Rethinking Physician Careers: How to Keep Building Past Mid-Career

It is faculty annual review time, and if I am being honest, I dread it. The reasons are not clear. I have been full professor for a while now, so the review carries less weight than it once did. I believe in the intent behind it. The process was built to support promotion, to make sure nobody was left guessing where they stood, and over time it evolved into a way to help faculty set goals. It is a process to look at where they have been, where they are, and where they are headed. Those are good things. I coach physicians on exactly this.

And still, every year, the annual review email elicits a groan.

The strange part is that I now sit on both sides of the table. As a division director, I walk my faculty through their reviews, and from that chair I can see the value clearly. As a coach, I believe in career planning the way I believe in evidence based medicine. So why does my own review feel like an administrative chore? I have been sitting with that disconnect, and I think the answer says something about how all of us were trained. If you feel it too, this post is for you.

We are goal setters who never chose the goals

Physicians are innately goal-oriented. Nobody survives premed, medical school, residency, and fellowship without sacrifice, deadlines, attention to detail, and resilience. On paper, we should love a yearly goal-setting ritual.

But look closer at the goals that got us here. Aside from the big one, “I want to be a doctor,” almost none of the smaller goals were set by you. Take organic chemistry, then the MCAT. Pass Step 1, then Step 2. Match, graduate, sit for boards. The sequence was handed to us fully formed. We did not design the path. We executed it, and we got very good at doing so. The boxes were decided for us, and our job was to check them.

Meanwhile, some of the most monumental decisions of our lives were made inside that sequence. Specialty choice. Practice type. The city where we would build a life. We made those calls in our mid-twenties, while we were still becoming the people who would have to live with them. Developmental psychologists describe the years from the late teens through the twenties as a distinct period of identity exploration, the stretch when people are still working out who they are in love, in work, and in worldview. Medicine looked at that same stretch of life and dictated our most permanent decisions in it.

Here is what I have come to believe about that. The values that motivate us, our internal compass, stay fairly consistent across a lifetime. How we rank them does not. What sat first at twenty-eight rarely sits first at fifty. The decisions were made by a version of you that ranked things differently, using a decision process someone else designed.

The operating system training gave you

Along the way, we absorbed an operating system: how to succeed as a premed, how to succeed as a medical student, how to pass boards, how to work inside a healthcare system. Those skills were necessary. They are also nearly the opposite of the skills required to grow as a person and build a career. Box-checking rewards compliance, speed, and deferral. Building requires choice, reflection, and the willingness to decide what the boxes should be.

Medical training teaches you to be a clinician. It rarely teaches you to be the architect of your own career.

Then one day the sequence runs out. You make partner, or professor, or simply make it. The boxes stop being set for you. They are yours to decide now, and nobody announces that the rules changed. So we keep running the trainee operating system in the wild, and an annual review that asks “what are your goals?” feels hollow, because the honest answer is that we were never taught to generate goals from scratch. Only to hit the ones we were given.

The ground shifted under our careers, and there is opportunity in it

There is one more reason mid-career is the right time to relearn this skill: the profession itself moved. There has been plenty of press about the shift from physician owner to physician employee, and most of it dwells on the downside. The downside is real. So are the numbers. In 2012, 60.1 percent of physicians worked in private, physician-owned practices. By 2024 that figure had fallen to 42.2 percent, according to the AMA’s Physician Practice Benchmark Survey. Most of us now work for someone else.

But notice the quiet upside. If something is not working, it has never been easier to change it. You are no longer tied to a practice you spent two decades building. If the system you work for sees you as an employee, you are free to see it as your employer. Employers can be evaluated and renegotiated with. They can also be replaced.

None of this negates loyalty to patients. That relationship factors heavily into every physician career decision I have ever coached, and it sits at the heart of why all of us are in healthcare. But the employment shift changes the metric, because at the end of the day, much of this is business, and both sides know it. The generation before us largely could not ask the question that is now on the table: what does this employment model make possible for me that ownership never did? Mobility. A renegotiated FTE. A hybrid role. A portfolio career built across more than one institution.

A door like that is only useful if you know where you want to go. Which brings me to the work itself.

What rebuilding a career looks like in practice

In my cohort coaching, physicians spend six weeks building what I call a career architecture document, a personal blueprint that moves through four phases: Identify, Align, Develop, and Sustain. It is the working spine of The Developing Doctor Operating System. You do not need my program to start the work, though. The process matters more than the paper, and the process comes down to four honest moves.

Name what is true

Start with the moment, or more often the pattern, that tells you something has to change. Then audit your training the way you would audit anything else. You are not broken. You are the expected output of a rigorous system that over-developed certain capacities and under-developed others. Name both lists. Then name your top five values, ranked, with one sentence each on what the value looks like when you are living it.

Check the alignment

Now hold your calendar up next to that values list. Where do the hours go, and which value does each activity honor? Add your signature strengths and your communication style to the picture. This step is a reality check, not a judgment. Most physicians find at least one large block of time serving nothing they value, and at least one strength sitting unused.

Choose a direction, from all four

A career can only move in four directions. Forward, into a bigger role. Backward, into smaller scope or fewer hours. Lateral, into similar work in a different setting. Outside, into a new domain entirely, including the nonclinical paths more physicians are exploring. Each direction has real costs and real gifts. The exercise is naming all four honestly before circling the one that calls to you. Most of us have never allowed ourselves to consider more than one.

Frame the next twelve months

Finish with three goals and three intentions. A goal names what you will accomplish, and it should be specific enough to have a deadline. An intention names who you want to be while you work toward it. “I will listen before I solve.” “I will protect my evenings.” Physicians are trained to set goals. Almost none of us were taught to set intentions, and the intentions are what keep the goals from rebuilding the same career with new furniture.

The review was never about the year

This is why I have started thinking about the annual review differently, including my own. It was never about the year. Checking last year’s boxes and penciling in next year’s is the trainee operating system wearing a grown-up costume. The real question underneath the form is bigger. You are building something across decades: a career, a life, and eventually a legacy. A single year only makes sense held up against that longer frame, and the longer frame only exists if you have done the work to draw it.

Rethinking a physician career: FAQ

Is mid-career too late to rethink a physician career?

No. Mid-career is arguably the first time you are qualified to do it. You made your original career decisions in your twenties, while your identity was still forming. Now you know who you are, what you value, and how you work. That self-knowledge is the raw material a career redesign runs on.

What are the four directions a physician career can move?

Forward into a bigger role, backward into smaller scope, lateral into similar work in a different setting, or outside into a new domain such as a nonclinical path. Each direction carries real costs and real gifts, and an honest career plan names all four before choosing one.

What is the difference between goals and intentions?

Goals name what you will achieve, and they should be specific, measurable, and dated. Intentions name how you will show up while you achieve them, such as “I will ask for help earlier.” Physicians are well trained in goals. Intentions are usually the missing half of the plan.

Does rethinking your career mean leaving medicine?

Usually not. Outside is only one of the four directions, and most physicians who do this work end up realigning the career they already have: a renegotiated role, a shifted FTE, a new setting, or a leadership step. The point is choosing on purpose instead of defaulting.