Central Valley Physicians Spring 2021

INSIDE: Meet Them Where They Are: Vaccinating the Masses Spring 2021

Vaccine Volunteers Fill CENTRAL Public VALLEY PHYSICIANS Health 1Gap

Closer to home + enhanced referrals = easier access to world-class care Chief of Cardiothoracic Surgery Bob Kiaii, B.Sc., M.D., F.R.C.S.C., F.A.C.S., is currently president-elect of the International Society for Minimally Invasive Cardiothoracic Surgery, and widely known for several surgical firsts and advancements in the field. He performed Northern California’s first robotic mitral valve repair last year after coming to UC Davis Health.

UC Davis Health offers nationally ranked medical specialties and prominent innovators — now with added convenience for our referring providers From the most delicate robotic and catheter procedures to the latest precision therapeutics, we’re proud to offer up-to-the-minute diagnostic and treatment options for both adult and pediatric referring providers across Northern California and the Central Valley.

Your referred patients benefit from shorter drives, less traffic gridlock, affordable lodging, and more support from local family and friends. We also offer robust telehealth and telemedicine options, for both initial consultations and follow up care.

Referring your patients to UC Davis Health specialty and subspecialty care is now easier than ever. Our physician referral liaison team is here to serve as direct lines of communication — helping to navigate and expedite referrals, obtain information, resolve process questions, and more.

Our liaisons can also help to: ■

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Facilitate access to our secure EMR system, PhysicianConnect Arrange meetings and/or webinars with our clinicians Assist with UC Davis Health clinical trials and telemedicine Keep you abreast of new services, providers and research programs Share information about CME and events such as tumor boards, grand rounds, lunch-and-learns and symposiums

We welcome you to reach out to your local UC Davis Health Physician Referral Liaison today: Stacy Hall | 916-882-1606 | sthall@ucdavis.edu

referrals.ucdavis.edu 2 CENTRAL VALLEY PHYSICIANS

Spring 2021

VOLUME 6, NUMBER 1 • SPRING 2021

{FEATURES}

12 22 26 28 30 36

{DEPARTMENTS}

VACCINE VOLUNTEERS FILL PUBLIC HEALTH GAPS

CHSU: LESSONS FROM THE FIRST YEAR

NEW STUDY, NEW OUTCOMES, NEW MEMORIES

THE RIPPLE EFFECTS OF ACES

OF MEDICINE: THE ROLE OF 38 JOY RESILIENCE IN FACE OF COVID-19

MEET THEM WHERE THEY ARE

MANAGEMENT: 42 PRACTICE MANAGING YOUR MANAGER

SEQUOIA PACE

FINANCIAL HEALTH AT 46 FINANCE: ALL STAGES

5 MESSAGE FROM THE PRESIDENT 7 MESSAGE FROM THE EDITOR 10 LETTER TO THE EDITOR LAW: EMERGENCY 20 EMPLOYMENT TEMPORARY STANDARDS

REVIEW: BLACK MEN IN 50 REEL WHITE COATS

52 IN MEMORIAM Spring 2021

CENTRAL VALLEY PHYSICIANS 3

From the Executive Director

PRESIDENT – Don H. Gaede, MD PRESIDENT-ELECT – Christina Maser, MD VICE PRESIDENT – John Moua, MD TREASURER – Marina Roytman, MD

On March 30th we celebrated World Doctors Day. Never in our lifetime have we been quite so aware of the global effort of physicians to provide care, compassion, healing, education, leadership and reassurance to our communities.

This edition of Central Valley Physicians is brimming with examples of the difference you make practicing medicine in the Central Valley each and every day. As you flip through the pages you’ll see many familiar faces representing the hundreds of physician volunteers currently working extra shifts at vaccine clinics, doSTACY WOODS nating blood to help meet the ever-increasing demand and finding new and resourceful ways to provide medical care for populations struggling to find it on their own.

PAST-PRESIDENT – Alan Birnbaum, MD BOARD OF GOVERNORS Mark Alson, MD Pamela Kammen, MD Brent Kane, MD Farah Karipineni, MD Anne Prentice, MD Jesus Rodriguez, MD Sonia Shah, MD Katayoon Shahinfar, MD Greg Simpson, MD Toussaint Streat, MD Benjamin Teitelbaum, MD Jai Uttam, MD CMA Trustee – Ranjit S. Rajpal, MD CENTRAL VALLEY PHYSICIANS Editor – Farah Karipineni, MD Assistant Editor – Karen Dahl, MD

While current statistics indicate we are gaining ground in the fight against COVID this is not the time to relax efforts. A group of our physicians dedicated many hours to creating a vaccine acceptance campaign in partnership with the Fresno County Department of Public Health. You can see the fruits of their labor airing on local television and radio stations in four languages. The creative efforts of this group of physicians was phenomenal. Follow their lead and remind your patients to continue to wear masks, practice social distancing and to get vaccinated. Many of your patients will have questions they may not think to ask, so take a moment to encourage the conversation during each and every office visit.

Managing Editor – Stacy Woods EDITORIAL COMMITTEE Farah Karipineni, MD, Chair Don Gaede MD Karen Dahl, MD Roydon Steinke, MD Michael Mcmillon, MD Manisha Mittal, MD CREATIVE DIRECTOR prime42: DESIGN | MARKET | HOST prime42.com

While we paused to publicly honor all physicians on March 30th, please know that you are deeply appreciated for the work that you do and the level of care you bring to our community each and every day.

We look forward to seeing you (in person) soon.

CONTRIBUTING WRITERS Erin Kennedy, Farin Jacobson, Debra Pharias, Kaysha Rajani Russell Maltes, Mark D. Kruthers, Esq, Manisha Mittal, MD, Kacey A. Medellin, MS, AMFT, Keenia Tappin, MD CONTRIBUTING PHOTOGRAPHERS Anthony Imirian CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO Central Valley Physicians

Stacy Woods

255 W Fallbrook Avenue Suite 104; Fresno, CA 93711 Phone: 559-224-4224 | Fax: 559-224-0276 Email address: swoods@fmms.org MEDICAL SOCIETY STAFF Executive Director – Stacy Woods Marketing Coordinator – Casey Nagle

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Spring 2021

A message from our President > Don Gaede, MD

3 reasons why this is a great time to be president of FMMS 1. We are in the middle of a pandemic

ABOUT THE AUTHOR Don Gaede, MD is board certified in Internal Medicine and fellowship trained in vascular medicine. He is a varicose vein specialist with extensive training and years of experience practicing vascular medicine.

Dr. Gaede earned his medical degree from Loma Linda University School of Medicine. His residency was completed at University of California, San Francisco, Fresno and his fellowship at Cleveland Clinic in Ohio.

Spring 2021

Our medical society came into being to help address crises just like this one.

In the late 1800s, small pox was still a world-wide scourge. And yes, there was vaccination hesitancy then too. FMMS stepped up to create a community-wide small pox vaccination program.

Fast forward to 2021: one of the primary goals of our medical society is encouraging everyone in our Valley to “take their best shot”—get vaccinated.

I don’t recall ever feeling more enthused about our medical society than when working with our Vaccine Acceptance Committee as we collaborate with the Fresno County Public Health Department to promote COVID-19 vaccination.

We’ve developed several vaccination PSAs, and recruited people like Jerry Dyer (Fresno mayor), DJ Criner (prominent Fresno black minister), John Binaski, Fire Chief City of Clovis (English) to “star” in them. We also have PSAs in multiple languages including Juan G. Bautista, MD (English and Spanish), Jose L. Bautista, MD (English and Spanish), Oscar Sablan, MD (English), Alexander Sanborn (American Sign Language), Tou Mouanoutoua, MD (Hmong), Pao Yang, CEO of Fresno Center (Hmong), and Sukhjit Dhillon, MD (Punjabi). Keep an eye out for these PSAs—they’re coming soon to a TV screen near you!

PSAs help, but we physicians are our patients’ best source of information about the vaccine. In speaking to my patients about it, I’ve learned that sometimes you have to bite your tongue and listen before you start sermonizing. Recently, I was winding up a follow-up visit of my 50-ish male patient: “Hey by the way, do you have any questions about the COVID-19 vaccine?”

He paused. “Well, my wife and I have been talking about it and we’re not sure we’re going to get it.”

CENTRAL VALLEY PHYSICIANS 5

I paused, thinking “What?? You’re not going to take the vaccine that our country just spent billions of dollars developing and is our only hope of saving thousands and thousands of lives--including your elderly parents--and getting our economy back on track??!!!”

But instead, I simply said, “Uh, ok. So--what kind of concerns do you have?”

“I don’t know--we’ve read some stuff about people getting sick from the vaccine. Plus, we figure we’re both pretty healthy, and so even if we got COVID, we’d probably get over it and be ok.”

“Well, I’m really glad you’re checking things out before you just jump in. Those are good things to consider.”

He nodded and smiled.

“Fortunately, the vaccine has undergone really extensive testing on tens of thousands of people and has been found to be very, very safe. In fact, I’ve already had both doses myself, and

only had minimal side effects.”

We talked a bit more. On the way out, he turned to me and said, “Thanks so much for taking the time to explain that to me!”

I felt better too, with the knowledge that I had listened instead before I preached, and because of that, he and his wife might get vaccinated when their time comes.

Furthermore, while some of us physicians are on the front lines treating COVID patients in hospitals and ICUs, and others are prescribing monoclonal antibody to keep our COVID patients from going into the hospital, and others are volunteering at the Fresno fairgrounds to administer vaccines, FMMS and CMA have been very active in making sure our physicians have adequate supplies of PPE. It’s very rewarding to be part of this historic effort.

2. As our nation struggles with racial and gender issues, the makeup of our Board of Governors has never been more diverse.

At a recent meeting, someone remarked that he wished more young ethnic minorities could see the faces of our board members, to help them realize that they too have a place in the field of medicine.

In keeping with that theme, our medical society is supporting a new program at UCSF Fresno that seeks to

diversify their surgical training programs to reflect the underserved and underrepresented patient population that they care for. They have set up an internship program for local pre-med students that will assist them in getting admission into medical school. We hope to support other similar efforts around our Valley.

3. We are about to confront another effort to overturn MICRA Next year, plaintiff’s attorneys plan to place a proposition on the ballot that would overturn the cap on non-economic damages (currently set at $250,000). The cost of medical care would rise significantly, and as a consequence our communities would have more trouble getting the care they need.

I paid less than $6,000 for my malpractice insurance this year. If I practiced in Miami, I would be paying 6 CENTRAL VALLEY PHYSICIANS

$47,000 for similar coverage. Like the COVID-19 pandemic, this ill-conceived proposition is just the kind of threat that our medical society and the California Medical Association were created to defend. To quote Benjamin Franklin, “We must all hang together or, most assuredly, we shall all hang separately.” I look forward to working with all of you, my colleagues, to keep our malpractice premiums reasonable and our medical practices flourishing.

Spring 2021

A message from our Editor > Farah Karipineni, MD

Spring is a time to celebrate growth

ABOUT THE AUTHOR Farah Karipineni, MD, MPH, is board certified in General Surgery and fellowship trained in Endocrine Surgery. She is currently practicing in Fresno as an Assistant Clinical Professor for UCSF. Dr. Karipineni earned her medical degree from University of California, Irvine School of Medicine. Her residency in General Surgery was completed at Albert Einstein Medical Center, and she completed her fellowship in Endocrine Surgery at Johns Hopkins School of Medicine.

Dr Karipineni has been published in journals including The American Surgeon, the International Journal of Surgery and the Journal of Surgical Education.

Spring 2021

Spring is a time to celebrate growth. It conjures up images of new blooms, baby chicks appearing in nests, and animals emerging from hibernation. But while growth is generally seen as a positive thing, it is, paradoxically, not always desired or even welcome. We tend to settle into the familiar groove of our routine, and when something comes along to push us off our comfortable tracks, it can be a fairly traumatic experience. The past year or so has been a testament to this, wherein we have been stretched and tested and worn out in ways we never hoped to be. But for those of us alive and lucky enough to still be breathing oxygen into our lungs, we can look back at how far we have been forced to grow, and all that we have overcome along the way. We may even see, in hindsight, that some of that growth was necessary or beneficial, though we would never have chosen its rocky path of our own accord.

In medicine, we see patients living this out on a daily basis.

Those of us who practice inpatient medicine see patients at their nadir.

Not only are they suffering from whatever brought them into the hospital, but in the times of Covid, they are doing so with no social support. Whether it’s the 81-year-old Spanish speaking cervical cancer survivor with a small bowel obstruction, the 20-year-old paraplegic from a motor vehicle crash, or the breastfeeding new mother with CENTRAL VALLEY PHYSICIANS 7

choledocholithiasis. My patients always humble me with their capacity to adapt to new circumstances when life threw them off track.

I am humbled and amazed by our staff as well, stretching themselves to fill in for family who cannot be there to support their loved ones in their time of greatest need.

On rounds, I hear of nurses giving out cell phone chargers and back rubs despite a mountain of other tasks. I witness physician assistants going the extra mile to update patients multiple times a day on discharge planning. And I see physicians spending more time with patients, or with their families on speakerphone or facetime, to put their minds at ease-all this, in the face of so many more hurdles than we all are usually forced to cross.

Recently, one of my cancer survivor patients said to me during follow up, “My cancer wasn’t a bad thing. It was part of my path to who I was supposed to become.” At the time, I recall her utter devastation with the diagnosis.

But without this life-altering experience—which led to major surgery, upheaval of her personal life and ultimately divorce and single motherhood—she would not have been forced to rise to the person she is today: confident, happy, and fulfilled. Her words resonated with my own experience in which the lowest points of my life, those that I almost didn’t survive, and only barely rose from, collide with my greatest moments of clarity, grit and purpose. Indeed, the parts of myself I hold in highest regard hail back to those darkest times.

All around us now, nature continues its beautiful yearly renewal. With all the abuse it has taken from human consumption, it seems implausible that spring could still be abuzz, year after year, with the breathtaking beauty of new life.

But it is. And here we are, too, alive in its beauty, ready to rise again from the storms we have weathered with our precious, hard-won growth.

“My cancer wasn’t a bad thing. It was part of my path to who I was supposed to become.”

And here we are, too, alive in its beauty, ready to rise again from the storms we have weathered with our precious, hard-won growth.

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Spring 2021

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Spring 2021

CENTRAL VALLEY PHYSICIANS 9

A Letter to our Editor, by Michael DeLollis, MD

RAPUNZEL AND THE PSYCHOTHERAPIST

In keeping with Dr. Gaede’s theme of “fun”, I offer this humorous sketch about psychotherapy A long time ago a young woman was picking herbs in a lovely garden in the Bavarian woods. Unbeknownst to her the garden was the property of a vengeful witch, who upon finding this offense, took the young woman’s daughter as compensation for the pilfered herbs.

The witch locked this child away in a tower. With nothing else to do in the long hours of captivity, this child, Rapunzel by name, grew prodigious amounts of hair. Eventually, owing to disrepair the stairs to the tower became unusable and the witch began using Rapunzel’s hair for access to the tower. She would stand at the bottom of the tower and call out “Rapunzel Rapunzel let down your long hair so that I may climb that golden stair.” Soon a cascade of flowing locks would tumble out of the tower window and the witch would climb up.

This ritual, as rituals want to do, repeated itself regularly until a prince happened to observe the process and intervened.

He rescued the maiden by climbing up her hair, cutting her hair and carrying her from the tower using her hair for a ladder. This couple married and raised children, who had children, etc.

Several generations later, a young female descendent of the line was picking herbs in a lovely Bavarian garden. Unbeknownst to her the garden was the property of a descendent of the vengeful witch, who upon finding this offense, took the young woman’s daughter as compensation for the pilfered herbs. It just so happens that this child carried the family moniker of Rapunzel to honor her ancestors. Ever notice how these family dramas seem to recur from generation to generation?

This young woman was, as before, locked away in a tower in the woods and with the appropriate family genes, grew some really radically long hair. This latter day witch began using these tresses as a means of egress into the tower and the ritual was brought forth into the current time. “Rapunzel Rapunzel let down your long hair so that I may climb that golden stair.” Again this ritual was repeated daily until one August a psychiatrist on her annual holiday in the Black forest observed the scene.

When the witch left, the psychiatrist uttered the magical phrase, “Rapunzel Rapunzel let down your long hair so that I may climb that golden stair.” Sure enough the hair came tumbling down. Rapunzel noting the different voice uttering the phrase invited the psychiatrist to come up and rescue her. At this time the following dialogue took place.

Rapunzel: Please climb my hair and rescue me.”

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Psychiatrist: Why don’t you come down here so that we can talk about your situation?”

R: “I can't come down.”

P: “What is preventing you from coming down?”

R: “The witch won’t let me leave the tower.”

P: “How does she prevent you?”

R: “She has commanded me to stay.”

P: “So you do every thing that she says?”

R: “Well...”

P: “So tell me how my coming up there would allow you to escape?”

R: “The witch doesn’t control you.”

P: “And she controls you?”

R: “She’s got me locked in this tower doesn’t she?”

P: “Does she?”

R: “Well, I am in this tower aren’t I?” P: “And no one can come or go from that tower?”

R: “Well no. She comes and goes every day.”

P: “And she needs some sort of key to get in and out that only she has?”

R: “No. She just climbs up this hair.”

P: “This hair? Who’s hair is it?”

R: “Mine.”

P: “So she doesn’t take it with her when she leaves?”

R: “That’s a dumb question. You can see that it’s still here.”

P: “For anyone to use?”

R: “I guess so.”

P: “Who decides who uses it. I mean who lets it down and takes it up?”

R: “I do.”

P: “So can anyone use it?”

R: “If I let it down.”

P: “Are you anyone?”

These conversations continued like this each afternoon through that August and several more. Eventually Rapunzel decided to use her own hair to climb out of the tower. She took that asset to Hollywood where she started Hair Club For Men. Thus she began rescuing princes.

As for the psychotherapist, she found an absolutely enchanting herb garden deep in the woods near the tower.

Countertransference does come to us all.

Spring 2021

We Help You Get Paid CMA’s reimbursement experts have recouped more than $30 million from payors on behalf of member physicians in the past 11 years.

PRACTICE MANAGEMENT ASSISTANCE CMA’s practice management experts provide free assistance to members and their staff on reimbursement, contracting and practice management related issues.

DIRECT PAYOR INTERVENTION CMA has recouped more than $30 million from payors on behalf of CMA member physicians in the past 11 years. These monies represent actual physician reimbursements that would have likely gone unpaid without CMA intervention.

EDUCATION CMA offers timely, high-quality education programs for physicians and their staff. From interactive in-person seminars to live and on-demand webinars, CMA provides the information needed to help run a successful medical practice.

PRACTICE MANAGEMENT NEWSLETTER CMA Practice Resources—known as CPR—is a monthly email bulletin that includes tips and tools to help physicians and their office staff improve practice efficiency and viability.

PAYOR CONTRACT ANALYSIS CMA members have free access to objective written analyses of major health plan contracts designed to help physicians understand their rights and options when contracting with a third-party payor, as well as which contract provisions are prohibited by California law.

“The value that CMA brings to physician practices cannot be understated. Membership is not a cost to my practice – it is an investment. I couldn’t run my practice without it.”

–Tom McKenzie, M.D., member since 1991

Need Help?

Contact CMA’s Reimbursement Help Line at (888) 401-5911 or economicservices@cmadocs.org

Vaccine volunteers fill

Public Health Gaps

By Erin M. Kennedy Volunteer Marina Roytman

Spring 2021

S

ome remember the massive effort it took to eradicate polio. Many want to be part of history by helping to end the current pandemic. Others are looking for ways to make a difference or speed the opening of schools and businesses. Whatever the reason, a small army of local healthcare professionals and physicians have voluntarily stepped up to vaccinate against COVID-19.

The retired orthopedic surgeon who took on the task of organizing the largest vaccination effort in Fresno County called it “the most complex vaccination project that’s been undertaken in the history of man.”

Timothy Brox, M.D., listed all the ways the COVID-19 vaccination effort is complex: “It is a physically friable vaccine that requires special handling. It requires a tremendous amount of participation from the public.

It requires a second dose and vaccination requires an observation period. It has irritable side effects.” He leaves out the complexity of politics and misinformation rampant on social media.

“This is not like when I was a kid and lined up for my sugar cube for my polio vaccine in school,” he added.

Vaccination logistics came together The public health department’s mass vaccination site at the Fresno County Fairgrounds came together quickly.

Dr. Brox, who retired from Kaiser Permanente, got a call from the county to “come help on a huge project.” He’d met Rais Vohra M.D., interim health officer for Fresno County Department of Public Health, while sitting on the Global Medicine Committee at UCSF Fresno, and he knew he wanted to help out in the pandemic.

“The system had to build databases on the fly and mass vaccination procedures on the fly. And we had to organize this while starting new clinics,” explained Dr. Brox, adding this came after a year in which Fresno County Public Health’s resources had been severely taxed from handling the coronavirus pandemic and the devastating Creek Fire.

It started slowly but now, with the help of physician and nursing volunteers, the site administers more than 2,000 doses a day.

Gregory Simpson, M.D., medical director of Spring 2021

dermatology at UCSF Fresno, praised the fairground clinic’s organization after volunteering there: “They are incredibly efficient. There’s one warehouse where you do the paperwork, one warehouse where they cycle you through and you get your shots, and one where you wait to make sure you’re not having a reaction to the shots. It’s really on a large scale that’s fantastic.”

That efficiency extends to how carefully doses are measured out to match the number of patients each day, observed volunteer Bonna Rogers-Neufeld M.D., a diagnostic radiologist with Sierra Imaging Associates specializing in breast imaging at WISH Fresno Breast Center. “At the end of the day I am only getting one or two doses at a time. They are absolutely diligent about not wasting each dose.”

Dr. Rogers-Neufeld also appreciated how easy the county health department made the volunteering experience. “There’s no paperwork for me to do,” she said.

“All I do is greet people, ask a couple of questions and faster than lightning I have a shot in and half the time patients don’t even know it. I’ve had no problems or seen any reactions. It’s a win-win.”

The county health department also makes sure everyone is comfortable giving shots. “On my very first day volunteering I was taught by a retired nurse from St. Agnes.

She had been a nurse for like 40 years and she taught me how to do vaccinations,” said Jessica Martin M.D., a UCSF Fresno resident in emergency medicine. “It makes me chuckle when people say ‘Oh good we got a doctor,’ like it’s going to be so nice to get vaccinated by a doctor. And I’m thinking in my head ‘If only they knew I’d only been doing vaccinations since the clinic.’”

Brand new medical students are getting early experience by volunteering alongside their teachers from California Health Sciences University. “These are first year medical students who typically wouldn’t have these types of clinical experiences until their third or fourth year,” said John Graneto D.O., dean of the university’s College of Osteopathic Medicine. Students become familiar with how to talk to patients and see firsthand how public health disaster relief works.

Of the 79 inaugural students matriculated at the new medical school in Clovis, 55 have signed up to volunteer at CENTRAL VALLEY PHYSICIANS 13

the fairgrounds mass clinic alongside 10 faculty members.

“It’s been very positive for them,” said Pamela Kammen M.D., a rheumatologist who is assistant professor of specialty medicine at CHSU. “They have the opportunity to work with patients who have different customs and personalities and learn how to deal with anxious and excited people.”

Wide range of medical volunteers making a difference Dr. Brox boasted that nearly 200 licensed clinical professionals are signed up to volunteer at the fairgrounds and on most days, clinical positions are staffed 65% with volunteers.

“They range the whole gamut from podiatry to dentists to M.D., D.O., through pharmacy to all the different types of nurses,” Dr. Brox said. “Right now I have a nurse 20 feet from here who has a fulltime job at one of the local ICU’s and she’s down here on her precious days off helping. We’ve had a retired nurse anesthesiologist whose license lapsed. He had to do 30 hours of continuing education and he had to pay to get his license reinstated.

And he did that so he could come down and help with the vaccination.”

Volunteers include public health professors, retired nurse managers, faculty from UCSF Fresno and CHSU and medical residents from UCSF and Valley Children’s Hospital. “We have doctors in their 70s who came to the clinic before their vaccinations were in effect. That’s a significant risk group willing to serve,” Dr. Brox said.

“That’s the kind of response and professionalism we encountered.”

When the call went out for medical volunteers, few hesitated. And just as their professional experiences have been varied, their reasons for volunteering run the gamut.

Dr. Graneto said one of his students told him “I want to be able to tell my grandchildren that I participated in helping in the pandemic in 2021.”

For Dr. Rogers-Neufeld volunteering felt like a natural extension of what she’s been doing since she was a small child and tagged along with her doctor father at a previous epidemic. “My dad went out to schools on the weekends to administer smallpox vaccines and give the polio vaccines, which we put in droplets on a sugar cube. He was a surgeon

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Fresno County Department of Public Health Volunteer Coordinator William Timothy Brox, MD

but it didn’t matter. Doctors and nurses banded together because the polio epidemic was just unbelievable.”

Few people today can truly understand, she said, how scary it was when science was not as advanced and little was known about transmission. Parents forbade children from swimming in streams or playing with other children.

“It was crippling,” Dr. Rogers-Neufeld remembered. “We just had no information. And now we have a world of information – probably too much information – but we knew how immediately it spreads.”

Vaccines that are routine for children now weren’t for Dr. Rogers-Neufeld. “In the world I grew up in we got the measles, we got chicken pox and there was no vaccine,” she said. “And my precious cousin Debbie died from measles at age 8. She died of measles caused encephalitis, which is a horrible way to see a child go. When you see the personal devastation of something that subsequently becomes completely preventable by a vaccine, it changes your whole world. And then you see your father helping to be part of the solution.”

Dr. Martin’s motivation was to learn more. “My family has been really wanting to get vaccinated, but nobody was in tier and no one really knew where to go.

So, I thought it would be nice to get better information on vaccinations and help out as well,” she explained.

“There is no minimum requirement that they’re asking of me which is really, really kind,” said Dr. Martin,

Spring 2021

a second year resident with long days and often overnight shifts. The county health department has a sign up portal for volunteers that makes it easy to see which shifts are open, she added.

Third-year UCSF Fresno resident Catheryn Salibay M.D. also had to figure out how to work volunteering in between long rotations working in family medicine clinics, studying for her medical boards and being a wife and mom. “I had a career in public health for eight years at the California Department of Public Health’s immunization branch,” Dr. Salibay said about what led her to medical school. “I was pretty much interested in everything and anything to help out the community. My time on weekends is precious, but I told my husband I really want to volunteer and I really want to give vaccines.”

For Dr. Simpson, it was a matter helping to lighten the load he’s seen his colleagues carrying. His University

world I could do to help out. What can a dermatologist to do to help out against COVID?” Volunteering to vaccinate gave him the perfect chance to make a difference.

Physicians are hardwired to make a difference observed Mark Alson, M.D., a diagnostic radiologist with Sierra Imaging. “Most people that are physicians went into medicine because they want to take care of people. So here’s an opportunity to take care of people,” he said. “My whole feeling is this needs to be done and I’ve got some free time, so I’ll do it ... I think most of the physicians are doing it because it is an easy way for us to help the community.”

Addressing health inequities with vaccinations Helping his own community is what prompted Albert

SPOC’s Drive-Through Vaccination Clinic administers 1000 doses per day, four days per week.

Dermatology Associates office is right next to Community Regional. “For the entire year, I’ve been watching the hospital really, really just be overrun with COVID,” he said. “The internal medicine residents who rotate with us in dermatology had just been through ICU rotations with just a day of rest between. They just looked pretty rough because of how much work and how much death and destruction they’d seen.”

He added, “I just wanted to figure out what in the

Spring 2021

Wilburn M.D. to come out of retirement to work at the vaccine clinic at Gaston Middle School in West Fresno.

“I’m a black physician and I’ve worked with underserved populations most of the time,” explained the retired Kaiser Permanente hospitalist. Before coming to Fresno in 1991, Dr. Wilbun worked in public health clinics in Columbus, Ohio, and in the Watts neighborhood in Los Angeles. “I’ve seen that inequity in healthcare and this pandemic just threw that in your face. The groups who were dying the most got the least amount of vaccines first.”

CENTRAL VALLEY PHYSICIANS 15

He added, “I think one of the few positive things that have come out of the pandemic is people can see now how unequal the whole medical system is.”

Fresno County has been trying to rectify those inequities. “We’re trying to run clinics both geographically and from a cultural perspective,” Dr. Brox said. “We’ve have one of our county nurses who is Hmong running a specialty clinic with Hmong volunteers. And Gaston Middle School is run with the African-American Coalition and the Economic Opportunities Commission for people of color to be vaccinated by those with the same personal experiences.”

Dr. Wilburn knows many in the Black community are reluctant to trust doctors – and especially government doctors – after past medical research used them as unknowing participants. “But when people decide to come

clinic. “A lot of people working there were raised in that area. I’ll hear them talking with patients telling them ‘I was born four blocks this way’ or ‘five blocks that way.’ They are eager to give back to the community and very assertive in encouraging people to get the vaccination.”

Getting appointments set up without computers or internet access or familiarity with online registration is difficult, so many are showing up without appointments, Dr. Wilburn said.

“We had a couple of older people who came in with the son who had an appointment,” he described. “We asked them to come back about 30 minutes before the clinic closed when we knew we might have extra doses. These people were both pushing walkers. Everybody was worried about them.”

They got in and got vaccinated. And they felt the same as most at the clinic, he said. “People seem much more relieved. A burden has been lifted.”

Private clinics extend the county’s vaccination efforts

Fresno Mayor, Jerry Dyer received his vaccine from Rick Lembo at SPOC

to the clinic they’ve already jumped that hurdle. I’m in a position where I don’t see that hesitancy. I’m not out in the community recruiting people,” he said.

He loves the diversity of those working at the Gaston

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Dr. Brox ticked off the categories of who has been vaccinated: “So far we’re doing 65 years and up. We’ve done all healthcare. We’ve offered to all in education.

We’ve offered to all food and ag workers. We’ve offered to all emergency workers who are not healthcare.”

He continued, “So the big change effective Monday, March 15, is we’re going to offer to everyone, age 16 to 64, who has a pre-existing condition. We’re asking for a note from your doctor attesting that you have that condition, but we’re also accepting selfattestations.”

Parceling out vaccinations this way is an imperfect attempt to get to those who would be most affected if they got sick. “But the disease has not really fit nicely into these categories and people who have not fit in these categories have had some of the most severe forms of the disease,” observed Dr. Brox.

Private practices and clinics have begun to step up to help expand the county’s efforts as more vaccine doses become available and more people become eligible for shots.

“There needs to be a great shout out to dentists or pediatricians or other small providers who have taken

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on the work to become an authorized vaccine provider,” praised Dr. Brox. “The hoops that those people went through is a testament to their dedication. The work to become an authorized receiver of vaccines and then injectors of vaccinations was not for the faint of heart.

People like Dr. Nicole Bahn and her pediatric group and the people at SPOC (Sierra Pacific Orthopedic Clinic) need huge kudos.”

Rick Lembo, director of sports medicine and patient care at SPOC, joked to Jeremy Ealand, COO that he was just trying to find a way to stay essential through the pandemic after school and college sports closed down and elective surgeries came to a halt. They worked at getting people screened, setting up SPOC for social distancing, telemedicine and then on the logistics of surveillance testing their staff. When vaccines were approved for use, they turned their attention to that.

SPOC was the first private clinic to get approved in the area on Dec. 29 and took delivery of vaccine doses on Dec. 30 and 31 to vaccinate their staff. “On New Year’s Day we were on a Zoom with the county and they asked if we would help vaccinate other healthcare providers. So we said sure,” Lembo described.

When the county opened up vaccines to those 75 and older, SPOC was ready to help again. Ealand and Lembo had a model for drive through COVID-19 testing but were told the county didn’t need that help in their area. The logistics for that were easily transitioned for drive through vaccinations, said Lembo. “We just flipped it to delivering vaccines to people who have been in the house for 10 months and they want it. But we caused complete gridlock in northeast Fresno for three days.”

“There was really no hesitation,” SPOC’s CEO Joe Clark said of the decision to turn their orthopedic clinic into a mass vaccination site. “My feeling is that we needed to do everything we could to get the county back open, get our schools back open and our kids playing sports again.”

The effort has also helped SPOC avoid potential furloughs. “We wanted to find a way to keep our employees working,” explained Lembo. “Our employees bought in from day one. They have never worked harder in 8 hours vaccinating and they ask to come do it again. They are proud to be part of it.”

Eye Q Vision and Sante employees and physicians

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have also come to help with SPOC’s drive through vaccinations, which are now delivering 1,000 doses a day, four days a week. “People aren’t waiting more than 30 minutes now. It’s like clockwork,” Clark praised Lembo’s set up.

Dr. Simpson said he’s still working out some of his office’s vaccination logistics. The paperwork, he said, is nothing compared to the scramble that happens in his dermatology office to use up all the doses opened that day.

“There is serious mayhem at the end of the day trying to get shots into arms,” he joked.

“We’d open up 10 shots because you have 15 on the schedule who qualified (by being over 65, etc.) and then you find out 12 of them have had the vaccine,” he said. “The last thing you want to do is waste shots. So the last two hours we’re calling in patients who meet the criteria and are already interested to see if they can come in. Or we call people who may not be patients yet. They’re new patients without all their paperwork in yet. And then my staff has got to register all that paperwork.”

But the work has been worth it to see how grateful older patients have been when offered a vaccination at their dermatology appointment.

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And when vaccination criteria opened up, Dr. Simpson said the requests poured in. “I’ve kind of felt like one of those old-timey telephone operators with the amount of calls I’ve been getting. My cell phone has been getting texts from teachers and just random people the minute they qualify. They’re texting me ‘Can I get a shot? Can I get a shot?’”

He’s happy to have his phone blow up if that means vaccine hesitancy is waning and more people are getting protected.

Those getting shots are grateful, relieved, happy Volunteers universally remark on how cheery patients are when they’re rolling up their sleeves to be vaccinated.

“In healthcare typically a new patient comes to us frustrated or in pain or not happy with the insurance process,” said Dr. Graneto, who was an emergency department physician for years before joining CHSU. “Even the words we use to start a visit with are negative words. We ask people ‘What’s your chief complaint today?’ But these encounters are really pleasant and these patients say ‘please’ and ‘thank you.’”

CHSU’s Dr. Kammen has appreciated how patients encouraged their students, “A number of them say ‘Oh this student did very well.’ Or they’ll say ‘I didn’t feel a thing.’ This kind of positive feedback helps the students a lot.”

Those encounters have definitely increased the new medical students’ poise, said Dr. Graneto.

“Every single student shows up a four-hour shift petrified and they leave with self-confidence having had a very pleasant experience and having participated, in a tiny way, in the cure.”

UCSF Fresno resident Dr. Martin has had multiple patients want to take photos or videotape their vaccination. She gets just excited about the possibilities that open up for people after vaccination “On Thursday I finally had more second dose vaccinations than first doses. I had one guy tell me ‘I have not seen my grandchildren

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Fresno Physicians (above) Don Gaede, MD, Pamela Kammen, MD, Kenny Bahn, MD, Bonna Rogers-Neufeld, MD, (below) Christina Maser, MD and Greg Simpson, MD volunteer at the Fresno County Department of Public Health Vaccination Clinics.

in over a year and now I finally feel like I can!’ Because Thursday was his second shot. That’s always sweet to hear.”

Lembo loves how enthusiastically grateful people have been: “I had a little grandma get out of her 10-yearold Mercedes and give me a huge hug because she got her vaccine and she can see her grandchildren now.”

Volunteer vaccinators all have a story of a patient that reaffirmed their choice to be involved. “The best story for me,” said Dr. Simpson, “is about a patient I’ve been seeing for years who is 78 and has been in a wheelchair since 3 or 4 because he had polio. He got polio before the vaccine was widespread. He was so incredibly happy that we were able to give him the vaccine for COVID. He was well aware of the affects because he’s had people close to him die of COVID.” “It helps me recharge,” explained Marina Roytman M.D., an internal medicine physician specializing in liver disease. She’s a UCSF professor of clinical medicine and has been treating COVID-19 patients at Community Regional. “I’m probably at the vaccine clinic most Saturdays. It helps me recharge to see healthy people. And these are people who now aren’t going to come die in the hospital.”

She continued, “If I can do 100 shots, these

are 100 more people who won’t get sick. And people are so delighted. They are so ecstatic and taking pictures. I’m probably in hundreds of pictures giving shots.”

Dr. Bonna-Neufeld agreed, “This is very refreshing.

My regular job is hunting for breast cancer. You actually do save a lot of lives because you find early breast cancer. But patients are not very happy with you that you’re delivering bad news … Here people are happy to see you.”

“So as long as there are people lining up for vaccines, I’ll be there to give them,” she said.

Christina Maser, MD and Greg Simpson, MD

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Mark D. Kruthers, Esq. > Attorney, Fennemore Dowling Aaron

California’s COVID-19 Emergency Temporary Standards

ABOUT THE AUTHOR Mark Kruthers is an attorney in Fennemore Dowling Aaron’s employment law practice group.

He provides advice and counseling to employers and management regarding federal and state employment laws, assists in the development and implementation of legally compliant employment policies and procedures, drafts employment related documentation (employee handbooks, employment agreements, compensation/ benefit plans, disciplinary documents, etc.), conducts employee training, and assists employers with numerous other employment related business tasks. Mark also represents employers and management in legal actions venued in both state and federal court. Mark can be reached at (559) 432-4500 or mkruthers@fennemorelaw.com

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While it seems as if the COVID-19 pandemic is starting to slow, employers still have questions about how to deal with COVID-19 in the workplace. At the end of 2020, California enacted a set of emergency temporary standards intended to help prevent the spread of COVID-19. The temporary standards remain applicable to all employers except those that have employees covered

by California’s Aerosol Transmissible Diseases regulation. Even then, for employees not identified in the employer’s Aerosol Transmissible Diseases Exposure Control Plan, the employer must comply with California’s emergency temporary standards.

It is important to note that California’s COVID-19 emergency temporary standards (the “ETS”) apply to workplace exposures and are not intended to address exposures outside of the workplace. When dealing with an employee who reports an exposure outside of work or an employee who otherwise needs to quarantine but has not been in the workplace so as to potentially expose other employees, different federal/state/county regulations would apply.

However, the ETS still provides employers with procedures to use to address COVID-19 exposures regardless of where they might occur.

Pursuant to the ETS, employers must develop and implement a written COVID-19 Prevention Program. Cal-OSHA is charged with enforcing the ETS and will expect to see the COVID-19 Prevention Program as part of the employer’s existing Injury Illness Prevention Program (“IIPP”). Starting February 1, 2021, Cal-OSHA was authorized to impose monetary penalties on employers who fail to have a proper COVID-19 Prevention Program in place.

While a large portion of the ETS is dedicated to outlining what must be included in the mandatory COVID-19 Prevention Program and describing the various training, masking, social distancing, and ventilation requirements, the portion of the ETS that employers struggle with the most is the mandatory investigation and quarantining requirements. Specifically, when an employer learns of the presence of COVID-19 in the workplace, an immediate investigation must take place. Of course, the infected individual must be excluded from the premises until he/she has recovered. However, the employer must also determine which employees were within 6 feet of Spring 2021

but is unable to work due to COVID-19 related symptoms, the COVID-19 case for a cumulative total of 15 minutes the employer’s obligation to continue the employee’s pay within a 24-hour period while the infected individual was may be offset by workers’ compensation or temporary in the “high risk exposure period.” For an individual with disability benefits received by the employee. symptoms, the “high risk exposure period” begins 2 days In situations where an employer experiences an before the onset of the symptoms and continues until 10 outbreak (3 or more COVID-19 cases in an “exposed days after the symptoms first appeared, and 24 hours have workplace” within a 14-day period), the employer’s passed with no fever and an improvement in the symptoms. obligations under the ETS increase dramatically. The For a person who tested positive for COVID-19 but has no employer must immediately provide testing to all symptoms, the “high risk exposure period” starts 2 days employees in the “exposed workplace” (even those that before the sample that led to the positive test result was might not have come into close contact with one of the collected until ten days after the collection of the sample. infected individuals) and continue testing on a weekly An employer must notify all employees who may basis until the workplace no longer qualifies as an outbreak. have had a COVID-19 exposure in the workplace of the If an outbreak turns into a major outbreak (20 or more possible exposure within 1 business day in a manner COVID-19 cases in an “exposed workplace” within a 30that does not reveal the infected individual’s personal day period), the testing identifying information. requirement increases to The employer also must twice weekly and the ETS offer those employees free requires the employer COVID-19 testing and pay Pursuant to the ETS, employers must to consider halting all the employees for any time develop and implement a written or part of the operations they spend getting tested.

COVID-19 Prevention Program to control the spread of Finally, the employer must the virus. In an outbreak exclude employees who situation, the employer have had a COVID-19 will need to be communicating with the local health exposure at work from the workplace. Those employees are department to make sure all appropriate precautions are not allowed to return to work until at least 10 days after the being taken. date of the last known exposure, assuming the employees The notification obligations discussed above are are not experiencing any COVID-19 related symptoms. based off the requirements in the ETS. Effective January 1, (However, a 14-day quarantine period is recommended.)

2021, AB 685 imposed additional reporting requirements If an exposed employee subsequently tests positive for upon employers including, among other things, notifying COVID-19 and/or develops symptoms, their time table the local health department and all employees present in for returning to work will be determined as described the same work area as the infected individual of potential above with respect ascertaining an individual’s “high risk exposure and providing potentially exposed employees exposure period.” As to any employees excluded from the with a summary of the COVID-19 related benefits available workplace, the ETS does not require a negative test result to them. Accordingly, an employer’s obligations under to return to work and securing a negative test result will not the ETS and AB 685 must be considered together when shorten the quarantining period(s) mandated by the ETS. determining how best to respond to COVID-19 in the If an employee is excluded from the workplace workplace. due to being exposed to COVID-19 at work, but is The above is only intended to be a brief discussion otherwise able and available to work, the ETS requires of the ETS and how it impacts California employers. the employer to continue to provide the employee with For more specific information, employers can review pay and benefits. This is true even if the employee has no the California Department of Industrial Relations’ ETS accrued or otherwise available paid time off. (Certainly, “questions and answers” webpage at www.dir.ca.gov/dosh/ if the employee is able to work remotely, the employer coronavirus/COVID19FAQs.html. may require him/her to so during the quarantine period.)

However, in the event the employee is excluded from work

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First Year Medical Students Thrive Despite Pandemic Challenges Deans, Faculty, Preceptors and First Year Medical Students from the CHSU College of Osteopathic Medicine Volunteer as Vaccinators at the Fresno Fairgrounds.

From left to right: Dr. Lisa Chun, Associate Dean; Dr. Jonathan Terry, Preceptor; Dr. Pamela Kammen, Faculty; Christine King, Student; Jake Dertinger, Student; Dr. John Graneto, Dean; Seaverson Stoll, Student; Joshua Garcia, Student; Tyler Laws-Mahe, Student; Mia Nurit Hirsh, Student. Photo courtesy of California Health Sciences University.

The COVID-19 pandemic brought an onset of challenges to medical education across the country. For the new California Health Sciences University College of Osteopathic Medicine (CHSU-COM) in Clovis, this meant asking their experienced leadership and educators to adapt their innovative curriculum delivery to introduce creative methods for teaching their inaugural cohort of 79 medical students.

The CHSU-COM rapidly converted to virtual education for their first-year medical students who started classes last July. John Graneto, DO, MEd, Dean of the CHSU-COM, is especially proud of how quickly both the faculty and students adapted to online courses.

Attending medical school during a global pandemic is certainly an unprecedented challenge that no one expected would arise. But these extraordinary medical students are flexible and resilient. The leadership and faculty creatively utilized the state-of-the-art technology built into the new medical school to deliver curriculum for their first-year students. For example, the nutrition and wellness faculty offered online cooking classes, the simulation center staff developed virtual simulation cases and the holographic anatomy curriculum easily transitioned to remote instruction. The students are eager to return to in-person 22 CENTRAL VALLEY PHYSICIANS

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courses, but they understand the importance of prioritizing the health and safety of the campus and community at large.

Dr. Graneto says, “Balancing the desire of the students wanting to come back on campus, while ensuring we are keeping within the safety and compliance guidelines of federal, state and local public health officials has been challenging at times.”

CHSU-COM has found a healthy balance between teaching classes virtually and holding small group, hands-on laboratory and specialized sessions within the public health and higher education guidelines and with proper safety protocols in place.

“The hands-on experiences are crucial for learning in the first year of medical school,” remarks Dr. Graneto.

Another challenge that the CHSU-COM faced was providing their students an opportunity to bond with each other as an inaugural cohort while being remote.

Forming relationships with classmates is important for wellness and gives students an additional support system.

The CHSU-COM Office of Student Affairs has been working with students to host virtual study groups and social nights, and provided the opportunity for Spring 2021

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students to form special interest clubs and professional organizations to help students feel connected to each other.

The faculty and staff have also been supportive by assisting each other in Zoom classroom logistics and meeting with each other in virtual sessions.

ANSWERING THE CALL TO VACCINATE OUR COMMUNITY

As COVID-19 vaccination efforts continue across the San Joaquin Valley, California Health Sciences University (CHSU) has found ways to assist in the administration of the vaccine and provide support for these important efforts, all in the spirit of furthering its mission to help improve health care outcomes for the people in the Valley.

Led by the CHSU President, Florence Dunn, their College Deans and the President’s Executive Council, the University quickly mobilized and determined ways that CHSU can help with vaccination efforts.

Both student and faculty volunteers from the CHSU College of Osteopathic Medicine and College of Pharmacy have been actively helping local public health departments and health care clinics to administer the vaccines to the community.

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While CHSU pharmacy students become intern pharmacists in their first year of pharmacy school and are trained to administer vaccinations, CHSU-COM accelerated the first-year medical students’ vaccination training so they could also become volunteer vaccinators.

Almost every week since inception, CHSUCOM students and faculty have been volunteering to administer COVID vaccines at the Fresno Fairgrounds mass vaccination site. Dr. Graneto collaborated with W. Timothy Brox, MD, and the Fresno County Department of Public Health to ensure that CHSU faculty, staff, and students can contribute to the mass vaccination efforts.

CHSU vaccinators have been logging hundreds of hours at the Fresno Fairgrounds and can help to vaccinate approximately 1,500 - 2,000 people per day.

Outside of the Fairgrounds, Anne VanGarsse, MD, Associate Dean of Clinical Affairs, Community Engagement and Population Health and CHSU’s visiting third and fourth year students from Kansas City University (KCU-COM) and A.T. Still University (ATSU-KCOM), as well as first year students have also been on the frontlines administering vaccines. Several students are assisting Golden Valley Health Centers in Atwater and Los Banos administer vaccines. The visiting medical students also joined forces with the CHSU College of Pharmacy students to administer vaccines to educators with Adventist Health in Reedley.

College of Pharmacy students are continuing to help aid in the vaccination efforts through their experiential education rotations, particularly at Saint Agnes Medical Center, in addition to volunteering on their own time.

With the vaccination efforts rapidly increasing, Dr. Graneto maintains a positive outlook about the COVID-19 pandemic and hopes things will progressively improve over the next few months.

“Providing education and encouragement to our faculty, staff and students to receive their COVID vaccine is now our highest priority so we can safely return to more in-person education and training activities,” said Dr. Graneto.

CHSU encourages widespread and early COVID-19 vaccination of all eligible individuals to help ensure the health of the community and restore the activities of daily lives that have been missed for the past year. Many eligible

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members of the CHSU campus community have already received their COVID-19 vaccinations.

ADDRESSING THE HEALTH INEQUITIES OF THE VALLEY The pandemic truly has informed community awareness of the health inequities that exist within the San Joaquin Valley, rural and inner-city areas. The health care access barriers and lack of health care providers has become even more evident. This has fueled the passion of CHSU medical students and reinforced their career pursuits even more. Volunteering at COVID vaccination sites gives them valuable insight into patient care and public health that may not exist under normal circumstances.

“I had never imagined how rewarding it is to participate in a vaccination campaign, especially as a provider,” said Andrea Torres, first year medical student. “The experience was definitely a great reminder of why I wanted to study medicine in the first place.”

Pre-medical students have also been inspired by the global pandemic. Known as the “Fauci Effect,” medical schools across the nation have seen an 18% increase in applications according to the Association of American Medical Colleges (AAMC). The CHSUCOM admissions team has developed creative ways to host virtual information sessions and interview days and is currently in the process of recruiting the second cohort of medical students to begin classes July 2021, which will include 121 students.

For more information about CHSU-COM visit osteopathic.chsu.edu.

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New

Study, New

Outcomes, New

Memories By: Kellie Hustedde, CCFMG When Leigh Ann O’Banion, MD, was completing her fellowship at the UCSF School of Medicine, she found that patients with a lower extremity amputation were spending almost a week in the hospital and taking six to eight months to begin walking independently again. When she became a physician at Valley Vascular Surgery Associates and UCSF faculty teaching at UCSF Fresno, she found a similar situation.

Convinced there was a way to improve patient outcomes, Dr. O’Banion created a multidisciplinary team that included all the resources a patient would need on their road to recovery. The team included health care professionals from Leon S. Peters Rehabilitation, San Joaquin Valley Rehabilitation, Community Regional Medical Center (CRMC), Hanger Prosthetics, peer counselors, social workers, and case managers.

A team approach is critical in providing information to patients before their operation and helps the patient understand and process what is happening and what to expect in terms of pain after their amputation. Including patients in the process from the very beginning produces better patient outcomes according to Dr. O’Banion.

With the team assembled, she began enrolling patients in the Lower Extremity Amputation Pathway (LEAP) study in March of 2019.

When Hanford resident Raymond Whaley accidentally stepped into a pothole and fractured his ankle on a chilly December night in 2019, he had no idea that he would become one of Dr. O’Banion’s LEAP study patients.

Amputation Patient Walks Seven Weeks After Surgery 26 CENTRAL VALLEY PHYSICIANS

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Through December and into January 2020, Raymond sought treatment for his ankle. When issues with his ankle worsened, he went to his podiatrist. His foot was swollen, discolored, and extremely painful. As a diabetes patient, Raymond was concerned that doctors would have to amputate part of his leg. While he was somewhat mentally prepared to hear that news, his wife was not. Their youngest daughter was getting married in a few weeks, and, as many fathers dream of doing, Raymond was going to walk her down the aisle.

After examining his ankle, Raymond’s podiatrist, Emmy Oji, DPM, of Valley Foot & Ankle Specialty Providers, called Dr. O’Banion. They found that Raymond had adequate blood flow in the big arteries of his leg and thought Raymond would heal very well with a below-theknee amputation. Dr. Oji then sent Raymond directly to the Emergency Department at CRMC. With the goal of walking his daughter down the aisle, his diabetes, and the type of amputation needed, Raymond was an ideal candidate for the LEAP study.

Members of the LEAP team met Raymond and his wife at CRMC. “I was in such pain that I was out of it, but I do remember that when I went in there … they got the team together, and … they were telling me about everything and how it was going to go, they were going to do the surgery in the morning, and I said ‘Ok, I’m ready for it,’” Raymond said.

Raymond had the lower part of his leg amputated the morning after arriving at CRMC. The weeks that followed were the whirl-wind of hard work, dedication, and determination Raymond had prepared for with the LEAP team.

The day after his amputation, Raymond met with the physical therapy team to start learning how to sit up, move from the bed to the wheelchair, and discuss further physical therapy.

Two days after the operation, Raymond headed to Leon S. Peters Rehabilitation Hospital where he underwent two weeks of intense physical therapy. He then headed home determined to continue relearning how to walk.

Knowing how important it was for Raymond to be prepared for his daughter’s wedding, Joe Beall with Hanger Prosthetics met frequently with Raymond to ensure he received his prosthetic in time. One week before the wedding, Raymond received a prosthetic leg that would allow him to begin the next phase of physical therapy and Spring 2021

start learning how to use a prosthetic leg.

At a follow-up appointment after his surgery, Dr. O’Banion was amazed at Raymond’s progress. Raymond told her, “I’m just trying so hard because everything within me wants to walk my daughter down the aisle, and I promised her, and I can’t back down.”

On March 5, just two days before his daughter’s wedding, Raymond received his custom-fit prosthetic.

That day, in his Hanford home, Raymond was able to walk independently with a prosthetic for the first time.

The next day, the Whaley family headed to Cambria, California for the rehearsal dinner. As Raymond’s son rolled him down the aisle while he was wearing a shirt that said “This wedding cost me an arm and a leg,” no one but Raymond and his wife knew that he would be able to walk his daughter down the aisle the following afternoon.

On March 7, 2020, as Raymond’s son began rolling him down the aisle in his wheelchair, Raymond stopped him. “I’m going to walk my baby down the aisle,” he said.

Stunned, everyone, including his daughter, watched as Raymond stood, placed his daughter’s arm in his, and walked her down the aisle, just seven weeks after his amputation.

“When you go through a tragic thing like I went through and they pick a surgeon and they come and are introduced to you, really listen to what they’re telling you.

What they’re telling you is going to help you. And you just have to be positive,” Raymond said.

While Raymond’s case was exceptional, the preliminary findings of the LEAP study are just as astounding. On average, patients enrolled in the LEAP study leave the hospital three days earlier, begin physical therapy two days sooner, and receive a prosthetic 56 days earlier than patients not enrolled in the study. Study participants also begin walking independently with their prosthetic on average two months earlier.

“The ultimate goal would be to implement this protocol in all hospitals across the country as the members of this team exist in all hospitals. It’s just a matter of getting people working together toward a common goal,” said Dr. O’Banion.

Dr. O’Banion is one step closer to that goal. Due to the significance of the preliminary findings, all three of Community Medical Centers’ hospitals will now be adopting the LEAP study protocols as a standard of care for lower extremity amputees.

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The Ripple Effects of ACEs

By Keenia Tappin, MD

“Adverse childhood experiences are the single greatest, unaddressed public health threat facing our nation today.”

– Dr. Robert Block, former President of the American College of Pediatrics.

From 1995-1997, Dr. Felitti from Southern California Kaiser and Dr. Anda from the CDC conducted the landmark Adverse Childhood Experiences (ACE) Study.

The study included ~17,000 Southern California Kaiser members who were 54% female, 46% male, 75% Caucasian, and 39% college educated. The study was designed to look for a correlation between exposure to abuse or family dysfunction during childhood and development of common deadly medical and public health problems in adulthood. The 10 ACEs included in the study were psychological, physical, and sexual abuse, emotional neglect, physical neglect, household substance abuse (alcohol or illicit drug use), mother treated violently, mental illness, depression in the household, parental separation or divorce, and having an incarcerated household member.

The negative adult health outcomes assessed included: severe obesity, being a smoker, being an alcoholic, lack of physical activity, 2 or more weeks of depressed mood in a year, lifetime attempt at suicide, illicit drug use, ≥50 sexual intercourse partners, and history of sexually transmitted disease. Adult chronic diseases assessed included: ischemic heart disease, cancer, stroke, chronic bronchitis/ emphysema, diabetes, hepatitis, fair or poor self-rated health.

This landmark study revealed two unexpected and pivotal facts about trauma during childhood. Firstly, ACEs are common. 36% of the participants had no ACEs, 26% had 1 ACE, 16% had 2 ACEs, 9.5% had 3 ACEs, and 12% had 4 or more ACEs. The top 3 ACEs were physical abuse (28%), household substance use (27%), and parental

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separation or divorce (23%). Secondly, there is a graded dose-response relationship between number of ACEs and development of negative adult health outcomes. For instance, when participants with 0 ACEs were compared to those with 4 or more ACEs, the latter group was 2.2 times more likely to be a smoker, 7.4 times more likely to consider themselves an alcoholic, 10.3 times more likely to have illicit IV drug use, and 12.2 times more likely to have a prior suicide attempt. In terms of chronic disease, participants with 4 or more ACEs versus those with 0 ACEs were 2.2 times more likely to have ischemic heart disease, 2.4 times more likely to have a history of stroke, and 3.9 times more likely to have chronic bronchitis or emphysema. Once the results came in the next question became, how exactly are these ACEs linked to risky health behaviors and diseases in adulthood? Is it simply that people who experience trauma are more likely to cope in unhealthy ways or is it linked to changes in the brain and other organs that occur during development? The answer is, it may be a little bit of both.

In terms of unhealthy coping mechanisms, smoking is a prime example. Nicotine has been shown to have positive mood regulation effects. Also, when used alone or with other substances such as alcohol, it can stimulate the dopamine reward pathway via increased dopaminergic neuronal firing. Individuals exposed to repetitive trauma may find solace in the short term positive effects of smoking or alcohol. Unfortunately, chronic smoking predisposes to emphysema, heart disease, and malignancy. Chronic alcohol use is a factor in developing cancer, hepatitis, and cognitive impairment.

Looking at neurodevelopment, trauma can have Spring 2021

many long standing effects on the brain. First, it is well known that the brain is not structurally complete at birth.

The infant’s brain is extremely adaptable and changes via pruning and strengthening of neuronal connection which occur based on interactions between the baby and their environment. According to the Harvard Center for the Developing Child, there are 3 types of stress responses which occur in the developing child. Positive stress is characterized by brief increases in heart rate and mild elevations in hormone levels. This is the type of stress that is essential for normal development. Examples include trying something new, first day of school, getting a vaccine.

Tolerable stress is the next level up, where an individual may have time-limited activation of the fight or flight stress response that is tempered by supportive relationships with a caring adult. After a short period of time, the child comes back to their emotional baseline and suffers no long lasting effects. Examples include, death of a loved one, natural disaster, or experiencing a frightening event. Lastly, there is toxic stress, which is characterized by prolonged activation of the fight or flight stress response system without adequate supportive relationships to ameliorate its effects. Examples include any of the ACEs (abuse, neglect,

household dysfunction) which occur repeatedly or an accumulation of multiple ACEs. This prolonged activation of the stress response leads to changes in the developing brain, hypothalamic pituitary axis, and other organs of the child. Changes can also be seen at the epigenetic level with modifications to the way one’s DNA is read and processed.

While the ground breaking ACEs study along with other key neurodevelopment research have helped us identify the problem and effects of ACEs, it does not offer us a solution. What do we do about children already exposed or the adults walking around with numerous ACEs suffering from the known long term consequences? Is there hope for them or are they simply a lost cause? Have faith, all is not lost! The solution to the riddle of ACEs lies in the building of resiliency. Resiliency is defined as the ability to recover from or adjust easily to adversity or change. While this skill is easier to develop in a child when compared to an adult, both can achieve this goal. It is accessible to all people at all ages. So how do we build resiliency?

Interpersonal relationships and connection to community are key factors for adults. We can be part of the solution by creating a space of love, safety, and connection for our children, for one another, and for ourselves.

Figure 1: The ACES Pyramid: https://www.cdc.gov/violenceprevention/images/acestudy/ace_pyramid_lrg.png References: 1. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245-258.

2. American Academy of Pediatrics. (2019). Adverse childhood experiences and the lifelong consequences of trauma. 2014.

For more information on ACEs, effects, and solutions: 1. CDC: https://www.cdc.gov/violenceprevention/aces/index.html 2. Harvard Center for the Developing Child- Toxic stress: https://developingchild.harvard.edu/science/key-concepts/toxic-stress/ 3. Dr. Nadine Burke Harris ,California’s Attorney General, Ted Talk on ACEs: https://www.youtube.com/watch?v=95ovIJ3dsNk 4. ACEs connection network: https://www.acesconnection.com/ 5. For information on Trauma informed care, ACEs screening, and primary care training for government reimbursement for ACEs screening see California ACEs Aware Initiative: https:/www.acesaware.org/

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Meet Them

Where They Are

BY FARIN JACOBSEN

Agencies collaborate to vaccinate hard-to-reach populations against COVID-19

F

inding a COVID vaccination clinic and registering for an appointment can be confusing even for a well-equipped, tech-savvy individual.

But for some people — namely agricultural workers, the elderly, and individuals experiencing homelessness — accessing and navigating government websites to find a vaccine clinic can be impossible without help.

With such populations, local officials say, the best solution is to bring the vaccine directly to the patients.

“Public Health is keeping those hard-to-reach populations top-of-mind,” said Madera County Public Health Director Sara Bosse. “That’s a really important role of the Department of Public Health is always to figure out how to equitably 30 CENTRAL VALLEY PHYSICIANS

make vaccinations available. But how you do that depends on what resources are available and what partners you have.”

Collaboration is a mark of a crisis, with multiple agencies working together for the greater good. Madera County’s Department of Public Health has contracted with community-based organizations and collaborated with the Madera County Farm Bureau and Ag Commissioner as well as other agencies that work closely with the agriculture community to get farmworkers vaccinated. The Madera County Office of Emergency Services was also a huge part of the health department’s response to the pandemic from the beginning, Bosse said.

“I think that [the collaboration] has been extremely helpful given the high demand on Public Spring 2021

Dr. Oscar Sablan and Dr. Marcia Sablan have partnered with AMORE to deliver vaccines to ag workers in rural Fresno County.

Over 1000 have been vaccinated at clinics at Pappas Family Farms, Holland Nut Company, Bar 20 Dairy and the Firebaugh Community Center.

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Health to be able to take on things that we weren’t funded to do up to this scale,” she said.

Fresno and Madera County public health departments, along with several partner agencies and employers, have come up with dedicated and creative solutions to serve their ag workers, seniors, and unhoused populations.

VACCINES REACH AG WORKERS THROUGH THEIR EMPLOYERS The Wonderful Company, which produces and packages POM Wonderful juice, Wonderful Pistachios,

they are, instead of getting people to vaccines, I think is something that we need to do more of,” he said.

The Wonderful Company offers COVID vaccines to employees at its two Wonderful Wellness Centers in Lost Hills and Delano in Kern County. But because produce for The Wonderful Company is grown throughout Central California, Tsai has headed pop-up mobile clinics to be sure that all employees have easy access to the COVID vaccine.

“As we know, throughout the pandemic agricultural workers, essential workers, and particularly Latinx communities have been disproportionately affected

Pop-up clinics have vaccinated employees at the POM facility in Del Rey in Fresno County as well as citrus farms in Visalia and Tulare County, and a pistachios and almonds facility in Madera County... and Halos oranges among other products, has vaccinated employees onsite through standing clinics and mobile clinics, said Dr. Raymond Tsai, the company’s executive medical officer.

“As an ag company, there is a lot of interest to be sure that our workers are vaccinated, both because it is good for business, frankly, to be sure that our workers are protected, but two, it’s just the right thing to do,” he said.

While vaccines are traditionally distributed by hospitals and clinics because of their existing infrastructure and staff, focusing on non-traditional ways to vaccinate atrisk groups is increasingly important, Dr. Tsai said.

“Thinking about how to get vaccines to people where 32 CENTRAL VALLEY PHYSICIANS

by COVID-19,” Dr. Tsai said. “These are populations that don’t get the privilege of being able to self isolate, meanwhile are also taking on the burden of ensuring the supply chain of food. I think there is also an almost society debt to these populations that have put themselves at the frontline and literally risked their lives during this pandemic.”

Pop-up clinics have vaccinated employees at the POM facility in Del Rey in Fresno County as well as citrus farms in Visalia in Tulare County, and a pistachios and almonds facility in Madera County, Dr. Tsai said.

The Wonderful Company partnered with Del Rey

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Packing Co., another ag company, to vaccinate their employees. First doses were given on February 10 and 11, and second doses were administered March 11, bringing the total to 605 people vaccinated.

“We’ve been using our mobile clinic to go out to those areas, and then doing one-day, large events to vaccinate our employees, but we always ask for extra vaccine because then we have the opportunity of advertising to surrounding ag employers to see if there’s interest in vaccination amongst their employees,” Dr. Tsai explained.

Another pop-up clinic held March 16 vaccinated more than 100 ag workers in the rural, westernmost part of Madera County.

Ease of access location-wise isn’t the only benefit of these employer-sponsored mobile clinics, Tsai said.

Leveraging pre-existing relationships with employers has been a working strategy for vaccinating ag workers because there is a level of trust and open lines of communication between the employers and employees.

“If this is company-sponsored, they don’t have to worry about losing time from work or that they’re going to get in trouble for not being at work,” Dr. Tsai said.

Fresno County Public Health Director Joe Prado said location is key, but there is another barrier to vaccinating food and ag industry workers: trust in the vaccine. In working to vaccinate people in those

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industries, the Fresno County Public Health Department found free education was key to getting closer to 80 to 90 percent of people accepting the vaccine.

“As we continue to penetrate these vulnerable communities and populations, you’ll see an increased uptake with proper education and letting people make that decision of whether or not they want to be vaccinated,” Prado said.

PACE PROVIDES A SENIOR-SPECIFIC VACCINE CLINIC In the early days of COVID vaccination drive-thru clinics, seniors 65 years or older were eligible to receive their vaccine according to state guidelines — but had to wait in their cars in line for hours.

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“Nobody wants to do that, especially someone that is more frail, has more comorbidities, or is more sick than your average 65-year-old,” said Nicole Butler, center director for Sequoia PACE (a Program of All-inclusive Care for the Elderly).

WelbeHealth’s Sequoia PACE center at 1649 Van Ness in downtown Fresno was one of the first five COVID vaccination sites in Fresno County and began doling out vaccines in early January, Butler said.

To make things easier on the senior population, WelbeHealth made appointments available by phone instead of using online registration and caters specifically

said.

“We tried to make our vaccination clinic a little bit easier, so we’ve only been vaccinating the senior population,” she said.

Sequoia PACE can vaccinate 120 seniors per clinic day; the clinic is held every Thursday.

Appointments are scheduled every 15 minutes and seniors are asked to come at their designated time, waiting in their car if they arrive early. Seniors can park right in front of the building, come inside to get their vaccine, wait 15 minutes in an observation area for any adverse side effects, and then go home, Butler said.

Sequoia PACE has reached out to local senior living facilities and provided transportation for their residents from those facilities to the vaccination clinic. to the 55 and older crowd.

Finding out where to get vaccinated and registering online for a vaccine is a common issue for seniors, Butler said.

“The [vaccine clinic] list is housed on the Fresno County website, which is not an easy website to maneuver,” Butler explained. “It’s go onto the county website, download 50 locations that are providing vaccination, and then start calling at the top of them.”

For those who don’t have the list or don’t have someone to help them schedule an appointment, this task can be daunting, time-consuming, and frustrating, Butler

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“We don’t want people lined up around the side of the building. We want it to be very calm and an easy experience for them — better than going to the doctor’s office,” she said. “It’s been really nice to do it in a setting that’s not as fast-paced as some of the other vaccination sites because this is not a fast population. I mean, they’re coming in with walkers and canes and wheelchairs and so it really allows for them to take their time.”

Sequoia PACE has reached out to local senior living facilities and provided transportation for their residents from those facilities to the vaccination clinic. Now they’re reaching out to see if the independent living facilities would

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The health department hasn’t surveyed the unhoused population to see if the group is apprehensive about getting vaccinated, but the vaccine seemed well received... want staff to come to them to vaccinate seniors, but PACE is finding that most of the elderly living in those facilities who wanted the vaccine have already gotten it, Butler said.

SINGLE-DOSE SHOTS SEEM BEST FOR UNHOUSED POPULATIONS People experiencing homelessness have a higher risk of mortality from COVID-19, according to the California Department of Public Health, and thus became eligible for the COVID vaccine on March 11. However, the Madera County Department of Public Health was a step ahead.

The department had already worked with the Madera Rescue Mission, which provides shelter to men, women, and children experiencing homelessness, to deliver vaccinations on February 10 and March 10 due to two COVID-19 outbreaks at the mission, said Bosse.

“Our health officer prioritized that group due to that vulnerability, and so we moved forward with people who are actually living at Madera Rescue Mission,” she said.

The health department administered 30 Moderna vaccines and 7 Janssen vaccines to people staying at the mission. The Janssen COVID-19 vaccine manufactured by Johnson & Johnson is administered as a single dose.

“We got feedback that the single-dose vaccine is ideal for the population, certainly because scheduling followup appointments is really a challenge for a lot of reasons,” Bosse said.

At this point, county health departments are taking whichever vaccines they are allotted and vaccinating as many people as possible, as quickly as possible, officials say.

“We’re looking forward to an increase in single dose vaccines and I think that’s really the ideal vaccine,” Bosse said. “It’s also easier to handle so that we can actually go out to encampments and … be able to set up a clinic that’s walking distance from locations where we commonly find our unhoused populations. That’s the plan in Madera County.”

Part of Madera County’s strategy is to engage with the unhoused population through a chronic disease staff Spring 2021

member who is well-known and trusted in the unhoused community. The individual has worked with the county’s unhoused population for years with regards to testing and treatment of sexually transmitted diseases, Bosse said.

That staff member will be key in helping those unhoused individuals feel comfortable and — with the help of multilingual staff members and community-based organizations that speak indigenous languages — get their questions answered about the COVID vaccine, Bosse said.

“We need supports to be able to educate and inform that group as well about the benefits of vaccination — and we’re ready to do that,” Bosse said. “The strategy is to go to them and provide [vaccines] in a location that’s really convenient.”

The health department hasn’t surveyed the unhoused population to see if the group is apprehensive about getting vaccinated, but Bosse said the vaccine seemed well received at the Madera Rescue Mission.

“People were really open to getting the vaccine,” she said. “But with any group, especially those who have challenges with accessing information that’s largely digital… we want to make sure that people are well informed and when they’re making a decision that they have all the information.”

Bosse looks forward to the day everyone is eligible for the COVID vaccine, as long as the doses are available and the infrastructure is in place to administer doses to anyone who wants to be vaccinated.

“I think the most important thing for people to know is that Departments of Public Health want to vaccinate people. We don’t want to prevent people from getting vaccinated,” she said. “So the eligibility process that we’re following is really because I don’t have enough vaccine for everyone. It would be, honestly, easier for us to just open enough to be able to vaccinate anybody.

“As soon as we have enough vaccine, we’ll get around to everyone.”

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SEQUOIA PACE WELBEHEALTH IS A PHYSICIAN-LED, CALIFORNIA PACE OPERATOR WHOSE MISSION IS TO UNLOCK OUR MOST VULNERABLE AND FRAIL SENIORS' FULL POTENTIAL WITH EMPATHY AND LOVE Its teams coordinate every aspect of their participant's care so they can live in their own homes and communities rather than a nursing home. This care coordination includes all necessary medical and dental care, therapies, long-term care and services, meals, socialization, transportation, day center services, and activities in a fully coordinated 24/7 program.

WelbeHealth delivers these services through PACE (Program of AllInclusive Care for the Elderly), a Medicare and Medicaid program.

PACE is a well-established financing and care delivery model for older adults age 55 and older who meet their state definition of needing nursing home care. The PACE model of care aims to keep frail elders as well as possible, manage any medical crises at home, and reduce admissions to both hospital and long-term service and support (LTSS) settings.

BETTER OUTCOMES WITH COST SAVINGS Among the 138 PACE organizations operating in 30 states, ninety percent of participants are dually eligible for Medicare and Medicaid, 9 percent are eligible only for Medicaid, and less than 1 percent are eligible only for Medicare. The typical participant has 5.8 chronic medical conditions, including dementia, coronary artery disease, cerebrovascular disease, and diabetes.

These people have a 24 percent lower hospitalization rate using PACE than dually eligible beneficiaries 36 CENTRAL VALLEY PHYSICIANS

who receive Medicaid nursing home services. At the same time, states pay on average 13 percent less than the cost of caring for a comparable population through other Medicaid services, including nursing homes and home and community-based waiver programs.

This model of care makes a significant positive impact on quality of life for medically frail seniors and is essential to communities at a time when more than 10,000 baby boomers turn 65 each day.

PACE has demonstrated significant improvements in participants' quality of life, life expectancy, depression rates, and sense of health empowerment and engagement. It also serves as a helpful partner to families and caregivers. It generates significant taxpayer savings by improving participants' health and well-being.

For frail elders, whose needs span both medical care and LTSS, the impact of Covid-19 has been catastrophic. High morbidity and mortality rates among those infected have been widely reported, with the most severe impact occurring in the nursing home resident population.

However, less than 7 percent of PACE enrollees have tested positive for Covid-19 and 1.66 percent have died of the virus. These rates are below other care models serving nursing homeeligible individuals, according to the National PACE Association.

A SHIFT TO TECH

WelbeHealth rapidly shifted to a fully remote home-based care model. In a matter of days, its teams deployed senior-friendly technology allowing low-income patients to access integrated care teams from the safety of their own homes on a 24-hour a day basis. These internet-connected WelbeLink computer tablets not only kept participants better protected from COVID-19 by facilitating remote care, WelbeHealth teams also invented new programming to combat social isolation through group therapy.

In late 2020 when vaccination disbursement began in California counties, WelbeHealth was among the nation's first PACE programs to begin rapid and safe vaccinations among its participants. Its teams vaccinated the majority of its elderly patients and team members by utilizing strong relationships with healthcare partners and county governments. It is also acting as a community vaccinator, successfully vaccinating thousands of Californians against Covid-19.

Since 2019, WelbeHealth has maintained its standing as one of the fastest-growing PACE operators in the U.S., opening four California programs to serve greater Stockton and Modesto, the Pasadena-GlendaleBurbank region, the greater Long Beach area, and Fresno. It has plans for additional expansion in underserved communities.

For more information, visit https://welbehealth.com

At the onset of the pandemic, Spring 2021

Advanced Treatment for Major Depressive Disorder Very often patients suffering from depression obtain no relief from multiple medications. In many cases drug therapy can cause significant side effects resulting in non-compliance.

Safe and Effective Technology

559-433-1TMS Spring 2021

No anesthesia required No memory loss No down time from normal activities Accurate Neuronavigation System

www.depressionfresno.com CENTRAL VALLEY PHYSICIANS 37

Kasey A. Medellin > Roubicek and Thacker Counseling

The Role of Resilience in the Face of COVID-19

ABOUT THE AUTHOR Kacey Medellin, MS, AMFT is a Registered Associate Marriage and Family Therapist at Roubicek and Thacker Counceling. Kacey specializes in working with those who are experiencing anxiety, depression, relationship concerns, and trauma. She holds a strong belief that all individuals have resiliency in their core, and are capable of taking control over their own lives.

Kacey approaches counseling from an attachment perspective, as well as through the lens of interpersonal neurobiology.

Kacey has the goal of helping others create self-understanding through connecting the body and the mind.

38 CENTRAL VALLEY PHYSICIANS

Resilience in its simplest form is defined as the human experience of “bouncing back” after facing adversity. It is said that resilience often comes in the form of optimism, which is the ability to self-regulate strong emotions, as well as the ability to use failure or adversity as helpful feedback for continued growth and progress.

Resilience is a wonderful and optimistic outlook… but what happens when adversity and challenge come in the shape of a global pandemic that rages through our communities for months on end with no clear end in sight?

The onset of COVID-19 in the early months of 2020 brought with it an enormous storm of medical, economic, social, emotional, physical, and political stressors. This storm of stress has resulted in challenging and draining experiences for medical professionals on the front lines, as well as those working behind the scenes. Many have been significantly impacted as a result.

The emotional depth of this pandemic has crusaded its way through our world. In many situations it has become quite evident that Post Traumatic Stress Disorder (PTSD) is now the aftermath for those who have endured the trauma of caring for people impacted by COVID-19. Too many have worked too hard, for too long, without taking the time to care for their own needs, and are suffering as a result.

The National Institute of Mental Health understands PTSD to be a fear response or a condition that can develop in those who have been through significantly traumatic, shocking, or dangerous experiences.

With our unique and multifaceted understanding of how this past year has impacted the medical field, there are times when you will need to take steps to connect with yourself and become more aware of the impact the pandemic has had on your own emotional well-being. Building resilience in the wake of this pandemic is not something that anyone should have to do alone. Reaching out to others for support will be an essential part of this process.

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When looking to foster and build resilience in light of recent events, it is important to take the necessary steps in moving forward into our “new normal.”

In the medical field, oftentimes, the process involved in pushing through and surviving every shift can come with a myriad of stress response side effects. The American Psychological Association suggests that the physical effects of long term chronic stress can involve: Depression Irritability or anger Anxiety Emotional eating or skipping meals Alcohol, drug or tobacco use Excessive reliance on sleep aids or caffeine Social withdrawal

There is also a common misconception that many of the psychological or emotional responses to stress are situational, rather than possibly connected to deeper underlying traumatic experiences. These responses can include:

school, medical programs, hands-on training, residency, fellowships, and so much more… you know what it takes to put in the hours and get through the day. And you know the impact that these things have had on you, both the good and the bad. Life is not just about surviving… it is also about thriving, healing, balancing, and putting what matters at the top of your list.

A trained mental health professional can help you create meaning from the trauma and grief that has presented itself throughout this past year, as well as throughout your life. Our country has come together in many ways to celebrate and offer appreciation for you, our healthcare heroes. There are those of us who are here not just to appreciate you, but are ready to help you create meaning and foster resiliency through what you’ve experienced, and what lies ahead.

1. https://www.nimh.nih.gov/health/education-awareness/shareableresources-on-coping-with-covid-19.shtml 2. https://www.apa.org/topics/stress/body

High blood pressure Heart disease Elevated heart rate Diabetes Sickness often due to suppression of the immune system Ulcers Erectile dysfunction Fertility problems Low sex drive Irregular menstrual periods A decrease in muscle tone Insomnia Headaches

So what if resilience isn’t about “bouncing back” at all? What if we were to collectively agree that it actually comes down to being able to work through, talk about, and understand our hardship and create a narrative where that hardship is an important part of building who we are. In other words, writing a story of perseverance.

Perseverance isn’t about bouncing back to where or who we were before, it is about accepting every new experience and going along for the ride to see what we will learn from it. As medical professionals, you know first hand the meaning of perseverance through medical Spring 2021

CENTRAL VALLEY PHYSICIANS 39

Radiologist’s Recommendation Puts Focus on

Surgeon’s Judgment Authored by Gordon Ownby, General Counsel, Cooperative of American Physicians, Inc. (CAP)

Consultants are not apt to directly tell the referring physician how he or she should treat the patient. But a radiologist’s repeated recommendations to a surgeon for clinical follow-up can come very close.

A 45-year-old teacher and avid skateboarder visited the ER after crashing at a local skate park and landing in dirt.

Dr. ER, the emergency room physician, noted a 4 cm laceration to the right suprapatellar region of the left leg. Dr. ER flushed the wound with sterile water and repaired the laceration with subcutaneous and superficial sutures. Dr. ER gave the patient aftercare instructions, advised him to return to the ER if things did not improve or got worse, and directed him to follow up with his primary care physician.

Though Dr. ER took a history of a tetanus shot within five years, his chart also recited, twice, “NOT UTD WITH TETANUS SHOT.” The patient claimed that Dr. ER told him that he did not need antibiotics.

The patient returned to Dr. ER three days later complaining of a diffuse, dull, and severe worsening of left knee pain. The knee was markedly swollen though 40 CENTRAL VALLEY PHYSICIANS

the wound was healing well. An ultrasound was negative for DVT and an X-ray was “unremarkable,” save for some tissue swelling. The temperature of the crutch-using patient was 98.7. Dr. ER prescribed Naproxen and Norco, but no antibiotics were applied or prescribed.

Three days hence, the patient visited his PCP, who took a history of the skateboarding accident. The patient complained of worsening pain, swelling, tingling, and numbness into his toes. The PCP noted the edema was progressing proximally and that the patient was still using crutches. The PCP counseled the patient extensively on wound care and advised the gentleman to look for potential signs of infection. The PCP told the patient that if tingling and numbness persist, he should remove his compression socks and to go to the ER again if there was no improvement. The PCP recommended an

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© Can Stock Photo / dolgachov

orthopedic consult and recommended a return in a week to remove sutures.

No antibiotics were applied or prescribed.

Instead of returning to the PCP the next week, the patient visited Dr. OS, an orthopedic surgeon.

Though the patient reported head sweating, Dr. OS’ examination found no sweating and “extremities cool.” Dr. OS found a healing laceration on the anterior surface of the patella, moderate to severe pre-patellar bursitis, and moderate bruising of the anterior knee. X-rays were normal.

Dr. OS assessed some form of internal knee derangement and ordered an MRI. According to the patient, he asked Dr. OS about draining the knee but was told that an aspiration would likely complicate his condition. No antibiotics were applied or prescribed.

When the patient returned two days later, the MRI results were available. Dr. OS incorporated the MRI findings into the “Comments” section of his chart that day, including: “(1) extensive anterior soft tissue edema with loculated 9.8 cm heterogeneous collection superficial to the extensor mechanism consistent with hematoma. Adjacent defect of the vastus medialis myotendinous junction is identified with propagation of collection deep to the muscle belly. Focal laceration/perforating injury is considered.

The cutaneous defect is incompletely visualized at the limits of the study. Please correlate with clinical concern for infected collection/superimposed abscess. (2) Joint effusion/hemarthrosis with contained debris and/or blood degradation products as well as dissecting/ruptured popliteal cyst. Again, correlation with clinical concern for infected synovitis is recommended given history of laceration. . .”

The radiologist’s recommendations notwithstanding, Dr OS’ assessment included traumatic pre-patellar bursitis.

The patient claimed that Dr. OS reported that everything was fine in the MRI. The sutures were removed, and Dr. OS advised the patient to modify his activities and to return in two weeks. No antibiotics were

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applied or prescribed.

On his return to Dr. OS two week later, the patient reported some improvement but was still unable to bear weight on the left leg. His temperature was 99.3. Dr. OS aspirated the knee and sent 22cc of cloudy fluid to the lab.

Though the patient’s CBC white blood count was normal with a left shift, the WBC of the aspirate was 120,000.

Dr. OS contacted the patient and told him that he needed surgery “tonight.”

On his hospital admission, the patient was diagnosed with septic arthritis and underwent an emergent arthroscopic surgery, converted to an open I&D after findings of extensive infection. Cultures grew coagulase negative staph infection for which the patient received IV antibiotics. A hematologist on his care team opined that the patient’s current anemia was multifactorial but included an untreated four-week infection. Acute renal failure was attributed to IV vancomycin toxicity.

In the patient’s subsequent lawsuit, he claimed Dr. OS failed to properly diagnose his condition or treat his infection, resulting in a stormy hospitalization and enduring damage to his knee. The dispute was resolved without going to trial. (The patient also sued Dr. ER.) Discussing all the medical considerations involved in Dr. OS’ care of the patent is beyond the scope of this column. From a litigation standpoint, however, Dr. OS’ failure to document his thinking in light of the two – quite emphatic – recommendations from the radiologist regarding possible infection created a fact pattern that a jury would find compelling for the plaintiff.

CAP provides California physicians with superior medical malpractice coverage and a myriad of no-cost risk and practice management resources to help keep them safe and successful.

If you’d like to learn more about the benefits we offer to our members and how much you can save by switching your medical malpractice coverage to CAP, contact Albert Malasig at 650-543-2185 or via email at AMalasig@ CAPphysicians.com. CAP is a proud supporter of the Fresno Madera Medical Society.

CENTRAL VALLEY PHYSICIANS 41

Debra Phairas > President, Practice and Liability Consultants, LLC

Managing your Manager Physicians find it challenging to supervise practice managers as they often fail to adequately assess their abilities during the initial hiring process. As a result, many physicians engage the help of consultants when recruiting and hiring for this position.

“Managing is like holding a dove in your hand. Squeeze too hard and you kill it, not hard enough and it flies away.” —Tommy Lasorda TRAITS OF AN EFFECTIVE MANAGER

ABOUT THE AUTHOR Debra Phairas is President of Practice & Liability Consultants, LLC a nationally recognized firm specializing in practice management and malpractice prevention.

Her background includes medical clinic administration and loss prevention management for NORCAL Mutual.

Debra Phairas is the president of Practice & Liability Consultants and has over 35 years of healthcare administration and consulting experience. www.practiceconsultants.net

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An effective manager is a leader; someone who has the capacity to monitor the various facets of managing a practice. This person: • Should possess a sound understanding of practice operations, • Must be driven to accomplish practice goals and • Must have a vision.

In addition to these attributes, an effective manager is an excellent relationship builder and communicator: one who can facilitate information exchange and partnerships throughout all facets of the practice.

While managers cannot be expected to be adept in all the areas they manage, they should be able to lead the team to perform optimally, while creating a cohesive work environment.

Hence the most important attribute of a good manager is being a good leader: someone who inspires the team to perform to their fullest.

HIRE THE BEST!

Good managers must have managerial talent, mutually respectful staff relationships and the ability to “manage up” effectively with their physicians. A skilled and effective manager can “pay” for their salary many times over by saving or making the practice money, so invest wisely.

Often, practice managers start in other areas of a practice, such as in the clinic, in billing or at the front desk. Some practices have successfully promoted individuals from within the organization into management positions, while others have not. This is called “The Peter Principle” or rising to the level of highest incompetence. For this reason, careful consideration and evaluation of the potential candidate and their skills must be made.

Furthermore, reevaluation of practice needs must be made periodically, as

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growth occurs. In some instances, a practice manager will be successful when the practice is small but will fail to grow or increase skill levels with the practice.

COMPENSATE ACCORDINGLY

Don’t be pound-foolish. Survey local practices of similar size for salary ranges, and access industry-specific salary survey comparables that break down administrator/ manager salary ranges by size of practice, revenues and other factors. www.salary.com and www.mgma.com are resources.

SET EXPECTATIONS

Before hiring a candidate, set specific expectations and boundaries.

Determine the areas of the practice that you want to be involved with and the responsibilities and authority completely delegated to the manager. For example, many physicians completely delegate human resources and operational issues to the manager but remain involved in other areas such as strategic planning, considering a new provider, opening/closing offices, marketing, web site content, equipment purchases, EHR, and other IT decisions.

Expectations for work hours, demeanor, behavior and dress should be clearly defined in writing. They should include such requests as: • Greeting staff members each morning, • Team huddles to build relationships with staff and to plan the day.

• Monthly or quarterly meetings to proactively manage the practice.

DEFINE SUCCESS

Frequently managers perceive a lack of realization or attention to their accomplishments.

It is imperative that physician owners set timedefined objectives, which meet owner needs and challenge the manager and track progress. Both the physician and the administrator must agree on ideally quarterly goals/ objectives for the practice or the manager’s professional growth in writing. This document will become the outline of goals for their annual performance review.

PROVIDE PROFESSIONAL TOOLS

Most managers cannot directly supervise more than eight staff members effectively. Therefore, a front office, clinical or billing supervisor may be necessary to support

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the practice manager and avoid burnout. It is important that the owner/physician provide this support and encourage the manager’s professional development as well.

Continuing education courses keep the manager’s skills sharp, just as CME helps increase a physician’s knowledge. Encourage your administrator to join Medical Group Management Association, (MGMA) or your medical specialty society administrator organization and attend the joint meetings. Encourage the manager to seek out other professional opportunities that may become available locally, state or nationally.

DEVELOP WORKING PARTNERSHIPS

Managers should be treated like non-owner partners in the organization and should fully participate in all owner meetings, including annual strategic planning meetings.

All projects should have target dates, checkpoints to monitor progress and periodic updates in between. Utilize tools such as Microsoft Outlook, which has a task feature to assign and track tasks, set deadlines and requests for updates.

CREATE A COLLABORATIVE CULTURE

Remember, as physicians, you set the culture of the practice. Don’t let actions speak louder than words.

If you want your manager to build a cohesive team, look to build a cohesive team with your manager and other staff members.

PROVIDE POSITIVE FEEDBACK

Reward your manager with sincere thanks, praise and creative perks such as:

CENTRAL VALLEY PHYSICIANS 43

• Spa day • Sports tickets • Extra time off • A monetary bonus • Gifts that you know the manager will appreciate.

A personally planned, thoughtful way of expressing appreciation often means more to your manager than just a bonus. Even a note of thanks is appreciated.

ENCOURAGE TEAM SPIRIT

It’s important to remember, a manager is not just a task master. He or she is also a team builder and a leader.

Set goals for quarterly team building/morale events or hold periodic contests with various themes such as the “best idea” that increases revenue or reduces expenses.

positive and ready to tackle areas where improvements are needed.

CROSS-TRAIN

Too many physicians will not discipline or fire managers because they are the only person trained to accomplish most administrative tasks. This is holding the practice hostage and not recommended.

Insist that the manager train another staff person to perform certain tasks such as accounts payable. This will minimize embezzlement exposure and enable the organization to function in the absence of the manager if necessary.

READ FINANCIAL REPORTS

• Anticipatory budgets should be prepared by the third ASSESS PERFORMANCE REGULARLY quarter of each year by the manager. Financial reports to If you have clearly outlined your goals in written be shared with owners should be ready no later than one week after the close of the month. These reports should form, it is simple to transition this document into a include the following: performance review checklist and ascertain progress in • Dashboard report with terms of how goals are key highlights being accomplished and • Profit/Loss report and if timelines are in order.

Continuing education courses keep MD productivity report It is important to • Your medical specialty the manager’s skills sharp, just as CME assess relationship and benchmarks: team building efforts as helps increase a physician’s knowledge.

• A/R Aging, Turnover, part of the evaluation Gross and Adjusted process. Acquiring Collection percentage feedback from employees • Staffing Ratios, Staff wage percentage to collections is one way to assess these attributes. This is called and Full Time Equivalents a 360-degree review.

• Recommendations for overhead expense ratios This is accomplished by asking staff to evaluate When purchases or contracts are involved, managers management abilities anonymously via a web site–based should prepare cost-benefit analysis for physician meetings survey such as www.surveymonkey.com or www.formsite. and give three top ranked recommendations. com. This survey will provide the physician(s) with SAY GOODBYE information regarding strengths and improvements from If the manager is not able to function or perform the staff’s perspective. However, keep in mind that poor on the level communicated clearly during the interview performers may use this as a method to get even, so watch process after numerous discussions and attempts to correct for ratings that are out of line with the norm and eliminate the situation, it may be time to consider cutting your losses. them. The survey should be structured to measure both If a decision is made to terminate employment, strengths and weakness in a constructive manner. documentation of performance deficiencies via The annual performance review should start with performance reviews and written warnings is essential to positive performance areas first, then “sandwich” in protect the practice. constructive feedback to avoid defensiveness. End with Obtain legal advice if there has been little or poor positive praise for tasks/projects well done. documentation of substandard performance to avoid legal The manager should leave the discussion feeling difficulties.

44 CENTRAL VALLEY PHYSICIANS

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FMMS Joy of Medicine www.FMMSJoy.org

It’s Ok To Ask For

Help RESILIENCY CONSULTATIONS The Fresno Madera Medical Society recognizes the overwhelming stresses and immense workloads that physicians face today. Stress, anxiety, depression and grief are common, but they can be managed. Resiliency Consulta�ons can provide relief, an increased ability to cope, healing and an opportunity for personal growth.

FMMS sponsors up to four (4) annual sessions with approved and ve�ed providers confiden�ally, conveniently and FREE to physicians living and prac�cing in Fresno and Madera Coun�es.

Par�cipa�ng in a Joy of Medicine Resiliency Consulta�on is completely confiden�al. Neither FMMS, your employer, nor the California Board of Medicine will be no�fied if you choose to par�cipate.

Par�cipa�ng providers offer a wide range of appointment �mes that strive to accommodate the unique and busy schedules of physicians.

Providers are paid by FMMS directly, discreetly and anonymously. Insurance will not be asked for or billed.

Physicians have the op�on of extending their par�cipa�on at their own expense a�er the fourth visit.

It’s OK to ask for help! Call today to schedule a free Resiliency Consulta�on and begin the process of reconnec�ng to your Joy of Medicine.

RECONNECT TO YOUR

Joy of Medicine

SCHEDULE ROUBICEK and THACKER 559-323-8484 AN APPOINTMENT

Call and identify yourself as a physician practicing in Fresno or Madera County

Background photo created by freepik

Russell Maltes > Client Adviser, Regency Investment Advisers

Financial Health at All Stages

ABOUT THE AUTHOR Russell Maltes is a client adviser at Regency Investment Advisers. He works with individuals, families, and businesses to address the broad spectrum of financial planning and investing. His entire 20 plus year career has been in financial services.

Starting in banking in the late ‘90s, Russell has worked for Merrill Lynch, Charles Schwab, Transamerica, and now Regency.

Russell and wife Taryn are both Fresno State alums and children of retired U.S. Navy veterans. They live in Clovis and share two children.

46 CENTRAL VALLEY PHYSICIANS

As I look back through my education experience, I can still remember reading Lord of the Flies in the seventh grade. I can still write the quadratic formula from memory, and if I focus, I can recite the first line of the Gettysburg Address.

All worthy endeavors of the education system and at the time, seemed like important things to learn. Yet aside from the occasional trivia conversation or to impress people at parties, they have not yet proven to be crucial in my adult life.

What do I not remember learning? How income taxes work. Who is FICA and why are they taking a chunk of my hard-earned pay? Why should I care about compound interest? Which is better: a 401k or Roth IRA? How do I build my credit history and use debt responsibly? What happens to all my stuff when I pass away?

Most people are left to answer these questions, and more, on their own.

Unfortunately, Financial Literacy is not a top priority in grade and high school curricula. Many of us start our adult lives with what our parents and family teach us about finances. The internet age has closed that gap but filtering the good information from the bad on the Web has its own challenges. We are left with fending for ourselves, a sort of trial by fire, and ultimately learning from our financial mistakes. According to Forbes Magazine, two-thirds of Americans cannot pass a basic financial literacy test. This lack of financial Spring 2021

smarts costs our fellow Americans billions of dollars a year in interest, fees, penalties, and missed opportunities. And it has led to some alarming statistics: • Over 40% of Americans do not have enough saved to cover an unexpected expense of more than $400.

• Excluding mortgages, the average American has $38,000 in debt. 20% of their monthly income goes to debt service.

• 18% of Americans making $100,000 or more live paycheck to paycheck.

• 31% of Americans have less than $5,000 in retirement savings, with 21% having saved zero.

There is more. Trillions of dollars are owed in credit card and student loan debt. Many folks have resigned to making minimum payments with no end in sight.

Excluding current students, there is a troubling number of borrowers who are not making their student loan payments in a timely manner. The cost is difficult to quantify.

Interest on any debt drives up the cost of the original purchase. Carrying debt, and worse not making payments on time, will impact your ability to buy a home or start a business. And in your personal life, financial stress can affect you both physically and emotionally.

What is the solution? Two words: education and planning. The good news? You have options. The information is out there. If you are so inclined, the tools for self-education are better than ever. The Do-It-Yourselfer can file taxes, set up investment and retirement accounts, even write a will. If your time and energy are best spent elsewhere, a good financial adviser can take care of the heavy lifting. They can answer the questions you may not even yet know to ask. They can coordinate with other professionals like accountants and attorneys to complete your financial picture, avoiding the pitfalls so many people have experienced going it alone. They do however come at a cost. The value of which only you can decide is right for you. The best ones will help you understand the cost benefit equation and help you make the best decision for you and your family.

The importance of planning should not be overlooked. Like anything else in life, the chances of reaching any goal go up dramatically when we make a plan and stick to it. A plan gives us a sense of direction.

It dictates the everyday action that ensures that we are progressing to the goal. It gives us a measurement tool, a

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way of evaluating progress. A good plan can pivot as the inputs and circumstances change. Ultimately, it gives us the peace of mind that the resources and energy we dedicate to a goal are spent efficiently and wisely.

There is a standard suite of financial topics to understand for each phase of your career and life. Over the course of this series, my goal to is to share information pertinent for each part of your financial life cycle. There are several topics that should be addressed now while others can wait. Building a strong foundation early can pay dividends down the road. Likewise, as you settle into your career and your life begins to take shape, you will be faced with new financial challenges. Finally, as your career matures and you are ready to look at the next chapter of your life, yet more issues will need your attention. My hope is to give you some things to think about, provide a sense of urgency, and ultimately get you to take action.

Tracy Zweig Associates A REGISTRY & PLACEMENT FIRM

Physicians

Nurse Practitioners Physician Assistants

Locum Tenens Permanent Placement Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 jnguyen@tracyzweig.com www.tracyzweig.com

CENTRAL VALLEY PHYSICIANS 47

A Dermatologist’s Cell Phone During A Pandemic 2.0 CME

2.0 CME

THURSDAY, MAY 27, 2021 6 - 8 PM

This Dermatology CME will be presented by three board-certified dermatologists from UCSF Fresno discussing their experiences during the COVID-19 Pandemic. Dermatology is an incredibly visual field, and the progression from seeing patients in person, to tele-dermatology (and through our cell phones) was drastically accelerated during the prior year. The range of discussion will be very broad and will include cases of interest to all manners of physicians.

OBJECTIVES  Improve visual identification of common rashes  Facilitate primary care providers in providing immediate options for dermatologic conditions  Expand differential diagnoses for cutaneous outbreaks

FACULTY

LUIS DEHESA, MD

Assistant Clinical Professor UCSF University Dermatology Associates

GREGORY SIMPSON, MD

Associate Clinical Professor UCSF University Dermatology Associates

LESLIE STOREY, MD

Assistant Clinical Professor UCSF University Dermatology Associates

Accreditation Statement: The Fresno Madera Medical Society for Continuing Medical Education is accredited by the California Medical Association to provide continuing medical education for physicians.

Credit Designation Statement: The Fresno Madera Medical Society for CME designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

FREE for FMMS Members | Register at FMMS.ORG

SAVE THE DATE Saturday, August 7, 2021 Rebecca Trotzky-Sirr, MD, MS

Assistant Professor of Emergency Medicine Medical Director - LAC+USC Jail Emergency Medicine

Medication Assisted Treatment

MAT Training s

Plu Tools for Managing Complex Chronic Pain and

Strategies for Empathetic Conversations with Patients

SAVE THE DATE For More Information Visit www.fmms.org

Clinical Association of California Endocrinologists Presents

CA CE

Hot Topics in Diabetes & Endocrinology for Primary Care 2021 Virtual Event Series SATURDAY, APRIL 24

SATURDAY, JUNE 19

SATURDAY, AUGUST 21

SATURDAY, NOVEMBER 6

8:00 a.m. – 12:30 p.m.

8:00 a.m. – 12:30 p.m.

8:00 a.m. – 12:30 p.m.

8:00 a.m. – 12:30 p.m.

TARGET AUDIENCE

TOPICS

The Hot Topics in Diabetes & Endocrinology for Primary Care series is geared

Each CACE Hot Topics program will be unique with numerous topics being covered including:

nurse practitioners, physician assistants, pharmacists, and other healthcare professionals interested in the treatment of diabetes and other common endocrine diseases in California.

Amenorrhea / PCOS Case Studies in Diabetes CGM / DM technology CHD / Renal Disease CVD – Beyond Lipids Guidelines – Stepwise Approach Diabetes Diagnosis and Pre-Diabetes

REGISTRATION INFORMATION not wish to earn CME credits. Attendees who would like to earn CME credits for their participation in the CACE Hot Topics program can register for the low price of $35.

REGISTER at http://www.endoconnection.com/ca/meetings

Spring 2021

Hyperparathyroidism Incidentalomas Insulin Therapy Male Hypogonadism MDI / CSII Menopause Management Osteoporosis Thyroid Conundrums

For Questions, contact CACE at cace@wjweiser.com

CENTRAL VALLEY PHYSICIANS 49

By Karen Dahl with Special Thanks to Lerraughn Morgan, MD In February, the Valley Children’s Pediatric Residency Program celebrated Black History Month and one of the activities was a screening and discussion of the documentary Black Men in White Coats. Being neither black nor a man, I thought I would learn quite a bit from this film.

Well, that turned out to be a significant understatement.

The documentary is the story behind a movement of the same name with the following mission: “to increase the number of black men in the field of medicine by exposure, inspiration, and mentoring. To accomplish this, we are partnering with various medical schools across the country to produce outstanding short documentary videos which bring awareness to this issue that not only affects the black male population, but also the nation as a whole.”

The film highlights the crisis of lack of diversity in our profession and the consequences this has on the health of the black community (black men in the US have the lowest life expectancy). Did you know that less black men applied to medical school in 2014 than in 1978? How did that happen? A common tagline in the documentary is “You can’t be what you can’t see” and only 2% of American doctors are black men. In our culture, images of black men in sports and entertainment (and incarcerated) are far more prevalent than images of black men in scientific fields such as medicine and engineering. This documentary presents a problem, but the solutions discussed in the film are mostly for the black community and for medical school admissions processes.

I will admit that some of what I learned made me uncomfortable with my privilege and lack of awareness and support for the issues identified. But most importantly, it led me to do something. During the discussion after the film, one of the participants asked “What can I do?” Dr. Michael Galvez, who has a passion for mentoring black and brown 50 CENTRAL VALLEY PHYSICIANS

students, said “Just do something.” Our pediatric residents pondered asking about career goals during well child visits at a very early age and being a source of affirmation and encouragement for children who want to succeed beyond athletics.

This idea was inspired by the following story from one of my colleagues, Dr. Lerraughn Morgan, who examined an 8-year-old African American boy in the cardiology clinic.

“As I proceeded through my evaluation, I casually asked the young man ‘what do you want to be when you grow up?’ He enthusiastically replied ‘an engineer’. Although his quick and decisive reply was not anticipated, what caught me off guard was that his mother was crying. When I asked her why she was crying, her response was that no one had ever asked him this question. This experience resonated with me as an African-American male. This demonstrates how important it is as a community to motivate children of underrepresented minorities to explore fields such as science, technology, engineering, and medicine.”

Please join FMMS in doing something: we are offering free screenings of this film through FMMS Connect the Docs viewing and sponsoring a discussion zoom call on May 6th.

For other ideas, check out the following website: https:// www.blackmeninwhitecoats.org/the-mission/. There, you can watch video series and podcasts. If you are inspired to become a mentor, you can sign up at this website: https:// www.blackmeninwhitecoats.org/500-mentors/. Since black men make up only 2% of physicians in the US, help is needed from other communities to become mentors. Each of us has a history of success on the road to becoming a physician, and understands the discipline and commitment needed to succeed and therefore we each have something to contribute to young men considering this field. Just do something!

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FRESNO MADERA MEDICAL SOCIETY

WRITING CONTEST 2021 The Fresno Madera Medical Society invites all current residents and medical students to enter our 2021 writing contest. The guidelines are simple: In 350 400 words, respond to the following question:

"Of all the patients you have encountered thus far, which one has been the most memorable and/or had the most impact on you and why?"

All submissions, space permitting, will be published in the Summer Edition of our Central Valley Physicians Magazine. The top three articles will receive a cash prize. Please use anonymous re-naming for any patients, and others as judged necessary. The publication can be anonymous if requested and appropriate.

Contest Rules: 1) Deadline for submissions: Tuesday, June 1, 2021.

2) Top three articles will be awarded as follows: 1st Prize: $500 2 nd Prize: $300 3 rd Prize: $200 3) The articles must be 350 - 400 words. It may be subject to minor editing.

4) A panel of 3 physicians on the FMMS executive board will judge the contest.

The articles will be evaluated anonymously.

Submission Deadline: June 1, 2021. You can email your articles to Stacy Woods - swoods@fmms.org

Fresno, California - Dr. Edward James McLaughlin II, a resident of Fowler, passed away peacefully on Sunday morning, January 10, 2021 at the age of 90, at Fresno Community Hospital.

He is survived by his wife, Julie; his four daughters, Cathy McLaughlin, Laurl Sisco, Mary Ferris, and Nancy McLaughlin; his stepsons, Michael Brajkovich and wife, Maren, and Matthew Brajkovich; grandchildren, Miles, Alexis, Matthew, Joshua, Madeline, Jamie Marie, Abigail, Aveah, Mila, and Ziah; and great-grandchildren, Isabella, Alani, and Izrael.

James was born in Clinton, Iowa, on October 26, 1930, the only child of Edward and Martha McLaughlin.

He graduated from medical school at the University of Iowa College of Medicine, was inducted into the U.S. Air Force as a general medical officer, and then specialized in radiology. He interned in Phoenix, Arizona, practiced briefly in southern California, and then moved to Fresno.

“Dr. Mac,” as he was affectionately called by colleagues and friends, co-founded Wishon Radiology which served the California Central Valley, including Valley Children’s Hospital (of which he was most proud), for decades. He was senior partner, retiring in 1996, however as one cannot keep a good man down, he soon returned to medical practice part-time until 2014, at the age of 84.

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James’ first wife, Nancy, passed away after 29 years of marriage. He remarried in 1988, to Julie, to whom he remained married, residing in Fresno and then nearby Fowler. Besides his profession as a “miracle worker,” James was a gentleman farmer of pistachios (one of the first in the San Joaquin Valley) and grapes, an avid sports fan of the Fresno State Bulldogs, competitive marksman shooter in his younger years, collector of Mesoamerican and other artifacts, and member of the Knights of Columbus. James enjoyed traveling to foreign countries and especially spending time with family at their vacation homes in Lake Tahoe, Palm Desert, and Carlsbad, sharing endless stories with his grandchildren. James enjoyed life, and he embraced the day with cheerful morning hollers of “Tempus Fugit!” (time flies), and “Now is the time for all good men to come to the aid of their country!”

James Edward McLaughlin, lived a full and honorable life-respected, cherished, and loved by his family, friends, and colleagues-and passed peacefully with his devoted wife at his side.

Dr. McLaughlin was a member of the Fresno Madera Medical Society for 57 years.

Due to Covid-19 restrictions, private services will be held.

CENTRAL VALLEY PHYSICIANS 52

Walnut Creek, California - Constantine Alexander Michas died peacefully on Tuesday, November 3rd, 2020 at the age of 79. Con was a resident of Fresno, California for 38 years.

He moved to Walnut Creek, California three years ago.

At the time of his death, he resided at Carnelian Assisted Living, a memory care provider there.

Con was born in Vancouver, British Columbia on May 21st, 1941 to John and Catherine Michas. The older of two sons, he attended General Gordon Elementary School and Kitsilano Secondary School. He attended the University of British Columbia, graduating in three years, and directly entered UBC’s Faculty of Medicine, class of 1966. He was an intern at Cook County Hospital in Chicago and a surgical resident at the University of Michigan where he met his wife of 51 years, Justine Taylor of Mt. Clemens, Michigan. They settled in Sacramento where he completed the last year of his residency at the University of California at Davis. He stayed on as associate professor, developing the first burn unit there. In 1979, he joined Surgical Associates of Fresno and practiced general and vascular surgery for 30 years. Con was a Fellow of the American College of Surgeons and was active in the medical community of Fresno. He was devoted to his Spring 2021

patients, to his office staff, and to the staff, nurses and doctors at Fresno Community, Clovis Community and Saint Agnes Hospitals.

In addition to Justine and his brother John Michas of Vancouver, BC, Con is survived by his four children: Christina, Alex, Andreas and Gregory; their spouses: Jimmy Wallenstein, Ariane Michas, Sara Michas-Martin and Tyla Michas; six grandchildren: Oscar and Sylvie Wallenstein, Ophelia and Soren Michas, Jonah MichasMartin, and Ethan Michas; and a large extended family.

All of his children and their families returned to reside in California, satisfying his greatest wish that they be near one another.

Con traveled widely, grew fruit and vegetables in his garden, and played poker with friends. He loved a beautiful landscape, skiing and hiking in Tahoe, and his home in Carmel-by-the-Sea. He was proud of his Greek heritage, loyal to his Canadian roots, and became a US citizen in 2012. He had a wonderful positive spirit. He was generous and kind. He loved to hug. Above all, Con loved to be surrounded by his family and friends. He will be dearly missed.

CENTRAL VALLEY PHYSICIANS 53

On Tuesday, February 23, 2021, Kenneth Lee Jue, MD, devoted husband, beloved father and grandfather, and dedicated pediatric cardiologist, passed away peacefully at his home. He was 86 years old.

Ken was born in 1934 in Berkeley, CA He received his undergraduate degree from University of California at Berkeley (1955) and his medical degree from University of California San Francisco Medical School (1960).

After finishing his residency and fellowship in Cardiac Pathology at the University of Minnesota, he joined Valley Children’s Hospital in 1965 where he remained until his retirement in 2012. Ken was instrumental in securing funding for the new hospital that opened in 1998 as well as establishing satellite offices throughout the San Joaquin Valley. He pioneered and encouraged the development of the outstanding cardiology and cardiothoracic surgery program at Valley Children’s Hospital. He was one of the driving forces behind the continuous improvement, technology advancements and quality standards that have helped set Valley Children’s Hospital apart from children’s hospitals in California and across the country.

Ken loved playing tennis, skiing, classical music and traveling with his family. He was truly a lifelong learner and educator. Ken loved being a doctor - usually ignoring his

54 CENTRAL VALLEY PHYSICIANS

appointment book and spending however much time was needed with his patients. He made sure that each patient had an opportunity to receive a treat, either an oatmeal or chocolate chip cookie, before leaving his office.

Ken met Isabelle Hall while at UC Berkeley and they were married in 1960. Ken was always happiest with Isabelle at his side. Besides being with his wife Isabelle, Ken got the most joy being with his children and grandchildren. He is survived by two of his children, Susan Copeland (Richard) and Christopher Jue (Claudia) and his five grandchildren. Matthew, Ryan, Ryder, Devin, and Madison. Ken is also survived by his brother Clifford Jue, and nephews, Brad, Eric and Daryl, and their families.

A memorial service was held via live stream on Thursday, March 11th, 2021 at 11am from Whitehurst Sullivan Burns & Blair. Donations can be made to the Dr. Kenneth and Isabelle Jue Pediatric Cardiology Education Fund at Valley Children’s Hospital of Central Valley.

Dr. Jue was a member of the Fresno Madera Medical Society for 55 years.

Fond memories and expressions of sympathy may be shared at www.whitehurstsullivan.com for the Jue family.

Spring 2021

Get your free copy of From Exam Room to Courtroom: Lessons Learned from Real Medical Malpractice Cases

Avoid Lawsuits in Your Practice In the most recent compilation of CAP’s “Case of the Month” column, you will find 10 case studies of physicians involved in medical malpractice legal disputes. These cases offer important insights to help you reduce medical risk and increase patient safety in your practice.

Get Your FREE Copy at CAPphysicians.com/COMFM

Learn more about common areas of liability such as: Physician misjudgment Gaps in communication and documentation Oversights during specialist referrals As a leading provider of superior medical malpractice coverage in California for more than 40 years, the Cooperative of American Physicians, Inc. (CAP) is pleased to offer this free resource to help you and your staff run a safe and successful practice.

Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code.

Spring 2021

CENTRAL VALLEY PHYSICIANS 55

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