Central Valley Physician Spring 2019

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Spring 2019

GENDER PAY GAP CONTINUES TO WIDEN What’s Your Next Move? 7 Million In Grants To Fresno County Match Day

NOT ALL HEROES WEAR CAPES‌ SOME WEAR DOCTORS’ COATS Your priority is protecting your patients. Our priority is protecting you. For more than 40 years, the Cooperative of American Physicians, Inc. (CAP) has provided our physician members with superior medical malpractice coverage. Our mission is to help independent California physicians deliver the best care possible, while realizing personal and professional success. Sarah E. Pacini, JD Chief Executive Officer

CAP members also receive proactive risk management services, in-house legal and claims support, practice management resources, and so much more. Find out what makes CAP different.

CAPphysicians.com 800-252-7706



Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code. Spring 2019



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From The Executive Director

MEMBERSHIP DOLLARS GAVE BACK $7 MILLION TO FRESNO AND MADERA COUNTIES Recently the California Medical Association and Physicians for Healthier California (CMA’s Foundation) granted $38 million to GME programs in California. Fresno and Madera Counties received over $7 million of that funding. Every primary care program received funding, as well as UCSF Fresno’s Emergency and Obstetrics programs.

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

These funds were part of the $1 billion the California Medical Association successfully secured through the California state budget to improve provider payments and graduate medical education. Despite the voter-approved tobacco tax (Proposition 56) that were being earmarked to improve provider payments, Governor Jerry Brown attempted to redirect the tobacco tax revenues to support the State’s General Fund obligations. Restoring these funds was CMA’s main priority, and they were successful in getting those funds allocated towards the intendent purpose, which included $40 million in GME funding.

Christine Maser, MD, Katayoon Shahinfar, MD Nadarasa Visveshwara, MD, John Moua Pamela Kammen, MD, Ravi Rao, MD, Jai Uttam, MD Jessica Vaughn (Resident Board Member) CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS EDITOR Farah Karipineni, MD

If you are a member of CMA and the Fresno Madera Medical Society (FMMS), we have you to thank for the funding. Your membership dollars allowed CMA to work on behalf of the 44,000 members to support physician-led advocacy from legislation and policy-making to regulatory, those dollars supported another year of high-achieving milestones and accomplishments for the practice of medicine.


Just imagine what could be done if we had more members in the state! The reality is Fresno and Madera has about 60 percent market penetration when it comes to total number physicians in the two counties. Kaiser, our largest group, has 100 percent membership, which tells me that they see the value, and what we can accomplish legislatively for physicians in the state of California.

Nicole Butler, Trilok Puniani, MD, Alan Birnbaum, MD

ASSISTANT EDITOR Don Gaede EDITORIAL COMMITTEE Farah Karipineni, MD - Chair Roydon Steinke, MD, Cesar Vazquez, MD

Having only 60 percent membership says we have some work to do. How do we get members to join when they receive the benefits of our advocacy either way? We remind them how important those membership dollars are to the profession, to the future of healthcare and remind them what medicine would look like in the state if we had not been successful. If you are a practicing physician, see Medi-Cal patients, and are receiving the Prop 56/Tobacco tax bonus funding, ask yourself why you are not a member. If you don’t see Medi-Cal patients you may still be receiving other benefits that CMA has accomplished on your behalf. CMA defeated the AB 3087 commission to set prices on your profession, and defeated the $400 billion SB 562 single-payer system. CMA also led successful efforts to have Anthem and HealthNet rescind and delay Modifier 25 cuts, and -- most importantly -- led the campaign to fight against Prop 46, which would have drastically increased the cap on malpractice damages. Join today and be apart of the movement that drives the success of your profession and provides resources, goods, and services to physicians like you.

Alya Ahmad, MD FAAP CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Cesar Vazquez, MD, Trilock Puniani, MD Don Gaede, MD Erin Kennedy, Nicole Butler, Jennifer Seita Sara Goldgraben, MD, Michael C. Rubicek, PhD, LCSW Lori Weichenthal, MD, Alya Ahmad, MD FAAP CONTRIBUTING PHOTOGRAPHERS Nicole Butler, CCFMG Staff, USCF Fresno Staff CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711 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 Marketing and Events Coordinator, Kailey Fontes Receptionist, Becky Gentry

Nicole Butler



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1,000 Writing Contest! $

Do you have an inspiring or interesting story to tell? Do you have a particular ax to grind? Do you secretly yearn to become the next Oliver Sacks, Robin Cook, or Atul Gawande? Great—we want to hear from you! Whether we physicians are communicating with each other, our patients, our political representatives, or the public at large, good writing skills are invaluable. The Fresno-Madera Medical Society would like to encourage these skills. Hence, we are launching this writing contest.

Here are the rules: 1. $1,000 will be awarded to the physician who submits the best piece of writing by May 1, 2019. 2. The physician must be a member of FMMS in active practice. 3. The article should be 400 to 1,000 words long. It may be subject to minor editing. 4. The subject matter must relate to the medical field. 5. A panel of 3 physicians on the FMMS executive board will judge the contest. The articles will be evaluated anonymously; in other words, the names of the authors will not be revealed to the judges until they have chosen a winner.

You can email your article to Kailey Fontes at kfontes@fmms.org.

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Physician, Heal Thyself

At Your Own Risk

A study of U.S. surgeons showed that less than half had seen their primary care physician in the past year, and 30% did not even have a primary care physician.



My late father often repeated the adage, “Any man who serves as his own lawyer has a fool for a client.” We physicians may not represent ourselves in court, but we often try to treat ourselves, or neglect our own medical care, and end up with a fool for a patient. My uncle was a family physician who practiced in the Kenai Peninsula of Alaska. He was my childhood hero, and no doubt was the one of the reasons I went into medicine. At the end of medical school, he invited me to spend 6 wonderful weeks working with him in his clinic in Soldotna. On weekends, my wife and I would walk with him out to the airstrip he had cleared from his 80-acre homestead (“The Gaede Eighty”), climb into his 3-seat Piper PA-12 Supercruiser, and fly to remote lakes and glaciers or soar across the Cook Inlet to hunt caribou. So understandably his unexpected death of an MI at age 69 shook me like no other death ever had. My dismay was compounded when I learned that he might have survived much longer had he made the effort to get good medical care. All the details are not clear, but after he developed cardiac symptoms, he apparently declined to undergo conventional treatment, ignored the seriousness of the matter, and instead attempted to treat the condition himself. Several factors conspire against good medical care for doctors. First, we’re very welltrained in medical care, we know our own medical history better than anyone else, we have easy access to multiple drugs and diagnostic tests, so why in the world would we need to consult anyone else? I am as guilty of this practice as anyone. So far, I haven’t committed malpractice on myself, but how do I and other physicians recognize the point when this practice becomes risky and dangerous? Second, we’re very busy doing very important things--saving lives, for heaven’s sake! We work very hard, and I sense that many of us are workaholics. A GI colleague once told me that several physicians declined to take an anesthetic during their colonoscopy, so they could return to the office or operating room the same afternoon. We often don’t take the time to seek our own medical care. Between the seemingly

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endless needs of our patients and EMR documentation, plus making time for our family, friends, exercise, relaxation, and the next Warriors game, how could we possibly squeeze in enough time to see a physician? On the other hand, how can we do an optimal job of caring for patients if we ourselves do not pay close attention to our health? A study of U.S. surgeons showed that less than half had seen their primary care physician in the past year, and 30% did not even have a primary care physician. But those that had seen their physician in the past year were more up to date on their health screening, and had higher quality-of-life scores. A study of British National Health Service physicians showed that most went to work even when they were ill, and worked on days when people in other professions would be have stayed home and rested. The third hurdle we physicians face in getting good medical care is that the physician-patient relationship is different for us. If you are a physician treating another physician, you might do things a bit differently. For example, you might be reluctant to tell a colleague they need to lose weight or cut down on their drinking. You might defer doing a rectal exam. At the other extreme, in an effort to be extra-thorough, you might order a slew of questionably necessary tests. I felt some of this tension when I established care with my primary physician, so at the first visit I made it clear to him that I wanted to be treated in all ways as a regular patient, which included no courtesy privileges, and no waiving of the digital prostate exam. “Curbside consults” are easy for us to obtain from our colleagues, but obviously do not constitute good medical care. And our clinical style with a fellow physician might become too casual at times. A number of years ago while I was performing a procedure on a fellow physician, we both became engrossed in an animated conversation. Suddenly I realized I wasn’t paying attention to what I was doing, and had almost made a serious error. I subsequently adopted the “sterile cockpit” rule—no casual chit chat while performing the most critical part of any procedure, regardless of who the patient may be. For a number of years, our medical society held annual physical exam events for member physicians. Generously hosted at the Kaiser Hospital, comprehensive medical exams were performed by multiple physicians from multiple specialties. The raison d’etre of this event was to offer an opportunity for physicians to obtain a comprehensive medical exam by their peers, including lab and x-rays, and conveniently scheduled after regular business hours. The intent of this

program was noble: it enabled many physicians to receive a medical exam that they might not otherwise have taken the time to do. Plus, it was free! But this tradition also struck me as a bit ironic. If anyone can afford to pay for a medical evaluation, we doctors can. And to think that a “one-night-stand” medical exam by multiple physicians is equivalent to having a thorough exam by one’s own primary care physician is misguided--at best. Case in point: these annual doctor-doctor exams ended over 10 years ago after a lawsuit was filed over an overlooked x-ray abnormality. But let me also make clear that when we are treating another physician, we should not hesitate to make it a bit easier for them to receive good medical care. That might mean squeezing them into a busy schedule, or seeing them at lunch time or after regular hours. I have been the recipient of such generosity by my colleagues on several occasions, and try to “pass it forward” to any colleagues that I treat. Since healthier doctors can give better care to their patients, making sure our fellow physicians get good health care is a practice that benefits our entire community. “Physician, heal thyself!” is not sincere advice; it’s a taunt. Let’s discover the wisdom in this ancient phrase, and make sure we get the regular medical care that we all need. ABOUT THE AUTHOR ­ Dr. Gaede, a Fresno native, is board-certified in Internal Medicine and specializes in Vascular Medicine, with an expertise in the treatment of varicose veins, circulation problems, blood clots, and advanced techniques using ultrasound and sclerotherapy.

The Central Valley’s First Osteopathic Medical School approved to Accept Applications


The Valley’s First Medical School unveils some key features of their unique program, innovative curriculum and more. California Health Sciences University (CHSU) recently hosted an event to unveil their innovative approach to medical education for the first, four-year medical school in the Valley. Dr. John Graneto, Dean of the College of Osteopathic Medicine, provided an overview of the new campus and some key features of the buildings including a 20,000 square foot Simulation Center. The Center will house one of the world’s most advanced pediatric patient simulators, Pediatric HAL® as well as two other high-fidelity manikins from Gaumard Scientific, recognized for their innovation in simulation. Pediatric HAL® teaches the specialized skills needed to effectively communicate, diagnose, and treat young patients,

using real diagnostic and therapeutic equipment in a variety of clinical areas. The vital signs, audio/video and learner performance data was captured by SIMULATIONiQ , from Education Management Solutions. SIMULATIONiQ is the industry’s leading simulation management platform, providing seamless, end-to-end simulation curriculum and learner performance management. The CHSU College of Osteopathic Medicine is looking forward to accepting applications beginning May 3, 2019 for the fall 2020 entrance year. Construction of the first floor is complete and the foundation for the second story is being installed. The College of Osteopathic Medicine team recently went to tour the campus up close and got to sign their names on the metal beams.

A message from our President > Trilok S. Puniani, MD

A Message From The Outgoing President: Reflections on 2018 It was truly a great honor to be the President of FMMS. The year 2018 was an amazing time and a rewarding experience for me. We had a stellar group of Board Members and Committee Chairs, and I am thankful to all of them for their valuable time, support, and contributions. There have been so many accomplishments at FMMS in 2018 which were shared with you through email, “snail mail,” and print publications throughout the year. ABOUT THE AUTHOR ­ Dr. Trilok Puniani is a board certified in Neurology and Vascular Neurology, he completed is residency training at New York Medical College and Westchester County Medical Center, in Valhalla, NY and his fellowship training at Methodist Hospital and Baptist Memorial Hospital in Memphis, TN. Upon completion of residency and fellowship in Neurology, Puniani moved to Fresno in 1989 and started a private practice later joining Kaiser Permanente in 1997 where he is currently Chief of the Neurology Department.

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The Medical Society had an overall increase in our Membership by 5.9% from 2017, which is a remarkable achievement. In 2018 we had:

• 652 Active members (increase of 4.1% from 625 members in 2017) • 433 Residents • 210 Retired physicians • 1295 Members in total

Highlights of Medical Society’s Achievements

The Medical Society hosted over 30 different events in 2018. In addition, we successfully launched a podcast called “Central Valley Physicians,” which features member physicians who address various medical topics for our community. The Summer Meltdown was once again a great success for the FMMS Scholarship Foundation. The foundation awarded over $40,000 in scholarships to medical students from the valley.



The Annual PGI, Yosemite Conference, which provides CME to physicians, has been a great attraction for over 60 years. Physicians from various parts of the country attend this conference and enjoy one of America’s most spectacular national parks, with its breathtaking scenery, exquisite waterfalls, and the famous Half Dome. The Medical Society is actively involved in bolstering physician wellness and well-being programs. As you probably

know, physician burnout has reached epidemic proportions in the United States. This is a serious condition resulting from chronic occupational stress and fatigue. It is estimated that over half of all physicians suffer from burnout, manifested in the form of depersonalization, loss of enthusiasm for the profession, and cynicism. Physician burnout negatively impacts patient care. Among physicians, risk for suicide increases when drivers of underlying mental comorbidities such as depression, anxiety, and chemical dependency are overwhelming, which inevitably result in tragedy if unaddressed or not treated. With the contribution of our Wellness Committee and our affiliate Medical Society in Sacramento, we launched The Joy of Medicine Summit on December 1, 2018 at Tenaya Lodge. It was designed to help physicians navigate the stressors of life and prioritize their own well-being in order to provide better patient care while maintaining balance in their own lives. This summit was a great success, which provided for warm camaraderie and refreshing group discussions among the physicians who participated. Partnering with the California Medical Association, the physician community is recognized as a key lobbying organization in protecting the practice and profession of medicine to provide the best patient care. The CMA has played pivotal roles in:



• Defeating AB 3087 (legislation to arbitrarily cap rates for health care services) • Passing Proposition 56 (raise state’s tobacco tax) • Providing funding to support payments for physicians participating in the Medi-Cal program, medical student loan repayment, funds for graduate medical education

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A message from our President > Trilok S. Puniani, MD

• I nfluencing numerous legislative initiatives on behalf of physicians The Medical Society has business partners that provide our members with billing services; support for security and compliance needs; cybersecurity protections; medical, dental, workers’ compensation, disability, and other insurances; investment advisors; and many more services with discounted rates.

of the state. This crisis could force patients to seek medical help for routine illnesses at hospital emergency rooms instead of visiting their primary care physician. 3. Retaining and recruiting new member physicians: To seek sustained growth of new physician members and retain current physicians, the Medical Society must continue to promote high value programs which are beneficial to the physicians.

Every year, for the past 27 years, the Medical Society bestows a Lifetime Achievement Award in recognizing a physician member who has gone above and beyond the call of duty in providing for the health and welfare of our community residents during their career in medicine.

How can we move forward?

The 2018 Lifetime Achievement honorees, well-known for their compassion, dedication, and hard work were:

• Advocate for health reform and positioning ourselves to implement health policy • Ensure access to quality medical care • Promote physicians’ wellness • Prevent a shortfall of physician crisis in the Central Valley through the following: - Regulations for hospitals to hire doctors, which would provide monetary incentives for recruiting and retaining physicians - Advocacy for reimbursement rates comparable to commercial health by Medical and Medicare for primary care physicians and specialists in Central Valley and rural areas - Incentives to retain doctors completing their residency training in the Valley - Creating career pathways for students and paying stipends for education in the health field

•K enneth Bird, MD (Retired Public Health Officer for Fresno County Department of Public Health) •D avid Hadden, MD (Pathologist and Fresno County Coroner for 28 years) •H erbert Boro, MD, (Retired Infectious disease physician, Kaiser Permanente; passed away on November 4, 2018) • J esus Rodriguez, MD (Special Project Award, family medicine practitioner, Kaiser Permanente)

The Challenges

Despite our successes, we still have some other challenges. 1. The public health crisis of our time: Opioid Misuse and Addiction. In collaboration with the Central Valley Opioid Safety Coalition, the Medical Society is offering a free educational series on this issue for members in order to raise awareness of this critical issue. 2. S hortfall of primary care providers: A 2017 report from the Health Force Center at University of California, San Francisco, projects a serious shortfall of primary care doctors. The coming decades will also witness scarcity of psychiatrists, physicians’ assistants, and nurse practitioners. The Central Valley has an outsized need for doctors. Known for concentrated poverty and some of the most polluted air in the country, the Valley’s 4 million residents suffer from higher rates of asthma and obesity compared to other parts

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As physicians, we need to lead our community by working together and leveraging our partnership with the CMA through a variety of legislative and regulatory strategies to accomplish our goals:

I know that our Medical Society will continue to be successful under the leadership of Dr. Vasquez. He will bring forth new ideas and maintain our forward progress. I am excited for him to serve as the President of the Medical Society. Trilok S. Puniani, MD Past President, FMMS



ENDURANCE VS. RESILIENCY Are you thriving or just surviving? MICHAEL ROUBICEK, PHD, LCSW

To endure requires a strong mindset where you continually push your body and mind to the limit without giving up. It is remaining firm under suffering or misfortune without yielding. We often associate it with an endurance run or race or something physical and we think of the marathon or ultra-marathon experience as an example. Most physicians, more so than other professionals, understand what this term means. You’ve have been through the rigors of medical school, residency and additional training. And that experience tends to continue long into your career of practicing medicine…just add a few more patients, do one more surgery, just one more hour to finish paperwork, etc. “I’m fine, I’ve survived this long, I can handle it, It’s no big deal.” When this pattern continues, it can lead to the very challenging situation or condition of burnout.>>


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As you review articles in the CVP magazine and other publications, much is being said today around the country about the subject of physician burnout. Our professional organizations are talking about it; workshops and educational events are springing up across the country that focus on ways to identify and deal with it. There are far too many of us who are not really “living” our lives; we simply exist, survive, or just get through the day. We endure; sometimes because we believe there are no other options, and other times we wear it as a badge of success that shows how much we can achieve. Anjani Amladi, MD describes his experience with burnout in the Summer 2018 edition of CVP (p 56-58). He writes: “In my naiveté while in medical school, I didn’t think that physician burnout was a real thing. My attendings seemed really happy, as did the senior residents who were supervising me. So the concept of physicians hating their jobs, quitting the profession, or worse, abusing staff, being rude to patients, and at the extreme committing suicide didn’t make sense to me. Then during residency, it started happening to me. Long hours, little sleep, hectic call schedule, lack of time to exercise, eating poorly, multiple attendings quitting in close succession, and other events made it very difficult to appreciate the job I worked so hard for. And the worst part—there was no outlet. If you want to be a “good resident” the recipe is to keep your head down, plow through the mountain of work you have, don’t complain, and appear to the outside world as if you have everything under control. And on some days, particularly early in training…I hated it.” His is a very good illustration of how we learn to endure and continue to endure regardless of whatever comes our way. Each of us knows someone who “lives” life; this term suggests they “thrive”, they have vitality, energy, fulfillment and a degree of contentment and satisfaction. They are engaged in the work of their profession; they are an active participant in their day to day world; they are “living” their lives. We have also met others, who do not “live” life, but they are not “dead”; they are burdened with pressures, struggles, and difficulties that significantly get in the way. They are just enduring; and they seem to lack the ability to recharge or bounce back. We recognize this as burnout. Resilience is that ineffable quality found in some people who have been knocked down by life and have come back at least as strong as or stronger than before. They overcome and rise above. They “live” life; they “thrive”. Psychology has identified some factors associated with resilience, including optimism, positive attitude, the ability to self-regulate emotion, and seeing failure as helpful feedback for growth and change. Optimism helps blunt the impact of stress on the mind and body and increases our ability to keep a “cool head” in evaluating more effective decisions, choices and actions. Evidence suggests that resilience can be cultivated. When endurance is counterbalanced with resiliency, we find balance in our lives and experience peace and contentment. We develop the ability to offset the cost of endurance by building in resiliency that allows us to recharge, or bounce back from the pressures, expectations and burdens of the day. Dr. Farah Karipineni wrote, “Like most of us I entered the field of Medicine





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Dr. Gigi Osler, President of the Canadian Medical Association makes the following points from their study: (Hospital News; January 2019, p.18)

• Physicians are tired, burned out and looking for change. • 26% of physicians reported high levels of burnout; 34% reported symptoms of depression • The health of a Physician is directly related to the quality of care patients receive. • Regarding Physician Health: It’s time for action!

From the AMA website: (https://www.amaassn.org/practice-management/physicianhealth/how-beat-burnout-7-signs-physiciansshould-know) If constant stress has you feeling exhausted, cynical or detached from patients, take notice. You may be in danger of physician burnout, which is more prevalent among doctors than other professionals. Based on research and experience of expert physicians, the AMA offers CME that can help you prevent physician burnout, create the organizational foundation for joy in medicine, create a strong team culture, improve physician resiliency and prevent physician distress and suicide.



brimming with altruism and hope” (CVP Winter 2019, p.6). Many of us started our careers with enthusiasm and excitement. We had high hopes, great desires, strong determination and a belief that we could make a difference in the lives of others. We believed we could achieve that if we endured. She points out the importance of trying to “preserve our humanity in a field that is constantly under threat by various pressures—time, insurance, documentation, productivity benchmarks and the list goes on”. In other words, it is not just enduring or surviving; we need to develop ways to thrive if we are to preserve our humanity in the face of these threats. The solution is that we develop resiliency. In addition to our professional stresses, most of us face struggles associated with our personal lives…relationship conf licts, parenting concerns, financial issues, household management responsibilities as well as our own physical health difficulties. The stresses and strains of life take their toll whether they are related to our professional or our personal lives. In the article about physician suicide (CVP Winter 2019, p. 1619), Maria Castellucci reminds us of the importance of reaching out. It is far too common for physicians to avoid discussing their concerns or to seek help for them. Fear is a significant factor that keeps us from reaching out. And it manifests in several ways: • Fear of the stigma • Fear of public shame or embarrassment • Fear of discipline by the organization or the medical board/ losing license • Fear of being perceived as weak, ineffective or needy • Fear of the judgement of others • Fear of vulnerability; which may be experienced as a loss of control • Fear that disclosure or discussion makes things worse rather than better

NDURANCE VS ESILIENCY The AMA also offers a free weekly subscription to a Burnout Management Tip of the Week where they send insights, suggestions and ideas.

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ENDURANCE VS RESILIENCY It can be a big struggle to openly talk with others about concerns, issues, problems, or troubles; even though the need for support, encouragement, and validation is significant for all of us. Physicians commonly neglect taking care of themselves; most wait until they are in crisis before reaching out. Often, resisting seeking help is a symptom of our commitment and dedication to endurance. We believe we must endure and if we stop, that is a sign of weakness or failure so we redouble our efforts and work harder. In reality, the harder work should be

devoted to building our underdeveloped abilities and skills in resiliency. Fortunately, enduring doesn’t need to remain the common pattern. Reaching for a glass of wine or a beer at the end of a long day is not the answer either. We may find that temporarily eases the discomfort, but we know nothing changes for the better as a result. There is help available. You can reach out rather than continue to just survive or push to get through the day. It’s called a Resiliency Consultation. The FMMS has created an opportunity for member physicians to reach out for

Resiliency Consultation • Consultations are confidential. o No information will be shared and anonymity is maintained • Consultations are completely voluntary and not mandated by any entity • Convenient. Providers work to accommodate schedule availability o Telehealth options are also available An FMMS member physician can: • Utilize up to four (4) individual sessions annually at no cost o Additional visits, if desired, can be arranged with the provider at a cost • Review provider profile information (roubicekandthacker.com/team) and select a provider of choice • Contact the provider practice directly (559-323-8484) and request a Resiliency Consultation appointment Potential topics for discussion include: • Finding/creating better balance in personal/professional lives • Incorporation of healthy practices into a daily lifestyle o Exercise, nutrition, sleep, recreation, positive activities • Relaxation and Stress management. Mindfulness practices • Relationship support and conflict resolution 16


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a discussion with a competent provider (see Meet The Team) who can help guide a process of what Dr. Karipineni called “preserve my humanity” and what Dr. Amladi referred to as “get myself back on track” and “rekindle the love for my profession”. It is a strategy to help move us forward toward more fully “living” life. Resiliency Consultations are designed to help facilitate a discussion wherein you, the physician, can explore making changes in routines, developing healthier patterns, implementing strategies that lead to greater balance, and promoting a more full “living” of life. It can help restore some of the energy and devotion to the healing art in the practice of medicine that you came into your professional life with. It can lead to greater balance and more positive engagement in personal and professional activities and pursuits. It can improve the quality of relationship interactions and deepen intimate connections; it can fill the need for support that we all seek. It has potential to lead to greater fulfillment and peace. And it can prevent falling deeper into a situation of burnout that robs us of the joy and meaning available to us. We work in a stressful profession. We often see the sickest of the sick and are constantly surrounded by illness. The expectation to be perfect and always “get it right” is constantly before us. The demands of patients and organizational pressures and requirements can leave us caught in the middle. Yet, there are many rewards to be found in caring for those in need. Our interactions

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and associations with each other can be affirming and uplifting as we enjoy the support we offer each other. If you find yourself struggling or questioning; if you would benefit from a discussion that can lead to making some adjustments, then a Resiliency Consultation may be just the thing for you. The first step is recognizing and admitting that there is a need and then reaching out for help and support. Don’t postpone or procrastinate; don’t brush it off and wait until things get worse before you act. Don’t continue to just endure. Take the time to have the discussion; it may be one of the best things you can do to bring greater joy back into your life.




Career Transition CESAR VAZQUEZ, MD

One of our medical societies’ ongoing themes and that of many other healthcare organizations across the state has been physician wellness and burnout. Many of us have heard or read the statistics. For example, the Medscape national burnout study showed that 42% of physicians report burnout. Over the next 10 years, 25% of physicians are expected to retire and the number of older Americans requiring healthcare is expected to double by 2040. They project a shortage of 100,000 physicians by 2030, which will result in even more burn out impacting physicians and their patients. Recognizing this important dilemma, the CMA has partnered with Dr. Tait Shanafelt from Stanford to launch wellness programs that are available to students, residents and practicing physicians in order to address this problem. Dr. Shanafelt and his team from the Mayo Clinic have overseen multiple national surveys that included more than 30,000 US physicians. These found increasing rates of burnout among doctors; in 2014, more than half of those surveyed were



suffering from emotional exhaustion, loss of meaning in work or a sense of ineffectiveness and a lack of engagement with patients. Moreover, his studies have found that as physicians suffer, so do patients—burnout has been found to contribute to physician errors, higher mortality among hospitalized patients and less compassionate care. It is a trend, he said, that is “eroding the soul of medicine.” Rather than focusing on the root causes of burnout, I believe the bigger issue is addressing how physicians can take action and find alternative career solutions that match their skills and interests. More importantly, are we missing key opportunities to help doctors make a successful career transition perhaps into non-clinical roles, if that is what they are looking for? Some doctors want more tangible solutions that will help with a career pivot that does not require a lengthy process and potential loss of income. This requires an honest appraisal of our core skills to evaluate opportunities beyond the clinical realm. Like our Stanford neighbors, I am proud of FMMS

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leadership and creativity to bring physician wellness to our valley as exemplified by the success of our inaugural Joy of Medicine Summit this past December. In a recent WSJ article, commentator Michael Malone writes, “Why are some top professionals able to maintain peak performance throughout long careers, while others who may be even more talented quickly fade and fall behind?” Furthermore, he goes on to say, “Why do some lesser performers suddenly take off in mid career and accomplish astonishing things?” To answer these questions - which also apply to medicine - the author interviewed two tech giants. One was John Hennessy, the current chairman of Alphabet, parent company to Google, president of Stanford University and Godfather of Silicon Valley, who stated that your primary skills - or as physicians our medical skills - can only take us so far, driving success for the first 10-15 years. After this period, the need for secondary skills, or soft skills, are crucial to make a successful career transition. Doctors need to know how to interact well with colleagues, serve on committees, network, and get involved with leadership. If these skills are not cultivated it has been shown that productivity falls off, and we become stagnant and feel trapped. Left with only our primary skills, which may not be transferable or re-purposed, we become victims of the system, experiencing burnout, isolation and sometimes hopelessness. This complicated scenario can play out for physicians at any stage, not just for those in midor late-career. Like many of you, I’m inspired and love to read about leadership and the capacity that good leaders have to influence others in positive ways to change our culture. In researching this topic, I’ve learned that you don’t have to be born with certain traits or skills, but rather anyone regardless of personality type can learn and become an effective leader with the potential to bring changes in their communities and the lives of others. As the Godfather of Silicon Valley says, “I had to learn a new set of skills in a short time because when you move from a specialized field (like medicine) and step into leadership, your technical talent becomes less important and new tools are needed like learning how to bring people together and be a catalyst to unify a team around a single vision.”

Embarking on a career transition is not the most linear or straightforward process. Many of us know that as doctors our first job as clinicians is all but guaranteed considering the doctor shortage. However, when it comes to making a non-clinical career move, it is not always that easy and additional resources are often needed to be successful. Medical societies should provide value by helping doctors make connections and find key resources that open the door to excellent and proven career choices that provide professional satisfaction and steady income. Stress and

A word of caution is pertinent here. Before undertaking a career move, it is important to know that according to studies, burnout can be traced to issues with workflow, paperwork, regulations, IT, EHR and others.

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burnout are not the only reasons doctors look to make a change. Some examples include the need to serve and impact medicine through health administration or health policy and leadership where the care model shifts from a one-to-one, doctor-patient model to a one-to-many. Other examples are doctors that are slowing down and nearing retirement, or some have physical challenges that limits their ability to perform the physically demanding work of a practicing physician, or, of course, those who no longer find fulfillment or meaning in their current role. Many of the doctors I have interacted with who complain of burnout are not interested in relaxation techniques, mindfulness therapy or goat yoga. Rather, they seek solid, trustworthy resources and opportunities to help them succeed towards a less stressful, non-clinical career path. A word of caution is pertinent here. Before undertaking a career move, it is important to know that according to studies, burnout can be traced to issues with workflow, paperwork, regulations, IT, EHR and others. Once some or all of those problems are corrected, physicians may feel renewed with improved work life balance and career satisfaction. A professional coach or consultant can help make the necessary adjustments which may be all you need to help isolate the problem and help get back on track. I am cognizant of the fact that there is great virtue with



full-time clinical medicine and absolutely nothing wrong with staying in practice 30-40 years and well into retirement age. I have had the honor of practicing with people such as the late Drs. Gillespie and Flanagan. They were part of a different generation—they were lifers, dedicated souls, who never complained about the burn out. They kept their heads down and worked, providing for the health and emotional needs of patients and families of this awesome community. Like many of you, it is a privilege to observe and work alongside those kinds of doctors while learning the art and craft of medicine through their compassion and dedication. For those in that category, who are the lifers, I congratulate you for your dedication and service to this noble and sacred calling. However for many others (and I am referring to the newly minted younger legion of doctors graduating from residency), that model might not be their life plan. You see, the generation of Americans who lived through the industrial age and worked for the same company like General Motors or Boeing Aircraft or practiced medicine their whole life is a relic of the past, and more importantly, does not reflect the mindset of new generation physicians. Younger physicians are regularly opting for the employed physician framework due in no small part to rising student debt, the uncertainty of private practice, and the popularity of integrated care. Moreover, there is a desire for tech-savvy upwardly mobile ambitious doctors to focus on attaining new skills, expand their sphere of influence, and work side gigs to supplement their income. Non-clinical careers for doctors is an often misunderstood subject. First, we must eliminate the stigma associated with searching for non-clinical options in medicine and encourage those who are struggling with burnout. Everyone has a unique set of circumstances and reasons for considering this change. It is our responsibility to support and guide our medical colleagues not just by referring them to a psychologist or suggesting to wait it out till retirement, but rather by providing information they can access and take action for a more fulfilling next chapter in their life. There is a plethora of non-clinical career information online which can be confusing and overwhelming. However, I think an excellent starting point is the annual two-day SEAK conference held in Chicago. The majority of the 375–400 attendees who come from all over the country are board certified and currently practicing medicine. Physicians attend the conference for many reasons including the



desire to change careers and obtain a new position, either part-time or full-time, and to meet with recruiters to learn what additional opportunities are available for them. As a conference participant in 2017, I was very impressed with how well-attended it was and with the numerous informative and professionally delivered talks on a variety of high-value topics. There were also job-fair styled recruiting tables set up during the conference to allow attendees to meet one-onone with recruiters and career coaches. Overall, for those thinking of career changes, the cost of registration and travel is worth it and many doctors have found career-boosting jobs they didn’t know existed. If you don’t have time to attend a conference, another great resource available that provides great information is the Physician Non-Clinical Careers with Dr. John Jurica podcast. The host interviews physicians that have already made the transition and provides specific steps towards accomplishing this goal. Some examples of these alternative careers include: • Physician career coach • Physician freelance writer • Physician advisor • Administration and leadership role • Medical device company consultant • Medical science liaison (MSL) • Physician entrepreneur • Equity researcher or consultant for venture capital or angel investor • Medical informatics role • Medical communications and advertisement role • Professional speaker • Federal government officer • Medical expert witness Having a medical degree is not the endpoint of a career path but the starting point. Clinical medicine is only one of the many options available where one can leverage knowledge and skills to explore the myriad possibilities available to those who seek them. One of my objectives for this coming year is to have our medical society be a resource for relevant information on this very important and timely subject. Doctors should not have to accept and struggle with physician burnout when viable alternatives are available, as evidenced by the hundreds of satisfied doctors who have made the career move. Now is the time to take action.

Spring 2019



More than one doctor a day dies by suicide in the United States and untold numbers of physicians burn out and leave the profession every year. In a recent 2019 Medscape survey, over 50 percent of the 15,000 physicians from across the country who responded to the survey reported symptoms of burnout or depression. Rates of burnout were highest among our front line physicians including family medicine, obstetrics and gynecology, internal medicine and emergency medicine. This epidemic of physician burnout, depression – and suicide – is tragic for physician families and their medical communities but also for patients and society. A recent report by the Massachusetts Medical Society, the Massachusetts Health and Hospital Association and the Harvard T.H. Chan School of Public Health, called physician burnout a public health crisis.>>

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Physician members of FMMS will automatically receive a complimentary copy of the directory. Additional directories can be purchased for the following rates:

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Consider these repercussions: Burnout has been linked to more medical errors, less patient satisfaction with their care, and more health care providers leaving the profession to find work in other arenas. Let’s look at this possibility of health care providers leaving their profession and how it plays out in the San Joaquin Valley. The San Joaquin Valley has one of the lowest ratios of primary care providers as compared with other regions of California. There are 133 active physicians (excluding medical residents) per 100,000 population compared with the state rate of 222 active physicians per 100,000 population, according to a Healthforce Center at UCSF report. The situation will only worsen in the coming years. Thirty percent of physicians in the Valley are over the age of 60 and are expected to retire within the next decade. In 10 years, California is expected to have a shortfall of up to 4,100 primary care clinicians, according to the California Future Health Workforce Commission. Recent studies suggest that by 2030, the entire nation will experience a physician shortage of more than 40,000. Add to this the health care providers cutting their careers short due to burnout and this truly does look like a health care crisis for the San Joaquin Valley. Finally, add one more ingredient, one that is not talked about as much. It is estimated that more than 400 physicians die by suicide each year. This is twice the rate of the general population. It is estimated that with the death of these 400 physicians, over one million patients lose their doctors. And although not widely reported, many physicians in our Valley have lost their lives to suicide. What is burning out our health care providers? It is not the direct care of patients, a special experience that draws most health care providers to this profession. It is an increased bureaucratic load, more time spent with electronic medical records, long hours and a growing sense of lack of respect and autonomy. So what is the cure? Recent studies have suggested that the antidote to burnout is engagement. Yes, physicians and other health care providers need to “practice what they preach” and develop healthy practices that support their well-being and resilience. They also need to feel that they are working in health care systems and a society as a whole that recognizes and supports their work. They need to feel that they are part of the solution to the many health care issues that all members of our society face rather than just another cog in the wheel of the health care system. Physician wellness is a priority at UCSF Fresno. We are committed to creating an environment that is safe, inclusive and supportive. On March 20, 2019, UCSF Fresno hosted national expert Dr. Dike Drummond, “The Happy MD,” who will present several workshops for local health care providers aimed at helping them lower stress levels, build a more balanced life and reenergize their passion for practicing medicine. This event is part of ongoing efforts by UCSF Fresno to promote physician and health care provider wellness. It is a commitment to our community: Happy doctors lead more content lives and are vital to improved patient outcomes. Changes will not occur overnight. It begins with everyone understanding that we need happy MDs and health care providers to be a healthy community. Lori Weichenthal, MD, is Assistant Dean for Graduate Medical Education at UCSF Fresno



Spring 2019

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Under Proposition 56, the University of California (UC) received $40 million to support a statewide graduate medical education program. UC has contracted with PHC to administer the annual $40 million in grants.

7 million in grants to fresno county Physicians for a Healthy California Awards Over $7 Million in Grants to Fresno County Residency Programs


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Physicians for a Healthy California (PHC) recently announced that more than $38 million in new state tobacco tax revenues has been awarded to graduate medical education (GME) programs across the state to fund 156 slots for physician residencies. The first “CalMedForce” grants will help address the state’s physician shortage, particularly in underserved communities where patients often lack access to timely and quality health care. This first round of funding includes awards to 73 separate GME programs located in hospitals, medical centers and community clinics to offer residencies to 156 recent medical school graduates. Of those 10 were located in Fresno County. • Saint Agnes Medical Center Family Medicine Residency Program (Family medicine) $450,000 • Saint Agnes Medical Center Internal Medicine Residency Program (Internal medicine) $1,225,000 • UCSF Fresno Emergency Medicine Residency Program (Emergency medicine) $900,000 • UCSF Fresno Internal Medicine Residency Training Program (Internal medicine) $225,000 • UCSF Fresno OBGYN Residency Training Program (Obstetrics/gynecology) $900,000 • UCSF Fresno Pediatrics (Pediatrics) $1,125,000 • UCSF Fresno Family Medicine Program (Family medicine) $225,000 • Valley Children’s Pediatric Residency Program (Pediatrics) $1,295,000 • Valley Health Team Family Medicine Residency Program (Family medicine) $675,000 Funding for this new GME program comes from Proposition 56, the $2-per-pack tax on tobacco products approved by California voters in 2016. “These CalMedForce grants will help California grow and strengthen the physician pipeline to meet the demands of our state’s growing and changing patient population,” said Lupe Alonzo-Diaz, MPAff, PHC president and CEO. “This investment will improve access to care and increase timely access to a physician for patients in underserved communities.” While the $38 million in grants will serve as a down payment on increasing graduate medical education, the available funds did not meet demand for these residency slots. In its first award cycle, CalMedForce received 131 applications totaling more than $147 million in requests to support 594 residents.

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Michael W. Peterson, MD, associate dean at UCSF Fresno, said, “Receiving these grants as part of a competitive application process is truly gratifying and represents an important step forward in the Valley. Thank you to Physicians for Healthy California. To begin to address the health care needs of our region’s growing, aging and diverse population, many more physicians are needed and to do that, ongoing support for infrastructure in resident education is critical.” The San Joaquin Valley has fewer licensed physicians practicing in the region than other parts of the state and California as a whole. There are 133 active physicians (excluding medical residents) per 100,000 population compared with the state rate of 222 active physicians per 100,000 population, according to a Healthforce Center at UCSF report. The situation will only worsen in the coming years. Thirty percent of physicians in the Valley are over the age of 60 and are expected to retire within the next decade. The California Future Health Workforce Commission estimates the state will face a shortfall of 4,100 primary care physicians by 2030. In 2016, voters approved Proposition 56, which increased the tax on cigarettes and electronic cigarettes by $2 per pack. The tax generates about $1 billion a year and is intended for the purposes of increasing access to health care and supporting crucial health care programs, including a $40 million graduate medical education (GME) fund to sustain, retain and expand GME programs. The goal of the fund is to increase the number of primary care and emergency physicians in California. The fund is administered by PHC, the foundation for the California Medical Association.

About the CalMedForce Program

Under Proposition 56, the University of California (UC) received $40 million to support a statewide graduate medical education program. UC has contracted with PHC to administer the annual $40 million in grants. PHC gathered feedback from various stakeholders as it developed the program processes and award criteria. This included surveying the GME directors of primary care and emergency medicine residency programs in October 2018. The survey gathered information on potential opportunities and challenges in sustaining, retaining and expanding their residency programs. The PHC Advisory Council took great lengths to validate the application, eligibility criteria and scoring criteria aligned with the statute.




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etween $600,000 and $3.2 million, depending on the study. That’s how much less female physicians earn over a 30-year career compared to their male counterparts. No matter which specialty or which salary study, the gap in pay between genders is significant – and shocking. Nationally, women earn 18% less than men across all professions for full-time wage and salary workers. That difference has been steadily narrowing since 1979 when it was 38% and the U.S. Bureau of Labor Statistics first began comparing earnings. But for doctors, the gulf between men’s and women’s pay is larger and growing wider. Only one profession – financial manager – has a bigger pay disparity between genders, according to the Bureau of Labor Statistics.

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Social media discussions of the issue have become heated ever since Plano, Texas, Internist Gary Tigges told the Dallas Medical Journal in September: “Yes, there is a pay gap. Nothing needs to be ‘done’ about this unless female physicians actually want to work harder and put in the hours. Female physicians do not work as hard and do not see as many patients as male physicians. This is because they choose to, or they simply don’t want to be rushed, or they don’t want to work the long hours. Most of the time, their priority is something else – family, social, whatever.” Dr. Christina Maser, medical director of University Surgical Associates and an associate clinical professor of surgery with UCSF Fresno, said Dr. Tigges has a point: “I do see my male colleagues willing to do elective cases on a Saturday routinely. I do think many prioritize their income over their families and take more opportunities to do that.” >>



From left to right: Christina Maser, MD, Janae Barker, DO, Farah Karipineni, MD 28


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“I do see fewer patients, but I see some of the most complicated patients in our clinic,” said Dean Health Systems’ family medicine physician Heather A. Kennedy, D.O., who is from Fresno and did some of her training locally. And while she bills for those patients at a higher rate, they take much more time to do complete work ups and more time to chart, she said. “I estimate I’m doing 2 hours a day of extra work that I’m not getting paid for. Dr. Tigges’ remarks touched off a firestorm of denouncements and closer looks at the pay gap studies. But for all the outrage on social media over the statistics and the reasons given for the discrepancy, few want to talk about their own pay or open up comparisons of their medical group pay structure. “Transparency of salaries is a big deal,” said Janae Barker, D.O., a pediatrician with Valley Children’s Medical Group who also practices at an Oakhurst clinic. The lack of knowing exactly what other doctors are making put women at a disadvantage in negotiating their pay. “If you don’t start right out negotiating for competitive pay, then you lose out later as you move up,” Dr. Barker explained. “I think social media platforms are making a big difference,” she added, referring specifically to invitation-only Facebook groups for doctors who are mothers and for women surgeons. “I’m not sure if men talk about their salaries, but women are now.” Salary isn’t always the big attraction or negotiating point here locally, asserted Joyce Fields-Keene, chief executive officer of Central California Faculty Medical Group (CCFMG). The more pressing issue, Fields-Keen said, is attracting physicians of all genders to the Central San Joaquin Valley. “Our shortages are so dramatic here. We are doing whatever we can to attract physicians. We pay based on your specialty and your skill and years of experience. We don’t make a distinction between genders.” CCFMG’s women physicians now outnumber men in eight out of 25 specialties in the academic practice with surgery surprisingly having one of the largest ratios of women to men. Nationally less than a quarter of general surgeons are female. That women to men ratio is particularly striking among the faculty in UCSF Fresno’s surgery program and the women there credit Dr. James Davis, program director of the Acute Care Surgery Fellowship Program and Chief of Trauma at Community Regional Medical Center. “Dr. Davis does a good job of making things fair,” said Dr. Farah Karipineni, an endocrine surgeon with CCFMG and an assistant clinical professor with UCSF Fresno. “And he does a great job with things like pregnancy and maternity leave.”

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The gender pay gap measured many ways – most of it in double-digit percentages “Some people are oblivious or staunchly deny there is a pay gap,” said Dr. Barker. “I’ve had that experience, which is really interesting.” But the salary numbers compiled now from numerous sources and analyzed various ways tell a different story:

27.7%, or $105,000 less, was the gap in pay between female and male physicians found in a 2017 Doximity survey of more than 65,000 licensed U.S. doctors. That that was up from the 26.5% gap found in Doximity’s 2016 survey.

39% was the gap an American Association of University Women (AAUW) study found between men and women physicians and surgeons. Data was compiled from U.S. Census and Bureau of Labor Statistics monthly surveys for the year 2017.

18% less for primary care physicians and 36% less for surgeons is what women earned compared to men in the 2018 Medscape Physician Compensation Report. That gap had widened from 2016 when it was 16% for primary care physicians and 33% for surgeons.

17% for primary care and 37% for specialty care was the gap the Medical Group Management 2017 Physician Compensation and Production Survey found. It used comparative data for 120,000 providers in more than 6,600 practice groups, including physicianowned, hospital-owned and academic practices.

8% is the pay mismatch between genders among academic physicians, a 2016 study published in JAMA (Journal of the American Medical Association) Internal Medicine found. It analyzed salaries of 10,241 academic physicians at 24 public medical schools, including those in California.

For all professions California has the lowest gap between men’s and women’s median earnings; it stood at 11% in 2017. And California’s physicians also see more parity in pay than doctors in other states. But in places where the pay increased rapidly the past two years, such as Riverside, Calif., the gender pay gap got larger. Riverside made the 2017 Doximity list for the top five metropolitan areas where men far out-earn women physicians, making on average 31%, or $115,991 more, annually.



Joyce Fields Keene Chie f E xe cu tive O f f icer o f Central C alif ornia Facul t y M edic al Group (CCF M G)

Explaining the widening gap There’s as many reasons given for it as there are studies measuring the expanding financial inequality. Explanations range from taking time off to have babies to lower productivity and less seniority, to billing less assertively and negotiating less powerfully for pay, as well as to outright discrimination. Anupam Jena, M.D., associate professor at Harvard Medical School and lead author of that JAMA Internal Medicine study, said the pay difference cannot be only ascribed to specialty choice, experience, Medicare reimbursement amount, or status conferred from published papers, clinical trials and research grants. Take all those into consideration in crunching the numbers and you still find disparity. He insisted in his published report: “This study puts the nail in the coffin by assessing every possible reason for why males may have greater earnings than females … there’s actually discrimination occurring, whether conscious or subconscious.” Today more than 50% of medical school graduates are women, but still they lag behind the number of men in medical school



leadership positions, leadership roles in hospitals and in higherpaying specialties like surgery, cardiology and orthopedics. “Many women choose a specialty that allows them to work when they want or have more flexibility,” Fields-Keene said, because of child-rearing. “Our physicians are also teachers so they want to work in an academic program” where pay might be lower but flexibility higher. But those same faculty are increasingly urging their women students to specialize in those higher-paying fields, Fields-Keene said, adding, “And more and more, I do see women specializing.” Women physicians say unlike male colleagues they must consider how to have a family while working long, physically taxing hours during their prime childbearing years. Dr. Kennedy delayed going to medical school for that reason until her children were in school. And Dr. Barker said one of the reasons she considered pediatrics was because she wanted to have children. Pediatrics is one of the lowest paid medical specialties, but it also has the one of the smallest gender pay gaps. Dr. Barker, who gave birth to her third daughter in March, had her first baby in medical school and her second while a resident. “I’m blessed to have a stay-at-home husband,” she said, explaining how she managed. “I only ever have taken six weeks maternity leave, because I really enjoy working. Even so, you have to make adjustments that men don’t usually have to make. I had to extend my residency by a month when I had my second. So I think there’s some truth in that argument. Staying up on continuing medical education is difficult if you take a break for your career to have a baby and raise small children.” Psychiatrist Torie Sepah said she she climbed the ladder in the medical profession by “downplaying any aspect of being a woman.” She wrote in a recent blog for Physician: “I wore bigger and bigger scrubs as a third-year medical student, hoping to keep my pregnancy a non-topic while on rotations…I returned two weeks post C-section … I never mentioned I had just given birth to the all-male team during my CCU rotation …I cringe now when remember what my attending told me on my last day of my rotation, ’You worked hard, you kept up. It is as though you didn’t even just give birth. No different. You will make an excellent physician’.” Dr. Barker said she knows plenty of women like that. “A lot of them chose not to disclose their pregnancy when going for interviews for a residency program, because it’s seen as a liability.” Female physicians with children work an average of 11 fewer

Spring 2019

hours a week than those without kids, according to a 2017 study published in JAMA Internal Medicine. But as Drs. Sepah and Barker point out those physician mothers also go home and work another job – one that’s often invisible to their male colleagues. “I’m the only one who can breastfeed, but I’m not the only one who can do bath time or make sure the household is running smoothly,” said Dr. Karipineni, who has one child, is pregnant with twins, and is married to another surgeon. “I wish I could say our roles at home are even, but there’s no such thing as paternity leave. My leave is intimately connected to my gender. And taking on that caregiver role leaves me less time to [advance my career], and some [of] that gets translated into the pay gap.”

The nicer sex is seen as weaker at salary negotiations Women physicians also say they often don’t learn how or get encouragement culturally to be tough negotiators and f that can mean millions of lost dollars over their lifetime. That tendency to undervalue their worth can also come to play in how women physicians bill differently than their male colleagues. Such gender differences were starkly apparent to Dr. Barker at a conference she attended as part of her pediatric chief residency stint. During role playing to illustrate best practices in conflict resolution, she said, “It came naturally to the male physician to be in this conflict situation around negotiating his salary. And the woman, who was a surgical resident and already bolder by nature, was not as comfortable. In the debrief we talked about how it’s inherent and everywhere that most women can’t be as assertive. And women who push harder in negotiations are seen as too aggressive. The women were worrying more about their image.” Dr. Kennedy agreed that those unconscious cultural biases and ways of interacting in the workplace come into play in other ways when it comes to pay. “I notice nursing staff respond better and are more willing to help the male doctors than the female doctors,” she said. “So we end up doing extra work our male colleagues have someone else doing for them. It may be the way we ask for help.” Dr. Maser said she sees women being more compliant in negotiating and interacting in a way at work that may not get others to pitch in and help. “Women come to work with a motherish attitude of ‘I’ll just take care of it and get it done.’ So they’re working more than they are getting paid…We’re just wired differently.” Fields-Keene disagreed: “I don’t think the women surgeons I know are timid. They are a determined group. They had to be to

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get where they are. I don’t think there are any differences in gender when it comes to that. It really depends more on the specialty and certain personalities are attracted to certain specialties.” “We women physicians are not a meek group of people,” Dr. Karipineni agreed. “But women having more responsibilities at home is not just by choice but because of gender disparity in roles there too. If responsibilities at home were more equal, specialty considerations might be different.” Fields-Keen insists it’s often what specialty you are that determines your pay. But the studies show that even in high-paid specialties, when years of experience are accounted for, a gender pay gap persists. Dr. Barker said she got lucky with a wonderful woman mentor who helped her learn salary negotiation skills. “She said ‘Number one, you have to know your worth. Being assertive is not being aggressive. You’ve worked really hard and you’ve trained really hard. You deserve to be paid for that.’” Another place where Dr. Barker picked up tips was from the physician moms’ Facebook group, now nearly 70,000 members strong. “That has been a place where I got a lot of mentorship. There’s lots of advice on how to advance your career and negotiate for your worth.” Dr. Barker said women on social media have been discussing the fact that female physicians tend to bill lower. “Male physicians tend to bill higher for what they are seeing. I think as women we don’t want to put a burden on the system or maybe we don’t value our own work,” she said. “I know most physicians don’t get training on how to bill. As a new physician I’ve had to try to figure it out on my own.” Fields-Keene sees the solution to righting pay inequities in attracting women to the Valley’s medical training programs, then encouraging and mentoring them in male-dominated specialties, and finally in keeping them here after their training. “We really have to grow our own here,” she said. “Fifty percent now of those who train here, stay here. The Valley is really so underserved that any doctor is going to have really high clinical volumes.” And then once women are established in physician practices here, Fields-Keene said, “It’s really clear, how hard you work is how you get paid.” Dr. Maser has a different take: “I don’t know if we’ve defined the problem well enough to be able to figure out a solution. There are may be more attributes a woman can bring that contribute to the bottom line besides RVU’s (relative value units).”





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sounds like a significant responsibility. And, it is. Especially when you’re charged with leading more than 300 doctors in Kaiser Permanente Fresno’s five-county service area. But for Kaiser Permanente’s new Physician in Chief Dr. Shahzad Jahromi, serving as a leader is just part of who he is.

Jahromi had always been interested in biology and medicine, even in elementary school. He grew up in Iran where high school education included a year of hands-on training in a specialized field to prepare students for real-world careers. When stints in car and refrigeration repair shops couldn’t hold his attention, Jahromi’s father found him a spot in a hospital emergency department. There he found his love of service and leadership saying, “There was a great physician there that I was able to work with, and after that I knew that’s what I wanted to do. And I pursued it.” >>

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and his wife were expecting their second daughter and wanted to move closer to his wife’s family. In 2005, Jahromi and his family moved to Fresno, where he said he found “the best of both worlds” – family roots, a state-of-the-art hospital and the 144th Fighter Wing, a unit of the California Air National Guard. Jahromi joined the Occupational Medicine Department at Kaiser Permanente Fresno and transferred from active duty to the Fresno Air National Guard where he currently serves as lieutenant colonel. In his second year of high school, Jahromi moved to Southern California to live with extended family. This was during the Iran-Iraq war and once he graduated high school, he was required to serve in the military. By moving to California, Jahromi was able to pursue his love of medicine without having to delay school and fight in the war. While in Southern California, Jahromi focused on finishing high school and college. After graduating from medical school, he completed his combined medical residency in Family Medicine and Occupational and Environmental Medicine at Wayne State University, Detroit Medical Center. It was there that he was recruited by the United States Air Force as a flight surgeon.

FORWARD THINKING MODEL OF CARE With a focus on wellness and prevention, Jahromi was promoted through the Occupational Medicine Department and eventually selected as Physician in Chief. He describes his management style as humble and resilient. He prefers serving

SERVICE BEFORE SELF During a routine military presentation to the medical residents, something sparked Jahromi’s attention. The thought of becoming a flight surgeon intrigued him, but he wasn’t sure he wanted to commit. Then everything changed. “What sealed it for me was 9-11,” Jahromi said. “I’ll never forget the day I was in the clinic and I saw the planes get shot down. I’ll never forget that day. And then I went home, and I called and said yes, I want to serve.” After residency he went directly into active duty at Vandenberg Air Force Base in Santa Barbara County. But he



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as an advisor to other physicians and wants them to use him as physicians to carry on Kaiser Permanente’s integrated model a sounding board. “I don’t manage my doctors,” Jahromi said. of care. “We work together.” “Not all physicians fit within our model,” he said. His leadership is unfolding during a new era of medicine for Jahromi said he’s looking for physicians who work well with Kaiser Permanente. Kaiser Permanente plans to open its first others and place patient care above all else – a testament to his medical school in Pasadena in 2020. The Kaiser Permanente military and medical background. School of Medicine will focus on using technology and “I want accountability for everyone,” he said. “From the collaboration as the forefront of care. Most exciting, the lowest person to the highest person, including myself. That’s school is waving tuition fees for students for the first five years. important to me.” Jahromi hopes the medical school will help him recruit new As he looks toward the future, Jahromi said he’s focused on physicians as a way to address the physician shortage in the helping to grow Kaiser Permanente Fresno’s membership. Valley. “If we are who we say we are – that we provide the best Kaiser Permanente wants to make sure people that cannot care for our patients and we’re an integrated model of care afford medical school have an equal opportunity to become focused on quality, patient outcome, and standard of care – a physician,” he said. “With the physician shortage, it’s a great why shouldn’t every person in the Central Valley be a Kaiser way to introduce the Kaiser Permanente model to the medical member? That would be my goal.” students. We are hoping they will do their residency with Kaiser and stay within our system.” He’s also working on partnerships with other medical schools. California Northstate University Medical School in Sacramento Very often patients suffering from will soon be sending their depression obtain no relief from medical students to Kaiser multiple medications. In many cases Permanente Fresno for drug therapy can cause significant hands-on training. side effects resulting in nonJahromi said medical compliance. school has changed and stuEdgar Castillo-Armas, MD dents are no longer sitting Psychiatrist in classrooms attending lectures. Instead, students Transcranial Magnetic Stimulation (rTMS) delivers magnetic pulses to stimulate nerve cells in the are receiving hands-on, inarea of the brain that controls mood. Rapid teractive training alongside change in the magnetic field induces a current of physicians. They’re seeing sufficient amplitude and duration which in turn patients and conducting will excite the neurons. research.

Advanced Treatment for Major Depressive Disorder

VISION FOR THE FUTURE As Physician in Chief for one of the highestperforming health care systems in the nation, Jahromi is focused on building a network of

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No anesthesia required No memory loss No down time from normal activities Approved by the FDA Covered by most insurances & Medicare


www.depressionfresno.com CENTRAL VALLEY PHYSICIANS


Stories Matter How Narrative Medicine Is Socializing The Art Of Healing



arrative Medicine: I have heard of that, but what is it? I often get asked this question. As a master’s student of Narrative Medicine, I am still trying to hone in on the best response to that question. For many, Narrative Medicine (NM) is not a novel concept. We have watched movies or read books of doctors helping, listening, or learning from patients as they wrestle with their illness. Many writers like William Carlos Williams, Abraham Varghese, or Rita Charon have authored stories that convey the art of healing. In Rana Awdish’s “In Shock,” a physician chronicles her own journey of becoming a patient in her last



years of training. As the roles reverse, the fractured disparities of doctor-patient interactions become real. She calls upon the need for doctors to be present, “bearing witness to the patient’s pain”. Just like an artist, a clinician should train “to see the negative space on a canvas… The healing potential of medical knowledge is magical. It is also a lie. Medicine cannot heal in a vacuum, it requires connection…” The alliance we make with patients goes beyond what providers opinionate with just diagnosis, treatment, and plans. Caring for patients is fostered with attentiveness.

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In NM, the student learns the skill of dwelling deeply her, but these were tears of joy. She later told me that she could into the literary work by close reading, observing and/or now see him without the label, and celebrate his birth. He had listening. The close reader studies the elements of “temporality, brought a special beauty into her life. narrative situation, voice, metaphor, and mood” (Rita So, is NM an amalgamation of medical knowledge and Charon) and applies this methodology to “ enter into” the humanism in medicine? Have we lost touch with realness patient’s experience. Just like a lens, NM gives the observer the and connections to the lives of our patients? I don’t have the apparatus to focus on the struggle the patient may feel in that answers just yet. However, I do know that if we practice close fractured, ambiguous space. listening and observing “like a reader,” we can interface better While working overseas in the Middle East as a hospitalist with the people we care for. As Rana Awdish writes, “…to in an academic training pediatric hospital, I was rounding inhabit that vulnerable space…patients and families desire to on a 5-day-old newborn baby admitted for a complicated be seen and to be heard.” When we permit ourselves to share congenital esophageal atresia. I breezed into the patient’s “ M amma, What difference does it make what his diagnosis hospital room. I glanced at the is? He is your child, your son. He has beautiful brown eyes, neonate and noted that this baby boy had features of Down soft skin, and a gentle gurgled smile, like an angel. You love Syndrome (DS). We ordered him; care for him the same if not more. His having Down confirmatory genetic testing. Days later, with the positive Syndrome, a disorder, a genetic condition, does not change results, we told the Bedouin that.” - Dr Alya Ahmad mother, at the infant’s bedside, that her last son of 9 children had Down Syndrome. Although illiterate, she immediately a bit of that precarious space with our patients, we may be able retorted with, “Is he a Mongoloid?” In the West, the term to comprehend their story. My answer, thus, is that NM is one Mongoloid is antiquated and offensive, yet in the Middle East, methodology that we as providers can use to integrate the it remains a commonly used term to how DS is recognized. stories of medicine into the practice of it. Stories can heal. After his discharge, I continued to monitor his pediatric Stories provide perspective. Stories are how we engage with care in my clinic. At each visit, the mother persistently quizzed the narrative of our patients. The insight into their lives is me about his diagnosis. Each time, I would detail his genetic revealed from their account. Stories are descriptive, creative, testing, display pictures, diagrams, and the karyotype studies and exploratory. Stories can be inspirational. The reader’s quest to assure her the accuracy of his condition. Yet, she remained is often to engage with the writer, and ruminate on the artist’s unimpressed with my exhaustive details. It was her 5th visit to purpose. Stories also reveal. We often see ourselves in our the clinic, and her recurring interrogation about his diagnosis patients; their apprehensions are not far from our own. continued. Ready to regurgitate my medical jargon, I looked Many are taking NM to write publicly or privately about into her charcoal, colored eyes. I paused for a moment. I issues related to taking care of people and the health care heeded to her pale constrained face, her furrowed frown, and system. By journaling and blogging on healthcare complexities, tense pursed lips-she looked as though she was still angry reflecting on clinical experiences, and raising awareness, one about this diagnosis. In that instance, I sensed what she wasn’t advocates to a wider audience. Stories have power. Thus, the asking and what she had been wrangling with. narrative of medicine is the art of storytelling in healthcare I said. “Mamma, What difference does it make what his and its integration into the art of healing. I invite you to share diagnosis is? He is your child, your son. He has beautiful brown your stories and experiences, in written, visual, or media form. eyes, soft skin, and a gentle gurgled smile, like an angel. You Stories matter. love him; care for him the same if not more. His having Down Syndrome, a disorder, a genetic condition, does not change Alya Ahmad, MD FAAP that.” Pediatric Hospitalist She glared at me. Then, blinking quickly her eyes filled, as www.thecontextofcare.com tears strolled softly down her face. She wept and I wept with

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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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Help for practices of all sizes: legal handbooks, practice mgmt. guides, patient education materials, etc.

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Local bank offering comprehensive banking solutions that help make the job of managing finances easier

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Financial advisors offering services in investment management, financial planning and retirement plans.

Stephen Guinn (559) 438-2640 www.regencyinvests.com

Get paid: members receive one-on-one assistance. We have recouped $16 million from payors in the last 10 years.

FMMS: (559) 224-4224 CMA: (888) 401-5911

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For information on becoming an FMMS Business Partner call 559-224-4224

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Match Day



March 15 is one of those dates that every physician knows all too well—it’s MATCH DAY. The term widely used in the medical community to represent the day when the National Resident Matching Program (NRMP) releases results to applicants seeking residency and fellowship training positions in the United States. According to the NRMP, this year the Main Residency Match celebrated its largest in history, with a record 38,376 US and international applicants listing program choices for 35,185 positions. The number of available first-year (PGY-1) positions rose to 32,194, an increase of


1962 (6.5%) over 2018. The influx of positions is due, in part, to the increased numbers of osteopathic programs that joined the Main Residency Match because of the ongoing transition to a single accreditation system for graduate medical education programs, the NRMP noted. “Match Day is a rite of passage for medical school graduates as they learn where they will spend the next three to seven years of their lives living, working and caring for patients and fine tuning the skills necessary to be excellent patient care providers and advocates,” said Michael W. Peterson, MD, associate dean at UCSF Fresno.

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In the central Valley, our residency programs filled all open positions and this summer we will have 128 new residents and 18 fellows adding to over 300 residents currently in the area. UCSF Fresno residency programs received 5,654 applications and conducted 1,092 interviews for 91 residency positions. Saint Agnes Medical Center’s Physician Residency Program reviewed 1430 applications and conducted 289 interviews for 24 positions. All positions filled were from the top 25 residents on the rank list. Valley Children’s interviewed 140 candidates for only 13 “AN AIM OF SAN positions. JOAQUIN VALLEY “It is truly our privilege as PRIME IS TO TRAIN Valley Children’s doctors, PHYSICIANS FOR nurses and team members OUR UNDERSERVED to work with this remarkable REGION AND TO group of new physicians and INCREASE THE future pediatricians as they DIVERSITY OF begin the next phase in their THE PHYSICIAN education.” says Dr. Jolie WORKFORCE.” Limon, Valley Children’s Chief of Pediatrics and Executive -KENNY BANH, MD Director, Medical Education. Of the 128 new residents coming to the area, five are UC Davis SJV PRIME medical students. These students include: • Monique Atwal is from Selma and a graduate of the UCSF Fresno Sunnyside High School Doctors Academy and UCLA. She will be pursuing psychiatry. • Kenneth Job is from Fresno and a graduate of Buchanan High School and UC Davis. He will be pursuing family medicine. • Neetu Malhi is from Fresno and a graduate of Central High School’s East Campus and Fresno State. She will be pursuing internal medicine. • Stephanie Melchor is from Visalia and a graduate of El Diamante High School and UCLA. She will be pursuing obstetrics and gynecology. • K ristine “KC” Ongaigui is from Fresno and a graduate of the UCSF Fresno Sunnyside High School Doctors Academy and Stanford. She also is an alumna of the UCSF Fresno Summer Biomedical Internship Program. She will be pursuing pediatrics.

Council member Nelson Esparza representing District seven in the City of Fresno hands out certificate of recognition to the SJV PRIME students

“An aim of San Joaquin Valley PRIME is to train physicians for our underserved region and to increase the diversity of the physician workforce,” said Kenny Banh, MD, assistant dean for undergraduate medical education at UCSF Fresno. “These

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Neetu matched with UCSF Fresno and will be pursuing Internal Medicine CENTRAL VALLEY PHYSICIANS 41

Kenneth Job is from Clovis and a graduate of Buchanan High School and UC Davis.

Monique Atwal from Selma and a graduate of the UCSF Fresno Sunnyside High School Doctors Academy and UCLA.

Stephanie Melchor from Visalia and a graduate of El Diamante High School and UCLA, matched at Stanford.



graduating students are from the region and have an ultimate interest in practicing medicine in the Valley or working with underserved populations. We are incredibly proud of them and we’re excited to celebrate their future.” Saint Agnes will be adding first year residents to its new Family Medicine residency program while the Internal Medicine residency celebrates their second year with a successful match of 12 residents, including 4 preliminary physicians who will train for a year and move on to their subspecialty training. The majority of Saint Agnes incoming interns are natives to California, including a husband and wife team and handful from the Central Valley. • Adam Danielson is from Fresno and was born at Saint Agnes Medical Center. • Nancy Dang, and her Husband Kevin Orita, will complete their Doctor of Medicine degree at St. George University in May and are natives to Laguna Hills, CA. • Manpreet Sigh is from Reedley and received his Doctor of Medicine at Ross University. • Sarbjot Grewal is from Fresno and received her Bachelors of Medicine and Bachelors of Surgery degree at Dayanand Medical College in India. • Namitha Malakkla is from Fresno and received her Doctor of Medicine degree from the American University of the Caribbean School of Medicine. Fresno Residency programs continue to recruit talented residents from top medical schools, to help serve our growing population and the physician shortage we are still struggling with in the Valley. “Though the shortage continues to outpace our progress, we’re moving forward in the right direction each year,” said Hemant Dhingra, MD program director for the Saint Agnes Medical Residency Program. “Our patients and communities need more residents in order to care for our growing population, it is important to recruit talented students that have a connection to the region.” Dhingra continues.

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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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Public Health


The Power of Prevention BY SARA GOLDGRABEN, MD

With a sink overflowing of chronic diseases such as heart disease and obesity, we can continue to mop up the floor like we have been doing for decades in the United States, or we can work upstream to turn the faucet off or at least slow it down. I’m Sara Goldgraben, MD, MPH, MBA and I’m a Board Certified Preventive Medicine and Public Health Physician. I attended New York Medical College and completed my residency in General Preventive Medicine and Public Health at Stony Brook University Medical Center in New York. I completed a dual Masters of Public Health and Business Administration from Stony Brook University. In August 2018, I became the Health Officer for Fresno County in Central California. The mission of Fresno County Department of Public Health (FCDPH) is the promotion, preservation and protection of the community’s health. We accomplish this through identifying community health



needs, assuring the availability of quality health services and providing effective leadership in developing public health policies. We are committed to working in partnership with our communities to eliminate health disparities. At 6,000 square miles, Fresno County is the sixth largest county by land mass and tenth largest county by population in California. The United States Health Care system is very good at managing the acute diseases, but what about chronic diseases which are preventable and make up the majority of the leading causes of death? With the baby boomer generation getting older and needing more care and a young population with high rates of obesity and other chronic diseases such as diabetes and heart disease, we really have a high workload and there are a large number of physicians

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who are burned out. Since the model has been fee for service for so long without an emphasis on healthy lifestyle and prevention, we are overloaded with disease even in the younger population. In Public Health we are doing our best to work upstream and help slow down the large burden. But it will take time before the effects are seen.

It’s much better to be proactive with our health early on and preserve what we have. We should be teaching patients how to live a healthy lifestyle and encouraging them to have their children live a healthy lifestyle when they are young. If we can keep ourselves healthy by making good choices before we get sick, we will be able to enjoy a better quality of life for much longer.

Access to care and a physician shortage means people go without seeing a doctor for years. This is a real problem as seven out of the top ten leading causes of death, are chronic disease like diabetes, heart disease, and cancer. When you see a doctor early on they can help you to prevent disease by doing screening exams based on things such as your age, risk factors, and routine lab work. When you lack access to care, by the time you notice a problem, the disease is sometimes very advanced and more difficult to treat. Patients have advanced disease from never seeing a provider in years and not knowing what they could do to live a healthier lifestyle, such as not smoking and drinking. With education and knowledge, we can prevent disease or reduce the severity. This would improve quality of life. I once worked in a Veterans Affairs Medical Center in New York and went to speak to a diabetic patient about his smoking habits and to see if he was interested in our smoking cessation clinic. When I got to his bedside I noticed he had a below the knee amputation and he was waiting to be taken to the operating room to get an above knee amputation. When I mentioned if he had ever considered quitting smoking, he replied, “What’s the point? I already lost my limbs.” It was sad but I understood where he was coming from.

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Prevention is having access to clean drinking water, getting your vaccines to protect yourself from diseases, wearing your seatbelt every time, and putting your children in car seats which are properly installed to avoid severe injury or death in the event of a motor vehicle accident. Social determinants impact health care and health status and manifest as health inequities. The health challenges are far beyond what any one organization can address. The process of focusing priorities will allow for expanded opportunities to align limited resources and target strategies in communities where change is needed and people are primed for action.

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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.


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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.

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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. Continue Medical Education FMMS provides opportunities to further your knowledge with Continuing Medical Education. CME symposiums and dinner 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 1200 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. 48


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In Memoriam

In Memoriam DR. WILLIAM HASTRUP, JR. January 12, 2019

His greatest love and source of joy were his family relationships. He was a dutiful son to his mother, Louise Hastrup, loving husband to Gerry, and proud father of three children John, Kristen, and Mikael.

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Dr. William Hastrup, Jr. passed from this life on January 12, 2019 at his home in Fresno, California at the age of 67. He lived a life of service to the people of his community and country, filled with adventure, an optimistic personality and an engaging smile. He was the eldest son of the late William Hastrup, Sr. and Louise Hastrup, currently a resident of Fresno. He graduated Fresno High School in 1969 and received his undergraduate degree in Biology from UCSB followed by his doctorate of medicine from UCLA. From 1978 to 1982, Dr. Hastrup served as a naval officer and flight surgeon connected to Fighter Squadron 124, a tactical unit training aircrews to fly F-14 Tomcats. Dr. Hastrup concluded his naval service in San Diego, where he met an attractive young nurse named Geraldine “Gerry” Simpson who became his wife in 1981. The couple then moved to Seattle, Washington, where Dr. Hastrup completed his radiology residency and fellowship at the University of Washington. In 1986, Dr. Hastrup returned home to Fresno and joined Wishon Radiology, working primarily

at Valley Children’s Hospital until his retirement in 2018. He also held a faculty appointment as assistant clinical professor of radiology at UC San Francisco for 20 years, and served on the UCLA Medical Alumni Association Board of Directors. Dr. Hastrup loved the outdoors and maintained an active lifestyle, running the Boston Marathon in 2016, 2017, and 2018. He loved to travel the world over, entertain friends, participate in philanthropic activities, and teach and encourage medical students to follow in his footsteps. He was a member of Westminster Presbyterian Church. His greatest love and source of joy were his family relationships. He was a dutiful son to his mother, Louise Hastrup, loving husband to Gerry, and proud father of three children John, Kristen, and Mikael. He was a caring brother to his siblings, Jane, Erik, and Elisa. He especially loved his five grandchildren, Kate, Elizabeth, Joshua, Henry, and Ramona. Dr. Hastrup was a member for the Fresno Madera Medical Society for 35 years.



y g o l o r h p e N o n s e Fr

n o i t a d n u o F y e n Kid

Fresno Nephrology Kidney Foundation is a local 501(c)(3) nonprofit organization that is committed to improving the lives of those affected by kidney disease. Our organization achieves this objective by bring awareness with early detection and education. Our mission is to help prevent kidney disease and support those affected. We focus our services and support in the local community. Through these services we have a spectrum of programs such as life style activities to keep active, access to vetted resources, direct financial assistance, local support groups and a platform for peer engagement. We collaborate with local healthcare providers and business partners in the related industry so that we can maximize our reach to resources.



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Our board of directors are an eclectic group of individuals who are impacted by kidney disease in one way or another. They bring in an array of ideas and prospective to help the foundation execute its mission. The Fresno Nephrology Kidney Foundation hosts multiple events throughout the year to help achieve its objective. We hold fun and interactive events such as: • A nnual Kare for Kidney Race • Kidney Awareness Health Fair • Support Group • Direct Financial Assistance • Transportation Voucher • Education Resources

We hope to make a meaningful impact on the community. For more information please contact us. 7726 N. First Street Box 275 Fresno, Ca 93720 (559) 776-8481

www.facebook.com/Fresno-Nephrology-Kidney-Foundation www.FresnoNephrologyKidneyFoundation.org


Nephrology Symposium 2019 4.0 CME Saturday June 1, 2019 7:30 am - 1:00 pm Bitwise Industries 700 Van Ness Avenue Fresno, CA Accreditation Statement: The Fresno Madera Medical Society (FMMS) is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medicaleducation for physicians.

Register at fmms.org

Credit Designation Statement: FMMS designates this live activity for a maximum of 4 hours AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Spring 2019




Good news for anyone who can’t stand waiting

Focus on Metabolic Diseases

When you’re injured or ill, a month Providing the most contemporary data andcan seem like an eternity to waittofor appointment. evidence-based approaches thean evaluation and treatment of disorders commonly

Fortunately, we offer same- or next-day appointments, encountered in primary care medicine extended hours and a range of services to address your needs.

with an underlying focus on metabolic health.

Need a physical? We’ll get you one within the week. Saturday, Julyschedule 13, 2019 It’s primary care on your – available right here 7:30 a.m.– Noon in Fresno and Clovis. Call (559) 450-7267 to schedule an appointment Saint Agnes Medical Center with a physician at one of our Saint Agnes Care sites. Shehadey Pavilion 1303 East Herndon Avenue, Fresno, California

And for those unexpected illnesses and accidents that For more details, visit happenwww.samc.com/medical-education after-hours and on weekends, we offer urgent care When you’re confident you’ve chosen the right at two convenient locations. hospital for your maternity care, you’re free to think of just For about anything. It’s why so many more information, visit samc.com/urgent-care. women choose Saint Agnes Medical Center. Along with all-private rooms, we partner with more convenient. Medical care has never been Valley Children’s Healthcare to give you and your baby access to a Level III NICU and one of the top maternal fetal medicine programs around.


Saint Agnes Medical Center Visit www.samc.com to learn how peace of mind is just one of the many things we deliver.

Saint Agnes Care



Saint Agnes Care locations to meet your primary care needs: Avecinia 2006 Shaw Ave., Clovis 93611 LQMG 1221 E. Spruce Ave., Fresno 93720 Northwest 4770 W. Herndon Ave., Fresno 93722 Surinder P. Dhillon Internal Medicine 6079 N. Fresno Street, Ste. 101, Fresno 93710

Saint Agnes Urgent Care (559) 450-CARE (2273) Northwest 4770 W. Herndon Ave., Fresno 93722 Main Campus 1245 E. Herndon Ave., Fresno 93720 Most insurance plans accepted

Spring 2019

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