This is a review of which I feel particularly proud. It comes from a feature in the prestigious British Medical Journal called "Medical Classics" that was printed on the 25th anniversary of the publication of Healing the Wounds. For a contemporary review, see below.
Healing the Wounds
First published by Pantheon in 1985
by James Curran, GP locum, Glasgow
British Medical Journal, p 1061, May 2007, Volume 334
David Hilfiker wrote Healing the Wounds in 1982; it is based on his experience of working in rural medicine in the 1970s in Grand Marais, a small town in Minnesota, USA, whose population in the summer months is supplemented by an influx of tourists. The book largely consists of a collection of anecdotal descriptions of semi-fictionalized cases of patients he treated.
From the description so far, and a familiarity with the sort of autobiographical books doctors tend to write, one could expect a series of semi-humorous vignettes full of eccentricity and whimsy or tales of a doctor modestly saving lives against the odds. However, Healing the Wounds is not that sort of book. The cases Hilfiker describes are not always the ones with happy endings. He writes about difficult childbirths, missed diagnoses, the experience of an unsuccessful resuscitation after a cardiac arrest, and futile attempts at therapy for insoluble emotional problems.
He portrays this side of his work so as to make some points about the job of being a doctor. Each chapter describes a case or two, which Hilfiker then uses to discuss a particular aspect of medical practice—its inherent stress, uncertainty, and error; the difficulty in keeping clinical knowledge up to date; the conflicting duties to the patient and society. For want of a better phrase, these are all the "things they didn't teach you about at medical school," the things that Hilfiker feels:prevent him from giving his patients effective care. Healing the Wounds sounds like a glum read, but this is not the case. The writing is clear and effective, and what emerges is an honest and refreshing look at medical practice. It is obviously a personal look because Hilfiker discusses his own thoughts and reactions, but it never becomes self indulgent or solipsistic—he never over analyses matters, and wherever possible he uses examples from other doctors or published work to illustrate his points.
As he states in a new afterword to the latest edition of this book, David Hilfiker is more affected than most doctors by the issues he describes. Not everyone would draw exactly the same conclusions as he has. However, what he describes are things that affect all of us to varying degrees—priorities to be balanced, trade-offs to be made, lines to be drawn. For that reason—and because this is one of the best complete descriptions of a doctor's work—this is a book that deserves to continue to be read.
A Review of HEALING THE WOUNDS
A Physician Looks at His Work
By Jonathan Yardley
September 18, 1985
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.