Formal succession planning runs on a simple grid, and I was taught it the way most people are taught it, in the academic centers and health systems that run it formally. You take the key leadership roles one at a time and you ask three questions about each. Who is ready today, if something happened tomorrow and the seat emptied. Who could be ready in a year with dedicated mentoring and a development plan. And who is on the longer list, the people who could be ready in three to five years with the right added experience, coaching and sponsorship.
It is a good instrument. It forces a room to be specific about something everyone would rather keep vague, and it produces a written record of names against seats.
Work down the list and you will see something the grid was not designed to show you.
For the non-clinical administrative roles there are regularly two or three names in the first two buckets. Someone is ready today. Someone else is close. The room moves through those seats quickly because the answers are already known, and the answers are already known because somebody has been working on them. The names carry development plans with an owner and a date attached, and you can see them on the page.
Then you reach the clinical roles, and the shape inverts. The room quietly agrees that no one is ready today. There may be one name for a year out, offered with a caveat. And then the long list arrives, and everyone contributes to it easily and warmly, and the people on it are described as strong candidates who could be ready in three to five years if the stars aligned. Those names carry no plans. The cells are blank.
A long list at five years with an empty column at the front is not a pipeline. It is a way of feeling good about not having one.
The same people built both columns. The same instrument, the same afternoon, the same organization. Whatever explains the difference, it cannot be that this organization does not develop its people, because the same grid says otherwise a few roles earlier. It cannot be that healthcare is uniquely hard, because the finance and operations roles are part of the same leadership team.
Some of the people not in the ready-today bucket were asked and said no. They were offered the track and they did not want (or were afraid) to leave the bedside, which is a coherent thing to want and is not a developmental failure. The trouble is that the grid does not distinguish the person who declined from the person nobody approached. It records both as not ready. A room that cannot tell those two apart does not have a pipeline either way. It has a list.
There are real differences between the two columns. The clinical seat is usually part-time work laid on top of a full practice, so developing someone for it costs clinical revenue where the administrative version costs a stretch assignment. The clinical ladder has almost no rungs between practicing and chief, where the administrative one has four or five. And the pool does not transfer sideways — you cannot backfill a cardiology chair from an orthopedics department.
Every one of those is a reason the clinical column needs more machinery than the administrative column. It has less.
The interim from another department
A department chair leaves unexpectedly. The conversation has to happen immediately and it has two parts. Who serves as interim, and then, more slowly, whether there are real internal candidates who would hold up in a national search or whether this is going to be an external hire with an internal courtesy interview.
The interim is almost always the harder question, which surprises people who have not sat in that room. The permanent search has months and a committee and a firm. The interim has about a week. And the room goes quiet, because the ready-today bucket for that seat is empty and everyone present knows it.
So the interim gets named from outside the department. A capable chair from a department that could be argued is adjacent. An assistant dean who the administration trusts.
That happens often enough that it has stopped registering as unusual. An interim chair from another department is a public statement, made in writing, distributed to the faculty, that a department could not put forward a single person prepared to hold its own seat for six months.
There are respectable reasons an interim comes from outside. Neutrality, when the internal candidates will be in the search pool. A policy barring the interim from the permanent job. Someone qualified who was asked and turned it down. What separates those from the other thing is whether the room can name the person who said no. When nobody was ready, there is no name to say.
In a community hospital or a private group the same event wears different clothes. The interim medical director arrives from another service line or from the management company, and there is no grid anywhere that records it happened.
Everyone in that department reads the announcement. Nobody says out loud what it reports.
Then the search committee conversation begins, and someone says that it was hard to find a good candidate for this department last time.
It is said as a fact about the market. What it actually reports is a recurrence — we have stood in this room before, we are standing in it again, and in the years between the two visits nobody was developed. The organization experiences a pipeline failure and files it as a hiring problem. Filed that way, it will happen again, and the next person to say that line will believe they are describing bad luck.
Advice is free and advocacy is not
The clinical side of that grid is not short on mentorship. It is saturated with it. Every academic department, every group, every leadership program I have been near has senior people giving generous, sincere guidance to junior people, and the guidance is good.
The distinction I did not hold clearly enough for most of my career is that a mentor talks with you and a sponsor talks about you, in a room you are not in. Sylvia Ann Hewlett’s work on sponsorship, across Forget a Mentor, Find a Sponsor and The Sponsor Effect, made the difference concrete: a mentor invests time and knowledge, which are renewable. A sponsor invests reputational capital, which is finite and does not come back if you are wrong about the person.
That difference explains the number I find hardest to argue with. Of the people who identify themselves as sponsors, only about a quarter actually advocate for their protégé’s promotion — the defining act, the one thing sponsorship is. The rest are giving advice, taking the lunch, writing the letter, and calling it sponsorship.
It is structural. Organizations that build these programs count pairings, because a pairing is an objective, verifiable statistic that describes the program. Advocacy happens in a closed room with no minutes. Everyone involved behaves well and the mechanism still fails.
I should share my own standing. I lead the clinical side of an anesthesia company. Hospitals pay us for clinical leadership, and the group of medical directors I am responsible for holds the seats this piece is about filling. If the argument prevails, it creates demand for something my company sells. Read it with that attached.
The seniority of the mentor is the hinge. Ibarra, Carter and Silva found that high-potential women had more mentors than their male peers and less senior ones, and were advancing less: overmentored, undersponsored, not moving. Inside medicine that framing has become close to consensus. The refrain in academic medicine now is that trainees are over-mentored and under-sponsored.
A mentor who cannot walk into a succession conversation and put your name on the table is not a sponsor, however good the advice and however much you like them. That is a fact about where they sit, not about their character. Most of us have confused the two for years.
The apparatus measures the half that does not decide anything
The profession’s response to the empty column has been to build leadership programs.
A 2025 review in Leadership in Health Services looked at 96 physician leadership programs. Roughly three-quarters measured learner satisfaction. Two-fifths measured knowledge acquisition. Fewer than one in five measured organizational impact. An earlier systematic review of 45 studies found favorable organizational outcomes documented in six of them.
In that review of 45 studies, three tracked whether participants advanced into higher leadership roles. Three.
And the programs that do count it are the ones that built sponsorship into the design. The AAMC’s Council of Deans fellowship places its fellows alongside sitting deans, and it reports what happened next: ten of thirty-seven became deans. ELAM pairs its fellows with senior sponsors inside their own institutions who are accountable for getting them access to governance and succession conversations, and it follows where its alumnae land.
That is not a controlled trial. It is close to the only place in this literature where anyone measured the outcome that matters, and it happens to be where a sponsor was built in on purpose. Weigh it that way.
The rest of the apparatus is not lazy. Placement happens outside the program, months or years later, in a room the program has no access to and no standing in.
Where sponsorship does happen it happens informally, and that has a consequence someone finally counted. Roughly seven in ten sponsors have a protégé who shares their race or gender. Relationship-driven selection inside a narrow leadership tier reproduces that tier by arithmetic. Nobody has to intend it.
The objection, which is a good one
The strongest response to everything above is that sponsorship is favoritism with a better name.
It is also not mine. When Johns Hopkins researchers interviewed twelve clinical department chairs about how sponsorship worked in their departments, the themes the authors came back with were playing favorites and paying it forward.
So let me concede it. It is favoritism. Senior leaders are going to advantage particular people, and they already do, and no policy is going to stop that.
The question is whether the advantage is deliberate and distributed, or accidental and concentrated. Unstructured sponsorship is favoritism nobody admits to, running quietly on proximity and resemblance, and the seven-in-ten figure is what it looks like when someone finally counts. Naming it makes it auditable. Declining to name it does not make it stop.
And the hesitation is not only about fairness. Putting your name behind someone means that if they fail publicly, you were wrong publicly, and no version of sponsorship removes that. It is supposed to cost something. A recommendation that costs the recommender nothing carries no weight.
What it costs to actually do it
The obligation is not to mentor more. We are already saturated, and the saturation is the problem wearing a friendly face.
The obligation is to spend something.
I have found it useful to hold that as a few concrete tests rather than a philosophy, and I offer them as one version rather than the version. Say a name in a room the person is not in, this quarter, and attach your own credibility to it instead of describing them neutrally. Route the visible work — the board presentation, the system committee, the problem with an audience — to the person you claim to be developing, rather than to whoever it would be easiest to hand it to. Answer the question you were not asked: you did not ask, but the person you should be looking at for this is.
And when you cannot get into the room where the placement happens, say so to the person you are mentoring. I can teach you and I cannot place you, and you need someone who can. That sentence costs the most of any of them, and it is the honest one.
If you are on the other side of this — capable, well mentored, and not moving — the question is whether anyone who speaks for you is in the room where that grid gets filled out. Ask the person who has been advising you, and pay attention to whether the answer is yes, no, or a change of subject.
The grid will come around again next year. Someone will read the clinical roles, and the room will agree that no one is ready today, and the long list will be offered warmly by people who mean it.
The list is not the problem. The list has been the same for years. What no one in that room has to answer is what any of us did, in the twelve months since we last said this out loud, to move one name from the long list to the front of it.
Past the Door is free, and it will stay free.
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