The Work
Ask any chair or program director what's driving their best people out the door, and the word that comes back first is almost always burnout. This isn't wrong, exactly, but it's incomplete in a way that matters. Burnout describes the effect. It doesn't describe what that effect is a symptom of.
The Real Diagnosis
What's actually happening is identity strain. It accumulates: through a promotion that changes what the job requires without changing how the person sees themself, through a clinical practice that stops matching the reasons someone entered it, through years spent meeting a role's demands without anyone asking whether the role still fit. Given enough time, that strain compounds into identity rupture: the point at which a physician's sense of who they are can no longer absorb the distance between the role they're occupying and the self occupying it. Institutions see the downstream version of this constantly: disengagement, unplanned departures, a model physician who begins to behave disruptively. What they're usually looking at isn't a motivation problem. It's an identity that stopped fitting the life it was built to serve.
Why This Keeps Happening
The reason this happens as often as it does traces back to something structural: belonging in medicine is usually contingent. It's earned and re-earned — through RVUs, publication counts, grant dollars, and committee work — a running tally, reviewed each cycle, rather than something dependable. This type of contingent belonging can carry a career a long way. It's an excellent engine for achievement, and it explains why so many high performers look, from the outside, entirely secure. But contingent belonging cannot hold an identity through a real transition. The moment performance changes — a shift in clinical role, a step back from a title, retirement itself — the belonging it was funding disappears with it. What looks like a person who “lost their confidence” during a transition is often a person whose belonging was contingent all along, and who is discovering that for the first time under the worst possible conditions to learn it.
Trustworthy Belonging
What does hold firm through a transition is something categorically different: trustworthy belonging. This isn't belonging that's permanent — no institution can promise that — but belonging whose character doesn't shift the moment output does. Trustworthy belonging isn't a status an institution declares upfront. It's demonstrated, the way any trust is: in the moments that actually test it. When a person's standing doesn't drop when their numbers do, that's trustworthy belonging. So is watching a colleague get held accountable for a real mistake without losing anyone's regard.
When a person's standing doesn't drop when their numbers do, that's trustworthy belonging.
Trustworthy belonging isn't a trait some physicians have and others don't — it's a property of a culture. An institution that builds this deliberately gives its people somewhere to stand during exactly the transitions that would otherwise rupture them. That's the real difference between growth that turns inward to protect itself and growth that takes root together. It's that difference that decides what comes next.
What Institutions Miss
Many institutions mark the beginning of a role — a new hire advertisement, an onboarding process, a promotion announcement. But marking isn't the same as ritual: none of it holds a person through real uncertainty, or carries enough weight to actually change how someone understands themselves. And whatever thin ceremony exists at the start disappears entirely by the end. That absence isn't a minor oversight — it's why identity strain keeps arriving disguised as burnout: there's no institutional language for what's actually happening, so it gets named after its symptoms instead of its cause.
What Growth Actually Requires
Every transition produces some kind of growth — the question is what shape it takes. When the belonging underneath a role was contingent, most people respond to a real transition by protecting what's left: working harder, narrowing further, treating the changed role as a threat to be managed. That's still growth, in a sense — nobody stays perfectly still under real strain — but it's growth spent holding a threat at bay rather than building anything new. The other outcome is growth that takes root: the same disruption, met with enough structural or relational support that the expanded identity integrates rather than assimilates — becoming someone larger on purpose, rather than merely merging into the identity we think others value. Neither outcome is about willpower. Both are shaped, heavily, by whether the belonging underneath the person was ever built to hold.
That's the work — building trustworthy belonging deliberately, at the institutional level and secure identities at the individual level, before the next transition arrives.
That's worth a conversation, wherever you're standing.