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Internal medicine physician Kara Pepper discusses her article, “From burnout to balance: 5 stages of career transformation.” Drawing from her own journey away from burnout and her experience coaching hundreds of physicians, she outlines five predictable stages doctors often traverse when seeking more autonomy, purpose, and sustainability in their work. Kara describes the progression from Stage 1: Stuck, where burnout feels inescapable, through Stage 2: Noticing, acknowledging the need for change and identifying misalignments; Stage 3: Discovery, actively exploring alternatives and embracing self-compassion; Stage 4: Data Collection, analyzing options like job adjustments or starting a practice and addressing practicalities like finances; to Stage 5: Action, making concrete moves toward a new career path. Throughout the conversation, Kara offers actionable advice for each stage, such as seeking external support, identifying core values, researching possibilities, planning meticulously, and surrounding oneself with supportive peers, ultimately encouraging physicians to take manageable steps toward creating a career that aligns with their well-being.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back after almost four years, Kara Pepper. She’s an internal medicine physician. Today’s KevinMD article is “From burnout to balance five stages of career transformation.” Kara, welcome back to the show.
Kara Pepper: Thanks for having me.
Kevin Pho: Alright, so tell us about your latest article and what it’s about.
Kara Pepper: So I think in this season of, it’s not even post-COVID ’cause we’re still in it, there’s a lot of ups and downs that people are feeling trying to figure out what comes next for them personally and professionally. And more and more physicians are trying to figure out: should they stay in medicine, should they leave, or should they just make a pivot that makes their career more sustainable?
As someone who’s now in my seventh year of coaching and personally gone through massive transformation—leaving my practice, starting a practice that grew to 17 states, and being in solo practice, here I am in my clinic—this transformation process of getting unstuck to finding your voice and figuring out what comes next is where I spend a lot of time supporting my colleagues.
That’s what the article is really based on. It’s a very predictable process of transformation; it’s basically five general steps. We all learned about the stages of change as we’re coaching our patients on behavioral change, but I would describe these five steps as, first, just feeling stuck.
This is the water cooler talk: everything’s hard, everything’s miserable, health care is broken, I guess this is just how it is. You feel like nothing’s going to get better. There are things that can be done in each one of these stages to help you find some breathing room and take the next step.
If you are profoundly burned out and you are struggling with depression or anxiety, even if you’re high-performing, the first step that you need is really just to take some breathing room, to find some space to edit your life, meaning there’s a season for everything. You do not need to be the head of the committee. You do not need to be on the PTA. If you have FMLA leave in your access, taking a leave of absence is important just to get your head on straight. When we’re in that fight-or-flight space, making balanced decisions about what comes next is virtually impossible.
Once people actually get some breathing room and get out of that sympathetic drive, the next step is just to notice your own suffering: what is working great for you and what is not? Figuring out what feels really good is a huge key into what comes next. The question that I often ask people in that stage of life is: what actually makes you mad? What makes you resentful?
I used to be so angry when people would ask me to go play tennis at 10 in the morning. Not that I have any hand-eye coordination as an internist, but I really just wanted the freedom to have autonomy over my schedule, and I would be so angry with these folks. So, what are the things that really frustrate you, and what is that signaling that you really need in your life?
Once you start to discover that you actually can have some air in your life, you have the ability to make some change, and you know what your values are, the next step is just what we’re good at, which is this process of discovery. There has to be a better way, and there is. Medicine is not one-size-fits-all.
I often point to my husband, who’s an MBA. If he was still working in the same job that he did at 27 when he finished his training, people would think there’s something wrong with him. They’d ask, “Do you not aspire for more in your life? Are you really the same person you were 20 years ago?” And yet, in medicine, we’re expected to take a job out of training and just stay there indefinitely.
What are all the options available to you? Often folks will tell me, “The only thing I know how to do is just practice medicine,” but you have so many more skills than that. Just get curious, wipe the slate clean. What would your ideal day even look like?
Then after that, it’s joining communities, looking outside your echo chamber to talk, going to conferences, getting involved in communities outside of medicine to see what people are doing, looking at startups—what are all the novel ways that people are using their skills? That’s a way to start saying, “I don’t have to do this alone. Let me look towards people who’ve already started to figure these problems out.” Get yourself plugged in.
Lastly is taking action. That does not mean you need to blow up your entire life and build a solo practice like I did, but it means that you can take a tiny step. What is the next financial plan that I need to start planning for? Do I need to save up a nest egg in order to make a transition? Do I need to meet with my mentors and ask for help? Do I need to start looking for other jobs? Do I need to set a goal and reverse engineer it? Doing some tiny little thing to move yourself forward is key.
That’s the very brief overview of what this transformation looks like. You don’t have to leave medicine, or you can, but at this point, you do not have to be stuck. Our life is so much more than what we do for a living. The last thing that we want is to look back on this season in our life with regret and say, “I wish that we would’ve done things differently.” You have power and permission to make change.
Kevin Pho: So tell us briefly how your own personal story fit into those five stages, that paradigm that you described for us.
Kara Pepper: I worked for a hospital-owned practice for 14 years. Every two years, I was trying to navigate what’s the next thing for me. I wouldn’t have described myself as being bored, but I think that was part of it.
During the interview for that practice, they said to me, “We want to hire you and retire you.” And I remember in my bones just being terrified by that. What do you mean I have to do the same thing for 30 years? So I was always trying to navigate not only taking great care of patients and being a good team player, but also trying to grow in a system that simply wanted me to see patients.
I had taken a sabbatical ’cause I’d gotten really burned out; I’d gotten additional certification. Then COVID happened, and it really dawned on me that I could be dead next week showing up, taking care of patients. It really became clear that I could not continue to work in a system where I felt stifled, where I didn’t have autonomy, and where frankly, I just wanted a process of trying things that were new, and I couldn’t do that in a system that was very slow.
I infamously made an appointment with the lead physician who ran our practice and went in really just for advice. Halfway through the meeting, he said to me, “So what are you saying? Are you thinking you’re leaving?” And for the first time ever, I said, “Yeah, I’m leaving.” I had not discussed it with my husband. I had no community around me. I had no idea what I was going to do, but I knew in my bones that things had to be different.
I say all of this to say: don’t do it like me. You need to be able to have a plan and have community around you. There are a lot of folks who are helping support physicians like me move into solo practice if that’s what they want to do. Ultimately, I left. I rode out my non-compete by building a telemedicine practice for folks with eating disorders, but it grew to 17 states over the course of two years. Now I’m back in person seeing patients and, on the side, helping physicians build solo practices.
There’s a lot there, but ultimately I needed to take my own advice, which is to build a life around what I really value. I could practice medicine forever at this point; I really, truly love it. It’s been fun.
Kevin Pho: I talk to a lot of physicians, particularly early-career physicians, and after five years or so, they’re in that first stage where they feel stuck. One of the reasons they feel stuck is because of hundreds of thousands of dollars of student loans or other financial reasons, and they don’t have that flexibility to look beyond their current job because of that financial anchor. For those physicians, and there are a lot of them in that position, what’s your advice if they’re in that first stage of feeling stuck?
Kara Pepper: We know that if you look at the data for physicians who’ve graduated in the past six years, the average length of stay in their first job is about two years. People join because of perceived financial security, and they leave because of the culture and the leadership.
What I would argue is that you have so many skills. It’s not just practicing medicine in the very first job that you took. You can practice medicine in many different ways. While, yes, not everyone has this magic trust fund that’s going to pay off their student loans, it is a financial consideration, but it is not a limitation.
One of the benefits of my previous job was that there was a pension associated with it for physicians. Every time I’d come home telling my husband, “I’m so burned out, I can’t do this anymore,” he’d say, “But the pension, there’s going to be this financial payoff. Just hang on a little longer.”
I would tell people, just like I needed to, to go look at the data: how much money are we talking about here, and what are all the ways that I can recoup those losses? When I really sat down and did the math—not the emotional math, but the actual math—it did not make any sense for me to stay another 15 years in order to recoup that pension amount.
We make data-driven decisions in our business and in our clinical lives every day. Make data-driven decisions around this and understand that there are many ways that you can pay your loans off. You do not have to stay in the first job that you take out of training.
Honestly, Kevin, I do think we don’t do a good job preparing our newest colleagues on how to anticipate these changes in our first couple of years. We think of residency or fellowship graduation as the finish line, but it’s the steepest learning curve of our career. We’ve got a lot of personal things going on in that decade of life, and I think we as mid-career physicians or senior physicians need to be preparing our youngest colleagues to say, “This is what you’re going to be in for,” not just in the culture of medicine and the clinical skills, but what does this mean financially, and how can we help support people through that transition?
Kevin Pho: As part of your discovery, you created this telemedicine practice that’s in 17 states. You do a lot of coaching of other clinicians as well. What are some other examples of successful physicians who’ve looked beyond their clinical practice?
Kara Pepper: Do you mean people who have left clinical medicine entirely or found something that supplemented what they did in clinical medicine?
Kevin Pho: Either left clinical medicine entirely or found something that supplemented what they did in clinical medicine.
Kara Pepper: As a physician coach, I know lots and lots of people who are doing coaching, but I think the folks who are not doing that—yes, we hear about people doing real estate, yes, we hear about people doing other financial models—but following the things that make you uniquely you is huge.
There are physicians who are writing books. There are people who are doing ancillary service-lines; for example, they understand revenue-cycle management, and they built businesses around that ’cause they knew it so well they had to figure it out for their clinical practice. I know folks who have developed clothing lines. I know folks who have done color theory. I know folks who are artists. I know folks who are doing all kinds of tech and bio development.
There’s never a one-size-fits-all approach. We are unique individuals. I think we don’t need more grind; we don’t need more homework. There is a way to follow what makes you uniquely you and use that to develop even just a hobby. You never know, that may turn into a side-hustle that actually produces revenue that supplements your clinical income.
As people start to transition to something new, there’s usually about a two-year transition period where people need some sort of self-funding, whether it’s working as a consultant, doing medical expert work, or doing telemedicine work. There are all kinds of avenues for us to use our skills to supplement our income as we’re moving on to what’s next.
This is why community is so important, because you don’t have to figure this out alone. There are millions of us out there who are trying to figure out how to have sustainable careers, and people have ideas for you. Get plugged into those communities.
Kevin Pho: I think that’s really important to say because you and I, we’re plugged into these communities where physicians, as I always like to say, are more than our degrees. There are so many doctors that we see doing so many different things outside of the exam room and outside of the hospital. It’s tremendously important for physicians who are not in our world, or newly-graduated physicians, to get plugged in and realize that we can be so much more than just what we do clinically and really expand our horizons, because that type of exposure isn’t typically taught in medical school or residency.
Kara Pepper: That’s right. You’re drinking from a fire-hydrant, understandably. The cynic in me thinks there’s probably a reason that we’re not exposed to the business of medicine and other financial skills in that way, because it makes us dependent on that system. But if you can learn how to manage complex medical illness, get a baby out of an abdomen within two minutes, or manage transplant surgery, you can learn these skills. This is not that hard; this is just another skillset.
Kevin Pho: Now, during your coaching experience, when you talk to so many other physicians who may be burned out, the question often arises: should they stay in what they’re doing and maybe cut back to part-time and find something that can supplement it clinically, versus dropping out of clinical medicine entirely, or even finding a new job entirely? Those are three avenues. How do you normally guide physicians through those choices?
Kara Pepper: I really do believe that we know internally what the right choice is for us. When we are living in survival-mode, in that sympathetic state where we are just churning through every day and exhausted and depleted, it is really hard to make decisions that are not going to recreate the same scenario. You can go find another job, but your brain is coming with you, and you are going to end up recreating that same dynamic in the new place.
The first step for me is always just to create some space, and that feels nearly impossible for many of us who are working 60-plus hours a week. But it’s not an optional step. You have to be able to take care of yourself, settle your nervous system, and get into that parasympathetic space. It’s like when you’re walking the dog or standing in the shower, and all of a sudden you have this brilliant idea, or the answer to this problem you’ve been trying to solve comes to you.
It’s exactly that. For some people, cutting back to a lower FTE may be the first step, just to clear some space for them to actually think straight so that they can make an informed decision that is going to change the trajectory instead of repeating the trajectory they’re already on.
Kevin Pho: We’re talking to Kara Pepper. She’s an internal medicine physician and a physician coach. Today’s KevinMD article is “From burnout to balance five stages of career transformation.” Kara, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Kara Pepper: The reason I do this work is because I truly believe that physicians can change the world. We have all of the skills, but we are often feeling stuck, thinking that the only thing we know how to do is practice medicine. You are so much more than what you do for a living, and you have so much impact that you can make. As we take care of our patients, we need to take care of ourselves.
If you are on your death-bed, looking back at today, what is the thing you know in your bones that you need to start or stop doing immediately? The thing that made you want to throw up a little bit as you heard me say that—it’s that thing. How can you just take the first tiny little step towards doing the things that you need to start or stop doing?
That’s where you start.
Kevin Pho: Kara, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.
Kara Pepper: Thanks for having me.