If Leadership Feels Lonely, You’re Probably Doing It Right
Earlier in this series, we discussed how to handle uncertainty, let go of always needing to be right, and engage with power rather than shy away from it.
Now let’s talk about something physician leaders often feel but rarely mention: Loneliness.
When you ask others about leadership, they warn you about the politics. They say moving from clinician to executive requires a different skill set. But no one warns you about the loneliness.
No one really prepares you for that moment in a conference room with leaders from finance, quality, HR, marketing, and IT, when you suddenly feel out of place.
While everyone is discussing money and metrics, your mind drifts to things that aren’t on the slides. You think about the nurses who spend more time documenting than caring for patients.
You think about the doctors drowning in messages and losing meaning. You think about the patients who are unable to keep their outpatient appointments for various reasons.
Driving home that evening, you start to wonder if you’re really meant for this role.
The Fear We Don’t Name
We talk a lot about imposter syndrome in leadership.
But physician leaders often face an even bigger fear.
It’s the fear that makes you wonder, “Am I becoming someone I don’t want to be in this role?”
This fear often sneaks up on you. It sneaks up when you’re getting ready for another day of meetings, and something makes you hesitate. It sneaks up when a patient thanks you, and you realize you haven’t felt that kind of connection in months.
This feeling is more than just doubting your abilities, which is what imposter syndrome is about. It’s a sense of dissonance.
Zaleznik’s Insight: Two Kinds of People
Abraham Zaleznik, a psychoanalyst who studied leadership, used a framework from William James to describe two personality types: the “once-born” and the “twice-born.”
Once-born personalities move through life in relative harmony with their environment. Their identity flows easily from belonging. They adapt. They fit. They stabilize.
Twice-born personalities experience things differently. Their lives involve more questioning, more tension, and what Zaleznik called a “feeling of profound separateness.” They don’t just accept the system as it is.
Zaleznik made an interesting observation:
Managers tend to be once-born.
Leaders tend to be twice-born.
That feeling of not quite fitting in?
It might not be a weakness.
It might actually be what makes you a better leader.
Medicine Builds Deep Belonging
To see why this affects physicians so deeply, consider how medical training shapes identity.
Medical students reportedly learn over 50,000 new words in medical school. The learning process is rigorous, training you to place others’ needs above your own. While learning all those new words, you also learn how to triage and prioritize in the most horrendous situations. You learn how to be as dispassionate and objective as anyone can be in those conditions. You see people at their worst, both psychologically and physically, and learn to take it in stride. You learn to think about trade-offs and explain them to patients. And through all this, you also learn about hierarchy, belonging, and endurance. You don’t just learn new words in medical school. The process of learning them changes your identity.
So when you move into leadership and find yourself between groups, not quite a clinician anymore, but not fully an executive either, it can feel unsettling.
The Leadership Meeting
Let’s go back to that leadership meeting from above.
During the discussion about money and metrics, your mind wanders to what isn’t being measured. You can stay quiet to fit in with your new group, or you can speak up and risk causing friction. It’s a choice between two types of discomfort.
Some people choose silence. Others avoid leadership altogether. Both choices are understandable.
But here’s what Zaleznik realized:
If you felt completely at home in that meeting, you wouldn’t be doing that internal math.
You wouldn’t notice what isn’t on the slides.
That discomfort is actually a tool.
Sometimes, it’s the only tool in the room that picks up on what matters.
How Leadership Gets Socialized Out of Leaders
A talented physician gets tapped for leadership. They go to programs. They learn budgeting. They get good at running meetings. Slowly and almost without noticing, they stop asking certain questions.
Not because anyone told them to stop.
Because asking them creates friction.
Because friction threatens belonging.
Because belonging feels safer than tension.
Zaleznik called this process socialization, which means developing in a way that helps keep things as they are. The process produces competent managers. But developing as a leader is different.
It requires tolerance for ambiguity and comfort with tension.
It requires the ability to stand slightly apart and be less absorbed into any one tribe, so as to maintain a broader perspective on all tribes.
If your leadership journey has made you feel more comfortable but less clear, that’s something to pay attention to.
What Separateness Actually Does
Zaleznik described managers as people who see themselves as conservators of an existing order. Their identity is tied closely to the system.
Leaders, he wrote, might work within organizations, but they never fully belong to them. Their sense of self isn’t tied to being a member. That sense of being separate isn’t about rebelling. It’s essential to clarity.
You can’t evaluate a system you’re completely fused with.
You can’t question assumptions you’ve fully absorbed.
That small sense of distance and discomfort is what helps you see things clearly.
Let’s Not Romanticize It
I’m not going to pretend this is easy.
A lot of leadership writing quickly jumps to the idea that it’s all meaningful, without spending enough time on the hard parts. So let’s pause here for a moment.
It is exhausting to be the one who raises the uncomfortable question.
It is tiring to repeatedly notice when actions don’t fit values.
It hurts when nothing changes after you speak.
Calling that loneliness ‘leadership capacity’ doesn’t make it feel any less lonely.
You still carry it.
The real difference is whether you’re carrying it for a purpose.
The Practice
Here’s a practical step you can try.
Stop asking:
“Why don’t I fit?”
Start asking:
“What does my discomfort allow me to notice?”
Then, try to get specific. Keep a private list for a few weeks. Write down moments like:
“Everyone celebrated the metric, but I felt uneasy.”
“The plan made operational sense but violated something I value.”
“The meeting moved quickly, but something important went unsaid.”
Don’t fix them yet. Just pay attention to what you’re noticing. Patterns will emerge.
And when you start to see patterns, try to be curious rather than jump to conclusions.
Say:
“Can we pause on one thing before we move on?”
“I want to test an observation.”
“I’m noticing something I can’t fully articulate yet.”
That’s what real leadership looks like.
The Bigger Picture
Healthcare right now has extraordinary management sophistication. We measure many things.
We do our best within the system’s limits.
But we are facing a leadership crisis, because many of the people who can see the inconsistency between metrics and meaning have learned to disengage where it matters.
Those who feel a bit out of step and haven’t completely blended into institutional thinking are often the ones who see things most clearly.
You might be one of them.
The Final Reframe
That loneliness you sometimes feel in leadership meetings?
That’s not fragility.
That’s the signal.
If leadership always felt comfortable, if you felt fully at home in every decision, you wouldn’t be leading. You’d be maintaining. And right now, healthcare doesn’t need more maintenance.
It needs people willing to stand slightly apart. To see clearly. To name what others are avoiding.
That place can feel lonely.
But it might also be the most important place to be.
This concludes 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.
