Being a Chief Medical Officer in the fast-moving world of telehealth and digital health startups is part tightrope walk, part mountain guide. It requires threading the needle between clinical integrity and business viability. This tension never fully resolves. After years of navigating this role across multiple healthcare companies, a few core principles have emerged that separate effective CMOs from those who flame out.
1. Transparency Over Comfort
The single most powerful tool in a CMO's arsenal is radical transparency. When you're asking physicians to participate in a business model that has inherent constraints, don't pretend the constraints don't exist.
If you're getting paid $50 per visit and can't afford to pay providers $65, say that. Have the actual, factual conversation about what's possible, what the market will bear, and what you can do to make the economics work. Doctors and nurse practitioners respect honesty far more than they respect sugar-coating. They're problem-solvers by training. Give them the real problem and they'll often surprise you with creative solutions.
What doesn't work? Telling people to do more with less without transparency about why. That's a recipe for losing your best people.
2. Patient Safety and Community Standards Are Non-Negotiable
This is table stakes. Everything else flows from this.
As a CMO, your first responsibility is ensuring that the care your organization delivers meets community standards and prioritizes patient safety above all else. This isn't a negotiation. It's not something you can compromise on to hit growth targets or keep investors happy.
That means asking hard questions: Is this diagnosis appropriate to make over video? Is this treatment supported by evidence? Would a reasonable physician in my community deliver this care? If the answer is no, you have to be willing to say it. Even when it's uncomfortable.
This principle is what allows you to navigate everything else that comes next.
3. "No Margin, No Mission": The Business Reality
Working as a medical director for a non-profit, I learned a saying that has stuck with me: "no margin, no mission." It's blunt, but it's true. Caring for humans requires resources. A company that burns through cash while ignoring business fundamentals won't survive long enough to care for anyone.
This creates a real tension: you have to care deeply about both the needs of patients and the needs of the business. And you have to talk about that openly, without pretending the tension doesn't exist.
The job isn't to make the business pristine and ignore patients. It's also not to ignore business realities in the name of perfect care. It's to figure out, honestly and transparently, what's actually possible given your constraints.
That's where the real conversation happens.
4. Use Markets and Data, Not Mandates
Guy Friedman (CEO of SteadyMD) taught me this: let markets tell you what you need to do. If you have more patients than you can see, you probably need to increase the price of the visit so provider compensation and work experience can be improved. If you're struggling to find clinicians to see patients, that is your signal that there is a mismatch.
This is far more effective than top-down mandates about productivity or utilization. Markets provide real-time feedback about what's actually sustainable. Listen to them.
5. Make the Clinical-Business Decision Explicitly
The CMO role exists because business leaders and clinical leaders sometimes see different paths forward. Your job isn't to make everyone happy. That's impossible. Your job is to make explicit decisions about where you're willing to compromise and where you won't.
Sometimes it means saying, "This treatment just isn't supported by evidence, and I can't get behind it as a company." Other times it means developing evidence-based clinical guidelines that allow for high quality and personalized care within your platform's constraints. For example, working with your clinical team to define appropriate BMI thresholds for GLP1 therapy or establishing protocols for when telemedicine is appropriate versus when patients need in-person evaluation. These guidelines protect both patients and the business by creating clear standards everyone can trust. Sometimes it means accepting that a particular external partner has a different risk tolerance than you do. That's okay. You can work with them anyway.
What's not okay is pretending the tension doesn't exist or being unclear about where you stand.
6. Evaluate Appropriateness Constantly
Here's a test you can do in seconds on any telemedicine visit: Is this appropriate for video care? Not every problem is. A patient with shoulder pain and radiculopathy, for example, might need imaging or hands-on exam before you're prescribing systemic steroids. If you can't confidently make the diagnosis and provide community-standard treatment, you shouldn't be treating.
And if you're operating in a black box (you treat the patient once and never see them again with no way to follow up), that's a red flag about whether you should be treating at all.
This isn't about being overly cautious. It's about being honest about the limitations of your platform and not letting economic incentives push you beyond appropriate care.
7. Build Relationships First, Then Solutions
When stepping into a CMO role, resist the urge to start implementing immediately. Your first 30-60-90 days should be almost entirely about relationships and understanding.
Talk to everyone. Business stakeholders about their constraints and priorities. Clinical stakeholders about what's actually hard day-to-day. Let people feel heard. Then, and only then, write an executive summary of the biggest problems and potential solutions.
This isn't slow. It's actually faster, because you're not solving the wrong problems or implementing solutions that don't address root causes.
Think of it like big wall climbing: before you start moving the rope up 200 feet, you need to understand the terrain, the resource constraints, and what everyone actually needs. Thoughtless action kills climbers and kills companies.
8. Embrace the 80% Solution
Healthcare leaders are trained to be cautious, to run everything through committees, to get perfect data before deciding. This instinct has value. Patient safety depends on it in some contexts. But it also creates paralysis.
Make 85% correct decisions and iterate. Don't let perfect be the enemy of done, but don't sacrifice patient safety for speed. This requires good judgment about which decisions fall into which category.
Quick iteration on compensation structures, provider onboarding, platform features? Absolutely. Rushing safety decisions or clinical protocols? No. Learn the difference and move accordingly.
9. Accept That You Can't Be Everything to Everyone
This is perhaps the hardest truth of the CMO role: if you're doing your job well, some stakeholders will be unhappy with you sometimes. You'll err toward clinical safety and physician wellbeing. That's your responsibility. But that sometimes means the business doesn't get exactly what it wanted, or investors don't, or patients don't.
That's the job. Someone has to make the call when those incentives conflict. If you're trying to make everyone happy, you're not really making any principled decisions at all.
10. Know Your Risk Tolerance and Communicate It
Different healthcare companies have different risk tolerances. Some are comfortable with novel treatments where evidence is mixed. Others are more conservative.
As a CMO, you need to know where your company and your personal risk tolerance intersect. You need to communicate that clearly to business leadership.
The Bigger Picture
The role of Chief Medical Officer has become increasingly critical as healthcare digitizes, adopts AI technologies, and decentralizes. It's not a clinical role wearing a business suit or a business role wearing a clinical coat. It's something different: a translation layer and decision-maker at a fundamental tension point.
The CMOs who excel at this aren't the ones who have all the answers. They're the ones who can sit with complexity, ask good questions, listen carefully, and make principled decisions when perfect information isn't available. They're not afraid of hard conversations. They know that their job sometimes means saying no. That includes saying no to business ideas, to clinical corners being cut, to things that don't align.
Mountain guides understand something fundamental about risk that applies directly to the CMO role. A great guide doesn't simply lead clients to the summit. They manage the entire risk environment. They assess weather conditions, avalanche risk, the physical capabilities of each team member, the time available, and the cumulative stress on the group. Sometimes the right decision is to turn back 200 feet from the peak because the risk-reward calculation no longer favors the ascent. The guide's reputation isn't built on summits. It's built on bringing everyone home safely while pursuing meaningful objectives.
Similarly, a CMO manages risk across clinical, operational, and business dimensions. You assess the clinical evidence for treatments, evaluate the business sustainability of service lines, understand the regulatory environment, and weigh the long-term reputation risk against short-term revenue opportunities. Sometimes the right call is to walk away from a lucrative opportunity because the clinical risk or regulatory exposure is too high. Sometimes you slow down the company's growth timeline because rushing would create unmanageable clinical or compliance risk.
This requires a clear-eyed risk assessment and the courage to communicate it. You need to help business leaders understand that managed, appropriate risk-taking is what keeps companies alive and growing. You also need to help them see that certain risks aren't actually risks worth taking. The goal isn't zero risk. The goal is intelligent risk management: taking the right risks at the right time in service of sustainable growth and genuine patient care.
And they do it all while actually caring about the outcomes: for patients, for clinicians, and yes, for the business too. Because at the end of the day, if the business fails, nobody wins. If you cut clinical corners to keep the business alive, you've failed at the fundamental purpose of healthcare.
That's the secret: it's not really a secret at all. It's just showing up with integrity, clarity, and a willingness to do genuinely hard work.
Share Your Thoughts
Have experiences with the CMO role or healthcare leadership? I'd love to hear your perspective.