Central Valley Physicians Spring 2017

Spring 2017

COMING SOON...

MULTIPLE MEDICAL SCHOOLS SUDDENLY THE VALLEY IS A MEDICAL SCHOOL HOT SPOT

Medi-Cal Hurdles Facetime Your Doctor Neurology On The Hill Stroke: Every Minute Counts

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CENTRAL VALLEY PHYSICIANS

800.356.5672 CAPphysicians.com/quote Spring 2017

VOLUME 2, NUMBER 2 • SPRING 2017

{FEATURES}

12 14 18 22 28 38 44 Spring 2017

FACETIME WITH YOUR DOC

{DEPARTMENTS}

STROKE: EVERY MINUTE COUNTS

26 CLASSIFIEDS

NEUROLOGY ON THE HILL MEDI-CAL HURDLES

50 PUBLIC HEALTH UPDATE:

Legionnaires’ Disease

53 IN MEMORIAM

FUTURE MEDICAL SCHOOLS WALK WITH A DOC FMMS ALLIANCE

CENTRAL VALLEY PHYSICIANS

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Letter From The Executive Director

HE’S A COMEDIAN….

ACTOR… TELEVISION HOST…AND A PHYSICIAN In my career I have worked in several different industries. My first “real” job was in commercial property management working in downtown San Francisco for a premier high-rise building. It was a good ‘eye-opening’ job and it taught me a few things. 1. You can’t live in San Francisco, eat and drive a car all in the same month. 2. Commercial property management was not a fit for me. From NICOLE BUTLER there I moved in to entertainment marketing for Sony PlayStation and it was more of a fit – or if anything fun. Then I decided I wanted to move back to Fresno to work for Duncan Enterprises in product marketing. After a few years I decided that healthcare marketing is where I wanted to go. And the marketing director at Hanford Adventist took a chance and hired me with absolutely no healthcare experience at all. From there I spend the next 15 years working for health plans, hospitals and senior care services, learning along the way the healthcare industry is challenging. It’s hard to sell a service that no one really wants. No one wants to go to the hospital, no wants to get sick – but my job was to market and sell these services to the residents of the valley.

Healthcare today is still challenging, but in other ways. For months when talking with physicians I would push Prop 56 stating that these funds would help central Valley by providing access to care for our Medi-Cal population, and I believed that physicians would receive increased compensation. When Proposition 56 passed in November, $1.2 billion was supposed to go towards Medi-Cal provider reimbursement through the new tobacco tax.

Governor Brown’s proposed budget wrongly redistributes that revenue into the general fund, thus intensifying California’s access to care issues.

Please take a moment to call or email your legislators and Governor Brown, to oppose the proposed budget. Legislators value your opinion and need to hear directly from their physician constituents. To look up contact information for your assembly and senate representatives, go to http://findyourrep.legislature.ca.gov and call Governor Brown at (916) 445-2841. It’s easy, and it’s effective. Encourage your colleagues to do the same; these funds should be for Medi-Cal provider reimbursement, not the general fund.

Ok, now for some exciting news, we have a date for Summer Meltdown. Friday, August 5 and the entertainment will be Matt Iseman. For those who don’t know him, he is a comedian…. actor… television host of American Ninja Warrior…AND a physician! Most recently he was the winner of The New Celebrity Apprentice. As a reminder, this is our premier fundraising event of the year, supporting the Fresno Madera Medical Society Scholarship Foundation. Matt will be the perfect fit to an already fun event. We expect another sellout, so make sure to get your tickets early.

Happy Spring Everyone!

Thank you,

PRESIDENT Alan Kelton, MD PRESIDENT-ELECT Trilok Puniani, MD VICE PRESIDENT Cesar A. Vazquez, MD TREASURER Alan Birnbaum, MD PAST-PRESIDENT Hemant Dhingra, MD BOARD OF GOVERNORS Christine Almon, MD, A.M. Aminian, MD, Jennifer Davies, MD, Joseph Duflot, MD, William Ebbeling, MD, Don Gaede, MD, David Hadden, MD, Christina Maser, MD, Katayoon Shahinfar, MD, Roydon Steinke, MD, Janae Barker, DO, Uma Swamy, MD, Alfred Valles, MD CENTRAL VALLEY PHYSICIANS EDITOR Don Gaede, MD MANAGING EDITOR Nicole Butler EDITORIAL COMMITTEE Don Gaede, MD - Chair, Alan Birnbaum, MD - Associate Editor, Ranjit S. Rajpal, MD, Hemant Dhingra, MD, Roydon Steinke, MD, Cesar Vazquez, MD, Nicole Butler CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Alan Birnbaum, MD, Don Gaede, MD, Alan Birmbaum, MD, Erin Kennedy, Malissa Rose, Jay Lewis, Ken Bird, MD, Trilok Puniani, MD, Elizabeth Zima, Vivian Paz CONTRIBUTING PHOTOGRAPHERS Nicole Butler CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 1040 E. Herndon Ave., Suite 101 Fresno, CA 93720 Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY OFFICE HOURS: Monday through Friday 9 a.m. to 5 p.m.

MEDICAL SOCIETY STAFF Executive Director, Nicole Butler CMA HOUSE OF DELEGATES REPRESENTATIVES Alan Kelton, MD, A.M. Aminian, MD, Patrick Golden, MD, Brent Kane, MD, Ranjit Rajpal, MD, Oscar Sablan, MD, Roydon Steinke, MD, Toussaint Streat, MD, Don Gaede, MD ALTERNATES Trilok Puniani, MD, Naeem Akhtar, MD, Praveen Buddiga, MD, William Carveth, MD, Trilok Puniani, MD, Swarnpal Sekhon, MD *Automatic Delegate

Nicole Butler Executive Director Fresno Madera Medical Society

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CENTRAL VALLEY PHYSICIANS

Spring 2017

Fresno Madera Medical Society CME Cruise to Alaska

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July 22, 2017

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Fresno Madera Medical Society is hosting its first Continuing Medical Education while cruising Alaska.

Earn up to 12 hours of CME while enjoying the cruise with Family, Friends, and Colleagues.

Please join us and book by March for the discount.

Inside Cabin - Starting at $3213 per couple includes Port Taxes & Registertion Fees

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For more information or to book now contact Air KingTravel & Tours at 1.888.565.5050 or by email at nita@airkingtours.com CME $295 for Physicians - $225 for Physician Assistants, Nurse Practitioners, Nurses & Others Target Audience: Physicians, Physician Assistants, Nurses, Nurse Practitioners

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

How to Make a Virtuous Sin Tax

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

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I dislike paying taxes as much as anyone, but I’ve always been intrigued by the concept of “sin taxes.” These are taxes on alcohol, cigarettes, and other goods deemed harmful to society. Sin taxes have a double effect: they not only can generate money for programs like schools or healthcare, but--at least theoretically--they also discourage the sinning.

In Mexico, 70% of the citizens are obese or overweight, so they adopted a 1 peso per liter tax on sugary drinks in 2014.

Consumption dropped 5.5% in the first year, and an additional 4.2% in the 2nd year.

In November, California voters passed a $2 tax on cigarettes and e-cigarettes, partly to discourage smoking, but also to generate additional money for the Medi-Cal program .

Will it work? There’s a good chance it will. Lately, whenever

I ask my patients about their smoking habits, they say something like, “Yeah, I’m still smoking, but this new $2 tax is making me think very seriously about quitting.”

A 2014 report by the Surgeon General stated that raising prices on cigarettes was “one of the most effective tobacco control interventions,” because increasing price is proven to reduce smoking, especially among kids. Studies suggest that for every 10 percent increase in the price of cigarettes, smoking goes down 4 percent.

Cigarette companies know this--they wouldn’t have spent almost $65 million trying to defeat Prop 56 if they didn’t perceive the tax as a real threat to their sales.

Their internal memos, disclosed in tobacco lawsuits, confirm this: “Of all the concerns, there is one-taxation--that alarms us the most” (Philip Morris memo 1985).

Spring 2017

Will it work? There’s a good chance it will. Lately, whenever I ask my patients about their smoking habits, they say something like,

“Yeah, I’m still smoking, but this new $2 tax is making me think very seriously about quitting.”

Phillip Morris and R.J. Reynolds’ ads claimed that Prop 56 was a “tax hike grab” by insurance companies and other wealthy special interests. Those socalled “insurance companies” are our state’s Medi-Cal programs, and those so-called “wealthy special Interests” are actually the taxpayers of California.

As I stated earlier, the bulk of the revenue from Prop 56 is intended to increase funding for Medi-Cal. This will help pay for the some of extra healthcare costs caused by smokers. Furthermore, an increase in the Medi-Cal reimbursement rate should increase the availability of physicians for a historically underserved population. Some revenue will also go to our state’s smoking cessation programs Proposition 56 passed in large part because California voters recognized that this $2 cigarette tax is a matter of fairness. Why should non-smokers have to pay for the increased healthcare costs of smokers? The cost is not trivial--it’s estimated that each California family pays $413 per year in taxes to fund healthcare for smokers.

But hold the phone--Governor Brown’s January 6 budget proposal blatantly disregards the intent of the voters. It proposes to take some of the Prop 56 money to fill in a shortfall in Medi-Cal funding. Unlike the tobacco companies’ false claims, this is a genuine “tax hike grab”--and it was explicitly forbidden by the

Spring 2017

language in Prop 56, which states “ . . . the revenue derived therefrom . . . shall not be considered General Fund revenues . . .”

I spoke with CMA senior vice-president Janus Norman about this. He said CMA will consider “all options” to prevent Prop 56 money from being diverted for other uses. “All options” includes the possibility of litigation, but CMA hopes to settle the issue satisfactorily through the legislative process.

Fortunately, with Dr. Richard Pan in the state Senate and Dr. Joaquin Arambula in the state House, CMA has 2 strong allies to help make our case. These physicians are each chairs of their respective Budget Subcommittees on Health and Human Services.

The legislature has until June 15 to pass the budget.

This is a relatively short time frame for us physicians to voice our concerns to our legislators. So we should begin doing so now--tell them to keep Proposition 56 revenues where the voters explicitly intended them to go.

Don Gaede, MD Go to http://findyourrep.legislature.ca.gov to find your members of the California legislature, and then email them or give them a call. It’s easy, and it’s effective.

CENTRAL VALLEY PHYSICIANS

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President Report > Alan Kelton, MD

Central Valley Physician

ABOUT THE AUTHOR ­ ­ ABOUT THE AUTHOR AlanDr. Kelton, MD, is board and Ronald Morton is acertified board-certified specializes in Internal Medicine.

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

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Greetings, welcome to our spring edition of Central Valley Physician. I should have had little trouble thinking of a timely topic relating to healthcare in the valley, with the Trump presidency, the travel bans, Trumpcare vs. Ryancare, hate crimes and the violent suppression of free speech in these recent weeks. Oh, what to write this edition?

The CMA and the AMA oppose the travel ban, Executive Order 13769, revoked January 27, but to be reapplied with changes March 16. Simple. We have an immigrant workforce of physicians without whom we would all suffer, as many as 1 in 4 of all US physicians. There are as many as 10,000 physicians in the US from the original seven-country ban and with the recent exclusion of Iraq from the list we would still have many thousands of highly-trained,

highly-needed physicians who would be fearful of travel to their country of origin or of having to apply to renew a visa. I even have colleagues from other countries not affected by the ban also become fearful of routine travel outside of the US. These expectations and fears do not fit with the ideals of a free country, a country that is supposed to be generous and freedom-loving.

It is often the immigrants who really teach us about American ideals of hard work, self-reliance, entrepreneurism and tolerance.

I have heard a local doctor state that we have all of the old-world cultures without the old-world problems here in the valley. If a patient asks about a doctor to whom I refer, I may make a comment about a difficultto-understand accent but not about a doctor’s nation of origin, ethnicity, sex or appearance because in the U.S. these issues

Spring 2017

I should have had little trouble thinking of a timely topic relating to healthcare in the valley, with the Trump presidency, the travel bans, Trumpcare vs. Ryancare, hate crimes and the violent suppression of free speech in these recent weeks.

really do not matter-or at least, should not matter.

Some immigrant physicians are more American than me, and will be able to discuss sports and pop culture with patients, things about which I am usually clueless. For those patients that persist in knowing the doctors nation of origin, I have found it helpful to point out that the reason many of these doctors are so good at what they do is that they have had to endure specialty training twice in order to be able to practice in the US. As an example, when as a senior resident on call Christmas Day 2002 at the VA hospital, I needed to prep a patient for helicopter transport to Stanford for an aortic dissection and had twenty minutes for lines, drip and monitor. (The late Dr. Cohen would have taken the case but we were short of platelets in our area.) I knew my best option was to call my internal medicine R2, Cristin

Spring 2017

Vorobchevici, a “doctor-in-training� who had been a surgeon in his home country of Romania, to stabilize the patient. When I need to talk to a friend about my various musculoskeletal gripes I often call my friend, Rohit Sundrani, a highly-trained interventional cardiologist who himself had been an orthopedist in India. The late Rabi Kundu, gastroenterologist, was a surgeon before coming to the U.S. and he pioneered work in natural orificial transluminal endoscopic surgery (NOTES). His previous career and extensive knowledge of the GI system made him an outstanding gastroenterologist here in Fresno, here in central valley of California, right here in the United States. Let us not harm ourselves or our families by inhibiting the influx of these and other immigrants to our country.

CENTRAL VALLEY PHYSICIANS

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Lock Down Your Systems and Data: Advanced security measures can help protect your systems and sensitive data. Consider enabling login verification (with security cards or fingerprint scans), timed user log outs and user lockout after failed login attempts. Also, encrypting emails, text messages and patient health information (PHI) helps protect sensitive data after a breach and may prevent the need for a HIPAA notification.12 Actively Monitor Your Data: A data activity monitoring system monitors your systems for unusual or suspect activity and alerts system administrators to potential security threats. This can help you identify threats and possibly avoid a breach. The HHS OCR HIPAA Audit Protocol is a good place to start for determining monitoring protocols.14 Develop a Breach Response Plan: You likely have response plans in place for medical emergencies or severe weather events.

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CENTRAL VALLEY PHYSICIANS

Spring 2017

facetime GET A LITTLE

BY MALISSA ROSE

WITH YOUR DOC

BEDSIDE TELEMEDICINE NOW AVAILABLE IN SKILLED NURSING FACILITIES CENTRAL VALLEY

Nowadays, you can do anything with your tablet or mobile device – pay bills, monitor your body’s movement and what you eat, or remotely operate your home’s temperature, lighting and security system. So why not chat with your doctor? Thanks to CEP America, now you can.

Sierra Vista Healthcare, a Skilled Nursing Facility (SNF) in downtown Fresno, is the first SNF facility in the state to utilize telemedicine services in conjunction with CEP, a multi-specialty physician partnership and solutions provider for hospitals and other healthcare facilities.

CEP developed the telemedicine platform, On Duty, for Skilled Nursing Facilities to offer virtual physician night and weekend coverage and to supplement medical oversight for all patients. It helps reduce delays in care, alleviate unnecessary transports to the locals ERs and decrease overall healthcare expenses.

Via a secure high-definition video platform with the use of an iPad or tablet, nurses can help patients connect with their physician on-thespot. The patient and physician can see and communicate directly with one another, giving the physician clinical insights, including a visual exam, needed to guide the nurses about changes in medication, care, or to address other needs. To further engage and connect loved ones and caregivers, family members can also be patched in on the video conferencing call.

“TeleSNF capabilities with On Duty further our commitment to getting the patient the right level of care when and where they need it,” says Rick Newell, MD, Chief Transformation Officer and Director of Telehealth for CEP. “Instead of the nurse picking up the phone and calling 9-1-1, or calling for an expensive medical transport when there is a change in the patient’s condition, they pick up a tablet and have a virtual visit with our physician.”

Sierra Vista Healthcare, an affiliate of Aspen Skilled Healthcare, Inc., began utilizing this service on November 1, 2016.

“We’re looking at what healthcare is going to look like in the future, because there are so many things we’re graded on – from readmissions, to customer service and care. Telemedicine for us was a chance to improve our patient care,” says DeAnn Walters, administrator for Sierra Vista Healthcare. “This is part of our intervention to reduce readmits to our hospital partners, improve the customer experience and achieve better clinical outcomes.”

Spring 2017

According to Surinder Yadav, MD, Vice President of Operations for CEP, Aspen Skilled Healthcare, Inc., is a pioneer in delivering telemedicine to its skilled nursing patients.

“In an increasingly competitive environment, SNFs are looking for ways to differentiate their services and achieve the Triple Aim,” says Dr. Yadav. “Not only are SNFs now held accountable to value-based metrics and will be impacted by Medicare reimbursements tied to performance, but they are also a key post-acute care setting for bundled payments.

Leveraging a telehealth solution has the potential to reduce both hospital and skilled nursing facility readmissions, save costs, and provide patients with time sensitive care.”

Sierra Vista Healthcare has a total of two rotating hospitalists via On Duty. Walters says the patient experience has been positive and well-received. Typically, the types of video interactions that occur are to examine a wound, or to discuss pain issues or changes in mental conditions.

“One of our patients was actually familiar with telemedicine services because he lived rurally and had used this service before,” Walters says.

“He felt more understood because he could actually see the doctor’s face.”

Dr. Yadav explains that telemedicine can benefit both the patient and the physician in several ways, more so because they are able to directly interact at a moment’s notice.

“With telemedicine, the physician is able to visually assess the patient at the bedside whereas before, this may have been lacking particularly in urgent or emergent care situations where the only ‘assessment’ resource was a phone call from the nurse,” he says. “The physician is also able to assess multiple data points, including vitals with the nurse, and can examine the patient visually with the nurse guiding at the bedside.”

CEP aims to implement telehealth solutions as a core part of their practice offerings to enhance the delivery of care in both acute and postcare settings. Currently, CEP is working with several organizations who are considering telemedicine in the SNF capacity and other clients are already leveraging CEP’s tele-urgent care and tele-psych solutions.

“This is definitely the future of medicine,” says Dr. Newell. “CEP is developing several use cases for telehealth technology to extend the reach of our physicians and innovate in ways to better serve our patients and clients.”

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Spring 2017

stroke When a patient is having a

BY TRILOK PUNIANI, MD

every m i n u t e counts

I always say that “time is brain” because it’s estimated approximately 2 million brain cells die every minute when a stroke is occurring.

At Kaiser Permanente Fresno Medical Center, we have significantly reduced the time it takes to administer life-saving medication to stroke patients arriving in the emergency department.

Last year, we launched the Stroke EXPRESS Program, which is providing a faster, better way to diagnose and treat stroke patients.

Here’s how it works: When a patient having a stroke arrives in the emergency department, a “Stroke Alert” notifies an expert, closely-coordinated team of physicians, nurses, radiologists and rehabilitation therapists.

They immediately meet at the patient’s bedside and get to work. A cart with a high-definition camera linked to a computer monitor, speakers and a microphone is positioned next to the patient’s bed.

A stroke neurologist appears on the cart’s screen and begins to interact with the patient and hospital staff to determine if, indeed, this is a stroke.

Each member of the stroke team is responsible for executing tasks in parallel, meticulously and quickly. This collaboration allows us to provide high-quality critical care to our patients faced with a lifethreatening condition.

Our Stroke EXPRESS Program is in use at all Kaiser Permanente hospitals in Northern California.

At a recent international conference on stroke, Kaiser Permanente Northern California neurologist and research scientist Mai Nguyen-Huynh, MD, and Jeff Klingman, MD, the neurologists who pioneered the Stroke EXPRESS program, presented preliminary data on the impact of the program on our patients.

The preliminary results are remarkable.

According to guidelines set by the American Stroke Association, a patient suffering from a stroke caused by disruption of blood flow due to a clot in the brain’s arteries should receive clot-dissolving

Spring 2017

medication within 60 minutes of arriving at the hospital. That medication, known as alteplase or tPA (tissue plasminogen activator), can improve the chance of survival and minimize permanent disability. The sooner a patient receives alteplase, the better their outcome.

Not only is Kaiser Permanente Northern California routinely achieving “door-to-needle” times for alteplase of under 60 minutes; on average, we are administering alteplase treatment in 33 minutes, nearly half of the recommended time.

This appears unmatched by other health care systems anywhere else. The research presented by our neurologists also showed that Kaiser Permanente is implementing the Stroke EXPRESS program in a fair and equitable way. In the period after full implementation there were no disparities in rates of alteplase administration or door-to-needle times due to age, race, gender, or Kaiser Permanente membership.

Because Kaiser Permanente Northern California provides the Stroke EXPRESS program at all of its 21 medical centers in Northern California, the data shows that our system was able to quickly identify those 19 percent of stroke patients who may need additional care and transport them to another hospital that specializes in advanced stroke care, while providing brain-saving alteplase to the vast majority of the patients who need it – in record time.

As the Chief of Neurology at Kaiser Permanente Fresno, which is a certified primary stroke center, I’m proud of our Stroke EXPRESS Program and its impact on our patients. My team of neurologists take care of patients recovering from strokes. We believe our approach is minimizing the long-term complications of stroke.

Dr. Trilok Puniani is the Chief of Neurology and Director of the Stroke Program at Kaiser Permanente Fresno. He’s also the President-Elect of the Fresno-Madera Medical Society.

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The California Medical Association and the Fresno Madera Medical Society

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

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Spring 2017

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ABOUT THE AUTHOR ­ Alan M. Birnbaum, MD, is Board Certified in Adult Neurology and is with Spruce Multispecialty Group. Dr. Birnbaum is currently Medical Director of the Saint Agnes Medical Center Stroke Program and a Board Member of Fresno Madera Medical Society.

Neurology e H h i T l l n O

BY ALAN BIRNBAUM MD

As 2017 develops, physicians need to accept that delivering healthcare extends beyond just seeing patients in the office or the hospital. We must directly engage with national political forces. We need the stamina to deal with processes that generate the rules impacting our professional lives and the welfare of our patients.

I belong to the American Academy of Neurology (AAN). Over the past decade the AAN has developed a program to empower our political prominence. Since 2004, it has forged the ever larger yearly Neurology On The Hill (NOH) legislative advocacy program, as well as developing leaders through its Donald Palatucci Leadership Forum. When last November, immediately after a most curious Presidential campaign, the AAN called for active participants to travel to Washington, DC, I realized that someone should represent the interests of Central California neurologists.

With that, I found myself late February in a ballroom of the Pentagon City Ritz-Carlton, along with another 215 American neurologists, getting a one day course in the issues that the AAN Governmental Relations committee had decided were most critical to our profession, as well as the basics of influencing members of Congress by personal visits. >>

I sat with other California neurologists, some entering NOH for the first time, others returning for the ninth or tenth session.

Fortunately I found myself agreeing with the Academy’s four point program. The AAN advocates passage of the FAST Act, Furthering Access to Stroke Teleneurology, a demonstrated effective tool for rapid response to cerebrovascular disease.

Locally Kaiser-Permanente has developed such a service (see Dr. Puniani’s acrticle on page 14), Community Regional Medical Center has retained one. I see teleneurology as a valuable future adjunct to our current program at St. Agnes.

The AAN wants full funding of the Brain Initiative, to ensure that productive research in basic neuroscience continues, as the basis for emerging effective treatments. Unless our best and brightest consider research as a career path, care remains static, not meeting the challenge of many disorders. Alzheimer’s disease perhaps the most prominent challenge, as our population ages.

The AAN has no complete answer to escalating prescription drug costs, affecting both tradenamed and generic medications alike, but advocates considering a variety of approaches.

Regardless of how wisely we prescribe for our patients, many already cannot their pharmacy bill. Particularly egregious has been profiteering on generic drugs, some such as ACTH per Seymour Diamond, MD, hit by profiteering price hikes from $4 a vial to $28,000!

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Especially the AAN has developed a set of nine interconnected principles to preserve and expand healthcare access, particularly to trained and experienced neurologists, whose seasoned insight can save money…and lives.

With that training in hand, plus my new green paisley bowtie, the signature badge for our 216 neurologists, on February 28 we made visits in larger groups to Senators, and in small groups to Congressmen, matched on a District-related basis. Primarily we met with legislative aides. At the office of Senator Dianne Feinstein, a cardiologist doing a year’s fellowship in public clearly understood our concerns!

In other offices, such as those of Congressmen, we found more education required, as we delivered our Association’s message. Integral to the entire process is not just a fifteen minute visit, but from that, establishing a basis for continuing communication. For myself, that meant the 22nd Congressional District’s Devin Nunes, who faces the difficult conundrum of on one hand working for the Republican Party line, to “repeal and replace” the ACA, the Affordable Care Act, while on the other hand trying to represent the interests of constituents whose dependence on Medi-Cal is as high as any district in the state, perhaps even the nation. These are citizens who if, the American Health Care Act (AHCA), passes in its current form, will be among the 14 million to eventually 24 million citizens the nonpartisan Congressional Budget Office projects will lose coverage. It seems ironic that many wellmeaning Americans who voted for “change” may end up as the victims of AHCA, if it passes in its current form.

Considering what imperfect control we now have over our practices, and the welfare of our patients. I am glad I went at this critical time to Washington, DC. In the future, as a California Governor once said…”I’ll be back!”

Spring 2017

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Spring 2017

CALIFORNIANS WITH

MEDI-CAL FACEHURDLES TO SEE SPECIALISTS THROUGHOUT THE STATE

BY ELIZABETH ZIMA

California’s communities face a severe shortage of physicians, which is expected to get exponentially worse as the population continues to grow and our aging physician workforce moves toward retirement.

Medi-Cal enrollment has surged since 2014, but the percentage of California physicians serving MediCal patients has dropped, a trend that is hampering access to care for enrollees. One in every three Californians (14.3 million) is dependent on Medi-Cal for health care, so this disparity also negatively impacts a patient’s ability to access needed treatment, according to a recent study by the California Health Care Foundation.

There is a fundamental problem with Medi-Cal that is hindering patient access to care, and to specialists in particular – Medi-Cal physician reimbursement is so low that physicians cannot cover the cost of providing care. Currently, California has some of the lowest reimbursement rates for providers ($18 for an office visit), creating an unsustainable disparity between the number of Medi-Cal patients and the physicians who are able to accept them as patients.

“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, MD, a Long Beach clinic family physician and former president of the California Academy of Family Physicians. “We’re really disappointed and concerned with what it’s going to do for patient access.” >>

Spring 2017

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Medi-Cal Hurdles > Seeing Specialists

The volume of poor and uninsured patients that need to see specialists has overwhelmed the health care system in Los Angeles causing appointment delays.

Dr. Dressner says he is extremely frustrated with the problem. “If I have patients that need a rheumatology consultation, it can take two years for them to get an appointment,” he explains. Some of his patients have to travel over 50 miles to see specialists who will take MediCal because none of the specialists in the immediate area will.

Not only are physicians frustrated with the lack of access to care, the patients themselves are frustrated with their treatment. Barbara Appling, a 56-year-old diabetic, was referred to an orthopedist in the Los Angeles area near her home.

“I called the office repeatedly for an appointment. It took four months to get one. Then, when I went to the office,

patients.

Debra Lupeika, MD, a family physician providing care through the Shasta Community Health Center in Redding, says some of the most difficult issues she faces are getting her sickest patients referrals to specialty providers.

The frustration of not being able to refer wears on her – like the time her patient suffered without an appointment.

“She had complicated medical problems, and she was homeless,” Dr. Lupeika says. “She had a cancer on her face that had been partly removed, but it came back. We couldn’t get a biopsy. It is really hard to get our patients into specialists due to insurance issues.”

Lack of access to specialists also plagues San Diego County.

“The challenge that we face is that reimbursement to physicians is the third-lowest in the country. So that limits access to specialty care,” says Patrick Tellez, MD, MPH, a pediatric allergy and immunology specialist and Chief Medical Officer for North County Health Services, which provides I called the office repeatedly for an appointment. health care to a diverse community of IT TOOK FOUR MONTHS to get one. Then, when low-income patients at 13 health centers in North San Diego and Riverside counties.

I went to the office, I was there for 40 minutes “Our mission, as a primary medical, dental waiting to be seen – until the office manager told and behavioral health practice attending to over 65,000 patients annually, is to assure me THEY COULD NOT SEE ME. that our patients are able to access and receive needed primary and specialty care I was there for 40 minutes waiting to be seen – until the that meets the high standards that every one of us expects office manager told me they could not see me.” Appling has when we are the patient,” says Dr. Tellez. “However, when both Medi-Cal and Medicare insurance. The office staff the reimbursement for specialty care is so low, specialists member told her the doctor didn’t take either. can only afford to accept a small percentage of patients that “I’m very frustrated that I cannot see a doctor when I truly need and deserve the care.” need to. People have refused to take Medi-Cal since I got “So, while in an average month we as primary care it,” she said. Due to low Medi-Cal reimbursement rates, providers may make about 2,500 or more referrals physicians who see Medi-Cal patients often do so at a to specialty care, due to affordability, wait times and financial loss to their practices. In order to maintain viable constrained access, less than half are able to be seen. As a practices that can continue to serve their communities, result, this has the long-term adverse impact of increasing physicians who take Medi-Cal often need to limit the the cost of care for everyone. Improving access to number of Medi-Cal patients that can be treated in their specialty care has been shown to help prevent preventable practice. complications of chronic disease, which lowers the longBecause they do not have ready access to physicians, term cost of care… it acts like a rising tide that floats all Medi-Cal patients are more likely to postpone needed care boats.” due to long appointment wait times. They are also twice Of California’s 58 counties, Merced County has the as likely to use emergency room visits to access specialty 43rd worst physician-to-patient-ratio, with just 45.4 care (compared to individuals with private insurance or family physicians per 100,000 residents. That’s far less Medicare). than California’s statewide ratio of 77.3 doctors per In areas where the numbers of specialists are low, 100,000 residents. According to the Merced County 2016 physicians are more likely to report difficulty obtaining Community Health Assessment, the entire county is referrals for Medi-Cal patients than for privately insured considered a health-professional shortage area.

“

”

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CENTRAL VALLEY PHYSICIANS

Spring 2017

Eduardo T. Villarama, MD, family physician and regional medical director of Golden Valley Health Centers in Merced, says he is aware of many instances when patients who needed to see a specialist were turned away. “We have more than 70 percent Medi-Cal patient population, and specialty care providers regularly turn them away or are not able to accommodate the demand because the specialists are not reimbursed appropriately.”

He says a few of his patients, “one with seizure disorder and the other we suspect to have multiple sclerosis,” have had to wait for at least six months to be seen by a specialist in neurology. “I know for a fact that the patients being insured by Medi-Cal played a role in our abilities to get them in sooner.”

Ample research demonstrates that the Medi-Cal system is struggling from chronic underfunding. Last year, the California Medical Association (CMA) co-sponsored the Proposition 56 tobacco tax to raise money to improve access to and quality of medical services for all Californians – especially our most vulnerable communities who rely on Medi-Cal. The language was clear – tobacco tax revenues must be used to increase access to health care by providing improved payments for treatment and services. However, Governor Jerry Brown’s $120 billion budget proposal for the 2017-18 fiscal year takes $1.2 billion of the Prop 56 tobacco tax money to cover existing state budget obligations in Medi-Cal.

Spring 2017

With 14.3 million Californians – and 50 percent of all the state’s children – relying on Medi-Cal programs to provide basic and specialty care for serious diseases, the stakes are high.

The Governor’s proposed budget simply adds more patients to the back of the line and maintains the status quo, which does nothing to help patients gain needed access to doctors and dentists.

“People voted overwhelmingly in support of improving payments for programs and providers to ensure that patients can see a doctor when and where they need one,” says CMA President Ruth Haskins, MD, “We must honor the will of the voters and use the estimated $1.2 billion in new health care revenue for its intended purpose, instead of writing a blank check to the general fund.”

CMA and the California Dental Association are calling on the legislature to uphold the will of Prop 56 voters and use the tobacco tax revenues to increase Medi-Cal patient access to doctors and dentists. Our plan strengthens Medi-Cal and Denti-Cal, which will lead to healthier patients and long-term financial savings to the state.

Serve Medi-Cal patients? Please send your experience and perspective to communications@cmanet.org. CMA wants to highlight the access to care challenges facing you, your patients and community.

CENTRAL VALLEY PHYSICIANS

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CL

DS

F I S IE S A

FOR RENT

POSITIONS AVAILABLE Medical Consultants Needed for Fresno Field Office This is an excellent opportunity to help your community and to obtain valuable experience. The Department of Consumer Affairs, Division of Investigation, Health Quality Investigation Unit is seeking wellqualified individuals to be a Medical Consultant for the Fresno Field Office.

Are you interested in being an integral part of the Medical Board of California enforcement process? Do you have the ability to conduct interviews, exercise sound judgment in reviewing conflicting medical reports and preparing opinions, analyzing problems, and taking appropriate action?

Interested individuals must submit an application for examination.

Visit jobs.ca.gov/JOBSGEN/5CACC.PDF for additional information and instructions.

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CENTRAL VALLEY PHYSICIANS

If you have any questions please contact Herbert Boro, MD, F.A.C.P. with the Health Quality Investigation Unit in Fresno at (559) 447-3045 or by email at herbert.boro@mbc.ca.gov.

Family/ General Practice Physician Needed A multi-disciplinary organization is looking for a FP/GP/DO/Medical Director for our Fresno medical office. Candidates must have an active CA license.

As a member of our team you will enjoy a Monday-Friday workweek, no weekends, late nights, or hospital calls.

Part time and full time available!!

Premium medical office 3500sf with completed tenant improvements.

Maple/Herndon, easy access to Herndon/Rte 41/168. Next to MRI, specialists and Saint Agnes Hospital. $1.55/sq ft negotiable. Call (559) 322-7766 between 3 pm-5 pm.

Medical or Business office space Medical office space, 1331 square and 1319 feet. Many new exterior improvements.

1046 and 1060 E. Shields Ave. Contact Shannon Mar, (559) 999-6165 or smar@guarantee.com.

FOR SUBLEASE

Class A Medical Office Space, approximately 1500 square feet. 1781 East Fir Avenue, Suite 102, available 7/1. Rent: $2250 plus security deposit.

Contact Robert at (559) 800-7476 or administration@cvphysiatry.com

Benefits include 401K, health, dental and vision insurance.

Great-pay, potential to bonus by performance criteria and protocol. 100% employer paid malpractice.

For immediate consideration please submit your CV by email to matt@firsthealthmedical.com or by fax to (559) 435-3462.

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

Spring 2017

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http://www.imq.org/education/caprrc.aspx CENTRAL VALLEY PHYSICIANS

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COMING SOON...

MULTIPLE

MEDICAL SCHOOLS

SUDDENLY THE VALLEY IS A MEDICAL SCHOOL HOT SPOT

BY ERIN M. KENNEDY

Add Manipal to the ever-growing list. Manipal Global Education Services, which owns American University of Antigua​College of Medicine,​is planning to bring a medical school to Fresno. Manipal​has partnerships with nearly 30 American universities​,​and traces its roots to India’s first private medical school. ​Its plan to build ​California Central Valley College of Osteopathic Medicine (CCVCOM)​ in Fresno ​is the fourth of several groups intending to bring medical education closer for C ​ entral ​ Valley students – and, hopefully, increase the number of doctors in a region of California that is high on need for the professionals, but low on numbers.​>>

Spring 2017

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Future Medical Schools > Planned For The Valley

CALIFORNIA HEALTH SCIENCES UNIVERSITY The Assemi family’s California Health Sciences University followed in November, 2016, publicizing preparations for a college of osteopathic medicine. CHSU expects to accept its

Why Fresno? Why now?

“We find this community to be exceedingly friendly” explained Howard Teitelbaum, DO, PhD, chief academic officer for CCVCOM. “We’ve so gratified by the reception “I THINK IT’S ALMOST A CRIME IN THIS COUNTRY been from hospitals and from the WITH THE RESOURCES AND TECHNOLOGY community physicians. They recognize the need for medicine WE HAVE IN MEDICINE THAT WE STILL HAVE here … And California exports UNDERSERVED POPULATIONS.” more medical students than any other state.” first doctor of osteopathic medicine class in the fall of 2019 in “We have urgent needs here for doctors,” agreed Dr. new buildings on the northern edge of downtown Clovis, with Arambula, who grew up in Fresno and worked as an emergency long-term plans for a new campus near Clovis Community medicine specialist at Adventist Medical Center–Selma before Medical Center. CHSU established a private pharmacy school heading to Sacramento in April. in Clovis four years ago and intends up to 10 health-related The Valley is “disproportionately affected” by physicians colleges. shortages, said State Sen. Anthony Cannella (R-Ceres) when In January, Assemblyman Joaquin Arambula (D-Fresno) he introduced SB 841 to speed up the process of establishing a introduced a bill that would allow California State University, medical school at UC Merced. His bill provided $1.85 million Fresno, to offer a doctor of medicine degree. If passed, Fresno in September to expand the SJV PRIME program from eight to State would still need to seek legislative funding for the MD 12 students annually. program.

Need is the big motivating factor for all. Access to healthcare

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Spring 2017

is 31% lower in the San Joaquin Valley than in the rest of California.

California Healthcare Foundation’s oftquoted 2014 study found the San Joaquin Valley fell far short of the recommended number of doctors and especially lacked in doctors reflective of its population. While almost half of the Valley’s population is Latino only 5% of physicians were Latino.

Further exacerbating the shortage was the fact that only 52% of the region’s primary care physicians were accepting new MediCal patients.

The growth in the number of doctors statewide is slightly outpacing population growth, but distribution of that physician workforce varies widely. Fresno County had 63 primary care physicians per 100,000 people and Madera County had 51 per 100,000 compared to the 163 primary care physicians per 100,000 practicing in San Francisco County. And the greater Valley region, stretching from San Joaquin County to Kern County, had even fewer doctors – 48 primary care providers compared to an average of 64 statewide per 100,000 people.

The region – often described as the “Appalachia of the West” – also presents unique health challenges with high rates of poverty and higher rates of diabetes, asthma, obesity, teen pregnancy and premature births than the rest of California. Add to that the fact that 20% of adults do not speak English and a third have not obtained a high school diploma.

“There’s a lot of people realizing there is a real problem here,” said Douglas Wood, DO, PhD, FACOI, chief academic officer and founding dean for CHSU’s College of Osteopathic Medicine. “I think it’s almost a crime in this country with the resources and technology we have in medicine that we still have underserved populations. We would like our graduates to serve and improve the health of those underserved populations.”

Valley’s challenges provide unique opportunities Dr. Teitelbaum elaborated that it’s not just the need for more healthcare access that drew Manipal to consider Fresno.

Spring 2017

DR. HOWARD TEITELBAUM, CCVCOM CHIEF ACADEMIC OFFICER

Previous job: Chair and Professor, Department of Preventive and Community Medicine Lincoln Memorial University DeBusk College of Osteopathic Medicine, Harrogate, Tennessee (2009-2016) Unique qualifications: Dr. Teitelbaum has been teaching or served in education leadership positions since 1969. He was principal investigator for a $500,000 grant-funded Comprehensive Study of Osteopathic Medical Education in the U.S. (2003-2004) sponsored by the American Association of Colleges of Osteopathic Medicine and the American Osteopathic Association. He has published and has special interests in epidemiology and research methodologies, and public health approaches to substance abuse and sexually-transmitted diseases.

Other experience: • Associate Dean, Research and Sponsored Programs and Graduate Studies, Department of Medicine, DeBusk College of Osteopathic Medicine (20072009) • Associate Dean, Graduate Programs, and Professor Department of Internal Medicine, Chief Division of Preventive Medicine Epidemiology and Public Health, New York College of Osteopathic Medicine (2006-2007) Honors: • Northup Award, Educator of the Year, Osteopathic Medical Association, LMU-DCOM, 2011 • Clinical Professor of the Year, DeBusk College of Osteopathic Medicine, 2008, 2009, 2010, 2011 • President for the American Association of Colleges of Osteopathic Medicine. 1996-1998 • Vice President for the American Osteopathic Board of Preventive Medicine, 2009-present Education: • 1986-87 Chief Resident Preventative Medicine, Yale University School of Medicine • 1985 D.O. Michigan State University, East Lansing • 1978 M.P.H. Harvard School of Public Health, Boston, Massachusetts • 1970 Ph.D. Michigan State University, East Lansing - Philosophy and Statistics • 1968 M.A. Michigan State University, East Lansing - Curriculum Development • 1965 B.S. California State Polytechnic College, Pomona, - Mathematics

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CALIFORNIA HEALTH SCIENCES UNIVERSITY SITE PLAN “There are things you have to have before setting up a medical school,” he said and then lists: hospitals and clinics to give students exposure; physicians willing to be mentors; affordable

July 1, 2016 – four months before CHSU – and has been advertising for administrative and faculty positions. The Commission on Osteopathic College Accreditation granted both schools applicant status, the first step in seeking accreditation.

“WE REALLY NEED PRIMARY CARE IN Manipal has deep pockets and experience THIS COUNTRY. NINETY PERCENT OF creating medical schools. Besides Dr. Teitelbaum, MEDICINE IS PRACTICED IN AMBULATORY who has 46 years of medical teaching and curriculum development experience, Manipal CARE SETTINGS THESE DAYS.” sent its senior vice president of Finance and Institutional Development for Manipal Education housing for students and to attract physician faculty; city Americas, Vikram Kaul, to Fresno to set up CCVCOM. Dr. government support; and “a community that prizes education.”

Teitelbaum said he’s hopeful the first students will walk through Fresno offers all of these, Dr. Teitelbaum asserted. “Plus Fresno CCVCOM’s doors in 2018, but said 2019 is more probable. is the fifth largest city in California.”

CHSU is also looking at fall 2019 to welcome DO students CCVCOM’s already gotten a nod of support from Fresno to its permanent campus on 60 acres on the west side of Mayor Lee Brand. The mayor sees it not only as a way to Temperance Avenue just north of Highway 168 in Clovis. increase the supply of physicians, but also to bring more jobs Brothers Farid and Darius Assemi told the Fresno Bee they are to Fresno – an estimated 100-400 jobs and $45-$50 million in working with an out-of-town investor to help fund the startup of annual economic benefit to the region. the osteopathic medical school.

CCVCOM has expressed interest in a downtown Fresno site CHSU’s chief academic officer just finished helping set up but hasn’t settled on any property. The school, which has yet a DO school in Arizona. Dr. Howard said he would like to to make a big public announcement, applied for accreditation replicate the success he had there with creating small group

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Spring 2017

learning that’s discussion based rather than having students sit through lectures.

And the school, like CCVCOM, will be working with community health centers and emphasizing primary care clinical experiences. They’ve already gotten support from Adventist Health, Community Medical Centers and Nathan Magsig last year when he was Clovis mayor. He is now a Fresno County supervisor.

“We really need primary care in this country. Ninety percent of medicine is practiced in ambulatory care settings these days,” said Dr. Howard. Osteopathic medicine emphasizes preventative medicine. “And I’m convinced that healthcare is better delivered in teams.”

CHSU’s campus in Clovis will be set up to foster that collaborative learning between health professions.

Both DO efforts will be concentrating on attracting students with Valley ties that they hope will bring them back to the Valley to practice after their residencies. CHSU will also be looking to local doctors to fill its faculty ranks. “This is the fourth medical school I’ve worked in and there has been no problem in recruiting faculty. I expect it will be the same here,” said Dr. Howard. “Our thought is we would also have physicians who would continue to practice, but come in one afternoon a week to interact with our students.”

Healthcare needs great enough to require multiple schools If successful, the Fresno-Clovis schools would double the number of osteopathic medical colleges in California. Currently there are two DO colleges, one in Vallejo and one in Pomona.

Neither felt they were in competition or that the close proximity would be a hindrance to filling their classrooms. “We feel the more the better, because there’s such a need here,” said Dr. Howard.

It was the overwhelming need to increase access to healthcare that Arambula said led him to leave his medical practice in Selma and run for state office. “As we’ve seen expansion of healthcare insurance coverage

Spring 2017

DR. DOUGLAS WOOD,

CHSU CHIEF ACADEMIC OFFICER Previous job: Vice President for Health Affairs and Dean (2012 - 2016) University of New England College of Osteopathic Medicine Unique qualifications: Dr. Wood has an intense interest in creating better ways to train physicians. He did his dissertation for his 1986 PhD in Educational Evaluation and Research in Medical Education on An Empirical Study of the Effects of Differences in Teaching Methods on Knowledge Acquisition and Attitudes Toward Medical Rounds. He was also principal investigator for an inter-professional education project, From Campus Curriculum to Rural Community Health Centers: A Statewide Model of Osteopathic Inter-Professional Education, funded by the Josiah Macy, Jr. Foundation. And he headed a $7.1 million five-year demonstration project involving 18 allopathic medical schools for the Health Resources and Services Administration.

Other experience: • Founding Dean of A.T. Still University School of Osteopathic Medicine in Mesa, Arizona, and later Senior Vice President of Academic Affairs, Provost (2005-2012) • Osteopathic Medical Education Advisor (2000-2003) National Center for Complementary and Alternative Medicine of the National Institutes of Health, Bethesda, Maryland Honors: • American Osteopathic Association’s “Great Pioneer in Osteopathic Medicine” (2011) • Walter F Patenge Medal for Public Service from Michigan State University’s College of Osteopathic Medicine (2011) • Riland Medal for Public Service from New York Institute of Technology’s New York College of Osteopathic Medicine (2008) • President for the American Association of Colleges of Osteopathic Medicine from 1995-2005.

Education: • 1986 PhD Wayne State University, Detroit - Education Evaluation & Research in Medical Education • 1973-74 Fellowship in Nephrology, Henry Ford Hospital, Detroit • 1967-70 Residency in Internal Medicine, Mount Clemens General Hospital, Mount Clemens, Michigan • 1966 D.O. Kansas City College of Osteopathic Medicine, Kansas City, Missouri • 1961 B.S. University of Michigan, Ann Arbor - Zoology

CENTRAL VALLEY PHYSICIANS

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411

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ON MEDICAL SCHOOL EFFORTS

Who

What

Where

When

Assemblyman Joaquin Arambula MD (D-Fresno)

Introduced AB207 on Jan. 23 to authorize California State University, Fresno, to offer a doctor of medicine degree.

CSU Fresno

March 2017, assembly committee on higher education will consider whether an amended bill should get a vote. If passed a funding bill would have to follow. It’s anybody’s guess when (or if) the first students would be admitted.

Manipal Global Education Services, got its start as India’s first private medical school, owns American University of Antigua medical school and has medical schools in Malaysia, Nepal and India.

California Central Valley College of Osteopathic Medicine (CCVCOM)

Downtown Fresno – no firm site yet

July 1, 2016, applied for accreditation. Could have students as early as fall 2018.

Assemi family, primarily known for building homes under the name of Granville Homes

California Health Science University (CHSU) College of Osteopathic Medicine.

CHSU started a Pharmacy school 4 years ago.

New Clovis campus being built on 60 acres on the west side of Temperance Ave. just north of Hwy. 168

Nov. 23, 2016, applied for accreditation. Could have students as early as fall 2019.

State Sen. Anthony Cannella (R-Ceres) and co-authors Assemblyman Adam Gray (D-Merced) & Sen. Cathleen Galgiani (D-Stockton)

SB 841 which resulted in $1.85 million in September to expand the SVJ PRIME program.

The collaboration with UC Davis, UC Merced and UCSF Fresno places students in their 3rd & 4th year of medical school under the supervision of doctors in Valley hospitals and clinics.

UC Davis for the first 2 years of classes and then clinics in Merced, Madera and Fresno counties and with UCSF Fresno faculty at Community Regional Medical Center

Next year’s class will increase from 8 to 12 students. SJV PRIME partner campuses have committed through June 2019.

CENTRAL VALLEY PHYSICIANS

Currently recruiting faculty at: http://chsu.org/com/

Spring 2017

we have not seen the expansion of doctors to take care of school here. It would also take legislative funding and that may those patients,” said Arambula. “I knew I had to come to be even a bigger hurdle.

Sacramento to bring something back home to improve that.”

He and Castro said they are open collaborating with the Arambula’s father, Juan Arambula who represented the UC system to offer joint degrees if it achieves the same goal same Assembly district from 2004 to 2010, started the effort faster. “There are so many assets already in place at Fresno to bring a medical school to the Valley a decade ago with a State with the masters in Public Health and Social Work that study done in conjunction with Community Medical Centers. can feed into the foundational aspects of a medical school and Then healthcare leaders were looking to the University of then there’s lots of health aspects we already have in place with California system.

Community Medical Centers and UCSF Fresno’s residency “It was frustration from having conversation with the UCs program,” said Castro. during a forum in Fresno that led me to propose this bill,” the Whatever the method, Arambula is focused on creating a younger Arambula said of AB 207, which would authorize physician pipeline back to the Valley. “When students have to Fresno State to offer a doctorate in medicine. “The UCs were go away to medical school, they are less inclined to come back talking about looking at 2020 and extending medical schools to the Valley. If I can create a guiding path to medical school to another 10,000 students. I think we needed a medical here in the Valley from our local institutions we may be able to school yesterday.” encourage more to stay.”

Arambula said there’s a precedent already set with Fresno Castro said for many students even considering medical State now offering doctorates in nursing practice, physical school may be out of the question when it’s far from family therapy and more recently audiology. Those came about support and includes the added cost of housing in expensive because the state legislature saw great needs and shortages in urban areas. “We have so many place-bound students in the those health professions in the Valley. A similar situation exists Central Valley,” he explained. “Even though they have the for physicians, Arambula argues. intellectual capacity and the grades they don’t have the ability Fresno State President Joseph Castro said he supports what Arambula is trying to do. “I think there’s widespread agreement Assisted Living • Memory Care throughout the Valley that the time is now here to have a public medical school.

This is the largest region in California without access to a publicly funded medical school,” he said. “I really think it’s an equity issue that we don’t have a medical school in the Valley. The Inland Empire has a medical school.”

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Future Medical Schools > Planned For The Valley

to leave. It’s not like they can be in San Francisco or Davis even.”

Because it takes so long, all the medical school efforts should be running in parallel, asserted Arambula. “There’s a significant risk that these (private) institutions don’t get up and running,” he said. They still need to get accredited, they may have to cap the number of students they take and there’s a bigger challenge in costs – both in setting up a medical college and in making it affordable for poor student from the Valley, Arambula explained.

“They claim to be able to provide the medical education at the same costs as the public universities. I’ve not seen that to be true,” Arambula said, citing recent reports of private schools costs of $50,000 or more. “We have the highest areas of concentrated poverty in California in the Valley. I’m struggling to see how burdening our students with more costs is the answer.”

Dr. Teitelbaum agreed, “Medical education is expensive.”

But he believes it’s up to medical colleges to help their students find funding, whether through community scholarships, the military or in promises from local practices to pay off those medical school debts in return for so many years giving back in underserved communities.

Dr. Teitelbaum said CCVCOM wants this to truly be a

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CENTRAL VALLEY PHYSICIANS

place for Valley students. “One of things we’d like to do is make a dent in improving the health status of this community.

We’ll be about compassion, diversity, equity and excellence … We want the community to think of it as their medical school.”

Residency positions key to getting doctors to stay here While UC Merced and UCSF officials applaud the efforts to increase the pipeline to more physicians in the region they assert that creating more medical schools doesn’t completely solve the problem.

“While a medical school offers many advantages for a region, a host of related issues must be considered and addressed. Any growth in medical school enrollment must be tied to an increase in residency positions if the goal is to increase doctors in the region,” said Michael W. Peterson, MD, associate dean at UCSF Fresno Medical Education Program.

Currently those residency programs are capped by federal funding formulas that don’t take into account the specific shortages in a region rather than physician supplies statewide.

Community Medical Centers contributes a significant portion of its community benefit funds to help pay for UCSF Fresno’s training at its hospitals.

“The most important predictor of where physicians will

Spring 2017

ultimately practice is where they complete their training,” Dr. Peterson added. “Our goal is on continued expansion of medical education in the region that best utilizes existing resources, is in line with our health care workforce needs and draws students from the Valley who want to stay in the Valley to provide care.”

Since 2011, 50% of all UCSF Fresno’s residents and fellows have stayed after their training to set up practices locally.

Annually, UCSF Fresno trains approximately 250 medical residents in eight specialties, 10 oral and maxillofacial surgery dental residents, 50 medical fellows in 17 subspecialties, and approximately 300 medical students on a rotating basis.

“It is important to point out that any increase in medical student enrollment must be accompanied by increases in residency positions in order to retain physicians in the region,” agreed Thomas W. Peterson, PhD, provost and executive vice chancellor at UC Merced. “If doctors leave to complete their training elsewhere, they are less likely to return.”

Thomas Peterson said to “expediently and cost effectively address the physician shortage” here, UC Merced will continue focusing on training opportunities in the Valley with SJV PRIME. The SVJ Prime program currently has 30 students and has graduated two classes, with a total of eight students currently

Spring 2017

training in residency programs. “Over three-quarters of our students come from backgrounds underrepresented in medicine. Most come from socioeconomically disadvantaged backgrounds in the Central Valley,” said Kenny Banh, MD, assistant dean for undergraduate medical education and student services at UCSF Fresno. “Our hope is that they will stay in the Valley.”

In the 2014-15 state budget, the California legislature approved $1 million for a study on improving health care access in the Valley, including study of creation of a medical school. Findings of the study are expected to be released by summer.

While an eventual medical school at UC Merced is still the hope, Thomas Peterson noted, “Establishing a high-quality, University of California medical education program requires significant infrastructure and tremendous resources, and is subject to an external approval process.”

Fresno State’s Castro agreed “It does take a change in the law and significant investment in funding” to bring a medical school to the Valley. “But I think it could be something really special and powerful,” he added.

CENTRAL VALLEY PHYSICIANS

37

By Malissa Rose Central Valley physicians are not just telling their patients to exercise – they’re doing it with them. Once a month, local physicians and clinicians from all specialties participate in the Walk with a Doc program sponsored by

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CENTRAL VALLEY PHYSICIANS

the Fresno Madera Medical Society, Alliance Health and the San Joaquin River Parkway and Conservation Trust, Inc. The free walks are held at the Trust’s River Center in Fresno and at the Lions Town & Country Park Pavilion in Madera.

The Walk with a Doc program gives community

Spring 2017

BY MALISSAROSE

Central Valley physicians are not just telling their patients to exercise – they’re doing it with them.

Once a month, local physicians and clinicians from all specialties participate in the Walk with a Doc program sponsored by the Fresno Madera Medical Society, Alliance Health and the San Joaquin River Parkway and Conservation Trust, Inc. The free walks are held at the Trust’s River Center in Fresno and at the Lions Town & Country Park Pavilion in Madera.

The Walk with a Doc program gives community members the chance to walk with a doctor and ask any health and wellness questions they may have, all while getting the health benefits that come along with it.

It is said that walking for as little as 30 minutes a day can reduce the risk of coronary heart disease, improve blood pressure and blood sugar levels, elevate moods and reduce the risk of osteoporosis, cancer and diabetes.

Walk with a Doc is a national organization with a mission to encourage physical activity and reverse the consequences of a sedentary lifestyle to improve overall health and wellbeing. >>

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FRESNO Held at 8:30 a.m. every third Saturday of the month San Joaquin River Parkway and Conservation Trust, Inc. 11605 Old Friant Road Fresno, CA 93730

MADERA Held at 8:30 a.m. the first Saturday of the month Lions Town & Country Park Pavilion 2300 Howard Road Madera, CA 93637

(559) 224-4224 FMMS.ORG San Joaquin River Parkway and Conservation Trust, Inc. The River Center is free to the public and open seven days a week. There are clean restrooms, ample parking and water fountains.

Weekdays: 8 a.m.-5 p.m.

Weekends: 8 a.m.-3 p.m.

(559) 248-8480 Riverparkway.org

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As the Fresno Madera Medical Society President at the time, Orthopedic Surgeon Sergio D. Ilic, MD, brought the program to the Central Valley in 2012. One year later, Cardiologist Ranjit S. Rajpal, MD, expanded the program in Madera.

“I feel that the more we share medical knowledge, the better,” Dr. Ilic says. “Walk with a Doc is a venue where people don’t feel intimidated to ask questions. They have the doctor’s full attention for 60 to 90 minutes at a time while exercising. They meet new people, share their experiences and we walk together.”

Dr. Ilic says it’s also a chance for physicians to teach people about the latest health trends that may need further clarification.

He appreciates that he can offer scientific facts that support why it is important to exercise and why walking is an ideal method.

"We become like a family when we walk with people rather than talk in the office,” Dr. Rajpal says. “As a physician, you're

Spring 2017

“Walk with a Doc is a venue where people don’t feel intimidated to ask questions. They have the doctor’s full attention for 60 to 90 minutes at a time while exercising. They meet new people, share their experiences and we walk together.”

demonstrating that you're concerned with their health and you mean it."

In the 36 years he's cared for patients, Dr. Rajpal says he's witnessed a lack of motivation and an increase in sedentary lifestyles, but the Walk with a Doc program excites people.

"A number of my patients have been motivated to show up on the walks and have made changes to their lifestyle," he says.

"They are excited and have asked me when the next walk is."

In addition to providing vital health information, Dr.

Spring 2017

Rajpal says the walks provide an opportunity for community members to ask physicians and other medical professionals about current public health issues or bills that require a public vote.

"The walks help us connect with our community," he says.

"These are people who become our spokespeople and help share the message with others."

During the walks, typical questions asked to Dr. Rajpal regard the benefits of walking for heart disease, or questions

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about heart failure, heart attacks or diabetes. He says there are also a number of orthopedic questions and A-fib is a hot topic. He makes it a point to discuss other benefits of walking, like how it can help with depression and chronic pain.

Dr. Ilic recalls one walk during the spring when participants were frequently sneezing. Luckily, an allergist was available that day and provided helpful information.

"This opportunity is free access to a variety of doctors that will answer any questions, even if they are not pertinent to exercising and working out," Dr. Ilic says.

In fact, he says the most questions asked during a walk were directed towards an OB/GYN. About 20 people attend the Fresno walks each time, on average, but it is hoped that more people can participate.

As a Board of Trustees member for the California Medical Association’s Sixth District, Dr. Rajpal is working to offer Walk with a Doc in other counties.

Maria Fermoile, PT, DPT, OCS, and business partner Chris Telesmanic, PT, DPT, OCS, regularly participate in the walks to offer physical therapy-related advice.

"The mantra in our office is 'movement in medicine'," she says. "We believe that everybody needs to move and that through movement, you're going to feel better on multiple levels – your joints feel better and your whole body feels better. Walking not only helps our cardiovascular systems, but there are psychological benefits as well. We want to help lead our community to being healthier."

Fermoile chose to volunteer for the program three years ago when she came across the Trust's Walk with a Doc Facebook post.

"I thought, wow, what a great program!" she says. "It's a great combination of getting out in nature, walking,

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being active, and having the opportunity to ask doctors questions."

Fermoile recalls a time when a local professor required students to participate in Walk with a Doc as a class assignment. She was delighted to see over 50 students attend and says anatomy and physiology came alive as they walked and educated students!

“We feel the San Joaquin River Parkway is an essential tool for public health,” says Finn Telles, director of Business Development for the Trust. “Partnering with the Fresno Madera Medical Society for Walk with a Doc directly aligns with one of our mission goals to provide our community with recreational opportunities. The Trust is an attractive setting with paved trails and public access areas that help engage activities to benefit physical, mental, community and environmental health and wellness.”

Many of the walks take place on the Lewis S. Eaton Trail.

The trail is a multimodal pathway at the heart of the San Joaquin River Parkway that connects to Woodward Park.

This pathway allows for flat walking on a paved surface with gradual inclines and declines. Walkers can enjoy expansive views of the river bottom, bluffs and nature.

Walkers usually cover about one to two miles of trail during a one and a half hour session. Depending on the group’s abilities, some walks are led on the unpaved nature trails to give guests an even closer look at the wild flora and fauna that the San Joaquin River ecosystem provides.

“We hope that by building partnerships with local health organizations to increase the awareness of the health benefits of the Trust will ultimately increase the quality of life and health of our community,” Telles says.

“In addition to Walk with a Doc, we offer a number of opportunities for our community to get outside – including guided nature walks, canoe and kayak tours with professional guides, and educational programs and camps for kids. To include Walk with a Doc as one of the programs we offer makes sense and hopefully more doctors in Fresno will prescribe their patients to get outside and walk – the Trust is a great place to do so!”

Spring 2017

Walk with a Doc Take a Step Towards Better Health Walk with a Doc is a FREE walking program for anyone who is interested in taking steps to improve their heart health.

Each walk is hosted by a friendly, local physician. In addition to numerous health benefits received just by walking, you will also get the chance to talk with a doc.

FRESNO

2016 SCHEDULE

Where: San Joaquin River Parkway & Trust 11605 Old Friant Rd Fresno, CA 93730 When: 3rd Saturday Time: 8:30 am Dates for Fresno February 20 March 19 April 16 May 21 June 18 July 16 August 20 September 17 October 15 November 19 December 17 Spring 2017

MADERA Where: Lions Town & Country Park- Pavilion 2300 Howard Rd Madera, CA 93637 When: 1st Saturday Time: 8:30 am Dates for Madera February 6 March 5 April 2 May 7 June 4 July 2 August 6 September 3 October 1 November 5 December 3

Join us for Walk with a Doc

For more information or questions, please call (559) 224-4224 or visitPHYSICIANS www.fmms.org.

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Fresno Madera Medical Society Alliance

Who We Are and What We Do!

BY VIVIAN PAZ, PRESIDENT, FRESNO-MADERA MEDICAL SOCIETY ALLIANCE

When I moved back to Fresno County with my physician husband a few years ago, I did not know many acquaintances who had experiences like mine – moving all over the country to new cities for my spouse’s medical training or occupying myself and our children while he was attending to patients’ needs. Our Vice President, Mandy Silveira, also struggled with not being connected to other physician families when her husband returned home to the Central Valley after finishing residency. Thankfully, Nicole Butler and her staff from the Fresno Madera Medical Society reached out to us to let us know about the Fresno Madera Medical Society Alliance (“Alliance”), which is an organization comprised of spouses and other members of the medical family who get together periodically to socialize, network, provide health education, and engage in philanthropic endeavors that support the work of the Fresno Madera Medical Society Foundation. >>

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Spring 2017

To give a little background, the Alliance was established in 1935 – 52 years after the formation of the Fresno-Madera Medical Society in 1883. The Alliance was female-dominated when it began – it was even called the “Women’s Auxiliary.”

Today we are a non-profit organization diverse in age, gender, race, ethnicity, and religion. We have members who are senior citizens, young professionals, working parents, stay-at-home moms, as well as men whose wives are practicing physicians or medical residents. Despite our differences, our similar experiences and our commitment to support our spouses and our community bond us.

This year the Alliance is making a concerted effort to recruit more members to our organization. As a busy working mom (I have a 10 month old and three-year old and I manage my husband’s dermatology practice) I know that some may be wary about joining another organization and over-committing themselves. Our organization is designed to serve as an outlet to some of the stresses the medical family may endure - not to add more work and stress. We strive to be a resource for the medical family at every stage of the journey, beginning with reaching out to medical residents and their families when they move into the area to make sure they are aware of what our community has to offer. We connect new physicians and their families to established physician families to foster friendships and professional relationships. We create a welcoming space for spouses of retired physicians and widows of physicians to keep them engaged in our medical community, and for many of us – to listen in their wisdom of how to manage a family while our spouses are busy helping patients and complying with all the complexities of managed health care, insurance, and government regulations.

We create this supportive environment by periodically gathering for social events and community service projects.

Every few months, we organize an afternoon luncheon at a member’s home where members can socialize, network, and foster friendships. Several of us with young children and grandchildren also get together for play dates and other fun activities. Once or twice a year we participate in a community service event. For example, last November several members prepared a home-cooked meal for families staying at the Ronald McDonald House at Children’s Hospital in Madera. The meal fostered teamwork and friendships among our members and provided some comfort to families who were under tremendous stress as their children underwent medical treatment for serious health conditions. In previous years the Alliance has produced and disseminated print materials about stroke awareness and we have also worked on projects that provide awareness to minimize teenage pregnancies in Fresno and Madera counties.

The Alliance is also committed to supporting the Fresno Madera Medical Society and its efforts to retain and attract

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Regular membership $110/annually for spouses, domestic partners

Sustaining Membership $95/annually for spouses or domestic partners of a retired or deceased physician

Medical Resident Spouse / Medical Student Spouse $20/annually

Checkbook Members $110 For those whose time is extremely limited, but want to support the Alliance programs by paying their dues

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fMMSA > Who They Are and What They Do

physicians to live and work in our community. Last year we co-hosted a Latin Jazz networking reception at Arte Americas, a cultural arts center in downtown Fresno. We had over 100 attendees including residents, practicing physicians and retired physicians and their spouses. We also help the medical society coordinate the silent auction for the annual installation dinner in November. The proceeds of the silent auction go directly to the Fresno Madera Medical Society Foundation to support scholarships for local students pursuing medical degrees.

In the coming months we have several events lined up, including: an Easter Egg Hunt on April 10th, a spring potluck, a RIDE54 Cause group cycling session, a family picnic in cosponsorship with the FMMS, a Greek food cooking workshop

by Marie Antoniou, one of our talented members, a costume party for children in October, another service event at the Ronald McDonald House in November, and a Christmas luncheon in December. We do hold monthly board meetings at the Fresno Madera Medical Society conference room each month, but the meetings are optional to general members so there is very little time commitment.

Hopefully I have convinced you that the Alliance is worth time and investment. For those physicians who are reading this article, please share it with your spouse or domestic partner. If they are interested, we have a few membership categories they can consider: •R egular membership - $110 annually for spouses, domestic partners; • S ustaining Membership - $95 annually for spouses or domestic partners of a retired or deceased physician; •M edical Resident Spouse / Medical Student Spouse - $20 annually; and •C heckbook Members – For those whose time is extremely limited, but want to support the Alliance programs by paying their dues - $110 All dues paid for Alliance membership also automatically provide memberships to the California Medical Society Association Alliance and the American Medical Association Alliance. Both organizations do a nice job of providing additional print and online resources for medical families. You can go online to our website at http://www.fmmsalliance.org/ home.html to download an application and mail in your check, or you can contact me at Vivian@pazderm.com or our Vice President, INC. Mandy Silveira at A REGISTRY & PLACEMENT FIRM mandymsilveira@gmail. com and we will email you a link to pay your dues online. Once you are registered, you will Nurse Practitioners ~ Physician Assistants be added to our listserve and we will inform you about the details of upcoming events and activities. You can also follow us on Facebook at @FMMSAlliance.

Mandy does a great job of posting events and photos to keep our Locum Tenens ~ Permanent Placement members informed of events.

Voice: 800-919-9141 or 805-641-9141 I hope you or your spouse will consider FAX: 805-641-9143 joining the Alliance. I look forward to meeting tzweig@tracyzweig.com you at one of our www.tracyzweig.com upcoming events!

Tracy Zweig Associates Physicians

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Spring 2017

MARRIOTT MARQUIS SAN DIEGO MARINA • MAY 5 - 7, 2017 • SAN DIEGO, CA

With featured speaker

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Spring 2017 VALLEY PHYSICIANS 49 TM THIS ACTIVITY HAS BEEN APPROVED FOR AMA PRACENTRAL CATEGORY 1 CREDITS

Public Health

Update

Ken Bird, MD Public Health Officer • Fresno County Department of Public Health

Legionnaires’ disease (LD) is an emerging infectious disease first discovered following an outbreak of severe pneumonia at the 1976 American Legion Convention in Philadelphia. It has become increasingly common in this country, with a demonstrated 286% increase in

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reported cases per 100,000 population from 2000 to 2014. Eighteen cases of LD were reported to the Fresno County Department of Public Health (FCDPH) in calendar years 2015 and 2016, and four of these were associated with healthcare facilities.

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Over the last several months, there is seldom a week that goes by without a call over the Centers for Disease Control and Prevention’s (CDC) national epidemiological network for cases of LD that may be related to specific venues (usually hotels or healthcare facilities).

The CDC attributes these increases in LD to an older U.S. population, increased numbers of at-risk individuals, aging plumbing infrastructure, and increased recognition of, and testing for, the disease. However, there are those who mention climate change as a contributing factor also.

Legionnaires’ disease is a severe form of pneumonia caused by any one of several species of bacteria known as Legionella when water contaminated with the bacteria is aerosolized and inhaled or, less commonly, aspirated.

Legionnaires’ disease begins as many other community or hospital acquired pneumonias do, with cough, fever, and shortness of breath. It can also cause headache, neurological symptoms and gastrointestinal symptoms. Symptoms begin 2-10 days after exposure. The illness has a 10% fatality rate and is not transmitted from person to person. Less commonly, the organism can cause a mild flu-like illness that resolves in 2-5 days, and is known as Pontiac Fever.

Individuals at highest risk for infection and death include those with renal or hepatic failure, diabetes, chronic lung disease, smoking history, immune disorders, and age 50 or above.

Legionella species are ubiquitous in nature, especially in aquatic environments, and can survive in extremely varied water conditions, including treated water systems. Proliferation of the bacteria is dependent upon symbiotic relationships with other microbes, especially those found in biofilms, making relatively stagnant areas within complex water systems of some facilities subject to colonization.

While infection with LD is commonly connected to

facilities with these complex water systems, many have no such connection, and may be from exposures at locations closer to and including, the home. Fixtures such as shower heads, faucet aerators, humidifiers, nebulizers, whirlpool baths, hot tubs, misters (including those found in the produce sections of food stores), and decorative fountains have all been implicated.

When a case of LD is reported to FCDPH a communicable disease specialist is assigned to obtain information regarding possible exposure while travelling or while an inpatient or outpatient at any healthcare facility. While these travelassociated and healthcare-associated cases of LD are becoming more common, even more frequent are sporadic cases which cannot be associated with travel venues or healthcare facilities, and must be assumed to have been contracted in or near the home.

If a healthcare facility is implicated as a source to Legionella infection, FCDPH communicable disease and environmental health staff work closely with the involved facility, the California Department of Public Health’s Healthcare Associated Infections Branch and the California Department of Public Health’s Licensing and Certification Branch to isolate the possible source(s) of the organism. This work involves medical record and laboratory review of patients in whom LD may have been missed, careful consideration of LD in patients subsequently presenting with pneumonia, and a full environmental assessment of the facility for likely sources of the organism. This is followed by appropriate sampling and testing for the organism. Should Legionella bacteria be found in samples of water or fixtures, facilities are required to implement a plan for remediation which usually involves hyperchlorination or super-heated flushing. Following remediation, retesting is required until the organism is no longer detectable. A schedule of periodic follow up samplings and testing is then prescribed for a period of time.

During this investigation strict control measures are implemented to prevent further infection. These include:

• Ensuring that sterile water is used in all respiratory devices and procedures

• Avoiding the use of ice from facility ice machines • Avoiding the use of facility tap water for drinking • Avoiding patient showers unless point of use filters are in place • Shutting down spas, cooling towers, misters, and decorative fountains Because there are healthcare facilities in Fresno County that have been implicated as sources of infection of LD, and because sporadic cases seem to be on the rise, local providers were notified on October 19, 2016 to have a high suspicion for the infection, and healthcare facilities were subsequently advised to develop water management programs.

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Spring 2017

In Memoriam

In Memoriam Joan Louise Voris

Joan Louise Voris August 5, 1941 – February 11, 2017

Joan Louise Voris, age 75, passed away on Saturday, February 11, 2017, at Community Regional Medical Center in Fresno, CA. She was born on August 5, 1941, in Brooklyn, NY, to Albert T. Voris, MD, and Gay L. Voris. Upon completion of Albert’s residency in psychiatry in New York state, the family settled in Belmont, CA. Joan graduated from Carlmont High School in 1959. Like her father, she attended Stanford University where she earned an Artium Baccalaureusin Biological Sciences in 1963, graduating Phi Beta Kappa. Her time as an undergraduate was marked by overseas study in Florence, Italy, an experience she recalled fondly. She continued at Stanford to earn her Medical Degree in 1968.

While finishing medical school, Joan met her husband, Zrino Bezmalinovic, a young pathologist. Twin daughters arrived in 1967. The family initially settled in San Francisco, CA, while Zrino completed his medical training. Their son was born in 1970, and in 1971, the family moved to Fresno, CA, where Zrino began his career in the Pathology Department at Valley Medical Center. Although Joan’s attention turned to raising her family, she did not leave medicine behind. As the children grew, Joan covered for local pediatricians. Eventually, she began practicing at the Pediatric Clinic at Valley Medical Center, and at the age of 47, she entered the pediatric residency program at UCSF Fresno, complete with regular 24 hour call in order to complete her certification from the Board of Pediatrics.

Joan joined UCSF Fresno as a faculty member in 1990,

and while continuing to work in the Pediatric Clinic, was part of a team that published seminal work on the diagnosis of childhood sexual abuse that continues to be cited. Her administrative and leadership roles grew, first as Director of the Ambulatory Clinics, and in 2002, as Associate Dean of UCSF Fresno.

When she retired in 2015, she left as the longest serving Associate Dean in Fresno history, having overseen a 70 percent increase in physicians trained at UCSF Fresno and the establishment of many new fellowships. Joan was fortunate to have been recognized for her contributions to the community, in 2010, by the Marjorie Mason Center as one of the Top Ten Professional Women, and in 2012, by the Fresno-Madera Medical Society with the “Physician Community Service Lifetime Achievement Award,” although she was never comfortable with such public expressions.

Her story cannot be told without the mention of cancer.

First diagnosed with Hodgkins Lymphoma in 1981, Joan survived to see her children graduate from high school and beyond. She battled breast cancer in 2002, and was diagnosed with colon cancer in 2012. Although the last years of her life were measured by cycles of chemotherapy, her strength of character never diminished. Her family is forever grateful to the countless physicians, nurses, and staff who treated her with kindness and dignity. She was preceded in death by her husband, Zrino Bezmalinovic, MD She is survived by her children, Beatrice BezmalinovicDhebar and husband Anirudh Dhebar of Wellesley, MA, Margaret Bezmalinovic of Sacramento, CA, and John Bezmalinovic and wife Tracy of Fresno, CA; and grandchildren, Mia Bezmalinovic, Arun Dhebar, and Chetan Dhebar.

She was a member of Fresno Madera Medical Society for 23 years

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In Memoriam

In Memoriam C. Alan Sevener, MD • Stephen Bruny, MD C. Alan Sevener, MD June 16, 1938 – September 23, 2016

Dr. Sevener passed away on Friday, September 23, 2016, with his loved ones at his side. Dr. Sevener was born in Charlotte, MI, on June 16, 1938, to Clinton John Sevener, MD, and Arlene Sevener. He attended Loma Linda School of Medicine and served his residency at Glendale Adventist Hospital. Alan also served for two years on the United States Air Force Pilot Training Base in Del Rio, TX. Dr. Sevener established a private practice in Tulare, CA in 1970. In 1988, he joined The Permanente Medical Group, Fresno and retired after 20 years. He is survived by his wife, Gladys Tiwanak Sevener; son, Michael Sevener and wife Teresa; daughter, Angel Sevener Brazil and husband Mike; daughter, Cindi Sevener Reyna and husband Rick; son, Tony Sevener and wife Alison Tharp; brother, Stuart Sevener and wife Bonnie; nine grandchildren; and ten great-grandchildren. He is also remembered and loved by many friends and relatives in Hawaii.

He was a member of Fresno Madera Medical Society for 50 years

Stephen Bruny, MD November 15, 1924 - December 10, 2016

Dr. Stephen Bruny, of Fresno, CA, passed away peacefully on Saturday morning, December 10, 2016, at his home surrounded by love, faith and family. Stephen was born on November 15, 1924, in Pioria, IL. After serving in the United States Navy, he attended and graduated from Vanderbilt University Medical School. Dr. Bruny retired in 2015, after 65 years practicing medicine as a radiologist, something that brought much joy to his life.

He is survived by his true love of 56 years, Carol Bruny; along with six children; and eight grandchildren.

He was a member of Fresno Madera Medical Society for 58 years

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Spring 2017

In Memoriam

In Memoriam

Gordon J. Harmston, MD • Cristin Vorobchevici, MD Gordon J. Harmston, MD January 28, 1921 – June 1, 2016

Born on January 28, 1921, in Provo, UT, Dr. Gordon J. Harmston passed away peacefully on Wednesday, June 1, 2016, at the age of 95. He was the son of Marion “Max” Eugene Harmston and Ora Addie Johnson Harmston. Dr. Harmston received his medical degree from the University of Utah in Salt Lake City, UT in 1945. While serving in the United States Army Medical Corps during World War II, he met and married Betty Schumacher in 1946. They made their home in Logan, UT where he started a general medical and surgical practice. Dr. and Mrs. Harmston had three sons, William, Kent, and Thomas.

After completing his residency in radiology at the University of Utah, Salt Lake County Hospital, the family relocated to Fresno, CA in 1957. Dr. Harmston established a thriving radiology practice and opened five radiology departments throughout San Joaquin Valley hospitals. Tragically, in 1964, his beloved wife Betty passed away unexpectedly. He met and later married Cecile Self in 1966, welcoming her three year old daughter Amy to his family of three sons. After a successful medical career, Dr. Harmston retired in 1978. A self taught professional photographer, he specialized in landscapes and seascapes. Another of his many interests included aviation and became a proficient private pilot flying until age 83. He was known as the “Flying Radiologist” throughout the San Joaquin Valley and was a member of the United Flying Octogenarians (“UFO’s”). Dr. Harmston and his wife Cecile were avid Fresno State Red Wavers traveling to games for years. Known fondly as “Red”, he had more friends than you could count. In 2011, Dr. and Mrs. Harmston made their Morro Bay beach home their permanent residence. Sadly, after a long and courageous battle with cancer, Cecile passed away on November 7, 2013. Dr. Harmston is survived by his three sons, William Harmston, Kent Harmston and wife Betty, and Thomas Harmston and wife Mary; step-daughter, Amy Holliday; and four grandchildren.

He was a member of Fresno Madera Medical Society for 30 years Cristin Vorobchevici, MD* June 17, 1967 – March 11, 2017

*At the time of print, no obituary had been published.

He was a member of Fresno Madera Medical Society for 7 years

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

PRSRT STD. U.S. POSTAGE

PAID

Permit No. 30 Fresno, CA

State of the Heart SAINT AGNES CARDIOLOGY SYMPOSIUM 2016 Saturday, April 23 • 8 a.m.-2 p.m.

Saint Agnes Medical Center, Shehadey Pavilion 1303 East Herndon Avenue • Fresno, California

Almost as close as your bike to that pothole.

This symposium focuses on cardiovascular disease management and emerging paradigms in treating coronary and structural heart disease.

It will address practice gaps in disease management and provide education to improve patient outcomes.

Speakers Paradigms of Revascularization for Chronic Coronary Artery Disease Verghese Mathew, MD, FACC, FSCAI Agnesof Radiology DangerConsultant, and illness all around.

Division are of Cardiovascular Diseases andSaint Department Urgent Care Professor of Medicine, Mayo Clinic College of Medicine

Sometimes you can avoid them, (559) 450-CARE Protected PCI: Treating Complex Coronary Artery Disease in 2016 other times you can’t.

Anthony A. Hilliard, MD Don’t worry.

Assistant Professor of Medicine Director, Adulthas Cardiovascular Lab locations Northwest Saint Agnes Urgent Care now two convenient Loma Linda University International Heart Institute 4770 W. Herndon Ave. to provide the care you need, when you need it.

Fresno 93722

Invasive Management of Intractable Angina • 8 a.m.-7 p.m.

And with extended hours through Gurpreet S. Sandhu MD, PhD the weekend Monday-Friday and Director, no need Dr. forEarl an appointment, Wood Cardiac medical Cath Lab,care Mayo Clinic • 9 a.m.-3 p.m. has never been more convenient.

Saturday-Sunday Transcatheter Mitral Valve Therapies Oluseun O. Alli, MD For more information, call (559) 450-CARE Assistant Professor of Medicine or visit SAMC.com/Urgent-Care University of Alabama at Birmingham School of Medicine Main Campus

Preregistration is required • No charge

1245 E. Herndon Ave. Fresno 93720 • 10 a.m.-6 p.m., Daily

Please register online at www.samc.com. Registration must be received by April 16, 2016, to be guaranteed a participant syllabus. If you have questions or problems registering online, Agnes email medicaleducation@samc.com or Saint call (559) 450-7566. Most insurance plans accepted Urgent Care Registration at the door is dependent on space availability.

TM

5 AMA PRA Category 1 Credits to be awarded