Purpose This study seeks to improve our understanding of physician leaders’ leadership work challenges. Design/methodology/approach The subjects of the empirical study were physician leaders (n=23) in the largest central hospital in Finland. Findings Five largely identity-related, partially paradoxical dilemmas appeared regarding why working as “just a leader” is challenging for physician leaders. First, the dilemma of identity ambiguity between being a physician and a leader. Second, the dilemma of balancing the expected commitment to clinical patient work by various stakeholders and that of physician leadership work. Third, the dilemma of being able to compensate for leadership skill shortcomings by excelling in clinical skills, encouraging physician leaders to commit to patient work. Fourth, the dilemma of ‘medic discourse’, that is, downplaying leadership work as “non-patient work”, making it inferior to patient work. Fifth, the dilemma of a perceived ethical obligation to commit to patient work even if the physician leadership work would be a full-time job. The first two issues support the findings of earlier research, while the remaining three emerging from our analysis are novel. Practical implications We list some of the practical implications that follow from our study and which could help solve some of the challenges. Originality This study explores physician leaders’ leadership work challenges using authentic physician leader data in a context where no prior empirical research has been carried out.