Though there was little glamour in his job as a family physician in the icy reaches of northern Minnesota, David Hilfiker appeared to be living out a noble ideal. Working for seven years in a clinic staffed by four doctors who provided the only medical services for 55 miles in any direction, Hilfiker, a graduate of Yale and the University of Minnesota Medical School, faced the salmagundi of rural practice: midnight births, fatal accidents, broken limbs, sore throats and chronic illnesses of the aged. Caught up in an unending drama of life and death, Hilfiker was privy to the most intimate hopes and dreams of his patients. Meanwhile, burdened by their most terrible fears and griefs, he felt a growing sense of isolation and loneliness. “Eventually the pain became too much,” writes Hilfiker in his book, Healing the Wounds: A Physician Looks at His Work (Pantheon, $14.95). “I knew I could not continue.”
In 1982 Hilfiker left his practice for a year of rest in Finland with his wife, Marja, and their three children. At the time Hilfiker did not know whether he would ever return to medicine. But his instinct for service won out, and he accepted an offer to work for a church-sponsored clinic in Washington, D.C. In his small apartment on the third floor of Christ House, a 34-bed recovery shelter for the homeless, Hilfiker, 41, discussed with correspondent Mark Frankel the trials of a doctor’s life.
What made you decide to leave your practice in Minnesota?
There was no single precipitating event. But I seemed to resent more and more the small things, like being phoned at home when I was not officially on call. Some evenings I even tried to avoid going down to the emergency room to see a patient when I was on call. I simply had no reserves left. The pressure of getting through a busy appointment schedule bore down on me, filling each day with tension.
Being a doctor requires more than merely making yourself available. You have to be eager to look for the extraordinary clue about an individual’s health. When I found myself so concerned with efficiency that I withheld my full attention from patients, I knew I was in trouble.
These sound like classic symptoms of professional burnout.
Yes. I needed to get out before I started to practice incompetently. There was, however, a deeper pain. Like many physicians, I entered medicine out of a desire to be of service to people. But the simple fact that there were too many patient needs for the time and energy I had available left me with a nagging sense of guilt. On the one hand, I was privileged to share the most intense moments of my patients’ lives. At the same time, I was riding an emotional roller coaster, and the feeling grew that I would be torn apart if I didn’t protect myself from other people’s needs. While my soul called for a life of service, my emotions called out for the life of a hermit.
Were your colleagues aware that you were going through a crisis?
Some of them might have noticed I had lost excitement for my work, but no one ever suggested I was not practicing good medicine. Of course it’s very threatening for doctors to discuss these kinds of problems. Nobody wants to be treated by a doctor who might be burning out. But the sad truth is that doctors as a group suffer because of their work. The statistics are stark: One study indicated that the United States loses the equivalent of seven medical-school graduating classes each year to drug addiction, alcoholism and suicide. Many experts estimate that up to 10 percent of all practicing physicians are impaired in some way.
Are medical schools adequately preparing students for the pressures they will face as doctors?
I’m not sure that anybody could adequately prepare them. When I attended medical school, the assumption seemed to be that our common sense would take care of us when it came time to use our interpersonal skills. Perhaps our professors never taught us otherwise because they didn’t really know themselves. Everybody was more comfortable dealing with the “hard” sciences of pathology and neuroanatomy. It came as quite a shock, once I was out in practice, to discover that my common sense was not developed enough to help my patients through the chaos of their emotional response to illness.
Is it possible for doctors to know as much as they should about the scientific aspects of their profession?
I don’t think you can keep up with one speciality, much less all that’s happening. The information explosion is enormous. When you’re working 50 hours a week, it’s simply not possible to stay current. I’m 12 years out of medical school and I feel very ignorant. I couldn’t handle a cardiac arrest in a hospital anymore. That is something I did as recently as four years ago, but it would be dangerous at this point because I’m too rusty on both the procedures and the medication.
Do you find, nevertheless, that patients expect you to be omniscient?
Not only am I expected to be omniscient, many patients believe I’m omnipotent. I’m expected to cure things that are incurable, like colds. Half the people I see have viral infections. I keep telling them there are no cures for viruses, but they think that if they just get sick enough, or if they just make their story plaintive enough, I will finally, albeit reluctantly, reach into my bag and pick out a medicine that I save only for the worst cases.
Have patients always perceived doctors in this way?
Up until the 1930s, when antibiotics were discovered, physicians were fairly limited in what they could do for patients. They could diagnose diseases and prognosticate. It has only been within the last 50 years that we’ve been able to do more. This new power to treat illness aggressively has also changed people’s perceptions of a doctor’s capabilities. Because of its technological wonders, modern medicine has created an expectation of perfection. Physicians now occupy an almost mystical role in society.
But even doctors are not immune from making mistakes.
Of course not. But the technology seems so exact that error seems almost unthinkable. Hence we are not prepared for our mistakes and we don’t know how to cope with them when they occur. For example, a few years ago I had a woman under my care who thought she was carrying a child, but four separate pregnancy tests over a period of several weeks were all negative. I determined the fetus must have died and recommended a routine procedure to clean out the uterus. But to my horror, I found myself aborting a live fetus. During the days, weeks and months after the operation, my guilt and anger grew. I spoke with pathologists and obstetric specialists trying to figure out why the pregnancy tests had been inaccurate. I still don’t know the answer.
I spoke honestly with the couple, telling them everything they wanted to know. But I never shared with them my own agony. I decided it was my responsibility to deal with my guilt alone. I have not yet completely come to terms with it, and I go back over it in my mind during sleepless nights. In general I have a difficult time putting mistakes behind me, which is absolutely essential if you are going to be a good physician.
Have you ever found yourself in the position of consciously playing God with people’s lives?
It has happened quite frequently. There have been occasions, for example, when a debilitated nursing home patient came down with a fever and appeared to have an infection, and I simply didn’t treat him or her as aggressively as I would a 40-year-old schoolteacher. Those patients didn’t go to the hospital. They didn’t get intravenous medication. They didn’t get the benefit of my immediate twice-a-day attention. It’s not that I want to make these incredibly important decisions about life and death by myself. But unfortunately, since medical science now gives us the power to play God, we have little choice. It’s a question of how well we are going to do it.
How has the nature of your work changed since you moved to Washington?
I no longer staff an emergency room, deliver babies or take responsibility for patients in the intensive care unit. Instead I work primarily within my offices caring for patients whose medical problems are generally quite straightforward. Specialists are readily available when problems get too complex. I work here as part of a health-care team and do not feel so much pressure to solve all of my patients’ problems by myself.
One of the most important changes for me has been to make it explicit that as a doctor I am to be a servant and not an entrepreneur. I have chosen to earn $22,000 a year plus housing rather than $110,000. I’m not under as much pressure to make every minute count, so I can spend more time with my patients. I am, of course, still struggling with the same basic tensions I faced in Minnesota. The intensity of my patients’ needs, my ignorance and uncertainty, the mistakes and ethical dilemmas, are still present.
Is taking on the wounds of others an inevitable part of practicing medicine?
It is for anyone who is serious about being a healer as opposed to being strictly a technician. But the main dilemma confronting American doctors, whether rural practitioners or high-tech surgeons, is that we all face expectations from our patients, from our profession and from the society at large that are utterly unrealistic on a day-to-day basis. We are asked to be Renaissance men and women in an age when that is no longer possible. In reality it is only by recognizing and respecting our own imperfections and limitations as physicians that we can effectively administer to others.