Central Valley Physicians - Fall Issue by Fresno Madera Medical Society

Fall 2017

THE CURIOSITY

FACTOR

WHAT TAKES THESE DOCTORS FAR BEYOND PATIENT CARE

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CENTRAL VALLEY PHYSICIANS

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Fall 2017

VOLUME 2, NUMBER 3 â&#x20AC;¢ FALL 2017

{FEATURES}

22 24 26 28 34 42 50 Fall 2017

ALASKA CRUISE TOTAL SOLAR ECLIPSE SAFARI NIGHT

{DEPARTMENTS} 6

LETTERS TO THE EDITOR

14 CLASSIFIEDS 18 BECOMING A MEMBER 54 IN MEMORIAM

CURIOSITY FACTOR SUMMER MELTDOWN ST. AGNES MEDICAL CENTER EAT MORE PLANTS

CENTRAL VALLEY PHYSICIANS

Letter From The Executive Director

GET INVOLVED. I’m a firm believer that getting involved in your community is beneficial for both your mind and your body. As a native of Fresno I still think of Fresno as a small community, yes all 975,000 of us. What I mean by that is you can meet someone new and it will take about 2 minutes to discover you have a common friend or colleague; therefore Fresnans are some of the most connected people. Fresno Madera Medical Society has more physicians, residents and students in the history of the medical society and we have less involvement today then we did 10 years ago. I get it, we are all busy! But we need to see more doctors get involved, even if its only showing up to one event or one meeting the entire year. As we gear up for another year I would like to see more doctors get NICOLE BUTLER involved, even if its only showing up to one event or one meeting the entire year. Come support medicine in the Valley, get to know someone new and build a stronger network --- it is that strength that can make you more productive, a better resource and more balanced in your mind and body. With that being said, below are six ways you can get more involved. 1. Look for our Events – This year we hosted over 30 different events (yes we are exhausted) and I can guarantee there is something for everyone. If there was not an event that was suited to you, let me know your ideas. Some of our best ideas came from a quick email or text that simple said … have you thought about doing a family event… BAM done and today those are our best attended events. 2. Volunteer Your Time - I am asking for 2-3 hours a year. Really that is it! Come to a meeting, we have many to choose from. Write me an article for the magazine, send me an idea for our PodCast, come by the medical society and tell me what we should be doing more of, less of, or what we should be doing better. I will always make time for a member. 3. Shop Locally - The medical society provides discount opportunities for you and your practice. These are partners that provide discounted services to you, and I am shocked how few of our members use these services. They are there to SAVE YOU MONEY!!! If you have not contacted Cooperative of American Physicians (CAP) to have you malpractice insurance quoted, you are losing money. If you have not called Mercer or Preferred for your insurance and workmen’s comp you are LOSING money. Buy from our vendors, we have worked hard vetting them, negotiating with them and marketing there services to you. Spend the time to get quotes, I can guarantee they will save you money, and that savings will be more than the cost of your membership. 4. Join a Committee or Program - We have 8! Find one that you have an interest in and get involved. Our committees are CME, Editorial, Physician wellness, Historical, Legislative, House of Delegates, Scholarship Foundation, Membership, and Summer Meltdown. Most of these committees meet just a couple times of year and if you cannot make the meetings you can always call in to participate. 5. Support Your Local Residents and Students - How many residents do you know? Currently we have around 300 residents in town and everyone should spend some time getting to know these doctors. Some of them may be your future doctor; all of them are the future of health care. Yes, they too are busy, but would enjoy meeting a practicing doctor. 6. Connect with the Medical Society – If you are not already receiving emails from me, send your email address. We send out a wide variety of emails on events and activities we think doctors may be interested in. Sometime they may be of interest to you and sometimes they are not and I know you may feel we send out too many email, but it is our only way to connect doctors to one another. So regardless if you are a member, make sure we have your email address on file. I can promise you I will never share your email or personal phone numbers with anyone, not even to another doctor without first getting permission.

PRESIDENT Alan Kelton, MD PRESIDENT-ELECT Trilok Puniani, MD VICE PRESIDENT Cesar A. Vazquez, MD TREASURER Alan Birnbaum, MD PAST-PRESIDENT Hemant Dhingra, MD BOARD OF GOVERNORS Christine Almon, MD, A.M. Aminian, MD, Jennifer Davies, MD, Joseph Duflot, MD, William Ebbeling, MD, Don Gaede, MD, David Hadden, MD, Christina Maser, MD, Katayoon Shahinfar, MD, Roydon Steinke, MD, Janae Barker, DO, Uma Swamy, MD, Alfred Valles, MD CENTRAL VALLEY PHYSICIANS EDITOR Don Gaede, MD MANAGING EDITOR Nicole Butler EDITORIAL COMMITTEE Don Gaede, MD - Chair, Alan Birnbaum, MD - Associate Editor, Ranjit S. Rajpal, MD, Hemant Dhingra, MD, Roydon Steinke, MD, Cesar Vazquez, MD, Nicole Butler CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Don Gaede, MD, Alan Kelton, MD, Alan Birnbaum, MD, Tianna Arredondo, Roydon Steinke, MD, Erin Kennedy, Cesar Vazquez, MD CONTRIBUTING PHOTOGRAPHERS Nicole Butler, Tianna Arredondo, Alan Birnbaum, MD, Naeem Aktar, MD, Erin Kennedy CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711 Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler Events and Membership Coordinator, Nicole Tenorio Receptionist, Becky Gentry

Lastly, October 1 marks the beginning of 2018 Membership. New members can join today and receive membership for the remainder of this year and all of next year for a discounted price. Sincerely,

Nicole Butler

CENTRAL VALLEY PHYSICIANS

Fall 2017

Smarter Healthcare Begins in Clovis

Why is Sierra Gateway District right for you? Healthcare designated locations abound in the Sierra Gateway District! From premium undeveloped real estate to ready-to-go medical office spaces, Clovis is be the right solution for expanding healthcare in the Central Valley!

92.1 % 38% LOWER HOME PRICES

Median home prices are 38% lower than median state prices. This means affordable housing for employees and cheaper development costs.

WELL EDUCATED JOB POOL

#1 ranked Clovis Unified School District & 92.1% of adults holding HS diplomas.

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JOBS ADDES

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PLUS • Shortage of medical providers – demand is HIGH • Variety of sites, sizes, and locations add flexibility to your project • Medical business clustering is mutually beneficial to healthcare providers • City of Clovis is extremely business friendly • Exceptionally close freeway access to HWY 168 • Adjacent to Clovis Community Medical Center & Cancer Center (Summer of 2018) California Health Sciences University (Fall of 2019), and Valley Childrens Health Clovis (Early 2018)

Contact Andrew Haussler Community & Economic Development Director (559) 324-2060 • andrewh@ci.clovis.ca.us

Central Valley Physicians

Letters

to the editor If you would like to submit a letter to the editor or to the FMMS Members please send an electronic file to nbutler@fmms.org. All submissions will be reviewed by the editorial committee for approval and you will be notified if we run the submission. Articles should run from 400 to 1,000 words, but submissions of any length will be considered.

I am asking you to actively participate in our medical society and one of the many activities beginning with the many committees up to the Governing Body and the House of Delegates of the California Medical Association. Yes, the fees are too high and I have opposed every rate increase; and I want political neutrality - join us. Join the family of physicians from the very recent graduates of medical school from many countries to the ones from decades ago, from in the many branches living across Fresno and Madera counties that come together at our meetings and keep us in the loop. That’s where I met who became lifelong friend, the late Alfonso Falcone, M.D. Ph., whose ancestral home was Sicily. Our discussions and badinage leading among many others to Emperor Fredrick II, the son of Constance the last Norman queen of Sicily, who settled the turf wars between physicians and pharmacists around 1205. By the way, I paid my respects the emperor’s tomb in Palermo in Sicily reminiscing the turf wars of today. Let me present the Nominating Committee. We are charged to present and vet to the leadership all members eligible members for the many positions from sub-committees to leadership positions, and to improve the process. Our choices are only recommendations, because every member can throw his or her hat into the ring, and it is not uncommon that self-nominates have won up to the presidency of the American Medical Association. By the way they do not need a second. Andre Minuth, MD

CENTRAL VALLEY PHYSICIANS

Fall 2017

It was interesting to read the excellent articles regarding “Medicine in the Military” a while back. To have a more balanced picture I will add another viewpoint. I was drafted at age 33 and four children and sent for a year to Viet Nam. While I was gone one child learned to walk and another to talk. Heart Breaking! Military Position - Infantry battalion surgeon positioned in a fire support base in the Jungle Bed - Canvas cot with mosquito net canopy Piped in music - Radio Security - Sand bags, a helmet and a 45. I did not then and do not now like guns Office - Briefcase Clothing Cabinet - A nail in the wall Alarm Clock - 105 howitzer. Is that why I have tinnitus? The damn thing would go off at all hours of the day and night. Toilet - an oil drum, the contents of which were burned each day. I will not discuss the smell. Shower – a bucket with holes punched in the bottom. Attitude - Bad Lesson Learned - If you join the military, see that you have a positon “in the rear” or ever better, State side but definitely somewhere the family can be with you. In Charge of the Life Brigade I am a proud man. My peers elected me to various positions of leadership, SAMC Chief of Staff, President of the County Medical Society and E.E.O. of Matrix the I.P.A.; what a compliment! Some thought from the past now that I have retired; again! As I led the charges into the “valley of death” and the “jaws of hell” it was at times a little disconcerting to look back over my shoulder to find that most of the troops were back at the base camp discussing what was the best thing to do, or going off in the direction they had decided was best. Maybe quoting “The Charge of the Light Brigade” was not, or was appropriate as the charge was a disaster. “Someone had blundered”. As a group, physicians are intelligent, hardworking, and somewhat opinionated. Understandably, they tend to view things from their own standpoint, the standpoint of their specialty and rarely from the standpoint of physicians as a group. Just as they are difficult to lead from the front, it is equally difficult to herd these crazy cats by trying to drive them in a predetermined direction. It would be unbelievable what could be achieved if these cats were oarsmen all rowing in the same direction, working together; we would have a power to move things in the right direction at an amazing speed. Thank you everyone; it was a good ride and I loved every minute of it! Sincerely, Patrick O’Brien, MD Patrick O’Brien, MC (Medical Corps) Major, Combat Medic Badge, Retired (Thank God!)

Fall 2017

CENTRAL VALLEY PHYSICIANS

A message from our Editor > Don H.Gaede, MD

Beyond Medicine

ABOUT THE AUTHOR Dr. Gaede is a Fresno native and is board-certified in Internal Medicine and specializes in Vascular Medicine, with an expertise in the treatment of varicose veins, circulation problems, blood clots, and advanced techniques using ultrasound and sclerotherapy.

CENTRAL VALLEY PHYSICIANS

When the Communists took over Czechoslovakia in 1948, they erected three parallel electrified fences on the border with West Germany. The fence was taken down over 25 years ago, but the Czech deer near the border have never forgotten where it was. Researchers discovered that they never cross the invisible line that separates the Czech Republic from Germany. The German deer are equally loath to cross into the Czech Republic. What’s more, their offspring follow the same restrictive pattern as their parents did. All of which makes me wonder: what invisible borders have I erected in my mind? What irrational rules are penning me in, keeping me from reconfiguring my medical practice, from reconfiguring my life? Alan Pierrot, featured on page 28, did more radical configuring than most of us can ever imagine

doing. He began his career in orthopedics, then left that path to develop the Fresno Surgery Center. Now he is now pursuing a third endeavor as an oil painter. I’ve always been fascinated by the concept of reincarnation. In fact I sometimes imagine I’ve just been reincarnated, and get to choose a different career. Brain researcher, professional soccer player, and Broadway singer all come to mind as possible options. Of course, if I don’t play my karmic cards right, I could be reincarnated as a portabella mushroom, and as stress-free as such a life might be, it would also tend to restrict my career choices. But you don’t have to be reincarnated to pursue your alternative dreams. Years ago, I played on a co-ed soccer team with Drs. John Telles, Sandy Sherriffs, Tony Molina, Linda Fraley, and Geren Nichols. I

Fall 2017

don’t know about my teammates, but every time I got on the field, I was channeling my inner Pelé. For an hour and half every Sunday afternoon, I was indeed a professional soccer player. Harvey Edmonds, Marshall Flam, and I have been putting on a concert of opera and Broadway songs for the past 3 years at the Mercedes Edwards Theater in Clovis --“Doctors at the MET”. When we’re singing there, we leave our medical professions at the door. I can’t possibly channel the evil and relentless detective Javert from Les Mis if I’m still wondering whether— maybe--I should have ordered an MRI on that patient I saw yesterday. We three have something more than music in common: all of us received unsolicited career advice at an early age. Harvey was only 12 when his mother highly recommended that he plan for a career in medicine, since working in his father’s business (Edmonds Jewelry) was simply not an option for him. Marshall was in a doo-wop singing group in high school, on the verge of signing a record contract, when an acceptance letter from MIT arrived in the

Fall 2017

CENTRAL VALLEY PHYSICIANS

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Fresno Madera Medical Society

2017 Installation & Awards Gala

Save the Date Friday, November 17, 2017 - 6 pm Fort Washington Golf & Country Club

Award Winners Announced & Installation of Trilok Puniani, MD

CENTRAL VALLEY PHYSICIANS

Fall 2017

mail. In case there was any confusion in Marshall’s mind about which one of those appealing opportunities he should pursue, his father helped him “clarify” his thinking. My high school choir teacher told me one day after class, “Don, let me give you some advice. You’ve got a nice voice, and you enjoy music. But don’t do what I did; don’t become a music teacher. I know you’ve been thinking about medical school in your future. Pursue that goal— because you can always enjoy music as an avocation.” Medicine can be an all-consuming career, and if that’s what you want, then go for it. But this career can also consume your soul if you’re not careful. According to survey after survey, physicians are increasingly becoming burned out. Fully 50 percent of us have signs of burnout, and 10 percent of us are so burned out, we’re thinking of calling it quits altogether. Those of us working on the front lines of medicine—critical care, emergency room, and primary care— are some of the most vulnerable to this problem. That’s why our CMA targeted physician burnout as one of the key areas to focus on in 2017. Finding the right balance in your life is critical, to allow enough time for your mind and body to rejuvenate. There are lots of ways to do this. But I’m convinced that having an avocation--a passion for something outside of medicine--like music, gardening, painting, writing, photography, woodworking, cycling--you name it--makes your life more fulfilling, makes you more resilient, and helps prevent career burnout. Those electrified borders you erected in your mind are not there anymore. Allow yourself the freedom to think outside of your fences, to explore what lies beyond. You just might be pleasantly surprised.

Fall 2017

CENTRAL VALLEY PHYSICIANS

President Report > Alan Kelton, MD

Why CMA?

ABOUT THE AUTHOR ABOUT THE AUTHOR AlanDr. Kelton, MD, is board certified and Ronald Morton is a board-certified specializes in Internalwho Medicine. He in earned his ophthalmologist practiced medical degree from University Nevada’ Bakersfield for over 30 yearsofand is s School of Medicine wasCounty awarded the a past presidentwhere of thehe Kern Outstanding Student in Internal Medicine Medical Society. He is currently retired and and the Endorcine Societywith Medical Student enjoys traveling his wife of 46 Achievement Award. He completed residencies years, Ingrid. at University of Utah School of Medicine and UCSF Fresno. Dr. Kelton enjoys camping, visiting Yosemite and spending time with his family.

CENTRAL VALLEY PHYSICIANS

Greetings. Welcome to my final editorial as the President of the Fresno Madera Medical Society. There remain so many issues about which I could write. I have decided to dedicate my last editorial to the CMA. When non-member physicians ask about the cost of membership or why they should join, I remind them about MICRA. $72 million was the first “award” in 2016 in Missouri. $417 million was the most recent and it happened in California. These millions are dollars awarded by juries to plaintiffs with ovarian cancer. The claim is that topical use of the talcum powder sold by this company caused the cancers in these cases, that J & J was aware of the risk, and did not inform users that their product may be dangerous. According to the AP the California case award of $68 million was compensatory and $340 million (yes, not $417 million) punitive damages. I would argue that we do not have to even discuss the science (of which there is little good evidence for the complaints), it is clear that these

cases have nothing to do with justice. Ovarian cancer is an awful and not screenable cancer that affects too many women. I have seen cases in my family, my friends and my patients. I would be happy to never see it again. Maybe the $417 million would be better used for research for a cure or for a reliable screening test. Any takers? I did not think so. This is not about justice. Now imagine if this was a jury case against one of us, a physician in California. Could a jury be sympathetic? Could a jury be swayed that it is your greed that makes you work long hours, only to be able to bill more and in so doing became too busy to recognize the early signs of cancer? Or that you did not warn about talcum powder use? Seems easy to imagine. Now what if the attorney reviews your records and finds that there is no evidence that you warned your patient about the symptoms of pelvic cancers as is required by state law. Yes, a useless law, but it is the law. The sympathetic jury convinced of your greed and sloth finds you liable for an avoidable ovarian

Fall 2017

cancer. Now how much to award? How often could you be sued if a patient or family can hit the jackpot? How much will your insurance increase? In California, we have MICRA (Medical Injury Compensation Reform Act of 1975)-read about it at cmanet. org. This act limited non-economic, aka “pain and suffering” claims, limited attorney fees and this ultimately stabilized malpractice insurance rates after multiple malpractices crises in the 1970’s. We owe this legacy of a stable insurance market to the CMA. In 2014, trial attorneys, through a “drug testing for doctors” campaign attempted to pass proposition 46 a measure in increase noneconomic damages. The CMA was again there to help coordinate opposition to this measure that was not written with the intent to increase justice. Malpractice and the compensation for those who have

Fall 2017

catastrophic outcomes of disease or treatment are complex issues. It is clear, however, that a few large awards do not increase justice or quality of care, but can decrease access to care and increase the cost of care through defensive medical practices, and through increased malpractice rates. We all know physicians who have come from states with no caps on damages. Their stories are frightening. In California, patients (a category which includes physicians and their families) can sue for the rare cases of malpractice and be compensated for medical care costs, other economic losses and for future losses. This should be enough, unless we develop a better way to support those who suffer from disease or injury. Why CMA? MICRA is the answer. Let us stay organized. Have a good rest of your year.

CENTRAL VALLEY PHYSICIANS

F I S IE S A

FOR RENT

POSITIONS AVAILABLE Chief Residents Needed for SAMC GME Program Leaders wanted! The newly accredited Internal Medicine Physician Residency Program at Saint Agnes Medical Center is seeing well-qualified PGY3s to serve as Chief Residents. This is an excellent opportunity to grow your leadership skills and be a member of a vibrant and transformational team. Interested individuals should contact GME@samc.com or visit http://www.samc.com/physicianresidency-programs for more details and application instructions. Veteran State Home Fresno (CalVet) Has openings for a full-time and part-time physicians. This is a State position with State benefits. For more information or if you are interested please email asha.sidhu@calVet.ca.gov or call 559-681-7800 or apply online at calhr.ca.gov. Medical Consultants Needed for Fresno Field Office This is an excellent opportunity to help your community and to obtain valuable experience. The Department of Consumer Affairs, Division of Investigation, and Health Quality Investigation Unit is seeking well-qualified individuals to be a Medical Consultant for the Fresno Field Office.

CENTRAL VALLEY PHYSICIANS

Are you interested in being an integral part of the Medical Board of California enforcement process? Do you have the ability to conduct interviews, exercise sound judgment in reviewing conflicting medical reports and preparing opinions, analyzing problems, and taking appropriate action? Interested individuals must submit an application for examination. Visit jobs.ca.gov/JOBSGEN/5CACC.PDF for additional information and instructions. If you have any questions please contact Herbert Boro, MD, F.A.C.P. with the Health Quality Investigation Unit in Fresno at (559) 447-3045 or by email at herbert.boro@mbc.ca.gov. Family/ General Practice Physician Needed A multi-disciplinary organization is looking for a FP/GP/DO/Medical Director for our Fresno medical office. Candidates must have an active CA license. As a member of our team you will enjoy a Monday-Friday workweek, no weekends, late nights, or hospital calls. Part time and full time available!! Benefits include 401K, health, dental and vision insurance. Great-pay, potentialto bonus by performance criteria and protocol. 100% employer paid malpractice. For immediate consideration please submit your CV by email to matt@firsthealthmedical.com or by fax to (559) 435-3462.

Medical Office Space Madera, CA, 2600 square feet near Madera Community Hospital call 559-673-4000 or email mmedina@cgafresno.com. Home lease/office across Clovis Community Hospital.2.5 acres,horses/ fruit trees,~1800sf, 3bd/3ba. $1K referral fee for MD tenant! Small pets OK. Call 559-321-7972. Premium medical office 3500sf with completed tenant improvements. Maple/Herndon, easy access to Herndon/Rte 41/168. Next to MRI, specialists and Saint Agnes Hospital. $1.55/sq ft negotiable. Call (559) 322-7766 between 3 pm-5 pm.

FOR SUBLEASE

Class A Medical Office Space, approximately 1500 square feet. 1781 East Fir Avenue, Suite 102, available 7/1. Rent: $2250 plus security deposit. Contact Robert at (559) 800-7476 or administration@cvphysiatry.com.

If you would like to submit a listing to our Classifieds, contact nbutler@fmms.org. Listings are free for members with reasonable rates for nonmembers.

Fall 2017

Continuing Education for Medical Office Professionals Brought to you by

Coding & Reimbursement Update 2018 New Year, New Codes, New Reimbursement Opportunities Attend PMI’s most comprehensive review of changes and important health care legislative updates for 2018 in one class!

Wednesday December 6, 2017 Coding & Reimbursement Update 2018* 9:00 am-12:00 pm Program #22554-1206 OR 1:00 pm-4:00 pm Program #22555-1206

Location:

Fresno Madera Medical Society 255 W. Fallbrook Ave,. Suite 104 Fresno, CA 93711

Fee:

$199 per session Includes course material

Highlights • Review CPT® new, revised, and deleted codes. • Hear about Federal EHR programs and penalties for non-compliance including the latest updates to Meaningful Use measures. • The movement toward quality will continue to impact providers. Find out what ranking providers for quality and costs means for your reimbursement in 2018 and beyond. • Take an interactive tutorial on the Physician Compare website to view performance measures. • The instruction and class manual will serve as a valuable resource all year long. • Get an explanation of changes that impact various specialties. • Review Medicare Part B Fee Schedule changes. • Instructor will share updates on MACRA/MIPS reporting procedures and deadlines. • Receive a brief overview of incentive programs offered by private carriers.

Phone: 559-224-4224 x 114 Mail:

Fresno - Madera Medical Society Nicole Butler Executive Director 1040 E. Herndon Ave Suite 101 Fresno, CA 93720

Make checks payable to: Fresno - Madera Medical Society *Registration for this program is required

A class manual with helpful resources and links for use beyond the classroom will be provided. Participants must bring a 2018 CPT coding book to this class.

3 Practice Management Institute grants CEUs for its certified professionals based on total number of instructional hours (1 CEU per hour of classroom instruction). CEUs may be applied to annual renewal requirements as noted on pmiMD.com.

CENTRAL VALLEY PHYSICIANS

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Recognizing the Signs of Physician Burnout More than half of U.S. physicians report symptoms of burnout — a 25% increase from 2013 to 2017.1 This is a serious concern, because physician burnout can lead to patients suffering adverse events2 or leave physicians unable to express empathy and compassion with their patients.3 In this special report, the Risk Management Specialists at NORCAL help you identify the signs of physician burnout so you can address it before it harms your practice.

[Burnout] is a systemic problem. It’s not just that some physicians have high-risk personalities.7 Although burnout is a condition that occurs in one’s work life, it also tends to affect relationships with family and friends.

Definition of Burnout The gold standard for measuring burnout is the Maslach Burnout Inventory (MBI), which is a validated, 22-item assessment. The MBI assesses three main indicators of burnout:8

EMOTIONAL EXHAUSTION — Feelings of emotional overextension and exhaustion by work. Burnout causes the physician to feel the demands of the job are too great to meet. A physician might say: “I feel burned out from my work.”

DEPERSONALIZATION — Callous and impersonal reaction to those who are served on the job (patients, in the case of a physician). Burnout causes the physician to detach and become less sensitive to patients’ needs. A physician might say: “I really don’t care what happens to my patients.”

PERSONAL ACCOMPLISHMENT — Feelings of incompetence, poor achievement and low motivation. Burnout causes the physician to doubt his or her self-worth and professional effectiveness. A physician might say: “I have not accomplished many worthwhile things in this job.”

For the full report visit burnout.norcal-group.com. Numbered references available at burnout.norcal-group.com

MEMBERSHIP

Becoming a Member Top 10 reasons why you should join today.

When you become a member, you support your local medical society and hire CMA, a powerful professional staff to protect your profession from legal, legislative, and regulatory intrusions. Below are the top 10 reasons to be a member of Fresno Madera Medical Society (FMMS) and the California Medical Association (CMA).

1. Protect MICRA

3. Stay in the Know

CMA staunchly defends the landmark Medical Injury Compensation Reform Act (MICRA) year after year, saving each California physician an average of $75,000 per year in professional liability insurance premiums.

FMMS publishes the quarterly magazine, Central Valley Physicians, as well as CVP Podcasts for physicians, as a way to stay up-to-date with current events that affect medicine in the Valley. In addition, CMA produce publications to keep you up-to-date on the latest health care news and information affecting the practice of medicine in California.

2. Collaborate with Colleagues FMMS bring together physicians from all over the Valley, from different specialties and modes of practice to develop strong unity through leadership, collaboration, socials, educational events, and community service.

4. Shape the Future of Medicine Through aggressive political and regulatory advocacy, CMA and its county medical societies

CENTRAL VALLEY PHYSICIANS

Fall 2017

MEMBERSHIP

CMA was founded in 1856 by a small group of physicians who knew it was their duty to fight for their patients and for their profession.

are positioned among the most influential stakeholders in the development and implementation of health policy. In addition, members receive direct access to our state and national legislative leaders to influence how medical care is provide today and in the future.

5. Save Money There are several ways to save money when you are a member. Discounted health insurance for you and your staff, automatic 5% savings on workers’ comp insurance, CME and Online educational courses, auto and home insurance, car rental, office supplies and much more. >>

NEW! New Monthly Membership! Fresno Madera Medical Society and California Medical Association membership is easy to maintain and hassle-free with automatically recurring monthly payments at an affordable price. If you are not a member, enroll today at www.cmanet.org/monthly to start receiving your benefits! If you’re a current member, and would like to switch to monthly payments keep an eye out for your renewal invoices and choose the monthly payments.

QUESTIONS? Contact CMA’s Member Service Center at (800) 786-4262 or memberservice@cmanet.org.

Fall 2017

CENTRAL VALLEY PHYSICIANS

MEMBERSHIP

Ask yourself who will have the most impact on the way you practice “medicine - the government, or physicians in organized medicine through CMA? Be involved or be left behind. ” - J. Brennan Cassidy, M.D.

6. Get Paid

10. Together We Are Stronger

Members receive one-on-one assistance from CMA’s reimbursement experts, who have recouped $15.5 million from payors on behalf of CMA physicians in the past nine years.

Together we stand taller and stronger as we fight to protect patients and improve the health of our communities. We are a dominant force in health care – but all the great work we do wouldn’t be possible without the support of members like you. Fresno Madera Medical Society was founded in 1883, as the first professional organization in Fresno County. Chester Rowell, MD, and a small group of physicians created the organization two years before the city of Fresno was incorporated, and formed the cornerstone of organized medicine in the area. Today, Fresno Madera Medical Society has over 1200 physician members working together to provide care to Valley residents.

7. Continue Medical Education FMMS provides opportunities to further your knowledge with Continuing Medical Education. CME symposiums and dinner events are provided throughout the year with current topics that relate directly to your patient care. Learn from the experts and hear from recognized speakers.

8. Education and Training for Your Practice FMMS provides monthly Medical Managers Forum to arm your office staff with practical information and tools to overcome new challenges in healthcare, run the office successfully and move your practice forward.

9. Lead by Example FMMS and CMA provide many opportunities to get involved, including opportunities to volunteer; serve on a committee, council or board; and shape the future of the medical profession and giving back.

Christina Maser, MD, FACS Associate Clinical Professor, UCSF Medical Director, University Surgical Associates Member since 2006

QUESTIONS? Contact FMMS at (559) 224-4224 ext 118 or CMA’s Member Service Center at (800) 786-4262. Fall 2017

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Alaska Cruise

FRESNO MADERA MEDICAL SOCIETY

CONTINUING MEDICAL EDUCATION Photography by Naeem Akhtar, MD

July was the first Fresno Madera Medical Society Continuing Medical Education cruise. Physicians and their families spent 7 days cruising through Alaska seeing the amazing sites of Juneau, Skagway, Ketchikan and

Glacier Bay, then ending the cruise with a stop in Victoria B.C. all while earning 15 CME hours. FMMS is already working on the 2019 cruise location and we hope that everyone can join us on the next adventure.

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Total solar 8/21/2017, Casper Wyoming; Alan M. Birnbaum, MD My wife and I traveled by air from Fresno to Denver, then by our friends’ RV, to Casper, Wyoming, a trip planned a year in advance. I had become aware of the event circa 2014. Our immediate group included the four of us, but Casper had attracted tens our thousands of eclipse viewers, in part due to the preceding week’s ASTROCON convention. We stayed at the Mainstay Suites, several miles east of downtown, where there were well over a hundred eclipse viewers, including the President of Riverside Telescope Makers, who had brought both a white light and an H-alpha scope. We had the usual zero-power viewers, but also a total of four Lunt Sunoculars, three 6 x 30 and my 8 x 32, plus a Meade Coronado PST that I had purchased at Astrocon. We observed from the Mainstay Suites parking lot, where the view was excellent, just a little haze. The owners of the property as requested had turned off their parking lot lights, which otherwise go on automatically when it gets dark! Totality started around 1042 MDT, and ended about 1045, a total of around 2 minutes and 25 seconds. Weather was excellent with a tiny bit of haze otherwise a cloudless sky. As we were within a mile of true eclipse midline, we experienced 100% totality. As totality started, reclining on a portable lounger, I took a few photographs, with my 25X zoom Sony RX10Mk3, using its automatic exposure bracketing system,

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actually about four series of nine photos, each 1.0 stop apart, using the lens near but not quite at its maximum reach. I then spent 80% viewing totality using Nikon Monarch 7 10 x 30 binoculars, to allow seeing as much of the corona as possible; I didn’t bring my 18 x 50 Canon IS, which might have been better. Most striking was the thin, irregular ruby ridge of red around the circumference of the moon. That was far more apparent than was the corona, something I appreciated better in my photos, and those forwarded by other viewers. Certainly it was worth taking five days out of my wife to see at least one total solar eclipse, even if it did take use over eleven hours to get back to Denver! This is a phenomenon which in a few minutes, proves to one and all that science since Copernicus has generated a correct understanding of how the universe works, such that “celestial mechanics” are exact and mathematically proven. We do have tentative plans to travel to Austin or San Antonio, Texas, in April 2024, for the 4/08/2024 total solar eclipse, which from that location will be two minutes longer. As to whether I will live to see the great Perseids Eclipse, of 8/12/2045, six minutes or longer, on the same day as the great yearly meteor shower that evening, who knows! As an experience, UNFORGETTABLE!

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SAFARINight

The Fresno Madera Medical Society and the Fresno Madera Medical Society Alliance

Photography by Alan Birnbaum, MD and Nicole Butler

250 Safari Night was a great family event with over ed in attendance. Physicians and their families enjoy with lete comp Zoo an exclusive night at the Fresno ntation. private giraffe feeding and special animal prese

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THE

CURIOSITY

FACTOR WHAT TAKES THESE DOCTORS FAR BEYOND PATIENT CARE By Erin M. Kennedy

AN INTENSE DESIRE TO KNOW MORE gets medical students quickly past the “ick factor” in surgery and, when they later become doctors, drives them to ask “what if” questions that often lead to medical breakthroughs. For some, that curiosity entices them away from their patient care role long before retirement and into careers they never envisioned. For one Fresno orthopedic surgeon, curiosity propelled him to pioneer the first outpatient surgery center in the U.S. – and then to help others do the same. Curiosity led a local neurologist into the courtroom as a barrister – once – then into pharmaceutical research. And it’s what drove a Fresno podiatrist eventually to help set up a health care system in war-torn Afghanistan. >>

It’s more and more common to hear about physicians leaving their medical practice for other careers – mostly citing burnout. A Mayo Clinic-funded survey of nearly 7,000 physicians in 2014 found 54% reporting at least one serious symptom of burnout and an increasing dissatisfaction with work-life balance – up significantly from a survey done in 2011. Web sites now abound offering career-change coaching for MDs. And DropOutClub. com, a social networking site, is where nearly 40,500 doctors commiserate and talk about the taboos of leaving the profession they worked years to enter. But when these three entrepreneurial local doctors made the change, it wasn’t because of burnout. They were just following their curious natures into new realms. “I find physicians to be extremely caring, motivated, independent-minded – and entrepreneurial,” explained Mark Scoffield, M.D., a former foot and ankle surgeon who is now vice president and senior director of the AMOR (Alliance for

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Medical Outreach & Relief) Afghanistan Health Organization. AMOR built and runs the 100-bed Afshar Hospital and six clinics in Kabul. Dr. Scoffield also works with Vetted Partners, a flexible funding provider for other entrepreneurial-minded physicians.

ENTREPRENEUR IS PART OF THE DOCTOR DNA “I was fascinated by the notion that someone with an idea could write up that idea and get others to agree with it and then fund it,” said Alan Pierrot M.D., a former orthopedic surgeon, explaining how he became the founding partner of Fresno Surgery Center, which eventually became Fresno Surgical Hospital. Pierrot – he insists folks call him “Alan” these days and drop the “Dr. Pierrot” formality – never set out to be an entrepreneur or to pioneer a new surgical delivery model. “I picked my profession when I was in seventh grade. I loved biology and I

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had a pretty strong bent toward public service,” said Pierrot. “Lenders didn’t want to take the risk without some kind of “That was it and I never questioned the choice. I just loved it.” operating model, and there was no other surgical hospital in He loved medicine through his military training during existence on which to base this. At the time, the building trades Vietnam, through his first week in a new Fresno practice when were suffering in a weak economy and looking for opportunities he did three operations, and a decade later when his practice to stimulate construction. Our investor group found a willing was thriving. But he also became captivated by the world of business investing. “In those days doctors were the targets A Mayo Clinic-funded survey of nearly 7,000 physicians in of investment schemes. We had money to 2014 found 54% reporting at least one serious symptom invest and we were fairly unsophisticated,” of burnout and an increasing dissatisfaction with work-life Pierrot said. He wanted to learn more. “That balance – up significantly from a survey done in 2011. connected with me and intrigued me. I thought it was wonderful that you didn’t have to be part of General Motors to pursue an interesting new idea. I started fiddling around with putting ear in the Carpenter’s Union Pension Fund, which loaned groups of people together for investing in office space.” the money on the stipulation that union labor would be Pierrot said he got lucky. The healthcare environment in the contracted.” early 1980s was the perfect petri dish to create a new model for By 1988, Fresno Surgery Center was again first in the nation, elective surgeries. this time by providing to provide overnight post-surgical care in “There was a confluence of two ideas,” he explained. a non-hospital setting. The California state legislature was the first to encourage a more competitive approach to health care by eliminating ANOTHER COMMON TRAIT: PURSUING the requirement for a Certificate of Need. At the same time EXCELLENCE OBSESSIVELY surgeons in Arizona were discharging patients after minor During his business building years, Pierrot said, he was unable elective surgeries on the same day, rather than keeping them to keep up with the demands a fulltime orthopedic practice and overnight – and having good results. also be the kind of general partner investors needed. “I had the “So the idea that people could have outpatient surgery was sole responsibility of looking out for the money, looking out for coupled with the idea that anybody could build anything in the interests of the patients and interests of surgeons,” Pierrot healthcare if the market would support it, allowed physicians to recounted. He began seeing fewer patients and reading more pursue the development of surgery centers,” Pierrot said. business books to learn a new trade. Investment dabbling had been unknowingly prepping Pierrot The book that became his business bible was “In Search of for the skills he needed to take advantage of those two Excellence: Lessons from America’s Best-Run Companies” ideas. In 1984, he led 76 physician investors in opening and by Robert H. Waterman Jr. and Thomas J. Peters. “It was Thomas Thaxter, MD, along with surgeon investors, opened inspirational,” Pierrot said. “It made sense to me that companies the 12,000-square-foot Fresno Surgery Center – the first needed to focus on customer service to succeed…and it was outpatient-only surgery center in the nation. It wasn’t long obvious to me that healthcare didn’t do it. Healthcare was only before the center needed to expand and add hospital beds to committed to technical excellence in those days.” provide more complex surgeries requiring longer recoveries. In Again, Pierrot became a pioneer, focusing on customer two years the group successfully pursued legislation to add 20 service a decade before the HCHAPS (Hospital Consumer beds, the nation’s first ever surgery center with beds. Assessment of Healthcare Providers and Systems) patient He wrote in a 2003 Outpatient Surgery Magazine article experience surveys were instituted to require hospitals to pay about how once again the doctor group became pioneers, attention to how patients felt about their stay. The Fresno by overcoming. In 1986 they overcame California Hospital Surgical Hospital also surveyed their patients before it was a Association opposition in 1986 to get state laws changed to requirement, adjusting based on the feedback. permit surgery centers to add hospital beds. Only six outpatient “The patient appreciation was measurable,” Pierrot enthused. facilities were approved for the change and only for up to 20 The surgical hospital surveyed its patients long before it became beds with patients limited to a 72-hour stay. routine, and it was getting 50% to fill out the hard copy surveys. Although their investor group had expanded to 96 doctors “Patients wrote on the margins and they went on and on they couldn’t muster the $5 million it was going to take to add about the wonderful experiences and how grateful they were. on to the Fresno Surgery Center. Pierrot wrote in his article: I began to realize people were really angry at the arrogance of

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Pierrot explained the draw: “It was just fun. I did it more. I took classes and I read books. I’m just perking along. It’s a whole other different challenge. And it intrigues me. I still get excited that something that is round looks round when I paint it two dimensionally. That still tickles me.”

PASSING THE BAR WAS ABOUT THE LOVE OF LEARNING

healthcare, doctors and hospitals – particularly hospitals. We all became zealots about customer service and everyone read the book – doctors, nurses and housekeepers.” Pierrot said while insurance payers and Medicare were slow to see the value of surgical centers with attached overnight beds, he could see it was “a superior model for delivering elective surgical services.” By 1992, after 19 years as a surgeon, Pierrot quit his practice and became a consultant to help others create outpatient surgery centers in other parts of the country. It wasn’t a difficult transition, he said: “I went from something I loved doing to something else I also loved doing. I took on another challenge that was important to me and that I cared about.” Market forces convened and changes in payment mechanisms aborted Pierrot’s dream of taking the surgical centers to the rest of the country. He sold his business in 2006 and at age 65.

IT’S A CONSTANT SEARCH FOR ‘INTERESTING AND MEANINGFUL’ “There I was trying to figure out how to make my life interesting and meaningful. I think that’s the question you’re in all the time,” Pierrot said. “I did explore building Alzheimer’s facilities. It just didn’t connect with me. I was a surgeon and really loved figuring out how to deliver surgical services.” It was a book that again piqued his fascination and provided something new to learn and a new passion to follow: painting. Pierrot’s still life and realist paintings are showing these days at Sense of Place Gallery and he’s selling his work through his web site www.alanpeirrot.com

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Fresno neurologist David Margolin, M.D., Ph.D., was doing interesting, challenging work conducting clinical trials on Alzheimer’s disease medications when he decided he needed more brain stimulation and to add J.D. (juris doctorate) to his list of degrees. “I enjoy studying more than anything else,” he explained. He also has a Ph.D. in psychology along with his medical doctorate. “My wife got an MBA online and I thought that’s what I’d do.” But after studying his options, Margolin enrolled in San Joaquin College of Law and followed his curiosity. For him it was fun, and he saw the possibilities of incorporating what he was learning into medicine. Dr. Margolin said he never intended to become an attorney, but the competitor in him wanted to see if he could pass the California bar. “I took two weeks off for fulltime studying for the bar,” Dr. Margolin said. “It was the most intense studying I ever did. It was kind of enjoyable because it was such a focused, intense thing.” He passed. And became an attorney in 2011 – briefly. “I was thinking I would practice law and incorporate my medical knowledge. But that wasn’t a model that the big law firms were using. I thought I should at least put it to use once,” Dr. Margolin said. He tried a property law case pro bono through Central California Legal Services which provides access to the legal system and representation for the disadvantaged. He went before Fresno Superior Court Judge Robert H. Oliver and prevailed. Dr. Margolin joked, “I thought I’d quit while I was ahead. I was batting 1.000.” He did use his attorney title once more, penning a law journal article about the legal intricacies of deciding when those with dementia have the capacity to make medical decisions, such as whether to take dementia medication. “As a neurologist it’s unavoidable that you get called on to testify on people’s mental capacity when you specialize in Alzheimer’s. So I had expertise here,” Dr. Margolin said. That brief detour from his work specializing in the care of patients with Parkinson’s and Alzheimer’s disease wasn’t the end of his searching for interesting ways to apply his knowledge. After 22 years of experience as a principal investigator on medication research trials, Dr. Margolin now works for a contract research organization which oversees medical monitoring of drug research for pharmaceutical companies. He

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“Then a group of businessmen gave me the opportunity to help develop a hospital in Afghanistan,” Dr. Scoffield said modestly about his work with AMOR. “After 20 years of war they didn’t really have any healthcare infrastructure. All my background setting up outpatient centers I was able to apply to this challenge. They had no established policies and procedures in the whole country, and no established standards of care. Measuring for continuous quality improvement is really innovative for them. “And the fun thing is you get to do real medicine,” Dr. Scoffield added. “Penicillin is still a miracle drug for them. They have nothing there and they need everything.” His next big project with AMOR is planning for a clinic in rural western Fresno County to “I was thinking I would practice law and incorporate my medical serve farmworkers. Dr. Scoffield knowledge. But that wasn’t a model that the big law firms were also has a side interest in Vetted using. I thought I should at least put it to use once.” - DR. MARGOLIN Partners, an alternative financing tool for physicians who are starting up or expanding. “That’s closed his practice in 2013 and now works fulltime monitoring my side job since 2009. I do work in my spare time and the main the safety of patients in clinical drug trials. thing we offer doctors is flexibility and understanding of their “It’s been a pretty seamless transition,” Dr. Margolin said of business practice.” giving up direct patient care. “Of course there’s new things to learn like budgeting and standard operating procedures.” And on the side he’s now trying to master Spanish – because TIPS FOR SWITCHING CAREERS learning is fun and he’s curious to see how far he’ll get. “I’m not Drs. Scoffield and Pierrot have advice for physicians who are going for any degrees,” Dr. Margolin said, “but my goal is to be seriously considering side careers or career switches: you can’t fluent.” do it all and it will take time away from patients.

ALWAYS LOOKING FOR BETTER WAYS TO PROVIDE MEDICAL CARE Dr. Mark Scoffield was just trying to improve his Fresno podiatry practice and create a better place to provide surgical care for patients when he started developing the skills he’d use years later to build a healthcare system in a war-ravaged country. He followed Pierrot’s lead to create his own ambulatory surgery center in the 1990s. And he got intensely interested in doing it right. “It took me about three years. I had to learn accreditation, about OSHA and Medicare requirements and building codes,” Dr. Scoffield said. “My phone started ringing with other doctors asking ‘How did you do this?’” That led to consulting work to help doctor groups create their own ambulatory centers and imaging centers. He had a role in helping create about 100 outpatient care centers across the country. Eventually, Dr. Scoffield gave up his practice and Scoffield Surgery Center disappeared.

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“The number one challenge I had as a consultant,” Dr. Scoffield said, “was once I explained what they needed to do, very few physicians actually carried out the plan. They said they were too busy.” Pierrot said that’s a real problem for most physicians. “There’s a whole world out there, but doctors are too busy to take advantage of the opportunities. Being a doctor is all-consuming. But you have to find a way to allocate time for yourself and that usually means less income,” he said. The solution? “When I got interested in business, I just said I’m not going to be available to see patients on Friday,” he said. Pierrot said the tradeoff was worth it: “I decided I was be better off learning to be good at business than seeing more patients. I made the decision to make a little less money than my colleagues, but I had the reward of a whole new world that I learned about.” And that whole new world was what first intrigued and then pulled these three entrepreneurial doctors into their new careers and away from their patients.

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Summer Meltdown was once again a success for the Fresno Madera Medical Society Scholarship Foundation. This yearâ&#x20AC;&#x2122;s event had over 400 in attendance and it was filled with fun and laughs with comedian Matt Iseman. In June of this year, Fresno Madera Medical Society Scholarship Foundation awarded over $35,000 in scholarships to medical students from the valley and it is this as well as generous donations from physicians and community members that make these scholarship possible. FMMS began giving scholarships in 1961, with money raised through popular polio vaccine clinics. Since then FMMS has awarded over $500,000 in financial support. A special thank you to our event sponsors for the evening. Cooperative American Physicians, Community Medical Centers, California Health Sciences University, Saint Agnes Medical Providers, Wells Fargo Mortgage, CalViva Health and Saint Agnes Medical Center

Photography by Alan Birnbaum, MD Nicole Tenorio. Photo booth photo by Emily & Steven Photography.

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SAINT AGNES MEDICAL CENTER

RECEIVES ACCREDITATION FOR INTERNAL MEDICINE RESIDENCY PROGRAM Add by Tianna Arredondo Our Central Valley has always had a demand for physicians of all types, especially primary care providers. In the past two years, Fresno County has experienced a boom in medical enrollment due to the Affordable Care Act. Local hospitals have been organizing and planning to meet this new demand, and one Fresno hospital has developed a new internal medicine residency program which will bring lasting change to the Valley. Saint Agnes Medical Center was recently accredited for an internal medicine residency program by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME is responsible for the accreditation of 10,741 residency programs, educating a total of 134,661 future doctors throughout the county. The ACGMEâ&#x20AC;&#x2122;s comprehensive and inclusive curriculum standards provide residents with well-rounded experiences that they need to treat patients effectively. The recently revised requirements create a context for the residents by structuring a learning environment which encourages future physicians to take responsibility for their attitude, education, and individual knowledge base. >>

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The ACGME Residency Programs require facilities to address the physician’s personal development; more specifically, the ability to meet with patients one-on-one and address their healthcare needs. During residency clinics, physicians will be working in holistic teams addressing complex problems. According to their website, ACGME creates this solid foundation and inclusive learning environment by requiring a well-paced learning environment, enforcing multiple required standards: • Emphasisis on patient safety and quality of care improvement • Directly address the importance of physical well-being • Mandate a team-based care framework for both clinical and educational training hours • Update practices and methodologies in collaboration with many other specialty organizations

WHY SAINT AGNES MEDICAL CENTER HAS TAKEN THE INITIATIVE TO LAUNCH A HOLISTIC RESIDENCY PROGRAM Saint Agnes is a part of a large healthcare network known as Trinity Health. SAMC expects 20,000 hospital discharges annually based on hospital patient data and the known disease burden in the Central Valley. Patients commute to Fresno, California to be seen at the SAMC facility from places like Madera, Merced, Dos

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Palos, Selma, Kingsburg, Firebaugh, and Los Banos. Similar to the origins of SAMC, born out of the need to address community health problems, the new era of healthcare leaders have decided to venture into the unknown. Together they are the Central Valley trailblazers of holistic patient-care approaches, based on the premise of addressing the specific needs of the many, disadvantaged Central Valley Communities.

THE SAMC PEDAGOGY “Our curriculum weaves our culture into medicine, so that it creates a well-rounded physician. Our future physicians really need to understand our patients and the Valley. In the Fresno Unified School District alone there are 53 languages currently used. We have an incredibly diverse population with diverse needs.” - Dr. Lucka Dr. Lucka explained excitedly, “…it was very interesting for me to come to Saint Agnes and work on something like this. I knew it would meet the needs of the Central Valley and have an impact on providing care to the community. When we start these programs our intent is to have residents value the standard of care that we deliver; addressing the body, mind, and spirt. We’re addressing the whole person. We hope to [have residents] stay with us and continue to serve our community after they complete their medical training.”

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A teaching pedagogy is the particular method or practice used by an institution or school. Dr. Lucka detailed the SAMC pedagogy which will be implemented with the first residency cohort, “The program planning began with internal medicine since it is the area of greatest need. Now I am working on Family Medicine. The Central Valley is extremely unique, we are underserved. We’re the top of the terrible in terms of morbidly and air quality. Your zip code determines your longevity and differs dramatically between the Riverpark and West Fresno Area. We want to include information like that in our teaching so that these future doctors can see there isn’t one group of people you’re serving. They’ll be serving based on zip codes in multiple areas and they’ll have to know who they’re addressing. A resident especially needs to be aware of this if they’re coming to the Central Valley.” According to the Central Valley Health Policy Institute (CVHPI) Place Matters Report, Central Valley residents can expect to rely on their geographical location to determine who is healthy, who is sick, and who will live longer. These patterns are due to residential segregation and fundamental cases of health inequities among different racial, ethnic, and socioeconomic groups. Social factors determine premature mortality, and social factors expose Valley residents to myriads of environmental hazards. According to national statistics, adults 25 and older without a high school diploma are three times more likely to die before the age of 65 than those with a college education. In the San Joaquin Central Valley, the percentage of population without a high school diploma is 30%, twice that of the United States national average of people without their high school diploma. Life expectancy varies by as much as 21 years in the San Joaquin Valley depending on the zip code. Zip codes with the lowest life expectancy can expect to live until 69 years or less, while people can expect to be 90 years or more in zip codes with the highest life expectancy. Dr. Lucka is passionate about serving the needs of Central Valley: “Studies show that physicians usually stay where they are trained, I know that some of the other institutions here in the Central Valley have retention rates around 40%.” Dr. Lucka is hopeful that this happens for them as well. The SAMC residency program was created to combine a curriculum and program tailored to meet the needs of Central Valley patients.

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GME PROGRAM COORDINATOR, DR. DANA ZUPANOVICH LUCKA ED.D. Dr. Lucka has spent the last 20 years at Fresno State as a Fundraiser for Health Programs. She gravitated to the SAMC culture when she was teaching at Fresno Pacific University, after receiving her doctoral degree in Higher Education Leadership. Dr. Lucka fit exactly what SAMC needed. Dr. Lucka is an Instructional Leader and Health Care Practitioner; she understands curriculum development within many contexts. Her extensive 20 year healthcare and education background, has prepared her to understand the most effective practices to implement in relation to patient care in the Central Valley. During her previous stint at Fresno State she was responsible for creating and fundraising for health focused programs. Dr. Lucka has maintained her focus on working tirelessly to advance healthcare in the Central Valley. She currently works to inform medical residents on what the many Central Valley Communities are like.

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CENTRAL VALLEY POPULATION HEALTH OVERVIEW Dr. Lucka continued to explain the needs of Central Valley patients, “Speaking in terms of internal medicine residents must also have [other experience as well] a little bit of emergency medicine, a little bit of geriatrics, and so on. With the aging of the baby boomer population, we have a critical need here in the Central Valley especially with the Medicaid and Medicare senior residents. The number of seniors is growing; [this trend is] known in some places as the grey tsunami.” “To the best of my knowledge there are only three board certified geriatric physicians in the area. The need is great, so we’re looking at where and when we can have clinical rotations. It’s a challenge, because the pedagogy is designed to create a physician who can leave and go create a practice in the area focused on geriatrics. We are working towards having the foundational information they can grow from.” Lucka continued.

According to the CVHPI Elderly Longevity and Community Health Analysis Report, Fresno County’s most relevant health needs are; • Address heath needs concerning: access to care, obesity, diabetes, asthma, and mental health • Extended provider hours • Information about how to navigate the healthcare system and maintain personal, holistic health • Information teaching patients how to properly research healthcare questions • Eligibility awareness throughout the healthcare process • Decreased stigma of patients who: use public health insurance, need language assistance, and/or receive care in an emergency room setting • Sensitive care for the elderly • More health and wellness education for the youth • Staff trained in cultural responsiveness, humility, and diversity • Safe settings at provider locations as well in the direct areas surrounding health care settings

What is The Best Medicare Plan?

Contact Susan Hatch today! RSVP 8-5 M-F Toll Free 1-866-481-9092 Phone: (559) 307-2287 License # OF19062

Email: CaMedicarePlans@sbcglobal.net Website: MedicareToday.net

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0003272202-01

Get to a Medicare Meeting by Susan Hatch (PHIASProfessional Health Insurance of Advanced Studies). Susan is a licensed, independent insurance agent who represents ALL Medicare Supplement plan types. A talk radio guest, objective researcher, senior advocate & national speaker about Medicare. Author for The California Broker Magazine & “Your Medicare Supplement Corner”, as seen in The Fresno Bee, every Monday. Awarded the #1 Medicare Supplement agent in California. Accredited with the BBB, A member of The Congress of California Seniors & The National Committee to preserve Social Security

And with the elderly, detrimental indicators that need to be addressed are: • In-home falls • Body mass Index of 25+ • Delayed mammogram • Eating fast food more than 2x per week • Sedentary/no physical activity • Non-compliant with colorectal screening

SAMC LEARNING ENVIRONMENT Dr. Egerton explained, “We are creating a learning environment so the cohort of doctors we’re training will be aware and focused on treating Central Valley patients. Our curriculum will be addressing all aspects of internal medicine and provide residents with adequate exposure through a continuity of care clinic; which will expose our students to an experience where they can follow a patient through an extended period of time.” Lean Six Sigma is a term used to reference a collaborative impact methodology in the healthcare setting leveraged to improve performance by strategically improving efficiency and streamlining processes in a healthcare setting. It combines lean manufacturing and lean enterprise, to eliminate waste the term known by many in the industry as the “lean process”.

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Dr. Egerton continued to explain how the SAMC staff, residents, and leadership will work together to create a supportive learning environment, “Residents will care for patients in the hospital, as well as following through the care continuum and coordination of care beyond the acute care setting. We have planned this specifically so they will be well versed in how they access care. We will also teach them about the quality of medicine, process improvement, and quality of care improvement, while working through our quality improvement office SAVI [SAMC’s performance improvement vehicle which uses lean methodology].”

MEDICAL RESEARCH The ACGME network provides a platform for doctors, executives, and residents in the network to access all current medical records, research, and technologically advanced procedures through the organizations online database. ACGME provides access to this information so that practicing doctors can utilize the most recent practices or methodologies available. Dr. Egerton explained the intentions for the medical research model, “Residents will be encouraged to choose a project, which will then become clinical studies with abstracts — which will be reported on and accessed by the Trinity Health Network. The Trinity Health Network also provides platforms for these residents to present their work in various venues and will also give residents resources to assist them in preparing to take their board examinations before they leave our program.” The ACGME has residents throughout the county simultaneously performing research as a part of their residency curriculum mostly relating to the specific focus of the residency program. The SAMC Internal Medicine Residency Program will specifically focus on each different specialty of Internal Medicine through research initiatives. Students will be encouraged to choose a topic below to perform ongoing research within one of the internal medicine disciplines: Adult Congenital Heart Disease Advanced Heart Failure and Transplant Cardiology Cardiovascular Disease Clinical Cardiac Electrophysiology Clinical Informatics Critical Care Medicine Endocrinology, Diabetes, and Metabolism Gastroenterology Geriatric Medicine Hematology Hematology and Medical Oncology Hospice and Palliative Medicine Infectious Disease

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CHIEF MEDICAL OFFICER, DR. WALTER EUGENE EGERTON, M.D., FAAP Dr. Egerton is a North Carolina Chapel Hill native who served in the United States Army as a Medical Core Officer. His specific medical training was as a Pediatrician with a specialty in Adolescent Medicine. After years of serving The United States he was promoted to Physician Executive. When he finished serving in the Army he moved into Quality Improvement for the State of Maryland and District of Columbia Quality Improvement Office, which is a part of the government oversight of the health care quality improvement program - for participating hospitals. Following his career in Quality Improvement, Dr. Egerton became interested in Direct Care, which is when he reentered hospital medicine as a Physician Advisor at Saint Agnes Baltimore, in his role as the Chief Medical Officer for one of the Marilyn hospitals. In that role Dr. Egerton worked on a standalone program for each facility. With his expertise and medial training he is no stranger to what is happening at SAMC now and will be helping to lead the first Central Valley Cohort.

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I nternal Medicine-Pediatrics Interventional Cardiology Medical Oncology Nephrology Pulmonary Critical Care Pulmonary Disease Rheumatology Sleep Medicine Transplant Hepatology Dr. Egerton continued to explain how the medical education piece of the program will assist students in reaching their research goals, “Each specialty mentioned will have a focus on the book knowledge so that residents understand what is needed to be an effective physician. This program is about creating a Public Health and Population Health standpoint and awareness for what is going on in the Central Valley.” Following the completion of research and the residency program, residents will begin to study and prepare for their medical board examinations. SAMC faculty and staff will be working hard to prepare the residents for a successful first examination attempt. “It’s important for us to have successful students, because that’s what we, as SAMC, will be judged on. It’s a point of contention for a lot of programs. Dr. Egerton explained “The program I come from was in a large, inner city hospital. We

had 6 straight years of board exams being passed on the first attempt -- that was a big deal for the program.” Although passing medical board exams on the first try may sound overwhelming, the confidence and care in Dr. Egerton’s tone was reassuring and enthusiastic. He hinted at the importance of understanding the excellence and dedication that must be incorporated into medical practice and patient care.

UPSTREAM VERSUS DOWNSTREAM CARE

As medical models have evolved over the years so has the focus on patient care. The SAMC program is also structured to prepare future physicians for the most modern patient care models in the industry. Drivers of healthcare are most often identified or explained as healthcare costs contributing to the total amount of capital spent on health care in any given region, state, or country. Dr. Egerton explained the importance of understanding how patient care has changed due to drivers of healthcare and patient care models, “From the population health standpoint it’s important to educate people on the Assisted Living • Memory Care science of it. We’re an education driven society, everyone goes on the internet to learn. Patients will walk in the office knowing more about the diagnosis than the physician at times, or they will ask unexpected questions — but the reality is that doesn’t mean anything [for either party] until you put in context of how to keep the patient healthy.” Resident focused care that you will be proud to recommend. Egerton continues with “We’re trying to go Personalized care plan • Incontinence Program from reactive or palliative Medication management including injections • Purposeful activity programs medicine — to proactive or Nurse on-site 7 days a week • Diabetic Wellness Program preventive medicine. That’s what we’re trying to teach, [patients and physicians 5605 N Gates Ave • Fresno, CA 93722 alike] if we can have our 559-682-3114 physicians spending just as oakmontoffresno.com much time educating their patients as they are treating RCFE #107206882

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Fall 2017

them — they help them to stay well.” approach. Dr. Luka and Dr. Egerton are working hard together Dr. Egerton explained the shift in healthcare trends, “The to lead the inaugural residency program this upcoming first healthcare industry is moving from pay as you go or feeterm in July of 2018. for-service, to a value-based system in which the alternative Over the next four years, SAMC plans to submit payment models emphasizes taking care of the whole accreditation applications for Family and Emergency population and not just taking care of people when they get Medicine programs. They are also looking to launch a sick. We are teaching physicians the thought-process behind Transitional Medicine program which would function as an determining population health and the drivers of healthcare ongoing biomedical research program with the purpose of in our community. That includes focusing on what kinds of finding and incorporating new diagnostic tools and treatments behaviors are happening in the community. That way doctors into the SAMC and Trinity Health Network patient care can be focused on creating accountability in healthcare for model. SAMC is also working hard to incorporate mental and their patients, so that hopefully they take ownership of their emotional health needs of patients into patient care model and personal health. In turn the idea is that patients will take the residency curriculum. necessary preventative maintenance [in their lives], so that Medical Students interested in applying can email questions they can stay out of the hospital. This happens by coming to to gme@samc.com. In addition to the categorical and the physician’s office, or taking care of themselves on a regular transitional residents being recruited this fall, the Internal basis; so that the patient is not just waiting until their health is Medicine Physician Residency Program is looking to hire out of control.” one or more Chief Residents in administrative and leadership “It’s all about how healthy you can keep patients, not roles. Interested applicants should submit their CV, letters of how quick you can fix them when they are sick. We are recommendation, personal statement, transcripts, USMLE teaching patients how to manage their healthcare, so scores and other material to GME@samc.com with “CMR” they can stay healthy. And not just come to their doctors in the subject line. when things are way out of control. Back in the day we taught about the practice of medicine, there is a science to it, there is an art to it, INC. but now we have to teach A REGISTRY & PLACEMENT FIRM the business of medicine. Because medicine affects the population as a whole, healthcare is the biggest Nurse Practitioners ~ Physician Assistants driver of our GDP and the largest contributor to the deficit in America.” - Dr. Egerton

Tracy Zweig Associates Physicians

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EAT FOOD, MOSTLY PLANTS Everyone knows the old adage, “An ounce of prevention is worth a pound of cure.” How about this one? “Eat food. Not too much. Mostly plants.” That simple but profound statement is from Michael Pollan’s brilliant book - In Defense of Food, an Eater’s Manifesto. In his book, he exposes the big food giants, who are becoming ever more creative in delivering “edible food-like substances”--not really food, but food made in a lab.

By Cesar Vazquez, MD

Despite years of research, journal articles, public health campaigns, and documentaries uncovering the negative health effects of our sugar-rich, chemically-laden, meat-based diets, we continue to indulge ourselves in these habits -- the so called Western diet -- which is responsible for more than 80 percent of the chronic diseases we see today. My friend Michael Lesner, executive producer of the long-running PBS show “American Health Journal” made some sobering remarks in a recent talk. In America, the working economic model centers not on prevention of chronic diseases, but on an ever increasing array of highly expensive and sometimes unproven treatments. Not surprisingly, the primary aim being to maximize reimbursements for hospitals and doctors while at the same time, liberating the patient from any sense of personal responsibility for how they got to where they are. In contrast, he said, people living in Canada and the

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European Union often do not have access to the latest diagnostic techniques or advanced surgeries and, rather than waiting until they weigh over 400 pounds to qualify for bariatric surgery, they focus on prevention. The governments of these countries have known this truth for decades, and devote a significant amount of their health care budget to programs that keep the population healthy. Another way of saying this is ”Take control of your health and don’t get sick…period. In the book entitled “Prevention vs Treatment, What’s the Right Balance” edited by Halley S Faust, MD and Paul T Menzel, PhD, the writers argue “in the Western world’s health care it is commonly observed that prevention is underfunded, while treatment attracts greater overall priority.” This well-researched anthology guides us through a series of essays looking at our current philosophy and why - in our culture - we place so much value on treatment. Elisabeth Rosenthal has recently written an excellent

Fall 2017

KIDS EAT book entitled: “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.” In her book she proposes the answer to the above question in her “Economic Rules of The Dysfunctional Medical Market:” 1. M ore treatment is always better. Default to the most expensive option. 2. A lifetime of treatment is preferable to a cure. 3. Amenities and marketing matter more than good care. 4. As technologies age, prices can rise rather than fall. 5. Th ere is no free choice. Patients are stuck. And they’re stuck buying American. 6. M ore competitors vying for business doesn’t mean better prices; it can drive prices up, not down. 7. E conomies of scale don’t translate to lower prices. With their market power, big providers can simply demand more. 8. Th ere is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all. 9. Th ere are no standards for billing. There’s money to be made in billing for anything and everything. 10. Prices will rise to whatever the market will bear. Whether you agree with these conclusions or not, the reality is that most of us in health care believe that our system needs fundamental and comprehensive reform. I first heard about the Physicians Committee for Responsible Medicine (PCRM) during my pediatrics residency. I was attending the National Conference of the American Academy of Pediatrics when I happened to meet a representative from PCRM in the exhibit hall. Their mission is to prevent and even reverse serious health problems, such as obesity, diabetes, heart disease, high blood pressure, elevated cholesterol, migraines, and arthritis through a vegan

Fall 2017

45,485 POUNDS OF SUGAR EVERY 5 MINUTES

Snack company KIND dumped 45,485 pounds of sugar in Times Square to spark conversation about how much added sugar children consume. The American Heart Association recommends children eat no more than 100 calories (about six teaspoons) of added sugars, also known as free sugars, daily. But, children are eating much more than that — over 270 calories according to data in the 2015-2020 Dietary Guidelines for Americans. Most comes from sweetened drinks. KIND estimates the average 9-year-old eats their weight in added sugar each year. The 45,485 pounds of sugar in New York City’s Times Square is meant to represent how much added sugar American children are eating every 5 minutes. “Hopefully it empowers consumers – especially parents – to make more informed food choices,” said Stephanie Perruzza, RD, Health & Wellness Specialist at KIND. Added sugars are sugars manufactures add to foods, as well as honey, syrups, fruit juices and fruit juice concentrates. Children who consume too much added sugar are at risk to become overweight or obese. Studies have also said such sugars increase the risk of death from heart disease. Perhaps the biggest problem with added sugars is that they are what many call empty calories, meaning they have no nutritional value. “Added sugars provide excess calories without any beneficial nutrients,” Perruzza said. “By reducing them in children’s diets, you’re creating more of an opportunity to introduce nutritious food options like fruits, vegetables, whole grains.”

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diet. Even though it was not taught in my medical school, this idea resonated with me. I’ve since used many of their resources (found at pcrm.org) to enhance my own knowledge about the power of plant foods, and make me an effective vehicle to help others who are struggling with obesity-related chronic illness. Their president and founder, Dr. Neal Barnard, has written numerous journal articles and authored 18 books,

including the New York Times best-sellers: Power Foods for the Brain, 21-Day Weight Loss Kickstart, and the USA Today best-seller Dr. Barnard’s Program for Reversing Diabetes. Dr Barnard was invited to speak at the Food Revolution Summit held in April of this year. Twenty-four of the top food experts including best-selling authors like Drs. Dean Ornish, Michael Lustig, and former Surgeon General David Satcher were interviewed by John Robbins. Mr. Robbins was part of the family of Baskin-Robbins fame, but walked away from his family’s business empire because he realized it made people unhealthy. Replays of the interviews can be seen foodrevolutionsummit.org. Finally, a new documentary I highly recommend is entitled “What the Health.” It exposes the collusion and corruption in government and big business that is costing us trillions of healthcare We know discussing financial strategies and dollars, and keeping us sick. Food insecurity and obesity choosing insurance and investments may burden our Central Valley. not be your favorite thing to do. But making According to Kidsdata.org, choices now can help give you - and your almost 43% of school aged children in this region are obese family - confidence in your future. So you can compared to the California get back to the things you love doing. No average of 38.5%. Many of our adult healthcare professionals matter what your financial goals are, I’m here know that the data for adults is to help. Let’s get started today. even worse. Advertisements for unhealthy food and beverages dot the landscape of our poorest Jaisy Prem, MBA Financial Representative neighborhoods The proliferation Principal Securities Registered Representative of fast food restaurants are also Financial Advisor leading factors contributing to California insurance license: # OK57537 1350 E. Spruce Ave poor health status and limited Fresno, CA 93720 access of healthy food and drinks. (559) 650-2674 As physicians who care for the prem.jaisy@principal.com wellbeing of others, we must stand together with a united voice, and share the truths about ©2017 Principal Financial Services, Inc. Principal, Principal and symbol design and Principal the life-preserving effect that Financial Group are registered trademarks and service marks of Principal Financial Services, Inc., a Principal Financial Group company. Insurance products issued by Principal National a plant-based diet has on our Life Insurance Co. (except in NY), Principal Life Insurance Co. Securities and advisory products offered through Principal Securities, Inc., 800/247-1737, member SIPC. Principal health, and our quality of life. National, Principal Life, and Principal Securities, Inc. are members of Principal Financial

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The California Medical Association and the Fresno Madera Medical Society

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TOGETHER, WE ARE STRONGER. Itâ&#x20AC;&#x2122;s through a strong membership foundation that CMA remains a dominant force in health care, leading the charge on several fronts, including the following: Continuously defending the Medical Injury Compensation Reform Act (MICRA) Advocating for specialty scope of practice that protects patients Leading public health efforts, including decreasing youth smoking and passing a landmark immunization law Other benefits of membership include professional, personal and practice resources, which commonly offset the price of dues. Learn more at www.cmanet.org/groupdiscounts.

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In Memoriam Robert Carney Meltvedt, MD September 1, 1922 – July 2, 2017 The family of Robert Carney Meltvedt, M.D. is saddened to announce he passed away on July 2, 2017. Robert “Bob” Meltvedt was born on September 1, 1922, in Marshalltown, IA. He began his life on a farm and attended Marshalltown grade schools, junior and senior high school, graduating in 1940. After high school graduation, he enlisted in the United States Army Air Corps in 1942, and was soon called to active duty. After pilots training, he was Commissioned Second Lieutenant, received his pilot wings in 1944, and was sent to P47 fighter training. He flew several missions in World War II, and earned several decorations including the Distinguished Flying Cross. After the war, Bob enrolled in the University of Southern California to finish his engineering degree while also staying active in the Air Corp Reserve. He was recalled briefly to active duty during the Korean Conflict. On January 20, 1952, he married Beverly Mae Johnson. After working in the aeronautics engineering field for Northrop Aircraft, he decided to pursue his dream of becoming a physician. After medical school at USC, he began private practice in Obstetrics and Gynecology in June 1961. After a long career in Fresno, Dr. Meltvedt delivered his last of over 10,000 babies in 1994, but continued to practice surgery until his full retirement in 2008. In addition to raising their five children, Bob and Bev loved to take golf vacations to Hawaii, visiting with their grandchildren, and enjoying their large circle of friends. With his pilot background, he continued to be interested in military aviation and enjoyed spending time at Eagle Field, the site of his early military training. He loved music and had an extensive library of music audio and videos from the Big Band era. Robert was preceded in death by his wife of 55 years, Beverly Mae Meltvedt; his parents, Carney and Irva Meltvedt; his brothers, Richard Meltvedt, and David Meltvedt; and his sister, Mary Ann Trobaugh. He is survived by his son, Robert Meltvedt, Jr.; his daughters, Karen Meltvedt Brown, Elizabeth Dunshee, Deborah Meltvedt, and Mary Kay Meltvedt Payne; 11 grandchildren; seven great-grandchildren; and countless friends and extended family. Dr. Meltvedt was a member of the Fresno Madera Medical Society for 45 years.

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Fall 2017

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Fresno Madera Medical Society 1040 E. Herndon Ave., Suite 101 Fresno, CA 93720

PRSRT STD. U.S. POSTAGE

PAID

Permit No. 30 Fresno, CA

State of the Heart SAINT AGNES CARDIOLOGY SYMPOSIUM 2016 Saturday, April 23 • 8 a.m.-2 p.m. Saint Agnes Medical Center, Shehadey Pavilion 1303 East Herndon Avenue • Fresno, California This symposium focuses on cardiovascular disease management and emerging paradigms in treating coronary and structural heart disease. It will address practice gaps in disease management and provide education to improve patient outcomes.

Speakers Paradigms of Revascularization for Chronic Coronary Artery Disease Verghese Mathew, MD, FACC, FSCAI Consultant, Division of Cardiovascular Diseases and Department of Radiology Professor of Medicine, Mayo Clinic College of Medicine Protected PCI: Treating Complex Coronary Artery Disease in 2016 Anthony A. Hilliard, MD Assistant Professor of Medicine Director, Adult Cardiovascular Lab Loma Linda University International Heart Institute Invasive Management of Intractable Angina Gurpreet S. Sandhu MD, PhD Director, Dr.the Earlright Wood Cardiac Cath Lab, Mayo Clinic When you’re confident you’ve chosen

hospital for your maternity care, you’re free to Transcatheter think of just about anything. It’s whyMitral so manyValve Therapies women choose Saint Agnes Medical Center. Oluseun O. Alli, MD Along with all-private rooms, we partner with of Medicine Assistant Professor Valley Children’s Healthcare to give you and your at Birmingham School of Medicine University of Alabama baby access to a Level III NICU and one of the top maternal fetal medicine programs around.

Preregistration is required • No charge

Visit www.samc.com to learn how peace of Please register online www.samc.com. Registration must be received by April 16, 2016, mind is just one of the many things weatdeliver.

to be guaranteed a participant syllabus. If you have questions or problems registering online, email medicaleducation@samc.com or call (559) 450-7566. Registration at the door is dependent on space availability. TM

5 AMA PRA Category 1 Credits to be awarded