Practicing Physicians

Viewpoint: Enhancing the ProfessionalFulfillment of PhysiciansShanaree Brown and Richard B. Gunderman, MD, PhD

Abstract

Academic medical centers (AMCs) devotecountless hours to studying the diagnosisand treatment of disease, yet little or notime to determining the factors thatenhance or detract from physicians’professional fulfillment. This isunfortunate because physicians’ degree

of professional engagement, the qualityof care they provide, and their tendencyto burn out all depend on the fulfillmentthey find in work.

Indeed, if AMCs are to thrive, it is vital tounderstand and promote the

professional fulfillment of physicians. Thisarticle reviews the sources of professionalfulfillment among physicians and outlinesways to enhance it within physicians’organizations.

Acad Med. 2006; 81:577–582.

If academic medical centers (AMCs) areto thrive in the years to come, it is vitalthat we understand and promote theprofessional fulfillment of physicians. Wephysicians must ask ourselves, Whatmakes us feel excited about our work andmotivated to do a good job? Whatdiscourages us, leaves us feeling burntout, and perhaps even leads us to seekother career options? These are not trivialquestions. When work is challenging,promotes our personal growth, andenables us to make a difference in thelives of others, our organizations, aswell as our patients, students, andcommunities, are greatly rewarded. Onthe other hand, if we experienceconfusion, stagnation, or a lack ofappreciation, we are unlikely to performat our best, and those who depend on usmay suffer.

While the term most frequentlyemployed in the literature to describecareer contentment is “satisfaction,” webelieve that “fulfillment” better capturesthe sense of professional engagement andreward we seek to elucidate. Satisfactionmerely means “enough,” but fulfillmentimplies completion—the thoroughrealization of our potential.

This article provides an introduction tothe sources of professional fulfillmentamong physicians. We begin by reviewinglessons about the importance ofprofessional fulfillment from industriesoutside health care. Next we discuss keyfindings from the literature on theprofessional fulfillment of physicians. Wethen consider one of the most extensivelyempirically validated and coherenttheories of worker motivation advancedin the past fifty years, that of FrederickHerzberg. Finally, we present somepractical steps that leaders in AMCs cantake to enhance the motivation andprofessional fulfillment of our mostimportant human resource—thephysicians we work with every day.

In this article we do not delve into theimpact of personal factors on theprofessional lives of physicians; however,we recognize that personal factors play amajor role in achieving fulfillment. Nomatter what level of professional successwe physicians may enjoy, we are unlikelyto feel fulfilled if our personal lives are inshambles. Organizations seeking toenhance the professional fulfillment oftheir employees cannot afford to ignorethe influence of personal factors onoverall fulfillment.

At the very least, policies that indirectlystress the personal lives of physicians,such as promotion and compensationprograms that require excessive workhours, often undermine personalfulfillment and should be avoided. Thepotential for workplace policies toenhance the personal lives of physiciansalso should be taken into account. Forexample, an academic department mightpermit physicians with significant family

responsibilities to enter into job-sharingarrangements, while also allowing timeand providing recognition for physiciansto engage in voluntary service outside ofmedicine.

Lessons from NonmedicalIndustries

Most physicians have devotedconsiderably more time to the study ofmedicine’s scientific and technical aspectsthan its psychological, social, andorganizational aspects. Compared tobusiness school curricula, medical schoolcurricula tend to devote relatively littleattention to such topics as motivationand work performance. Yet the future ofacademic medicine hinges on whetherAMCs and health care organizations areled effectively, and we must be preparedto look beyond the bounds of medicinefor insights into these critical leadershippractices.

How seriously do leaders in nonmedicalindustries regard the professionalfulfillment of their employees? Whatbenefits do corporations reap throughefforts to enhance worker fulfillment?What are the effects of such programs onemployee turnover, costs of operation,and revenues? Do unsuccessful andsuccessful companies differ in theimportance they attach to theiremployees’ fulfillment?

A 1997 study from the Harvard BusinessSchool (HBS) found that the stock pricesof companies that invested extensively inemployee loyalty and satisfaction rose147% over a ten-year period. Thisincrease was almost double the increasein stock prices of their nearest

Ms. Brown is a third-year medical student, IndianaUniversity School of Medicine, Indianapolis, Indiana.

Dr. Gunderman is associate professor ofradiology, pediatrics, medical education, philosophy,liberal arts, and philanthropy, Indiana UniversitySchools of Medicine and Liberal Arts, Indianapolis,Indiana.

Correspondence should be addressed to Dr.Gunderman, Indiana University School of Medicine,702 Barnhill Drive, RI 1053, Indianapolis, IN 46202-5200; telephone: (317) 278-6302; fax: (317) 274-2920; e-mail: (rbgunder@iupui.edu).

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competitors.1 Similarly, the stock pricesof companies identified as Fortunemagazine’s “100 Best Companies toWork for in America” outperformedthose identified in the “Standard andPoor (S&P) 500” by 430%.2

In terms of actual dollars, a meta-analysisof 7,939 business units in 36 dissimilarcompanies showed that productivity andincome were strongly tied to employeesatisfaction. Business units in the top25% for employee motivation andsatisfaction had, on average, monthlyrevenues $80,000 to $120,000 higher thanthose in the lower 75%. Translating thisfigure into yearly revenue, the differencein income amounted to $960,000 to$1,440,000 per business unit.3

Southwest Airlines and Sears, Roebuck, &Co. provide specific case studies of theimportance of cultivating employeesatisfaction. Southwest Airlines pridesitself on its culture of employeecommunication, recognition, andinvolvement. Over an eight-year period,Southwest had the highest profitability ofany U.S. carrier, and a total market valuethat surpassed all the other U.S. carrierscombined. Although their employeeswere the most highly unionized and werepaid at or below the industry wagestandard, they also demonstrated thehighest productivity of any U.S. airline.4

A study at Sears, Roebuck, & Co. foundthat increasing employee satisfaction by4% enhanced customer satisfaction andboosted sales by $200 million. Afteraccounting for price– earnings ratios andafter-tax margins, this extra revenueincreased Sears’ market capitalization by$250 million.5

Examples of employers reaping therewards of enhanced employeefulfillment are not restricted to thenonhealth services arena. WhenMemorial Medical Center, Inc., in LasCruces, New Mexico, committed toenhancing cooperation, communication,and achievement among its employees,employee satisfaction increased, turnoverdecreased, and patients’ access to carewas improved. Since instituting itsemployee-centered policies, the medicalcenter has realized a 40% increase inemployee productivity. Memorialestimates that this has produced a returnof $1.74 on every dollar invested in theprogram.6

Why Physician FulfillmentMatters

Professional fulfillment amongphysicians has been linked to a multitudeof desirable social and financialoutcomes. Indeed, Haas et al.7 found thata physician’s self-reported satisfactionwas strongly linked to patientsatisfaction. Patients of physicians whorated themselves as being very orextremely satisfied with their work werefound to be more satisfied with their care,suggesting that physician fulfillmentaffects patients’ perception of the qualityof their health care. Similarly,Grembowski et al.8 found that patients ofphysicians who rated themselves ashaving high job satisfaction had greaterlevels of trust and confidence in theirphysicians.

Physician satisfaction has a profoundeffect in the practice setting and onmanaged care organizations (MCOs).9 –13

According to Beasley et al. overall jobsatisfaction was highly inverselyassociated with turnover, and Buchbinderet al. found that physician jobdissatisfaction was the most powerfulpredictor of physician departures.9,10

Turnover tends to create a sense ofinstability, requiring remainingphysicians to cover a larger patient load.This may reduce patient access to careand contribute to physician burnout,while possibly triggering a downwardspiral of declining morale and additionaldepartures.

Prolonged physician dissatisfaction hasalso been linked to increased healthproblems among physicians themselves.When physicians are ill, costs to thephysicians’ organizations rise further dueto lost work hours, and additionaldemands are placed on those who remainat work.14 –16

The costs of replacing dissatisfiedphysicians can be exorbitant. One studyestimates the total cost at approximately$250,000 per physician.11,12 Such costs areborn not only by individual practices, butby whole medical specialties. Growingdissatisfaction in a medical specialty oftenheralds future declines in the number ofphysicians choosing to practice in it.17 Asthe pool of specialized practitionersshrinks, medical practices must expendmore resources to attract a dwindlingpool of specialists, and patient access andquality of care are placed at risk.

In MCOs, physician dissatisfactionappears to undermine efforts to make thedelivery of health care more efficient.When physicians are unhappy at workwithin an MCO, their inclination toparticipate in a managed care plan isadversely affected. This, too, tends toexacerbate turnover, thereby creatingadditional recruiting and training costs.11

Similarly, patients of dissatisfiedphysicians are more likely to disenrollfrom managed care programs as a resultof the difficulty they experience informing and sustaining long-termpatient–physician relationships.7

Physicians’ sense of professionalfulfillment is positively correlated withpatients’ adherence to medication,exercise, and diet regimens.14 Reductionsin physician satisfaction are associatedwith decreased patient adherence toprescribed disease prevention andtreatment regimens, which placespatients at risk for adverse healthoutcomes. Since these outcomes oftenbear high price tags, the long-term coststo MCOs increase.

Sources of Physician Fulfillment

The current literature provides littlereason to be optimistic about theprofessional fulfillment of physicians.Fully 40% of young physicians state that,if given the choice, they would not gothrough medical school again. Twentypercent of all physicians report that theyare dissatisfied with their careers.9,17 Howcan we explain these high rates ofdissatisfaction, and what factors shouldwe focus on to enhance professionalfulfillment?

Konrad et al.18 elucidated ten factors thatshould be taken into consideration whenevaluating the satisfaction of communityphysicians: autonomy, relationships withcolleagues, relationships with patients,relationships with staff, income,resources, intrinsic satisfaction, free timeaway from work, administrative support,and community involvement. Similarly,Coyle et al.19 found that the followingeight factors could be used to evaluate thework satisfaction of academic generalists:autonomy, professional relationships,compensation, clinical resources,institutional governance, professionalstatus, teaching activities, andprofessional advancement.

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Despite the differences in the dailyroutines of community and academicphysicians, a similar set of factors seemsto underlie work fulfillment for both.Although there is disagreement as to howmuch weight each factor should receive,there is broad consensus that such factorsplay a major role in physicians’professional fulfillment and deserve moreattention.9,17,20 –24

Decreased autonomy, which manyphysicians associate with working in anMCO structure, fosters a sense of beingunable to care for patients adequately.21–24

This feeling of inadequacy, in turn, tendsto undermine professional fulfillment. Bycontrast, multiple studies have found apositive correlation between physicianfulfillment and the quality ofrelationships with staff and thesurrounding community.20,22 If staffmembers or community members areconfident about the capabilities of aphysician or that physician’scommitment to the best interests ofpatients, physician satisfaction tends toincrease.

Physician income, another factor inoverall physician satisfaction, is a hotlydebated topic. Some physicians, mindfulof their advanced education, complexskills, and long hours, feelundercompensated, while many outsidemedicine believe that physicians areoverpaid. The ethics of these positions arecomplex, but there is little doubt thatincome level and physician satisfactionare linked.25,17–22

Studies show that an annual income levelbelow $100,000 is associated withdecreased physician satisfaction. Asearnings rise above $100,000, physiciansatisfaction also rises. The positivecorrelation does not continueindefinitely, however; satisfaction peaksat incomes between $250,000 and$299,999.17,21 Moreover, the relationshipbetween income and physiciansatisfaction is not symmetrical.Dissatisfaction rises more sharply withdecreasing income than satisfaction riseswith increasing income.

The situation is similar for workhours.16,17 As the number of hoursworked per week increases, dissatisfactionrises at a steeper rate than the level ofsatisfaction increases as work hoursdiminish. Considering the relationshipbetween dissatisfaction and physician

turnover, the dynamics of income andwork hours both corroborate animportant finding of Pathman et al.20;namely, that in regard to physicianretention, reducing dissatisfaction ismore important than increasingsatisfaction.

Geographic location, practice ownership,and age are three variables that appear tobe linked to physician satisfaction,although they did not appear in eitherKonrad’s or Coyle’s analyses. Physiciansin west north Central and New Englandstates have higher levels of satisfactionthan physicians in the south Atlantic,west south Central, Mountain, andPacific states. These latter groups alsoreport higher rates of dissatisfaction.17

Practice ownership can affect satisfactionas well. Physicians reporting both fullownership and a low sense of ownershiphad decreased levels of jobsatisfaction.9,17,21

The relationship between physician ageand satisfaction is bimodal. Physiciansyounger than 35 years of age and olderthan 65 years of age have higher levels ofsatisfaction than physicians between theages of 36 and 64.17,21 Devoe et al.21

found that age alone was the principalpredictive factor in forecasting aphysician’s level of satisfaction. Ofcourse, if physicians become dissatisfiedearly in their careers, they are more likelyto move to another practice or evenswitch professions, both of which carryfinancial and social costs. Sincephysicians between the ages of 36 and 64also wield considerable influence over thecareer decisions of young peopleinterested in medicine, broaddissatisfaction among this age group mayexert deleterious effects on the entireprofession for years to come.

Gender also plays a role in physiciansatisfaction.9,17,27–29 Although genderalone is probably not a strong predictorof professional fulfillment, it is associatedwith other factors related to jobsatisfaction. When examining patients,female physicians report experiencinggreater time pressure than do their malecounterparts. Female physicians also earnmean incomes approximately $22,000less than male physicians, aftercontrolling for other variables.28

Compared to male physicians, femalephysicians perceive a lower sense ofcontrol over their patient load, the

selection of physicians for referral, andoffice scheduling.

In addition, female physicians reporthaving more patients with complex,psychosocial problems than malephysicians.28 The combination of havingmore complex patients and less controlover day-to-day aspects of practice isassociated with lower mental healthindices. This may help to explain thefinding of McMurray et al.28 that womenphysicians are 1.6 times as likely as mento report burnout.

When comparing generalists andspecialists in community practice,investigators have found little differencein overall satisfaction.20,30 There are,however, differences between the twogroups when it comes to satisfaction inacademic practices. Primary care facultytend to perceive fewer opportunities toadvance, greater professional roleambiguity, less collegiality, and lessability to make full use of their clinicalskills than do specialty faculty.30

Disparities among specialties are alsoapparent. Leigh et al.17 found that inrelation to family medicine, specialtiessuch as geriatric medicine,neonatal/perinatal medicine,dermatology, and pediatrics are moresatisfying, while internal medicine,otolaryngology, and obstetrics-gynecology are less satisfying. Otherstudies have corroborated theseresults.24,31–33 Psychiatrists andemergency medicine physicians alsoappear to have higher levels ofdissatisfaction.34,35 This disparity may beexplained by evidence that satisfaction islower in procedurally oriented fields thanin cognitively oriented fields.17

A Theory of Fulfillment

How can we integrate these and otherresearch findings into a coherent theoryof physician fulfillment? Over the years,assumptions about employee fulfillmentand productivity have spawned efforts totransform uncommitted workers intohighly motivated ones. Unfortunately,most plans, from financial incentives tosensitivity training to counseling, haveleft employers shaking their heads, withno significant increase in employeemotivation, satisfaction, orproductivity.36

Why? One possibility is that we have beenapproaching professional fulfillment

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from the wrong point of view. Mostpeople tend to view fulfillment anddissatisfaction as two poles of acontinuum. For instance, we tend toassume that low compensation causesdissatisfaction, while high compensationpromotes fulfillment.

Landmark investigations performed byFrederick Herzberg and colleaguescontradict this view.36 In 1966, Herzbergstudied 203 accountants and engineers,hoping to determine what factorscontributed to or detracted from theirlevels of work motivation. He asked twosimple questions. First, “Think of a timewhen you felt especially good about yourjob. Why did you feel that way?” Second,“Think of a time when you felt especiallybad about your job. Why did you feelthat way?”

Herzberg found that in addressing eachquestion, respondents did not refer to thesame factors. Instead, different factorswere associated with high and low levelsof fulfillment.36 Herzberg called thefactors invoked in response to the secondquestion “de-motivators.” Interestingly,these tended to be extrinsic factors notessential to the work itself, includingadministrative policies, supervision,salary, interpersonal relations, andworkplace conditions.

The factors cited in response to the firstquestion he called “motivators,” andthese were generally features intrinsic tothe work itself. Motivators included thenature of the work, achievement,recognition, responsibility, and growth.

Herzberg’s findings have been supportedby numerous studies in diversepopulations and work environments,including professional women,agricultural administrators, managersnearing retirement, hospital maintenancepersonnel, manufacturing supervisors,nurses, food handlers, military officers,scientists, housekeepers, teachers,technicians, women working on assemblylines, and Finnish foremen, to name but apartial list.36

Herzberg found that intrinsic motivatorschallenged people to work moreefficiently at a higher level of quality andenhanced fulfillment. If these werelacking, however, dissatisfaction tendednot to increase very much. By contrast,the extrinsic de-motivators played theopposite role. When these variables were

deficient, deep dissatisfaction resulted.However, enhancing extrinsic factorssuch as compensation and workplaceconditions did little to boost performanceor increase the sense of fulfillment.36

Herzberg likens efforts to enhanceextrinsic factors to recharging anemployee’s batteries, while enhancingintrinsic factors is like installing agenerator in an employee.36 The formerstrategy may produce benefits initially,but the ante will need to be raisedcontinually to maintain the same level ofperformance. The strategy of focusing onintrinsic factors, by contrast, tends to beself-sustaining, enabling employees tobecome their own sources of motivation.Installing a generator, or attending tointrinsic factors, is the only way to ensurelong-term and potentially permanentimprovements in performance andfulfillment.

When extrinsic factors such as monetarybonuses and new offices are used toreward improved performance, theextrinsic incentives tend to shift ourattention away from inherently fulfillingaspects of work. As a result, we feel less ofan internal dedication to excellence.36

Employees begin to depend on the extraincome, and if it is ever removed, or iffurther raises are ever withheld, theyexperience it as a punishment rather thana mere return to baseline. According toHerzberg, no amount of attention toextrinsic factors will enhance employees’professional fulfillment or performancebeyond the average.36 In order to achievegreater enhancements, employees mustfocus on the intrinsically rewardingaspects of work.

Enhancing Physician Fulfillment

Herzberg’s approach provides thefoundation of a strategy for fosteringphysician motivation and fulfillment.First, we need to identify those positionsand aspects of work where changes won’tbe too costly, attitudes are poor, the costsof de-motivation are becomingexpensive, and increased motivation andfulfillment would make a substantialdifference. Certainly these features applyto many facets of academic medicine.

Second, we need to understand andaccept that the nature of our work itselfmay have to change. Leaders often do notimmediately recognize that the content of

work and the way it is performed can orshould be changed. Fortunately, therapidly evolving nature of contemporarymedicine has accustomed physicians tothe necessity for change.

Third, we need to brainstorm a list ofalternative approaches to enriching work.Herzberg recommends that we do soinitially without regard to practicality,cost, or time. Later, we can return to thelist and weed out ideas that are too costlyor impractical. Finally, we need toeliminate suggestions that focus onextrinsic, de-motivating factors, such asfinancial bonuses.36

In increasing professional responsibilityto make a position more fulfilling,Herzberg favors “vertical loading” ofresponsibility, rather than “horizontalloading.” Horizontal loading augmentsrelatively meaningless aspects of a job,resulting in a decreased sense of personalcontribution and fewer opportunities forprofessional growth. Examples ofhorizontal loading include increasingproduction requirements, adding fruitlesstasks, rotating job assignments, orremoving the most challengingcomponents of the job. It’s like startingwith zero and then multiplying by,adding, or subtracting another zero. Theresult, of course, is still zero.36

By contrast, vertical loading involvesincreasing the intrinsically motivatingfeatures of work, such as responsibility,recognition, and achievement. Examplesof vertical loading include increasingpersonal accountability, additionalauthority, fruitful new tasks, andencouragement to develop expertise in acertain area. Unlike horizontal loading,the end result of vertical loading can beenhanced fulfillment.

Once we finalize our list of options forenhancing the intrinsically motivatingfeatures of work, Herzberg suggests thatwe start implementing them in a small,experimental group. By using anexperimental group we can closely assesschanges in performance, motivation, andsense of fulfillment. To gauge thesechanges, pre- and post-interventionevaluations should be conducted. Inorder to avoid confounding effects,extrinsic, de-motivating factors shouldremain unchanged. It is important toanticipate that drops in performance andfulfillment may occur during the first few

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weeks of an intervention, as peopleacclimate to the new system.36

Administrators may find it especiallydifficult to adjust to the new system,because of anxieties about short-termdeclines in performance. They may alsofeel as though some interventions areundermining their responsibilities. Overtime, however, the rise in physicianmotivation and fulfillment will beaccompanied by a concurrent increase inproductivity and quality. With anxietiesallayed, administrators may find that theyhave more time to attend to coremanagerial and supervisory functions,thus enhancing their own performanceand sense of fulfillment.

Because the specific sources of physicianfulfillment vary widely among differentgroups of physicians and practicesettings, a universally applicable masterlist of interventions is impossible tocompile. The first priority in every case,however, is to accentuate the intrinsicallyrewarding aspects of the work.37 Aboveall, we need to feel that we have made areal difference in the lives of others.

As medicine has become morecompartmentalized, there is a danger thatthis source of deep fulfillment isbecoming less apparent.33 For example,reducing face-to-face contact betweenphysicians and patients weakens theirrelationship and with it physicians’ sensethat we are making a real difference. Toincrease the fulfillment of academicphysicians, we need to ensure that theintrinsically fulfilling aspects of the workare accentuated, not suppressed.

Other fundamental factors related tophysician fulfillment are growth andrecognition. Given the length and rigorsof medical education, as well as the vitalrole of lifelong learning, there is littledoubt that physicians must be committedto ongoing intellectual growth. Infocusing on the acquisition of knowledgeand skills, however, we must not neglectpersonal and professional growth.Physicians should be encouraged tobecome involved with organizations andservice opportunities that expand theirpersonal and professional horizons,rather than to consider voluntary servicea detriment to efficiency andproductivity. Such service opportunitiesmight include teaching Sunday school,serving on the board of a schoolcorporation or community service

organization, or providing free medicalcare in a medically underservedcommunity at home or abroad.

Few opportunities for growth are asvaluable as truly constructive criticism,and few things contribute more toprofessional fulfillment than earnestappreciation and praise. When AustinRegional Clinic implemented a form ofpeer review and feedback focused onpromoting fulfillment, their annualphysician turnover rate dropped from8% to 3%.38 A structured forum foraddressing and correcting problems, aswell as recognizing improvements, offersimmense intrinsic motivation.

Conclusions

We ignore the subject of physicianfulfillment at our peril. For academicmedicine to thrive in the coming years,we need to attend more carefully thanever to the factors that enhance anddetract from the quality of work we do. Ifwe operate with a clear understanding ofthe psychology of professional fulfillmentand the various organizational strategiesthat foster it, we can promote a powerfulsense of fulfillment among physicians.This, in turn, can help to rekindle thenoble aspirations that drew us to careersin medicine in the first place.

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Teaching and Learning MomentsA Call from the ChairmanAs a burned-out intern on one of themore difficult rotations of the year, Iimmediately guessed that a call toschedule an appointment to meet withthe department chairman was probablynot good news. I was barely keeping myhead up from the exhausting routine ofthe renal service at Michael Reese Hospitalin Chicago, where I was about midwaythrough my internship. At the end of eachday, I had a continuous low-gradeheadache and my thigh muscles burnedwith each flight of stairs I climbed. I recalltrying to remember if I may have doneanything wrong that would have gottenme in trouble, but to be honest, I was sotired that I quickly moved on toindifference concerning the meeting—itwas just another box to check off as“done” on the scut list that I kept attachedto my bent aluminum clipboard. Thechairman of my department was JordanCohen, and our brief conversation that dayhad a significant impact on my career.

I was not the typical internal medicineintern in some ways. I was relativelyyoung and from the start of my medicalcareer I knew that I was interested in acareer in public policy. I had alreadyspent two summers as an intern onCapitol Hill during college, and I knewthat it was not likely that I would take atraditional career pathway in medicine.While at Michael Reese, I had begun toexplore attending either law school or adoctoral program in health policy. I wasmiserable, and had begun to regularlycomplain to my classmates andattendings that internal medicine wasnot for me. Every day I asked myself whyI was putting up with the gruelinginternship and the prospect of two moreyears beyond that when I was already

heading toward a career in which Iwould probably not practice medicine inthe traditional sense. Somehow the wordgot back to Jordan, and that was whatprompted the call to meet.

I don’t recall the details of the discussion,but I do remember that Jordan startedoff with a general question about how Iwas dealing with the stress of internship.At this point, I had made up my mind toleave, but I thought I would be politeand listen. Jordan asked me about mycareer goals. When I told him that I washeaded toward a career in health andscience policy, he did not miss a beat. Hetalked about the potential impact I couldhave as an internist in public policy andwent on to lay out why he thoughtcompleting residency would provideimportant experience and credibility for acareer in health policy. Somehow I leftthat meeting surprising myself byagreeing to stick it out a bit longer in theprogram.

As often happens in circumstances likethis, the I’m-not-putting-up-with-this-anymore moment passed. Throughoutmy residency, Jordan continued todemonstrate his support for my unusualcareer path. In my senior year ofresidency, he allowed me to complete anunusual elective rotation with the policyoffice of the American College ofPhysicians in Washington, DC, anexperience that reinforced my desire topursue a career in policy. I completed theinternship and the residency, and Jordanwas always on my list of mentors I stayedin touch with as I moved along in mycareer. He encouraged me when Iapplied to the Robert Wood JohnsonClinical Scholars program and again

when I applied to the graduate programof the Wharton School at the Universityof Pennsylvania. After completing myfellowships and graduate school, I wenton to the RAND Corporation and later tothe Centers for Disease Control andPrevention. When I became deputydirector of the National Institutes ofHealth and Jordan was president of theAssociation of American MedicalColleges, I was delighted to be in regularcontact with him again. In the health andscience policy community in Washington,Jordan is uniformly respected for hisability to bring constituencies together inthe interest of the public—anextraordinarily valuable and rare skillwithin the Beltway these days.

I recently ran across my internship classphotograph with Jordan seated in themiddle of the front row. It reminded methat Jordan was what so many of uswanted to be when we grew up—acompassionate physician, an excellentteacher, a skilled researcher, an activemember of the broader medicalcommunity—and on top of all of that, hehad this cool Omar Sharif thing goingon. I know that I was not the only internin our class to receive a call for a well-timed one-on-one conversation that hada lasting impact. We all chose differentcareers paths, but we all benefited fromhis leadership, his mentorship, and mostimportantly, his standard of excellence—though none of us ever became quite ascool as Jordan.

Raynard S. Kington, MD, PhD

Dr. Kington resides in Takoma Park, Maryland.

Teaching and Learning Moments

Academic Medicine, Vol. 81, No. 6 / June 2006582