Lessons From a ‘Difficult Patient’
When David G. Hillman, MD, first started working in internal medicine, he was eager to help the sick.
He was fascinated by the idea that the human body, often seen as an inanimate machine, could be a complex, adaptive machine whose response to a given stimulus could reflect a complex, multilevel interaction between its intrinsic attributes and its external environment.
Dr. Hillman’s view was that, when properly understood, human biology was an inexhaustible source of insights into how to improve human health.
It was a view that reflected not only his own expertise and training but also the way the profession had been established. Dr. Hillman started out as an internist, a family practitioner who specialized in pediatrics. For years, he had worked in the world of primary care. He was accustomed to patient encounters in which the doctor’s primary goals were to help the patient get well and to improve their quality of life. The doctor’s ability to focus on providing primary care, though, often led him to inadvertently turn to the diagnosis of a disease, to the treatment of an illness, without initially having intended to do so.
Dr. Hillman’s time in internal medicine was a departure from this practice; it marked the beginning of a career marked by the pursuit of problems that go far beyond those that can be addressed solely by helping the patient get well and improving their quality of life.
When Dr. Hillman entered medical school, the prevailing medical view was that there was a very small pool of specialists who could diagnose and treat medical conditions, and yet this pool of specialists was limited at its size. The specialty of internal medicine, however, was founded in the late 1800s when physicians began to provide full-time care for hospitalized patients. There wasn’t a lot of need for further specialization. In the 1940s, it became clear to the profession that more of its patients were coming to them because of the problems that stemmed from their diseases rather than because of the diagnosis of their conditions.
The profession’s response was often to