Keeping the Flame: Why Some Doctors Never Stop Being Physicians

During my early years in practice, I often crossed paths with a gastroenterologist who was approaching eighty. I never knew him well, but I watched him.

He moved briskly through the hospital corridors from one patient's room to another. He seemed to spring toward the bedside rather than being dragged there by some sense of professional duty. When I was asked to provide a pulmonary consultation on one of his patients, he would listen carefully to my assessment. If I offered an explanation for a cough or other respiratory problem that he had not considered, his face would brighten. He seemed genuinely pleased to have learned something new.

There was still a spark.

One day I asked him what kept him young. At that stage of my career, I had not yet formulated the question I was really trying to ask: How had he maintained his enthusiasm for medicine after so many decades?

He was too busy seeing patients to linger over his answer.

"It's all about helping people," he said. "That has kept me engaged, motivated, and mentally sharp."

Then he hurried off to see his next patient.

I have thought about that brief conversation many times during my own forty-year career in medicine. I began thinking about becoming a physician when I was still in middle school and continued watching my own career unfold until I retired from clinical practice in 2014. As a medical educator, I also had the privilege of watching careers begin in others during their undergraduate years, medical school, and residency training.

Along the way, I watched my senior colleagues as carefully as I watched my patients. What could I learn from them? Why did some physicians remain enthusiastic, curious, and deeply engaged with their patients after decades of practice, while others seemed to lose something essential after only a few years?

Gradually, I realized that I was asking a larger question:

What allows some doctors to retain the sense of vocation that brought them into medicine, while others gradually come to experience medicine as merely a job?

When Medicine Becomes an Occupation

There are many ways to define a successful physician.

One can build a large practice, develop an excellent reputation, maximize reimbursement, and earn enough money to enjoy a comfortable life. There is nothing inherently wrong with any of those accomplishments.

But if financial success becomes the principal measure, there is little to distinguish a successful physician from a successful banker, home builder, or hedge fund manager. Medicine becomes an occupation practiced skillfully and profitably.

Something is missing.

I watched some young physicians enter medical school with extraordinary enthusiasm, progress through residency with determination, and emerge into practice eager to begin their careers. Yet within a few years, some were exhausted and disillusioned.

The diagnostic puzzles that once fascinated them competed with appointment schedules, insurance authorizations, electronic medical records, messages, quality measures, and the pressure to move the next patient through the office.

The patient could gradually become a work unit.

The office visit became fifteen minutes to complete a task.

The physician who once imagined a lifetime of intellectual challenge and intimate human connection could find himself watching the clock.

We call much of this burnout. Its causes are complex, and no single explanation accounts for it. But I believe one contributor is the gradual loss of connection between what physicians spend their days doing and what brought them to medicine in the first place.

The machinery necessary to practice medicine can begin to replace the purpose of practicing medicine.

What the Patient Expects

Why should maintaining that purpose matter?

The simplest answer is that our patients expect it.

When a new patient walks into a physician's office, that visit is rarely the beginning of the patient's journey. More often, it is somewhere in the middle.

A patient with new symptoms may already have spent hours in an emergency department undergoing an urgent evaluation before being referred to an unfamiliar specialist. Another may have spent weeks at home noticing worsening symptoms, finally deciding to seek help, selecting a physician, obtaining insurance approval, navigating a portal, and waiting weeks for an appointment.

By the time that patient sits in the examination room, the symptoms have acquired a meaning far beyond whatever eventually appears in the medical record.

Could this be cancer?

Could this be heart disease?

Will I get better?

What is going to happen to me?

And then the physician enters the room.

Within the first few minutes, the patient begins deciding whether this is a good doctor.

The physician who sits down, leans forward, listens, and temporarily ignores the computer sends an immediate message: Your problem matters to me.

The history becomes more than a series of boxes to be checked. The physician pursues an answer, dissects the important details, considers alternatives, and begins assembling the pieces into an initial diagnosis and management plan.

When the patient leaves believing that the physician has understood the problem, anxiety is often diminished even before treatment begins. There is a plan. There is someone to call. There is a path forward.

The opposite experience is equally powerful. A patient who senses that the physician's attention is divided between the clock, the computer, and the next appointment may leave feeling that something important never happened.

The physician may have completed every required task.

But the patient may still feel that he or she was never truly seen.

What the Physician Needs

There is another reason to preserve what initially brought us into medicine.

We need it ourselves.

Most physicians can remember some version of the enthusiasm they felt early in their training. Ask first-year medical students why they chose medicine and the answers may sound idealistic, but that does not make them meaningless.

"I want to help people."

"I love science."

"I want to solve difficult problems."

"I want to understand how the human body works."

"I want a profession in which what I do matters."

Medicine offered something few other professions could offer: an opportunity to use science and intellect while being invited into the most intimate moments of another person's life.

Illness strips away much of the distance people ordinarily maintain between themselves and strangers. A person who met you ten minutes earlier may tell you about fears, bodily functions, family conflicts, sexual concerns, financial worries, or the possibility of death.

That access is an extraordinary privilege.

Yet the pressures of medical practice can make it easy to forget that privilege. We can gradually exchange the compass that brought us into medicine for the checklist that gets us through the day.

The danger is not simply that our patients receive less satisfying care.

We receive less from medicine ourselves.

Purpose, Curiosity, and Connection

After watching physicians for much of my adult life, I have come to believe that three qualities help sustain the good physician: purpose, curiosity, and connection.

Purpose means remembering why we became physicians.

For most of us, the original answer was not reimbursement, productivity, or efficiency. It was some variation of wanting to help people while doing work that challenged our minds and had meaning.

That purpose needs to be revisited. It is remarkably easy for the urgent tasks of a profession to displace its important ones.

The second quality is curiosity.

The best physicians I knew never entirely lost their fascination with medicine. A puzzling symptom remained a puzzle worth solving. An unexpected laboratory result generated a question. A consultant's different interpretation was not a threat but an opportunity to learn something.

Medicine changes too rapidly for any physician to master it permanently. Perhaps that is one of its great gifts. A physician can practice for forty years and still encounter something tomorrow that he has never seen before.

Curiosity keeps medicine intellectually alive.

The third quality is connection.

The fascinating diagnostic problem belongs to someone.

That someone has been waiting for us, worrying about what the symptom means, wondering whether we will be able to help.

Clinical excellence without human connection is incomplete. But compassion without knowledge and curiosity is incomplete as well. The good physician must bring both to the bedside.

Purpose reminds us why we are there.

Curiosity keeps us learning.

Connection reminds us whom all that knowledge is for.

Keeping the Flame

I did not understand all of this when I watched that eighty-year-old gastroenterologist moving briskly through the hospital.

At the time, I simply wondered what kept him young.

Years later, I think I understand what I was actually observing.

He still wanted to help people. He was still interested in what he didn't know. He still became excited when another physician taught him something about one of his patients. And despite decades of hospital rounds, he still seemed eager to walk into the next patient's room.

He had retained his purpose, his curiosity, and his connection to the people who depended upon him.

Perhaps becoming a good physician is not something we accomplish when we graduate from medical school, finish residency, pass our boards, or establish a successful practice.

Perhaps it is something we must keep becoming throughout our careers.

The older gastroenterologist had not discovered a secret for staying young.

He had discovered something more important.

He had found a way not to forget why he became a doctor.