Spring 2020
opioid addiction
MAKING IT E A SIER TO PR EVEN T, R EDUCE AND TR E AT
Shining Light • Dealing With Emotional Turbulence • Doctors Making a Difference II
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Spring 2020
VOLUME 5, NUMBER 1 • SPRING 2020
{FEATURES}
16 26 28 37 48 54 Spring 2020
SHINING LIGHT ON HIDDEN HEALTH ISSUES DEALING WITH EMOTIONAL TURBULENCE OPIOID ADDICTION VALLEY PEOPLE NEED VALLEY BLOOD
{DEPARTMENTS} 6
PRESIDENT’S MESSAGE
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EDITOR’S MESSAGE
10 CHSU UPDATE 49 CLASSIFIEDS
OPPOSE THE “FAIRNESS FOR INJURED PATIENTS ACT” FMMS ANNUAL REPORT
CENTRAL VALLEY PHYSICIANS
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PRESIDENT Alan Birnbaum, MD PRESIDENT-ELECT Don Gaede, MD VICE PRESIDENT/ TREASURER Christina Maser, MD PAST-PRESIDENT Cesar A. Vazquez, MD BOARD OF GOVERNORS Janae Barker, DO, Shamsuddin Khwaja, MD, Katayoon Shahinfar, MD, John Moua, MD, Pamela Kammen, MD, Ravi Rao, MD, Sonia Shah, MD, Marina Roytman, MD, Jesus Rodriguez, MD, Greg Simpson, MD, Brent Kane, MD, Jai Uttam, MD, Jessica Vaughn, DO (Resident Board Member) CMA Trustee; Ranjit Rajpal, MD
GUARDSUP Help FMMS Guard The Front Line With Your Tax Deductible Donation
Spike Customs
Donate at
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CENTRAL VALLEY PHYSICIANS EDITOR Farah Karipineni, MD
CENTRAL VALLEY
Doctors have come together to care for us in this time of crisis and now we have an opportunity to come together to help protect them. The demand for Personal Protective Equipment (PPE) has created a severe shortage worldwide. In an effort to help meet local demand, the Fresno Madera Medical Society is partnering with several local non-profit creative spaces including Fresno Ideaworks, Root Access Hackerspace, and PiShop Fresno in addition to Spike Customs to produce protective face guards for use right here in the Central Valley. These businesses have volunteered their time, their space and their 3D Printers to create this much needed protective gear and we need your help to purchase supplies.
CENTRAL VALLEY PHYSICIANS
MANAGING EDITOR Nicole Butler ASSISTANT EDITOR Don Gaede, MD EDITORIAL COMMITTEE Farah Karipineni, MD - Chair, Chang Na, MD Roydon Steinke, MD, Cesar Vazquez, MD Hemant Dhingra, MD, Nicole Butler, Trilok Puniani, MD Alan Birnbaum, MD, Alya Ahmad, MD FAAP CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Alan Birnbaum, Alya Ahmad, MD FAAP, Malissa Trenholm, Stacy Woods, Erin Kennedy, Nicole Butler, Farah Karipineni, MD, MPH CONTRIBUTING PHOTOGRAPHERS Erin Kennedy, Nicole Butler, Stacy Woods, CHSU Staff CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711 Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler Membership and Events Manager, Stacy Woods
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FMMS Joy of Medicine www.FMMSJoy.org
It’s Ok To Ask For
Help RESILIENCY CONSULTATIONS The Fresno Madera Medical Society recognizes the overwhelming stresses and immense workloads that physicians face today. Stress, anxiety, depression and grief are common, but they can be managed. Resiliency Consulta�ons can provide relief, an increased ability to cope, healing and an opportunity for personal growth. FMMS sponsors up to four (4) annual sessions with approved and ve�ed providers confiden�ally, conveniently and FREE to physicians living and prac�cing in Fresno and Madera Coun�es. Par�cipa�ng in a Joy of Medicine Resiliency Consulta�on is completely confiden�al. Neither FMMS, your employer, nor the California Board of Medicine will be no�fied if you choose to par�cipate. Par�cipa�ng providers offer a wide range of appointment �mes that strive to accommodate the unique and busy schedules of physicians. Providers are paid by FMMS directly, discreetly and anonymously. Insurance will not be asked for or billed. Physicians have the op�on of extending their par�cipa�on at their own expense a�er the fourth visit. It’s OK to ask for help! Call today to schedule a free Resiliency Consulta�on and begin the process of reconnec�ng to your Joy of Medicine.
RECONNECT TO YOUR
Joy of Medicine
SCHEDULE ROUBICEK and THACKER 559-323-8484 2020 AN Spring APPOINTMENT
CENTRAL VALLEY PHYSICIANS 5 County Call and identify yourself as a physician practicing in Fresno or Madera
A message from our Editor > Alan M. Birnbaum, MD
May You Live In Interesting Times As the Ides of March 2020 approach, your Medical Society President accepts that much of what he writes today will be wrong by the time our Spring Central Valley Physician issue reaches you. That aura of error I must accept. Today’s word and this year’s theme is “interesting.” Barely a month ago the major healthcare issue of interest seemed to be resurgence of the very questionable “Medicare for All“ concept, that would teeter the financial balance of our American healthcare system. Such was advocated by those strong in rhetoric but weak in understanding of the final balance sheet. That threat likely has passed, yet with the prospect of useful stepwise system improvement come 2021 still possible.
ABOUT THE AUTHOR Alan M. Birnbaum, MD, is boardcertified 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.
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Instead as the eleventh week of 2020 starts, COVID-19 has seized center stage worldwide. Unlike inf luenzas A and B, with fatality rates of 0.1%, this novel Coronavirus, probably emerging from wild animal sources in China, requires hospitalization often including ventilatory support, for about 15% of those who become ill. Of 100 symptomatically infected, around 3% fail to survive. That has sadly included several Chinese physicians in Wuhan who first recognized the disease. So, illness severity rises to at least ten to perhaps even thirty times that of the usual f lu. Celebrities have reported symptomatic infection. A Brazilian diplomat now diagnosed as Coronavirus positive posed with President Trump and Vice
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President Pence only few days before his diagnosis.
I have had plans to f ly to Toronto in late April for the American Academy of Neurology annual convention. Every Uncertain is the value of currently available antiviral year this week long event attracts thousands in my specialty. medications. Newer antivirals are under active My reservations are all made. A few days ago, however, AAN advised that if necessary, I could cancel at minimal expense up to the day before its start! As I have read a description of the dire well your Medical Society has curtailed scheduled events. situation there from an Italian infectious
disease specialist. The speed of disease impact there was striking.
investigation. Some look towards available albeit expensive medications meant for immunomodulation, on the theory that an overly active immune response is core to the most severe cases of pulmonary gangrene. As I write, Fresno and Madera Counties have just two known cases of COVID-19. Yet by the time you read Spring CVP, that number surely will be higher. Hopefully we will not be ravaged like northern Italy. I have read a description of the dire situation there from an Italian infectious disease specialist. The speed of disease impact there was striking.
The economic impact has been dramatic. Barely 2 months ago, our President took personal credit for stratospheric stock market valuations. Oddly, as the federal response fumbles and stumbles, he defers any responsibility for the fiscal downturns. The sick angry bear chases the healthy bull from his green pasture. Personally, I try not to think what has happened to my accumulated retirement funds, as a message f lashes across my screen of a further 10% equity avalanche. Decades ago, I read an ancient Chinese curse, an aphorism I have since often used:
“May you live in interesting times.” Locally our hospital leaders are quietly making contingency plans which surely will be activated by early April when we publish. My wife reports to me We shall survive these next several interesting that local stores are bare of hand and historic months, but at a cost financial, sanitizer. She read of an alternative, physical, and not the least, emotional. a 2:1 mixture of rubbing alcohol and aloe vera gel, only to find that on local shelves these items are similarly depleted. Masks? Don’t ask! How true, how ironic the source. We shall survive these Events everywhere, of all sorts, educational, athletic and next several interesting and historic months, but at a cost social have been canceled to avoid larger public gatherings financial, physical, and not the least, emotional. given of what WHO rightly terms a pandemic.
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A message from our Editor > Farah Karipineni, MD, MPH
The Age of Wellness In the age of wellness committees and meditation apps, the coronavirus pandemic has made techniques to combat stress more important than ever. As health care providers, we like to prepare, and without data, preparation is challenging. But more than ever, I am assured of the goodness of our community and that we will rise to the challenges, as daunting as they are projected to be. As of this writing, elective surgical activity has almost ceased. We are all doing our part to reduce clinical activity to only what is absolutely necessary. Those of us at the front lines, in the ER’s and in the ICU’s, are working hard to provide care for the sickest. Those of us in elective practice are thinking critically about who needs urgent attention and who can wait, in order to protect our patients, our community, our employees, and ourselves. ABOUT THE AUTHOR Farah Karipineni, MD, MPH, is board certified in General Surgery and fellowship trained in Endocrine Surgery. She is currently practicing in Fresno as an Assistant Clinical Professor for UCSF. Dr. Karipineni earned her medical degree from University of California, Irvine School of Medicine. Her residency in General Surgery was completed at Albert Einstein Medical Center, and she completed her fellowship in Endocrine Surgery at Johns Hopkins School of Medicine. Dr. Karipineni has been published in journals including The American Surgeon, the International Journal of Surgery, and the Journal of Surgical Education.
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In the midst of this pandemic, a recent house fire destroyed the vast majority of my family’s belongings, and we have been displaced from our home for the foreseeable future. This has given me even more cause for reflection. I am reminded how much I take for granted in life—the ample space for my children to roam, the breathtaking but fleeting blooms of my camellia tree, and a place to do laundry whenever I please. Unlike the Rohingya and Syrian refugees, my version of displacement is free of persecution and involves hotel accommodations and a good insurance policy. And that just scratches the surface. So many similar house fires end very differently, with disfigurement or loss of life. Likewise, so many health care workers or loved ones around the world have succumbed to COVID-19. We do not know what the future holds for our community in the eye of this pandemic, but I do know that collectively, we are willing to do whatever possible to protect the vulnerable. So often, I am reminded of the small miracle that occurs every day when we wake up, reach work safely, help patients feel better, and go home healthy and happy to
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our loved ones. So often, despite the grave conditions we treat inspire agreement, while others will spark dissent. It is my goal daily, we forget that we too are susceptible to those conditions. that diverse viewpoints in the magazine are expressed with Life is fragile; every day we are healthy, and every patient we respect for each other’s differences . I also hope we can focus are able to help, is truly a gift worth celebrating. This becomes far more evident when things go wrong, but Life is fragile; every day we are healthy, and at the very least, those moments can serve to remind us how amazing every patient we are able to help, is truly a gift it is that things ever (and actually, worth celebrating. usually) do go well. Along with deep gratitude, I have been reflecting on the purpose of our publication to better serve our members. Central Valley Physicians is a magazine by, for and about physicians practicing in the Valley. Our experiences, expertise, interests, and belief systems are as diverse as those of our readers. Some topics may
on what brings us together—a commitment to the specific challenges, needs and general experience of practicing health care in the Valley.
A more rewarding path is waiting. Join Dignity Health as a Primary Care Physician. We’re hiring for our clinics in Bakersfield and Tehachapi. Learn more at dhmf.org/bakersfield
We’re working to inspire a stronger, healthier world. Join us.
Spring 2020
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PHOTO COURTESY OF CHSU.
BY MALISSA WADE
CHSU Offers Local Valley Students More Opportunities to Pursue Health Care Education Inaugural Class Begins in July 2020 The Valley’s first four-year medical school pushes forward In July 2020, California Health Sciences University (CHSU) will welcome a total of 75 students to serve as the pioneering vanguard of the Valley’s first four-year Doctor of Osteopathic Medicine (DO) program. “The CHSU College of Osteopathic Medicine (COM) was established to help remedy the shortage of health care services offered in the Valley,” says Florence T. Dunn, CHSU President. “This cutting-edge program is designed to train caring, compassionate and competent physicians through utilization of our innovative outpatient and
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inpatient Simulation Center with 3D holographic anatomy technology and active team-based curriculum facilitated by our experienced team of dedicated educators.” The new building for the College of Osteopathic Medicine is located on CHSU’s expanded campus near the Clovis Research and Technology Park, a growing hub for health care facilities with Clovis Community Medical Center, Kaiser Permanente and Valley Children’s Hospital within close proximity. A Ribbon Cutting Ceremony was scheduled for April
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PHOTO COURTESY OF CHSU.
1, however based on guidance received from the California Department of Public Health (CDPH) to protect public health and slow the rate of transmission of COVID-19, the University decided to postpone the event. A new date will be announced. The three-story building includes a fully equipped teaching and demonstration kitchen, an Osteopathic Skills lab, three large classrooms specifically designed for a team-based learning curriculum, multiple study rooms and a student lounge. The facility’s outdoor areas include a courtyard, electric car charging stations, covered parking and views of the Sierra Nevada Mountains. “We are looking forward to welcoming our inaugural class this summer,” says John Graneto, DO, MEd, Dean of the College of Osteopathic Medicine. “ Future graduates from our program will make a tremendous impact in solving the health care provider deficit in our Valley. Our goal is to attract a diverse student body and help them accomplish their goals of training and staying in central California to practice. While it’s not just about graduating doctors in four years, the medical school will have an impact on educating the community, influencing healthy eating, and other medical topics.” The first class of 75 medical students will matriculate in July 2020 with the class size increasing to 150 by 2022. There will eventually be a total of 600 students in the 4-year program at one time. “An inaugural class is the most exciting because they are not only adventurous in spirit and determination, but they recognize the historic impact of what is being started here that will affect the health care of the region for generations to come,” Dr. Graneto says.
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The CHSU COM Program Difference “Our commitment and focus on our mission to improve the health care outcomes of people living in the Central Valley, especially the underserved population, is one of the many distinguishing elements of our college,” President Dunn explains. “With proper nutrition being essential to good health, we’ve included it throughout the curriculum and have also encompassed early service-learning opportunities for students to be embedded in our agriculturally-based community. Medical Spanish is also integrated to ensure graduates meet the needs of our Hispanic/Latino community.” During the first two years, students will learn within a modified two-pass systems-based clinical integrated curricular model. Delivered mostly in a team-based learning (TBL) environment, this delivery model has shown to improve knowledge, retention and performance. “This model integrates realistic patient scenarios with scientific principles, problem solving skills, active learning and clinical practice,” Dr. Graneto says. “Medical knowledge, osteopathic manipulative medicine, clinical skills, nutrition as medicine, and patient-centered care are components of this unique curricular model,” he added. In years three and four, students will gain hands-on experience through their clinical clerkships based at regional hospitals, clinics and health care facilities with qualified local health care providers. Students will rotate through four-to-eightweek clerkships in areas including: family medicine, internal medicine, surgery, pediatrics, behavioral medicine, emergency medicine, and more. “Our students will have the opportunity to train at the nine
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PHOTO COURTESY OF CHSU.
hospital systems in the Central Valley, along with numerous private practices, clinics and Federally-Qualified Health Centers in our region,” Dr. Graneto says. “We are mostly excited to provide each student with a longitudinal early clinical experience beginning in year one.” There are currently over 60 employees at the CHSU College of Osteopathic Medicine, with over 30 full-time and part-time faculty, 16 staff and 13 simulated patients. CHSU will continue to seek additional faculty and staff members as the program progresses.
Keeping it Local “Having a local medical school allows us to retain our best and brightest students to become osteopathic physicians in our community,” President Dunn says. “It’s imperative to have a local medical school to meet the demand for physicians in the Valley. We know that medical students are very likely to stay and practice in the area in which they went to medical school and completed their graduate medical education. We will recruit, train and retain a high percentage, of local and even non-local graduates to serve our community, just as we have already experienced with our Doctor of Pharmacy program.” Many local physicians have and will benefit through involvement in CHSU’s medical education and the training of its medical students. President Dunn says hundreds of local physicians, especially DOs, have already agreed to participate in the medical education and training of CHSU COM students. These physicians also have the opportunity to utilize resources available at the new College of Osteopathic Medicine building. “Students who attend medical school in their hometown,
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especially in our area with a low cost of living, should experience greater affordability and success with a strong support system at home,” President Dunn says. “The community will surely benefit when the deficit of health care providers is eliminated and the medical needs of families in our local area are fulfilled, especially the underserved population.” In addition to its existing Doctor of Pharmacy (PharmD) program established in 2014, the university plans to open up to 8 additional post-baccalaureate colleges to train health care professionals in the coming years. The timing and specific discipline for each new school will be determined based on the need and opportunity for job placement within the region. Further development of the campus will occur in multiple phases as each new health science related college is established. Other buildings being considered in the university’s campus expansion plan include up to nine additional college buildings, a research lab, a student center, a library, and an auditorium, along with support buildings. The campus could ultimately approach 2,000 students and nearly 300 faculty and staff in the future.
About CHSU CHSU is accredited by the WASC Senior College and University Commission (WSCUC). Founded by the Assemi family in 2012, it is the first university of its kind in the Central Valley that offers a local pharmacy and medical school. Students can enjoy the unique combination of high quality of life, affordable cost of living and plentiful health provider career opportunities the Valley provides. The CHSU College of Pharmacy opened in 2014 and
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ean
COP,
Leadership, Facu will graduate its third class of Doctor of Pharmacy students in May 2020. Applications for the Class of 2024 Doctor of Pharmacy program are now being accepted. Starting in May 2020, the CHSU College of Osteopathic Medicine will begin accepting applications for the second cohort of medical students to matriculate in July 2021. The university is guided by its Board of Trustees from varying health care, education and business backgrounds. Long-time educator and community leader, Dr. John D. Welty, President Emeritus of California State University, Fresno, serves as the Board Chair. For more information about CHSU and its pharmacy and medical schools, visit www.chsu.edu, or call (559) 325-3600.
Office of the Dean
John Graneto, DO, MEd, FACOP, FACOEP-dist, FNAOME Dean, Professor, Vice President for Health Affairs
Lisa Chun, DO, MS.MEd, FNAOME, CPE, OHPF
Associate Dean, Osteopathic Clinical Education, Associate Professor
CHSU College of Osteopathic Medicine Office of the Deans: Mahboob Staff Qureshi, Leadership, Faculty and MD, MPH, PhD
John Graneto, DO, MEd, FAAP, FACEP Dean, Professor, Vice President for Health Affairs
Lisa Chun, DO, MS.MEd, FNAOME, CPE, OHPF
Associate Dean, Academic Affairs Professor
Anne VanGarsse, MD, FAAP, CHCEF, CPE
Associate Dean, Clinical Affaris, Community Engagement and Population Health, Associate Professor
Associate Dean, Osteopathic Clinical Education, Associate Professor
Randy Culbertson, DO, MBA
Associate Dean, Graduate Medical Education, Assistant Professor
Susan Ely, PhD
Assistant Dean, Student Affairs and Enrollment, Professor
Mahboob Qureshi, MD, MPH, PhD
Associate Dean, Academic Affairs, Professor
Chun, DO,MD, MS.MEd, AnneLisa VanGarsse, FAAP, CHCEF, FNAOME, CPE, OHPF CPE Associate Dean, Osteopathic
Associate Dean, Clinical Affairs, Community Clinical Education, Associate Professor Engagement and Population Health, Associate Professor
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Randy Culbertson, DO, MBA Cathy Burford Associate Dean, Graduate Medical Receptionist Education, Assistant Professor
Susan Ely, PhD
Assistant Dean, Student Affairs and Enrollment, Professor
Academic Affairs CENTRAL VALLEY PHYSICIANS
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expected to provide the same level of service as a large, multispecialty group. Investigate technological services or sharing resources with other providers. It is not recommended to use a family member as an interpreter. Lay personnel are rarely familiar with medical terminology. Additionally, the patient may not want a family member to access their confidential health information. An adult family member should serve as interpreter if a family member must be used—unless no adult is available, and care must be provided immediately to prevent harm. It is preferable to have a trained clinical staff member provide interpretation; alternately, your practice can use certified interpreter services. Consult your local hospital or the patient’s health plan for a list of qualified interpreters. Other resources include a local nationality society, the Registry of Interpreters for the Deaf, or the local center for the deaf. Also, keep consent forms—especially for invasive procedures—translated into the applicable non-English languages by a certified translator. The Agency for Healthcare Research and Quality (AHRQ ) has prepared a guide, Improving Patient Safety Systems for Patients With Limited English Proficiency, which recommends that practices focus on the following: • Medication use: Understanding medication instructions is complicated for all patients, but even more difficult for LEP patients. Both patients and providers need to communicate accurately about mode of administration, allergies, and side effects. • I nformed consent: Obtaining informed consent remains a hallmark of patient safety and a critical medical and legal responsibility. Achieving truly informed consent for LEP patients may require extra effort, but LEP patients should not be excluded from learning about choices that might affect their health and well-being.
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• Follow-up instructions: Understanding discharge instructions is especially challenging for LEP patients. Speaking Together: National Language Services Network, a project funded by the Robert Wood Johnson Foundation, which created the Speaking Together Toolkit, found the need for greater use of interpreters at key moments of information exchange, such as at assessment and discharge—not just during the acute phase of treatment. Relatively simple communication tools can provide some helpful solutions. These include: • A skMe3™: Rx for Patient Safety: Ask Me 3 • The teach-back method: AHRQ: Use the Teach-Back Method: Tool #5 • The SHARE approach: AHRQ: The SHARE Approach—Using the Teach-Back Technique: A Reference Guide for Health Care Providers • Patient experience surveys: The Doctors Company: Patient Experience Surveys To protect your patients from harm resulting from their LEP, develop and implement a plan for language access in your practice. For more information, see the Centers for Medicare and Medicaid Services’ Guide to Developing a Language Access Plan. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
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Fresno Madera Medical Society
69
TH
ANNUAL
YOSEMITE POSTGRADUATE INSTITUTE Physicians from across the state gathered at the Yosemite Valley Lodge in Yosemite National Park from
February 28-March 1st to participate in the 69th Annual Yosemite Postgraduate Institute. The event offered 17.0 CME and included a wide variety of topics geared toward Primary Care including special workshops on Wilderness Survival Strategies led by Sue Spano, MD, and New Solutions for the Opioid Epidemic led by Rais Vohra, MD. Activities included a fine print viewing at the Ansel Adams Gallery, a Camera Walk with Joseph Hawkins, MD and a dinner presentation on Life/Work Balance by Mike Roubicek, PhD.
In contrast to recent years, attendees arrive to sunshine and dry roads offering excellent opportunities to hike and explore the breathtaking beauty of Yosemite during the first two days of the conference.
Sunshine gave way to clouds and snowfall by late Saturday night and most awoke to a fresh dusting of snow on Sunday morning to cap off another successful Yosemite Conference.
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BY MALISSA WADE
Shining
Light 16
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ON HIDDEN HEALTH ISSUES IN THE CENTRAL VALLEY
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Many Valley physicians are becoming concerned about a growing public health epidemic in Fresno that is widely unknown. It’s dark, secretive and terrifying. Sex and labor trafficking is alive and thriving along Fresno’s Parkway Drive, a frontage road to Highway 99 – and to make matters worse – there’s an entire community of children caught in the middle. “There’s war all over but we got kids right here in our back yard suffering from horrible things,” says Dr. H. Terry Hutchison, PhD, Pediatric Neurologist at Community Regional Medical Centers and Clinical Professor for University of California San Francisco-Fresno. “It’s astonishing children have to go through this, they live a life of terror.” The sons and daughters of prostitutes and labor workers have no other option than to be exposed to the manipulation and coercion of people who prey upon them. With THESE KIDS ARE DEPRIVED their mothers working, they IN MANY WAYS AND IT have nowhere to BECOMES A SELF-FULFILLING go, nothing to PROPHECY do, and no one to trust. They call the Parkway Drive motels their home and the parking lots littered with needles and broken glass their front yards. If their mother doesn’t make enough money to afford a motel room for the night, the children end up on the streets. Other times, they live in small rooms with multiple people amongst bed bug and mold infestations. They don’t have food to eat or clean clothes to wear. They don’t even know if they can make it to school each day. “It’s amazing how much this problem is entirely unknown,” Dr. Hutchison says. “Girls at age 13 are accosted every day by sex traffickers within just a half mile walk to school and boys are approached by gangs. There’s also an abuse, manipulation and exploitation of labor towards the people who live in and work to clean the motels.” According to a study from Brandeis University, Fresno is considered one of the worst places in the United States to raise a child. It is also ranked as the second-worst metro area in America to raise children based on the Child Opportunity Index (COI). The COI score for a given metro area summarizes the neighborhood opportunity experienced by the typical child in that metro area. Among the most high-risk are the homeless and children who are living on Parkway Drive. “These kids are deprived in many ways and it becomes a self-fulfilling prophecy – after they finish school there’s nothing left for them but gang life and they’re not even aware of a whole other world that’s out there,” Dr. Hutchison says. “We tend to think this violence, threatening
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DR RABIA PARVEEZ, DR FARAH KARIPINENI, DR MOHAMMAD SHAIKH, AND DR SADIA GHAFFAR AT THE LIVE AGAIN FRESNO FUNDRAISER.
and coercion going on can’t happen, but it does and it’s a growing problem.” In 2018, more than 300 felony arrests were made on Parkway Drive. “I thought this was an important thing to bring to light because issues that interest doctors are pertinent to health,” says Dr. Farah Karipineni, MPH, Endocrine Surgeon at Community Regional Medical Centers and UCSF-Fresno Assistant Clinical Professor. “There’s a huge sex traffic ring in Fresno that affects women and children. There’s drugs and needles in the parking lots where the kids play, young girls are being preyed upon, and the Fresno Housing Authority is involved because the kids are technically homeless. This might be the beginning of shedding light to this issue.”
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Luckily, there’s help. Richard Burrell, founder of Live Again Fresno, has established an afterschool mentorship program to help these children cope with the devastating environment they live in by providing healthy meals, a safe place to stay, and mentors to help with school work and their mental and emotional development. Thanks to the help of many local physicians and community leaders volunteering as mentors, this issue is being brought to light on many levels. Drs. Alya Ahmad, FAAP, Pediatrician Hospitalist for Community Regional Medical Centers and UCSF-Fresno Associate Clinical Professor; Samia Ghaffar, Orthopaedic Spine Surgeon and UCSF-Fresno Assistant Clinic Instructor; H. Terry Hutchison and Farah Karipineni have all served as mentors or supporters of this program in an effort to expose
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DR GHAFFAR MENTORING STUDENTS AT THE AFTER SCHOOL PROGRAM
the 131 enrolled children to individuals who will not only inspire them to follow a different path in life, but who will help eradicate their fear of medical professionals. “It’s important for me to introduce health care professionals to these kids so they realize that doctors are not bad people,” Richard says. “When a doctor is building a relationship with a child, whether it is Dr. Ghaffar or Dr. Karipineni, students see them as a mentor and friend, and later find out they’re a doctor or surgeon. When this happens, the lens they see through is now shattered, they don’t see doctors as scary anymore. A lot of our kids are scared to death of doctors and dentists because they almost have the same view of them as the police. This helps reshape that paradigm.” When Richard began Live Again Fresno in 2014, the fifth to
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eighth grade children were asked what they wanted to be when they grew up and where they would like to travel if money and transportation weren’t an issue. Astonishingly, their expressions were blank. “They couldn’t imagine themselves traveling or being anything other than what they see in their neighborhood. That did something to me internally,” Richard says. “I felt these children were very limited by their living space so I reached out to doctors, professors, lawyers, and various professionals in hopes to take the lid off of these young people’s imaginations. If we talk to them to today, they now have a different response. We’ve connected them to a whole different set of people so they can see themselves becoming something other than a sex worker or parolee.”
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LEFT TO RIGHT RICHARD BURRELL, FOUNDER OF LIVE AGAIN FRESNO, WITH DR HARROL HUTCHISON AND DR ALYA AHMAD”
Richard says building a network of professionals to spend time with the kids – whether it is to read to them, play a game or play sports outside – has been one of the most important things Live Again Fresno has done. “The majority of our students are African American and Mexican. They see people who look like them wrapped up in crime so it’s rare they see someone with the same ethnicity or skin color who are physicians or surgeons,” Richard says. “They now have folks they can identify with and picture themselves in other careers.” About Live Again Fresno Live Again Fresno is a local community-based afterschool program that serves the surrounding neighborhood of Adams Elementary and the 15 motel properties along Parkway Drive, also known as Motel Drive. There are currently 131 children enrolled in the program with nearly all of them being motel residents. Richard started the program in 2012 to help the 40 children living in one of the motels. “These kids faced pretty big challenges living in a motel property,” Richard explains. “It was next door to 27 registered sex offenders, a large gang population and tons of sex trafficking.” Being a parent himself, Richard recognized one important basic need wasn’t being met – the availability of healthy food
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after school. With the help of a local source, Richard was able to supply the children healthy food after school out of the truck of his car every day. He spent a year getting to know the kids and gain the trust of the neighborhood. Eventually, art and music therapy practices were also incorporated to help the children express themselves. “One of the benefits as to why we exist is in many cases young boys who live in these neighborhoods don’t have opportunities to tell their stories,” Richard says. “By living in a gang culture, they don’t have the vocabulary to articulate their feelings, worries and fears – they are expected to ‘man up.’ There is a lot of pressure placed on these children.” Growing up in the same environment, Richard knows firsthand the difficulties these children face. As a son of a prostitute himself, Richard and his family came to Fresno because his mother was fleeing from people who were threatening her life. But it didn’t take long for her to get pulled back into the things that got her into trouble in the first place, and Richard was caught in the middle. “My upbringing led me to be able to navigate myself in this type of community in ways that others can’t navigate or connect,” Richard explains. “My life experience gave me a unique insight to the workings of the places we serve.” However, getting acceptance from the neighborhood was difficult and took time. From 2012-2014, Richard says he and his volunteers experienced a lot of rejection from residents because they were often mistaken as law enforcement, investigators or from Child Protective Services. “No one would talk to us,” Richard says. “After about a year people started to understand we were there specifically for the kids. One part of the battle is identifying and connecting with the children, and because of our consistency, the neighborhood began to trust us – they look after us and the mothers have become huge advocates for bringing in new families we can help.” From 2012-2016, Live Again Fresno operated within the
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very same motel property the children lived. The motel landlord gifted the organization a free room that served as the children’s sanctuary and safe place. In 2016, Richard advocated for the families to City Council and the State Assembly to illicit help in finding ways to create pathways for these children to get out of motel life. Now, Live Again Fresno operates in a storefront office and shuttles the children from Parkway Drive. Richard hopes Live Again Fresno will be able to soon purchase this space in order to build a private park for the kids. The program also boasts a strong social-emotional learning component in partnership with Fresno Pacific University and San Jose State University that is designed to track, gather and share the student’s literacy data. With a total of 36 students enrolled in the program from one school alone, Fresno Unified School District has been instrumental in helping Live Again Fresno provide students internet access for homework assignments through the donation of tablets and laptops. Conversations are also happening to eventually provide medical services to residents via a mobile clinic. Dr. Karipineni has been able to help enroll some mothers in Medi-Cal. “Richard calls these kids ‘high-opportunity youth’ instead of ‘at-risk youth’ because they have a dramatic amount of potential,” Dr. Karipineni says. “These kids are our future. At that age they are so impressionable – they can decide if they want to be a prostitute or as a young man they decide how to treat women because that’s all they see. These kids are at a crossing point and they deserve better than that.” In addition to providing meals, mentorship and help with school, Live Again Fresno also makes it a point to take the children on trips outside of their neighborhood. As a consistent volunteer and personal mentor to a young girl within the program, Dr. Ghaffar has been instrumental in shaping the children’s perspectives. Last Christmas, she took the children to Build-A-Bear Fresno so they could select, stuff and accessorize their very own teddy bear. Along with other physicians and volunteers, she has also helped take the children to places such as The Island
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Waterpark, animal farms, and trampoline parks or to do fun activities like karaoke. Dr. Hutchison also held a Christmas party at his home and gave the children rides on his fire truck. “My biggest goal is that they see that there is a life different
RICHARD CALLS THESE KIDS ‘HIGH-OPPORTUNITY YOUTH’.
from theirs,” Dr. Ghaffar says. “When they see a pimp with a nice car or a prostitute with a new watch they think that is the way you make money, so when they see me they see someone who is dressed well, educated, speaks well, has a nice car and travels, they then see there is another way to make money. We show them there is a different life outside the hotel walls.” The program has seen huge success so far with its first class of children entering their sophomore year in high school. “Prior to 2018, every summer we have lost the group of
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students who go from eighth to ninth grade to teen pregnancy, sex work, prostitution or the authorities, but this year we have our first sophomores – it’s a huge success,” Richard says. Additionally, in 2019, only 25 children were enrolled in Live Again Fresno, but because of resident engagement and canvassing efforts, enrollment is now 131. “I’m happy we’ve connected to this many children,” Richard says. A Growing Health Concern There are an estimated 27 million people being trafficked worldwide. According to Human Trafficking in the Central Valley, over 700 victims have been identified and rescued from 2018-2019 in Fresno. Sadly, the average age of a victim entering sex trafficking is 12-14 years old. Aside from the sex and labor trafficking rings the children of Parkway Drive are exposed to, there are a myriad of other health concerns at play that affect their sexual, mental and physical health. The children also face sanitation issues and extreme poverty. DR GHAFFAR AT A BUILD A BEAR EVENT Not only do motels like the ones on Parkway WITH PRESTON, ONE OF THE KIDS FROM THE Drive attract drugs and human trafficking, FRESNO LIVE PROGRAM but they often become a form of alternative housing for extremely poor families. “The poverty in Fresno is remarkable,” Dr. Ahmad says. “Fresno seems to have the highest with mold.” disparity of social complexities in patients that I’ve Dr. Ghaffar feels the sexual health of these children is also at seen so far. I think the depth of poverty here is pretty stark risk. and kind of paradoxical because we are in the middle of a rich “The kids are exposed to the sex profession because a lot farmland. This area is abundant but yet has the highest poverty of their moms are involved in it,” Dr. Ghaffar says. “They get rates and even higher rates in food scarcity.” sexually introduced to sex at a young age so as far as their Due to exposure from the motor vehicle and trucking sexual health; they are more prone to learning about it early exhaust along Highway 99, the Adams Elementary on in their lives. Where they live is also dirty. When I’m there I community also has the highest concentration of asthma rates force the little ones to put their shoes on. It’s just not a healthy in the entire County of Fresno. environment; it’s a huge sanitation issue.” Richard fears the children’s mental health is also at stake. “These young people are imprisoned by spending hours Physician Involvement is Key locked in a hotel room. They don’t play outside so it creates a Last year, Drs. Ghaffar and Karipenini were instrumental mental prison,” Richard explains. “The outlets these kids turn in raising awareness about this program and the health to are self harming and self medicating. It’s also evident in our concerns it addresses by being involved in Live Again Fresno’s population there are huge sanitation health issues in just the roundtable discussions with the mayor’s office, members of the hotel rooms alone due to bed bugs and the walls being infested
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City Council, the Housing Authority, and the Fresno County Again Fresno as a part of their community service learning Behavioral Health Department. component. As a direct result, Live Again Fresno was able to enter into a “This would be an ideal situation for the health of these two-year contract with the Fresno Department of Behavioral people,” Dr. Hutchison says. “They don’t have much access to Health to receive funding for its afterschool program under the healthcare and if they have access, they don’t know how to get Youth Empowerment Center model. it, don’t have the transportation to get there, or they are afraid For many physicians, involvement in this program not only because of the coercion or manipulation they’re subject to. inspires and helps the children abolish their fear of medical professionals, but it helps the physicians themselves develop SLAVERY IS ANOTHER WORD FOR IT better care giving practices. “It’s important for us as providers to see children in the – THESE PEOPLE ARE IN A SITUATION context of where and how they live,” Dr. Ahmad says. “It WHERE THEY ARE AFRAID AND THEY changes the way we provide care, especially for children who CAN’T GET OUT. are at risk so we can understand some of the traumas and insecurities they face. I’ve seen the change and sense of security they have when they have a safe place to go, someone to talk to, friends, and a program that supports their learning in a Slavery is another word for it – these people are in a situation proactive way.” where they are afraid and they can’t get out. The kids growing “I think physicians have a responsibility to deal with these up in this environment have developed a way of protecting issues because a lot of the solutions lie outside of the hospital. The weakest link in our society is the homeless and the at risk INC. youth,” Dr. Karipineni A REGISTRY & PLACEMENT FIRM says. “Fresno is so divided in terms of water resources and schools – each child’s opportunity index is so different Nurse Practitioners ~ Physician Assistants based on their zip code. This part of Fresno is probably the worse in the country. It’s important for physicians to realize these discrepancies when they treat patients in the hospital or at their office – these challenges could be a large barrier to Locum Tenens ~ Permanent Placement providing the right care.” Along with many Voice: 800-919-9141 or 805-641-9141 other residency faculty FAX: 805-641-9143 members, Dr. Hutchison is working to get the tzweig@tracyzweig.com UCSF-Fresno residents www.tracyzweig.com involved in Live
Tracy Zweig Associates Physicians
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themselves – they have blank expressions and they show no emotions to avoid trouble.” From a young age, it was embedded in Dr. Ghaffar to give back to the community. After nearly two years as a volunteer and mentor for Live Again Fresno, it has become her mission to get other physicians involved. “What I’ve seen is all they want is someone to love them, pay attention to them and to guide them,” Dr. Ghaffar says. How You Can Help Live Again Fresno is hosting a formal event to benefit the Parkway Drive neighborhood, called Hope in Bloom, Friday, May 15, at Chukchansi Park in downtown Fresno. The event begins with cocktails and a silent auction from 6-7 p.m., and dinner and a presentation about the organization’s efforts at 7 p.m. Tickets and sponsorships can be purchased at www.liveagainfresno.org/hopeinbloom. For more information or to make a donation online, visit www.liveagainfresno.org, or call (559) 294-1390. To inquire about physician volunteer opportunities, please email Richard Burrell at Richard@liveagainfresno.com.
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“Undocumented”
By Dr. Alya Ahmad, Pediatrician, Community Regional Medical Center Hospitalist and UCSF-Fresno Associate Clinical Professor “We need to do a D.N.A. on her!” the social worker exclaimed. “What’s that?” I asked. “It means Do Not Announce,” she replied. The social worker had just come out of the room of a 13-year-old Hispanic girl admitted from the emergency room the night before. The girl’s presence would have to be held in secret. “No contact from anyone asking about her. No one is to know that she was admitted to our unit.” The social worker’s face was red as a beet, her eyes fringed with creases, her voice shaky but controlled. She looked flustered. I couldn’t tell what had rocked her--the tight-fitting mask that she was just taking off or what she had just heard from the girl. It was supposed to be a simple case of a child admitted for possible tuberculosis. The girl had traveled with her father from numerous, unnamable small towns after crossing the border. It must have been an arduous 2-month journey, as the girl came to the ER barefoot and in grimy clothes. The girl’s father who brought her was coughing up blood and sick appearing. Since she had a positive skin test for TB, we were compelled to rule out active, contagious, or dormant, latent TB. It was 2 a.m. when the resident called me. I asked, “If she is clinically stable, can this be done as an outpatient?” He paused, and hesitantly replied, “She has no shoes and her clothes are covered in dirt. It is too late in the night to go back to whatever small town they came from. We can admit her tonight and sort out the details in the morning.” “So she has no place to go? There’s
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no one other than her father?” I asked. I tried to hold back my take away jobs, smugglers, gangsters, make our country unsafe dismay at the effect of poverty since my recent move to the … and all that jargon. However, seeing him in his wretched Valley. state, I could only see him as a patient desperate to survive. “Yup!” the resident asserted. “That man who brought her here--he is not her father. He is The next morning we reviewed the piecemeal medical her rapist!” the social worker exclaimed. The social worker history and workup in ward rounds. There was more history had spent an hour in the patient’s room, listening to the girl’s we needed. We entered her room with the negative airstory of the treacherous trek. Suddenly, the bustling nursing pressured machine room blowing loudly. We were gloved, station turned deadly silent. Not knowing how to react, we sat masked, and gowned in blue to protect ourselves from there dumbfounded. The social worker gushed out the details contracting TB. We barraged her with our questions. She of the story as if holding them in made her feel toxic. “They muttered a few short answers. As we pulled off the As we pulled off the masked gear and gloves, I had an urge to masked gear and gloves, I had an urge to reassure her. “We reassure her. “We will update your father about how you are will update your father about doing. He is sick in the ER, waiting to go to the adult floor,” I said how you are doing. He is sick in the ER, waiting to go to the in Spanish. She immediately looked up in bewildered shock. adult floor,” I said in Spanish. She immediately looked up in bewildered shock. hid in small shacks that she had to share with this man. He “He is not my father!” she retorted in Spanish. She resumed would force her to sleep with him and had penetrated her. She wringing the hospital blanket between her fingers. I looked admitted that her own mother had sold her to this man so they towards my senior resident a little delighted to get a response could have food for her younger brothers in El Salvador.” from her. The senior resident, typing in electronic orders on her chart, “Oh, is he your relative ... uncle? “I asked. froze. He looked over toward me with a painful glare, his hands “He is not my uncle,” she mumbled. She looked up then back locked on the keyboard. It could not be any worse than this. down again and said no more. What could be the circumstance that causes a mother to be I didn’t know if I had heard her correctly, not knowing if it so desperate, I wondered? Was it a last measure of hope, or was was the language barrier or buzzing from the negative airflow it complete hopelessness? machine. The tight-fitting masks muffled our voices and The police were called, and the man readily confessed to the dulled our senses. I was uneasy. Something didn’t seem right. illegal crossing, his abduction of a child, and even to the rapes. Minutes later, we were in the ER to meet this man. He lay on He spoke of the child’s mother who had handed over the girl the bed in the hallway with signage above his bed, Yellow Zone so that her family could survive with the “work” the girl was Bed C. He had dark oily black hair with a slight spattering of supposed to do. gray. He face was thin, and his cheeks and lips drooped on the It took over a week to get her a foster home placement. Each left side as if he had a stroke. His skin was wrinkled, coarse, and day she smiled a little more. She cleaned her room in the thick, with a stubble beard. He looked like he was in his 60’s, hospital, sweeping it daily. She set out the books provided by but the chart revealed he was just 42 years old. He smelled of donations. She lined up the colored pencils with paper neatly dirt and had a sweaty feverish stench. His voice was raspy as he on the table. Her drawings of houses, flowers, with birds and coughed spasmodically between broken sentences. It was easy butterflies canvassed the hospital walls. to see that he had nothing of value on him. He had somehow crossed the US-Mexican border and traveled many miles to get here. Looking at him, I could see he represented everything you hear or read about in the news. How the undocumented are sneaking across the border, to
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DE AL IN G W IT H EM OT IO N AL
E U L B T R U NCE If you’ve ever flown, you’ve likely experienced it. It can happen on any
flight. Turbulence is the shaking of the plane due to air pressure or weather
conditions outside. The aircraft might shake a bit, or rock about in jolts, strong enough to knock a person over. It can dislodge certainty in a person and can send them into a psychological tailspin of worrisome freefall (yikes, pun intended?). It can even be so unnerving that many refuse to fly because of it. So what happens when you experience emotional turbulence? Oftentimes we use turbulence to describe our emotional or psychological distress. It can assist us in giving words to what we feel inside our hearts and minds. And every once and awhile, it can catch you off guard. >>
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I’m not sure about you, but when I experience emotional or flight-related turbulence, the thing I almost always do is hold my breath. Until I had some training on grounding techniques, I figured holding my breath in anxietyprovoking circumstances would help me feel better. Turns out, NOPE. Your brain needs free-flowing oxygen both to make decisions and calm yourself. So once I learned some simple breathing and grounding exercises, I realized turbulence isn’t so bad. Below is one such grounding exercise (I’ve used this exact one in the air AND on the ground). You can always check out “breathing exercises” or “grounding for anxiety”, to find a method that works for you. Happy breathing!
Back to Basics Most people who walk into my office are looking for someone to talk to about the emotional distress they’re experiencing such as feelings of depression and anxiety, or problems they’re experiencing in their relationships. What they’re really seeking are solutions to these problems that will reduce their emotional pain. Sometimes people get so caught up in their thoughts, feelings, and problems that life seems so complicated and they forget about the ordinary things in life. At times like these it helps to get back to basics. Getting back to basics means doing those seemingly mundane activities that actually have a significant impact on our mental health. For now, I’ll focus on three basics that have been shown to enhance our ability to think clearly, regulate our emotions, and improve our overall mood. I like to call them “The Big Three.”
1. GETTING ENOUGH SLEEP. Sleep is an important factor in helping us deal with everyday challenges, responsibilities, and the demands of a hectic schedule. Study after study has shown the benefits of restful sleep such as improved physical health, enhanced memory, boost in creativity, increased attention, and lower levels of stress. Even though we don’t fully understand absolutely everything sleep does for us, we know we feel horrible when we don’t get enough of it. And while it may not be possible to get 8-10 hours of sleep every night, there is always room for improvement and any step made in the right direction is a step towards better mental health.
2. EATING REGULARLY. The bottom line is our body needs energy to get us through the day and we get out energy from the
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food we eat. Eating regularly and adequately aids in reducing stress, improving cognitive functioning, and maintaining healthy bones, organs, and muscles. I can think of several ways to justify eating just one meal a day, or just snacking whenever I hear my stomach talking to me. It’s just too easy to forget or be too busy to have an actual meal when we have so much to do and so little time. For many of us it may be unrealistic to fit in three balanced meals every day, and that’s okay. A helpful goal would be to make sure you’re eating routinely and sufficiently to provide your body and mind with enough nutrients to sustain you throughout the day.
3. EXERCISING. Call it what you want - working out, sports, outdoor hobbies, physical activities - just try to do more of it. Everyone knows that exercise is good for your physical health. It can help you shed some pounds, improve your physique, and enhance your sex life. But those aren’t the reasons most people make exercising a priority. Most people exercise regularly because it provides them with an overall sense of well-being. They feel more energetic, get more peaceful sleep, enjoy increased feelings of relaxation, and feel more positive about themselves and their lives. The best part is that anyone can learn to use exercise as a mood booster, regardless of age of fitness level. So remember, when you feel overwhelmed with life challenges and daily stressors, take some time to reflect on the basics and ensure that these common activities, which on the surface seem trivial and often burdensome but are actually crucial, are given the time and attention they deserve.
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opioid addiction
BY ERIN M. KENNEDY
opioid addiction M AKING IT E A SIER TO PREVENT, REDUCE AND TRE AT
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While scores of people were overdosing on fentanyl and heroin in far off states such as West Virginia, Ohio, Kentucky and Pennsylvania, California was battling a different drug demon – methamphetamine. It seemed like opioid abuse had bypassed the Golden State. Still the national epidemic, prompted local medical providers to look at pain control in a different way and has changed attitudes about those already addicted to narcotics. Kelvin Higa, M.D., remembers the bariatric surgery patient that really convinced him of the need to reduce opioid use: “She was on so much narcotics that her GI tract wouldn’t work. She didn’t have a motility issue she had an opioid addiction issue. We took her slowly down off narcotics to get her to eat again normally. It took two years and I saw her every week, but we did it.” Community Regional Medical Center emergency room physician Rais Vohra, M.D. saw the agony opioid addicts went through firsthand. He was one of the first in California to seek funding to help provide medical relief from withdrawals and help getting into treatment. “We’re eliminating barriers for people who are ready to go into addiction treatment,” he said. Some like addiction specialist Marc Lasher, D.O. have been out on the streets for decades working to reduce the harm from needle sharing and to gently nudge drug users into sobriety. >>
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opioid addiction
Dallas Blanchard has been helping Dr. Lasher collect used needles from intravenous drug users every Saturday for nearly two decades.
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To turn the opioids tide here, it will take a multi-pronged approach of reducing prescriptions to prevent addiction, making addiction treatment easier to get and helping those who are injecting their opioids from spreading deadly diseases like HIV and Hepatitis C. It starts with adjusting attitudes and destigmatizing addiction so people seek treatment early, said Dr. Vohra. “The language we use in talking to and about patients who are struggling with drugs has a powerful effect,” he explained. “A compassionate, patient-centered approach which recognizes the legitimate struggle that someone is experiencing can go a long way.”
20,000 needles a week helps reduce harm of addiction Most of the patients lining up at the Saturday Fresno Free Medical Clinic are arriving on battered bikes. They carry dozens of used needles and syringes in grungy plastic ice chests to exchange. But a few, like Mike S., pull up in new cars to see the physician who’s been doling out clean needles to intravenous drug users for more than 20 years. Dr. Lasher also drains abscesses, dresses wounds and dispenses antibiotics, naloxone for overdoses, and buprenorphine for withdrawal symptoms out of a big yellow refurbished school bus parked near Roeding Park. And if they’re ready, Dr. Lasher will prescribe Buprenorphine and make an appointment for people to see him the next Monday at Aegis Medical System where he works as an addiction medicine specialist. Mike S., who asked that his last name not be used, got hooked on opioids decades ago after a motorcycle accident and surgery to repair the damage to his leg. “I used to show up with $100 a month and get a bottle of pain pills from (another) doctor. It was exactly like a drug dealer,” described Mike, who is nearing retirement age. When prescriptions are cut off and buying pills on the street gets too expensive, people turn to more dangerous injectable narcotics. “Heroin is so much cheaper and readily available,” explained Dr. Lasher. Mike’s off narcotics now, but he still comes to Dr. Lasher for
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Legislature Clarifies Law Requiring Physicians to Offer Naloxone to Patients In January, a new law took effect that requires opioid prescribers to also offer prescriptions for opioid-overdose reversal drugs such as naloxone. The California Medical Association (CMA) received numerous calls from physicians regarding the ambiguity of the new requirements. The California Legislature recently enacted a bill that clarifies the circumstances under which physicians are required to offer opioid-overdose reversal drugs. Effective September 5, 2019, AB 714 specifies that the requirement to offer naloxone applies only if the patient is receiving a prescription for an opioid or benzodiazepine medication. If a patient is receiving such a prescription, the law requires that the prescriber offer naloxone or other similar drug if: The prescription dosage for the patient is 90 or more morphine milligram equivalents of an opioid medication per day An opioid medication is prescribed within a year from the date a prescription for benzodiazepine has been dispensed to the patient The patient presents with an increased risk for opioid overdose, including a patient with a history of opioid overdose, a patient with a history of opioid use disorder, or a patient at risk for returning to a high dose of opioid medication to which the patient is no longer tolerant. In addition, the law now specifies that the education physicians must provide patients who are prescribed naloxone or other similar drug must be about opioid overdose prevention and use of the opioid reversal drug. Physicians do not need to provide the education if the patient declines or if the patient has received the education within the past 24 months. The new law further clarifies that the requirement to offer naloxone do not apply when the opioid or benzodiazepine medication is being administered in a facility or prescribed to a patient who is terminally ill. To learn more about prescribing controlled substances, including this new requirement, see CMA health law library document #3201, “Controlled Substances: Prescribing.” This document, as well as the rest of CMA’s online health law library, is available free to members at cmadocs.org/health-law-library. Nonmembers can purchase documents for $2 per page.
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opioid addiction
Medical school volunteer Karina Perez (at left) assists Dr. Marc Lasher who is seeing longtime patient Mike S. at the Fresno Free Medical Clinic, a converted 1970s-era bus that he parks near Roeding Park every Saturday from 1-3 p.m.
care. “I trust him. He has stuck with me and respects me,” said Mike, who came to the Fresno Free Medical Clinic for follow up on a wound that was treated in the emergency department weeks before. And as word has spread over the years of Dr. Lasher’s compassionate treatment of those suffering from addiction, the line has grown at the Saturday clinic and needle exchange. “We’re exchanging more than 20,000 needles in two hours now,” said Dr. Lasher. When he and longtime volunteer Dallas Blanchard first started 20 years ago, they handed out about 1,300 needles each Saturday as they dodged the authorities. Giving sterile needles to addicts was illegal until 2012 when California law changed. As the law has changed, so have attitudes. Dr. Ken Bird, retired Fresno County Health Officer, praised Dr. Lasher in his 2017 monthly letter to county residents: “All too often, IV drug users are discriminated against and ostracized. As a result, they fall through the cracks and suffer great physical and emotional health problems. At the Fresno Needle Exchange, there is no stigma, there is no judgment, and there is no pressure. It is a safe confidential place, where anyone suffering from an IV
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drug use addiction can come to find help and resources.” Most in the medical community appreciate his work, so Lasher was surprised recently when a city council member showed up with a police officer to shut him down. “I had to show them the law and tell this this is what we’ve been fighting for,” Dr. Lasher said. “Needle exchange is part of the comprehensive community program for dealing with drug addiction. It’s not the answer, but it is part of the solution.” The Fresno exchange is one of about 51 needle exchange programs in California and 400 needle exchange programs operating in the U.S., Puerto Rico and the U.S. Virgin Islands, according to the North America Syringe Exchange Network. In the Central San Joaquin Valley there’s also one in Hanford and one in San Luis Obispo. Numerous studies have shown such exchange programs are associated with decreases in HIV and hepatitis. Mike S. knows Dr. Lasher’s care helped save him. “He’s the best-hearted doctor. No other doctor would do this,” he declared.
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Immediate addiction, withdrawal relief provided 24/7 Any time of the day or night, people struggling with opioid addiction can walk into Community Regional Medical Center’s emergency department and find immediate relief in the form of medication to suppress cravings and withdrawal symptoms – and help getting right into an addiction recovery program. They’re also likely to encounter another big-hearted physician, Dr. Vohra. “As an emergency medicine doctor and specialist in toxicology I’ve seen the destruction that opioid addiction has on our patients and the despair they feel. We now have new hope to offer these patients,” said Dr. Vohra, who helped establish Community Regional as one 53 clinical sites participating in California’s grant-funded BRIDGE program.
Dr. Marc Lasher takes the medical history of former opioid user Mike S. who doesn't trust many doctors so comes to the Fresno Free Medical Clinic for a follow up on a wound.
The program aims to create easy access and encouragement for patients to enter and remain in treatment by dispensing Buprenorphine with the active component Suboxone to control withdrawal symptoms and, to cut cravings for opioids. The medication is highly effective and is now considered the best option for longterm management of substance use disorder, said Dr. Vohra. “We want them to get medications, information and encouragement by simply walking into our ER — or any other place in the hospital,” explained Dr. Vohra, a UCSF Fresno professor of emergency medicine and clinical pharmacy who sees patients at Community Regional. He’s also medical director of the California Poison Control System and interim Fresno County Public Health Officer. Dr. Vohra estimates he and his addiction navigator Chala Vang see 20-30 patients a month and have helped nearly 400 so far in the pilot project funded by California Department of Health Care Services. Vang helps patients with insurance paperwork, transportation directly to drug rehab, or referral for follow up care in the community. “There’s actually lot of treatment programs now and a lot of insurance companies are setting up telemedicine programs for this,” said Dr. Vohra. Many patients who are working prefer the telemedicine option so they can get their
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buprenorphine prescription and talk over the phone or by skype with a physician about their progress, said Vang. Dr. Vohra is now seeking funding to expand the program and hire more addiction navigators. “The State of California has set aside $20 million for addiction navigators. Their vision is to have one in every ER,” he said. “We need more navigators to get to other kinds of patients. We’re still working to get the word out, especially to surgical patients and pregnant women” who may be struggling with opioid addiction.
Approaching surgical pain relief differently For the past few years many Community Medical Centers and Kaiser Permanente surgeons have been using Enhanced Recovery After Surgery (ERAS) protocols to help reduce opioid use and improve outcomes. In a paradigm shift, instead of fasting 12 hours, patients are given a high-calorie, high-carbohydrate drink a few hours before surgery to boost their metabolic recovery. Dr. Amir Fathi, director of hepato-pancreato-biliary surgery at Community Regional, who helped establish ERAS at the hospital, goes further and has patients try to stop smoking and work on their nutrition for several days before surgery to get their blood sugar under control. He told MedWatch Today that using ERAS produced “better outcomes, less infection, shorter length of stay, less re-admissions, and dramatic decrease in the narcotic pain medication usage.” With ERAS patients are also encouraged to get up and move a few hours after surgery and surgeons stay away from pain medication that inhibits movement. “Key was the pre-operative counseling and managing the expectations of pain,” said Dr. Pearl Ma who practices with Dr. Higa at Advanced Laparoscopic Surgery Associates Medical Group (ALSA). “We tell patients it’s normal to feel some pain, that ‘You should feel sort of sore like we made you do sit ups.’ And we tell them, ‘If you feel gas pain, but best thing to do is to get up and walk with it.’ We ask them if maybe their pain is emotional or anxiety and there are other things besides pain medication that help better,” Dr. Ma said. “We ask patients not to ask for pain meds unless they really need it.”
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Dr. Rais Vohra
Having nurses onboard to help the efforts and coordinate how to help patients deal with pain rather than just giving them a narcotic has made a huge difference as well. “We reduced our opioid use by 60% right away from ERAS,” said Dr. Ma. Kaiser Permanente Fresno saw similar results of a 59% decrease in the number of surgical patients prescribed opioids between 2015 and 2018, according to the study published in the Annals of Surgery. ALSA surgeons went even further to look at the pain relief they were using during surgery. Many in their field were turning to Experal instead of the usual opioids. “We were looking for a magic bullet to do surgery without pain,” Dr. Ma said of the promises of Experal. So she and Dr. Higa did a double-blind study to see if their bariatric surgery patients did fare better. They’ve just published their results. “We found the medication didn’t really do any better. There was no difference in the amount of pain meds patients needed in the hospital,” said Dr. Ma. The study concluded: “A greater percentage of patients in the standard bupivacaine group did not require any narcotics at home which was significant on postoperative days 2-4. In order to become completely opioid free after bariatric surgery,
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resources should be focused on multimodal approaches instead of reliance on type of anesthetic medication used.” Dr. Higa said surgeons who don’t work on reducing opioid prescriptions create problems for their colleagues: “The people who bear the brunt of this are the primary care doctors because they’re getting the calls from patients demanding more pills. The surgeon fixes a problem and send them home with 20 pills and some patients become addicted and the primary care doctor has to deal with that.” Statistics show patients have a 6% chance to become hooked on opioids if they are exposed to them in surgery or afterwards, said Dr. Ma. But that’s 6% too many. Dr. Ma and Dr. Higa aim to eliminate all opioids from their practice. They’re starting new protocols this month. “We won’t give patients any narcotic pills to go home with and we let them know we’ll evaluate if they need them. I think we’ll find that patients get used to the idea,” said Dr. Higa.
An opioid Rx for every two people in Fresno, Madera counties Prescriptions for opioids peaked in Fresno and Madera counties in mid-2015 and have been steadily declining, according to the Central Valley Opioid Safety Coalition’s
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opioid addiction data. Opioid prescriptions were down 33% between the high point and April 2019, but still being written at a rate of 507 for every 1,000 people in Fresno and Madera counties, according to the California Department of Public Health. That’s one prescription for every two people locally. In 2018, the latest year available, Fresno and Madera counties residents dying from opioid overdoses were highest among those ages 55 to 64 – a group more likely to have had surgery and pain medication prescriptions. That year 41 people died from opioid overdoses locally and 178 people were rushed to hospital emergency department with overdoses. Since 2008, nearly 800 people have died from opioids in the two counties. But those numbers too are decreasing each year. The widespread distribution of naloxone, also known as Narcan, to reverse overdoses is saving lives locally. Dr. Lasher estimates he hands out 30-35 boxes of Narcan nasal spray each week. “We’re arming the local population and training them
how to use it at home,” he said. “Every week I hear about 12 reversals.” Patient Mike S. says he always picks up boxes or Narcan when he sees Dr. Lasher and makes sure he takes a few doses with him everywhere he goes. “I’ve personally saved eight people with Narcan,” he said. On this Saturday, Mike S. also stepped off the Fresno Free Medical Clinic bus with a prescription for antibiotics and an admonition to come back in two weeks to check his leg wound. He looked around at the trash bins brimming with used needles and the people leaving with boxes of sterile syringes and shook his head. “Look at all the kids here. It’s sad. There’s a growing epidemic,” he observed. “This is not something they chose. It chose them,” said Mike, who knows firsthand how opioids pick the unlucky.
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Transcranial Magnetic Stimulation (rTMS) delivers repetitive magnetic pulses to stimulate nerve cells in the area of the brain that controls mood. Rapid change in the magnetic field induces a current of sufficient amplitude and duration which in turn will excite the neurons.
www.depressionfresno.com Spring 2020
COVID-19
leaves the valley in need of blood donations It was the morning of Wednesday, March 11th and the Hospital Services department of our Central California Blood Center fired off the daily blood inventory report to the company’s key managers and directors. Normally in early March, CCBC’s red blood cell product inventory is on goal, with about 1400 units or about a 10-day supply, originating from blood donors at high schools, colleges and company blood drives However, the arrival of COVID-19 on American shores, initially from cruise ships, then from Asia travel, was beginning to disrupt everything. And with it, blood donations. That morning’s inventory report showed that the supply had fallen to less than 600 units, only about 30% of goal, less than a 4-day blood supply, with critical type O negative blood at less than a 2-day supply. >>
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Regardless of a pandemic or almost any other imagined disaster, the need for blood transfusions will continue. Even if hospitals forego all non-essential medical and surgical procedures, blood, platelets and plasma would continue to be required for trauma, GI bleeds, Labor and Delivery, neonatal, hematology, oncology, emergency surgery and others. As of March 11, local hospitals were continuing ahead with these normal blood usage patterns. Prior to March 11, the blood bank community foresaw trouble. The predictions of COVID-19 spread were credible. Leaders in Washington, California, New York and other states began speaking of hospitals reducing or halting elective cases to make
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bed space for eventual COVID-19 patients. I knew that CCBC would need to have a two-pronged strategy: first, convincing healthy people to keep donating blood, and second, coordinating with hospital leaders so that the inevitable ratcheting down of elective procedures--which in turn would lower demand for blood--would increase blood availability. In early March CCBC had begun to see a palpable slowdown in blood donation. In the absence of clear national directives regarding the safety and need for blood donations, people were uncertain whether blood donation was safe or even needed. CCBC had reached out to many of our contacts in schools, community, faith-based organizations, in Fresno State and in the
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Fresno County Health Department to try to disseminate the message that blood donations were going to continue to be needed and were safe, according to the FDA and CDC. We emergency-funded a media buy for social media and TV ads, in English and Spanish, specially designed to recruit healthy blood donors during the pandemic. Dr. Rais Vohra and Director David Pomaville from the Fresno County Department of Health came to the blood center and recorded public service videos with Dr. Patrick Sadler, our medical director and me. We felt like we could get ahead of this and be proactive. For the US blood bank world, the first shot fired in the war on COVID-19 happened in Seattle the week of March 2nd , when 60 people had been quarantined in the Kirkland nursing home. In reaction to this news, Seattle-area schools began to close, resulting in school blood drives canceled. Major blood drive sponsors, including Boeing, reportedly canceled blood drives. Around the nation, Blood Centers of America (BCA) began tracking canceled blood drives nationally and, by Friday March 6, recorded 26. That weekend, Seattle’s blood bank, Bloodworks Northwest, put out a request to all US blood centers to send help. The request was for more than 500 O positive and 100 O negative units for a total of over 1000 units. With most of the nation’s blood supply already low, initially NO ONE RESPONDED to Seattle’s call. Fortunately, a few days later, Bloodworks was able to obtain modest shipments from American Red Cross, Vitalant and Carter Blood Care in Dallas. From March 5 to Friday March 13 in the following week, there was a deluge of canceled community blood drives, with over 35 canceled with CCBC (estimated loss of almost 2000 donations) and over 1700 canceled with our BCA partners. Red Cross system similarly reported over 1700 canceled drives in that period. With that many projected donations coming off the books, it was difficult to imagine how blood centers would make up those losses. America’s Blood Centers, the national trade association for all (non-Red Cross) independent blood centers, American Red Cross, and others form the Interorganizational Task Force established after 9/11. They began advocating in the federal government for national messaging on the need for healthy blood donors. On March 12th Dr. Peter Marks of FDA’s Center for Biologics Evaluation and Research (CBER)
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publicly appealed for blood donation, explaining its safety. On March 19, a week later, US Surgeon General Dr. Jerome Adams made an impassioned appeal during a Presidential press conference for blood donation, citing his personal experience as an anesthesiologist using blood for wounded warriors at Walter Reed. Dr. Adams called out to the healthy individuals of our nation for blood donation. “You will be doing something good for your country. You will be doing something great for your community, and you might just save a life. Social distancing does not mean social disengagement.” Dr. Adams awesome words definitely moved people. The next day, along with state governors and local officials, thing began to turn around. Coverage from our local media reached a crescendo. We thank ABC 30, CBS 47, KSEE 24, Fox 26, Univision, Fresno Bee, Cumulus radio, Valley Public Radio and others for the generous and excellent coverage they provided. Above all we thank you Central Valley VOLUNTEER BLOOD DONORS for what came next--a most amazing and sustained response. In less than a week the local blood supply was fully restored. I wanted to describe this experience we just went through together. We know it is only an early skirmish in the battle of Central Valley people vs. coronavirus, but I wanted to share that our people came up big! Likewise, we appreciate all the health care workers who will fight on the front lines for us, and we support them in every way we can. I also must call out for praise our Central California Blood Center staff, who continues to perform with such spirit and professionalism. We know we are all in for a lengthy fight against this virulent coronavirus and the fear it causes in us, but we also know we are in it together to win it together. The need for blood will continue all during the epidemic. While at the time of printing, things have stabilized, we know we continue to need to book healthy donors for the challenging weeks ahead.
Christopher Staub President and CEO Central California Blood Center Valley People Need Valley Blood March 26, 2020
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A LOOK
BACK
at physicians H . M . G i n s b u rg , H a ro l d H a n s o n , & Harriet Hanson
Doc t o r s W ho M a d e a D i f f e r e nce i n t he Ce n t r a l Va l l ey BY MALISSA WADE
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Drs. Harold Hanson and Harriet Hanson children Eric and Mark (pictured with Tim Johnson) play in f lood waters in Chiang Mai Thailand.
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Hanson Family in Chiang Mai Thailand with locals a n d h e a l t h c a r e w o r k e r s f r o m M c Co m i c k H o s p i t a l .
Doctors are every day heroes. They heal the sick and bring hope to the weary. That alone is enough, but these physicians took it one step further. Central Valley Physicians H.M. Ginsburg, Harold Hanson, and Harriet Hanson, were not only locally practicing physicians with full panels of patients, but they were also known as admirable civic leaders and passionate community influencers. Their devotion to serving others helped thousands more beyond their scope of practice – spilling over into the community – and abroad.
HYMAN M. GINSBURG, MD (1905-1981) General Surgery/Obstetrics and Gynecology
T h e l o w e r f l o o r o f t h e M c Co r m i c k hospital with 40 beds for children, and more acutely ill pateints.
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Years ago, a physician’s work was not just their occupation, it was their life. They worked around the clock. Their patients knew them as not only their caregivers, but also as a family friend. >>
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Such was the case with the late Dr. H.M. Ginsburg. He, his wife and two children lived in a home on the campus of Fresno County General Hospital so he could be available at a moment’s notice. In addition to practicing medicine, Dr. Ginsburg was a distinguished leader within many of Fresno’s religious, fraternal, athletic, educational and civic groups. “He was from the old school – he was a doctor 24/7, 365 days a year,” says Dr. Ginsburg’s daughter, Bettylee Wapner, of Fresno. “And he was also that way as a leader and community leader – he gave his all.” Born in New York City, Dr. Ginsburg’s family moved to Denver, where he completed medical school in 1927 at the University of Colorado. He then came to Fresno to complete residency training at Fresno County General Hospital. After graduating in 1928, he went back to Denver, and just six months later, was asked to return to Fresno to assume the role of Medical Director and Chief Surgeon for Fresno County General Hospital. During his tenure as the hospital’s Superintendent and Chief Surgeon, Fresno County General Hospital became a leading center for the care and rehabilitation of Poliomyelitis victims. During the Polio epidemic, Bettylee says Dr. Ginsburg brought Sister Elizabeth Kenny to Fresno who invented the controversial treatment for Polio that involved hot compresses followed by careful muscle rehabilitation movements. “I remember meeting her and she was so impressive and strong,” Bettylee says. Dr. Ginsburg had a passion for helping physically challenged children. He served as president of both the National Foundation for Infantile Paralysis and the Fresno County Society for Crippled Children. The March of Dimes awarded Dr. Ginsburg for his efforts in helping to raise funds for Polio research. Additionally, Dr. Ginsburg served as a board member and physician for the Fresno Nutritional Home, President of the American Red Cross, and the Fresno Grand Jury. Also prominent in the Lions Club, he was past President, a District Governor in 1944, and an international counselor of the organization for many years beginning in 1945.
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D r. H a r r i e t H a n s o n a n d o t h e r T h a i d o c t o r s m a k i n g r o u n d s i n t h e a d u l t w a r d a t M c Co r m i c k Hospital in Chiang Mai Thailand
A devout member of the Tehran Temple and supporter of Shriners Hospitals for Children, Dr. Ginsburg was elected as the Temple’s Potentate (president) for one year in 1958. He was also president of the Jewish Welfare Federation for 14 years and the state Chairman for the Joint Defense Appeal. After serving as the county hospital’s Superintendent and Medical Director for 20 years, Dr. Ginsburg decided to establish his own General Surgery and Ob/Gyn private practice in downtown Fresno. “We had a slogan and what we said was that he took patients from the cradle to the grave,” says Dr. Ginsburg’s son, Dr. Brian Ginsburg, MD, of Fresno. “He delivered kids and took care of them and the parents. Everyone knew him.” In 1973, Dr. Ginsburg received the Distinguished Leader’s Award by the Jewish Appeal. He was a member of the Fresno Lodge of B’nai B’rith and served as President, Vice President and on the Executive Board. He was the national Treasurer of the B’nai B’rith Youth Organization and Vice President of its District No. 4, which covered eight western states and British Columbia. “He was so involved with kids, schools and handicapped children that in the 1960s he was elected to the Fresno Unified School Board,” Brian says. “He and all the other members of the school board back then were really dedicated to taking care of kids and the entire city of Fresno. He probably could have even ran for mayor he was so well-known.” As a 12-year member of the Fresno Unified School District Board of Education, and president from 1965-1972, Dr.
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Ginsburg’s main goal was to expand and improve the district’s facilities and programs to accommodate the handicapped. He spearheaded efforts to obtain federal government funds for these programs that led to the establishment of a Regional Occupational Center in Fresno. As a culmination of his efforts, the H.M. Ginsburg School was established at Fresno’s Powers-Ginsburg Elementary School in 1977. An avid sportsman himself, Dr. Ginsburg also spent many years as the Team Physician for Roosevelt High School’s athletic teams. To encourage student athletes, Dr. Ginsburg originated the B’nai B’rith “Student Athlete of the Year” award in Fresno. He received awards for his contributions to youth and athletics from the Helms Athletic Foundation and the Breitbard Foundation. Additionally, he was inducted into the Fresno Athletic Hall of fame for his connection with athletic teams and schools in 1972. Dr. Ginsburg also served as president of the Fresno Madera Medical Society in 1968. He was active in developing medical policies in the areas of professional training, doctorpatient relationships, peer review, and medical insurance programs and costs. He served as Chairman of the Society’s Scholarship Committee and devoted time to the FresnoMadera Medi-Cal Pilot Project and the Foundation for Medical Care of Fresno County. In addition to inspiring many, Dr. Ginsburg also inspired his son to become a physician. “His influence made me want to be a doctor,” Brian says. “I was born at the county hospital, we lived at the hospital, and I went to Roosevelt all right behind the hospital – being in that influence all the time … he influenced me quite a bit.” Dr. Brian Ginsburg graduated from the University of California, Fresno, in 1953 and attended medical school at the University of Southern California. He returned to Fresno to complete residency training then practiced with his father from 1962 on. Brian also served with his father, side-by-side, as a
Team Physician for Roosevelt High School’s football team until retirement. “It’s hard to name his biggest accomplishment because he was so prominent and so good at everything he did,” Bettylee says. “All of his accomplishments were good – he was on the school board, president of the Temple, ran the county hospital as the head physician, and he committed 13-15 years to each and every endeavor, so how do you answer that?” Dr. Ginsburg passed away in 1981 at the age of 75. “There was an obvious strong and continuing pattern of public service and service to individuals in Dr. Ginsburg’s life. He gave time, talent, leadership, inspiration, hope and comfort. He said, ‘I wanted to repay the community for all the blessings that it
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has given me’ (Recollections, The Historical Committee of the Fresno-Madera Medical Society, 2003).”
HAROLD AND HARRIET HANSON, MD General Surgery and Pediatrics
Drs. Harold and Harriet Hanson are known for their longstanding careers devoted to helping the underserved. They spent ten years providing general surgery and pediatric care at a hospital in northern Thailand, while also raising a family of their own. When they returned stateside, they practiced as physicians while continuing overseas work. For 44 years, the couple established and operated the Hanson
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Medical Mission Fund that shipped vital medical equipment and supplies to over 60 hospitals in 22 underdeveloped nations around the world – with a total value exceeding $10 million – all from the heart of the Central Valley. Starting at a young age, both Harold and Harriet felt a deep calling to live a life of service to others.
HARRIET HANSON, MD Pediatrics
H a l l o w e e n 1968 H a n s o n children enjoyed double fun of Thai holidays and US holidays. Gordan with Harriet Hanson.
At just nine years of age, Harriett felt compelled to help the needy when she met a woman at her Sunday School in Marysville, Calif., who worked with a Navajo tribe in Arizona. This was during the depression when alcoholism and tuberculosis, along with poverty, was prominent. “She spoke to the Sunday School kids sitting on the floor and she said, ‘Now, if you ever feel that God is calling you to help the poor and the sick, will you respond? Will you answer that call?’ I didn’t understand that, but I raised my hand,” Harriet says. “That was my call and it meant so much to me.” Originally wanting to be a nurse, Harriet soon realized she was doing well in school so she decided to be a doctor. “My family had no money, we were struggling just to make ends meet. Where I got the idea that I could go to medical school, I didn’t know,” Harriet says. “It just seemed to be logical that I should do that – my gifts were such that I should do it.” Harriet graduated high school as valedictorian then attended a junior college in Sacramento after the war ended. She then attended the University of California, Berkeley, where she was also very active in a Christian group. “I got very involved with a lot of students who felt the same as I did; the postwar world was a mess and we were going to do something about it,” she says. “I met Harold and he too had the same goals so it was just a natural coming together.” Harriet and Harold wed at the end of their first year of medical school in 1951. Living in San Francisco, the couple continued to work hard and study, while having three babies during their schooling and training. Their first child unfortunately only lived for two weeks due to a congenital diaphragmatic hernia.
HAROLD HANSON, MD General Surgery
Born to Swedish immigrants, Harold grew up on a farm outside of Bakersfield. The town was so small that it didn’t have a high school, so Harold was bussed 50 miles each day to attend high school in Bakersfield. Riding the bus for hours every day gave Harold the opportunity to study. With a love for animals, and involvement in 4-H and Future Farmers of America, Harold wanted to be a farmer like his father until his mother sat him down one day and suggested he should be a veterinarian. There were no veterinary schools in California at the time so Harold applied and was accepted at Washington State. Before his second year of vet college, he attended a Christian Youth Conference in the Sierras. There, he took a class
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about Christian stewardship and the importance of using our abilities, capabilities and interests to serve God and man. “I sat there on that log and said to myself, ‘I should be a medical missionary’,” Harold remembers. “I then transferred to Berkeley where I met Harriet who had the same desires and plans. We spent ten years in San Francisco, Harriet in pediatrics and I in surgery. We did well.”
Working in Thailand The couple completed residency training and then six months of intensive missionary orientation in New York through the Presbyterian Church while living in a dormitory-like setting to get accustomed to living in modest conditions. By 1960, they were ready to go overseas. They were assigned to Thailand because a hospital in Chiang Mai needed help with training its nurses, residents and interns. They spent one year studying the Thai language before moving. Once there, the Hansons worked for ten years at the McCormick Hospital, Thailand’s largest and oldest Christian hospital, built in 1840. Besides clinical work serving as the hospital’s Chief of Pediatrics and Chief of Surgery, the Hansons went on dozens of hospital clinic trips with nurses to outlying remote villages to treat and immunize the Thai people. They also helped to modernize the hospital by enhancing its medical library with books and journals; started an international card catalogue
T h e H a n s o n 's H o s t e l F a m i l y f r o m 1969-1970 .
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B o y 's 40 - y a r d d a s h . M a r k Hanson far lef t and Eric Hanson 4th from the right .
system; began an organized disease diagnosis system using the World Health Organization method; and initiated a standard patient chart retrieval system, among many other things. Additionally, they helped with the planning of the hospital’s new pediatric and surgical buildings. Harriet mostly treated children who suffered from infectious disease, protein deficiencies and total malnutrition. “I was suddenly seeing children with diseases and conditions that I had only read about but had never treated such as typhoid fever, diphtheria, tetanus, dengue, hemorrhagic fever, hepatitis, cholera, malaria, TB of the spine and kidneys, and bladder stones in children as young as eight months,” she says. “Kwashiorkor and marasmus were huge problems as were empyema and intestinal parasites.” Harold recalls that within Harriet’s department, the incubators for premature infants (and there were a lot of preemies in Thailand) were cardboard or wooden boxes with a light bulb for heat. Tetanus in newborns was also common. Children born at home with the help of untrained village midwives typically had the umbilical cord cut with a piece of sharpened bamboo that introduced infection. “Adult tetanus we could treat, but not newborn tetanus; unfortunately they all died,” Harold says. “The families would bring them in after two days or so and the antitoxin by that time did not help.” Within Harold’s department, common fractures were skull fractures from falling coconuts and road accidents. The hospital didn’t have electrocautery to stop bleeding from the brain. He was often called upon to perform cases that others weren’t trained to do such as neurosurgery. “A lot of the things I did were quite crude,” he says. “I had to do brain surgery, simple brain surgery for simple problems, but it was
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A p r i l 1966 w h e n t h e H a n s o n a n d S e v e r a l o t h e r P r e s b y t e r i a n M i s s i o n f a m i l i e s w e r e v a ca t i o n i n g a t c h u r c h ca b i n s a t N o n g k h a e n e a r H u a h i n (a b o u t 10 0 m istill l e sbrain s o usurgery.” t h o f B a n g ko k . H a n s o n s s t a t e t h a t t h e s e w e r e s o m e o f t h e n i ce s t v a ca t i o n s t h e y e v e r h a d .
The poverty the Hansons witnessed and the experiences they had made them realize their next calling. The people of Thailand not only needed help, but they needed updated and sufficient medical equipment and supplies. When the Hansons traveled to the states on furlough, they brought back with them to Thailand hundreds of dollars worth of surgical equipment stuffed in the bottom of their suitcases. They also wrote to Harriet’s former colleagues at San Francisco Children’s Hospital to tell them of McCormick Hospital’s needs. As a result, they were able to procure used but still functioning Armstrong infant incubators. Additionally, four supporting Presbyterian churches in California provided $700 for an electrocautery machine. This was the start of their 44 year-long commitment (1959-
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2003) of shipping critical medical supplies and equipment to hospitals overseas. By the time they left Thailand, the Hansons received 305 separate gifts from churches and individuals totaling $57,772. Continuing Missionary Work from Home In 1970, the Vietnam War was heating up, causing an influx of soldiers on rest and recuperation in Bangkok where their children were to attend boarding school. The Hansons wanted their children to receive the best education and they needed to care for Harold’s ailing and widowed father, so they decided to return home. “I am very glad we did,” Harriet says. “Our sons excelled in high school and college and father Carl moved in with us.” Harold practiced general surgery and Harriet pediatrics in Fresno. But what they did afterhours and on the weekends is what they’re most known for – organizing large shipments of medical necessities for those in need with the help of dozens of volunteers. “What am I most proud of? Shipping to poverty-stricken hospitals overseas,” Harold says. “We knew from our experiences and overseas contacts that many of the hospitals in the world were deficient in equipment and trained doctors.” The Hansons developed a home-grown charity organization under the Medical Benevolence Foundation of the Presbyterian Church called the Hanson Medical Mission Fund. Associated with 17 churches, the Hansons wrote hundreds of letters to many church elders, deacons and pastors to solicit donations. Many churches raised and sent money. Twice a week for decades, individuals, families, nurses, physicians, teachers, churches, businesses and organizations came together to help the Hansons stockpile, clean, pack and sort donations to be boxed and loaded into 40-foot shipping containers. Individuals and businesses graciously loaned large warehouses, empty houses and business buildings to store items. They also donated crates, forklifts, courier and trucking services. “It was the best thing we ever did,” Harold says. “One reason they all loved to come help us was because Harriet cooked delicious hot meals.” When the Hanson’s family room, extra bedroom, patio and carport became too full to store additional donations, 15,000 more square feet of storage space was subsequently donated by Sam Reeves (Fambro/Dunavant Warehouses in south Fresno); Pat Picchiuti in north Clovis; and Dr. Dick Shimada in Caruthers. Boyajian Trucking of Selma not only hauled containers to and
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from the Port of Oakland to be shipped, but they also transported other containers full of donated government medical excess property from Stockton’s Navy base. The Hansons and their volunteers shipped 87, 40-foot sea containers. It took 600-700 boxes of medical equipment and supplies to fill a single container and about 1,000 hours of labor to collect, clean and repair items. Each shipping container held several million dollars worth of supplies and equipment. Their son Eric recruited many people from his workplace, Sierra Pacific Orthopedic Center, to help pack the containers on Saturday mornings. Over time, word of mouth spread and hospitals in 22 countries would contact them to ask for help, particularly hospitals in India. In all, the Hansons shipped to over 60 hospitals in south Asia, Africa, Thailand, Laos, Vietnam and Brazil. Almost all of the equipment and supplies were donated by hospitals, institutions, the U.S. Defense Department warehouses, medical supply houses, doctors, nurses and even patients. Some high-priority items were purchased. The amount the Hansons shipped depended on dollar donations received and their bank’s credit limits. Expenses included truck rentals; fuel and maintenance for their vehicle and trailer to pick up donations throughout California and Nevada; equipment repairs; wages for some hired employees; food for work parties; and a multitude of incidentals such as nails, tools, office supplies; and trans-ocean and intra-country shipping costs. As word spread locally, they continued to receive equipment such as hospital beds when local nursing homes converted to electric beds. Harold was also granted the opportunity to collect and donate everything that was not needed or left behind when Valley Children’s Hospital moved to its new location in Madera in 2000. After an earthquake struck a California VA hospital, Harold was notified he and his team of volunteers could gather any items that were left after the hospital took what they could use. This resulted in four truckloads. In addition, nurses at many hospitals would save and donate medical supplies and sterile packs of gauze and towels that were opened during surgeries but never completely used. “Nurses were a big help because they don’t like to throw anything useful away,” says Harold. “At each hospital, nurses would have a receptacle bag outside surgery in which they would place items in for donation. I would go every week or two and collect them. We would sterilize and pack the items at home.” Harold says that years ago it was common practice in America to use glass syringes one time then throw them away, so he
decided to purchase a desktop sterilizer to wash and clean them so they could be saved and donated, until plastic syringes took over. Harold recalls a 150-bed hospital in Brazil reached out to them for help after the country went into a depression. Brazilian Christians built the new hospital, but it was completely empty because there were no funds to supply it. “They couldn’t run it,” Harold says. “It was a beautiful hospital, but it was empty – no beds, no equipment, nothing. Hanson Medical Mission Fund totally equipped that hospital.” After devoting a lifetime to helping others, Harold and Harriet say they owe it all to their faith. “The teaching of the prophets in the Bible’s Old and New Testament to help the sick and the poor inspired us,” Harold says. Additionally, Harriet says she’ll never forget the woman from the Navajo reservation who came to speak to her Sunday School. “She looked terrible, her hair was a mess and it looked like her dress was made out of flour sacks,” Harriet recalls. “You wouldn’t think little kids would be interested in what she was saying, but I think we all were. She was always in my mind, all throughout college and medical school.” After 44 years, the Hansons reached retirement and turned their organization over to a local agency – but their giving nature didn’t stop there. Their three children still carry on the family tradition.
An Outreach Legacy There’s no doubt the Hanson’s three children have been influenced by their parent’s work in missions because each of them now help others in their own unique ways. Their eldest, Eric, is a local orthopedic surgeon of Sierra Pacific Orthopedic Center in Fresno. For 13 years, he has traveled to Thailand every year with his wife and a team. Together with their church, they’ve helped to bring clean water to remote mountain tribes and build churches, clinics and schools. They have also helped introduce coffee production as a substitute for opium. Their middle son, Mark, holds a PhD in Psychology and mostly helps families with children who suffer from Autism and Asperger Syndrome in Massachusetts. Their youngest son, Gordon, is an Economics professor at the Kennedy School at Harvard University. His specialties are immigration from Mexico and Latin America, and trade with China. At Harvard, he is also working with a team to study how to combat childhood poverty around the world by using data from satellites and other sources. “They all have the same outreach ideas of helping others,” Harriet says. “Our family is our greatest achievement.”
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PROTECT ACCESS AND CONTROL HEALTH CARE COSTS FOR CA PATIENTS; Oppose the so-called “Fairness for Injured Patients Act”
Late last year, wealthy out-of-state trial attorneys filed an initiative for the November 2020 ballot that would substantially raise health care costs for all Californians, reduce access and exploit patients for profit. While most reporting to date has focused on the proposed changes to California’s existing law—the Medical Injury Compensation Reform Act (MICRA)—this misguided initiative would effectively eliminate California's medical lawsuit limits to create new financial windfalls for California's trial lawyers. Proponents of this measure must collect 623,212 valid signatures, which must be verified no later than June 25, 2020. Recent reports show that they’re on track to meet those numbers and qualify for the November ballot, which is why we need your commitment to oppose this dangerous initiative now more than ever. In 2014, our coalition fought and handily defeated Proposition 46, clearly saying NO to changes in MICRA that would have quadrupled the cap on non-economic damages. This measure goes far beyond what Proposition 46 would have done and the cost to taxpayers would be substantially greater. As recently noted by the independent Legislative Analyst Office, the "Fairness for Injured Patients Act" will cost California taxpayers tens of millions "to high hundreds of millions of dollars annually" in health care costs. Proposition 46 taught us the power of a strong coalition, and this time around it will be even more important. To learn more about the new initiative, and to donate to the “no” campaign, please visit protectmicra.org. >>
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WHAT IS MICRA AND WHY IS IT IMPORTANT? In the mid-1970s, California physicians were
that involved CMA and other health care
embroiled in a malpractice insurance crisis.
providers, the insurance industry and
Driven by frivolous lawsuits and excessive
trial lawyers continued until September
jury awards, medical liability insurers levied
11, when the Legislature passed AB 1XX, a
massive insurance premium increases
collection of statutes that is now known as
and canceled insurance policies for many
the Malpractice Insurance Compensation
physicians across the state. The situation
Reform Act (MICRA).
worsened in early 1975 when malpractice carriers announced that premiums for some
Governor Brown signed the CMA-supported
physicians would increase by as much as
bill on September 23, 1975, and MICRA today
400 percent, effective May 1. Many medical
remains the model for national medical
physicians had four choices, none of them
liability tort reform, as the law has been
acceptable: Raise fees and make medical
hugely pivotal in making access to care a
care unaffordable for many patients,
reality for patients.
drop their professional liability insurance coverage, leave the state, or quit practicing
Fast forward to current times, and on
medicine.
November 4, 2014, the voters of California spoke loudly and definitively, sending the
Seeking a stronger focus on the issue,
trial lawyers’ attempt to change MICRA
the California Medical Association (CMA)
(Proposition 46) to a solid defeat by a vote of
channeled physician outrage into a
67 percent to 33 percent. The message was
massive grassroots campaign that
clear – Californians don’t want to increase
mobilized thousands of physicians, patients,
health care costs and reduce health access
and other medical professionals to call
so trial attorneys can file more lawsuits.
and write their legislators to demand that
An increase in the MICRA cap on non-
the state act to cut the cost of malpractice
economic damages has been rejected
insurance.
in California again and again: 10 times in court, five times in the Legislature and
On May 13, 1975, CMA led more than 800
overwhelmingly by voters in 2014.
physicians, nurses, lab technicians and hospital personnel in a Capitol rally calling
The efforts of the California Medical
on then Governor Jerry Brown to convene
Association (CMA) and the component
a special session of the Legislature to deal
medical associations across the state
with the crisis. Three days later, on May
proved what we can do for the future of
16, Brown yielded, issuing a proclamation
health care, the quality of medicine and the
for a special session that began on May
dedication to patients everywhere.
19. Negotiations and legislative hearings
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CENTRAL VALLEY PHYSICIANS
Spring 2020
CL
DS
F I S IE S A
Internal Medicine Practice For Sale - Fresno,
CA. Revenue $1.4 million on 70 MD hours/week. Perfect for two doctors to take over. This practice is part of a five doctor group that includes a lab, Cardiac Ultrasound, Nuclear Cardiology Stress Testing, Gastroenterology Specialty Services, and Bone Densitometry. Offered at $493,000. Contact Medical Practices USA for more information. 925-820-6758. email: gary@medicalpracticesUSA.com. www.MedicalPracticesUSA.com
MEDICAL EQUIPMENT FOR SALE. MIDMARK 622 Power Table High/Low -This table is less than ten years old and in excellent condition except vinyl top is marked with ink pen. Price: $2500
MIDMARK 404 Exam Table Standard modern
style exam table with new vinyl top that is replaceable with different colors. Price: $750
MIDMARK 271 Matching Air-Lift Stool - Price: $75
PHILLIPS TC-30 Page Writer With high-tech
very durable Mobile Stand. This machine has a new replacement harness. Price, including stand $2500
ELLMAN Surgitron
FFPF EMC With ELLMAN Vapor-Vac II Vacuum With Mobile Stand Price, including stand & vacuum $3000
MILTEX SURGICAL INSTRUMENTS
Thousands of dollars of surgical instruments for minor surgery. 50% Replacement Cost Contact: Michael S. Stubblefield, M.D. at 559-284-1246 or email: msstubblefield@icloud.com
PEDIGO Mayo Stands (2) - Price: $50 each
If you would like to submit a listing to our Classifieds, contact swoods@fmms.org. Listings are free for members with reasonable rates for nonmembers. Spring 2020
CENTRAL VALLEY PHYSICIANS
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PUT YOUR MEMBERSHIP TO WORK! When you join the Fresno Madera Medical Society, you join the California Medical Association as well. Together FMMS-CMA can help with the success of your practice. Your annual dues can be more than offset when using membership services and discounts, and you get personal assistance with practice management and payment recovery issues to improve your bottom line. Join the FMMS to be a better leader for your staff and patients, and to amplify your voice to influence policy and legislation. The FMMS brings together an active community of physicians in order to improve the larger community. Our mission is physician-driven, and we want to help you solve your biggest practice management issue. Join the FMMS today!
BENEFIT Automobile & Homeowners Insurance
Breadcrumb Cybersecurity
CAP Cooperative of American Physicians
Car Rentals
Classified Ads CME Certification & Tracking CME Seminars
Confidential Hotline
Consultancy Services Driving Emblem
Insurance
MACRA Assistance
Save up to 8% more.
CONTACT Mercury Insurance Group (866) 602-5259 www.mercuryinsurance.com/cma
Discountd rates on all penetration testing, vulnerability assiessments and HIPPA/MACRA MIPS SRA Programs
Jennifer Guidry (559) 578-4800 www.breadcrumbcyber.com
Member discounts on malpractice protection, risk management and practice management.
Albert Malasig (650)543-2185 www.CAPphysicians.com
Save up to 25% on car rentals for business or personal travel.
Avis (800) 786-4262 www.cmanet.org/groupdiscounts
Free classified ads in Central Valley Physicians
FMMS: (559) 224-4224
Discounted CME courses to help physicians maintain their licenses, and easy tracking of course credit.
Institute for Medical Quality (IMQ) (877) 880-1335 imq.inreachce.com
FMMS is an accredited provider for Continuing Medical Education providing free and low cost seminars for members.
FMMS: (559) 224-4224 www.fmms.org
Confidential support and assistance to physicians affected by substance abuse, or an emotional or physical problem.
CMA: (650) 756-7787 www.cmanet.org/resources/confidential-assistance
Discount on hourly consulting fee for practice assessments, valuation, brokerage, partnerships, etc.
Practice & Liability Consultants (415) 764-4800 www.practiceconsultants.net
CHP approved emblem provides physicians expemption from speeding laws when en route to an emergency
FMMS (559) 224-4224
Discounts on medical, workers’ comp, dental, disability, long-term care, level term life & business overhead expense.
Mercer (800) 842-3761 www.mercer.com
Free tool kit on quality measures & online tool to create custom MIPS plan.
FMMS (559) 224-4224
BENEFIT
CONTACT
Up to 89% off the cover price of hundreds of magazines for your home, office, and waiting and patient rooms.
Consumer Subscription Services (800) 289-6247 www.cmanet.org/magazines
Medical IDs
Discounts on 24-hour emergency identification and family notification services.
MedicAlert Foundation (800) 253-7880 www.medicalert.org/cma
Medical Office Services
Discounts on medical billing. No upfront costs. 1st month free and 2nd month 1/2 price.
Rita Nye (559) 359-6170 www.medicalbillingmos.com
Messaging App
Free secure messaging app for physician-to-physician/care team communication.
DocBookMD www.cmanet.org/docbookmd
Notary Services
Need a document notarized? Members can receive free Notary Services at the FMMS office.
FMMS 255 W Fallbrook Ave Suite 104 (559) 224-4224
Save up to 80% on office supplies and more.
Staples Advantage (800) 786-4262 www.cmanet.org/staples
CMA’s 24-hour Physicians Confidential Assistance hotline. Free and will not result in any form of disciplinary action.
Completely Confidential Doctor - Doctor Assistance (650)756-7787
Help for practices of all sizes: legal handbooks, practice mgmt. guides, patient education materials, etc.
CMA Resource Library www.cmanet.org/resource-library
Magazine Subscriptions
Office Supplies
Physician Assistance
Practice Resources
Premier Valley Bank
Local bank offering comprehensive banking solutions that help make the job of managing finances easier
Premier Valley Bank www.premiervalleybank.com
Regency Investment Advisers
Financial advisors offering services in investment management, financial planning and retirement plans.
Stephen Guinn (559) 438-2640 www.regencyinvests.com
Get paid: members receive one-on-one assistance. We have recouped $16 million from payors in the last 10 years.
FMMS: (559) 224-4224 CMA: (888) 401-5911
15% discount on tamper-resistant security prescription pads and printer paper.
RxSecurity (800) 667-9723 www.rxsecurity.com/cma-order
Discounts on website design packages, including mobile-friendly design.
Mayaco (209) 957-8629 www.mayaco.com/physicians
Reimbursement Assistance Security Prescription Pads Website
For information on becoming an FMMS Business Partner call 559-224-4224
FRESNO MADERA MEDICAL SOCIETY
ANNUAL REPORT AND
YEAR IN REVIEW
The Fresno Madera Medical Society (FMMS) seeks to promote the practice of medicine, the delivery of healthcare, medical education, and the well-being of the physicians in Fresno and Madera counties. We strive to bring together physicians from the valley, in all modes of practice to promote quality medical care. FMMS was founded in 1883 and is credited with being Fresno County’s oldest professional organization and formed the cornerstone of the structure of organized medicine in the area. Although the Society’s services and structure have changed over the years, as have physicians and their practice techniques, the Society continues to represent over 1400 physicians in the two-county area advocating for the profession and health of the community. Our membership also includes hundreds of residents and it will soon include medical students; both are the next generation in medicine for the central Valley.
JOY OF MEDICINE
Individual Wellness Sessions Recognizing the overwhelming stresses and immense workloads that physicians face today, FMMS sponsors up to four (4) annual sessions with approved and vetted providers. These services are confidential, convenient and free of charge. In 2019, over 50 sessions took place to physicians in Fresno and Madera. To schedule an appointment, our vetted provider directly and mention that you are a physician accessing the FMMS Joy of Medicine Program. www.fmmsjoy.org Hosted the 2nd Annual Joy of Medicine Summit at Tenaya Lodge hosting over 100 physicians and their family. The weekend began with a mixer on Friday evening followed by a full day of Wellness for physicians, a luncheon and keynote speaker for spouses/significant others and a kid’s lunch and
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CENTRAL VALLEY PHYSICIANS
activities for the little one’s ages 3 and up. Saturday evening offered a family dinner and gingerbread decorating. Sunday was a relaxing day to spend with the family. Launched Physician Peer Groups – For Physicians to connect with your colleagues on a deeper level. These groups give physicians an opportunity to meet with a group of colleagues that understand and identify with what it means to be a physician. Physician Peer Groups are not group therapy, but a means for physicians to connect with one another to discuss personal and professional successes and challenges. Groups meet monthly in a local physician’s home and are facilitated by one of our qualified providers. If you are interested in hosting or joining a group, please contact FMMS.
Spring 2020
ANNUAL REPORT AND YEAR IN REVIEW SHAPING HEALTHCARE IN 2019 TOGETHER, FMMS AND CMA:
• Announced the first ever CalHealthCares awards; Announcing it will pay off $5,866.772.94 in student loans for 21 Physicians and Dentist in Fresno and Madera who commit to see more Medi-Cal patients.
• A dvocated for local public health policies to increase access to care for the uninsured, patients seeking medication assisted treatment and patients experiencing a mental health crisis.
• Secured $2.2 billion in provider rate increases through the Proposition 56 tobacco tax.
•R ecouped more than $1.3 million from payors on behalf of physician members.
• Sponsored AB 744, which revamps the rules regarding telehealth services to increase access to care and ensure physicians are fairly compensated for telehealth services.
•F MMS proved 85 hours of Continuing Medical Education (CME)
•F MMS Scholarship Foundation granted $40,000 medical school scholarship to students from Fresno & Madera Counties
• Led the fight to pass SB 276, which cracks down on fraudulent medical exemptions for childhood vaccinations.
10 YEARS OF FRESNO MADERA MEDICAL SOCIETY MEMBERSHIP 1376 Physician Members
FRESNO MADERA MEDICAL SOCIETY - YEAR 2019 ASSETS Checking/Savings: $224,427.73 Investment Accounts: $277,747.15 Accounts Receivable: $4,684.25 Other Current Assets: $22,950.41 Property and Equipment $6,384.71 Total Current Assets
LIABILITIES & EQUITY Current Liabilities Retained Earnings-Fund Balance Net Income TOTAL LIABILITIES & EQUITY
$235,570.67 $240,804.15 $59,819.43 $536,194.25
$536,194.25
2019 FRESNO MADERA PHYSICIANS
102 Different Specialties 85 hours of Continuing Medical Education (CME) $40,000 medical school scholarship granted to Student from Fresno & Madera Counties
Spring 2020
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Our providers make house calls Urgent Care is more convenient than ever. Now, you can stay home, stay safe and get the medical care you need with Saint Agnes Video Visit. From your tablet or smartphone, you can chat with one of the same urgent care providers you would usually see in-person – and for the same cost as your regular urgent care co-pay. And did we mention, there’s no waiting. To make an appointment, call (559) 450-SICK (7425). When it’s time for your visit, you’ll receive a link to initiate your video visit. There’s no download or special app required. It’s health care made easier.
Online and on time ...Health care designed with you in mind.
Commonly treated conditions n
Common female infections
n
Eye, ear, and mouth problems
n n
Minor injuries and pain Insect bites
n
Cold and flu
n
Respiratory infections and allergies
n n
Skin and nail problems Mild stomach problems
n
Other
Saint Agnes Urgent Care samc.com/Urgent-Care
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CENTRAL VALLEY PHYSICIANS
Spring 2020