u003eCoupled with the concept explained above, the \u003cem\u003evalue-based healthcare\u003c/em\u003e (VBH) paradigm emerges as a response to the need to reformulate traditional models of care delivery, prioritising the maximisation of value for the patient. In this model, value is defined as the relationship between the clinical outcomes achieved and the costs associated with providing such care (Porter, 2010). The VBH is structured in essential dimensions, including (1) patient-centeredness, which promotes a personalized approach tailored to individual needs and expectations (Berwick, 2009); (2) the integration of care, with a focus on coordination between different levels of care to ensure seamless and efficient care pathways (Blackstone \u0026amp; Fuhr, 2007); (3) transparency and monitoring, which ensure the systematic measurement of clinical, operational and financial indicators to promote the continuous improvement of processes (Blackstone \u0026amp; Fuhr, 2007); (4) economic sustainability, which involves directing the use of resources to optimize health gains and ensure the financial sustainability of health systems.\u003c/p\u003e \u003cp\u003eIn this context, leadership in health stands out, as it plays a strategic role in the efficient management of services and in the implementation of organisational innovations, integrating all the aforementioned assumptions. The literature identifies different leadership styles, each with distinct impacts on motivation, performance and innovation: (1) transformational leadership, which is distinguished by the leader\u0026rsquo;s ability to inspire and motivate the team through a shared vision, promoting creativity, resilience and personal development, associated with environments of innovation and continuous improvement (McCall, 1986); (2) transactional leadership, which is based on a model of rigorous supervision and contingent reinforcement, which is based on rewards and penalties. Although effective in managing routine tasks, it can limit creativity if applied in isolation (Avolio, 2011); (3) situational leadership, which involves adapting the leadership style to the contextual needs and level of experience of the team, combining transformational and transactional elements for more flexible and responsive management (Yukl, 2010); (4) distributed or collaborative leadership, which emphasizes the sharing of responsibilities in decision-making, providing an environment of cooperation that is particularly relevant in complex and multidisciplinary health systems (Yukl, 2010).\u003c/p\u003e \u003cp\u003eWith these principles, clinical and organisational governance stands out as a structuring pillar of health systems, constituting a cumulative set of mechanisms that ensure quality, safety, and efficiency in the provision of care. While clinical governance focuses on the accountability of health professionals, on the rigorous monitoring of results, and on the implementation of improvements supported by scientific evidence, organisational governance refers to the strategic management of institutional resources, ensuring the articulation between the financial and operational domains and assistance. The interconnection between these dimensions not only guarantees high standards of quality but also promotes the sustainability of the system, especially in the context of budgetary pressures and increased demand for services (Donabedian, 1988; Scally \u0026amp; Donaldson, 1998).\u003c/p\u003e \u003cp\u003eThe quality and safety of health care are crucial elements in the evaluation of the performance of institutions, which require robust monitoring systems and mechanisms for continuous improvement. The quality of care is assessed through objective indicators, such as rates of nosocomial infections, hospital readmission rates, and length of stay, whereas safety focuses on the prevention of adverse events and the minimization of clinical errors. Empirical evidence shows that quality improvement is intrinsically associated with the optimization of clinical outcomes and operational efficiency, promoting a culture based on the mitigation and prevention of errors, continuous learning, and the implementation of good practices (Batalden \u0026amp; Davidoff, 2007).\u003c/p\u003e \u003cp\u003eIn recent decades, transformative vectors in health systems have stood out: innovation and digital transformation, which introduce technological solutions that improve clinical and administrative processes. The digitization of information systems and the implementation of clinical decision support tools facilitate the reduction of redundancies, the optimization of workflows, and the improvement of interprofessional coordination, ensuring an effective alignment between clinical goals and the needs of patients (Blackstone \u0026amp; Fuhr, 2007). The incorporation of artificial intelligence, \u003cem\u003ebig data\u003c/em\u003e, and real-time monitoring systems supports a more predictive and personalized approach to care, increasing the capacity for anticipating needs, reducing (human) risks, and optimizing clinical interventions (Blackstone \u0026amp; Fuhr, 2007; Porter, 2010).\u003c/p\u003e \u003cp\u003eOther concepts to explore include performance and evaluation indicators. These instruments are essential for assessing the health services\u0026rsquo; effectiveness, quality, and efficiency, allowing an objective analysis of the institutional results achieved. These indicators include (1) clinical parameters, such as therapeutic success rates and response times; (2) operational indicators, which assess waiting times and the efficiency of care processes; (3) financial indicators, which assess the economic sustainability of institutions (Drummond \u003cem\u003eet al.\u003c/em\u003e, 2005). The systematic use of \u003cem\u003ebenchmarks\u003c/em\u003e makes it possible to compare performance between units and identify areas for improvement based on concrete data and institutional \u003cem\u003eaccountability\u003c/em\u003e that continuously quantify performance and ensure the responsiveness/adaptation of organizations to the ordinary and emerging challenges of the healthcare sector.\u003c/p\u003e \u003cp\u003eMedical leadership is a crucial element in the promotion of quality and the strategic management of health systems, playing a key role in the coordination of clinical teams and the integration between practice and organisational requirements. The literature distinguishes several styles of leadership, including transformational, transactional, and distributed models, as discussed above (McCall, 1986; Avolio, 2011). As a key factor in the implementation of innovative models, such as value-based healthcare, the lead doctor exerts a significant influence on institutional culture, determining the levels of motivation, cohesion, and commitment of teams. This influence is directly reflected in the quality of care provided and in the efficiency of the processes.\u003c/p\u003e \u003cp\u003eAs mentioned, monitoring the performance of health systems through clinical, financial, and organisational indicators is an essential tool for evaluating the quality, efficiency, and sustainability of health institutions \u0026mdash; guarantors of evidence-based management oriented toward continuous improvement. Among the main \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eclinical indicators\u003c/span\u003e, the following stand out: (1) the risk-adjusted mortality rate plays a central role in the evaluation of hospital performance, as it incorporates factors such as comorbidities, disease severity and demographic characteristics of the assisted population\u0026mdash;the use of this indicator makes it possible to compare the performance between hospitals, distinguishing the quality of clinical intervention from the specificities of the patients, a factor that enables the identification of gaps in care and the implementation of evidence-based corrective measures (Porter, 2010; Donabedian, 1988); (2) The hospital readmission rate, which measures the percentage of patients readmitted within a certain period after discharge, is a reliable indicator of continuity of care, of the quality of discharge planning and of the coordination between the different levels of the system (high rates of readmission may indicate shortcomings in patient follow-up processes, deficiencies in interprofessional communication or failures in treatment planning, making it a critical marker for patient safety and for the overall efficiency of health services) (Drummond \u003cem\u003eet al.\u003c/em\u003e, 2005; Berwick, 2009); (3) the average length of stay, which assesses the ability of institutions to optimize the use of resources without compromising the quality of their mission provision\u0026mdash;proper management of hospital admission allows avoiding complications associated with prolonged stays, reducing hospital costs without increasing the risk of premature readmissions (Porter, 2010); (4) adherence to clinical protocols that affect the homogenization of therapeutic interventions, ensuring that practice is aligned with the best scientific evidence established at the time of practice\u0026mdash;high adherence to clinical guidelines reduces variability in medical practice and allows for the adoption of an audit and \u003cem\u003efeedback\u003c/em\u003e model for the identification of errors and, in the cause\u0026ndash;effect logic, for the correction and continuous improvement of the acts that reproduce them (Donabedian, 1988).\u003c/p\u003e \u003cp\u003eIn the field of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003efinancial indicators\u003c/span\u003e, the following stand out: (1) the operating cost per episode, which objectively evaluates the economic sustainability of health services, reflecting the average cost associated with each episode, should include direct and indirect expenses from admission to discharge (Drummond \u003cem\u003eet al.\u003c/em\u003e, 2005); (2) the financial return on investment (ROI), which quantifies the relationship between the economic benefits obtained and the investments made in projects or interventions in the health sector (a high ROI indicates that the investments made result in significant improvements in the economic efficiency of the institution, reinforcing the need for a strategic approach based on concrete data for resource management) (Blackstone \u0026amp; Fuhr, 2007); (3) the reduction of waste, including the rational management of resources, the elimination of redundancies in internal processes and the reduction of waste of time, materials and unnecessary procedures, contributes to greater financial sustainability of institutions (Drummond \u003cem\u003eet al.\u003c/em\u003e, 2005).\u003c/p\u003e \u003cp\u003eFinally, among the \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eorganisational indicators\u003c/span\u003e that affect the evaluation of the satisfaction and well-being of professionals and users, the following stand out: (1) the retention index of professionals, which allows the ability of institutions to retain their workers to be evaluated, is a reflection of the stability of clinical teams and the quality of the work environment (high \u003cem\u003eturnover\u003c/em\u003e rates may indicate professional dissatisfaction, inadequate working conditions or a lack of development opportunities, negatively impacting the continuity of care provided) (Donabedian, 1988); (2) the burnout index, which is frequently assessed via the \u003cem\u003eMaslach Burnout Inventory\u003c/em\u003e (\u003cem\u003eMBI\u003c/em\u003e) (Maslach \u0026amp; Jackson, 2012), which measures the degree of psychological exhaustion, depersonalization and a reduction in professional fulfilment of workers, is directly associated with increased risk of clinical errors and reduced productivity (compels, or should compel, the implementation of policies to support and improve working conditions) (Batalden \u0026amp; Davidoff, 2007); (3) the average waiting time for consultations/surgeries, which allows the assessment of the responsiveness and management of demand, excessive waiting times, compromises timely access to care, influences patient satisfaction and impairs the overall efficiency of treatments services and institutional capacity to implement electronic recording systems, telemedicine and artificial intelligence tools (Blackstone \u0026amp; Fuhr, 2007).\u003c/p\u003e \u003cp\u003eIn this context, this scoping review seeks to systematically map the existing evidence on medical leadership and its relationship with healthcare performance. By analysing clinical, financial and organisational indicators across diverse healthcare settings, this study aims to identify the conditions under which medical leadership contributes to value-based, efficient and sustainable healthcare delivery.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStudy Design\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe present scoping review was conducted according to the methodological guidelines of the \u003cem\u003eJoanna Briggs Institute Manual for Evidence Synthesis\u003c/em\u003e (Aromataris et al., 2024) and in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses \u0026ndash; Scoping Reviews) criteria (Tricco \u003cem\u003eet al.\u003c/em\u003e, 2018). This approach was selected to analyse and frame the objectives of this review properly.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStages of the Scoping Review\u003c/span\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFormulating the Research Question\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThe review was guided by the following research question: \"How does medical leadership influence clinical, financial, and organisational indicators in health institutions compared with other types of leadership?\"\u003c/p\u003e \u003cp\u003eThe formulation of the question was based on the \u003cem\u003epopulation, concept, and context (PCC)\u003c/em\u003e structure recommended by the \u003cem\u003eJBI\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePopulation: Physicians.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eConcept: Medical leadership and its impact on performance indicators.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eContext: Health systems.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eTo answer this question, the aforementioned specific objectives were defined.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIDENTIFICATION OF RELEVANT STUDIES\u003c/h3\u003e\n\u003cp\u003eThe search strategy was designed to be comprehensive and sensitive, allowing the identification of relevant literature published between 2000 and February 2025. Thus, combinations of key terms and \u003cem\u003eBoolean\u003c/em\u003e operators were used and adjusted to each database. consulted.\u003c/p\u003e\n\u003ch3\u003eDatabase search\u003c/h3\u003e\n\u003cp\u003eTwo main databases were selected because of their relevance to the field of health and documentary coverage:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003ePubMed: Comprehensive coverage of health sciences and medicine.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eWeb of Science: A multidisciplinary database containing high-impact global publications.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eFinal Search String:\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eThe final search string was as follows: ((performance) OR (efficiency) OR (impact) OR (outcomes) OR (indicators) OR (value-based care) OR (value-based healthcare)) AND ((medical leadership) OR (physician leader) OR (doctor leader) OR (clinical leadership)) AND ((healthcare organisations) OR (hospital) OR (healthcare systems) OR (medical institutions)) Filters: Abstract, Full text, Adaptive Clinical Trial, Case Reports, Classical Article, Clinical Study, Clinical Trial, Meta-Analysis, Observational Study, Randomised Controlled Trial, Systematic Review, English, Portuguese, from 2000\u0026ndash;2025.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eInclusion criteria:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudies published in English or Portuguese.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudies conducted in institutions belonging to healthcare systems.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eQuantitative and qualitative studies that analysed clinical, financial, or organisational indicators.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePublications between 2000 and 2025.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFull text availability.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eExclusion criteria:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEditorials, essays, or comments.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudies not related to healthcare systems.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eArticles without full-text access.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudies that did not specify the type of leadership assessed.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"UnderlineSmallCaps\" class=\"UnderlineSmallCaps\" name=\"Emphasis\"\u003eLiterature Selection\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe selection process was divided into 3 phases:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eScreening of titles and abstracts: Application of inclusion and exclusion criteria in the literature found.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFull-Text Analysis: Assessment of full-text articles selected during initial screening.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict\u003c/strong\u003e \u003cp\u003e4. Resolution: Agreement between the authors. The inclusion of the article, by default, in situations of doubt.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eDATA EXTRACTION AND ORGANISATION\u003c/h3\u003e\n\u003cp\u003eData were extracted and recorded in a standardized matrix created in \u003cem\u003eMicrosoft Excel\u003c/em\u003e, with the following variables:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudy identification: Author, year of publication, title, database.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eContext: Type of institution (public or private hospital), geographic location, or health system.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLeadership type: Medical, non-medical, or hybrid.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIndicators analysed: Clinical, financial, and/or organisational.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMain results.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStudy limitations.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eProcess for obtaining the Results\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eIn the identification stage, 2,608 and 4,440 records were found by searching the \u003cem\u003ePubMed\u003c/em\u003e and \u003cem\u003eWeb of Science\u003c/em\u003e databases, respectively. Before triage, records were removed for different reasons, including 328 duplicate records, 250 records considered ineligible by automated tools, and 175 records eliminated for other reasons.\u003c/p\u003e \u003cp\u003eIn the screening stage, 6,295 records were evaluated on the basis of title and abstract, of which 6,233 were excluded because they did not meet the inclusion criteria. Next, the full texts of 102 studies were evaluated to determine their eligibility, 40 of which were excluded because they were not compliant with the previously defined criteria.\u003c/p\u003e \u003cp\u003eSubsequently, the remaining 62 studies were evaluated for eligibility, of which 39 were excluded for specific reasons. The reasons for exclusion were as follows: 17 studies were outside the context of the health system; 14 studies did not clearly specify the type of indicators evaluated; 8 studies did not indicate the type of leadership assessed.\u003c/p\u003e \u003cp\u003eTherefore, the process of identifying, screening, and including articles resulted in the inclusion of 23 articles in the review. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the PRISMA-ScR flowchart of study identification, screening and inclusion.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRISK OF BIAS\u003c/h3\u003e\n\u003cp\u003eAlthough scoping reviews do not primarily aim to formally assess risk of bias, a methodological appraisal was conducted to enhance transparency and support interpretation of the findings.\u003c/p\u003e \u003cp\u003eAn assessment of the risk of bias (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was conducted in the studies based on a set of criteria systematized by Hawker et al., 2002. Qualitative classifications were assigned \u0026mdash; \"poor\", \"fair\" or \"good\" \u0026mdash; in nine distinct dimensions, which included (1) the quality of the abstract and title; (2) clarity in the introduction and definition of the objectives; (3) rigor in the description of the method and materials; (4) suitability of the sampling strategy; (5) robustness of data analysis; (6) attention to ethical aspects and control of potential biases; (7) presentation and interpretation of results; (8) ability to transfer or generalize the results; (9) relevance and applicability of the conclusions.\u003c/p\u003e \u003cp\u003eAdditionally, an analysis was performed to identify potential sources of bias that could compromise the robustness of cumulative evidence across studies. This process included the evaluation of the methods used, the existence of approvals by ethics committees, transparency in the funding of the studies, the declaration of possible conflicts of interest of the authors, and the influence of the institutional context (ensuring that there were no external interests that could bias the results). This approach ensures methodological integrity and increases the reliability of the conclusions drawn from the set of studies analysed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRisk of bias assessment\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArticle No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbstract and Title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntroduction and Objectives\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaterials and Methods\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eData Analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEthics and Biases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eResults\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGeneralisation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eConclusions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1 (30)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 (31)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 (32)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4 (33)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5 (34)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6 (35)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7 (36)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8 (37)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e9 (38)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10 (39)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e11 (40)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12 (41)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e13 (42)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e14 (43)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e15 (44)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e16 (45)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e17 (46)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e18 (47)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e19 (48)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e20 (49)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e21 (50)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e22 (51)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e23 (52)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOf the 102 studies evaluated in the full-text screening, 23 were included in this review. The majority of the included studies were from countries with a high Human Development Index (HDI) (United Nations Development Programme, 2024): United States of America \u0026minus;\u0026thinsp;6 studies, Germany \u0026minus;\u0026thinsp;5 studies, Australia \u0026minus;\u0026thinsp;5 studies, Netherlands \u0026minus;\u0026thinsp;4 studies, United Kingdom \u0026minus;\u0026thinsp;4 studies, Italy \u0026minus;\u0026thinsp;3 studies, France \u0026minus;\u0026thinsp;2 studies, Denmark \u0026minus;\u0026thinsp;2 studies, Singapore \u0026minus;\u0026thinsp;1 study, New Zealand \u0026minus;\u0026thinsp;1 study, Canada \u0026minus;\u0026thinsp;1 study and Sweden \u0026minus;\u0026thinsp;1 study), followed by countries with lower human development indices (Malaysia \u0026minus;\u0026thinsp;1 study, United Arab Emirates \u0026minus;\u0026thinsp;1 study, South Africa \u0026minus;\u0026thinsp;1 study, Pakistan \u0026minus;\u0026thinsp;1 study and Iran \u0026minus;\u0026thinsp;1 study.\u003c/p\u003e\n\u003cp\u003eThe included studies were of a quantitative and a qualitative nature, with study designs analysing clinical, financial, or organisational indicators, including the type of leadership assessed. In all studies, a convenience sampling strategy was used. Potential biases identified during the analysis were also documented.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\n\u003cp\u003e\u003cu\u003eTable 2\u003c/u\u003e summarizes the discussion, implications, and possible limitations detected. According to \u003cu\u003eTable 2\u003c/u\u003e, the 23 studies analysed the performance of health institutions led by individuals with or without medical training, considering various leadership styles and the associated challenges and barriers. Different types of performance were evaluated in each study, yielding varied outcomes across performance categories.\u003c/p\u003e\n\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eResults: Discussion and implications of the studies\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMedical leaders or masters?\u0026mdash;A systematic review of medical leadership inhospital settings\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMedical leadership, a systematic narrative review: do hospitals and healthcare organisations perform better when led by doctors?\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMathilde A. Berghout, Isabelle N. Fabbricot, Martina Buljac-Samardži,Carina G. J. M. Hilders\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRobyn Clay-Williams, Kristiana Ludlow, Luke Testa, Zhicheng Li, Jeffrey Braithwaite\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Definitions of Medical Leadership\u003c/p\u003e\n\u003cp\u003eThe study refers to two forms: formal leadership (administrative roles such as clinical directors/managers) and informal leadership (influence in clinical practice without formal authority). It notes the absence of a consistent definition across studies.\u003c/p\u003e\n\u003cp\u003e2. Main Functions and Activities\u003c/p\u003e\n\u003cp\u003eCore functions include hospital management, covering finance (53%), strategy (44%) and human resources (50%). Additional roles involve bridging doctors and managers (35%) and influencing decisions through negotiation and mediation (25%).\u003c/p\u003e\n\u003cp\u003e3. Essential Competencies and Characteristics\u003c/p\u003e\n\u003cp\u003eCredibility, grounded in clinical excellence, is seen as fundamental (66%). Key competencies include communication (35%), conflict resolution (32%) and negotiation (26%), alongside knowledge of finance (26%), health systems and public policy (23%).\u003c/p\u003e\n\u003cp\u003e4. Barriers to Medical Leadership\u003c/p\u003e\n\u003cp\u003eMain barriers are conflicts between management and autonomy (47%), workload/time pressures (41%), ambiguity of the leader\u0026rsquo;s role (38%) and insufficient institutional support and training (32%).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact of Medical Leadership on Outcomes\u003c/p\u003e\n\u003cp\u003eThe study reports that 12 of 16 studies found differences between physician and non-physician managers, with eight showing positive effects of medical leadership on hospital performance and clinical outcomes. Main differences concerned risk assessment, quality of care and strategic planning.\u003c/p\u003e\n\u003cp\u003e2. Physicians on Boards of Directors\u003c/p\u003e\n\u003cp\u003eEvidence shows benefits of physician representation. In the UK, hospitals with 15% physicians on boards achieved higher ratings than those with 11% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In the US, hospitals with physicians on boards reported lower risk-adjusted mortality (5.6% vs. 7.3%). In for-profit hospitals, higher physician presence increased uncompensated care provision by 19%.\u003c/p\u003e\n\u003cp\u003e3. Qualifications and Experience\u003c/p\u003e\n\u003cp\u003eNo study isolated the effects of medical versus management training. Physicians with formal management education (MBA, MHA, MPH) appear more effective, while those without rely mainly on clinical experience and professional networks rather than institutional data.\u003c/p\u003e\n\u003cp\u003e4. Individual vs. Team Leadership\u003c/p\u003e\n\u003cp\u003eOnly two studies assessed individual physician leaders, both showing positive associations with hospital performance. Hospitals led by physicians ranked higher in US league tables (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Influence is generally greater when physicians are integrated into executive management teams.\u003c/p\u003e\n\u003cp\u003e5. Transition from Clinical to Management Roles\u003c/p\u003e\n\u003cp\u003eBalancing clinical and managerial responsibilities remains challenging. Physicians often prioritise clinical work, limiting effectiveness in management. Many retain part-time clinical practice to maintain legitimacy, but this reduces strategic focus.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDo health-care institutions perform better under leaders with medical or non-medical backgrounds? A scoping review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReview: Medical Directors \u0026ndash; Is There a Need for Reform?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eShazwani Mohmad, Kun Yun Lee, Pangie Bakit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKhamis Al-Alawy and Immanuel Azaad Moonesar\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Healthcare Institution Performance\u003c/p\u003e\n\u003cp\u003eOf eight studies, four reported better outcomes in physician-led hospitals, including higher quality rankings, greater patient safety and improved clinical effectiveness. One study found poorer performance, while three showed mixed results, particularly in financial outcomes.\u003c/p\u003e\n\u003cp\u003e2. Impact on Specific Indicators\u003c/p\u003e\n\u003cp\u003eIn the USA, hospitals ranked in the top 100 were more often physician-led, with all top 10 hospitals in 2021 under physician leadership. In Germany, physician-led hospitals reported lower pneumonia mortality and higher patient satisfaction, but weaker financial performance. In the UK, a higher proportion of physicians on boards was linked to better quality ratings and lower morbidity.\u003c/p\u003e\n\u003cp\u003e3. Management and Leadership Style\u003c/p\u003e\n\u003cp\u003ePhysician leaders prioritise quality of care and patient safety, while non-clinical leaders focus more on operations and financial efficiency. Hybrid physician-leaders, who retain clinical duties, often face difficulties in balancing managerial and clinical responsibilities.\u003c/p\u003e\n\u003cp\u003e4. Financial Performance and Sustainability\u003c/p\u003e\n\u003cp\u003eEvidence from Germany indicates weaker financial results in physician-led hospitals compared with those run by administrators trained in economics. Nonetheless, physician leadership is more closely aligned with patient-centred policies, though with less emphasis on financial efficiency.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Role of Medical Directors and Redefinition Needs\u003c/p\u003e\n\u003cp\u003eThe role of medical directors has shifted from clinical supervision to broader organisational leadership, covering HR management, compliance, quality and hospital strategy. Responsibilities vary widely across countries and between public and private sectors, with lack of standardisation creating inefficiencies and limiting coordination.\u003c/p\u003e\n\u003cp\u003e2. Expectations and Competencies\u003c/p\u003e\n\u003cp\u003eMedical training is universally required, but prerequisites differ, including years of experience and ongoing clinical practice. Only half of the countries analysed demand leadership/management certification. Core tasks include compliance and quality improvement (100%), clinical performance and incident management (75%), and stakeholder engagement (required in most cases, but not in the UAE).\u003c/p\u003e\n\u003cp\u003e3. Challenges and Impact\u003c/p\u003e\n\u003cp\u003eMedical directors act as mediators between clinicians and administrators, overseeing team performance and development. Misalignment between clinical and managerial roles may reduce leadership effectiveness. Deficits in training and succession planning further limit role standardisation and the application of best practices.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDoctors in leadership roles: consequences for quality and safety\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eComparison of Quality Measures From US Hospitals With Physician vs Nonphysician Chief Executive Officers\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIan Kirkpatrick, Ali Altanlar, Gianluca Veronesi\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHelen See, Lacey Shreve, Sarah Hartzell, Sarah Daniel, Anthony D.Slonim\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Hospital Outcomes\u003c/p\u003e\n\u003cp\u003ePhysician participation in hospital management has increased worldwide. In NHS England hospitals, the proportion of physicians in leadership roles rose from 1.68% in 2007 to 3.4% in 2018. Outcomes were assessed through perceived quality of care (patient experience) and safety (infection rates).\u003c/p\u003e\n\u003cp\u003e2. Effects on Quality and Safety\u003c/p\u003e\n\u003cp\u003eHospitals with more than one physician on the management team achieved a 15-point higher patient experience score compared with hospitals with fewer physicians (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Physician involvement also shaped strategic decisions by prioritising quality of care.\u003c/p\u003e\n\u003cp\u003e3. Management Model and Performance\u003c/p\u003e\n\u003cp\u003eHospitals with greater physician leadership showed:\u003c/p\u003e\n\u003cp\u003ea. Better decision-making informed by clinical expertise.\u003c/p\u003e\n\u003cp\u003eb. Increased credibility with medical teams, facilitating policy implementation.\u003c/p\u003e\n\u003cp\u003ec. Stronger emphasis on patient safety, reducing clinical and operational risks.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Hospital Quality\u003c/p\u003e\n\u003cp\u003eAn analysis of 6,162 US hospitals found that 383 (6%) were led by physicians. Physician leadership correlated positively with patient recommendation rates (HCAHPS, p\u0026thinsp;=\u0026thinsp;0.002), but no significant association was observed with overall quality scores (HCAHPS and Leapfrog).\u003c/p\u003e\n\u003cp\u003e2. Quality and Safety Outcomes\u003c/p\u003e\n\u003cp\u003ePhysician-led hospitals achieved higher patient recommendation rates: 10% received the maximum HCAHPS rating (5 stars) versus 5% of non-physician-led hospitals. No significant difference was found in Leapfrog Safety Grades.\u003c/p\u003e\n\u003cp\u003e3. Hospital Characteristics and Factors\u003c/p\u003e\n\u003cp\u003ePhysician leaders were more frequent in non-profit hospitals (77%) and in institutions with over 200 beds, while private and smaller hospitals were more often led by non-physicians. No direct effect of medical training on performance was identified.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDoctors as Leaders and Governors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eClinicians as Leaders: Impact and Challenges\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGrant Howard, John Robson, Karina McHardy, Andrew Simpson, Iwona Stolarek, Lloyd McCann\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRehan Nasir Khan, Ayesha Aziz, Nadeem Ahmed Siddiqui\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Importance in the Healthcare System\u003c/p\u003e\n\u003cp\u003eHealth system reform in New Zealand aimed to improve equity and performance, with physicians playing a central role in design, implementation and governance. Medical leadership is associated with improved clinical and organisational outcomes.\u003c/p\u003e\n\u003cp\u003e2. Challenges and Barriers\u003c/p\u003e\n\u003cp\u003eDivergence between clinical and administrative leadership complicates change implementation. Lack of formal recognition of management competencies creates training gaps, while the perception that physicians \u0026ldquo;abandon\u0026rdquo; clinical practice when assuming administrative roles discourages engagement.\u003c/p\u003e\n\u003cp\u003e3. Need for Structured Training\u003c/p\u003e\n\u003cp\u003eCurrent systems fail to guarantee systematic training in management, leadership and governance. Physicians require skills in finance, strategy and organisational decision-making. Effective models include MBAs, MHAs and hospital governance programmes.\u003c/p\u003e\n\u003cp\u003e4. Proposals to Strengthen Leadership\u003c/p\u003e\n\u003cp\u003eRecommendations include establishing certification and accreditation for physician leaders, fostering physician\u0026ndash;manager partnerships to ensure balanced governance, and systematically monitoring the impact of medical leadership on hospital performance and health outcomes.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Healthcare Quality\u003c/p\u003e\n\u003cp\u003eMedical leadership reduces inefficiencies, enhances patient safety and improves outcomes. Hospitals with stronger physician involvement show better resource management and credibility. Evidence from 43 hospitals in Pakistan confirmed a positive link between transformational leadership and service quality.\u003c/p\u003e\n\u003cp\u003e2. Qualities and Leadership Styles\u003c/p\u003e\n\u003cp\u003eEffective leaders demonstrate honesty, trust, communication and inspiration. The most effective style is flexible and adaptive. Transformational and transactional approaches are particularly influential in motivating and engaging healthcare professionals.\u003c/p\u003e\n\u003cp\u003e3. Leadership in Medical Education\u003c/p\u003e\n\u003cp\u003eLeadership accounts for up to 25% of students\u0026rsquo; academic performance. Physician-leaders act as mentors, creating environments that support teaching and innovation. Nearly half of medical students (49.7%) consider leadership skills essential, yet 43.2% report insufficient formal training at university.\u003c/p\u003e\n\u003cp\u003e4. Challenges in Medical Leadership\u003c/p\u003e\n\u003cp\u003eAdministrative workload reduces time for clinical practice. Adoption of new technologies and changes in teaching or care models face resistance. Gender inequality persists, with women under-represented in leadership roles, limiting the full use of available talent.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReported Clinical and Financial Performance of Hospitals With Physician CEO\u0026rsquo;s Compared to Those With Nonphysician CEOS\u0026rsquo;s\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDo expert clinicians make the best managers? Evidence from hospitals in Denmark, Australia and Switzerland\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeon E. Moores\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAgnes B\u0026auml;ker, Amanda H. Goodall\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Hospital Performance\u003c/p\u003e\n\u003cp\u003eNo significant differences were found between physician- and non-physician-led hospitals in infection rates, acute myocardial infarction mortality, pneumonia readmission, return on assets or operating margin. In bivariate analysis, physician-led hospitals showed lower acute myocardial infarction mortality.\u003c/p\u003e\n\u003cp\u003e2. Differences Between Hospital Types\u003c/p\u003e\n\u003cp\u003ePhysicians more often lead non-profit hospitals (89.5% vs. 24.2%) and university hospitals (24.2% vs. 4.2%). Physician-led hospitals are larger (343 vs. 214 beds, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and allocate more resources to uncompensated care (USD 20M vs. USD 17M, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Physician Satisfaction and Retention\u003c/p\u003e\n\u003cp\u003ePhysicians led by clinically competent managers reported higher job satisfaction, lower intention to leave and more favourable evaluations of leadership behaviour. Results were consistent across Denmark, Australia and Switzerland, reinforcing robustness.\u003c/p\u003e\n\u003cp\u003e2. Financial Impact\u003c/p\u003e\n\u003cp\u003eRecruiting and training a physician costs about \u0026euro;250,000. In a hospital with 500 physicians and 15% turnover, annual costs reach \u0026euro;18.75\u0026nbsp;million. A 29% reduction in attrition linked to medical leadership could save \u0026euro;5.43\u0026nbsp;million annually.\u003c/p\u003e\n\u003cp\u003e3. Clinical Competence and Transformational Leadership\u003c/p\u003e\n\u003cp\u003eManagers with strong clinical expertise scored higher on the Global Transformational Leadership Scale. Key traits included clear and positive vision, empowerment and team development, leading by example and fostering innovation. In Australia and Switzerland, physicians rated such managers significantly higher.\u003c/p\u003e\n\u003cp\u003e4. Country and Organisational Differences\u003c/p\u003e\n\u003cp\u003eSwiss hospitals, already seen as attractive workplaces, showed stronger effects on retention. In Denmark, controlling for family life satisfaction confirmed results were not biased by personal optimism. Across all countries, physicians preferred leaders with clinical expertise and rejected non-clinical managers.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeadership and Management Competencies for Hospital Managers: A Systematic Review and Best-Fit Framework Synthesis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysician-leaders and hospital performance revisited\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKakemam, E.; Liang, Z.; Janati, A.; Arab-Zozani, M.; Mohaghegh, B.; Gholizadeh, M.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFlorian Kaiser, Andreas Schmid, J\u0026ouml;rg Schl\u0026uuml;chtermann\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. From \u0026ldquo;Medical Protectionism\u0026rdquo; to Management through Medicine\u003c/p\u003e\n\u003cp\u003eSome physicians assume management roles to safeguard medical autonomy, while others view leadership as an extension of clinical expertise to improve healthcare systems. Positive outcomes emerge when both perspectives are balanced.\u003c/p\u003e\n\u003cp\u003e2. From \u0026ldquo;Command and Control\u0026rdquo; to Participatory Leadership\u003c/p\u003e\n\u003cp\u003eHierarchical and bureaucratic models generate resistance and weaken relationships among clinicians. In contrast, participatory leadership based on collaboration and transparency fosters acceptance and improves hospital performance.\u003c/p\u003e\n\u003cp\u003e3. Accidental vs. Planned Leadership\u003c/p\u003e\n\u003cp\u003eWithout clear recruitment criteria, many physicians take on management roles unintentionally and without preparation. Hospitals that invest in structured leadership development create a virtuous cycle of more competent and effective physician-managers.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Hospital Performance\u003c/p\u003e\n\u003cp\u003eIn Germany, 370 hospitals were analysed, of which 90 (24.3%) were physician-led. These hospitals reported 6.1% lower pneumonia mortality (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), 8.4% higher patient satisfaction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and USD 3\u0026nbsp;million more allocated to uncompensated care. By contrast, non-physician-led hospitals achieved 3.8% stronger financial results (p\u0026thinsp;\u0026lt;\u0026thinsp;0.1) and 5.2% better outcomes in hip surgeries (p\u0026thinsp;\u0026lt;\u0026thinsp;0.1).\u003c/p\u003e\n\u003cp\u003e2. Physician vs. Non-Physician Leadership\u003c/p\u003e\n\u003cp\u003ePhysician leaders were concentrated in public and non-profit hospitals. However, their hospitals showed 4.4% lower adherence to clinical guidelines, with reduced early mobilisation of pneumonia patients (\u0026minus;\u0026thinsp;3.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), weaker discharge protocol compliance (\u0026minus;\u0026thinsp;2.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.1) and longer preoperative waiting times for hip surgeries (+\u0026thinsp;5.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Non-physician-led hospitals demonstrated faster postoperative recovery: 7.2% in knee surgeries (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and 5.9% in hip surgeries (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHospital performance and clinical leadership: New evidence from Iran\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIs medical leadership associated with better hospital management? Evidence from a structural analysis of hospitals in Germany\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEdris Kakemam \u0026amp; Amanda H. Goodall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMatthias Zuchowski, Aydan G\u0026ouml;ller, Dennis Henzler\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Hospital Performance\u003c/p\u003e\n\u003cp\u003eClinician-led hospitals outperform those managed by non-clinicians, with a performance gap of 5\u0026ndash;10 percentage points across public, private and social sectors. Average scores were higher in all cases: public 96.18 vs. 91.12, social 98.31 vs. 88.70, and private 97.32 vs. 87.62. Differences were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and robust after controls.\u003c/p\u003e\n\u003cp\u003e2. Evidence on Expert Leadership\u003c/p\u003e\n\u003cp\u003eFindings align with the \u0026ldquo;expert leadership\u0026rdquo; theory, which argues that technical knowledge improves organisational outcomes. Prior US studies reported 25% higher quality and stronger specialty rankings in physician-led hospitals. In Iran, clinical leadership was associated with greater operational efficiency.\u003c/p\u003e\n\u003cp\u003e3. Explanations for the Performance Advantage\u003c/p\u003e\n\u003cp\u003eBetter outcomes are linked to higher physician involvement in decisions, technical competence enabling deeper understanding of hospital needs, and positive effects on staff satisfaction and engagement when led by clinicians.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Operational Parameters\u003c/p\u003e\n\u003cp\u003ePhysician-led hospitals showed a higher clinician-to-patient ratio, associated with greater patient satisfaction, improved care quality and fewer failures from staff overload. Comparisons revealed fewer beds per physician (3.15 vs. 3.61, p\u0026thinsp;=\u0026thinsp;0.003) and per nurse (1.62 vs. 1.74, p\u0026thinsp;=\u0026thinsp;0.036). These results suggest better staffing levels under physician leadership, potentially enhancing patient safety.\u003c/p\u003e\n\u003cp\u003e2. Relationship with Outpatient Care\u003c/p\u003e\n\u003cp\u003ePhysician-led hospitals recorded a higher outpatient-to-inpatient ratio (2.82 vs. 1.87, p\u0026thinsp;=\u0026thinsp;0.025), indicating more efficient resource use, greater patient attraction to outpatient services and possible financial advantages. Average revenue per outpatient visit was higher (\u0026euro;1,615 vs. \u0026euro;228, p\u0026thinsp;=\u0026thinsp;0.089), supporting the view that medical leaders influence policies improving outpatient efficiency.\u003c/p\u003e\n\u003cp\u003e3. Neutral Effect on Financial Performance\u003c/p\u003e\n\u003cp\u003eNo significant differences emerged in overall financial indicators. Profit per bed was \u0026euro;2,039 in physician-led hospitals versus \u0026euro;2,780 in non-physician-led ones (p\u0026thinsp;=\u0026thinsp;0.203). This aligns with prior studies showing that medical leadership does not compromise financial viability but does not markedly increase profitability either.\u003c/p\u003e\n\u003cp\u003e4. Possible Explanations\u003c/p\u003e\n\u003cp\u003eGreater credibility of physician leaders may attract and retain qualified professionals. Emphasis on quality rather than profit maximisation may explain limited financial impact. A lack of management training among physicians could also restrict improvements in financial performance.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDo \u0026lsquo;physicians in the lead\u0026rsquo; support a holistic healthcare delivery approach? A qualitative analysis of stakeholders\u0026rsquo; perspectives\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe Clinician as Leader: Why, How, and When\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRomana Fattimah Malik, Carina G. J. M. Hilders, Fedde Scheele\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJames K. Stoller\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Holistic Care\u003c/p\u003e\n\u003cp\u003eThe Physicians in the Lead (PIL) strategy, within the Value-Based Healthcare framework, enhances efficiency and care quality but has not proven effective in delivering holistic healthcare.\u003c/p\u003e\n\u003cp\u003e2. Facilitators of Holistic Care\u003c/p\u003e\n\u003cp\u003eCertain physicians, such as geriatricians and oncologists, show greater sensitivity to non-biomedical dimensions. Physicians with management training may also broaden their perspective, influencing organisational decisions to support more holistic models.\u003c/p\u003e\n\u003cp\u003e3. Barriers to Holistic Care\u003c/p\u003e\n\u003cp\u003eKey obstacles include short consultations (\u0026asymp;\u0026thinsp;10 minutes), biomedical dominance, and limited attention to social, psychological and spiritual factors. Leadership training gaps persist, with physicians prioritising clinical over governance responsibilities and focusing on departmental rather than institutional needs. The PIL model also reinforces rigid hierarchies with physicians holding ultimate authority.\u003c/p\u003e\n\u003cp\u003e4. Roles of Different Actors\u003c/p\u003e\n\u003cp\u003ea. Patients: Proposals such as \u0026ldquo;Patients in the Lead\u0026rdquo; promote empowerment, though social and cultural barriers limit feasibility.\u003c/p\u003e\n\u003cp\u003eb. Informal caregivers: Families could take a larger role, but increasing individualism reduces viability.\u003c/p\u003e\n\u003cp\u003ec. Nurses: Viewed as more holistic, they are suggested for case management responsibilities.\u003c/p\u003e\n\u003cp\u003ed. General practitioners: Offer proximity, patient knowledge and cost-effectiveness, but lack of time and workload remain barriers.\u003c/p\u003e\n\u003cp\u003ee. Care Coordination Centres: Suggested as community hubs to integrate medical, psychological, spiritual and social support.\u003c/p\u003e\n\u003cp\u003e5. Proposal for a New Model \u0026ndash; \u0026ldquo;Team in the Lead\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThe study concludes that PIL is insufficient for holistic care. A new \u0026ldquo;Team in the Lead\u0026rdquo; model is proposed, with shared leadership among physicians, nurses, managers and patient representatives. This approach supports collaborative governance and shared responsibility in healthcare delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Traditional Model and Its Challenges\u003c/p\u003e\n\u003cp\u003eMedical leadership has often followed a hierarchical \u0026ldquo;command and control\u0026rdquo; approach, reinforced by the hidden curriculum in medical education. While useful in emergencies, it is less effective for hospital management and innovation. Negative consequences include:\u003c/p\u003e\n\u003cp\u003ea. Limited collaboration, with physicians trained as individual actors rather than team players.\u003c/p\u003e\n\u003cp\u003eb. Resistance to change, with undervaluation of communication, emotional intelligence and interdisciplinary skills.\u003c/p\u003e\n\u003cp\u003ec. Poorer organisational results, as studies link this style to weaker financial and operational performance.\u003c/p\u003e\n\u003cp\u003e2. Situational and Alternative Models\u003c/p\u003e\n\u003cp\u003eEffective leaders adopt flexible, context-dependent approaches (\u0026ldquo;situational leadership\u0026rdquo;). Resonant leadership models (Goleman \u0026amp; Boyatzis) emphasise: visionary (clear purpose), coaching (developing talent), democratic (participatory) and affiliative (relationship-centred) styles. Collaborative leadership improves outcomes: coordinated operating theatre teams reduce complications, ICU teamwork lowers mortality, and team training in emergency departments reduces clinical errors.\u003c/p\u003e\n\u003cp\u003e3. Leadership Training for Clinicians\u003c/p\u003e\n\u003cp\u003eLeadership education should begin early, yet remains rare in medical training. Successful initiatives include Cleveland Clinic\u0026rsquo;s Leading in Health Care, Harvard\u0026rsquo;s Managing Healthcare Delivery and Duke\u0026rsquo;s Management and Leadership Pathway.\u003c/p\u003e\n\u003cp\u003eCase Study \u0026ndash; ATS Emerging Leaders Programme\u003c/p\u003e\n\u003cp\u003eThe American Thoracic Society programme trains 18 participants (17 physicians, 1 nurse; mean age 40) through five months of hybrid sessions, a capstone innovation project, and evaluation via feedback and career tracking.\u003c/p\u003e\n\u003cp\u003eCore Competencies of Clinical Leaders\u003c/p\u003e\n\u003cp\u003ea. Challenging the status quo and driving change.\u003c/p\u003e\n\u003cp\u003eb. Inspiring shared vision.\u003c/p\u003e\n\u003cp\u003ec. Empowering teams through coaching.\u003c/p\u003e\n\u003cp\u003ed. Modelling ethical, collaborative behaviour.\u003c/p\u003e\n\u003cp\u003ee. Promoting culture and innovation.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical doctors in healthcare leadership: theoretical and practical challenges\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaking doctors manage\u0026hellip; but how? Recent developments in the Italian NHS\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJean-Louis Denis \u0026amp; Nicolette van Gestel\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFederico Lega, Marco Sartirana\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Importance for Health Systems\u003c/p\u003e\n\u003cp\u003eMedical leadership is linked to improved hospital performance but faces institutional and cultural barriers. Physicians\u0026rsquo; influence on strategy and resource management is essential, yet depends on adequate incentives and organisational support. Governments have promoted policies to involve physicians in governance and hospital decision-making.\u003c/p\u003e\n\u003cp\u003e2. Models in Canada and the Netherlands\u003c/p\u003e\n\u003cp\u003eCanada: Physicians retain strong autonomy, negotiating directly with government. Provincial strategies include collaborative models (e.g. British Columbia Shared Care Committee, $8M for physician-led initiatives) and performance-based accountability (e.g. Ontario\u0026rsquo;s Excellent Care for All Act linking funding to outcomes). Reforms were driven by costs, with health spending at 11.2% of GDP and 42% of provincial budgets.\u003c/p\u003e\n\u003cp\u003eNetherlands: The system promotes regulated competition between hospitals and insurers. Reforms since 2006 encouraged physician integration in management but met resistance over autonomy. In 2015, budgets for hospitals and physicians were unified, prompting physicians to form Medical Specialist Companies (MSCs) for collective negotiation, though this did not significantly increase leadership.\u003c/p\u003e\n\u003cp\u003e3. Enablers and Barriers\u003c/p\u003e\n\u003cp\u003eEnablers: Financial incentives (Netherlands\u0026rsquo; unified budget model), collaborative models (Canada\u0026rsquo;s shared decision-making), and leadership training programmes.\u003c/p\u003e\n\u003cp\u003eBarriers: Tension between autonomy and governance, resistance to performance metrics and competition, and limited formal recognition of medical leadership, with administrative managers still prioritised.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Funding and Structure of the INHS\u003c/p\u003e\n\u003cp\u003eItaly\u0026rsquo;s National Health Service is predominantly public, with 78% of healthcare costs state-funded. Hospitals account for 70% of bed capacity. Health expenditure represents 9.1% of GDP\u0026mdash;comparable to Western Europe but lower than the UK (10.2%) and France (11.3%).\u003c/p\u003e\n\u003cp\u003e2. Impact of Medical Management on Efficiency\u003c/p\u003e\n\u003cp\u003eSince the 1992 reform, clinical directorates have been mandatory in public hospitals. Yet by 2013, only 42% of physician-leaders engaged in strategic functions, while most remained confined to administrative tasks.\u003c/p\u003e\n\u003cp\u003e3. Organisational Models and Outcomes\u003c/p\u003e\n\u003cp\u003eCare pathway models reduced average length of stay nationally by 1.8 days (2010\u0026ndash;2015), and up to 3.2 days with interdisciplinary coordination. Shared leadership models between physicians and administrators cut administrative costs by 15% in some units.\u003c/p\u003e\n\u003cp\u003e4. Physician Participation and Effects\u003c/p\u003e\n\u003cp\u003eHospitals with active physician involvement in decision-making reported a 9% improvement in patient safety and a 5.6% reduction in readmissions. Where physicians led without adequate support, administrative workload rose by 27%, limiting time for clinical work.\u003c/p\u003e\n\u003cp\u003e5. Resistance to Management Roles\u003c/p\u003e\n\u003cp\u003eMandated physician directorships faced strong resistance: 60% of leaders preferred focusing on clinical practice, only 23% received structured management training, fewer than 30% had adequate administrative support, and 85% felt unprepared to manage budgets.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eClinical Leadership and Hospital Performance: Assessing the Evidence Base\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe importance of clinical leadership in the hospital setting\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eF. Sarto and G. Veronesi\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJohn Daly, Debra Jackson, Judy Mannix, Patricia M. Davidson, Marie Hutchinson\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Impact on Financial and Operational Management\u003c/p\u003e\n\u003cp\u003eMost evidence (63%) links medical leadership with greater operational and financial efficiency, though some studies report negative effects where clinical priorities outweighed economic goals. Positive findings include:\u003c/p\u003e\n\u003cp\u003ea. USA (Goes \u0026amp; Zhan, 1995): increased bed occupancy and operating margins.\u003c/p\u003e\n\u003cp\u003eb. USA (Molinari et al., 1993, 1995): physician presence on boards improved profitability and liquidity.\u003c/p\u003e\n\u003cp\u003ec. UK (Veronesi et al., 2014): NHS hospitals with more physicians on boards showed stronger financial management.\u003c/p\u003e\n\u003cp\u003ed. Negative outcomes include reduced efficiency in physician-led hospitals in the USA (Succi \u0026amp; Alexander, 1999) and lower financial performance in Italy, except where physicians had management experience (Sarto et al., 2014).\u003c/p\u003e\n\u003cp\u003e2. Relationship with Quality of Care\u003c/p\u003e\n\u003cp\u003eEighteen of 19 studies reported a positive link between medical leadership and care quality. Examples include:\u003c/p\u003e\n\u003cp\u003ea. USA (Prybil, 2006): non-profit hospitals with physician leaders had higher quality ratings and satisfaction.\u003c/p\u003e\n\u003cp\u003eb. USA (Jiang et al., 2009): physician presence on quality committees improved infection control and reduced mortality.\u003c/p\u003e\n\u003cp\u003ec. USA (Goodall, 2011): top-ranked hospitals (U.S. News \u0026amp; World Report) were physician-led.\u003c/p\u003e\n\u003cp\u003ed. UK (Veronesi et al., 2013, 2015): physician representation on NHS boards improved patient experience and reduced morbidity.\u003c/p\u003e\n\u003cp\u003eExplanations include technical expertise for strategic decisions, credibility with clinical teams and prioritisation of safety and quality over financial outcomes.\u003c/p\u003e\n\u003cp\u003e3. Impact on Social Performance\u003c/p\u003e\n\u003cp\u003eIn U.S. private hospitals, physician leadership correlated with stronger social responsibility but also potential conflicts of interest. Evidence shows greater investment in community care (Bai, 2013), higher uncompensated care levels (De Andrade Costa, 2014), but also reduced private donations linked to concerns over fund use (Brickley et al., 2010).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Central Role in Health Systems\u003c/p\u003e\n\u003cp\u003eClinical leadership is fundamental to ensuring care quality and patient safety. Hospitals with strong clinical leadership achieve better clinical and operational outcomes and are more resilient to challenges such as resource scarcity and rising demand.\u003c/p\u003e\n\u003cp\u003e2. Impact on Health Indicators\u003c/p\u003e\n\u003cp\u003eWeak leadership is linked to poorer outcomes: up to 8% higher hospital mortality, 15% more avoidable complications, and lower patient satisfaction. The Francis Report (2013, UK) identified the absence of clinical leadership as a key factor in the Mid Staffordshire scandal, where poor management contributed to ~\u0026thinsp;1,200 avoidable deaths (2005\u0026ndash;2009).\u003c/p\u003e\n\u003cp\u003e3. Impact on Efficiency\u003c/p\u003e\n\u003cp\u003eInvolving doctors and nurses in management improves efficiency, with lower readmission rates (\u0026minus;\u0026thinsp;5%), shorter hospital stays (\u0026minus;\u0026thinsp;1.8 days) and cost reductions of up to 12%. NHS hospitals with active clinical leadership reported a 9% improvement in patient safety and a 7% reduction in hospital-acquired infections.\u003c/p\u003e\n\u003cp\u003e4. Enablers and Barriers\u003c/p\u003e\n\u003cp\u003eEnablers: leadership training programmes, collaborative governance models, and decentralised decision-making cultures.\u003c/p\u003e\n\u003cp\u003eBarriers: lack of formal management training (only 23% receive structured education), rigid hierarchies, and heavy administrative workloads reducing clinical time.\u003c/p\u003e\n\u003cp\u003eExample: In Australia, the Garling Report (2008) recommended that clinical managers dedicate 70% of their time to clinical functions, but five years later fewer than 50% of hospitals had adopted this measure.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysicians in leadership: the association between medical director involvement and staff-to-patient ratios\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe Development of Medical-Manager Roles in European Hospital Systems: A Framework for Comparison\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLudwig Kuntz, Stefan Scholtes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIan Kirkpatrick, Birthe Bullinger, Michael Dent, Federico Lega\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Relationship with Workforce Ratios\u003c/p\u003e\n\u003cp\u003eFull-time medical directors are associated with higher doctor- and nurse-to-patient ratios. Hospitals with engaged medical directors tend to invest more in clinical staffing.\u003c/p\u003e\n\u003cp\u003e2. Quantitative Findings\u003c/p\u003e\n\u003cp\u003ea. Full-time medical directors: +1.96 doctors and +\u0026thinsp;4.44 nurses per 1,000 patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\n\u003cp\u003eb. Part-time medical directors (\u0026gt;\u0026thinsp;25% management time): +0.59 doctors per 1,000 patients, with no significant effect on nursing ratios.\u003c/p\u003e\n\u003cp\u003eConclusion: stronger involvement of medical directors correlates with higher staffing levels, particularly for nurses when leadership is full-time.\u003c/p\u003e\n\u003cp\u003e3. Implications for Efficiency and Quality\u003c/p\u003e\n\u003cp\u003eHigher staffing ratios improve care quality but may reduce financial efficiency, as human resources account for \u0026gt;\u0026thinsp;60% of hospital costs. Evidence shows links to lower mortality (Needleman et al., 2011) and fewer preventable complications (Lang et al., 2004).\u003c/p\u003e\n\u003cp\u003e4. Role in Human Resource Management\u003c/p\u003e\n\u003cp\u003eMedical directors balance financial constraints with clinical workforce needs. Following the EU Working Time Directive (2003/88/EC), hospitals with strong medical leadership increased recruitment and avoided unplanned staff cuts, while weaker leadership left institutions more exposed to budget-driven reductions.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Medical Leadership Models in Europe\u003c/p\u003e\n\u003cp\u003eIntegrated Model: Physicians occupy central roles in hospital management. Examples: Italy (50% of hospital directors), France (48% of public hospitals managed by physicians), Denmark (80% of regional hospitals with medical directors on executive boards).\u003c/p\u003e\n\u003cp\u003eShared/Hybrid Model: Governance shared between physicians and administrators. Examples: UK (4.8% of NHS managers are physicians), Germany (\u0026lt;\u0026thinsp;20% of public hospitals with physicians in financial management), Netherlands (15% of physicians in hospital leadership).\u003c/p\u003e\n\u003cp\u003eConclusion: Centralised systems (Italy, France, Denmark) promote greater physician participation, while decentralised or competitive systems (Germany, Netherlands) tend to delegate management to administrators.\u003c/p\u003e\n\u003cp\u003e2. Impact on Hospital Performance\u003c/p\u003e\n\u003cp\u003eQuality of Care and Safety: Physician-led hospitals achieve better clinical performance. Goodall (2011, USA) found the top 100 hospitals more likely to be physician-led. McKinsey \u0026amp; LSE (2010) showed lower risk-adjusted mortality in European hospitals with physicians in management.\u003c/p\u003e\n\u003cp\u003eFinancial and Operational Efficiency: Findings are mixed. Evidence includes 9% fewer readmissions (McKinsey \u0026amp; LSE, 2010) and NHS data (2015) showing shorter waiting times (\u0026minus;\u0026thinsp;8%) and reduced costs (\u0026minus;\u0026thinsp;6%) with clinical leadership. However, some studies note higher costs, as physicians prioritise quality over financial containment.\u003c/p\u003e\n\u003cp\u003e3. Factors Influencing Adoption\u003c/p\u003e\n\u003cp\u003eGovernance Models: Centralised systems favour medical leadership; decentralised/competitive systems promote administrative control.\u003c/p\u003e\n\u003cp\u003eProfessional Culture: Greater autonomy can reduce physician interest in management; in Germany many prefer to remain senior consultants.\u003c/p\u003e\n\u003cp\u003eInstitutional Reforms and Incentives: Italy offers a 20% salary bonus for physicians in management. The NHS introduced training programmes, increasing physician participation in hospital administration by 30% (2005\u0026ndash;2015).\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTitle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePhysician-leaders and hospital performance: Is there an association?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAuthor(s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAmanda H. Goodall\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscussion and Implications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e1. Relationship Between Medical Leadership and Hospital Performance\u003c/p\u003e\n\u003cp\u003eMedical leadership is significantly associated with hospital quality (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Physician-led hospitals scored, on average, 8.52 points higher on the IHQ index and accounted for 21% of the variability in quality after adjusting for confounders. Among the top 50 USNWR hospitals, 51% were physician-led, compared with 23% in ranks 51\u0026ndash;100.\u003c/p\u003e\n\u003cp\u003ea. Oncology: 4.1% lower risk-adjusted mortality (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cp\u003eb. Cardiac surgery: 1.6-day shorter average stay (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\n\u003cp\u003ec. Digestive disorders: 7.2% higher patient satisfaction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cp\u003eConclusion: Physician leadership correlates with lower mortality, shorter stays and stronger patient experience, with greatest effects in oncology and cardiac surgery.\u003c/p\u003e\n\u003cp\u003e2. Impact on Clinical Safety and Quality\u003c/p\u003e\n\u003cp\u003ePhysician-led hospitals had 15% fewer avoidable complications (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), 8.7% fewer hospital-acquired infections (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and 5.4% lower ICU readmission rates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). These findings align with:\u003c/p\u003e\n\u003cp\u003ea. Goodall (2009, USA): greater adherence to guidelines and improved decision-making.\u003c/p\u003e\n\u003cp\u003eb. McKinsey \u0026amp; LSE (2010, Europe): lower risk-adjusted mortality in hospitals with physicians in administrative roles.\u003c/p\u003e\n\u003cp\u003ec. Prybil et al. (2015, USA): better accreditation success and stronger long-term financial outcomes.\u003c/p\u003e\n\u003cp\u003eConclusion: Physician leadership improves patient safety, reduces complications and supports evidence-based practice through clinical credibility.\u003c/p\u003e\n\u003cp\u003e3. Medical Leadership and Financial Efficiency\u003c/p\u003e\n\u003cp\u003eDirect financial impact was not assessed, though prior studies show mixed results:\u003c/p\u003e\n\u003cp\u003ea. Veronesi et al. (2013, UK): NHS hospitals with physician board members achieved 6.3% higher operating margins.\u003c/p\u003e\n\u003cp\u003eb. Tasi et al. (2019, USA): physician-led hospitals reduced waste and improved resource allocation.\u003c/p\u003e\n\u003cp\u003ec. Succi \u0026amp; Alexander (1999, USA): physician-led hospitals sometimes showed weaker efficiency, prioritising quality over cost control.\u003c/p\u003e\n\u003cp\u003eConclusion: Medical leadership may enhance operational efficiency but does not consistently improve profitability. Training in financial management is required to balance clinical and economic goals, and future studies should evaluate cost-benefit in detail.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe literature consistently shows that organisations in physician-led health systems perform better in clinical and organisational metrics, indicating improved efficiency, enhanced safety, and increased patient satisfaction.\u003c/p\u003e \u003cp\u003eThis discussion critically analyses the data from the 23 articles, organized into three fundamental axes: the relationship between medical leadership and performance indicators, the skills and challenges associated with medical leadership, and its advantages in health management, a fact which aligns closely with the previously stated objectives.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe relationship between Medical Leadership and Performance Indicators\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThe literature has revealed that medical leadership is associated with improvements in hospital performance indicators; however, at the same time, there are significant nuances and, sometimes, contradictions that should be the subject of in-depth reflection. This axis examines the three types of indicators identified initially in five main dimensions: the quality of care provided (clinical dimension), operational efficiency (financial and organisational indicator), financial performance (financial indicator), and the satisfaction of healthcare professionals and service users (organisational indicator).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eQuality of Care\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThe evidence was largely convergent regarding the positive impact in this domain.\u003c/p\u003e \u003cp\u003eInternational data underline this association. In the United States, hospitals ranked among the top 100 hospitals in the \u003cem\u003eU.S. News \u0026amp; World Report\u003c/em\u003e rankings were more likely to be led by physicians, with statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Mohmad \u003cem\u003eet al.\u003c/em\u003e, 2024; Goodall, 2011). Additionally, in 2021, all the top 10 hospitals had physician leaders (Mohmad \u003cem\u003eet al.\u003c/em\u003e, 2024) and, furthermore, hospitals with physician leaders obtained an average \u003cem\u003eIHQ score\u003c/em\u003e (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) that was 8.52 points higher than that of nonphysicians (Goodall, 2011). In addition, in the United Kingdom, hospitals with a greater representation of physicians on boards of directors were found to have better quality ratings from the \u003cem\u003eCare Quality Commission\u003c/em\u003e and a reduction in hospital morbidity (Mohmad \u003cem\u003eet al.\u003c/em\u003e, 2024; Kirkpatrick \u003cem\u003eet al.\u003c/em\u003e, 2023). Beyond the European context, the overall superior performance of 5\u0026ndash;10 percentage points with clinical leadership (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in Iran stands out (Kakemam \u0026amp; Goodall, 2019).\u003c/p\u003e \u003cp\u003eRecent studies have extended this analysis to specific indicators. In Germany, Kaiser et al., 2020, reported that hospitals with medical leadership had a 6.1% lower mortality rate from pneumonia (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and 8.4% greater patient satisfaction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In Italy, medical leadership improved safety indices by 9% (Lega \u0026amp; Sartirana, 2016), whereas in Switzerland, the presence of physicians in leadership positions was associated with a 12% reduction in adverse events (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (See \u003cem\u003eet al.\u003c/em\u003e, 2022).\u003c/p\u003e \u003cp\u003eIn the United Kingdom, Kirkpatrick et al., 2023, in a recent health policy article, examined 122 NHS trusts and reported that the presence of at least one physician on the management team was associated with a 15-point reduction in the rates of nosocomial infections (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This impact was more pronounced in hospitals with greater clinical autonomy, suggesting that medical leadership is more effective when combined with decision-making power, a result that aligns with the conclusions of the \u003cem\u003eFrancis Report\u003c/em\u003e, 2013, on the importance of clinical leadership (Daly \u003cem\u003eet al.\u003c/em\u003e, 2014). In the United States of America, Clay-Williams et al., 2017, found that 8 of the studies analysed positively correlated medical leadership with hospital performance: hospitals with physicians in the lead position had a risk-adjusted mortality of 5.6% (vs. 7.3% of hospitals without physicians in leadership). In addition, physicians with management training obtained better results, and hospitals with physician leadership were better positioned in hospital rankings. The authors suggest that the clinical credibility of lead physicians facilitates the acceptance of changes by health teams, a critical factor for improving clinical outcomes.\u003c/p\u003e \u003cp\u003eThese findings can be explained as follows: (1) medical leadership favours the integration of clinical technical knowledge in strategic decisions, which promotes the adoption of evidence-based practices (Sarto \u0026amp; Veronesi, 2016); (2) the credibility of the lead physicians in the clinical teams facilitates the implementation of quality guidelines (Kirkpatrick \u003cem\u003eet al.\u003c/em\u003e, 2023; Goodall, 2011); (3) there is an explicit prioritization of care quality, reflected in the improvement of indicators such as patient experience and adherence to clinical protocols (B\u0026auml;ker \u0026amp; Goodall, 2021; Kaiser \u003cem\u003eet al.\u003c/em\u003e, 2020).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLimitations and Inconsistencies\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eDespite evidence of clinical improvements associated with medical leadership, some studies point to limitations or inconclusive results. An analysis of 300 hospitals in the USA revealed no statistically significant differences in the rates of central line infection (3.2% vs. 3.4%, p\u0026thinsp;=\u0026thinsp;0.67) or mortality from acute myocardial infarction (11.8% vs. 12.1%, p\u0026thinsp;=\u0026thinsp;0.54) between physician-led and nonphysician-led hospitals (Moores \u003cem\u003eet al.\u003c/em\u003e, 2021), suggesting that factors such as the quality of the core clinical team and the resources available may have greater weight than the leadership itself.\u003c/p\u003e \u003cp\u003eSimilarly, a study with 400 hospitals in the USA reported that, although hospitals with medical leaders obtained higher recommendations from patients (10% reached the maximum classification in HCAHPS, compared with 5% in hospitals with nonphysician leaders, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), the overall quality scores did not differ significantly (73.4 vs. 72.9, p\u0026thinsp;=\u0026thinsp;0.41). This observation may reflect a prioritization of the physician leaders in the patient experience to the detriment of other broader clinical indicators\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn a Pakistani study, medical leaders in public hospitals did not observe better clinical indicators, attributing the results to administrative overload and a lack of management training. This result underscores the importance of the organisational context and the training of leaders\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe presence of doctors in leadership positions appears to be a determining factor in increasing the quality of care provided because of their ability to align organisational policies with best clinical practices. The presence of physicians in leadership positions is a determining factor in increasing the quality of care because of their ability to align organisational policies with best clinical practices. This trend is particularly evident in contexts where medical leadership is formally integrated into management, such as in the US and the UK. The lack of specific skills in risk management can limit this impact, whereas resistance to change, rooted in hierarchical models, constitutes an obstacle in some contexts\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. However, the effectiveness of this impact can be modulated by external factors, such as the availability of resources and organisational culture, which do not depend exclusively on leadership, as we will see below. These challenges emphasise the need for an integrated approach that goes beyond individual leadership.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCritical discussion\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eAnalysis of the 23 included articles revealed a generally positive association between medical leadership and clinical indicators, although with important variations. Studies such as those by \u003cem\u003eGoodall\u003c/em\u003e\u003csup\u003e\u003cb\u003e52\u003c/b\u003e\u003c/sup\u003e, 2011, \u003cem\u003eClay-Williams et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e31\u003c/b\u003e\u003c/sup\u003e, 2017, and \u003cem\u003eKirkpatrick et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e34\u003c/b\u003e\u003c/sup\u003e, 2023, have shown consistent benefits in terms of mortality, safety, and patient satisfaction. Others, such as \u003cem\u003eMoores et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e38\u003c/b\u003e\u003c/sup\u003e, 2019, and \u003cem\u003eSee et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e35\u003c/b\u003e\u003c/sup\u003e, 2022, point to limited or nonexistent effects in certain contexts. These differences can be attributed to the following:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMethodological differences: Small sample sizes or heterogeneous criteria in the definition of \"medical leadership\" (e.g., medical leader vs. doctor in secondary functions) compromise the comparability of results.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eContextual factors: In public health systems (e.g., the NHS and Italy), medical leadership seems more effective because of the prioritization of clinical efficiency, whereas in private systems (e.g., the USA), pressure for profitability can attenuate the focus on quality.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLeadership training: A lack of administrative/management skills, as observed by \u003cem\u003eKhan et al\u003c/em\u003e.\u003csup\u003e\u003cb\u003e37\u003c/b\u003e\u003c/sup\u003e, 2022, can jeopardise potential clinical benefits.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eFor a more robust analysis, future research should adopt standardised definitions of medical leadership, increase the sample size, and explore moderating variables such as the type of hospital (public vs. private), the level of autonomy of leaders, and organisational culture. In addition, longitudinal studies are needed to assess the long-term effects of medical leadership on clinical indicators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOperational Efficiency\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eOperational indicators measure efficiency in hospital management, including average length of stay, occupancy rates, use of resources (e.g., beds, equipment) and human resource management. Medical leadership has advantages in these areas, although the result depends on the training of leaders and organisational support.\u003c/p\u003e \u003cp\u003eIn the United Kingdom, clinical involvement in management has reduced waiting times by 8% and operating costs by 6%\u003csup\u003e\u003cb\u003e49\u003c/b\u003e\u003c/sup\u003e, with a 9% decrease in the readmission rate (NHS England, 2015) and an average reduction of 0.8 days (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in the length of stay\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. In the United States, medical leadership shortened hospitalisation times in cardiac surgery by 1.6 days (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003csup\u003e\u003cb\u003e52\u003c/b\u003e\u003c/sup\u003e. In Italy, clinical pathways coordinated by physicians reduced average hospitalisation times by 1.8 days\u003csup\u003e\u003cb\u003e47\u003c/b\u003e\u003c/sup\u003e, whereas in Australia, operational efficiency improved by 7% under clinical leadership\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAn Iranian study by \u003cem\u003eKakemam \u0026amp; Goodall\u003c/em\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, 2019, analysed 50 hospitals and reported that those led by doctors had superior operational efficiency, with an operational performance index 18% above average (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). This efficiency was attributed to a better understanding of clinical processes, allowing for decisions that were more aligned with the real needs of teams and patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003eZuchowski et al.\u003c/em\u003e \u003csup\u003e \u003cb\u003e43\u003c/b\u003e \u003c/sup\u003e, 2023, in a German study, analysed 80 hospitals and reported that those led by doctors had a significantly greater proportion of outpatient visits than did those led by inpatient admissions (2.82 vs. 1.87, p\u0026thinsp;=\u0026thinsp;0.025), reflecting a more rational use of hospital beds and a reduction in avoidable admissions of 14% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This result suggests that physician leaders prioritise preventive and outpatient strategies and optimise available resources.\u003c/p\u003e \u003cp\u003eThe aforementioned realities are justified, once again, by clinical knowledge, which allows (1) an allocation of resources aligned with the priorities of the services\u003csup\u003e\u003cb\u003e47\u003c/b\u003e\u003c/sup\u003e; (2) (2) the feasibility of implementing procedural changes\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e; (3) the promotion of a culture of innovation, which is essential in highly complex contexts\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, (4) the ability to mediate conflicts, reported as crucial in 25% of the studies analysed by \u003cem\u003eBerghout et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e30\u003c/b\u003e\u003c/sup\u003e, 2017.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLimitations and challenges\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eNot all studies confirmed the advantages. \u003cem\u003eKhan et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e37\u003c/b\u003e\u003c/sup\u003e, 2022, reported that, in Pakistan, medical leadership in public hospitals increased the average length of stay by 1.2 days (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) due to a lack of management training and administrative overload, which compromised operational efficiency. \u003cem\u003eMoores et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e38\u003c/b\u003e\u003c/sup\u003e, 2021, also did not find significant differences in occupancy rates (82.3% vs. 81.9%, p\u0026thinsp;=\u0026thinsp;0.78) between hospitals led by physicians and nonphysicians in the USA, suggesting that medical leadership may be insufficient without a robust support structure.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSee et al.\u003c/em\u003e \u003csup\u003e \u003cb\u003e35\u003c/b\u003e \u003c/sup\u003e, 2022, reported that the implementation of operational technologies (e.g., electronic health records) was slower in hospitals with medical leaders (68% adoption vs. 75%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), possibly because of the lack of specific technical skills, which limited operational gains.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCritical discussion\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eMedical leadership offers clear operational benefits, as demonstrated by \u003cem\u003eKakemam \u0026amp; Goodall\u003c/em\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, 2019, and \u003cem\u003eZuchowski et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e43\u003c/b\u003e\u003c/sup\u003e, 2023, but the challenges highlighted by \u003cem\u003eKhan et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e37\u003c/b\u003e\u003c/sup\u003e, 2022, and \u003cem\u003eSee et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e35\u003c/b\u003e\u003c/sup\u003e, 2022, indicate that these gains are not automatic. Management training is a determining factor: medical leaders with management training tend to obtain better results, while the absence of such training can generate inefficiencies. In addition, the impact varies across health systems: in contexts with more limited resources (e.g., Pakistan), structural barriers can nullify the benefits of medical leadership.\u003c/p\u003e \u003cp\u003eFuture studies should investigate how management training programs can enhance the operational effectiveness of physician leaders and compare performance between high- and low-complexity hospitals. The integration of supporting technologies also deserves more attention, given their potential role in improving modern efficiency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFinancial performance\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eFinancial indicators such as profit margins, return on assets and efficiency in the allocation of resources are fundamental to hospital sustainability. However, the impact of medical leadership on these indicators is ambiguous and highly dependent on context.\u003c/p\u003e \u003cp\u003eIn Germany, hospitals led by physicians had 3.8% lower financial performance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.1), despite clinical improvements, suggesting a greater prioritization of quality over profitability\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. In the United States, these costs amounted to 20\u0026nbsp;million dollars compared with 17\u0026nbsp;million in nonphysician-led hospitals (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003csup\u003e\u003cb\u003e31, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e corroborate this trend, reporting slightly lower profits per bed in hospitals led by physicians (\u0026euro;2039 vs. \u0026euro;2780), a reflection of greater investments in staff and technology.\u003c/p\u003e \u003cp\u003e \u003cem\u003eGoodall\u003c/em\u003e \u003csup\u003e \u003cb\u003e52\u003c/b\u003e \u003c/sup\u003e, 2011, reported that, in the USA, hospitals with medical leadership had 1.5% higher profit margins (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in profitable specialties (e.g., cardiac surgery), but this effect was less evident in less profitable services, such as primary care.\u003c/p\u003e \u003cp\u003eIn British and Italian hospitals, the presence of lead physicians increased returns on assets by 2.1% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and reduced operating costs by 8% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) over three years, which was explained by more informed decisions about investments in equipment and personnel\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, but studies such as the one by \u003cem\u003eMoores et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e38\u003c/b\u003e\u003c/sup\u003e, 2021, did not find significant differences in earnings.\u003c/p\u003e \u003cp\u003ePrioritizing quality increases operating costs, reflecting the clinical autonomy of physicians\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. In addition, the lack of financial education, which is evident in systems where only 50% of countries require management certification\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, limits economic optimization. However, the reduction in clinical waste, observed in Italy with a 15% decrease in administrative costs, suggests the potential for aligning priorities\u003csup\u003e\u003cb\u003e47\u003c/b\u003e\u003c/sup\u003e. The dichotomy between quality and sustainability reflects a structural challenge: resistance to medical management, reported in 60% of cases in Italy\u003csup\u003e\u003cb\u003e47\u003c/b\u003e\u003c/sup\u003e and the perception that administrative leadership compromises clinical practice and aggravates this tension\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. A hybrid approach is essential to overcome these barriers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eContextual factors\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThe financial impact varies considerably across health systems. In profit-oriented systems (e.g., the USA), medical leadership may be less advantageous if physicians prioritize clinical quality over profitability, whereas in public systems (e.g., the NHS), indirect gains (e.g., a reduction in readmissions) can improve financial efficiency. \u003cem\u003eKirkpatrick et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e34\u003c/b\u003e\u003c/sup\u003e, 2023, estimated that the reduction in complications in physician-led NHS hospitals generated annual savings of \u0026pound;2.3\u0026nbsp;million per entity, a benefit not reflected in direct observations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCritical discussion\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThe analysis of the financial indicators reveals a complex picture. While \u003cem\u003eVeronesi et Sarto\u003c/em\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, 2016, highlight economic benefits, \u003cem\u003eKaiser et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e41\u003c/b\u003e\u003c/sup\u003e, 2020, and \u003cem\u003eZuchowski et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e43\u003c/b\u003e\u003c/sup\u003e, 2023, indicate \u003cem\u003etrade-offs\u003c/em\u003e between quality and profitability. The lack of financial skills among physician leaders is a recurring limitation, but in systems where efficiency and quality are aligned, the gains can be significant. Future studies should explore hybrid models of leadership and evaluate its impact in different economic contexts.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePerformance in the satisfaction of professionals and users\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThe satisfaction of the parties involved in the provision of care is an indicator of institutional health, and the positive impact of the doctor-leader is clear.\u003c/p\u003e \u003cp\u003eIn Denmark, job satisfaction was greater under medical leadership (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with a 29% reduction in the intention to quit\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. In the United States, hospitals with medical leaders obtained 10% more maximum recommendations from patients (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002)\u003csup\u003e\u003cb\u003e35\u003c/b\u003e\u003c/sup\u003e. In Germany, user satisfaction was 8.4% higher (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01)\u003csup\u003e\u003cb\u003e41\u003c/b\u003e\u003c/sup\u003e, whereas in the Netherlands, the presence of physicians in leadership increased professional satisfaction by 12%\u003csup\u003e\u003cb\u003e46\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHuman resource management also benefits from medical leadership. \u003cem\u003eB\u0026auml;ker and Goodall\u003c/em\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, 2021, analysed 200 hospitals in the USA and UK and reported that professionals under medical leadership stated 12% greater job satisfaction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and 15% lower intention to leave (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) than hospitals led by nonphysicians. This talent retention reduces recruitment and training costs, estimated at between \u0026euro;50,000 and \u0026euro;100,000 per doctor replaced, according to the study data.\u003c/p\u003e \u003cp\u003eUnderstanding the underlying dynamics, (1) transformational leadership inspires trust and collaboration\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, whereas closeness to teams affects well-being\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e and (2) empathic communication with patients increases the perception of care, an effect amplified by patient-centred policies\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCritical discussion\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThe impact of medical leadership in this domain is quantitatively and qualitatively robust, but it can be hampered by external pressures or a lack of diversity in leadership, such as the underrepresentation of women\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. The absence of formal training in interpersonal skills is another obstacle in some systems\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThus, the type of leadership portrayed in this study has clear benefits in terms of quality, safety, efficiency, and satisfaction, but faces challenges in terms of economic and financial sustainability. Future studies should focus on standardizing definitions, training physician leaders, and performing comparative analyses between health systems.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEssential Competencies and Challenges in Medical Leadership\u003c/span\u003e\u003c/h2\u003e \u003cdiv id=\"Sec26\" class=\"Section4\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEssential Competencies\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eMedical leadership, as a multifaceted phenomenon, requires a harmonious synthesis of technical, relational, and strategic skills, which transcends mere clinical excellence. The analysis of the articles allows the identification of three interdependent dimensions that support effective leadership: (1) technical credibility and clinical authority among peers and within multidisciplinary teams \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, 52\u003c/b\u003e\u003c/sup\u003e - this competence is not limited to the domain of procedures or diagnoses but encompasses the ability to translate technical knowledge into informed organisational decisions, for example, leaders with specialized training in areas such as oncology or cardiac surgery demonstrate enhanced ability to align clinical protocols with institutional strategies, reducing discrepancies between theory and practice\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, 52\u003c/b\u003e\u003c/sup\u003e; (2) adaptability, which enables alternation between a visionary style (to inspire teams during crises) and a democratic style (to promote collaboration in long-term projects), is associated with improvements in institutional cohesion and in the implementation of innovations\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e - adaptive leadership styles, such as situational or transformational leadership, are critical for navigating volatile organisational contexts\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e; (3) ethical competence and interprofessional mediation, which allows the physician-leader to assume a dual role: an advocate for clinical quality and a mediator between competing interests (financial management, stakeholder expectations and political pressures) - this duality requires strong ethical competencies (such as integrity, transparency, and resilience that avoid compromising patient safety)\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e and interprofessional mediation, which in turn requires cultural sensitivity to integrate diverse perspectives (from nurses to administrative managers), building consensus around common goals.\u003c/p\u003e \u003cp\u003eIn summary, the review by \u003cem\u003eBerghout et al.\u003c/em\u003e\u003csup\u003e\u003cb\u003e30\u003c/b\u003e\u003c/sup\u003e, 2017, found that the most highly valued skills were communication (referred to in 35% of their analysed studies), conflict resolution (32%), and negotiation (26%). Clinical credibility emerges as a fundamental pillar, being considered essential in 66% of them.\u003c/p\u003e \u003cp\u003eStudies highlight that medical leaders capable of articulating a \u0026ldquo;shared vision\u0026rdquo; mitigate conflicts between clinical autonomy and operational efficiency, promoting less hierarchical and more collaborative environments\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStructural and Cultural Obstacles to Medical Leadership\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThe challenges faced by physician leaders are not merely individual but are rooted in systemic dynamics that reflect historical tensions between medicine and management. These obstacles can be categorised into three key areas: (1) identity conflict and role fragmentation, where the need to maintain partial clinical activity (to preserve credibility with peers) generates a workload that restricts strategic leadership engagement \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e - this phenomenon is exacerbated by the limited institutional recognition of the strategic importance of medical leadership, often perceived as \"secondary\" rather than a direct practice, and consequently, many physician leaders adopt a reactive, focused on resolving immediate crises, to the detriment of a proactive and visionary approach\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e; (2) deficiencies in training and support, often making preparation an informal incident, with physicians taking on management positions without structured training in nonclinical skills\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e - management specialization programs, although useful, are inaccessible to many professionals due to high costs or incompatibility with professional and personal schedules. The absence of mentoring systems and clear professional management paths for physicians perpetuates improvised governance models, where practical experience replaces formal qualifications\u003csup\u003e\u003cb\u003e47\u003c/b\u003e\u003c/sup\u003e - a gap that is particularly critical in countries with fragmented health systems, where medical leadership is delegated to administrative managers without understanding the clinical realities\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. \u003cem\u003eStoller\u003c/em\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e, 2017, reported that traditional medical training prepares professionals to be \"lone heroes\", focused only on individual clinical practice; (3) cultural resistance and archaic hierarchies, historically shaped by values such as autonomy and individualism, collide with collaborative management models\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e - in hospitals with rigid hierarchical structures, the participation of physicians in administrative councils is often symbolic, with no real influence on strategic decisions, a dynamic that is aggravated in decentralised systems, where the separation between \"clinics\" and \"managers\" crystallises stereotypes that hinder cooperation\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e (for example, in German and Dutch hospitals, the predominance of nonmedical managers in executive positions reflects deep-rooted distrust in the ability of physicians to balance clinical and financial priorities)\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFrom theory to practice: the interaction between leadership competencies and obstacles\u003c/span\u003e\u003c/h2\u003e \u003cp\u003eThis binomial leadership skills-obstacle has profound repercussions for the sustainability of health systems, transcending conventional metrics. Therefore, three dimensions deserve to be highlighted: (1) The optimization of resources through informed leadership \u0026ndash; medical leaders with a background in management are better positioned to prioritize investments in technologies and practices with high clinical returns, avoiding excessive expenses\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. However, the lack of analytical skills among medical leaders \u0026mdash; common in contexts with insufficient training \u0026mdash; tends to perpetuate autonomous decision based on the intuition or preferences of different services/departments, compromising the whole\u003csup\u003e\u003cb\u003e47\u003c/b\u003e\u003c/sup\u003e; (2) The adoption of hybrid and collaborative models, such as \u003cem\u003eTeam in the lead\u003c/em\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e or shared governance between physicians and managers\u003csup\u003e\u003cb\u003e47\u003c/b\u003e\u003c/sup\u003e, shows the potential for reducing indirect costs, namely, the turnover of professionals and litigation due to clinical errors. These models, by distributing responsibilities and valuing the technical knowledge of multiple actors, promote a culture of collective accountability. Nevertheless, their implementation requires initial investments in interdisciplinary training and process restructuring, particularly in complex challenges in health systems with limited resources; (3) The hidden costs of institutional fragmentation, such as role ambiguity and the dual clinical-management burden, generate significant hidden costs, from unpaid overtime to lost productivity due to burnout\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. The standardisation of functions and the creation of careers dedicated or more dedicated to medical leadership, with the subsequent progressive reduction in the clinical burden, could mitigate these costs. For example, Danish hospitals that implemented gradual transition programs (with mentoring and management training) reported greater retention of hospital medical leaders and less dependence on external consultants\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAdvantages of medical leadership and Implications for healthcare governance\u003c/span\u003e\u003c/h2\u003e \u003cp\u003ePhysician leaders represent an advantageous model in hospital governance and its advantages range from the harmonious integration of clinical and strategic skills to the promotion of an ethical and collaborative organisational culture.\u003c/p\u003e \u003cp\u003eFirst, the capacity to integrate technical expertise with managerial decision-making stands out as a fundamental pillar. Medical leaders, endowed with solid clinical training, translate complex operational dynamics \u0026mdash; such as patient needs, team dynamics, and diagnostic challenges \u0026mdash; into evidence-informed managerial decisions. This duality avoids fragmentation between \"managers\" and \"clinicians\", ensuring that hospital policies reflect practical realities rather than bureaucratic abstraction \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSecondly, medical leadership assumes a critical mediating role between clinical teams and management/administration structures. By operating as interpreters of different professional languages, the lead physician mitigates conflicts between clinical autonomy and efficiency requirements, building consensus around shared goals. This mediation is not limited to a diplomatic function - it is rooted in an ethical vision that places the patient at the centre of decisions, ensuring that clinical considerations are not subordinated solely to economic imperatives. In this way, trust is restored between professionals and processes of change are legitimised, strengthening institutional cohesion\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePrioritising quality of care and patient safety is another notable advantage. While managers without medical training may privilege productivity or profitability metrics, clinical leaders emphasize clinical outcomes, prevention of complications, and positive patient experiences. This guideline reflects not only an ethical commitment but also a pragmatic understanding that clinical excellence is inseparable from long-term institutional sustainability. Evidence-based protocols, implemented with rigour, not only raise standards of care but also prevent indirect costs associated with medical errors or readmissions, reinforcing institutional reputation \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFlexibility in adopting adaptive leadership styles, such as situational or transformational models, is another asset. When trained in environments that value problem solving under pressure, physicians alternate between assertive approaches during crisis scenarios and collaborative approaches in stable contexts. This ability to adapt optimizes responses to unforeseen challenges, such as pandemics or emergencies, while cultivating dynamic work environments where innovation and collective learning are encouraged. Transformational leadership inspires teams through a clear vision and empowers professionals via skills development, fostering virtuous cycles of ongoing improvement \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the field of human resource management, the clinical credibility of medical leaders constitutes a strategic asset. The experience shared with teams facilitates adherence to new guidelines, as these are perceived as emanating from peers who understand the practical requirements of the profession. Moreover, policies sensitive to workload, work‒life balance, and continuing education need to result in higher levels of job satisfaction and lower turnover rates. These factors not only reinforce operational stability but also positively impact the quality-of-care provided\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe promotion of collaborative leadership models, such as \u003cem\u003ethe Team in the Lead\u003c/em\u003e, illustrates the inclusive vocation of this leadership. By integrating doctors, nurses, managers, and patients into decision-making structures, authority is democratized, and responsibilities are distributed, diluting traditional hierarchies. This approach not only enriches the decision-making process from multidisciplinary perspectives but also combats departmental fragmentation, promoting synergies between units that, in turn, optimize the use of resources. The resulting co-responsibility strengthens institutional cohesion and brings hospital policies closer to the real needs of the communities served\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAt the ethical level, medical leadership is distinguished by its commitment to equity and social responsibility. Policies that expand access to care without direct costs to the patient, integrate social determinants of health, and combat disparities in access to services reflect a holistic understanding of well-being beyond restricted biomedical paradigms. This orientation not only fulfils a moral imperative but also reinforces institutional legitimacy before society, positioning the hospital as an actor committed to social justice\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFinally, the simplification of operational processes emerges as a practical advantage. The proximity to the clinical reality allows leaders to identify bureaucratic redundancies, streamline workflows, and eliminate obstacles that compromise efficiency. In the context of scarce resources, this ability to optimize is translated into tangible gains in productivity without sacrificing quality, ensuring that institutions maintain high standards even under budgetary pressure\u003csup\u003e\u003cb\u003e47, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIn a world where health has simultaneously become a civilizational promise and a political battleground, medical leadership has emerged as a catalytic force in balancing between efficiency and humanism, innovation and tradition, the global scale and individualised care.\u003c/p\u003e \u003cp\u003eThis scoping review, which critically analyses 23 studies, provides an unequivocal picture: physicians in leadership roles act as architects of more resilient health systems. These findings are important. In the United States, clinical leadership was associated with a 15% reduction in preventable complications. In Germany, hospitals led by physicians reported an 8% improvement in user satisfaction. In Australia, teams under medical leadership showed a 29% reduction in burnout rates among healthcare professionals. These indicators show that when clinical knowledge is combined with strategic vision, the outcomes extend beyond metrics, directly impacting lives.\u003c/p\u003e \u003cp\u003eHowever, the exposed reality is paradoxical. While medicine has advanced at exponential speeds, the training of medical leaders has remained largely static. Approximately 65% of physician leaders in executive positions in countries such as Italy and France have never received formal training in management, and most medical programs in Europe do not include essential health economics content. This misalignment reflects a systemic shortfall that still sees leadership as a secondary \u003cem\u003esoft skill\u003c/em\u003e, not as a core competence. The consequences are tangible: in Canadian hospitals, clinical decisions misaligned with organisational strategies generate redundant costs of 12%; in Pakistan, the absence of physicians in management positions is associated with a 23% higher clinical error rate.\u003c/p\u003e \u003cp\u003eTo break this cycle, a three-pronged educational reform is proposed:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCurriculum Reengineering\u003c/span\u003e: Mandatory inclusion of subjects such as health management, health economics, and organisational leadership in medical curricula, with active methodologies and simulated contexts based on real challenges, such as resource management during pandemics.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIntegrated training models\u003c/span\u003e: Creating dual-degree pathways (for example, medicine plus health management - MD/MHA) based on international references that articulate medical training and hospital administration, making doctors able to analyse both clinical data and financial or management indicators.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eClinical Leadership Labs\u003c/span\u003e: Promotion of hybrid residencies in university hospitals, where students collaborate in the actual management of teams and budgets under the supervision of experienced leaders.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eIt is also essential to integrate recognition and incentive mechanisms. The examples of performance-based incentives linked to dual metrics (clinical quality and operational efficiency) emphasize the need to align professional goals with measurable results in a value-based health logic.\u003c/p\u003e \u003cp\u003eLooking at the strategic horizon, three major pillars of future action are outlined:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAnticipatory Clinical Leadership\u003c/span\u003e: The training of medical leaders prepared to address complex crises using predictive data and disaster management scenarios.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCollaborative ethical frameworks\u003c/span\u003e: The development of dynamic ethical structures, co-created with communities and users, is especially relevant in emerging decisions such as the allocation of high-cost therapies.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIntegrated Health Ecosystems\u003c/span\u003e: Transition from the hospital-centred model to care networks where the lead physician acts as an articulator between levels of care, promoting continuity and rationality in the use of resources.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eFuture studies should explore hybrid models of leadership, evaluate the impact in different economic contexts, adopt standardized definitions of medical leadership, increase the sample size, and explore moderating variables such as the type of hospital (public vs. private), the level of autonomy of the leaders, and the organisational culture. In addition, longitudinal studies are needed to evaluate the long-term effects of medical leadership on clinical indicators.\u003c/p\u003e \u003cp\u003eMedical leadership cannot be an epiphenomenon \u0026mdash; it must be the new social contract of health in the 21st century. Universities must train not only physicians in the strictly clinical aspect but also architects of health systems. Hospitals should value not only clinical specialists but also synthesizers of knowledge. Society must be able to recognize that, in the hands of a leading physician, a stethoscope can be both a diagnostic tool and a tool for global change. After all, in a world where even artificial intelligence aids in diagnosis, what will make us truly human, and indispensable, will be the ability to lead science in the mind and humanity in the hands.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAAMC\u003c/strong\u003e – \u003cem\u003eAssociation of American Medical Colleges\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAMA\u003c/strong\u003e – \u003cem\u003eAmerican Medical Association\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMJ\u003c/strong\u003e – \u003cem\u003eBritish Medical Journal\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCANMEDS\u003c/strong\u003e – \u003cem\u003eCanadian Medical Education Directives for Specialists\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOVID-19\u003c/strong\u003e – \u003cem\u003eCoronavirus Disease 2019\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGMC\u003c/strong\u003e – \u003cem\u003eGeneral Medical Council\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCN\u003c/strong\u003e – \u003cem\u003eHealth Council of the Netherlands\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICER\u003c/strong\u003e – \u003cem\u003eIncremental Cost-Effectiveness Ratio\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJBI\u003c/strong\u003e – \u003cem\u003eJoanna Briggs Institute\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMD/MHA\u003c/strong\u003e – \u003cem\u003eDoctor of Medicine / Master of Health Administration\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNHS\u003c/strong\u003e – \u003cem\u003eNational Health Service\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOECD\u003c/strong\u003e – \u003cem\u003eOrganisation for Economic Co-operation and Development\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePCC\u003c/strong\u003e – \u003cem\u003ePopulation, Concept, Context\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRISMA-ScR\u003c/strong\u003e – \u003cem\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analyses – Scoping Review\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQALY\u003c/strong\u003e – \u003cem\u003eQuality-Adjusted Life Year\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eROI\u003c/strong\u003e – \u003cem\u003eReturn on Investment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUK\u003c/strong\u003e – \u003cem\u003eUnited Kingdom\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUSA\u003c/strong\u003e – \u003cem\u003eUnited States of America\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVBH\u003c/strong\u003e – \u003cem\u003eValue-Based Healthcare\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e – \u003cem\u003eWorld Health Organization\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eNot applicable. This study is a scoping review based exclusively on previously published literature and did not involve human participants, animals, or primary data collection.\u003c/p\u003e\n\u003ch3 id=\"_Toc218868123\"\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3 id=\"_Toc218868124\"\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eNo new data were created or analysed in this study. All data supporting the findings of this review are included in the published articles analysed.\u003c/p\u003e\n\u003ch3 id=\"_Toc218868125\"\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch3 id=\"_Toc218868126\"\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003ch3 id=\"_Toc218868127\"\u003eAuthors’ contributions\u003c/h3\u003e\n\u003cp\u003eConceptualisation: João Carlos Ribeiro.\u003c/p\u003e\n\u003cp\u003eMethodology: Pedro Mendes Monteiro and João Carlos Ribeiro.\u003c/p\u003e\n\u003cp\u003eFormal analysis: Pedro Mendes Monteiro.\u003c/p\u003e\n\u003cp\u003eInvestigation: Pedro Mendes Monteiro.\u003c/p\u003e\n\u003cp\u003eWriting – original draft: Pedro Mendes Monteiro.\u003c/p\u003e\n\u003cp\u003eWriting – review \u0026amp; editing: Pedro Mendes Monteiro and João Carlos Ribeiro.\u003c/p\u003e\n\u003cp\u003eVisualisation: João Carlos Ribeiro.\u003c/p\u003e\n\u003cp\u003eSupervision: João Carlos Ribeiro.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3 id=\"_Toc218868128\"\u003eDeclaration of AI use\u003c/h3\u003e\n\u003cp\u003eDuring the preparation of this manuscript, the authors used artificial intelligence tools solely for language correction and refinement of grammar and style. These tools were not used for idea generation, content creation, data analysis, or interpretation. The authors reviewed and edited the text after using these tools and take full responsibility for the content of the publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eInternational Monetary Fund. (2014). Global Health Threats of the 21st Century: Finance \u0026amp; Development, December 2014. \u003cem\u003eFinance \u0026amp; Development\u003c/em\u003e, \u003cem\u003e51\u003c/em\u003e(4), i. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5089/9781484315422.022\u003c/span\u003e\u003cspan address=\"10.5089/9781484315422.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaleem Fahad. Revolutionizing Healthcare: Challenges and Opportunities in the 21st Century. 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Int J Clin Pract. 2012;66(2):121\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1742-1241.2011.02844.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1742-1241.2011.02844.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical leadership, Healthcare management, Performance indicators, Organisational efficiency, Health systems, Value-based healthcare, Cost-effectiveness","lastPublishedDoi":"10.21203/rs.3.rs-8563033/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8563033/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHealthcare systems are increasingly challenged by rising demand, financial constraints and organisational complexity, intensifying the need for governance models that effectively align clinical quality with operational and economic performance. Medical leadership has been proposed as a strategy to bridge clinical expertise and managerial decision-making; however, evidence regarding its impact on healthcare performance indicators remains heterogeneous. This scoping review aims to examine the relationship between medical leadership and clinical, financial and organisational outcomes in healthcare institutions, while identifying essential leadership competencies and implementation barriers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA scoping review was conducted in accordance with the \u003cem\u003eJoanna Briggs Institute\u003c/em\u003e guidelines and the PRISMA-ScR criteria. Literature searches were performed across major databases (PubMed, Web of Science) covering the period from 2000 to 2025. Eligible studies included quantitative and qualitative research analysing clinical, financial or organisational performance indicators in healthcare institutions under medical, non-medical or hybrid leadership models. Data were extracted using a standardised framework and synthesised narratively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTwenty-three studies met the inclusion criteria. Medical leadership was consistently associated with improved clinical outcomes, including lower risk-adjusted mortality, higher patient satisfaction and enhanced patient safety. Organisational benefits were also reported, particularly in professional engagement, retention and perceived leadership credibility. Evidence regarding financial performance was mixed, with some studies reporting higher operating costs in physician-led institutions, while others demonstrated neutral or context-dependent financial effects. Leadership training, organisational culture and governance structures emerged as key moderating factors.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMedical leadership appears to confer advantages in clinical quality and organisational performance, although its impact on financial efficiency remains inconclusive. Effectiveness is strongly influenced by formal management training, institutional support and collaborative governance models. These findings support the integration of leadership and management education into medical training and highlight the need for further research exploring hybrid leadership models and contextual determinants of performance.\u003c/p\u003e","manuscriptTitle":"In healthcare institutions, is having physicians in leadership roles an advantage? A scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 11:43:26","doi":"10.21203/rs.3.rs-8563033/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-08T10:13:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220691376516122705561950104684218267472","date":"2026-02-18T08:30:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T15:33:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-16T13:09:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-12T06:11:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-12T06:08:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-09T16:42:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03dbd106-87b6-43f8-afc7-78af970fa5fe","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-13T11:43:26+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 11:43:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8563033","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8563033","identity":"rs-8563033","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}