Managing Up as a Physician Leader
You Have a Boss Now, Too
You took the leadership role because you wanted to shape things. But here is the part that catches people off guard: managing up as a physician leader is a completely different skill than managing up as a faculty member.
As a junior faculty member, managing up meant making a case for protected time. Now you are a division chief, a vice chair, or a medical director. The person above you is a dean or a C-suite executive with fifty competing demands. The relationship you build with them will determine how much you actually accomplish in your role.
Why This Feels Political (and Why It Is Not)
I hear this from physician leaders constantly. "I don't want to play politics." But managing your relationship with your dean or C-suite leader is not politics. It is leadership.
Michael Watkins makes this distinction clearly in The First 90 Days. He writes that newly promoted leaders who fail to build productive relationships with their bosses are among the most likely to derail. Not because they lack talent. Because they treat the upward relationship as optional.
It is not optional. Your dean controls your budget. Your chair controls your hiring lines. The CMO controls whether your quality initiative gets institutional support. If the person above you does not trust you, your best ideas die in your office.
Understand What They Actually Need From You
This is the part most physician leaders skip. They walk into a dean's meeting focused entirely on what they need. More FTEs. A bigger budget. Support for a new program. But the conversation lands differently when you start by understanding what your leader is under pressure to deliver.
Your dean is reporting to a provost or a health system CEO. They have revenue targets, accreditation milestones, faculty retention numbers, and strategic plan deliverables hanging over them.
When you understand those pressures, you can frame your requests as solutions to their problems, not additions to their plate. That is the difference between an effective leader and a frustrated one.
Three Practices for Managing Up as a Physician Leader
Make your leader look good. Not through flattery. Through execution. When your division hits its targets, acknowledge their support publicly. When you solve a problem before it escalates, let them know briefly. Leaders who make their bosses look competent earn enormous latitude. Think of it like a point guard making the right pass. The assist matters as much as the score.
Deliver bad news early and with a plan. Nothing erodes trust faster than surprises. If a faculty member is about to leave or a budget line is going to miss, tell your leader before they hear it from someone else. Bring your assessment and a recommendation. "Here is the problem, here is what I think we should do, and here is what I need from you" is the sentence that builds credibility over time.
Protect their time ruthlessly. Senior leaders are drowning in meetings and decisions. The physician leader who handles things at their level without escalating every issue becomes indispensable. Distinguish between what your dean needs to decide and what you should handle and simply inform them about afterward.
When You Disagree With the Decision
This is where managing up as a physician leader gets genuinely hard. Your dean makes a decision you think is wrong. A hiring freeze that stalls your best initiative. A strategic direction that ignores clinical reality.
You have to push back. But how you do it defines you.
Amy Edmondson's research on psychological safety in The Fearless Organization applies upward as well as downward. When you are the one disagreeing upward, the burden is on you to make it safe.
Be direct and private. Share your reasoning, not just your conclusion. Acknowledge the constraints they are working under. And if the decision stands after you have made your case, commit to executing it. Publicly undermining a decision you lost is the fastest way to lose influence permanently.
The Long Game
Managing up as a physician leader is not a single conversation. It is a relationship you build over months and years. The leaders I coach who do this well share a few things in common:
- They schedule regular check-ins and come prepared every time
- They celebrate wins and share credit generously
- They are honest about problems without being alarmist
- They understand that trust is built in small moments, not grand gestures
Your ability to influence upward is what separates a physician leader who holds a title from one who actually moves the institution. The skills are learnable. And most people in academic medicine have never been taught how to do it.
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