Feeling the void

Many years ago, a wise family practice mentor said to me “One of the nice things about being a physician for many years is that my patients have grown old with me. Unfortunately that means I am losing more of them.” Those words came back to me recently after the loss of my third male patient in six months, all close to my age. Two of them, avoidable deaths but work and inflammation came before healthy habits and lifestyle changes. The third was from a quick and devastating disease that was not avoidable.

The wife of the third man came in for a visit yesterday. We talked a little bit about his disease and its quick progression. She talked about the usual things–their 30 year marriage, children, hopes for grandkids. I told her that I would miss him after our many year patient-doctor relationship. I hesitated, then shared with her that it had been a rough year with patient losses and that he was one of three men that died much too young–at 70 he had been the oldest. She looked at me and said “then you feel the void.”

Obviously, not the same way that she does, but indeed, I feel the void.

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How Will You Define Yourself?

Dr. Murphy recently wrote this article for the GLMS President’s e-Voice. I liked it so well I requested permission to re-post it. Dr. Murphy is President of the Greater Louisville Medical Society, Medical Director of Murphy Pain Center, Assistant Clinical Professor at the University of Louisville School of Medicine, and serves on the board of the International Association for Pain and Chemical Dependency. He blogs at Confluential Truth.

How Will You Define Yourself?

I am a doctor, but a doctor is not what I am.

– penned in my spiral notebook, circa May 1985

Despite a medical career’s insatiable hunger for attention, my chosen path does not define me, but it has provided glimpses of who I am.

For example, during my internship at Balboa Naval Hospital I was occasionally assigned to draw blood for labs. One such afternoon, my blood-rounding brought me to a diminutive, bent, hairless, elderly man sitting quietly in his bed on the open bay ward. After a brief exchange of pleasantries, he offered an atrophied left upper extremity for blood acquisition. Upon completion he warmly thanked me and even complimented me on being a “good needle-sticker.”

Later, I learned that the diminutive octogenarian was a retired two-star admiral who was admitted to this ward because he had refused any special treatment in deference to his lofty rank. If a no-privacy open bay ward was good enough for his sickly comrades, it was good enough for him too.

Besides an amazing lesson in leadership, my encounter with the admiral taught me that, regardless of how powerful, wealthy, famous, weak, poor, or humble one might be, we each travel a path to the same destination.  In days past, simply rumor that he was onboard ship would have created an air of anxious hyper-attention. But in his life’s final chapter he was humbly grateful that the apprentice doctor sent to draw his blood didn’t botch the needle stick.

What defined this person: his accomplishments? his failures? his youthful conquests? his final chapter?

Are we defined by life’s moments? Perhaps the sum of life’s moments?  Is one’s present moment – or even one’s final moment – life’s truest summation?

I have my doubts.

Despite our yearnings to the contrary, our present evaporates and becomes our past – no different than a dream. And we are not defined by our dreams – nor our past.

So, if not the past, are we defined by the present?

I have more doubts.

The brain does not work at the speed of light – not even close. In fact, every conscious thought results from a chain of chemical reactions initiated by sensory stimuli. Therefore, awareness of a moment in time can only occur after the stimulating event.  Awareness of the present is really just a memory.

So does the present even exist? Yes it does; in theory (i.e. the theoretical present). But I can’t prove it.

During a deposition I gave years ago, with the lawyer’s argument hinging upon proving the medical record to be comprehensive, she asked, “Isn’t it true that if it wasn’t documented, it didn’t happen?”

My response was, “If it wasn’t documented it simply means it wasn’t documented.”

I still stand by that.

Like the medical record, your perception of the present moment is legitimate documentation that your present moment exists.  But that’s all it is – documentation. Not proof.  Again, awareness of the present is really just a memory.

I have lots of memories – especially of my patients. And being a physician to a significant number of elderly patients, I deal with loss on a regular basis. While it is never easy to say good-bye, I usually find solace in knowing that I tried to provide comfort in a patient’s latter steps along life’s journey.

Obituaries, written to summarize these journeys, usually pique my curiosity.  Some are just a few lines. Some are novellas. Some offer comparison photos of the youthful and the elderly visage.  Regardless of length, obituaries cannot define a life.

For example, by the time you read my article, the iconic Nelson Mandela will have been laid to rest – after perhaps the most extensive obituary in the history of the media – and still the world will have only gotten an infinitesimal account of his life.  At the end of it all, will we have defined the man?

Not a chance.

About a year ago, I read the obituary of a local doctor, P. Patrick Hess, M.D. He was eloquently described as: “A dedicated pediatrician, gifted artist, collector of oddities, beloved husband, father, grandfather, voracious reader, with a quick wit – Patrick Hess had an obsessive curiosity and a driving desire to unravel the mysteries of the world.”  It went on to mention his family, accomplishments, education, and professional endeavors – all lovely. But I felt there was more to this man’s life. Then I read his poem and felt something had indeed been defined.

 All physicians are artists, 

not always in disguise. 

Our way of looking at a patient, 

allowing our minds to roam all over those perceptions of our previous life,

often forgotten, 

to scan these memories and pull something from our unconscious mind – all with the purpose of creating something.  

Something to help the patient.

This creation is, 


a work of art.

Every imperceptible moment that passes is not only a new reality; it is rebirth, renewal, and redefinition.  Therefore, like the theoretical present, we can only be theoretically defined.

How will I define myself? I guess this will have to do:

 I am a doctor, but a doctor is not what I am.

circa January 2014

How will you define yourself?

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The Patient and the Chocolate

Having just spent the last 10 minutes giving my patient a very hard time about his increased girth and ongoing weight gain, I sighed, stood up and indicated that the visit was over. As I walked to the door he said “Just a minute Dr. Nieder. I have something for you”. He reached in his pocket and pulled, with just a little difficulty, a tin of Godiva chocolates out of it.

“Happy Easter Dr. Nieder.”

I was startled and a little speechless. I stammered a thank you, then reminded him that he needed to come back again in three months instead of the usual six because his numbers, both blood pressure and lab work, were starting to rise. I walked back to my office, sat the gift in the middle of my desk and contemplated it. He had to have known that I’d be frustrated that not only had he made no progress on his weight loss but had picked up a few pounds. It reminded me of an apple given to a teacher. A sweet thank you for my efforts. But I don’t feel deserving–I can’t find the right words to say to motivate him.

Perhaps that was what the gift was about–appreciation of my effort. In the end, he has to make the choices and changes, and I have to accept that he’s doing the best he can in his circumstances.

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A nail in the Patient-Physician Relationship coffin

Brenda works as a nurse at the other big healthcare system in town. She is a bit of a stoic. During our 25+ year relationship there were times I thought she didn’t like me until I realized what a no-nonsense personality she possesses. Thus it was upsetting to see distress in her face and hear her frustrated tone as she said, “You’ve been my doctor a long time, but I have been told that I can only see doctors in our system for my visits to be covered on my insurance.”

This came as no surprise to me. Just a few weeks earlier our hospital president made the same announcement to our employees. It is infuriating to hear relationships destroyed with a flippant “We have good doctors here. There is no reason for our employees to see doctors in other systems.”

First of all, a 25-year relationship with someone makes for a damn good reason to continue to see them. And yes, we have great BloodPressure2doctors in our system. But sometimes better talent is in another hospital. I want my patient to benefit from the best talent available. And sometimes a better physician with a bedside manner that engenders patient trust trumps a “best” physician. Trust goes a long way in helping patients heal.[1,2,3] Creating more silos for our patients is not the answer to improving care but in these days of tightening budgets regardless of how much “patient engagement” rhetoric is thrown about, the bottom line is what is most on the hearts and minds of the system CEOs.

As administration continues its attempt to be transparent, I may scream on hearing one more “faith-based platitude”. I do not believe that putting dollars before patient care is a religious value. On the competition’s side their mission statement urges quality health care in a manner that responds to the needs of the community and also honors a faith heritage. Regardless of the faith heritage,  shattered trust is not a community need.

In the aforementioned meeting, our hospital president also stated that discussions to join with the competition for  supply volume discounts were in process. How about negotiating the salvation of patient-doctor relationships with them as well? Systems can continue to insist on patients using the facilities where they work for testing and procedures but this strategy could encourage doctors, regardless of where they work, to continue to have privileges in BOTH systems. Then we have a win-win for patient employees, their doctors and the systems.

As hospital networks struggle to balance their budgets in this competitive marketplace, here is my prediction: healthcare systems will survive based on the level of care they give the patients they serve, not by destroying the trust that patients put into those systems and their physicians. As Karma will have it, what goes around, comes around. Or if you prefer, in your faith-based work culture: Proverbs 26:27 – Who so diggeth a pit shall fall therein: and he that rolleth a stone, it will return upon him.

1. Effective physician-patient communication and health outcomes: a review. Stewart, MA. CMAJ : Canadian Medical Association Journal. 1995 May 1; 152(9)1423 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1337906/
2. Better Physician-Patient Relationships Are Associated with Higher Reported Adherence to Antiretroviral Therapy in Patients with HIV Infection. John Schneider, MD, MPH. et al. J Gen Intern Med. 2004 November; 19(11): 1096–1103. doi:  10.1111/j.1525-1497.2004.30418.x http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494791/
3. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Kaplan, SH, et al. Med Care. 1989 Mar;27(3 Suppl):S110-27. http://www.ncbi.nlm.nih.gov/pubmed/2646486


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