At a certain point in your career, improvement becomes less straightforward.

Earlier on, be it in med school, residency, or even early attending life, the formula may have been clearer. More knowledge, more training, more practice, more effort. If you put in the work, you get better outcomes.

But later, once you’re established, earning well, and objectively successful, the problems shift.

You may find yourself stuck in decisions you already “understand” at a logical level. You might continue enacting patterns (both professional and personal) that you’ve already identified as unsustainable, maladaptive, or even straight-up harmful. You may find yourself constantly reaching for new goals, telling yourself that it’ll solve something, only to repeatedly keep finding that once you attain them, problems don’t magically disappear.

Put simply: wherever you go, whatever you do . . .  there you are.

At that point, many physicians start thinking about getting some form of outside support—not because they’re struggling in any obvious way, but because they want to stay sharp, self-aware, and intentional. And that’s where confusion can set in.

Should this support be in the form of therapy or coaching?

What Coaching Actually Is

I know I’m speaking in broad strokes here, but generally, coaching is built around performance. At its core, coaching assumes that you are generally a capable, functional person who already knows, more or less, what you want and that the main obstacle is execution. A coach can help you clarify goals, create structure and accountability, and build follow-through. The work is forward-looking. Coaching is mostly oriented around action: what you’re trying to build, improve, or change.

For doctors, this often looks like trying to become more effective in roles you already inhabit. You might be working on how to lead a team without micromanaging, how to delegate without things falling apart, or how to carve out time for something you say matters but never quite gets done. Sometimes it’s about building something entirely new—a practice, a side income stream, a different kind of career path—and needing help staying consistent with it.

In these contexts, coaching can be extremely effective. There’s a kind of clean efficiency to it. You identify the goal, align your behavior, and track progress. If you do the work, things tend to move.

Importantly, coaching usually doesn’t require you to fundamentally question yourself. It works from the assumption that your goals make sense and that any difficulties are just a matter of structure, consistency, or follow-through rather than something deeper.

What Therapy Actually Is

Therapy generally operates on a different premise. Therapy is usually less concerned with what you’re trying to achieve next, and instead, it's more concerned with how your internal world shapes what you do. These influences often function in ways that don’t fully make sense to us, even if/when we might consider ourselves highly self-aware.

In therapy, the focus isn’t just on behavior, but rather on the patterns of emotions, psychological schemas, past experiences, future meaning-making, and many other dynamics that organize behavior in complex, multi-faceted ways.

  • Why are you disproportionately struggling to make a decision that seems objectively straightforward on the surface?
  • Why do you find yourself reacting more strongly in certain situations than the situation seems to warrant on the face of things?
  • Why do you keep encountering the same kinds of dynamics—at work, in relationships, in how you relate to responsibility—even when you can clearly see them as they’re happening?

These are not simply problems of “knowledge.” In fact, most physicians that I work with in therapy can often articulate insight about their patterns quite clearly. They know what they “should” be doing. But knowing simply isn’t enough.

The deeper questions are why that knowing doesn’t neatly and reliably translate into actual change.

Therapy starts from the assumption that you are not fully transparent to yourself—not in a pathological sense, but in a fundamentally human one. Our life choices are shaped in complex ways by internal expectations, emotional associations, our histories, and ways of organizing life experiences that we didn’t consciously choose but in which we nonetheless operate. Defense mechanisms can run deep for us—things like avoidance, denial, suppression, repression, projection, humor (yes, even humor!), deflection, and many more.

And because of that, deeper change usually doesn’t happen simply by deciding to do something different. Sure, it can happen sometimes, and it’s great when it does. But for all the rest of our life struggles, change takes time and understanding. It necessitates gradual shifts in the system underneath, so that different choices start to feel not just possible, but natural. Therapy is one vehicle to facilitate those possibilities.

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Why This Distinction Matters

On the surface, both therapy and coaching look like “investments in yourself.”

You’re talking to someone regularly. You’re trying to improve something. You’re paying a nontrivial amount of money to do it. Both can make you feel like you’re “doing” something—even if nothing fundamental is actually changing. And when you’re deciding between the two, one of two things tends to happen. Either coaching and therapy seem similar enough that the distinctions get blurred, or the common impulse many physicians have to over-index on “problem-solving mode” makes coaching feel like the more logical, even seductive choice.

But they’re not interchangeable. Therapy and coaching are designed for fundamentally different kinds of concerns. And they work at different levels.

This is where many high-income physicians get tripped up. It's not because they’re careless, but it's because the distinction is easy to miss when you’re used to solving problems, being the doer-fixer at work and at home, and defaulting to that modus operandi almost everywhere in your life.

If you’re trained to think in terms of identifying a problem, applying a strategy, and executing on it, coaching will almost always feel like the more intuitive choice. It sounds more efficient, more actionable, and more aligned with how you’ve learned to operate. However, not every problem is actually a problem of strategy or execution. When you approach every problem that way, it becomes easy to apply the right tool to the wrong kind of concern.

The Common (and Costly) Default

Most physicians default to coaching.

It feels more aligned with how you’re trained to think: identify the issue, apply a strategy, measure results. It carries less stigma. It sounds more like optimization than introspection. Coaching sounds like something competent, high-functioning people do to get even better. Therapy, for many physicians, can still feel like an admission of “weakness” or pathology—even when what is actually needed is not a diagnosis, but instead, a deeper look at the patterns that keep repeating.

In a profession that rewards composure, stamina, and being the person others rely on, it can feel safer for doctors to say, “I’m optimizing my performance” than “I need help understanding why I keep ending up here.” Coaching can feel proactive, polished, and professionally acceptable. Therapy can feel more vulnerable.
And importantly, coaching allows you to stay within a familiar identity—someone who improves through effort, discipline, and doing more of what has already worked.

But here’s where things start to go off track. A significant number of the problems physicians try to solve with coaching are not actually execution problems. They’re pattern problems, and patterns don’t change just because you set better goals. I’ve worked with physicians who could walk me through exactly why they needed to cut back—and then found themselves saying yes to the same commitments the very next week.

  • A doctor says they want to set better boundaries. But they feel guilty and paralyzed every time they try.
  • A doctor says they want to reduce their workload. But they experience anxiety and dread whenever they think about actual ways of reducing it.
  • A doctor says they want to make a decision. But they keep delaying it despite having all the information.
  • A doctor says they want more time for their personal life. But they feel restless or uneasy when they actually have it.

In these situations, the barrier is not a lack of clarity. It’s not that they don’t know what to do. It’s that some part of them is not aligned with doing it. It’s that something in them is organized around maintaining the very pattern they’re trying to change. Even if the pattern is costing them, it’s also fulfilling some function that’s often outside of their awareness, making it hard to simply let go.

Avoiding Therapy Out of Fear?

On top of stigma, one common concern I hear from physicians about therapy is that they might end up with a diagnosis that could create problems later with credentialing, licensing, board certification, or disability insurance. Coaching, by contrast, can seem to avoid many of these issues. Even when doctors want or need therapy, some understandably wonder whether coaching would be the “safer” option from a documentation or discovery standpoint. This concern is understandable, and it is sadly one reason that many physicians hesitate to seek therapy.

When a therapist is in-network with insurance, a diagnosis code is generally required as part of the claim. Even out-of-network reimbursement or superbills can create a paper trail that includes diagnostic information. For physicians who are especially concerned about privacy, it can often be beneficial to work with a therapist on a private-pay basis and choose not to submit claims for reimbursement. This can offer much more control over what information is shared with insurance companies or other third-party payers.

Of course, private-pay therapy does not erase a therapist’s legal and ethical obligations. Therapists still have limits to confidentiality, including mandated reporting, imminent safety concerns, court orders, and other specific situations governed by law. But outside of those hard lines, confidentiality is still the default. Private-pay therapy can give both the physician and the therapist more room to be thoughtful about documentation, diagnosis, and disclosure.

This is also why timing matters. It is usually far better to seek therapy earlier, when the concerns are stress, burnout, anxiety, relationship strain, perfectionism, grief, or a growing sense that something is off, rather than waiting until things have deteriorated to the point where there is a bona fide question about impairment or the ability to practice safely. Prevention is not just healthier; for physicians, it can also be professionally protective.

Once someone is already in a crisis; under review; or being referred by an institution, board, employer, or physician health program, the confidentiality and privacy landscape may be much more complicated. But when care is voluntary, private, and completely separate from one’s workplace or medical institution, more room often exists to address problems before they become career-threatening.

Coaching can feel appealing because it usually does not involve diagnosis or treatment of a mental health condition. But it is important not to confuse “less documentation” with “the right level of care.”

If the issue is leadership, communication, career strategy, or a specific performance goal, coaching may be a reasonable fit. But therapy may be the better fit when the problem is not just what to do next but why the same pattern keeps showing up in the first place. Maybe you keep overcommitting even though you know better. Maybe you cannot relax even after reaching the milestone. Maybe criticism lands harder than it should. Maybe your relationships are absorbing the cost of your career. Maybe you understand the problem intellectually, but you still feel unable to change it.

And of course, therapy is also the more appropriate intervention when symptoms of things like depression, anxiety, panic, trauma, substance use, significant relationship problems, or others are present. But honestly, it does not and should not have to wait until things get to that point. Therapy can be useful long before something becomes a crisis.

A physician’s best move is not to avoid therapy out of fear. The goal is to seek the right care early, understand the privacy and documentation issues involved, and make an informed decision about whether to involve insurance at all.

More information here:

When Coaching Starts to Stall

Coaching works best when there is minimal internal conflict. You know what you want. You agree with your goals. You’re able (at least in principle) to follow through.
If that’s the case, then structure and accountability via coaching can move things forward quickly.

But when there is internal conflict (be it known or unknown to you)—when part of you wants one thing and another part resists it—coaching can often become an ineffectual attempt to bulldoze through that conflict.

You set the goal. You create the plan. You try to execute. But then something inevitably pulls you off course—subtly, but consistently.

At that point, it’s easy to assume you need more discipline. Or a better system. Or a different coach. But often, the issue is not at the level of execution. It’s at the level of why the goal feels difficult to carry out in the first place—what makes it feel costly, threatening, or hard to sustain over time.

When Therapy Becomes the More Efficient Option

One way the distinction between therapy and coaching starts to become clearer is when you notice a particular kind of frustration. You know what you want to do. You’ve thought it through. You can even explain it to someone else. And yet, you don’t do it. Or you do it briefly, and then find yourself pulled back into the same pattern. At that point, it’s tempting to assume you need more discipline. Or a better system. Or a clearer plan. But often, none of those are actually missing. What’s missing is deeper insight into why change feels difficult to initiate and sustain in the first place.

This is also where I sometimes see physicians land after coaching has helped, but only to a point. The goals may be clear. The strategies may be sound. But something still keeps pulling them back into old patterns. That does not mean coaching was useless. It may mean the work has moved from the question of “what should I do?” to the questions of:

  • Why is this so hard for me to keep doing?
  • Why does this decision feel so loaded?
  • What makes this boundary hard to hold?
  • What is being protected by staying in this pattern?

These are not questions that necessarily produce immediate action steps. But engaging them more deeply can begin to shift your internal conditions over time, so that change becomes possible and more sustainable.

In therapy, you don’t deal with problems of mere “execution.” Those kinds of problems don’t tend to resolve by doubling down on structure, problem-solving, coping mechanisms, or habit change alone. Those things can help, but they’re rarely sufficient on their own. What tends to shift things is understanding what the pattern is doing: what it organizes, what it protects, and why it persists. That’s where therapy becomes the more efficient option.

Instead of trying to override the resistance, therapy creates space to be curious about it long enough to understand it more deeply. And from that insight, change tends to follow in a way that is more durable and less effortful.

The Financial Angle

From a financial perspective, this distinction matters more than it might initially seem.

High-income physicians rarely lose ground because they lack information. And sometimes, too much information is part of the problem (see: analysis paralysis).
Not because the math is complicated, but because the behavior is.

They lose ground through friction—staying too long in the wrong role, working in ways that are unsustainable, repeating decisions that don’t align with their longer-term goals, saying yes to things they’ve already decided they don’t want to be doing, delaying decisions that were already clear in hindsight, and filling available time with more work even after deciding they want less of it. These are not small inefficiencies. They compound over time, often in ways that are hard to notice in the moment. And they are frequently driven not by a lack of strategy, but by the internal dynamics that shape how decisions are made.

When those dynamics shift, the external changes tend to follow more easily and more sustainably.

More information here:

A More Useful Way to Think About It

Therapy and coaching are not competing services. They are different tools, designed to work on different kinds of problems. And sure, there are also situations where therapy and coaching can coexist. A physician might work with a coach on, say, a concrete leadership, career, or business goal, while using therapy to understand the internal patterns that keep making change so difficult. But an important thing here is role clarity. Coaching should not become a substitute for therapy when the real issue is emotional, relational, or psychological. And therapy does not need to become coaching to be useful.

If the problem is primarily about how to do something—how to execute, structure, or follow through—then coaching is often the right fit. If the problem is about why you keep doing something that doesn’t serve you, even when you can clearly see it, therapy is usually more relevant.

Most physicians are very skilled at the first category. They’ve been trained, repeatedly, to identify problems and solve them efficiently. It’s the second that tends to be under-addressed. And this is often where the more persistent friction actually lives.

Final Thought

By the time you’re a high-income physician, you’ve already proven that you can learn, adapt, and perform at a high level. The question is not whether you’re capable of change. It’s whether you’re trying to solve the problem at the level where it actually exists.

Sometimes, it’s at the level of strategy and execution. And sometimes it’s the patterns underneath that approach. Knowing the difference—and choosing accordingly—is part of what it takes to stay sharp over the long term.

Have you ever had to choose between coaching and therapy? How did you think about it? What did you decide? Did it end up being the right decision?