Central Valley Physicians Fall/Winter 2021

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Fall/Winter 2021

Serving Fresno, Madera, Kern and King Counties

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INSIDE: Physicians Recognized for Contributions to Medicine

Fall/Winter 2021

Students Making A Difference CENTRAL VALLEY PHYSICIANS 1

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From the Executive Director

Happy New Year! During our recent Joy of Medicine Summit at the Tenaya Lodge– our final event for 2021 – I took a few moments to reflect on the past 12 months. Despite the ongoing pandemic, there is a lot we have to be grateful for as an association. Under the leadership of Don Gaede, MD, and the 2021 Executive Committee and Board of Governors, 2021 was a growth year for the medical society with increased membership, increased advocacy, numerous physician wellness activities and 160.0 hours of CME – nearly twice the amount STACY WOODS we have ever offered before. Our board has dedicated countless hours to advocating for medicine and healthy communities, volunteering at vaccine clinics, donating blood, providing CME and always leading by example. In November not only did we honor three incredible physicians for their unwavering dedication and service to our community (see page 21) but we also installed our new officers including 2022 President John Moua, MD, President-Elect Marina Roytman, MD, Vice President Jennifer Davies, MD and Secretary/Treasurer Pamela Kammen, MD. The future of FMMS is extremely bright. Despite the ongoing struggles with COVID, it is a wonderful time to be a physician and a wonderful time to be a member of the Fresno Madera Medical Society. While we look forward to 2022 with hope and optimism, we acknowledge that year two dealing with the pandemic only increased the enormous strain placed on physicians, adding urgency to the work of our Physician Wellness program. If you or a colleague is in need, we encourage you to reach out to our wellness partners at Roubicek and Thacker to schedule a resiliency consultation. The consultations are available to all physicians working or practicing in Fresno or Madera County regardless of membership. FMMS provides up to 4 confidential sessions per calendar year at no cost to the physician. To schedule an appointment call Roubicek and Thacker at 559-323-8484 and schedule a consultation today. Looking forward to a healthy and happy new year.

PRESIDENT – Don H. Gaede, MD VICE PRESIDENT – John Moua, MD TREASURER – Marina Roytman, MD PAST-PRESIDENT – Alan Birnbaum, MD BOARD OF GOVERNORS Mark Alson, MD Pamela Kammen, MD Brent Kane, MD Farah Karipineni, MD Anne Prentice, MD Jesus Rodriguez, MD Sonia Shah, MD Katayoon Shahinfar, MD Greg Simpson, MD Toussaint Streat, MD Benjamin Teitelbaum, MD Jai Uttam, MD CMA Trustee – Ranjit S. Rajpal, MD Karen Dahl, MD CENTRAL VALLEY PHYSICIANS Editor – Farah Karipineni, MD Assistant Editor – Karen Dahl, MD Managing Editor – Stacy Woods EDITORIAL COMMITTEE Farah Karipineni, MD, Chair Don Gaede MD Karen Dahl, MD Roydon Steinke, MD Michael Mcmillon, MD Manisha Mittal, MD CREATIVE DIRECTOR prime42: DESIGN | MARKET | HOST prime42.com CONTRIBUTING WRITERS Farin Jacobson, Kaysha Rajani, Rowan Sultan Shahna Duerksen, MA, Marina Roytman, MD, Amanda Flood CONTRIBUTING PHOTOGRAPHERS Anthony Imirian CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO Central Valley Physicians 255 W Fallbrook Avenue Suite 104; Fresno, CA 93711 Phone: 559-224-4224 | Fax: 559-224-0276 Email address: swoods@fmms.org

Stacy Woods

MEDICAL SOCIETY STAFF Executive Director – Stacy Woods Marketing Coordinator – Casey Nagle



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A message from our Editor > Farah Karipineni, MD

Honoring Time

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

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As we usher in yet another new year, I am filled with gratitude for all that 2021 had to offer. It was not all positive; but I can honestly say it all led to some degree of personal growth. The more we reflect, the more we learn, and even though in the moment those growth opportunities don’t feel exactly welcome, they are often the most valuable ones in the rear view mirror. For me, one of these opportunities for growth was the stark reminder of how exquisitely finite a currency our time on earth is. Watching my kids grow up is daily proof of how quickly time melts away, and how precious each moment is. Living in the moment with twin toddlers is as necessary as it is impossible. Yet, for all its importance, living in a culture that prizes wanting more, having more, and doing more, does not help us live in the moment. We have to actively, purposefully and thoughtfully go against that culture to be still enough to savor the moment we are in. At a recent event for medical students at CHSU, I advised students to treat their time as their most valuable earthly possession. That sometimes saying “no” to one thing is necessary in order to say “yes” to something else.

For some of us, the finite nature of life struck far too close to home in 2021, watching loved ones fall ill or pass. I am so sorry for your losses.



It’s an important exercise, and relevant to the New Year, which is always an appropriate chance to rethink what we are saying “yes” to. For some of us, the finite nature of life struck far too close to home in 2021, watching loved ones fall ill or pass. I am so sorry for your losses. I lost my beloved mother-in-law a few months ago, as well, and the realization that we would have no future memories together was first unfathomable and then unbearable.

choices with my time that I wouldn’t if only I knew when my last moments with a certain loved one, or even my own last moments, would be. Yet, life is filled with mundane things that must be done, regardless of the finite nature of our time here. It feels like an impossible task to live every moment like it’s our (or a loved one’s) very last, and I don’t think we need to achieve

Yet, life is filled with mundane things that must be done, regardless of the finite nature of our time here. It feels like an impossible task to live every moment like it’s our very last.

Upon reflection, some of the unbearability of her death was stewing with the knowledge that I could have done better. I didn’t facilitate as many visits with the grandchildren as she would have liked, didn’t call as often as I should have, didn’t show my love for her enough. I thought we had more time, truly. I made choices as if we would live forever, prioritizing other things. I still do this, in so many ways, making so many

that lofty goal in order to honor the time we’ve been gifted here. I think remembering that time is our most valuable, non-renewable resource—not money, or CV line items, or work, or many of the things that threaten to shift our focus—can help restructure how we spend it to make our precious days more meaningful in the ways that matter to us. Happy New Year!



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Digital Detox

ABOUT THE AUTHOR Don Gaede, MD is board certified in Internal Medicine and fellowship trained in vascular medicine. He is a varicose vein specialist with extensive training and years of experience practicing vascular medicine. Dr. Gaede earned his medical degree from Loma Linda University School of Medicine. His residency was completed at University of California, San Francisco, Fresno and his fellowship at Cleveland Clinic in Ohio.

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I wriggled out of the sleeping bag, put on my socks and gloves, and checked my watch: 6:10 AM. Yesterday’s smoky haze had cleared, and I could see the glacier on Mt. Banner glistening in the morning light. Grabbing my fishing rod, I tiptoed past my campmates and then rock-hopped to the end of a long peninsula that gave me access to the deep-blue waters of Garnet Lake. I was stunned by the still beauty of the lake’s surface, which offered a mirror-like reflection of both Mt. Ritter and Banner. I didn’t have long to meditate on the pristine surroundings. A 10inch brook trout, surprising large for a fish in a 9,700-foot high lake, had swallowed my PowerBait. After a valiant fight on the line, I reeled it in, and it didn’t take long before I brought in 2 more beauties. Sautéed with butter, olive oil, salt and pepper, they made for an iconic high Sierra breakfast that morning, shared with my fellow campers. Later, my wife and I clambered aboard a foldable kayak that had been transported there by one of our horses. We paddled around one of the lake’s islands; islands so beautiful they struck me as candidates for some sumptuous Japanese garden. This was my 4th year of backpacking with a physician-led group of outdoor adventurers. The group’s founders began taking trips to the high country over 30 years ago. It has since grown to include non-physicians, but doctors still form its core. Considering the work schedules and other commitments we physicians deal with, I wondered how I could explain the longevity of this group. So I spoke with the other 4 physicians about why they take the time to go on this annual trek. One spoke about a feeling a humility and awe when in the presence of such immense beauty. Another said witnessing the breath-taking sunrises and Aspen glow sunsets gave her a sense that she was in a sacred place. Another talked about the chance to develop a real sense of camaraderie with other people of similar education and interests. I think it also has something to do with “digital detox.” It’s hard to get to know someone when your cell phone might start ringing at any moment, and you’re getting texts, plus you’re checking on what your friends are up to on Facebook. But after a few days away from all that distraction, sleeping under the moon and stars, your mind starts to unwind. You find yourself listening more deeply, and having meaningful conservations more frequently. One of our conversations centered on the neologism “solastalgia,”



formed by the combination of the words “solace” and “nostalgia.” The word has been described as the homesickness you have when you are still at your home but your environment is changing in distressing ways. According to philosopher Glenn Albrecht, who coined the term, “Solastalgia is when your endemic sense of place is being violated.” We talked about how climate change is causing the wildfire season in the Sierras to extend months longer than it used to, and how that is permanently damaging the beautiful forests we have enjoyed all our lives, and often polluting the air we breathe. A number of us experienced a distinct sense of solastalgia as we drove through the mottled forests on the way to our destination. Fortunately, in the area where we were camped, next to majestic mountain heights and gem-like mountain lakes, the forests were still healthy, the water was crystal clear, and the air was (mostly) clean. Even though we were all officially “off call,” this trip wasn’t completely devoid of doctoring. On the last day of our trip, a woman in the next camp was suddenly struck by an attack of Meniere’s disease, and couldn’t walk even 100 feet back to her tent. Not surprisingly, every one of us 5 physicians had different ideas about how to best treat



her. Fortunately, after some passionate debates, these ideas finally coalesced. We decided to help her shelter in place, gave her two Zofrans and an Ativan, and hoped she’d be better in the morning. The next day she indeed was a little better, but in no way was she able to climb onto a horse for the ride out. Eventually, a rescue helicopter was called. A week-long backpack in the high country is not something everyone can do or even wants to do. But this trip connected our group in a deep way, and facilitated lifelong friendships. We look forward to next year’s adventure in the high Sierras. Our medical society’s Connect the Docs program has a similar goal, and is based on the premise that getting physicians to spend time together in a non-clinical setting is a great way to facilitate closer relationships, restore enthusiasm and energy, and prevent physician burnout. FMMS has already hosted seminars on barbecuing and wine tasting, and a pickleball clinic. We would also like to develop physician peer groups: events at which a physician hosts a get-together with some fellow physicians to talk about what excites them or concerns them, hosted by one of our qualified providers at Roubicek and Thacker. If you have an interest in hosting or attending such an event, please contact FMMS.

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Students Explore Careers in Primary Care


Changing the Landscape of Health Outcomes in the Central Valley


Local Medical Students Named as 2021 Gold Foundation Student Summer Fellows


Making Dreams Come True

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Students Explore Careers in Primary Care Five students from Madera South High School were selected to be the first to participate in California Area Health Education Center (AHEC) Scholars - a program focused on bringing more health professionals to underserved areas of our valley. The purpose of this program is to recruit, train, and retain a health professional workforce committed to underserved communities. This opportunity allows the scholars to explore the primary care setting and enhance their skills through a variety of experiences. Five Madera South High School CAN students were selected to be in this first cohort; Perla Reyes, Ruby Tiscareno, Azucena EugenioVasquez, Jenny Alvarez, and Ana Boch. The AHEC program consists of a three-part curriculum. The 40-hour online curriculum hosted by UCSF-Fresno allowed students the ability to dive into community health topics as well as interdisciplinary case studies. The 40-hour clinical training provides students the opportunity to interact and engage with Camarena Health patients in underserved or rural areas to gain hands-on skills. Lastly, the community-based health project, which



consist of identifying a need in underserved communities and helping to address it. Throughout the program, students had the ability to engage in webinars, clinics and community exploration, self-guided research, and casedbased learning. “The AHEC Scholars program gave Madera Unified District students the ability to participate in a unique program in which students are provided the opportunity to connect with their community through a variety of experiences,” said Camarena Health Workforce Development Manager Jazmin Rios. “The goal is to ultimately enhance their skills are they pursue careers in healthcare, better preparing them for their futures.” Camarena Health AHEC Scholars engaged with the community by completing their in-house clinical at a variety of locations. Scholars were stationed at our Camarena Health Urgent Care, Camarena Kids, Almond Women’s Health, and 6th Street Health Center locations.

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This allowed them to experience the diverse care that community health centers provide to patients. For their project, the students chose to collaborate and develop a brochure to address and educate patients on the importance of immunizations and well-child visits. During their spring break, scholars volunteered their time to assist with COVID-19 vaccine distribution in the community. “The students that participated in this program were eager to learn about their communities needs and how to support them,” said Rios. “They participated in our COVID-19 vaccination clinics during their free time, assisted patients with questions, and assisted with the

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completions of forms. They were excited to help patients and arrived ready and with a smile.” All five scholars received a $1,000 scholarship for completing the program. They each plan to begin a college education this fall with intention of entering a healthcare profession. Reyes will be attending Fresno State to major in nursing, Tiscareno will be attending Fresno State to major in biology, Eugenio-Vasquez will be attending Fresno Pacific University to major in nursing, Alvarez will be attending UC Merced to major in chemistry, and Boch will be attending UC Santa Cruz to major in neuroscience.



Changing the Landscape of Health Outcomes in the Central Valley By: Avtar Nijjer-Sidhu, Ph.D., R.D. Assistant Professor and Co-Course Director, Physician’s Role in the Health System California Health Sciences University, College of Osteopathic Medical School Anne VanGarsse, MD, FAAP, CHCEF, CPE, FAAPL, Associate Dean for Clinical Affairs, Community Engagement and Population Health California Health Sciences University, College of Osteopathic Medical School

What does it really mean when we say the California Health Sciences University College of Osteopathic Medicine (CHSU-COM) is changing the landscape of health outcomes in the Central Valley? How do we even attempt to explain this to current and future students that they are on the precipice of making long lasting change. For years, medical school curriculum has been comprised of two main areas: 1) academic biomedical sciences and 2) clinical sciences however, CHSU-COM integrated a third area which focuses on the Health Systems Science (HSS) curriculum. The HSS curriculum delves into improving quality and health outcomes while addressing the delivery cost of health care for patients and population groups. First-year osteopathic medical students are introduced to the Health System Science curriculum through an eight-week introductory course in which they are exposed to topics about the complexities in health care, value-based care, quality improvement, population health, social determinants of health and Adverse Childhood Experiences, teamwork and physician leadership, and cultural humility. These key concepts are then applied to a 1 ½ year longitudinal project in which the osteopathic medical students attend Federally Qualified Health Centers (FQHC), government or community-based organizations



once a month to engage in their service-learning experience (SLE). Through the SLE, the medical students design, develop, implement, and evaluate a population health project at their designated site. The students apply the scientific methods of research to improve health outcomes of the targeted patient population. The purpose of this longitudinal course is to give future physicians a basic understanding of the complexity of our health care system, their role within this system, and the ability to reflect on occurrences within both public and population health that impact one’s professional development. The longitudinal course introduces population health research and management and the principles of health systems and quality improvement. It provides an opportunity to further explore the topics included in the Health System Science curriculum and its interplay with public health, health disparities, and social determinants of health. The underlying goal is to have osteopathic medical students trained in academic and clinical sciences and be versed in topics such as health disparity and health inequities. It is difficult to diagnose a patient who may be facing food insecurity, but it is even harder to understand these concepts if one has not been exposed to them. With the implementation of both the Health System Science curriculum and SLE, we aim to improve patient health outcomes at the population health level while improving

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© Can Stock Photo / Kurhan

patient experience and understanding the financial magnitude of health care cost especially of the most underserved and vulnerable patients in the Central Valley. The SLE is in its second year of inception and has thus far 78 students have engaged in a population health, quality improvement, community based, or research project resulting in 36 different projects aimed to positively impact health outcomes. The variety in projects range from improving traditional Healthcare Effectiveness Data and Information Set (HEDIS) outcomes and preventative measures such as improving HbA1c testing rates to developing an in-home self-monitoring blood pressure program, to identifying the pandemics effect on access to health care in relationship to existing social determinants of health. For academic year 2021-22, we will have 121 first-year osteopathic medical students start their SLE in October across six health systems (FQHC, HMO), one public health department, and one community based-organization. With each incoming class, we hope to expand our clinical and community partnership to continue exposing osteopathic medical students to the dynamics of our ever-changing health care system and its ability to positively impact the lives of so many in this valley.

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Local Medical Students Named as 2021 Gold Foundation Student Summer Fellows

Natalie Pena-Brockett

Three California Health Sciences University College of Osteopathic Medicine students were named as 2021 Arnold P. Gold Foundation Student Summer Fellows including: • Natalie Peña-Brockett • Zachary Josse • Sarah Holzmann These second-year medical students at the CHSU medical school in Clovis were selected for their summer project titled, How the Implementation of Street Medicine Programs among the Homeless Population Reduces the Implementation of the Emergency Department Facilities and Resources in Bakersfield, California. John Graneto, DO, Dean of the CHSU College of Osteopathic Medicine says, “There were only 24 students



Zachary Josse

Sarah Holzmann

across the country chosen to receive a Gold Student Summer Fellowship, so it is a delight to have three of our CHSU medical students selected.” Their group project aims to identify factors associated with emergency department (ED) visits among individuals who are unhoused in Bakersfield, California, and evaluate the efficacy of street medicine interventions. The study will examine patterns of emergency department use and its associated factors, including acute and chronic disease. Through patient surveys and data extracted from electronic medical records, the project will determine the impact of the street medicine team’s efforts, such as potential reduction of ED visits for this population. “I am proud of CHSU-COM Gold Foundation Student Summer Fellows for their project choice, which

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helps to advance our mission and I look forward to seeing the impact and positive results for this medically underserved community they seek to help,” stated Dr. Graneto. The Gold Foundation offers Gold Student Summer Fellowships annually to provide an opportunity for medical students to deepen their understanding of the challenges of health inequities, to enhance culturally responsive practice, and to address community health needs. These initiatives, which can be either research or service projects, help students to develop skills to become relationship-centered physicians while addressing a public health need in an underserved population. For a complete listing of all 2021 Gold Student Summer Fellows, please visit https://www.goldfoundation.org/newsroom/news/24-medical-studentsnamed-2021-gold-student-summer-fellows CHSU Welcomes 120 New Medical Students in Second Cohort On Tuesday, July 20, the class of 2025 was welcomed to California Health Sciences University College of Osteopathic (CHSU-COM) campus for their first year during an extensive orientation. The new student doctors were excited to meet their peers, faculty and advisors.

Top feeder schools include UC Davis, UC Irvine, UC San Diego, UCLA, Fresno State and UC Berkeley. The new cohort was selected from a competitive group of approximately 4,000 applicants. With 83% of students from California and 38% from the Central Valley, the University is hopeful most of this cohort will stay local upon their graduation, especially since there are 35 different languages spoken among the students. Impressively, 33% of the class of 2025 speaks Spanish, and complemented with the required medical Spanish course at the CHSU-COM, these future physicians will be well-prepared to serve Spanish-speaking patients. “In three short years, our inaugural class of DO physicians will begin residencies and make an immediate impact on the health care provider deficit in our hospitals, clinics, and private practices,” stated Dr. Graneto. “From that point on, there will be a steady stream of new physicians joining the community every year,” he added. CHSU-COM plans to hold a White Coat Ceremony for both the class of 2024 and 2025 student doctors this October to signify their entrance into the medical profession.

The second cohort includes 120 students, which brings the total number of medical students at CHSU-COM to 199. CHSU-COM is pleased to have all students back on campus to resume in-person classes and labs. COVID vaccinations are required for all students, faculty and staff at the University, to ensure a safe and healthy environment for in-person learning. “Every year when we admit a new cohort of students, we are making another step towards achieving our mission to improve the health care outcomes of people living in the Central Valley,” said John Graneto, DO, Dean of CHSUCOM. The class of 2025 proudly boasts an average 3.51 undergraduate GPA and average MCAT score of 507.

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By: Rawan Sultan, OMS-III

Making Dreams Come True

Rawan Sultan, OMS-III

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Becoming a physician has been a dream of mine since I was 5 years old. I was born and raised in Fresno, CA so being able to return to the Central Valley to continue my medical education has been rewarding and aligns with my goals and commitment to this area. I attend A.T. Still University School of Osteopathic Medicine in Arizona. This school is unique because students spend 1 year in the Phoenix, Arizona area and then spread across the country in groups of 10 to work in underserved communities. Now I am a third year medical student at the Visalia, CA community health center currently on my Surgery rotation at Kaweah Delta Medical Center. When I returned back to the Central Valley to continue my medical education, I resumed volunteering with Live Again Fresno. This non-profit organization provides support and a family to children living on Parkway Drive, a strip of motels with high sex trafficking, crime, drugs, gangs and violence rates. We play at the park, work on social emotional activities, and expose the children to different educational and fun activities. I value the connections I have made with these families, because it helps me understand the community more and know what problems should be prioritized. A unique aspect of my medical school is that we get an extra year of clinical exposure during our second year of medical school. We work with a preceptor weekly for the entirety of our second year. I feel as this is beneficial in strengthening our clinical skills and prepares us for the third year clerkships. I had the honor to work with Dr. Hutchison, Pediatric Neurologist at UCSF Fresno. I used to be his medical scribe before medical school, so it was nice to return now as a medical student and be a team member of the patient care. His dedication and compassionate care that he provides to all his patients is something I aspire to do. Along with my classmates, I volunteered at multiple vaccine clinics administering the Covid-19 vaccines to our

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hardworking farm workers and to people who did not have reliable transport to get a vaccine. We also administered the flu vaccine and provided health education to our community. It was very rewarding to participate in giving the vaccine to my community during this pandemic. Additionally, I joined the Central Valley Pre-Med Mentorship program where I’ve been mentoring students who identify as first generation, underrepresented in medicine. My goal is to provide guidance and meaningful mentorship to students from disadvantaged backgrounds so they can successfully reach their goals. I have created a connection with my mentee, and meet with him on zoom or over the phone to provide guidance and mentorship. Through my own experiences, I’ve realized the importance of mentors in medicine. My passion for mentorship continues with the MiMentor Central California which is an organization that provides guidance/events/mentors to students in the Central Valley. I led sessions on applying to medical school and taking the MCAT for pre-meds on Zoom. I value mentoring and enabling others to reach their potentials so I am so thankful to be a part of all of these opportunities.

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Towards the end of my second year, I enjoyed teaching the Stanford Youth Diabetes Coaching program for 8 weeks where I taught and mentored high school students about diabetes and hypertension. The students were from Fresno High School and were committed to helping fight the diabetes epidemic prevalent in our community. I learned each child’s strengths and encouraged them to reach their potential with their coaching and beyond in their careers. Each week I was inspired by all of the knowledge the students were learning, and passing on to their communities. I am planning to continue this program again this school year and am currently working with the director to join the California Area Health Education Center (AHEC) scholars program focusing on community health education. While I continue with my third year rotations, I am excited to explore all of the medical fields and find what is right for me. I am very thankful that I have best friends and my family close to me during this challenging yet rewarding time. After medical school, I would love to continue to serve the Central Valley’s medical needs.



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.



ROUBICEK and THACKER 559-323-8484

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

UCSF CAPP Program The COVID-19 pandemic has brought to light and only further exacerbated longstanding problems with ensuring adequate access to mental health care, which, according to the California Health Care Foundation has been the top health issue among Californians polled two years in a row.

One in 5 US children ages 3-17 has a current mental, emotional, developmental, or behavioral condition, with suicide now the 2nd leading cause of death amongst 1024 year olds. Fifty percent of all mental illness begin by age 14, 75% by age 24, with a 2-10 year lag between the onset of symptoms and time to diagnosis and treatment, with disproportionately greater impact on families living in poverty and those experiencing structural racism disproportionately affected However when behavioral health (BH) conditions are detected early and treated appropriately, those individuals experience a greater quality of life, better self- care, improved adherence to medical and behavioral health treatments, and better overall health outcomes. Meanwhile pediatric mental health resources are scarce, as anyone who has tried to refer to, or seek treatment for themselves or a loved one can attest. In California, there are 13 child psychiatrists per 100,000 in California, vs the 47/100,000 recommended by the American Academy of Child and Adolescent Psychiatry. Availability of developmental pediatricians and child therapists is similarly scant. In order to meet the ever-growing need for mental health care, pediatric mental health care access programs

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have evolved as an evidence-based model for significantly expanding this access to care, through education- and consultation-based workforce development of primary care providers. Integrated care delivered within the medical home has been shown to improve health and functional outcomes, satisfaction with services, and cost savings. Parents and guardians report high levels of satisfaction with their PCP’s handling of their child’s mental health issues after consultation (MCPAP) that strengthens the role of the PCP as mental health provider. …. A stepped care approach supports rational utilization of specialty mental health resources for more complex and acute presentations, while lower complexity problems can be addressed within the medical home, through iterative, relationally based consultative support. This helps ensure that youth are seen by the right provider, at the right time, for the right length of time, with less stigma and greater ease of access. SAMHSA holds up the program as a cost-effective, evidence-based model for integration and alleviating workforce shortage issues.



The UCSF Child & Adolescent Psychiatry Portal (CAPP) offers • •

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Real-time, direct-connect consultation UCSF Psychiatry & Behavioral Sciences faculty offer no-cost, timely, practical, person- & family- centered, culturally attuned, and trauma-informed guidance on screening, assessment, diagnosis, and treatment planning One-time second step UCSF Psychologist consultation for families and/or PCPs offers expert guidance in early childhood mental health, cognitive behavioral, family systems and other psychotherapeutic modalities Continuing medical education on common pediatric mental & behavioral health conditions, in order to improve knowledge, skills & confidence, as well as networking opportunities with PCP and behavioral health colleagues Website resources Guiding Principles: Beyond the basics of providing diagnostic and treatment planning support, CAPP consultants conceptualize consultation through a developmental lens, with an emphasis on early intervention and prevention, in a whole-person, wholefamily approach. Expertise: Guided by trauma-informed systems of care principles, including youth and family voice and choice, as well as cultural humility, CAPP's practical guidance on common conditions like ADHD, anxiety and depression is intended to help PCPs expand their comfort zone and confidence. UCSF also has extensive expertise in autism, eating disorders, gender dysphoria, and substance abuse. Psychologist Consultation: CAPP Psychologists have unique expertise in a number of areas, including early childhood development and cognitive and dialectical

behavioral therapy, and provide specialized guidance to PCPs and families when deemed appropriate during initial consultation between PCP and child psychiatrist consultant. School Consultation: CAPP has consulted to schools, specifically to teachers and school mental health counselors and therapists on the developmental impact of quarantine and how to manage mental and behavioral health concerns as they present at school. ACEs Screening: As one of five ACEs Aware core training grant recipients, CAPP consultants provide guidance on next steps to PCPs in a stepped care approach, in order to ensure that PCPs feel adequately supported as they implement ACEs screening in their practice, and to ensure appropriate triage of concerns and symptoms Education: CAPP hosts a variety of educational offerings, including monthly webinars on timely topics informed by common consultation questions.

For more information, including a link to enrollment, upcoming medical education events, and resources, see https://capp.ucsf.edu.

Valley Physicians Recognized for Life-Saving Protocols, Programs By Farin Jacobsen

Three local legendary physicians accepted accolades during the Fresno Madera Medical Society Installation and Awards Gala on Friday, Nov. 19, surrounded by their peers, colleagues and mentors. One created today’s emergency medical services system in Fresno County when there wasn’t one, another created a pediatric oncology program at Valley Children’s when there wasn’t one, and the third led local healthcare systems in responding to an unprecedented global pandemic. Dr. Gene Kallsen at UCSF Fresno and Dr. Vonda Crouse at Valley Children’s received lifetime achievement awards and Dr. Rais Vohra was recognized with a special projects award for his COVID-19 response.

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Vonda Crouse, MD

Back when the north end of State Route 41 ended at Bullard Avenue, and Valley Children’s hospital was at Shields and Millbrook avenues in Fresno, a local pediatric oncology program was nonexistent. “Yes, we had kids that had cancer, but oncology was all administered by adult oncologists,” explained Dr. David Hodge, a recently retired local pediatric surgeon. “And there's a world of difference between treating adults and treating children with cancer.” Dr. Vonda Crouse came to work for Valley Children’s in 1987 and changed all of that, establishing the hospital’s pediatric oncology program. “I think it's one of the best programs that Children's has to offer,” said Dr. Hodge, who worked alongside Dr. Crouse for decades. “It has made it such that many, many children have not had to leave the Valley to get the care that they need.”



Dr. Crouse was recognized with a Lifetime Achievement Award from Fresno Madera Medical Society at its annual awards banquet. Dr. Crouse has led the fight against pediatric cancer for the past four decades, starting with a fellowship in pediatric hematology/oncology at Children's Hospital Los Angeles. She was a pediatric oncologist at The Children's Hospital in Denver and assistant professor of pediatrics at the University of Colorado Health Sciences before joining Valley Children’s. Vinod Balasa, medical director for Valley Children's Cancer and Blood Disorders Center has worked with Dr. Crouse for the last 10 years and heads the program she started. “She started out being the only physician to care for children with cancer when there were no physicians anywhere up and down the Valley to do that,” Dr. Balasa said. “And for many, many years, she either worked alone or just with one person being on call every night, taking care of these children, and she worked tirelessly.” In her acceptance speech, Dr. Crouse recalled the early days of her career in Fresno when Woodward Park Drive-In stood on Blackstone north of Herndon, long since replaced by Costco. “When I was on call so much at the very beginning, I could go over there (to the drive-in movies) and we could take the kids and the dogs and my beeper, and it didn't matter,” she said. “I could make phone calls and it was all very good; (I would) only miss half the movies.” In those days, there was no department of pediatric hematology or pediatric oncology at Valley Children’s, Dr. Crouse explained. “I was really grateful for the commitment that Valley Children's had made at that time in the 80s to increase the number of pediatric subspecialists,” she said, remembering that patients would have to be rescheduled when thick Valley fog would prevent UCSF doctors from driving down to see them in special clinics. “When I came to Fresno I was the first board certified pediatric hematologist oncologist with CCS privileges, and now we are 12,” she said. Dr. Balasa noted that Dr. Crouse is also the hospital’s principal investigator for Children's Oncology Group,

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which researches and develops oncology treatments. “Through that she’s ensured that children here in the Central Valley are able to receive the same state-of-the-art treatment that they could get anywhere else in the world,” Dr. Balasa said. “She's truly been dedicated to this work. I'm very lucky and honored to be associated with her and to be able to work with her and I'm hoping to do so for many more years to come.” Yvonne Wood, now the Throughput Manager at Valley Children's, was a brand new nurse taking care of oncology patients at Valley Children’s in 1990 when she met Dr. Crouse.

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“I think that we're all better for knowing Dr. Crouse,” she said. “She's quiet. She's so smart. She was ahead of her time.” Wood described how Dr. Crouse taught the staff to call her with a report on a patient, including their thought process — it was an SBAR (Situation-BackgroundAssessment-Recommendation) report before SBAR was introduced in the medical field in the early 2000s. “If we were going to call her and wake her up in the middle of the night for something, we better know what was going on, what we thought was going on, what we thought should happen next, and why,” Wood said. “And if we're wrong, that was okay; she would teach us and she loves to teach. … She never got mad. She was just there to grow the world.” Dr. Crouse graduated from USC School of Medicine in 1974, at a time when only 9 percent of students in medical school were women, radiologist Dr. Bonna RogersNeufeld told the crowd when she introduced Dr. Crouse at the awards ceremony. “It was difficult to get into medical



school but it was also difficult to get a job even if you did get out.” In a career that has so far spanned four decades, with 35 years at Valley Children’s hospital, Dr. Crouse’s work has included “many clinical trials and hundreds of papers cited all over the world,” Dr. Rogers-Neufeld said. Dr. Crouse is a member of several professional societies, including the American Academy of Pediatrics and the American Society of Pediatric Hematology and Oncology. She has published her work in professional journals, including Pediatrics and the American Journal of Epidemiology. “In that long tenure she now is able to see the children of the children that she saved,” Dr. RogersNeufeld said. Dr. Crouse is known for her dedication to Camp Sunshine Dreams, a camp that serves kids with cancer and their siblings, ages 8 to 15. The camp is staffed with nurses and doctors and the children enjoy camp activities like arts and crafts, archery, sports, music, dance, movie night, campfires, and kayaking. Dr. Crouse is no stranger to climbing the rope ladders and shooting archery with her patients. “She spends her entire day out and about, driving kids around on golf carts if they can’t walk very well,” Wood recalled. “She's out taking pictures all day long … she’s amazing.” George the giraffe was chosen as Valley Children’s mascot because giraffes have the largest heart of all land



animals. People who have worked with or have been cared for by Dr. Crouse would argue that the size of her heart would rival George’s. “She just loves,” Wood said. “Her heart is so big for these kids and what they do. She loves to see them do well. That's the goal, right? To get them well — healthy and well and out of the hospital. So to be at camp and to see them playing and normal and with their siblings, that's her, that's her thing; she just wants everyone to be well and happy.” With more than 30 years' clinical experience in pediatric oncology, she has treated more than 3,000 children diagnosed with cancer. And she keeps tabs on many of them. “Her mind is a steel trap” for her patients, Wood said. “I can talk about kids that I knew back in 1990 that I took care of and she'll know what they're doing. She'll know if they're married, if they have kids, what they're up to.” If other staff hears anything about former patients — “her kids” as Wood calls them — Dr. Crouse loves to hear about it. “They’re her world,” Wood said. “It’s amazing to me how she can remember. She knows their diagnosis. She knows how old they are. She knows where they are, what they're doing. She loves everyone.” Parker Fritsch has been Dr. Crouse’s patient since his acute lymphoblastic leukemia diagnosis and bone marrow transplant in 2008. His fondest memories with Dr. Crouse are from his years at Camp Sunshine Dreams. “Her camp name is Crush,” he said. “We got her a golf cart and it was yellow and white and we put big stickers on it and it said ‘The Crush Mobile’ … I just love seeing her face as she smiles driving around the kids down to the lake or over to the campfire. Just seeing Dr. Crouse’s smile as she's up there being part of that community, it's amazing that oncology has brought all of us together up there and she is, without a doubt, a key member of that staff.” “Dr. Crouse has done so much for the community in Fresno and the oncology community out of Valley Children's that it's really hard to put a label on what her biggest accomplishment would be,” Fritsch said. “I think that just being there for her patients, whether it be up at Camp Sunshine Dreams … or being in the hospital, Dr. Crouse is 100 percent on board for her patients’ health and for her patients’ well being. It doesn't matter what time of day or night, Dr. Crouse is always going to be there and that, to me, is her greatest accomplishment.” Fall/Winter 2021

Lifetime Achievement: Gene W. Kallsen, MD

It might be taken for granted that a person can call 911 in Fresno County and an ambulance staffed with a well-trained paramedic will show up in less than 10 minutes to take them to the hospital. But someone had to put that Emergency Medical Services system in place, and that person was Dr. Gene Kallsen. Dr. Kallsen, known as the father of EMS in Fresno County, became the county’s first EMS medical director in 1981 and recently retired from a medical career spanning five decades, including four decades teaching. He was honored with a Lifetime Achievement Award from Fresno Madera Medical Society. “Dr. Kallsen has his fingerprints on every aspect of this EMS system,” said Todd Valeri, president and CEO of American Ambulance. “I think that anybody who dials 911 for a medical emergency in Fresno today has an expectation of quality, has an expectation that their call when received at the dispatch center will be appropriately triaged, and that the closest, most appropriate ambulance is going to respond, Fall/Winter 2021

that the paramedics and EMTs who arrive on scene are going to be trained and competent, and that they're going to interface with local hospital staff to make sure that patients receive the best care possible,” he said. “I can tell you that wasn't always the case.” In the mid-1970s when emergency medicine had still not been recognized as a medical specialty, Dr. Kallsen applied to UCSF Fresno’s Emergency Medicine residency. Back then, EMS was a “disjointed system,” Valeri said. There were four ambulance companies on rotation, so the closest ambulance was not sent to each call, which lengthened response times — and it was not guaranteed that a paramedic would be in each ambulance. Dr. Kallsen completed his residency in 1979, the same year the American Board of Emergency Medicine was approved, and began making changes in how EMS was run in the county. “He, along with other key stakeholders, got together and said we're going to run Fresno County where the ambulance closest to you is going to come to you, and it's going to be a really well run EMS dispatch center,” said Dr. Danielle Campagne, vice chief of emergency medicine at UCSF Fresno. “Those amazing contributions really shaped what we do today and we don't even think about all the forethought he put into creating our community as we live today.” Valeri recalled his first experiences with Dr. Kallsen in the quality assurance realm, when Dr. Kallsen directly mentored paramedics to help them improve the services they offered. “Dr. Kallsen was very serious. In fact, many of us young paramedics were a little intimidated,” Valeri said. “However, getting to know him and work alongside and to be taught by him, I really got to see his passion for prehospital care and his deep concern for patients. He just simply wants us to all do our best in that environment and he demanded that.” Dr. Campagne admired that Dr. Kallsen always leads by example. “He is cool as a cucumber. He is so calm. He's so kind. He's very compassionate,” she said. “As a resident in training watching him as faculty, he was always my favorite CENTRAL VALLEY PHYSICIANS


person to watch because he's always very calm under fire… I always felt like I wanted him to be my doctor if I was ever injured and I want to be a physician just like him.” Dr. Kallsen was recognized for building the emergency medicine program at UCSF from 11 faculty and 18 residents up to 34 faculty and 40 residents. An endowed chair at UCSF Fresno was named in his honor in 2015. “Gene knows not only how to do, but also how to teach,” noted Dr. Alan Kelton, Chief of General Medicine Division at UCSF Fresno in his introduction of Dr. Kallsen at the awards banquet. “He's taught well over 270 emergency medicine residents, but really he's taught hundreds more, OB, surgery, internal medicine, family practice, so many have learned from him, and so many have benefited.” Dr. James Comes, Chief of Emergency Medicine at UCSF Fresno also recognized the impact Dr. Kallsen had shepherding the emergency medicine program into what it is today. “We have faculty that have expertise in toxicology and wilderness medicine, and ultrasound and hospice and palliative medicine and critical care and pediatrics and law,” he said. “I mean, could you imagine what our community would be like if we didn't have the training programs that we have here today? And (Dr. Kallsen) is instrumental in that space.” Dr. Kallsen humbly accepted his Lifetime Achievement Award, but only after commending his fellow healthcare workers on their frontline battles with the COVID-19 pandemic. “First, I want to say something about the heroes who have been going to work for the last 18 months,” he said, choking up. “I haven't had to face this pandemic as most of you have. I’m very proud of what you've done.” 26


Dr. Kallsen said it was serendipitous timing that steered the trajectory of his career in emergency medical service. “I am forever grateful for the dumb luck of my time,” he said. “You know, you couldn't have planned for the specialty that you've trained in to become a specialty within a month from the time you're finished residency. You just couldn't plan that. “You couldn't plan that within a year after that the EMS legislation for the state finally went into law, and all of a sudden every county had to have an EMS medical director, and all of a sudden the state had to have an EMS commission. To get to be on the ground floor, there was the opportunity that just fell in my lap.” His colleagues would argue that it is more than luck and opportunity that led Dr. Kallsen to a long, impactful emergency medicine and teaching career — it was his willingness and ability to lead, make decisions, and foster collaboration. Dr. Campagne recalled the years of her residency UCSF Fresno EM Residency - 1984 during which University Medical Center was a county-run hospital and Community Medical Center downtown was a private hospital. “(Dr. Kallsen) was really instrumental in that merger and bringing County medicine and community hospital together,” she said. “I couldn't imagine now not having this giant regional trauma center that has all these specialties together. I think that is a perfect example of him always thinking 20 or 40 years in the future to make our community a better place to live. “Without him I think our community would not be what it is today.”

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Special Project - Covid Response: Rais B. Vohra, MD

For the last 20 years, Fresno Madera Medical Society has honored annually a physician who has been involved in a special project that affects Valley residents, patients, and the community as a whole. This year, the recipient was honored for an effort in a project he never asked for nor expected: becoming the face of the local fight against the COVID-19 pandemic. Dr. Rais Vohra, an emergency room physician, medical educator at UCSF Fresno, and head of the region’s Poison Control Center, was hired as Interim Health Officer for Fresno County Department of Public Health just a few months before COVID-19 hit the county. When accepting his special project award, Dr. Vohra recalled being asked what he pictured himself doing in 10 years on his first day in Fresno about a decade ago. “My answer was not, you know, ‘I want to be burned in effigy by the most privileged and misinformed members

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of our society during a global pandemic.’ That was not my answer. But here we are,” he said, as the banquet hall erupted in laughter. David Pomaville, former Director of Public Health for Fresno County, hired Dr. Vohra in October 2019 and knew he was going to be a great fit based on his experience and ability to communicate warmly and effectively. “His talent with regard to the ability to distill complex medical topics into small bite-sized pieces that people can understand is one of his greatest gifts,” Pomaville said. Dr. Vohra also comes up with quotable phrases, which he would display on a whiteboard in the health department’s conference room. Pomaville’s favorite Dr. Vohra quote: “Your chance of being affected by misinformation is far more likely than being infected with COVID-19.” Keeping the public informed and protected is top



priority for Dr. Vohra; he holds weekly Zoom conferences with media partners to keep everyone up to date on the county’s COVID-19 statistics and responses. When Dr. Vohra was encouraged to take a break from work to spend time with his family at the beach, Pomaville was left to organize the weekly media briefing. He brought in six physicians who each gave a presentation. At the end of it, one of the presenters asked, “So it took six physicians to come in and do what Dr. Vohra does in one meeting,’” Pomaville recalled. “And that’s Dr. Vohra. He’s able to work so effectively across a broad number of topics and build confidence with his peers and with the public.” Throughout the pandemic, Pomaville recalled Dr. Vohra working at the public health department and then working a shift in the Community Regional Medical Center emergency room. “It was so important and so impactful during the pandemic for us to have somebody working on the frontlines in medicine, providing treatment to patients and getting that reality back to us at public health,” he said. “You might think that that's a given that we know and understand what's happening in the medical community, but making that connection was so powerful.” Dr. Vohra is known for bringing his calm demeanor to every conversation and communicating effectively with the



media, medical providers and government officials, said Joe Prado, Interim Assistant Director at Fresno County Public Health. “Dr. Vohra has this unique talent. He knows how to write a prescription for the entire County of Fresno population. He knows exactly where we need to be and where we need to go,” Prado said. Dr. Vohra’s public health team has worked tirelessly to bring local agencies together to collaborate throughout the pandemic in a region that is largely agricultural and medically underserved. Prado recalled a story from the first week COVID-19 vaccines were approved. It was unclear how many doses would be available to Fresno County and who would be eligible for them. Prado came to Dr. Vohra and said they needed to take a risk, a word that made the interim health officer sit up in his seat and ask what risk needed to be taken. “We need to start figuring out how to vaccinate our farmworker population,” Prado said he told Dr. Vohra. “Dr. Vohra immediately looked me straight in the eye and said ‘Let’s do it. Let’s go for it.’” Dr. Vohra’s energy to say yes to serving vulnerable populations motivated discussions and quick action, Prado said.

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“We ended up being a model for the state of California on how to vaccinate the farm worker population,” he said. “We really helped to demystify how to run a medical clinic. It doesn't have to be a medical provider. We had farmers running medical clinics. “Dr. Vohra supporting that from the very beginning really helped to encourage our entire community ‘we've got this.’ Just know that we have to work outside our norm to be able to do this.” Dr. Vohra’s team spirit and positive attitude helped inspire leaders at Sierra Pacific Orthopedic Center — which isn’t traditionally public health-focused — to pitch in and make the community safer. Rick Lembo, Director of Sports Medicine at SPOC, was inspired to set up a mass vaccination site after his own positive COVID swab. After a Sunday meeting with the public health department, SPOC gathered the assets and logistics to open its parking lot by Wednesday to start vaccinating thousands of Fresno County residents. “One thing I learned throughout this and that I admire the most was (Dr. Vohra’s) sense of reassurance, whether it be to health care providers, his fellow providers, to the general public, or in the media,” Lembo said. “He continued to always show resolve and common sense through a very, very tumultuous time. Very clearly he spoke of what's going to happen, what needs to happen and what else we can expect.” Dr. Robin Linscheid Janzen said Dr. Vohra brought her onto the team at the public health department about six months into the COVID-19 pandemic and she has been able to see firsthand how he steers people toward goals while making them feel comfortable and heard. “He's good at seeing the whole big picture but also empowering people to kind of take those steps to get to that goal of making our county healthier,” she said. “We've had disaster after disaster with COVID and then Creek Fire and he's just really been able to provide that reassuring leadership and direction for the County to provide services to those in need. “He has done a great job of really partnering with community based organizations, with providers, community members, our schools, our faith based community, to really keep them all informed and utilize

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them as resources to help the county be healthier, and to stay safe during COVID.” As expected by his colleagues, Dr. Vohra accepted the award not just for himself, but on behalf of everyone working with him in public health, the frontline heroes, and those he has gotten to know through Zoom calls during social distancing in the past two years. “I've had the privilege to lead the pandemic response and the health department, and to have this very special role which I've never, ever in my wildest dreams, thought that I would ever have,” he said. “So I feel really honored. To be recognized in this way by my peers and by my mentors and colleagues, is really special and I'm very touched. I'm also very humbled because I know that this award is not just for me, but for really the whole team and the network that we've had to become in order to take care of our patients and to take care of ourselves. “We've all had the patience and goodwill to stick with each other and really just learn from each other and cover each other's blind spots.”

Dr. Vohra Yosemite







Valley Medical Students Receive White Coat CHSU-COM Hosts First White Coat Ceremonies for 199 Student Doctors California Health Sciences University College of Osteopathic Medicine (CHSU-COM) hosted their first official White Coat Ceremonies on Saturday, October 2 at Paul Shaghoian Memorial Concert Hall. The two ceremonies were held on the same day for 199 medical students in the classes of 2024 and 2025 since the ceremony for the inaugural class of 2024 was postponed a year due to COVID. The White Coat Ceremony signifies a rite of passage to emphasize the importance of compassionate patient care at the very start of medical training. John Graneto, DO, Dean of the CHSU College of Osteopathic Medicine welcomed guests and shared the history of the white coat. He also spoke to the students about the importance of maintaining professionalism and humanism in health care careers. “I’m very proud that today our CHSU student doctors better represent the populations we serve through our University’s and medical community’s focused efforts on diversity, equity and inclusion in medicine and medical education” said Graneto. He added, “You develop your professionalism through relationships, reflection and resilience; these are



things you “wear” even when not in white coat. Each time you wear your white coat should remind you of the honor to provide care for another human being.” Rebeccah Rodriguez Regner, DO, presented the keynote address at the ceremonies. Dr. Rodriguez Regner is a board certified Family Medicine and Sports Medicine physician who serves on the U.S. Olympic and Paralympic Committee as a Team USA physician. The white coats were generously sponsored by the Osteopathic Physicians and Surgeons of California (OPSC), an organization focused on advancing and supporting osteopathic physicians in California by serving their mission to engage, educate, and advocate for DOs, so doctors can focus on being doctors. Founded in 1961, their association serves over 9,000 current and future Doctors of Osteopathic Medicine throughout California. Attendees were required to be fully vaccinated and wear masks during the ceremony.

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The Wounded Healer ABOUT THE AUTHOR Shahna Duerksen, MA, AMFT Registered Associate Marriage & Family Therapist, AMFT# 101647 Shahna specializes in working with those experiencing depression, anxiety, burn-out and relationship distress as well as adoptive parents and partners of sex addicts. Promoting personal growth, hope, and healing, Shahna believes in the power of presence and ‘with-ness’ with her clients. Shahna seeks to create a collaborative experience where current issues, symptoms and patterns are looked at from past and childhood/early life experiences, and help the client discover how these impact their life today. Fall 2021

Throughout the pandemic, medical professionals have been lauded as “heroes, warriors, and fighters.” They’ve devoted their lives to healing the sick and comforting the dying. While the work they do is truly amazing – even heroic – they are still human beings that experience their own psychological distress and emotional wounds. So what happens when the one who comforts now needs comforting? Who supports the wounded healer who has witnessed immense suffering?

Rapidly increasing numbers of healthcare professionals – wounded healers – are experiencing mental health and physiological symptoms as the fight against COVID-19 wages on1. A January 2021 study by the University of Utah found that “more than half of doctors, nurses, and emergency responders involved in COVID-19 care could be at risk for one or more mental health problems, including acute traumatic stress, depression, anxiety, problematic alcohol use, and insomnia. The researchers found that the risk of these mental health conditions was comparable to rates observed during natural disasters, such as 9/11 and Hurricane Katrina.” During the pandemic, healthcare professionals have had the sacred honor and emotional burden of holding the hand of the gravely ill in place of their loved ones. They’ve held iPads and phones to patients’ faces as loved ones said their final goodbyes. And they’ve been with their patients as they take their final breaths. With no time or space to process our natural human need to find existential meaning in death, the wounds continue to grow deeper and more profound. Healers often feel the weight of spoken and unspoken personal and professional expectations to be a “superhero”, pushing their bodies and emotions CENTRAL VALLEY PHYSICIANS


© Can Stock Photo / SYNEL

to physical and mental exhaustion. Often, healthcare professionals' symptoms of psychological distress go unnoticed, unspoken and untreated due to stigma or perceived professional consequences associated with asking for help. Unfortunately these unrealistic expectations add to untreated mental health conditions that can lead to more severe health concerns and death. Recognizing when you can’t cope, or hope, any longer, and allowing others to hold your own pain, wounds and suffering is vitally important. Reaching out for support is not a sign of weakness. Ending the stigma associated with mental health is literally a life and death situation. Normalize mental and emotional well being. Ask for help just as one does their physical health. Caring for others requires that you also care for yourself. As a wounded healer, it's your turn to be healed and comforted.

TIPS FOR HEALTHCARE PROFESSIONALS: 1. RECOGNIZE your symptoms. Acknowledge you are struggling2. “Identify your emotions and symptoms that are bothering you and how they impact you daily. These are expected emotional responses, and it is okay to feel them, in any combination. Calling them what they are helps you gain perspective, and focus on your approach for feeling better”. Honor your own pain and wounds empathetically with compassion for yourself. 2. ASK for Support. You cannot heal yourself. Reach out and share the unspoken feelings with trusted, confidential individuals and programs. Tell someone if you're overwhelmed; a colleague, friend or family member who can provide perspective, advice and direction. Find a trusted mental health professional for psychological support. 3. GET TREATMENT for your untreated mental health symptoms and conditions. It’s not enough just to have good support systems in place, healthcare professionals need to actively use them. Be proactive. You do not have to be in crisis or suicidal to access preventative counseling services. Access your employers assistance programs for confidential counseling services and other mental health resources. Utilize the in-person, tele-health or other resources available to you.

Resources: Call: National Suicide Prevention Lifeline: (800) 273-8255 (TALK) to talk with a trained crisis counselor. If you are in crisis, thinking about hurting yourself, or need mental health support call the 24/7 free, and confidential hotline. Call: Safe Call Now 1-206-459-3020 or 1-877-230-6060 a confidential, comprehensive, 24-hour crisis referral service for all public safety employees, all emergency services personnel and their family members nationwide. Text: Text “10-18” or “SCRUBS” to 741741. If you don’t want to talk on the phone, you can also text. Crisis Text Line offers free 24/7 mental health support. Virtual Support: There are several free, confidential and virtual support services available for frontline health care professionals. Find these and other excellent resources at: www.nami.org/Your-Journey/Frontline-Professionals 1. 2.

https://healthcare.utah.edu/publicaffairs/news/2021/01/covid-mental-health.php | Article: Jan. 2021. More than half of COVID-19 Healthcare workers at risk for mental health problems. NAMI https://www.nami.org/Your-Journey/Frontline-Professionals/Health-Care-Professionals



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San Joaquin Valley Medical Scholarship Foundation By: Sergio D. Ilic, M.D.

It is common knowledge that there is a severe shortage of doctors in Fresno and the San Joaquin Valley, especially Primary Care Doctors. In addition, it is well established that Primary Care Specialties are reimbursed at a lower rate by insurance companies, including Medicare and Medical. Family medicine, primary care, pediatrics, OB GYN, gerontologists, and other providers have difficulty making ends meet after paying for the expenses of running a practice and daily living. Furthermore, one of the biggest hurdles to become a primary care physician is the high debt medical students graduate with, which is usually between $250,000 and $400,000 dollars, depending on where they went to medical school. This doesn’t include daily living expenses. This is the equivalent of graduating with a home mortgage, with the aggravating difference that the interest rate on that debt is usually 8% or higher, with the added difficulty that most of the time, it cannot be refinanced. Further exacerbating the situation is the fact that within 5 years, about 30% of practicing doctors will be within retirement age. By 2030, by attrition, the state could lose 10,000 primary care clinicians including Nurse Practitioners and Physician Assistants1. The federal government’s Council on Graduate Medical Education recommends 60 to 80 primary care doctors per 100,000 people. Statewide in California, the number is just 50 per 100,000 and in some places, it’s even lower: 35 in the Inland Empire and 39 in the San Joaquin Valley, according to a report from The Future Health Workforce Commission. Among the causes of the physician’s shortage are the high graduation debt, low reimbursement by the insurance companies, PCPs often shy away from rural underserved areas, and health care professionals do not reflect the Fall/Winter 2021

diversity of the state, which influences where new doctors and other health professionals choose to practice2. To improve this situation, Dr. Kathy Flores, Dr. Dan Stobbe, Dr. Sergio D. Ilic and Karen Paolinelli, CEO of Madera Hospital, have created a tax deductible (to the extent allowable by law) Charitable Foundation, the San Joaquin Valley Medical Scholarship Foundation (SJVMSF), a 501 (c) 3 EIN # 84-3316050, with the goal of paying FULL TUITION for 5 medical students for each medical school year for a total of 20 medical students each year that are committed to practicing medicine here locally in the San Joaquin Valley. There are several meaningful scholarships that can be obtained by medical students, but the amount of money they award doesn’t significantly reduce the grand total debt that students graduate with. That is the big difference with the SJVMSF. The objective of the foundation is to pay for the total amount of the tuition. The recently created California Health Sciences University in Clovis, has founded the first Medical School in the San Joaquin Valley, a Doctor of Osteopathic Medicine (D.O.). The tuition is $55,000 per year. The SJVMSF needs $1,100,000 dollars per year to pay for 20 students. ($55,000 x 20 = $1,100,000). The foundation needs to be funded with $25 million dollars. When invested, we will aim at generating 5% per year. This will produce $1,250,000. This will allow some cushion for the years the market is down, and for tuition increases. The donations will be handled by WealthPlan Partners. They manage over $400 million dollars of Charitable Foundation’s money, and they estimate the goal is achievable. The local representative is Amy NuttalZwaan, Certified Financial Advisor.



The SJVMSF will target students from the San Joaquin Valley. Some of the poorest communities in the nation are clustered in the Central San Joaquin Valley. Census data (2010) show 25.4% of Fresno County residents live in poverty compared to 15.1% of all Californians. In some rural towns the rate of poverty is 40% or more. The biggest challenge for these young people is lack of financial resources to pursue health professions education. The main strategy is to recruit students from Modesto to Bakersfield. It is expected they will commit to become Primary Care Doctors and to return and work in underserved areas, if possible, where they came from, for a period of 4 to 5 years following the completion of their education. If they forfeit their commitment, they will have to pay the scholarship amount at marketplace interest rates. The selection of students from these areas will help to decrease the diversity gap. They will provide better healthcare to their communities and will improve the local economy by creating better paying jobs. An added benefit is that they will lead by example. Ideally, the SJVMSF, will be funded all at once. One of the frequently asked questions is ‘’what happens if this

doesn’t happen?’’ Once the $5-million mark is reached, one student’s tuition will be financed. A total of 10 million will finance 2 and so on, consecutively. The plan is to keep the expenses of the SJVMSF at a minimum. The Board of Directors will work ad honorem. Eventually, a secretary will be needed, and this position will have to be salaried. If you want to make a tax-deductible donation to a good cause, please do so by donating to the SJVMSF. To know more about the Foundation, please go to the web site at www.sjvmedicalscholarship.org. The web site contains a short video and a link for donations. We also encourage you to ask others, in the medical profession as well as in other sectors, to also donate to this critical cause. The more people that become aware of our mission, the greater the probability of fully funding the scholarships and closing the gap. You can reach the Foundation at Foundation@ sjvmedicalscholarship.org. Sergio D. Ilic, M.D.

Join California's fight against COVID-19 Enroll your organization in California's COVID-19 Vaccination program


$10,000 GRANT

Applications started before the Dec. 17 deadline must be submitted by Jan. 21 California is offering providers up to $55,000 to support vaccination efforts. Receive a grant of a minimum of $10,000 toward your vaccination efforts. Grant funding can also be approved retroactivly to support your COVID-19 vaccine efforts. Have questions about the application or want more information on the grant process and how to enroll? Please go to calvaxgrant.org or call the Fresno Madera Medical Society for more information at (559) 244-4224.

CMA 2021

Legislative Wrap-Up Entering 2021, hope abounded that the pandemic would dissipate, allowing life to return to normal. But the collective longing for normalcy would go unmet. The California State Legislature continued to operate under public health protocols that limited in-person contact and relied upon non-traditional approaches to advocacy. As veteran legislators began settling back into their Capitol offices, 18 new elected legislators were sworn into the Legislature: twelve Democrats and six Republicans. With these additions, the Democrats increased their existing supermajorities in both the Senate and the Assembly. Implementing lessons learned from the prior year on how to better navigate the Capitol’s hybrid-working approach and prohibition on in-person meetings, the California Medical Association (CMA) took an aggressive approach to the year. Specifically, CMA sponsored and cosponsored a larger number of bills than standard practice, entered a greater number of partnerships and coalitions, and maintained an aggressive posture throughout the year, despite calls from legislative leadership to decrease the number of bills under consideration. CMA Senior Vice President , Centers for Government Relations and Political Operations

By the end of the first quarter of 2021, CMA had already provided approximately $250 million in state tax relief to the physicians of California. The aggressive positioning of the association allowed CMA to take advantage of abnormalities in the legislative process. For example, during his presentation of the January 10 budget proposal, Governor Newsom called for the Legislature to take early action on specific items designed

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to either re-open K-12 public schools or boost the economy. This break from the traditional state budget process allowed CMA to lead a multi-industry coalition effort to enact the largest state tax rebate in the history of California, through CMA-sponsored AB 80 (BURKE). This bill provided full state tax conformity with federal tax rules regarding the deductibility of forgiven Paycheck Protection Program loans for physician practices. Thus, by the end of the first quarter of 2021, CMA had already provided approximately $250 million in state tax relief to the physicians of California. With an early victory on state tax conformity, CMA was well positioned for the traditional state budget. Despite programs and efforts to mitigate the economic impacts of the pandemic, many Californians still face severe hardships. Over 4 million Californians remain unemployed and approximately half of the jobs lost during the pandemic have not been recovered. Affordable housing, homelessness and school re-opening remained the top overarching policy areas California’s legislative leadership and the Governor sought to address.

CMA was able to utilize the budget process to make significant progress towards achieving interoperability within the health care delivery system. Specifically, the 2021-22 State Budget establishes the California Data Exchange Framework, which puts California on a path toward making all electronic health data available at the point of care for every patient. Although pandemic response was also a top priority, it was not among the highest profile matters at the beginning of traditional budget deliberations. However, the COVID-19 pandemic clearly identified rampant inequalities in health care. Whether it was testing, access to physician practices or availability of hospital beds, the case was clear that too



many areas of the state did not have sufficient access to health care. CMA refused to concede the point. Though pandemic response was only a portion of what the state needed to address through budgetary allocations, CMA persisted and worked to achieve many victories including: • EXTENDING THE TELEHEALTH FLEXIBILITIES and expansions from the COVID-19 public health emergency, including payment parity for telehealth (including audio-only) in Medi-Cal, for an additional year. This will provide $179 million in reimbursements for these services and ensure patients continue to have access to care via telehealth. • MAKING PERMANENT THE PROPOSITION 56 TOBACCO TAX FUNDING, ensuring certainty of $1.2 billion in total funds ($413.9 million in general funds) annually to continue the Medi-Cal supplemental payments. This will increase practice stability for Medi-Cal practitioners and access to care for Medi-Cal beneficiaries. • EXPANDING ELIGIBILITY FOR FULL-SCOPE COVERAGE to individuals 50 and older, regardless of documentation status; cmadocs.org • EXTENDING COVERAGE TO ALL CHILDREN UNDER 5, eliminating the risk of these patients sliding into and out of coverage while a physician is managing their care; • SECURING $50 MILLION, ONE-TIME IN GME FUNDING to support startup costs for new residency programs. • PROVIDING GRANTS OF UP TO $50K TO PHYSICIAN PRACTICES to incentivize participation in the state’s vaccine network for a total of $37 million in one-time support for the community vaccination rollout effort. • FIXING THE STATE AND LOCAL TAX (SALT) DEDUCTION CAP. For an individual with a $200k per year total combined (business and wage) income, this change amounts to an estimated $3,900 per year total tax reduction for those who choose to pursue this option. In addition to these victories, CMA was able to utilize



the budget process to make significant progress towards achieving interoperability within the health care delivery system. Specifically, the 2021-22 State Budget establishes the California Data Exchange Framework, which puts California on a path toward making all electronic health data available at the point of care for every patient. Under the framework, the State of California will develop a standard data sharing agreement through which all physicians, hospitals and health plans will exchange health care data. The state will also work with CMA and others to develop a program of technical assistance to support small and safety net practices. With the main budget bill enacted, CMA turned its attention to the passage of the association’s remaining sponsored bills and priority bills of interest. Below are summaries of outcomes in particular issue areas. SCOPE OF PRACTICE A primary focus of CMA’s Government Relations team was to ensure that the singular occurrence of the passing of a major scope bill did not turn into a harmful pattern. Despite many attempts, CMA was able to stop bills that sought to further erode important patient protections. Most notably, AB 1328 (IRWIN) if enacted, would have increased pharmacists’ scope by authorizing them to order and interpret all CLIA-approved tests, as opposed to only monitoring and managing the efficacy and toxicity of drug therapies. In partnership with the American College of Obstetricians and Gynecologists, CMA was successful in defeating this legislation. In addition, AB 407 (SALAS) would have allowed optometrists to treat more severe eye diseases with the use of pharmaceutical agents and therapeutic pharmaceutical agents without increased education and training. Recognizing the detrimental impact this bill would have, CMA teamed up with the California Academy of Eye Physicians and Surgeons and successfully limited the optometrists’ expansion to include treatable areas, such as the front of the eye, eyelids and adjacent tissue, as well as shortened the list of approved drugs for the conditions they may treat. ADMINISTRATIVE BURDENS CMA-sponsored SB 510, authored by Senator Richard Pan, M.D., requires the health plans and insurers to

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cover COVID-19 testing and vaccinations during the pandemic without barriers like patient cost-sharing or prior authorizations. At a time when health inequities have been laid bare in the health care system, SB 510 ensures that all Californians, regardless of race, income or geographic region are able to receive vaccination and testing, which will remain necessary until the conclusion of the pandemic. This bill implements valuable lessons learned over the course of the pandemic, setting up a framework in preparation for future public health crises.

the importance of identifying and treating mental health conditions across the board. CMA-sponsored SB 428, authored by Melissa Hurtado, requires commercial health care service plan contracts or health insurance policies to provide coverage for adverse childhood experiences (ACEs) screenings. This bill makes commercial plan coverage consistent with the screening coverage currently provided for Medi-Cal beneficiaries to assist the California Surgeon General’s goal of providing universal screening for all Californians.

Protecting practices from future sudden dramatic cost increases is necessary to increase the resiliency of physician practices during significant public health crises.

IMPROVING PUBLIC HEALTH, INCREASING ACCESS TO CARE CMA has worked tirelessly for decades to decrease the harmful impacts of tobacco. With the successful passage of Proposition 56 in 2016, the state increased the taxation on traditional cigarettes, but inadvertently created a financial incentive for traditional smokers to switch to vaping products that where taxed at a lower level. Authored by Senator Ann Caballero, SB 395 imposes a 12.5% tax on e-cigarettes to reduce their use and generate revenue for important health care workforce initiatives. Most significantly, the majority of the ongoing funding— an estimated $30 MILLION each year—will be used to support the Medi-Cal Loan Repayment Programs for Physicians and Dentists.

CMA also sponsored SB 242 by Senator Josh Newman, which requires health care plans and insurers to reimburse provider costs related to the procurement of critical safety supplies, such as personal protective equipment. These increased costs have impacted physician practices of all sizes. Protecting practices from future sudden dramatic cost increases is necessary to increase the resiliency of physician practices during significant public health crises. The passage of SB 242 will ensure health plans meet their obligation to protect provider networks and ensure access to care for all Californians. TELEHEALTH AB 457 by Miguel Santiago ensures that patients are notified of their rights to have a telehealth visit with their own physician. It would further guarantee that, when patients do access services through a third-party corporate telehealth provider, they receive high quality, integrated care including the sharing of medical records. Essentially, AB 457 stops health insurers from steering patients away from their treating physicians to third-party, cmadocs.org | Page 3 direct to consumer companies utilizing a “next doc up” model of care. Thus, it ensures that patients have the right to turn to their treating physicians to continue receiving coordinated, fully integrated care. MENTAL HEALTH COVERAGE The COVID-19 pandemic has increased the spotlight on

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FIGHT ON! Though the pandemic persists and the changing dynamics of state legislature continue to create chaos, the voice of the physician community is breaking through. The accomplishments, achievements and acclaim of this year showcased CMA’s ability to move forward an agenda to protect physician practices, increase access to care and build a prosperous future for the medical profession. Our fight is not finished. Next year, we will continue to push for additional relief from onerous administrative burdens, to protect physician autonomy and to preserve an economic environment that allows physician practices to keep their doors open to the communities they serve.

In unity, Janus L. Norman



The Power to Harm By Marina Roytman

Marina Roytman

My patient died of COVID. As we breached 770,000 COVID-19 deaths in the US, my statement is hardly unique. In fact, we have become so used to it, we don’t stop to acknowledge the tragedy of it. But my patient was different: he did not have to die. Don’t get me wrong: my patient had lots of opportunities to die in the 4 years that I have known him. He was an alcoholic who refused to acknowledge it. He had several bouts of alcoholic hepatitis from which he miraculously recovered and went back to drinking. I kept seeing him. After a particularly bad bout of alcoholic hepatitis, he acknowledged that alcohol was killing him and stopped. His family and I breathed a collective sigh of relief. He stopped drinking, but never acknowledged that he was an alcoholic. He adamantly refused to engage in substance abuse treatment programs. He was fine, he argued, he stopped drinking on his own and he would stay stopped. I begged, pleaded and cajoled to no avail. I knew that with the amount of damage to his liver he was living on borrowed time. Eventually, even with the best care his liver will begin to fail and he will die. Unless he got a liver transplant, to qualify for which he needed to engage in



substance abuse treatment such as Alcoholics Anonymous. Which he refused to do. I kept seeing him. In time he developed ascites and we managed it. He developed hepatic encephalopathy and we handled it. We prevented a variceal bleed, which would have killed him by a series of endoscopic interventions. My patient and his family hung on to my every word and followed my instructions to a “t”. Low salt diet? No problem: they researched tasty low salt recipes and he ate them. Enough lactulose to produce 3-4 bowel movements a day? No problem: done, with the chart documenting the endeavor. Repeated endoscopies? Done, done and done. He bragged about his amazing liver doctor all over town. He just did not go to AA. His liver continued its slow but inexorable decline. Diuretics stopped working and he needed his abdomen drained with increasing frequency. He kept it up with a cheerful smile on his face. His encephalopathy was harder to control with first line medications and he and his family cheerily went along with 2nd, 3rd and 4th lines of treatment. He was losing muscle mass, his family tempted him with tasty protein-rich treats. He was declining,

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nevertheless. He would not go to AA. I continued to see him. He eventually developed spontaneous bacterial peritonitis, a common complication of advanced cirrhosis. The hospital course was rocky, rockier than any of his previous hospitalizations. I was watching his liver tests worsen with dread. I made a few exploratory phone calls to the transplant centers and heard an expected reply: no substance abuse treatment, no transplant. I continued to see him. This last hospitalization happened during the winter COVID surge. One of the very few positives that came of COVID-19 societal disruption was the availability of AA meetings on line. At the 11th hour of his life, my patient agreed to attend the virtual meetings opening the door to the possibility of liver transplant. I continued to see him and allowed myself to hope. Given how sick he was and the fact that he was earnestly engaging in substance abuse treatment he was evaluated quickly and placed on a transplant waiting list within a few weeks. I continued to see him and allowed myself to hope a little more. The vaccines came in late December of 2020. The winter surge decreased to a slow trickle. My patient was doing relatively well and managing to stay out of the hospital while keeping his (much needed) spot on the transplant list. I continued to see him, however less frequently, as I thought that the worst was behind us and that we had a backup plan. I saw him in the clinic in the late spring and told him to get vaccinated for COVID-19. As with all my previous recommendations, my patient and his family cheerfully agreed and left with the list of vaccination sites in town. It did not occur to me to give this interaction a second thought. I thought that I would continue to see him every few weeks to months and tinker with his medications until he got his transplant. Alas, this is not how this story ends. Several weeks after his last visit with me, I received a call from his family telling me how fortunate they were to have avoided the COVID-19 vaccination. Thinking that I must have misunderstood, I pressed for details. They told me that they were on their way to get vaccinated, when their friend, a practicing medical professional, stopped by their house

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and talked them out of it. They felt very fortunate that she stopped them just in time... The Delta variant was just starting to rear its ugly head. I threw everything I had into trying to convince him to get vaccinated: the best scientific arguments, the data on safety and effectiveness, the pictures of my teenage daughters getting the shots, all the work that we have done together to get to this point. To no avail: he was not getting vaccinated. I continued to see him. The Delta surge was brutal in my hospital. ICUs overflowed, patients crowded in hallways, staff exhausted. Part way into it I got the dreaded phone call: my patient was in the ED and he had COVID. I went to see him. He did not look too bad and was his usual jokey self just with an addition of the high flow nasal cannula. I continued to see him. His stability did not last long. His respiratory status deteriorated and along with it his liver function. He became more confused, swollen and stopped making urine. We started dialysis. After all, he was on the transplant list and was viable, right? He began oozing blood out IV sites. The ICU staff began giving me sidelong glances. He was in multi-organ failure and it was time to let him go. I continued to see him. The next day I led the family meeting, COVID style. Me in full PPE, patient’s family on the iPad and patient himself being kept alive with multiple machines. I went through the script and made him comfort care only. The family agreed as they agreed with my countless recommendations over the years. Except for the one for vaccination. He died within minutes of terminal extubation. I could no longer see him. My PPE kept fogging up from the boiling volcano of anger inside of me. I cried tears of outrage and my tears temporarily cleared my field of vision only to fog up again. How could a member of my profession have caused this devastation by talking this fragile patient out of COVID-19 vaccination? To quote Eleanor Roosevelt: “Freedom makes a huge requirement of every human being. With freedom comes responsibility.” Freedom without responsibility is egoism. In the time of our county’s great need, let us practice Eleanor Roosevelt brand of freedom.



Caring for Youth with Substance Use Disorder Adapted by Caroline McGuire from a resource of CA Bridge, a program of the Public Health Institute There are unique challenges faced by young people who use drugs. Adolescents and young adults are experiencing fast-growing rates of opioid overdose and hospitalization, yet have the lowest rates of access to treatment. There are life-threatening and life-altering consequences. According to the National Institute for Drug Abuse, substance use during adolescence can result in involvement with the criminal justice system, poor school performance, and health and mental health issues.1 For some, there is also an increased risk of overdose, especially as fentanyl becomes more pervasive in illicit drugs. The stakes are high. Physicians need to know how to screen, identify, and treat youth with substance use disorders.

SCREENING The American Academy of Pediatrics recommends routine screening at all primary care visits.2 Implementing screening can help identify youth at risk, normalize conversations around use and promote healthy behaviors and help-seeking from medical providers throughout their life. Two screening tools validated for use with adolescents are Screening to Brief Intervention (S2BI) and Brief Screener for Tobacco, Alcohol and Other Drugs (BSTAD). S2BI and BSTAD can be self-administered or provider-



administered and take less than 2 minutes. Both tools guide the provider to recommended responses and next steps. However, there are limitations. S2BI and BSTAD can screen negative if patients are not using alcohol, tobacco or marijuana. Onset of Symptoms and Precipitated Withdrawal The onset of withdrawal symptoms are dependent on the type of opioid your patient is using. For short acting opioids, withdrawal symptoms typically begin about 12 hours after use (though can be as early as 8 hours). Fall/Winter 2021

For long acting opioids, withdrawal typically begins about 24 hours after use. For methadone, withdrawal typically begins around 48 hours after use, but can be delayed to even greater than 72 hours after use. Precipitated withdrawal is the sudden onset of severe opioid withdrawal after the administration of a medication that displaces opioids from the mu receptor (e.g. naloxone or buprenorphine). Precipitated withdrawal is usually timelimited and resolves with supportive care.

Identifying Withdrawal If a young person presents with any of the following symptoms, they could be in withdrawal and be a candidate for medication for addiction treatment (MAT).

Signs & Symptoms of Opioid Withdrawal Objective Signs

Subjective Signs

Tachycardia Diaphoresis Restlessness and/or agitation Dilated pupils Rhinorrhea or lacrimation Vomiting, diarrhea Yawning Piloerection (“goose flesh” or “goose bumps”)

Patient reports feeling “bad” due to: Nausea Stomach/abdominal cramps Body aches Achy bones/joints Restlessness Hot and cold Runny nose

If your patient is exhibiting these symptoms, ask about withdrawal. Patients often refer to experiencing withdrawal as feeling ‘sick.’ If they are experiencing opioid withdrawal, you can treat them, stop the withdrawal, and start them on the path to recovery.

How do I determine appropriate dosing? Dosing of medications is related to current symptoms and substance use history. There are no weight-based dosing recommendations for buprenorphine. See the CA Bridge treatment protocols for more guidance.

TREATMENT Medication for Addiction Treatment (MAT) reduces mortality for opioid use disorder (OUD) by preventing withdrawal, controlling cravings, and increasing compliance with treatment.3,4,5 Treatment should be focused on safe, low-barrier, effective care. MAT is considered best practice for treating OUD during pregnancy (buprenorphine or methadone are both safe options).6 Overall, guidelines for youth patients are the same as those for adult patients. For treatment guidelines, use the CA Bridge Buprenorphine Hospital Quick Start. Below are some frequently asked questions when it comes to treating youth with SUD: Are there age restrictions in prescribing buprenorphine? Buprenorphine is approved for those over the age of 16 and widely used off label for patients under the age of 16 . Fall/Winter 2021

Should I prescribe naloxone? Yes, co-prescribing or dispensing naloxone is critical and life-saving. See the CA Bridge Guide to Naloxone Distribution for guidance on accessing free naloxone through the Department of Health Care Services. California Substance Use Line: (844) 326-2625 If you are new to treating youth with substance use disorders - you are not alone. The California Substance Use Line offers free, expert, confidential, 24/7 phone consultation for substance use evaluation and management, including guidance on medications for opioid use disorder. This line is available to any health care provider in California.



CONSENT AND DISCLOSURE When it comes to providing medical care to minors, consent and disclosure can seem complicated. A minor 12 years of age or older may consent to medical care and counseling related to the diagnosis and treatment of a substance-related problem. But parental consent is required for a minor’s participation in MAT. Below are some frequently asked questions regarding consent: Is parental consent required for treatment of withdrawal? A minor 12 years old or older may seek drug treatment without parental consent (although, parents must be given the opportunity to participate in treatment, unless the provider deems it inappropriate and documents this). However, Family Code Section 6929(e) does not authorize a minor to receive replacement narcotic abuse treatment (such as methadone, levo-alphaacetylmethadol or buprenorphine) without parental consent. When is a minor considered emancipated in terms of consent for medication treatment? Providers can make the determination of self-sufficiency based on age (15 or older), living apart from parents, and managing their own finances, regardless of income source. A pregnant minor is not legally authorized to consent to care unrelated to the pregnancy. The law doesn’t specify the treatment type, but the care they can consent to would be treatment that a pregnant person would usually require, like prenatal care. What documentation of consent is needed? The documentation burden for patients started on medication in the ED or the hospital is the same as for adults. In addition, make sure to collect documentation 1. 2. 3. 4. 5. 6. 7. 8. 9.


indicating emancipation status, if applicable and obtain a minor’s written authorization for disclosure of health information. When does a minor need to consent to share health information regarding substance use with parents? Always try to obtain a minor’s written authorization for disclosure of health information. However, where parents have sought drug treatment for a minor and the minor receives care, the physician must disclose the medical information to the parents upon their request, even where the minor objects.7 What about a youth whose parents are divorced? Do both parents need to consent to treatment? If both parents agree on the proposed medical care of the minor, have both parents sign the applicable consent forms. If parents disagree, then obtain a copy of the custody order to determine which parent has the authority to make health care decisions for the minor and include the custody order in the minor’s medical record.8 For more guidance on consent, please see this guide from the National Youth Law Center.

CONCLUSION Youth that are struggling with substance use disorder often go underdiagnosed and undertreated. But that doesn’t need to be the case. There is evidence-based treatment that is easy for both patients and providers that can help support this special population into adulthood. Most adults with opioid use disorders start using opioids before age 25, onethird of them before 18.9 Early screening, identification, and intervention can truly change the course of a child's life.

Kelly SM, Gryczynski J, Mitchell SG, Kirk A, O’Grady KE, Schwartz RP. Validity of brief screening instrument for adolescent tobacco, alcohol, and drug use. Pediatrics. 2014;133(5): 819-826. doi: 10.1542/peds.2013-2346. COMMITTEE ON SUBSTANCE USE AND PREVENTION. Substance use Screening, Brief Intervention, and Referral to Treatment. Pediatrics. Jul 2016;138 (1): e20161210. doi: 10.1542/peds.2016-1210. Liebschutz JM, Crooks D, Herman D, et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med. 2014 Aug;174(8): 1369‐1376. doi:10.1001/jamainternmed.2014.2556. Wakeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA. 2020;3(2): e1920622. doi: 10.1001/jamanetworkopen.2019.20622. D’Onofrio G, Chawarski MC, O’Connor PG, et al. Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention. J Gen Intern Med. 2017 Jun;32(6): 660-666. doi: 10.1007/s11606-017-3993-2. Committee on Obstetric Practice. Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017;130(2): e81-e94. doi: 10.1097/AOG.0000000000002235. Family Code. California Law. Section 6929(g). Effective January 1, 2020. Accessed July, 2021. California Hospital Consent Manual. 48th ed. Sacramento, CA: California Hospital Association; 2021. Hadland SE, Wharam JF, Schuster MA, Zhang F, Samet JH, Larochelle MR. Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2001-2014. JAMA Pediatr. 2017;171(8):747-755. doi:10.1001/jamapediatrics.2017.0745.


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Amanda J. Flood

7 NEW YEAR’S RESOLUTIONS IT’S NOT TOO LATE TO START Amanda J. Flood, MS, AMFT Registered Associate Marriage & Family Therapist, AMFT # 124673 Under supervision of Kyle N. Weir, PhD, LMFT

ABOUT THE AUTHOR As a Registered Associate Marriage and Family Therapist, Amanda works with individuals, couples, and youth experiencing anxiety, PTSD, and depression or low self-esteem due to chronic illness, abuse, religious/spiritual concerns, or codependency. Amanda is familiar with the deaf and hard of hearing community, and their culture. She is conversationally fluent in sign language. Amanda considers herself hopeoriented with a focus on acceptance, self-determination, and mindfulness. She focuses her work with clients on guiding them to take ownership and find meaning in their lives in a non-judgmental, positive, and secure environment. Amanda firmly believes that all people have value and worth that cannot be diminished. She approaches counseling from a Humanistic, Existential, Person-centered perspective. Amanda was born and raised in the Central Valley. She received her Bachelor of Science in Sociology from Brigham Young University of Idaho and her Master of Science in Marriage, Family, and Child Therapy from University of Phoenix, Fresno Campus.

Fall/Winter 2021

With the holidays behind us and the new year ahead of us, we can begin to move forward with the hope of progress in our personal and professional lives. As a physician, you spend your days immersed in issues that involve the emotional complexity of human life and death. It’s an aspect of life that many do not experience on a daily basis, but which provides insight and reflection for those who occupy these roles. Such experiences often influence the making of personal goals and New Year’s resolutions. While it may be mid-January, it’s never too late to reflect upon our lives and set goals that will improve our quality of life. CENTRAL VALLEY PHYSICIANS


Resolutions don’t need a new calendar year to be set, but if you are still considering ways to optimize selfimprovement in 2022, here are some ideas: LESS SCREEN TIME In 2017, Preventive Medicine Reports published a study that examined the potential correlation between screen time and depression. Those with 6 hours of daily screen time were more likely to have moderate or severe depression (1). Things like banning screen time just before bed and saying “hi” to the kids in the morning before you say “hi” to the phone are some small, but effective ways to reduce screen time. LAUGH MORE You spend shift after shift witnessing people take their last breath. You understand the value of each moment, each word, each human connection. Laughter has the power to heal. According to a 2010 article by Ramona Mora-Ripoll (2) , Laughter has shown physiological, psychological, social, spiritual, and quality-of-life benefits such as lowering blood pressure, improving self-regulation, increasing pain tolerance, and improving coping abilities. Play with a child, tell jokes, exchange embarrassing stories from the follies of your youth. Your body will thank you. TREAT YOURSELF LIKE A TODDLER A) Sleep schedule. Now, more than ever, sleep is elusive. Nights, weekends, holidays. You work them all. The National Sleep foundation claims we are a society of chronic under-sleepers. Researcher indicates that with poor sleep comes increased medical errors, decreased learning, and a decline in motivation (3). Some physicians make sleep a priority by napping before a shift or turning down invitations that will keep them out too late. B) Time-outs. Taking a time-out isn’t justsitting in a corner; it’s whatever fills your bucket. Call your parents, meditate, engage in deep breathing or progressive muscle relaxation.



C) Snacks. No one needs to school you on keeping your body fed, but there are real barriers to having access to nutritious food while in the workplace. Your heavy workload makes it difficult to make time to eat, access to food stations or hours of operation can be inconvenient or limited, there are limited food choices available, the work paradigm under which you perform may obligate work and patients before your own care, and most people find it unprofessional to eat in front of patients. Some physicians have tried toting a water bottle with them, bringing food from home, and snacking between patients to avoid the “catch-up” phenomena at the end of a shift (4). ACTUALLY TAKE THAT VACATION TIME How long have you been saying, “Next month, I’ll take a vacation?” Why not now? Make the most of the time you have. You know how quickly lives change if struck by tragedy. It may require schedule changes, but your mental health will thank you for taking some time off to relax and rejuvenate. CONSIDER TAKING A DOSE OF YOUR OWN MEDICINE You spend all day telling patients how to take better care of their health. But are you following your own advice? We know that mental health, physical health, and environment are intrinsically connected, and contribute to our overall health and well-being. There are likely a few things you could do to improve your own health. Could you stand to drink a little less, move a little more, or do something to lower your blood pressure? Perhaps this is the year you finally take steps towards improving those lingering health concerns. SOME THINGS NEVER CHANGE Did you know that sunsets are still beautiful, and that flowers still smell sweet? Psychology professor, Nancy Fagley, of Rutgers University, would tell you to squeeze those things into your schedule. One of her studies suggests

Fall/Winter 2021

that appreciation plays a bigger role in happiness than we previously knew. The study indicates that appreciation is twice as significant as gratitude in determining overall satisfaction with life (5). AVOID PERFECTION Getting to where you are today required meticulous attention to detail and the need to get things right. Your internalized high standard makes you a hard worker, but may lead to feelings of inadequacy, being overly selfcritical, and placing impossible demands on yourself. An unhealthy need for perfection puts physicians at risks for being mentally unwell, particularly if they blame themselves during times of loss and failure that are inescapable in the field of medicine. Brené Brown described perfectionism as a way of thinking, where people are afraid that the world is going to see them for who they really are and they won't measure up. Think about ways you can practice self-compassion. Practicing self-compassion looks like giving ourselves

that same kindness and care we would give to a good friend. Self-compassion amplifies performance by triggering a “growth mindset,” which is the belief that improvement is achievable through commitment and hard work. (6). If your only New Year’s resolution is to give yourself a break, know that being better at being kind to yourself is the foundation for any self-improvement. The work you do as a healthcare provider is admirable and critically important, but you are more than just your job. You are also a human being with a wide range of complicated feelings, emotions, goals and worries. Oftentimes, we become so caught up in the day-to-day grind and the needs of others that we forget to take time for our own health and self-improvement. I encourage you to spend at least ten minutes in the next week considering your goals and resolutions for the year ahead. Should you find this difficult to do, or realize there are obstacles standing in your way, reach out for assistance from a trained mental health professional.

Your overall health and well-being is worth investing in.

Here’s to making 2022 your best year yet!

1. 2. 3. 4. 5. 6. 7. 8.

K.C. Madhav, Shardulendra Prasad Sherchand, Samendra Sherchan,Association between screen time and depression among US adults, Preventive Medicine Reports, Volume 8, 2017, Pages 67-71, ISSN 2211-3355, https://doi.org/10.1016/j.pmedr.2017.08.005. (https://www.sciencedirect.com/science/article/pii/S2211335517301316) Mora-Ripoll R (2010). Therapeutic value of laughter in medicine. Alternative Therapies in Health and Medicine, 16(6): 56–64. Howard S. K. (2005). Sleep deprivation and physician performance: why should I care?. Proceedings (Baylor University. Medical Center), 18(2), 108–113. https://doi.org/10.1080/08998280.2005.11928045 Lemaire, J. B., Wallace, J. E., Dinsmore, K., & Roberts, D. (2011). Food for thought: an exploratory study of how physicians experience poor workplace nutrition. Nutrition journal, 10(1), 18. https://doi.org/10.1186/1475-2891-10-18 N.S. Fagley, (2012) Appreciation uniquely predicts life satisfaction above demographics, the Big 5 personality factors, and gratitude,Personality and Individual Differences, Volume 53, Issue 1,Pages 59-63,ISSN 0191-8869,https://doi.org/10.1016/j.paid.2012.02.019. (https://www.sciencedirect.com/science/article/pii/S0191886912000888) Chen,S. (2018) Give yourself a break: The power of self-compassion. https://hbr.org/2018/09/give-yourself-a-break-the-power-of-self-compassion

Fall/Winter 2021



The value of perspective Advice. Beyond investing. With so much at stake when it comes to protecting all that you’ve worked so hard to achieve, it may be a good time to review your financial plan. At Litle Wealth Management, our approach starts by understanding your life and what you want to accomplish. Then we work together to create a framework designed to give you the confidence to do what matters most, no matter what the markets are doing. We want to help ensure you have all you need for today, tomorrow, and for generations to come. Let’s start the conversation. Troy A. Litle Senior Vice President - Wealth Management 559-248-4022 troy.litle@ubs.com Lisa Ann Tadich Financial Advisor 559-248-4007 lisaann.tadich@ubs.com

Litle Wealth Management UBS Financial Services Inc. Fig Garden Financial Center 5200 N Palm - Suite 101 Fresno, CA 93704-2225 559-226-2800 800-423-8797

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ubs.com/team/litlewealthmanagement As a firm providing wealth management services to clients, UBS Financial Services Inc. offers investment advisory services in its capacity as an SEC-registered investment adviser and brokerage services in its capacity as an SEC-registered broker-dealer. Investment advisory services and brokerage services are separate and distinct, differ in material ways and are governed by different laws and separate arrangements. It is important that clients understand the ways in which we conduct business, that they carefully read the agreements and disclosures that we provide to them about the products or services we offer. For more information, please review the PDF document at ubs.com/relationshipsummary. ©UBS 2021. All rights reserved. UBS Financial Services Inc. is a subsidiary of UBS AG. Member FINRA/SIPC. D-UBS38805F6F



Fall/Winter 2021

Pediatric Residency Program

GRADUATE WINS NATIONAL COMMUNITY SERVICE AWARD This prestigious, annual award is given to just one resident in the entire country in recognition of their contributions to the local communities surrounding their pediatric residency training institution, above and beyond the requirements of their program. “The award was a complete surprise,” said the El Dorado Hills native, who graduated in June from Valley Children’s Pediatric Residency Program. “I feel very grateful and very thankful to my mentors at Valley Children’s for nominating me because I feel like I grew a lot during my residency.” While Dr. Nguyen’s residency training focused on the pediatric population in general, his advocacy work focused specifically on children and teens identifying as LGBTQ+, non-binary or gender non-conforming, and working with community members, transgender advocacy groups and physicians to raise awareness for and address the unique challenges this population faces in healthcare and in their communities. This outstanding dedication to advocacy impressed Dr. Nicole Webb, Valley Children’s pediatric hospitalist and Dr. Nguyen’s mentor, and inspired her to nominate him for the award. “Dr. Nguyen had extensive experience working with and advocating for equitable and affirming care for transgender and non-binary youth prior to coming to Valley Children’s, and he took exceptional interest in knowing and understanding that community in the Central Valley to the fullest extent possible,” said Dr. Webb. “He was tireless in his dedication to providing a voice to a community that is often silenced or ignored, and to doing so in a way that enthusiastically and patiently encouraged others to learn and participate.” A lasting result of Dr. Nguyen’s work was the inclusion of new fields into Valley Children’s electronic medical record (EMR) patient information forms, including chosen names, pronouns and items for social Fall/Winter 2021

worker follow-up. By having these fields directly in the EMR, anyone on the healthcare team can ensure they are filled in with the information that makes the patient and family feel respected and accepted. Because a patient’s medical record in the EMR “follows” them throughout their hospital stay, any care member who accesses the record will know to use the patient’s chosen name and/ or pronoun, and any new documentation automatically populates with that information, so it becomes a natural part of the care team’s workflow. “In healthcare we often ask ourselves, ‘How can we do better? How can we be better?’” said Dr. Nguyen. By making identity-affirming information an engrained aspect of the medical record, Dr. Nguyen believes it will create a more supportive environment for patients identifying as LGBTQ+ and their families. The AAMC held a virtual ceremony last night and presented Dr. Nguyen with his award. In addition, a $1,250 contribution will be made to Fresno Equal Opportunity Council (EOC), which Dr. Nguyen chose as the non-profit organization recipient. Although the ORR Community Service Award is given to only one resident nationally each year, Dr. Nguyen is quick to say the recognition is not his alone. “Advocacy is never a one-person thing,” said Dr. Nguyen. “Seeing people come together to fight systemic challenges has been the most gratifying part. The award is the cherry on top.” Valley Children’s Pediatric Residency Program, Affiliated with Stanford University School of Medicine, trains physician leaders and scholars to provide compassionate, collaborative interprofessional care as general or subspecialist pediatricians. Valley Children’s residents have the opportunity for rotations at partner locations – including Kaiser Permanente and Saint Agnes Medical Center in Fresno and Dignity Health – and local pediatricians’ offices. CENTRAL VALLEY PHYSICIANS


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

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Fall 2021



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San Diego Anesthesiologist Installed as

CMA President 2021-2022 On Saturday, October 23, 2021, San Diego physician Robert E. Wailes, M.D., was installed as president of the California Medical Association (CMA) at the association’s annual House of Delegates (HOD). This year’s meeting was conducted virtually, due to the ongoing public health emergency.

In his address to the delegates, Dr. Wailes—a Southern California pain specialist and board-certified anesthesiologist—recognized the great challenges and great accomplishments the profession of medicine faced over the past year. “Working together our state became an example for others to follow on our pandemic response and vaccine efforts,” said Dr. Wailes. He also noted, however, that our progress went far beyond the pandemic. “In the past year, CMA revised its mission statement to include health equity and justice as core to our mission. That part of the mission statement is more than just words on a page. It is a value proposition that we should all take seriously and work towards. Under my presidency ensuring health equity will be a priority for me and CMA as we move toward changes in both public policy arena and in the house of medicine to make that a reality.”



Before serving as president-elect over the last year, Dr. Wailes served as chair of the CMA Board of Trustees for the three years and as vice chair for three years before that. He has also served as president of the San Diego County Medical Society and represents the American Academy of Pain Medicine at the American Medical Association. Dr. Wailes is the founder, co-owner and medical director of Pacific Pain Medicine Group in Oceanside and Encinitas. He is also an active member of the medical staffs at Scripps Hospital in Encinitas and Tri-City Medical Center in Oceanside and serves as medical director for the Ketamine Research Institute. Dr. Wailes earned his M.D. from Wake Forest University School of Medicine in North Carolina and holds a bachelor’s degree in public finance and pre-medical sciences from UC Berkeley. He completed an internship at Mercy Hospital and Medical Center in San Diego in 1982 and his residency at UCSD Medical Center in 1984. Dr. Wailes has been providing pain medicine services in Southern California for more than 30 years, and has lived with his family in Carlsbad since starting his practice in 1984. Donaldo (Don) M. Hernandez MD, FACP, was elected as president-elect of the California Medical Association. He is an Internist in full-time, hospital-based practice in Santa Cruz County

Fall/Winter 2021

In Memoriam Donald R. Huene, M.D.

FEBRUARY 13, 1934 - JULY 05, 2021

Donald R. Huene, M.D. was born on February 13, 1934, in Queens Village, New York to Arthur H. and Elsie B. Huene. He passed away on July 5, 2021. He was married to Annette S. Huene, his friend from age 9, for 49 years until her passing in 2007. He attended the same grammar school and university as his wife. He graduated from Cornell University with a degree in Physics. Donald and Annette married during his time in medical school. He graduated from University of Rochester School of Medicine and Dentistry with a medical degree, then trained for two years in General Surgery at Stanford University. He completed training at the U.S. Naval School of Aviation Medicine in Pensacola, Florida, after which he was stationed in Argentia, Newfoundland, as a Navy Flight Surgeon. After finishing his deployment in Newfoundland, he returned to The University of Rochester School of Medicine for Orthopedic Surgery Residency. In 1967, he and his family moved to Fresno, California, where he started a practice in Orthopedic Surgery. He lived and worked in Fresno for 54 years, retiring at the age of 87. He held fourteen patents in the medical field.

Fall/Winter 2021

He is survived by his two sons, one daughter, three daughters-in-law, one son-in-law, and fourteen grandchildren. He was preceded in death by his wife of 49 years, Annette S. Huene and his youngest son, William (Bill) A. Huene. Per his request, no services will be held. In lieu of flowers, contributions can be made in his name to Community Regional Medical Center or to St. Agnes Medical Center Department of Surgery.



In Memoriam

Sathaporn “Dr. Sam” Vathayanon April 25, 1934 - September 18, 2021

Fresno, California - A sweet and gentle man with a big heart, Dr. Sathaporn Vathayanon (affectionately known as Dr. Sam) was born in Bangkok, Thailand. Through the encouragement of his mother, he broke from his family military tradition and pursued a career in medicine.

It was not uncommon for former patients and relatives of former patients to approach Dr. Sam in the community and thank him for giving them more time to be with their loved ones. Dr. Sam was a beloved member of the Fresno community for over 50 years.

After medical school, Dr. Sam was recruited by Dr. Byron Evans to practice medicine at Valley Children's Hospital. He arrived in Fresno in 1969 and preformed central California's first coronary bypass operation in 1970. He had privileges at Valley Children's Hospital, Fresno Community Hospital and St. Agnes. One of Dr. Sam's proudest memories was on June 11, 1985 when as chief surgeon he operated on a 7-year old Honduran Indian boy who had a rare but fatal heart defect. Called the Fontan procedure, at the time it was so rarely used, a heart specialist team might perform it only once a year and even more rare on a pediatric patient. His second proudest memory was helping with the 2004 Asian tsunami relief efforts. Dr. Sam went to Phuket, Thailand to help those in need of medical care. He was there for about two and a half weeks and saw up to 75 patients a day.

Dr. Sam passed peacefully in his sleep on Saturday, September 18, 2021. He will be deeply missed by many grateful patients, family and friends.



He is survived by his children, Catherine Trapasso, Jeffrey Vathayanon and Jennifer Curti. He is also survived by his grandchildren, Camilla, Sophia and Isabella Curti. In lieu of flowers, memorial contributions in Dr. Sam's memory may be made to the American Heart Association, Website for donations: Heart.org, PO Box 840692, Dallas, TX 75284 or to the Parkinson's Foundation, Website for donations: Parkinson.org, 200 SE 1st St., Suite 800, Miami, FL 33131.

Fall/Winter Fall 2021

In Memoriam Dr. Sidney Ethan Carpenter, M.D may 03, 1964 - december 03, 2021

DR. SIDNEY ETHAN CARPENTER was born May 3, 1964, to the late Sir Lafayette Carpenter, Sr. & Mattie Mae Jane Carpenter in Los Angeles, California. Sidney joined Greater Ebenezer Missionary Baptist church in Los Angeles at an early age and was baptized on December 3, 1972. Sidney was a member of the Greater Ebenezer Missionary Baptist Church’s Monday Night Youth Ministry, First Aiders Ministry and Youth Choir. Sidney spent many years in the Boy Scouts of America. In his adult years he would say one of his greatest accomplishments was becoming an Eagle Scout. Sidney also spent much of his spare time with his brother Terrance camping, hiking and exploring. The two were inseparable. Sidney graduated from Los Angeles Center for Enriched Studies in 1982 and was accepted in Medical School at UCLA. He graduated from UCLA in 1986 and went on to obtain his medical Degree from the University of Irvine, California in 1992. Upon obtaining his medical license, He taught as an Associate Professor in the School of Medicine & was subsequently employed as a Pathologist at Kaiser Permanente in Fresno, California where he worked for over 20 years. Sidney was well known, well respected & well admired for his knowledge of medicine. The University of California, San Francisco, Fresno Latino Center for Medical Education and Research awarded Sidney with a Doctor of the Year award in 2009. Sidney studied dance and performed with many organizations. Sidney lived life

Fall/Winter 2021

on his own terms and he touched the hearts of so many. When he was not at work, He entertained & brought smiles to others at work & the local community with his skill of Dance. Known as the “Dancing Man,” He brought joy & inspiration to so many. He loved the nature & outdoors & had traveled to several national-nature sites. He especially loved the Yosemite National area where he hosted many reunions for his family. Sidney married his best friend, Sonhai Hackett on March 8, 2016. He was preceded in death by his father, Sir Lafayette Carpenter, Sr., His mother, Mattie Mae Jane Carpenter, his brother, Robert Carpenter and his mother-in-law Ardis Hackett Banks. He leaves to cherish his earthly presence: His husband, Sonhai Hackett of Clovis, California; His brothers, Rev. Sir Lafayette Carpenter, Jr. (Faye) of Wendell, NC & Terrance Elbert Carpenter(Apple) of Los Angeles, California & His sister, Alisa Jane CarpenterWilliams of Durham, NC; His aunts, Elsie Hodge-Bridges of Upper Marlboro, Md & Elaine Hodge-Shelton(Bob) of Raleigh, NC & His uncles, Nilous E. Hodge (Elaine Williams-Hodge) of Raleigh, NC; & Mack & Sidney Carpenter of Zebulon, NC; as well as a host of nieces, nephews, cousins, friends & co-workers. He will be truly missed. Services are pending for a later date.



In Memoriam Dr. Melvin R. Helm, Jr. january 24, 1966 -December 24, 2021

Doctor Melvin R. Helm, Jr. was born January 24, 1966 and passed away unexpectedly December 24th, 2021 while scuba diving. Mel (as his friends and family knew him) held a vast list of accomplishments, but the greatest joy in his life was being the father to his three daughters, Isabella, Gabriella and Madeline. He is also survived by his loving fiancé Lavinia Terra of Clovis, his parents Melvin and Janice Helm, his sister Tracy Bratton, his niece and nephew Taylor and Travis Lindenmuth, all of Caruthers. Mel attended Caruthers schools where he is remembered by his classmates for his quiet humor as well as his amazing Elvis impersonations at the talent show each year. In High School, Mel was a friend to all. He was an active trumpet player in the band, involved in many school clubs and was captain of the varsity tennis team. After graduating from Fresno State University, Mel went on to earn his medical degree from Universidad Autonoma de Guadalajara. While in Mexico, he taught himself Spanish in less than a year and graduated at the top of his class. Mel was a Board-Certified Neurologist who trained at Albert Einstein College of Medicine in New York City. After finishing Medical School, he returned to his Central Valley roots where he opened the California Headache & Balance Center in Fresno. Mel’s medical practice is the only clinic in central California that specializes in



difficult headache problems as well as conditions related to dizziness and imbalance. He was a well-respected doctor of neurology and will be greatly missed by his many patients as well as the Central Valley medical community. Mel was also a member of the Advisory Board for the College of Science and Mathematics at Fresno State University. Mel had a lifelong interest in astronomy and astrophotography. In 2007 he co-founded and served as co-president of Sierra Remote Observatories (SRO), a large group of astronomical observatories located in California’s Sierra Nevada Mountains. Mel’s passions for space as well as the ocean began as a child. He was a Certified Dive Master, Master Scuba Diver, Self-Reliant Diver, and Enriched Air Diver. A memorial celebration of Melvin’s life will be held at New Covenant Community Church on Saturday, January 8th at 1:00 pm. The church is located at 1744 E. Nees Ave. in Fresno.

Fall/Winter Fall 2021

Fall 2021



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