There is no path that goes all the way.
—Han-shan1
As the average age of academic health system (AHS) faculty has been increasing,2 those at the midcareer stage make up a growing proportion. A great deal of an AHS’s competitive success depends on these highly trained experts achieving their potential as clinicians, investigators, educators, and leaders. Their institutions have invested a great deal in them, and expect them to remain highly productive for many more years. Yet this large, essential group is receiving comparatively little attention. In this Perspective, I draw on more than 40 years of working closely with AHS faculty—including 25 years at the Association of American Medical Colleges—and extensive familiarity with the literature relevant to faculty careers to explore the needs that many midcareer faculty share and to suggest actions they can take on their own behalf.
To begin, what is midcareer? Early-career is characterized by straightforward exploration, by growing competence in one’s field, and by steady progress from dependence to self-reliance as a practitioner. Although clear demarcations are lacking, by midcareer, professionals have mastered a great deal of specialized knowledge and carry substantial responsibilities; their expectations of themselves are at their highest, as are those of their institutions. Yet at some point during this phase, a reevaluation of career and life possibilities typically occurs,3 with many faculty experiencing a transitional period of uncertainty about how to remain competitive and what “rejuvenation” of their careers might include.4,5 I have found that at the midcareer stage, the following questions take on greater meaning: How do I decrease involvement in activities that are not a good fit? How can I reserve more energy for my family and personal health practices? What commitments can I renegotiate? How can I regain a sense of momentum and generate fresh ideas? In what ways might I increase my influence? Should I do more or less community service? Do I need to move?
However healthy such questions are, not many resources are available to help midcareer faculty articulate and examine them. Often, early-career faculty retain access to nurturing mentoring relationships and other sources of institutional support; by midcareer that close monitoring is likely to have weakened. Because late-career faculty tend to focus predominantly on retirement planning, their needs are of a different nature.
In this Perspective, I begin by describing difficulties that many AHS midcareer faculty must overcome in reevaluating their careers. I then offer suggestions that midcareer faculty can take to continue to grow even when a promotion or access to more resources is unlikely. I conclude with recommendations on how AHSs can facilitate the continuing productivity and engagement of midcareer faculty.
Before turning to why many AHS faculty find themselves at a developmental standstill, I ask first: What would a strong arrival at a midcareer assessment look like? Faculty who made wise choices earlier in their careers by assuming roles that matched their strengths, and who continue to align their goals with organizational priorities, have a big advantage. Also central to success is learning to handle a wide range of interpersonal and organizational issues and addressing weaknesses as they become apparent. As these increasingly agile individuals reach midcareer, they usually are equipped to assess whether they want to continue in their current path or explore alternatives. For instance, an associate professor concludes that because it is unlikely that she can meet the criteria for full professor in her department, she will shift her focus to gaining leadership roles within two professional societies. With this new focus on expanding her network, she potentially could move to a less research-intensive AHS or become more of a community activist in her area of expertise.
What Gets in the Way of Growth?
In my experience, many midcareer faculty are not prepared to look ahead in a proactive way. One difficulty common to those in specialized occupations such as medicine and science is that training is so lockstep and forging a professional identity so consuming that other aspects of development are marginalized. In addition to ongoing demands to maintain clinical and scientific mastery and to adapt to technical requirements such as the electronic medical record, AHS faculty face pressures to publish, to excel as educators, and often most important, to generate income.6 Moreover, numerous competencies that are not taught during the long training process or during early-career have become critical to one’s work; these include, for example, skills in negotiating, personnel management, relational communication, and emotional intelligence.
Consolidation of a professional identity also has become more complex. Not long ago, a medical or scientific degree and faculty appointment established a career, especially when a strong mentor helped. Further, during midcareer, successful faculty had the option of a sabbatical (related to “shabbat,” meaning to rest) to facilitate continuing learning. These days, however, there is more intense competition for fewer resources, making success more elusive and momentum more difficult to sustain. Recent studies of academic biomedical scientists have found “an unequivocal downsizing of their capability to perform basic investigative research,” with resulting poor morale.7 Many faculty end up feeling disappointed in themselves and their institutions even though they believe they have done everything that was expected of them, including sacrificing time with family and other keen interests.
Some midcareer dilemmas result from organizational politics. For example, to secure the recruitment of a new department head, the dean offers her husband leadership of a program that Dr. A has been building for a decade; Dr. A now feels as if she is experiencing “career death.” Other dilemmas stem from interpersonal conflicts with or loss of faith in the boss. Many women and minorities also experience an extra layer of challenge that remains invisible to many majority men8; for instance, being held to higher standards of “likeability” or for performing community service while often being paid less. Even though difficulties stemming from organizational politics and inequities are not unusual, the faculty members who experience them feel isolated and stymied by them—they feel that their situations cannot be addressed or discussed. If such issues are not constructively worked through, they tend to solidify into resentments or other kinds of barriers.
However, self-assessment in conjunction with an objective look at one’s options does not come naturally, even to professionals skilled at scientific analysis and dedicated to lifelong learning. Accustomed to thinking of oneself as an expert, it can be hard for midcareer faculty to admit uncertainty. Extreme busyness also keeps people ensnared in bad habits and functions as a chronic excuse for postponing a searching look at possible career changes. Other stances common to physicians and scientists (and to cultures within which they work) interfere with growth, such as impossibly high expectations of oneself (e.g., “always responsible”) and “compassion fatigue”—that is, the inability to feel empathy for others or for oneself.9 Built-in expectations of personal overextension are so ingrained that many AHS faculty are at high risk of burnout (a syndrome of emotional exhaustion and sense of low accomplishment).10 Burnout and the resulting attrition are always costly, though many costs remain hidden, except from colleagues whose confidence and schedules are affected.
The Normal Work of the Second Half of Life
Images shape assumptions. The traditional career model of a linear trajectory with steadily accumulating authority and income has a tenacious hold. Although they may sense that this expectation is outdated and unrealistic, many faculty members lack other examples. Promising alternative ways of looking at growth are emerging from studies into adult development and resilience, which I review below.
Understanding human development as predictable life stages with alternating periods of stability and transition helps to normalize the questions that arise at midlife. For instance, Vaillant’s11 longitudinal studies of adult development found that typically following the “career consolidation” phase (during which one’s goals are to achieve compensation and competence in one’s field) is the “generativity” phase. The tasks of the generativity phase include unselfishly guiding the next generation, which in turn makes possible new levels of meaning for oneself. Mastering the tasks of this phase triples the likelihood of experiencing a “vital elderhood,” in other words, that one’s 70s and beyond will be joyful and healthy. Because AHS faculty experience continuous pressure to generate income and promotion criteria reward continuing career consolidation, those who focus on teaching, mentoring, and community building may feel undervalued; but individuals who do not transition into a more generative orientation risk sacrificing their chances at a vital elderhood.
Research on physicians who have achieved long-term professional satisfaction is also revealing. One study found that satisfied physicians control their work hours; establish sound business practices; develop diversified interests; maintain relationships with family; seek feedback from colleagues; and proactively address their weaknesses.12 Clearly, healthy professionals must take multiple steps to prevent stressful working conditions from overwhelming them.13 By contrast, professionals who experience burnout ignore early warning signs (e.g., irritability, fatigue) and fail to see how their choices begin establishing negative patterns that are hard to break, such as poor eating practices. Because it implies failure, burnout is difficult to recognize in oneself—even though physicians know that taking care of themselves is key to optimal performance and to patient safety. How do achievement-driven professionals develop the self-acceptance that is a necessary precondition to change?
Challenge is the doorway to growth. From a psychodynamic point of view, sources of turbulence common at midlife (such as shame at failing to live up to one’s image of success) are not signs of pathology; rather, these disturbances are necessary for growth.14 Unfortunately, instead of appreciating that these symptoms of misalignment draw our attention to potential problems, the first impulse is to suppress them, hindering the work of individuation—that is, the lifelong project of becoming more nearly the whole person we were meant to be. As most mythic and heroic quests teach, wholeness is only arrived at by negotiation between one’s strengths and weaknesses and by passage through failure and loss. In this light, our questions are key to finding ongoing meaning in the gift of life.15 But investigating unwanted aspects of ourselves is so uncomfortable that many never learn to accept their own and, hence, others’ imperfections. Those who depend on materialistic values or individual accomplishments as “protection” against the eternal verities of impermanence and interdependence further limit their capacity for compassion and joy.
How can adults get better at making use of this discomfort and the multidimensional complexity that surrounds them? The capacity for complexity is closely linked to the abilities to question one’s own beliefs, synthesize the perspectives of others, and appreciate that change is the natural order of life. To foster increases to this agility, people require “optimal challenges,” that is:
The persistent experience of some frustration or quandary that is perfectly designed to cause them to feel the limits of their current way of knowing with sufficient supports so that they are neither overwhelmed nor able to escape the conflict.16
Interpreting constraints and disappointments then as necessary learning opportunities can spur individuals to accept responsibility for changing what they can change.
Into Action
To cultivate insights that facilitate change and more objectively see the world through a wider aperture, one often should begin with a critical self-inventory, which is impossible to conduct in the midst of routine demands. Thus, the first and often most difficult requirement is setting aside time for a deliberate introspective “pause”—perhaps an extended vacation or time off following a personal or leadership development program designed to facilitate inner quiet and reflection. Key to lifelong learning, such pauses are enriched by reflective reading and writing.17 Rich questions for reflection are included in List 1.
List 1
Questions to Facilitate Reflection and Conduct a Critical Self-Inventory at the Midcareer Faculty Stage
- What does success mean to you now? How and why have your definitions changed over the years?
- What would it take five years from now to feel good about where you are?
- Which commitments do you find most meaningful? If your calendar does not reflect these, what are your options for shifting activities?
- When do you feel expanded? Constricted? How can you do more of the former and reduce your involvement in the latter?
- What makes you anxious? What is happening in these situations?
- How clearly are you distinguishing your desires from the expectations of others?
- What do you need to improve on that is essential to your future health and happiness? What is your plan for this? What support systems and disciplines do you need to develop?
- What are your “learning goals”? (Treat these as if they are as important as performance goals.)
To boost insight into what is needed to keep growing, it is usually helpful to collect feedback. Even successful professionals tend to lack insight about which behavioral tendencies obstruct their progress—often these are strengths they are overdoing (e.g., commitment to patients becoming unhealthy self-sacrifice) or interpersonal behaviors they need to stop doing (e.g., dominating conversations more often than listening or a perfectionism that leads to unrealistic standards). Feedback helps professionals close gaps between their good intentions and the actual impact of their behaviors. The simplest method is to ask trusted, qualified individuals “how can I do better?” and then to listen for themes.18
Deciding which activities to decrease or increase involvement in may be aided by assessment of what one brings to each activity (e.g., motivation, specialized skills) and what an activity garners (e.g., money, meaning, enjoyment, learning).19 Similarly, appreciative inquiry20 suggests that one begin with the questions “What is working well?” and “How can I have or do more of that?” This approach encourages people to think about instances when they were really engaged, which prompts exploration of values and commitments. By shifting attention from constraints to those aspects of a situation that can be influenced, one can discover previously hidden ways to reconfigure activities.
Highly skilled professionals have inherent mobility. When one can clearly articulate a strong preference, a first step toward a new goal often presents itself. That one also becomes more alert to obstacles is less a sign that there’s something wrong than that things have begun to move. For instance, someone with a high preference for autonomy starts to explore possibilities for creating an innovative institute; although many challenges arise, she learns something from each obstacle and gradually establishes a viable enterprise.
A common trap for midcareer faculty is the assumption that being highly skilled in a particular area, especially if demand for the activity is great, means one must persist with that work. But such a singular focus misses the forest for the trees. What may appear to be the only option (e.g., acquiescing to more call when already exhausted) may only postpone a hard reassessment. Another error is to assume that just because one could move into a leadership role, one should, even when administrative responsibilities are not a good fit.
Translating preferences into a workable career plan requires investigating and experimenting with alternatives. One way to begin is to articulate one’s questions and unknowns and any ideas for filling in the blanks—for instance, might a reference librarian assist? Ibarra21 also recommends trying out activities (perhaps on a volunteer basis) and seeking new role models and reference groups in areas of possible interest.
When taking a career in a new direction, some tensions are predictable between the individual’s needs and those of others. Therefore, the plan should take into account the likely impact of the proposed changes, and how these will be broached and managed. Preparing for uncomfortable conversations with bosses, partners, and others likely to be invested in the status quo is critical; role-play can help.22
Although tradeoffs and setbacks are inevitable, midcareer is not too late to change direction or build new skills. A desire for safety and security, however, interferes with agility. The most common regrets people tend to have are those resulting from passivity—for instance, not investigating options that might be more rewarding.23 Individuals suffering from burnout or who are unable to envision alternatives may benefit from professional counseling. For those with good self-awareness and motivation, a career coach can facilitate reflection and new directions.
Improving Institutional Practices
One recent study found that upon entering midcareer, it is not unusual for even successful clinical investigators to lack a “steering wheel” to guide them, that dips in confidence and clarity are common, and that more guidance and a broader spectrum of available career paths would be beneficial.24 Another study found that many faculty entering late-career are despondent to find themselves “casualties of a system that demanded much from them in their youth but offers little support as they age into a vulnerable career phase.”25 Fortunately, there are many cost-effective ways that AHSs can better assist faculty during midcareer that also will increase their return on their investment in these professionals.
Because many questions at midcareer are predictable, AHSs can offer anticipatory guidance, including assisting faculty to define what broadening or scaling back might entail.26 Faculty development programs can target midcareer needs; for example, facilitated small-group cohorts could engage in exercises that encourage reflection, clarification of goals, and experiments with change. Given that the time one spends on meaningful activities is inversely related to burnout, annual reviews should incorporate assessment of the faculty member’s satisfaction with his or her effort distribution.27 Mentoring programs can also do more to help midcareer faculty connect to sources of continuing advice and inspiration; newly retired or emeritus faculty might be tapped for this in mutually beneficial ways.
Although longer sabbaticals may not be feasible, one- to three-month mini-sabbaticals could focus specifically on building leadership or other types of skills. Departments engaged in succession planning and “growing their own” leaders are better able to facilitate the continuing engagement of midlevel and senior faculty. By setting term limits on roles such as chief, vice chair, or residency director, institutions can also increase the number of available leadership opportunities.
Efforts to add flexibility to personnel policies are also critical as more men and women are intent on work–life integration over the entire course of their professional lives.28,29 A “lattice” structure (in contrast to “ladder”) enabling various kinds of horizontal growth could supplement the traditional vertical path so that individuals have options for customizing activities during each decade of their long careers.30 Broadening the traditional definition of career success would allow more support for and recognition to those who continue to contribute in substantial ways but who are not seeking (or are not a good fit for) senior administrative positions. Finally, now that more preventive and treatment interventions are available to support resilience, another timely innovation is measuring clinical faculty burnout as a critical organizational quality indicator.31
Summing Up
Despite a strong desire for meaningful work, many faculty members arrive at midcareer with symptoms of burnout; even healthy faculty may feel developmentally stalled. Recognizing that a reexamination of goals at midcareer is salutary can help faculty shift attention from what is constraining them to those aspects of themselves and their situations that they can modify. It is never too late to regain a sense of self-efficacy and joy—to be more of a creative force in one’s own life. AHSs that assist faculty with adjustments inherent in this midlife stage are facilitating the continuing productivity and engagement of a resource critical to their future.
Acknowledgments: For their helpful comments during the evolution of this paper, the author gratefully thanks Stephanie Abbuhl, MD, Lori Bastian, MD, Jennifer Havens, MD, Luci Leykum, MD, Mark Linzer, MD, Niki Steckler, PhD, Amparo Villablanca, MD, and Janet Williams, MD.
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