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PurposeThe purpose of this paper is to seek clarity on the factors that increase acceptance of a leadership identity and influence a physician leader to participate in the leader role at a higher level.Design/methodology/approachTo explore the direct and mediating effects of positive psychological climate (PPC) and role endorsement (RE) on physician professional participation (PP) in leadership, a survey was disseminated to members of the American Association of Physician Leadership.FindingsFindings show that positive relationships support the individual in acceptance of a second identity as a leader, therefore, to a higher level of PP. The double mediation with PPC and RE found in this model warrants additional meaning toward the cultivation of positive relationships.Research limitations/implicationsA broader understanding of physician leadership may benefit from a more comprehensive collection procedure other than self-reported data, including one in which data is collected in a 360-degree feedback format.Practical implicationsRole endorsement serves as a mediating mechanism to PP (citizenship behaviors) for both PPC and social intelligence competencies. These data indicate that the presence of role endorsement for physicians changes their degree of participation and impacts their own role identity. This immediately helps to direct development efforts for physicians during their transition from physician to physician leader.Originality/valueThis study confirms the mediating relationship of REupon the PP of physician leaders, with both implications for practice and a broader understanding of the nature of physician leadership.