ONE DAY IN THE FALL OF 1983, DR. ARNOLD RELMAN, THE EDITOR OF THE NEW ENGLAND Journal of Medicine, telephoned Dr. David Hilfiker, a young family physician practicing in Washington. A few weeks earlier Relman had received a manuscript from Hilfiker that had attracted special attention as it circulated from office to office at the prestigious journal, Relman recalled recently. Nevertheless, he called Hilfiker to give him a chance to withdraw the article from publication.
Hilfiker was on the verge of doing serious damage to his career, Relman thought. He had in his hands a first-person account of Hilfiker's medical mistakes and his attempts to come to terms with them. No punches were pulled. Hilfiker openly admitted he had once aborted a healthy fetus after misdiagnosing it as dead, and detailed the shock, remorse and agony he felt in the aftermath. Like an Old Testament prophet, this obscure young MD was volunteering to stand on the medical mountaintop and confess his mistakes where all his colleagues would be sure to see them.
"I thought he was exposing himself to serious criticism. I wanted him to think about it carefully before confessing to a couple of serious mistakes that a lot of doctors would say could and should have been avoided," Relman recalls.
Hilfiker was unswayed. The article, "Facing Our Mistakes," was published in early 1984 and immediately attracted controversy. As predicted, there were letters excoriating excoriated Hilfiker's skill as a physician. Outweighing any criticism, however, were the letters Hilfiker received telling of other doctors' sleepless nights, remorse and pain. "I was prepared to be torn apart on the mistakes article," says Hilfiker. "Eight or ten physicians recounted similar experiences, and there were a lot of letters that said 'Yeah, that's exactly what it's like. Thanks for opening up.' "
The decision to publish his mistakes was but one step in the personal and professional odyssey of David Hilfiker. It has carried him from a comfortable middle-class life as a rural GP to the blighted concrete landscape of inner-city Washington. Along the way Hilfiker, 41, has established himself as a sort of medical whistle-blower, recounting the fears, frustrations and pressures afflicting contemporary physicians -- and the toll extracted from them, their patients and families -- in magazine articles, lectures, television interviews, professional journals and a book, Healing the Wounds: A Physician Looks at his Work.
For seven years he practiced family medicine in Grand Marais, Minn., 35 miles from the Canadian border. His work left him alternately exhilarated and exhausted. One of three doctors who constituted the only medical care for 60 miles in any direction, he found himself pushed to his personal and professional limits, performing operations he was occasionally unprepared for, available to his patients day and night.
By the end he could barely pull himself through a day. Burned out, emotionally depleted, and frightened, he was losing his doctor's touch. Hilfiker quit in 1982 and went to Finland, his wife's home. He spent the next year examining both society's expectations of physicians and his own.
Physicians are confronted with an impossible job, he concluded. "They are asked to be Renaissance men and women in an age when it is no longer possible; they are expected to be ultimate healers, technological wizards, total authorities," he writes. Attempting to cope with the tensions of their daily routine, they have retreated from their patients behind fac,ades of Medicine, telephoned Dr. David Hilfiker, a young family physician practicing in Washington. A few weeks earlier Relman had received a manuscript from Hilfiker that had attracted special attention as it circulated from office to office at the prestigious journal, Relman recalled recently. by the Church of the Savior. The Community of Hope, an unusually successful social agency started by a Church of the Nazarene minister that has operated in the 14th Street area since 1977, is where he spends most of his time.
The clinic is far removed from most doctors' gleaming chrome and vinyl offices. The rough white-washed walls of the waiting room are bare except for racks of medical pamphlets and painted quotes from Martin Luther King Jr. and Ralph Waldo Emerson. With an annual operating budget of $180,000, and some 400 patient visits every month, there is little opportunity for cosmetic considerations.
Hilfiker now devotes his time to cases that many of his medical colleagues would consider routine, even mundane. His days are spent providing patients with primary health care, such as counseling about hypertension or diabetes or examining a sexually active teen-ager for signs of venereal disease. The young physician shares a bond with his patients at the Community of Hope, though few of them realize it. He, too, has come here seeking a cure. His problems however are altogether different from the illnesses he treats each day. His "wounds," he says, are psychic, the legacy of his medical career.
PHYSICIANS by nature tend to be compulsive and driven; Hilfiker is no exception. Marja Hilfiker, who met her future husband as a high school exchange student, acts as a relaxed, stabilizing influence on her husband. She remembers in medical school "he read someplace that the average medical student studies 55 hours a week . . . He certainly had the intellectual abilities of an average medical student, and so he would spend exactly that much time every week" studying.
Hilfiker says he has few memories of his childhood; the amnesia has helped propel him into psychotherapy. "I have very little idea of how I came to be who I am," he says.
The facts are these: Shortly after he was born in Upstate New York, the eldest of four children, the family moved to St. Louis. His father, a minister in the United Church of Christ, a liberal Protestant denomination, accepted the post of director of a settlement house in a black neighborhood. After five years the family moved to the town of Tonawanda, outside Buffalo, N.Y., where Hilfiker attended high school. A precocious "model child," he was both an Eagle Scout and the high school valedictorian. The parents and children were close, according to his sister, Lois Kanter, a legal services lawyer. Their parents' influence was profound, she adds. His brother Ted concurs. "Being of service to people," he says, "was always a focal point in my father's life and in our family life."
Hilfiker graduated from Yale in 1967. He studied literature and philosophy and joined the protests against the Vietnam war. He speaks of his decision to enter medical school, at the University of Minnesota, as if he was taken by surprise. It came as no shock to Marja. He was 23, deeply involved in the human potential movement and its searching spinoffs ("Zen, eastern mysticism, psychedelic drugs"). He was propelled by an interest in psychiatry, a curiosity about physiology, and a desire for "something to do every day."
"I was somewhat freer than a lot of medical students because I was basically there for the education . . . not necessarily to practice," he says now. "My interest has always been responding to people in totality . . . I'm not that interested in medicine, I'm interested in healing." Nonetheless, he was voted the doctor most likely to succeed as a "clinician" by his class of 200 students.
The idea of actually practicing medicine did not strike him until he visited Grand Marais in 1973, during his third year of medical studies. Minnesota, like many states, was then suffering from a shortage of qualified rural doctors. Hilfiker was sent to work alongside Dr. Roger McDonald, a physician with more than 20 years' practice. The experience was life-changing.
"It was the happiest year of my medical career . . . I had a ball," he remembers. McDonald served as his teacher, the town as his classroom. Hilfiker and his wife were warmly welcomed by the small community. He found himself with unimagined freedom to practice independently. "He was an excellent physician," says McDonald, with whom Hilfiker built a deep personal rapport. Yet within months of returning to Grand Marais to establish his own practice in 1975, the stresses began to mount. The experience was no doubt intensified by the crucible of rural practice: At the small local hospital he often found himself serving simultaneously as personal physician, emergency room physician and admitting doctor. Unable to disengage himself, the demands of his patients "kind of flooded over me and overwhelmed me," he says now.
Marja remembers that her husband tried repeatedly to find a way to accommodate the stress he felt: cutting down office hours, reserving more time for himself. Ultimately, nothing offered lasting solace. He started looking for reasons to avoid going to the hospital to see patients. He was unable to expend the extra energy that distinguishes a good doctor. During the long winters he would don his cross-country skis and wander the forests alone for a few hours each day.
"He was clearly depressed," Marja remembers. "David doesn't withdraw very easily or completely. He keeps functioning well, that's the last thing to go for him . . . But he just kept going mechanically."
Finally he realized, in Marja's words, "there was no place to go." He received a year's "sabbatical" from his practice. He and Marja made plans to spend a year in Finland. When he left Grand Marais in 1982, he was not sure he would ever practice medicine again.
I T IS Wednesday evening, the night for worship at Potter's House, a "faith community" and part of the Church of the Savior, a small Christian church founded on the premise of service to the poor. The service is held in a storefront restaurant and bookstore on Columbia Road.
The mood is relaxed, low-key, reminiscent of a college coffee-house. A visiting minister delivers a sermon titled "What Made Jesus Angry?" "When we look at things that are happening today, should we be angry, too?" he asks, reading off a list of budget cuts striking programs for the poor. In this room, the question is moot. Among the 100 or so people at the service, Hilfiker is clearly at home. The reason he is in Washington, the reason he is practicing medicine at the Community of Hope, can only be understood in the light of his involvement with the Church of the Savior.
His arrival at the church came at the end of a long, wandering search for "wholeness." For years he called himself an agnostic. It was Marja who led the way. While her husband climbed Mount McKinley in 1973, she quietly decided she was, at heart, a Christian, and began attending church. Her husband felt hurt and left behind initially, he recalls. He responded by reading all the theology he could in the hope of better understanding her conversion. His pursuit was, typically, dogged and rational. In 1978 he joined the local Free Evangelical Church in Grand Marais.
Another turning point came shortly before leaving for Finland, when Hilfiker attended a religious retreat outside Washington. There he briefly met Dr. Janelle Goetcheus, a Church of the Savior member and family practitioner. Their lives were strangely parallel. Goetcheus too had grown dissatisfied with normal practice; since 1976 she had run a clinic in Adams-Morgan serving the poor and homeless she felt were neglected by most physicians.
Something within him stirred that weekend. He returned with Marja a few weeks later to learn more about the church. It was like coming home. Here was a community that shared his need to be of service. No longer would he have to practice medicine alone, torn between the practicalities of business and the cries of the spirit. He wrote Goetcheus regularly from Finland.
"He shared where he was in his spiritual journey, he was asking questions of what we were about," Goetcheus recalls. After returning to America the next year, it was clear: This was where he belonged. It was also clear to Marja, who shared his urge to come to the city. For her, life in Minnesota had been "too comfortable, a slight bit of boredom, a sense of not enough challenge and substance," recalls Marja, 39. She has found satisfaction working as a volunteer helping adults prepare for their general equivalency diplomas.
As she explains this, Marja Hilfiker is sitting at the large black table that dominates the dining area of their home. The family's four-bedroom apartment is a little small, but new and modern. It is easy to forget the apartment is on the top floor of a shelter for homeless men and women on Columbia Road.
David Hilfiker arrives wheeling the well-used, 10-speed bicycle that is his main transportation around Washington. He heads directly into the kitchen. He has only a few minutes for lunch before leaving for the weekly staff meeting at the Community of Hope. Grinning broadly, he talks with Kai, the youngest of his three children, while operating on a couple of peanut butter and jelly sandwiches. Kai reminds him where they stopped the night before while reading C.S. Lewis' The Lion, the Witch, and the Wardrobe.
THE POOR APPROACH their physicians far differently than his former clientele did, Hilfiker has discovered. "I sense fewer expectations on their part," he explains. "They are simply grateful for what I can provide, for the fact that we're here, that they can afford to come and see us . . . that I want to be here."
That in turn has led to a far more significant discovery, according to those around him. "He has learned from us that when you can't cure, it's still good to stay in there and care," observes Lois Smith, the director of the Community of Hope clinic. "That's frustrating for doctors because they are taught to cure" and judge themselves upon their success.
At the Community of Hope, normal medical economics have been jettisoned with the perks, prestige and comfortable trappings. Because Hilfiker receives a flat salary (sliding fees at the clinic run from $2 to $30), he feels free to spend as much time with patients as necessary. During a typical four-hour day, he will see 12 to 15 people.
Doctor and patient usually present sharp contrasts, and this winter day is no exception. Hilfiker, a product of Yale and the University of Minnesota Medical School, has the tall, rangy body of a runner and a cross-country skier. His long face is all angles and planes; at times it borders on severe. His patient is black, a 37-year-old graduate of the streets and the Job Corps; he is short, compact, his round face hidden by a beard.
"What's this infection? Tell me about it," asks Hilfiker, starting the examination.
"Jock itch: I believe that's where it started. I understand there's worm or some type of infection . . . , " the man responds. Hilfiker diagnoses a probable case of ringworm. He begins to coax his patient through an hour-long recitation of his medical and personal history. It's not a happy list: gastric ulcer at 15; gall bladder removed, sarcoidosis; a gunshot wound in a fight. More recently it includes a year's incarceration in what he calls the "institution"; foreclosure; seven children; welfare and a frustrating search for steady employment. Hilfiker listens sympathetically, asking questions when his patient falters.
The ulcer, it seems, has started acting up again. Hilfiker asks questions: Does he drink? ("No"). Smoke? ("Trying to quit"). Eat spicy foods?
"Of course I eat spicy foods. I'm a black man!" he replies, laughing at the obviousness of the answer. Hilfiker chortles agreeably.
Before ending the exam, Hilfiker gives the man a prescription for Zantac for his ulcer and a two week supply of medication. He encourages him to watch his diet and return in a couple of weeks. But there is one final question.
"Will I live for two weeks?" he asks. Although he is in no danger and his tone is light-hearted, there is an undercurrent of anxiety. It is symptomatic of the assurance patients instinctively seek from physicians. But Hilfiker does not rise to the occasion. "You know that's not for me to say," he responds. His face softens as he laughs. He implies limits to his powers; outside this examination room there are many things beyond my power, he seems to say. Here, I will do my best.
Hilfiker is no longer regularly roused in the middle of the night by the ringing of the telephone, summoning him to the side of a new mother in labor or a retiree in cardiac arrest. He is content in the relative calmness and daily routine of working in the clinic. He is no longer the omniscient and omnipotent miracle worker; he is satisfied to be known as the "doctor who rides a bike" by those living near the Community of Hope.
"My job is to do what I can with the body in a sensitive way," Hilfiker says of his new role. "I don't pretend to be a complete healer anymore. Other people help me." At the same time, he can now face his professional limits, notes Smith. "David is very willing to say, 'I cannot do it. I can only do so much.' "
Hilfiker no longer performs minor surgery or emergency operations, and he restricts himself to those procedures in which he is sure of his skills in an attempt to avoid mistakes. He decided against doing any obstetrics when physicians responding to his article in The New England Journal of Medicine pointed out what he agrees are serious holes in his obstetrical and gynecological knowledge. His extreme caution is a luxury, possible only because he works in a city filled with specialists and hospital emergency rooms. He still contends with the inconvenience of being on call every third week, but it is mild compared with the rigors he endured previously.
Afterward, back in his office, Hilfiker dictates notes on the examination into a tape recorder. Smith pokes her head through the door. A small, bright-eyed woman with a cap of premature gray hair, she and Hilfiker discuss finding a place to stay for a neighborhood man about to be discharged from the hospital who is incapable of caring for himself. Then she tells him his next patient has failed to arrive or call. Her tone is matter-of-fact; this happens regularly.
There is little in the room linking it to Hilfiker -- only a small brown plaque directly over his desk. It reads in part: "Lord of Life, I pray you, light my mind to know the remedies for my patients' ills, and touch my heart to feel compassion for their sufferings."
Patients speak of Hilfiker warmly. Compared with the hospital clinic she once relied on, says Debra Watson, a mother of three who has been under Hilfiker's care for two years, "he seems more family-wise, more close-knit rather than just treating a person and shoving them out the door."
But for all his disarming honesty and frankness, there is an unmistakable reserve about Hilfiker. While devoting his life to service, he cherishes his privacy. He put the conflict in print: "While my soul called for a life of service, my emotions called for a life of a hermit," he wrote in Healing the Wounds. Colleagues who have worked alongside him daily nonetheless remark on the difficulty of penetrating Hilfiker's defenses. "My relationship with David? I'm not sure what it is," says Cathy Osare, a medical assistant at the Columbia Road Health Services who has worked with him for more than two years.
Sometimes there is anger. Smith recalls an incident when an ambulance was summoned for a woman complaining of chest pains. Once it arrived, however, the paramedics spent 10 minutes trying to convince the patient her symptoms were emotional. Hilfiker stood by "furious" and demanded she be admitted to an emergency room.
"When a physician will not see a person because they don't have any money and forces them into second-rate medical care, that's oppressive," says Hilfiker.
"Yeah, I'm angry at the medical establishment, I'm angry at what they do, but not at them. I'm angry at the results of their policies, the money we make and all those things . . . But there's another side of me that understands. I really do believe that oppressors really are in need of compassion as much as the oppressed. In fact, sometimes more."
H ILFIKER stands before the lectern in the vast expanse of a lecture hall. He has been invited by students at the George Washington University Medical Center to speak. Wearing a pair of spectacles, white pants and a sweater vest, he seems a lonely and vulnerable figure. It is lunchtime, and many students rustle brown paper bags as he speaks.
As future doctors he asks them to "reach across the chasm that separates rich from poor." But when a woman asks amid a rumble of agreeing murmurs how she can do that while paying her $100,000 debt from medical school, Hilfiker offers no easy solution.
Still, outside in the sunshine, he is satisfied. He has had his say. He is already planning his next book, to deal with his experiences at the Community of Hope, he remarks as he unlocks his bike. All doctors are "wounded healers," he believes. He has resumed his practice only after striking a tenuous compromise between his own needs and professional demands. "I need to be of service, but if I do it too long I get dragged down," he admits. "Writing gives me distance and perspective; it allows me to soar. Medicine puts me in touch with the earth . . . I need to do both."
In Minnesota, today would be perfect to be outside, to be in the woods. There it would be peaceful, the sound of the wind blowing through the branches the only noise. There, he once said, he felt closest to God, at one with the still, pristine world. But he has found his niche in Washington. There is so much to do here, today. He sits on the saddle, pushes off with his toe and disappear