From Doctor to Patient: Cancer, Pain and Dying Video Transcript

Achieving Communication Excellence (ACE) Lecture Series
Interpersonal Communication And Relationship Enhancement (I*CARE)
Dr. Richard B. Patt
From Doctor to Patient: Cancer, Pain and Dying
Date: November 6, 2012
Time: 57:03

Richard B. Patt, M.D.
Former Associate Professor of Anesthesiology and Neuro-Oncology
Director of Anesthesia Pain Services and Deputy Chief, department of Pain and Symptom Management, MD Anderson Cancer Center
Medical Director of Inpatient Services, Hospice at The Texas Medical Center President and Chief Medical Officer, The Patt Center for Cancer Pain and Wellness


Dr. Walter Baile: Good morning. So, why don't we get started for our ACE Lecture Series today? My name is Walter Baile and I'm director of the I-Care Program, Interpersonal Communication and Relationship Enhancement here at MD Anderson and we're really, really pleased today to welcome Dr. Rick Patt as our speaker. And I wonder if we could just do a few housekeeping things that if you could put your cell phones and pagers on silence so we don't interrupt and I just want to let you know this is not the Clint Eastwood empty chair. This is-- so Rick is not going to talk to it, but he may want to sit down during his talk. I just wanted to give you a little bit of background on Dr. Patt. So, Rick trained in anesthesiology at Albert Einstein College of Medicine where he completed a pain fellowship. And afterwards migrated over to Rochester University and Strong Memorial Hospital where he was Associate Professor of Anesthesiology, Oncology and Psychiatry and helped establish the first pain medicine fellowship program there. Afterwards he came to MD Anderson and served on the faculty, was actually recruited by Dr. Stratton Hill who is here today, one of the fathers of pain medicine in the country, which started here at MD Anderson. And Rick dramatically increased the interventional pain program here allowing our patients with cancer to receive interventional techniques and interventions for cancer pain that before that weren't available. In 1996 he left the institution to establish the Patt Center for Cancer Pain and Wellness where he cared for cancer patients and patients with chronic pain and then had some other positions in the medical centers such as medical director of the Texas Medical Center Hospice inpatient service. Rick has been quite prolific in his writing on pain over the years. He was editor, co-editor of one of the first textbooks on cancer pain and has published extensively in the field and been on numerous editorial boards. I think it’s really important to note that during the course of his career Rick has faced two very personal challenges including first dealing with addiction and dependency on stimulants, tranquilizers and opioids, for which he received-- went into a recovery program in 2006 and lately dealing with metastatic lung cancer and today he's going to touch on his experiences as a physician and healthcare professional and dealing with both of these issues. And the topic of his talk is From Doctor to Patient: Cancer, Pain and Dying. So, I'd like you to please welcome Dr. Rick Patt.


Dr. Rick Patt: Hello everyone. I remember standing here a few years ago and this has been kind of a challenge for me. I haven't come face to face with a PowerPoint presentation in a long time and we'll just muddle through it together. Thank you very much for coming. And when we conceived of this talk I initially conceived of my goals as trying to understand and communicate what I've learned from this recent experience of being ill what could I generalize that would be helpful for other healthcare professionals. I don't think that I'm going to be able to accomplish that. What I've come to recognize is that even though death and dying is something that we all will sometime experience in our lifetimes, the-- it seems to be such a profound experience that the responses I got from other people and what I've learned I just don't think I can generalize it. The best I can do I think is to tell my story and describe some of my observations and what I've learned with the idea that perhaps it will be helpful. I'm not a scholar on death and dying, so I'm going to keep this pretty straightforward. And again, I was really struck...I'm the kind of person that communicates and I'm-- if you've got a secret, don't tell me. [Laughter] I come to understand things; I process things and come to understand them by talking to other people about them. And that's been I think one of the most interesting features about my being ill, I really loathe the idea of kind of feeling like I was crawling off in a private corner to lick my wounds just because I'm ill. And I never liked it when I was in the workplace with someone for years and then one day they just weren't there.

So, I resolve to continue to live my live at full speed and be open about what was going on with me health wise. And I've been talking on Facebook about it. There was a very in depth article in the Houston Chronicle and I've got a blog now in the Houston Chronicle and this has been pretty well received but I think with some trepidations. Again, I have really been surprised that although all of us recognize that the end of our lives is sometime on the horizon whether it's in our 50's or 60's or 70's or 80's, it's still a pretty finite period of time. We still don't talk about it well. But, by the same token I found that when I was candid about what I was going through many people really felt relieved. I think otherwise they didn't quite know how to act around me. And it was useful for me to give them permission to discuss this stuff with me.

I'm going to just expand on some of the kind introductory comments that Walter made, because they-- I think my story is a big part of what I'm going to share today. I was foreign medical graduate, ending up doing pain medicine at a time when it was really not a very well recognized or popular field. My anesthesia colleagues really couldn't quite understand why I would want to spend so much time around people who were awake and had chronic complaints. [Laughter] And-- but I was drawn to it. I spent some time at MD Anderson Cancer Center, ended up here for a period of time before anchoring a private practice. In Rochester, it was fairly busy and this is-- I found a couple of old pictures, one when I had hair in the lower left and then kind of a rare picture of me with two of my mentors, Dr. Jain and Dr. Goldiner from Memorial Sloan-Kettering.

In any case, I came to MD Anderson at a time when there was a recognition that we were probably falling short in our efforts to manage to the whole patient including pain and other symptoms and one of the most interesting things I've experienced is being here for a period of time, planting the seeds and then coming back as a patient and seeing how successful the patient management program has become and how well established it is, because it had really always been a second class citizen and so, it's obvious that you all have done a very good job here. And as Walter pointed out I was pretty busy writing and doing other things and, in fact, I looked at my curriculum vitae and I say this not to brag, but to really question just what I was up to at the time. [Laughter] You know I think-- I'm going to get around to the fact that I developed a substance abuse problem, but I think while I was here I was kind of addicted to being a doctor. It-- you know-- I really thrived on all of these accomplishments and really feel like had I been more attentive, and I just identified so exclusively with my achievements that I think if I had been more attentive to other aspects of my life, things might have gone a bit differently. However, I did make a transition to private practice and in the long run I really missed being at MD Anderson. It really is a marvelous institution. I developed a solo private practice. I was pretty isolated. I really-- there really was no good model for what it was I wanted to accomplish. And we practiced from my home, which was near the old VA Hospital. And it was a really big old house and we really went all out in developing it. My neighbors were not too happy. As you can see, we purchased the figures from a miniature golf course from Galveston and placed them around them yard. But this is what the backyard looked like. This is the office. Here in the middle is myself. We built an apartment for my father who is still with me and is 95 years old. This was our exam table. It was an antique opium bed and patients would come to see us and really see me and sit in basically a very home-like setting and we had-- it may not have been the most sanitary of settings, but we had dogs coming around back and forth, but people seemed to respond very well. And it really was in stark contrast to you know the more antiseptic and institutional approach where I had been used to seeing patients. And this is what the back yard looked like. I engaged with somebody who shared my vision and I think I had too much time and too much money [Laughter] but I'm just going to take you through what people would see while they were waiting for their appointment. He built a mountain out of genuine rock and there was a series of caves that ran through the bottom of it. And let's see--

There was a stone passageway that was hidden and you could just kind of push and it would open to a spot that was under a waterfall. This dome-like structure was built into the mountain top. There were these big planters. Of course, we had to have a big slide from the bedroom into the pool. And, of course, as a musician I had to have an outdoor stage and fire towers and it was really a delightful setting that unfortunately has been torn down for townhomes now. But let me tell you more about what happened with me.

Around 2005 I really needed some help and didn't seek the kind of help I needed. Again, this transition was much harder on me than I expected. I really hadn't wanted to leave MD Anderson. I really wanted to think that this is a truly unique and heads above-- there's just no comparison to what you can accomplish here in training or clinical care or research in the setting of cancer. I really missed it. I missed all the activity. Again, you saw how much I was traveling and lecturing and I'm sure that those were my excesses in that area were things that contributed to my lack of longevity here. But, I started to self-medicate and over a pretty short period of time developed substance abuse problems and for at least a brief period, was an impaired physician. Didn't recognize it, but ultimately surrendered my license and this really was associated with devastation of every aspect of any idea I had about any kind of routine. I had identified myself as a physician first and foremost and again I had to surrender my license. I faced you know loss of livelihood and lots of other potential losses, but I got into a good rehab program that is kind of tailored for physicians. And ultimately the Texas Medical Board restored my license and as they continued to see progress revised my board order favorably each year so that I could return to medical practice.

But it was a pretty humbling experience. I really, you know wasn't qualified to work elsewhere. I worked as a Barista at Starbucks. At least I could get healthcare insurance. I had performed insurance examinations, really did whatever I could, but it was a really interesting time and it really helped me see beyond the fact that I was a doctor and I didn't have other dimensions to my personhood. And I really ultimately was able to achieve a lot of satisfaction in doing a good job in whatever setting I was in. Again, I want to ask your forbearance because I'm not so accustomed to talking about this and I want to make sure that in focusing on the slides that I haven't missed any points that I wanted to share with you.

[Shuffling items around]

Yeah, I do want to emphasize that I was personally lucky in that the only people that were really hurt by my illness were myself and my family. But you know I really look back, even though it was a brief interval to the period of time where I was caring for patients and charged with you know giving them the best care that they could expect and without recognizing I was impaired, it was-- with great shame and you know it’s something I regret, but I’m pleased to have been able to move beyond that. Fortunately my family stuck by me and I was really off to a relatively even keel when I learned about my illness. One of the things that was different was that as a result of a good recovery program I was really able to experience satisfaction with simply going to work as a primary care physician and seeing patients over the course of the day, feeling like I had done a good job and that was the end of my workday. You know, I really began to master getting more balance into my life. But, of course, just when you feel balanced is when things often get unbalanced. And this is what I mean, by this distinction between sobriety versus recovery. You know the first couple of years I think I'm about, it'll be eight years or nine years out this month. You know it's all you can do to simply be abstinent, but it really begins to sink in as a lifestyle over time, at least that's the way it was for me. I'll get back to that again in minute.

Anyway, I just wasn't feeling quite right. A couple of other guys my age were kind of just, it was like a little rash epidemic of pancreatic cancer and I got kind of nervous about it and got a little workup started and found that, in fact, I did-- it was unrelated to my symptoms but I had a large adrenal metastasis and got myself out of the community and over here to get a proper workup and evaluation and learned that I did have a stage 4, you know advanced non-small cell lung carcinoma. And at the time I arrived at a treatment plan that was to consist of kind of a watchful waiting to see what the tempo of disease progression would be and kind of preemptive evaluation with supportive care or palliative care. You know I was-- what I learned and I've emphasized that even as a physician, it's very, very hard to understand the ways these various tumors behave and what can be expected from treatment and different kinds of treatments. I even found in my super-specialists that they couldn't be expert in every aspect of even lung cancer. That you know, that over in radiation they you know they have you know more information in certain areas than they do in medical oncology, interventional, likewise. What I essentially learned that my cancer was just not very chemo responsive and the potential benefits of getting chemotherapy really did not seem to weigh favorably against even a moderate decrement in my quality of life, which had really come into focus as being more and more important to me. So, we watched, we waited, we saw that, in fact, the cancer did grow very quickly and I began to have more symptoms and got a consultation for radiation therapy. And ultimately although that was intended with palliative intent, we ended up treating all of the disease sites and I've had a good response. I'm-- you know there have been some problems and some side effects, but they've been pretty manageable and you know that's pretty exciting. But you know it doesn't change the general and overall picture.

You know this is a pretty extraordinary institution and it’s beautifully appointed, but you know there's a saying that you can dress up and put makeup on a pig and it's still a pig. And just you know I really had this idea of sort of delivering myself into the belly of the beast and I did not like the idea of too much of my wife's and my time being spent here at Anderson just walking the hallways, just kind of gives me the willies sometimes. And you know I've found that that's more so since I've become a patient and not just a care provider. And so that was one of the things that figured into my decision. In an odd way though, let me see if this is-- oh let me see, in an odd way my experience with recovery influenced my decisions a lot. I really, you know I guess what I would say is that my dependence on alcohol and drugs served me very well for a short period of time.

You know, I think that anytime that you have a drink or something to manage your problems, you're doing so as a coping tool and for a while you know my problems did seem to get better. And so, I really went into rehab very reluctantly. It wasn't what I would have chosen, but it was clear that that was inevitable and that was something I needed to do. But, in looking back I think that I really grieved the fact that I couldn't rely on substances as a coping tool and I kind of went through the five stages of grief that Dr. Kubler-Ross talks about. I think I can-- let me just summarize them you know, anger, denial. You know I was mad this wasn't anybody-- of anybody's business you know and just as well equipped to take care of patients as I'd ever been and maybe even better denial. I really didn't have a problem, bargaining is something that I need to do, but I'll do it in my own way in my own time. Grief and finally acceptance. So, you know I'd really had given up a lot. You know I had lost my medical practice. I'd really lost my profession. I'm not going to be giving anesthesia or doing pain practice anytime soon. I really-- you know lost everything the way I saw it at the time and I emerged from it okay. You know as much as I identified with being a superstar doctor, that's not really who I was. And like I said my family stuck by me and I continued to you know enjoy the things that were really important to me, after the fact. But I really had to go through this process of grief that when the time came to consider the end of life it seemed just a little easier to deal with.

Anyway, around this time we decided to put on a benefit. I was going to focus on the things that did bring me joy in life. And music is one of them and in trying to get the word out about-- and again just in this place where this can be of benefit, I'd rather have it be at a time-- if there's going to be a party I want to be there and you know enjoy it, not after the fact. In trying to get the word out, the Houston Chronicle became interested in my situation and did a very intensive feature and told my story, kind of just like I did with no holds barred and just kind of put it on the table for what it is. And it was really kind of neat because it served as a fulcrum for my having a chance to reunite with patients and family members whom I’d cared for and other doctors that I'd worked with and people just have been really great and coming forward and our getting together again.

So, what I vowed to do was to really try to continue to live life fully, identify what's important and to really focus on that. I use this as an opportunity to reconnect with people that I hadn't in a long time. I helped organize an elementary school reunion back in Baltimore. That was a lot of fun and playing music has come to be more and more important to me. And both-- for a lot of reasons. You know it's-- when I started to get sober I turned to music as kind of a recovery tool as something that I could learn how to do. And it really became a metaphor for being present. You can't-- you really need to be in the moment when you're playing in a combo and you can't sort of be behind the beat or after the beat for very long without it showing up. And interestingly it's only this phase of my life where I feel like I feel like I've really started to find my voice and really be able to communicate with my music. And for me, it's really been a great way to be with people. So, what are we doing, did I skip one? Yeah, so this is my outfit in some of its manifestations. And when I went back to Baltimore for my elementary school reunion they put on a big show at a local movie theater. You know I just found a lot of camaraderie.

When we went ahead and did the benefit, both of my brothers who are musical flew in and played with us. And it's really been a joy. The benefit, the motto for it was, "Enjoy Every Sandwich", which was something that Warren Zevon, who also had terminal lung cancer told David Letterman when he asked for any advice near the end of life. And so, if it's not a sandwich enjoy you know whatever the little things are that please you. And I've been very active as a board member of the Houston Blues Society and they helped promote this event that brought all of the kind of cream of local blues musicians out and about 500 people came to this event and just really had a good time. It was music interrupted by a short burlesque entertainment. [Laughter] Again, it was my party so I got to do pretty much whatever I wanted. This is Texas Johnny Brown at the top who's a local legend. This is Milton Hopkins over here who played with B.B. King on the road for about 15 years. We had a big silent auction where I was able to get rid a lot of the stuff that had accumulated and the community gave a lot of stuff and it was just a really good time.

But again, just an example of how miracles really do happen, for the silent auction somebody volunteered recording time at their studio. So, really in the course of just a couple of days we recorded a CD. We wanted to get it ready for the benefit. The people from the chronicle that were doing the story were able to use their photographs for the artwork for the CD. And this is something I just never would have done it if I hadn't gotten sick. I wouldn't be up here talking to you if I hadn't gotten sick.

So, really a lot of doors have opened and you know one of the things that I had to come to grips with in my recovery from drugs and alcohol was this whole sense of entitlement, which runs pretty rich especially in doctors. You know I think that we feel we're special. We work really hard. Our accomplishments can be very dramatic and we sort of deserve a place at the front of the line and if anybody is entitled to a miracle, it should be me because of all the good work that I've done. But you know in treatment for alcohol and drug abuse, you see that you know everybody is really the same. People make mistakes and the further I was able to get away from this sense of entitlement; the happier I was able to be. So, I just didn't feel like there was any reason I qualified more for a miracle cure than the next guy did. And that together with my background as a doctor you know helped me you know make my decisions in a way that was just pretty matter-of-fact.

What I saw was a whole variety of response from people when I told them that I was sick and dying. Often very out of proportion to the relationship that I had with them and it helped me recognize that their response was really much more often what they were experiencing and their concerns about their own mortality than about me and that's fine. I got a tremendous onslaught of recommendations for miracle cures and especially alternative therapies that you know I can't begin to describe the spectrum of recommendations that I received and lots of offers of prayer and stories about miracles. But you know-- I had decided to approach this phase of my life in a creative way. You know I'm all about miracles, but my current experience of a night of uninterrupted sleep or pain free day or even an improvement in my bowel habit are sufficient miracles for me to get real and authentic thanks about.

I'm looking around and I'm just struck by the fact that I feel lucky to have the information that I have about you know what lies ahead. I don't have exact information, I don't know how things are going to go but you know I feel that it's given me kind of a special chance to really live this part of my life in an intentional way. And I don't see any reason why this part of my life shouldn't be just as valuable, just as meaningful and just as authentic as what's come up until now. And so, I'm kind of feeling like maybe this could be the best part of my life. Maybe everything that I've experienced up until now has served me and brought to me to this point. And so I'm all about trying to integrate these things together.

When I can, I'm really trying to regard this as kind of a fieldtrip. I mean it's a really interesting time and you know the-- I've experienced some symptoms and some fatigue and other problems that are all pretty manageable, but you know overall I'm doing pretty well. And I'm giving people you know kind of being candid with people has really given them permission to just be extra sweet and you know give me an extra hug and an extra few minutes. You know I have been sitting in with musicians that I've never played with before because you know they don't know if this going to be the last time you know we have to play together. And you know it's really exquisite and a great chance-- I mean we all I think wake up each day and feel like we want to make this day really count and kind of live it as if maybe it's our last day. But, I've sort of had that brought into really sharp focus and you know I think it's-- it’s really been exciting and so-- what else do I want to talk about, very little else I'm sure.

Oh yeah, I guess I characterize my main strategy in treating this cancer is surrender. You know, I give up. And you know I know that we all kind of have a visceral response to that. Our culture is all about fighting the good fight; you know about all the tools that we have in our arsenal to go forward and again be the one in ten or a hundred or a thousand that's going to be victorious. You know ultimately we're going to succumb to something and I just didn't want this last period of my life whether it's a few months or a year or two to be all about a street fight that I didn't ask for that I really can't possibly win. You know I feel like my decision to forego chemotherapy has let me do lots of stuff over the last eight months that I wouldn't have been able to accomplish otherwise.

Is this tough on my wife and friends and family, of course it is, but it's going to be tough on them no matter what choices I make. The doctors have not really fought me too hard. I mean there's been a recognition that this is a reasonable approach. Now, I would have really been in a fix if this was a much more treatable cancer. And I suspect that my threshold would be a little bit different than average, you know that I might forego treatment in even some more gray areas. But in this particular one it's really been easy for me and it's really been-- it's just a great feeling. You know I think that the pain, the fatigue, the respiratory problems are all manageable. But actually I meant to say that what I learned the most-- and again so my choice is to try to make the cancer my ally. What can I learn from this experience that is useful that may or may not help somebody else but is useful for me and the loss of control has really been one of the most difficult problems.

And the fatigue that I experienced was just overwhelming and when I first went to doctor's sleepover camp, you know when I had my first night of surgical internship and I saw my list of things to do get longer instead of shorter, you know, I got a little bit tearful. I mean it was pretty upsetting and what I learned was that you just need to you know just toughen up and go forward and you know find some strategies for doing what was ever-- what you were called on to do. Well, I can't do that anymore and when you know-- when my body tells me that I need to rest I really need to rest. And it was really disturbing and I fought it until at one point I just said well, I guess I'll just take a nap. And then I felt better. [Laughter] It's kind of like just being willing to finally I'm sorry after a stupid argument. And so, I contend that in some settings that surrender and giving up to something is a very reasonable strategy. You know you can look at what happened in Europe after World War II. You know the side that surrendered you know got rebuilt. They got all our foreign aid. And so, at least in my case it's been kind of a relief to be able to do this my own way and to stay away from the belly of the beast as much as I can.

I think that that concludes my comments. I know they've been a bit off the cuff and I thank you for contending with that and again, I want to repeat what an honor and privilege it is to be invited back to give this lecture. Thank you for coming.

[Applause and standing ovation]

Can I take questions? Thank you. Thank you very much. That's very nice.


Dr. Rick Patt: I feel very special. Thank you very much.

Dr. Walter Baile: So, what Rick didn't also tell you is, is that he actually has two wives, a real wife and his guitar. And he brings his guitar everywhere with him, because if he has a spare moment he--

Dr. Rick Patt: It's in his office right now.

Dr. Walter Baile: It's in the office right now. [Laughter] So, I wanted to-- we have a few minutes if people have questions. I think Rick has been so candid and so open that I wonder whether or not any of you have questions or comments or things you'd like to observe or say about your own experience with patients. Yes?

Dr. Walter Baile: Can you say who you are?

Dr. Rick Patt: We all know who he is.

Dr. Stratton Hill: I’m Dr. Stratton Hill, I’m retired from here. You made a distinction between sobriety and recovery.

Dr. Rick Patt: Yeah.

Dr. Stratton Hill: You said sobriety first and then recovery. Can you expand on that a little bit?

Dr. Rick Patt: Sure, I think it's a concept that is, is pretty well entrenched in the recovery community and that is the first challenge of any kind of meaningful rehab is to get off of drugs with no exception. Avoid any substances that are going to change how you feel and that's kind of a useful initial step, but until, however, you do it and it's not that there is a simple clear template by which everyone manages substance abuse or we'd do a lot better in treating it, but unless you develop a positive approach and a lifestyle that really recognizes that an alternate and more authentic way of dealing with our problems whether it be religious or work related or A.A. related, but recovery I think is a-- just a more comprehensive approach. I know-- I don't know that I'm explaining it that articulately, but I wondered when I became ill whether I might succumb to a relapse. And when I learned about being sick I really had no desire at all and I just couldn't imagine that being high would make any of this any better. You know just it was clear to me that it would be dumb. So, that's what I'd say about that, unless you have any more thoughts.

Dr. Stratton Hill: No, I got you.

Dr. Rick Patt: You got me, I'll--

Dr. Walter Baile: Any more questions?

Attendee: In dealing with what you're going through, can you share with us what was most helpful for your partner, your wife.

Dr. Rick Patt: Thank you.

Dr. Walter Baile: Can you just repeat the question.

Dr. Rick Patt: Sure, what was most helpful from my spouse? I think that Pauline, you know I mean what really is most important to me now is the integrity of our relationship. And so, one of the things that she did was to let me know just how tough this was for her. Because again, this whole sense of entitlement, it's so easy for me to come from this place where it's all about me and you know not necessarily poor, poor me, but I, you know I've been interacting with a lot of people about this. And this is really, really hard for her and she feels you know if she's had a bad day or has a minor you know problem, she really feels guilty about bringing it up. And that's not good for either of us, so-- but, yeah I'd say that was the most helpful.

Attendee: Thank you.

Dr. Rick Patt: Sure, you bet.

Dr. Walter Baile: Yes, there's a question up here in the back.

Dr. Vivian Porche: Hi Dr. Patt. It's Vivian Porshe. It's so good to see you again.

Dr. Rick Patt: Hey, great to see you.

Dr. Vivian Porche: You talked so much about your life, and pain care and being a good doctor. What I wanted to know is you know because of your work in palliative care and you know the pain service and all of that, what can you tell us to be better physicians as we're helping our patients every day? What- you know how can we be better doctors? How can we be more empathetic?

Dr. Rick Patt: Thank you Vivian. How can we do a better job now that I'm seeing it from the other side of the fence? And I think it's so easy. It's the same things that make you want to ask that question. And that is, in my book, it's just listen to the patient. Take an extra minute right up front so that you clearly communicate that you're willing to listen to them and kind of-- it would seem to be obvious to be associated with that. I-- you know we all come to this with our own agenda and at least one time, one of my consultations, you know I felt like the doctor didn't know anything about me. Couldn't be bothered to have taken the time to learn about me before seeing me. And had their own agenda that I was just-- it was clear that I was not going-- this couldn't-- just didn't have the chance to communicate why I was really there and what questions I wanted to have answered. And I felt very badly for someone less equipped if they were in that situation. It's really just to listen to the patient. You know, and that's-- I've learned more that way than anything.

Dr. Vivian Porche: May I give you that hug?

Dr. Rick Patt: Please.

Dr. Vivian Porche: Most people that know me know that I am very prayerful; yes you better give me that hug. Oh, no I didn't want it. Most people that know me know that I'm a very praying person, very prayerful, very religious and you were saying something a minute ago about offering prayers. Do you, do you not want them. Because I'm not saying it for me. I really am trying to let you know that God loves you and what he has in store for you is a good thing, whenever it's time because that's-- and that's for all of us. But should I not, should I. My patients that I do it for, of course, appreciate it but I would like to know from you.

Dr. Rick Patt: When I was very active in hospice I began to pray with patients and I didn't even really understand what I was doing. I just knew that it was something that they found helpful and they invited me to do it and it was very helpful.

Dr. Vivian Porche: Yes.

Dr. Rick Patt: And just everybody, everything in the room changed when we did that.

Dr. Vivian Porche: Yes.

Dr. Rick Patt: But no, when someone tells me that they're going to pray for me, I encourage them. I am not really asking for them-- it's not my business what they pray for you know.

Dr. Vivian Porche: And I pray. But, I'm really not praying that I'm going to win. I don't think that's going to happen. And-- but I'm praying for lots of other things.

Dr. Vivian Porche: Yes, yes.

Dr. Rick Patt: I mean miracles are-- we can be creative and miracles can take on all kinds of characters.

Dr. Vivian Porche: Yes, like you said when you said you know just your bowel habit, I mean you know just-- that's important too. Thank you.

Dr. Rick Patt: Did you want to ask a question.

Dr. Tim McDonell: Sorry, first of all thanks very much for taking the time to be here today and sharing your experience with us. That's very helpful. My name is Tim McDonald. I'm on the faculty here as well and just kind of a follow up that was mentioned in her question, I mean some of which you alluded to today would cause one to suspect that faith is playing a role in your outlook in all of this. Can you tell us a little bit about the role of faith and your perspective?

Dr. Rick Patt: Well, thanks I think. [Laughter] Because you know I'm really still exploring that and I could stop there but I won't. I-- I do have faith. I'm not quite sure that I could articulate in what, but I really feel that things are as they're supposed to be and I kind of feel like we're not designed and built in a way that we are really intended to understand it all. And I just feel very comfortable that things are going as they should. You know, I don't necessarily subscribe to a particular dogma, but you know I'm very moved when I see how helpful other people's faith is to them. So, yeah I think we're very lucky if we can have that to draw on. Thanks.

Dr. Tim McDonell: Thank you.

Dr. Walter Baile: Thank you. We have time for one last question if there are any, yes?

Dr. Rick Patt: I'll sprint over there. [Laughter]

[Taking mic to audience]

Attendee: Because of your experience and background with substance abuse I did notice that you mentioned that you do deal with pain. And I'm wondering if you could share a little bit about pain control with someone with a history of substance abuse?

Dr. Rick Patt: I think that-- and we have a couple of pain specialists in the house and I think they'd probably agree with the comments I'm going to make that there is a concern and kind of a myth that people with this kind of history are going to be train wrecks. And sometimes they are, but it's like any other time that we clump patients together and it's useful to categorize patients and to make generalizations. They can be further subcategorized and I think that most pain specialists have pretty routinely experienced that when there is a real history of sobriety that is well documented and that the hardest thing about treating these patients is to get them to take any pain medication at all. They tend to resist it. They're so-- these are people that know that there's one saying that is-- I think it goes one drink is too many and one thousand drinks is not enough. And you know people say I don't drink, I'm allergic. I break out in handcuffs. [Laughter] You know just-- you know it's not going to take much for them to have a really disastrous outcome and I know in my case I-- you know I didn't take anything and stuck with anti-inflammatories for just as long as I could and I'm now taking some stronger medications, but in a well supervised program and I'm continuing to be monitored by the board. But it's certainly very different for people with you know very recent abstinence and then we've also talked about people on methadone maintenance as another category basis, but that's-- we won't discuss that now. In fact, that was a very useful question. Well again, I'm really moved. Thank you so much and I'm really glad to have been here today. It's really been a highpoint for me.

Dr. Walter Baile: Thank you so much for coming.

Dr. Rick Patt: Thanks again.