A few years into building tools inside our electronic health record, I watched a well-intentioned redesign of the in-basket, the clinician's message queue, get most of the way to launch before anyone in the room had recently lived a clinic day inside it. The logic was clean. The interface was modern. And it would have added clicks to the single most time-pressured part of an oncologist's afternoon, because the people designing it had reasoned about the workflow instead of carrying it. I had carried it that week. That is the whole argument of this essay, compressed into one anecdote: clinical informatics is a clinical discipline, and it degrades in predictable ways when the people leading it are not also the people doing the work it governs.
I say this as someone with standing on both sides of the line. I'm a practicing medical oncologist who still attends on the solid-tumor service. I'm also board certified in clinical informatics, the American Board of Preventive Medicine subspecialty, which I sat for in 2016, the same year I finished my oncology boards. Informatics is not a hobby I do adjacent to medicine. It is a board- certified medical specialty, with its own body of knowledge, its own examination, and its own standard of practice. We should treat it like one.
Informatics is a clinical specialty, not a technical service line
The most common failure mode I see in health systems is organizational: clinical informatics gets filed under IT, and clinicians are invited in as "advisors", consulted late, thanked politely, and routed around when the schedule gets tight. The arrangement feels reasonable. The systems are technical, the vendors are technical, the budgets live in technology. So the clinician becomes a stakeholder to be managed rather than a leader who decides.
This is backwards, and the certification exists precisely because it's backwards. Clinical informatics became a board-certified subspecialty in 2013 for the same reason cardiology or critical care did: the work requires a clinician's judgment applied to a defined domain, and that judgment cannot be outsourced to people who don't carry the clinical consequences. A decision about how staging data is captured, how a best-practice alert fires, or how a genomic result lands in the chart is not primarily a software decision. It is a decision about how medicine gets practiced, made through software. Whoever owns it owns the clinical workflow whether they realize it or not.
The "advisor" model fails on a specific mechanism: it separates authority from accountability. The technical team has the authority to ship; the clinician has the accountability for what happens at the bedside, but no real control over the thing that produced it. When those come apart, you get systems that are internally coherent and clinically wrong, and nobody who can fix them is also the person who has to live with them. Putting a practicing clinician at the helm re-fuses authority and accountability in one person. That is not a courtesy to clinicians. It is a control mechanism for the institution.
What changes when a practicing clinician actually leads
The difference shows up in what gets optimized. I direct cancer clinical informatics at our cancer center, and I still see patients. That second clause is not a credential I list for color, it's the thing that keeps the first one honest. When you write notes in the system you're trying to improve, you stop optimizing for the demo and start optimizing for the Tuesday afternoon when the clinic is running forty minutes behind. You feel the cost of the extra click because you paid it that morning. You know which alerts get reflexively dismissed because you've dismissed them. You can tell the difference between a field that's hard to capture and a field nobody captures because capturing it helps no one.
This is also why the leader-versus-advisor distinction is not semantic. An advisor reacts to a roadmap someone else set. A clinician-leader sets the roadmap, which means clinical reality shapes the work from the first decision rather than being consulted as a courtesy near the end. The redesign I opened with got caught in time, but it got caught because a clinician with authority was in the room, not because the process was built to surface clinical cost early. In too many organizations, that catch depends on luck. It should depend on org-chart.
There's a research analogue I find clarifying. Across years of building real-world models in oncology, the constraint was never the algorithm; it was whether the clinical inputs existed as trustworthy structured data. The people who could see that bottleneck were the ones who understood both the modeling and the clinic. Leadership is the same shape of problem. The bottleneck in clinical informatics is rarely the technology. It's the translation between what medicine needs and what software does, and translation is a job for someone fluent in both, with the authority to act on the translation.
The pipeline problem, and why education is the lever
If clinical informatics needs clinicians at the helm, the obvious question is where they come from. The honest answer is that we have not built the pipeline to produce them, and that gap is the one I've spent the most deliberate effort trying to close.
The problem starts earlier than people assume. We tend to treat informatics as something a clinician picks up late, a fellowship, a master's, a mid-career pivot. But the clinicians who are most fluent are the ones who encountered the discipline as a normal part of becoming a physician, not a specialty bolted on afterward. That conviction is why I built clinical informatics into the medical student curriculum and created a graduate medical education elective, and why my colleague Dara Mize and I argued for a unified approach to clinical informatics education spanning undergraduate and graduate medical education at the 2022 AMIA Annual Symposium. The point of "unified" is that the medical student, the resident, and the fellow are on one continuum, not three disconnected audiences, and the discipline should be present at every stage rather than appearing, abruptly, as an option for the already-committed.
It also has to be built as an institutional strategy, not a personal hobby of whoever happens to care. Our group laid out exactly that in the Vanderbilt Clinical Informatics Center's education strategy in Applied Clinical Informatics in 2025, a deliberate, center-level plan for training the next generation rather than a collection of one-off courses depending on individual enthusiasm. The difference matters because individual enthusiasm leaves when the individual does. A discipline that wants practitioners at the helm has to manufacture them on purpose, at scale, with the same intentionality we bring to any other specialty's training.
A short version of what I think the pipeline owes the field:
- Expose every trainee early. Informatics belongs in medical school and residency as a normal competency, not a niche elective for the already-converted.
- Build dual fluency, not translation by committee. The goal is clinicians who can reason in both clinical and technical terms themselves, so the translation happens inside one head instead of across a meeting.
- Make it a career, not a side quest. There have to be real leadership roles , with authority and accountability fused, for trained clinician-informaticians to grow into, or the training produces advisors by default.
What I'd ask of the people who staff these roles
So this lands somewhere actionable, here is what I'd ask of two audiences.
If you're an academic leader or sit on a search committee for a CMIO, an informatics director, or a "physician champion" role, write the job as a leadership position with decision authority over the clinical systems it covers, not an advisory seat reporting into a technical org that can route around it. And weight active clinical practice as a qualification, not a nice-to-have. A leader who has stopped seeing patients is, within a few years, an advisor in everything but title; the feedback loop that keeps their judgment calibrated has gone quiet. Protected clinical time for an informatics leader is not a concession. It is the instrument that keeps the role honest.
If you're a trainee weighing this path: you do not have to choose between practicing medicine and shaping how medicine is practiced. The board certification exists, the career exists, and the field needs people who can hold both at once far more than it needs more pure technologists or more clinicians who merely complain about the software. The most useful thing you can be is the person in the room who carried the workflow that morning and can also change it that afternoon.
Clinical informatics will keep growing whether or not clinicians lead it. The only open question is whether the systems we all practice inside get designed by people who practice inside them. I've staked my own career on the answer being yes, in the clinic, in the education work, and in the leadership roles where the two finally meet. The field is young enough that the people entering it now will decide whether "clinical informatics" keeps the word clinical doing real work, or lets it fade into a polite adjective. Make it do the work.