CVP Fall 2019

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Fall 2019

Practicing medicine elsewhere provides a personal

perspective on U.S. healthcare

Letters to the Editor • Facing the Mountain • Cybersecurity

Time to Clean Up

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16 22 26 30 32 41 46 Fall 2019













From The Executive Director

TWO FOR ONE DEAL… Fall bring so many things with it… New year of school for the kids, cooler weather… sometimes, and at the medical society it brings a new year of membership.


A couple of days ago a resident called me to ask about one of our upcoming events, and I asked him if he was a member (before I knew he is was a resident) and he said he was not sure. Which of course I took to heart, telling me we are not communicating well enough with our residents so they know they are a member of the Fresno Madera Medical Society and the California Medical Associates.

PRESIDENT Cesar A. Vazquez, MD PRESIDENT-ELECT Alan Birnbaum, MD VICE PRESIDENT Don Gaede, MD TREASURER Brent Kane, MD PAST-PRESIDENT Trilok Puniani, MD BOARD OF GOVERNORS Christine Almon, MD, Janae Barker, DO, Jennifer Davies, MD Patrick Golden, MD, Shamsuddin Khwaja, MD Christina Maser, MD, Katayoon Shahinfar, MD Nadarasa Visveshwara, MD, John Moua, MD

Therefore, I am here to tell every Resident in the Central Valley, YOU ARE a Member of the Fresno Madera Medical Society AND the California Medical Association. It’s a two-forone. The reason you are a member is the Residency program you are with understands how important it is to be part of organized medicine in your career and how your associations work for you and the value we provide. This continued conversation, in my head, got me to thinking… Do physicians understand the purpose of societies and what “Organized Medicine” is? I think everyone may have a slightly different answer, but I would say Organized Medicine is the organization of the medical profession as a whole. The cohesive structure of the medical profession in an organized group then becomes an “Interest Group” which can provoke a powerful organized voice to affect policies and procedures in both societynand within the profession of medicine. Associations like FMMS and CMA pave the way for physicians to be a step ahead of the change’s they face with the practice of medicine and the business of health care. We understand the unique challenges you have as health care providers and we provide the voice needed to drive the future and support the invaluable benefits that physicians and medical groups provide to our communities. So, as you continue in your career know that your Associations are working in your best interest, and the only way we are able to do this is if physician join as members annually. For any physician that is not currently a member, join your colleagues who are standing with the other 44,000 physician members of the California Medical Association and the 1,400 local physicians of the Fresno Madera Medical Society, as I mentioned it’s a two-for-one deal for both FMMS and CMA.

Pamela Kammen, MD, Ravi Rao, MD, Jai Uttam, MD Jessica Vaughn, DO (Resident Board Member) CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS EDITOR Farah Karipineni, MD MANAGING EDITOR Nicole Butler ASSISTANT EDITOR Don Gaede EDITORIAL COMMITTEE Farah Karipineni, MD - Chair, Chang Na, MD Roydon Steinke, MD, Cesar Vazquez, MD Hemant Dhingra, MD, Nicole Butler, Trilok Puniani, MD Alan Birnbaum, MD, Alya Ahmad, MD FAAP CREATIVE DIRECTOR CONTRIBUTING WRITERS Cesar Vazquez, MD, Marissa Li, MD Erin Kennedy, Nicole Butler, Farah Karipineni, MD Ravi D. Rao, MD, Patrick MacMillan, MD, Tina Tedesco CONTRIBUTING PHOTOGRAPHERS Joseph Hawkins, MD, CHSU Staff CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711

Lastly, check out all of the upcoming events… AS A MEMBER your registration is usually FREE and if its not, call me I will find someone to sponsor your attendance.

Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: MEDICAL SOCIETY STAFF


Executive Director, Nicole Butler Membership and Events Manager, Stacy Woods

Nicole Butler



Fall 2019

Dr. Jason Bailey Nuclear Medicine

Dr. Susan Barrows Women’s Imaging

Dr. Nitasha Klar Batth Neuroradiology

Dr. Pramode Bhandary Women’s Imaging

Dr. Lydia Canavan Women’s Imaging

Dr. W. Keith Carson Body Imaging

Dr. Judy Champaign Women’s Imaging

Dr. Frank Chang Women’s Imaging

Dr. Kevin Day Body Imaging

Dr. Marc Draeger Women’s Imaging

Dr. Bruce Ginier Neuroradiology

Dr. Hans Hildebrandt Body Imaging

Dr. Kurt Hildebrandt Body Imaging

Dr. Edwin Hsu Nuclear Medicine

Dr. Monique Meyer Neuroradiology

Vascular & Interventional

Dr. Chanh Nguyen

Dr. Ivan Ramirez Musculoskeletal

Dr. Eric Raymond Musculoskeletal

Dr. Mariela Resendes Musculoskeletal

Vascular & Interventional

Dr. Martin Rindahl

Dr. Jason Roberts Nuclear Medicine

Vascular & Interventional

Dr. Jeffrey Saavedra

Dr. Douglas Sides Women’s Imaging

Vascular & Interventional

Dr. Frank Tamura Neuroradiology

Dr. Gabriela Tarau Body Imaging

Dr. Ronald Thant Body Imaging

Dr. Phillip Tran Musculoskeletal

Dr. Philippe Vanderschelden Neuroradiology

Dr. Paul Speece

Dr. Chandra Venugopal

Vascular & Interventional

1867 East Fir Avenue, Suite 104, Fresno, CA 93720 559.325.5809 / Fall 2019



Central Valley Physicians


to the editor Dear readers, your letters are greatly appreciated. For the sake of journalistic integrity and giving voice to your valued opinions, we may publish your letter or an except thereof in a future issue. Please keep letters to the editor to under 300 words or less and provide if you would like to list your name or omit that information. If you would like to submit a letter to the editor or to the FMMS Members please send an electronic file to

Dear Readers, A letter to the editor responding to the summer edition’s cover story, “Transforming Medicine for Transgender Patients”, was submitted. In this letter, it was asserted that transgenderism is a disorder that has been incorrectly “depathologized” and its treatments therefore misguided. While we respect the writer’s wishes not to publish the letter’s contents, the sentiment merits some discussion. It is, obviously, a controversial one with dissenting views in our current sociopolitical climate. I fully acknowledge that not all our readers share the same opinions on this or, for that matter, any controversial topic. I also recognize that as with any marginalized population, unique challenges arise from hormone therapy, surgery involving sexual organs, and various mental health issues. The intent of printing the article was not to condemn or support transgenderism on a personal level—that choice is rooted in each person’s deep-seated belief system and is beyond the purpose of this magazine. The intent is to increase awareness of the heath care disparities facing this growing and underserved population. That a transgender patient has access to the management of diabetes or prostate cancer surveillance is a profound problem that is quite distinct from whether they have access to hormone replacement therapy or gender-specific surgery. I believe the former is a much larger and more important issue for clinicians in general to be aware of, and while the latter often carries significant mental and physical health risks, pathologizing it is not the solution. Ultimately, increasing clinician awareness and access to appropriate health care for this underserved group are tasks that transcend social, political, and religious divisions. Doing so upholds the basic ethical principles of our practice. This is outlined well in the journal article, “Bioethics in Practice: Ethical Issues in the Care of Transgender Patients” by Denton et al. I hope that our piece was able to shed light on the importance of these principles in our community, regardless of each one’s personal beliefs. Sincerely, Farah Karipineni, Editor, Central Valley Physicians Magazine



Central Valley Physicians

Letters to the editor In response to – The society dilemma with no clear solution “...perhaps we can collaborate with our own Shakespeare in the park actors or other performing and creative arts organizations, and through these our unhoused community members explore their own experiences, celebrate the good in their lives and possibly a non-conventional pathway to renewal and success.” Maybe my Central Valley roots prevent me from appreciating the value of distant lobbyists enjoying a 4 hour meeting over a beautiful lunch and/or dinner to discuss our homeless problem, I don’t know. I do know that when I take the time to read a publication that purports to represent local physicians, particularly when dealing with a problem as pervasive as Fresno / Madera homelessness, I would like some meat to chew on. Perhaps some thoughtful consideration of our LOCAL political environment, mental health resources, law enforcement, charitable and religious efforts. Maybe some recent local discussions regarding Fresno city ordinances and their impact (if any) on the issue. Even anecdotal stories by local physicians dealing with the homeless situation on a daily basis. If all of that requires too much effort, I’d even settle for (gasp) a poll. Nope.


Much easier to avoid the methamphetamine epidemic, and ridiculously inject Shakespeare quotes, I suppose. Perhaps if it were a paragraph or two, but it droned on with nonsense for.... 3.... pages.... Ahhh, but definitely take the ink to bold-type praise the feel good efforts of lobbyists to perpetuate this rudderless journey, in a single annual meeting... What a great gathering of minds and talent, truly intent on rigorous debate and discussion to develop real world, evidence based advice for law makers. Surely in a comfortable environment, conducive to their lofty goals...and appetites, of course. I realize that most busy physicians don’t take the time to read the CV Physicians magazine, but shouldn’t readers expect more than Shakespeare, particularly on this topic? I get that it was just the President’s commentary and not a paper or study, but Shakespeare? In how many paragraphs? The very people you purport to represent, and should understand best, are over-worked and beyond stressed, day in and day out. Value the time spent by your readers with content derived from thoughtful deliberation, diligent and even challenging proposals, or insightful stories relevant to our LOCAL homeless problem as it relates to Central Valley providers. Save the Shakespeare for administrators.


A message from our President > Cesar Vazquez, MD FAAP

Homelessness Topic Continues my response to a letter to the editor on page 7

I appreciate your comments and understand the concerns you’ve raised. There are several imprecisions in your remarks that merit a response to the extent of unmasking any confusion or better yet, upholding the integrity of our physician leaders. I disagree with your insinuation that our dedicated and praiseworthy Valley doctors are lobbyists and need to travel up and down the state to satisfy their appetites and deliberate on “lofty goals in a comfortable environment”. It not only undermines their hard work, but disregards the time away from loved ones, and trivializes the passion to serve in leadership roles to help advance California’s precarious healthcare debate. These are not “feel good efforts” and despite “being overworked” and “beyond stressed”, they continue to plow forward to engage in public service as a call to action for the needs of the valley. ABOUT THE AUTHOR ­ Dr. Cesar Vazquez is board certified in General Pediatrics. He earned his Bachelors of Science in Electrical Engineering and after working in the aerospace industry for a few years, he decided to pursue his dream of becoming a doctor. He attended the University of California Irvine Medical School followed by a General Surgery Internship at Cedars-Sinai Medical Center in Los Angeles. He then completed a Pediatric residency through the University of California San Francisco-Fresno and spent an additional year at Stanford University as a fellow in Pediatric Cardiology. Dr. Vazquez practiced for 18 years before transitioning to his current position as a physician advisor at St. Agnes Medical Center where he’s involved with utilization review, commercial denials, and clinical documentation improvement. Dr. Vazquez currently serves as president of FMMS.



The California Medical Association’s House of Delegates (HOD) convenes over a weekend (not 4 hours) and it’s a culmination of a year-round resolution process involving - not a single - but quarterly meetings during the year. When the HOD convenes, nearly 500 delegates elected by members of component medical societies, specialty societies, sections and forums, representing every mode of practice and region of the state come together to work on the critical healthcare issues affecting the state. Homelessness is one of four major issues that will be discussed at this year’s House. Shakespeare might seem like an odd choice but program supporters embrace its benefits. Simply put, while focusing on the bodily and housing needs should take priority, we must avoid dehumanizing this population and not lose sight of their dignity and spirit by being overly focused on politics or trivial, often embellished anecdotal stories. And yes, I too experienced hardship and the pangs of homelessness in my youth and feel qualified to give an opinion on this issue. I believe that following the model of a very successful and life-changing program that started in the Bay Area could bear fruit and bring value to our community.

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Please review these recent articles: “Homeless people don’t often go to plays. So this woman brought Shakespeare to them.” Washington Post “Shakespeare troupe’s workshop for homeless brings hopes, fears to center stage.” SF Chronicle Finally, the use of Shakespeare to explore difficult life altering events among at-risk groups is founded on the intersection of human psychology, group therapy and the arts. According to, the San Francisco based non-profit who sponsored the program and whose mission is to provide for individuals most basic needs so they can focus on bigger goals, studying Shakespeare teaches language skills, critical thinking,

consequences of choices, emotional intelligence, empathy, and selfreflection. This gives rise to new ways of thinking, and helps people recreate themselves as their best selves. There is substantial evidence validating this approach which appeals to the literary arts for context and meaning in unimaginable circumstances. For example, Marin County Shakespeare Company has taught Shakespeare in several prisons starting in San Quentin since 2003. Other successful programs include the Michigan-based Shakespeare Behind Bars, Rehabilitation Through the Arts in New York, and the Shakespeare Prison Project at Racine Correctional Institution. And through these programs, research shows improved coping skills and recovery from a variety of social and environmental determinants that resulted in either incarceration or homelessness. Many physicians I’ve talked to gleaned value and a breath of fresh air on this problem and by no means feel imposed upon by the content of the story. Quite the opposite, they welcomed this forward thinking and creative alternative to help improve precious lives - sans “administrators”. Cesar Vazquez, MD FAAP President Fresno Madera Medical Society

CVP Ad Diabetes Symposium.pdf 1 9/30/2019 11:09:43 AM

DIABETES SYMPOSIUM Saturday, November 16, 2019


Saint Agnes Medical Center 1303 E. Herndon Ave. Fresno, CA 93720








4.0 CME At the conclusion of this ac�vity, the par�cipants will be able to; • Iden�fy and select op�mal insulin formula�on for safety and efficacy. • Recognize the benefits of rapid onset and rapid off insulin. • Iden�fy and recognized the u�lity of a closed loop system. • Iden�fy resources which help pa�ents and families with diabetes manage and cope with chronic disease. • Compare treatment op�ons for type 2 diabetes based on the non-glycemic risks and benefits of each class of diabetes medica�ons.

Register at or call (559) 224-4224 ext. 114 Accredita�on Statement: The Fresno-Madera Medical Society (FMMS) is accredited by the Ins�tute for Medical Quality/California Medical Associa�on (IMQ/CMA) to provide con�nuing medical educa�on for physicians. Credit Designa�on Statement: FMMS designates this live ac�vity for a maximum of 4.0 AMA PRA Category 1Credit(s)™. Physicians should claim only the credit commensurate with the extent of their par�cipa�on in the ac�vity.

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

Migrant Detention Crisis “Broken spears lie in the roads; We have torn our hair in grief. The houses are roofless now, and their walls are red in blood.” -Aztec poet, 1528

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.



As a comparative literature major at UC Berkeley many years ago, I chose to focus on Latin American literature for one very specific reason—much of it was not literature at all. An aspiring journalist (I would find my passion for surgery later), I hoped to unveil the subversive political agenda addressing deep-seated hegemonic relationships present in much of Latin American literature. Upon reading firsthand Aztec accounts of 16th century Spanish colonization, like the heart-wrenching one above recorded in Miguel Leon-Portilla’s The Broken Spears, I still recall the sense of injustice that screamed out to me across the centuries. How could the world go on after such terrible injustice, I asked myself so naively. When I was a child, I vividly recall the first time I realized that racism was not at all a thing of the past as my elementary American history class presented it so neatly. I recall the fist moment I experienced the simple yet jarring fact that human life is not equal, and that something so seemingly arbitrary as the shade of our skin or the zip code we are born in set in motion either a world of full stomachs and privilege, or hopelessness and tragedy. I had the fortune of attending a very progressive high school, where my Spanish teacher required us to watch the movie El Norte, depicting the reality of many undocumented immigrants risking their lives for dreams of a better life. Many left children and parents behind to work more for less because even that was a better situation than where they were born. I couldn’t help but wonder if their desperation to flee their countries had anything to do with blatant pillaging of the Americas so long before. When I was 7, we hired a Cuban refugee named Nino to live with us as a full time groundskeeper of our family farm. Nino was quiet yet lovable, and quickly became a part of our family. My parents would ask me to translate tasks for him, and after awhile, Nino asked me to translate in his behalf as well. This is how I came to love the Spanish language, as a connection to stories full of hope and

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pain. This is how I found my college major and how I still Adults and children are held for days, weeks, or even months connect with my Latino/a patients, with a sense of purpose in cramped in cells with no access to soap, toothpaste, clean helping people who I feel an inexplicable yet deep kinship with. water, or feminine hygiene products. They face overcrowding, And this is how I came to know of Nino’s story. with one report from the Department of Homeland Security’s In the late 1980’s, when the Soviet Union crumbled, inspector general finding 900 people crammed into a cell Cuba followed swiftly behind, enormously dependent on designed to accommodate a maximum of 125. Babies are the socialist regime for economic prosperity. The situation drinking from unwashed bottles and lack diapers. They are was made worse by the United States’ refusal to participate kept in chilly rooms with lights on 24 hours a day as another in trade with the island. Castro’s response to the terrible shortage of food and the daily necessities of “Asylum seekers are being criminalized, human life was inaction. Nino was part of the political opposition against this rights are being violated, and thousands of lives regime. Eventually, fearing for his are irrevocably traumatized in migrant detention life, he fled Cuba by boat, arriving in Miami where he found legal aid and camps across the country.” sought asylum. The same agency that helped him attain refugee status also placed him with us, and that is how he came to live with us for over a decade. form of abuse, contending with outbreaks of flu, lice, chicken “Tú eres igual como mi niña,” he would often tell me during pox and scabies. As of 3 months ago, 24 immigrants have died our chats as I tried to fathom what he had been through, both during the current administration. Many of these deaths are fascinated and horrified. It was not until later that he would tell the direct result of the conditions of ICE detention centers. me—blinking through hopeless tears, cradling her picture in Our immigrant patients are also affected by a recent his calloused hands—how he lost his daughter to hepatitis the executive order that paints immigrants as a “public charge” same year as her quinceañera. That rumpled photograph of her for accessing essential safety net programs such as health on that joyful day held a permanent place in his pocket. Even insurance, housing and food assistance. These patients are as a child, I could not imagine how one could go on after this often gainfully employed, however their jobs do not confer kind of loss. insurance or a living wage. I have seen firsthand patients who But go on he did, as did so many others in his position I have are too afraid to follow up electively after urgent or emergent come to know as friends and patients. I have collected their surgery—they do not want to change their emergency stories, imagining children like my own walking barefoot Medi-Cal to cover elective services fearing a threat to their miles in the dark among the howls of coyotes, women and immigration status. This translates into thousands of our men stuffed flat under the carpet flooring of a van, loved patients just in the Valley who will not receive adequate care ones dying of dehydration along the way. Those who make it as many cannot afford out-of-pocket fees for follow-up of are hungry for a better life the way no other person could be, their chronic conditions or even cancer. We need to educate working longer, harder, better, and more faithfully because of ourselves, and our patients, on their rights in the context of it. They live simply, sometimes crammed into one-bedroom receiving necessary medical care while not compromising apartments sleeping on floors, cleaning the facilities we their immigration status. work in, processing the food we eat, sometimes raising our children. Still others are working on farms and reportedly Surely crimes against humanity are far worse than those given stimulants to produce more eager workers. And yet, it is a against borders. The photos of these detainees’ conditions better life than the alternative. are no different than the existence of the stray dog I adopted Asylum seekers are being criminalized, human rights from the pound. Is a minority child worth no more than a are being violated, and thousands of lives are irrevocably stray dog? No—it is less; much of the reporting on how ICE traumatized in migrant detention camps across the country. supporters treat and speak of these children is abhorrent. Some

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of us watch these accounts in horror, others numb, still others in inexplicable defense. We as physicians cannot afford to be silently numb, or even silently horrified. This is a time that calls for us to be loud. Because it simply cannot be that six hundred years later, we are still leaving our neighbors with hair torn in grief and walls red with blood. It simply cannot be.

Here are some ways to get involved and make a difference: • Join Doctors for Camp Closure, a group of physicians who oppose the inhumane detention of migrants and refugees who are attempting to enter the USA. Visit d4cc.squarespace. com for more information. • Urge your health administrators to divest from Immigration and Customs Enforcement (ICE). Companies like Amazon, Microsoft, Palantir, Salesforce and Aramark— frequently employed by the healthcare industry—are profiting from the criminalization of immigrants and worsening the crisis in detention centers. UC spent at least $281 million on over 25 contractors who also do business with ICE. Tweet @ UofCalifornia #CloseTheCamps. • Urge Gavin Newsom to sign AB32, a bill recently passed to remove the profit motive from incarceration, which include detention facilities. California’s largest detention centers are operated by a company called Geo Group, contracted until 2023 with the Department of Corrections and Rehabilitation; AB32 could prevent contract renewal or at least force them to comply with federal court orders to reduce crowding. • Urge Nancy Pelosi to sponsor HR 322. This critical bill prevents the current administration from preventing or discouraging immigrants from accessing “safety net” programs to which they are entitled including essential health, nutrition and housing programs. This executive order hurts immigrants and their families who are on the pathway to a green card, promoting health disparities and widening the gap.



Fall 2019

$50 off

if you book by December 1, 2019

Fresno Madera Medical Society

69th Annual Yosemite Postgraduate Institute February 28 - March 1, 2020

Topics Include: Undiagnosed Diseases with Case Studies CDC Guidelines on Pediatric Concussions and Traumatic Brain Injuries Preparation for Emergencies in your Primary Care Office MAT - What you should know about Treatment of Opioids Poison Control & Case Studies HIV Pre-Exposure Prophylaxis(PrEP) Sports Injuries: Hot Topics Cardiac Screening for those in Sports New Diets: Low Card, Keto, Paleo, & South Beach Endocrine Emergencies Trauma Informed Care Workshop - Wilderness Survival Strategies Mindfulness & Life/Work Balance

16.0 CME

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Registration is now open - Call (559) 224-4224 ext. 118 for more information or visit Fall 2019





The Central Valley’s First Osteopathic Medical School approved to Accept Applications California Health Sciences University College of Osteopathic Medicine (CHSU COM) continues to successfully advanced towards accreditation. Recently, Dean John Graneto, DO announced that the medical school in Clovis was awarded Pre-Accreditation status, following the Commission on Osteopathic College Accreditation (COCA) meeting. Pre-Accreditation is the highest status a College of Osteopathic Medicine can achieve prior to graduating its first class, as warranted by the COCA. The COCA is empowered by the U.S. Department of Education as the programmatic accreditor for all colleges of osteopathic medicine. “We are proud to advance to this next step towards accreditation, which is a critical step in the approval process,” stated Dr. John Graneto, Dean at the CHSU College of Osteopathic Medicine. “The CHSU COM can now offer



enrollment to our inaugural class, as well as begin instruction on Tuesday, July 21, 2020, said Graneto. Applications for 2020 enrollment began in May and have exceeded expectations of the medical school and interviews for the inaugural class of medical students have begun and will continue through next spring. Pre-Accreditation provides the CHSU COM with the following rights: 1) degree granting authority, 2) graduate eligibility for all residency programs in the U.S., and 3) graduate eligibility to subsequently be licensed in all 50 states. CHSU medical students will also be eligible for private student loans, scholarships from national organizations and regional foundations, and loan forgiveness programs upon graduation. CHSU Doctor of Osteopathic Medicine program will matriculate 75 medical students in the first class next year,

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growing to 150 students per class within two years. The Class of 2024 will utilize a modified twopass, systems-based curricular model to improve knowledge, retention, and performance. This model integrates: • Problem solving skills for critical thinking • Active learning techniques • Clinical practice in simulation • Dedicated COMLEX prep time • Holographic anatomy in collaboration with case Western Reserve University School of Medicine • Osteopathic principles and practice • Nutrition as medicine • Medical Spanish A primary teaching method for students during the first two years of curriculum is Team-based Learning (TBL) supplemented with: • Clinical skills and labs • Simulation and standardized patient encounters • Team projects • Interprofessional collaboration • Community outreach and service learning • Research and scholarly activities, every medical student will participate in: • A longitudinal clinical experience, beginning in year 1 • A population health/community medicine project throughout all years • Developing a final poster, presentation or publication Clinical clerkships will be during years 3 and 4 and will be at regional hospitals, clinics, and health care facilities with health care providers in the community. Students will rotate through clerkships in Family Medicine, Internal Medicine (general and specialty), Surgery, Obstetrics and Gynecology, Pediatrics and Behavioral Medicine. Learning in the four year will include Community Health Centers, Emergency Medicine and various elective and subspecialty rotations. Construction on the campus is progressing fast. CHSU announced, with confidence, the official ribbon cutting ceremony is planned for April 1, 2020.

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Ravi D. Rao, MD Medical Oncology, CARE, Fresno



Fall 2019

Imagine this: Your auto insurance company has spent the last few years buying up car body repair shops all over the country and now owns your local body shop. You have a fender bender and are told that you can use only this body shop for repairs. You are unhappy with the repair and complain, but you are unable to get through. Phone calls to the body shop and to the auto insurance company take up so much time that you finally give up. You consider switching to another insurance company; however, you discover that other insurance companies have also set up similar exclusive repair arrangements with body shops that they now own. You seem to have no choice at all. Is this even legal? In the U.S. medical system, this is perfectly legal. There now exists a formidable bureaucratic machinery whose goal it is to encumber physician practices with the primary goal of controlling costs and enhancing profits of health insurance companies. These payors have developed and honed what I call ‘behaviorcontrol methods’, and they have been deploying them on physicians with increasing frequency. The most commonly used measures are: using a cumbersome system of “prior authorizations”, time consuming “peer-to-peer” discussions for appeals, retroactive denials for therapy already provided, built-in delays in the authorization process (asking for an inordinate number of medical records, for instance), and use of guidelines that are unnecessarily restrictive, to name just a few. Into this milieu enters the Pharmacy Benefit Manager (PBM). PBMs were initially designed to be third party administrators with the task of handling the extra complexity of some of the newer expensive drugs that were being developed

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by pharmaceutical companies. PBMs began their life in Oncology, and now have come to manage drugs used in almost all specialties. Ideally, a PBM would contract with an insurance company and get paid an administrative fee for the efforts. Typically, (at least in the beginning) these were third parties, meaning they were independent insurance companies. As the PBM market became larger, their market clout increased. They now receive after-sales discounts from drug manufacturers, worth tens of millions of dollars every year. By designating a particular drug as ‘preferred’, PBMs can drive sales, and thereby extract more discounts from that particular manufacturer. The PBM then keeps the discount for itself. The details behind these discounts are opaque, and not made public. Add these discounts to the administrative fees, and suddenly this industry became very profitable. The biggest PBMs now end up making more profits than some pharmaceutical companies. With massive profits came consolidation and acquisitions. Health insurance companies began to acquire these PBMs. The top three PBMs are: Express Scripts, CVS Health, and OptumRx. All 3 of these are either owned by, or own insurance companies. For example, Express Scripts (by itself the 25th largest company in the US), is owned by Cigna and OptumRx is owned by UnitedHealth Group. In the meanwhile, CVS (the parent pharmacy company that started CVS health) became so profitable that it ended up buying the Insurance giant Aetna. These top three companies now control 80% of the market. Patients are now restricted to use the PBM that is owned by their insurance company. Needless to say, they also have large lobbying budgets and have tremendous political clout.



This resulting situation, however, has become problematic for patient care and physician practice. PBMs now have a built-in bias to act Health on behalf of their insurance Insurance Rx sent company partners and its company shareholders, and not on behalf of the patient. Since 80$ paid to pharma approving a new medication 90$ paid to PBM prescription reduces profits of PBM the PBM/insurance company, the PBM is now incentivized 10$ kickback to PBM to deny the drug, or to as “rebate” Pharma company 100$ allocated to this Rx (gets 80$, returns substitute it with a cheaper 10$ as a rebate) drug. They have tremendous power, and are now using it ruthlessly. As anyone who has called an insurance company about a denial knows, the appeal process is cumbersome and time-consuming. The criteria used for approvals and denials are rigid and do not accommodate patients with specific needs (for instance, those with allergies, kidney hire extra staff that are solely dedicated to these tasks. I see the or liver problems). The decisions are made by non-medical role of a PBM as “sand in the gears” of the medical system. personnel, who are not trained in any manner to understand the patient specific issues. Some examples may help understand the depth and scope Anecdotally, we know that these denials are common, and are resulting in harm to patients on a daily basis. How common is the problem of denials/delays nationwide? We will never know, as PBMs never disclose their internal data on delays or on denial rates. However, from talking to colleagues here in California, and from other parts of the country it appears that patients from every Oncology office in the country are suffering as a result of their interactions with PBMs. Not only is the problem getting more serious, it is also ‘spreading’, from Oncology to Dermatology, Rheumatology, Cardiology, Neurology, and so on. A majority of newer Oncology drugs are now oral and are therefore dispensed via PBMs. This means that my staff and I personally routinely interact with a PBM almost on a daily basis. This process is very time-consuming; my office now has had to



of the tactics used by PBMs. One common scenario is that the PBM denies a drug that is being prescribed completely appropriately per the FDA label. An appeal then leads to a quick reversal, which indicates that the initial denial was merely a delay tactic (to test our resolve, perhaps). On other occasions, I am told that another drug in the same class is the ‘preferred’ drug. Another new and very frustrating tactic that has been deployed is called “step therapy”. PBM will choose one of several drugs to be their ‘preferred’ option. This is based on profit motive and not on the patient’s benefit, and the physician is forced to follow their protocol. PBMs dictate medical decisions by denying care, and then leave the physician to deal with the aftermath. No medico-legal repercussions flow back to these staff that are making these decisions. None of the staff making the decisions has a license to practice medicine. Indeed, on one rare occasion,

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100$ allocated to this Rx

when I actually did speak a doctor on the PBM staff while doing a ‘peer-to-peer’ review on an oncology decision, it turned out that I was talking to a pediatrician. The PBMs have the best of both worlds– total power to dictate care and complete impunity. These delaying tactics take Health their toll in terms of time Insurance wasted and stress the patient company and medical staff. Patients get confused and cannot (now owns understand why their the PBM) treatment has been denied. Entire 100$ is profit When patients call the PBM, Patient denied drug.. they are told that “your doctor did not do the right paperwork’. Many patients come to believe that their doctor’s staff made an error, hence the delays. There are numerous stories now in the public domain documenting these horrors. Some of my patients and their families tell me of waiting 4-5 hours each day on the phone to sort out some of these problems. So, are there any solutions? In my opinion, all possible solutions will fall into 3 categories. First: since conflict of interests in PBMs are linked to their relationships to insurance companies, these relationships must be severed. A PBM should be independent of the insurance company, and the staff in PBMs should be required by law to act on the patients’ behalf. Exclusive arrangements between the insurance company and PBMs should be banned. This will allow patients and physicians to switch from using “bad” PBMs to those who provide better service. Second: rebates received from drug manufacturers should be publicized, and should be paid back to the payors (or even better, to patients, who have often just paid a large co-pay to fill an expensive prescription). Third, and most importantly, if the PBM’s decision leads to a bad patient outcome, they should be legally liable.



Rx sent.. ..denied or delayed


Phone calls, paperwork, appeals

Denial for “medical necessity”, etc.

Patient does not get prescribed drug

I believe that unless there is a public backlash against PBM behavior, they will end up changing the practice of medicine irreversibly. Change will not be easy, but it must happen. Dr. Ravi D. Rao is board certified in oncology and hematology. Dr. Rao attended the All India Institute of Medical Sciences in New Delhi, India, where he completed his internship. He attended the University of Wisconsin Hospital and Clinics in Madison, Wisconsin, completing his residency in 2000. He completed a fellowship, became an attending physician and an Assistant Professor of Oncology at the Mayo Clinic, Rochester. Dr. Rao has been involved in clinical research, with a special interest in new drug development. He has several publications and has received several awards for his work, such as the Division of Oncology Scholarly Award from Mayo Clinic.

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Joy of Medicine 2nd Annual


Join FMMS Saturday December 7th 8 am - 3 pm Reconnect to the Joy of Medicine Join the Fresno Madera Medical Society at the beautiful Tenaya Lodge at the entrance to Yosemite for a powerful day of fellowship and hands-on educational sessions to help build resilience and bring joy back to the practice of medicine. In addition to 4.0 CME there will be opportunities to enjoy the breathtaking scenery and organized family activities. Bring your spouse or significant other to enjoy lunch with special presentation while children (ages 3 and up) have lunch and an activity of their own. Enjoy a 10 minute chair massage or one of the many spa services available through Tenaya Lodge. Take advantage of the package deal to stay Saturday night and fill your Sunday with hiking, archery, ice skating, indoor swimming or a day trip to Yosemite. Special Friday night room rates also available.

Friday Dec. 6 - Evening Social Fireside S’Mores

Hot Chocolate

Ice Skating

Saturday Dec. 7 - Summit 4.0 Hours CME

Cooking Demonstration

Fireside Chat

Chair Massage Family Dinner

Nature Walk Gingerbread Decorating Competition

Faculty Rajiv Misquitta, MD

Amanjot Sethi, MD

Space is Limited Reservations Required Rates guaranteed through Oct. 21 Fall 2019

Michael Allhouse, DO

Register: or 559-224-4224

Jeff P. Crane, PhD

FMMS Members: Physicians $250

Spouse Free, Child $10* *Includes Activity and Lunch

21 conference only rates available




Driving east toward the central California town of Dinuba stood the snow capped peaks of the High Sierra Range. It’s not always possible to see them due to the trapped air from multiple pollutants, but as I made my way to visit Nancy, I couldn’t help but bow to the tremendous power of the Apu, the spirits of the mountains, the designation given to them by the ancient Inca people. I smiled knowing the journey Nancy made to reach her highest self on earth was nearing completion. Nancy faced her demons and was returning to the mother of us all. She faced the mountain with the clearest of vision. I met Nancy Harris in our Palliative Care clinic when I was covering for a colleague and we kept seeing each other thereafter. As she opened up to me I began to think of our visits more as an emotional catharsis rather than a symptom management visit. We saw each other over the course of several months and each time I noticed a more liberated woman. An emancipation of profound magnitude unveiled before my eyes. Nancy was born in Bakersfield, CA, a few years following World War II. She met her husband Charlie in high school during homeroom class. Coincidentally, they shared the same last name. Their daughter Natalie said, “They were the iconic couple of the 1960’s. >>



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Charlie, “handsome” and athletic, and Nancy, “the beautiful cheerleader.” They made a life for themselves in Washington State while Charlie played college football before returning to the Central Valley where they settled and raised their two daughters, Natalie and Juli. Nancy eventually returned to college and completed her bachelor’s degree and teaching credentials. She completed an amazing tenure of over two decades teaching young elementary school children. Nancy made the decision to stop her chemotherapy, along with the support or her oncologist and family, after much contemplation. The decision, her daughters would later tell me, was a huge moment and turning point for her. She was in her sixth year since being diagnosed with a Gastrointestinal Stromal Tumor (GIST). She would smile and tell me the things she was doing. Going to the central coast of California, taking a trip to Paris, and putting herself first—a selfproclaimed unnatural trait for her. But like all my patients, I tend not to see them as a “person with a disease” but as a human being, and someone who had a life before cancer or any other medical affliction. According to her daughters, she filled her life with good deeds and service to her community. Her passion for helping those with special needs, a devotion to her church and holding a position on the Planning Commission for the city of Dinuba serve as reminders of her civic achievements. During our last visit at the clinic Nancy disclosed some significant and painful childhood trauma. Each tear displayed a memory of some tragic moment. It was our deepest session. As we neared the end of the hour she smiled and told me, “I am letting this go. I don’t want it to influence my life anymore.” I asked if we could meet the next week and she agreed. I fully expected us to have more clinic visits, but as her fate unfolded, it would be our last time speaking to each other. I received an email from her daughter, Natalie, less than a week later, letting me know that something dramatic changed in her mom’s condition. I was incredulous. I recently saw her and she looked better then I could remember. She was physically and emotionally strong. I agreed to come out to the house at their request. I was grateful they asked as I felt our business was not complete (or, as I came to realize, it was my lesson that was incomplete). I met her husband, Charlie, at the door and he led me to their bedroom where I met Nancy’s daughters, Juli and Natalie, who held vigil with their mother. The precious intimacy among them painted a portrait of a loving family. We talked and I listened as they shared their many memorable experiences with their beloved. Nancy lay there peacefully, undisturbed by my presence. I felt the privilege of being there. These transformational moments are seldom lost to me when I realize how fortunate I am to be allowed to share a few moments with a



grieving family rejoicing in the legacy-filled life of someone so dear to them. Birth is something we celebrate. Life is something we also celebrate. Death is a time of transition to hold in the same celebratory regard. After answering some medical questions and saying goodnight, Charlie walked me to the door. He relayed some regrets, but spoke affectionately of his family, togetherness and what really matters. I got into my car thinking the experience had concluded. However, as I drove along the residential streets of Dinuba I realized Nancy had helped me much more then I assisted her. Emotions poured out of my soul as the healing washed over me. Once again, I was the pupil. The paradox proved undeniable. The mountain was no longer visible in my rearview mirror. The past no longer owned the moment, and the future was only a mirage. Emerson wrote, “What lies behind us and what lies before us are tiny matters compared to what lies within us.” Nancy and her family penetrated my seeming impervious veneer of steel physician’s armor and touched my humanity. I received a message the next day that Nancy had taken leave of her physical body. I felt her spirit laughing and flying freely. Free from any earthly bondage that might conspire to chain her to the posts of worldly regrets. I smiled again knowing she left on her terms. Charlie and Nancy would have celebrated fifty years of marriage, Juli would later tell me. Her commitment to marriage aligned squarely with all her vows. She was a loving and committed grandmother. She retired from teaching after she was diagnosed with cancer to spend more time with her grandchildren, Natalie shared with me. She also entered a clinical trial so she “could possibly help her grandchildren and their children.” Giving and thinking of others came naturally to Nancy. Her selflessness splashed effortlessly onto those she loved and the community she served. The mountain, a universal metaphor, lives as an archetype in the collective unconscious of our mind. I witnessed Nancy become the mountain. For her, it was not a hurdle to surmount, or a battle to face, nor an emotional hike, but the embodiment of what is holy, healing and real--the essence of life (or Sami as it is known to the Inca). Her journey is boundless, and her spirit breathes eternal joy onto those whose mission is unfolding. Nancy became the Great Teacher of all lessons. Her legacy, I suspect, will have a variety of meanings to everyone she touched, including all her students from decades of teaching. Juli proudly told me that her mom’s memorial service was “packed.” She described her mom as a person filled with compassion and love and whose encouragement touched many souls. I knew Nancy only a short while, but her impact shattered the hollow bones of my destiny. As I contemplate her transition I imagine her returning to the birthplace of wisdom, grace, and spiritual healing.

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Fresno Madera Medical Society Cordially invites you to the 2019

Installation & Awards Gala Friday, November 22, 2019 6 pm Social 7 pm Dinner, Installation & Awards

Fort Washington Golf & Country Club 10272 N. Millbrook Avenue Fresno, CA 93730

Table of 8: $500 - Single Ticket: $65

Installation of Alan Birnbaum, MD

Fresno Madera Medical Society President

Event Sponsors

Cooperative of American Physicians, Inc. NORCAL Mutual For more informaiton please visit www.fmms,org or call (559) 224-4224 ext. 114

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Health Care DREAM CMA’s economic advocates recoup 29 million on behalf of physician members



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By Tina Tedesco


The physicians of California have a powerful ally when it comes to dealing with problematic payors—the California Medical Association (CMA) Center for Economic Services (CES). Staffed by practice management experts with a combined experience of more than 125 years in medical practice operations, the CES team has recovered $29 million on behalf of its physician members in the past 10 years. Each member of the CES team brings something unique to the table, allowing them to bounce ideas off each other when trying to help practices. “We are the dream team of health care,” said Mark Lane, CES Director of Publications and Resources. “There are few issues presented that we do not have experience dealing with in some capacity. We can also draw upon our vast network of contacts to find a resource or point person to help address almost any issue. No other organization, that I am aware of, can assist physicians or their practices on this level,” said Lane. Lane began his career as a claims processor for plans such as Blue Shield and Health Net. Before long, he had moved up to a position in provider relations, allowing him to get a unique vantage point on the relationship between physicians and payors.

Empowering Physician Practices CES also provides one-on-one practice management assistance to physician members and their staff on reimbursement, practice operations and contract related issues. The center’s goal is to empower physician practices by providing resources and guidance to improve the success of the practice. Assistance ranges from coaching and education to direct intervention with payors or regulators. “The ultimate goal is to empower practices to be able to advocate successfully for themselves,” said CES Vice President, Jodi Black. “Sometimes processes fail and that’s when we intervene on their behalf.” >>

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In 2018, CES recovered nearly $11 million on behalf of physician members, up from $3 million in 2017. One of the biggest success this year was getting Anthem to agree not to pursue a $4.2 million recoupment from a member practice. Anthem had notified the practice it was planning to recoup more than $4 million due to problems with the renewal of a fictitious name permit. CMA escalated the issue to the medical director at Anthem, highlighting that upon renewal, the medical board showed no lapse in the permit. As a result, Anthem agreed not to pursue the recoupment and agreed to release the approximately $600,000 in pending claims for payment. Another success story was getting Medicare to agree to reinstate billing privileges and release almost a million dollars in pending payments to another practice that had its billing privileges had been revoked when Medicare discovered an undisclosed criminal offense by an employee of the practice. CMA, AMA and Noridian, California’s Medicare Administrative Contractor, worked together to get the practice’s appeal reviewed within three days, rather than the normal 90 days as allowed by law, to help get the practice’s billing privileges reinstated and avoid overpayments dating back nine years.

Meet Your Advocates Jodi Black, Vice President Jodi is the Vice President of CMA’s Center for Economic Services. She has spent the past 14 years working through practice operational issues and advocating on behalf of members of CMA and its county medical societies. Prior to her time at CMA, Jodi spent 15 years working with a group of emergency physicians. “My team not only provides one-on-one assistance when needed, but we also work hard to educate and empower practices to be able to advocate successfully for themselves.””



“This is money that would have likely gone unrecouped if we didn’t step in,” said Black, who has been with CMA for 14 years, building relationships with both physicians and payors on behalf of CMA. Prior to joining CMA, she spent 15 years working with a group of emergency physicians, a field she entered while still in college. She changed her major to health care administration because she believed in the cause so much. CES is constantly developing resources and tools to assist practices with new laws, including its monthly e-bulletin, CPR, webinars and phone conversations. These services are free to all members. “It feels great to help our doctors, so they can get back to work helping their patients,” said Juli Reavis, CES Associate Director, who focuses largely on helping physicians with California’s new out of network billing and payment law (AB 72). The law, which went into effect July 1, 2017, placed limits on what physicians can bill patients for using an out of network physician at in network facility. CES created more than 10 new resources to help practices succeed and comply with these new requirements.

You Are Not Alone In 2018, CES assisted physicians and their office staff with more than 1200 calls from 682 different practices from 29 different component medical societies. Sixteen percent of those calls were from first time callers. Often, the only way CES finds out about an issue is by members contacting the call center. Typically, if an issue is affecting one practice, it’s impacting others. Small errors, sometimes on the part of the payor, sometimes on the part of the physician, can have a snowball effect. “Our goal is to take the noise out of the system so doctors can get back to treating patients,” said Black. “I always felt a need to help others and prevent pain and suffering wherever I could,” said Lane. “The role I serve at CMA, assisting physicians and their practice staff, has given me the opportunity to fulfill my mission. It’s the most rewarding role I have ever had in my 25 years of health care.”

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When do I call CMA? CMA members can call on CMA’s practice management experts for free one-on-one help with contracting, billing and payment problems. If you answer “yes” to any of the following questions, it might be time to call for help: Are your claims not being paid in a timely manner or according to your contract? Do you need assistance regarding the new law on payment and billing for outof-network services (AB 72)?

Are you receiving untimely requests for refunds or is a payor recouping money without first notifying you in writing of a refund request? Do you need assistance creating a business case as to why a payor should consider contracting/re-contracting with your practice? Do you need help with Medicarerelated issues?

Are you receiving unreasonable requests for medical records? Do you need help identifying common practice mistakes costing you money? Have you been presented with a managed care contract and you’re not sure if the terms are consistent with California law? Have you done everything you can to resolve an issue with a payor, including appealing, and have been unsuccessful?

Are your claims being denied after obtaining prior authorization?

Call CMA’s reimbursement helpline today at (888) 401-5911 and they will arm you with the knowledge you need to identify and fight unfair payment practices. Learn more about how CMA’s practice management experts can help you at

Meet Your Advocates Cheryl Bradley, Physician Advocate Cheryl specializes in Medicare issues. Before joining CMA, Cheryl served as a provider outreach and education specialist for Noridian Healthcare Solutions, California’s Medicare contractor. She came to CMA with over seven years of Medicare experience. “Our goal is to empower CMA member physicians and their staffs to use tools and resources that increase their understanding of the health care topics at hand – and their bottom lines.” Mark Lane, Director of Publications and Resources For more than a decade and a half before joining the CMA team in 2010, Mark began his career as a claims processor for plans such as Blue Shield and Health Net. Before long, he had moved up to a position in provider relations, giving him a unique vantage point on the relationship between physicians and payors. “Communication really is the answer to a lot of payor issues. CMA has the contacts and the relationships to cut through the red tape and get things done.” Kris Marck, Physician Advocate Before joining CMA in 2011, Kris spent 23 years working on the payor side of the health care industry. This previous experience makes her a very effective and approachable advocate for physicians in need of reimbursement and contracting assistance. “Working with payors is challenging and the reimbursement process is complex. Don’t hesitate to call us. It’s easy to give the easy answer, but it’s difficult to go and find the right answer. We’ll get you the right answer.”

Juli Reavis, Physician Advocate Juli primarily focuses on helping members navigate the new AB 72 billing restrictions for out-of-network services at in-network facilities. “We are fighting to ensure that payors do not game the system to set artificially low physician payment rates. If you’re being negatively impacted by AB 72’s new billing and payment restrictions, call me. I can help.” Learn more at Victoria Travis, Executive Assistant Victoria is often the first point of contact for practices in need of reimbursement assistance or practice management advice. “We hear from physicians on an array of payment issues, and we are here to help guide you, provide clarification and be a voice for you to help combat payment challenges.” Mitzi Young, Physician Advocate Mitzi has spent more than 20 years in health care settings, including county organized health programs, surgery centers and specialty health care practices, and brings a variety of skills suited to help CMA members tackle their practice management questions. “With over 125 years of practice management experience on the CES team, we can help medical practices work smarter, not harder.” The CES team can be reached at (888) 401-5911 or Tina Tedesco is a freelance writer in Sacramento.




The healthcare industry faces a growing risk from cyber attacks, which makes it critical for physicians to devote sufficient resources to designing and implementing a strategy that can mitigate that risk. The internet is a medium that offers many benefits. It provides easy access to useful resources and to people around the world. At the same time, criminals across the globe have unprecedented access to us. Recent events have shown that healthcare organizations can be severely impacted by cyber attacks. It can be discouraging to learn that large organizations like Sony and Target are victims of these attacks. After all, if firms with large security budgets and staff cannot avoid them, how can a much smaller organization? It also may be tempting to think that an individual or small organization has little value to attackers and is thus an







unlikely target. Recent ransomware attacks are evidence to the contrary. Criminals have received millions in ransom payments from individuals as well as from small organizations. Cyber security experts agree that no organization can prevent every possible attack. It is still important to take steps to reduce your security vulnerabilities. You should also be prepared to respond to and recover from an attack. You may not experience every possible type of attack, so your immediate focus should be on addressing the types of attacks most likely to affect you.

HERE ARE SOME SUGGESTIONS: Keep your machines “clean.� As recommended by the National Cyber Security Alliance and others, this means keeping software on all Internet-connected devices up-to-date. Install updates and security patches as soon as possible.

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Hackers stole personal information on 143 million U.S. consumers from Equifax in 2017. In the same year, a ransomware attack crippled the U.K.’s National Health Service. A large hospital chain in the U.S. had a similar ransomware incident. What do they all have in common? Hackers exploited software vulnerabilities. In all three cases, a patch had been available for weeks, but was not installed. So, if you thought you couldn’t do better on cyber security than a large organization, here is an area where perhaps you can. Backup often and maintain offline copies of backups. Many ransomware victims can recover without paying the demand because they are able to obtain damaged files from backup. However, be sure that if one of your computers is infected with ransomware, it can’t reach and compromise the backup data, or any computer connected to the backup data. Keep your “human firewall” up to date. Phishing and social engineering are among the most prevalent attacks against small and medium-sized organizations. This means that email programs and web browsers are major conduits for malware delivery. Firewalls, spam filters, and anti-malware software all play a part in protecting against this. But cyber crime is lucrative. Attackers change tactics to avoid these counter-measures. Malware propagation by phishing and social engineering relies on exploiting human as well as technical weaknesses. Consider cyber security awareness training for yourself and for employees who use email or browse the web. Informed people who understand attacker tactics can be an effective last line of defense. For example, simply taking a moment to examine an email for suspicious indicators before opening an attachment or clicking a link can avoid having to clean up a cyber mess. Use current malware defenses. Antivirus and malware products have changed and are still evolving. “Old-school” antivirus programs relied on the vendors identifying their unique pattern or signature and publishing that information for its clients. This approach already had a built-in flaw. Your computer could be infected if you received the malware before the vendor discovered it and published an update. Attackers are now developing malware that regularly changes the signatures, making it more difficult to identify. Newer products (“next-generation antivirus”) still recognize signatures. In addition, they use machine learning techniques to identify unusual behavior. Check your antivirus product to see if it includes such advanced capabilities.

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Protect your email account. Email services are often free (Google, Yahoo, AOL, etc.). While the cost may be trivial, the value of your email account can be significant to you and an attacker. If someone gained access to your email account, what could they find that is valuable? Your address book? Would you want phishing messages sent to friends and associates from your email account?

DO YOU HAVE ACCOUNTS WITH ONLINE MERCHANTS AND SERVICES? Consider this scenario: A hacker takes control of your email account and discovers (from your emails) that you are an Amazon customer. The hacker can go to Amazon’s website, enter your email address, and click “Forgot Password.” Amazon will send a password reset link to your email, which the hacker now controls. If you have credit cards saved in your account, the hacker can login and make purchases. Exercise care with your email credentials. It is okay if you go directly to the mail provider’s website and log in. But be wary if you find yourself directed to a login page after clicking on a link in an email or an attachment. The page may look like your email service. But check the address (URL). Some prominent national figures have had their email accounts hacked in this way. If your email service offers it, consider using two-step verification. This generally involves entering a code that is sent to your mobile phone or provided in an automated voice phone call. So even if someone obtains your password, they cannot login without physical access to your phone. This is also a good idea for any other online accounts that you want to keep safe. Keeping computers safe is an ongoing challenge. Attacker tactics change constantly. It is important to maintain an awareness of the latest threats and countermeasures. Fortunately, there are many online resources available for help. One good place to start is the National Cyber Security Alliance - Authored by Tom Andre, CAP’s Senior Vice President, Information Services. CAP provides California physicians with superior medical malpractice coverage and a myriad of no-cost risk and practice management resources to help keep them safe and successful. If you’d like to learn more about the benefits we offer to our physicians and how much you can save by switching your medical malpractice coverage to CAP, contact Albert Malasig at 650543-2185 or at for additional information and a quote.




Practicing medicine elsewhere provides a personal

perspective on U.S. healthcare

As presidential candidates debate how to fix America’s healthcare system, and study after study shows the U.S. is tops in medical costs while ranking near the bottom in health outcomes, a few local physicians have firsthand expertise to put those studies and debates in perspective.

By Erin M. Kennedy

Study after study shows the U.S. has the highest medical costs while at the same time ranking near the bottom in health outcomes. As politicians in state and local government and the presidential candidates debate how to fix the problem, several local physicians have firsthand expertise to put it all in perspective. After dozens of medical missions in more than 10 different countries, Marty Clayman, M.D., a pediatric anesthesiologist who works mainly at Valley Children’s Hospital, definitely has informed opinions on healthcare delivery here: “I personally think our system is severely flawed. But to really correct it, what’s needed is much more than what was done eight years ago. The ACA (Affordable Care Act) is healthcare finance reform. It’s not healthcare reform.” Dr. Hemant Dhingra, a Fresno nephrologist and program director of St. Agnes Medical Center’s internal medicine residency program, got his initial training and start in India. He thinks “overall we have the best system in the world” But he agrees it could be improved: “We need a capitalistic approach with a socialistic delivery. People should not be struggling to pay and get healthcare.” >>



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Assessing the myriad viewpoints of his colleagues with international experience, Dr. Clayman ruefully observed: “We’re not a homogeneous bunch.” While they don’t agree on the prescription to fix our system, the insights gained elsewhere have lead them to agree that U.S. healthcare is expensive and inefficient with too much regulation and bureaucracy. There’s lot to admire, they said, about the way other countries deliver medicine – even in poor third-world nations. Roydon Steinke, M.D., a Fresno obstetrician and gynecologist, completed his medical school and residency training and started as a doctor three decades ago in his native Canada. The socialized medicine that current Democratic presidential candidates are touting is similar to Canada and is definitely not the solution, Dr. Steinke asserted. “Most of my friends from medical school days have fled Canada,” he said. “They got



tired of doing medicine with the poor remuneration and all the government regulations and the patient lines to get into care.” Dr. R. Loch Macdonald, M.D., a vascular neurosurgeon with University Neurosciences Institute in Fresno, has a similar Canadian background but more recent experience practicing in Toronto. He disagrees. Primary care and internal medicine doctors actually get paid more in Canada where patients have more access to preventative care and simple procedures, he explained. On the flip side, Canadians may have to wait longer for elective surgery and may not have access to treatments that aren’t well shown to have a long-term benefit. “Doctors get paid to do procedures in America and there is an almost limitless access to procedures at least for those who can pay,” said Dr. Macdonald, a faculty member with UCSF

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Fresno’s department of neurosurgery. “So if you go to a surgeon in the US you’re likely to have some surgery recommended.” That’s a difference that does make healthcare more expensive here. Waste and unnecessary care is glaring in U.S. healthcare America’s healthcare system might learn from the efficiencies other countries employ out of necessity because of poverty. “We notice the tremendous amount of waste in our system,” said Jeffrey Thomas, M.D., the chief medical and quality officer at Community Regional Medical Center, who is currently on his fifth medical mission to Armenia. Thomas, an obstetrician and gynecologist, spends two to three weeks at a time in Armenia’s second-largest city Gyumri at the country’s busiest birthing center and will do 30 major gynecological surgeries and up to 30 deliveries between teaching other doctors. In Armenia doctors get book learning but not the hands-on training or continuing education that Dr. Thomas can bring. Dr. Thomas observed, “What we use once and throw away, will get two years of longevity there. For instance, laparoscopic trocars – in Armenia, they’ll use them until they fall apart and just sterilize them between use.” He provides another example: “Two years ago I bought king-sized bedsheets at Target and asked my nurses to sew them into the forms we had for various surgical drapes. When we went back a year later that was the standard and they were still in use. Here in America we would burn through a thousand of those in a year.” If you walk into a cleft lip surgery in the U.S. you’ll see dozens of surgical instruments laid out near the operating table, said Dr. Clayman, who mainly does cleft lip and pallet surgeries while overseas. “A surgeon does exactly the same thing with six instruments in China instead of 50,” he said, “and the outcome is exactly the same thing.” Dr. Dhingra, who is CEO and President of The Nephrology Group in Fresno, acknowledges that much of U.S. medicine has “redundant care” built in. “I think a lot of the inefficiencies here are because of the legalities,” he said, referring to malpractice claims, byzantine insurance controls and regulatory oversight. “We need some simplicity. The more you add layers of regulation and insurance, the more complex and the more expensive it gets.” Having worked extensively on both sides of the Canadian border as a neurologist, Dr. Macdonald says the big difference and influence on costs he sees is patients’ and doctors’ attitudes toward healthcare. “There is a culture difference,” he explained. “Americans decide what they want and they want it

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perspective now. If they want stem cells injected into their knee then they will just look for the best doctor and get in tomorrow no matter what.” The difference, he explained, is in Canada patients believe their doctor when he tells them that stem cell injections aren’t a proven or effective treatment and they get on a waiting list for a knee replacement in six months. “In general the doctors in Canada are more evidence-based in their practice,” explained Dr. Macdonald. Canadian doctors want to see several randomized clinical trials with clear results before using a new method or treatment.

the arguably top medical training and technology, Americans aren’t healthier or living longer than their peers in developed countries. While American medical schools and American hospitals regularly dominate top 10 rankings by various healthcare studies and organizations, the World Health Organization doesn’t even include the U.S. on its list of 10 best healthcare systems. And the U.S. is absent from Bloomberg’s 2019 top 20 Healthiest Country index, which evaluates variables such as life expectancy, obesity, chronic diseases, tobacco use, and environmental factors such as clean air and water.

The Organization for Economic Cooperation and Development “For the most part it’s cash pay and rates are transparent and (OECD) regularly compares its publicized which has a combination of private and government 36 member countries on a number insurance much like America. Because we’ve inflated the values of health measures. In the most so much in here, no normal person could pay cash for even an recent comparison, the U.S. spent the highest share of its GDP (gross appendectomy like they can in Armenia.” domestic product) on healthcare - Dr. Thomas of Armenia at 17.1%, but fell to the bottom of 10 comparable countries when looking at the death rates for diseases most affected by health He gives an example of where Canadian and American care quality and access. The U.S. is the worst among those doctors approach care differently. With a very small brain comparable countries for the number of people per 100,000 aneurism the risk of rupturing is less than 1% per year while the population with years lost to disability or premature death. risk of repair causing damage or a rupture is more than 10% in And hospital admission rates for things like asthma, congestive some patient populations, Dr. Macdonald said. In Canada the heart failure and diabetes are higher in the U.S. aneurism would just be watched. “But here I see people being operated on in their eighties for that,” he said. Dr. Clayman observed the U.S. “is only number one in medical expenditures.” Tops in medical expertise and costs, but not outcomes The U.S. has the highest medication prices in the world, according to an analysis by research firms SSR Health and IHS. And doctors’ care and hospital services are pricier here than in other countries. According to the Rand Corp. spending on hospitals now makes up the largest share of the $3.5 trillion the U.S. invests in its healthcare system annually. Hospital prices increased 42% for inpatient care between 2007 and 2014, while charges for physicians giving that care increased 18% in the same time frame, Yale researchers found. Despite the resources devoted to healthcare in America and



But Dr. Clayman also defends America: “You have to be careful about low outcomes data. We collect our data differently. In England a woman coming in at 20 weeks in premature labor may be counted as a miscarriage. And if a baby dies within the first year of life in some countries it’s a ‘fetal mortality,’” he said. While in the U.S. those would be recorded as infant mortalities. According to OECD data, American patients survive heart attacks and ischemic strokes and breast, colorectal and cervical cancers in higher numbers than those in comparable countries. American patients also have less post-op sepsis, and fewer

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post-op clots than surgical patients in comparable developed countries. Where American patients don’t thrive is in paying for their hospitals stays. U.S. patients struggle to pay for medical care It’s sometimes shocking to those from other countries when they see how much patients pay out of pocket in the U.S. for their medical care – even when they have good insurance. Most comparable countries limit what patients must pay themselves no matter whether it is a socialized, governmentrun health system or private insurers pick up the bill. Even many Third-World and developing countries provide healthcare at affordable prices, said local physicians with firsthand experience. “For the most part it’s cash pay and rates are transparent and publicized,” said Dr. Thomas of Armenia, which has a combination of private and government insurance much like America. “Because we’ve inflated the values so much in here, no normal person could pay cash for even an appendectomy like they can in Armenia.”

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Dr. Clayman found the same thing in China where the government pays for most care, but patients do pay out of pocket for some things. “About 10 years ago my father-in-law had a heart attack in China,” Dr. Clayman said. “And he got good medical care there. He paid full price and it was a faction of what it was here.” More recently Dr. Clayman fell and got a concussion while in Myanmar on a medical mission. “I had a CT scan in an old, old scanner. It was fine and they didn’t even charge me.” Dr. Dhingra said while India has evolved in the 20 years since he left to be more like America’s system of payment, the poor still go wanting for care. In his role as a board member with the American Association of Physicians of Indian Origin, he travels frequently to India for scientific exchanges. During these trips, he’s watched the insurance system develop. Now those who work for India’s federal or state governments have very good insurance and hospitals, but they must still pay full costs up front and then get reimbursed by insurance. There’s no private employer-based insurance, but private insurance is available for the wealthy. What’s been lacking is a safety net system, Dr. Dhingra said.




He has hopes for the Auyshman Bharat national health protection program launched in 2018 in India to fill the gaps in healthcare for the poor. “The poor go to the government hospital. They’re not necessarily the best though. Unlike if you are poor here. You can go downtown to Community Regional (Medical Center) and you can get the best care,” Dr. Dhingra said.

Dr. Dhingra came to America on a student visa in 1998 to do an internal medicine fellowship and left his pathologist wife and 4-year-old son behind in India. “I thought maybe if I had a degree from abroad in another health system that would make me a wiser person and I could contribute more. The idea was to come back,” he said. “What really kept me in this country was the uniformity of care here.”

“The classic example is in my field nephrology and dialysis,” he explained the difference in access and costs. “I don’t think in India you can survive on dialysis for more than one year if you have to pay for it yourself because it is too expensive. Here the government supports it from dialysis to transplant if that’s an option. We have people living here 20 years on dialysis, available to their children and grandchildren.”

Dr. Dhingra boasts that India has top-notch physicians and hospitals. But only the top echelons of the country can afford that care. “Education-wise I don’t think you can compare with the Indian system. We have so much competition in sheer numbers and the selection is on merit that you get the top of the top. We export doctors to the world,” he said.

Inequalities, access issues still exist but not like elsewhere It was the disparities in healthcare he saw that eventually drove Dr. Dhingra to emigrate from India. “I had no intent of coming here…but I saw the contrast in the delivery,” he said. “In India your health is as good as your status is.”

In America, Dr. Dhingra saw that those great physicians and hospitals were available to all: “If you are homeless and you go to the emergency room and you will get the same healthcare pretty much and maybe better, in my opinion, than someone who has insurance. Because the homeless person will not have to worry about a co-pay.” That egalitarian approach freed Dr. Dhingra to really practice



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Dr. Macdonald however sees plenty of advantages to Canada’s more socialized system: “For the patient it’s easier to access primary care and simple medical things. And if you go to the hospital for an emergency then you don’t have to worry about your house being taken away if you can’t pay.

medicine, he said. “Here I just look at what your problem is and what the solution is. And it doesn’t have anything really to do with your economic status. That’s what really impressed me and I just stayed.”

“But it’s more difficult to get access to things that aren’t emergent,” he added, “like cataracts or knee surgeries. You could get that tomorrow in Fresno, but it would be months out in Canada. And access to high level complicated things like bone marrow transplant in Canada is restricted to proven treatment for those likely to benefit.”

Dr. Steinke, who left Canada decades before Dr. Macdonald, sees that rationing of healthcare and the waits in Canada as a travesty. “If you smoke or have diabetes you don’t get “What Obama did with ACA would be tantamount to the Wright coronary stenting or bypass. brothers getting the first plane off the ground and then having It’s their way of rationing,” Dr. Steinke asserted. “People over President Roosevelt say that within five years we’re going to have 70 don’t get hip replacements. 747’s flying cross country. It just went too fast.” I remember a patient in her - Dr. Steinke last fifties here that I did major cancer surgery on. In Canada she would’ve likely been put on Dr. Thomas said he too has seen that, “the disparities in palliative care. She went back to Canada two times after her healthcare in a Third-World environment are much more surgery doing train trips to see people.” pronounced. Elective surgery is somewhat unheard of.” He asserts that the regulations around who’s a good candidate That’s why Dr. Calyman said he concentrates mostly on doing for surgery or treatment “made doctors and patients into liars simple cleft lips and cleft pallet surgeries when he’s overseas. or drove them to do morally wrong things.” Dr. Steinke gave “Whatever we might say about the American system, what an example from his time in Canada, “To schedule a tubal gets done here doesn’t get done in a lot of places because of ligation took two years when I was practicing in Quebec. But if funding. In these countries people may be shunned or abused a woman got pregnant and had an abortion they would tie her or abandoned because of this cosmetic defect. We’ve helped tubes at the same time.” people who lived 70 years with this deformity.” No easy fixes for complicated U.S. While the poorest Americans can often access the best care healthcare system through U.S. emergency rooms and most have access to some Dr. Steinke does agree with his peers that Americans may have sort of insurance through Medicare or Medicaid, many are gone too far the other way expecting immediate treatment for still falling through the cracks when it comes to basic and everything and demanding private hospitals rooms. “We are preventative care. Patients, especially here in the central San spoiled,” Dr. Steinke said. “We need changes, but they really Joaquin Valley, may have insurance, but that doesn’t mean they have to be thought out.” can find physicians who take that government insurance, Dr. Dhingra pointed out. And even when they find a doctor, the Dr. Steinke feels the U.S. rushed to fix its system. “What wait for an appointment may be months. Obama did with ACA would be tantamount to the Wright brothers getting the first plane off the ground and then having

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perspective President Roosevelt say that within five years we’re going to have 747’s flying cross country. It just went too fast.” The ACA moved the U.S. in right direction to make care a bit more equal for all, Dr. Dhingra said. “But while the ACA did provide insurance, nobody is taking it because they are not getting reimbursed. I don’t think we can fix this fast. It’s complex,” she acknowledged. Dr. Dhingra still insists medical delivery here is so much better than most countries: “If we can just make efficiencies, figure out the complicated end of life discussions, and simplify insurance payments then we’ll have the best system in the world. We just need to simplify.” And while many on the outside of healthcare are leaning toward the socialist model of Canada for that simplification, Dr. Macdonald said “It’s not necessarily better. Some things are better and some things are worse. Some things that work there and would really not work here.”

Switzerland has a model Dr. Steinke would recommend: “They spent more than 200 years looking at the pros and cons of various health plans in Germany, Russia, England, etc. And they were responsive to the people.” A hospital experience in Switzerland convinced Dr. Steinke that careful approach worked. He broke his arm badly at a ski resort and had to be driven to the regional trauma center late in the afternoon. “I walked into ER and there was only one patient in a cubicle, and more doctors and nurses than patients,” he described. “Their system is so efficient. Every person has their own doctor and chooses their own health plan. And it’s only if a doctor sends a patient to the ER that they go and the patient has to pay themselves for the ER. That payment might come out of a welfare check or pension for someone who is poorer. No one abuses the system there.”

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Background For over a decade medical research, performed primarily by the U.S. military, has increasingly demonstrated the value of transfusing massively bleeding trauma patients with a balanced mix of red blood cells (RBCs), plasma, and platelets that recapitulates “fresh” whole blood. The rationale for this practice – known as damage control resuscitation (DCR) – is that the early transfusion of these patients with plasma and platelets (along with RBCs) ameliorates: (1) the acute coagulopathies of trauma (i.e., disseminated intravascular coagulation and hyperfibrinolysis); (2) the dilutional coagulopathies associated with the infusion of non-plasma-based resuscitation fluids; and (3) the traumatic endotheliopathies that lead to coagulation factor dysregulation and inflammation.1 The PROPPR trial demonstrated similarly improved, DCR-related patient outcomes in the setting of civilian trauma.2 Accordingly, the American College of Surgeons recommends that liquid-state plasma be “on hand and available for immediate release” in support of massively bleeding trauma patients.3 This “do-not-wait-to-give-the-yellow-stuff ” approach is supported

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further by results from the recently published PAMPer multicenter randomized clinical trial (RCT), which revealed that the prehospital administration of Thawed Plasma (TP)* results in a substantially lower 30-day mortality rate than standard-care resuscitation with crystalloids.4 While the similarly-designed COMBAT study, a single-center RCT, yielded negative results (likely at least in part due to the impressively short accident-to-hospital transport times seen in the Denver, Colorado community),5 additional work investigating the pre-hospital use of plasma in trauma patients is in progress. Nevertheless, the demand for plasma that is available for immediate (i.e. without the delay inherent in thawing) use has surged. Maintaining a TP inventory (with only a 5-day shelf life) and/or thawing frozen plasma (e.g., Fresh Frozen Plasma [FFP] or Plasma Frozen Within 24 Hours After Phlebotomy [PF24]) rapidly ondemand is challenging – especially for smaller rural hospitals and in the pre-hospital setting. The former too often leads to product wastage, i.e., when products expire unused, while the latter can lead to unacceptable delays in transfusions, given that thawing frozen plasma generally takes 20-to-30 minutes. Mehr et al. reviewed how



Key Points about Liquid Plasma (LP) • LP is:

• M anufactured from whole blood collections; • S tored in a liquid, refrigerated (1-6° C) state; • Never frozen; and • Immediately available for transfusion. • LP has a 26-day shelf life when manufactured in CPD/CP2D anticoagulant-preservative solutions. • While LP contains stable levels of most clotting factors, variably reduced levels of Factors V and VIII, von Willebrand Factor, and Protein S (e.g., to 50-60% activity) are seen after 14 days and further gradual declines are seen thereafter. • LP serves as a “bridge product” to meet the plasma transfusion needs of massively bleeding trauma patients. • Its use should be coordinated via an approved protocol agreed upon jointly by the transfusion service, the emergency department/trauma team, the operating room, and other affected departments/services.

massively bleeding trauma patients in their institution received an average of eight units of RBCs before plasma was made available for transfusion (at a median of 26 minutes into resuscitation).6 Maintaining a refrigerated plasma inventory for immediate use is therefore considered essential at some facilities. For these reasons, demand for Liquid Plasma (LP), which typically has an outdate of 26 days, has increased substantially in the United States during the past several years. A number of studies have compared the hemostatic properties of LP to those of TP and Thawed FFP. Coagulation factor levels are generally maintained equally up to 7 days; and hemostatic levels in LP (though lower than for TP and Thawed FFP) appear sufficient for at least 14 days. Platelet-derived microparticles, moreover, are in abundance and can boost thrombin generation potential as well as correct endotheliopathy in vitro for 28 days.7-9 Some centers conservatively apply a shelf-life of <14 days to avoid significant coagulation protein loss. Given the lack of in vivo studies, LP is generally used as a “bridge product,” i.e., to be transfused only until other plasma components – e.g., TP or thawed FFP – can be issued.

Liquid Plasma’s Indication LP is indicated for “the initial treatment of patients who are undergoing massive transfusions because of life-threatening trauma/hemorrhage and who have clinically significant coagulation deficiencies.”10

Liquid Plasma’s Contraindications These include:10 • The prolonged transfusion management of massively bleeding patients (for whom LP is indicated only for “initial treatment”)



– i.e., these patients, after having received approximately 2 units of LP, should thereafter receive traditional, frozen-then-thawed plasma products. • The treatment of single or isolated coagulation factor deficiencies where other (e.g. fractionated plasma derivatives or recombinant) products are available with higher factor concentrations. • Contraindications that also apply broadly to the use of traditional plasma products – i.e., LP should not be used as a: • Volume expander when blood volume can be safely and adequately replaced with other volume expanders; • Substitute for a readily available coagulation factor-enriched product (e.g., cryoprecipitate, single factor concentrates, and prothrombin complex concentrates) or other, more suitable treatment modalities (e.g., vitamin K); and • Reversal agent for heparin (where protamine sulfate is the suitable antidote).

Liquid Plasma – Other Considerations • The dosage, administration, and potential risks of LP are identical to those of traditional plasma products.10 • For TRALI (transfusion-related acute lung injury) mitigation purposes, LP is manufactured from whole blood donated by male, never-pregnant female, and/or HLA-antibody-screened parous female donors. • Because LP contains viable leukocytes, some customers request this product be irradiated to prevent transfusion-associated graft-versus-host disease. Such adverse events, however, are vanishingly rare in the literature and there is no consensus on the use of irradiation in this setting. • LP sometimes has a pink-red hue associated with the settling of trace quantities of intact red blood cells. This coloration usually is not seen in thawed FFP because these cells are lysed, and their contents distributed uniformly throughout the product, as a result of the freeze/thaw process. • It is unknown whether these intact red cells are more or less immunogenic than the lysed red cells found in frozen-and-then-thawed plasma. • It therefore also is unknown whether or not the potential benefits of administering Rh immune globulin following the transfusion of Rh(D)-negative women of childbearing age with Rh(D)-positive LP outweigh the risks and costs. • Given that the use of Group A plasma has become standardof-care during the initial transfusion support of adult trauma patients,11 the exclusive/near-exclusive use of Group A LP (as opposed to Group AB LP, that is in short supply) is strongly recommended. • Note: A meaningful safety advantage has not been observed in association with the use of “low titer”-anti-B/A,B (i.e., as opposed to “un-titered”) Group A plasma. • Most U.S. programs therefore have accepted the use of un-titered Group A plasma when transfusing their massively bleeding patients. With increased morbidity/mortality observed after excessive

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crystalloid use in the prehospital setting, some are beginning to explore the substitution of >14 day-old LP which, in addition to volume expansion, provides an isotonic solution with variable levels of coagulation factors. • Studies are needed to better characterize potential benefits in this setting.12

Summary: The expanded prehospital and early resuscitative use of plasma and consequent need for immediately-available plasma for massive hemorrhage have led to a steady increase in LP requests. The practical impact of this has been reduced time-to-transfusion and decreased expiration rates for frozen-then-thawed plasma products, thereby leading to greater efficiencies and hospital satisfaction. LP’s equivalency has not yet been extensively studied; thus its primary use to date has been as a bridging product.


profile of liquid-state plasma. Transfusion 2013;53:579-90. Boström F, Sjödahl M, Wehlin L, et al. Coagulation parameters in apheresis and leukodepleted whole-blood plasma during storage. Transfusion 2007;47:460-3. AABB, America’s Blood Centers, American Red Cross, Armed Services Blood Program. Circular of Information for the Use of Human Blood and Blood Components (Revised October 2017). Bethesda, MD: AABB. Dunbar, NM, Yazer MH, Biomedical Excellence for Safer Transfusion (BEST) Collaborative and the STAT Study Investigators. Safety of the use of group A plasma in trauma: the STAT study. Transfusion 2017;57:1879-84. Chang R, Holcomb JB. Optimal fluid therapy for traumatic hemorrhagic shock. Crit Care Clin 2017;33:15-36. Blood Bulletin is issued periodically by America’s Blood Centers. Publication Committee Chair: Chris Gresens, MD; Editor: Mack Benton. The opinions expressed herein are opinions only and should not be construed as recommendations or standards of ABC, ABC SMT Committee, or its board of trustees. Publication Office: 725 15th St., NW, Suite 700, Washington, DC 20005. Tel: (202) 393-5725; Fax: (202) 393-1282; E-mail: Copyright America’s Blood Centers, 2019. Reproduction is forbidden unless permission is granted by the publisher. (ABC members need not obtain prior permission if proper credit is given).

Lier H et al. Coagulation management in multiple trauma: a systematic review. Intensive Care Med. 2011;37:572-582. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015;313:471-82. Massive transfusion in trauma guidelines. American College of Surgeons. 2013. Sperry JL, Guyette FX, Brown INC. JB, et al. Prehospital plasma during A REGISTRY & PLACEMENT FI air medical transport in trauma patients at risk for hemorrhagic shock. NEJM 2018; 379-315-26. Moore HB, Moore EE, Chapman MP, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomized trial. Lancet 2018;392:283-91. Mehr CR, Gupta R, von Recklinghausen FM, Szczepiorkowski ZM, Dunbar NM. Balancing risk and benefit: maintenance of a thawed Group A plasma inventory for trauma patients requiring massive transfusion. J Trauma Acute Care Surg 2013;74:1425-31. Matijevic N, Wang Y-W, Cotton Voice: 800-919-9141 or 805-641-9141 BA, et al. Better hemostatic profiles FAX: 805-641-9143 of never-frozen liquid plasma compared with thawed fresh frozen plasma. JTACS 2013;74:84-91. Gosselin RC, Marshall C, Dwyre DM, et al. Coagulation

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

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There have been many times in my life where I have struggled with understanding how to proceed after a difficult situation. It was like the old adage, “when life gives you lemons, make lemonade” was just not working for me. Because of this, I have often found myself wondering how so many people could think or act positively after something that would be horrifying to anyone, while I could not. The truth of the matter is that everyone has moments like this; everyone goes through moments where they feel no one else can relate. And we all struggle in those moments. It is situations like these that have made me wonder: Is it just me who is unable to see the positives? Was I the only one who, when given a difficult situation in my life, just didn’t know how to deal with it? The truth is NO; I am not the only one. I am not the only one who struggles to have compassion for myself when I am handed a challenging or painful situation. I had to learn that I cannot always just sit there and live in the moment of pain in my life. I could not just be upset about feeling or struggling with the hard stuff. Instead, I had to learn to hit pause for just a moment. One of the ways that I have found effective for myself and many others is the use of a Compassion Break. Compassion Breaks are when we allow ourselves to pause, tune in, and feel our emotions. In fact, there is a four step break that when we are going through the hard stuff, can be important for us all to follow. These four steps include pausing, tuning into our bodies and noticing how our body is affected by our emotions.



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Step 1: Bring mindful acceptance to what we are doing and what is happening in our lives. By doing this, we can begin to stop struggling with what is happening. Step one is to say to ourselves (either out loud or quietly in our own thoughts): “This is a moment of suffering”. Suffering can mean many things to each one of us but recognizing the pain is important for us to have an overall sense of compassion for ourselves; this is what we call selfcompassion. Step 2: Normalize the experience of having difficult feelings (we all do sometimes). We must recognize that we all undergo feelings of pain, upset, frustration, etc.; therefore, we must remind ourselves that we are not alone in that feeling. There has been many times in my 7 years of conducting counseling where a client will ask me, “How can you possibly understand what I am going through?” The short answer is that I may not know how it feels to lose a child but I can recognize that this is a loss that no one wishes to undergo and I can help my clients understand that I can feel that pain and hurt right alongside them. There is absolutely no need for us to feel alone in our experience or feel guilty or ashamed of what is a part of our life. Step two is to say to ourselves (either out loud or mentally): “I am not alone in this” and “I don’t have to feel alone”. I tend to forget this in the moment. I tend to forget that I am not alone and don’t have to show strength all of the time but it is time when we need others that we find a different type of strength; we find that strength in not being alone. Step 3: Be compassionate to yourself. I’m sure everyone can agree that we are our harshest critics but it should not always be that way. We must all remember to be kindhearted to ourselves in the moment. One easy way for us to bring ourselves joy, kindness and compassion in the moment would be to place both of our hands over our heart or on our cheeks. By placing our hands on our heart (or on our cheeks), we are raising our Oxytocin levels (the “cuddle hormone”). After placing our hands on our cheeks or our heart, we should tell ourselves, “This is a hard moment but I know I can get through it.” Step 4: What do I need right now? Now this is the fun one and doesn’t have to be done each time. This is an optional step that you only have to do if you want to

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or have time but it helps me remind myself that I am important and have needs. This step has me ask myself, “What do I need right now?” Now for anyone who knows me, the one surefire way of having me clear my mind is for me to go skydiving. I love the rush of fresh air in my face, the picturesque view, and the adrenaline but there is absolutely no way for me to jump out of a plane on a moment’s notice. So, what do I do? I have spent many years challenging myself to believe that I had to find one thing I could do to calm me in moments where I felt lost, challenged, anxious, or any other feeling that would often keep me not focused on things that matter to me. Is there something that I can tell myself to make the moment a little bit easier for me? Something that I will often find myself doing is seeing if my parents can have a grandparent moment and maybe pick up one of my children from an activity when I feel too overwhelmed to do so. Other ideas include asking questions like “Can I be patient?” “Can I ask for help?” Or is there something you can do for yourself to help you in the moment? Some ideas include: going for a walk to give yourself a little break and refocus; calling your friend who you keep wanting to, but put it off instead; meditate to get you focused on something else for a little while; or even take a bubble bath. Small things that we can do for ourselves (either through the actions of ourselves or others) will allow us the time to be compassionate to ourselves. Overall, it’s important to remember that you are important and what you are going through is important and should be noticed. You are worthy. You are in pain. You are going through something. You do not have to be alone. You can get through this. You can go for a walk or talk to a friend or do anything really that helps you get out of the moment. You can do it! Recognizing the overwhelming stresses and immense workloads that physicians face today, Fresno Madera Medical Society Sponsors up to four (4) Resiliency Consultations to physicians with Roubicek and Thacker. These services are confidential, convenient and free of charge. To schedule an appointment call the provider’s office 559-323-8484 and request an appointment with the provider of your choice. Identify yourself as a physician practicing in Fresno or Madera County and participating in the FMMS Joy of Medicine Program and request a Resiliency Consultation.



Summer Meltdown


Benefiting Fresno Madera Medical Society Scholarship Foundation

SPONSORS Cooperative of American Physicians G.L. Bruno Associates California Health Sciences University Community Medical Centers Paul Chen Accountancy Inc United Health Centers Saint Agnes Medical Center



Richard LeRoy, Jr., MD Robynne Whetton

E & J Gallo Jeremy Brownstein

Trilok Puniani, MD Carolyn and Bernie Lutz

Kings River Winery Nadarasa Visveshwara, MD

LIVE AUCTION DONORS Dr. Alan and Kathy Birnbaum Chef Jon Koobation Chef Matt Moore The Painted Table The Lodge at Riverstone Red Rock Environmental

Madera County Fire Station No. 7 Central Valley Astronomers Scribble & Script Wonder Valley Ranch Old Schoolhouse Restaurant and Tavern Fresno Underground Suppers

Dr. Barton and Carol Fischer Dr. Patrick and Cynthia Ginn Toca Madera Winery Debbas Gourmet Chocolate

SILENT AUCTION DONORS ApCal Belmont Nursery Blue Moon Yoga Breathless Sparkling Wines United Skate Clovis Chukchansi Gold Resort Dr. Howard and Cindy Terrel Cline Family Cellars Concannon Vineyards Delaware North- Tenaya Lodge at Yosemite Downing Planetarium at Fresno State Don Gaede, MD Dr. Patricia Falcone Dust Bowl Brewing Elaine’s Pet Resort Fensler Restaurant Group Fixation Lash Spa Fresno Filmworks Fresno Football Club

Fresno Grizzlies Baseball Club Fresno Philharmoic Gallery II In N Out Burger InSight Vision Center Medical Group J. Lohr Winery Kern County Raceway Kim’s Petting Zoo Kuppa Joy Lagunitas Laugh Factory Hollywood Le Vigne Winery - Paso Robles Mad Duck Craft Restaurant and Brewery Make-up by Manda Manhattan Steakhouse and Bar Maya Cinema Moksha Hollistic Wellness Center Muses Day Spa Orloff Jewlery

Philip Lorenz Project Survival Cat Haven Quady Range Pistol Club Raphio Chocolate Rubio’s Coastal Grill San Diego Symphony San Fransisco Symphony Six Flags Studio 318 - Perry Cooper The Bone Store The Doctors Toca Madera Winery Vino Grille Yosemite Mountain Sugar Pine Railroad

Public Health



Flu Season is Upon Us As many of us who already got the flu shot know, the flu season is upon us. The CDC estimates that approximately 8% of the population will be infected in any given season. And while it is always unpredictable, there are clues that the upcoming months may be especially troublesome. We often look to the Southern Hemisphere to predict the severity of the flu season in the Northern Hemisphere. In Australia, where winter has just ended, a particularly virulent flu strain (H3N2) was responsible for a long and aggressive flu season. The flu represents a . Last year, the CDC reported an estimated 37 million to 43 million flu illnesses in the United States. What’s worse, there were between 36,400 to



61,200 flu-related deaths. The season lasted a whopping 7 months, from October to May, the longest in a decade. A pediatric flu death has already been reported in our own state for the 2019-2020 season—a 4-year-old child with a preexisting health condition. This early death may be another prediction of difficult months ahead. It is important to get the flu shot early in the season, before the epidemic starts. It takes about two weeks to build immunity against the virus after receiving the vaccine Particularly, the elderly, pregnant women and children over 6 months should be vaccinated early to prevent exposure. Some defer the flu shot, arguing that it is ineffective. It is

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true that the flu shot only offers partial protection. Last year, its effectiveness was only 37% in adults and 61% in children—partly due to a poor match in strains of the virus including a late and unexpected wave of H3N2. So why should we get the vaccine and encourage others to do the same? Partial protection is still important, since the complications from influenza infection are the most dangerous aspect of the illness. There is good evidence that vaccinated patients who get the flu do not have as severe a course or as many complications as those who are not vaccinated. For the elderly, a specific flu shot called Fluzone may be best, as there is evidence that for patients over 65, high-dose vaccination may provide greater protection. FluMist is another formulation that avoids needles— it is a nasal spray favored by children and those who are afraid of needles. Per CDC recommendations, children age 6 months to 8 years may need two doses of the vaccine to cover the entire sesason. Both Fluzone and Flumist, as well as the standard flu shot, protect against H3N2.

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In Memoriam

In Memoriam DAVID BARRETT, MD 9/2/1976 – 3/31/2019

Dr. David Barrett of Clovis, CA, passed away on March 31, 2019 at the age of 42 after a 4-year battle with cancer. Dr. Barrett will be remembered for his loving and gentle manner. He blessed the lives of many as a pathologist and his service. He is survived by his wife, 4 children, parents and 9 siblings. Dr. Barrett was a member of the Fresno Madera Medical Society for 6 years.

LEE IRVING FRENCH, MD 10/24/35 - 8/18/19

Lee started his adventure in the cold of northern Minnesota. Soon after his birth, his father was called up to the Army, who sent the family all over the southeast helping the US prepare for possible German invasion. Jessie L. Harris (Mom) and the boys joined Rollie Lubin French (Dad), in Germany for the Occupation. After three years they returned to the U.S. setting down roots in Vermillion, SD. Lee graduated from high school in 1953, and graduated from the University of South Dakota, in 1958. Lee attended medical school at Temple University, graduating in 1960, and married Jacquelyn Croyle. They would have four children. Lee did his internship at Santa Monica Hospital, in California. In 1961, he joined the Air Force, hoping to learn to fly, (another story). He served in Freising, Germany, until 1964. He completed his medical residency at Kern County General Hospital, Bakersfield. In 1967, Lee hung out his shingle in Fresno, California, practicing Family Medicine. He was active in the medical community, and with his family in Boy Scouts, Indian Maidens, and church. He loved helping his patients and sorely missed delivering babies (due to the malpractice crisis). In 1978 life changed for Lee, hospital privileges were being denied to the Family Practice physicians, at the same time his wife started divorce proceedings. (Lee proceeded to buy a sail boat.) In 1981, Lee married Jo Ann Campbell. In 1982 He took residency this time in Internal Medicine at UC San Francisco/Valley Medical Center, Fresno, California. In 1984 he reopened his Medical Practice in Fresno, with many of his former patients returning for care. In 1994 French moved to Prescott, AZ joining the VA Medical Center eventually fulling one of the Night Officer of the Day spots. Working for the government gave him more time to travel, camp, and visit family. 2004 Lee retired from medicine, to enjoy his garden, water his newly planted trees, and enjoy Arizona’s outdoor activities. By 2013, Lee’s dementia was limiting his life, so we moved to be closer to his son Mark and his family in Prescott Valley, AZ. The kindness and gentleness that he had shared with the world continued until his last day, August 18 2019.



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French is survived by his spouse; Jo Ann French, Children; Mark J. French, Elizabeth French, Adrienne (French) Johnson, Laura (French) Werner. Sibling; Marilyn Edith (French) Sullivan, Grandchildren; Aleah Werner, Chelsey French, Jaimie French, Lexie French, Marcus Werner, Natalie French, Savanah Werner, Tyler French. Predeceased Siblings; Rodney Miles French, Rollie Winston French. Dr. French was a member of the Fresno Madera Medical Society for 28 years.

BRIAN E. CAVALLARO, MD 04/02/57 – 07/13/19

Dr. Brian Cavallaro was a board-certified ophthalmologist and President of the Board at EYE-Q Vision Care, specializing in the diagnosis and management of glaucoma and cataracts. But to those who knew him, he was so much more. He was a leader, guiding the Board through key decisions and important issues with grace and ease. He was an expert in his patients’ care, diligently finding treatment plans and solutions for his patients, improving their quality of life and forming positive, authentic relationships along the way. He was a trusted team member for his coworkers, striving to be a consistent resource as well as an advocate for improving EYE-Q on behalf of staff and patients. At the core of his being, Dr. Cavallaro was a devoted husband and father, putting his family before all else. He was passionate, intelligent, dedicated, and kindhearted. His positive, energetic spirit affected everyone he met, and his premature passing is detrimental to the community as a whole. Dr. Cavallaro’s father, Salvatore Cavallaro, was a Navy physician. He met Dr. Cavallaro’s mother, Marie, upon his return from World War II. Dr. Cavallaro and his four siblings, Bode, Hugh, Cathy, and Karen, were raised in Nazareth and Easton, Pennsylvania. Dr. Cavallaro met his wife of 16 years, Maria Cavallaro, while they both worked at EYE-Q in the Central Valley. He was most proud of his six children: Andre, Mijo, Dylan, Chloe, Sofia, and Madeline. Dr. Cavallaro was overjoyed to be able to meet his first grandchild, Pia, daughter of Mijo, born on Monday, June 3, 2019. Dr. Cavallaro received his Bachelor of Arts degree from the University of California, Berkeley, continued on to earn his Master of Science degree at the same institution in 1988. Dr. Cavallaro then earned his medical degree at Chicago Medical School at Rosalind Franklin University. Subsequently, Dr. Cavallaro joined the U.S. Army, completing his internship in 1991 and his residency in 1996 at the Walter Reed National Military Medical Center in Washington, D.C. He also completed a glaucoma fellowship at the worldrenowned Bascom Palmer Eye Institute at the University of Miami. Dr. Cavallaro was a decorated Army ophthalmologist for eleven years. While he was in practice with the U.S. Army, he worked his way up in rank and ultimately served as the Director of Glaucoma Services at Walter Reed National Military Medical Center in Washington, D.C. He earned numerous awards and honors during his service. Dr. Cavallaro was honorably discharged in 2001 and joined EYE-Q Vision Care immediately after as a board-certified ophthalmologist. He became a shareholder and member of the board in 2002, and was elected President of the Board in 2013. In his nearly 18 years at EYE-Q, Dr. Cavallaro focused on advancing the practice and the industry as a whole, resulting in hundreds of positive patient reviews and making him a respected, valued presence in the community. He performed thousands of surgeries during his time with EYE-Q. Dr. Cavallaro was a member of many local and international organizations, including the Association of Research in Vision and Ophthalmology, the American Academy of Ophthalmologists, the American Society of Cataract and Refractive Surgeons, the American Glaucoma Society, the Fresno Madera Medical Society, the Alpha Omega Alpha Honor Medical Society, the Bascom Palmer Alumni Association, and the University of California at Berkeley Alumni Association. As a strong supporter of our community, Dr. Cavallaro helped guide EYE-Q’s philanthropic outreach to provide a multi-year founding gift to the Community Cancer Institute in Clovis. Personally, he also supported the Marjaree Mason Center, Valley Caregiver Resource Center, the Veterans Parade, the American Red Cross, and the Cancer Research Institute, among many other organizations. Dr. Cavallaro was a member of the Fresno Madera Medical Society for 18 years.

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

High-tech. Higher purpose. As our surgeons’ skilled hands control innovative treatments in our operating rooms, Saint Agnes stays in touch with our highest goal: protecting every blessing that walks through our doors. Caring for the Central Valley. With all our hearts. 56


Saint Agnes Medical Center Fall 2019