Fahad Aziz, MD; Nizar Jarjour, MD
WMJ. 2026;125(2):235-236. Published June 2, 2026.
“What makes life worth living in the face of death?.” —Paul Kalanithi
In his book When Breath Becomes Air, Kalanithi poses a deeper question: What truly matters? At the edge of the operating room, the focus shifts from what can be done to what is worth doing.
In academic medicine, we are trained to act, not to pause. Productivity becomes our measure, while clarity recedes. Yet the question returns. The challenge is rarely lack of opportunity, but lack of clarity.
THE BURDEN OF OPPORTUNITY
Academic medicine offers many opportunities –but little guidance –on what to choose. There are clinical responsibilities, committees, papers, projects, and teaching. Each matters, but together they make everything feel equally important.
In this environment, being busy can feel like having purpose. Calendars fill, CVs grow, yet something still feels off –not from lack of effort but from lack of alignment. The central question is not what can we do –because the answer is always “a lot ”–but what should we do?
The system often rewards saying “yes.” Over time, this becomes a habit, and careers grow by continually adding more instead of through deliberate choice. This is the burden of opportunity: too much to do without clarity about what truly matters.
THE BIG ROCKS CONCEPT
In academic medicine, the problem is rarely a lack of opportunity – it is knowing what deserves attention first. A simple way to think about this is the idea of “big rocks.” Imagine a jar that represents a professional life. If it is filled first with small, nonurgent tasks, there is no room left for the work that truly matters. But if the big rocks go in first, everything else can fit around them.
The big rocks are the foundation of a meaningful career. They are not just tasks—they are what give work its purpose and lasting impact. For most physicians, these include caring for patients, advancing knowledge through research, mentoring the next generation, and protecting personal well-being and family. These commitments shape identity, sustain fulfillment, and define long-term success. When they are protected, everything else falls into place with clarity and direction. When they are not, even the busiest schedule can feel unfocused and unfulfilling.
Around these big rocks are the “pebbles”—important but secondary responsibilities like committees, reviews, and teaching activities. They support the system and add value, but they are not the foundation. Then comes the “sand” – the small, reactive tasks that fill time without adding meaningful progress. These are easy to say yes to and often feel urgent, but over time they crowd out what matters most.
What counts as a “big rock” is not always easy to define. One approach is pursuing what you enjoy most. Equally important is focusing on what you do well and what needs to be done.
Once these priorities are clarified, the challenge shifts to protecting them. Without clear boundaries, every request begins to feel equally important, and decision-making becomes reactive. Work increases, but focus is lost.
When the big rocks are clear and protected, decisions become easier. The question is no longer whether something is a good opportunity, but whether it supports what matters most. In that sense, clarity does not limit opportunity; it helps identify the right ones.
WHY → MISSION → VISION: A FRAMEWORK FOR INTENTIONAL CAREERS
Clarity in academic medicine does not happen on its own; it must be developed. A simple way to think about it is: WHY → Mission → Vision. This is how purpose translates into daily work and, over time, real impact.
The WHY is the starting point. It is neither a title nor a list of responsibilities, but the reason the work matters – especially on the difficult days. Finding this WHY comes from paying attention to moments that feel meaningful: a patient interaction that stays with us, a trainee who grows under our guidance, a discovery that excites us. These moments are signals. Over time, patterns emerge. The work that gives energy – the work that feels worth the effort – is where the WHY lives. When this is clear, decisions become easier and more grounded.
The mission is how that WHY shows up every day – reflected not in plans, but in what is actually done: how time is spent, what is prioritized, and where effort goes. A simple way to define it is: We are to… for… so that… For example, “I am to provide compassionate care for patients with complex medical conditions so they can live healthy, meaningful lives.” This keeps daily work connected to a deeper purpose.
The vision looks ahead. It is less about tasks and more about direction – who we are becoming over time. It connects today’s work to future impact, whether that means building programs, advancing a field, or shaping the next generation.
When these three are aligned, work feels focused and meaningful. When they are not, even a full and productive career can feel scattered.
DECISION-MAKING AND THE COST OF ‘YES’
Clarity in academic medicine becomes more meaningful when it shapes decisions. The challenge is less about knowing what is important and more about making choices in real time, when opportunities appear reasonable, valuable, and difficult to decline.
A simple approach is to use an “opportunity filter” built on three questions: Does this align with core work? Will it create meaningful impact? Will it sustain energy? This structure brings consistency to decision-making and helps distinguish true progress from mere activity.
Yet every decision carries a cost. Each “yes” consumes time, affects energy, and fragments attention. These costs are often not immediate, but they accumulate. Hours are redistributed, energy is unevenly spent, and attention is divided across competing demands. Over time, this leads to a loss of focus and coherence.
Every “yes” is also a “no” to other priorities. A new committee may come at the expense of research time. An additional project may displace mentorship, reflection, or personal well-being. These trade-offs shape one’s career trajectory, often quietly and gradually.
Over time, patterns of decisions – not any single choice – define a career’s direction. The goal is to choose selectively, focusing on opportunities that create meaningful progress.
STRATEGIC YES VS DEFAULT YES
In academic medicine, many decisions are made quickly and habitually, without reflection. Each “yes” contributes to a path that often recognized only in retrospect.
Most decisions follow a default yes – quick, automatic, and driven by habit, obligation, or the desire to be helpful. It comes without pause, leaving little time to consider alignment, impact, or cost. Over time, this leads to accumulation – more roles, more tasks, more responsibility – often without clarity.
A strategic yes is different. It is intentional and grounded in purpose. It introduces a pause and reframes the question: “Can this be done?” becomes “Should this be done?” It is guided by alignment, not pressure.
The difference is simple: a default yes is reactive; a strategic yes is intentional. Rather than saying yes less, the shift is about saying yes with clarity. Over time, these patterns of decisions – not isolated choices – guide the direction of a career.
THE DISCIPLINE OF SAYING NO
In addition to thoughtful “yes” decisions, careers are also built by the ability to say “no.” Declining can feel uncomfortable, but without it, priorities blur, focus fragments, and meaningful work is replaced by accumulation.
A “strategic no” is best understood as clarity with respect. Rather than disengagement, it reflects alignment – a way to protect what matters while honoring the value of the request. In this sense, setting boundaries reflects leadership, focus, reliability, and self-awareness – not defensiveness.
Equally important is how the message is delivered. A clear, respectful response preserves relationships while maintaining direction. Simple statements are often sufficient: acknowledging the opportunity, expressing appreciation, and stating current priorities.
At times, decisions may not be easy or clear. In such situations, seeking guidance from mentors – particularly early in one’s career – can help maintain focus on what matters most.
REFINEMENT: THE PRACTICE OF PRUNING
Careers in academic medicine rarely become overextended all at once. They grow slowly – one committee, one project, one role at a time. Each addition seems reasonable, but over time, this accumulation fills schedules and drifts from its original purpose.
The challenge extends beyond growth to ongoing refinement. Pruning is the process of realignment, ensuring that current commitments still reflect mission and direction. As priorities evolve, not everything that once fit continues to do so.
This requires periodic pauses – stepping back to ask: Does this still matter? Does this still align? Without this reflection, past decisions persist by default instead of intentional design. Like a tree, growth without pruning leads to excess and imbalance. Thoughtful pruning does not limit growth; it directs it, creating strength, clarity, and sustainability over time.
Finally, periodic pruning can eliminate ongoing time commitments, freeing time and energy to explore more meaningful opportunities. In some cases, faculty who feel overburdened may need to address workload with academic leaders, including potential reduction of assigned responsibilities. Ideally, this follows careful self-reflection to distinguish assigned expectations from additional commitments voluntarily assumed over time, including committee work, teaching, travel, and consulting.
A CALL TO INTENTIONAL PRACTICE
The question returns: What truly matters? Academic medicine will always offer more than can be done. The enduring challenge is to choose deliberately – because over time, a career is defined not by volume, but by direction and what is chosen.