Central Valley Physicians Fall 2018 by Fresno Madera Medical Society

Fall 2018

HEaL HEaL

ONE PATIENT AT TIME Diversity Difference Can Curatives Kill? Summer Meltdown

Fall 2018

Thereâ&#x20AC;&#x2122;s No Heartbeat

CENTRAL VALLEY PHYSICIANS

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Fall 2018

VOLUME 3, NUMBER 3 • FALL 2018

{FEATURES}

14 23 24 26 32 44

DIVERSITY DIFFERENCE PUBLIC HEALTH OFFICER THERE’S NO HEARTBEAT HEal ONE PATIENT AT A TIME CAN CURATIVES KILL?

{DEPARTMENTS} 6

MESSAGE FROM THE EDITOR

PRESIDENT’S MESSAGE

12 CONSTRUCTION BEGINS (CHSU) 36 MEMBERSHIP MATTERS 38 RETIREMENT FOR EVERY STAGE OF LIFE 42 CLASSIFIEDS 48 PRACTICE MANAGEMENT 50 IN MEMORIAM

SUMMER MELTDOWN

Cover photo by Anthony Imirian. Pictured on the cover is Rafael Gonzalez, MD, Leyla Farshidpour, Kenny Banh MD and Enid Picart

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CENTRAL VALLEY PHYSICIANS

From The Executive Director

TODAY IS THE FIRST DAY OF FALL… REALLY? FALL IS ALREADY HERE?

This year is flying by and we have so much going on these days since we have expanded our staff. We now have time to work on new projects and benefits for our members. We have a couple of new business partners that we are working with. The first is Breadcrumb, a local cybersecurity firm NICOLE BUTLER supporting the security and compliance needs of small, medium and enterprise healthcare organizations. FMMS members receive discounted rates on all penetration testing, vulnerability assessments and on their HIPAA/MACRA/MIPS compliant cyber Security Risk Assessment (SRA) program. Jennifer and Brian are already working with several of the medical groups in town and are great to work with. Call Jennifer at (559) 578-4800 or email JGuidry@breadcrumbcyber.com and let her know you are a FMMS member.

PRESIDENT Trilok Puniani, MD PRESIDENT-ELECT Cesar A. Vazquez, MD VICE PRESIDENT Alan Birnbaum, MD TREASURER Don Gaede, MD PAST-PRESIDENT Alan Kelton, MD BOARD OF GOVERNORS Christine Almon, MD, Andres Anaya, MD (Resident Board Member) Janae Barker, DO, Jennifer Davies, MD Joseph Duflot, MD, Patrick Golden, MD David Hadden, MD, Prahalad Jajodia, MD Brent Kane, MD, Shamsuddin Khwaja, MD Christine Maser, MD, Katayoon Shahinfar, MD Nadarasa Visveshwara, MD CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS

The other great company is Medical Office Services. They provide comprehensive medical billing that will increase your revenue and reduce the stress of collections. FMMS member offices receive the first month FREE and the second month half price, and no upfront cost. Medical Office Services is a physician owned company, and Rita is the one to call about the services and cost. She can be reached at (559) 359-6170.

EDITOR Don Gaede, MD MANAGING EDITOR Nicole Butler EDITORIAL COMMITTEE Don Gaede, MD - Chair, Alan Birnbaum, MD - Associate Editor, Roydon Steinke, MD, Cesar Vazquez, MD,

For a complete list of our partners, look on the FMMS.org website. We strive to work with local companies that are there for our members when they call. If you know of another company that you would like us to reach out to let me know. Next month we are launching a job board for our members. Physician offices can go to our website and post open positions that they need filled. These positions can be anything from a front officer person, billing, MA even another doctor if that is what you are looking for. This will be a free service for members, an easy platform to post open positions and we will provide marketing support to get your job post seen by the right people. In addition to the new services, we have some important events coming up that I want everyone to know about. Wednesday, October 24 - Office Manager Forum – “How to Negotiate Like a Pro” Friday, November 16 – Fresno Madera Medical Society Awards Gala and President Installation, Fort Washington Golf & Country Club Saturday, December 1 - Joy of Medicine Summit, Tenaya Lodge Friday, December 7 – Fresno Madera Medical Society Holiday Party, Fresno Lexus

Nicole Butler, Trilok Puniani, MD, Farah Karipineni, MD CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Don Gaede, MD, Erin Kennedy, Nicole Butler, Jennifer Seita, Farah Karipineni, MD and Lisa Buscho, RN BSN and Richele Kleiser CONTRIBUTING PHOTOGRAPHERS Anthony Imirian 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

Please watch your email and mail for more information on these events. Also, watch your mail for your 2019 membership dues statement. These will start to mail in the middle of November and will cover dues for the following year. If you are not a member, now is the time to join. If you pay your membership dues before the end of the year, you get the remainder of this year and all of next year for the annual fee. If you have any questions or would like to join feel free to call me, of visit FMMS.org

Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler Marketing and Events Coordinator, Kailey Fontes Membership and Events Manager, Stacy Woods Receptionist, Becky Gentry

Enjoy the Fall weather, and enjoy the holidays that are right around the corner.

Nicole Butler

CENTRAL VALLEY PHYSICIANS

Fall 2018

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

Why We Support Measure P

ABOUT THE AUTHOR Dr. Gaede, a Fresno native, 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

Cesar and I are both very fortunate—each of us lives within a few blocks of Woodward Park and the Eaton Trail. We have easy access to a scenic place where we can walk, run, bicycle, or just have a picnic with our families. But most Fresnans aren’t so lucky. The vast majority of Fresnans live miles away from attractive green space. With the exception of Roeding Park on the southern edge of Fresno, the vast majority of green space and walking trails are located in the far northern part of our city. And even in the north, park facility and landscape maintenance needs often sit unaddressed. To make matters worse, the total amount of park acreage in our fair city is embarrassingly low. According to The Trust for Public Land, Fresno ranks 94th out the largest 100 American cities for parks and green space. In other words, only 6 large cities in this country have less green space than Fresno. We must do better than that. At the top of the green space rankings are cities like San Francisco and Minneapolis--no surprise. But check out Bakersfield—it ranks twice as high as Fresno, and spends twice as much per resident as Fresno on its park system. Fresno’s spending trend is going in the wrong direction--our expenditures for the PARCS Department have decreased by 39% over the past 10 years. Let’s be frank—we Fresnans have a weight problem. One third of our adolescents are overweight or obese. Our parents are doing even worse – 57% percent of Fresno County’s adults are overweight or obese. So although Cesar is a pediatrician and Don is an internist, we both give the exact same recommendation to our patients: Eat a healthy diet, and get regular exercise! Unfortunately, most Fresnans are not doing so. Obesity often starts in childhood. But physical activity of any kind, combined with a plant-based diet, can help prevent and even reverse this disorder, by speeding up the break-down of fat in the body and helping to build muscle mass. Research shows that over 80% of adult hospital admissions in the U.S. are due

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Let’s be frank—we Fresnans have a weight problem. One third of our adolescents are overweight or obese.

to preventable causes—causes that could be avoided with adequate exercise and attention to diet. Bariatric surgery and prescription drugs are not the solution. Instead, we need to focus on early intervention, and give children greater opportunities to access local parks and engage in outdoor physical activities where they also feel safe. Intuitively, it makes sense that the closer you live to a park, the more likely it is that you will take a walk in that park. A 2005 study from Australia published in the American Journal of Preventive Medicine confirmed this hunch. But researchers also found that proximity to a park was not enough by itself to

of $39 per household each year (or just $3.25 each month) applied equally to visitors and Fresno residents according to www.fresnoforparks.com The funds will be spent in this way: • 4 6% on maintaining clean and safe parks, i.e., fixing up bathrooms, improving access for persons with disabilities, and addressing other deferred maintenance at existing park facilities; • 21% on new parks and recreational facilities;

This coming November, we will have a chance to do something significant to enhance the health of our children and the quality of their lives.

get people walking--the park also needed to be an attractive and safe place to walk. Those Aussies that lived close to such a park were 50% more likely to take regular walks. Money spent to improve parks and bicycle lanes is a good financial investment. The CDC reports that community design interventions that improve walking and bicycling infrastructure lead to increase in physical activity, essentially paying for themselves in lower healthcare costs. One study showed that for every dollar invested in walking trails and dedicated biking lanes, between $1.20 and $3.80 is saved as a result of reduced health care utilization and fuel consumption. This coming November, we will have a chance to do something significant to enhance the health of our children and the quality of their lives. The Fresno Clean and Safe Neighborhood Parks Tax Initiative – Measure P – will raise an estimated $38 million per year through a 3/8 (0.375) cent sales tax in the city of Fresno. The cost will be an average

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• 8 .5% on youth and senior recreation, after-school programs, and job training; • 11.25% on improved walking and biking trails, the San Joaquin River Parkway, and beautification of roads and freeways; and

• 12% on expanded access to arts and culture. A nine-member commission will ensure the money gets spent in the right areas. Appointed by the mayor and city council, the commission must include members with expertise in parks management, youth development, trails and San Joaquin Parkway development, and arts and culture development. The motto of our medical society is “Physicians United for a Healthy Central Valley.” Let’s all unite to support this proposal that promises to enhance the health and quality of life for all the citizens of Fresno. Don Gaede, M.D., Secretary-Treasurer, Fresno-Madera Medical Society Cesar Vazquez, M.D., President-elect, Fresno-Madera Medical Society

CENTRAL VALLEY PHYSICIANS

President Report > Trilok Puniani, MD

The Time Has Come: Let Hospitals Hire Doctors

ABOUT THE AUTHOR Dr. Trilok Puniani is a board certified in Neurology and Vascular Neurology, he completed his residency training at New York Medical College and Westchester County Medical Center, in Valhalla, NY and his fellowship training at Methodist Hospital and Baptist Memorial Hospital in Memphis, TN. Upon completion of residency and fellowship in Neurology, Puniani moved to Fresno in 1989 and started a private practice later joining Kaiser Permanente in 1997 where he is currently Chief of the Neurology Department.

It is a little-known fact that California is one of a handful of states that prohibits the direct employment of doctors by hospitals. The state’s ban on corporate medicine was created more than a century ago in response to mining companies hiring their own physicians, which led to concerns over whether the physicians worked in the best interests of their patients or their employers. Only five states -- California, Colorado, Iowa, Ohio and Texas -- explicitly prohibit hospitals from employing physicians. Even in these states, certain types of hospitals and providers are exempt from these prohibitions. For instance, California allows physician employees at teaching hospitals, some community clinics, narcotic treatment programs, and certain non-profit organizations. The rationale for the prohibitions on employment of physicians by hospitals is based on the potential for conflict between a physician’s loyalty to the patient and the financial interests of the corporation. While the intention behind this policy is noble on the surface, it is actually detrimental to hospitals serving rural, lowerincome patients. The policy against the corporate practice of medicine, as expressed in Section 2400 of Business and Professions Code, is intended to prevent unlicensed persons from interfering with or influencing the physician’s professional judgment. From the Medical Board’s perspective, the following health care decisions should be made by a physician licensed in the State of California, and would constitute the unlicensed practice of medicine if performed by an unlicensed person: • Determining what diagnostic tests are appropriate for a particular condition • Determining the need for referrals to, or consultation with, another physician/ specialist • Responsibility for the ultimate overall care of the patient, including treatment options available to the patient • Determining how many patients a physician must see in a given period of time

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Fall 2018

or how many hours a physician must work • S election, hiring/firing (as it relates to clinical competency or proficiency) of physicians, allied health staff and medical assistants • S etting the parameters under which the physician will enter into contractual relationships with third-party payers •D ecisions regarding coding and billing procedures for patient care services

Medical Centers. In these instances, the physician groups and hospitals contract with private insurance companies to cover the services for most of their patients.

Rural areas are suffering

While large urban areas can attract and support physicianowned medical groups, the hiring prohibition is causing concern for rural areas and the Central Valley, which are already in dire need of physicians. A study by the California Healthcare Foundation found a significant scarcity of physicians in 18 of the state’s 58 counties. For example, the state average is one physician for every 575 residents, but

Obviously, the types of decisions and activities resulting in control over the physician’s practice of In particular, the Central Valley has an outsized need medicine should be made by a for doctors. Known for concentrated poverty and some licensed California physician, of the most polluted air in the country, the Valley’s 4 not by an unlicensed person or entity. million residents suffer from higher rates of asthma and The California Medical obesity compared to other parts of the state. Association, which represents about 43,000 doctors, is opposed to the idea of letting hospitals hire doctors. According to their website, “The CMA fiercely defends California’s bar on the corporate in a rural county like Modoc, which has three physicians, practice of medicine, which prevents corporate interests from there is only one doctor for every 3,520 people. According unduly influencing physicians’ professional judgments in the to the County Health Rankings & Roadmap Report, the name of profit and to the detriment of patients. Hospitals and San Joaquin Valley had 48 primary care physicians and 80 other corporate interests do not have the same ethical and specialists per 100,000 residents, which is well below the moral obligation to the patient as a physician does; therefore, it level recommended by the Council on Graduate Medical is essential to maintain the firewall between medical decisions Education. For comparison, the Bay Area had 86 primary care and the corporate bottom line.” doctors and 175 specialists per 100,000 residents. Some entities have found ways to deal with this firewall. Physicians in small communities are at a disadvantage Kaiser Permanente, for example, is the combination of Kaiser because their patient population is comprised largely of Foundation Health Plan and The Permanente Medical Medi-Cal and Medicare patients. These programs provide Group, which is the doctor group. They collaborate with the lower reimbursement rates than commercial health insurance. Kaiser Foundation of Hospitals to create a unique, federally Additionally, a new report forecasts a substantial shortage recognized Health Maintenance Organization. While not of qualified and diverse behavioral health professionals in an HMO, Mercy Medical Group is a physician group that California within 10 years. The coming decades will also works with Dignity Health, formerly Catholic Healthcare witness large numbers of primary care doctors and nurse West. Sutter Health, another physician group, collaborates practitioners reaching retirement age. with the Sutter Hospital system. Similarly, Central California California is heading for a serious shortfall of primary Faculty Medical Group, Fresno collaborates with Community care doctors, psychiatrists, physician assistants, and nurse

Fall 2018

CENTRAL VALLEY PHYSICIANS

practitioners over the next few decades. This crisis could force patients to seek medical help for routine illnesses at hospital emergency rooms instead of their primary care physicians. In particular, the Central Valley has an outsized need for doctors. Known for concentrated poverty and some of the most polluted air in the country, the Valley’s 4 million residents suffer from higher rates of asthma and obesity compared to other parts of the state. It is a daunting task for young physicians, who are often hundreds of thousands of dollars in debt, to move to a small town and try to build a practice from the ground up. Therefore, most young physicians would prefer to be employed by a hospital rather than go into private practice. This is evidenced

Push for reimbursement rates for Medi-Cal and Medicare comparable to those of commercial insurance for primary care physicians and specialists in the Central Valley, including its rural areas. Provide incentives to retain doctors completing their residency training in the Valley. Create career pathways for students and pay stipends for education in the health field. One example is the University of Kansas Medical School’s “Scholars in Rural Health” program, which recruits undergraduates willing to complete an M.D. and practice in rural Kansas. Successful candidates are guaranteed admission to the medical school and can receive a full scholarship.

The healthcare system is changing. Better care is provided at all hours of the day by hospital-based physicians, in-patient critical care physicians, teleneurologists, teleradiologists, and neurohospitalists.

The doctrine of prohibiting the hiring of doctors by hospitals is a vestigial practice of a bygone era. As long as doctors, not unlicensed persons or entities, oversee the responsibilities and tasks set forth by the Medical Board, hospitals should be permitted to hire doctors. Trilok Puniani, MD President FMMS

by a 2015 survey conducted by research firm Merritt Hawkins, which found that 92% of first-year medical residents would prefer to work directly for a hospital rather than practice as an independent contractor. According to an updated study from the nonprofit Physicians Advocacy Institute and Avalere, nationwide: Hospitals employed 42 percent of physicians in July 2016, up from 1 in 4 physicians in July 2012. From July 2012 to July 2016, the number of hospitalemployed practices increased by 36,000 practices, reflecting a 100 percent increase The healthcare system is changing. Better care is provided at all hours of the day by hospital-based physicians, in-patient critical care physicians, teleneurologists, teleradiologists, and neurohospitalists. The community will be better served when these physicians are provided with a sense of security and hired by hospitals. To avoid a healthcare crisis in the Central Valley, we must: Set regulations for hospitals to hire doctors, which would provide monetary incentives for recruiting and retaining physicians.

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References / Links: State Prohibitions on Hospital Employment of Physicians (OE1-01-91, 00770, 11/91)-OIG.HHS.gov The Medical Practice Act. Business and Professions Code (B&P) Section 2052. Medical Board of California “SB 376: Direct Employment of Physicians Report to the Legislature” September 10, 2008. California Medical Association Website > Learn > Top Issues > Protecting the Physician-Patient Relationship. Physicians Advocacy Institute and Avalere. Association of California Healthcare Districts. https://insuremekevin.com/californiahospitals-prohibited-from-hiringdoctors/#RdHdOGuw2Q7QYJpk.99

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Fresno Madera Medical Society Cordially invites you to the 2018

Installation & Awards Gala Friday, November 16, 2018

6 pm Social 7 pm Dinner, Installation & Awards Fort Washington Golf & Country Club 10272 N. Millbrook Avenue Fresno, Ca 92730 Table of 8: $500 - Single Ticket: $65

Event Sponsors Cooperative of American Physicians, Inc. NORCAL Mutual

CENTRAL VALLEY PHYSICIANS

Spring 2018

Construction Begins on New Campus for California Health Sciences University (CHSU) After celebrating the groundbreaking in May 2018, construction has begun at California Health Sciences University’s new campus. Located at 2500 Alluvial Avenue in Clovis, near the intersection of Alluvial and Temperance Avenues, the first state-of-the-art building on the campus will house their proposed College of Osteopathic Medicine. The University is hoping to open this second College in 2020, pending approval from their accreditors. Groundwork for this first building is nearly complete, and the concrete has been poured for the footings and foundation. The University is posting construction progress on their website and social media channels. In addition to building the new campus, the University has been busy assembling the leadership team that will help to launch their osteopathic

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medical school. John Graneto, DO, Dean of the proposed College of Osteopathic Medicine states, “I’m very pleased to have recruited a full complement of experienced Associate Deans to round out our medical school management.” Planning for curriculum, completion of accreditation documents, and establishing clinical relationships are now cornerstones of their work. “Next, we will focus on recruiting over 30 full-time Faculty members over the next several months,” says Dr. Graneto. The University is currently seeking candidates for Clinical Faculty (Primary or Specialty Medicine) and Osteopathic Principles and Practices (OPP) Faculty. Visit chsu.edu/com to read more about the proposed College of Osteopathic Medicine program and learn more about employment opportunities.

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DIVERSITY

DIVERSITY DIVERSITY DIVERSITY DIFFERENCE BY ERIN M. KENNEDY • PHOTOGRAPHER ANTHONY IMIRIAN HMONG WOMEN HAVE HIGHER RATES OF CERVICAL CANCER AND HMONG MEN ARE PRONE TO SUDDENLY DYING IN THEIR SLEEP FOR UNEXPLAINED REASONS. LATINOS ARE 50% MORE LIKELY TO DIE OF DIABETES OR LIVER DISEASE THAN WHITES. AND BLACK WOMEN ARE THREE TIMES MORE LIKELY TO DIE IN CHILDBIRTH – ESPECIALLY IF THEY GO TO A HOSPITAL THAT PRIMARILY TREATS AFRICAN-AMERICAN PATIENTS. >>

BONNIE HER, MD Family Practice CMP Chestnut

And more and more studies say the reasons for these health disparities may have a lot to do with the lack of access to medical providers who share their language or understand how these particular patients approach healthcare. “Honestly I think it could be life and death,” Bonnie Her, a Hmong family medicine physician, said about the need for diversity among physicians – especially in the central San Joaquin Valley with its high numbers of immigrants, low education levels and high poverty rates. “I just a met a young patient in her 40s. Her pap smear came back abnormal and she hadn’t followed up,” said Dr. Her, who practices in Fresno and knows the struggle to get Hmong immigrants to understand the need for preventative care and health screenings. “It is definitely a cultural thing. There’s high rates of cervical cancer among Hmong patients because it’s so private and not talked about, so they don’t go in for annual checkups. I think it’s a lot easier if there’s someone like me to see.”

It’s the norm with many immigrants to wait until they’re extremely sick or in severe pain before they seek medical attention. In their native countries the grandma healers, village shamans, midwives and folk remedies were relied on to keep people well and deal with chronic conditions and minor injuries. “When I see a 40-year-old man, I know he’s not there just for a cholesterol check but something really serious,” said Dr. Oscar Sablan, who has practiced internal and family medicine in predominantly Latino Firebaugh for more than 30 years with his wife Dr. Marcia Sablan. And for some minority groups, even when they speak up in English, they’re used to having their health complaints dismissed. Most recently in the news, tennis star Serena Williams shared how her life-threatening postpartum complications almost went untreated because her request for a CT scan and blood thinner were dismissed first by a nurse and then a doctor. She had a history of pulmonary embolism and

DIVERSITY 16

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OSCAR SABLAN, MD Internal Medicine Sablan Medical Clinic, Firebaugh

knew the signs when she started having trouble breathing the day after her daughter’s delivery. African-American women give birth prematurely and die from complications related to childbirth at disproportionately higher rates. “The first thought is going to be that it’s because of socio-economics – where you live, where you work, what’s your education, do you smoke,” said Dr. Adanna Ikedilo, an obstetrician/gynecologist practicing in Fresno, “but when you take all those away, it’s still high. So what is it in particular that is causing all this? “I know first you have to listen to your patients,” Dr. Ikedilo asserted. That’s something all these physicians say is key for any patient no matter their culture or background. ACCESS TO DIVERSE PROVIDERS IMPROVES OUTCOMES

While health outcomes on many conditions are worse for minorities here in the Valley, a new Health Affairs study showed California has better outcomes than the rest of the nation in part because of the state’s diversity. In 2015 California became the first state in the nation to have the majority of residents identify as non-white. That Health Affairs study found every group except for blacks had a higher life expectancy than the U.S. average and surmised that a big contributing factor was the higher number of medical professionals catering to the specific needs of those communities.

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ADANNA IKEDILO, MD Obstetrician/Gynecologist Central Valley Womens Health

California medical licensing survey data shows that Latinos, African-Americans and Native American physicians are more likely to practice in medical underserved areas like Fresno and Madera counties. And these physicians are also to more likely to care for Latino and African-American populations. Valley physicians from diverse cultural backgrounds say bridging cultural gaps is key to helping patients overcome their bias against western medicine and become educated in how to create a healthier life. And increasing diversity among physicians also contributes to a diverse approach to medicine that serves patients from all backgrounds. “I think diversity is a very good friend in everything,” said Dr. Tejwant S. Dhillon, a cardiologist who has lived and trained on three continents. “When I tell my story to patients they really appreciate the experiences I bring to their care.” Plus having a diversity of role models encourages more young people from various cultures to consider medicine as a career, these doctors said.

And those with limited English, don’t understand their medical care and instructions as well and have increased risk of complications. Valley doctors say it’s the same for other cultures and other languages. “You can just see the relief when a patient sees that you can talk to them directly,” said Dr. Sablan. Both he and his wife speak fluent Spanish. “Then they can send their grandchild or child out of the room when we’re talking about delicate personal matters. And it’s especially important for female patients to have my wife there.” Dr. Her remembers many instances where patients nearly made the wrong decision or delayed care because they didn’t understand their medical providers. But one instance has stuck with her: “When I was training in Merced where they had a high number of Hmong patients, there was a woman having her seventh child. The baby was breech, but she wanted to deliver vaginally like all her other babies. The baby was in distress and she really needed a C-section.” Traditional Hmong have a strong prohibition against surgery, fearing that opening the body will allow their soul to escape and cause more illness. This mother was refusing the

DIVERSITY LANGUAGE IS A KEY TO BETTER CARE

Research shows that Latino patients with limited English visit the doctor far less than those who speak English well.

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recommended surgery until Dr. Her came and talked to her in a way she could understand about the very real possibility of losing the baby and maybe even dying. “It was a healthy boy and everyone was so happy. She had seven daughters and had been told this one was going to be a girl too,” said Dr. Her. “I told her, ‘Look if you hadn’t gone forward with that C-section you might have lost that boy you’ve been waiting all these years for.’” As soon as Dr. Her was old enough to interpret for her parents who emigrated from a Thai refugee camp, she went along to all their medical appointments. She knows well how simple constructs in western medicine don’t really translate to Hmong. “A big one is depression. There’s no such thing,” Dr. Her said. So that leaves physicians guessing if complaints about chronic back pain, headaches and neck pain or arthritis might actually warrant a mental health evaluation. “I tried doing the typical memory test. There’s no way to go backwards from December to June in Hmong. We don’t have a calendar in Hmong,” she continued. “And there’s no single word for diabetes in Hmong, so you have to say ‘your blood sugar is high,’ but even that doesn’t even adequately explain it. I tell them it’s a systemic thing and it affects your eyes and your nerves.” Back when she was a child interpreting for her

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elders, Dr. Her doesn’t remember any doctors or nurse practitioners who spoke their language. Now there are seven physicians in Fresno who do. But it’s still not enough when Fresno has the second largest Hmong population in the U.S. outside Minneapolis. There still exists a disparity in the diversity of physicians in Fresno and Madera counties for most minority groups. While nearly 56% of the population is Latino only 13% of doctors are Latino. Less than 1% of physicians in those two counties are black or Native American in an area where 5% of the population is black and nearly 4% is Native American. Communication between doctors can stumble even with those who speak English or are educated, said Dr. Ikedilo – especially when it comes to sex or what some see as embarrassing bodily functions and especially if their culture has a tradition of being private about those things. “I enjoy the advertisement they have on TV for endometriosis, because this is how so many of my patients are” being reluctant to talk about painful menstruation or sexual intercourse, she said. “You really have to encourage them to speak.” And Dr. Ikedilo noted, today’s quicker appointments might not allow the time for patients to feel comfortable getting to what’s really bothering them. Technology is bridging that communication gap for her: “Through MyChart they will ask it all – anything and everything and about sex. “I don’t do Facebook or Snapchat, so my reading

CENTRAL VALLEY PHYSICIANS

TEJWANT S. DHILLON, MD Cardiologist The Heart Group Cardiovascular Associates, Inc.

pleasure is going through Haiku checking my Epic all the time,” she said holding up her iPhone. “So I may be in contact with my patients all the time and alleviate their fears and point them in the right direction. Not everyone knows that if you have leaking while you’re pregnant that’s abnormal and you should go to the hospital. There are actually some people who will wait until their next visit to ask about that!” “A doctor should know how to communicate” with all sorts of people, said Dr. Dhillon. “It’s an art and it’s learned over time.” KNOWING CULTURAL DIFFERENCES, LIVING CONDITIONS BRIDGES HEALTH GAPS

While it’s essential to speak the same the language in the Valley’s underserved areas, Dr. Sablan said, gaining trust in the community and understanding how patients live is even more critical to bridging the health gaps that exist in immigrant populations. “That trust is really important,” Dr. Sablan explained. “With small communities they tend to have doctors who come for a few years and are gone. If they know you are going to be in the town then they have that trust.” Dr. Sablan may speak Spanish like his patients, but he doesn’t share their cultural heritage. He grew up in Saipan and studied medicine in Hawaii. But once he committed to Firebaugh Dr. Sablan said he took the time to become part of the community and truly understand the challenges and strengths of those that

lived there. He became a member of the school board and Dr. Marcia Sablan sat on the city council. The couple built their home and clinic there, and raised four children there. “We can not only talk to patients, but we understand what is available in the grocery store,” he said, “and we know what people can afford when we’re advising them on their diabetes. Marcia started a community garden so now our patients have fresh food they grow and the vegetables that are typical for their diets.” Dr. Sablan also understands how difficult it is to for patients to follow referrals to specialists: “They often have to pay someone to take them to see the specialist in Fresno and then buy a meal when they’re there. They either take a whole day or half day off and they don’t get paid for it. It becomes an expensive hardship.” He’s even adjusted his practice to bring in equipment and increase hours to accommodate his patients health access challenges. One car families often have to wait until after 5 p.m. to bring in sick children and his staff knows to begin rescheduling those who missed appointments for days when it’s expected to rain. “When it rains they don’t go into the fields and they don’t get paid for that day or two,” Dr. Sablan said of many of his farmworker patients. “That’s when they’ll try to go to the clinic or doctor’s office.” Diverse healthcare approaches also serve patients Although he hasn’t ended up treating a large number of Indian patients where his language skills and cultural understanding would be helpful, Dr. Dhillon said the approach he learned in his culture has served him well with his patients from all backgrounds. Dr. Dhillon, a cardiologist who grew up in India, went to medical school in the Punjab region, lived for a time in New Zealand and did his fellowship training in New York City. “I’ve taken the good things from my country and the good from America and western medicine and combined them,” he said. In American medicine, Dr. Dhillon has observed, practitioners are relying more and more on technology. “My Indian training was hands on. We had to make a lot of clinical diagnosis by touch and talking with patients. Here doctors just talk. We were taught to really see the patient.” Dr. Dhillon appreciates being able to marry the two methods: “Technology here is excellent, excellent;

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Fall 2018

nothing to compares. But when you rely on it, you lose providers can broaden their approaches to fit cultural, genetic something. Doctors are seeing less and less of patients and differences. more and more of computer screens and lab numbers. If I see a “So should the surveillance be different?” she said, especially patient who looks awful but their labs say they are fine, I don’t in regards to the high incidence of complications and maternal believe the labs. I want to know more.” deaths in black women around childbirth when there is Dr. Ikedilo has a similarly diverse background that has no socio-economic or obvious health difference coming informed her perspective and how she approaches patients. into play. “Should the medications be different? Should the She was born in Nigeria, raised mostly in Jamaica, went to delivery options be different? Should the education they get be medical school in Grenada, and did her residency in Baltimore. different? We need to have the power as providers to manage a “In Nigeria I was already used to a lot of different cultures and woman differently from the norm.” religions, so I grew up being very, very careful to be respectful of other cultures,” she said. “And our motto in Jamaica is ‘Out of many, one people.’ So when I came to Fresno this was something I was already used to dealing with. “We do know your culture beliefs and your religious beliefs do impact your outcomes in terms of medical treatment. So for me it truly is knowing my patients and what is important to them and being choose the business bank that fits sensitive to it, giving them kind of care where they are not lacking in anything but I’m respectful to their culture,” Dr. Ikedilo said. That spirituality plays into treatment is a norm that Dr. Dhillon grew up with Considering a commercial loan? also. The more he practices, the more Invest in the right banking team. At Central Valley Community Dr. Dhillon said he is appreciating Bank, we’re just the right amount of both big and small – the strong that Indian perspective on health with lending power of a big bank together with the values and relationships of a community bank. We’re local too – and know the emphasis on nutrition, yoga and the marketplace and what is right for you and your medical meditation to stay well and rebalance the practice. body and mind. Whether you want to expand, start a new product line, modernize “My son is studying Ayurvedic or hire new employees, sit down with our expert lenders today and medicine along with western medicine. find out why so many of our satisfied customers refer us to friends The allopathic approach is very good for and colleagues. chronic disease,” he said. “For instance, Get to know the most trusted, safe and secure business partners in the key with diabetes is really prevention, the region. when a lot of people are trying to cure it or at least treat it long term.” And along with looking at the whole person, Dr. Ikedilo is an advocate of treating every medical circumstance and patient as unique. “What I am realizing is it is not a one-size-fits-all kind of care. It’s not that cookie-cutter. Not Investing In Business Relationships. everyone is going to fit into this box of how we normally manage a woman’s www.cvcb.com • (559) 298-1775 care” especially in obstetrics. She Proudly serving the San Joaquin Valley and Greater Sacramento believes policy may need to change so

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DIVERSITY IN MEDICINE COMES AT SLOW PACE AS PATIENTS CHANGE RAPIDLY - THE WASHINGTON POST A new working paper provides compelling evidence for how a more diverse medical workforce could improve health outcomes. Researchers recruited more than 1,300 black men in Oakland, Calif., and randomly assigned them to either a black male doctor or a nonblack male doctor in the same clinic. Before meeting their doctors, patients selected which preventive screening tests they would like, if any. These included both noninvasive tests, such as blood pressure measurements, and invasive tests, such as diabetes and cholesterol screening, which require blood samples. Initially, all patients chose roughly the same number of screening tests. But after a conversation with their doctor, black men with a black doctor were substantially more likely to opt for every test than those with a nonblack doctor. The effect was particularly pronounced for invasive tests, which require more trust between doctor and patient: Patients with black doctors were 47 percent more likely to get diabetes screening and 72 percent more likely to get cholesterol tests. “I was really surprised by the size of the effect,” said Marcella Alsan, lead author of the study and an associate professor of medicine at the Stanford School of Medicine. “We wanted to go beyond just documenting disparities and see if there was a way to intervene. This seemed to have a bigger impact than we expected.” Black men paired with black doctors were also much more likely to discuss their other health problems, and black doctors wrote more notes about their patients — including about personal problems they were struggling with — than did nonblack doctors.

There’s still more to do to encourage diversity in medical schools Valley physicians know that changing the faces in medicine will serve our diverse patient population better, but it’s a slow process. Dr. Sablan has been working at it for decades gently planting the idea in his Firebaugh community that medical school could be a possibility: “The really smart kids never thought of medicine as a profession. They become teachers or bank managers or accountants. So when I see a kid that’s really smart I say, ‘Well you become a doctor, so you can take care of me when I’m older.’” That’s the kind of encouragement Dr. Her didn’t get as a Hmong female. “The mentality is that you’re supposed to get married and have kids,” she said. Dr. Her did just that. She married at age 14 while in high school, had her first child at 15 and another while in college at Fresno State University. It was the support of the Health Careers Opportunity Program at the university that helped launch her into medicine and then later her in-laws who cared for her children while she moved across the country to pursue her dream. “It’s hard and it’s something you have to make a lot of sacrifices along the way…but I’m loving it,” she said. As the first woman in her family of 11 to graduate from college, she knows that she’s blazed a trail and is mentoring other Hmong to follow it. She works with the Duncan Polytechnic High School’s certified nurse assistant class in Fresno and talks to lots of girls who are curious about what it takes to become a doctor. Dr. Ikedilo had the opposite upbringing in an African country with an OB/gyn father. “Where I am from the expectation was to be a professional, so I have not lived that experience, but I definitely understand it. I know the struggle is real,” she said of what she saw among black girls in Baltimore where she did her residency. She has had students shadow her at work, but she wants to do more. Dr. Ikedilo holds up a brochure of a local group and said she’s looking into how she can help them change the dynamics that keep some for seeking medical careers or finishing medical school. Black women are now entering medical school at twice the numbers of black men. “There were only 500 black men nationally who matriculated into medical school this past year … and it’s not just a one-off,” lamented Dr. William McDade, former chair of the AMA Council on Medical Education, at the AMA’s CHANGEMEDED conference in 2015. He pointed to data from the Association of American Medical Colleges with similar low numbers going back a few years. And a 2010 study by Academic Medicine showed the Latino physicians shortage had actually gotten worse over the preceding three decades. “You might even ask yourself, ‘What difference does it make if we don’t change the face of medicine?’” Dr. McDade told the AMA group. “There’s strong evidence that suggests that racial, ethnic and linguistic diversity in health care providers is correlated with better access to and quality care of minority populations.”

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Fall 2018

Fresno County Appoints New

Public Health Officer The Fresno County Board of Supervisors has appointed Sara Goldgraben, MD, MPH, MBA as the new Fresno County Public Health Officer. Dr. Goldgraben received her medical degree from New York Medical College and is the former Public Health Officer for Lake County. Dr. Goldgraben is a California Board-certified physician with a master’s degree in public health and business administration. She also holds a bachelor’s degree in biomedical engineering. Her training and experience in preventative medicine includes strong analytical skills, data driven decision making, and a solid understanding of health issues facing Central Valley residents. “I am confident Dr. Goldgraben will be an excellent addition to the leadership team at the Fresno County Department of Public Health. She is eager to start working in our community to improve health outcomes for the residents of Fresno County,” says David Pomaville, Fresno County Department of Public Health Director.

Dr. Goldgraben will serve as Fresno County’s medical expert regarding public health matters. She will provide guidance and direction to leadership across the Fresno County Department of Public Health programs. Working in partnership with colleagues and health professional organizations, she will consult on, interpret, and enforce County and State laws and regulations to protect and promote the health and wellbeing of all county residents. Dr. Goldgraben holds medical licensure in California and also speaks conversational Spanish. Goldgraben succeeds Dr. Ken Bird, whose retirement took place back in March.

Innovative Strategies to Treat Opioids Abuse The healthcare community in Central Valley has seen an increase in problems arising from the use of prescription pain management medications. The Central Valley Opioid Safety Coalition is continuing its an educational series to raise the level of understanding of this critical issue. This installment lecture includes topics on;

- Innovative Strategies to Reduce Opioid Misuse - ED Bridging - Use of Opioids in Pregnancy CME & CE Dinner Event 2.0 Applied for - Email Invitation to Follow

November 1, 2018 - 6 PM to 8 PM Fort Washington Country Club 10272 N Millbrook Ave., Fresno, CA

Fall 2018

Preregistration is required - No charge Please register online at www.fmms.org or by calling (559) 224-4224. Registration must be received by October 28 to be a guarantee participant.

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“ ”

THERE’S NO HEARTBEAT. Three words no one ever wants to hear. Three words no one ever wants to deliver. BY FARAH KARIPINENI, MD

And yet, as a community of physicians, we deliver those crushing words on a daily basis. None of us would ever take the task of bearing this piece of news lightly, but for me, it was not until I was on the receiving end of them that I truly grasped how profoundly a physician can shape the experience of a family member or patient in this particular depth of despair.

I have delivered this news more times than I can count. I would like to say that I recall each time vividly, that I remember each patient’s name, story, and the faces of each family member as I broke the news that ended their world. But alas, I do not. I recall the poignant ones: the 26week pregnant mother who lost the fetus in a motor vehicle crash; the 12-year-old schoolgirl shot in the chest; the 40-year-old roofer who arrested in the operating

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room as we stretched his ribs to massage his heart. I do not remember the exact words I used to convey this most unwelcome information. What I do recall is the mixed sense of fear, dread, pity and my own grief immediately prior to entering the room. For yes, I would walk away scarred, and my scar was important for me to acknowledge, but it did not deserve to take up space in that haunted room. I had to be fully present for their grief.

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And then I became the patient. It was a muchan intentional, collective effort to treat our patients like wanted pregnancy requiring multiple cycles of assisted human beings. We can grasp that almost sacred moment reproduction, our life’s savings, money we didn’t have, where we inhabit another’s suffering and bear witness to a lot of failures, hundreds of injections, and so, so much their struggle, in an effort to heal not just their ailing body, guarded hope. The words seemed to come too easily to but also their ailing spirits. For in those inevitable dark the physician who delivered them, far too easily. They were moments when there is no heartbeat, that may be all we accompanied by no eye contact, no outward emotion, and have to offer. But it may be enough. no additional words. While I am sure that I was more than a transaction or a diagnosis to this practitioner, there was a devastating failure to acknowledge my humanity in the experience. My mind immediately wandered to my patients—how often had I unwittingly made them feel the same way? Until I required health care on a regular basis, I was often surprised by how grateful my patients are The Cooperative of American Physicians by what I consider common is run by physicians like myself. decencies. Giving them my cell Applicants are carefully selected to make phone number for emergencies. Making them feel heard in the sure only high- quality physicians office. Collecting details about become members of the risk pool. their personal lives and families. Overall, I have saved a significant amount To me, this all falls under the umbrella of caring for, and about, a of money on my patient. Not just a patient’s medical premiums and am problem, but a patient. A human glad I made the being, just like me. But after being on the patient change. side for far longer than I wish, I realize why patients have such low expectations. Humanity in medicine is in crisis. Health care - Don Gaede, MD workers feel overworked and Vascular Medicine underappreciated, and institutional FMMS Member 39 Years values center around financial success rather than employee and patient wellbeing. When dollars are our bottom line, and not people, we put every patient interaction at risk of being reduced to a transaction. Recognizing this challenge in our current healthcare system can be discouraging, but it can also be uplifting. We can make

Fall 2018

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HEaL HEaL ONE PATIENT AT A TIME

He believes the HEaL mobile clinic will benefit the community threefold by serving as a model to train the next generation of San Joaquin Valley physicians, increasing diversity of the medical profession and creating a positive impact in the Valley for those who do not have access to care.

“It is such a cost savings to do outreach and preventative health over trying to cure people when they are at a terminal stage of disease,” - Dr. Banh. Over the past few years there have been several exciting developments at UCSF-Fresno, bringing critical medical services and training programs to the Valley. One of the more recent additions is their San Joaquin Valley Program in Medical Education (SJV PRIME) program, a training program tailored to preparing medical students to address the unique health needs of the region’s diverse and underserved populations. And equally important, it is aimed at retaining physicians here in the Valley. This Fall, USCF-Fresno will celebrate another exciting milestone as they launch the San Joaquin Valley’s first student-run mobile clinic: the UCSF-Fresno Health Education and Learning (HEaL) mobile clinic.

BY JENNIFER SEITA • PHOTOGRAPHY BY ANTHONY IMIRIAN

CENTRAL VALLEY PHYSICIANS

Fall 2018

First of its kind

Kenny Banh, MD, Assistant Dean of Undergraduate Medical Education and Student Service at UCSF Fresno, has been awarded the California Medical Association’s (CMA) Compassionate Service Award for 2018. He will be presented with a plaque at the 147th annual CMA House of Delegates, which will convene October 14-15, 2018, in Sacramento. This prestigious award honors a physician member that best illustrates the association’s commitment to community and charity care.

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The HEaL mobile clinic is the brain-child of Kenny Banh, MD, FACEP UCSF-Fresno Assistant Dean of Undergraduate Medical Education and Student Services. Dr. Banh also serves as the San Joaquin Valley PRIME Director, so he saw first-hand the need for both the educational component, and the community health benefit for the Valley’s most underserved populations. Dr. Banh’s passion for education and helping those in our community is the driving force behind the HEaL mobile clinic. In his free time, he has put together all of the components for the mobile clinic – from supplies to staff and everything in between – all on a 100% volunteer basis. Everyone involved, all equipment and supplies have been volunteer or donation-based. He believes the HEaL mobile clinic will benefit the community threefold by serving as a model to train the next generation of San Joaquin Valley physicians, increasing diversity of the medical profession and creating a positive impact in the Valley for those who do not have access to care. “It’s my mission to not only do the patient care, which a

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Daisy Manzo (L), Jose Acosta (R) and Lorena Garcia (R) are MD candidates who are a part of the San Joaquin Valley PRIME program are photographed with Lee Haggerty (L) Programmer / Analyst for the Simulation Lab at UCSF Fresno

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Fall 2018

lot of people do, but to make sure that we’re giving While there are many organizations working to mentorship, exposure, advocacy and opportunities for outreach to our Valley’s diverse populations, none are people to advance themselves, believe in themselves,” student-led and completely educationally-focused. said Dr. Kenny Banh. Currently, Valley medical students must seek out One of the most exciting parts about this program organizations to volunteer their time with to get realis the opportunity it presents for the Valley’s medical life clinical experience. students. Students and residents will be able to gain invaluable hands-on clinical experience, under the Strategic Outreach leadership of a board-certified physician, out in rural Because of the vast health care disparities in San hard-to-reach communities throughout the region. Joaquin Valley the HEaL mobile clinic will focus “It’s important to meet people where they are and see how they really live,” said Dr. Banh. “The idea is to give students the “We really want to understand these communities. opportunity to get out of the hospitals, explore It is vital that they have a positive experience because the community and see we want them to come back for follow-ups.” how the people of the - Dr. Rafael Gonzalez community are living. You have to get out to these rural areas and see that you have people working in the farmlands, growing all of the fruits and vegetables on multiple underserved groups, who will all receive that are so great in the Valley, yet they themselves have services completely free. To start, rural access and no access to food – they’re in food deserts. They have migrant health will be prioritized, including family and maybe one mini-mart within ten miles and nothing pediatric care. The clinic will also include services to else around them. We tell them to try to eat diabetic promote gender health through partnerships with the or heart sensitive foods, and they don’t have access to LGBTQ communities to provide a safe, supportive transportation and limited resources to purchase that.” environment at every stage of the coming out or transitioning process. Another clinic is dedicated Need for Underserved Care to providing health care and screening services to It’s no secret that the Central Valley is home to some the homeless population in the Valley. The clinics of the most underserved populations in the state. With offer people what is often their only access to health more than 25%, or one in four, of our residents living care. All while giving medical students (and soon in below the poverty line, the need for core services like undergraduates) hands-on experience and to learn comprehensive healthcare is higher than ever. Couple first-hand about the challenges and rewards of patient that with the area’s extreme shortage of primary care care and community medicine. physicians and it becomes painfully obvious how “We are engaging with different community important community health services are to the health organizations to see how we can best serve and create a of our Valley – both our communities and our bottom sustainable service for these groups,” said Dr. Banh. line. As part of the mobile clinic’s volunteer staff, HEaL Dr. Banh noted that many larger cities support their Director of Operations Rafael Gonzalez, MD and underserved communities with student-led clinics Director of Outreach Leyla Farshidpour are working that provide free health services to their disadvantaged to partner with advocacy groups throughout the communities. Educational institutions like University region to identify the best methods of care specific to of California, Davis and University of California, San each population; looking at each individual patient Francisco each offer dozens of student-led clinics, population and identifying the best location to assess which are noticeably absent in the Central Valley. the most people at one time, how to prepare the mobile

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van depending on the type of issues they are likely to see and more. “We really want to understand these communities,” said Dr. Rafael Gonzalez. “It is vital that they have a positive experience because we want them to come back for follow-ups. We want to maintain relationships with the patients and develop a rapport with them to get them the best health outcome possible.” Every group will bring its own set of challenges and diagnosis to manage, and the unknown is part of the excitement. Said Dr. Gonzalez, “If I could anticipate the needs, that would be great. But, one of the exciting things is that we’re going to learn a lot and help a lot of people at the same time.” Working in a mobile environment without the luxury of the amenities that come along with being in a traditional clinic means being overly prepared for each group. Care will include things like primary care and counseling, but will also be tailored to each unique population like wound and foot care for the homeless population, flu shots for children and families, hormone therapy for the LGBTQ community, and attacking public health issues like IV drug use, cleaning up needles in homeless camps, and more. “We’re tackling issues that are a public health risk,” said

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Banh. “Not only do these issues effect the patient, but it effects the surrounding communities as well.” With continued years of emergency room visits for issues that end up costing thousands of dollars for what could have been treated for hundreds with regular care, the hope is that this mobile clinic is a way to form relationships and provide continuity of care for some of the Valley’s most disadvantaged residents. Community-Based Approach

The HEaL mobile clinic is truly a labor of love. It’s a passion project for Dr. Banh and because of his dedication he has been honored with the 2018 Compassionate Service Award by the California Medical Association. Dr. Banh has utilized his connections to really engage partners throughout the Valley to contribute and support the program. And the community is stepping up to the challenge. One of the first organizations to support HEaL is American Ambulance, who donated an ambulance, which serves as the mobile clinic. That, combined with initial grant funding from the Central Valley Community Foundation and Legacy Health Endowment has launched the start of what could very

Fall 2018

well be the future of medicine in the Central Valley. to ensuring high-quality care specific to populations “It’s been amazing, the amount of outreach and support we and communities in the Valley, specifically underserved have received,” said Dr. Banh. communities. Through Dr. Banh’s tireless efforts to get the student-run As an answer to providing access to both medical education mobile clinic up and running he has formed partnerships and component and the health disparities in the Valley, Kenny strategic alliances with businesses and organizations to outfit Banh, MD, Assistant Dean of Undergraduate Medical the mobile clinic – from pharmaceuticals to electronic medical Education and Student Service at UCSF Fresno, has created a records – so that the patients seen in the mobile clinic will have student-led clinical program. the best care possible. The main objective is to tackle providing care to Additionally, multiple UCSF doctors are lined up, waiting to disadvantaged residents, removing barriers like access to volunteer their time to oversee the students while out treating resources, transportation and language. The mobile unit will patients. With physicians’ schedules as full as they already are, be fully operational next year, but will start outreach later this they are still finding time to give back to the community and year. The goal is to go out once a week to rotating sites. donate their time and leadership to this cause. And the reality is, to practice medicine in the San Even with all of the support, Dr. Banh and his team are Joaquin Valley, having knowledge of how to effectively offer still searching for financial support and businesses willing to underserved care is imperative. underwrite costs for equipment and supplies to keep the clinic As the mobile clinic gets established the goal is for the clinic going well into the future. They know that sustainability is to be integrated into the curriculum for all of the primary care going to be the deciding factor in determining success. Said and emergency medicine residencies as part of their required Banh, “You never want to enter into a community and then service learning. withdrawal from them. If I’m going to do something, then I want to make sure its sustainable.” The HEaL mobile clinic will be up and running this Fall and will initially be going out once a week to rotating sites. The service footprint stretches throughout the 8-county San Joaquin Valley – from Very often patients suffering from Stockton to Bakersfield. depression obtain no relief from “If you are in the Valley and you multiple medications. In many cases are far away from services, we are drug therapy can cause significant interested in working with you,” side effects resulting in nonsaid Dr. Gonzalez. “We want to be compliance. accessible to everyone.” Edgar Castillo-Armas, MD Psychiatrist

Advanced Treatment for Major Depressive Disorder

A Model for Care

“This initially started as an opportunity to provide clinical experience for UCSF PRIME students, but we are also so excited about this because it allows us to outreach to hard to reach populations in the Valley,” said Dr. Gonzalez. The San Joaquin Valley Program in Medicine (PRIME) program at UCSF-Fresno is a tailored track at University of California, San Francisco School of Medicine for medical students committed

Fall 2018

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CAN CURATIVES KILL? Reducing the Risk of Medication Error LISA BUSCHO, RN BSN/NORCAL GROUP

CENTRAL VALLEY PHYSICIANS

Adverse Drug Events and Medication Errors An adverse drug event (ADE) is defined as “harm experienced by a patient by exposure to a medication.”1 The Institute of Medicine says an ADE is “an injury resulting from drug‐related medical interventions.”2 Like any adverse event, occurrence of an ADE does not necessarily indicate an error or poor quality care. However, adverse drug events account for nearly 700,000 emergency department visits and 120,000 hospitalizations annually.1 One way a patient can experience an ADE is through a medication error. A medication error can occur at any step in the process, beginning when a clinician prescribes a medication and ending when the patient actually receives the medication. It can be an error of omission or an error of commission.1 The Institute of Medicine’s report, To Err is Human, describes a medication error as “an error in the process of ordering or delivering a medication, regardless of whether an injury occurred or the potential for injury was present.” Further, statistics in the report revealed that 1.5 million Americans are injured by medication errors every year and the average hospitalized patient experiences at least one medication error each day.2

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Potential for Harm According to the Agency for Healthcare Research and Quality, there are more than 10,000 prescription medications available for clinicians to choose from.1 The Centers for Disease Control and Prevention (CDC) statistics show the number of drugs ordered or provided to Americans during office visits equals 3.2 billion, 317.6 million during emergency room visits, and 329.2 million during outpatient hospital department visits per year. Available data also indicates that drug therapy is involved in 75.2% of overall patient office visits, 79.6% of emergency room visits and 72.5% of outpatient hospital department visits. 3 According to the CDC, 85% of American adults take one medication daily and nearly one‐third of adults take five or more medications per day.4 Additional Risk Factors Associated with Medication Errors Areas requiring added vigilance due to an increased potential for medication error include: •T ransitions in patient care (e.g., between healthcare providers, discharges from facilities or between levels of care) • P olypharmacy (e.g., patients who take five or more medications) •A ge-related (e.g., elderly or pediatric patients require closer monitoring) •L imited health literacy (e.g., lack of understanding medication information, differing names for the same drug, rationale for use, correct dosage, administration, or frequency, etc.) •C ombined use and over-use of over-the counter (OTC) medications, herbal remedies or alternative medications • P rescribing high-alert medications

Why Reconcile? Many medication errors are preventable and medication reconciliation is one strategy for medication error risk mitigation. In a review of closed claims data from the NORCAL Group of companies (7/1/10-6/30/15), medication errors are a common allegation against physicians. The data shows medication errors as the fourth most frequent and the fifth most expensive allegation against our insured physicians. A number of factors contributed to the medication errors that occurred in these claims, including: •T he patients’ comorbid conditions • I nadequate patient histories • P roblems with medical record documentation •C ommunication problems between providers These contributing factors are closely tied to conducting medication reconciliation. Data revealed that almost one-quarter of the medication error claims involved these issues that are potentially related to a breakdown in the medication reconciliation process. Medication reconciliation takes clinical skill and can save lives. The Institute of Health Improvement indicates that the goal of medication reconciliation is to prevent ADEs by creating and maintaining the most accurate list possible of the patient’s medications including drug name, dosage, frequency, and route — and using that list to guide therapy.5 Medication reconciliation in the office site should be thought of as a patient safety measure and not viewed only as an accreditation function. Using a systematic and formal process with clearly designated responsibilities can

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improve and streamline the process. Consider the following: 1. Obtain an accurate list of prescribed medications, OTC drugs, herbs, vitamins, and supplements. 2. V erify the list with the patient using other reliable sources when possible: drug vials, patient’s medication list, pharmacy, checking for changes in dosage, routes, frequencies, etc. 3. Reconcile and correct inadvertent discrepancies in the list (e.g., duplicates). This does not necessarily mean the clinician is verifying the appropriateness of the medications or dosages, as that should hopefully have been determined by the prescriber (who should be in a position to make that determination). However, it is important to determine whether any medication that the patient is taking or receiving as a result of your visit or procedure is reconciled. This may require communication, consultation, or coordination with another prescriber. This can also be an opportunity to educate patients on their medication management. 4. D ocument in the record changes to the medication list

(e.g., finalize the list in the electronic health record) and provide a copy to the patient.

Risk Management Recommendations • Create and maintain a current medication list for all patients. • Develop a systematic, standardized and formal process for medication reconciliation. • View medication reconciliation as a patient safety measure that is incorporated into the patient evaluation process by the clinician. • Understand that medication reconciliation includes reviewing and verifying medication history, clarifying appropriate dosing, frequency, contraindications, and/or interactions; reconciling conflicts; and finalizing changes to the medications in the medical record. • Keep a heightened awareness of additional risk factors associated with medication errors and ADEs. The NORCAL Group of companies — including NORCAL Mutual Insurance Company, Medicus Insurance Company, FD Insurance Company, NORCAL Specialty Insurance Company, and Preferred INC. Physicians Medical RRG — provide A REGISTRY & PLACEMENT FIRM medical professional liability insurance to physicians, health care extenders, medical Nurse Practitioners ~ Physician Assistants groups, hospitals, community clinics and allied health care facilities throughout the country. They share an A.M. Best “A” (Excellent) rating for their financial strength and stability. NORCAL Group has a team Locum Tenens ~ Permanent Placement of risk management specialists available Voice: 800-919-9141 or 805-641-9141 to assist policyholders with the assessment FAX: 805-641-9143 of their practice and to help identify any tzweig@tracyzweig.com potential pitfalls that www.tracyzweig.com may arise.

Tracy Zweig Associates Physicians

CENTRAL VALLEY PHYSICIANS

Fall 2018

Retirement for Every Stage of Life Throughout your career, retirement planning will likely be one of the most important components of your overall financial plan. Whether you have just graduated and taken your first job, are starting a family, are enjoying your peak earning years, or are preparing to retire, your employer-sponsored retirement plan can play a key role in your financial strategies. How should you view and manage your retirement savings plan through various life stages? Following are some points to consider.

Just starting out

If you are a young adult just starting your first job, chances are you face a number of different challenges. College loans, rent, and car payments all may be competing for your hard-earned yet still entry-level paycheck. How can you even consider setting aside money in your employer-sponsored retirement plan now? After all, retirement is decades away â&#x20AC;&#x201D; you have plenty of time, right? Before you answer, consider this: The decades ahead of you can be your greatest advantage. Through the power of compounding, you can put time to work for you. Compounding happens when your plan contribution dollars earn returns that are then reinvested back into your account, potentially earning returns themselves. Over time, the process can snowball.

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CENTRAL VALLEY PHYSICIANS

Say at age 20, you begin investing $3,000 each year for retirement. At age 65, you would have invested $135,000. If you assume a 6% average annual return, you would have accumulated a total of $638,231 by age 65. However, if you wait until age 45 to begin investing that $3,000 annually and earn the same 6% return, by age 65 you would have invested $60,000 and accumulated a total $110,357. Even though you would have invested $75,000 more by starting earlier, you would have accumulated more than half a million dollars more overall.1 That’s the power you have as a young investor — the power of time and compounding. Even if you can’t afford to contribute $3,000 a year ($250/month) to your plan, remember that even small amounts can add up through compounding. So enroll in your plan and contribute whatever you can, and then try to increase your contribution amount by a percentage point or two every year until you hit your plan’s maximum contribution limit. As debts are paid off and your salary increases, redirect a portion of those extra dollars into your plan. Finally, time offers an additional benefit to young adults — the potential to withstand stronger short-term losses in order to pursue higher long-term gains. That means you may be able to invest more aggressively than your older colleagues, placing a larger portion of your portfolio in stocks to strive for higher long-term returns.2

Getting married and starting a family You will likely face even more obligations when you marry and start a family. Mortgage payments, higher grocery and gas bills, child-care and youth sports expenses, family vacations, college savings contributions, home repairs and maintenance, dry cleaning, and health-care costs all compete for your money. At this stage of life, the list of monthly expenses seems endless. Although it can be tempting to cut your retirement savings plan contributions to make ends meet, do your best to resist temptation and stay diligent. Your retirement needs to be a high priority. Are you thinking about taking time off to raise children? That is an important and often beneficial decision for many families. But it’s a decision that can have a financial impact lasting long into the future. Leaving the workforce for prolonged periods not only hinders your ability to set aside money for retirement but also may affect the size of any pension or Social Security benefits

CENTRAL VALLEY PHYSICIANS

you receive down the road. If you think you might take a break from work to raise a family, consider temporarily increasing your plan contributions before you leave and after you return to help make up for the lost time and savings. Or perhaps your spouse could increase his or her contributions while you take time off. Lastly, while you’re still approximately 20 to 30 years away from retirement, you have decades to ride out market swings. That means you may still be able to invest relatively aggressively in your plan. But be sure you fully reassess your ability to withstand investment risk before making any decisions.

R eaching your peak earning years

The latter stage of your career can bring a wide variety of challenges and opportunities. Older children typically come with bigger expenses. College bills may be making their way to your mailbox or inbox. You may find yourself having to take time off unexpectedly to care for aging parents, a spouse, or even yourself. As your body begins to exhibit the effects of a life well lived, health-care expenses begin to eat up a larger portion of your budget. And those pesky home and car repairs never seem to go away. On the other hand, with 20+ years of work experience behind you, you could be reaping the benefits of the highest salary you’ve ever earned. With more income at your disposal, now may be an ideal time to kick your retirement savings plan into high gear. If you’re age 50 or older, you may be able to take advantage of catch-up contributions, which allow you to contribute up to $24,500 to your employer-sponsored plan in 2018, versus a maximum of $18,500 for most everyone else. (Some plans impose different limits.) In addition, if you haven’t yet met with a financial professional, now may be a good time to do so. A financial professional can help you refine your savings goal and investment allocations, as well as help you plan ahead for the next stage. 3

Preparing to retire

With just a few short years until you celebrate the major step into retirement, it’s time to begin thinking about when and how you will begin drawing down your retirement plan assets. You might also want to adjust your investment allocations with an eye towards asset protection (although it’s still important

Fall 2018

to pursue a bit of growth to keep up with the rising cost of living).4 A financial professional can become a very important ally in helping to address the various decisions you will face at this important juncture.

You may want to discuss:

• Health care needs and costs, as well as retiree health insurance • I ncome-producing investment vehicles • Tax rates and living expenses in your desired retirement location • Part-time work or other sources of additional income

Estate planning

You’ll also want to familiarize yourself with required minimum distributions (RMDs). The IRS requires that you begin drawing down your retirement plan assets by April 1 of the year following the year you reach age 70½. If you continue to work for your employer past age 70½, you may delay RMDs from that plan until the year following your actual retirement.

Other considerations

Throughout your career, you may face other important decisions involving your retirement savings plan. For example, if your plan provides for Roth contributions, you’ll want to review the differences between these and traditional pre-tax contributions to determine the best strategy for your situation. While pre-tax contributions offer an upfront tax benefit, you’ll have to pay taxes on distributions when you receive them. On the other hand, Roth contributions do not provide an upfront tax benefit, but qualified withdrawals will be tax free.5 Whether you choose to contribute to a pre-tax account, a Roth account, or both will depend on a number of factors. At times, you might face a financial difficulty that will tempt you to take a loan or hardship withdrawal from your account, if these options are available in your plan. If you find yourself in this situation, consider a loan or hardship withdrawal as a last resort. These moves not only will slow your retirement saving progress but could have a negative impact on your income tax obligation. 6 Finally, as you make decisions about your plan on the road to retirement, be sure to review it alongside your other savings and investment strategies. While it’s generally not advisable to make frequent changes in your retirement plan investment mix, you will want to review your plan’s portfolio at least once each year and as major events (e.g., marriage, divorce, birth of a child, job change) occur throughout your life.

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Principal Jaisy Prem, MBA Financial Advisor 1350 E. Spruce Ave Fresno, CA 93730 559-650-2674 prem.jaisy@principal.com 1This hypothetical example of mathematical principles does not represent any specific investment and should not be considered financial advice. Investment returns will fluctuate and cannot be guaranteed. 2All investing involves risk, including the possible loss of principal, and there can be no assurance that any investment strategy will be successful. Investments offering a higher potential rate of return also involve a higher level of risk. 3There is no assurance that working with a financial professional will improve your investment results. 4Asset allocation is a method used to help manage investment risk; it does not guarantee a profit or protect against a loss. 5Qualified withdrawals from Roth accounts are those made after a five-year waiting period and you either reach age 59½, die, or become disabled. 6Withdrawals from your employer-sponsored retirement savings plan prior to age 59½ may be subject to regular income taxes as well as a 10% penalty tax (unless an exception applies). Insurance products issued by Principal National Life Insurance Co. (except in NY), Principal Life Insurance Co., and the companies available through the Preferred Product Network, Inc. Securities and advisory products offered through Principal Securities, Inc., 800/247-1737, member SIPC. Principal National, Principal Life, the Preferred Product Network, and Principal Securities, Inc. are members of the Principal Financial Group®, Des Moines, IA 50392. Jaisy Prem, Principal National and Principal Life Financial Representative, Principal Securities Registered Representative, Financial Advisor. The material provided does not necessarily reflect the views or opinions of Principal Financial Group®. Broadridge is not affiliated with any company of the Principal Financial Group®. Principal Financial Group® does not endorse the commentary, opinions or views of the article. This material should be considered general information and should not be used as the primary basis for a financial decision. It is provided with the understanding that the member companies of the Principal Financial Group® are not rendering legal, accounting, or tax advice.

CENTRAL VALLEY PHYSICIANS

PUT YOUR MEMBERSHIP TO WORK! When you join the Fresno Madera Medical Society, you join the California Medical Association as well. Together FMMS-CMA can help with the success of your practice. Your annual dues can be more than offset when using membership services and discounts, and you get personal assistance with practice management and payment recovery issues to improve your bottom line. Join the FMMS to be a better leader for your staff and patients, and to amplify your voice to influence policy and legislation. The FMMS brings together an active community of physicians in order to improve the larger community. Our mission is physician-driven, and we want to help you solve your biggest practice management issue. Join the FMMS today!

BENEFIT Automobile & Homeowners Insurance

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CAP Cooperative of American Physicians

Car Rentals

Classified Ads CME Certification & Tracking CME Seminars

Confidential Hotline

Consultancy Services Driving Emblem

Insurance

MACRA Assistance 38

Save up to 8% more.

CONTACT Mercury Insurance Group (866) 602-5259 www.mercuryinsurance.com/cma

Discountd rates on all penetration testing, vulnerability assiessments and HIPPA/MACRA MIPS SRA Programs

Jennifer Guidry (559) 578-4800 www.breadcrumbcyber.com

Member discounts on malpractice protection, risk management and practice management.

Fran Hipskind (559) 623-3595 www.CAPphysicians.com

Save up to 25% on car rentals for business or personal travel.

Avis or Hertz (800) 786-4262 www.cmanet.org/groupdiscounts

Free classified ads in Central Valley Physicians

FMMS: (559) 224-4224

Discounted CME courses to help physicians maintain their licenses, and easy tracking of course credit.

Institute for Medical Quality (IMQ) (877) 880-1335 imq.inreachce.com

FMMS is an accredited provider for Continuing Medical Education providing free and low cost seminars for members.

FMMS: (559) 224-4224 www.fmms.org

Confidential support and assistance to physicians affected by substance abuse, or an emotional or physical problem.

CMA: (650) 756-7787 www.cmanet.org/resources/confidential-assistance

Discount on hourly consulting fee for practice assessments, valuation, brokerage, partnerships, etc.

Practice & Liability Consultants (415) 764-4800 www.practiceconsultants.net

CHP approved emblem provides physicians expemption from speeding laws when en route to an emergency

FMMS (559) 224-4224

Discounts on medical, workersâ&#x20AC;&#x2122; comp, dental, disability, long-term care, level term life & business overhead expense.

Mercer (800) 842-3761 www.mercer.com

Free tool kit on quality measures & online tool to create custom MIPS plan.

FMMS (559) 224-4224

CENTRAL VALLEY PHYSICIANS

Fall 2018

BENEFIT

CONTACT

Up to 89% off the cover price of hundreds of magazines for your home, office, and waiting and patient rooms.

Consumer Subscription Services (800) 289-6247 www.cmanet.org/magazines

Medical IDs

Discounts on 24-hour emergency identification and family notification services.

MedicAlert Foundation (800) 253-7880 www.medicalert.org/cma

Medical Office Services

Discounts on medical billing. No upfront costs. 1st month free and 2nd month 1/2 price.

Rita Nye (559) 359-6170 www.medicalbillingmos.com

Messaging App

Free secure messaging app for physician-to-physician/care team communication.

DocBookMD www.cmanet.org/docbookmd

Notary Services

Need a document notarized? Members can receive free Notary Services at the FMMS office.

FMMS 255 W Fallbrook Ave Suite 104 (559) 224-4224

Save up to 80% on office supplies and more.

Staples Advantage (800) 786-4262 www.cmanet.org/staples

CMAâ&#x20AC;&#x2122;s 24-hour Physicians Confidential Assistance hotline. Free and will not result in any form of disciplinary action.

Completely Confidential Doctor - Doctor Assistance (650)756-7787

Help for practices of all sizes: legal handbooks, practice mgmt. guides, patient education materials, etc.

CMA Resource Library www.cmanet.org/resource-library

Premier Valley Bank

Local bank offering comprehensive banking solutions that help make the job of managing finances easier

Premier Valley Bank www.premiervalleybank.com

Principal

Financial professionals helping clients establish priorities and develop strategies to acheive financial success.

Jaisey Prim at Principal (559) 650-2674 www.principal.com/centralcalifornia

Financial advisors offering services in investment management, financial planning and retirement plans.

Stephen Guinn (559) 438-2640 www.regencyinvests.com

Get paid: members receive one-on-one assistance. We have recouped $16 million from payors in the last 10 years.

FMMS: (559) 224-4224 CMA: (888) 401-5911

15% discount on tamper-resistant security prescription pads and printer paper.

RxSecurity (800) 667-9723 www.rxsecurity.com/cma-order

Discounts on website design packages, including mobile-friendly design.

Mayaco (209) 957-8629 www.mayaco.com/physicians

Magazine Subscriptions

Office Supplies

Physician Assistance

Practice Resources

Regency Investment Advisers Reimbursement Assistance Security Prescription Pads Website

For information on becoming an FMMS Business Partner call 559-224-4224 Fall 2018

CENTRAL VALLEY PHYSICIANS

MEMBERSHIP MATTERS As 2019 is quickly approaching, look at some of the top reasons you should join Fresno Madera Medical Society and the California Medical Society.

When you become a member, you are part of a dedicated network of physicians of over 1400 in Fresno and Madera County and 40,000 in California. Physicians that are working together to achieve a united healthcare front and fight against unfair insurer reimbursement practices, restrictions on physicians autonomy and the erosion of valuable legislation that protect your practice. Below are some of the top reasons you should become a member of Fresno Madera Medical Society (FMMS) and the California Medical Association (CMA). Tobacco Tax

In 2016, CMA led a coalition to take on Big Tobacco to improve patient access to care through Medi-Cal, which serves one-third of the state’s population. California voters overwhelmingly approved Proposition 56, which added a $2 tax on tobacco products and stipulated that funds should increase access by improving provider payments. California’s 2018-2019 state budgets continues to provide over $1 billion annually to improve provider payments so more Medi-Cal patients can access care when they need it most. Other key investments include graduate medical education (GME) funding increases and medical school loan repayments.

CENTRAL VALLEY PHYSICIANS

Resounding defeat of Assembly Bill 3087 (Kalra) – legislation that would have created a commission of unelected political appointees empowered to arbitrarily cap rate for all health care services in all clinics, hospitals and physician practices in California. Continued efforts every year to protect MICRA 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. 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.

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

political and regulatory advocacy, CMA and FMMS position themselves 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. 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. Get Paid - 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. Continuing Medical Education - FMMS provides

opportunities to further your knowledge with Continuing Medical Education. CME symposiums and dinner events provided throughout the year with

Fall 2018

current topics that relate directly to patient care. Learn from the experts and hear from recognized speakers. 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. Together We Are Stronger! 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.

CENTRAL VALLEY PHYSICIANS

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. 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.

CENTRAL VALLEY PHYSICIANS

F I S IE S A

California Correctional Health Care Services is seeking 2-3 IM/FP Primary Care Physicians.

Up to $327,540 annually plus $50-$60K w/OnCall - can be $380-$390K! Benefits include: 4-day workweek; 10 patients per day; generous paid time off; State of CA Pension that vests in 5 years; plus 401(K) and 457 retirement options â&#x20AC;&#x201C; tax defer up to $48K; and much more! Contact Danny Richardson, Hiring Analyst, at (916) 691-3155 or danny.richardson@cdcr.ca.gov. EOE.

Orthopedic Practice for Sale - Fresno, CA.

Annual revenue $4 million until its sudden closing due to divorce dispute. Everything in place to restart immediately. Perfect for new startup or existing practice looking to add a second location or to relocate from your current location. Contact Medical Practices USA for more information. Email: info@MedicalPracticesUSA.com www.MedicalPracticesUSA.com 800-576-6935

Fall 2018

FOR SUBLEASE

Valley Childrenâ&#x20AC;&#x2122;s Pediatric Residency Program

This position is intended for a recently graduated board eligible pediatric resident with the aim of further development of leadership, teaching and administrative skills while also providing the opportunity to perform clinical work as a hospitalist. The Chief Resident Position reports to the Pediatric Residency Program Director and is responsible for elevating the scholarly and academic level of pediatric resident education for the Valley Childrenâ&#x20AC;&#x2122;s Pediatric Residency Program. Has an active role in resident recruitment, including but not limited to attendance at regularly scheduled meetings meeting with candidates on interview dates, and participating in preparation of rank list. Shares in the responsibility for the administration of the residency program and for the education of individual residents and medical students and advocates for the lifestyle and quality of life of the pediatric residents in regard to the program. Functions as leader, liaison and advocate for the pediatric residents and is an active, visible component of all parts of the program and is aware of all aspects of the program. For more information email Kauyeung@ valleychildrens.org

Fall 2018

Premiere medical office space for sublet.

The entire facility is 5000 square feet with modern aesthetic furnishings. Can include access to accredited ambulatory surgical facility with ability to perform procedures under general anesthesia or sedation as part of an office-based procedure. There are 4 exam rooms and nursing station, well suited for ophthalmology, gynecology, dermatology, plastic surgery or ENT practices. Support staff can be provided on request. Please inquire at (559) 797-9000 or email hedi@ wpsfresno.com.

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

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Summer Meltdown beneďŹ ting Fresno Madera Medical Society Scholarship Foundation

CENTRAL VALLEY PHYSICIANS

Fall 2018

Summer Meltdown

2 0 1 8

Fall 2018

CENTRAL VALLEY PHYSICIANS

Summer Meltdown Cooperative of American Physicians G.L. Bruno Associates