Dr. Malia Reckons

First impressions are important. Or so I have heard many times in my life.

Late this afternoon I had to wonder if that was a good thing or not. Having an IMP medical office, and choosing to use a "micro" design for it, means I do everything. That includes the cleaning and vacuuming.

Today was a busy day, and I had patients booked until 7:00pm. With a lot of extra work to do after that, I was looking to find a few minutes to get some chores done. So at 4:40pm, twenty minutes before my next appointment, I decided to vacuum the office.

Folks had carried granular salt pellets into the office with their shoes all day, so a good vacuuming was needed ASAP. Plus, the 5:00pm appointment was for a "meet-and-greet" with a person considering joining the practice, and, if possible, I prefer the office be neat for those visits.

So I got Dyson out. My trusty vacuum has served me well all these years. Dyson is a highly-appreciated member of my office staff!

Dyson posing in the office front room after another job well done!

I started vacuuming as I usually do, in my back room, and worked around the exam table, desk, patient chairs; then I made my way toward the door to the front room. The door was open and I moved forward with the vacuum in front of me, finally stepping through the doorway.

Then my heart skipped a beat. I looked up, and sitting in one of the chairs was someone I had never met before: the person for the 5:00 "meet and greet" appointment. She had arrived fifteen minutes early!

Turning off the Dyson, I stepped out to introduce myself and chuckled about the vacuuming, and about being red-in-the-face. Luckily, she had read about my office in the recent newspaper article and understood that having no staff is part of the design for my IMP office and provides other inherent benefits.

Perhaps it is good that her first visit to the office offered a glimpse of the doctor "walking the walk" for his solo-solo IMP and doing some housekeeping. Time will tell, I guess. I have to hope the first impression, though less typical for a physician, was a good one.

Yet, in truth, I am a doctor for what comes later, when the real appointments begin. And then we'll always have that first impression to chuckle about.

--Timothy Malia, MD

Sharing a Friday morning chuckle with a patient is one of the great parts of my job. Fatigue of the week balanced with good humor is highly recommended before entering the weekend.

My patient, due to an injury, has been out of commission and not been exercising recently. Weight control is an issue for him so he assumed he had been picking up weight because of less regular exercise. This led to a valuable discussion about exercise, its role in weight control and its other benefits.

Our chuckle came with a reference to a classic line from the movie Legally Blonde (2001) starring Reese Witherspoon as Elle Woods, a less-than-likely, yet surprisingly capable (incomprehensibly capable?), Harvard Law School student. The movie, though generally considered mediocre, has many funny quotes. Besides lessons about Prada shoes and proper hair care after a perm, the one I suggest remembering is:

I just don't think that Brooke could've done this. Exercise gives you endorphins. Endorphins make you happy. Happy people just don't shoot their husbands, they just don't.

Yes, even pop-culture movies can point to healthy habits!

In this case, beyond lessening the likelihood of homicide, we are reminded of the biochemical benefits of exercise. Folks often report exercise helps them feel well and happy. Not uncommonly, patients tell me that with exercise they feel more motivated to eat healthfully and cut calories. I have yet to see patients explain that improving their diet motivates them to exercise more. Exercise seems to offer a physiological and mental benefit beyond what it should. Perhaps Elle Woods, Witherspoon's character in the clip above, is right when she points out the potential benefits of natural endorphins from exercise.

I previously have described how exercise improves sleep for adults and children. I support anything that improves patients' sleep. Difficulties with sleep are frequently uncovered during an appointment, or even present as the primary issue for an appointment. Poor sleep is associated with many other health problems and there are many reasons to not scrimp on it.

Besides the benefits of positive mental state and improved sleep, exercise also improves cardiovascular health, increases our physiologic capacity to use oxygen, and can improve our general fitness as measured by how well our clothes fit. Also, based on research reports, exercise with weight training even improves mental sharpness in older women; and, one may presume, the rest of us as well.

Yet, though many people do not know it, there is actually little or no research showing that exercise by itself leads to weight loss. It can only be helpful for weight loss when combined with a healthful diet and calorie control.

The theory is that vigorous exercise may trigger a physiologic response of  increased hunger and result in increased calorie intake 2-6 hours later. Consider how easy it is to have a second serving at dinner, choose to have a "little" dessert or sit back with an evening beer on any particular day. After a 30 or 45-minute work-out burns perhaps 300 calories, it takes almost no effort, and even minimal guilt, to take in those calories a few hours later and negate any benefit for weight control.

Interestingly, it seems that increasing general activity throughout the day, perhaps just burning 10 calories more per hour by getting up from your desk and walking for 1-2 minutes, may offer more benefit for weight loss than going to the gym every other day because it may not trigger hunger and the extra calories a few hours later. You may not get the muscle toning or improve cardiovascular health, but for weight control it may be better.

I do not mean to suggest you should not exercise. On the contrary, as noted above, there are significant benefits to exercise. I do recommend it, highly. But, if you are hoping for weight loss, you must see exercise as part of the plan and be careful to not consume extra calories due to hunger a few hours later. My hope is that such knowledge will lessen the risk of disappointment, frustration and dampened motivation.

But, for today at least, I was able to remind my patient that even if he has an injury and is not able to get "regular exercise," he can limit weight gain with control of calories and an increase of mild physical activity.

And that is my advise for all of us:

1) increase your general physical activity throughout the day and control your calories if you are hoping to lose weight;

2) if you do get vigorous exercise, be careful with your hunger and calorie intake a few hours later;

3) enjoy the endorphins floating around your brain with any and all exercise; and

4) don't shoot your spouse!

--Timothy Malia, MD

Was reminded today about old guys not hearing their wives.

It was because of a 33 year old man with wax plugging his ears. But, still, it is always a funny topic to discuss.

Basically, there is a medical reason older men do not hear women well. So, ladies, go easy on your men when you think they are not listening because, maybe, just maybe, they are suffering from presbycusis.

But, no worry, presbycusis is not infectious. Rather, it is hearing loss of old age.

Consider American Gothic (1930) by Grant Wood, and it does not take much imagination to think the woman, just moments prior, said something and is not happy with the non-response from her man.

Yet she should not take it as a passive-aggressive slight. He simply may not have heard her well, or, perhaps could not make out all of what she said.

The reason? Presbycusis tends to make it more difficult to hear higher frequency, or high-pitch, sounds. Since women tend to have higher pitched voices, a male partner will more often not hear clearly what she says before she has problems hearing him, even if they have identical hearing loss on a hearing test (audiogram). 

At the National Institute of Health website about presbycusis, there is a nice explanation of hearing loss of old age:

With presbycusis, sounds often seem less clear and lower in volume. This contributes to difficulty hearing and understanding speech. Individuals with presbycusis may experience several of the following:

• The speech of others seems mumbled or slurred.
• High-pitched sounds such as "s" and "th" are difficult to hear and tell apart.
• Conversations are difficult to understand, especially when there is background noise.
• A man's voice is easier to hear than the higher pitches of a woman's voice.
• Certain sounds seem annoying or overly loud.
• Tinnitus (a ringing, roaring, or hissing sound in one or both ears) may also occur.

With this post, I hope that some marriages can be a little happier as wives forgive their husbands for seemingly not paying attention, and husbands make an effort to listen more attentively just in case they have presbycusis.

Finally, if you think you or a loved one are having problems with hearing, please discuss with your physician, get examined and consider having a hearing test.

It might just save your marriage!

--Timothy Malia, MD

I had a busy Saturday today. It just dawned on me that part of it may be worth considering for the health care reform conversation.

My daughter was dropped off for the SAT Spanish test at 7:30, and picked up at 9:45. I drove my son to one side of town at 1pm for baseball batting practice, and to the other side of town for soccer practice at 3:30. Went grocery shopping in the early evening.

But, in between all that, I did run over to the office and, with a better-rested brain than I had yesterday, caught up with a few messages (might check/answer a couple emails before sleep tonight, too, but that's for another post perhaps).

And I saw two patients. The day made me feel like Hermes flying around with caduceus in hand!

The first patient I saw was a follow up of an abscess on a patient's thigh from two days ago. Besides checking the infection, we discussed that the culture swab of the infection was growing Staph aureus and how we needed to wait to learn if it was MRSA or not, but that he should continue the antibiotic I had prescribed.

The second had called me early this morning shortly after 7am. She was worried about a two-day fever with heachache and neck pain/stiffness that ibuprofen was not helping. She was deafened by meningitis as a child, so it is important to consider a worse case scenario and possible new meningitis. It likely was not, but it must be considered, so she was booked, with me, not sent to an emergency room. Physical exam was not worrisome and I was able to reassure her and discuss issues for which she should contact me.

Whether I saw her or not, I am proud that she was able to access me when she was worried , that I knew her history and could make a plan for her care. The design of my practice means my patients always contact their own primary care physician if they are very sick.

Typically, I would not be explaining these Saturday morning appointments. I only book Saturday appointments as needed and as I am able. I think these are the first two in about six weeks. Proper timing for follow up for an abscess, and to check a patient with headache, fever and neck pain are examples of when I will book them because that is what I do when I can. I am a physician. To do otherwise goes against the essence of the profession.

But, today, I do explain them because I saw a fantastic blog post by Dr. Gordon Moore. He pointed to another post from the popular blog kevinmd and a post that was originally an Op-Ed in USA Today in December, 2008 which discussed the limited access to care leading to increased services in emergency rooms by patients with insurance even more than the uninsured. 

Dr. Moore related that point very nicely to his own mother's hand injury. He lives in Seattle, and his mom in New York. Through skype he was able to see the swelling and bruising, and, trying to not be his family's doctor, suggested contacting her physician. She called back after being advised to go to emergency. In the post, he outlines how he researched possible problems, including checking with an orthopedic colleague, and got her information about splinting the injury until she could be seen on Monday. 

The point is that primary care, when done well, offers proper care and saves money.

We need a more robust primary care system.

One where doctors can know the patients they speak to when called on the weekend (in my old practice, when I was on-call that was only about 10% of the time).

One where a doctor can access information to be sure the advise offered is good quality (in my old practice, I always felt too busy to research an issue and get back to a patient when I was on-call).

One where a doctor, as often as possible, can see a patient at a less-common time if appropriate (at my old office I would have to send a patient to an urgent care center if needing to be seen after hours and could not book after 4:30 because all staff left at 5pm).

Dr. Moore comments how we need to take a larger portion of our health care money and better support primary care so more doctors can have vibrant, sustainable practices offering the care we all desire.

Doctors started in this profession to provide great care and help patients be healthy and happy. Ask any doctor, and I guarantee they will say that is true. And, not just that, in their hearts they still want that.

The system is wearing down the docs. We are often tired, frustrated and jaded. We are doing the best we can, but, very often, we have come to believe it is all futile and are working hard to get things done in a dysfunctional system.

But, with a more robust primary care system, not only can senior citizens get reasonable care for hand injuries, and patients with abscesses get proper follow up, and patients with potential serious infections be reassured, but we all can lower health care costs when money is saved down stream.

Oh, and one last thing, with a more robust primary care system, the emergency rooms will be freed up for those patients who truly need the fine services they can provide.

--Timothy Malia, MD

Recently, I mentioned having been interviewed by local reporter Chris Swingle.

Today, the article made the front page of the Rochester (NY) Democrat & Chronicle and very nicely covered the philosophy and practical aspects of the IMP (Ideal Medical Practice) design.  It refers to a few of us in the Rochester area with these small, low-overhead offices; I am covered near the end and close out the piece.       

(Timothy Malia, MD--my office inside the Perinton Square Mall, Fairport, NY)

A few weeks ago, I posted about the concepts behind IMP offices and have frequently discussed issues of timely access to care and using time with patients differently than is commonly done throughout the current medical system. Today's article touches upon those topics and the good/bad aspects of making an IMP office work in the real world.

Please check the article, share some thoughts and pass it on to other people.

An IMP office is not for everyone. But I firmly believe the motivating forces and basic concepts for the IMP design are profoundly important in truly improving health care services in America. And, in truth, we have not yet begun to consider that in the current national dialogue.

Perhaps articles like this will move us forward in the conversation and toward true reform of health care.

--Timothy Malia, MD  

PS -- For the fun of it, here's the part of the article that I'm in:

 Dr. Timothy Malia said 10 percent to 20 percent of his practice is elective skin work such as hair removal or Botox treatments, although that's been less popular during the recession. Malia started his practice in Perinton in 2006 after eight years at a large practice.

"Over the years, I just felt I was on the road to burnout," said Malia. The increasing documentation required and the pressure to see more patients per day became too much, he said.

Now his goal is to get patients in the same day and see them on time. He promises patients $5 in cash or a gift card if he's more than 15 minutes late.

Malia earns less than when he was salaried, but he said he's much happier. He has 600 to 700 patients, rather than the 2,000 he had in a large practice; he's still taking new patients. His overhead costs are about 20 percent to 25 percent of his practice, half the ratio at a large practice.

"I can pause and use the time to ask the questions that I think I need to ask," said Malia. "I have time to listen to the whole story." During appointments, he dictates treatment plans — such as how to handle a problem ankle or changes in the dosing of medications — into voice-recognition software, generating a typed printout that the patient takes home.

William Daniels, 69, of Rochester, a patient of Malia before and since he started an IMP, was skeptical at first of losing the conveniences of a pharmacy, eye doctor and other services in the same office. But now he sees no disadvantages. On a Saturday night, after three days with a fever, Daniels called Malia, who met him at the office and diagnosed pneumonia. Malia said the large setting didn't have that flexibility.

Malia and other IMP doctors say patients rarely call off-hours. Malia said he's woken up maybe once a year. "It's counterintuitive, but the fewer barriers, the less they need to contact you."

Fantastic video parody of planning for air travel in a system like our health care (non)system!

A must see.

Thanks to friend and colleague Dr. Gordon Moore for pointing this out in his blog post at Ideal Medical Practices.

I'll let the video speak for itself.

--Timothy Malia, MD

Whooping cough is often thought to be an "olden days" infection but, in truth, it is still common. We adults are often the inflicted, and the source for its spread.

Familydoctor.org has a great outline about whooping cough to get a reasonable perspective.

A friend and colleague, Dr. Marty Schulman, was recently on his local Fox News affiliate in San Diego discussing whooping cough and the need for booster shots in adults. (note: video may load slowly, it did for me initially)

 

Caused by the bacteria Bordetella pertussis ("pertussis"), whooping cough is highly infectious and causes a severe cough that can  trigger shortness of breath, thus leading to a "whoop" as one gasps for air during coughing fits.

Adults can be bothered by the cough, but because their lung airways are wide, do not typically require hospitalization. But babies have narrow lung airways, and if they get a pertussis infection, they can have respiratory distress, need hospitalization or even die.

Standard care for infants includes vaccination for pertussis at the 2-month, 4-month and 6-month check ups (as part of the DTaP shots for diphtheria/tetanus/acellular pertussis), but, until the third vaccination is given, a baby remains at increased risk of infection.

The most common source for pertussis is an adult who unknowingly has whooping cough. Why? Because the protection we gain from pertussis vaccination in childhood can ebb over the years.

To combat that loss of protection, we now give teenagers a booster vaccination with Tdap (tetanus/diphtheria/acellular pertussis) to increase protection for both tetanus and for whooping cough. Older adults, however, should also receive an additional booster with Tdap at some point, especially parents of infants and older adults.

The Tdap vaccine was only approved for teens and adults in 2005, so the idea of getting a pertussis booster is still relatively new. Like any new idea, it is taking time for medical providers and patients to consider the effort important.

I admit I have been inconsistent with getting adults a booster for pertussis and giving Tdap to patients beyond the teen years. Hopefully, this year, with motivation gained from Dr. Marty Schulman's reminder, I will improve my habit and lessen the risk for infection for everyone.

We doctors can use your help with this. Let us work as a team. Next time you have the chance, ask your physician about the Tdap shot and whether it is time for you to get a booster. We will all be better off for the effort.

--Timothy Malia, MD

Jimmy Valvano died of metastatic bone cancer in 1993, just 8 weeks after he gave the speech below.

You should watch it. Or read it. Or watch it then read it. Or read it then watch. Or all of the above. It is that good. It will be ten minutes well spent.

Jimmy V was a college basketball coach with a full personality who lived with zeal. Born in Queens, NY and raised in Seaford out on Long Island, his first varsity coaching work, just one year after his own graduation, happened to have been at my alma mater, Johns Hopkins. But it was 1983 that brought Jimmy V to national attention. That year he coached the NC State Wolfpack men's team thru a memorable NCAA Tournament and one of the greatest upset victories in college sports history. The Cardiac Kids of NCState shocked the world by beating the highly favored University of Houston team which had two future NBA hall-of-fame players.

The image of Jimmy V running and spinning across the court just after NC State's buzzer-beater winning basket, almost searching for someone to hug and share in the happiness, is an indelible image of sports celebration for the ages. See clips of that great victory, and Jimmy V's joyous celebration HERE.

Yet, as exciting and motivating as that victory was, Jimmy V's greatest public moment proved to be nearly his last. In 1993 he was given the inaugural ESPN Arthur Ashe Courage and Humanitarian Award. It was publicly known that he had cancer, and he used the award ceremony to announce his new foundation, The Jimmy V Foundation for Cancer Research, and to deliver its motto: "don't give up, don't ever give up."

The speech in its entirity is below as well as a full transcription. But a few lines are worthy of special note; and we all should take them to heart:

"To me, there are three things we all should do every day. We should do this every day of our lives. Number one is laugh. You should laugh every day. Number two is think. You should spend some time in thought. Number three is, you should have your emotions moved to tears, could be happiness or joy. But think about it. If you laugh, you think, and you cry, that's a full day. That's a heck of a day. You do that seven days a week, you're going to have something special."

"I always have to think about what's important in life to me are these three things. Where you started, where you are and where you're going to be"

"I think you have to have an enthusiasm for life. You have to have a dream, a goal. You have to be willing to work for it. "

"...it's motto is "Don't give up, don't ever give up." That's what I'm going to try to do every minute that I have left. I will thank God for the day and the moment I have. If you see me, smile and give me a hug. That's important to me too."

"Cancer can take away all my physical abilities. It cannot touch my mind, it cannot touch my heart and it cannot touch my soul. And those three things are going to carry on forever. "

Jimmy Valvano's ESPY speech, March 1993:

Thank you, Thank you very much. Thank you. That's the lowest I've ever seen Dick Vitale since the owner of the Detroit Pistons      called him in and told him he should go into broadcasting.

The I can't tell you what an honor it is, to even be mentioned in the same breath with Arthur Ashe. This is something I certainly will treasure forever. But, as it was said on the tape, and I also don't have one of those things going with the cue cards, so I'm going to speak longer than anybody else has spoken tonight. That's the way it goes. Time is very precious to me. I don't know how much I have left and I have some things that I would like to say. Hopefully, at the end, I will have said something that will be important to other people too.

But, I can't help it. Now I'm fighting cancer, everybody knows that. People ask me all the time about how you go through your life      and how's your day, and nothing is changed for me. As Dick said, I'm a very emotional and passionate man. I can't help it. That's being the son of Rocco and Angelina Valvano. It comes with the territory. We hug, we kiss, we love. When people say to me how      do you get through life or each day, it's the same thing. To me, there are three things we all should do every day. We should do      this every day of our lives. Number one is laugh. You should laugh every day. Number two is think. You should spend some time in thought. Number three is, you should have your emotions moved to tears, could be happiness or joy. But think about it. If you      laugh, you think, and you cry, that's a full day. That's a heck of a day. You do that seven days a week, you're going to have      something special.

I rode on the plane up today with Mike Krzyzewski, my good friend and wonderful coach. People don't realize he's ten times a      better person than he is a coach, and we know he's a great coach. He's meant a lot to me in these last five or six months with my battle. But when I look at Mike, I think, we competed against each other as players. I coached against him for fifteen years, and I always have to think about what's important in life to me are these three things. Where you started, where you are and where you're going to be. Those are the three things that I try to do every day. When I think about getting up and giving a speech, I can't help it. I have to remember the first speech I ever gave.

I was coaching at Rutgers University, that was my first job, oh that's wonderful (reaction to applause), and I was the freshman      coach. That's when freshmen played on freshman teams, and I was so fired up about my first job. I see Lou Holtz here. Coach      Holtz, who doesn't like the very first job you had? The very first time you stood in the locker room to give a pep talk. That's a special place, the locker room, for a coach to give a talk. So my idol as a coach was Vince Lombardi, and I read this book called "Commitment To Excellence" by Vince Lombardi. And in the book, Lombardi talked about the fist time he spoke before his Green Bay Packers team in the locker room, and they were perennial losers. I'm reading this and Lombardi said he was thinking should it be a long talk, or a short talk? But he wanted it to be emotional, so it would be brief. So here's what I did. Normally you  get in the locker room, I don't know, twenty-five minutes, a half hour before the team takes the field, you do your little x and o's, and then you give the great Knute Rockne talk. We all do. Speech number eight-four. You pull them right out, you get ready. You get your squad ready. Well, this is the first one I ever gave and I read this thing. Lombardi, what he said was he didn't go in, he waited. His team wondering, where is he? Where is this great coach? He's not there. Ten minutes he's still not there. Three minutes before they could take the field Lombardi comes in, bangs the door open, and I think you all remember what great presence he had, great presence. He walked in and he walked back and forth, like this, just walked, staring at the players. He said, "All eyes on me." I'm reading this in this book. I'm getting this picture of Lombardi before his first game and he said "Gentlemen, we will be successful this year, if you can focus on three things, and three things only. Your family, your religion and the Green Bay Packers." They knocked the walls down and the rest was history. I said, that's beautiful. I'm going to do that. Your family, your religion and Rutgers basketball. That's it. I had it. Listen, I'm twenty-one years old. The kids I'm coaching are nineteen, and I'm going to be the greatest coach in the world, the next Lombardi. I'm practicing outside of the locker room and the managers tell me you got to go in. Not yet, not yet, family, religion, Rutgers Basketball. All eyes on me. I got it, I got it. Then finally he said, three minutes, I said fine. True story. I go to knock the doors open just like Lombardi. Boom! They don't open. I almost broke my arm. Now I was down, the players were looking. Help the coach out, help him out. Now I did like Lombardi, I walked back and forth, and I was going like that with my arm getting the feeling back in it. Finally I said, "Gentlemen, all eyes on me." These kids wanted to play, they're nineteen. "Let's go," I said. "Gentlemen, we'll be successful this year if you can focus on three things, and three things only. Your family, your religion and the Green Bay Packers," I told them. I did that. I remember that. I remember where I came from.

It's so important to know where you are. I know where I am right now. How do you go from where you are to where you want to be? I think you have to have an enthusiasm for life. You have to have a dream, a goal. You have to be willing to work for it. 

I talked about my family, my family's so important. People think I have courage. The courage in my family are my wife Pam, my      three daughters, here, Nicole, Jamie, LeeAnn, my mom, who's right here too. That screen is flashing up there thirty seconds like I care about that screen right now, huh? I got tumors all over my body. I'm worried about some guy in the back going thirty seconds? You got a lot, hey va fa napoli, buddy. You got a lot. 

I just got one last thing, I urge all of you, all of you, to enjoy your life, the precious moments you have. To spend each day with some laughter and some thought, to get you're emotions going. To be enthusiastic every day and as Ralph Waldo Emerson said, "Nothing great could be accomplished without enthusiasm," to keep your dreams alive in spite of problems whatever you have. The ability to be able to work hard for your dreams to come true, to become a reality. 

Now I look at where I am now and I know what I want to do. What I would like to be able to do is spend whatever time I have left      and to give, and maybe, some hope to others. Arthur Ashe Foundation is a wonderful thing, and AIDS, the amount of money      pouring in for AIDS is not enough, but is significant. But if I told you it's ten times the amount that goes in for cancer research. I      also told you that five hundred thousand people will die this year of cancer. I also tell you that one in every four will be afflicted with this disease, and yet somehow, we seem to have put it in a little bit of the background. I want to bring it back on the front table. We need your help. I need your help. We need money for research. It may not save my life. It may save my children's lives. It may save someone you love. And ESPN has been so kind to support me in this endeavor and allow me to announce tonight, that with      ESPN's support, which means what? Their money and their dollars and they're helping me-we are starting the Jimmy V     Foundation for Cancer Research. And it's motto is "Don't give up, don't ever give up." That's what I'm going to try to do every minute that I have left. I will thank God for the day and the moment I have. If you see me, smile and give me a hug. That's important to me too. But try if you can to support, whether it's AIDS or the cancer foundation, so that someone else might survive, might prosper      and might actually be cured of this dreaded disease. I can't thank ESPN enough for allowing this to happen. I'm going to work as hard as I can for cancer research and hopefully, maybe, we'll have some cures and some breakthroughs. I'd like to think, I'm      going to fight my brains out to be back here again next year for the Arthur Ashe recipient. I want to give it next year! 

I know, I gotta go, I gotta go, and I got one last thing and I said it before, and I want to say it again. Cancer can take away all my physical abilities. It cannot touch my mind, it cannot touch my heart and it cannot touch my soul. And those three things are going to carry on forever. 

I thank you and God bless you all.

... and THANK YOU, Jimmy V, for your vigor to live and these great words to inspire.

--Timothy Malia, MD

PS -- I would like to acknowledge David McClure for passing along a blog by Jon Bischke called, "Don't Give Up. Don't Ever Give Up!" about finding motivation to not give up on making entrepreneurial efforts thrive. It pointed me back to the Jimmy V speech so I could share it with you..

Just saw a very interesting article by Pauline W. Chen, MD in the NYTimes about what qualities are needed for being a doctor and a study that considered the issue.

Well, actually the study referred to the personality traits needed for medical students in Belgium followed through seven years of training. I am not an expert on Belgian medical education but my sense is that the training roughly resembles the United States' standard of four years of college and four years of medical school, but over a seven year period.

A quick look at the actual study's summary finds that just under 50% of the original students were still involved by the end; and I do not know if they actually tracked the students who left and what they proceeded to do with themselves; but I for one would be interested in that as well.

(Doug Menuez/Getty Images from NYTimes ... been there, done that!--TM)

This reminds me of my medical school days when I was a student representative, and full voting member, on the Admissions Committee. It was a great experience that I think of often; likely a better experience than I initially thought it would be when I was chosen by my classmates.

First, I had the opportunity to interview dozens of very bright, eager applicants with stars in their eyes about what they dreamed of for a medical education and career (all while fatigue of my own education was dimming the glimmer of the stars in my eyes! I wonder if they noticed). I for one enjoy meeting intelligent, optimistic people.

Second, I came to know a good number of attending physicians and medical college administrators behind the closed doors of committee meetings. They impressed me. And they helped shape me and who I have become today. I learned that they were often times brilliant, and down-to-earth; serious, but understanding of life's hard knocks; opinionated, but, when push came to shove, open to others' perspectives.

Third, I learned about the criteria used for medical school admission, the importance of GPA but only as a relative gauge compared to the undergraduate school attended, the weight of the MCAT (standardized medical school test), and the subjective criteria we tried to glean from supporting materials. In case after case before us in the admission committee meetings, I recall how we considered the GPA/MCAT and then really did dive into the interview, life experiences and letters of recommendation to consider the "whole person" and what she or he would bring to the school and the field of medicine.

At times, an applicant with numbers suggesting brilliance but weak or questionable supporting materials was denied admission while another who was judged "smart enough" was accepted due to our assessment of the personality and qualities not measured on standardized tests or in Organic Chemistry lab. A very imprecise science, but we felt it worked well. And the administrators had data to show what criteria predicted early academic success and decreased the chance of failing out in the first two years; and what correlated to assessments in the later clinical years of school.

So this NYTimes article caught my attention, stirred emotions, and brought up old memories and experiences that have shaped me.

Chen's article points out how the system here in the United States, on the surface at least, appears to focus on academic ability and standardized test scores. It hints that many people feel there is only lip service paid to the subjective measures of personality and applicant qualities culled from letters of recommendation, interviews and personal statements/essays. My memories of the years on the Albany Medical College Admissions Committee would argue against that, but I doubt applicants and their families, filled with anxiety, will believe me.

The research in Belgium tried to study, objectively, some of these questions by assessing personality traits and then following the students through the training years.

They found that success in the later years, when students were more involved with actual patient care and less in the classroom/lecture hall, was not associated with the same criteria as the earlier years. This speaks of the need for caution in choosing criteria for judging medical school applicants.

Over time the personality qualities associated with grade point average were "extraversion, openness, and conscientiousness." Those three traits increased in importance in the later years of education. And, they note: "Conscientiousness, perhaps more than any other personality trait, appears to be an increasing asset for medical students."

My guess is that these findings do not surprise many people when we consider what a doctor does. And, back in November, I commented in a blog post on this issue and noted that being "a compassionate and rational doctor is the crux of the matter" as a friend from college, who is now an internist out west, reminded me in a note about a clinical situation she faced.

We do need to consider that the students in the Belgian study were likely all considered "smart" to begin with. Then, in the end, more than half those "smart" students were no longer followed. But, assuming similarity to the American system, those early years were the most academically-based so the early attrition may have lost some students who might have proved excellent in the later years and then in their medical careers. That would be unfortunate.

As Chen notes in the NYTimes piece, if we want medical schools to turn out lab researchers we may need to consider different criteria for applicants than if we want practicing medical clinicians.

So, which is it? Smarts or personality? What do you want your doc to have, and in what balance? I guess that is the challenge for today's students and the admissions committees for medical schools. Their decision and methods of choosing will affect us for years to come. Hopefully the optimal balance will be found.

Perhaps that Belgian research and Chen's article should be required reading.

--Timothy Malia, MD

In the NYTimes there is an article discussing the methods and costs of smoking cessation. Not the best article on the subject I think, but worth reading, especially to point people's attention to the issue. It mostly considers the costs of smoking cessation aids and not the actual methods needed, though it does speak of caution for some unproven methods marketed to the public.

I believe there is no health issue more important for me to help patients with than smoking cessation in regard to health maintenance and preventive medical care.

Let me restate that for clarity: helping patients stop smoking is the most important thing I can do.

Smoking cessation trumps diet, exercise, sleep, and even general high blood pressure, obesity, diabetes, etc, as a priority in my office. If any of those other problems are severe, of course, they can represent an acute urgency and therefore become the greatest priority. But, in general, nothing is more important than stopping smoking.

To demonstrate that, I suggest you check the website for the Framingham Risk Assessment tool. Playing with that calculator one can see how much smoking increases the risk of heart attack in the next ten years.

For example, a typical 44 yr old man with total cholesterol 200 and HDL (good chol) 45, not on blood pressure medicines but with systolic blood pressure 130 has a 3% risk of heart attack in the next ten years if not smoking. The risk increases to 9% if smoking! A woman with same demographics has <1% risk if a non-smoker, but a 3% risk if a smoker.

If age is increased to 64 years, the man has a 12% risk if a non-smoker and a 16% risk if a smoker. While the woman has a 3% risk if a non-smoker and a 6% risk if a smoker. These are all very big increases of risk!

No other criterion increases the risk as much. Using the 44 yr old man criteria again, if not a smoker but with total cholesterol very high at 300 and HDL (good chol) at just 40, his risk only rises to 8%, not as much as smoking.

Besides the risk of severe problems, like heart attacks and strokes, non-smokers and former smokers also have fewer respiratory infections and lower risk for a great number of cancers, even beyond lung cancer.

The data supports what we all have heard and what I am saying: for good health, there is nothing more important than not smoking. And so, for good measure, I will repeat myself in saying, "helping patients stop smoking is the most important thing I can do."

From the article, I think my favorite quote is:

There are 45 million adult smokers in the United States, but even more — 47 million — former smokers, according to Cheryl Healton, chief executive of the American Legacy Foundation, an antismoking, nonprofit group financed by tobacco litigation settlement money. 

I think that is great. There are now more former smokers than smokers in the United States! Good work for all you who have successfully stopped smoking. And, good luck to all of you hoping to join them in that demographic group.

If you are thinking about smoking cessation, please work with your personal physician closely. He or she should be able to help, and I hope they consider it as much a priority as I do.

A couple thoughts I wish to point out that were not mentioned in the article include:

(1) If considering Zyban (bupropion, aka Wellbutrin) be sure your doctor knows about any seizure history or significant head trauma in the past. It can lower the seizure threshold, so there is some risk for problems in that way.

(2) If using any of the medicines by mouth, like bupropion or Chantix, watch carefully for side effects, and do not stop them suddenly without being in touch with your physician. They can cause annoying side effects, some are quite bad, and stopping them can trigger other symptoms as well.

(3) The studies assessing the benefit of all the products also include close monitoring, counseling and follow up. Without those, you are lessening the potential benefit of any medicine or treatment you try.

(4) One must consider how smoking and cigarettes fit into life and how they are used for self-treatment of stress. Many of the treatments for cessation focus on the nicotine addiction, and that is fine, but very often it is the habit and the psychological meaning one gives the smoking behavior that needs to be addressed.

Smoking cessation is not just about nicotine addiction. It is a life change, and must involve a very big change of day-to-day habits, traditions and routines. You deserve to give it full attention and gather all the support you can to break through to better health and become an ex-smoker.

Good luck if you are trying to stop smoking. I hope 2010 is the year you will always remember for beating the habit ... and for saving a lot of money to boot!

--Timothy Malia, MD