Dr. Malia Reckons

From my friend, colleague, mentor, and former chief resident, Dr. Gordon Moore, I offer this full quote from his blog at http://idealmedicalpractices.typepad.com/ideal_medical_practices/2009/12/what-is-an-ideal-medical-practice.html

What is an ideal medical practice?

We are the cutting edge of office practice innovation in the US.  There are  many who would wear that mantle, but the clothes don't fit.

The cutting edge does not define primary care as a branch in a carefully designed hospital based system flow chart.

The cutting edge does not define primary care as a thousand details calling for endless analysis of minutia to justify every act, every stroke of the pen.

The cutting edge does not define primary care as grateful recipients of vendor technology to achieve 'meaningful use.'

The cutting edge does not define primary care as the practice capable of running fastest on the hamster wheel while spouting off about guideline adherence for a handful of clinical conditions.

We are the foundation of effective primary care.  Our patients are more likely to say:

• I can get care when and how I need it
• I have a PCP who knows me as a person
• My PCP cares for the bulk of my health care needs
• My PCP coordinates any care I need in the health system

The shape, size, financial arrangement, team configuration are means to the end.  We vary in shape, size, financial arrangement, team configuration to better serve our patients in vital and professional practice.

Real health reform also has the potential to save lives ... we now pay doctors to provide more care rather than better care.

David Leonhardt's post on the NYTimes on-line blog Prescriptions is quoted above and is an interesting piece that points to the need for true cost-cutting in health care, especially Medicare, but also how the political realities make it so difficult for Congress to make it happen. He sees hopeful signs that a good number of Senators are gearing up to fight the scare tactics and political struggles to pass legislation that may make needed cuts.  http://www.nytimes.com/2009/12/09/health/policy/09leonhardt.html?hp

Leonhardt points to some bill amendments that may help in shaving excess costs which are not really helpful to patients' well-being. Honestly, some of these ideas I have mixed feelings about. For example, I am a supporter of home-health care as I have seen it work fantastically well for many patients, and I believe it can benefit the patients and their families, and likely cut overall care costs. However, evidence suggests there is a huge portion of home health care costs that is waste and being paid to services not providing optimal care. I would hope the system can cut out the waste and support the beneficial care; yet I worry some patients will lose good services due to the need to cut overall costs.

But my colleague, Dr. Gordon Moore, points to what I think is the more important opportunity. And the quote from Leonhardt's article points to the same. True health care reform will benefit patients' health and actually involves more than just the funding of care and health insurance. See Moore's full blog post about that here --  http://idealmedicalpractices.typepad.com/ideal_medical_practices/2009/12/it-is-abundantly-clear-that-our-medical-system-wastes-enormous-amounts-of-money-on-health-care-that-.html

The current system rewards volume of care and not quality of care. Dr. Moore, in his blog, explains well what is needed to bring real reform -- better primary care medicine that allows for responsive, high-quality care based on an on-going patient-physician relationship supported by respect and communication. Specifically, Moore says:

Blanket policy that fully funds the work of effective primary care will improve population health, improve the experience of care and reduce per capita health care costs.

This policy  can and should be linked to primary care delivered effectively.  Patient experience defines the level of achievement of effective primary care:

• I can get care when and how I need it
• My PCP/nurse know me as a person
• My PCP/primary care office cares for the bulk of my health care needs
• My PCP/office coordinates all care I need in the larger health system

A prior post of his referred to the success of some offices using Ideal Medical Practices techniques which were studied and found to be providing exceptional care -- http://idealmedicalpractices.typepad.com/ideal_medical_practices/2009/09/real-.html

And a final post of his referred to an article by Barbara Starfield looking at the inadequacies of some descriptions of "medical homes" -- http://idealmedicalpractices.typepad.com/ideal_medical_practices/2009/06/effective-whole-person-care-ie-family-medicine-should-define-health-reform-b-starfield.html

Starfield makes a clear description of what exceptional primary care should look like:

• First contact care, which requires accessibility and responsibility for reducing unnecessary specialist care,
• Person-focused care over time delivered by the patient’s chosen physician, who assumes responsibility over long periods of time for all health care,
• Comprehensiveness of care, and
• Coordination of care when people have to go elsewhere for problems outside the competence of the primary care practitioner.

I find it ridiculous that a full explanation of what screening means has not been a major part of the public conversation about the new recommendations for breast cancer screening by the U.S. Preventive Services Task Force (USPSTF). I wish to clarify  this issue to allow for a more fruitful discussion about these, and other, medical recommendations..

Recently, I posted thoughts about, and a defense of, the USPSTF http://drmaliareckons.posterous.com/breast-cancer-screening-part-1-overview the group charged with evaluating medical research and evidence of benefit for a large variety of health services. The USPSFT makes  recommendations, and regularly amends them as new information about services and relative effectiveness becomes available. In later posts I will consider the breast cancer screening recommendations more specifically and consider some common sense ways to understand them and other medical services.

The importance of screening is obvious as it is an integral part of primary care medicine. Yet the public has no perception of the significance or concomitant risks; and the popular media seems to have made no effort to explain it. The opportunity to do so has been available recently with a string of related news items. Besides the recent change in breast cancer recommendations, there was also a report in October that the American Cancer Society (ACS) may be changing its stance on "cancer screening." It was reported that the organization may start pointing to the fact that aggressive "screening," though it saves lives, may have been over-sold and, in actuality, the issue is more subtle and that testing can often lead to further evaluations and treatments that can have negative impact on life.

After being reported in the NYTimes http://www.nytimes.com/2009/10/21/health/21cancer.html the ACS website published a formal statement from its CEO, John Seffrin http://www.cancer.org/docroot/MED/content/MED_2_1x_A_Special_Message_from_CEO_John_Seffrin_PhD_on_Cancer_Screening.asp to try to clarify the perspective, a response  which I actually feel only added to the general public's confusion, and muddied the water of later conversations.

Adding to the support for understanding the concept of screening is that on the heels of the new USPSTF recommendations about breast cancer screening was a change in the formal recommendation by the American College of Obstetricians and Gynecologists (ACOG) for pap smears and cervical cancer screening http://www.acog.org/departments/dept_notice.cfm?recno=20&bulletin=5021 which advised a later start of the testing and less frequent testing due to risks of problems after possible treatments and the limited benefit of doing pap smears more often.

Yet even with a string of headlines about changes to formal medical recommendations related to screening, I have seen essentially no effort to help the public understand the fundamental concept. And, considering the strong feelings and visceral emotions many people have expressed, this failure is very unfortunate. We physicians should feel an obligation to clarify this, post haste.

So let's get to it.

Screening tests look for important conditions before any problems / signs / symptoms become apparent.

Whether a screening test is "good" or not, and whether we should use time and energy for the test, is a judgment call that must consider a variety of factors related to the test and the medical condition being screened for. Let's consider some of these factors as well as how breast cancer screening relates.

• Screening tests are only meant for low risk patients.

I can think of no other point more important to understand related to screening for medical problems. In the last few weeks I have had multiple conversations with people, including some who work in health care; seen commentators on TV; and read newspaper and web-based articles which seemed to miss this point as they attacked the USPSTF's recent recommendations for breast cancer screening.

Low risk patients for breast cancer would be women with no first-degree relatives (mother, sister, daughter) or not more than one more-distant relatives (cousin, aunt, grandmother) with breast cancer, as well as no known high-risk breast cancer genetic markers. But, also, in considering risk for breast cancer, we also should think about use of estrogen-based birth control pills, age of first pregnancy and total time used for breast feeding.

Finally, if a finding is noted by the patient or a physician, the patient is no longer in the "screening pool." Rather, that person is being "evaluated," and not screened, for a problem.

The USPSTF recommendations are not meant for any women with suspicious findings on exam or with any increased risk for breast cancer. This is fundamentally important and can not be stated too strongly or too frequently.

• The condition being checked for must be relatively common.

If a condition is not relatively common, doing mass screening would mean we must test a huge number of patients, using massive resources, and not find many cases. Logic will dictate that we should not use our medical providers and resources looking for problems that are not common.

Breast cancer is certainly a frequent health problem with estimates that about 11% of all American women will be diagnosed in their life. But it is clearly occurs more frequently as women age with most cases in women over 50, and the highest rate of disease in women over 60. Though we often remember and discuss the women diagnosed at young age, that is much less common than breast cancer in older women.

• The condition must be significantly dangerous.

If we are screening, our goal is to offer patients more years of good health. If the diagnosis is not dangerous or the illness load is not great, our energies and resources will offer little "bang for the buck."

Breast cancer is a major killer for women. But, again, it kills many more older women than younger women. Some would say that the number of years saved when a younger woman is diagnosed with early screening makes that screening effort more valuable. But since screening is meant for whole populations we must consider the prior points and, since younger women have such a lower frequency of breast cancer, that the relative total burden saved by screening efforts is small compared to the effort of full screening.

Another unfortunate aspect of breast cancer, as well as other cancers, is that we often can not know how deadly a cancerous growth might have been if it were not removed. Evidence suggests that some cancers are more aggressive and others less. This means that when breast cancer screening uncovers a problem, a doctor can not tell a patient what the risks fully are. We are always working with incomplete information. At times, a more aggressive cancer may already have spread, while a less aggressive cancer may be far from metastasizing. Yet the formal medical recommendations may be the same for treatment options because we simply can not tell the difference.

• A screening test should uncover a problem "early" enough for treatment to prevent severe illness / death.

Some screening tests find pre-cancerous findings that allow for an early procedure that significantly lessens long term risk for the patient. These are optimal. Examples include Pap smears for cervical cancer and colonoscopies that allow for removal of pre-cancerous polyps from the large intestines.

Other screening tests only provide possible early detection, after actual cancer has begun. That is obviously less preferred. Breast cancer screening with mammograms fits that bill. It is the best we have, but it's not a great screening test. And, when seen in light of the last point that we do not always know what cancer lesions are more aggressive or less aggressive, we can see that it is not a great method to look for breast cancer, though it is our best weapon.

• A screening test should be relatively innocuous.

No test we recommend for a large number of patients on a regular basis should be exceedingly dangerous, painful, difficult to carry out or expensive. Otherwise, ultimately, patients would not want to have the tests done, we might be causing more health problems than we are preventing and the financial burden would be prohibitive for our whole system. Clearly, none of those results is acceptable.

Mammograms and related tests like ultrasound and MRI, along with clinical breast exam, are not comfortable according to many women, but they certainly are not, on their own, exceedingly painful, dangerous or difficult. In this regard the tests used for breast cancer screening are quite reasonable, even if, as noted above, they are not of the best quality for uncovering cancer.

• A screening test should make accurate diagnoses.

A test needs to be accurate. If a test seems to find a problem that is really benign ("false positive"), a patient too often will have unnecessary emotional stress and will go through testing that has additional risks. And, if a test appears benign when it actually misses a true condition ("false negative"), we are offering reassurance to a patient and failing the primary purpose of our efforts.

It is imperative that we only suggest patients undergo screening tests which are accurate and have as few false positives and false negatives as possible.

Regrettably, our breast cancer screening tests do have many false positives leading to a great deal more testing that ultimately proves unnecessary, especially in patients under 50 years of age, as well as too many false negatives because the technique of mammograms, basically looking for a slight variation of the shadow of x-ray images through breast tissue is very subtle and can miss early cancerous changes.

• Treatment options for a condition uncovered should be effective.

If a screening test does find a condition, it is only right that a reasonably effective treatment is available for the patient that can lessen suffering and improve life.

Some cancers simply do not have good treatments for when they are found. I think of pancreatic cancer which is very difficult to find early, thus is often found quite late, and most often requires a significant abdominal surgery.Other screening tests, such as Pap smears for cervical cancer, find pre-cancerous changes and allow for relatively easy treatment that prevents progression to full cancer.

Breast cancer, luckily, does have treatment options, including surgery, radiation and at times chemotherapy. Unfortunately, those treatments are at times inadequate as the screening tests find the cancers too late, or the cancers found are inherently aggressive and already have metastasized.

So there you have it. Screening, a fundamentally important practice in primary care medicine, needs to be better understood by the public. And I hope this primer helps in that effort.

I still plan for two more posts related to the recent change of the breast cancer screening recommendations and the hullaballoo it has triggered. Watch for them soon.

Timothy Malia, MD

The Afghanistan war and the decision to have a build up of the military there makes me think of the old Nick Lowe/Elvis Costello song, "Peace, Love & Understanding."  And I wonder how many of the Afghans, after the many decades of war, invasions, militant recruitment efforts, corruption and violence, would relate to it.

But I imagine the title as "Health, Schools & Understanding" now.

As I walk through
This wicked world
Searchin for light in the darkness of insanity.

I ask myself
Is all hope lost?
Is there only pain and hatred, and misery?

And each time I feel like this inside,
There's one thing I wanna know:
What's so funny bout peace love & understanding? ohhhh
What's so funny bout peace love & understanding?

What's so funny about health, schools & understanding?

As a physician, I do believe that medical care is a necessary part of any organized, healthy society. I feel that supporting the health and welfare of the Afghan society is a fundamental need if we are to have success in the country. If we are to have a "build up" in Afghanistan, I hope we consider carefully what its substance is made of. Besides more troops to physically battle enemy militants, I hope we can physically battle poor water quality as well as poor health, and confront educational limits throughout Afghan society, and develop projects the Afghans can use to build a better future.

An Op-Ed piece by Nicholas Kristof in the NYTimes this morning points to these issues. http://www.nytimes.com/2009/12/03/opinion/03kristof.html?_r=1

Kristof notes the massive cost of our military efforts in Afghanistan and relates it to the profound distrust many in the population may have for foreigners. He suggests a bigger effort to build what I might call a stronger infrastructure of health and education.

And as I walked on
Through troubled times
My spirit gets so downhearted sometimes
So where are the strong
And who are the trusted?
And where is the harmony?
Sweet harmony.

Cause each time I feel it slippin away, just makes me wanna cry.
What's so funny bout peace love & understanding? ohhhh
What's so funny bout peace love & understanding?

What's so funny about health, schools & understanding?

Though I regret the death of any innocents and the general violence of war, I can see some logic in the need to use military force to battle those who are spreading terror around Afghanistan and to spread it to the world, including here in the USA. But I fear it is very shortsighted to believe all-out military force will bring "success" to the efforts in Afghanistan, or anywhere. Any success of that kind may be short-lived as the society itself will only have been stained, and strained, ever more, and not profoundly stronger.

Just as in Vietnam, where the population had been at war for decades, including a long battle with the French just before we entered the situation, Afghanistan has suffered the trauma of war and an unstable society for decades, and also has battled outsiders on their own soil. A new tact must be used that goes beyond military might -- an effort to bring "sweet harmony" perhaps.

So where are the strong?
And who are the trusted?
And where is the harmony?
Sweet harmony.

Cause each time I feel it slippin away, just makes me wanna cry.
What's so funny bout peace love & understanding? ohhhh
What's so funny bout peace love & understanding? ohhhh
What's so funny bout peace love & understanding?

What's so funny about health, schools & understanding?

Here is hoping for the best in Afghanistan, for its people and all Americans who are willing to serve there. I believe everyone wants "the best" for the country. Let us hope the formula being used is the right one for long-term benefit.

... and here is a soulful version of the song, with the singer and the songwriter, to help us consider the issue (captioned too) ...

What's so funny about health, schools and understanding?

--Timothy Malia, MD

Sleep problems are common, especially insomnia. I often recommend increasing daytime physical activity and exercise to help with that. Though a nice bedtime story can only help ...

But, honestly, many suggestions floating around the medical world are based on unsupported assumptions or simply guesses based on hypotheses of benefit. And I have at times wondered about the exercise-to-help-with-sleep advise since some folks claim that exercise, especially in the evenings, makes it more difficult to fall asleep.

The other day, however, I was happy to see a piece in the NYTimes that examined whether there was truth in the claim that exercise helps with sleep http://www.nytimes.com/2009/12/01/health/01really.html and to learn that there is strong evidence that this advise has been proven true.

And it gets better. Not only does daytime exercise improve sleep for adults, but it makes kids fall asleep faster and sleep longer!

No copay, no side effects, no addiction risk ... get the kids moving, keep moving yourself ... and sleep well.

FYI, here are some of the research articles mentioned in the NYTimes piece:

http://www.ncbi.nlm.nih.gov/pubmed/19633062?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1

http://www.ncbi.nlm.nih.gov/pubmed/15892929?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1

http://www.ncbi.nlm.nih.gov/pubmed/8980207?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1

-- Timothy Malia, MD

It is only an anecdote, but today I received two glowing reviews about Rochester General Hospital (RGH) and specifically about the personal, respectful service provided by both the medical and support staff there.

In both cases the individuals described having a recent negative experience at another major local hospital, Strong Memorial (SMH). One patient specifically described a prior bad experience at RGH many years ago and how astounded he was at the exponentially improved service he has been receiving for two significant health problems he has had the last seven months.

I hear good and bad about hospitals and medical services around town almost every day from my patients. At times, one person will be happy and later the same day another will be unhappy about the same place. So today I was struck by how satisfied these people were, and how their words seemed to mirror each other perfectly.

Perhaps the comments are reflecting some real improvement in patient care and service at RGH.

If so, I say, "BRAVO, RGH! Keep up the good work."

As a primary care doctor, it is great to know my patients and their families may receive high-quality, respectful care and service when they are sick and most in need of support and compassion.

I checked the website for RGH and saw a small video about giving better service to patients and families. Typically, I think such things are superficial bunk. But, today I'm thinking, and hoping, it represents reality. http://www.rochestergeneral.org/

How about you? Are you seeing changes, for good or bad, in the care and service you are receiving at hospitals and medical facilities?

--Timothy Malia, MD

A college friend was in touch last evening. She is an internist on the other side of the country and was seeking feedback and a fresh perspective for a clinical dilemma for a complex patient. The case involved a mix of health problems wrapped in psycho-social challenges, plus the additional wrinkle that the patient was new to her. In total, I see the case as requiring exactly what good primary care can offer along with a dose of specialist medical treatments.

But, in the end, I was most struck by a phrase she used: "compassionate, rational physician."

Those words have been echoing around my mind because I realize they are the crux of the matter in health care. Balancing them is the art a physician seeks to master -- using the higher mind with rationality as well as responding to the heart with compassion.

Physicians have an obligation to be well educated and knowledgeable. In wielding that knowledge, we should be rational and work objectively.

Yet we are human, both patient and physician, and depend on emotions. One may say that ultimately we are swimming in the milieu of our own subjective, emotional sea more than walking on some hard, objective land.

I am reminded of a favorite saying I learned back in medical school: People won't care what you know until they know that you care.

Is our medical system, or even our whole society, actually helping doctors find the best balance of compassion and rationality?

My first answer is NO.

Bean counters can track the number of appointments seen in a day, the number of referrals, the number and cost of prescriptions, etc. They may even judge the quality of certain care plans and whether treatments follow recommended guidelines relatively well. But they can not measure the other half of the art: the subjective, the compassion.

And, further, I fear the support for physician well-being is being eroded in the all out rush for office efficiency that actually may be leading to some loss of effectiveness.

Just as we need physicians to be rational in making the right decisions and giving the best advise, we also need them to be compassionate so the advise can be accepted and trusted by the patient, who, let us remember, is actually the most important member of the health-care team.

What do you think?

--Timothy Malia, MD

How much would your doctor charge you for an appointment if you had no insurance? If you are like most people (almost all people?), you likely have no idea. Changes in insurance and health care payment methods make this question more relevant than ever, however. And today an article in the NYTimes touches upon this very issue and how some folks are making choices about where to receive care based on out-of-pocket costs and internet resources to evaluate those costs. You can see the article here http://www.nytimes.com/2009/11/28/health/28patient.html?ref=health

My emotions are mixed on this issue.

First, I think how wonderful it is that patients are taking control of their health care and finding ways to pay for their own medical services. They appreciate the importance of the care and are finding ways to fit it into their lives.

Second, I think it is great that some doctors are lifting the veil of secrecy and letting patients know what charges are for medical services. Such transparency, I believe, must be part of how America starts getting control of health care costs and allows for true "value" of care. That is, "quality" as related to "cost" (V=Q/C) should be understood as essential for wellness and sensible health-care financing.

But, third, this article scares me to my core. Why? Because of what it could lead too, what I think of as "Walmart health care." I previously wrote about free antibiotics being offered at a local supermarket pharmacy and how that hints at the "competition" that may be coming in health care, and, which I fear, may lead to the loss of great, small-office, primary care medicine. See that post at http://drmaliareckons.posterous.com/free-antibiotics-and-doctorpatient-responsibi

My fear comes from my mind's extrapolation of what primary care medicine could look like if full competition came to the market. I imagine what I would do in that economic environment if I were in charge of a big local hospital. Basically, in that situation, my goal would be to bury small, private medical offices and get their patients into my hospital and clinics.

Before I go on, please understand this process is already underway as the large systems and hospitals now buy up small primary care offices and their salaries. This essentially has led to primary care medicine being subsidized by the hospitals as they take a loss on the primary care offices and the physicians' guaranteed salary but make the money back from other hospital and medical services throughout the system. But I fear that further changes will amplify the process and accelerate us toward a system that I believe will limit patients' options for high-quality, personalized care.

Now, back to my mind's extrapolation. Imagining myself in charge of a local "Big Hospital" in a medical care environment with "full competition" for primary care, I look for ways to get patients to use my high cost services by giving away cheaper services, Blue Light Specials if you will. Here are two promotions I could imagine offering to do that:

1) For expecting parents, I offer FREE sick appointments for the child's first two years if they deliver the baby in the hospital and use a pediatrician within the hospital's system. The hospital would make money from the delivery and all the well-child checks (about 8-10 visits the first two years of life). They then would give "free" sick visits, with no copay or no charge at all. Babies typically have 2-6 sick visits in those two years which would basically be about $150-$500 perhaps in total, and, assuming a $10-$30 copay for the family, a savings for them of $20-$180 out-of-pocket.

As a small, private family physician I could not "compete" with that if a family came to me and asked if I could give them free sick visits for the first two years of life too. I would say, "no," but then try to remind the parents of the personalized care and access they would have with me but possibly not in the Big Hospital system. Then they would have to decide how to proceed.

2) For older patients who often have a few prescription medicines for which they at least have a monthly copay for, or perhaps pay fully out-of-pocket, I would offer a deal on the medicines if they used the hospital's endoscopy suite for colonoscopy or the radiology department for mammograms. The patients would be saving some money out-of-pocket for the medicines but the hospital would be making a better profit from the medical procedure and having the patients tied to the hospital-based primary care doctors and the specialist doing the procedure, as well as having them start to use the hospital-based pharmacy.

Again, how could I possibly "compete" with that if the patient will be saving money on services (prescriptions) I as a private family physician have no way to affect?

So, we move forward in the health care discussion, and new designs for funding health care are upon us. Some patients are uninsured and need to save money each step through the health care maze. Others are facing increasing co-payments for appointments and services. While others have larger deductibles and are looking to stretch those dollars.

But are we maintaining value for those dollars when we think of only the cost but not the quality? Do small-office, private primary care doctors offer a service that makes their value greater than just the cost would suggest? Are the bigger systems, the "Big Hospital" clinics, due to their size, going to "compete" differently than any private medical office can possibly imagine?  

I do not know the answer to these questions, but I do worry about how our society will ultimately answer them. We are seeing the small, private pharmacies disappear because the marketplace has changed because of the big store pharmacies. Will that be the same for small, private primary docs in the near future? The way things are going, I do not doubt such demise could come our way.

Oh, and by the way, for simple appointments I charge $66 if a patient pays on the day seen, and for a more complex appointment, $99. I give a discount for payment when seen.  I think that's fair as the patient saves me the work of billing/collecting, and it's a smart business decision for the ever more competitive medical environment I am in. See, the change is upon us!

--Timothy Malia, MD  

I just read something that is really exciting, at least for me, a family physician. Dane County in Wisconsin has significantly slashed the premature birth rate for the African-American population over the last 10-15 years. Check the article here http://www.nytimes.com/2009/11/27/us/27infant.html?hpw

Reading the article I was struck at what may be leading to the low rate of premature births. It does not relate to any significant change in the formal medical community as the obstetrical care has not changed. Rather, there is a mention of a community health clinic* where a patient can receive needed care. But the care itself was atypical with a mention of longer appointments and the provider (nurse mid-wife) connecting with the patient. Services reached out into the community with visits at the home and referrals for needed care that many people do not relate to premature births, such as dental care. Reading the article I got a sense the patients mentioned were being a bit more empowered in their own health while being helped in finding good services for their needs.

Note how the programs Dane County used are available state-wide but similar results for premature births have not been found in other counties. It seems the Dane county medical community, teaming up with the social services community, used less common methods to support and improve health of the patients. By mobilizing themselves to use the available programs, the community may have truly improved the lives of many mothers and their babies -- the system, when implemented well, served a great purpose.

Basically, they were "thinking outside the box" and offered services and care the patients needed beyond just what they, the doctors and social service providers, often typically focused on. That is, they offered "patient-centered care."  Sadly, the programs are available to other counties but not being implemented as well. Why is it that using available resources actually equates to "thinking outside the box?" What is keeping us from improved health and medical services when much of what is needed is available but simply not being used to the fullest extent and benefit?

Such a story as the Dane County drop in premature birth rate is stirring to me as it shows how important it is that we consider what the patients really need in their lives, not just how we are taking care of a health condition or medical problem.

When a life is healthy and better supported, the medical care will be easier to maintain.

Let us keep that in mind as we consider "health care costs" as a percentage of the economy -- perhaps there is more to it than just the numbers.

--Timothy Malia, MD.

* -- Anyone who knows me realizes I was not a fan of President GWBush. But, to be fair I do acknowledge respect for a few things his administration did. Domestically, they supported community health clinics very well, and this article reminds me of that. Internationally, the administration did a fine job in supporting the increased funding and efforts to control HIV/AIDS in Africa.

Those who give thanks, live long and prosperous lives.

The harder the times, the sweeter the psalm written by the psalmist.

Thanksgiving Day is a great American holiday, and for many of us a day of family, parades and football. But, perhaps most famously, it is a day of eating. Rich, delicious foods are shared at our tables: turkey, stuffing, sweet potatoes, apple pie, pumpkin pie, ice cream, and so many other favorite foods often held as special family traditions (for the Malia clan it's my mom's rich chocolate sauce on ice cream, a tradition I'm proud to say my daughter is the first to pick up at an sufficient quality so it may be passed on!)

I wonder, however, if we should be considering the health benefits of our celebration on the fourth Thursday of November. No, I would not say that gorging ourselves with excessive calories of each of our favorite foods is healthful. But I would say the sentiment, the core meaning of the day, is good for us. Thankfulness adds to our wellness, psychologically and physically.

This evening I was reminded of this at a beautiful event, the 16th Annual Interfaith Thanksgiving Service presented by the Perinton Lay Clergy Council held at St. John of Rochester Church here in Fairport. The service included prayers, music and talks from various religious denominations in the area: Catholicism, Islam, Judaism, Native American/Iroquois, Hindu and Baha'i.

Words by the Imam of the local Islamic Center, Dr. Muhammed Shafiq, and Rabbi David Abrahams of the Congregation Etz Chaim reminded me of how thankfulness ties to health, however. The theme of the service was Giving Thanks in Hard Times which obviously is appropriate considering the effect the tough economy has had on so many of us while reminding us that we still have so much to be thankful for.

Rabbi David Abrahams commented that in studying Psalms it is obvious that the harder the times, the sweeter the psalm written by the psalmist. That reminded me of so many patients I work with each day who have been suffering for reasons they neither expected nor deserved in the last year or two. In any year there are deaths and unexpected health problems, but now we have added many months of financial struggles for so many of us.

If you are reading this and are feeling the hard times, for your health, both physically and spiritually, please remember that your hard times can make your psalm more sweet. Drink in that idea for Thanksgiving and keep your focus on those beautiful parts of your life so you can fully appreciate the sweetness.

Dr. Shafiq's comments made me see even more fully the importance of thankfulness and health. Mentioning the words of the prophet Mohammed, he explained the lesson that those who give thanks, live long and prosperous lives. Discussing the idea after the service, he further explained that the message was that to those who give thanks to God for what has been provided, more good is provided in ways of profound wellness in health and life in general. Other, related ideas come to mind: kharma, the recently popular Secret self-help phenomenon, or even the common phrase, "what goes around, comes around." Each points to the beneficial effect that positive power, including thankfulness, has in our lives.

Take time this week and be thankful for your God, or any way you know or see your God, and appreciate all you have from that relationship. Then sit back and let your life be full.

-- Timothy Malia, MD

PS -- The Perinton Lay Clergy Council has a special fund, the Perinton Good Neighborhood Fund, which is available to clergy in the area to help individuals in financial need. See the webpage at http://www.pem-emp.org/pgnf.html or, for more information or to offer a donation, you may email Rabbi Abrahams at smaharba@hotmail.com.