Not reflected in the algorithm


The following hardly qualifies as a healthcare data point. I’m sure the wizards who carpenter the algorithms that model healthcare access and costs have not have included a weighted value for the news, appalling to me, that Dr. Henry Nieder will retire this month. Not that my particular distress has a claim on the endless scheming that is the better healthcare political wrestling match.

No one in his right mind would imagine that if you liked your doctor you could keep him, at least not without hedging for mortality or any particular physician’s choice to make a new plan after 31 years in the business. But I did, twice. In the ’70s, Russ Hoxsie, a good and decent man who was also a doctor, did his best to stanch the relentless decline in my apparent good health. Our get-togethers were not appointments, they were visits, occasions for me to spend time with someone charming, knowledgeable, and humane. We talked, he inquired, he poked (in places no one ever had before), he recommended, he warned, and I listened, and sometimes forgot.

Russ’s retirement should not have poleaxed me the way it did. After all, he had had a long, distinguished career, and there were medical issues that plagued him. Apparently, the conversations I had so enjoyed when we visited were not as medically helpful to him as they had been to me. It may be that I was experiencing early-onset regressive tendencies, honing my stubborn resistance to change. Over time I have come to think that landing at Martha’s Vineyard was a sort of homecoming for someone who preferred things as is, not susceptible to scaling up over time. What was a 6,000-person Island when I arrived was the perfect hideout for such a congenital regressive. After all, in 1970, the actual steamship Nantucket sailed to both the Vineyard and Nantucket; the lovely, venerable Nobska spent the winters at the old Vineyard Haven steamship wharf with its huge, cool shed where you went to rummage through the freight to find what you had ordered. There were no subdivision control rules or zoning rules in most of the towns, no Martha’s Vineyard Commission overseeing us all. It ultimately took nearly four decades of perennial debate for Tisbury to decide to reroute traffic from the Steamship Authority up the 100-yard Union Street hill to Main Street to relieve traffic at Five Corners; almost as long to change the Barnes Road/Vineyard Haven–Edgartown Road intersection from blinker to roundabout. And back then, presidents went elsewhere in August. For a dedicated foot dragger, it was the place to be.

Russ, the physician, endured, but as the humanist he was. At the Martha’s Vineyard Times, I published his “Let’s Walk, Lilly” columns, and later a book of those columns. They were therapeutic meditations on places and people, diseases and healthy practices. Lilly, a springer spaniel, was his traveling companion and sometimes muse. As he had been when he practiced for all those years at the Vineyard hospital, so his writing was — observant, compassionate, benevolent, and often amused.

Then this. Henry Nieder wrote to all of his communicants, “My work taking care of all of you these many years has been a great pleasure and very rewarding. At times the work of a family doctor is challenging. It is always fulfilling. I thank you for being my patients.”

Although I missed the letter, at a semiannual visit we had a few weeks ago, he told me of his plans. He had joined, then taken over Russ Hoxsie’s practice in 1988, the way Dr. Amar Luzic will take over from Henry in September. Henry says Dr. Luzic will be terrific, and of course he will. Russ Hoxsie made a brilliant choice, selecting Henry. He was confident, I’m sure, that here was a young man cut from familiar cloth, a stayer who would one day thank his patients for their custom and trust and conversation — and mean it.

By now, Henry has looked after my wife, my father, my children when they graduated from Dr. Michael Goldfein’s pediatric practice, and me. He is a listener, cautious in diagnosis and conservative about treatment. My mother, who lived to 87, outlasting my father by several years, was a grumpy patient, rarely pleased by something she didn’t want to hear, namely, that she was OK. Perhaps she hoped that her worst fears would be realized at last. She might then be seriously ill, sure, but she would also be right. She just knew she suffered from a grave illness located, she said, “down there,” and she thought that Dr. Nieder was missing it. She told him so, but, unlike so many others of her acquaintance, he was not intimidated. “No, Charlotte,” he said, “you’re just getting older.” Infuriated, she died of pneumonia a couple of years later.

Henry and I chatted, after he had approved of my weight, my cholesterol, and my beating heart. I chided him for throwing in the towel. I didn’t want to learn a new family doctor, didn’t want to explain things again, didn’t want any of this humane medical relationship of three decades to evaporate. He said there were things, important to him, that he wanted to be about. Who could reasonably complain over that? Apparently I could, a bit, and did.

Before our visit ended, he took my numbers and plugged them into a new algorithmic model based on a huge population of other doctors’ patients, some of whose numbers were better than mine, some worse. Of course, there was no value included to measure the effect on the faithful of the retirement from practice of this kind, patient, and skilled physician, who had served the members of his flock nearly as long as each one needed him.

But the algo designers had placed some bets. If this, then that. If you have these numbers, you have a 24 percent chance of having a heart attack in the next 10 years. Was that bad? Or so-so? I found the algo online and ran it myself, making slight adjustments here and there to see if I might change, or hoodwink, the odds. I also found another model, a European edition all the rage in the G-Seven, whose constituents treat themselves so generously, and it returned a 16 percent probability. And, I comforted myself, these were the outcomes for the population whose data the algo munched, not for any individual contestant in life’s race, not especially for me. In his good-natured, amused way, Henry did not herald the model as more than it was, namely, a well-built conjecture. He proposed a plan. I demurred. I said I’ll think about it and have a decision the next time I see you.