The Canadian health care system faces profound challenges, from emergency department closures to growing patient wait times and significant physician shortages. These systemic vulnerabilities demand robust leadership and advocacy, roles in which physicians are uniquely positioned to excel. Yet, despite their pivotal role, physicians often lack formal training in governance — the policies, processes, and decision-making frameworks that shape health care delivery. This commentary underscores the urgent need for governance education as a core component of medical training. It explores how knowledge of governance enhances physicians’ ability to navigate organizational complexities, advocate equitable policies, and contribute to system-level improvements.

Through real-world clinical examples, we highlight the relevance of governance in areas such as resource allocation, patient safety protocols, and the ethical integration of artificial intelligence into care. We propose a four-layer framework for governance education, spanning foundational knowledge, operational applications, system navigation, and mentorship. Teaching strategies are provided for each layer to bridge knowledge gaps at both individual and systemic levels.

Integrating governance into medical education and leadership development equips physicians to address the increasing complexity of health care delivery. By fostering these skills, we can empower physicians to lead, innovate, and advocate sustainable improvements in patient outcomes and health system efficiency.

KEYWORDS: governance, medical education, individual-level, systems-level

Do V, Rizzuti F. Developing governance knowledge and skills of physicians: importance and recommended action. Can J Physician Leadersh 11(1): 40-44. https://doi.org/10.37964/cr24790

It is well known that Canada’s health care system is struggling. Health system vulnerabilities have been more clearly exposed as a result of the COVID-19 pandemic, and it has now unfortunately become commonplace to learn about emergency department closures and increasing wait times for care.¹ Millions of Canadians are without a family physician.² There is frequent debate regarding the “universal” nature of our system, the risks and benefits of potentially increasing private/corporate involvement, and how to address human resources needs.

In this rapidly evolving health care landscape, the role of physicians extends far beyond clinical practice. As the complexity of health systems increases, understanding governance becomes essential for physicians at all levels. Governance encompasses the policies, processes, and evaluations that guide decision-making and operational effectiveness in health care institutions.³ This commentary explores the importance of governance training and skills development for physicians, highlighting how it enhances their roles and contributes to better patient outcomes and organizational efficiency.

Governance and the health care system

Governance is often perceived as a distant concept, associated primarily with board meetings and annual general meetings. However, the reality is that governance permeates every aspect of a physician’s daily practice. From the protocols followed in clinical settings, to the ethical guidelines that dictate patient care, governance frameworks underpin the functioning of health care institutions. For example, understanding the governance surrounding medical staff bylaws can clarify decision-making pathways when addressing conflicts about resource allocation or clinical responsibilities. By understanding these frameworks, physicians can navigate the complexities of their environment more effectively.

Studies have shown positive associations between hospital board engagement in health care quality activities and health care outcomes.^4,5 One way that hospital and health care governance bodies can be more engaged is by having clinician expertise prominently represented. For example, a physician serving on a quality improvement committee can help ensure that clinical realities inform strategic decisions about patient flow reducing emergency department bottlenecks. Clinicians’ roles in governance and high-level decision-making are prudent and important, yet physicians are not formally educated or trained in governance.

Despite the importance of governance in health care delivery, physicians often have very little experience with governance practices. Further, despite increasing recognition of the importance of physician leadership, studies have noted that physicians often feel unprepared for these leadership roles, sometimes noting that opportunities to further build their related skill sets are lacking.

Governance and the role of physicians

The Canadian Audit and Accountability Foundation notes that governance refers to the structures, systems, and practices an organization has in place to assign decision-making authorities and define how decisions are made.⁶ These systems also oversee service delivery and performance reporting. The World Health Organization notes that effective strategic governance policy frameworks outlining the roles of the state, the health care providers, and citizens are critical to achieving health system goals.⁷

Tangibly, an understanding of governance means:

• Understanding the role of associations, regulatory bodies, and how they differ^8-10
• Understanding fiduciary duty, as well as the roles and responsibilities of a board and executive and how they differ from the rights of members
• Understanding governance documents, bylaws, policies, and procedures
• Being able to chair an effective meeting and standardize its process, such as by using Robert’s Rules of Order

Advocacy and policy

A strong grasp of governance enables physicians to advocate effectively for patient-enhancing care practices and policies. For example, when advocating new diagnostic technology in a resource-limited setting (most settings are thus limited), understanding governance frameworks can help a physician navigate institutional processes to secure funding and approval. By understanding how governance influences resource allocation, care protocols, and health policy, physicians can better represent the interests of their patients in an institutional framework. This advocacy is vital for ensuring that patients receive effective, safe, and equitable care.

Clinical examples abound in relation to this matter. A physician (co)leading a multidisciplinary team in a hospital must navigate governance structures to streamline care transitions for patients with complex issues. Similarly, understanding governance is crucial for implementing new infection control protocols that reduce hospital-acquired infections. Governance education provides physicians with tools to engage effectively in these scenarios, bridging clinical expertise with systemic decision-making.

Governance education also includes training that fosters essential leadership skills among physicians. As they gain insights into organizational structures and decision-making processes, they become better equipped to take on leadership roles. This transition is critical as health care increasingly requires physician leaders who can advocate for both their patients and the institution’s strategic goals. By understanding governance, physicians can lead initiatives that improve care delivery while also advocating for their colleagues’ needs and concerns.

Knowledge of governance is also critical as we consider new opportunities in health care, such as the role and influence of artificial intelligence (AI). With the growing effectiveness of AI, it is clear that it will have a significant role in our health care system moving forward. Ethical and regulatory concerns are frequently brought up, and governance frameworks are required to address these concerns early on and ensure that we launch these innovations safely and effectively. Physicians have important roles in these processes, such as contributing to and otherwise informing the design of AI algorithms that respect patient privacy and ensuring transparent accountability mechanisms.

Next steps

To address these challenges and gaps, we recommend a number of actions.

1. Medical education partners: Organizations, such as the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and the Association of Faculties of Medicine of Canada, as well as accreditation entities, such as the Committee on Accreditation of Canadian Medical schools and the Committee on Accreditation of Continuing Medical Education, should devote resources and undertake research to establish frameworks for integrating governance into medical education. There is potential for governance to be integrated into the revisioning of the CanMEDS framework.
2. Capacity building: Develop governance capacity-building and training programs for physicians and physician trainees across the continuum of medical education and practice.
3. Integration into education: In the long term, it is important that governance considerations be integrated into the fabric of medical education so that learners develop them integrally and are able to use these skills in health systems change.
   
   

In Tables 1 and 2, we propose a framework for governance education, providing examples of specific skills and teaching activities to advance this work. Table 1 outlines four layers of governance knowledge, with examples at both the individual and system levels. For the purposes of this framework, individual level refers to governance knowledge or activities directly impacting a physician’s personal practice or immediate team, whereas system level refers to governance knowledge or activities influencing larger organizational, institutional, or health system operations. Some of these examples could be considered at both an individual and system level.