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I think the doctor-hospital analogy is incomplete and presents a bad mental model.
I agree that there's no way for the President (or most of Congress for that matter) to be knee-deep in substantive issues across the entire breadth of current affairs. There's just too much going on too fast. So, you have to be able to delegate and this act of delegating begins by selecting appropriate subordinates to help with your overall management strategy. You have to trust these people to handle the issues because you, the President, don't have enough time to double check all of their work.
In the MD-hospital-nurses example, I would think that the MD just signs off on run-of-the-mill stuff, but slows down to double or triple check higher risk courses of care. The MD can do this because there's a little bit more time (i.e. a patient with a broken leg isn't going to literally die if they have to wait another day or something) and because patients are independent from one another. The guy in room 1 has no bearing on the condition of the guy in room 6.
Not so with the Presidency. "All politics is local" and all that. Your broad economic policies are full of cross pollination influences with one another. There's no such thing as isolated bilateral foreign policy (that isn't secret). What you do with one country is seen by the entire world. Even domestic and foreign policy aren't fully separated domains. As we've seen with Israel-Gaza, a fairly uninvolved foreign policy can whip back to smack you in the face at home (Ivy League protests etc.) In reality, you're managing a complex system with a lot of non-linear feedback loops.
So whom you pick to do what matters or else you're going to have to try to manage a ton of fast moving non-linear parts on your own. Or, you just don't manage much and chaos and Congress pick up the slack. This is bad not only for self-evident reasons, but because your administration is now playing a reactive policy game instead of a pro-active policy game. That's a fantastic way to lose reelection.
Biden has demonstrated that he picks loyalists from way back who mostly serve to insulate him from the real world and create policy with overly deliberative, consensus driven, PowerPoint processes. I think this is pretty self evident, especially from the recently leaked comments from staffers. They're also myopic and tend to gravitate towards personal issues that effect themselves and their social circle. This is why the Biden admin has tried multiple times to grant sweeping student loan forgiveness despite the fact that those loans are hyper-concentrated among a tiny demographic that already reliably votes Blue. But a lot of senior advisors and staffers (who make pennies, especially in the HCOL area of Washington, D.C.) probably carp about "student loans" enough that it feels like a big issue.
This style of policy making might be okay if the rest of the executive were allowed to just function on its own with mostly rubber stamps from the Oval Office, but it doesn't seem that's the case. To me, it appears the Biden Admin doesn't want anything to happen without, at least, their awareness and approval. But how does that square with 10-4 hours and an insular inner circle that doesn't fully brief The Big Guy?
I watched the messaging on Israel-Gaza constantly get fucked up again and again. "We support Israel's right to defend itself ... but also the Palestinians deserve freedom....worst attack on Jews since the Holocaust....don't attack Rafah...let's talk about a ceasefire....also free hostages...on both sides." Tony Blinken had to wait for hours to meet MBS in Saudi because MBS knew Blinken had zero authority himself and it was all about getting The Big Guy (and his circle) on board in order for anything to happen.
This U.S executive branch isn't a hospital or corporation. It doesn't have smooth self-sustaining ongoing operations. It's more like a startup every 4-8 years, but with tens of thousands of new employees and also tenured, deeply embedded lazy people. The President has to delegate fast and effectively and try to build solid communication and feedback loops both to him and to chief subordinates. Failing to do that yields either chaos (Trump admin) or utter gridlock (Biden).
Biden and the Democrats got here by thinking in these oversimplified terms. "He's a little old, but the team around him can handle it." This has not been true since FDR invented the imperial presidency and specifically transformed the office from a figurehead position. The President matters.
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