Purpose– The purpose of this article is to describe and analyse the identity challenges that physicians with medical leadership positions face.

Design/methodology/approach– Four qualitative case studies were performed to address the fact that identity is processual, relational and situational. Physicians with managerial roles were interviewed, as well as their peers, supervisors and subordinates. Furthermore, observations were made to understand how different identities are displayed in action.

Findings– This study illustrates that medical leadership implies identity struggles when physicians have manager positions, because of the different characteristics of the social identities of managers and physicians. Major differences are related between physicians as autonomous individuals in a system and managers as subordinates to the organizational system. There are psychological mechanisms that evoke the physician identity more often than the managerial identity among physicians who are managers, which explains why physicians who are managers tend to remain foremost physicians.

Research limitations/implications– The implications of the findings, that there are major identity challenges by being both a physician and manager, suggest that managerial physicians might not be the best prerequisite for medical leadership, but instead, cooperative relationships between physicians and non-physician managers might be a less difficult way to support medical leadership.

Practical implications– Acknowledging and addressing identity challenges can be important both in creating structures in organizations and designing the training for managers in healthcare (both physicians and non-physicians) to support medical leadership.

Originality/value– Medical leadership is most often related to organizational structure and/or leadership skills, but this paper discusses identity requirements and challenges related to medical leadership.