Building the Health System of 2035: What the Strategic Conversation Is Missing
Health system leaders are being asked to think differently right now.
Not just about the next quarter or the next budget cycle but about what kind of institution they need to be by 2035. What care they will deliver, where, how, and who will deliver it. The strategic questions are real and the urgency behind them is real.
A recent piece in Becker’s Hospital Review, developed in collaboration with PwC, laid out a compelling framework for how health systems should be thinking about the decade ahead. Four forces driving transformation. Four questions every provider leader should be asking. A clear argument that the days of incremental change are over and that the organizations that move decisively now will be best positioned for what’s coming.
It is a strong framework. And it is missing something important.
The Question That Doesn’t Get Asked
Of the four questions the framework poses what care is being delivered, where, how, and who delivers it; the last one is where graduate medical education lives.
The article addresses the “who” question through the lens of workforce optimization. AI augmentation. Eliminating routine work. Enabling clinicians to operate at the top of their licenses. Reimagining workflows so that the people delivering care can deliver more of it, more efficiently, with better support.
All of that is right. And none of it addresses where those clinicians come from.
The physicians who will be practicing in 2035 are in training right now. They are residents and fellows in teaching hospitals across the country, learning not just the clinical skills of their specialty but something harder to measure and more durable. How to think, how to lead, how to function under pressure, how to navigate the institutional environments they will spend their careers inside.
The training environment they are in today will shape the kind of physicians they become. The culture they absorb. The habits they form. The model of professional identity they carry into every institution they ever work in after this one .
No workforce optimization strategy reaches that far back. But graduate medical education does.
What GME Actually Produces
There is a tendency in health system strategy to treat graduate medical education as an accreditation obligation. A compliance function. Something that runs in the background, managed by a small team, reviewed annually, and escalated to senior leadership only when something goes wrong.
That framing fundamentally misunderstands what GME is producing.
Graduate medical education produces the physicians health systems will depend on. Not just their clinical competence, though that matters enormously but, their understanding of what institutional medicine looks like from the inside. Their tolerance for complexity and ambiguity. Their ability to work across disciplines, communicate across hierarchies, and function within systems that are imperfect and always will be.
It also produces something less visible but equally consequential: institutional culture.
The residents training in a health system today are watching how that institution handles difficult. How leadership responds to uncertainty. Whether the environment they are training in models the values it claims to hold. Whether the people responsible for their education are resources, respected, and empowered to do their work well or whether they are quietly absorbing complexity that the institution has never formally acknowledged.
That observation repeated across hundreds of residents, across years of training becomes the culture of medicine. And the culture of medicine becomes the quality of care.
The Gap Between Educational Mission and Institutional Strategy
Most health systems with teaching programs have an educational mission statement somewhere. It lives in a strategic plan, an accreditation document, a website page.
What is less common is a health system that has genuinely integrated its educational mission into its broader institutional strategy. That has asked seriously and with resources behind the answer: what kind of physicians it needs to produce in order to be the kind of health system it intends to be by 2035.
That question requires knowing what the institution intends to be my 2035. And it requires someone in the room when that conversation is happening who understands graduate medical education well enough to translate between the strategic vision and the educational infrastructure.
This is the gap. Not a lack of commitment to education, most teaching hospitals are genuinely committed. But a structural disconnection between where institutional strategy gets made and where educational decisions get made. Between the C-suite conversation about workforce and the GME office conversation about program composition. Between the long-range plan and the rank list.
Those conversations rarely happen in the same room. And the distance between them has consequences that compound over time.
What Alignment Actually Looks Like
Health systems that treat GME as a strategic asset rather than an accreditation obligation share a few characteristics worth naming.
They know what they need their physician workforce to look like in five to ten years by speciality, by skill set, by the kind of care their community will require and they have connected that knowledge to their training programs. They are not just matching residents because the system works that way. They are deliberately building a pipeline.
They resource their GME infrastructure as a leadership function, not an administrative one. The people managing that infrastructure have the authority, the support, and the institutional visibility to do their work at the level it actually requires. The DIO has a seat at the strategic table. The GME office has a direct line to the questions that matter.
They invest in the learning environment as seriously as they invest in the clinical environment. Because they understand that the two are not separate. The resident who trains in a well-functioning, well-led, thoughtfully designed educational environment is learning something about institutional excellence that they will carry into every place they practice.
And they recognize that the return on that investment is long. It does not show up in the next quarter’s operating margin. It shows up in the physicians who stay, who lead, who build the next generation of institutional culture from the foundation of what they experienced in training.
That is a long return. And it is a real one.
A Note on This Moment
Health systems are entering a period of significant leadership transition, strategic repositioning, and institutional recalibration. New CEOs are arriving with mandates to build for the future. Boards are asking harder questions about sustainability. Leadership teams are being asked to define not just what they do but what they intend to become.
This is precisely the moment to bring GME into that conversation.
Not as a compliance update. Not as an accreditation report. But as a strategic question: what is the educational infrastructure of this institution producing and is it aligned with where the institution is going?
The health systems that ask that question now and invest in honest answers will be better positioned for 2035 than those that don’t. Not because graduate medical education is the only thing that matters, but because the physicians it produces are the people who will be delivering care in that future health system.
You cannot optimize for 2035 without investing in the pipeline that gets you there.
Closing Reflection
Every strategic framework for the future of health systems eventually arrives at the same place: the people.
The technology matters. The care models matter. The partnerships and the financial structures and the digital foundations all matter.
But at the end of every shift, in every hospital, in every community this system serves, there is a physician- trained somewhere, by someone, in an environment that shaped them in ways they may never fully name; making decisions that determine whether a patient is safe, heard, and well care for.
Graduate medical education is how health systems shape that moment. Not directly, not immediately, but over years and across careers and through the culture that training environments quietly build.
The health system of 2035 is being trained right now.
The question is whether anyone building the strategy for the future has thought seriously about what the training looks like.