Central Valley Physicians Fall 2020

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Fall 2020


Physician Diversity Something to Celebrate Connecting Mind, Body and Soul


Forge Ahead

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Last issue of the CVP magazine, there was a typo on the story Responding to COVID. The caption should have read. “Dr. Robin Linscheid Janzen, US Representative James Costa and Public Health Officer Rais Vohra, Volunteering their time at a local surveillance testing site for COVID.”


11 19 21 27 35 39 45 Fall 2020
















From The Executive Director


It is with mixed emotions that I say goodbye to Fresno Madera Medical Society. After five plus years of learning and growing in my current position I have decided to take my career to the next level and accept a position in operations at Welbe Health.


Welbe Health is a physician owned and operated startup company launching PACE programs throughout the country. I will be part of the team launching their fourth program, Sequoia PACE in Fresno.

Working with Fresno Madera Medical Society and California Medical Association has provided me a wealth of experience and knowledge that I will carry with me for the rest of my career. I am grateful for the opportunity that I had serving the physicians and residents of Fresno and Madera Counties and I’m proud of the growth in membership and services during my time as Executive Director. I am excited to share that Stacy Woods has accepted the executive director position for Fresno Madera Medical Society. As you may know, Stacy has been with FMMS for the past two years running several of our programs such as our Joy of Medicine Program, Scholarship Fundraising and the Cardiology Symposium. Prior to FMMS she was with the Fresno Philharmonic for 6 years working as the Director of Membership and Marketing. She has the experience and knowledge needed to run a membership organization. I will be staying on in the short term working on CME until Stacy has hired and trained additional staff to take on some of her current responsibilities. I am still in Healthcare, therefore some of you will still be hearing from me. Thank you for the opportunity to work with so many great physicians over the years and I hope to stay in contact as much as possible. My cell phone number is (559) 259-8592 and my email is Nicole.Butler@WelBeHealth.com

PRESIDENT Alan Birnbaum, MD PRESIDENT-ELECT Don Gaede, MD VICE PRESIDENT/ TREASURER Christina Maser, MD PAST-PRESIDENT Cesar A. Vazquez, MD BOARD OF GOVERNORS Janae Barker, DO, Shamsuddin Khwaja, MD, Katayoon Shahinfar, MD, John Moua, MD, Pamela Kammen, MD, Ravi Rao, MD, Sonia Shah, MD, Marina Roytman, MD, Jesus Rodriguez, MD, Greg Simpson, MD, Brent Kane, MD, Jai Uttam, MD, CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS EDITOR Farah Karipineni, MD MANAGING EDITOR Stacy Woods ASSISTANT EDITOR Don Gaede, MD EDITORIAL COMMITTEE Farah Karipineni, MD - Chair, Chang Na, MD Roydon Steinke, MD, Cesar Vazquez, MD Hemant Dhingra, MD, Nicole Butler, Trilok Puniani, MD Alan Birnbaum, MD, Alya Ahmad, MD FAAP CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Alan Birnbaum, MD, Malissa Wade, Erin Kennedy, Farah Karipineni, MD, MPH, Manisha Mittal, MD, Emily Coriale, David Logan, Karen Dahl, MD, Carmela Sosa, MD, Michael Danovsky, Ph.D. CONTRIBUTING PHOTOGRAPHERS Erin Kennedy, Nicole Butler, Stacy Woods, CHSU Staff, Anthony Imirian CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711 Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler Membership and Events Manager, Stacy Woods




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FMMS Joy of Medicine www.FMMSJoy.org

It’s Ok To Ask For

Help RESILIENCY CONSULTATIONS The Fresno Madera Medical Society recognizes the overwhelming stresses and immense workloads that physicians face today. Stress, anxiety, depression and grief are common, but they can be managed. Resiliency Consulta�ons can provide relief, an increased ability to cope, healing and an opportunity for personal growth. FMMS sponsors up to four (4) annual sessions with approved and ve�ed providers confiden�ally, conveniently and FREE to physicians living and prac�cing in Fresno and Madera Coun�es. Par�cipa�ng in a Joy of Medicine Resiliency Consulta�on is completely confiden�al. Neither FMMS, your employer, nor the California Board of Medicine will be no�fied if you choose to par�cipate. Par�cipa�ng providers offer a wide range of appointment �mes that strive to accommodate the unique and busy schedules of physicians. Providers are paid by FMMS directly, discreetly and anonymously. Insurance will not be asked for or billed. Physicians have the op�on of extending their par�cipa�on at their own expense a�er the fourth visit. It’s OK to ask for help! Call today to schedule a free Resiliency Consulta�on and begin the process of reconnec�ng to your Joy of Medicine.


Joy of Medicine


CENTRAL VALLEY PHYSICIANS 6 County Call and identify yourself as a physician practicing in Fresno or Madera

A message from our President > Alan M. Birnbaum, MD

A Public Health Prescription

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



As we enter the seventh month of the COVID-19 pandemic, we find it compounded by health-related political turmoil. As we try to breathe air pollution choking our skies, we now realize that personal health and public health parallel and impact each other. For perhaps most of us, over years if not decades, public health seemed an abstract and largely irrelevant topic. Did we care about the odd infectious disease that surely would not affect us? No. Did we consider our air, water, sunlight, as anything save immutable and reliable given quantities? No. I hope that I have been environmentally aware, starting with backpacking into the Sierra during college, and participating in an environmental studies course. Yes, I have been a Sierra Club member since my college years. Many local physicians have been environmentally aware and active, your incoming FMMS President Dr. Don Gaede a prime example. Yet as I look out my window this second Sunday of September, visibility down to an unprecedented 1.00 mile, and AQI, air quality index, up to an unhealthy 224 this evening, courtesy in part from the 202,000-acre Creek Fire devastating our nearby Sierra, we must realize that that our community, and our nation face not just a bad situation today, but unless we act now, a very bad future. Sharing this morning’s data with Rais Vohra, MD, our Fresno County Acting Health Officer, he responded, “This is truly apocalyptic,” then continued: “Climate change is not only real, it represents the most substantial health

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hazard of our lifetimes. Case in point: you can quarantine from a virus, but you can’t hide from the pervasive damage that our species has wrought on ecosystem after ecosystem. We need to get serious about our reckless abandonment

disaster. The fourth and final quarter of 2020 looms. Surely it has become time for us to tend to our own health, while realizing that public health forms its foundation. Maintaining our health includes seeing our personal physician, completing surveillance testing where indicated, and taking Did we care about the odd infectious disease medications when prescribed. that surely would not affect us? No. Did we Our public health prescription however, requires persistent awareness of consider our air, water, sunlight, as anything save our environment, understanding potential immutable and reliable given quantities? NO. healthcare reform, study of all issues, and attention to the values and plans of politicians at all levels of government. Does Candidate X understand of environmental stewardship – as physicians that feels the issues? Has he or she demonstrated not just an like it is out of our lane, but then again scientific progress understanding, but also participated in positive actions? always does when it pushes people out of their comfort What about his or her opponent? We cannot of course vote zone. Remember that there was a time when doctors felt exclusively based on the public health issue, but as the first it was not their duty to advise people to stop smoking. Now it’s a laughable bit of trivia, but in the same vein how will future For decades now, Vice President Al Gore, generations judge our reactions to the who save for Electoral College vagaries, environmental catastrophes that we are observing all around us?” might have become President, has preached Recently, California’s Governor, that message by his book and movie, “An Gavin Newsom, inspecting one of Inconvenient Truth,” and for that shared the innumerable fire sites, pointed out that Nobel Peace Prize in 2007. behind these wildfires was climate change, global warming. In our mountains that led to drought, facilitated bark beetle infestations, killing trees, then they became tinder that Tuesday in November approaches, it should be one of the readily caught fire when struck by lightning. most important determinants in our decision. Once our For decades now, former Vice President Al Gore, who ballot arrives in the mail, we consider not one, but many save for Electoral College vagaries, might have become choices. For some offices we may need to consider crossing President, has preached that message by his book and party lines, if we follow this approach. movie, “An Inconvenient Truth,” and for that shared the And then, VOTE. Mark that ballot, put it into the mail, Nobel Peace Prize in 2007. Interestingly, his prevailing or take it to an election center. As a last resort, go to the polls opponent, George W. Bush, once in office, as part of his on Election Day! reading program, came to realize our vulnerability to the other great public health hazard, and initiated a Federal Alan M. Birnbaum, MD pandemic response program, that unfortunately was partially dismantled during the year prior to the COVID-19

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

Caring in the time of COVID As I left the OR on a busy Thursday evening, I had an empty feeling in my gut. As is my usual practice, especially during rocky times like these, I ran through the possible reasons in my head. What was I feeling so dissatisfied about? My cases had been stressful that day but with no complications; the patients were safe, my kids were fine, the day was finally over—why did I still have a lingering sense of emptiness, almost dread?

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.



With the exception of one patient, I hadn’t actually seen or spoken to any of my patients’ family members that day. Of course, this was due to COVID; no family members were able to accompany patients in the preoperative area, nor were they allowed to wait in the waiting room. Gone are the days, at least for now, of walking into the waiting room to meet anxious family and friends to eagerly report on the surgery and postoperative care. That day, two of my patients’ emergency contacts did not answer the phone postoperatively, and one elderly patient had no family contact to call after surgery, just her nursing facility waiting to pick her up when ready. I had no one to update about those three patients after surgery. In surgery, no one involved in my patients’ care can understand or consider the risks of surgery as carefully as I do. My hands are assuming those risks, and even if the risk of a certain complication might be less than one percent, it occupies my thoughts far more than that as I perform the familiar steps of the case. And once that case is over, even if everything went according to plan—as it almost always does—all the stress of performing those steps perfectly falls away. I move on seamlessly to the next battle, as if I had just been rebuilding furniture, rather than a human being. But does the stress really fall away, I wonder? I realized during COVID that the best part of my surgery days is not at the end of the case, when I close skin, place the sterile bandage on and leave the OR. The low points might linger—the stubborn tumor, the inf lamed tissue, the aberrant anatomy. The

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best part of my day—when I get to release the stress of Amid the myriad mounting hardships of raging the case, the ball that did local fires, climate change, social and political not drop, all that hung in the balance—is when I get to call instability, and of course the pandemic, these loved ones and deliver the personal reflections comfort me as a physician in at best news, that the surgery least one small but profound way. went well and their precious family member is doing well. This is by far my favorite part of the day, and it is so much patients and family members in much higher acuity more meaningful in person than over the phone. situations, with far more hanging in the balance during the pandemic. During COVID, I have had many family members cry over the phone when I call them to deliver this good news. Amid the myriad mounting hardships of raging local Sometimes they are expressing relief more than sadness. fires, climate change, social and political instability, and of But often, it is the pain of being apart during a critical course the pandemic, these personal ref lections comfort time. During these conversations, sometimes I feel like me as a physician in at least one small but profound way. crying too. I apologize that they are not able to be with their The emptiness of my OR days reassures me that I am in loved ones during this time, promising that I treated the this profession for the right reasons. It also inspires me patient like my own family, hoping that promise is at least to redouble my efforts in these times to connect more the smallest consolation. They graciously thank me, but meaningfully and effectively with patients and their of course we both know it cannot be the same. I can only families, knowing that it means the world not only to their wonder how these conversations must feel for practitioners, wellbeing, but also to my own.

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At the 2008 Meeting of the National Medical Association, the AMA issued a long overdue apology to Black physicians, pledging to right past wrongs and to work tirelessly to achieve physician diversity that “at a minimum reflects the diversity we see among those who need care.� Twelve years later, amid a new national reckoning with the effects of institutional racism, it is instructive to review the progress our profession has made toward achieving this goal. The Association of American Medical Colleges (AAMC) collects and reports data on US medical students and full-time faculty. In 2008, the year of the AMA pledge, the AAMC reported the percentage of matriculants to US medical schools were 6.4% Black and 7.2% Hispanic. In the 2018-19 academic year, matriculants to US medical schools were 7.1% Black and 6.2% Hispanic. Percentages of full time faculty at US medical schools followed a similar trend from 2008 to 2018, with a modest decrease in White faculty (69% to 63.9%), corresponding increase in Asian faculty (13% to 19.2%), and relative stability in Black (3% to 3.6%) and Hispanic (4.2% to 5.5%) faculty. In comparison, on the 2010 US Census, individuals identifying as Hispanic accounted for 18.5% of the population, Black or African American 13.4%, and Asian alone 5.9%. If the goal is to train a physician workforce that at a minimum reflects the diversity of those who need care, we must do better. >>

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Why is it important to increase the percentage of Black and Hispanic physicians? The current makeup of the physician workforce is a result of centuries of intentional exclusion of underrepresented minorities (URM), particularly Black people, from medical training and practice. This segregation continued well into the 1960s, barring Black Americans from a path of upward social mobility, economic and political power. Achieving a diverse medical workforce that reflects the US demographic and correcting the severe imbalance of power in the medical infrastructure are issues of equity and justice. Training more physicians from traditionally excluded groups is a key component of the effort to eliminate health disparities. In the 2018 AAMC survey of US medical school matriculants, 60.5% of Black students and 41.9% of Hispanic students planned to practice in underserved communities, compared to only a quarter of Asian and White students. Eventual location of practice is highly correlated with intent during medical training, and studies confirm that Black and Hispanic physicians are much more likely to practice in shortage areas than non-URM colleagues.



A long history of racial malpractice against Black patients has degraded trust in the medical system. Black physicians can help rebuild that trust. Studies show that Black patients on average prefer to receive care from Black physicians, report a more positive experience with and are more receptive to treatment recommendations by Black physicians. In a recent study, 1300 Black men recruited from a local barbershop were asked to choose among four screening tests, then were randomly assigned to a clinic visit with a Black or non-Black doctor. Patients in both groups selected the same number of tests prior to their visit, but Black patients paired with Black doctors were significantly more likely to follow through with the screening measures, even invasive tests. Video of interactions between clinicians and patients demonstrated better communication and longer interviews between Black patients and Black doctors, and their patients were more likely to discuss additional health problems.

What are the barriers to creating a representative physician workforce? White households own 85.5% of all wealth in the US, whereas Black and Hispanic households own 4.2% and 3.1%, respectively. The Black and Hispanic poverty rates of 26.2%

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and 19% are more than twice the White poverty rate of 9%. Thirty-eight percent of Black children in the US live below poverty level. However, an AAMC analysis of economic diversity of US medical students from 2007 to 2017 showed that approximately 75% of all medical students come from the top two quintiles of household income. This distribution has been consistent over the past three decades.

to entry, beginning with the development of programs to support and mentor local URM youth, active recruitment of URM students in college, and re-evaluation of medical school acceptance criteria. The cancellation of the MCAT due to COVID 19 has forced many institutions to waive the MCAT for applicants this year and provides a unique natural experiment to determine the true value of this test. In medical school and residency, Black and Hispanic students need Black and Hispanic mentors and role models, but these are in short supply. Academic centers must take a critical look at faculty recruitment and advancement policies and make the necessary and painful changes needed to create a truly anti-racist culture. In a recent review of the 4,032 professors of surgery in the US, there were 11 Hispanic women, and 15 Black women. We know this striking imbalance did not occur by chance. Now we must get past knowing there is a problem, and start doing something to correct it.

White households own 85.5% of all wealth in the US, whereas Black and Hispanic households own 4.2% and 3.1%, respectively.

Given the higher share of Black and Hispanic children growing up in generational poverty, it is not surprising that an education gap between White and URM students begins in elementary school and widens as students begin standardized testing. Teachers often have and convey lower expectations of Black students, especially Black girls. In an interview of 20 women physicians of color in Oakland, 40% described high school or college guidance counselors discouraging them from applying to medical school, and more than 50% doubted their ability to succeed in medicine because they could not find a role model with their racial or ethnic identity. In the AAMC study of MCAT scores, an average score was predictive of passing the first year of medical school training but not subsequent years of medical school or residency training. Nevertheless, this heavily weighted test stands between prospective URM students and a career in medicine. As the importance of standardized tests increased, so increased the costly test preparatory industry, further disadvantaging lower income applicants.

Tracy Zweig Associates A






Nurse Practitioners Physician Assistants

What can we do now to increase the percentage of Black and Hispanic physicians? When the AMA excluded Black physicians, it did so not by overt national by-laws proscribing Black membership, but rather passively under the rhetoric of respecting States rights and local customs. This allowed hospitals to deny Black physicians admitting privileges and prevented Black physicians from entering specialty training. Our failure over the past 12 years to significantly increase the percentage of Black medical students is also a failure of passivity. Historic exclusion of Black physicians was intentional; inclusion today must be equally intentional. US medical schools must work to remove barriers

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Locum Tenens Permanent Placement Voice: 800-919-9141 or 805-641-9141 FAX : 805-641-9143 jnguyen@tracyzweig.com www.tracyzweig.com



Practice News and Resources Free to FMMS/CMA Members!

November 4th The New Rules of Communicating During COVID 19 11:30 am – 12:30 pm

Presented by Betsy Hayes, APR, Fellow PRSA Due to the pandemic, things are quite different right now including how we should communicate with our patients. Join us for this session and lear n strategies and best practices including: • Creating a Communication Plan (including in person, electronic and social media strategies) • Deciding who should be messaging • Developing and delivering appropriate content • Being responsive with the right frequency

November 18th Coding Update 2021 11:30 am – 12:30 pm

Presented by Mary Jean Sage CMA-AC E/M changes are coming! Now is the time to get ready. Join Mary Jean Sage of the Sage Associates for an hour detailing significant changes to the E/M code set for 2021. • Define which codes will be governed by these new rules in 2021 • Know how to use time for new and established patients in 2021 • Define the key terms in the revised MDM guidelines • Plan how to implement change in their practice

We Help You Get Paid CMA’s reimbursement experts have recouped more than $30 million from payors on behalf of member physicians in the past 11 years.

PRACTICE MANAGEMENT ASSISTANCE CMA’s practice management experts provide free assistance to members and their staff on reimbursement, contracting and practice management related issues.

DIRECT PAYOR INTERVENTION CMA has recouped more than $30 million from payors on behalf of CMA member physicians in the past 11 years. These monies represent actual physician reimbursements that would have likely gone unpaid without CMA intervention.

EDUCATION CMA offers timely, high-quality education programs for physicians and their staff. From interactive in-person seminars to live and on-demand webinars, CMA provides the information needed to help run a successful medical practice.

PRACTICE MANAGEMENT NEWSLETTER CMA Practice Resources—known as CPR—is a monthly email bulletin that includes tips and tools to help physicians and their office staff improve practice efficiency and viability.

PAYOR CONTRACT ANALYSIS CMA members have free access to objective written analyses of major health plan contracts designed to help physicians understand their rights and options when contracting with a third-party payor, as well as which contract provisions are prohibited by California law.

“The value that CMA brings to physician practices cannot be understated. Membership is not a cost to my practice – it is an investment. I couldn’t run my practice without it.” –Tom McKenzie, M.D., member since 1991

Need Help? Contact CMA’s Reimbursement Help Line at (888) 401-5911 or economicservices@cmadocs.org



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We have our



Total funds raised to date and $14,000.00 LISTED BELOW ARE ALL OF THE DONORS. Organization Donations from:

Loren Alving, MD

Richard Polson

Balwinder Bains

Sharon Pryor

CalViva Health

Jacques Benninga

Laura R Martinez

Central Valley Community

Michael Chakov

Randy Rebella


Lisa Chun

Charlaine Roberto

CTEC Fresno County Office of

Pam White

Marina Roytman, MD


Terril Efird, MD

Jennifer Russell

Fresno Madera Medical Society

Ahmad Emami, MD

Marcia Sablan, MD


Lorrae Emory

Anthony Sablan

Fresno Madera Medical Society

Karen English

Lara Safadi


Vickie Fouts

Susan Sanders

Ford Motor Company

Byron Fox

Laura Sanford


Kristen Garneau

JoAnne Sargent

IdeaWorks Fresno

Amitabh Goswami, MD

Judith Saunders

Jewish Federation of Central

Don H Gaede, MD

David A. Schools


Glenn Hananouchi. MD

Katayoon Shahinfar, MD


Mary Hansen

Cynthia Sinclair

Riley's Brewing

Sumera Hayat, MD

Alan Sortor, MD

Root Access

Susan Hill

Sean Tower, MD

The PiShop

Pamela Kammen, MD

Jai Uttam, MD

tieks by Gavrieli

Hanna Krebs

Ko Vang

Tiger Livy Productions

Patrick MacMillian, MD

Maria Vargas

Traveler Surf Club

Anna Marie Gonzalez, MD

Kent Yamaguchi, MD

Pio Martin

Vendetta Yenter

Personal Donations from:

Christina Maser, MD

Michael Yezbick

Roberta Alexander

John Moua, MD

Mark Alson, MD

William Podolsky, MD

Thank you to all that donated

Cecilia Alvidrez

Bonnie Polson

to the GuardsUP program.

Electric Vehicles Keep Getting Better.

Drs. Alex Sherriffs, Joan Rubinstein, and Don Gaede started down the EV road a few years ago after purchasing a Nissan Leaf and a Chevy Spark. They have now moved on to the Kia Niro EV (Drs. Sherriffs and Rubinstein) and the Tesla Model S (Dr. Gaede), with nearly 300-mile ranges. All 3 have a passion for clean air as well as the Sierra Nevada, and recently returned from an 8-day backpack trip out of Courtright Reservoir. They also have solar panels on homes,



so you could say their cars are running on sunshine. There are now more than 2 dozen models of electric cars to choose from that have 250+ miles of range. Dr. Sherriffs, who serves on the Valley Air District Board and the California Air Resources Board, says “Switching from gas-burning to electric vehicles is one of the keys to cleaning up our Valley’s polluted air. He adds, “We doctors can help show the way.”

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When you join the California Medical Association and Fresno Madera Medical Society you join nearly 50,000 members statewide who are actively protecting the practice of medicine and defending public health.

SIGN UP AT WEB: cmadocs.org/join

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PHONE: 559-224-4224 ext 118





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A total of 12 pediatric physicians were the first to graduate from the program in June 2020, with half of the inaugural class choosing to stay and practice in the Fresno area. “I was excited to move back to Fresno and train at Valley Children’s because I knew how well-respected and valued the organization is to the community and I wanted to serve our medically underrepresented and highly deserving patient population,â€? says Valley Children’s Pediatric Residency graduate Dr. Devon Ward, who is also a Fresno native. “I’m proud to be a part of this community and feel that it was very important for me to stay here and give back.â€? With an already impressive 50 percent retention rate, the Valley Children’s Pediatric Residency Program is helping to remedy the Valley’s physician shortage. “Our Board of Trustees’ goal in deciding to start this residency program was to improve access to the children of the Central Valley,â€? says Valley Children’s Chief of Pediatrics Dr. Jolie Limon MD, FAAP. “The access to healthcare in the Valley is among the worst in the country and certainly the state; we have approximately 48 primary care providers per 100,000 people, while the Bay area and Los Angeles have close to 100 per 100,000. To take care of a population, the number should be more like 70 per 100,000.â€?Â

Established in 2017, the Valley Children’s Pediatric Residency is unique in that it fosters an innovative educational environment to not only produce highly-qualified clinicians, but to also instill the importance of serving as child advocates. “In addition to creating more physicians, we are also committed to teaching residents to be leaders and advocates for children,â€? Dr. Limon says. â€œThis includes learning to identify issues that affect our communities and create upstream solutions for advancing the health of kids, as well as learning how to work with local and national agencies such as the American Academy of Pediatrics to advocate for children and their health.â€? The program is nationally recognized by the Accreditation Council for Graduate Medical Education (ACGME), a non-profit council that oversees graduate medical training programs in hospitals throughout the country. The residency program also features partnerships with hospitals and medical groups throughout the area so residents have the opportunity to complete rotations at partner locations including Kaiser Permanente, Saint Agnes Medical Center, and various local pediatrician offices. Dr. Limon says the Valley Children’s Pediatric Residency Program is built on four pillars: 1. Interprofessionalism – We work in teams and train in teams. We value the input and participation of nurses,

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pharmacists, social workers, respiratory care providers, chaplains, etc. This promotes better team work and better patient outcomes. 2. Advocacy – Pediatricians are not just clinicians, they are the voice of children who cannot vote. 3. Individualized Curriculum – We recognize that every resident is different with individual career goals. Since we do not rely on residents for service within the hospital, we can provide a very personalized curriculum while meeting ACGME requirements. For example, a future neonatologist can choose to complete a transport rotation to get experience flying on the helicopter for neonatal transports. 4. Well-being and Resiliency – Now more than ever, this is a critical component we’ve built into the program since inception. We offer well-being stipends that can be used for whatever the residents feel keep them “well.â€? This may



be a gym membership, hiking equipment, art supplies, or running shoes, for example. We hold annual retreats as well as provide half days off so residents have time for their own medical appointments, car maintenance, etc. Residents are also welcome to utilize the Valley Children’s patient dog therapy program.

“I feel honored to have been a pioneering member of the Valley Children's Pediatric Residency Program,� says graduate Dr. Albert Vu, who has chosen to stay and practice in Fresno. “The teaching staff, program leadership, and my colleagues have enriched my life beyond what I thought imaginable. I am excited to represent such a wonderful institution, to carry on the mission of improving the health and well-being of children, and to see what other positive impacts I can have on the Central Valley.�

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Dr. Ward shares the same passion and excitement and feels the residency program has prepared her well.

“I believe this program has given me a solid foundation of medical knowledge and an understanding of how to practice evidence-based medicine,� she says. “Throughout residency, I received so much valuable experience from our wide catchment area and high volumes of patients with diverse medical conditions and needs. The program also placed an emphasis on familycentered care, which has taught me to be a compassionate physician who knows how to communicate and work well with families.� Dr. Ward is currently practicing as a Primary Care Pediatrician at Sky Park Pediatrics and Dr. Vu is serving as a Complex Care Pediatrician with the Charlie Mitchell Children’s Clinic, both affiliated with Valley Children’s. “I had the privilege of training at this clinic during residency and learned from many great mentors and worked with many dedicated and supportive staff members,� Dr. Vu says. “I was also able to build my own patient panel and I grew connected to my patients and have enjoyed seeing them grow these past three years. I want to continue developing these relationships and help fill the need for providers in this region.�

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Residency faculty are thrilled six physicians of the first graduating class have chosen to stay and practice within Valley Children’s facilities, including Drs. Ward and Vu. “Dr. Ward is from the Valley and so this is her community â€“ she understands the Valley’s needs and has established many connections,â€? Dr. Limon says.“Dr. Vu is not from the Valley originally but fell in love with the mission and our community. He is equally important as he carries on the culture of Valley Children’s which is a community source of pride.â€? Not only did the residency program impact Dr. Vu, but his significant other Dr. Thanh Huong Nguyen, has also chosen to stay onboard with Valley Children's to provide care at the affiliated Fresno Children's Pediatrics. The couple met their first year of medical school at the University of Colorado and have continued their journey together ever since. The couple says they are drawn to the Fresno area due to its growth, comfortable pace of life, variety of locally sourced foods, and nearby trails and national parks.

Throughout the three-year program, Drs. Ward and Vu enjoyed many valuable experiences.

 � � �

“The most memorable moments were seeing patients for follow-up appointments after treating them in the Intensive Care Unit,â€? Dr. Ward says. “It is miraculous to see a child who was once in critical condition later run around and laugh. One of the best parts of residency is getting to rotate throughout the hospital, which allowed me to see the same patients in different practice settings. The most important thing I learned was how essential it is to thoroughly communicate with families. Being a good listener and getting to know each patient’s family helps me understand their beliefs and values, which enables me to provide the best care. My favorite rotation was my continuity clinic at Sky Park Pediatrics. I loved getting to know each family on a routine basis. I really enjoyed working at this clinic as a resident, which made it so exciting to be given the opportunity to work here full time.â€? “The most memorable times over the last three years have been watching the residency program grow and being able to lead my own team as both a second and third year resident,â€? Dr. Vu says. “I enjoy passing forward what knowledge and insight I can while instilling the same sense of passion I have



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for this community with the hopes that many of these excellent physicians will also stay after graduation.� As a diverse region, both residents feel training at Valley Children’s provided them with experiences they wouldn’t have had elsewhere.   “The program has prepared me extraordinarily well as I have been able to see a wide variety of cases during my training,� Dr. Vu says. “As for rare issues and disorders that many only read about in textbooks, my colleagues and I have been able to manage multiple times. As Valley Children's is equipped to handle complex cases with our onsite sub-specialists and is the referral site for multiple hospitals in the region, I have also had enough patient volume to build my knowledge and skills to confidently treat my patients.�

There are currently 38 residents training within the Pediatric Residency Program. The number of physician trainees is expected to grow as the hospital’s next goal is to develop a Neonatal Intensive Care Unit Fellowship in 2021 and a Pediatric Hospitalist Fellowship program (PHM) in 2022. “This is especially significant as PHM is a new board specialty classified by the American Board of Pediatrics and American Board of Medical Specialties,â€? Dr. Limon explains. â€œMany of our hospitalist faculty were grandfathered in and passed the boards last year for this designation, including myself. Moving forward, a pediatric resident will need to complete a fellowship in Hospital Medicine to practice Inpatient Medicine. Our NICU Fellowship is important as we are the only level IV NICU in the Valley and provide care for a 45,000 catchment area – our NICU has grown from eight beds in 1971 to 88 beds currently.â€?

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Fall 2020




California Health Sciences University College of Osteopathic Medicine (CHSU-COM) has officially welcomed their first cohort of medical students. These inaugural student doctors made history on July 27, 2020 when they began their journey towards becoming physicians at the Valley’s new medical school. The inaugural cohort is comprised of 79 students, 34% of which are from the Central Valley and 81% of the students are from California. The students range in age from 21 to 42 years old and are closely split between males and females (41 and 38, respectively). >>

Fall 2020



“Today is a historic moment for the Valley. It is my distinct pleasure to welcome the inaugural class of 2024 to California Health Sciences University College of Osteopathic Medicine,” stated John Graneto, DO, Dean of the CHSU-COM, in an address to his faculty and new medical students. During the competitive 2019-2020 admissions cycle, the admissions team received nearly 4,000 applications and invited 7% of those candidates to an in-person interview. Candidates that were offered admission were carefully selected based on their overall portfolio including MCAT scores, GPA, letters of recommendation, personal statement and completion of pre-requisite courses. Three of the students hold doctoral degrees and 18 hold master’s degrees. The students’ average undergraduate GPA is 3.4 and average MCAT score is 505.5. The inaugural class includes highly qualified students that completed their undergraduate education at well-respected institutions such as: UCLA, UC Irvine, UC Davis, UC Berkeley, UC Merced, Fresno State and Fresno Pacific University. “The CHSU-COM admissions committee seeks to admit students who possess the academic, professional, and personal qualities necessary to become exemplary osteopathic physicians”, said Dr. Graneto. The inaugural cohort at CHSU-COM is very diverse. Twentyseven different languages are spoken amongst the students in the inaugural class, including over 30% that speak Spanish. Enrolling a diverse student body is an important first step in breaking down inequities in health care. “Many of our medical students and future physicians will be able to serve patients while speaking to them in their native language to gain trust and confidence, thus improving the



Fall 2020

health outcomes and wellness of our wonderfully diverse community,” said Dean Graneto. Sixty faculty and staff are working in the state-of-the-art facility located in Clovis, complete with large classrooms, a medical library, osteopathic skills lab, demonstration and teaching kitchen and a Simulation Center which includes a 12 room outpatient OSCE suite and a 7 bed simulated hospital wing. “Today marks another step towards achieving our mission to improve the health care outcomes of people living in the Central Valley” stated Dr. Graneto. The CHSU College of Osteopathic Medicine has already

Fall 2020

begun making admission offers for their second cohort of an approved class size of 112 medical students matriculating in July 2021. By 2022 and beyond, the CHSU-COM will increase their cohort size to 150 medical students, bringing their total student population to over 600 at one time. CHSU-COM is committed to working with existing facilities and new clinical settings to help increase the number of residency positions in and around the Central Valley. It has been shown that a large percentage of physicians stay and practice within 50-100 miles of where they complete their residency. The University’s mission is to increase health care access by educating new physicians and build new opportunities for residency in the local area, thereby



significantly increasing the number of physicians in the Central Valley to create better health access to our communities. Clinical clerkship and Graduate Medical Education opportunities are essential to providing valuable training and mentorship for medical students. Today’s physicians that invest time in training the next generation of physicians will enjoy having peace of mind that their patients will be in good hands when they retire. They can take pride in knowing they have made a positive and lasting impact on a new physician that will propel the medical profession forward and provide for a healthier community. Physicians that are interested in the opportunity to help educate and train medical students are encouraged to join the on-campus faculty team or become a clinical preceptor. Visit osteopathic.chsu.edu for more information.



Fall 2020


Maria Melgarejo


“My parents are immigrants and worked in agriculture. We grew up really poor and I would go to the fields with them and see the physical toll that farming and hard labor takes on your body. I saw malnourished and injured workers and remember how difficult access to health care was. There were only one or two clinics that were open and the wait lines were long, so many had to use the emergency room as primary care. Having to wait there for hours to get treated for something like a cough, sore throat or ear pain didn’t make sense. So that's really what motivated me to want to give back to the community and become a physician, especially to serve the Latino population and low income areas to make an impact in a small town like Sanger.”

Fall 2020



Matthew Lansman


“I grew up in a single mother household, and my mom was diagnosed with breast cancer. Seeing her go through treatment was a very scary experience, she lost her hair, she was vomiting, and a kid I didn’t know what to do. I had to take care of my younger sister, I’ve only got one parent and don’t know what will happen if I lose her. When my Mom had surgery at Clovis Community, I remember meeting her surgeon and she knew I was worried and scared. The way she reassured me and made me feel better was incredible and I felt an overwhelming sense of relief when she was taken back to surgery. That surgeon made such an impact on me that I thought when I grow up, I want to help other people in this same situation.”



Fall 2020

Carter Muajmoo Yang Hometown: Sanger, CA GRADUATED FROM UC DAVIS

“I am a Hmong American and my family are Hmong refugees from Laos due to the Vietnam War. My family came to the United States in 1979 and my grandfather named me after Jimmy Carter, who was President when they came to the United States as a way to honor this nation and to mark their new life as refugees in a foreign land. One of the many reasons why I wanted to go to medical school was because of my paternal grandmother’s sacrifice. When she gave birth to my father, she passed away 30 minutes after giving birth due to a retained placenta. Because of the lack of medical care in the jungle of Laos, she bled to death. As a result, my father was raised as a motherless orphan. My father survived on mashed rice as nourishment and hope. This story is my inspiration to live my grandmother’s legacy. I am very excited to start medical school at California Health Sciences University. I am the second eldest of ten siblings and the first one in my family to pursue medical school. There is a large Hmong population in Fresno, Clovis and Sanger so I would like to stay local and serve my community here as a physician.”

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Fall 2020


T W O - M O N T H S U P P LY O F F R E E P P E TO MORE THAN 300 FRESNO AND MADER A PHYSICIANS Since the onset of the COVID-19 pandemic, lack of personal protective equipment (PPE) has compounded the hardships for medical practices and hindered their ability to provide care for Californians. To alleviate the strain on practices and improve patient access to care, the California Medical Association (CMA) mobilized with its local county medical societies, the state of California and Altais to bring more than 40 million pieces of PPE—including medical-grade masks, gloves and gowns— to physicians free of charge, so that they can safely provide care for California residents. From the beginning, the need was urgent, and the demand was clear. CMA jumped into action, reaching out to California’s Office of Emergency Services to see what it would take to quickly get PPE into the hands of physicians. The result was an unprecedented project—in both scale and complexity—requiring an exceptional level of logistical planning, execution and collaboration between CMA, local county medical societies and several logistical partners. This was an entirely new operation for CMA, setting up a statewide distribution system for essential equipment that the state of California was struggling to get into the hands of physicians who desperately needed it. The CMA team, led by Mike Steenburgh—vice president of membership, marketing and component relations—got to work, rallying county medical societies and reaching out to Pride Industries, a Roseville-based non-profit that specializes in supply-chain management. Together, they established a statewide distribution network that took materials from state warehouses, repackaged them into individual kits for medical practices and loaded the material on trucks to be distributed at dozens of drive-through events across the state—sponsored by health care services company Altais.

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On Thursday, August 6, 2020, the PPE distribution event was in Fresno and CMA staff arrived early to the parking lot at People Church and unload the dozens of pallets of PPE and equipment necessary to ensure a safe and effective drive-through event. Soon after our volunteers began to arrive onsite to help complete set up. Hours before the events even began, cars started lining up by the dozens as physicians who had been up against insurmountable supply chain issues could hardly believe there would be enough PPE to fulfill the need. Each box distributed included 1,600 nitrile examination gloves, 320 N95 respirators, 90 isolation gowns, 40 face shields and 800 surgical masks. In addition to a box of PPE, physicians were given a 20-bottle case of 500ml hand sanitizers, when available. Although the thousands of PPE kits will not permanently solve PPE issues for medical practices, the infusion of a roughly twomonth supply of masks, gloves and gowns was welcome relief for thousands of physicians who simply could not secure the equipment they needed through traditional channels. Nearly 10,000 boxes of PPE were handed out at drive-through distribution events, and more than 6,600 boxes were directly shipped to practices who needed equipment but could not attend their local events. Event teams worked tirelessly in an assembly-line fashion checking reservations, guiding traffic, loading PPE and thanking physicians for their hard work. At roughly 45 lb. for a box of PPE, volunteers loaded nearly half a million pounds into physicians’ cars over three weeks, sometimes loading for a near full eighthour day in 100+ degree weather.

Fall 2020

When asked what this means to them, time and time again physicians relayed the hardship of trying to scour the internet for PPE, often paying exorbitant prices for miniscule amounts, if they can even find it, just to keep enough on hand to stay open on a day-to-day basis. “Amazing,” “necessary” and “grateful” were among the words that resounded from event to event. In Fresno and Madera Counties alone, the Fresno Madera Medical Society distributed over 300 boxes of PPE. That means $1,500,000.00 worth of PPE was given to physicians, at no charge to them, to jumpstart and restart efforts to provide care to the residents of the Central Valley. “To say that physicians and health care are essential at this time is an understatement, and PPE is an essential part of their ability to administer care,” said CMA President Peter N. Bretan, Jr., M.D. “CMA and its county medical societies are proud to work with the state to ensure that physicians of California can keep their practices open, and keep themselves and their patients safe.” CMA and Fresno Madera Medical Society remain committed to distributing PPE to our physicians in the central Valley. Remaining surplus is being shared with medical groups who did not qualify under the parameters of the initial program—which was limited to practices with fewer than 50 providers—and are struggling with securing adequate PPE supplies or experiencing financial hardship because of the increasing costs of PPE. Interested groups can contact CMA at memberservices@ cmadocs.org to learn more.





Fall 2020

Connecting Mind, Body and Soul in 2020 BY MANISHA MITTAL, MD

We live in uncertain times more now than ever before. A few months ago, I could plan holiday travel, flying from Semana Santa to Seville, Spain while squeezing in a quick visit to an old friend in Zurich. I answered emails and, worked on presentations in flight to make up for time off before heading home. Yes, we lived in a perfectly cushioned, comfortable and luxurious lifestyle, with the world at our fingertips. Or at least we believed so. What has ensued in the past several months exposed that. The assumed holiday ironically only added to a more sympathetic response: flight or fright reaction. In short, we are in fact living in a bubble that will burst one day and awaken us. Perhaps 2020 is the year. For so many, 2020 has been the year of a pandemic nightmare, hatred, depression, environmental failure, and an unveiling of our racist darkness. Or, if you clear your glasses, this is the year of a reality check, self-reflection, awakening and enlightenment. This is the tipping point, a window of opportunity for the whole world to come together to reflect and make evolutionary progress for our planet and mankind. The COVID-19 pandemic, with its high mortality rate and ease of spread, has brought our lives to a standstill, partially halting our pollution of Mother Earth. It has allowed Mother Nature to recover partially from all the pollutants we callously dumped on her. They can breathe in Beijing now, but the U.S. is burning with our divides on race, culture, and politics. The pandemic has exposed so many of our environmental and socioeconomic failures. Yet there is hope that together we shall overcome. We can bridge the gaps and rise again from the ashes.

Fall 2020

Dear readers, this is a golden opportunity to reinvent yourselves. You have within you an unbounded eternal energy to bring wellness, peace and harmony to yourself and your surroundings. The best way to harness this energy is to connect with your inner self. How? I encourage you to dive in re-enliven your mind, body and soul connection to balance your physiology and health. The inner bliss that comes with this is unparalleled to any beach, mountain, park or promotion. This is a window of opportunity for the whole world to harness our inner potential, for the virus does not ask your culture, your country, your race, your language, it talks to your immune system. As a rheumatologist and practitioner of holistic medicine, I can tell you no two individuals with autoimmune disease respond in a similar fashion. Your body, genetics, environmental exposures and thoughts are unique. You are your best friend and only you are able to balance your physiology. There is not a single diet that can work for all. Modern medicine, even with its fragmented approach, agrees with the concept of connecting mind, body and soul. For instance, practicing meditation helps you transcend the confines of the mind, body, and senses, and connects you directly with your soul. Meditation is your inner pharmacy which, when awakened, does all the self-repair and healing. This is your inner pharmacy which, when awakened, knows all the self-repair and healing. Each and every cell in your body has that inner intelligence to correct any mitotic aberrant activity. This inner silence calm is your faith, your religion, your culture, your race, and when fully enlivened, it awakens to cosmic consciousness where every soul is united as one. As is said in the Mahaupanishad Vasudhaiva Kutumbkam, “The whole world is one family.”’




Becoming a Member Top 10 reasons why you should join today. When you become a member, you support your local medical society and hire CMA, a powerful professional staff to protect your profession from legal, legislative, and regulatory intrusions. Below are the top 10 reasons to be a member of Fresno Madera Medical Society (FMMS) and the California Medical Association (CMA).

1. Protect MICRA CMA staunchly defends the landmark Medical Injury Compensation Reform Act (MICRA) year after year, saving each California physician an average of $75,000 per year in professional liability insurance premiums.


2. Collaborate with Colleagues FMMS bring together physicians from all over the Valley, from different specialties and modes of practice to develop strong unity through leadership, collaboration, socials, educational events, and community service.


Fall 2020


CMA was founded in 1856 by a small group of physicians who knew it was their duty to fight for their patients and for their profession.

3. Stay in the Know FMMS publishes the quarterly magazine, Central Valley Physicians, as well as CVP Podcasts for physicians, as a way to stay up-to-date with current events that affect medicine in the Valley. In addition, CMA produce publications to keep you up-to-date on the latest health care news and information affecting the practice of medicine in California.

4. Shape the Future of Medicine Through aggressive political and regulatory advocacy, CMA and its county medical societies are positioned among the most

influential stakeholders in the development and implementation of health policy. In addition, members receive direct access to our state and national legislative leaders to influence how medical care is provide today and in the future.

5. Save Money There are several ways to save money when you are a member. Discounted health insurance for you and your staff, automatic 5% savings on workers’ comp insurance, CME and Online educational courses, auto and home insurance, car rental, office supplies and much more. >>


Contact CMA’s Member Service Center at (800) 786-4262 or memberservice@cmanet.org.

Fall 2020




Ask yourself who will have the most impact on the way you practice “medicine - the government, or physicians in organized medicine through CMA? Be involved or be left behind. ” - J. Brennan Cassidy, M.D.

6. Get Paid Members receive one-on-one assistance from CMA’s reimbursement experts, who have recouped $28 million from payors on behalf of CMA physicians in the past nine years.

7. Continuing Medical Education FMMS provides opportunities to further your knowledge with Continuing Medical Education. CME symposiums and virtual events are provided throughout the year with current topics that relate directly to your patient care. Learn from the experts and hear from recognized speakers.

8. Education and Training for Your Practice FMMS provides monthly Medical Managers Forum to arm your office staff with practical information and tools to overcome

new challenges in healthcare, run the office successfully and move your practice forward.

9. Lead by Example FMMS and CMA provide many opportunities to get involved, including opportunities to volunteer; serve on a committee, council or board; and shape the future of the medical profession and giving back.

10. Together We Are Stronger Together we stand taller and stronger as we fight to protect patients and improve the health of our communities. We are a dominant force in health care – but all the great work we do wouldn’t be possible without the support of members like you. Fresno Madera Medical Society was founded in 1883, as the first professional organization in Fresno County. Chester Rowell, MD, and a small group of physicians created the organization two years before the city of Fresno was incorporated, and formed the cornerstone of organized medicine in the area. Today, Fresno Madera Medical Society has over 1400 physician members working together to provide care to Valley residents.

Christina Maser, MD, FACS Associate Clinical Professor, UCSF Medical Director, University Surgical Associates • Member since 2006

QUESTIONS? Contact FMMS at (559) 224-4224 ext 118 or CMA’s Member Service Center at (800) 786-4262. 43


Fall 2020

PPE Relief The California Medical Association and the California Office of Emergency Services distributed more than $80 million worth of personal protective equipment (PPE) free to nearly 15,000 practices in California.*


36 Events

Physicians Served

Over 15 Days

Boxes Distributed


in person

PPE Distributed

15 Million

Examination Gloves

40 Million Pieces



by mail

1.4 Million


Isolation Gowns

Bottles of Sanitizer

6.5 Million

1.5 Million

15 Million

N95 Respirators

Face Shields

Surgical Masks

Value of PPE Distributed

Items per Box 1,600 Nitrile Examination Gloves 800 Surgical Masks 320 N95 Respirators 90 Isolation Gowns 40 Face Shields

Practices Reached


Per Box

$5,000 Total

$80.6 Million Volunteers

Over 1,000

*Distribution is ongoing and these numbers are accurate as of September 1, 2020.

Fall 2020



COVID-19 is taking a toll on medical professionals. Let’s invest in their well-being.


“She tried to do her job, and it killed her.” That was the heartbreaking eulogy offered by the father of Dr. Lorna Breen after the Manhattan emergency room physician took her own life earlier this week. Breen was the medical director of the emergency department at New York-Presbyterian Allen Hospital and treated dozens of COVID-19 patients. She had no history of mental illness, but her family said Dr. Breen, who survived COVID-19 herself, was traumatized by devastating scenes of treating patients with the disease – stories she shared with her family in her final days. News of Dr. Breen’s death sent shockwaves through the medical community, and received national attention, but for many in the medical profession, it is an all-too-familiar story. Even before the COVID-19 outbreak, burnout has been a growing concern among physicians, nurses and other medical practitioners – one that is taking its toll on those who take care of us. Rates of suicide, depression and substance abuse are higher among physicians and nurses than among the general population. A recent report by the American Psychiatry Association found an estimated 300 to 400 doctors kill themselves each year. That’s about 40 of every 10,000 physicians – a rate more than double that of the general population. To help address the factors that create and cause burnout for health care professionals, the California Medical Association



has partnered with the Service Employees International Union and the United Nurses Association of California to push for state funding to support Care 4 Caregivers Now. This new initiative has already trained dozens of physicians and nurses as practice coaches who are available to offer guidance and mentorship to their colleagues on the front lines of this crisis and other health care workers facing stress or burnout. Coaching is a nonjudgmental, engaging, caregiver-centered way of providing emotional support to talk through these difficult times. While not a substitute for therapy or medical care, coaching has been demonstrated to provide several benefits, including relief for emotional exhaustion and reduced levels of self-reported burnout. Coaching is a recognized method of creating resiliency within the healthcare workforce, helping physicians and nurses cope with the unique mental health challenges workers are facing in the current crisis. In addition to horrifying accounts of people effectively suffocating to death – many of them dying alone because of strict quarantine protocols – physicians and nurses also have to worry about getting sick themselves and potentially infecting their colleagues and family members. According to her friends, this was part of what weighed on Dr. Breen before her death. We should not let the death of Lorna Breen be in vain. We should use it as a rallying cry to highlight the need for wellness services for medical practitioners and to ensure stories like this do not happen again.

Fall 2020

Investing in wellness now can pay dividends for health care providers and the patients who depend on them. As California spends money on protective gear to protect the physical wellbeing of healthcare workers, we are imploring Gov. Gavin Newsom to invest in the well-being and mental resiliency of those on the frontline protecting public health. While we all hope the COVID-19 outbreak will soon pass, we know this pandemic will have lasting impacts will have on our health care system. The horror and stress of treating patients during this time will only exacerbate the problems of burnout, depression and anxiety among physicians, nurses and other medical providers. The COVID-19 crisis has taxed the limits of our health care system. Our clinicians, who have risen to the challenge, are facing unprecedented risks, including physical safety, significant disruptions in social support, moral dilemmas and emotional distress.

Fall 2020

Understanding their fears and anxieties is critical to meeting the needs of our clinicians. Investing in their well-being will help keep nurses, physicians and other medical professionals on the front lines, and ensure they are getting the care they need as they continue to care for all of us. Emily Coriale, PharmD, is Chief Operating Officer of the California Medical Association’s Wellness Program. David C. Logan, PhD, is Chief Executive Officer of the California Medical Association’s Wellness Program.



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

BENEFIT Automobile & Homeowners Insurance CAP Cooperative of American Physicians

Car Rentals

Save up to 8% more.

CONTACT Mercury Insurance Group (866) 602-5259 www.mercuryinsurance.com/cma

Member discounts on malpractice protection, risk management and practice management.

Albert Malasig (650) 543-2185 www.CAPphysicians.com

Save up to 25% on car rentals for business or personal travel.

Avis (800) 786-4262 www.cmanet.org/groupdiscounts

Classified Ads

Free classified ads in Central Valley Physicians Magazine

Resiliency Consultations

3 Free, anonymous resiliency consultations yearly through Joy of Medicine Program

Roubicek and Thacker 559-323-8484

FMMS is an accredited provider for Continuing Medical Education providing free and low cost seminars for members.

FMMS: (559) 224-4224 www.fmms.org

Confidential support and assistance to physicians affected by substance abuse, or an emotional or physical problem.

CMA: (650) 756-7787 https://www.cmadocs.org/confidential-line

Discount on hourly consulting fee for practice assessments, valuation, brokerage, partnerships, etc.

Practice & Liability Consultants (415) 764-4800 www.practiceconsultants.net

Driving Emblem

CHP approved emblem provides physicians expemption from speeding laws when en route to an emergency

FMMS (559) 224-4224

Human Resource Services

20% discount plus free consulting calls with HR Business Partner package

Sierra HR Partners, Inc. (559) 431-8090 www.sierrahr.com

Discounts on medical, workers’ comp, dental, disability, long-term care, level term life & business overhead expense.

Mercer (800) 842-3761 www.mercer.com

Free tool kit on quality measures & online tool to create custom MIPS plan.

FMMS (559) 224-4224

CME Seminars

Confidential Hotline

Consultancy Services

Insurance MACRA Assistance 47


FMMS: (559) 224-4224

Fall 2020



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Physician wanted to share call at Clovis Community Medical Center. Join hospitalists Dr. Myint Zaw and Dr. Mylea N. Wiley in clinical rotations. For more information email Dr. Wiley’s email at nichole323@aol.com



Looking for a doctor to share my office space in Clovis, two exam rooms available and the cross streets of the practice are Shaw and Fowler, please call for more information (559) 593-6467

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



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For Sale - If interested, call 559-432-8852

File Folder Shelving – End Tab Filing – Letter sized Two extra-large record folder-shelving units in excellent condition. That hold letter-sized files. Removable file

dividers included. The shelving units have the following measurements:

One sided extra large shelving unit: 9”x 60”x 80” Three 36 in. sections, Two 24 in. sections for TOTAL LENGTH of 160 in.

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Lateral Files - Two horizontal letter-sized lockable file cabinets each with five sliding shelves. Each cabinet has the following measurements 15”x36”x62” Shelves 10.5”x 15”

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Public Health



When we set out to write this article, our intent was to briefly discuss the impact of COVID-19 on our kids. But then along came the wildfires, a natural disaster of another kind with profound impacts on our kids, their health and the health of their families and communities. We have included some comments about the wildfires in the context of this COVID-19 pandemic.



At this point, it seems that every adjective to describe COVID-19 has been used---unprecedented, fast-moving, unlike anything we have seen in a century. All of those words---and more---continue to apply to COVID-19 and our response to this pandemic. Our understanding of the disease as medical professionals is changing almost daily and guidance from the Federal and State agencies is changing almost as often.

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And, in many ways, those same adjectives apply to the recent wildfires that have devastated our own mountain areas as well as dozens more across our State, Oregon, Washington, and beyond. But here is what we know for certain when it comes to children and COVID-19:

Children are not immune to COVID-19.

From an August 11, 2020 article in the Journal of Pediatric Infectious Diseases, “children comprise a small proportion of overall COVID-10 cases at 5.2% of laboratory-confirmed infections in the U.S.” Despite an ongoing narrative questioning the impact of COVID-19 on kids, children can contract the virus, become very ill, and some will not survive. Valley Children’s has administered nearly 14,500 COVID-19 tests to our patients as of September 14, 2020 with a positivity rate of 8.8%. Since the start of this pandemic, approximately 170 children have been hospitalized at Valley Children’s with COVID-19, and a third of them were hospitalized solely for COVID-19. Sadly, we have experienced one fatality from the virus.

A specific pediatric complication is Multisystem Inflammatory Syndrome (MIS-C) which can follow COVID infection and is

characterized by high fevers and may affect other body systems, including the heart, lungs, kidneys, brain, skin, eyes or gastrointestinal organs. This will almost always result in severe enough disease for the child to be hospitalized, often needing intensive care, and some children have died from that condition. We have treated a number of children who have met the criteria for MIS-C during this pandemic.

Children with underlying health conditions---just like adults---are a special concern, as well as kids with complex medical conditions. The rates of

childhood asthma, diabetes, and obesity, as examples, are very high in our communities and put children at increased risk for severe disease should they acquire COVID. Children with complex conditions such as cystic fibrosis, metabolic syndromes and genetic syndromes are also at increased risk.

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Children can transmit COVID-19. Studies

at leading universities in this country and around the world have demonstrated that kids can transmit the virus. Headlines from summer camps in Georgia to school re-openings---and then closings---across the country demonstrate the risk of transmission between and among kids and the adults caring for them.

COVID-19 transmission can occur anywhere. Many families have expressed concerns about

visiting their pediatrician or coming to the hospital for fear of being exposed to the virus. Families need to be alert to the risk in the community and among their extended family. In many ways, families are safer in healthcare settings where every precaution for our visitors, patients, families and staff are employed. No family should risk future health consequences by delaying a visit to their physician or an Emergency Department if needed.

COVID-19 is having an impact on potential increased future vulnerability for other childhood diseases. The Centers for

Disease Control and Prevention (CDC) is reporting fewer childhood vaccines being administered during this pandemic as compared with January-April 2019. (www.cdc.gov) In addition, the CDC continues that “the identified declines in routine pediatric vaccine ordering and doses administered might indicate that U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases.” Routine immunizations and well child checks for infants are particularly important.

There currently is not an effective oral treatment or a vaccine for COVID-19. The

best way for children, their families and for all of us is to protect ourselves is by social distancing, masking, and good hand hygiene. Remdesevir has been of benefit to some patients, and we have used it to treat patients at Valley Children’s.

The impacts of COVID-19 extend beyond the physical consequences and its psychological impacts are significant concerns, as well---for all kids and particularly for school-age children whose traditional ‘back to school’



experiences have been disrupted by the pandemic. As with all significant events in a child’s life, there are some key principles to keep in mind:

• Children and teens react, in part, to what they see the adults around them doing/saying. When parents/guardians deal with COVID-19 calmly and confidently, that is the best support they can provide for their children. • Watch for behavioral/emotional changes in children and teens. Not all children respond to stress in the same way (nor do adults). If families are unsure or worried about their kids’ emotional health, encourage them to reach out to their child’s teacher, school psychologist, pediatrician, pediatric psychologist, or others. Ask for help.


6. 7.

• Limit the family’s exposure to news coverage, particularly social media.


• Make sure that children can spend time with parents/guardians or other family members doing meaningful activities (besides school) e.g., cooking, playing board games, talking with grandparents or other relatives so that they know they are safe, etc.). As if COVID-19 wasn’t enough, then came the Creek Fire. Another unprecedented event, this wildfire has provided further disruption to our lives---from those displaced by the fire to all of us dealing with declining air quality levels in the Valley. From a health perspective, layered on top of the ongoing concerns around COVID-19, we offer the following suggestions, useful for all of us but particularly important for children with asthma, cystic fibrosis or other pulmonology issues:



• Reassure children that they are safe and that as the adults in their lives, we will make sure they are safe. Let them know it is okay if they feel upset or worried.

• Try to keep a regular schedule with regular routines. For school-age children, the ‘virtual’ return to school, while bringing its own challenges, can help with this.

1. 2.


Stay indoors as much as possible. Keep children indoors with the doors and windows




closed. Use your “clean room”. If you have an air conditioner, run it with the fresh-air intake closed to keep outdoor smoke from getting indoors. Use your portable air cleaner as well. Reduce health risks by avoiding strenuous activities. Regularly check air quality at www.valleyair.org for daily air quality forecast. Wait until air quality improves to begin outdoor activities. Although it is important to keep wearing a cloth mask to protect you from COVID-19, a cloth mask will not protect you from the harmful effects of ash and smoke. N95 masks are best for protection from smoke and ash but are not available in pediatric sizes. It is best to stay indoors until air quality improves. Children should not participate in ash clean-up work as their lungs are more susceptible to airway toxicants. Environmental exposures can alter immune function and lung mechanics in at- risk populations, including children. Keep a 7-10 day supply of medication on hand. Call the doctor if your child has trouble breathing, shortness of breath, a cough that won’t stop, or other symptoms that do not go away. Call 9-1-1 or go right away to an emergency department if your child has significant difficulty breathing, is very sleepy, or refuses food and water. If your child has asthma, allergies, or a chronic health condition, he/she is at high risk from health effects related to wildfire smoke and ash. Be even more cautious about his/her exposure to smoke, and seek medical advice as needed. For children with asthma, follow the asthma action plan. If you are at risk for evacuation, make sure you have a supply of the child’s essential medical equipment ready to go. And if evacuated, please do not return to your house until you have been told to return by local authorities.

The healthcare system in our region is strong, prepared and very skilled in caring for all that comes our way. Our physician partners are often the first-line contact for families worried about their children. Valley Children’s Healthcare stands ready to partner with you as we all work to get through these dual challenges together. For more information: www.valleychildrens.org/covid19 https://www.valleychildrens.org/media-center/wildfiresafety

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In Memoriam

In Memoriam ANTHONY HORAN, MD Anthony Harding Horan, 80, died of cancer Aug. 13, 2020, at his home in Fresno, Calif., with his wife, Marcia Morrison, and son, Frank Horan, by his side. Tony was born in New York City to Francis Harding Horan and Elizabeth Rogers Horan in 1940. He spent his early years in the city and in Cornwall, where the family had a house. He attended St. Bernard’s, St. Paul’s, Dartmouth and Columbia University College of Physicians and Surgeons. He spent two college summers pumping gas and fishing at Yellowstone National Park. During the second summer, he and his twin sister, Elizabeth, summited the Grand Teton on a guided climb. His climbing career peaked in 1967 when he was chosen as the expedition MD on the first American ascent of Mount McKinley’s Cassin route. Despite the fact that their climb took place during the largest storm in North American history, all 14 expedition members reached the summit. While in medical school at Columbia in 1962, Tony worked as a technician on a summer project for Roger Guillemin, MD, and Andrew Schally, Ph.D. Fifteen years later, that project earned Guillemin and Schally a Nobel Prize for the structure of luteinizing hormone releasing factor. Tony also spent five months on research at the Weizmann Institute in Israel. Rather than pursuing a Ph.D. career, Tony aspired to become an MD scientist like his grandfather, John Rogers Jr., who graduated from Columbia P&S in 1892 and became a pioneer in the treatment of thyroid disease. After graduating from medical school, Tony completed a general medicine internship and a general surgery internship at St. Luke’s Hospital, followed by a urology residency at Columbia Presbyterian Medical Center, both in New York City. His training was interrupted by the Vietnam War and he served as an Air Force general surgeon in Cam Rahn Bay during the Tet offensive of 1967-1968. During his urology residency, Tony performed the first voluntary vasoligation ever performed at Columbia Presbyterian on a charity patient. He won first prizes for papers on human spermatozoa motility before establishing a private practice in New York. In the 1980s, Tony joined the VA system as a urologist in

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Walla Walla, Wash., and later transferred to the Veterans Hospital in Fresno. While at the VA, he published a paper on mean time to death from prostate cancer, which contested what he considered a world-wide epidemic of radical prostatectomies. This topic was the subject of his 2009 book, “The Big Scare,” which was revised and republished in 2017 as “The Rise and Fall of the Prostate Cancer Hoax.” After retiring from the VA system, Tony established a private practice in Evanston, Wyo., and later in Delano, Calif., where he had the opportunity to aid many adult and pediatric patients with untreated congenital malformations. He contributed to medical science for 30 years as an active member of the Western Section of the American Urological Association, during which he gave 59 conference presentations and had 49 peerreviewed publications. Tony was a surgeon and he was also an artist. He was a member of The Century Association of New York, where he exhibited paintings, and he joined community chorales in Walla Walla and Fresno. He and his wife, Marcia Morrison, were avid backpackers in the Western U.S., particularly in the Sierra Nevada. During the winter, Tony loved skiing, both downhill and cross-country, with any family members who could keep up with him. Until his last months of life, Tony enjoyed tennis, golf and reading Thomas Piketty’s “Capital in the Twenty-First Century” in French. In addition to his wife, he is survived by his son, T. Bramwell Welch-Horan, MD, and daughter-in-law, Jessica Merrill Horan; his grandchildren, Charlie, Oliver and Phoebe Horan of Houston, Texas; and his younger son, Francis H. Horan of Fresno. He is also survived by his brother, John Rogers Horan, and sister, Honora Horan, of Washington and Cornwall, respectively; and his twin sister, Elizabeth Horan Edgerly of Rhode Island.



In Memoriam

In Memoriam ROBERT ALLEN SHANKERMAN MD, Dr. Shankerman age 58, of Fresno, California passed away on Saturday, September 19, 2020. Robert was born April 10, 1962. Robert Shankerman was the chief medical officer at United Health Centers of the San Joaquin Valley, in charge of all of the doctors at its medical facilities. Shankerman spent five weeks battling the novel coronavirus, including two weeks in the intensive care unit at St. Agnes Medical Center before passing away Saturday, September 19. He was 58. “His death is a significant loss to the entire UHC Community, including his colleagues, coworkers and friends who are now grieving his loss,” UHC said in a news release. It was not immediately known how the longtime doctor contracted the virus, though his brother said Shankerman sometimes saw patients who were suspected of having COVID-19. Shankerman had been UHC’s Chief Medical Officer since 2014, responsible for clinical operations at 21 health ceters in the central Valley. UHC serves more than 125,000 patients as their primary health care in Fresno, Kings and Tulare counties. Many of his patients were migrant workers. “He dedicated his entire adult life treating people who were part of underprivileged communities,” said the doctor’s brother, Stephen Shankerman. “He worked 14- to 15-hour days. When people didn’t show up for work, he volunteered. “He played hero till the very end.” Shankerman received several high ratings for his services and care based on various online reviews, including 4 1 ⁄2 stars (out of 5 stars) on Webmd.com. Among his accomplishments at UHC since 2014 was establishing the UHC/UCSF Family Practice Residency Program at the Parlier Health Center, where Shankerman also saw patients twice weekly. Shankerman recruited, trained and placed medical practitioners as the organization transformed and expanded from 12 to 21 health centers in 2020. “As a voracious reader and student of current medical practices,” UHC said of Shankerman, “he was educator, mentor and tutor to 155 medical professionals, including recent graduates from numerous residency programs, national and international transfers and those senior members of the UHC medical staff.” UHC also described him as a “passionate and vocal advocate for taking appropriate preventative safety measures related to contracting the virus.” “He quickly implemented numerous protocols and practices across the organization to protect staff and patients alike,” UHC said. Shankerman received his medical degree from Tulane University and his post-graduate education from the Mayo Clinic in Rochester, Minn. The Mayo Clinic has annually been ranked on the nation’s best hospitals honor roll. Shankerman was previously affiliated with the UCSD Medical School in San Diego as associate clinical professor of medicine and previously served as chief medical officer for Clinica Sierra Vista. He was a diplomat for the American Board of Internal Medicine and certified as an HIV specialist. In 2001, Shankerman received the Physician Recognition Award from the American Medical Association. He is survived by his father, Floyd Shankerman: sister Cindy Loewenberg; brothers Steven Shankerman and Jason Shankerman; and life partner, Regis De Barros who is also a physician with United Health Centers. Dr. Shankerman was a member of the Medical Society for 11 years.



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In Memoriam

In Memoriam ALLEN MAU, MD Allen passed on September. 1, 2020 after a 12 day battle with Covid-19. He was born on December 9, 1928 in Honolulu, Hawaii, and was the son of Allen S. Mau and Winifred C. Mau. He celebrated his 13th birthday watching the attack on Pearl Harbor from the roof of his family home. He graduated from Roosevelt High School and attended the University of Hawaii for two years and then transferred to the University of Michigan and graduated from UM Medical School in 1954. Allen then took a rotating internship at the Cook County Hospital in Chicago and entered the USAF in 1956. He served at the USAF 5th AF hospital in Nagoya, Japan, followed by a year at Hickam AFB in Honolulu. Following his discharge he moved to Fresno and opened a family practice. He served on the staffs of Saint Agnes Hospital and Fresno Community Hospital, and was Chief of Staff at Fresno Community Hospital in 1971. He was a diplomat of the National Board of Medicine, a recipient of Family Board of Medicine, and a lifetime member of the California Academy of Family Practice. After his retirement from active practice in 1995 he continued to do volunteer work at the Poverello House Clinic. He is survived by his wife, Jeanne Lee Lowe and her children Larry, Lester (Vicky), Linda (Kerry), his daughter Alyson Lee (Bert), his son, Allen D. Mau, and his beloved cat, Runt. At this time there will be no public memorial service. Following cremation, ashes will be interned in Honolulu, with his father (after 85 years), his mother (after 40 years) and his sister, Gladys Wee Evenson (after 6 months). Dr. Mau was a member of the medical society for 49 years.

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