Central Valley Physicians Summer 2018

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Summer 2018


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Some Days I Hate My Job

CHSU Groundbreaking and Grads 2018 UCSF Fresno Graduates Rare Disease

Dragon’s Tongue

Summer 2018



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Summer 2018



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From The Executive Director

“WHAT DO I GET FOR MY MEMBERSHIP?” One question I get asked regularly by doctors is, “What do I get for my membership?” “Every doctor practicing in the state of California owes this legacy of a stable malpractice insurance market to the CMA.” That is a quote from a past FMMS president. Such a true statement; I wonder NICOLE BUTLER what one’s malpractice insurance would cost a year if negligence lawsuits had a cap of 1 million rather than the current $250,000? I am guessing a lot more than one year of membership dues. Was there another medical association in California that went after the tobacco industry and WON? The simple answer is -- NO, because once again, CMA did the filing, fighting and fundraising to get Prop 56 passed in the state, raising BILLIONS for practicing physicians. Yes, you are reading that right…BILLIONS. Is there another organization out there that helped increase Medi-Cal reimbursement to physicians in the state, or provided $40 million in funding for graduate medical education (GME)?

PRESIDENT Trilok Puniani, MD PRESIDENT-ELECT Cesar A. Vazquez, MD VICE PRESIDENT Alan Birnbaum, MD TREASURER Don Gaede, MD PAST-PRESIDENT Alan Kelton, MD BOARD OF GOVERNORS Christine Almon, MD, Andres Anaya, MD (Resident Board Member) Janae Barker, DO, Jennifer Davies, MD Joseph Duflot, MD, Patrick Golden, MD David Hadden, MD, Prahalad Jajodia, MD Brent Kane, MD, Shamsuddin Khwaja, MD Christine Maser, MD, Katayoon Shahinfar, MD Nadarasa Visveshwara, MD CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS EDITOR Don Gaede, MD MANAGING EDITOR Nicole Butler EDITORIAL COMMITTEE Don Gaede, MD - Chair, Alan Birnbaum, MD - Associate

And most recently, CMA successfully killed Assembly Bill 3087 (Kalra) that was the legislation that would have created a commission of unelected political appointees, not even doctors, to randomly cap rates for all health care services in clinics, hospitals and physician practices in California. Can you imagine someone telling YOU how much you are going to charge for services? My point is these “things” are in the best interest of our members. Therefore, I get confused when asked that question “What do I get for my membership?”. From now on, my response will be simple – How can you afford NOT to be a member? Who else is going to have your back? Who else is protecting your profession? Therefore, the next time you see a dues invoice from FMMS/CMA, please understand we are working daily to improve the status of your profession. I can guarantee you are getting your money’s worth it. On another topic, Fresno Madera Medical Society officially launched its Central Valley Physicians Podcast. The medical society created the podcast for valley residents to hear more about wellness and health from doctors in the Central Valley. We will be releasing a new podcast topic every week, on Wednesdays. They are currently on iTunes, the FMMS Facebook page and the FMMS website. Please encourage your patients to listen to them. If you would like to record a couple of topics, please call the medical society or email

Editor, Roydon Steinke, MD, Cesar Vazquez, MD, Nicole Butler, Trilok Puniani, MD CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Don Gaede, MD, Erin Kennedy, Mary Lisa Russell, Katherine Boroski, Ted Hard, MD, Anjani Amladi, MD and Nicole Butler CONTRIBUTING PHOTOGRAPHERS Anthony Imirian, Erin Kennedy and Nicole Butler 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 Marketing and Events Coordinator, Kailey Fontes Membership and Events Manager, Stacy Woods

Sincerely, Nicole Butler



Receptionist, Becky Gentry

Summer 2018






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Summer 2018




A message from our Editor > Don H.Gaede, MD

Why We Are Members

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.

We recently witnessed another demonstration of why we physicians need to be part of the California Medical Association. Assemblyman Ash Kalra’s bill to cap medical prices was defeated because physicians banded together in opposition. Had it not been for the CMA, the bill might have become law. We can all agree with Mr. Kalra that healthcare is too expensive in this state and in this country. We have the most expensive healthcare system in the world, and some of the poorest outcomes among First World nations. Kalra’s solution? Set up a 9-person commission that would put caps on fees charged by hospitals, physicians, and dentists. Like using a machete to remove a gallbladder, AB 3087 proposed the blunt instrument of price caps to bring down healthcare costs. It would have done more harm than good for healthcare in California. It would not have done anything to address the out-of-pocket healthcare costs. It would not have helped increase Medi-Cal reimbursement rates, among the lowest in the nation. It would have driven many physicians out of California, while making recruitment of new physicians more difficult. There is no one villain driving up healthcare costs in America. The Bipartisan Policy Center, a think tank which “believes the American answer will always rest in harnessing the best ideas from both parties,” lists 13 reasons why we pay more for healthcare than any country in the world. Elizabeth Rosenthal’s excellent book An American Sickness (a New York Times best-seller and one of The Wall Street Journal’s Best Books of 2017) lists 11 separate causes of our high healthcare costs, and 6 different ways to address them. Suffice it to say that when it comes to explaining our country’s high healthcare bill, there is plenty of blame to go around: •T he patients. We Americans are getting older, fatter, and less active. Baby boomers are turning 65 at a rate of 10,000 per day, and will continue to do so for the next 15 years. Americans are not exactly renowned for their healthy



Summer 2018

“We recently witnessed another demonstration of why we physicians need to be part of the California Medical Association. Assemblyman Ash Kalra’s bill to cap medical prices was defeated because physicians banded together in opposition.”

eating and exercise habits. We all want new drugs and procedures. Both patients and doctors demand the newest treatments, even if there is often little evidence that they are better. Inevitably, prices for newer treatments are higher than for the older ones.

•T he pharmaceutical companies. Drugs cost more here than anywhere else in the world. This is true for brand name drugs as well as generics. Medicare covers drugs under Part D, but because of lobbying by drug companies, it can’t negotiate prices. Drug companies often work to suppress competition between manufacturers of generic drugs.

•T he physicians. Physician salaries amount to about 10% of total healthcare costs in American, so even if physicians worked for free, healthcare costs would barely budge. Fee-for-service reimbursement incentivizes doctors and other healthcare providers to perform more procedures, often without regard to whether the patient’s health is enhanced. Quality-based reimbursement makes much more sense, but is very difficult to implement in a fair way. Also, we physicians prefer to enter high-paying specialties as opposed to primary care.

•T he hospitals. Healthcare systems are consolidating, decreasing competition for lower prices. Hospital charges often lack transparency for their patients.

Summer 2018

•T he insurance industry. UnitedHealth Group Inc., our nation’s largest private health insurer, earned more than $200 billion last year, with a gross profit margin of 24%. The CEOs of American health insurance companies are not only paid extremely well ($10-20 million/year, but much of their pay is in stock options. This means they are incentivized to enhance the price of their company’s stock, as opposed to lowering the cost of medical care. Although the Affordable Care Act set the administrative cost limit (medical loss ratio) at 80-85%, commercial insurers still spend significantly more on administration than Medicare.

• T he lawyers. Physicians sometimes order extra tests to avoid malpractice suits, driving up the cost of medical care without increasing quality. •T he system. Patients don’t have enough information to make decisions on which medical care is best for them. Buying healthcare is not like buying a used car; you can’t take your doctor or your hospital on a test drive. And for many people, the Affordable Care Act did not make healthcare more affordable. Assemblyman Kalra is asking the right question: How do we make healthcare less expensive for Californians? But AB 3087 was the wrong answer. We need to partner with our colleagues in the California Medical Association, and come up with truly affordable healthcare for all Californians.




California Health Sciences University recently broke ground on the next phase of the University’s Health Care vision for the Central Valley. A 70-acre piece of dirt will soon transform in to Fresno’s first medical school. It’s a dream come true for members of the Assemi family of Fresno. “This will change the Central Valley forever,” said Farid Assemi. “Providing a place for student in the Valley to go, a place for them to learn” Assemi continued. The University unveiled the design concepts for their first building. The new campus will start with a 90,000 square-foot building that will be three-stories and will feature a state-of-the-art simulation center, osteopathic skills lab, a large classroom with capacity for 300 students, and a second classroom with 200-student capacity. The new building will also include a library, student lounge with ample study spaces, faculty offices, and professional kitchen for educating students and the community about healthy meal preparation. >>


CHSU New Campus Northwest Elevation


As the construction begins, they will be working towards the goal of opening the College of Osteopathic Medicine in fall 2020, this will be dependent on completing the accreditation process successfully. The CHSU proposed College of Osteopathic Medicine is not able to solicit or accept applications for students until pre-accreditation is achieved. University officials also announced their plans to open up to 10 post-baccalaureate colleges to train health care professionals in the coming years. The timing and specific discipline for each new school will be determined based on the need and opportunity for job placement within the region.


A week after the groundbreaking, California Health Sciences University hosted their first College of Pharmacy Graduation. The ceremony for 62 Doctor of Pharmacy graduates, that started attending the school when it opened

in 2014. With more than half of their students from the Central Valley, the majority have already reported accepting job offers. Upon passing their board licensing exams, more than 80% of those with jobs will be working as pharmacists in the Central Valley. President Florence T. Dunn addressed more than 1,100 guests including graduates’ family, friends and colleagues; faculty and staff members and the Board of Trustees. The keynote address was delivered by Senator Edward Hernandez, OD. “Our first graduation marks a major historical milestone for our University,” said Florence Dunn, President of CHSU. “We are honored to celebrate the addition of 62 new pharmacists into the health care profession, many of whom will serve our local region.” Through both of these significant events, California Health Sciences University has taken big steps achieving the mission of helping remedy the shortage of health care providers in the Central Valley. The momentum continues as the College of Pharmacy welcomes the class of 2022 this fall.

C H SU C OL L E GE OF P H A R M AC Y C L A S S OF 2018 GR A DUAT E S: Kwabena Adarkwah

Daisy Lieu

Amir Afshar

Henna Mahal

Giovauna Alberre

Clifton McKinney

Fadhl Ali

Julio Cesar Mercado

Mina Al-Shahed

Harjoyt Mohar

Shadi Sahara Asayesh

Tsigereda Mulugeta

Hanin Atalla

Jankhna Nadkarni

Mher Attarian

Allen Keshishian Namagerdi

Kathryn Estaya Baeza

Lien My Thi Nguyen

Pawan Bagari

Minh Nguyen

Raju Bashar

Janik Oganesyan

Fouad Boulbol

Faith Olivares

Sharon Brar

Lauren Soojung Park

Hiwan Brhena

Krishma Patel

Jessica Wing Han Chan

Sean Patel

Doris Cheung

Seema Rai

Anabell Duclayan Corpuz

Vigil Beth Rapiz

Trang Duong

Katayoon Samadi

Michael Farr

Adam Jafer Shah

Roberto Garcia

Hayley Shuman

Varduhi Grigoryan

Nancy Thai

Cody Guenthart

Edwin Thao

Ngaumomy (Amy) Heu

Jasmin Thind

Yuqin Hu

Amanpreet Toor

Clare Jeon

Daniel Danh Truong

Hemjot Kaur

Naly Vang

Manpreet Kaur

Carolina Castillo Velez

Sann Lao

Chong Yang

Dong Chinh Le

Kang Yang

Nghia Tan Le

Harry Yegiazaryan

Cuihong Leung

KC Diane Yovino

CMA defeats dangerous rate setting proposal AB 3087 would have decimated California’s health care delivery system BY KATHERINE BOROSKI

In late May, the California Medical Association (CMA) killed a reckless legislative proposal that would have put a new government bureaucracy in charge of health care. Assembly Bill 3087 (Kalra) would have created a commission of unelected political appointees empowered to arbitrarily cap rates for all health care services in all clinics, hospitals and physician practices in California. By unilaterally setting the price for all medical services, the bill would have essentially eliminated the commercial health care market in California. Due in large part to staunch opposition led by CMA, the bill died in the Assembly Appropriations Committee. “No state in America has ever attempted such an unproven policy of inflexible, government-managed price caps across every health care service,” said CMA President Theodore M. Mazer, M.D. “Had this bill passed, it would have reversed the historic gains for health coverage and access made in California since the passage of the Affordable Care Act.” Since passage of the ACA, the state’s uninsured rate has dropped to an all-time low of 7.1 percent.



Spring 2018

A Groundswell of Physician Opposition Key to the bill’s demise was a groundswell of physician opposition. Through CMA’s Grassroots Action Center, thousands of physician members contacted their legislators because AB 3087 would have: • Decimated California’s health care delivery system. • Disrupted care and limited choice for millions of California patients. • Caused 175,000 health care workers to lose their jobs. • Forced hospitals to close and pushed health care providers into early retirement • Caused a “brain drain” of talented medical students and residents fleeing California for more ideal working conditions.

The Wrong Answer to a Real Problem This poorly conceived legislation would have done nothing to solve the fundamental problems of the health care payment system. “Simply setting physician rates without addressing the rising cost of providing care will do nothing to address health care spending,” said San Francisco pediatrician Shannon Udovic-Constant, M.D., vice chair of the CMA Board of Trustees. “AB 3087 would have driven a lot of physicians out of our state, and it doesn’t address the underlying reasons around rising health care costs in our state.” This dangerous rate setting proposal would have also moved California away from value-based care and universal access, backwards to an antiquated fee-for-service model that discourages contracting and stifles innovation. Instead of addressing the underlying issues, this bill would have forced hospitals to close, pushed health care providers into early retirement and caused a “brain drain” of talented medical students and residents fleeing California for more ideal working conditions.

Medicare Should Not Be a Benchmark for Costs AB 3087 would have required the commission to cap prices for commercial payments for all services to Medicare rates, which is a fundamentally flawed approach that does not address coverage and benefits or the costs to provide care. Medicare was created to reimburse medical services for an age-specific population based on federal budgetary and regulatory constraints. Medicare rates do not keep up with inflation or the cost of running a practice. Adjusted for inflation in practice costs, Medicare physician pay has declined 19 percent from 2001 to 2017, or by 1.3 percent per year on average. Medicare rates are not intended to represent the fair market value of health care services. Rather, they fluctuate based on variables unrelated to the services provided, such as the federal budget.

AB 3087 Did Not Address Medi-Cal Rates Medi-Cal is the largest Medicaid program in the nation, with 13.5 million people—about one-third of the state’s population—enrolled in the program. And yet, California still pays among the lowest reimbursement rates of all 50 states, creating a serious access issue for patients. California’s Medi-Cal rates don’t come close to covering the cost of providing care—meaning that physicians lose money for every Medi-Cal patient they serve. Due to low Medi-Cal rates, physicians must make up revenue through their commercial contracts to keep their doors open. Because the AB 3087 proposal did nothing to address California’s substandard Medi-Cal rates, hospitals and health care providers would have continued to be underpaid by these governmental programs, putting them in an untenable situation.

AB 3087 Would Have Driven California’s Physicians Out AB 3087 also ignored the recommendations from the University of California, San Francisco’s report—commissioned by the Assembly—to achieve universal access to health care, which includes implementing a comprehensive strategy to overcome the physician workforce shortage in the state by removing barriers that prevent physicians and other clinicians from specializing in primary care and practicing in underserved areas. Currently, six of nine California regions are facing a primary care provider shortage, and 23 of California’s 58 counties fall below the minimum required primary care physician-to-population ratio. The state needs 8,243 additional primary care physicians by 2030—a 32 percent increase. “AB 3087 would have caused an exodus of practicing physicians, which would exacerbate our physician shortage and make California unattractive to new physician recruits,” said Dr. Mazer. “When I look at the economics of my own practice, it’s enough to tell me that I could not survive that environment and continue to see Medi-Cal patients. And probably at this stage of my career, it would drive me out of practice earlier that I might otherwise.” The bill also operated on the false premise that the cost of professional services—in other words, what physicians and hospitals charge for their services—is what’s behind the increase in health care spending in California. Data shows, however, that the price of prescription drugs and increases in health care utilization are what’s driving health care spending growth. Professional services had relatively low impact on spending growth. In fact, nationally, California had lower than average annual growth in per capita spending on physician and clinical services over the past 20 years. The primary driver of spending on doctor visits is increased utilization, not price. “Physicians want real solutions to these problems too,” said Valencia Walker, M.D., chair of the CMA Council on Legislation. “We remain focused on real solutions that would protect the access and coverage gains made under the ACA, further value-based care, ensure patients can access health care in a timely and affordable manner, and tackle California’s health care workforce shortage.”

California Physicians: Thank You for Your Support “I want to thank each of you for your support and dedication to CMA,” said Dr. Mazer. “We could not have dealt this bill such a resounding defeat without the united voices of our physician members. Together, we stand stronger.” CMA applauds the Assembly for recognizing that this deeply flawed legislation would result in enormous costs to the state and restricted access to care for millions. CMA remains fully committed to working with stakeholders on a practical solution that addresses the affordability and accessibility of health care in California.

Join the Fight to Protect Medicine Your voice is key to our success. All you need is the desire to make an impact, and CMA will give you the rest. Join CMA’s Physician Advocate Program today! Learn more at www.cmanet.org.



Mary Lisa Russell

The odds were against Jennifer Luciano surviving delivery of her baby girl – a diagnosis of pulmonary hypertension (PH) left her with a high chance she wouldn’t. It was touch and go for a while but a multidisciplinary team of physicians at Community Regional Medical Center (CRMC) gave Luciano a second chance at life – and being baby Kamryn’s mom. Pulmonary arterial hypertension (PAH) is a rare disease to start with but to see a pregnant PH patient is even more uncommon according to Dr. Vijay Balasubramanian, medical director of the UCSF Fresno Pulmonary Hypertension program at CRMC. Women are at higher risk for pulmonary hypertension and the causes are broad – anything from autoimmune disease, the use of diet pills or even drug abuse. Dr. Balasubramanian said deterioration in pregnancy is reported to occur between the 20th and 24th weeks of gestation, early in the third trimester, and in the postpartum period. Sudden hemodynamic instability is associated with a high maternal mortality. He said in such cases, right ventricular failure is the most common cause of death. “If you ask people treating PH patients or look it up in literature, it’s not like they’ll have 100 or 150 cases that you may find,” said Dr. Balasubramanian. A 2012 Journal of Pulmonary Medicine article found pulmonary hypertension in pregnant patients carries high mortality rates – between 30 to 56%. And in another recent study – the largest from 13 participating PH centers from Europe, the United States, and Australia – reported data was from only 26 pregnancies. In the 10 years since he started the PH program at Community Regional, Luciano’s is the first Dr. Balasubramanian has seen. He cautioned that although the outcome was successful this was incredibly risky and not recommended for a PH patient. However, in Luciano’s case, she was halfway through her pregnancy before being diagnosed with PH. “As much as we would love to have these success stories on a regular basis, we strongly discourage young women who are unfortunate enough to have this condition to get pregnant,” he said. >>





When Dr. Balasubramanian first started treating Luciano, her arteries were hardened and she wasn’t getting enough oxygen in her blood. This raised her blood pressure causing strain on the right side of her heart. Luciano was past 24 weeks in her gestation and was bearing a viable baby. Dr. Balasubramanian knew there was no time to waste so he immediately gathered the medical experts he needed at CRMC to safely see his patient through delivery. Data suggest that outcomes of pregnant patients have improved with the availability of new PAH therapies, advances in surgical and perioperative management and use of a team-based, multidisciplinary approach. The data is based upon small case series from expert centers.

MULTIDISCIPLINARY MANAGEMENT “I got the patient into the hospital around 24 to 25 weeks and put her on Prostacyclin therapy which was the best way to treat her. She was on my PH floor in the hospital and was electively being followed up by the perinatologist getting fetal scans every day. So it was a coordinated effort.” Dr. Balasubramanain said it was important to get the highest expertise in perinatology, obstetrics/gynecology and neonatology to ensure the health of the baby, and then involve the cardiothoracic anesthesia expert, the extracorporeal membrane oxygenation (ECMO) team as back up, and to devise a plan as to when to deliver the patient. “The longer she remained pregnant, the worse it was for her and the higher the chance she would have a poor outcome,” he said. Perinatologist Bryan Morgan said Dr. Balasubramanian made

it very easy to coordinate the care of the patient. Dr. Morgan is an assistant clinical professor, UCSF, and medical director of the University Women’s Specialty Center. “It was an unusual patient but we always use a team approach with high risk pregnancy cases,” he said. Obstetrician, gynecologist, urogynecologist Anubhav Agrawal said he had multiple meetings with Dr. Balasubramanian and the teams. “We had everyone on board so we knew what we were going to do,” said Dr. Agrawal an assistant clinical professor, UCSF Fresno. “We had anesthesia involved, trauma surgery, interventional radiology was involved – so many people to help this patient,” he said. With a plan in place the teams then met with the patient and her family. “The patient was paying attention to everything in detail because it was a complex situation. It clearly helped to have a patient that listened so carefully along with her family members. They wanted to understand every aspect,” Dr. Balasubramanian said. “They knew the pros and cons and were able understand all the complex explanations.” He said the teams spent a lot of time giving explanations and talking with the family because it was important to them as her physicians.

THE DELIVERY PLAN The physician teams decided it would be best to deliver the baby at 31 to 32 weeks giving baby Kamryn enough time to mature reasonably and to deliver her by C-section in an elective manner. That way it would be a quick procedure. Dr. Agrawal was the primary surgeon who did the actual C-section

and delivered the baby. “It wasn’t the C-section that was challenging, it’s just everything on a C-section has a risk of bleeding so you want to make sure you do things in a hemostatic efficient way,” said Dr. Agrawal. “I felt comfortable doing it, it’s just sometimes you don’t know what to expect when you deliver the baby and post-op bleeding.” That was a huge worry for Luciano and her physicians. If anything had gone wrong during the delivery, Luciano said having the ECMO team there to respond gave her a sense of relief and hope. Extra corporeal membrane oxygenation (ECMO) is artificial lungs and circulatory support – a life-saving measure in the unfortunate event of “acute right failure” during the intraoperative or perioperative period. The ECMO team was immediately available in the operating room as a precaution. Dr. Mohamed Fayed, assistant professor, pulmonary critical care, UCSF Fresno, was part of the ECMO team on standby. “Cases like these need a specialized center to be able to use all resources available to save the patient,” said Dr Fayed. “CRMC/ UCSF Fresno is capable of arranging all teams together to have the best outcome.” “Knowing this lifesaving team was at the ready and with me the whole time was comforting, truly a blessing,” said Luciano. Dr. Oji A. Oji, chair of CRMC’s department of anesthesia, was another integral part of Luciano’s team. He knew the case was very unusual, complex and high risk for both mom and baby. “It is always a pleasure when the desired outcome is achieved in these situations,” he said. “It was definitely an experience of a lifetime.” Dr. Agrawal’s primary concern for Luciano was how she responded after the baby was delivered. And could she survive with increased burden to the heart or complications. “We were all systematic on the day of the procedure,” said Dr. Agrawal. “This was a very rare case with a high chance of maternal mortality. Fortunately she healed very quickly and recovered nicely.” After the C-section the physician teams and clinicians kept careful watch on the patient and baby. “Every time we have a successful outcome it makes us feel good. That’s the joy of doing what we do,” Dr. Agrawal said. He said the case was a great example of team work with his fellow surgeons and doctors. “We all get along well … we work together to improve patient care,” he said.

A FUTURE TO LOOK FORWARD TO The care Luciano received was life-saving – a true miracle in her eyes. “I went from preparing for death to having a second chance in life,” she said.

It’s been just a little over a year and Luciano is in pulmonary rehabilitation and slowly returning to physical activity. Kamryn and her other daughters keep her busy and her family really helps her out. “I’m just so grateful and blessed to have had all those doctors taking care of me, saving me,” she said. “It really makes me appreciate every breath I take.”

SUMMARY OF RECOMMENDATIONS FOR PATIENTS WITH PAH AND PREGNANCY: • A lthough recent studies suggest improved outcomes in the modern era, maternal morbidity and mortality clearly remain high. • In general, patients with PH, particularly PAH, should be counseled to avoid pregnancy. • Given this high mortality rate, rapidly evolving treatment practices, and the need to make complex decisions, early referral to an experienced PH center, ideally one with experience in the management of PAH in pregnancy, is an essential part of care of the pregnant patient with PAH.



Summer 2018

Dragon’s Tongue Touched by the


Dr. Hard is an emergency physician at Petaluma Valley Hospital.

“Flames stream from its mouth; and sparks of fire leap out. Out of its nostrils goeth smoke as if from a boiling pot or caldron. Its breath kindleth coals and a flame goeth out of its mouth . . .”

Certain dates of historical importance often install themselves in our collective memory. Usually these are times of unexpected, catastrophic events with tragic consequences. Most of us remember where we were during the September 11, 2001, Twin Tower attacks. Likewise, older individuals recall exactly when they heard President Kennedy was assassinated on November 22, 1963. Before that, a few aging survivors still remember the “Day of Infamy” at Pearl Harbor, December 7, 1941. As physicians, we often recall patients we have lost, better than our successes. Perhaps nature has hard wired the human brain this way, as a protective mechanism for ancient man. Pain, fear, and loss have a special spot in our minds. In the distant past, the memory of a close, dangerous encounter (and future avoidance) may have been better for survival than the recall of a triumphant hunt. And thus the morning of October 9, 2017 would be indelibly seared in my mind. >>

(Description of a dragon, the Devil’s beast, from Job 41:19-21) TED HARD, MD

Summer 2018



On Sunday, the day before, I had driven 130 miles to Santa Cruz to retrieve a backpack I had lost coming off a flight from Alaska. After posting a number of texts in the Delta Airlines “Lost and Found,” I received an unexpected call from an Italian man who had found my backpack at the airport. He wondered if I wanted to pick it up. Why he waited three weeks to call is unclear. Still, I asked no questions and drove to Santa Cruz. Inside the backpack was a disk of wildlife photographs I didn’t want to lose. I returned to Santa Rosa in the early afternoon, driving Route 1 along the Pacific Coast Highway, past Pigeon Point and Pescadero, then north to Half Moon Bay. The temperature was a comfortable 65, winds 8 mph, with a partially overcast sky. Although the ocean seemed restless, it was a pleasant October day.1 Upon returning to Santa Rosa, we went out to eat with friends that evening, then retired early, hoping to start the week with a good rest. Nothing would prepare us for the night to come. At 1:30 in the morning the telephone rang. My good friend and retired physician Bob Scheibel called. He had woken to the sound of transformer explosions and found a fire working its way along the Foothills ridge. He thought he needed to leave. I got up and looked outside. There was no smell of smoke and no obvious sight of fire. I thanked Bob for “When we moved to Rocky Point in Fountaingrove his call and offered him a place to stay. At the time, I remember the wind seemed in 2007, a wildfire was the furthest thing from our particularly fierce. Inside, a gust had blown cup off a table. I walked through the house minds. I recall looking over the Santa Rosa Valley one aand closed all the windows. “What’s going lovely October morning, remarking to a neighbor on?” my wife asked. “Fire up in the Foothills — Bob may come down for a while.” that we were truly blessed”. Feeling safe and secure, and sure there was no pending danger to our Fountaingrove home, I made a potentially fatal mistake. I turned off the light and went back to bed. Californians are used to calamity. We have earthquakes from time to time. (Remember Napa, August 24, 2014, magnitude 6.0; and Loma Prieta, 1989, magnitude 6.9. By comparison, the “Great Quake” of San Francisco, 1906, was rated as magnitude 7.8). Wildfires also char the landscape. The Oakland Hills fires of October 1991 killed 25 people, destroyed 2,800 homes, and remains in our distant memory. Likewise, the Valley fire in Lake County on September 12, 2015, which killed four people and destroyed 1,955 structures, came close. I drove through Middletown last year and noted the scattered signs of fire: charred trees, hillsides of burned brush; but the town seemed in the process of rebuilding, and the home sites that burned were mostly cleared. When we moved to Rocky Point in Fountaingrove in 2007, a wildfire was the furthest thing from our minds. I recall looking over the Santa Rosa Valley one lovely October morning, remarking to a neighbor that we were truly blessed. We were living in an area described by Luther Burbank as “the chosen spot of all this earth, as far as nature is concerned.” From my perspective, the location seemed incredibly safe. No worry about fire or floods, hurricanes, or tornados. The open space across from our home had few trees and the brush was frequently cleared. The only thing we might be concerned about was an earthquake. In preparation, I kept a large “earthquake” box filled with flashlights, water, blankets and supplies, just in case we lost power for a couple of days. My neighbor reminded me of an old joke: “If you don’t have earthquake insurance, just set your house on fire.” The concept seemed amusing at the time. Not so now. Missing from our hindsight was the Hanley fire of September 1964. This fire followed a remarkably similar path to the Tubbs fire, starting in Calistoga, fanned by wind, working its way west along Mark West Springs Road to Santa Rosa. Due to some heroic work by



Summer 2018

firefighters the old Community Hospital was saved, just as flames reached the hospital grounds. The Hanley fire was apparently started by a deer hunter in Calistoga who carelessly dropped a burning cigarette. No one was killed. The flames scorched an area of 53,000 acres and destroyed 84 homes. At Rocky Point, cardiac thoracic anesthesiologist Dr. James Finn was a friend and neighbor of mine. Jim had a Bay tree in his backyard, which still retained burn scars from the fire of 1964.5 Perhaps this should have been a warning. Cal Fire has posted fire danger zones over the years, and the Fountaingrove area of Santa Rosa remained a high risk zone marked in red on fire maps. Over the past two decades, builders, contractors, and buyers rarely considered the warning. The area was too beautiful, the views too scenic to pass up. The Fountaingrove Homeowners Association was even given an award for its meticulous clearing of brush and debris. Over time, builders erected a series of remarkable luxury homes along its ridges. The danger of wildfires seemed incredibly remote and homeowners were willing to take the chance. But Coffey Park? Coffey Park is in a highdensity, flat area containing 1,000 homes in western Santa Rosa across six lanes of open freeway. There is no way Coffey Park could have been a dangerous wildfire zone.

Summer 2018

There is a sharp knock on our door. It is two in the morning. The knock repeats loudly. “Hold on!” I’m sure Bob is coming down from the Foothills for a place to stay. But the man at the door is not my friend. It is a neighbor from across the street. “Fire coming!” he yells. “You’ve got to evacuate. Now!” I grab a few belongings: my cell phone, a laptop, a battery pack. When I look outside there is a faint glow along Fountaingrove ridge. I am in my pajamas. I realize I have time to dress. This is no big deal. I go back into the house. My wife grabs a few things. We have a cat and dog. The dog seemed eager to go. The cat did not agree. When we finally found the cat, he defiantly hissed and refused to come. My wife threw a blanket over his head and stuffed him into a dog crate. Outside, we made a quick decision to take both cars. (Similar decisions proved deadly on two occasions). If the fire came we didn’t want to lose a vehicle. We planned to meet in the CVS parking lot. We soon became separated. The cars fleeing down Brush Creek were bumper-to-bumper. I ended up getting stuck in traffic and fell further behind. Cell phones were still working and we were able to communicate every few minutes to be sure everything was all right. Bob Scheibel made a number of calls that night, warning friends a fire was coming. He remains one of our early heroes. When the electricity went out, he dashed for the garage. When he tried to pull the garage release to open the door, the spring pulley mechanism was off track. He couldn’t lift the door. He thought then about getting into his vehicle and smashing his way outside. He didn’t want to escape on foot. The Foothill estates are often acres apart and he knew there was no way he could outrun a fire. For a brief instant, the electricity came on and he opened the garage. When he finally sped out, the area was filled with smoke. By the time I reached the CVS parking lot, all spaces were full. I made a quick run to the Flamingo Hotel to see if there were rooms. The lobby was crowded with worried, displaced people. Everything was booked. I



returned to our vehicles where we settled for the night, having little insight what was ahead. We called a few friends. They were safe. Everyone else was evacuating, too. We were all sure we could go back to our homes in the morning. Our best source of outside information was KZST on 100.1 FM. Radio announcer Brent Farris had come into the station and taken over broadcast duties. For the

next six hours Farris provided continuing reports and updates. Calls were coming in constantly as the fire spread. The updates became more and more alarming. The fire had jumped 101. Flames were raging up Fountaingrove. Kmart was burning. So was the Hilton Hotel. And now the fire was approaching the radio station itself on Mendocino. The station was on reserve power. The place

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was getting hot. Kaiser Hospital was evacuating. Farris was not sure how much longer his staff could remain on the air before running for their lives. When we finally fell asleep it was 4 a.m. I awoke at daybreak, noting a strange orange glow permeating the sky. The radio was silent. Our cell phones were dead. All communications were gone.

Aaron Brown is an EMT who worked with a paramedic rig that night. The first 911 fire calls began to come in around 7:30 p.m. on Sunday evening. Many of the early calls were for grass fires, downed trees, or sparking power lines related to the wind. A number of fires were reported across Sonoma County. Over the next several hours, emergency dispatchers began receiving dozens of calls. By 10 p.m. fires were cropping up all over. One of these would be a blaze that started on Tubbs Lane just north of Calistoga. Fanned by gusts over 50 mph, the Tubbs fire was spreading fast. As the flames began to work their way west toward Santa Rosa, emergency rescues were needed as people were disabled and unable to flee. For the next eight hours dispatchers responded to numerous calls to bring injured or incapacitated individuals out of the fire. And each time Brown’s crew went back into a fire zone, they were more afraid. By midnight, 911 calls were approaching 300 per hour. During these first hours over 759 calls were received. Of these, 197 were pleas for assistance and help.9 By 11 p.m. all local fire engines were deployed and an urgent call to Cal Fire requested 25 additional “Strike Teams” for mutual aid. Each Strike Team is composed of five engines, with a team captain and 25 firefighters. The call for assistance eventually carried all the way to Los Angeles. Strike Teams were on their way. But the needs were urgent and help was required immediately. Worse, the calls were not only for the Tubbs fire. Fourteen other separate blazes occurred through Northern California that night. As dawn approached, the existing crews were spread incredibly thin.

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Often the paramedics stood by a three-man fire crew trying to fight an oncoming blaze. And each time the paramedics left for a call, they worried the firefighters might get trapped. Several times during runs the ambulance drove over fallen power lines. “It was the most harrowing night of my life,” EMT Brown said. “There were times when I didn’t think we would get out.” Paramedic Bill Chase was off duty that night. The family awoke at 2:30 in the morning to find Coffey Park ablaze. Chase sent his family ahead, then ran for a pair of hoses to help a neighbor water down spot fires that were rising across the yard. The air was filled with smoke. Fiery embers blew past their heads. They worked at this for 20 minutes until the water pressure fell. By then the winds were too fierce, the fire too hot to continue. When Chase saw his neighbor’s house go up in flames, he knew he had to leave. He raced for his car and tried to depart but the Coffey Park exit was clogged with other vehicles, trying to escape. It took nearly an hour to get out. When Chase finally reached safety, he was just ahead of the flames. Don Paulson is a nursing supervisor who has worked with local hospitals for 30 years. The family lived in an area behind Cardinal Newman High School. Paulson remembers well the loud pounding at his door. When he opened the door he was greeted with a sheet of flames. “You’ve got to get out!” a neighbor cried. Paulson rushed back into the house, alerted his wife, grabbed two of their four dogs

Summer 2018

(the other two were hiding) and ran for their car. When Paulson got outside, his vehicle was on fire. The entire exit was clouded with smoke. He realized if they went on foot they would not survive. Leaping into the burning car, he loaded up and blasted through the smoke. When his wife jumped into the car, her hair was on fire. “Another five seconds and we would have died,” Paulson recalled. Such encounters were repeated multiple times. By the time the fire burned through Santa Rosa 4,000 homes were lost. Many survivors were lucky; others not so fortunate. The Press Democrat tells of a couple who fled their Mark West home in two cars. The wife went ahead and the husband followed. At a sharp curve, the wife took a wrong turn. When the husband arrived at their preplanned meeting site she was not there. He waited through the night, praying for the best. In the morning they found her car and burned remains. “If I had known this would happen, I would have gone with her,” he said. In a few desperate minutes their lives had irrevocably changed. Near Fountaingrove, a family was visiting from San Diego, vacationing in an Airbnb rental with their teenage kids. When they evacuated they left in two cars. The children went ahead, the mother and father followed. A tree fell between the vehicles and suddenly blocked their path. Unable to proceed, the two parents returned to the home and took shelter in the swimming pool. Here they spent the night, treading from side to side, trying to keep safe from the horrible heat and flames. By morning, the mother was dead,



succumbing to exposure and smoke. Memorial Hospital is a Level II Trauma Center and the largest hospital in Sonoma County with 278 beds and 1,400 employees. The hospital is staffed with a night crew of nurses, aides, doctors and support personnel. When the two other major Santa Rosa hospitals, Sutter and Kaiser, evacuated, Memorial took the brunt of emergency patients. Many of the staff endured the night not knowing whether their homes were standing. “I can’t tell you how proud I am of our physicians and caregivers,” reported Todd Salnas, president of St. Joseph Health, which runs Memorial and Petaluma hospitals. Both hospitals served key roles during the first days of the fire. “Despite enormous personal losses, our staff continued to work through the fires, placing patient care above their own personal needs,” he said. The medical staff office at Memorial reports that 52 physicians lost their homes, as did numerous nurses and staff. After 37 years of practice, Dr. Mike Holmes, a wellrespected family physician, had decided to close his office in Sebastopol some months before. He looked forward to a change of life, continuing work in the Emergency Department at Sonoma West. When he first got the call at 5 in the morning he thought it was a joke. He recognized the calling number as that of a colleague. “Damn, I’m retired,” he told himself. The caller was Dr. Dave Fichman. “I don’t know if you know it or not,” Fichman said, “but there is a fire in Santa Rosa and a busload of patients are heading this way.” Dr. Holmes got up, dressed, and went to the hospital to help. He worked steadily for most of the next seven days, joining Drs. James Gude and Shelly Denno, providing almost continuous, non-stop, patient care. Dr. Joe Clendenin told a similar story. Although retired for a number of years, he has worked with the Red Cross assisting with large scale national disasters. Dr. Clendenin was returning from a trip abroad when he received the Red Cross call: there was a devastating fire in Sonoma County. The Red Cross needed help. Dropping his wife at his son’s home in San Francisco, Dr. Clendenin returned to Santa Rosa. For the next 10 days he worked in the Red Cross Evacuation Center at the Sonoma County Fairgrounds. Here he provided medical assistance for over 1,000 individuals who had been displaced. Along with Peggy Goebel, RN, the two gave continuous, 24/7, on-site medical care. Such stories are similar to dozens of other health care workers who gave up their personal interests for the wellbeing of patients during a time of incredible crisis. In every interview I conducted, physicians pointed out numerous other health care providers who assisted them in their work. By the end of the week, over 200 physicians in Sonoma County and an estimated 450 health care workers had lost their homes. At the time of this writing, most of them are still working; many, still displaced. The heroism, dedication, and commitment of these individuals are qualities for which we should all be both grateful and proud.



Thursday, October 12, 2017. The fires have left Santa Rosa and are roaming across the Sonoma Hills. Thousands of firefighters have come to the area, some from as far as Australia. The parking lot at the fairgrounds has become a tent city. Row upon row of fire trucks are there. And these are the off-duty crews. An equal number are out on the lines, fighting the fires. Multiple Strike Teams have been called to assist with mutual aid. Over 4,000 individuals are here from 14 different states. So is the National Guard. In the distance you can hear the sounds of jet aircraft as planes swoop over the hills, dropping clouds of pink retardant. Along with another 50,000 evacuees, we have been displaced. My wife and I, plus cat and dog, have found a room at the Oxford Inn in Rohnert Park. The hotel staff tells me there were hundreds of people turned away. Most of the evacuees staying here have lost their homes. Rumor comes from friends that we have lost our home, as well. I have to see for myself. This morning I am traveling with a county inspector. We drive along Mendocino Avenue toward Fountaingrove, passing through a blockade of sawhorses, police, and National Guard. When we enter the Fountaingrove Parkway I am stunned. Everything I remember is gone. The Round Barn, the Equus Restaurant, the Hilton Hotel. Nothing remains but rubble and ash. We continue east, curving up the roadway. In every direction is devastation. As we reach the top of Fountaingrove, we round a corner and look back on blocks and blocks of destruction. The sight is reminiscent of photos I have seen of Allied bombing in Dresden toward the end of the Second World War. Nothing is standing. Everywhere is in ruins. I step numbly out of the car and try to take a picture with my cellphone. For some reason the photo app doesn’t work. Is the scene too horrible to record? The area looks like a death zone. There is no sound, no murmur, no sign of life. We continue up to the crest of Fountaingrove and turn onto Rocky Point. I lived with my family here for nearly a decade. The house has warm memories for raising my children; hosting guests; enjoying hospital gatherings. We even had several weddings here. Everything is gone. The place is unrecognizable. Two years ago we downsized to a smaller house a few blocks away. As we get into the car and drive toward Helford Place, my heart is pounding in my chest. There is no way our home could have survived. A satellite photo I have downloaded shows nothing standing. When we turn onto the road, I count the burned-out homes. The remnants look like corpses. No roofs, no walls, no color. The corner house is gone. The next two houses burned. The neighbors’ homes behind and across the street are rubble. Suddenly, there it is, along with a cluster of a few others. The house is standing. I cannot believe my eyes. I open the front door with shaking fingers. There is a smell of smoke. I walk through the rooms expecting the worst. Miraculously, everything looks intact. Out in the back, the fire has burned down the fence and singed across the lawn. On a table next to the house, I find charred marks where the fire touched the walls. There is a hose stretched across the backyard. Was someone here? Did someone save our home? I sit down in shock. What has happened? How could we be spared? Given our location beneath the crest of Fountaingrove, it appears

Summer 2018

the fire swept across the top of the ridge, then swirled over the homes morning of October 9 were so strong they blew embers a half mile beneath. The flames skipped a block and took out several scattered ahead. The gusts were so fierce, the fire jumped six lanes of freeway houses, and then it was gone. The miracle of some homes standing on Highway 101. Sometimes, it only takes a single ember beneath a and others spared is a strange phenomena seen along the outer roof shingle, fanned by the wind, and a flame begins. When a house borders of wildfires. is hit by hundreds of embers and a heated environment over 1,000 Perhaps, it is like the concept of bacteria inoculum on a human degrees, everything goes. host. The susceptibility of the host is often dependent upon the size How hot was this fire? Dr. Bob Scheibel tells me he carried his of the inoculum versus the host’s natural immunity and defense safe from the ruins. Inside he had kept his most valued personal mechanisms. In terms of housing, the defense mechanisms are the papers. The safe was guaranteed to 1,000 degrees. When he opened roof, the composition of the walls, the type of trees and surrounding the safe everything was charred. Another account tells of man who vegetation. Wooden decks are often the beginning site of fires. So are kept a treasured collection of gold coins in his safe. Some dated back the redwood chips used to cover landscaped grounds. And then, of to Roman times. When he opened the safe all he found was a blob course, there is always luck. of ore. The heat of wildfires can sometimes reach 2,000 degrees. Dr. Gary Mishkin, an emergency physician and longtime friend, Pictures of vehicles in Coffey Park show hubcaps that have melted, tells me he was able to get to his house on the morning of October 9 some flowing off in molten streams. before all the roadblocks were set. His home was on fire, the flames whipped violently by the wind. Fiery pine cones blew past his Two years ago we downsized to a smaller house a few blocks away. head, like Molotov cocktails. When you get this much wind As we get into the car and drive toward Helford Place, my heart is and a fire this hot, there is little pounding in my chest. There is no way our home could have survived. hope. The winds during the early

Cartoonist Brian Fies drew an account of the fire, which was published in the Press Democrat on Oct. 29, 2017. The panels tell the story better than most. In his drawings, he describes the fire; the loss of his home; the bravery of his wife; and the ache of losing an entire collection of drawings that went down with the flames. Sure, he is alive and surviving. But the emotional loss of memories, of special memorabilia, of family encounters, cuts to the bone. Many have sifted through the debris, hoping to find a favorite memento, or a photograph, or perhaps a child’s drawing. Often these are items of special importance to an individual that are impossible to regain. How do you replace the dog tag and American flag of a son killed in Afghanistan? Or the wedding ring of a loved one lost to cancer? Houses and furniture and carpets you can replace. It is the loss of intangible memories that hurts the most. And then there are the pets. Over 500 pets were lost, the Press Democrat reports. One man recounted being blocked by a gate. He had to go around, accompanied by his dog. As they detoured

through the path of flames, his dog caught fire. There was nothing he could do to help. In one devastating period in Sonoma, Napa, Lake and Mendocino counties, 43 lives were lost and 8,900 homes gone. Twenty-four different fires burned that week. Of these, three of the fires are in the top 20 of the most destructive fires in the history of California. The Tubbs fire is considered number one. Wine experts caution that cabernet grapes that survived the fires will probably taste of smoke. I wonder, too, if you will be able to taste the tears. To families who have lost loved ones in the fire, the loss is unimaginable. And to those who have lost their homes, the emotional pain, the displacement, the thought of having to rebuild or move on, is difficult to fathom. To the first responders and law enforcement officers, the physicians, nurses, hospital workers, and caregivers who continued through the seven toughest days anyone can imagine, we owe great thanks. We have all been touched by the Dragon’s Tongue.

Email: travishard@aol.com Authors note: The stories and accounts used in this article were largely taken from conversations with friends and co-workers involved with the Tubbs fire. As an emergency physician, I often cross paths with many of these individuals during my normal work. After the stories started to unfold, I began taking notes of the incredible encounters of co-workers and staff, which formed the basis for this article. Many of the paramedics and fire personnel were reluctant to use their names, feeling they didn’t want to detract from colleagues who worked long hours through extremely hazardous conditions. Accordingly, I have changed names (where indicated) to honor these requests.

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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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Cardiovascular Update 2018: 38th Annual Central Valley Cardiology Symposium Rajit Rajpal MD, Program Chair

“Imagination does not become great until human beings, given the courage and the strength, use it to create.” Dr. Maria Montessori


On behalf of Fresno Madera Medical Society (FMMS), I would like to take this opportunity to invite you to Cardiovascular Update 2018, our Medical Society’s 38th Annual Central Valley Cardiology Symposium. Since its inception in Madera over three decades ago, the objective of Cardiovascular Update has been to create an inter-professional forum for physicians, nurses, students and other allied health professionals to come together to imagine, share and create solutions to advance the heart health of our Central Valley communities through education and dialogue on cutting edge developments in clinical and translational “Bench-to-Bedside” cardiovascular research, technology and innovation. We are deeply honored to have an extraordinary panel of distinguished experts and physician leaders who are internationally renowned as pioneering innovators at the forefront of recent advancements in cardiovascular medicine. Each of our speakers have published extensively on a wide range of issues in cardiovascular medicine and have demonstrated a profound commitment to educating and training the next generation of physician leaders.


Summer 2018

Daniel G. Blanchard, MD, is Director of

the UC San Diego Cardiology Fellowship Program and is a Professor of Medicine at the UC San Diego Medical Center in the Division of Cardiovascular Medicine. Dr. Blanchard’s first lecture will discuss the new ACC/AHA hypertension guidelines, including the management and treatment of resistant hypertension. His second lecture will provide an update on advancements in the medical management of atrial fibrillation, including an overview of the process of selecting NOAC therapies to meet patient specific needs.

Sumeet S. Chugh, MD, is Director of the

Heart Rhythm Center, and holds the Pauline and Harold Price Chair in Cardiac Electrophysiology Research, at the CedarsSinai Heart Institute. Dr. Chugh’s first lecture will outline the latest developments in Catheter Ablation Therapy for the management of atrial fibrillation. His second lecture will cover new methods and tools for recognizing risk factors for the prediction and prevention of sudden cardiac death in high-risk patients.

Paul S. Teirstein, MD, is the Chief of

Cardiology and Director of Interventional Cardiology for Scripps Clinic and Director of the Scripps Prebys

Cardiovascular Institute for Scripps Health. Dr. Teirstein’s first lecture will focus on the latest advancements in coronary revascularization with an emphasis on left main coronary artery disease, outlining techniques employed to distinguish left main atherosclerotic CAD anatomy for proper selection of surgical vs. percutaneous revascularization. His second lecture will address the expanding indication and evolution of TAVR for the treatment of symptomatic aortic stenosis. Our reputable panel of physician leaders will engage with some of the most pressing and critical issues impacting the cardiovascular health and wellness of central San Joaquin Valley communities. Our Valley is afflicted with some of the highest rates of cardiovascular disease in California and all of us in the medical community must come together to imagine and create solutions to address this epidemic. I encourage all FMMS members and the greater Central Valley medical community to attend and engage Cardiovascular Update 2018, for what promises to be a highly informative and stimulating learning experience. I would like to give special thanks to all of our guest faculty speakers, to the dedicated members of our symposium committee, and to the entire FMMS staff for their tremendous efforts in making this CME initiative possible.

Fresno Madera Medical Society

38 th Annual Central Valley


Madera County Office of Education 8:00a - 3:30p

6.0 CME

Sumeet Singh Chugh, MD - Cedars-Sinai Smidt Heart Institute Paul S. Teirstein, MD, FACC, FSCAI - Scripps Health Daniel G. Blanchard, MD, FACC - UCSD Medical Center

Registration: www.fmms.org Feature Topics Catheter Ablation Therapy for Atrial Fibrillation in 2018: Where do we stand? Update on Prediction and Prevention of Sudden Cardiac Death Hot Topics in Coronary Revascularization, Left Main Disease, and more Evolution of Trans Catheter Aortic Valve Replacement in Symptomatic Severe Aortic Stenosis: Expanding the Indications New Hypertension Guidelines: What do you need to know? Management of Resistant Hypertension Tips and Tricks in Medical Management of Atrial Fibrillation, including Tailoring of NOAC’s Therapy According to Patient

Summer 2018



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One always wanted to be a doctor. Another wanted to be anything but. And a third was inspired by childhood cancer to become a healer. Despite having different motivations to add M.D. to their names, and settling on different specialties and different practice environments, these three young physicians all had that similar “OMG! moment.” And the realization that they were full-f ledged, on-their-own doctors, the ones everyone expected to have the answers, didn’t creep up slowly. It hit unexpectedly with a bit of panic. Then came the deep breath and the determined: “I got this.” And, like muscle memory, all their years of training and practice kicked in. “I think we all have that in that first night shift where you are literally all by yourself and you’re like ‘Okay, we can do this. We have four hours left. We can do this,’ ” said Sarah Sifuentez, M.D., who practices emergency medicine at Kaiser Permanente Fresno. “I think that feeling is never going to go away. Because we’re always going to have those moments where we’re the lone doc on.” Tejal Pandya, M.D., is often the lone surgeon at Sierra View Medical Center in Porterville, where she works in a two-surgeon practice with her father. “It’s a new experience to be totally on your own,” she agreed. “But I haven’t encountered too many things where I didn’t know what to do or I was too nervous to do it on my own.”>>



Summer 2018

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One of the newest pediatric anesthesiologists at Valley Children’s Hospital, Garrett Terracciano, M.D., said he intentionally sought an environment where he would be on his own. “You really don’t know how you would react until you’re truly on your own,” he explained. He wanted to test his weaknesses, see if the skills he learned in residency were going to take him through this next phase. He’s just nine months into trying on this new role and he characterized it this way: “It’s empowering, it’s exciting, it’s terrifying, it’s humbling – all because you are kind of learning the things that you do right, you do wrong and you do in between. And it’s on you to make the necessary adaptations.” PRONOUNCED DIFFERENCES AND UNIVERSAL REALIZATIONS All three of these new doctors often had to remind themselves in those first few months that there wasn’t anyone looking over their shoulder anymore. No higher authority was asking pointed questions, expecting them to justify their treatment choices. “In pediatric residencies you have a lot of attendings around you and that’s a good thing for you and the patient,” said Dr. Terracciano, who had three post medical school trainings after




University of California, San Diego. He did a pediatric residency at Children’s Hospital of Philadelphia and an anesthesia residency at University of California, San Francisco before a one-year pediatric anesthesia fellowship at Seattle Children’s Hospital. Since finishing, he’s learned “nobody is going to tell you what to do – especially in anesthesia. You are kind of left to yourself to keep yourself accurate.” Dr. Terracciano tells people he was called to pediatrics. “I was just meant to be a pediatrician,” he told a crowd at a Children’s Miracle Network event. He credits the oncologist who treated him for leukemia at Children’s Hospital of Los Angeles when he was 12 for planting that desire. He found out later he really liked working with the sickest children in the PICU and followed his Philadelphia mentors who were dual trained in critical care and anesthesia. “I get to take care of kids all the time and every day it’s really sick kids with interesting physiology and interesting procedures here,” he said of his new job. But some days he’s a bit wistful about certain aspects of residency. “Nothing beats the collaboration of residency because you are forced with every case to discuss it,” Dr. Terracciano said. “Tomorrow I have two cases that are kind of complex and I can

Summer 2018

seek collaboration, but I don’t have to.” Dr. Sifuentez also misses conferring on cases like she did during her UCSF Fresno residency at Community Regional Medical Center, a Level 1 trauma center and one of the busiest ED’s in the state. “We’re used to presenting cases to our attending physicians,” she said. “You think about the case, you know what you want to order, but you present the case to your attending before you do. Then you go from that to: ‘I’m on my own and I have to think about the case on my own.’” In the collaborative, slower-paced environment at Kaiser that kind of discourse works well: “When I first started I would present to my colleagues. If there was a case that was a little confusing or I needed to hash it out a bit more I would literally present it to my colleague. I’d be like, ‘Hey Jaime (Dr. Jaime Antuna), can I just tell you about somebody really quick? Here’s what’s going on, here’s what I ordered and here’s what I’m thinking. Do you agree?’” Talking it through out loud helped Dr. Sifuentez figure out her practice style faster, she said – and helped her learn to trust herself. “I’d think, ‘Yeah I actually do agree with myself.’” Dr. Pandya still has one foot in the residency environment where she finished last fall; she’s now a part-time faculty member with her UCSF Fresno program doing surgery at Community Regional on the days she’s not doing surgery in Porterville. Even in Porterville, “some days there is surprisingly little difference between my residency and now,” she said. This is because the patient population and their problems are very similar throughout the region. And though volume is not as great as the busy academic surgery department, it can still be very busy with high acuity. But there are important differences. In some ways she notes that it can be a more challenging job: “I don’t have anyone to hand that unstable patient off to as I did when I was a resident,” Dr. Pandya said. “And I don’t want to, because I was the only one there and I know what I did. I know how many liters of f luid I’ve given a patient and I know where they are in their treatment. I want to make sure they settle down before I go home. I was trained to take ownership.” But when she has a long night in surgery she can tell her office staff to reschedule appointments at times so she gets a break. “It’s in some ways more f lexible and in some ways more responsibility,” she added. Dr. Terracciano said he too feels that weight: “The work week is obviously much less, but you have a lot more responsibility. I do get here an hour early to make sure I’m comfortable once the f lag drops.” There’s a real difference in her life these days, Dr. Sifuentez insisted emphatically. “The hours are much better than residency. I have a life now.”

Summer 2018




YOU MEAN I CAN’T JUST PRACTICE MEDICINE? But that new life comes with new challenges that these three doctors said residency didn’t prepare them for – the challenge of everything outside of direct patient care. “As a resident you can just practice medicine and that’s probably the only time in your life that you can, if at all.” said Dr. Pandya. But working in her father’s office she now realizes she has to pay attention to things like billing, building maintenance, supplies, and the office staff. “You literally can’t turn the lights on as a sole practitioner if you don’t think about it.” The three physicians said the things that caught them off guard can be boiled down to three words: processes, politics and paperwork. “I think that the surprises for me have come from two areas,” said Dr. Pandya. “There are certain things that you’re oblivious to as a resident, like the wheels that turn in the background… I think I was more aware of their existence because of where I grew up.” She and her brother spent their childhood days at her surgeon father Gaurang S. Pandya’s Porterville office, riding their bikes in the parking lot or helping out in back where her mother Ela Pandya was doing billing and paperwork. Dr. Pandya continued, “There are just so many of what are basically all the hoops. I knew there were hoops but I still



didn’t know the name, number and size of the hoops. It’s just overwhelming sometimes.” “The process part is a little bigger than you think,” agreed Dr. Terracciano. The other area of surprise for both Drs. Pandya and Terracciano have been the interactions with other doctors. For Dr. Pandya that aha moment came with her father: “I realized my dad has never collaborated in a friendly way with any other surgeons, because when they were trained they had the pyramid system” which weeded out the majority of the class before their residency ended. “Today our training is really collaborative and the dictum from our governing bodies is to be collegial and collaborative and multi-disciplinary.” The senior Dr. Pandya had an opposite training experience during his five years in New York as a brand new immigrant from India, struggling to figure out a new culture and survive in a cutthroat environment. “When two-thirds of your class is going to get fired before graduation, you are NOT friends,” Dr. Pandya continued about her father’s residency. “There would certainly be pages missing out of important textbooks in the library.” After surviving that and a stint in the Air Force, Gaurang Pandya settled his family in the Valley where he didn’t know anyone and no one wanted to loan him money to open an office. So he did what

Summer 2018

he’d been doing for years. And he doesn’t have back up on the dreaded paperwork either. “My parents have always just done it on their own,” she “Today I was doing ear-nose-throat cases, so on those days I might explained. “I realized that it was kind of hard for my dad to know do 10 to 16 tonsillectomies,” he said of his workload. A lot of what to do with a second surgeon.” routine simple surgeries isn’t necessarily an easier day then when “Then there was one day when it was really bad and we had he has one or two really complex cases. “The same amount of some really difficult cases. We were taking out the gall bladder in paperwork has to be done for all and that’s the difficult thing with two ladies on consecutive days who happened to have the same those easy cases.” problem that was equally, terribly advanced,” she described, “and “You do spend a lot of time on the computer documenting,” Dr. we did them together. The anatomy was so scarred and difficult Sifuentez agreed. “Medicine in general is different than I thought that we just had to start thinking like MacGyver. because I had this idealized view in my head.” “…The next morning we were sitting at the kitchen table “But the actual act of being a doctor it’s everything I dreamed thoroughly exhausted and he just looked at me and said ‘There is it would be,” she enthused, “the talking to patients, the doing no way I could’ve done that operation without a second surgeon!’ procedures, the literally seeing them on their worst day and I just looked and him and said ‘Now you know what I’m talking hopefully making them feel better. All of that is exactly what I about!’ I’m so used to that collaborative environment. To some thought it would be.” degree now we are teaching each other.” She said she can’t remember a time she didn’t dream of being Dr. Terracciano said he’s also finding a few bumps with the a doctor. Even as a child she was interested in science and taking generational differences between doctors. “There’s definitely a care of people, so becoming a physician was a natural fit. After level of hierarchy now,” he said that he didn’t notice as a resident. medical school at Brown University in Rhode Island, Dr. Sifuentez “We view hierarchies as an old school way. Because there are felt lucky to land a residency at UCSF Fresno, which gave her “great people in all generations and at any given moment you may be calling the shots or giving the orders.” INC. He’s become a bit more deliberate and careful A REGISTRY & PLACEMENT FIRM about his interactions than he was with fellow residents. “If you do something wrong or say something wrong as a resident people don’t hang on to it, because you’re just a temporary person moving through. After residency, people tend to watch what you do, listen to what you say a little more to see what kind of doctor they’re working with,” Dr. Terracciano said. He knows he’s building trust with colleagues and Voice: 800-919-9141 or 805-641-9141 nursing staff these first FAX: 805-641-9143 few months now that he’s on his own with no tzweig@tracyzweig.com attending to back him up www.tracyzweig.com and check his work.

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Summer 2018



exposure to all the possibilities of emergency medicine.” Dr. Sifuentez continued, “I think that is one of the privileges of emergency medicine, we get to be part of someone’s worst day. That sounds kind of morbid, but it’s a beautiful thing because you have the opportunity to really have a huge impact on them. And it’s a huge privilege to be there those in those hours.”

admitted. “But halfway through my surgery rotation, it hit me that nothing has ever made so much sense to me.” Lucky for her the USCF Fresno general surgery residency gave her a chance to discover that she also resonated in an environment that was “community based and where you really get to know the people.” It brought her full circle back to practicing with her father in a small town. “Now getting the opportunity to try and blend the UCSF Fresno environment and our “I EVEN WENT OUT OF MY WAY TO PUT SURGERY OUT OF MY MEDICAL private practice in Porterville in a unique way is amazing. It’s never been tried before SCHOOL EXPERIENCE SO I DID THAT ROTATION AT THE VERY END, and I appreciate my parents and Dr. Davis BUT HALFWAY THROUGH MY SURGERY ROTATION, IT HIT ME THAT for letting me go out on a limb and try. For me, for the region, for the program, I think NOTHING HAS EVER MADE SO MUCH SENSE TO ME.” - DR. PANDYA the potential for collaboration is limitless and brings new value to both sides if we IT TAKES TIME TO FIND YOUR PRACTICE STYLE can make it work in time.” Medicine is really a constant process of discovery and learning. And in post-residency that learning curve is really steep, these new ADVICE FOR THOSE ENTERING AND FINISHING doctors said. Those first months and years are about learning who RESIDENCY you are as a physician. Trying out different practice styles and places is what Sifuentez “As a resident you get used to your attendings practice style recommends for those approaching the end of residency and so you get used to presenting in a certain way,” Dr. Sifuentez thinking about their next step in the medical profession. explained. Residents get conditioned to do things in a way that gets “Get your feet wet in different practice environments – in a ready nod of approval from their attending physician. “And at community medicine and big places like Kaiser,” she said. “You the end of residency, you’re like ‘I know what this attending would never really know what it feels like without actually doing it want and I know what that attending would want, but which one of yourself. If you have just anecdotal stories about places then it’s not those attendings am I going to be?’ Which practice style am I going quite a tangible thing you can make a decision about.” to be?” Dr. Pandya advises those graduating out of residency to also be Presenting cases out loud to colleagues helped Dr. Sifuentez patient: “It’s a slow process growing into these new shoes…I’ve figure it out. “My style is a combination of a bunch of different heard people say it takes three or five years before you really have experiences. It takes maybe six months to a year to find it and say, your feet under you. And coming into the end of my first year I can ‘This is my practice style,’” she said. see that’s right.” Sometimes that process is about having faith in yourself and She added, “You have to find your patience again. Because when the years of learning leading up to being on your own, said Dr. you get to the end of your residency you think ‘Okay I’ve learned Pandya. “In my experience, I’ve been able to trust my training (at what I’m supposed to learn and I’m capable of being independent.’ UCSF Fresno) and I’ve learned to trust myself about how I’d like Just wait until you get into that first consult.” modify my practice to suit myself and how I’d like evolve. You are Drs. Pandya and Terracciano counsel those at the other end of really excited to be done with your formal learning, but it starts all training, just starting their residency, to savor it and be mindful of brand new, in a very different way, because you are on the spot by every moment. yourself.” “Try to get the most of the experience even if it seemed She spent a lot of years trying to deny her natural tendencies mundane,” Dr. Terracciano said. “When you do as many cases and her instincts. “My dad is a surgeon so because of that I avoided as we do, the little things you pick up along the way really pay off that road for a while” she said. “I still have broad interests outside when you get out.” of medicine, and I hope to find a good integration of these as time Dr. Pandya advised: “For incoming residents, just take it one goes on. But medicine just drew me in despite myself. I always did day at a time and know it goes by faster than you think. It’s almost have a tendency to care for others and want to know how to heal like you tread water for four years and then you look back and you them.” She ultimately found herself at Temple University School of think ‘Wow that went by fast!’ And it also felt like forever when you Medicine in Philadelphia. were in it. Now it’s over.” “I even went out of my way to put surgery out of my medical And now you’re on your own, a full-f ledged physician. school experience so I did that rotation at the very end,” Dr. Pandya



Summer 2018

SAINT AGNES WELCOMES THE INAUGURAL CLASS OF INTERNAL MEDICINE RESIDENTS In late 2017, Saint Agnes Medical Center received approval from the Accreditation Council for Graduate Medical Education (ACGME), a private, non-profit organization that evaluates and accredits graduate medical education (GME) programs throughout the country, to begin an Internal Medicine Residency program. With ACGME approval, Saint Agnes is officially an independent teaching hospital, accepting its first class of residents June 2018. “This is an exciting milestone for Saint Agnes and also has positive implications for our community,” said Nancy Hollingsworth, Saint Agnes Medical Center President and CEO. “As a teaching hospital, Saint Agnes has an even greater opportunity to attract and cultivate new physicians, in order to improve access to care and better serve our Valley’s growing population.” Residency is the final phase of a long educational process required for a physician to practice medicine, and is most influential in determining where he or she eventually practices. In addition to its 3-year Internal Medicine Residency program, Saint Agnes is making

plans to offer Family Practice and Emergency Medicine residencies, as well as a transitional year. “Our vision is to offer an exceptional training environment that prepares residents to practice medicine with quality and compassion while adhering to the highest clinical standards,” said W. Eugene Egerton, MD, Saint Agnes Medical Center’s Chief Medical Officer. Through its physician residency program, Saint Agnes will help to enhance the local supply of physicians serving Central California and improve access to care for residents in Fresno, Clovis and the surrounding communities. “Saint Agnes is deeply committed to graduate medical education and recognizes that its investment is crucial to transforming health care for the benefit of the people and communities we serve in the Central Valley,” said Dr. Charles Farr, Designated Institutional Official for Graduate Medical Education at Saint Agnes. The first Internal Medicine residency class is made up of four preliminary residents and 12 categorical internal medicine residents.

THE SAINT AGNES INAUGURAL CLASS OF INTERNAL MEDICINE RESIDENTS ARE: Inderbir Singh Baadh, MD - St. George’s University Camille Chow, MD - St. George’s University Mehrab Devani, MD - American University of Antigua College of Medicine Jasmeet Kaur Dhaliwal, MD – Rajendra Medical College Keerat Kaur Dhatt, MD - St. George’s University Jeffery Evans, MD - St. George’s University Ivan Alejandro Cortes Torres, MD - Universidad Autonoma de Guadalajara Ana Jimenez, MD - University of Kansas School of Medicine Kansas City Reddy Sanjay Venkat Manubolu, MD - Sri B.M. Patil Medical College BLDE University Hannah Knox, MD - American University of the Caribbean Shriramsingh Vinita Vishnoi, MD - Government Medical College Surat Noelle Jerrica Mueller, MD - Ross University School of Medicine

Summer 2018


Neilinder Singh Behniwal, MD – St. George’s University Neima Fatehi, MD – Meshed Medical School, Meshed University Endro Faiz Kusumo, MD – Keck School of Medicine of the University of Southern California Parisa Rezapoor, MD – Rafsanjan University of Medical Science and Health Services



Summer Meltdown benefiting Fresno Madera Medical Society Scholarship Foundation Join the Fresno Madera Medical Society for an extraordinary evening of fabulous food, sizzlin’ live and silent auctions and loads of laughter in support of the FMMS Scholarship Foundation.

Friday August 24, 2018

6 pm Clovis Veteran’s Memorial Ballroom Cocktails ♦ Hor d'oeuvres ♦ Gourmet Dinner ♦ Auctions Live Comic Relief

Matthew Broussard

Matthew grew up in a house of scholars. His father was a PhD chemist, his mother has a Master’s degree in Microbiology, and his brother is a mechanical/aeronautical engineer. Matthew followed in their footsteps and studied mechanical engineering as well as computational and applied mathematics at Rice University. He then decided to become a comedian. He has appeared on Conan, Comedy Knockout, Adam Devine’s House Party, The League, The Mindy Project, and Comedy Central’s Roast Battle.

Ken Lewis

Ken Lewis brings his no holds barred comedy style to packed rooms from Coast to Coast. Ken has been dubbed the Alter- Ego of Dr. Phil with his takes on life, dating, relationships, parenting, and marriage. Crowds erupt in a roar of laughter, followed by "Wait...I shouldn't be

Jimmy Earll

Born in French Canada, he is a Filipino-American with a backwoods, white boy name. Jimmy Earll draws the inspiration for his act from his observations of his family and friends, and he believes the people he chooses to surround himself with will provide a source of comedic material for years to come. He has a knack for making even the most obscure situations seem hilarious.

Tickets 38



Sponsorship Opportunities 559-224-4224 Summer 2018

Photographs by JOSEPH HAWKINS, JR., MD Yosemite National Park

PHOTOS WANTED! If you would like to submit your photos to Fresno Madera Medical Society, please contact Nicole Butler at nbutler@fmms.org. We would like to include different photography in the magazine every quarter. Summer 2018





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GRADUATING UCSF FRESNO PHYSICIANS TO CARE FOR PATIENTS AND TEACH FUTURE DOCTORS GRADUATES OVERCOME OBSTACLES, FALL IN LOVE WITH A FIGHTER PILOT, AND GROW ROOTS, LITERALLY The San Joaquin Valley has the lowest ratios of licensed medical doctors and doctors of osteopathic medicine per 100,000 people in California, according to a July 2017 report from the Healthforce Center at UCSF. In June, more than 100 medical residents and fellows along with three oral and maxillofacial surgery dental residents will graduate from UCSF Fresno. Of the 107 graduates, 44 percent will stay in the Central Valley to practice medicine, teach future physicians or continue with their medical education in fellowship programs.

A FEW OF THIS YEAR’S GRADUATING CLASS INCLUDED: ANDRES ANAYA, MD, is a Fresno native, Hoover High School alum and graduate of the UCSF School of Medicine. Dr. Anaya is completing a four-year residency in emergency medicine. As a medical student, Anaya conducted third-year rotations in obstetrics/gynecology and surgery at UCSF Fresno. After earning his medical degree, he returned in 2014 for residency training. Anaya’s path to becoming a physician was anything but typical. He is the eldest son of Mexican immigrants, both of whom are deaf. His first language was Sign Language. At the age of 5, Anaya began translating for his family. Economic, cultural and social challenges soon led to academic difficulties for him at school. Following high school, he took a job in a tire factory where he suffered an industrial accident. The accident landed him in the emergency department, leaving him temporarily paralyzed and physically and emotionally traumatized. It took several years to overcome his injuries, but from then on, he set his mind to becoming an emergency medicine physician. Fast forward to today, Anaya realized his goal. After graduation, he will stay in Fresno to care for patients at Saint Agnes Medical Center. >>

JAIMIE BRANDLEY, DO, graduated from Marin High

School in Novato, California, went to UC San Diego and graduated from medical school at Touro University California in Vallejo. Dr. Brandley’s father was a bench scientist and her mother was a teacher. After earning an undergraduate degree, Brandley taught high school science in Washington, D.C., as part of Teach for America. A love for both science and teaching and a desire to merge the fields motivated her to become a physician. As a medical student, Brandley completed fourth-year clinical rotations at UCSF Fresno. The welcoming and positive learning environment and the opportunity to work with diverse and underserved patients like the students she taught in D.C. inspired her to come back for residency training. A fondness for children and fulfillment of working with the whole family to improve health drew her to pediatrics. Brandley is completing a three-year residency in pediatrics, and after graduation she will join the UCSF Fresno Department of Pediatrics as faculty. While in Fresno, Brandley met the “love of her life,” Kelty Lanham, and married him. Lanham is an F-18 pilot currently stationed at Naval Air Station Lemoore. While it will be necessary for them to relocate where the Navy sends them, Brandley says they are seriously considering making the Valley their “forever home.” KARNDEEP SAMRAN, MD,

graduated from Madera High School, attended UC Berkeley and earned his medical degree from Michigan State University. Early on, Samran was drawn to the field of science. Having grown up on his family’s small vineyard in Madera, he originally envisioned a career in agriculture and plant sciences. However, he soon realized he enjoyed interacting with people and began focusing on a career in medicine. Psychiatry was a good fit because it allowed him to hear personal stories and see patients from a holistic perspective. Samran is finishing a fouryear residency in psychiatry. Throughout residency training, Samran started each day by tending plants on his family’s vineyard then headed back to Fresno to take care of patients. After graduation, Samran will grow his roots locally and give back to the community by working in the substance use department at the VA Central California Health Care System in Fresno. Frustrated by the stigma involved with mental illness, especially within communities of color, one of Samran’s goals is to promote mental illness awareness.




HOUSESTAFF AWARDS Residents vote for members of the housestaff, faculty and non-physician staff who exemplify standards of teaching excellence deserving of special recognition. Outstanding first year resident Outstanding resident teacher Outstanding attending teacher Outstanding non-physician teacher



OUTSTANDING NON-PHYSICIAN TEACHER – Quan Dang, PA Presented by, Dr. Mark Kestner, Community Regional Medical Center

BORBA HOUSESTAFF & FACULTY RESEARCH AWARD The Faculty Development and Scholarly Activity Committee reviews original research conducted by members of the faculty and house staff. Awards are given to recognize creative research judged to be the most significant and meritorious during the academic year.

RESIDENT - Eileen Shu, MD

FELLOW– David Jeffcoach, MD Presented By Sachdev Thomas, MD

FACULTY RESEARCH - Michael Darracq, MD, MPH Presented by Patil Armenian, MD

Summer 2018


Steven N. Parks, MD was known for

This award recognizes the resident

his vision, leadership and guidance,

who exemplifies the abilities to

during his 35 years of practice

communicate effectively, lead

in Fresno, Dr. Parks made many

treatment teams that foster a culture

outstanding contributions to the

of safety and uses data effectively

medical community, the profession,

when making decisions.

the Fresno-Madera Medical Society and other professional organizations.

Matthew White, DO

His dedication and commitment

Presented by, Wessel Meyer, MD

to medicine continue through this leadership award, established by the


medical society to recognize and encourage excellence in leadership development within organized

This award, established by the Dizon

medicine by residents and fellows and

family, recognizes the resident who

serves to stimulate similar efforts by

best personifies the UCSF Fresno

other physicians in training.

value of outstanding service to the community.

David Jeffcoach, MD Presented by – Alan

Andres Anaya, MD

Kelton, MD

Presented by Dominic Dizon, MD, MBA

LEON S. PETERS “RESIDENT OF THE YEAR” In December 2011, the “Leon S. Peters Resident/Fellow of the Year Award”


was established through funding

Medicine awards the prestigious

received from the Leon S. Peters

Kaiser Award for Excellence in

foundation in support of the first

Teaching to four members of the

UCSF Fresno Resident Council. The

clinical faculty. These awards

Resident Council has selected one

recognize outstanding teaching,

resident/fellow, nominated by his/

motivational skills and communication

her peers, who has demonstrated an


outstanding job in patient and family care, research project success, has

One of these prestigious awards is

volunteered in the community to

reserved for a member of the clinical

provide medical assistance where

faculty at the UCSF Fresno Medical

needed, and is overall a well-rounded

Education Program. The winner is

physician concerned about his/her

recognized at the commencement

patients, research and community.

ceremony at the UCSF School of

2018 GRADUATING CLASS Family and Community Medicine Gagandeep Aulakh, DO Touro University California College of Osteopathic Medicine Dr. Aulakh will join Kaiser Permanente in the Central Valley Theresa Day, MD University of Arizona College of Medicine Dr. Day will move to Tucson, Arizona, and apply for geriatrics fellowship programs. Kulraj Dhah, DO A.T. Still University of Health Sciences, College of Osteopathic Medicine Arizona Dr. Dhah will start a Primary Care Sports Medicine Fellowship at Kaiser Permanente in Fontana, CA. Jenny Nga Du, DO Touro University Nevada College of Osteopathic Medicine Dr. Du will join Urgent Care with Mercy Medical Group in Sacramento, California. Nicole Jernick, MD Georgetown University School of Medicine Dr. Jernick will begin the Hospice and Palliative, Medicine Fellowship at UCSF Fresno. Anh Le, MD St. George’s University School of Medicine Dr. Le will work in ambulatory care in Southern CA. Todd Macauley, DO Lake Erie College of Osteopathic Medicine

Medicine and is presented with a John McClain, MD Presented by, Ken Peters - President, Leon S. Peters Foundation, David Peters - Member, Leon S. Peters Foundation and Leann Mainis, MD

certificate and a significant monetary award. Robert Julian II, DDS, MD, FACS Presented by, Michael W. Peterson, MD,


Summer 2018


Dr. Macauley will practice in Urgent Care at Hoag Medical Group in Newport Beach, CA. Assad Malik, MD Ross University School of Medicine Dr. Malik will pursue urgent care and primary care jobs in the Bay Area.



Drs. Chris B. Smith, Kyle Almodovar and Scott Drew Madeline Nguyen, DO Touro University California College of Osteopathic Medicine

Alireza Soleimani Fard, MD Islamic Azad University, Tehran Faculty of Medicine

Dr. Nguyen is pursuing various outpatient clinics

Dr. Fard has accepted a faculty as Associate Program Director for the UCSF Fresno Hospice and Palliative Medicine Program.

Ebimoboere Okoro, MD American University of the Caribbean School of Medicine Dr. Okoro will join Kaiser Permanente’s Outpatient Medicine in Bakersfield, CA Laura Pierce, DO Touro University California College of Osteopathic Medicine

Emergency Medicine Andres Anaya, MD UCSF School of Medicine Dr. Anaya will join Saint Agnes Medical Center in Fresno, CA

Courtenay Pettigrew, MD Jefferson Medical College of Thomas Jefferson University

Maternal Child Health Fellowship

Brandon Chalfin, MD UC San Diego School of Medicine Dr. Chalfin has accepted a position with the UCSF Fresno Department of Emergency Medicine and UCSF Fresno Hospice and Palliative Medicine Program.



Ryan Neidhardt, MD State University of New York Upstate Medical University

Dr. Ng has accepted a position at Kaiser Permanente in the East Bay, CA.

Dr. Toor will work in ambulatory care in Canada.

Hospice and Palliative Medicine Fellowship

Dr. Mainis has accepted a position at Sutter Delta Medical Center, East Bay, CA

Timothy Ng, MD University of Hawaii John A. Burns School of Medicine

Nevkeet Toor, MD Saba University

Dr. Flagg’s goal is to establish a birthing center in Grenada and she is considering remaining at UCSF for a while in Family Medicine/Ob/Gyn.

Leann Mainis, MD Chicago Medical School at Rosalind Franklin University of Medicine & Science

Dr. Neidhardt has accepted a position with a multi-specialty hospital in Montana.

Dr. Pierce will practice with UC Davis Medical Group in Sacramento, California.

Shania Flagg, MD St. George’s University School of Medicine

Dr. Diamond will join a private practice in Asheville, North Carolina.

Dr. Alan Kelton immediate past present of the Fresno Madera Medical Society and Dr. Andres Anaya, Resident Staff Member of Fresno Madera Medical Society. Dr. Anaya will begin working for Saint Agnes Medical Center in the emergency department. Jordan Beshore, DO Western University of Health Sciences/College of Osteopathic Medicine Dr. Beshore will join UCSF Fresno Department of Emergency Medicine

Dr. Pettigrew has accepted a position with Kaiser Permanente in Fresno, CA. Eileen Shu, MD Columbia University College of Physicians and Surgeons Dr. Shu will join UCSF Fresno Department of Emergency Medicine Caleb Sunde, MD Keck School of Medicine of USC Dr. Sunde has accepted a position with Kaiser in South Sacramento.

Nelson Diamond, MD Duke University School of Medicine

Summer 2018

Daniel Vo, MD University of Miami Leonard M. Miller School of Medicine

Rebecca Murphy, DO Touro University California College of Osteopathic Medicine

Dr. Vo will stay in the Central Valley doing per diem work.

Dr. Murphy has accepted a position with Family HealthCare Network in Visalia, California.

Emergency Ultrasound Fellowship Nicholas Gastelum, MD UCSF School of Medicine Dr. Gastelum will stay with UCSF Fresno Department of Emergency Medicine. Emergency Medical Education Fellowship Xian Li, MD Louisiana State University School of Medicine Dr. Li will stay ty with UCSF Fresno Department of Emergency Medicine.

Stephanie Ng, MD Chicago Medical School at Rosalind Franklin University of Medicine & Science Dr. Ng has accepted a position with Kaiser Permanante in Fresno, California. Holly Yuan, DO A.T. Still University of Health Sciences, College of Osteopathic Medicine Arizona Dr. Yuan will join a private practice in Issaquah, Washington. Pediatrics

Orthopaedic Surgery Daniel Brown, MD Duke University School of Medicine Dr. Brown will begin a Pediatric Orthopaedics Fellowship with Campbell Clinic in Memphis, Tennessee. Gustavo Garcia, MD Keck School of Medicine of USC Dr. Garcia will begin a Foot and Ankle Fellowship in Las Vegas, Nevada. Arbi Nazarian, MD Chicago Medical School at Rosalind Franklin University of Medicine & Science Dr. Nazarian will begin an Adult Reconstruction Fellowship at the University of West Virginia School of Medicine in Morgantown, West Virginia.

Nicole Barbera, DO Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California

Dr. Amerin will join the Women’s Health Group in Thornton, Colorado.

Dr. Gray will begin a fellowship in PediatricHematology/Oncology at UCLA. Matthew Hadeed, DO Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California Dr. Hadeed will join UCSF Fresno Department of Pediatrics

Angela Benton, MD St. George’s University School of Medicine

Lisa Luu, DO Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California

Dr. Benton will join the UCSF Fresno Department of Pediatrics as a Chief Resident Elizabeth Black, MD Universidad Autonoma de Guadalajara Dr. Black will begin a fellowship in Pediatric Nephrology at UCSF Jaimie Brandley, DO Touro University California College of Osteopathic Medicine Dr. Brandley will join UCSF Fresno Department of Pediatrics Kevin Connolly, MD St. George’s University School of Medicine Dr. Connolly will join UCSF Fresno Department of Pediatrics as a Chief Resident

Summer 2018

Ashley Gray, MD St. George’s University School of Medicine

Dr. Barbera will begin a fellowship in Pediatric Emergency Medicine at INOVA Fairfax Hospital in Virginia.

Obstetrics/Gynecology Courtney Amerin, DO Rocky Vista University College of Osteopathic Medicine

Kevin Connolly, MD photographed with his family will be staying in Fresno and will be a Chief Resident with UCSF Fresno

Dr. Luu has accepted a position with Southern California Kaiser Permanente. Shalin Parekh, MD Cardiff University Dr. Parekh will begin a fellowship in Pediatric Cardiology at UCSF Jacquelynn Wagoner, DO Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California Dr. Wagoner will join the UCSF Fresno Department of Pediatrics as faculty Torin Waters, MD St. George’s University School of Medicine Dr. Waters will begin a fellowship in Pediatric Hematology/Oncology at University of Iowa



Danelle Wilson-Waters, DO Rocky Vista University College of Osteopathic Medicine

Acute Care Surgery Fellowship

Psychiatry Anjani Amladi, MD The Commonwealth Medical College

Dr. Wilson-Waters will practice pediatric medicine in Iowa

Dr. Amladi will begin a Child & Adolescent Psychiatry Fellowship at UC Davis David Mazariegos, MD University of Pittsburgh School of Medicine David Jeffcoach, MD UC Davis School of Medicine Dr. Jeffcoach will practice surgery in Ethiopia.

Torin Waters, MD and Danelle Wilson, DO meet each other 3 years ago when they both started the pediatric residency program, 6 weeks ago they were married and now moving to Iowa where Torin will begin a fellowship in Hematology at the University of Iowa and Danelle will be a hospitalist. Surgery Erinn Kim, MD Jefferson Medical College of Thomas Jefferson University Dr. Kim will begin a Plastic Surgery Fellowship at the University of Utah William Oh, MD New York Medical College

Dr. David Jeffcoach (and son) photographed with Dr. Jim Davis, was this year’s recipient of the Steve Parks leadership award. Jeffcoach and his family will be moving to Ethiopia where he will practice surgery.

Ikemefuna Akusoba, MD Ross University School of Medicine

Mark Abraham, MD University of Toledo College of Medicine

Dr. Akusoba will join The Weight Management Center at St. Luke’s Health Network, Pennsylvania. Ariel Shuchleib Cung, MD Universidad Anahuac Dr. Shuchleib will join his father in implementing bariatric surgery at his general surgery group in Mexico City.

Carolyn Black, MD UC Davis School of Medicine Dr. Black will begin a Physical Medicine and Rehabilitation residency at Harvard Spaulding Rehabilitation Hospital

Dr. Dang will begin a Diagnostic Radiology residency at Stanford University

Natzan Avisar, Ike Akusoba, MD Keith Boone, MD, Ariel Shuchleib, MD and Missina Hager. Surgical Critical Care Fellowship

Dr. Saraswat has accepted a position with Wake Forest Baptist Medical Center in North Carolina


Dr. Abraham will begin an Anesthesiology residency at Massachusetts General Hospital.

Brian Dang, MD Saint Louis University School of Medicine

Anju Saraswat, MD Northeast Ohio Medical University College of Medicine


Dr. Samran has accepted a position with the Substance Use Disorders Program at the VA Central California, Fresno, CA Internal Medicine (Preliminary)

Sammy Siada, DO UNT Health Science Center/Texas College of Osteopathic Medicine

Dr. Tran will begin a Plastic Surgery Fellowship at Indiana University

Karndeep Samran, MD Michigan State University College of Human Medicine

Minimally Invasive Surgery Fellowship

Dr. Oh will begin a Colon and Rectal Surgery Fellowship at Indiana University

Dr. Siada will begin a Vascular Surgery Fellowship at the University of Colorado Phu Tran, MD Baylor College of Medicine

Dr. Mazariegos has accepted a position in outpatient psychiatry with Kaiser Permanente in Sacramento

Yeng Her, MD Mayo Clinic School of Medicine Dr. Her will begin a Physical Medicine and Rehabilitation residency at the University of Wisconsin Quoc-Anh Ho, MD UC Davis School of Medicine Dr. Ho will begin a Radiation Oncology residency at the University of Arizona

Summer 2018

Emily Khatchaturian, DO Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - California Dr. Khatchaturian will pursue a research program Shimwoo Lee, MD New York University School of Medicine Dr. Lee will begin an Integrated Interventional and Diagnostic Radiology residency at UCLA Medical Center He Li, MD Texas A&M Health Science Center College of Medicine Dr. Li will begin an Ophthalmology residency at Ohio State University Havener Eye Center. Angel Morán, MD UC Davis School of Medicine Dr. Morán will begin a Radiation Oncology residency at UC Davis. Andrew Tran, MD State University of New York at Buffalo School of Medicine and Biomedical Sciences Dr. Tran will begin an Ophthalmology residency at the University of Pittsburgh Medical Center.

Grace Choi, MD Temple University School of Medicine Dr. Choi will begin a Nephrology fellowship at UC, Irvine. Karamjit Dhaliwal Binning, MD Ross University School of Medicine Dr. Dhaliwal Binning will be a Chief Resident in the UCSF Fresno Department of Internal Medicine

Raj Shah, MD Wake Forest University School of Medicine Dr. Shah will practice general medicine in Washington. Harpreet Sidhu, MD Chicago Medical School at Rosalind Franklin University of Medicine & Science Dr. Sidhu will begin a Nephrology Fellowship at UCLA.

Scott Drew, DO Touro University California College of Osteopathic Medicine

Christopher Smith, MD St. George’s University School of Medicine

Dr. Drew will practice General Medicine near Santa Cruz, Ca.

Dr. Smith will practice General Medicine in California.

(leave room for a caption, their names are at home)

Antonio Toribio, MD Loma Linda University School of Medicine

Paymon Ebrahimzadeh, DO Touro College of Osteopathic Medicine - New York Dr. Ebrahimzadeh will begin a Sleep Medicine fellowship at UCSF Fresno Kyle Heber, MD American University of the Caribbean School of Medicine Dr. Heber will practice primary care in Bakersfield, Ca. Faye Pais, MD St. John’s National Academy of Health Sciences

Dr. Toribio will join UCSF Fresno Department of Internal Medicine as faculty Matthew White, DO West Virginia School of Osteopathic Medicine Dr. White will begin a Rheumatology fellowship at Brown University and Roger Williams Medical Center. Internal Medicine (Chiefs) Sanjay Hinduja, MD Bharati Vidyapeeth Medical College - Pune

Internal Medicine (Categorical)

Dr. Pais will be a Chief Resident in the UCSF Fresno Department of Internal Medicine

Dr. Hinduja will begin a Hematology/ Oncology fellowship at UCSF Fresno.

Kyle Almodovar, DO Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - Ca

Jonathan Pham, DO Touro University California College of Osteopathic Medicine

Christine McElyea, DO Arizona College of Osteopathic Medicine of Midwestern University

Dr. Pham will be a Chief Resident in the UCSF Fresno Department of Internal Medicine

Dr. McElyea will begin a Pulmonary Critical Care fellowship at the University of Southern Ca.

Chirag Rajyaguru, DO A.T. Still University of Health Sciences College of Osteopathic Medicine Arizona

Hiral Patel, DO Des Moines University College of Osteopathic Medicine

Dr. Almodovar will begin a Sleep Medicine fellowship at UCSF Fresno. Armen Bedrosian, MD UC Irvine School of Medicine Dr. Bedrosian will practice as a hospitalist at Saint Agnes Medical Center in Fresno, Ca. Chloe Brandow, DO Arizona College of Osteopathic Medicine of Midwestern University Dr. Brandow will be a Chief Resident in the UCSF Fresno Department of Internal Medicine.

Summer 2018

Dr. Rajyaguru will begin a Cardiovascular Disease fellowship at UCSF Fresno Rajpreet Saini, DO Touro University Nevada College of Osteopathic Medicine

Dr. Patel will join the UCSF Fresno Department of Internal Medicine as faculty. Nitin Thinda, MD Kasturba Medical College – Manipal Dr. Thinda will join UCSF Fresno Department of Internal Medicine

Dr. Saini will practice primary care in California.



Pulmonary and Critical Care Fellowship

Dr. Nat will join a private practice in the Central Valley.

Kenneth Juenger, MD Ross University School of Medicine

Steven Ratcliff, DO UNT Health Science Center/Texas College of Osteopathic Medicine

Dr. Juenger has accepted a position with Montage Health in Monterey, Ca. Amritpal Nat, MD Medical University of Lublin

Dr. Ratcliff will join the Pulmonary & Critical Care Department at the VA Central California, Fresno, Ca, as faculty and Director of the ICU.

Sleep Medicine Fellowship Ibrahim Raphael, MD American University of Beirut Faculty of Medicine Dr. Raphael will begin a Pulmonary & Critical Care fellowship in Oklahoma City, Ok. Infectious Diseases Fellowship Tiffany Ngai, MD St. George’s University School of Medicine Dr. Ngai will practice Infectious Diseases at a private practice. Gastroenterology Fellowship Jonathan Kung, MD St. George’s University School of Medicine

The Cooperative of American Physicians is run by physicians like myself. Applicants are carefully selected to make sure only high- quality physicians become members of the risk pool. Overall, I have saved a significant amount of money on my premiums and am glad I made the change.

Dr. Kung will begin an Advanced Endoscopy Fellowship at HarborUCLA Medical Center Thimmaiah Theethira, MD Mysore Medical College and Research Institute Dr. Theethira will join the UCSF Fresno Gastroenterology Program as faculty. Cardiovascular Disease Fellowship Bhavik Khatri, DO Nova Southeastern University College of Osteopathic Medicine Dr. Khatri will join the Cardiology Department at the VA Central California, Fresno Sood Kisra, MD Saba University

- Don Gaede, MD Vascular Medicine FMMS Member 39 Years

Dr. Kisra will join a private cardiology practice in San Bernardino, Ca. Duong Le, MD St. George’s University School of Medicine Dr. Le will join Kaiser Permanente in Antioch, California, as Cardiology faculty. Interventional Cardiology Fellowship Manminder Bhullar, MD Government Medical College Amritsar Dr. Bhullar will begin an Advanced Structural Heart Disease fellowship at Cedars-Sinai Medical Center in Los Angeles, Ca.



Summer 2018

cme cruise July 6-12, 2019 July 6 July 7 July 8 July 9 July 10 July 11 July 12 July 13

Rome (Civitavecchia) Messina, Sicily Valletta At Sea Cephalonia (Argostoli) Dubrovnik Zadar Venice

rome venice $2,306 | 7 Nights interior cabins starting at $1250

Up to 12.0 CME $295 Physicians $225 PA, NP, RN

Contact: Denise Martin Donathan - Travel Shoppe 559-445-5767 denise@shoppetravel.com *Rate shown is for a Veranda Cabin, includes all Port Fees and Government Taxes, is Per Person, Double Occupancy, airfare not included. Limited Availability.

Summer 2018






POSITIONS AVAILABLE Chief Residents Needed for SAMC GME Program Leaders wanted! The newly accredited Internal Medicine Physician Residency Program at Saint Agnes Medical Center is seeing well-qualified PGY3s to serve as Chief Residents. This is an excellent opportunity to grow your leadership skills and be a member of a vibrant and transformational team. Interested individuals should contact GME@samc.com or visit http://www.samc.com/ physician-residency-programs for more details and application instructions.

Veteran State Home Fresno (CalVet) Has openings for a full-time and part-time physicians. This is a State position with State benefits. For more information or if you are interested please email asha.sidhu@calVet.ca.gov or call (559) 681-7800 or apply online at calhr.ca.gov.



Medical Consultants Needed for Fresno Field Office This is an excellent opportunity to help your community and to obtain valuable experience. The Department of Consumer Affairs, Division of Investigation, and Health Quality Investigation Unit is seeking well-qualified individuals to be a Medical Consultant for the Fresno Field Office. Are you interested in being an integral part of the Medical Board of California enforcement process? Do you have the ability to conduct interviews, exercise sound judgment in reviewing conflicting medical reports and preparing opinions, analyzing problems, and taking appropriate action? Interested individuals must submit an application for examination. Visit jobs.ca.gov/JOBSGEN/5CACC.PDF for additional information and instructions. If you have any questions please contact Herbert Boro, MD, F.A.C.P. with the Health Quality

Summer 2018

Investigation Unit in Fresno at (559) 447-3045 or by email at herbert.boro@mbc.ca.gov.

Family/ General Practice Physician Needed A multi-disciplinary organization is looking for a FP/ GP/DO/Medical Director for our Fresno medical office. Candidates must have an active CA license. As a member of our team you will enjoy a Monday-Friday workweek, no weekends, late nights, or hospital calls. Part time and full time available!! Benefits include 401K, health, dental and vision insurance. Great-pay, potentialto bonus by performance criteria and protocol. 100% employer paid malpractice. For immediate consideration please submit your CV by email to matt@firsthealthmedical.com or by fax to (559) 435-3462.

California Correctional Health Care Services is seeking 2-3 IM/FP Primary Care Physicians. Up to $327,540 annually plus $50-$60K w/OnCall - can be $380-$390K! Benefits include: 4-day workweek; 10 patients per day; generous paid time off; State of CA Pension that vests in 5 years; plus 401(K) and 457 retirement options – tax defer up to $48K; and much more! Contact Danny Richardson, Hiring Analyst, at (916) 691-3155 or danny.richardson@cdcr.ca.gov. EOE.

Physician Job Description - Specialty: Internal Medicine / Family Medicine- NonOB, Out-patient only - Active CA license, Active DEA, American Board Certified, Current ACLS - Schedule: Mon-Fri (8am-4pm), 10-15 scheduled daily appointments - Compensation: $16,000/mo., Must pass credentialing process - Central California (near Bakersfield, CA) CONTACT: Patricia Spiro, CEO Forensic Expert Services (559) 904-5522

Summer 2018


Class A Medical Office Space, approximately 1500 square feet. 1781 East Fir Avenue, Suite 102, available 7/1. Rent: $2250 plus security deposit. Contact Robert at (559) 800-7476 or administration@cvphysiatry.com.

Premiere medical office space for sublet.

The entire facility is 5000 square feet with modern aesthetic furnishings. Can include access to accredited ambulatory surgical facility with ability to perform procedures under general anesthesia or sedation as part of an office-based procedure. There are 4 exam rooms and nursing station, well suited for ophthalmology, gynecology, dermatology, plastic surgery or ENT practices. Support staff can be provided on request. Please inquire at (559) 797-9000 or email hedi@wpsfresno.com.

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.



practice manager resources

AUGUST 6, 2018 ANNUAL OSHA STAFF TRAINING SESSION 11 am - 2 pm FMMS/CMA Member (Includes Lunch)

$0 first person from your office attends $35 for each additional employee

Non-Member (Includes Lunch)

$50 first person from your office attends $35 each additional employee

Course Content This workshop provides up-t0-date changes and practice requirements to meet the OSHA mandates. OSHA REQUIRES RE-TRAINING FOR ALL PRACTICE PERSONNEL ANNUALLY. Federal OSHA regulation Title 29, Part 1910-1030 requires that all employees who have potential for exposure to blood and bloodborne pathogens (BBP) MUST receive training BEFORE they begin such work and, must be RETRAINED ANNUALLY. If the practice is organized as a PA, LLP, or LLC

OSHA considers doctors to be employees and they must also receive required training. How to handle an OSHA inspection

Emergency Preparation

What is the General Duty Clause?

Workplace Violence

Bloodborne Pathogens

Shelter in Place Requirements

Hazardous Communication

Aerosol Transmissible Disease Standard

A certificate of course completion will be given to each attendee. While the certificate documents Safety Training required by Cal-OSHA regulations, it must also be supported by the employer’s in-office, site specific Exposure Control Plan.


Is Your Practice At Risk? Join

for a special evening event

How to Stay on the Right Side of Fraud and Abuse Laws and What to Do When They Claim You’re Not September 26, 2018

6 pm Fort Washington Country Club •

Stark, Anti-kickback, and other considerations in negotiating and drafting agreements with suppliers, service providers, other healthcare providers, and Health Plans.

What providers need to know about the False Claims Act, including among other issues, its application to billing and overpayments.

• •

The OIG’s 2000 Compliance Guidance and establishing an effective compliance program.

• •

Proper controls to prevent occupational fraud including embezzlement and data theft.

What to expect and how to respond to Government subpoenas, Civil Investigative Demands, search warrants, and civil lawsuits alleging a violation of the fraud and abuse laws. Best practices for protecting your patient’s data from both internal and external threats.

Daniel O. Jamison Dowling Aaron, Inc.

Anne N. Vaz Dowling Aaron, Inc.

Tickets| 559-224-4224

Nathan W. Powell Dowling Aaron, Inc.

Jennifer Gudry Breadcrumb Cybersecurity

FMMS Members Free Nonmembers $30



In my naïveté 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. Medicine rewards efficiency, productivity, and stoicism. If you want to be seen as 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. Thankfully, I was able to recognize that burnout was happening, and was able to get myself back on track. I have rekindled the love for my profession again. >>


Summer 2018

But it wasn’t easy. The first step was admitting that I was when we get back. In some work environments, there is a financial struggling, which at the time felt like I was admitting defeat. I incentive for physicians not take vacations. reached out to my closest friends and family for support, and also One very important aspect of practicing medicine that is often spoke with several of my co-residents. I found that I wasn’t alone overlooked is that physicians have little or no control over is who our with regard to the way I was feeling. Through this experience, I immediate supervisors are. As physicians we prioritize our patients learned to practice better self-care, and made a pledge to sit down and take pride in providing high quality compassionate care. But and talk about when things weren’t going well instead of keeping it when we work for someone who doesn’t share our same values and bottled up inside. ethics when it comes to treating patients, the likelihood of burnout My hope is that physicians and other health care providers can increases and job satisfaction suffers as a result. learn to do the same. The ability to take care of patients and their Given what we know about the origins of physician burnout, the families is a gift, but sometimes in our darkest moments it’s difficult goal should not be to treat the aftermath, but to focus on what can be to see the forest for the trees. done to prevent it. Being a physician is stressful, especially since we see the sickest of Christina Maslach is Professor Emerita of Psychology at the the sick, and are constantly surrounded by people who are seriously University of California at Berkeley, and is best known for her injured, severely ill, or dying. This job also comes with tremendous expertise in job burnout. She created the Maslach Burnout Inventory responsibility as the decisions made in clinical care daily could be the difference between life and death. “GIVEN WHAT WE KNOW ABOUT THE ORIGINS OF Regardless of which position you PHYSICIAN BURNOUT, THE GOAL SHOULD NOT BE TO hold in medicine, each job comes TREAT THE AFTERMATH, BUT TO FOCUS ON WHAT with its own unique set of stressors. Some examples are: call schedule, CAN BE DONE TO PREVENT IT.” patient load, scheduled shift, tensions within the department you work in, leadership, administrative duties, etc. These stressors are often amplified by the lack of control physicians (MBI) which is the most commonly used instrument for measuring experience in daily practice. We are quite often at the mercy of burnout. There are several different versions of the MBI, but there hospital administrators, insurance companies, patient satisfaction is one that applies specifically to medical personnel. The MBI is surveys, endless stacks of paperwork, prior authorizations, and designed to capture 3 important dimensions of burnout: emotional billing personnel when all we want to do is take excellent care of our exhaustion, depersonalization, and personal accomplishment. patients and their families. Dr. Dike Drummond is a Mayo-trained Family Practice Our personal lives are meant to be the arena in which we recharge, Physician and an expert in the prevention of burnout in physicians. relax, and recuperate. But when work demands eat away at time with He lists 5 main causes of burnout: the practice of clinical medicine, our friends and families, and we aren’t afforded time to recharge, the specific job within the field of medicine, having a (personal) having a life is often more of a burden than a means to decompress. life, the conditioning of medical education, and leadership skills of We are tired, still have work to do even when we’re away from the immediate supervisors. He also notes that the very attributes that hospital, and start viewing the people closest to us as another thing make physicians successful are also what can contribute to burnout. on the long list of priorities we’re having difficulty managing. These characteristics are as follows: Unfortunately, while physicians often encourage patients under a great deal of stress to exercise, eat healthy, take a vacation, practice Workaholic – When there is additional work to do, or challenges work-life balance and self-care. Physicians are usually the worst in the workplace, the response is to work harder and longer offenders when it comes to taking care of themselves, in large part because of the way we are trained. We are taught to value delayed Superhero – When you feel as though the weight of every problem gratification, are praised when we work through exhaustion, and rests on you, and you have to have all the answers at all times are chastised if we complain about fatigue, the system in which we work, or when we express emotion about a difficult day. Medicine is Perfectionist – Any mistake, no matter how small, is a full time job, even when we’re out of the office. There are patients unacceptable, and you hold others to the same standard we worry about who keep us up at night. Sometimes we avoid taking vacations, knowing that we are going to have a mountain of phone Lone ranger – You feel obligated to do everything yourself calls, e-mails, and stacks of paperwork waiting for us on our desks

Summer 2018



A WORD ON PHYSICIAN BURNOUT SYSTEMS INTERVENTIONS In 2017 the Mayo Clinic published an article about systems interventions that could help to reduce physician burnout. They recommend the following: Acknowledge and Assess the Problem. This step is not just necessary for change, but recognition of the problem shows that the organization cares about the well-being of their physicians and also fosters trust between physicians and leadership. However, this is not meant to be a one-time conversation. Physician well-being should be a performance metric, just as are quality, safety, volume, patient satisfaction, and cost. Leadership. The quality of leadership has a direct effect on physician well-being. Efforts should be made to hire experienced, qualified, and intuitive leaders that are able to identify physician strengths and foster them. Implement Targeted Interventions. The chosen interventions will depend a lot on specialty and clinical environment. It requires leadership to determine where the sticking points are for physicians and work to alleviate that burden. Cultivate Community. The key to community is a collaborative and supportive environment where physicians have the opportunity to interact with each other. One of my favorite things about my work environment is the doctor’s lounge. I meet with colleagues over coffee or during the lunch hour. It functions as a space in which to share an interesting case, bounce ideas off of each other, and decompress from a difficult day. Use reward and incentives wisely. Physicians are rewarded for “productivity,” which is often directly linked to financial compensation. With the productivity model, physicians boost productivity by spending less time with patients, ordering more tests, or working longer hours. Align Values and Strengthen Culture. It is important to think about how the values of an organization influence the culture, and to be mindful that these two components should reinforce each other. When the culture of an institution is in direct opposition of its stated values, it puts practitioners in uncomfortable situations that may compromise their ethics, morals, and values. Flexibility and Work-Life Integration. The number of hours physicians work often make it difficult to have a work-life balance. Flexible scheduling, vacation benefits, and coverage for life events (i.e. maternity/paternity leave, death of a family member, illness, etc.) are invaluable.



Provide Resources for Self-care. A sincere effort should be made to promote physician well-being, and not use resilience training as a means to squeeze more work out of a burnt out physician. The resources should also be well-rounded and include topics like work-life balance, physical health, healthy eating habits, sleep, and relationships. Facilitate and Fund Organizational Science. There should be a focus on developing evidence-based strategies to reduce burnout that can be shared by the medical community as a whole and ultimately implemented

INDIVIDUAL INTERVENTIONS Self-care is extraordinarily important when it comes to preventing burnout, especially if you work for an institution that does not have a culture that supports physician wellness and is invested in preventing and reducing physician burnout. Exercise regularly. There is overwhelming evidence that exercise helps decrease stress, improves mood and physical health, and also enhances sleep quality. Even if 15 minutes is all you have, make the most of it. Go for a walk around the hospital. Take the stairs instead of the elevator. There are many exercise programs available on phone apps and online that can be streamed.Watch your diet. Sometimes we are so busy that we forget to eat. When the hunger kicks in and we become ravenous it is amazing the kind of food we will allow ourselves to eat. Try packing a protein bar, or fruit with you instead of going for the donuts that are often abundant in the hospital setting. And don’t forget to drink plenty of water. Use your vacation. We often feel guilty for taking time out for ourselves. Sometimes we feel that we are abandoning our patients if we take any time off. However, if we wish to have a long career in medicine so that we can continue to care for our patients, we have to take care of ourselves first. If we are not well, it is impossible to do a good job taking care of others. Learn how to say no. Doctors are notorious for trying to prove that we can do anything and everything. Sometimes saying “no” is the best thing we can do for ourselves, particularly when we are feeling overwhelmed. Saying “no” is not a sign of weakness, it is a skill. Saying “no” requires you to know where your boundaries are and stick to them, which means being consciously aware of your limits and being able to communicate them to others. Learn to recognize the signs of burnout. We cannot recognize what we do not know. It is very important to learn what burnout looks like, and ask for help if you are struggling. Every year physicians succumb to burnout, and in some tragic cases develop substance abuse problems or even commit suicide. Know that resources are out there, and it’s ok to ask for help.

Summer 2018

Funding For



by those who understand

the industry Credit lines and loans, tailored to the medical industry, with rates starting as low as *6% and 24-hour underwriting. Need funding? Ask us about our options and services by contacting Dr. Mark Scoffield: mark@vettedfunding.com | 559-281-4699 | WWW.VETTEDFUNDING.COM Vetted Partners is a nontraditional consulting company focused on the funding and strategic growth of businesses. *for eligible applicants

Summer 2018



The Urgent Care waiting room just got a lot more


Good news for anyone who can’t stand waiting When you’re injured or ill, a month can seem like an eternity to wait for an appointment.


Surinder P. DhillonNorthwest Internal Medicine 4770 Ste. W. Herndon 6079 N. Fresno Street, 101, Ave. Suite 111 Fresno 93710 Fresno 93722

Saint Agnes

Medical Center Urgent Care Saint Agnes

(559) 450-CARE (2273) Northwest 4770 W. Herndon Ave., Fresno 93722 st


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Northwest 4770 W. Herndon Ave., Fresno 93722 s We


(559) 450-CARE



Saint Urgent Agnes Care Saint Agnes Care


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




so you can wait in your living room instead of a crowded waiting room. Simply choose your designated And for those unexpected illnesses and accidents that treatment time and one of our health care professionals happen after-hours and on weekends, we offer urgent care willchosen see you upon arrival. When you’re confident you’ve thepromptly right at two convenient locations. hospital for your maternity care, you’re free to To hold your place in line, think of just For about anything. It’s why so many more information, visit samc.com/urgent-care. women choose Saint Agnes Medical visitCenter. saintagnesinquicker.com. 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.


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With our convenient new Need a physical? We’ll get you one within the week. It’s primary care on your schedule –you available right wait here online check-in, can

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Main Campus 1245 E. Herndon Ave., 93720 Main Fresno Campus 1245 E. Herndon Ave.

Fresno 93720 Most insurance plans accepted

Most insurances accepted.

Summer 2018

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