Central Valley Physicians Summer 2019 by Fresno Madera Medical Society

Summer 2019

TRANS

FORMING

MEDICINE FOR TRANSGENDER PATIENTS UCSF Fresno Graduates Who Can Make The Call? FMMS Writing Contest Winner: Pain Managment

Dogsin the

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CENTRAL VALLEY PHYSICIANS

Summer 2019

VOLUME 4, NUMBER 2 â&#x20AC;¢ SUMMER 2019

{FEATURES}

4 26 28 42 44 48 50 Summer 2019

THE SOCIETY DILEMMA

{DEPARTMENTS} 4

MESSAGE FROM THE PRESIDENT

VALLEY AIR QUALITY

10 MESSAGE FROM THE EDITOR

TRANSFORMING MEDICINE

12 CHSU UPDATE

WHO CAN MAKE THE CALL?

14 UCSF FRESNO GRADUATES 39 CLASSIFIEDS

FMMS WRITING CONTEST WINNER: PAIN MANAGMENT

40 MOVIE REVIEW

FROM MEXICO TO UCLA

54 IN MEMORIAM

HUMBLE LEADERSHIP

52 PUBLIC HEALTH

COVER PHOTO: HANNAH KNOX, MD

CENTRAL VALLEY PHYSICIANS

A message from our President > Cesar Vazquez, MD

CESAR VAZQUEZ, MD, FAAP

THE SOCIETY DILEMMA WITH NO CLEAR SOLUTION

s we settle into these hot summer months in the Valley, I reflect on the less fortunate residents who must endure the triple digit heat while they struggle with life on the streets. This is not just a Valley problem but a systemic, society dilemma with no clear solution. CMA’s House of Delegates (HOD) convenes annually to debate on the most important issues affecting the practice of medicine and its members. These “Major Issues” are determined by a legislative process that includes delegates from each of the eleven California districts as well as the Board of Trustees. After considerable discussion, the most critical topics are selected for further discussion, education, and policy development.

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ONE OF THE TOPICS THAT WILL BE DISCUSSED AT THIS YEAR’S HOD IN OCTOBER IS HOMELESSNESS. THE INTENT IS TO GENERATE A REPORT WITH ACTIONABLE RECOMMENDATIONS ALONG WITH AN EDUCATIONAL SESSION PROVIDED TO THE HOUSE.

Before addressing CMA’s rationale for including this ageless subject at their flagship event, we turn to none other than Shakespeare for some literary perspective, and his keen awareness of this often overlooked reality. In Macbeth, Act 1, Scene 3, Banquo “What are these, so wither’d and so wild in their attire, that look not like th’inhabitants o’th’ earth, and yet are on’t? Or in The Merchant of Venice, Act 4, Scene 1, Shylock “You take my life when you do take the means whereby I live”. Meghan Freebeck is an advocate for the homeless in San Francisco. After visiting London’s famed Globe Theater in 2017 she later got an idea. She found out that in the 1600s, butchers, tanners, and other commoners paid nearly a day’s wage to watch one of Shakespeare’s plays. They were called groundlings because they stood on the ground while wealthier patrons sat higher in the stands. As an advocate for San Francisco’s homeless, she was determined to add something new besides helping people living on the streets get medical attention, housing and groceries. Through a partnership with the San Francisco Shakespeare festival, she set up workshops referred to as “food for the soul”. The objective was to apply the wisdom and lessons of Shakespeare to deepen social connections and improve their lives. Because Shakespeare’s plays cover a wide assortment of human experiences, the themes resonate today among people going through difficult times. For example, “The main characters of As You Like It go from being privileged members of the wealthy class to suddenly finding themselves homeless — and in some cases, penniless,” she said. “Theater skills are life skills — they assist in breaking down barriers, building bridges and helping people re-create themselves as their best selves,” she said. “That’s what I hope everyone took away from the experience.” So why does the CMA believe homelessness should be one of the major issues for discussion? According to U.S. Department of Housing and Urban Development, California has greater than one quarter of the country’s homeless population at 134,278. And Fresno/Madera County taking the prize for carrying the highest rate of unsheltered homeless (76%), a particularly vulnerable group. Despite our preconceived notion, according to the Substance Abuse and Mental Health Services Administration, only 20 - 25% of the homeless population in the U.S. suffers from some form of mental illness. The rest are stricken by an increased incidence of HIV/AIDS, tuberculosis, hepatitis, exposure-related health conditions, substance abuse, and other chronic diseases. This results in disproportionate utilization of healthcare resources which means higher

Summer 2019

ABOUT THE AUTHOR Dr. Cesar Vazquez is board certified in General Pediatrics. He earned his Bachelors of Science in Electrical Engineering and after working in the aerospace industry for a few years, he decided to pursue his dream of becoming a doctor. He attended the University of California Irvine Medical School followed by a General Surgery Internship at CedarsSinai Medical Center in Los Angeles. He then completed a Pediatric residency through the University of California San Francisco-Fresno and spent an additional year at Stanford University as a fellow in Pediatric Cardiology. Dr. Vazquez practiced for 18 years before transitioning to his current position as a physician advisor at St. Agnes Medical Center where he’s involved with utilization review, commercial denials, and clinical documentation improvement. Dr. Vazquez currently serves as president of FMMS.

CENTRAL VALLEY PHYSICIANS

hospitalization and emergency department use due to lack of access to preventive and primary care. Not for profit hospitals are intimately aware of this problem and are under pressure from the federal government to prove they deserve the tax-exempt status while struggling to survive on increased payor denials and ever more narrow profit margins. Moreover, congress’ decision to eliminate the health

insurance tax penalty has caused the uninsured rate to creep back up. As Steve Burrill, U.S. healthcare providers leader and vice chairman for Deloitte Consulting stated “We’re in an environment now where uncompensated care, which had been going down, is likely to be going up”. This brings us back to the policy questions about homelessness to be discussed at the HOD. These include improving outreach efforts, breaking down barriers, increasing charity care and community benefits, increasing affordable housing among others. In my opinion, there is a noticeable omission in this familiar task-list, which is: to heal the spirit and preserve the dignity of the homeless. “ Shakespeare should be for all” said Meghan Freebeck in her recent Washington Post article. Although Shakespeare’s plays have been around for more than 400 years, their relevance still resonates today, especially among people going through challenging times. WHILE OUR LEGISLATORS AND HEALTH POLICY EXPERTS TRY TO FIX THIS COMPLEX AND PERVASIVE SOCIETAL PROBLEM, WE SHOULD EXERCISE SOME CREATIVITY AND FOLLOW THE LEAD OF OUR SAN FRANCISCO NEIGHBORS. PERHAPS WE CAN COLLABORATE WITH OUR OWN SHAKESPEARE IN THE PARK ACTORS OR OTHER PERFORMING AND CREATIVE ARTS ORGANIZATIONS. AND THROUGH THESE WORKSHOPS, DELIVERED IN A SAFE AND NON-JUDGMENTAL ATMOSPHERE, HELP OUR UNHOUSED COMMUNITY MEMBERS EXPLORE THEIR OWN EXPERIENCES, CELEBRATE THE GOOD IN THEIR LIVES AND POSSIBLY A NONCONVENTIONAL PATHWAY TO RENEWAL AND SUCCESS.

CENTRAL VALLEY PHYSICIANS

Summer 2019

Now Enrolling

Certified Medical Coder Classes Certified Course and Exam Certification validates your achievement and demonstrates superior knowledge as an advanced coding professional.

Consecutive Wednesdays for 5 weeks August 28 September 4,11,18, 25 2019 REGISTER TODAY $995 FMMS Members $1250 Non-Members For more information call (559)224-4224 ext 112 or visit www.FMMS.org Saint Agnes Medical Center Administrative Center - The Plaza 1111 E. Spruce Avenue Leonard Conference Room Second Floor

In today’s complex practice environment, certified coders are in high demand. More physicians need Certified Medical Coders who are capable of understanding the complexities of the reimbursement process. Improve your practice’s financial health. Your certification will help limit audit liability and decrease claim denials. • Certification demonstrates to auditors, compliance officers, employees and peers that you have taken steps to attain advanced knowledge and skills. • Certified Medical Coders are employed in thousands of medical practices across the country. The CMC certification is recognized by CMS and leading healthcare groups nationwide. • Certification will help you communicate with improved confidence with physicians, third-party payers, patients and business associates. This program includes classroom instruction, course manual, homework exercises, exam preparation handbook, and certification exam. Participants may take up to six hours to complete the CMC exam. A passing score of 70% or better will confer with CMC certification.

8am - 4pm (lunch will be provided)

Recognition: PMI is recognized by the Centers for Medicare and Medicaid Services (CMS) as an example coding certification source for its Intermediary Provider Customer Service Program.1 This recognition by CMS and hundreds of Summer 2019 CENTRAL VALLEY PHYSICIANS 7 other healthcare organizations reinforces PMI’s position as a leading provider of certification for medical office staff.

From The Executive Director

THE SUMMER OF LOAN FORGIVENESS The California Medical Association and Physicians for a Healthy California (PHC) announced their commitment to pay off $58.6 million in student loans for 247 physicians under a new program created to expand access to care for Medi-Cal patients. NICOLE BUTLER

Nearly 1,300 health care providers applied to the CalHealthCares loan repayment program, which pays up to $300,000 in debt relief in exchange for meeting certain criteria such as maintaining a patient caseload of at least 30% Medi-Cal patients, being in good standing with state licensing boards, and other service time obligations.

PRESIDENT Cesar A. Vazquez, MD PRESIDENT-ELECT Alan Birnbaum, MD VICE PRESIDENT Don Gaede, MD TREASURER Brent Kane, MD PAST-PRESIDENT Trilok Puniani, MD BOARD OF GOVERNORS Christine Almon, MD, Janae Barker, DO, Jennifer Davies, MD Patrick Golden, MD, Shamsuddin Khwaja, MD Christina Maser, MD, Katayoon Shahinfar, MD Nadarasa Visveshwara, MD, John Moua, MD Pamela Kammen, MD, Ravi Rao, MD, Jai Uttam, MD Jessica Vaughn, DO (Resident Board Member) CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS EDITOR Farah Karipineni, MD MANAGING EDITOR Nicole Butler

Fresno and Madera Counties had 18 doctors that received a total of $4,816,583.64. Funding that will be paid out over the next 5 years as these physicians continue to provide care to an underserved population.

ASSISTANT EDITOR Don Gaede EDITORIAL COMMITTEE Farah Karipineni, MD - Chair, Chang Na, MD Roydon Steinke, MD, Cesar Vazquez, MD Nicole Butler, Trilok Puniani, MD

The awards are intended to improve access to care for low-income patients by creating economic incentives for physicians and dentists to provide care to Medi-Cal beneficiaries.

Alan Birnbaum, MD, Alya Ahmad, MD FAAP CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Cesar Vazquez, MD, Trilock Puniani, MD

On another note the medical society is planning this year’s Summer Meltdown event which will be held on Saturday, August 17, 2019 at the Bankers Ballroom on Fulton Street in downtown Fresno. This year’s entertainment will defy gravity, allowing your imagination to go on an adventure with bright colors, athleticism and laughs. Summer Meltdown CIRQUE will be a visual artistry of the human body – graceful, athletic, capable of performing feats that challenge our vision of the real world, weaving a tapestry of artistry, surrealism and theatrical humor.

Erin Kennedy, Nicole Butler, Jennifer Seita, Alya Ahmad, MD FAAP, Farah Karipineni, MD, Richard Pan, MD, Alex Sherriffs, MD, Roydon Steinke, MD, Amy McLain, BSN, RN, Leilani Gutierrez-Palominos Ravi D. Rao, MD CONTRIBUTING PHOTOGRAPHERS Anthony Imirian, CCFMG Staff, USCF Fresno 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

Tickets are still available and can be found online at www.fmms.org or by calling (559) 224-4224. Ex 114.

Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler

Have a wonderful Summer.

Membership and Events Manager, Stacy Woods Marketing and Events Coordinator, Kailey Fontes

Nicole

CENTRAL VALLEY PHYSICIANS

Summer 2019

CENTRAL VALLEY PHYSICIANS

A message from our Editor > Farah Karipineni, MD, MPH

Having Heart

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.

CENTRAL VALLEY PHYSICIANS

It was 5:45 in the morning on a Monday after a full weekend of call. Thoroughly exhausted, I shuff led into the elevator and was met by the stench of stale clothing mixed with cigarette smoke. A painfully thin teenager exited, looking lost. I allowed him to wander out, grateful to be spared his odor. I was apathetic, overtaken by a weariness I vowed as a medical student never to have. Morning rounds passed without incident. All our CABG patients were more or less stable. I collected each patient’s overnight events, vital signs, laboratory values, daily chest x-ray, EKG, f luid balance and wound status. With my attending’s blessings, I titrated their blood pressure drips to protect their blood vessels, kept them sedated and paralyzed if they were mechanically ventilated, fed them benzodiazepines if they were alcoholics, and added or subtracted tubes and lines as needed. Eager for a post-rounds lull, I sank into a chair in the cardiac care unit and opened my email. Because I was still around, a nurse asked me to renew some orders for electronic housekeeping. Then the pager rang with a consult, and my lull was over. The consult was for Roy, an elderly gentleman with a history of a recent valve replacement who needed to be on anticoagulation. He was being followed regularly at his Coumadin clinic, where his INR was checked biweekly and blood thinner dose adjusted appropriately. According to the primary team, the lab called his cell phone and instructed him to come to the hospital immediately for an INR level of 17. On questioning him, they found that he had been taking twice the prescribed dose of Coumadin. I went to the patient’s room to do a full history and physical exam. Roy was a 78-year-old gentleman with scraggly hair and pockmarked skin. He was probably 5 foot 7 but his stoop cut him 3 inches. The only part of his body that suggested any reserve was a small round belly. He was the kind of person I would pass on Broad Street without noticing. But just like the CABG patients I looked over so meticulously each morning in the unit, this man was once equally carefully looked after in his immediate postoperative period. Now he was back at home with a chronic pericardial effusion, failed

Summer 2019

Every effort requires a sacrifice, and by definition, the act of giving to one cause means taking away from another.

kidneys, and an INR that could cause him to spontaneously bleed from any vessel or orifice at any moment. I asked him why he doubled up on his Coumadin dose. The question made him suddenly energized, and he angrily replied that he takes all his medications twice daily, so why should Coumadin be any different? After my assessment, I called the attending and we reviewed his echocardiogram. He had a loculated pericardial effusion, stable in size over the past few months.

In that moment, Roy transformed in my eyes from an old man on the street to some kind of self less hero. Despite his tenuous health, he was not thinking of his own wellbeing. In his mind, he was running on empty not because the sticky f luid in his heart bag was preventing it from pumping, but because he was a burden on his family. He was sick of tiring his wife, not sick of his heart and kidneys tiring him. In that moment, the senselessness of his Coumadin overdose melted away, and he was wise and kind. Ignorant of things that I knew all about—Coumadin dosing, target INR, how to correct a What gives me hope in the face of sacrifice is the supratherapeutic INR, how to manage simple and loculated effusions—but knowledge that even when we think our heart far beyond me in things that matter cannot possibly expand to encompass everyone in life’s bigger picture. Nurturing and everything in front of us, it can. relationships, fulfilling duties, making personal sacrifices, and that too in the face of extreme physical limitations— as a young resident, those are things I The f luid around his heart was sticky, which meant that knew less about. effective drainage would be extremely risky. We revisited Life as a doctor is self less and selfish at the same time. him at dialysis that same afternoon to complete the consult. You are self less for your patients and your team, but you are He was sleeping restfully in the corner, paying no attention selfish in the face of life outside the hospital. Every effort to the whir of the dialysis machine or the Married…With requires a sacrifice, and by definition, the act of giving to Children rerun playing on his mini television. one cause means taking away from another. The taking The attending put his hand gently on Roy’s shoulder to away is often from outside the hospital, including sleep, say hello. After several nudges the patient awoke, grunting. sunshine, recreation, and, most importantly, loved ones. His breathing was labored. His blood pressure and oxygen What gives me hope in the face of sacrifice is the saturation were borderline acceptable, his heart barely knowledge that even when we think our heart cannot tolerating the f luid being drawn off. My attending knew the possibly expand to encompass everyone and everything patient well, and other than the high INR, was not troubled in front of us, it can. Yes, there may be f luid around it. The by his current state. “Doc, I can’t go on like this,” Roy said. f luid might even be sticky, too sticky to get rid of. The heart “My lady, she’s 70, she can’t keep running after me. She’s can accept this and make room to expand. tired. I can’t put her through this. And we got a 6-year-old It can make room, if we let it. to get to school every morning. You gotta do something.”

Summer 2019

CENTRAL VALLEY PHYSICIANS

BY NICOLE BUTLER

The Central Valley’s First Osteopathic Medical School approved to Accept Applications When California Health Sciences University completes the building phase of the new medical school, you won’t find a cadaver lab. Instead, it will have something better: a virtual reality anatomy lab using 3D holographic technology.

holographic technology will replace the traditional cadaver lab normally used for teaching anatomy. Therefore, CHSU will eliminate the need to obtain and store donated human cadavers for student instruction.

Recently they demonstrated the 3D HoloAnatomy system that students attending the College of Osteopathic Medicine will use to explore the intricacies of the human body. Virtual reality-type headsets will give every student a highly interactive learning experience that realistically simulates a body’s structure, organs, and systems. This cutting-edge

The 3D holographic anatomy curriculum will revolutionize how students learn and students can use holograms to easily separate and enlarge small organs and functions, giving them access to body systems like never before. The headsets are wireless, so students are able to move freely around the room, interacting with the hologram, class instructors and each

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Summer 2019

other. The system is described as “mixed reality” because users still can see their actual surroundings while wearing the specialized goggles. With virtual reality systems, often used for gaming, the user experience is entirely artificial. HoloAnatomy was developed by Case Western Reserve University in Ohio and adopted for use by its school of medicine in 2015. The technology is built on Microsoft’s HoloLens 2 platform, offering what the company calls an immersive mixed reality experience.

CHSU College of Medicine campus is well under construction and making great progress on the outer envelope of the building. They are starting to add insulation and sheet rock in some of the interior spaces. They are on target to have the building completed and moved in by early spring and anticipate the public ribbon cutting ceremony to be held April 2020. The school is now accepting applications for its first cohort of 75 students and has received over 2000 applications thus far.

CHSU recently partnered with Case Western and their HoloAnatomy™ program.

PHOTO COURTESY OF HARVARD BUSINESS SCHOOL

Summer 2019

CENTRAL VALLEY PHYSICIANS

2019

UCSF FRESNO

GRADUATES DOCTORS TO CARE FOR VALLEY PATIENTS AND TEACH FUTURE PHYSICIANS UCSF Fresno’s 2019 Commencement was held on June 13 2019. More than 100 medical residents and fellows completed training at UCSF Fresno this year. Many will stay in the Central Valley to care for patients, teach future physicians or continue their medical education. “Nearly 40 percent of physicians completing training in family and community medicine, almost 50 percent of pediatrics residents and 44 percent of internal medicine residents are remaining in the Valley to care for community members,” said Michael W. Peterson, MD, associate dean at UCSF Fresno. “This is outstanding news given the current and projected shortage of primary care clinicians in the region and state. Congratulations to these and all of our 2019 graduates.”

HOUSESTAFF AWARDS INCLUDED: Outstanding First Year Resident

David Tomajan, MD

Internal Medicine

Outstanding Resident or Fellow Teacher

Manavjeet Sidhu, MD

Emergency Medicine

Outstanding Attending Teacher

Tim Evans, MD, PhD

IM-Pulm

Outstanding Non-Physician Teacher

Tou Thao, Pharm D

CRMC

Borba House Staff Research - Resident

Emaad Farooqui, MD

Surgery

Borba House Staff Research - Fellow

Kirat Gill, MD

Pulm Critical Care

Faculty Research

Soe Naing, MD

Internal Medicine

ICare (VA award)

William Kelley, DO

Internal Medicine

UCSF Fresno Community Service Award

Rafael Martinez, MD

Family Medicine

Leon S. Peters

Lily Hitchner, MD

Emergency Medicine

Kaiser Award For Excellence In Teaching

Haifaa Abdulhaq, MD

IM - Hem/Onc

Lucas Seiler, MD

Orthopedic Surgery

Fresno Madera Medical Society Steven N. Parks Leadership

CENTRAL VALLEY PHYSICIANS

Summer 2019

CENTRAL VALLEY PHYSICIANS

2019 Specialty

Medical School

After Graduation Plans

Acute Care Surgery Fellowship

Nicholas Sheets, MD

West Virginia University School of Medicine

Dr. Sheets will practice Trauma Surgery in California.

Cardiovascular Disease Fellowship

Nareg Minaskeian, MD

St. George’s University School of Medicine

Dr. Minaskeian will begin an Electrophysiology Fellowship at the Mayo Clinic’s campus in Arizona.

H Kiran Reddy, MD

St. George’s University School of Medicine

Dr. Reddy will begin an Interventional Cardiology Fellowship at UCSF Fresno.

Moussa Saleh, MD

Loma Linda University School of Medicine

Dr. Saleh will begin an Electrophysiology Fellowship at Lenox Hill/North Shore University Hospital, New York.

Community Pediatrics Fellowship

Soe Maw, MD

University of Miami Leonard M. Miller School of Medicine

Dr. Maw will join the UCSF Fresno Department of Pediatrics as faculty.

Emergency Medicine

David Amsalem, MD

Vanderbilt University School of Medicine

Dr. Amsalem will be practicing Emergency Medicine in Bishop, California.

Stephanie Benjamin, MD

University of Cincinnati College of Medicine

Dr. Benjamin will begin an EMS/ Disaster Medicine Fellowship at UC San Diego in California.

Victoria Fanslow, MD

UC Davis School of Medicine

Dr. Fanslow accepted a position with Alaska Emergency Medicine Associates in Anchorage, Alaska.

Nathan Garvin, MD

University of Massachusetts Medical School

Dr. Garvin accepted a position with Kaiser Permanente in Fresno, California.

Jordan Harp, MD

University of Illinois College of Medicine

Dr. Harp will practice Emergency Medicine in California’s Central Valley.

Lily Hitchner, MD

UC San Francisco School of Medicine

Dr. Hitchner will join the UCSF Fresno Department of Emergency Medicine as faculty.

Danielle Holtz, MD

Loma Linda University School of Medicine

Dr. Holtz accepted a position with Asante Rogue Regional Medical Center in Medford, Oregon.

Janelle Lee, MD

Albert Einstein College of Medicine

Dr. Lee accepted a position with Kaiser Permanente in Santa Clara, California.

James McCue, MD

UC Davis School of Medicine

Dr. McCue will join the UCSF Fresno Department of Emergency Medicine as faculty.

Dimitri Steblovsky, MD

Boston University School of Medicine

Dr. Steblovsky accepted a position with Kaiser Permanente in south Sacramento, California.

Lauren Eby, DO

Touro University California College of Osteopathic Medicine

Dr. Eby will practice Family Medicine at Sutter Health in Santa Cruz, California.

Qiuying Huang, DO

Touro College of Osteopathic Medicine - New York

Dr. Huang will practice at an Urgent Care in California’s San Francisco Bay Area.

Family and Community Medicine

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Summer 2019

MICKEY SACHDEVA, MD, BORN AND RAISED IN FRESNO AND COMPLETED HIS PULMONARY AND CRITICAL CARE FELLOWSHIP AT UCSF FRESNO. He will now be practicing at Kaiser Permanente, an organization he chose based on the

health care delivery system and how it integrates all the elements of care–

physicians, hospitals, home health, pharmacy and other support programs

for the patients they serve. “I felt as though I would be happiest serving the city I love, surrounded by the people I love,” said Dr. Mickey Sachdeva.

Sachdeva completed all of his medical training here in Fresno, including

his residency in Internal Medicine, where he received the Steven N. Parks Leadership Award in 2013. He became interested in medicine from a

high school Biology teacher at Bullard High. The class focused on human physiology and genetics and throughout the year, the class continued to

spark an interest in the human body and its dynamic abilities. Since then, life experiences and his passion for science have been his motivation behind his pursuit of medicine.

Sachdeva attended undergraduate at UC Davis and Medical School at Ross

University. As he progressed in his medical career he found his passion and skills lie in the field of Pulmonary and Critical Care. In his spare time, he enjoys traveling, hiking, and golf.

RAFAEL MARTINEZ, MD, IS COMPLETING A THREE-YEAR RESIDENCY PROGRAM IN FAMILY AND COMMUNITY MEDICINE. Dr. Martinez immigrated to the U.S. from Mexico with his family when he was five years old. He grew up in Visalia and went to Redwood High School. From an early age,

he knew he wanted to pursue a career in health care, but it wasn’t until he worked as a health educator for Family Health Care Network that he was inspired to become a physician. The opportunity to care for patients across

the life spectrum, including pregnant patients, newborns,

adults and entire families, motivated him to pursue family

medicine. UCSF Fresno was his top choice for residency. He conducted rotations at UCSF Fresno as a medical

student and his family is in the area. After graduation, he will practice at United Health Centers in Parlier where he

trained as a resident and wanted to continue caring for patients there. A first-generation college graduate, Dr. Martinez said the path to becoming a physician is filled with many challenges, but he is fortunate to have the support of his family and

is humbled every day to care for people whose voices aren’t heard often and who don’t have representation. In his spare time, he enjoys reading about cars, traveling and spending time with his wife and 10-month old son.

Summer 2019

CENTRAL VALLEY PHYSICIANS

2019 Lynna Nguyen, DO

Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California

Dr. Nguyen will practice Family Medicine at Kaiser Permanente in Fresno, California.

Thomas Quigg, DO

Touro University California College of Osteopathic Medicine

Dr. Quigg will practice Family Medicine at Sutter Health in Santa Cruz, California.

Eliza Tran, DO

Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California

Dr. Tran will practice Family Medicine at Kaiser Permanente in Southern California.

Hiroyasu Kikawa, MD

American University of the Caribbean School of Medicine

Dr. Kikawa will practice Primary Care in California’s San Francisco Bay Area.

Especianise Loresca, MD

UC San Francisco School of Medicine

Dr. Loresca will practice Family Medicine at Sutter Health in Oakland, California.

Rafael Martinez, MD

Universidad Autonoma de Guadalajara School of Medicine

Dr. Martinez will practice Family Medicine at United Health Centers in Selma, California.

Laura Nunes, MD

Ross University School of Medicine

Dr. Nunes will practice Family Medicine at United Health Centers in Fowler, California.

Juan Rios, MD

St. George’s University School of Medicine

Dr. Rios will practice Family Medicine at United Health Centers in Selma, California.

Fay Roepcke, MD

St. George’s University School of Medicine

Dr. Roepcke will begin a Women’s Health Faculty Development Fellowship at Florida Hospital in Florida.

Gastroenterology Fellowship

Padmavathi Mali, MD

Osmania Medical College

Dr. Mali accepted a staff Gastroenterologist position in Gunderson Lutheran Medical Center in La Cross, Wisconsin.

Gastroenterology Fellowship

Dipti Sagar, MD

Magadh University - Nalanda Medical College

Dr. Sagar accepted a position as Medical Director in Gastroenterology in Los Angeles, California.

Hematology and Oncology Fellowship

Gregory Gilmore, DO

Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California

Dr. Gilmore accepted a position at The Oncology Institute of Hope and Innovation in Southern California.

Mohamad Barakat, MD

University of Aleppo, Faculty of Medicine

Dr. Barakat accepted a position at Pacific Shores Medical Group in Irvine, California.

Nicole Jernick, MD

Georgetown University School of Medicine

Dr. Jernick will join the UCSF Fresno Family Medicine Department as faculty.

Norr Santz, MD

Ross University School of Medicine

Dr. Santz will practice Hospice and Palliative Medicine in California.

Quentin Doperalski, DO

Touro College of Osteopathic Medicine - New York

Dr. Doperalski will join a private practice in Petoskey, Michigan.

Tamara Bininashvili, MD

Ross University School of Medicine

Dr. Bininashvili will begin a private practice in Salem, Oregon.

Hospice and Palliative Medicine Fellowship

Infectious Diseases Fellowship

CENTRAL VALLEY PHYSICIANS

Summer 2019

JUAN RIOS, MD, IS COMPLETING A THREE-YEAR RESIDENCY PROGRAM IN FAMILY AND COMMUNITY MEDICINE. Dr. Rios was born and raised in Reedley and graduated from Reedley

High School. As the son of a 17-year-old mom and growing up in a rural farming community, it was challenging to

evolve beyond the low expectations preconceived by his upbringing, he said. But, he was drawn to the sciences as a young student. While taking Advanced Placement

courses in high school, he noted the relationship between

science and medicine and the idea of working in medicine and applying science to real-life situations appealed to

him. After witnessing the declining health of loved ones due to limited access to health care, dedicating himself

to becoming a physician was an easy decision. Family

medicine was especially attractive because it allows for

the unique opportunity to care for a wide variety of patients on any given day. There was never any doubt that UCSF

Fresno is where he wanted to train, close to home. In fact, a

significant portion of his residency training took place in his hometown. The first in his family to seek education beyond high school, Rios found it intimidating trying to navigate college and medical school with very little guidance. But, he persisted. After graduation, Dr. Rios will work at United Health Centers in Selma, California. In his spare time, he enjoys spending

time with his wife and kids. He also enjoys regular exercise, watching baseball (Giants) and football (Cowboys) games, and his newest hobby, barbecuing.

LYNNA NGUYEN, DO, IS COMPLETING A THREE-YEAR RESIDENCY PROGRAM IN FAMILY AND COMMUNITY MEDICINE. Dr. Nguyen grew up in Orange County,

California, where she attended Oxford Academy. She chose to pursue family medicine because it allows

her to provide continuity care for patients as well as

to serve as an advocate for them. Family physicians

are in the best positions to provide patient education and anticipatory care for their patients, according to Dr. Nguyen. “In no other specialty can a physician implement life-changing interventions as well as

follow the outcomes through each developmental

milestone and generation,” she said. She picked UCSF Fresno for residency training because the family and

community medicine program is known for exemplary

community-based training that is well-rounded and full-

scope in both inpatient and outpatient settings with large

and diverse patient populations. The Southern California native is staying in Fresno to practice at Kaiser Permanente after graduation. In her spare time, she enjoys traveling, hiking, and playing board games with friends and family.

Summer 2019

CENTRAL VALLEY PHYSICIANS

2019 Internal Medicine (Categorical)

Aparna Desai, DO

Touro University Nevada College of Osteopathic Medicine

Dr. Desai will begin a Hospice and Palliative Medicine Fellowship at UC San Diego Medical Center in California.

William Kelley, DO

Touro University California College of Osteopathic Medicine

Dr. Kelley will join the UCSF Fresno Department of Internal Medicine as a Chief Resident.

SangOuk Lee, DO

Arizona College of Osteopathic Medicine of Midwestern University

Dr. Lee accepted an Academic Outpatient Clinic position at Saint Agnes Medical Center in Fresno, California.

Chelsea Park, DO

Edward Via College of Osteopathic Medicine Virginia Campus

Dr. Park will practice Primary Care Medicine in Texas.

Ben Rasmussen, DO

Chicago College of Osteopathic Medicine of Midwestern University

Dr. Rasmussen has accepted a position with Primary Care at UC Davis Health in Folsom, California.

Daniel Sims, DO

Arizona College of Osteopathic Medicine of Midwestern University

Dr. Sims will join the UCSF Fresno Department of Internal Medicine as a Chief Resident.

Sam Tonthat, DO

Touro University California College of Osteopathic Medicine

Dr. Tonthat will begin a Nephrology Fellowship at UC Irvine in California.

Matthew Beutner, MD

Ross University School of Medicine

Dr. Beutner will begin a Pulmonary/ Critical Care Fellowship at UCSF Fresno.

Phuong Dang, MD

Ross University School of Medicine

Dr. Dang will join the UCSF Fresno Department of Internal Medicine as a Chief Resident.

Sneha Gullapalli, MD

Kempegowda Institute of Medical Sciences

Dr. Gullapalli will begin a Pulmonary/ Critical Care Fellowship at the University of Miami in Florida.

Braden Lind, MD

State University of New York Upstate Medical University

Dr. Lind will join the UCSF Fresno Department of Internal Medicine as a Chief Resident.

Michele Maison-Fomotar, MD

University of Yaounde I Faculty of Medicine and Biomedical Sciences

Dr. Maison-Fomotar will begin an Infectious Disease Fellowship at UCSF Fresno.

Victoria Malkhasyan, MD

St. Georgeâ&#x20AC;&#x2122;s University School of Medicine

Dr. Malkhasyan will practice Internal Medicine in Los Angeles, California.

Mosaab Mohameden, MD

Misr University for Science and Technology College of Medicine

Dr. Mohameden will begin a Rheumatology Fellowship at the University of Cincinnati in Ohio.

Deepti Mundkur, MD

Kasturba Medical College Mangalore

Dr. Mundkur accepted a position with Arch Health Medical Group in San Diego, California.

Naga S. Palakodety, MD

Bhaskar Medical College

Dr. Palakodety will practice Hospitalist in California

Kara Schmidt, MD

Ross University School of Medicine

Dr. Schmidt has accepted a Chief Resident position in Quality and Safety at UC Davis in California.

Adam Shurbaji, MD

Weill Cornell Medical College of Cornell University - Qatar

Dr. Shurbaji will practice Internal Medicine in California.

CENTRAL VALLEY PHYSICIANS

Summer 2019

H KIRAN REDDY, MD, IS COMPLETING A THREE-YEAR FELLOWSHIP IN CARDIOVASCULAR DISEASE AND WILL CONTINUE HIS MEDICAL EDUCATION AT UCSF FRESNO AS A FELLOW IN THE ONE-YEAR INTERVENTIONAL CARDIOLOGY PROGRAM. Raised in Hanford,

California, Dr. Reddy’s history with UCSF Fresno

dates back to the late 1990s when he participated in UCSF Fresno’s Summer Biomedical Internship Program as a student at Hanford West High

School. Later, he conducted clinical rotations at

UCSF Fresno as a fourth-year medical student and returned to complete residency training in internal medicine. When he completes the additional

interventional cardiology fellowship, Dr. Reddy will have spent seven years training at UCSF Fresno.

He intends to stay in the Valley to care for patients

and work closely with his father, Hanford cardiologist,

Raj Reddy, MD. “We have a lot of cases of diabetes, end-stage renal disease, and hypertension,” Dr. H Kiran Reddy said. “These diseases happen early in life and many patients do not have good access to health care. Coronary artery disease

can occur as a result of untreated, secondary diseases.” His goal is to increase access to cardiac health care and make a

difference in Hanford and throughout the Valley. When not working, he enjoys spending time with his two children and wife Pooja Reddy, MD, who also completed internal medicine residency training at UCSF Fresno. Dr. Pooja Reddy is a current faculty member who works with internal medicine residents at the VA Central California Health Care System in Fresno.

St. George’s University School of Medicine

Dr. Singh will practice Internal Medicine at the University of Chicago in Illinois.

Arizona College of Osteopathic Medicine of Midwestern University

Dr. Brandow will begin a Sleep Medicine Fellowship at UCSF Fresno.

Jonathan Pham, DO

Touro University California College of Osteopathic Medicine

Dr. Pham will join the UCSF Fresno Internal Medicine Department as faculty.

Karamjit D. Binning, MD

Ross University School of Medicine

Dr. Dhaliwal-Binning will join the UCSF Fresno Internal Medicine Department as faculty.

Faye Pais, MD

St. John’s Medical College

Dr. Pais will begin a Pulmonary/Critical Care Fellowship at the University of Florida.

Navjit Dullet, DO

Touro University California College of Osteopathic Medicine

Dr. Dullet will begin a Diagnostic Radiology Residency at the University of Arizona.

Amit Chaudhari, MD

Rutgers New Jersey Medical School

Dr. Chaudhari will begin a Neurology Residency at UC Irvine in California.

Natasha Singh, MD

Internal Medicine (Chiefs) Chloe Brandow, DO

Internal Medicine (Preliminary)

Summer 2019

CENTRAL VALLEY PHYSICIANS

2019 Alysse Clark, MD

Oakland University William Beaumont School of Medicine

Dr. Clark will begin a Diagnostic Radiology Residency at Loma Linda University in California.

Gabriel Duhancioglu, MD

Chicago Medical School at Rosalind Franklin University of Medicine & Science

Dr. Duhancioglu will begin a Diagnostic Radiology Residency at the University of Arizona.

Camille Guzel, MD

Duke University School of Medicine

Dr. Guzel will begin a Physical Medicine and Rehabilitation Residency at Northwestern McGaw Medical Center/Shirley Ryan AbilityLab in Chicago, Illinois.

Rebeka Sipma, MD

Loma Linda University School of Medicine

Dr. Sipma will begin a Neurology Residency at UC San Diego in California.

David Tomajan, MD

Drexel University College of Medicine

Dr. Tomajan will begin a Physical Medicine and Rehabilitation Residency at Stanford University in California.

Dolores Torres, MD

UC San Francisco School of Medicine

Dr. Torres will begin a Neurology Residency at UC San Diego in California.

Sagar Wagle, MD

UC San Francisco School of Medicine

Dr. Wagle will begin a Diagnostic Radiology Residency at the Mayo Clinic in Rochester, Minnesota.

Brittany Young, MD

University of Wisconsin School of Medicine and Public Health

Dr. Young will begin a Neurology Residency at UCLA in California.

Interventional Cardiology Fellowship

Howard Lan, DO

Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California

Dr. Lan will join the Loma Linda University Medical Center Cardiology Department as faculty in Loma Linda, California.

Maternal Child Health Fellowship

Milana Pebenito, MD

Dr. Pebenito will practice full scope Family Medicine with Obstetrics & Gynecology at the Community Health Center in Petaluma, California.

Obstetrics/Gynecology

Andrea Seid, DO

Touro University California College of Osteopathic Medicine

Dr. Seid accepted a position at Sharp Rees-Stealy Medical Group in San Diego, California.

Lynsa Nguyen, MD

George Washington Dr. Nguyen will begin a Maternal Fetal University School of Medicine Medicine Fellowship at Vanderbilt & Health Sciences University in Nashville, Tennessee.

Tiffany Pham, MD

Pennsylvania State University College of Medicine

Dr. Pham accepted a position with Los Olivos Womenâ&#x20AC;&#x2122;s Medical Group in Los Gatos, California.

Mai Tran, MD

University of Miami Leonard M. Miller School of Medicine

Dr. Tran will practice Obstetrics and Gynecology in Washington state.

Omid Niavarani, DDS

University of the Pacific Arthur A. Dugoni School of Dentistry

Dr. Niavarani will join a private practice in Orange County, California.

Bryan Clevenger, DDS

University of the Pacific Arthur A. Dugoni School of Dentistry

Dr. Clevenger will join a private practice in Medford, Oregon.

Oral and Maxillofacial Surgery (OMFS)

CENTRAL VALLEY PHYSICIANS

Summer 2019

Orthopaedic Surgery

Pediatrics

Psychiatry

Summer 2019

Diana Lin, DMD

A.T. Still University, Arizona School of Dentistry & Oral Health

Dr. Lin will join a private practice in Philadelphia, Pennsylvania.

Jesus Fajardo, MD

Harvard Medical School

Dr. Fajardo will begin an Orthopaedic Adult Reconstruction Fellowship at the University of Buffalo in New York.

Kimberly Grannis, MD

Wright State University Boonshoft School of Medicine

Dr. Grannis will begin an Orthopaedic Trauma Fellowship at UC Davis in California.

Lucas Seiler, MD

University of Nebraska College of Medicine

Dr. Seiler will begin an Orthopaedic Hand Fellowship at University of Iowa in Iowa City, Iowa.

Jesse Alifano, DO

Touro University California College of Osteopathic Medicine

Dr. Alifano will join a private practice in Fresno, California and continue to work per diem with UCSF Fresno.

Rebecca Hadeed, DO

Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - Oregon

Dr. Hadeed will practice outpatient/ inpatient Pediatrics in Colorado.

David Yi, DO

University of North Texas Health Science Center/ Texas College of Osteopathic Medicine

Dr. Yi will join the UCSF Fresno Department of Pediatrics as a Chief Resident.

Ashkon Banihashemi, MD

St. George’s University School of Medicine

Dr. Banihashemi accepted a position with Kaiser Permanente in Roseville, California.

Hakim Kebir, MD

St. George’s University School of Medicine

Dr. Kebir will practice Pediatric inpatient medicine in Fresno, California.

Lubena Khambaty, MD

American University of the Caribbean School of Medicine

Dr. Khambaty will practice outpatient medicine in Southern California.

Stanford Ly, MD

Ross University School of Medicine

Dr. Ly will practice ambulatory care in Sacramento, California.

Amreeta Panesar, MD

Ross University School of Medicine

Dr. Panesar will practice Pediatric inpatient medicine.

Whitney Paullin, MD

St. George’s University School of Medicine

Dr. Paullin will practice outpatient Primary Care in Los Angeles, California.

Paulinder Ranu, MD

Ross University School of Medicine

Dr. Ranu will join a private practice in Fresno, California.

Ivett Renteria, MD

St. George’s University School of Medicine

Dr. Renteria will join the UCSF Fresno Department of Pediatrics as a Chief Resident.

Rhonda Watkins, MD

St. George’s University School of Medicine

Dr. Watkins will begin a Pediatric Sports Medicine Fellowship at Boston Children’s Hospital in Massachusetts.

Arlen Kwong, DO

Touro University California College of Osteopathic Medicine

Dr. Kwong will practice Psychiatry at the California Department of Corrections & Rehabilitation.

CENTRAL VALLEY PHYSICIANS

2019 Amina Sutherland-Stolting, MD

University of Groningen Faculty of Medical Sciences

Dr. Sutherland-Stolting will begin a Child & Adolescent Psychiatry Fellowship at UC Irvine in California.

Gurpreet Aujla, MD

Semmelweis University Faculty of Medicine

Dr. Aujla will practice locum tenens Psychiatry in California.

Kimberly Cranford, MD

University of Washington School of Medicine

Dr. Cranford will practice Psychiatry at Coalinga State Hospital in Coalinga, California.

Kirat Gill, MD

St. Georgeâ&#x20AC;&#x2122;s University School of Medicine

Dr. Gill will begin a Fellowship in Sleep Medicine at Stanford University in California.

Wisam Naji, MD

University of Al-Mustansiriyah Dr. Naji will join the Facey Medical Group in Valencia, California.

Mickey Sachdeva, MD

Ross University School of Medicine

Dr. Sachdeva accepted a position at Kaiser Permanente in Fresno, California.

Paymon Ebrahimzadeh, DO

Touro College of Osteopathic Medicine - New York

Dr. Ebrahimzadeh accepted a position in Southern California.

Kyle Almodovar, DO

Western University of Health Sciences /College of Osteopathic Medicine of the Pacific

Dr. Almodovar will join the UCSF Fresno Sleep Medicine Department as faculty.

YenYoan Chu, MD

Boston University School of Medicine

Dr. Chu will begin a Plastic Surgery Fellowship at Wayne State University in Detroit, Michigan.

Emaad Farooqui, MD

Chicago Medical School at Rosalind Franklin University of Medicine & Science

Dr. Farooqui will begin a Vascular Surgery Fellowship at the University of Southern California in Los Angeles, California.

Jahoon Koo, MD

University of Minnesota Medical School

Dr. Koo will begin a Vascular Surgery Fellowship at Oakland University William Beaumont in Royal Oak, Michigan.

Fatima Wilder, MD

Ohio State University College of Medicine

Dr. Wilder will begin a Thoracic Surgery Fellowship at Johns Hopkins University in Baltimore, Maryland.

Surgical Critical Care Fellowship

Emily Kreger, MD

Wayne State University School of Medicine

Dr. Kreger will practice Critical Care Surgery.

Wilderness Medicine Fellowship

Arun Ganti, MD

Washington University in St. Louis

Dr. Ganti will join the UCSF Fresno Department of Emergency Medicine as faculty.

Cara McAnaney, MD

University of Pittsburgh School of Medicine

Dr. McAnaney accepted an academic Family Medicine position at the University of Pittsburgh in Pennsylvania.

Pulmonary and Critical Care Fellowship

Sleep Medicine Fellowship

Surgery

CONGRATS GRADS! 24

CENTRAL VALLEY PHYSICIANS

Summer 2019

FMMS Joy of Medicine www.FMMSJoy.org

Remember when medicine was fun? RECONNECT TO YOUR

Joy of Medicine

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 Consultations 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 vetted providers confidentially, conveniently and FREE to physicians living and practicing in Fresno and Madera Counties. Participating in a Joy of Medicine Resiliency Consultation is completely confidential. Neither FMMS, your employer, nor the California Board of Medicine will be notified if you choose to participate. Participating providers offer a wide range of appointment times that strive to accommodate the unique and busy schedules of physicians. FMMS sponsors up to four Consultations per year. Providers are paid by FMMS directly, discreetly and anonymously. Insurance will not be asked for or billed. Physicians have the option of extending their participation at their own expense after the fourth visit. Make medicine fun again. Call today to schedule a free Resiliency Consultation and begin the process of reconnecting to your Joy of Medicine.

SCHEDULE

AN APPOINTMENT Summer 2019

ROUBICEK and THACKER 559-323-8484

Call and identify yourself as a physician practicing in Fresno or Madera County CENTRAL VALLEY PHYSICIANS 25

Valley Continues to Have Some of the

Worst Air Quality in the Nation.

By Alex Sherriffs, MD

The American Lung Association’s 20th Annual State of the Air released this April celebrated the health benefits of steady improvement in our nation’s and state’s air quality. Spending a lifetime breathing the Valley’s air quality of 3 decades ago would have shortened your life expectancy by 2 years. Ah, the good old days! Driven largely by the health goals and science integral to the 1970 Federal Clean Air Act, major air pollutants have been decreased by 90%. We still have major challenges, however, especially in our Valley. Some 400 Valley people--our patients, neighbors, family, friends- die prematurely every year because of our unhealthful air quality; this is more than die in auto accidents or homicides, which generate daily headlines. The bad news in this latest air quality report is that once again our Valley has the some of the worst air quality in the nation. Much more worrisome, for the first time in the history of the report, some two-thirds of the most polluted cities in the country were worse off than the year before; the worst of these are located in California. Be optimistic--people create the pollution, so people can control it. Transportation of people and goods is

CENTRAL VALLEY PHYSICIANS

Summer 2019

currently the main source of air pollution: trucks, cars, trains, buses, construction equipment. Agriculture is also a major source of pollutants. Even seemingly innocent pleasures such as charbroiling our food and burning wood in a fireplace are significant contributors to our air pollution. All of those activities are subject to increasing regulation. Has “sacrifice” for our health been an economic disaster? Hardly. Our air quality progress has been not just compatible with but indeed integral to a vibrant economy. Our nation’s greenest state has become the world’s 5th largest economy, an economy fueled by embracing positive change with a deep commitment to renewable energy, zero emission vehicles, statewide hydrogen fueling and electrical charging stations, regulations and incentives to replace highly polluting trucks with lower emission models, and electrification of school and transit bus fleets. Our state’s #6 global export is Valley almonds; #7 is electric vehicles! It isn’t all Tesla. Electric buses are assembled in Porterville, and manufacturing is coming. Climate change drives worsening air quality in many ways. Last year saw the highest levels ever measured in our Valley of deadly PM 2.5 particles; forest fires led to that spike. Forest management changes will certainly impact wildfires, but why are we having such devastating fires in November? People create the As a child, our pollution,so people families and our state took a can control it collective sigh of relief when October came and the fire season was over. Climate change models derived from fire data of the last century explain and predict a longer fire season with more and worse fires throughout the West in the years to come. More heat will increase ozone in our valley, a key driver of our nation-leading childhood asthma rates. More heat will mean more heat emergencies. Those of us who are accustomed to 3 weeks of triple-digit days each summer vastly underestimate the danger of heat. Heat events globally kill more people every year than all attentiongrabbing hurricanes, floods, fires, tornados, monsoons, and earthquakes combined.

Summer 2019

As physicians concerned for the well-being of our patients, we are proud of and continue to support our state’s commitment to lower the carbon emissions that are

We all can take actions every day which will have a positive impact driving climate change. AB32 (2006) and voter approval of Prop 23 (2010) have led to a suite of approaches including Cap & Trade, the direction of Cap & Trade monies to Climate Investments, investments directed to disadvantaged communities, the Low Carbon Fuel Standard, and policies supporting the development and deployment of zero emission cars, buses, and trucks. Our forward progress is now also threatened in Washington, DC with the misleadingly named “SAFE Rule”: unsafe, hazardous rollback is much more accurate. Years of collaboration between EPA, California’s Air Resources Board, and auto manufacturers led in 2016 to regulatory certainty (important for businesses), support for zero emission vehicles, and increasing mileage standards through 2025. A subsequent review showed industry exceeding goals at less than anticipated cost. Now the Administration intends to move backwards and freeze standards from 2020 to 2025 at the 2020 levels. The Administration also seeks to end California’s “waiver” to negotiate possibly more stringent than Federal standards with auto makers. Anyone seeking your vote for any position needs to hear that you know air quality and climate change are affected by virtually all our activities. It’s not just our senators’ or presidential candidates’ attitudes, priorities and leadership that matter. School districts choose to add solar or electric buses. Health care systems put in charging stations and can promote carpooling. We all can take actions every day which will have a positive impact—like speaking to elected officials, recycling, maximizing the energy efficiency of our next appliance, and optimizing the mileage or energy source for our next car.

CENTRAL VALLEY PHYSICIANS

BY ERIN M. KENNEDY

TRANS

FORMING

medicine for transgender patients

As a little boy, Hannah Knox dreamed of following her doctor parents into the world of medicine – and of growing up to be a woman. Today, as part of Saint Agnes Medical Center’s inaugural internal medicine residency group, she’s living both dreams. Her journey to both started in college at University of California, Davis, when she began preparing to go to medical school and experimenting with living as a woman. She waited until she was away from her parents to try on being female. “You can go to college parties in drag and that’s considered socially acceptable and even fun, like cool,” said Dr. Knox. “That’s how I first tried it. Then it progressed to my private life and then eventually I was cross dressing even in my public life.” >> 28

CENTRAL VALLEY PHYSICIANS

Summer 2019

CENTRAL VALLEY PHYSICIANS

By her senior year, Dr. Knox had begun transitioning hormonally. She was lucky that her university clinic had both a psychologist to help pave the way for a medical transition and a physician well-versed in how to start hormone transition therapy. Here in the Valley, access to such gender modification isn’t as easy. “In this town there’s just one person, Dr. Julie Nicole. There used to be three,” explained Dr. Knox. The Fresno Planned Parenthood also has a clinic for transgender medical needs, but it’s so impacted it hasn’t been accepting new patients. “That’s really unfortunate, because Dr. Nicole is booked for three months and I can’t get an appointment. I’m a busy resident. I don’t have time to drive over to the Bay Area for a 30-minute appointment and ordering of lab work. So there’s a need that needs to be filled. I can see myself doing that.”

AN UNDERCOUNTED, UNDERSERVED COMMUNITY

While there’s no definitive count of the transgender population, a 2016 study by UCLA law school’s Williams Institute estimated 0.6% of U.S. adults, or about 1.4 million, identified as transgender. California ranked second behind Hawaii with the highest percentage of adults identifying as transgender with 0.76%, or 218,400 adults. Nationwide an estimated 0.7% of adults ages 18 to 24, 0.6% of adults ages 25 to 64, and 0.5% of adults ages 65 and older identify as transgender.

CENTRAL VALLEY PHYSICIANS

Summer 2019

And Dr. Knox may be part of an even smaller minority in the medical community. No one has taken a count of LGBTQ physicians, but that’s about to change. In June, the American Medical Association began surveying its members asking them to fill out a voluntary, confidential survey on their sexual orientation and gender identity (SOGI data). This is a step toward better meeting specific needs of the AMA membership and report back on the diversity among physicians. In her June acceptance speech, the AMA’s first black woman president, Patrice A. Harris, MD, said: “We are no longer at a place where we can tolerate the disparities that plague communities of color, women, and the LGBTQ community. But we are not yet at a place where health equity is achieved in those communities. We are no longer at a place where underrepresented groups are not welcome in medicine, but we are not yet at a place where underrepresented groups are entering or graduating from medical schools at the rates of their peers.” Extrapolating from the Williams Institute’s statistics, there’s likely an estimated 6,800 to 8,700 transgender patients in Fresno and Madera counties and few experts in hormonal transition as a resource. But hormone therapy isn’t the only need for these patients. Primarily LGBTQ patients say

Summer 2019

“ We are no longer at a place where we can tolerate the disparities that plague communities of color, women, and the LGBTQ community.” PATRICE A. HARRIS MD

CENTRAL VALLEY PHYSICIANS

The need for mental health providers who

they’d love doctors who not only were accepting and respectful, understand LGBTQ patients is even greater, but knowledgeable about their unique health needs. given the high rates of depression and “People in the trans community often have issues anxiety among this population. accessing care,” often because of poverty or lack of insurance, explained Zoyer Zendel, a 32-year-old transgender man who is a longtime advocate with Trans-E-Motion, a nonprofit providing support and education for transgender individuals and their family and friends. “Add on lack of culturally sensitive resources and it’s really difficult. The compounding barriers make it feel hopeless sometimes. A lot of it, for me, has been lack of education – doctors being completely unaware of what this means for me in terms of care.” Transgender patients say they’re often in the position of educating their medical providers – especially when it comes to issues of fertility or sex-related cancers such as prostate or breast cancer. LGBTQ patient care began being incorporated into medical school curriculums in the last decade, so those who finished earlier likely didn’t get much training or exposure. In a survey of 450 oncologists from 45 different National Cancer Institute-designated centers, only half felt they had sufficient knowledge of how to best treat LGBTQ patients with cancer. This lack of knowledge can have alarming consequences, as a case study recently published in the New England Journal of Medicine shows. Doctors were slow to react or recognize a pregnancy complication when a

CENTRAL VALLEY PHYSICIANS

Summer 2019

transgender man came to an emergency room with severe ONE WOMAN abdominal pain. Hours later, he delivered a stillborn baby. WORKING ON ACCESS The need for mental health providers who understand Dr. Nicole was a first year medical student when she saw LGBTQ patients is even greater, given the high rates “TransGeneration,” an eight-part documentary following of depression and anxiety among this population. the lives of four transgender college students. She was Nearly four out of every 10 LGBTQ young people have fascinated and drawn to these patients. considered suicide in the last year, according to the “I really see trans people as the underdog of the medical Trevor Project, which surveyed 34,000 LGBTQ people world. On a personal level that really resonated with me,” aged 13 to 24. Survey results released in June showed said Dr. Nicole, explaining that as a poor, single mother 18% had attempted suicide and among transgender or during medical school she definitely felt like an underdog nonbinary young people suicide attempts rose to 29%. as well. Locally, steps are being taken to address the needs. “In that film I found out that Trinidad, Colorado, At Community Medical Centers, all employees who was the transgender center of the world at the time” she work with patients are undergoing mandatory training said. Trinidad was home to Stanley Biber, MD, a general on LGBTQ issues, terminology, legal rights, and how surgeon who performed, by his count, about 5,000 maleto have respectful conversations with LGBTQ patients. to-female genital reassignment surgeries and more than The Valley’s largest healthcare provider has also changed 800 female-to-male reassignment surgeries. Dr. Nicole its Epic electronic medical record system to include contacted Dr. Biber’s longtime apprentice and surgical nonbinary as a gender choice, as well as information heir, Dr. Marci Lee Bowers, and asked if she could come on transgender status, preferred names and preferred pronouns. Dr. Julie Nicole, a Fresno OB/ Gyn who does transgender medical INC. care, helped with Community’s training A REGISTRY & PLACEMENT FIRM by demonstrating on video how to query a transgender patient and take a sexual Nurse Practitioners ~ Physician Assistants organ inventory. She explained that a transgender woman keeps her prostate after genital surgery so will need a regular exam to check for cancer. And a transgender man may still have to see a gynecologist if they Locum Tenens ~ Permanent Placement retain their vagina or ovaries or have a Voice: 800-919-9141 or 805-641-9141 strong family history of breast, ovarian or FAX: 805-641-9143 uterine cancers.

Tracy Zweig Associates Physicians

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Summer 2019

CENTRAL VALLEY PHYSICIANS

“I really see trans people as the underdog of the medical world. On a personal level that really resonates with me,” said Dr. Nicole, explaining that as a poor, single mother during medical school she definitely felt like an underdog as well.”

CENTRAL VALLEY PHYSICIANS

Summer 2019

spend an elective rotation with her in 2008 at the end of sure there’s support for the transition. There’s six pages medical school. And in 2010, Dr. Nicole spent another of informed consent paperwork, blood tests, and several month with Dr. Bowers in elective studies when she was visits to get to the hormones that will help patients live as a resident. By 2013, Dr. Nicole was working with Dr. the gender they identify with, she explained. Bowers, who had moved her gynecological and surgery She’s trying to improve access for transgender patients practice to the Bay Area. by teaching other OB/Gyns, seeing patients in a LGBTQ When it was clear Dr. Nicole would be unable to get mobile health clinic at Common Space in downtown enough cases to get board certified by continuing at the Fresno last spring, doing lectures in San Luis Obispo and non-teaching hospital where Dr. Bowers worked, she Templeton, and mentoring UCSF Fresno residents as took a contract with Fresno’s Clinica Sierra Vista. She an attending with the UCSF Mobile Heal clinic. “I help learned Spanish and moved from her Bay Area home. “By with residents who are working with trans patients at the my third day I had a trans patient,” she said. clinic,” Dr. Nicole said. When she first came to Fresno there were two other doctors in the Valley well-versed in hormone treatment GREATER NEED FOR for transgender patients. But one moved out of state UNDERSTANDING AND and the other passed away in February. Now Dr. Nicole is inundated with requests. “The problem is starting EXPERTISE someone on hormones. I’ve been doing this 10 years Lack of access to knowledgeable physicians means many now,” she said. She also does hysterectomies on those in the transgender community go without care. “I haven’t transitioning to male. “There are just not enough doctors in Fresno who can do this. There are not enough general OB/ GYNs for that matter in this town,” said Dr. Very often patients suffering from Nicole. depression obtain no relief from She said all doctors multiple medications. In many cases should be able to refill drug therapy can cause significant hormone prescriptions for those started on side effects resulting in nonhormonal transitions, compliance. but many doctors still Edgar Castillo-Armas, MD send these patients to Psychiatrist her. “I should think a Transcranial Magnetic Stimulation (rTMS) delivers third or half of doctors magnetic pulses to stimulate nerve cells in the could handle someone area of the brain that controls mood. Rapid who needs a change of change in the magnetic field induces a current of a dose or is stopping sufficient amplitude and duration which in turn and starting or has will excite the neurons. been on black market hormones,” Dr. Nicole No anesthesia required said. “I should only be No memory loss seeing someone starting hormones from scratch.” No down time from normal activities Dr. Nicole knows the Approved by the FDA intricacies of working Covered by most insurances & Medicare with mental health providers and insurance to get approvals, making

Advanced Treatment for Major Depressive Disorder

559-433-1TMS

Summer 2019

www.depressionfresno.com CENTRAL VALLEY PHYSICIANS

been to see a doctor in two years because Dr. Nicole left Clinica Sierra Vista and my insurance doesn’t cover where she’s at now,” explained Jay Sanchez, a 34-year-old transgender man with diabetes. Before Dr. Nicole arrived in Fresno, Sanchez had to travel to San Luis Obispo to find a doctor to begin his transition in December 2015 – what he now refers to as his “manniversary.” Sanchez worries about his health and is frustrated with the lack of knowledge locally about transgender medical issues. “My dad has history of heart problems and history of stroke. I tried to go in to urgent care for heart palpitations, but they don’t listen,” Sanchez said. “They want to talk about my diabetes. My diabetes is under control, but I know testosterone increases the risk of heart disease and stroke. And because I’m not always able to get refills without a regular doctor, I go on it and go off it. And I know that also hurts your health and increases the risk.” A 2016 study published by the American Public Health Association found transgender patients who need to educate their doctors about transgender issues are significantly more likely to postpone or not seek needed care. Zendel said transitioning is hard enough without

CENTRAL VALLEY PHYSICIANS

having to explain over and over to an insurance provider or convince a doctor why a hysterectomy is needed for a healthy 24-year-old. “It makes you feel invalidated emotionally and intellectually,” he said. “That’s the stress we feel in this minority group.” Sanchez added, “The sensitivity of the doctor makes a difference. Understanding how anxious we are about our gender and how we identify and how important it is to have that affirmation that you are a person and you are who are who you say you are is crucial. I want to be open with a doctor, especially about my health.” A bigger problem, Dr. Nicole said, is doctors who just aren’t comfortable with a transgender patient – even if that patient is coming to them for high blood pressure or cardiac care. “I got one referral recently from a doctor who said he doesn’t take care of trans patients and wanted me to see them, but I said, ‘No this is about diabetes.’ “ Nearly three out of 10 transgender patient said a medical provider had refused to see them in the previous year because of their sexual orientation or gender identity, according to a 2017 report by the Center for American Progress, a liberal policy institute. And 21% of transgender respondents said a provider had used harsh or abusive language when they sought medical care.

Summer 2019

Healthcare discrimination against LGBTQ people could increase under the U.S. Department of Health and Human Services’ proposed roll backs of regulations prohibiting discrimination against transgender people in federally-funded programs. HHS has also proposed new regulations to provide more instances in which providers could refuse to provide key services on moral or religious grounds and has created a Civil Rights division to address claims brought by healthcare workers who raise objections to providing care to certain patients because of their own religious beliefs. “You cannot force people something they don’t want to do,” said Dr. Nicole. “But I ask them, ‘Would you refuse to take care of a patient from another race?’ I think who you take care of reflects a lot on your values as a human. Your patient population is really a reflection of your values.”

PERSONAL TRANSFORMATION MAY BENEFIT TRANS PATIENTS

Dr. Knox feels lucky and grateful to have found a doctor who showed her understanding, kindness and had the knowledge to help her become herself – finally.

She remembers wanting to be a girl as early as age 4 or 5. “I remember looking at the people around me and thinking I wanted to grow up to be female,” she said. “It wasn’t something I could really express then.” By age 7 she did express it while on a family vacation in the Florida Keys. The little boy she used to be became fascinated with coconut shell bras and grass skirts and with the gay men he saw. “Gay men especially express their sexuality in a gender ambiguous way, especially then in the 1990s. I said to myself I want to be like them. I want to express myself like them,” said Dr. Knox. She asked her father why they were dressed like that. “I knew they were men but they were wearing short shorts and tank tops. And that’s what I wanted to wear because that’s how I felt inside,” she explained. “My dad said they were ‘strange and weird’ and we didn’t need to talk about them. So I learned socially this was not acceptable… so that held me back for a long time.” Dr. Knox joked that if she had been able to express her desires to her parents “it probably would have been conversion therapy, which was very common back then.” She acknowledged it was a different time: “We didn’t even have puberty blockers back then. That’s an advancement

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in medicine that happened in 2012. Transgender medicine was not on the radar then.” During her work with a psychologist at college prior to her transition, Dr. Knox realized “I have innate transphobia…For me it was very difficult to accept myself, because I didn’t want to be ‘weird and strange,’ which is what my father taught me.” Dr. Knox suppressed exploration of her gender identity. She dressed androgynously the few times she came home from college and pierced her ears at a time when lots of heterosexual men, rock stars and actors were doing the

sexual orientation or gender identity questions, nor does she have an intake form that would collect that SOGI data. It’s something she hopes to get to some day to help in forming better relationships with her patients. For the most part, she said, knowing SOGI status wouldn’t change her treatment protocols. “But there are side effects of hormone therapy,” Dr. Knox elaborated. “Estrogen can cause a pulmonary embolism so if they’re smoking we really need to pay attention to that. If they have hyperlipidemia, estrogen causes elevations in their cholesterol so they need to make sure that’s controlled because they are at elevated risk of heart disease.” JUST BEFORE SHE GRADUATED FROM Her journey to becoming Hannah has shaped the kind of doctor she wants to be. “I UC DAVIS, DR. KNOX WROTE A LETTER knew I was going to go into medicine because TELLING HER FATHER SHE WAS my dad has groomed me from little to be a doctor. And if you had asked me when I TRANSITIONING TO HANNAH. was a kid I would’ve said neurology because same. Her pathologist mother once asked if she was gay, that’s what my dad was… But the doctor who started me but no one inquired further. on hormones and helped me through the process really Just before she graduated from UC Davis, Dr. Knox impressed me with how she took it upon herself to do the wrote a letter telling her father she was transitioning to research and fill a need. I realized that there’s not a lot of Hannah. At graduation she wore a female pants suit and people doing that kind of medicine.” women’s flats and announced the change to her mother. Dr. Knox is still figuring out how she might do “When I told my mom, she said, ‘Oh it will probably be a the same, either by specializing in endocrinology or phase. It’s just a phase don’t do anything drastic.’ My dad continuing in internal medicine. She doesn’t get much cried because he thought it would hold me back in life.” chance to practice what she hopes to do some day, Her mom stopped saying it was “just a phase” about though. five years ago and “my dad who thought I wasn’t going to get into medical school, a year later thought I had a better FOR NOW DR. KNOX REFERS chance because he had done his research,” Dr. Knox said. PATIENTS TO DR. NICOLE. Dr. Knox said her father has “come a long way since Eventually she’d like to complete the journey she started. then” and is very supportive of her and the LGBTQ Still ahead is finishing medical training and figuring out community, she said. She’s also found support, or at least how to be the kind of doctor she had during her transition acceptance for who she is, among her medical colleagues – and finishing that transition to fully female. “I want to and at Saint Agnes. have the reassignment surgery, but I just don’t have the “I never found (being transgender) to be an time and previously I didn’t have the money,” Dr. Knox impediment to getting in medical school or navigating at said. all,” said Dr. Knox, who attended American University of She also wants to do her part to make healthcare a more the Caribbean. Nor does it come up in patient care. “I’m welcoming place for transgender patients. “Medicine is very lucky that I can pass and I am able to do medicine.” still very conservative for the most part, which I sort of She said she’d like to be able to offer her patients the have issues with. But that’s okay, we’ll try to change things same kind of support she’s had from her family, friends slowly as society progresses.” and colleagues. She can understand the feelings that come up with not being able to live authentically and is careful, if she knows, to put preferred names and pronouns in patient charts and checks her tendency to call everyone “Dude.” Right now, Dr. Knox doesn’t have time in her clinic practice at the hospital to ask patients’

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Summer 2019

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Summer 2019

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Movie Review Internes Can’t Take Money By Roydon Steinke, MD

“Internes Can’t Take Money” 1937, stars Barbara Stanwyck and Joel McCrea. It presents Dr. Jimmie Kildare in his first film of a career that included many movies and TV productions. Joel McCrea portrays Dr. Kildare, a very handsome, commanding and capable surgical resident who had weaknesses and strengths that will be expanded on later. Janet Haley (Barbara Stanwyck) was a very difficult character to portray in this movie. She portrayed a stunning ex-con who could be vulnerable, charming, cunning and disarming. This movie is about doctors and the practice of medicine, in this case, in the gangster and underworld community of New York in the 1930s. Interpolated into the plot was a description yielding a sobering picture of the life of surgical residents. Their salary was $10 per month; whereas, a secretary or clothes pleater made $27.50 per week! They left the residency program in the same clothes they arrived with and only wore white clinical outfits provided by the hospital. They were not permitted to take money from

CENTRAL VALLEY PHYSICIANS

Summer 2019

patients because it was feared they would discriminate against patients who could not afford to pay. The residents’ careers were vulnerable and twice during the case of the movie it was elaborated that despite spending 10 years in high school, college and medical school, they could have their “ticket pulled” and not be allowed to practice medicine again. One resident was expelled for attempting an innovative surgical procedure in a desperate case. The disciplinary action was carried out in front of all of his colleagues. The main plot was about an ex-con, Janet Haley, who had her 18-month-old baby taken from her during her incarceration and was blocked from returning to her by a gangster who wanted to trap her, in turn, at his country estate where he might reunite her with her child. Dr. Kildare teamed with opposing gangsters to try to rectify the situation. Presented in this film are many astounding situations one might see as disturbing. Residents bantered with patients making them the butt of cynical and sarcastic humor. Strep throat was treated with hospitalization and blood cultures. The glaring episodes were surgical procedures performed outside of the hospital milieu. I could see these cases inf luencing a young Dr. Alan Pierrot watching a rerun to consider developing an outpatient surgical center! Also, only men were depicted as doctors in the movie. Despite these foibles, the movie is entertaining, humorous, suspenseful and gratifying to watch.

Summer 2019

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WHO CAN MAKE THE CALL? MAY MEDICAL ASSISTANTS CALL IN NEW PRESCRIPTIONS OR REFILLS TO A PHARMACY?

SHORT ANSWER:

It depends.

Authored by: Amy McLain, BSN, RN, Senior Risk Manager, Cooperative of American Physicians, Inc.

The Medical Board of California (MBC) cautions, “Physicians should view carefully his or her decision to allow medical assistants to perform this task.” It is not the physical act of picking up a phone and dialing a number that is of concern. Rather, “the authority to prescribe or refill prescriptions is only granted to licensed physicians and surgeons, podiatrists, or those individuals authorized by law to do so.” Medical assistants do not have the medical and pharmacological training, the licensure, or the legal authority to evaluate the appropriateness of a medication prescription or refill. Therefore, medical assistants may NOT call in new prescriptions or any medication refill that have changes. The good news is that California law authorizes medical assistants to “perform basic administrative, clerical, and technical supportive services.” The MBC interprets this law to allow a medical assistant--under the direct supervision of a physician--to call, email, or fax in routine medication refills that are “exact and have no changes in dosage level.”

CENTRAL VALLEY PHYSICIANS

Summer 2019

Steps to Follow

To be compliant with California law and to ensure patient safety, CAP recommends: •T he supervising physician provide a policy and procedure to be followed by a medical assistant in transmitting a prescription refill to the pharmacy. •T he medical assistant is trained and can demonstrate competence in performing the task of transmitting prescription refills to the pharmacy. •T he supervising physician must authorize the medical assistant to transmit a prescription refill to the pharmacy by writing a patient-specific medication order or assigning a standing order in the patient’s medical record. • The medical assistant documents the medication refill in the patient’s medical record, including the medical assistant’s name or initials, the date and time, a description of the task performed, and the name of the physician authorizing the refill. To learn more, visit the Medical Board of California’s website: www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/ Medical_Assistants_FAQ.aspx For more articles to help you solve common problems in your practice, download the Physician’s Action Guide to Reducing Risk and Improving Business. The Cooperative of American Physicians, Inc. (CAP) is a proud supporter of the Fresno Madera Medical Society and is pleased to offer this free resource to help physicians and their medical staff. Get your free copy at www.CAPphysicians.com/solve11. CAP provides California physicians with superior medical malpractice coverage and a myriad of no-cost risk and practice management resources to help keep them safe and successful. If you’d like to learn more about the benefits we offer to our physicians and how much you can save by switching your medical malpractice coverage to CAP, contact Albert Malasig at 650-543-2185 or at amalasig@CAPphysicians.com for additional information and a quote.

Summer 2019

CENTRAL VALLEY PHYSICIANS

PAIN

MANAGEMENT. A PL AY IN 6 ACTS BY RAVI D. RAO, MD

Act 6: Early this morning My phone rang exactly at 5 am. I disliked getting disturbed in my last hour of sleep as I could never fall back to sleep again. This time, the call disturbed a wonderful dream. However good this dream was, it was forgotten in a few minutes, as it was the ER that was calling. My patient Joe was in the ER. He was in severe pain and was going to be admitted for management of his pain. The ER doctor was calling to let me know, so I could consult on him later that day. Apparently, they had to start a morphine drip as nothing else seemed to control his pain. I went to the hospital in a couple hours to see him before going to my own office. He was sleeping in his hospital room with the morphine drip running, the IV pump beeping softly in the background. Joe was fast asleep and did not seem to care. He died a few hours later. Joe was finally in peace.

CENTRAL VALLEY PHYSICIANS

Dr. Ravi D. Rao is board certified in oncology and hematology. Dr. Rao attended the All India Institute of Medical Sciences in New Delhi, India, where he completed his internship. He attended the University of Wisconsin Hospital and Clinics in Madison, Wisconsin, completing his residency in 2000. He completed a fellowship, became an attending physician and an Assistant Professor of Oncology at the Mayo Clinic, Rochester. Dr. Rao has been involved in clinical research, with a special interest in new drug development. He has several publications and has received several awards for his work, such as the Division of Oncology Scholarly Award from Mayo Clinic.

Act 5: Six weeks prior I got a phone call in the middle of the night from an Emergency Room in a town around 100 miles away. >>

Summer 2019

Joe was in the ER, with a severe pain crisis, which began while visiting family there. He ended up in the ER. His doctor in the ER had called to talk to me. He was worried that Joe was asking for a rather high dose of opioids and wanted to check. “He has prostate cancer, with many bone metastases and has a legitimate reason for his back pain”, I remember telling that doctor. “Thank you”, he had said as he hung up.

behaved exactly like Joe does with you now, she had said. “I know”, I had replied wearily. But poor Joe had so many bone lesions, I just had to believe him when he says he has pain and needs more medications. Let’s refer him to a pain clinic, I decided, maybe they can help him with other drugs and treatments beyond oxycodone. Joe missed that appointment.

This phone call from out of town was not the first time I had received such a call asking about Joe. In the previous few months he had been in several different hospital ERs, complaining of pain and asking for opioid medications. So, when I saw him next, I showed him a report from the pharmacy about all his many prescriptions. “Joe, what is the matter? How can you need 15 prescriptions over four months, all for narcotics? From five different doctors?”, I had asked, incredulous. Why did he need so many more medications, even though I gave him all he had asked for? Sometimes the pain gets to be too bad, and sometimes I lose my pills, he had explained.

Nor did he go to the next one when we rescheduled for him.

On that same day, the results of his bone scan had come in. We reviewed it together; the scan looked worse. He had many more bone tumors than before. Today, my ribs hurt a lot more, he had said. “I ran out of oxycodone again, had to take more… Doc, can you refill my prescription and give me more pills, so I don’t run out again?” How could I have said no? I wrote a prescription for a higher number of oxycodone tablets. “I have such severe pain, why are people not more sympathetic to my situation,” he had grumbled to my staff as he left. He had ‘real’ pain from cancer eating away into his bones. Joe was not an addict, was he? How could I tell?

Act 4: Four months ago

“Doc, please call the pharmacist right away”, my office staff had said as soon as I got in that morning. Joe apparently turned in the oxycodone prescription I had given him sooner than he was supposed to, and asked for an early refill. The pharmacist refused to fill it, and had told him that he would release the drugs only if I personally spoke to the pharmacist to okay this. There was an urgent message from Joe that morning, asking that I make that call. I called the pharmacy. I had to navigate the annoying phone tree that Walgreens Pharmacy has… press 1 for pharmacy, 2 if you are a prescriber and finally, 0 to reach pharmacy staff. I was somewhat annoyed about this by the time the pharmacist came to the phone. “Do you really have to be so careful on a patient who has prostate cancer, has multiple known bone metastases and is already on chronic opioid therapy for cancer pain? Isn’t he entitled to be taken at his word? The poor man is in a lot of pain” … I had asked, in an injured tone. “Doc, I am sorry”, the pharmacist had replied...and continued... I know you mean well. You take care of my mother-in-law; and I know how difficult your job is. The pharmacist who was covering for me yesterday was being cautious. This patient’s usage pattern for opioids had triggered some alarms about possible opioid abuse. “Corporate policy required that we call you”, he said. “I am sure you are aware of the new policy changes coming down from the FDA and DEA. We have new corporate rules in place to avoid excessive medical opioid use. But I am really sorry about this particular case, we will take care of this. Thank you for calling... we will give him his oxycodone as soon as he gets in,” he had said. My phone call did the job. Joe was happy; his oxycodone pills were ready when he showed up at the pharmacy later that day. After that, I had to increase the number and dose with the new prescription, so as to not have him run out again. “Are you sure about the new directions on his prescription?” my medical assistant had asked. In my previous job as an MA in a pain doctor’s office, I knew patients who were narcotic seekers who

Summer 2019

Act 3: One year ago

“Joe, your bone scan looks bad. I see many new tumors in the bones; these are new since the last scan, I had said. This explains the recent increase in your PSA. Your prostate cancer has come back and now you have stage IV disease. Now we know why you have the new rib pain, I had explained. We talked about chemotherapy, hormone therapy and radiation. Stage IV prostate cancer is not curable,” I had explained as he sat there glumly. “We can prolong life, and improve the quality of your life, but we cannot cure you.” He had listened intently with a focused look in his eyes. He seemed to be somewhat sad, but was accepting of the information I gave him. We sat and talked a while. He then sat on silently a few more moments, thinking. As he left, he asked me: “Can you take over my pain prescriptions now..”? “Yes, I can”, I had replied. He seemed relieved.

Act 2: Two years ago

Two years after surgery for prostate cancer, Joe’s PSA had gone up slightly. Joe was dressed very smartly when he came to see me for the first time. His urologist had sent him over for a consultation. The cancer seemed to be back, but all the scans we did were normal. He was worried and asked many intelligent questions. It may take many years for the cancer to show up, and for you to have any problems, I had predicted. He was relieved. We will watch you closely, see you every 3 months, get lab tests and scans to monitor your health. “Doc, can you take over my pain medication prescription? I need to use oxycodone regularly” he had asked. I have chronic back pain, he explained. “Sorry, Joe, I cannot do that”, I remember replying. Please continue seeing your primary doctor for pain management. I remember asking: “Have you ever seen a pain doctor, to see if something less addictive may work for you?” He replied on his way out “No”. “Oxycodone is the only medicine that works for my pain“.

Act 1: Six years ago

Joe developed severe abdominal pain and had to be taken to the Emergency Room. The ER was packed. When he reached, he was complaining of severe 10/10 pain, so he was hurried along faster than other patients. He had a CT scan that showed that his pain was due to diverticulitis. A short wait later, Joe was seen by the Emergency Room doctor, and a little later by the on-call General Surgeon. Thankfully, the infection was not as critical as they had initially suspected; he did not need surgery right away. He needed antibiotics, pain management, and an outpatient follow up. He would likely need surgery in the future, the surgeon recommended. He could go home if he wished, he was informed. Joe was very thankful to be discharged. Just before discharge, his nurse turned to the ER doctor: “What about pain medications?” The ER doctor, distracted and busy, ready to move on to the next patient, wrote him a prescription for 200 tablets of oxycodone tabs. Take one every 4 hours, he had said as he quickly walked away to see the next patient.

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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!

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Immigrated from Mexico when she was 5. Now attending UCLA medical school in the Fall. BY LEILANI GUTIERREZ-PALOMINOS

CENTRAL VALLEY PHYSICIANS

Leilani Gutierrez-Palominos is a graduate of the UCSF Doctors Academy at Sunnyside High School in Fresno. From there she went on to earn her bachelor’s at UC Berkeley. Now she plans to attend medical school. UCSF FRESNO

I was 5 years old when my parents made the difficult decision to leave our impoverished hometown in Mexico. My elementary school there only offered coloring activities and my mother did not want my education to end like her’s did. To provide me with an American education and to escape violence, my parents gave up their life and family in Mexico. Growing up as an undocumented immigrant in the United States presented challenges, like not knowing if I could pursue higher education in the U.S. regardless of excelling academically. Still, I maintained a strong work ethic despite the possibility of deportation to my hometown in Mexico, where educational opportunities are scarce and medical neglect is rampant. Growing up in the Central Valley, I recognized there was a lack of resources, but there were far more opportunities than I had in Mexico. The UCSF Fresno Doctors Academy at Sunnyside High School, founded by Dr. Katherine A. Flores, is an especially important opportunity for students in Fresno Unified School District. Caruthers and Selma high schools also have Doctors Academy programs. The Doctors Academy is an educational pipeline program for students like me who are first in their family to dream of pursuing a medical career and are underrepresented in medicine. The DA offers academic preparation, medically related courses and summer internships with health professionals. These experiences solidified my early determination to become a doctor. At Community Regional Medical Center, I volunteered at the front desk alongside Dr. Kenneth O’Brien, who practiced medicine more than 56 years and retired only to volun-

Summer 2019

teer for a dozen more. Our daily conversations encouraged me to explore the hospital, from shadowing doctors to cleaning IV poles. Additionally, I interned at the Aesthetic Plastic Surgery Pavilion with Dr. Stephen Zuniga. Thanks to the opportunities the Doctors Academy offered, I had a stronger application when applying to UC Berkeley, and was awarded UC Berkeley’s Regents’ and Chancellor’s Scholarship which funded all of my undergraduate studies, thus removing the economic barrier which would otherwise have impeded me from attending. My undergraduate career at UC Berkeley was defined by my drive to tackle larger sociopolitical issues and work alongside underserved populations. Having witnessed pesticides destroy the lives of poor Latino farm workers cultivating the fields of California’s Central Valley, I majored in molecular and cell biology and spent four years conducting toxicology research in a chemical biology lab. I also applied a social justice lens to my interest in science by simultaneously pursuing a minor in global poverty and practice. Additionally, to promote awareness of health inequalities, pressing social issues and disruptive innovations, I led a team of undergraduates in creating one of the largest student-led TEDx Talk events in the world.

communities, like the ones I come from. My hope is that the community and elected leaders will continue to support aspiring doctors from diverse backgrounds by supporting the Doctors Academy and offering scholarships to medical students to serve communities where they are needed most. We must take the steps to support aspiring doctors now, in order to ensure the future health of our Central Valley. Now is the time to cultivate and empower the minds of our young, homegrown Central Valley aspiring doctors. Leilani Gutierrez-Palominos is a UCSF Fresno Sunnyside High School Doctors Academy graduate and on her way to medical school.

My existence in this country as a previously undocumented immigrant is inherently political. Thus, I am personally invested in advocacy efforts regarding underserved communities. Research shows that patients have better health outcomes when doctors share and understand their backgrounds. The population of Latinos in the U.S. is expected to grow, and yet the doctor population does not accurately reflect patient population. After graduating from college, I returned to Fresno to work with UCSF Fresno’s Doctors Academy to increase students’ knowledge of academic opportunities. Programs like the Doctors Academy are changing lives and creating even playing fields. Thanks in large part to the Doctors Academy, I will now be attending the UCLA David Geffen School of Medicine on a merit-based David Geffen Scholarship, which covers all of my medical education-related expenses. The mentorship at the UCSF Fresno Sunnyside High School Doctors Academy led me to this point. Now, I am on my way to medical school this fall. While I am very early on my path to becoming a physician, I look forward to serving humble

Summer 2019

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Summer 2019

Humble Leadership Attracts Prestigious Award Humble Leadership Attracts Prestigious Award

SEITAprogram for Dr. Lindvall’s practice, improving the way ment This year’s Steven N. Parks MD Leadership Award has been BY JENNIFER they address fractures and allowing them to better serve their awarded to a unique and well-deserved recipient – Lucas patients. Said Dr. Lindvall, “All residents are encouraged to Seiler, MD, Orthopaedic Surgery. As a fifth-year senior resiment program Dr. Lindvall’ s practice, thethe way Thisatyear’ s Steven Parks MD Leadership AwardSurgery, has been conduct extensiveforresearch and look at waysimproving to improve dent UCSF FresnoN.Department of Orthopaedic theybut address and allowing to better serve their to aproven uniquetoand well-deserved – Lucas field, not allfractures are implemented. He them actually modified how Dr.awarded Seiler has be more than just recipient a leader, but a patients. Said Dr. Lindvall, “All residents are encouraged to Seiler, MD, Orthopaedic Surgery. As a fifth-year senior resiwe practice.” catalyst to improve the department’s culture. conduct extensive research and look at ways to improve the dent at UCSF Fresno Department of Orthopaedic Surgery, field, but not all are implemented. Heexemplifies actually modified Dr.Steven Seiler N. hasParks proven to Leadership be more than just awas leader, but a the truehow The MD Award established His approach Dr. Seiler we practice.” to improve the department’ s culture. meaning of a leader both in bycatalyst the Fresno-Madera Medical Society to honor Dr. Parks’ to medicine and out of the operating room, legacy. It is earned by showing dedication and commitment Dr. Seiler thejunior true The Steven N. Parks MD Leadership Award was established has created as a exemplifies role model for to medicine and leadership development by residents and His approach serving meaninginofthea leader both by thethat Fresno-Madera Medical Society to honor Dr. Parks’ residents program byinpracfellows stimulate similar efforts in other physicians in ato ripple medicine ticing and with out ofhumility, the operating room, legacy. It is earned by showing dedication and commitment often taking training. effect in the has created serving as a role model for to medicine and leadership development by residents and on grunt work that is typicallyjunior department, residents the program by pracfellows that stimulate similar efforts in other physicians in saved for theinyounger residents. Dr. Seiler came to Fresno from University of Nebraska and it a ripple ticing with humility, often taking hastraining. been said that he brought with him the Midwestern husetting the effect in the on grunt is typically “Lucas is thework kindthat of person who mility and work ethic. In what is typically the most tested and highest of department, saved for the younger residents. Dr. Seiler came to Fresno from University of Nebraska and it assigns himself the least desirable trying time for a physician, Dr. Seiler has sailed through resistandards. has been thatand he brought himclass. the Those Midwestern husetting the call days and stays late to help dency withsaid a smile at the topwith of his that have “Lucaswith is the kind of person mility closely and work ethic. whatcommon is typically theofmost tested and interns ‘scutwork’ even aswho a worked with himInshare ways describing highest of assigns himself the least desirable time for a physician, Seiler hasover-achieving sailed throughand resichief resident,” said UCSF Fresno Department of Orthopaehistrying character: selfless, humble,Dr. principled, days and staysMartirosian, late to help dency with andasata the topleader of histhat class. that dicstandards. Surgery Residency Programcall Director Armen respected. Heaissmile known quiet hasThose earned thehave interns with ‘scutwork’ worked closely with him share common ways of describing MD. “And yet, attendings hear about these things fromeven otheras a respect of his junior residents, peers and attendings alike. And chief resident, ” said UCSF Fresno Department of Orthopaeselfless, humble,toprincipled, over-achieving and residents and staff, since Lucas himself does not discuss them.” it’shis nocharacter: surprise that he happens have the highest combined dic Surgery Residency Program Director Armen Martirosian, respected. He is known a quiet leader five-year in-training exam as score in his class.that has earned the MD. “And yet, hearcreated aboutathese respect of his junior residents, peers and attendings alike. And His approach to attendings medicine has ripplethings effectfrom in theother residents and staff, since Lucas himself does not discuss them.” it’ s no surprise that he happens to have the highest combined department, setting the highest of standards. What makes Dr. Seiler particularly deserving of this award is in-trainingofexam score in and his class. hisfive-year rare combination precise skill pleasant demeanor. Hishas approach to medicine has created as culture ripple effect in the “He truly improved our department’ and has “The surgical mentality can be egotistical,” said UCSF Fresno department, setting the highest of standards. What makes Dr. Seiler particularly deserving of this award is helped attract more residents like him,” said UCSF Fresno Department of Orthopaedic Surgery Chief Eric Lindvall, his FAOA. rare combination of precise skill and demeanor. Department of Orthopaedic Surgery Assistant Professor Jason DO, “While Lucas is confident, he’pleasant s not arrogant and “He has “The surgical can be ” said UCSF Fresno Davis, MD.truly improved our department’s culture and has it shows in manymentality ways – from theegotistical, way he interacts with the helped attract more residents like him,” said UCSF Fresno Department Surgeryhis Chief Eric ”Lindvall, other residentsof toOrthopaedic the way he manages patients. His selfless of Orthopaedic Surgery Assistant Professor DO, FAOA.voice “While Lucastremendous is confident,weight he’s not Dr.Department Seiler will return to Nebraska in August to begin a HandJason and insightful carries andarrogant he has and Davis, MD. it shows in many ways – from the way he interacts with the Fellowship at University of Iowa, but there is no doubt he will become a pillar in the department. other residents to the way he manages his patients.” His selfless be highly recruited to return to the department as faculty in Seiler will return to Nebraska in August to begin a Hand voice carries tremendous he has theDr.future. Asand partinsightful of his residency, Dr. Seiler created aweight qualityand improveFellowship at University of Iowa, but there is no doubt he will become a pillar in the department. be highly recruited to return to the department as faculty in the future. As part of his residency, Dr. Seiler created a quality improve-

Summer 2019

CENTRAL VALLEY PHYSICIANS

Public Health

Update

The Real Victims of Anti-Vaxxer Fake Medical Exemptions | Opinion April 2, 2019 • By Richard Pan, MD In 2000, the United States eliminated measles from our country, a disease that killed 500 people a year before vaccination. Measles could still be caught in another country by an unvaccinated person and brought back home, but vaccination rates were high enough in most communities to prevent further spread of the disease. With safe and effective vaccines, families gained the freedom to go about their neighborhood without worrying their children would catch serious diseases. As memories of these diseases faded, charlatans spread misinformation about vaccines and some parents were duped into becoming more anxious about vaccines than the diseases. Vaccination rates slowly fell and neighborhoods in the U.S. began losing their herd community, or community immunity, the protection achieved when over 94 percent of children are vaccinated against measles.

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In 2014, a measles outbreak began in Disneyland and spread across California and the country mainly by unvaccinated children. Parents were worried about the safety of their babies who were too young to be vaccinated, and their school children who had cancer or transplants, who could not protected by vaccination. Thousands of parents across California demanded state government restore community immunity to keep their children safe. In 2015, Senator Ben Allen and I authored legislation to abolish all non-medical exemptions to legally required vaccines for school enrollment. The law was a success: vaccination rates rose above 95 percent for each entering kindergarten class since implementation, thereby restoring community immunity. Unfortunately, a troubling new trend occurred.

Summer 2019

By law, children for whom a vaccine is ineffective or unsafe would We cannot allow a small number of unethical physicians to put receive a medical exemption for school from their physician, which is our children back at risk for infection. It is time to stop fake medical estimated to be less than one percent of children. However, there were exemptions and the doctors who are selling them. schools reporting that over 20 percent and even 50 percent of their students received medical exemptions. And these exemptions did Dr. Richard Pan is a pediatrician, former educator at the University not come from the childrenâ&#x20AC;&#x2122;s regular doctor, but from a few doctors California, Davis and a California State Senator representing the who granted many of the exemptions. An investigation of medical Sacramento region. He was elected to the State Assembly in 2010 and later exemptions in the San Diego Unified School District showed almost a elected to the State Senate in 2014 and 2018. California has some of the third were written by a single physician. toughest vaccine laws in the nation because of Dr. Panâ&#x20AC;&#x2122;s authorship of SB 277 A few unethical physicians are selling fake medical exemptions; in 2015, which abolished the personal belief exemption in California. many advertising to anxious parents how they could pay cash and obtain an exemption. They were monetizing their medical license and putting our children in danger in order to make a quick buck. Parents are again demanding that state act to keep their children and families safe. With the support of physicians, I introduced legislation to restore integrity to medical exemptions and maintain community immunity. The bill stops unethical physicians by requiring oversight over medical exemptions by the California Department of Public Health. State and county health officials will have the authority to review and invalidate inappropriate medical exemptions that compromise the safety of vulnerable school children. The ability to track information on exemptions will also allow public health officers to identify unvaccinated children during outbreaks to halt disease. Finally, data on inappropriate medical exemptions will help the state Medical Board in investigations of unethical physicians. Low vaccination rates are endangering the health and safety of children. This year, the State of Washington and Rockland County, New York have declared emergencies to YOU MAKE OUR COMMUNITY A BETTER PLACE. combat measles outbreaks affecting hundreds of people. In California, unvaccinated travelers have brought measles to the Golden State including an outbreak where two unvaccinated children with suspect medical FOR IMPROVING THE HEALTH OF OUR COMMUNITY exemptions were infected. We fought to win back our community SUPPORTING LOCAL ORGANIZATIONS TO immunity in 2015, and we need to keep it to protect the most vulnerable: babies, people BETTER OUR COMMUNITIES. with cancer, transplant recipients, and the two percent of children for whom the vaccine does not confer immunity. They will be the victims of fake medical exemptions. Who will act on their behalf? The primary role of government is to protect the public. We will act again to keep people safe. www.calvivahealth.org

THANK YOU PHYSICIAN PARTNERS

Summer 2019

CENTRAL VALLEY PHYSICIANS

In Memoriam

In Memoriam ELROY D BRANDT, MD 11/26/1931 â&#x20AC;&#x201C; 4/15/2019

Elroy D. Brandt MD, passed away peacefully on April 15, 2019, after a long illness, with his family by his side. Elroy was a physician and surgeon in Fresno, specializing in hand and plastic surgery, from 1976 to 2003. He was preceded in death by his parents and twin brother Leroy. He is survived by his wife, Linda, five children, and three grandchildren. He will be greatly missed by all of his family and friends. Dr. Brandt was a FMMS Member for 23 years.

DONALD L. MYERS 12/10/1951 â&#x20AC;&#x201C; 5/15/2019

Donald L. Myers, MD, age 67, of Clovis, California passed away on Wednesday, May 15, 2019. Donald was born December 10, 1951, in Ithaca, New York to Margaret Myers and Donald L. Myers. He is survived by his wife, Shelley Myers; daughter Leilani Hope Myers; and daughter Serena Rose Myers; father Donald L. Myers; brother Jeffrey Myers and sister Karen Myers. Donald was preceded in death by; mother Margaret Myers; brother Scott Myers. Dr. Myers was a FMMS Member for 15 years.

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Summer 2019

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

Say awww-some! That’s the word that best describe our medical volunteers at Saint Agnes Holy Cross Clinic. Thanks to their gifts of time and talent, hundreds of our community’s most vulnerable patients are receiving the care they so desperately need, but could not otherwise afford. As our patient population continues to grow, so does our need for clinical volunteers to help staff the clinic. If you’re a physician, advanced practice professional, or medical or nursing assistant, we’d love you to join our awesome team. If you’re interested in becoming a volunteer, please call 450-7802.

Saint Agnes Holy Cross Clinic at Poverello www.samc.com