Ricky, a 4-year-old boy, is wheeled into the emergency room. No one knows how long the youngster was in the water, but CPR had been initiated as soon as he was pulled from the lake.
Dr. David Hilfiker has run from his office next door, leaving behind a waiting room filled with patients. After a frantic hour of heroic measures, there is no pupil response, no heart activity and no spontaneous breathing.
Knowing how hard they worked, Hilfiker can't even look at the nurses and attendants as he dismisses them. A sheet is pulled up over the little body.
The boy's mother is a longtime patient. Hilfiker wants to stay with her until her husband arrives, but he can't. Other patients await his return.
Back in the examining room his patience is tried by a 60-year-old woman whose remaining joy in life seems to be complaining. And that's followed by a look at the chart of a new patient who is apparently going from doctor to doctor trying to get a prescription for Valium.
David Hilfiker walks slowly back to his desk. He sits. Buries his face in his hands and thinks. "I'm not sure I can take this today."
Days like this one, described in his book "Healing the Wounds" (Pantheon: $14.95), illustrate some of the stresses faced by physicians that nearly led Hilfiker to quit his profession, he said.
Very little of Hilfiker's work could be considered glamorous. First in a small town upper Midwest family practice, and today in two Washington health clinics that serve the poor, there is an unrelenting intensity in the work.
Sitting cross-legged in a hotel room, still a little jet-lagged from a cross-country trip the day before, the 40-year-old doctor recalled his initial attraction to rural medicine.
Curses of the Job
"I wanted to be where doctors were really needed and I wanted to be close to the people," he said. But even in the northern hinterlands of Minnesota he could not escape from what he describes as the curses of modern medicine.
"The stresses and contradictions of being a physician were overwhelming. I found myself anxious, nervous, depressed, very quickly burned out, and in a situation I could do very little about," he said, adding that it almost drove him from medicine.
Instead, he took a year off and began writing about the contradictions and the pain. Especially the pain. He wrote two articles on the subject for the New England Journal of Medicine, the premier American medical journal. And he struck a responsive chord in hundreds of physicians who wrote to him. "I sensed in these responses the powerful desire of doctors to speak honestly about the problems of their professional lives and the pressures they face every day for which neither the structure of their profession nor society at large in any way equips them," he wrote in the book which expands on the articles to treat in depth some of the problems of modern physicians.
He has been traveling around the country, speaking about things few doctors dare discuss, even among themselves. He talks about money and how it interferes with medical practice. He discusses how unprepared doctors are to play God, although they are tempted and expected to do so on a daily basis.
And he addresses medical malpractice, doctors' compulsion for efficiency and the maze of spiraling information and technology that is impossible to deal with.
Problem With Images
"First off," he said, "I think the image most people have of doctors is very detrimental to the doctor-patient relationship." He believes patients see physicians as "technicians, entrepreneurs and creators of luxuriant life styles."
He's convinced that this image is fueling today's medical malpractice crisis.
"The increasing emotional distance between physician and patient merely exacerbates the tendency to sue. . . .
"I'm very surprised in the whole malpractice crisis no one mentions how much money doctors make as being etiological." People perceive doctors as being rich and uncaring, he said, and then sue them if they make a mistake.
Hilfiker admits to being sued once and nearly brought to court on another occasion. "Both (patients) had reason to believe that I didn't care because I wasn't aware of the mistake and had never gotten back to talk with them about it."
He allowed that he has made "lots of mistakes" in his career, many "much more serious than the ones for which I was sued," but in those instances he recognized the error and went back to the patient to discuss it.
While some readers believe Hilfiker's book is critical of doctors, he is sympathetic. He finds it "perfectly understandable" that physicians behave as patients complain they do.
"When (doctors) are aloof, authoritarian, preoccupied with efficiency and power, when all they can talk about are their yachts and their money, that's a perfectly natural response to the contradictions (in medicine) which are almost impossible to resolve," he said.
After first describing his own response to these Catch-22s as depression and a desire to leave the profession, he said, "I also found myself doing things I swore I'd never do. Relating to patients in cold, aloof ways, becoming authoritarian. One part of myself was sitting here (he pointed above his right shoulder) watching myself doing it--and hating myself for it. Yet, it was the only way I could figure out to respond."
Like many practicing physicians, Hilfiker said, he entered medicine out of a desire to be of service to people. "What I failed to realize, however, was that the very nature of my work as a doctor would push me continually into the position of limiting the help I would give, of ignoring the needs of others.
"One of the pressing realities of my job was that I repeatedly found myself contradicting my own inner desire to be of service; a conflict that created in me a deep sense of guilt."
The Basic Conflict
At the heart of this conflict, Hilfiker found a simple fact: there were too many patient needs for the time and energy he had available. Yet, when he found himself unable or unwilling to increase the time or energy he was investing in his work, those needs did not conveniently stop to allow time for recovery.
"It is, in fact, one of the basic dilemmas of the physician--to be caught between a desire to be of service and a need for respite.
"This conflict surfaced in many different ways throughout any given day, producing a long-term sense of alienation from my patients and encouraging me to deal with them as problems to be handled rather than as persons in need of care."
Somehow--and Hilfiker has a few suggestions--medicine must start changing its ways because patients are demanding "whole person medicine" and are turning to "alternative healers because physicians have abdicated that role."
But again, need--in this case for an holistic approach--crashes head on into reality.
"One of the most depressing things about being a physician is running into your ignorance with virtually every patient you talk to. And it's just not technology we don't know.
"I'm asked to do sex therapy, I'm asked to do marital counseling, I'm asked about the latest vitamins, natural healing, acupuncture, and I'm expected to have expertise in all those areas when in fact I don't know anything about them.
"The negative response some physicians have to the call for holistic medicine is due to a feeling that they just can't do it; they can't accept one more demand on them."
What can be done?
"I think med schools need to begin talking about the fact that we cannot be the healers that we expect of ourselves. The day of the physician doing all we expect a doctor to do are gone.
"We also need to recognize the contradictions and how stressful the work is. Patients need to be aware of the stress their physician is under and to take that into account when dealing with him or her.
"To my peers, I say it's all right to talk about the pain. My belief is that as we as individuals can face our own pain, recognize, talk about it and share it, then we can begin to do something about our outrageous behavior."
But change will be slow coming, according to Hilfiker, and the fears it's going to get "much worse" before it gets better.
"I'm afraid about what is going to happen. I see the economics of medicine blowing us out of the water. I think physicians have gotten used to the idea that they deserve all this money, and as it becomes harder to make it we're going to react in very unhealthy ways." One example would be those doctors who take on more patients than they can serve well.
He paused, realized how grim a picture he'd painted and added with a hearty laugh: "There's never been a better time to be healthy."