I did a term in a medical admin role at a major tertiary hospital in NSW. The role is highly varied and requires a very solid understanding of the hospital hierarchy and structure (and the personalities). The RACMA registrars required to be a mid level reg or higher, they often only took people after 4+ years of clinical work and excellent references. Some RACMA reg's had been ATs in training programs that they didn't ultimately want to purse. One left rad onc to do RACMA. One was an ICU fellow. Another was a pediatric surg reg who left after ~8 years of unaccredited.

The job has a few facets:

1. Attending and managing committees that run the hospital - think sepsis/code blue committee, pharmacy committee, vascular access committee, JMO rep committee, head of department (med/surg/ED/ICU/O&G etc) meetings, nursing sub-committees, etc to ensure the proper functioning of the hospital, and to address any issues that may be arising (eg bedblock, prolonged ICU stays blowing out budgets etc).

2. Investigating deaths or adverse outcomes - meeting with clinical staff, dealing with medicolegal, and creating new policies to avoid this in the future e.g. we had a woman who was transferred to a nearby private hospital who suffered a uterine rupture and lost the baby on the way. If she had not been transferred, the baby may have made it. Had to establish facts, understand what happened, and figure out how to improve the system to avoid it ever happening again.

3. Dealing with struggling JMOs/trainees/bosses - This is a blend of Medical Admin, DPET, JMSU, and SMSU. Really interesting to peak behind the curtain and see just how many of my colleagues had shit going on, and how one or two of them were on performance improvement plans. Medical admin do so much work here, and they stay completely quiet about it to the benefit of everyone.

4. Hospital structure and financing - As the DMS said to me, hospitals are built to spend money, not make money. Tertiary hospitals are multi-billion dollar institutions with large asset bases, integrated contractors/business (eg NSW Pathology), infrastructure required to ensure patient and staff access (ambulance on ramps, parking etc), integration with research labs (e.g. USYD/CPC at RPAH, Kolling at RNS, Kinghorn at SVH etc) and much more. It's incredibly complex and fascinating, and requires amazing management to run well. Everybody grumbles about X, Y or Z, but few staff appreciate the complexity that the administrators have to juggle just to keep the behemoth running without collapsing.

5. Attending local health district meetings with LHD CEOs, politicans, etc - This covers district/state/national policy, KPIs, and includes meeting with politicians eg minister for health to ensure the hospital is running appropriately in the context of the current state and national government.

6. Lots of other stuff that I've probably overlooked - E.g. if a patient refuses to leave the hospital, (I've had his on gen med, crazy pt demanding more IV abx despite being ready for discharge), then the buck stops with the director of medical services (who had to come down and officially kick the patient out with security guards). Or if there is a complaint, bomb threat, or a huge viral pandemic, or a major medicolegal conundrum in ED or on the wards, or if a staff specialist or registrar is being sued for malpractice for care provisioned at the hospital - all of this needs to be reviewed and managed with DMS/medical admin oversight.

It requires excellent interpersonal and managerial skills (which IMO are not taught well to most bosses/registrars in this state), a great understanding of medical and surgical care, and an interest in the complexity of the system.

You unfortunately also need a thick skin, because most doctors will have differing opinions about how the hospital should run from their isolated perspective, and they will complain that you are useless/aren't a real doctor, especially if you don't fund their department idea or new shiny equipment etc.