The American medical community, ordinarily as smug and arrogant as any in our society, has of late been in a refreshingly self-critical mood. Some physicians have begun to ask themselves whether they are sufficiently attuned to their patients' psychological as well as medical needs, whether clinical detachment and authoritarianism are appropriate attitudes for people engaged in the healing arts. At some medical schools, administrators have begun to wonder if they are producing mere automatons, people with no interests or competence outside the examining and operating rooms, and are revising their admissions requirements and curricula accordingly.
These and related questions are considered in "Healing the Wounds," a thoughtful if somewhat self-satisfied account by a young physician of his years at a rural clinic in Minnesota. David Hilfiker's purpose in telling his own story is to describe "the conflicting pressures [doctors] face, which often seem to defy solution and . . . the responses they come up with, which often become problems in their own right." Though the book seems aimed primarily at other physicians and at medical students, it is written in language the layman can understand and addresses itself to problems that anyone who has ever visited a physician will immediately recognize.
For that layman, what is most useful about "Healing the Wounds" is its depiction, from the inside, of the stresses that make doctors behave the way they too often do. At their small clinic, Hilfiker and the two other physicians led intense lives in which they were rocketed back and forth, rarely with much warning, between routine examinations and life-threatening emergencies. "Every moment required the utmost vigilance," he writes. "But I was also expected to act normally, to be reassuring and calm."
It probably doesn't occur to many patients, as they grouse about their doctors' crowded waiting rooms, high fees and brusque manners, that much of what they complain about is a reaction to the expectations of the patients themselves. Physicians "are asked to be Renaissance men and women in an age when that is no longer possible; they are expected to be ultimate healers, technological wizards, total authorities." These expectations are indeed "utterly unrealistic," and they lead doctors to set up elaborate defense mechanisms in order to cope with them. As Hilfiker describes them, they are:
*Clinical detachment, which is essential to emergencies and other medical situations but can become "a generalized defense response" with the "unintended consequence . . . that the person tends to disappear and the patient becomes an object, a thing upon which the physician acts."
*Efficiency, which is necessary in order to use the doctor's time "as productively as possible" but which too often leads to a climate in which "efficiency and productivity [become] a yardstick for measuring oneself as a competent physician."
*The position of authority, which is not merely medical but in some circumstances legal, social and cultural, and which can make it "only too easy to perceive myself as inherently more important than others."
*Hierarchy, which encourages the physician "to see himself as the leader of a team all of whose members are dependent upon him," to regard persons lower on the totem pole as his inferiors and to ignore their advice -- if they have the impertinence to offer it -- on matters about which they may have more knowledge than he does.
*Wealth, which creates "tension between the physician as entrepreneur and the physician as servant" and which makes him "less sensitive to the economic realities" faced by many of his patients.
In his discussions of all of these defense mechanisms, Hilfiker is sympathetic with his fellow physicians; he has been there himself, by his own confession he has fallen into some of the very traps he deplores, and he knows that much of the problem is pure human nature. But his first sympathy is with the patient, an attitude that is far rarer in his business than it should be. He knows that the doctor's responsibility is first to serve those who come to him for help, and that these defenses can distract him from that responsibility or make him indifferent to the nonmedical needs of his patients.
To his credit, Hilfiker has attempted to follow his own counsel. He left the clinic in Minneapolis, and after an extended sabbatical came here to Washington to join the Community of Hope Health Services; his patients are the poor, many of them street people, and his salary of $26,000 borders, for an American physician, on the sacrificial. If he seems a touch prideful in his humility, he can be forgiven it; he is trying to live his own life by the convictions he expresses in this book, and for that -- as for the book itself -- he has earned our esteem.