Power Avoided is Power Surrendered
We’ve covered two main ideas so far in this series:
First, how medicine trains us to nail down uncertainty, while leadership asks us to sit with it.
Second, why jumping straight to solutions can actually break trust.
Now for a tough topic: power.
Most doctors are deeply uncomfortable with power.
Years back, when I took my first CMO job, a nurse friend said something that’s stuck with me. She looked genuinely sad and asked, “You’re such a good doctor. Why would you become an administrator?”
Caught off guard, I deflected with a joke, “Are you saying only bad doctors should become healthcare administrators?”
But honestly? That conversation still bugs me.
Why do so many of us struggle with leadership roles?
And what does that cost both us and the system?
I think the problem is we’ve confused leadership with control.
Nobody goes into medicine to boss people around. You become a doctor to help people.
So when leadership opportunities come up, it’s easy to just… step back.
“I just want to take care of patients,” we tell ourselves.
I get it. It feels safe. But it’s actually riskier than it feels.
The Risks of Power
Abraham Zaleznik opened his classic article on leadership, on which this series is based, with an uncomfortable truth: “Leadership inevitably requires using power to influence the thoughts and actions of other people.”
He noted three risks that come with power:
- The urge to go for quick wins.
- Assuming your authority or title is enough, rather than building real influence.
- And hubris marked by losing yourself in the desire for more power.
These risks are real. To manage those risks, organizations build elaborate systems of checks and balances. These systems are called committees.
Trying to eliminate the risks of power often eliminates leadership itself
But here’s what Zaleznik noticed: in trying to eliminate the risks of power, organizations often eliminate leadership itself. They replace actual leaders with “collective leadership” and “managerial cultures” where consensus matters more than conviction, process trumps purpose, and everything gets watered down through compromise.
I’ve seen this play out even in smaller clinics and hospitals, not just the big corporate systems.
Ever been part of a “Committee of the Whole”? Or sat on an executive committee that was so bloated that actual decisions became impossible? Where consensus, process, and compromise squeeze out real conviction, purpose, and clarity?
What happens? The people most comfortable with the use of power end up making the calls, not necessarily the ones who truly understand what benefits patients..
The Myth of Neutrality
In complex systems, power doesn’t disappear because you avoid it.
If you don’t use it, someone else absolutely will. Often, someone with less clinical knowledge, fewer ethical guardrails, stronger incentives to keep things the way they are, or a completely different vision for the future.
Think about what’s being decided in your organization right now.
Who’s actually in those rooms?
Who’s setting the RVU targets, designing the staffing models, and defining the quality metrics?
If you’re not there, if doctors with your values and clinical insight aren’t at the table, those decisions still get made. They just get made without you.
Opting out of power isn’t taking the moral high ground.
It’s abdication.
Authority vs. Influence
Clinical authority is pretty straightforward.
You’re the attending. Your name’s on the chart.
People generally do what you say.
Leadership influence?
A completely different game.
It requires persuasion, framing, timing, and narrative shaping.
You need to understand how decisions are actually made, not how the org chart says they should be made.
The trap I see physicians fall into all the time is the belief that clinical expertise should automatically translate into organizational influence.
They say, “I know the most about patient care, so obviously my input should carry the most weight.”
But organizations don’t work that way.
Knowledge is necessary, sure. But it’s not enough.
You also need the willingness to do the messy, uncomfortable work.
Really dive into data. Build coalitions. Manage up, down, and sideways. Pick your battles.
And yes, sometimes compromise on good ideas so you have the political capital to fight for the great ones. That’s not selling out. That’s leadership.
Moral Injury Is Often an Influence Gap
When physicians say they feel morally injured, they often mean they see what’s wrong but feel powerless to change it. They feel that the healthcare system’s behaviors don’t align with theirs. That’s not a values failure. That’s an influence gap.
Zaleznik made the distinction between managers who “shift balances of power toward solutions acceptable as compromises” and leaders who “develop fresh approaches to long-standing problems and open issues to new options.”
Moral injury happens at that intersection. You see clearly what’s wrong (clinical insight). You feel deeply that it matters (values). But you lack the positional or political power to change it (influence gap).
The standard response is resignation: “The system is broken. There’s nothing I can do.” But that’s usually not true. What’s actually true is: “I haven’t learned yet how to build the kind of influence this change requires.”
Power is the ability to shape outcomes
That’s a skill gap. And skill gaps can be closed.
A Relatable Example
Take the electronic health record. Pretty much every physician I know thinks it’s terrible. It steals face time with patients, turns us into glorified data-entry clerks, drives burnout through the roof, and probably makes care worse.
And yet, nothing changes. Why?
Because people with clinical insight lack organizational power. And people with organizational power lack clinical insight.
IT isn’t evil.
Finance isn’t trying to hurt patients.
Administration isn’t deliberately ignoring what physicians say.
But physicians aren’t in the rooms where these decisions actually get made.
And when we do get invited, we often show up with complaints instead of solutions, clinical purity instead of political savvy. Trust me, I’ve been that physician.
Building influence requires persuasion, framing, timing, and triaging the battles to fight.
So nothing changes.
Now imagine a different scenario.
A physician leader who gets both the clinical problem and the political landscape.
Who knows that IT needs to show ROI.
That finance needs to hit cost targets.
That administration needs to demonstrate meaningful use.
That leader doesn’t just complain about the EHR. She builds a coalition. Speaks the language of multiple stakeholders. Proposes solutions that address clinical needs without ignoring organizational constraints.
That’s power used well. And honestly? It’s the only way change actually happens.
If you care about patient safety, team well-being, or the soul of medicine, then learning ethical influence isn’t optional.
The question isn’t whether to engage with power. The question is whether the people who care most deeply about patients are willing to do the uncomfortable work of building influence.
What Ethical Influence Looks Like
Ethical influence means going beyond the org chart to understand how decisions are actually made.
It means building relationships before you need them. You can’t call in favors you haven’t earned.
It means speaking the language of different stakeholders — quality, cost, experience, safety, and reputation. Know which one matters most to each person.
It means choosing your battles. You can’t fight everything. You worked in the ER; you know how to triage.
And it means staying in the room even when it’s uncomfortable. The moment you walk out is the moment you lose influence.
None of this is taught in medical school.
Most of it isn’t taught in leadership programs either.
It’s learned through practice, through failure, and through watching who actually gets things done.
The Cost of Opting Out
Here’s what we get when clinicians with strong values opt out of organizational power:
- Metrics designed by people who are clueless about clinical expertise.
- Policies written by people who are clueless about clinical workflow.
- Budgets passed by people who are clueless about human behavior.
- Strategy set by people who are clueless about moral injury.
And then those same clinicians wonder why healthcare feels increasingly soulless.
You can’t fix a system in which you refuse to engage with power.
The One Practice
Ask yourself weekly: “Where am I opting out of influence because it feels uncomfortable?”
That awareness alone shifts how you lead.
Maybe it’s skipping the strategic planning meeting because “it’s all politics.”
Maybe it’s staying quiet when someone proposes a policy you know will fail.
Maybe it’s letting someone else represent the clinical perspective because you don’t want to deal with the conflict.
Every time you opt out, someone else fills that space. And they might not share your values.
The Zaleznik Insight
Zaleznik observed that leaders “work from high-risk positions; indeed, they are often temperamentally disposed to seek out risk and danger, especially where the chance of opportunity and reward appears promising.”
The risk he’s talking about isn’t physical danger. It’s the risk of engaging with power. Of being seen as political. Of making compromises. Of staying in uncomfortable rooms where your values get challenged. But that’s also where change happens.
Leadership isn’t about purity. It’s about leverage.
And if you’re not willing to build leverage, you’re not willing to lead.
The question isn’t whether healthcare needs fixing.
The question is whether you, a physician, are willing to do the uncomfortable work of gaining the power to fix it.
This is Part 3 of a four-part series exploring how physicians can navigate the manager-leader tension in healthcare. The series draws on Abraham Zaleznik’s “Managers and Leaders: Are They Different?” (Harvard Business Review, 1977), reinterpreted for modern healthcare leadership. The article was republished in 2004.
Next week: Why leadership often feels lonely — and why is not a bug.
