Faculty Spotlight: Gary Milechman, MD
An enthusiastic golfer, Gary Milechman, MD, sees many parallels between his hobby and his work as a cardiologist. “You can’t hit a golf ball far if your hands are tense and nervous,” he said. “You have to be relaxed, but very focused at the same time.” He takes the same approach to his work as a cardiologist, whether he is doing procedures, making complex decisions, or discussing a treatment plan with a patient.
Dr. Milechman recently joined the UCSF Division of Cardiology faculty, bringing more than 30 years of deep experience in many areas of cardiology. He previously worked at Mount Zion Hospital and Medical Center, California Pacific Medical Center (CPMC), St. Mary’s Hospital, and UCSF, and was a partner at Golden Gate Cardiology Medical Group, one of the premier cardiology private practices in San Francisco. He and his three partners were recruited to UCSF in 2016 to expand the Division’s clinical services.
Dr. Milechman and his colleagues are now based at 1 Daniel Burnham Court, and take turns providing full-time coverage for hospitalized patients at CPMC. Dr. Milechman also cares for inpatients on the Parnassus campus, serves as an attending physician in the cardiac catheterization lab several times a month, and teaches trainees at both UCSF and CPMC.
A Born Healer
Dr. Milechman was born and raised in the Bronx, where his father ran a shoe store. From his earliest years, he always knew he wanted to be a doctor. When he was about five years old, he was playing ball when it bounced into a crate full of glass Coke bottles. One of the bottles was broken, and when he reached in to grab the ball, he cut his arm down to the bone.
“I found my mother and we went to the emergency room,” said Dr. Milechman. “I remember telling the doc, ‘I want to watch you sew it up.’ He said, ‘Turn away, turn away!’ My mother said, ‘No, he’ll be fine.’ After it was numbed up, I watched the whole thing and thought it was fascinating.”
After earning bachelor’s degrees in chemistry and biology from Herbert H. Lehman College in the Bronx, he completed his medical degree from the State University of New York at Stonybrook, followed by his internal medicine residency and cardiology fellowship at Mount Zion Hospital and Medical Center in San Francisco.
He also spent two years working there as an emergency department attending physician, which provided him with a wide range of experience. “I treated patients with cuts, broken bones, abdominal pain, knee pain, earaches – anything,” said Dr. Milechman. “I had to look at things and manage them, and that helped make me a better doctor.”
He enjoyed working with his hands and considered becoming a surgeon. However, Dr. Milechman ultimately decided to pursue cardiology because he liked caring for heart patients during residency, and appreciated the opportunity to use his fine motor skills to perform cardiac procedures.
During his training, he worked with a number of mentors who helped him develop his clinical and diagnostic skills – imparting valuable lessons that he now shares with trainees. As a medical student, Dr. Milechman spent some rotations with Edward Meilman, MD, founding chairman of the Long Island Jewish Medical Center’s Department of Medicine.
“He said that when you have a differential diagnosis, you want to go from most likely to least likely, but that’s not the only list you have,” recalled Dr. Milechman. “You have another equally important list of diagnoses that you can’t afford to miss. Then there’s a third list, which includes conditions this patient could have that everybody else is missing. You need to think about all three lists. I still remember this approach, and I teach that now.”
Dr. Milechman also spent time training with Monty Zion, MD, chief of cardiology at Shaare Zedek Medical Center in Jerusalem. “He was a classically trained cardiologist from South Africa who trained with John Barlow, one of the great names in cardiology,” said Dr. Milechman.
“He was a master clinician in looking for clues and listening for problems – still very useful skills for talking with patients and figuring out what’s wrong.”
Broad Range of Experience
Dr. Milechman trained before the current era of sub-subspecialization, allowing him to pursue his interests in many different areas of cardiology. As a cardiology fellow, he spent considerable time with Melvin Scheinman, one of the founding fathers of cardiac electrophysiology and now the Walter H. Shorenstein Endowed Chair in Cardiology.
“Electrophysiology was just starting when I was a fellow,” said Dr. Milechman. “I was fascinated with the way the heart’s electrical system works and the way pacemakers work, and the interaction between the two. I liked both the procedural aspect as well as figuring out what kind of rhythms somebody has and why, and what will happen as a result.” He enjoys implanting devices, such as pacemakers and implantable cardiac defibrillators, for patients who need them.
He was also inspired by Dr. Scheinman’s respectful manner. “He’s such a mensch,” said Dr. Milechman. “He talks to the lowliest student the same way he talks to a group of the world’s leading electrophysiologists, and doesn’t talk down to anybody. That’s a quality I try to emulate.”
Dr. Milechman also enjoys working in the cardiac catheterization lab, opening up blocked coronary arteries and performing diagnostic tests such as angiograms. “It’s very satisfying and exciting,” he said. “Sometimes you’re taking care of patients who are having a heart attack, so you have to make the right decisions quickly. It’s a high-risk position, but also provides high immediate rewards.”
In addition, he has a keen interest in lipid management, based partly in his personal experience with heart disease when he was in his 30s. “I was dragging a hose up a hill beside my house, and I didn’t feel right,” Dr. Milechman recalled. “I got short of breath, even though I was in very good shape.” Even though he was young and otherwise healthy, he was diagnosed with symptomatic coronary disease, underwent an angioplasty, and decided to change his diet.
“I’m a low-carb, low-sugar guy,” said Dr. Milechman. “I haven't had a piece of chocolate cake in years! I’m not saying that my diet is right for everybody, but for my insulin-resistant patients with type 2 diabetes, and those with high triglycerides and low HDLs, my diet really helps. It’s different when I say, ‘I want you to eat like me,’ versus ‘Eat like this.’”
“I share my personal experience with patients, particularly young guys with coronary disease, because it's almost always a manageable problem if you treat the problem before it’s too late, when the heart is too damaged,” said Dr. Milechman. “I think it helps people to see me all these decades later, doing fine.”
Building Partnerships with Patients
Dr. Milechman considers teaching an essential part of his role as a cardiologist. He explains issues to his patients so they can make informed choices. “In almost all situations, patients are participants in their health,” he said. “If they understand why they need to be reliable in taking medication, or what a lifestyle change can do for their heart and health, they’re much more likely to do it.”
He strives to tailor his approach to each person. “People have different backgrounds, anxiety levels, and language skills, so you can’t teach everybody the same way,” said Dr. Milechman. “Also, I always talk to patients about something non-medical, to connect with them on another level. People have had very interesting lives, and I’ll ask them what college they went to or what their kids do. That helps people feel like you care about them as a person, not just as someone with high blood pressure. That helps patients take your advice in a different way.”
When appropriate, Dr. Milechman also enjoys sharing a sense of humor with patients. He has a whimsical collection of pins, and chooses a seasonal selection of eight or 10 to wear on his white coat. “Some people think I’m a pediatric cardiologist, but most appreciate that part of me,” he said. “By nature, I don’t have a serious, stern face.”
He avoids lecturing his patients. “I don’t think most people respond to ‘Do this or you’re going to die,’” said Dr. Milechman. “Everything we do is probability. If you don’t drive in the safest way, it doesn’t mean that you’re going to get into an accident or die – but the probability of arriving at your destination safely is higher if you use good driving judgment and technique…. I never take anything personally. If someone doesn’t want to follow my advice, I tell them, ‘I’ll still love you, and we’ll do the best we can by doing it your way – as long as you understand the tradeoffs.’”
Getting to know his patients in the clinic as well as being involved in their procedures and other facets of their care helps Dr. Milechman develop a nuanced sense of which treatment strategies are the best fit for each person. “Knowing the patient, their symptoms, and their likelihood to take prescribed medicines helps me make better decisions for each patient,” he said.
Training the Next Generation
In addition to explaining issues to patients, Dr. Milechman loves training medical students, residents, and fellows, and has won numerous teaching awards. He coaches them to ask patients open-ended questions to piece together a robust history. Sometimes a patient will tell him that they run three times a week and feel fine. “When I ask them where how far they run and how long it takes them, they might say they run two miles in 35 minutes,” he said. “Of course, you could walk two miles in that amount of time. Or I might ask them why they don’t run uphill, and they tell me that they get short of breath and have to stop. Those details help me get more of the story.”
Dr. Milechman investigates further when things don’t add up, and doesn’t rely on technology alone. “Even the most advanced testing is not perfect,” he said. “When the story and my exam don’t match the test, I reevaluate until I am certain what the problem is, and what the best course of treatment is.”
He also scours their EKG, physical exam, and other sources for clues that might contribute to a diagnosis. “I tell residents and fellows not to be too specific too soon,” said Dr. Milechman. “Look at the whole person, not just their neck veins. Is there something funny about the way their hands look? What is that pulsation in the neck? Why are they the color that they are? You have to look at things specifically, but you also have to take a bigger view.”
That wide-angle lens extends to the patient’s whole life. He often advises trainees to ask themselves two questions: what does this patient’s heart need, and what does the patient need? “Sometimes the two answers are not the same,” said Dr. Milechman. For example, a relatively young and healthy patient might benefit from the most aggressive treatment to address a narrowed coronary artery, but a frail older patient with kidney disease and limited mobility might be best served through a more limited intervention.
“A lot of our decisions come down to very simple questions,” said Dr. Milechman. “Will our proposed treatment make the patient feel better, live longer, or help prevent something bad from happening? The answers may be different depending on their life expectancy and other health issues. I try to consider the whole person, what’s most important to them, and the tradeoffs. Sometimes I’ll present the options, and let the patient decide.”
Even with his decades of experience, Dr. Milechman is constantly striving to improve, and also to keep pace with the dynamic changes in cardiology and medicine as a whole. “One of my medical school professors said, ‘I want you to learn everything I tell you – but in 10 years, one-third of what I tell you will be wrong,’” he said. “It’s true! Mechanisms of disease and ways of treating them are always evolving. You think you understand something, but there is always something that will be discovered, or a new way of thinking about a disease process. It’s very exciting.”
A Rewarding Career
Dr. Milechman continues to find deep satisfaction in his work, whether it involves successfully treating a patient with a major heart attack, or helping patients in less dramatic ways. “I had one patient with a lot of risk factors who I hadn’t seen in a year, and he looked great,” he recalled. “I said, ‘Wow, what are you doing?’ He said, ‘I’m following your diet and exercising more. My blood pressure is better, and my diabetes went away.’ Just having an impact on somebody like that means a lot.”
In addition to following his own advice about a healthy diet, Dr. Milechman has a daily morning yoga practice, and enjoys running in addition to golf. He is married to Pat Lennon, a physical therapist at The Redwoods, a residential retirement community in Mill Valley. Together they have three grown sons.