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Winter 2019

PASSION t o serv e t h e

un der serv ed Congress, It’s Time To Listen Physician Mental Health Stigma Rounding Back to the Valley Winter 2019



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12 14 16 20 23 26 40










Cover photo by Anthony Imirian

Winter 2019



From The Executive Director



2018 was a good year for the Fresno Madera Medical Society (FMMS) as well as many “wins” legislatively with the California Medical Associations efforts. FMMS continues to grow which is great; this really is a testament to the value of being a member of the Fresno Madera Medical Society and the California Medical Association. FMMS Membership has grown 20% since 2015 and we are now nearly 1400 physician-members strong in the central Valley. In addition, we launched our Joy of Medicine Program, our new FMMS website, expanded CME hours to over 50 hours of education, and have consistently added new member benefits throughout the year.

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

As you know, legislative services are a large part of your membership dues with the California Medical Association and sometimes these efforts do not always show value to a physician. Well, 2018 was a year that every physician should have seen those dues working for him or her. Because of your support, CMA was able to influence over 1,300 bills and legislative policy initiatives on your behalf.

Jessica Vaughn (Resident Board Member)

• Proposition 56 providing $1 billion annual return on behalf of physicians, medical groups and patients, details about this on page 20


• Defeated of Assembly Bill 3087 (Kalra) legislation that would have created a commission of unelected political appointees to arbitrarily cap rates for all health care services in all clinics, hospitals and physician practices in California

Farah Karipineni, MD - Chair

CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS EDITOR Farah Karipineni, MD

EDITORIAL COMMITTEE Roydon Steinke, MD, Cesar Vazquez, MD Nicole Butler, Trilok Puniani, MD, Farah Karipineni, MD CREATIVE DIRECTOR

• Sponsored Senate Bill 189, allowing appropriate coverage exemptions for medical group owners, resulting in premium savings for individual medical groups of up to hundreds of thousands of dollars • Provided legal victory for the medical staff and patients of Tulare Regional Health Center, which settled with full reinstatement of the medical staff, its officers and bylaws, and upheld the medical staff ’s rights to self-governance under California law These were just a few of the highlights from 2018, and we are now working hard and looking forward to 2019. Thank you for your membership and support all of which is vital to our efforts to increase medical practice profitability, save physician practices and protect the business of health care. If you are not currently a member, now is the time to join. Show your colleagues that you support them and that working together can accomplish so much more. Lastly item of interest, we sent out a FMMS Membership Survey in November and would really like for all or our members to take a few minutes to fill this out. It will help us focus our efforts to ensure we are supporting our physician members with issues and tops they need most. If for some reason you have not received the survey let me know and I will make sure you get a copy. There is a $200 VISA gift card up for grabs for those that complete the survey and opt in for the drawing.

www.sherrylavonedesign.com CONTRIBUTING WRITERS Alex Sherriffs, Maria Castellucci, James Davis, Janus Norman Don Gaede, MD, Erin Kennedy, Nicole Butler, Jennifer Seita, Farah Karipineni, MD CONTRIBUTING PHOTOGRAPHERS Anthony Imirian CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711 Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler Membership and Events Manager, Stacy Woods Marketing and Events Coordinator, Kailey Fontes

Cheers to 2019, let it be a prosperous year for everyone.

Receptionist, Becky Gentry

Nicole Butler



Winter 2019

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A message from our Editor > Farah Karipineni, M.D., MPH

These Are Stories To Be Told

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



Like most of us, I entered the field of medicine brimming with altruism and hope. As a comparative literature major in college, I believed in the power of the written word to transform moods, horizons, and even lives. Yet an illness of my own made me realize that while literature is undoubtedly powerful, physicians are in the trenches of a war that rages on the mind and the body. Here is where I found my purpose—to heal both with the art and skill of medicine. Not eager to give up my passion for storytelling, I told myself that writing could always be a favorite pastime. Then I discovered narrative medicine. Far from a pastime, storytelling in medicine has become a necessity to preserve my humanity in a field that is constantly under threat by various pressures—time, insurance, documentation, productivity benchmarks, and the list goes on. In such a milieu, taking the time to focus on the narrative of what we do, what it means to us, and what it means to our patients, has never been more vital an exercise. Physician writing combats the push towards reducing each sacred patient interaction to a mere billable event, and each medical provider to part of an impersonal service line. My time on the patient side of things has reminded me time and again that patients are not simply clinical diagnoses. In the same way, we physicians cannot be reduced to our medical subspecialty. Each of us brings the richness of our thoughts and experiences with us to every human interaction. Stories, woven from the depths of our suffering as well as our joy, these are stories to be told. Our sociopolitical views also matter a great deal: perhaps more than we know. The #thisisourlane movement is a powerful example of how physicians’ words can shape a movement. Societal health transcends the operating theater, the exam room, the trauma bay, and the hospital bed. Issues such as climate health, structural violence, and social justice affect our patients’ health at least as much as their ICD-coded diagnoses, and our opinions on these issues matter. It is my goal for Central Valley Physicians to play precisely this role in our esteemed community of healthcare providers. Whether the genre is personal, clinical, political, or purely entertaining, I hope that this magazine continues to serve as a place to express your thoughts, ideas and beliefs in the context of our beloved profession.

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

California Health Sciences University (CHSU) announced that Fresno County’s First College of Osteopathic Medicine (COM) has approval to accept applications from students for Osteopathic Medical School. “We are exceedingly proud to hold the distinction of being the first, 4-year medical school in the Valley,” exclaimed Dr. John Graneto, Dean of the CHSU College of Osteopathic Medicine. “We are now recognized as the 3rd Osteopathic Medical School in California and students can apply to our program starting May 3, 2019, when the application cycle opens.” CHSU, College of Osteopathic Medicine will be the thirty-fifth in the Nation to open and will admit its first 75 students beginning May 3, 2019, growing to 600 students in the program at one time. Construction of new CHSU campus is well underway.

The concrete foundation was poured just a few weeks ago to support the ground of the future classrooms, and they are currently in the second phase of the foundation work and the first structural steel of the buildings placed. The College of Osteopathic Medicine building will be the first to be completed in time for classes to begin in July 2020. The new three-story, state-of-the-art building has an expansive, 21,000 sq.ft. Simulation and OSCE Lab, Clinical Skills Lab, and two large classrooms designed for our team-based learning curriculum. The campus will also have a Teaching Kitchen to ensure students understand how to prepare healthy meals and the importance of proper diet in relation to good health. The next step in COCA accreditation comes in fall 2019 with a comprehensive site visit of the new medical school building is nearer to completion.

LETTER TO THE EDITOR Submit your letter to the editor by emailing Nicole Butler at nbutler@fmms.org


October 16, 2018, Andre N. Minuth, MD About 350 physicians gathered at the Annual Meeting of the House of Delegates of the California Medical Association in Sacramento on October 13 and 13, 2018. The surprise election of an outsider as the new President-Elect Peter Bretan, M.D. is a very rare occurrence. A similar event, to the best of the writer’s recollection, occurred in the 1950s when a delegate became President-Elect of the American Medical Association. Peter Bretan, M.D., a UCSF transplant urological surgeon from UCSF, who now practices in Watsonville won the run off after none of the three candidates achieved the necessary 50% + I vote to win outright. The win was very unexpected because the other two candidates had climbed all the right steps of the ladder to the presidency. The election was a confluence of concerns of the younger and older members of the CMA, joined by the medical students. There is the long simmering undercurrent for change in leadership because of the change from an administrator to a chief executive officer. The older members want a return to some of the tested ways of the past, the younger members desire more participation. The medical students have advanced beyond talking points to “Trust and Verify”. Sobering was a presentation by an UC Berkeley economics professor about the never-ending need to raise new taxes which included an airport tax on hapless travelers. There was general consensus that this was the wrong way to solve the chronic budget deficits, and the crushing load of student debts. Some of the changes to the governing structure have dampened the spontaneity emanating from the roots. The delegates are the listening posts across California. The delegates formulate the concerns into resolutions. Some examples of the past. Patients were dying because of the lack of dialysis access. The late Robb Smith Sr., M.D., a family doctor from Orange Cove, in the 1980s helped write and guide the resolution to increase dialysis access and home dialysis through the HOD of the CMA and the AMA. It entered federal legation and helped. It was Dr. Frank, a delegate, and a thoracic surgeon from Los Angeles, who year after year with his wife in tow, came before the HOD with anti smoking resolutions. Finally, with the help of medical students, the delegates, about a third still smoking while voting, caved in, and ordered the CMA to work on the legislation. It began with small parts of



Winter 2019

restaurants becoming smoke free zones. To be frank, the writer was one many other supporters very skeptical that it would work. Au contraire, it snowballed across the whole world. Then, there were two delegates from Southern California who met with two attorneys and hammered out the MICRA legislation to reign in financial malpractice catastrophe with reasonable caps. The then as now Governor Jerry Brown agreed to sign the if both agreed. They did. The delegates were consummate experts in the Rules of Order, and the legislation withstood the most ferocious assaults. Some of the issues that need to be addressed are: • Return the CMA to political neutrality. • The desire for more face to face meetings. • The over-concentration of power into the Board of Trustees which has usurped the prerogative of the House of Delegates to weed out some resolutions. Every resolution from a delegate must be submitted to the House of Delegates. • The over-concentration of power away from the elected President and Administrator, to the Chief Executive Officer, and an incidental President. • The financial fate of the CMA multi-million building in Sacramento. • The management by the CMA of the difficulties of the medical staff in a Tulare hospital. The CMA moved into expensive lawyering before a reality check. The hospital was moving towards bankruptcy and closed for a year. In conclusion: This is not the placed for specific recommendations. However, this sudden change in leadership of the CMA clearly signals dissatisfaction by the majority of members of the HOD, and the urgency of critical selfassessment and adjustments in leadership. Andre Minuth, M.D.


December 1, Tenaya Lodge at Yosemite The “2018 Joy of Medicine Summit” at the Tenaya Lodge on December 1, 2018 was successfully arranged by the Fresno Madera Medical Society on December 1, 2018 under Executive Director Nicole Butler and her staff. My wife and I drove sixty miles from Fresno and stayed spent two nights at the Tenaya Lodge in Yosemite. There was fresh snow outside and warm collegiality inside at the presentations, group discussions and dinner. The discussions continue as frank as ever in the privacy provided only by the medical society. The round table discussions after presentations were open and instructive. The presence of young children added vitality. The whole conference showed the benefit for personal contact among physicians including their families that can be supplemented but not replaced by teleconferencing. The attendees ranged from newly minted physicians to some who graduated over four decades ago, had driven up to one hundred sixty miles. Among them, a geneticist turned obstetrician-gynecologist in training, a mother who appreciated the brief breather away private practice and chores, and an anesthesiologist who married his wife after their first date and just celebrated their fifty second wedding anniversary. >>

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The composition of physicians since the ‘new society’ was successful. This is not the place to make specific legislation in the 1960s has changed from the East Coast recommendations except the study of ‘Sturgis Rules of mainly male establishment roots to diversity with many Order’, which costs about $15, reads like the Readers Digest female physicians who have achieved near equity in general, and helps physicians to become effective participants in and near total dominance in the training in obstetrics and governance. gynecology. The composition of foreign graduates has changed from mainly European to multi continental. Andre N. Minuth, M.D. The subjects of physician ‘burnout’ is very troublesome 8590 North 3rd Street • Fresno, CA 93720-1746 causing physicians to leave clinical practice early above the Tel: 559.439.2045 Cell 559.455.7086 rate of normal attrition. ‘Burnout’ seems a misnomer caused by deeper problems brought on by the health care laws of the 1960s that were passed in record time and that have now been implemented.  These laws were written by anonymous planner under exclusion of the The Cooperative of American Physicians American Medical Association is run by physicians like myself. and its components, which then Applicants are carefully selected to make consisted predominantly of single private practitioners, and equally sure only high- quality physicians important little discussion in become members of the risk pool. the U.S. Congress. Thus, then Overall, I have saved a significant amount no time given for feedback and consequentially much room for of money on my errors. The frequent declarations premiums and am of ‘news methods’ now in mode glad I made the seem patching up avoidable errors. Particularly galling was change. the subject of time-consuming clerical ‘prior authorization’ for the reimbursement of essential services, that dampens - Don Gaede, MD physicians’ productivity. The Vascular Medicine near disappearance of full-time FMMS Member 39 Years physician spouses, and the clergy for patients and physicians have left a void. The writer can remember many a case when the help and privacy provided by the clergy was essential.  Just like captains of ships on the high seas, and pilots of planes loft, medicine is not an 8 to 5 job. In summary, the program



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Secured the Proposition 56 supplemental budget bill, which appropriates over $1 billion in funding for improved access to care.

Achieved record-setting 6.24 percent increase in membership with a 92 percent retention rate.

Drafted and filed a 2020 Sugar-Sweetened Beverages tax ballot initiative.

Stopped predatory practices by health insurance companies, including attempts to substantially limit same-day services (modifier -25 payments).

Launched a mobile app, as well as updated brands and websites for CMA, PHC, CALPAC and 20+ component medical societies.

Defended the medical profession and patients from dangerous legislation, including AB 3087 (Kalra).

Helped the Tulare Regional Medical Center medical staff restore independence and self-governance against the hospital.

Recouped nearly $11 million from payors on behalf of CMA’s physician members – a record year!

Secured $30 million commitment from Blue Shield of California to support the launch of a Physician Services Organization.

Secured $200 million to establish a loan repayment program and $40 million for the University of California to support, retain and expand physicians trained in California.

Visit cmadocs.org for more information.


We are convinced that climate change threatens the health of our patients and our Valley’s future prosperity. The Beijinglike air quality experienced in the last round of wildfires is clearly related to a lengthening fire season resulting from climate change. There are many actions we can take individually and collectively which can make a difference.  A recent article in The Hill* highlighted opportunities for us physicians to make our voices heard as a new congressional term begins. The article was written by Mona Sarfaty, MD, MPH, Director of the Medical Society Consortium on Climate and Health, based at George Mason University. It concluded with these words: “With a new Congress being seated in January, my medical



colleagues and I hope every member is willing to face the reality that climate change is the biggest threat to our health and well-being. We hope they will also recognize that responding to climate change is our biggest public health opportunity. As physicians, our primary responsibility is to help our patients be as healthy as possible. To achieve this aim, we need Congress to do its part. Therefore, we want every member of the new Congress to hear our voices on this issue. We will know they are truly listening if they issue three responses: 1. They publicly affirm the reality of human-caused climate change and its harmful impacts on the health and well-

Spring 2018




CLIMATE CHANGE being of American families, communities and businesses and particularly our most vulnerable citizens. 2. T  hey develop and support legislation that will greatly accelerate America’s transition to a future powered by clean energy and enhanced energy efficiency, paced by meaningful goals and timetables, to improve the health of all Americans, now and in the future. 3. They develop and support legislation that will help American communities protect themselves and become more equitable and more resilient to the harms of climate change, so that people are not needlessly hurt.

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Congress, it is time to listen to America’s doctors and act for our health.” We encourage FMMS members to contact their congressional representatives and let them know you want them to act now on climate change. Links to contact your member of Congress: Rep. Devin Nunes https://nunes.house.gov/contact/ Rep. Jim Costa https://costa.house.gov/contact Sen. Diane Feinstein https://www.feinstein.senate.gov/public/ index.cfm/contact Sen. Kamela Harris https://www.harris.senate.gov/contact R ep. TJ Cox https://cox.house.gov/contact *https://thehill.com/opinion/healthcare/418477-congress-itstime-to-follow-your-doctors-prescription-on-climate-change



By Janus L. Norman, CMA Senior Vice President, Centers for Government Relations and Political Operations It has been said that “diligence makes the difference between all-time greats and one-hit wonders.” For over 160 years, the physician leadership of the California Medical Association (CMA) has practiced unmatched devotion to its members and the entirety of the physician community. CMA’s physician leaders care for their individual patients at all hours of the day or night and are stewards of the profession in their limited time off. This investment of sacrificed family and personal time has powered the state’s largest medical association forward. Innovations in the association’s governance structure have increased CMA’s ability to maintain its vaulted position within the Golden State’s political “Game of Thrones.”

Success in the legislative process is sometimes difficult to measure. Insiders often refer to published lists of powerful special interest groups or individuals, articles listing interest groups that have spent the most money on lobbying and/or campaign activities, or the number of mentions an association receives in news articles. If those are the measurements of success, CMA is at the top of the class: staff are consistently included in the Capitol Weekly Top 100; CMA is routinely recognized by news outlets as one of the most effective lobbying organizations in the state; and rarely does an article regarding health care legislation not include a quote from the CMA president.



Prominence is significant; it aids in the creation of political capitol. But distinction itself is not the goal. Physician leaders want to ensure CMA improves the health care delivery system by obtaining state budgetary appropriations to increase patient access and protect against ill-conceived legislation that would directly threaten their ability to financially maintain a practice and provide the best care.

“The 2018–2019 State Budget included over $1 billion in new funding to support supplemental payments for physicians participating in the Medi-Cal program.”

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RETURN ON INVESTMENT In 2016, CMA, the California Dental Association, the Service Employees International Union (SEIU) and their coalition partners beat the odds. Together, we convinced voters to increase the state’s tobacco tax by $2 in order to invest a majority of the revenue into increasing access to care. CMA contributed $1 million to the statewide Proposition 56 campaign. Now that the tax is being collected and distributed, the physician community sees the impact. The 2018-2019 State Budget included:

• • • •

Over $1 billion in new funding to support supplemental payments for physicians participating in the Medi-Cal program

An expansion of the number of CPT codes that are eligible for those supplemental payments $190 million for medical student loan repayment

$40 million in new funds for graduate medical education, which will be administered by Physicians for a Healthy California (formerly known as the CMA Foundation)

In the 2017-2018 legislative session, two detrimental proposals were introduced that would have upended the state’s health care delivery system. SB 562 (Lara, Los Angeles) would have required California to implement an extremely flawed single-payer proposal. AB 3087 (Kalra, San Jose) would have empowered a politically-appointed committee to price fix physician services. In both instances, the health care community looked to CMA for leadership and expertise.

“[...] the Legislature now looks to our House of Delegates for a solution to improve access and increase the affordability of health care in California.” On a weekly basis, opposition coalitions met at CMA headquarters to execute a substantial grassroots program, earned media strategy, Capitol lobbying strategy and a digital media campaign. The defeat of SB 562 and AB 3087 once again showcased CMA as an unapologetic leader in health care policy. As a result of defeating both bills, the Legislature now looks to our House of Delegates for a solution to improve access and increase the affordability of health care in California.

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During the first quarter of the year, the CMA Board of Trustees adopted CMA’s sponsored bill package. The bills focused on:

• • • •

Improving state oversight and regulation of predatory behavior by health plans (AB 2674 by Assemblymember Aguiar-Curry and AB 2427 by Assemblymember Wood)

Improving access to medication assisted treatments for individuals fighting opioid addiction (AB 2384 by Assemblymember Arambula) Improving the medical board disciplinary process (AB 505 by Assemblymember Caballero)

Increasing transparency and oversight in the pharmaceutical supply chain (AB 315 by Assemblymember Wood)

Protecting medical independence for physicians working in county sheriff’s departments (SB 1303 by Senator Pan)

“[...] all sponsored legislation made it through both houses of the Legislature and were sent to the Governor for consideration.” I am pleased to report that all sponsored legislation made it through both houses of the Legislature and were sent to the Governor for consideration. While the fate of each bill will vary, it is important to note this year the Legislature agreed with each of the policy principles of our sponsored legislation. For details of the major bills that CMA followed this year, visit cmadocs.org/leg-wrap-2018.

The call for leadership is once again before us. Guided by our grand history, we must continue to exercise our diligence, provide solutions and construct the development of the next iteration of California’s health care delivery. Let’s do it again! In Unity,

Janus L. Norman CMA Senior Vice President Centers for Government Relations and Political Operations

cmadocs.org | Page 2



Healthcare industry takes on high physician suicide rates, mental health stigma BY MARIA CASTELLUCCI - REPRINTED FROM MODERN HEALTHCARE

Dr. Michael Weinstein, a trauma surgeon at Jefferson Health in Philadelphia, has suffered from depression for much of his life. Although he has received treatment throughout his two-decade career, Weinstein never discussed it with his colleagues, fearful they would perceive him as weak. “It was something I hid because of the associated stigma and also lack of awareness that many people in the profession would potentially be having similar types of issues,� he said. Then, in 2016, it got worse. Seemingly out of nowhere, he fell into a deep depression. It was so bad, he began to contemplate suicide. His wife forced Weinstein to see his primary-care physician, who convinced him to take a leave from work and admit himself to a psychiatric facility, where he underwent electroconvulsive therapy. >>



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“I needed someone to tell me to stop working. It was the fear of telling people I couldn’t do this anymore, it felt like a sign of weakness or my own failing,” Weinstein said. The fear he felt to discuss and seek help for his suicidal thoughts is believed to be common among physicians and the major reason why experts believe doctors experience higher rates of suicide than the general population. Questions on medical licensure applications about past and current mental health conditions discourage physicians from seeking help out of fear they’ll lose their jobs. Additionally, a pervasive culture ingrained since medical school—where physicians are told to be strong and put the health of their patients before themselves—only adds to the pressure. “There is almost this macho culture that you might find in law enforcement and the military that physicians can relate to—that you have to tough it out,” said Dr. Christine Moutier, chief medical officer at the American Foundation for Suicide Prevention who has written extensively about physician suicide. Physician suicide has been a problem in healthcare for decades. Studies dating back to the 1920s show that physicians suffer from suicide at high rates. Physicians with mental health conditions have long been discriminated against and suicides have often been kept hidden from colleagues and the public. The difference in the past few years is that the industry is responding. Recent concerns around burnout have pushed organizations to rethink how they approach physician well-being, which has led to more action around how to deal with physician mental health concerns and suicide. “I think burnout has opened the door to deal with the entire portfolio of psychological problems with clinicians,” said Dr. Thomas Nasca, CEO of the Accreditation Council for Graduate Medical Education. “It has made it acceptable to have these discussions. It’s a real opportunity for us to begin to fix these problems.”

Incomplete data How many physicians actually die by suicide every year is not known. The American Foundation for Suicide Prevention has stopped using the commonly cited statistic that 300 to 400 doctors commit suicide each year. “We have taken it off our website,” Moutier said. “It’s not a literal number and we don’t have a way to capture it with that level of granularity.” The uncertainty about the suicide rate isn’t unique to physicians. The death investigation system in the U.S. doesn’t have a uniform reporting system. Coroners, who are elected county officials, aren’t required to have medical training or report the occupation of the deceased. And how the suicide occurs makes a difference in how it’s reported, said Dr. Michael Myers, a professor of clinical psychiatry at SUNY-Downtown Medical Center in New York who has studied physician suicide. If the suicide is public, such as when a doctor jumps to his death, it’s more likely to be reported as such. But if it occurs in a hospital setting or at home, administrators or family members can influence how the death is categorized. Myers recalls when a classmate suddenly died during his medical school training in 1962. “When we lost Bill, no one from the dean’s office spoke to us. The family shut down. No one talked about it.”

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TEN FACTS ABOUT PHYSICIAN SUICIDE AND MENTAL HEALTH 1. Suicide is generally caused by the convergence of multiple risk factors, the most common being untreated or inadequately managed mental health conditions. 2. An estimated 300 physicians die by suicide in the U.S. per year.1 3. In cases where physicians died by suicide, depression is found to be a significant risk factor leading to their death at approximately the same rate as among nonphysician suicide deaths; but physicians who took their lives were less likely to be receiving mental health treatment compared with non-physicians who took their lives. 2 4. The suicide rate among male physicians is 1.41x higher than the general male population. And among female physicians the relative risk is even more pronounced — 2.27x greater than the general female population. 3 5. Suicide is the second leading cause of death in the 24-34 age range (accidents are the first).4 6. The prevalence of depression among residents is higher than in



Even with the dodgy data, studies that have been conducted overwhelmingly show physicians die by suicide at a higher rate than the general population. A recent review of studies published in the past decade found the rate of physician suicide was between 28 and 40 per 100,000 compared with the overall rate in the general population of 12.3 per 100,000. “In almost every one of the studies, physicians come out with a higher suicide rate than the general population, that we can say with a high degree of certainty,” Moutier said. The issues with the data make it impossible to know if the suicide rate is getting better or worse. But Nasca at the ACGME doesn’t think that matters. He’s asked rooms full of physicians to raise their hands if they haven’t had a colleague commit suicide. Rarely anyone does. “It’s overpowering when you do that,” Nasca said.

“Publicly shamed” A major deterrent to physicians seeking mental health services is fear they will lose their medical license. In 2013, 43 states asked questions about mental health conditions on medical licensing applications for physicians seeking a license for the first time. States were also more likely to ask about past mental health conditions than questions about past physical disorders.

Disclosing a mental health issue can have humiliating consequences. The Medical Licensing Board of Indiana put Dr. Adam Hill on probation for two years after he voluntarily reported a relapse during a recovery program for substance abuse. Hill said he felt “publicly shamed” by the experience. His medical liability insurance also skyrocketed. A palliative-care physician at Riley Hospital for Children at IU Health in Indianapolis, Hill has recently been open about his issues with depression and alcoholism. And he admits he’s had suicidal thoughts. “There are all these bureaucratic checkpoints that stigmatize the individual, they make you fearful to step forward,” he said. “We tie people’s paychecks and their livelihood to whether or not they have these red flags in their own medical chart, which is openly discriminatory.” But there are movements to address the problem. Earlier this year, the Federation of State Medical Boards issued recommendations that boards remove questions on



applications that ask about past or current mental health conditions. And for state boards insistent about asking mental health questions, the FSMB recommended boards phrase it more generally to “any condition” the physician currently isn’t treating that could impair their ability to practice. In following this recommendation, a physician wouldn’t have to disclose a mental health condition they are seeking help for. But FSMB CEO Dr. Humayun Chaudhry readily points out these are just recommendations. They can’t force a state medical board to follow them. “Our preference would be that they don’t ask the question at all,” he said. “We don’t want the licensing process, which is there to protect the public, to add to the stigma that doctors seem to have about seeking care. That is not the purpose of the state boards. It’s to protect the public but to do so in a manner that is sensible and reasonable and is ultimately going to help everyone,” he added. Some state boards have opted not to ask any questions about mental health. North Carolina recently removed any questions about mental health conditions from its medical licensing renewal application. Instead, a statement has been added advising physicians to seek treatment for conditions that might affect patient care. The board is in the process of adding it to first-time applications as well. Also, like 45 other states, North Carolina has a health program that allows physicians to receive mental health treatment anonymously. When the mental health question was still on the application, physicians who were seeking treatment through that program didn’t have to disclose it to the board. “If people have a safe place to go where their license won’t be in potential jeopardy, they will take that step forward and ask for help and that’s evidenced by the fact that 45% of our participants are anonymous to the board,” said Joseph Jordan, CEO of the North Carolina Physicians Health Program.

Normalizing mental health disorders Medical license applications are just one piece of the puzzle to attack the stigma around mental health disorders in the profession. Physicians still struggle to talk openly about depression and other behavioral health conditions with their colleagues because of fear they’ll be judged. But there are anecdotes that show such fears might be misplaced. When Weinstein returned to Jefferson Health after a

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six-month leave of absence, he decided he’d be honest about where he’d been before rumors could swirl. After years of hiding his depression from colleagues, they embraced his story. Weinstein received emails from co-workers talking about their own experiences or of those they knew who suffered from mental illness or committed suicide. “The more we openly discuss these issues and write about them and tell people’s stories, I think more people will be able to get high-quality psychiatric mental healthcare,” he said. “We need to support one another. I know firsthand what the depressed brain is like … but no matter what you have gone through, there is a light and there are so many reasons to appreciate being alive.” Some institutions are trying to normalize the prevalence of mental health conditions among its physician workforce. When residents arrive at Mayo Clinic they are immediately told about the issue of mental health in the profession and why physicians might be reluctant to seek care. Residents are then informed about confidential counseling services available. Mayo has offered counseling services to its staff for over 20 years, but they weren’t actively promoted until about two years ago, said Dr. Sandra Rackley, medical director of trainee well-being at Mayo. “Most physicians wait until they are in a crisis when they reach out for help,” she said. Mayo’s efforts are in line with the ACGME’s update last year to its common program requirements that call for residency programs to provide residents with “immediate access at all times to a mental health professional.” “We have ensured there is infrastructure within all institutions (accredited for residency programs) to provide support to begin to address this issue,” Nasca said. The Association of American Medical Colleges, which represents all U.S. allopathic medical schools, is also encouraging schools to offer and promote mental health services for students and faculty. Some schools are even breaking their classes up into smaller groups so the students can forge closer bonds with faculty and each other. “I think that sense of community support is very valuable,” AAMC CEO Dr. Darrell Kirch said. Hill at Riley Hospital said the growth of physician wellness programs and increased access to mental health resources are all good signs, but he emphasizes they aren’t enough. “We really have to work on these licensing and insurance issues if we are really going to effect change,” he said. “It has to involve all of that, not just normalizing the conversation.” SOURCES

1.Center, C., Davis, M., Detre, T., Ford, D. E., Hansbrough, W., Hendin, H., Laszlo, J., Litts, D.A., Mann, J., Mansky, P.A., Michels, R., Miles, S.H., Proujansky, R., Reynolds, C.F. 3rd, Silverman, M. M. (2003). Confronting Depression and Suicide in Physicians. JAMA, 289(23), 3161. doi:10.1001/jama.289.23.3161 2.Gold, K. J., Sen, A., & Schwenk, T. L. (2013). Details on suicide among US physicians: Data from the National Violent Death Reporting System. General Hospital Psychiatry, 35(1), 45-49. doi:10.1016/j.genhosppsych.2012.08.005 3. Schernhammer, E. S., & Colditz, G. A. (2004). Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). American Journal of Psychiatry AJP, 161(12), 2295-2302. doi:10.1176/appi.ajp.161.12.2295 4. CDC National Center for Injury Prevention and Control. (2015). 10 Leading Causes of Death by Age Group, United States - 2014 Retrieved from http://www.cdc.gov/injury/images/lc-charts/leading _causes_of _death_age_ group_2014_1050w760h.gif 5. Mata, D. A., Ramos, M. A., Bansal, N., Khan, R., Guille, C., Angelantonio, E. D., & Sen, S. (2015). Prevalence of Depression and Depressive Symptoms among Resident Physicians. JAMA, 314(22), 2373. doi:10.1001/jama.2015.15845 6. Guille, C., Zhao, Z., Krystal, J., Nichols, B., Brady, K., & Sen, S. (2015). Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns. JAMA Psychiatry, 72(12), 1192. doi:10.1001/ jamapsychiatry.2015.1880

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similarly aged individuals in the general U.S. population — 28 percent of residents experience a major depressive episode during training versus the general population rate of 7-8 percent. 5 7. Among physicians, risk for suicide increases when mental health conditions go unaddressed and when self-medication occurs as a way to address anxiety, insomnia, or other distressing symptoms. Although self-medicating may reduce some symptoms, the underlying health problem is not effectively treated and this can lead to a tragic outcome. 8. In one prospective study, 23 percent of interns had suicidal thoughts, but among those interns who completed four sessions of web-based Cognitive Behavior Therapy nearly 50 percent fewer had suicidal ideation.6 9. Drivers of burnout include work load, work inefficiency, lack of autonomy and meaning in work, and work-home conflict. 10. Unaddressed mental health conditions are, in the long run, more likely to negatively impact one’s professional reputation and practice than reaching out for help early.




CMA’s one-time $1 MILLION INVESTMENT reaps billions a year for health care in CA BY KATHERINE BOROSKI In 2016, and with a onetime $1 million investment, the California Medical Association (CMA) led a coalition of health care advocates to take on Big Tobacco and drastically expand funding for existing health programs and research into cures for cancer and other illnesses caused by tobacco products. Under CMA’s leadership, California voters overwhelmingly approved Proposition 56, which imposed a $2 per pack tax hike on tobacco products that will generate over $1 billion a year dedicated to increasing access to health care by improving provider payments and other crucial health care programs.

Provider Payments The largest portion of Proposition 56 funds – over $500 million a year with an additional $500 million federal match – is dedicated to increasing provider payments in the Medi-Cal program, which serves one-third of the state’s population and half of the state’s children, so that more Medi-Cal patients can access care when they need it most. The tobacco tax funds are being used to provide supplemental payments for a total of 23 CPT codes, through both the fee-for-service and managed care delivery systems.   “The California Medical Association is proud to leverage a $1 million investment for Proposition 56 into a $1 billion annual return

DHCS will be increasing the supplemental payment for the eligible CPT codes to 85-100 percent of Medicare. This will in many instances more than double the amount that physicians are paid for caring for Medi-Cal patients. While California’s base payment rates for Medi-Cal physicians are still among the nation’s lowest, these supplemental payments will help increase access for the nearly 14 million Californians, including half of the state’s children, currently covered by the program.

on behalf of California’s physicians, medical groups

Graduate Medical Education

and patients.”

Thanks to Prop. 56, the California Legislature created a $40 million graduate medical education (GME) fund for the University of California (UC) to sustain, retain and expand GME programs, with the goal of increasing the number of primary care and emergency physicians in California. This program will be administered by CMA’s foundation—Physicians for a Healthy California (PHC)—on behalf of the UC and in coordination with a five-member executive board and 15-member Advisory Council. PHC expects to release these funds to GME programs in the current fiscal year.

– Dustin Corcoran, CMA CEO



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This GME funding is critically important as California is facing a serious physician shortage. A robust and well-trained primary care workforce is essential to meeting the health care demands of all Californians. There is overwhelming data that physicians who complete training in California are very likely to set down roots and practice in the communities in which they trained. This funding will allow California to train more physicians to address the serious physician shortages and resultant access to care challenges that are plaguing our state. CMA is committed to ensuring California is training enough physicians to meet current and future demand. Expanding funding for graduate medical education to ensure that there are enough residency slots to train physicians in regions where health care services are needed most is one of our top priorities.

Physician Loan Repayment The Prop. 56 tobacco tax also provided $190 million in expanded loan repayment opportunities for physicians practicing in underserved areas. Nationally, for the class of 2017, 75 percent of medical school graduates had education debt, with a median medical education debt of $180,000. CMA’s modest investment in support of Proposition 56 and its leadership in anti-tobacco initiatives, which will generate billions in new health care dollars, are part of our greater effort to combat the critical physician workforce shortage in California, which limits access to health care for patients – particularly in rural communities.

To learn more about how this money may apply to you as a physician or medical group, visit cmadocs.org/prop56. DHCS receives approval on Medi-Cal supplemental tobacco tax payments for FY 2018-2019 The California Department of Health Care Services (DHCS) recently received federal approval on its plan to increase Medi-Cal fee-for-service physician payments for the 2018-2019 fiscal year. The supplemental payments—made possible by the Proposition 56 tobacco tax funding—will raise payments for a total of 23 CPT codes, including 10 new preventive CPT codes. DHCS will be increasing the supplemental payment for the previously eligible CPT codes to 85 percent of Medicare (a 40 percent average increase in payments for these eligible codes compared with 2017 – 2018 payment levels). The 10 newly added preventive CPT codes will be paid at 100 percent of Medicare. >>

CMA publishes Prop 56 payment monitoring worksheet To help physician practices monitor their Prop 56 supplemental payments, the California Medical Association (CMA) has published a Prop. 56 Payment Monitoring Worksheet. The worksheet will automatically calculate the supplemental payment amount by CPT code so you can ensure that you are receiving your share of the supplemental tobacco tax money. The worksheet is available free to members at cmadocs.org/prop56.

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According to DHCS, the prospective fee-for-service supplemental payments are anticipated to begin as soon as September 24. The timeline for the retroactive payments back to the beginning of the fiscal year (which began July 1, 2018) is still being worked out, but DHCS expects to distribute retroactive payments in early 2019. There is no additional action required by providers to receive the supplemental payments. Reimbursement on claims for eligible codes (see table below) will automatically include the supplemental payments. The supplemental payments would apply to both fee-for-service and managed care delivery systems, however approval for DHCS’s managed care proposal is still pending. In the interim, DHCS is continuing to distribute supplemental payments at the 2017-2018 amounts and eligible CPT codes to the Medi-Cal managed care plans with the expectation that those funds be paid to physicians within 90 days of receipt from DHCS. A full list of the eligible CPT codes is listed below.

Medi-Cal Supplemental Payments CPT Code


*2016 FFS Base Rate

2018 Base Rate w/ Prop 56 % Increase Supp Funds


Level 1 Est. Pt Visit





Level 2 Est. Pt Visit





Level 3 Est. Pt Visit





Level 4 Est. Pt Visit





Level 5 Est. Pt Visit





Level 1 New Pt Visit





Level 2 New Pt Visit





Level 3 New Pt Visit





Level 4 New Pt Visit





Level 5 New Pt Visit





Psych diagnostic eval





Psych diagnostic eval w/ medical svcs





Other psych services - pharmacologic mgmt





Prev. Visit Est. Pt Ages < 1 year





Prev. Visit Est. Pt Ages 1-4 Years





Prev. Visit Est. Pt Ages 5-11 Years





Prev. Visit Est. Pt Ages 12-17 Years





Prev. Visit Est. Pt Ages 18-39 Years





Prev. Visit New Pt Ages < 1 Year





Prev. Visit New Pt Ages 1-4 Years





Prev. Visit New Pt Ages 5-11 Years





Prev. Visit New Pt Ages 12-17 Years





Prev. Visit New Pt Ages 18-39 Years




Physicians with questionsw can contact the Medi-Cal Telephone Service Center at (800) 541-5555 or CMAâ&#x20AC;&#x2122;s Reimbursement Helpline at (888) 401-5911. 22


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As a Trauma Surgeon, Firearm Injury Prevention Is My Lane JAMES W DAVIS MD, FACS Chief of Trauma, CRMC Chief of Surgery and Trauma, UCSF/Fresno

There has been much media attention on recent mass shootings, and multiple medical associations have come out in favor of firearm safety legislation (American College of Surgeons, American Association for the Surgery of Trauma, Western Trauma Association, American College of Physicians, American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and the American Psychiatric Association to name a few). The National Rifle Association pushed back, suggesting that doctors should “stay in their lane”. As a trauma surgeon, Firearm injury prevention is MY lane and the lane of every physician. Unfortunately, the problem of firearm injury is getting worse. In 2013, there were over 33,000 firearm deaths in the United States. According to the Centers for Disease Control and Prevention (CDC) , the number increased to 39, 773 in 2017, marking three straight years of increases and reaching the highest total in 50 years. Gunshot victims only make up about 4% of the National Trauma Data Base sample (about 15% of trauma admissions at CRMC), with motor vehicle crashes and falls making up

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the most common mechanisms of injury. But unlike motor vehicle crashes, where the mortality rate has fallen steadily over the last 25 years, the death rate from gunshots has risen to almost the same as motor vehicle crashes (10.5 versus 10.6 per 100,000 population). In fact, firearm injury and death rates are higher in the U.S than any other industrialized nation—20 times greater than Australia, 7 times greater than Sweden and 4 times greater than Switzerland. Why are there so many gun-related deaths in the United States? We have a lot more guns than anyone else. About half of all the guns in the world are owned by the 5% of the world’s population living in the United States, with an estimated 89-100 firearms per 100 Americans. However, only 22-30% of Americans own any gun, and shockingly, 3% of Americans own half the firearms in the U.S. The great majority of Americans are not gun owners and are certainly not represented by the National Rifle Association. What is the data? There is actually some good data available, despite best efforts to halt firearm injury research. In what follows, I will address some of the key issues and make some recommendations. >>



Legislation reducing firearms reduces death

In 1988, an economist named John Lott published a study in the University of Chicago Press arguing that ‘Shall Issue’ laws, which allow citizens to carry concealed weapons, steadily decrease violent crime and that criminals are deterred by the risk of attacking an armed victim. The belief was that as more citizens arm themselves, the danger to criminals increases. Subsequently the Stanford University School of Law replicated the study, but examined a longer time period (1977-2014). They found an overall decrease in the violent crime rate nationally during that time period. States with ‘right to carry laws’ had more guns and a 10-15% higher violent crime rate than states without ‘right to carry’. In this study, the national homicide rate had decreased but was propped up in states with 2 specific laws: ‘Right to Carry’ and ‘Stand Your Ground’. In Port Arthur, Australia in 1996, a 28-year-old man with an assault style weapon killed 35 and wounded 18. Australia responded by banning semi-automatic and military-style weapons across the country and had a national gun buyback

program. In 2014, the murder rate in Australia was less than 1/100,000; only 32 were by firearm and the rate of suicide by firearm was down 80%. A study published in Lancet (2016; 387: 1847-55), constructed a cross-sectional, state-level dataset that evaluated firearm-related deaths from the CDC, 25 firearm laws passed since 2009, firearm ownership, export rates, and unemployment rates. The overall outcome measure was firearm – related mortality per 100,000 population. They found that the state laws most strongly correlated with reduced overall firearm mortality were: • Universal background checks • Ammunition background checks • Firearm identification (microstamping) Based on these findings, they projected that on a national level, universal background checks would reduce mortality from 10.35 to 4.46 per 100, 000 population, background checks for ammunition would further reduce mortality to 1.99 per 100, 000, and that firearm identification would reduce mortality to 1.81 per 100, 000. Of note, the state laws most strongly correlated with increased overall firearm mortality were “Stand Your Ground” laws (Florida has seen an increase in homicide by 32% since it was enacted).

Advanced Treatment for Major Depressive Disorder Very often patients suffering from depression obtain no relief from multiple medications. In many cases drug therapy can cause significant side effects resulting in noncompliance.

Edgar Castillo-Armas, MD Psychiatrist

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Effectiveness of legislation in reducing homicides and suicides

In a 2018 study published in JAMA Internal Medicine (JAMA Int. Med, 2018:178: 692-700), strong state firearm policies were associated with lower suicides, regardless of other neighboring states laws. Strong policies were associated with lower homicide rates and strong interstate policies were associated with lower homicide rates. They concluded that strengthening state firearm

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policies MAY prevent firearm homicide and suicide with benefits beyond state lines. This study directly answers the criticisms about cities like Chicago, where there are strong firearm laws but yet a high firearm fatality rate. Neighboring Indiana has permissive laws and over 35% of the firearms recovered after street violence in Chicago can be traced back to sales in Indiana. A review of firearm deaths per 100,000 population and the strength of state firearm legislation as determined by the Gifford’s Law Center is revealing. The national firearm fatality rate is 11.8. California has an A rating and has 7.9 firearm deaths per 100,000 where states with weak firearm laws (F rating) are significantly higher: Arizona 15.2/100,000, Alaska 21.5/100,000, Arkansas 17.8/100,000 and Missouri 19.9/100,000. States with strong gun safety laws have fewer gun deaths per capita than states with weak laws. In short, firearm safety laws work.

Effectiveness of Weapons Removal from Domestic Violence offenders

Domestic violence or intimate partner violence (IPV) is an unrecognized epidemic in the United States. The most common cause of a mass shooting (defined as 4 or more victims) is not terrorism or workplace violence, it is IPV with the perpetrator being a family annihilator. IPV was the cause of 57% of the mass shootings in the United States from 20092015. According to Department of Justice statistics from 2004, comparing women who were murdered by a partner versus women who survived domestic abuse, 53 % of murdered women were in a house with a firearm, and only 15 % surviving women were in a home with a firearm. According to the FBI’s Supplementary Homicide Reports, domestic violence restraining orders with firearm prohibitions were associated with an 8%–19% decrease in total intimate partner homicide and a 9%–25% reduction in firearm intimate partner homicide (IPH). States that prohibited firearm purchase by abusers experienced a 10% decrease in IPH. The report also noted that there are still many loopholes that allow perpetrators to get guns.

Assault Weapons

Louis Klarevas, from the University of Massachusetts, published “Rampage Nation” in 2016 about firearm violence. He noted that after the assault weapons ban in 1994, death from gun massacres (6 or more victims) fell by 43%. In 2004

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when the ban lapsed, there was a 239% increase in massacre deaths. The New York Times surveyed a group of gun experts and asked them to rate some 30 policies for effectiveness dealing with firearm injury prevention. The highest scores were for an assault weapons ban and high-capacity magazines bans. In the last 6 years, there have been at least 8 mass shootings with 211 killed and over 1000 injured by assailants with assault style weapons.

American College of Surgeons Committee on Trauma: Firearm Strategy Team (FAST) Workgroup

A group of surgeons who are also gun owners convened to produce consensus recommendations for reducing and preventing firearm injuries. I had the privilege to be a member of this group. We held conference calls and meetings spanning 9 months with outreach to groups as disparate as the NRA and Everytown USA. The recommendations were published in the Journal of the American College of Surgeons (https://doi. org/10.1016/j.jamcollsurg.2018.11.002) and a partial list is as follows: 1. Robust and accurate background checks for all purchases and transfers of firearms 2. R  egistration of all firearms and the development and implementation of a database of all registered firearms 3. Education and Training. Formal gun safety training for all new firearm owners 4. O  wnership Responsibilities: endorses requiring firearm owners to provide safe and controlled firearm storage. Owners who do not provide safe and secure storage should be held responsible for adverse events related to discharge of their weapons 5. Mandatory reporting and risk mitigation: for individuals deemed an imminent threat to themselves and others firearm ownership should be temporarily or permanently restricted based on due process. While I agree with the efforts of the FAST Workgroup, I would have included an age limit 21 years for all weapons, a mandatory waiting period 7-10 days, ammunition background checks, weapon identification (microstamping), removal of firearms from domestic violence perpetrators, an assault-style weapons ban and a ban on large capacity magazines. This is NOT about gun control, this is about firearm injury prevention. This is about saving lives and decreasing injuries. This is my lane, and I hope it is yours as well.



under serv ed

to serv e t he




Compassionate, professional, dedicated, hardworking are the words colleagues use to describe this year’s Fresno Madera Medical Society’s award winners. But it’s their passion to serve the underserved – whether it be those with AIDS, the indigent, immigrant communities, Latino students, or homicide victims – that has marked these remarkable physicians’ careers. All four men also are known for using the power of presentation and words to create a healthier community. One did it through his educational lectures, another used local media and political campaigning, one wrote opinion pieces and health letters and the last uses Spanish language television, podcasts and social media. The 2018 Lifetime Achievement honorees are: Kenneth Bird, M.D., recently retired Public Health Officer for the Fresno County Department of Public Health and a prolific writer who urged all to lift the health status of our community David Hadden, M.D., a pathologist and the Fresno County Coroner for 28 years who is credited with creating the county’s first morgue and the current modern morgue >>

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Herbert Boro, M.D., an infectious disease physicians at Kaiser Permanente Fresno who cared for the Valley’s first AIDS patients and was the go-to expert on Valley fever before his death in November 2018 The 2018 Special Project Award went to Jesus Rodriguez, M.D., a family medicine practitioner at Kaiser Permanente Medical Group, for his efforts to mentor high school and medical school students and residents at the UCSF Fresno program. He was also recognized for encouraging and educating the Latino community to adopt healthier habits to control and prevent chronic diseases.

The whole community was his patient

Colleagues of Dr. Kenneth Bird praised his passion for serving the indigent and looking for ways to involve and connect other organizations to the mission of public health. ”He was really thinking about the whole health of a community and all the things that impact that,” said Rose Mary Rahn, the public health nursing director and Maternal, Child and Adolescent Health director. “It was not just about this disease or this one issue, but it could be related to poverty or education or homelessness. He looked at all the social determinants of health. And the whole County of Fresno was his patient.” And he took the health of his 6,011-square-mile patient personally, said David Luchini, assistant director of county public health. “He saw the high infant mortality rates, the high preterm birth rates, the high STD rates we’re dealing with in Fresno County,” he said. “It affected him when our syphilis rates would go way up. I just bothered him to know that something that so affected babies and was preventable was increasing.” Over the 15 years he worked with Dr. Bird,



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Luchini saw an evolution: “We grew from a focus on infectious diseases to overall wellness and the social determinants of health and how to delay or prevent those chronic disease. He built a lot of bridges with a lot of partners we didn’t have before.” Dr. Bird became the epitome of a public health doctor, but he didn’t start out that way. Although he wanted to be a doctor as long as he can remember, he started in pediatrics and took a detour into the navy as a flight surgeon before joining the Fresno County Department of Public Health in 1986. His first job was serving medically indigent patients as a primary care physician in Coalinga and he worked as the tuberculosis controller, the communicable disease controller and the health director for the Fresno County Jail before becoming the county public health officer during the last five years of his tenure there. David Pomaville, director of the public health department, noted, “Dr. Bird has helped Fresno County address many emerging health issues, including childhood lead poisoning, mosquito-borne illnesses, measles, congenital syphilis and many others. He’s provided medical leadership in preparing Fresno County address pandemic flu, biologic terrorism and Ebola. But his best gift he provided is his writing which articulates the concerns of public health in our community.” It takes a community to create a healthy community Dismal healthcare ratings for Fresno County spurred Dr. Bird to pick up his pen and urge others to do something about it. That first op-ed outlined what he calls his greatest accomplishment: The Eight Pillars of Public Health. “Within a few months of being appointed as interim health officer the health rankings came out (from Robert Wood Johnson Foundation) and we were almost dead last in California,” Dr. Bird described. “I was fussing and fretting about what to say if media called. And then I only got one call from a radio station. That was it. I thought ‘Have we just given up here or what?!’ That led to my first op-ed.” When he showed it to his boss, Pomaville urged him to put in a stronger call to action. That’s advice he took and used to create 43 op-eds and several Community Health newsletters. In his writing, Dr. Bird tackled things like needle exchanges for drug users, the opioid epidemic, teen sex, vaping, high syphilis rates, the cost of bad air quality, mental health inequities and the over proliferation of tobacco, junk food and alcohol advertising in poor neighborhoods. He explained how lack of dental care – something that 14% of children younger than 11 in Fresno County have never had – can affect nutrition, communication, socialization, sleeping and

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academic performance. He urged mothers to choose breast feeding for their babies and employers and communities to support that choice. “I’d have tackled even more topics but Dave held me back since he’s more politically astute than I am,” Dr. Bird added. That first op-ed may be his most enduring. Dr. Bird wrote about the eight public health pillars – individuals, families, employers, retailers, healthcare providers, educators, community/spiritual leaders and public/government officials – and how they must work in concert to support and encourage better health. His writings still stand on the Fresno County Public Health Department’s web site and the Pillars of Public Health has been incorporated into the department’s programs, said Pomaville. Retired only a few months, Dr. Bird is now turning his attention to the foster care system, knowing that children who experience trauma are nearly twice as likely to have serious and chronic health problems as adults. He’s part of a committee to look at improvements for foster children and is continuing his work advocating for an underserved community.

Becoming an advocate for the dead

Dr. David Hadden’s passion was about speaking up for those who could no longer speak for themselves. And he did it with a flair that reporters loved, said his longtime colleague, Pathologist Venu Gopal, M.D. “We would always say the dead tell tales so listen to the tale,” Dr. Gopal said. Dr. Gopal said that Dr. Hadden had a talent for being in the spotlight and loved explaining the inner workings of the morgue to any new reporter who came to Fresno. And when camera crews from the Discovery Channel would come to do reenactments of Fresno’s odder homicides, Dr. Hadden would often spice up the shoot by adding in extra action to make it more interesting, said Dr. Gopal. In May 2009, Dr. Hadden made headlines around the world when he invited the media in for a tour of the decrepit former Fresno County morgue to see maggots crawling out of the walls and dripping from the ceiling. He told the media that it wasn’t really fair to ask grieving families to come through a cramped, rundown building buzzing with flies to identify their loved ones. And it wasn’t right, he asserted, for the dead to be housed in such shabbiness before their final resting place. Dr. Gopal said Dr. Hadden put him up in front of the Fresno County supervisors at a board meeting to reiterate those same points.



Within a few years the county had a brand new, bigger, modern morgue equipped to handle the 1,400+ victims of unexplained deaths and crimes it sees a year. It’s a morgue that’s a model for coroner’s offices throughout the country, said Dr. Hadden’s colleagues and they credit him – the county’s longest serving coroner who was elected to seven terms and served 28 years – for making it happen. When Dr. Hadden first became county coroner there was no morgue at all. “We used hospitals and morticians’ offices with 40 watt bulbs to do our scientific investigations. So my first speech to the supervisors was to ask for a morgue,” Dr. Hadden described. “We had just had a murder of a little girl so I brought it up. I told them ‘We want to do right by this little girl and catch the criminal, but we couldn’t do it because we were interrupted 25 times during the autopsy at the funeral home.’ I told them, ‘The question is not how can we afford it, but how can we not afford it!’ ” He got his first morgue in an old building that was retrofitted. And just two decades later the county needed a new morgue so



Dr. Hadden who had retired after six terms, came back to run as coroner again and make speeches that would convince the county to invest in another morgue. While county supervisors and the public – and even some his colleagues – may have seen him as a grand-standing politician, Dr. Gopal insisted Dr. Hadden has a soft, caring side: “One of the things people didn’t know was how he interacted with the bereaved’s family. He would show so much compassion and empathy for the families.”

Circuitous route through criminology perfect for a doctor coroner

Dr. Hadden’s meandering journey to physician was the ideal training for coroner. He said he really wanted to be a detective or a police officer – not a doctor. He wanted a more adventurous life, he said, and tried to avoid following his family path into medicine.

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He started out in criminology at Fresno State, but was advised in spite of his good grades he might have a difficult time getting a job because of his stature. In his typical selfeffacing humor, Dr. Hadden explained, “I arrived in Fresno at 17 and thought surely I’d grow an inch or more. I didn’t.” He switched gears to go to Stanford University and took pre-med courses “so I could justify the high tuition to my father.” While others were stressed about getting good grades to impress a medical school, Dr. Hadden didn’t worry because he was hoping he wouldn’t ever get in. He did. Two years into medical school at the University of Maryland, he panicked at the thought of being a doctor and quit to join the navy. “I had one of the best jobs in the Navy as an intelligence officer,” said Dr. Hadden who also did a stint riding with fighter pilots. But when he heard senior officers talking about retirement in their 50s, he got anxious again about his next stage in life. “Having a working knowledge of bombing China, I thought wouldn’t make me that employable after the military at age 52,” he explained. He went back to medical school. “I just took to pathology because it was an investigative thing and it was like criminology which I loved,” Dr. Hadden said. “During my residency this professor wanted me to take and extra course in electronic microscopy, but I wanted to take forensic medicine. He told me I’d never use it. It’s not what you want to do as a career, because there’s no money in it. I said ‘No sir, I’m taking forensic medicine.’ I loved it. We went on homicide calls and I went to court and heard testimony.” He eventually came to Fresno to be near his parents who had retired to a ranch there. He decided to start a laboratory. It was his father who suggested he run for coroner. “His taking on the political side and becoming the county coroner was the best thing he did and the best thing for the community,” said Michael Adams, M.D., an internist who was a flight surgeon with Dr. Hadden in the Air National Guard out of Fresno. “He ran on the slogan ‘Doctor for Coroner’” against four others without any medical background and won easily. “He was a man who wore many hats, but the hat he always enjoyed was the coroner’s hat,” said Dr. Gopal. “It’s not just like a passion, it’s almost like an addiction for him. He’s not a CSI type, but he’s very empathetic and also curious to see how a person dies and what it takes to form an opinion as to cause and manner of death.” Dr. Hadden seems amazed that a guy who tried so many times not to be a doctor is celebrated for being one: “For 32 years I carried a badge. I walked away from medical school and

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then I get this award. Amazing.” Despite being retired, he’s not done explaining how the coroner’s office works. He’s writing a compilation of stories from his time as Fresno County’s longest serving and most memorable coroner.

Leaving a legacy of meticulous inquiry and caring

During his 71 years, Herb Boro, M.D., gave back to the community he grew up in by being a thorough diagnostician, a stickler for quality care, a diplomatic administrator, a generous educator and medical expert, and most of all as an everyday hero to his patients, said colleagues. And when AIDS was emerging, he became the go-to expert and advocate for patients in the Valley. “What set Herb apart and qualified him for the award is the contributions he made to medical education, his pioneering actions to care for patients infected by the newly discovered HIV/AIDS illness, and finally, giving credibility and time to the Health Quality Investigation of the California Department of Consumer Affairs,” said Roy Steinke, M.D., who presented the FMMS Lifetime Achievement Award posthumously to Dr. Boro’s widow. “He was one of the first practitioners to see HIV/ AIDS not as a political football, but as an infectious disease that required research, pharmaceutical development and treatment protocols.” Judy Boro said her husband who passed away Nov. 4, 2018, just 12 days before the medical society’s annual awards dinner, was touched by the recognition. “When Herb read the email he was very moved and he cried. He said that he really wanted to be here to accept it but knew he would not make it.” After medical school in Canada, a residency at Kern Medical Center in Bakersfield and an infectious disease fellowship at UC Irvine, Dr. Boro came back to Fresno to set up a solo practice for 13 years. He joined pioneer Dr. Robert Libke as one of the first infectious disease doctors in the region, and like Dr. Libke, became an expert in Coccidioidomycosis, or Valley fever. “He was clearly a national leader when it involved Valley fever,” said George Saul, M.D., an intensivist who began his career in Fresno in 1983 at the same time as Dr. Boro. “In general he provided such outstanding quality in consultation in terms of his meticulous care and ability to do simple things like take a detailed patient history.”



Patients appreciated the careful way Dr. Boro listened and picked up on the minutest details, said Dr. Saul. “He was amazingly compassionate and astoundingly non-judgmental. He never expressed frustration, but just jumped in and did what he needed to do.” Smita Rouillard, M.D. chief of the Permanente Medical Group, echoed that assessment: “I really admired his intellectual curiosity, his ability to think through care plans and his patience that he exhibited with everyone. He was an everyday hero to his patients. He would follow everything so carefully through until he resolved their issue.”

A physician leader and amazing teacher

Dr. Saul said his lifelong friend was a “physician’s physician” who raised the bar for everyone who came in contact with him. “There was hardly anything I didn’t admire about him. He was the most meticulous, precise diagnostician I think I ever met. I never called him and asked him for help without first carefully preparing and logically laying out the case. In that way he made us all better doctors.” Dr. Boro joined Kaiser Permanente Fresno in 1992 where he made his mark holding several leadership positions including Chief of Infectious Disease, Administrative Chief of Hematology Oncology, Assistant Physician in Chief for Service and Access, and Chief of Quality. “He was a force for patient safety and quality at Kaiser Fresno,” said Dee Lacy, MD, an infectious disease specialist who reluctantly came to Fresno only because she saw Dr. Boro as a great mentor. “And at one point when we were having issues with our surgical patients at another facility he became the Chief of Quality at that other hospital in order to bring up the level of care for all of the patients.” Dr. Lacy said she admired how we took ownership of whatever organization he was part of. “He had a strong sense of right and wrong. If he saw something that needed to be fixed he would stop and make sure it got fixed.” If Dr. Boro encountered a leaky faucet or too high water pressure during a bathroom stop on the way to a meeting, he’d make a call to maintenance before he started the meeting, Dr. Lacy said. “He was always curious and always trying to teach and always trying to get people to think,” Dr. Lacy said. “Our medical assistant remembered when I would be late for departmental meetings he’d say, ‘Well let’s put this time to good use. Renee if you saw a patient with a foot that was swelling, how would your work that up?’ And our medical



assistant would hope I’d come in before she’d have to answer.” Dr. Rouillard said she knew Dr. Boro not only as a colleague but as a mentor and “wonderful instructor.” “Dr. Boro provided excellent lectures on numerous infectious disease topics for his colleagues, hospitals staff and students without any compensation or any hint of self-promotion,” praised Dr. Steinke. “Herb was always the scientist.”

Leading by example to encour age healthier lives and more Valley doctors

Fresno County’s Spanish-speaking community is just as likely to encounter Jesus Rodriguez, M.D., out leading neighborhood walks, running marathons or hosting a medical advice call-ins on Univision TV as they are in a medical clinic. The adult family medicine physician reaches out beyond his Kaiser Fresno office to encourage local Latinos to move more and eat better through his social media posts, television appearances, podcasts and showing up at local health fairs. “His dedication and passion for community health and wellbeing shines!” said Alma Martinez, head of the Fresno Community Health Improvement Partnership’s Diabetes Collaborative and project manager for community outreach at Community Medical Centers. “As our collaborative’s physician champion, Dr. Rodriguez has led our ‘Walk with a Doc’ efforts and serves as the face and talent for our bilingual campaign urging the public to start an exercise regime. And he does this all on a volunteer basis. We are incredibly blessed with this heart for our community.” Dr. Rodriguez is also passionate about encouraging students starting out where he did to consider careers in medicine because the Valley needs more doctors – especially those who speak Spanish. “My view of higher education was high school when I was growing up. I had no concept of college,” said Dr. Rodriguez, who emigrated from Mexico when he was 6 and was raised by a single mother. It was a counselor and teacher at Madera High School, who encouraged Dr. Rodriguez to apply for a summer medical science program at Stanford University. It changed his world, he said. Ever since then he’s been trying to do the same for others. “According to Robert Frost an educator is not just a teacher but an awakener and Jesus you are that,” Dr. Rouillard said in presenting the medical society’s Special Projects Award to Dr. Rodriguez. “You awaken students’ belief in themselves and you

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give back to the community that gave to you when your family emigrated from Mexico. You inspire students to achieve a life that’s better than generations that proceed them. You have such a generosity of heart and spirit and you strive to spark an interest in learning.” Dr. Rouillard said she’s been inspired by something Dr. Rodriguez shared on his Twitter. Under a picture of Stanford University, his alma mater, he wrote: “When something has the potential to change to course of your life let others know about it so they have the same opportunity.” Dr. Rouillard added, “I think he lives his life in that manner. Everything that’s good that’s come his way he wants to share with others.” It was for his work mentoring students in The Doctors Academy at local high schools, medical students through the UC Davis PRIME program and residents at the UCSF Fresno program that he got the Special Projects Award. He’s seeing that work come to fruition. Recently while giving a tour of the hospital to new physicians, one of the young doctors reminded Dr. Rodriguez that nine years before, Dr. Rodriguez had helped him with mock interviews to prepare for getting into medical school. Dr. Rodriguez was thrilled to see that student coming back to practice medicine in the Valley. “He’s a huge advocate for the Latino population,” said his Kaiser colleague Vivian Torio, D.O. “He is also very well known for practicing what he preaches.” He leads by example as a triathlete. He’s run the Iron Man race and the Boston Marathon. But far from being preachy about getting health, his colleagues said, he’s generous in offering coaching if they too want to run races. Dr. Rouillard said she also admires how Dr. Rodriguez “makes medicine make sense to patients.” She said, “He’s able to translate it into something understandable to patients and he’s motivational. He makes his patients want to have their chronic disease under good control.” Dr. Rodriguez is humble about his accomplishments. “I really believe as healthcare providers we can make a huge impact on our community.” And that’s all he’s trying to do in a region where 51% of the population in Latino, where half the population either had diabetes or pre-diabetes and many don’t know it, he added.

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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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I completed my internship in general surgery followed by residency in general pediatrics with additional training in pediatric cardiology. After 17 years of practice I decided to impact medicine in the areas of population health, leadership, hospital administration, and through our strong ties with the CMA, help make changes in health policy to improve the lives of our community members.


Our society which was founded in 1883 continues to thrive and represent over 1000 physicians in the two county area advocating for our profession and health of the community. An important part of any non-profit organization is to have a board that is reflective of the very communities we serve and I am pleased to report that over the years, our board has become more diverse in specialties, gender, religious affiliations and ethnicity. We believe in people, knowledge, and networks that help make meaningful change possible. Our efforts must rely on teamwork, the whole being greater than the sum of its parts. That includes individual members advocating in their communities and delegates working to take the concerns of our valley to the capitol so our voices can be heard. Even though we hold different personal opinions and political views, our board has an amazing ability to work together through issues and not only reach agreement but



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to support each other when needed and to stick together once a decision has been made. Theses physician leaders take the time out of their busy practices to promote what is in the best interest of FMMS which helps further the reach and mission of our society with the goal of improving the practice of medicine and the quality of life for the people of our valley.


When I speak with non-member physicians, one of the most common complaints is the cost of our membership. With so many other financial obligations doctors assume to function as a California licensed physician including their required specialty and subspecialty membership premiums it may not make economic sense to justify yet additional membership. I can understand the hesitation to join our society if they don’t feel there is enough value. I would mention that joining FMMS includes membership to the CMA which is an extension of our society with many more benefits and opportunities to serve and grow in our careers.

2019 FMMS EXECUTIVE BOARD President – Cesar Vazquez, MD President-elect – Alan Birnbaum, MD Vice President – Don Gaede, MD Secretary-Treasurer – Brent Kane, MD Past President – Trilok Puniani, MD

FMMS BOARD OF GOVENORS Christine Almon, MD Janae Barker, MD Jennifer Davies, MD Patrick Golden, MD Pamela Kammen, MD Shamsuddin Khwaja, MD Christine Maser, MD Ravi Rao, MD Katayoon Shahinfar, MD Jai Uttam, MD Jessica Vaughn (Resident Board Member) Nadarasa Visveshwara, MD

WHAT ARE SOME OF YOUR GOALS FOR 2019 FOR THE MEDICAL SOCIETY AND HOW DOES THAT FIT IN TO SOCIETIES MISSION? With less than half of practicing physicians in the valley being members of FMMS, I believe the main goal of any component medical society president is to seek continued growth in overall membership with an emphasis on engaging physicians with high value programs and events which is key to driving retention. Our first survey was deployed a few weeks ago and with this feedback, we will do our best to make the necessary adjustments that reflect the will of our constituents. Another goal is to leverage our partnership with CMA and make use of a variety of legislative, regulatory and legal strategies to accomplish its public policy goals. The aim is to help all CMA members enjoy and support their chosen mode of practice and to navigate the rapidly changing health care delivery system. For this coming year, we will continue to build on the important topic of physician burnout and wellbeing. Thanks to the hard work and contributions from our wellness committee as well as inspiration from our affiliate medical society in Sacramento we held our inaugural Joy of Medicine Summit at Tenaya lodge on December 1st, 2018.

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One of my objectives for this coming year is to have our medical society be a touch point for information on nonclinical career transition. We will support this very important and timely subject by offering information about conferences, mentorship and advise from those who have gone through a career change, along with local educational summits specifically geared for physicians that are interested in exploring this option further. Another goal to form partnerships with local hospitals, the CMA, and other organizations to find creative solutions that impact cost drivers resulting from unmet social needs. Hospital readmissions are often based upon social determinants. Therefore it is paramount that hospitals and primary care physicians work with patients in the first 24-48 hours after discharge to make sure they have the medications they need and education to manage their health along with transportation to get to their appointments. Our medical society is uniquely positioned to provide guidance and leadership in this area to improve health outcomes and meaningful cost containment for this population. CENTRAL VALLEY PHYSICIANS



A report from the University of California San Francisco’s HealthForce Center released in the summer of 2017 projects that the state will suffer a primary care clinician shortfall over the next 15 years with the hardest hit areas in the Central Valley, Central Coast and Southern Border areas. Over the next 10 years, 25% of physicians are expected to retire and the number of older Americans requiring healthcare expected to double by 2040. They project a shortage of 100,000 physicians by 2030 which will result in even more burn out that impact physicians and their patients. Many of the indigent patients in the Central Valley have some of the most advanced pathology which could be prevented if treated early. If we continue along our current path, more and more Californians will need to visit the emergency room for conditions common conditions like asthma, ear infections or flu because they lack a primary care provider. I am hopeful that our doctor shortage will be addressed with new residency programs in internal and family practice medicine at St. Agnes medical center as well as the establishment of our new medical school in Clovis.


I think one of the best values to being a society member and the highest return on investment is our relationship with the California Medical Association. For over 160 years, the CMA has been devoted to its members and the entire physician community and recognized as one of the key lobbying organizations in the state. CMA endorsed Gavin Newson for California governor. Unfortunately a great many physicians are not members and are uninformed about how very much the CMA does for the doctors by protecting the practice and profession of medicine and ultimately patient care. Some of the recent highlights that the CMA has been credited with is the defeat AB 3087, a fee setting mechanism that would have empowered a politically appointed committee to price fix physician services. Also, in 2016, the CMA and its partners were pivotal to help pass Proposition 56 which increased the state’s tobacco tax by $2.00 and stopped the misappropriation of those funds by the current administration. As a result of these efforts, the 20182019 State Budget included: • Over $1 Billion in new funding to support supplemental payments for physicians participating in the Medi-Cal program



• $190 million for medical student loan repayment • $40 million in new funds for graduate medical education to sustain, retain, and expand California residency spots. With this new funding along with a shift from a volume based to a value based care model I believe the CMA together with our state legislators will help make policy changes and write laws that improve reimbursement and bring more value to the doctor-patient interactions and increased patient satisfaction. The most recent and landmark win for the CMA with the help of the American Medical Association is prevailing in the legal battle over self-governance rights of the medical staff of Tulare Regional Medical Center which has now reopened its doors to serve the healthcare needs of this central valley community.


I am blessed with this opportunity to lead this organization and my sincere goal as your new president is to be the most effective spokesman that I can be, to perpetuate our brand and communicate your concerns and needs and furthermore raise the bar so that our society can be a catalyst to help improve not only the care of patients but also assist doctors reach their full potential and maximize job satisfaction. Our primary skills as physicians can only take us so far driving success for the first 10-15 years after which secondary skills such as leadership and communication skills are crucial in order make contributions that impact not just individual patients but the society in general. Having the opportunity to bring people together and be a catalyst to unify a team around a single vision is the main reason I wanted to become president of the medical society. In this capacity, I will work together with our board around our core values to identify what assets we have, what do we want to accomplish and what actions do we need to take in order to achieve these goals. We know that diversity is good for organizations and business. A McKinsey report proved it, finding that companies in the top quartile for gender, racial and ethnic diversity were 35% more likely to generate above average returns. I believe this pertains to medicine as well. At the recent house of delegates I learned about a resolution sponsored by the young physicians section of the CMA that promotes diversity and inclusion in leadership and more importantly as a sustaining goal in the organization and in particular the county medical societies which are the fundamental source of CMA leadership. I am proud to say that as a minority our board recognizes the importance of diversity in our medical society. This is

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critical in broadening our thinking and approach to better understand important issues that affect members of our underrepresented communities. We must continue to mentor and recruit more women, racial and ethnic minorities as well as the LGBTQ community to consider careers in health care and enter into the leadership of our medical organizations so that the physician population will better reflect the overall population. We have an obligation to attract, retain, and enable the best mix of talent. This is important because it shows to young aspiring health care providers that regardless of their background they should feel welcome and be valued to serve their community in a leadership role.

One of the highlights for me was listening to the guest speakers from academia and other healthcare leaders who present their cutting edge, forward thinking research on improving healthcare providing essential background and insight to consider during the floor debates. In addition to meeting old colleagues, making new friends and the opportunity to network, it is exciting to watch democracy at work and to be part of this experience with a chance to help shape the future of health care in our state.


I believe physical activity of any kind helps not only reduce stress but also keep us fit and feeling good. That’s why I enjoy my early morning runs - rain or shine - which helps set the tone for the rest of the day. It’s important to take care of yourself in order to provide for the needs of those we care about in our lives. I also enjoy cooking with my family, reading and listening to podcasts on a variety of subjects.


As physicians in the central valley we have an opportunity to participate in activities such as legislative advocacy day where a group of local physicians travel to our state capitol to represent the valley, show our support and meet face-to-face with our elected officials. In April of 2018, we met with assemblymen Dr. Joaquin Arambula and Jim Patterson to share our concerns and discuss specific central valley issues. Last month, I had the opportunity along with several valley physicians to attended the house of delegates. When my daughter asked me “what’s the house of delegates?”, I responded: I explained that going to the house of delegates is like attending a session of the US congress where some 500 physician delegates elected by the 37 component medical societies from across the state convene annually to debate on the most important issues affecting healthcare and the practice of medicine. This year’s topic was, “Addressing the cost of health care” as a major issue for discussion.

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Back to the Valley BY JENNIFER SEITA


or many that have grown up in the Central Valley, there’s a sense of hometown pride that comes with being raised here. That sense of community has been a magnet for many “rising stars” in the medical field, sparking their return to the Central Valley to practice and teach. Some people call it a “boomerang”, but for these physicians, the decision to return is truly based in their commitment to giving back to the people and place they will always call home. The brightest of the Valley are going on to the most prestigious universities to learn and immerse themselves in the newest research, methodologies and technologies, and are bringing them back – right here – to the people in the Central Valley. As many small communities throughout the area struggle with doctor shortages, we’re continuing to attract some really good physicians we so desperately need. And we aren’t getting just anyone – we’re getting the best. We are proud to feature a few significant local physicians, each practicing in a different field and at separate facilities. But their stories share a common thread: family, local mentors and sense of community helped to shape each of the physicians into who they are today.



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John Moua, M.D. Pediatric Pulmonology

Medical Director, Community Regional Medical Center Pediatric Specialty Center Assistant Clinical Professor, UCSF Fresno Associate Center Director, Cystic Fibrosis Program, UCSF Fresno

Dr. John Moua’s Central Valley roots run deep and so does his love for its people. He grew up in Fresno and attended Edison High School. After high school, he continued his educational path towards becoming a physician at several renowned schools, and credits his achievements and success to a supportive community and mentors while growing up here. He first attended Cornell University, then received his medical degree from University of California, Davis, completed his Pediatrics Residency at UCSF Fresno and did his Pediatric Pulmonology Fellowship at University of California, Irvine. Upon completion of his fellowship, Dr. Moua was offered several positions in Southern California, but he says there was never any discussion on where he and his wife would end up. He always knew he would to return to the Central Valley to practice saying, “the Valley has always been a soft spot for me.”

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The Central Valley influenced even his specialty of choice - pediatric pulmonology. As a pediatric pulmonologist Dr. Moua specializes in the treatment of asthma, cystic fibrosis, chronic lung disease and more. “Part of the reason I ended up where I work and the population that I serve is that these people are my neighbors,” said Dr. Moua. “I grew up right by the fairgrounds. The people in Fresno and the Hmong community are very close to me. This is my way to give back to the community and for me to serve them is an honor.” In his current position as the Medical Director of Pediatric Services for Community Regional Medical Center’s Pediatric Specialty Care Center, he’s able to work collaboratively on designing true, familycentered care, similar to the Mayo Clinic’s patientfocused model of care.



“The framework here is different,” said Dr. Moua. “Our patients are able to see sub-specialists at the same time, in the same visit, rather than setting up several different appointments. And then all of those specialists are at the same table discussing together the treatment plan for the patient.”

According to Dr. Moua, the physician landscape looks very bright for the Central Valley. “Our retention rate at University of San Francisco, Fresno, is at about 40-50%,” he said. “We’re keeping doctors in the Valley. And we have a very special group of residents. Our goal is to maintain and retain the best and brightest right here in the Valley.”

Dr. Moua is also actively involved with teaching and medical education at USCF Fresno, helping the next generation mature and become successful physicians in the community.

Thomas Shute, M.D. Ophthalmologist EYE-Q Vision Care

Local ophthalmologist Dr. Thomas Shute is changing eye care in the Central Valley with the most advanced glaucoma and cataract surgery techniques. Born and raised in Clovis, Dr. Shute is a fourth generation eye care specialist. Dr. Shute recently returned to the Valley to practice at EYE-Q Vision Care. He graduated from San Joaquin Memorial High School, followed by University of California, San Diego for his bachelor’s degree and completed his medical training at UC San Diego School of Medicine. Following his internship at Travis Air Force Base, Dr. Shute served four years as a U.S. Air Force flight surgeon, which he deemed “the coolest gig a doctor can get.” He completed his residency and fellowship training at Washington University in St. Louis. His unique training brings the newest in technology and surgical services in cataracts and glaucoma treatments to the Valley. “I was at a point where I had done any and every glaucoma surgery out there, and I was rubbing elbows with physicians that are at the top of my field,” said Dr. Shute. “There’s nobody providing this service between Los Angeles and San Francisco so I wanted to bring this level of care to the people where I’m from. This has always been home.” Dr. Shute’s passion for eye care comes from his ability to optimize and restore vision – a “tangible” effect on a person’s quality of life. “When you get to see how a patient’s vision has improved or pressures have come down it is very rewarding,” he said. “And to be able to provide this care to the people I grew up with is very special.”



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“I consider Fresno to be a small-big town,” said Dr. Nelson. “It’s large enough and there’s so many things you can do in the area. Especially for raising a family. That’s one of the biggest attractions that drew us back here. I see the growth and it’s just amazing the things that are here now.”

Ashley Nelson, M.D.

Internal Medicine Family Practice & Sports Medicine Saint Agnes Medical Center

As a third generation physician, Dr. Ashley Nelson was always interested in biology and science. Born and raised in Fresno, her father was a local cardiologist and going into medicine was always part of her plan. She was lucky enough to study at many different places throughout her educational journey, including the Caribbean, England, New York and Pennsylvania. This allowed her to see things from a different perspective, serving a vast variety of patient populations and exploring different health care systems. While working towards her medical degree at the American University of the Caribbean, she met her husband Dr. Richard Oravec. Together, they completed their residencies and settled for a short time in Pennsylvania working as physicians. Over the years, while visiting family in Dr. Nelson’s hometown of Fresno, they knew they wanted to return. They began the licensing process and through some family connections, both landed interviews at Saint Agnes Medical Center, and eventually full time positions. Dr. Nelson practices Internal Medicine and Dr. Oravec specializes in Family Practice and Sports Medicine.

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Dr. Oravec grew up in a town in Pennsylvania very similar to Fresno, so planting roots in the Central Valley seemed natural for him. He’s also excited about the opportunity for primary care sports medicine here in the Valley. “The need for what I do is definitely here,” said Dr. Oravec. “We’re currently trying to develop relationships and provide primary care sports medicine services to local high schools, middle schools, colleges, recreational athletes and more; so the availability is there. It’s definitely an underserved area.” Both Dr. Nelson and Dr. Oravek share a passion for providing exceptional care to patients of all backgrounds, making them both unique assets to Saint Agnes Medical Center. “For professional growth it’s been such a good experience,” Dr. Nelson said. “Working with Saint Agnes especially. I’ve been building a new patient panel and really enjoying seeing new patients with various backgrounds from all over the Central Valley. Our family is really going to enjoy growing up here in Fresno, as I did.”



2018 Joy of

Medicine Summit

FMMS Physician Wellness Advisory Committee Hosts First Joy of Medicine Summit. A group of physicians and their families, braved snowy conditions on Saturday, December 1, 2018 to attend Fresno Madera Medical Society’s first Joy of Medicine Summit at the Tenaya Lodge at Yosemite. The inaugural Joy of Medicine Summit was designed to engage physicians, residents and spouses in a conversation that would assist in recognizing the signs of burnout, offer strategies to build resiliency and the means to thrive both professionally and personally. With 5 hours of CME available, a wealth of information was shared by speakers including Rajiv Misquitta, MD (The Power of Lifestyle), Ednann Naz, MD (Informatics: Friend not Foe), Michael Roubicek, PhD., LCSW (The Places You’ll Go) and Don Yoshimura, MD (Connect the Docs! Where do we go from here?). Spouses enjoyed a special lunch with keynote speaker Kathy James, ThD (Don’t Lose the Connection) and children enjoyed their own lunch and activities. Following lunch physicians and their spouses had the opportunity to indulge in a chair massage provided by the National Holistic Institute – Clovis. The afternoon CME sessions included Lightening Grand Rounds: How I Find Joy In Medicine with Shams Khwaja, MD, Manisha Mittal, MD, Ednann Naz, MD and Cesar Vazquez, MD.



Many physicians took advantage of the hotel package for a truly rejuvenating weekend at the mountain resort. The Tenaya Lodge did not disappoint, providing a winter wonderland as the backdrop for the first Joy of Medicine Summit with nearly 8 inches of fresh snow on Saturday for sledding and snowman building in addition to lodge favorites including ice skating and fireside s’mores. The day concluded with a family dinner and gingerbread workshop with competition for best in class for children, teens and adults. The Joy of Medicine Summit is part of an expanding FMMS Physician Wellness Program that will introduce new wellness benefits in 2019. The 2nd Annual Joy of Medicine Summit is scheduled for December 7, 2019 at Tenaya Lodge at Yosemite.

SAVE THE DATE 2nd Annual

Joy of Medicine Summit

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Dr. Vivian Torio supervises the decorating of gingerbread men.

Drs. Vivek and Manisha Mittal and family took time to play in the snow.

Team Vazquez hard at work.

Barton Fischer, MD assists wife Carole with frosting.

Dr. Mike and Lisa Roubicek begin work on The Gingerbread Grinch. A game of Suspend gets intense following the kids lunch.

The family gingerbread decorating workshop after diner provided great entertainment for all in attendance.

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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. Visit jobs.ca.gov/JOBSGEN/5CACC.PDF for additional information and instructions.

Valley Childrenâ&#x20AC;&#x2122;s Pediatric Residency Program

This position is intended for a recently graduated board eligible pediatric resident with the aim of further development of leadership, teaching and administrative skills while also providing the opportunity to perform clinical work as a hospitalist. The Chief Resident Position reports to the Pediatric Residency Program Director and is responsible for elevating the scholarly and academic level of pediatric resident education for the Valley Childrenâ&#x20AC;&#x2122;s Pediatric Residency Program. Has an active role in resident recruitment, including but not limited to attendance at regularly scheduled meetings meeting with candidates on interview dates, and participating in preparation of rank list.



Shares in the responsibility for the administration of the residency program and for the education of individual residents and medical students and advocates for the lifestyle and quality of life of the pediatric residents in regard to the program. Functions as leader, liaison and advocate for the pediatric residents and is an active, visible component of all parts of the program and is aware of all aspects of the program. For more information email Kauyeung@valleychildrens.org

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.

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MEMBERSHIP MATTERS In 2019 here are some of the top reasons you should join Fresno Madera Medical Society and the California Medical Society.

When you become a member, you are part of a dedicated network of physicians of over 1400 in Fresno and Madera County and 40,000 in California. Physicians that are working together to achieve a united healthcare front and fight against unfair insurer reimbursement practices, restrictions on physicians autonomy and the erosion of valuable legislation that protect your practice. Below are some of the top reasons you should become a member of Fresno Madera Medical Society (FMMS) and the California Medical Association (CMA). Tobacco Tax

In 2016, CMA led a coalition to take on Big Tobacco to improve patient access to care through Medi-Cal, which serves one-third of the state’s population. California voters overwhelmingly approved Proposition 56, which added a $2 tax on tobacco products and stipulated that funds should increase access by improving provider payments. California’s 2018-2019 state budgets continues to provide over $1 billion annually to improve provider payments so more Medi-Cal patients can access care when they need it most. Other key investments include graduate medical education (GME) funding increases and medical school loan repayments.



Resounding defeat of Assembly Bill 3087 (Kalra) – legislation that would have created a commission of unelected political appointees empowered to arbitrarily cap rate for all health care services in all clinics, hospitals and physician practices in California. Continued efforts every year to protect MICRA staunchly defends the landmark Medical Injury Compensation Reform Act (MICRA) year after year, saving each California physician an average of $75,000 per year in professional liability insurance premiums. Collaborate with Colleagues; FMMS bring together physicians from all over the Valley, from different specialties and modes of practice to develop strong unity through leadership, collaboration, socials, educational events, and community service.

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

political and regulatory advocacy, CMA and FMMS position themselves among the most influential stakeholders in the development and implementation of health policy. In addition, members receive direct access to our state and national legislative leaders to influence how medical care is provide today and in the future. Save Money - There are several ways

to save money when you are a member. Discounted health insurance for you and your staff, automatic 5% savings on workers’ comp insurance, CME and Online educational courses, auto and home insurance, car rental, office supplies and much more. Get Paid - Members receive

one-on-one assistance from CMA’s reimbursement experts, who have recouped $15.5 million from payors on behalf of CMA physicians in the past nine years. Continuing Medical Education - FMMS provides

opportunities to further your knowledge with Continuing Medical Education. CME symposiums and dinner events provided throughout the year with

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current topics that relate directly to patient care. Learn from the experts and hear from recognized speakers. Education and Training for Your Practice FMMS provides monthly Medical Managers Forum to arm your office staff with practical information and tools to overcome new challenges in healthcare, run the office successfully and move your practice forward. Together We Are Stronger! Together we stand taller and stronger as

we fight to protect patients and improve the health of our communities. We are a dominant force in health care – but all the great work we do wouldn’t be possible without the support of members like you.



In Memoriam

In Memoriam HERBERT W. BORO, MD April 21, 1947 - November 4, 2018

Herb had a solo practice for 13 years in Fresno in Infectious Disease. He joined The Permanente Medical Group, Fresno in 1992 and retired in 2011.


Herbert Boro, MD, FACP passed away on Sunday, November 4, 2018 with his loving family at his side. Herb was born in Annapolis, MD on April 21, 1947 to Leon and Barbara Boro. He had a happy childhood growing up in Fresno and graduated from Fresno High School in 1965. He was very active in the Fresno High School Senate. Over the last several years, he was President of the FHS Senate Alumni Committee. He graduated from UC Davis with a BS in Zoology and BA in Bacteriology in 1970. He attended Memorial University of St John’s Newfoundland, Canada and graduated with an MD in 1974. He completed his internship and residency at Kern Medical Center in Bakersfield, CA. He completed an infectious disease fellowship at UC Irvine. Herb had a solo practice for 13 years in Fresno in Infectious Disease. He joined The Permanente Medical Group, Fresno in 1992 and retired in 2011. While at Kaiser Permanente, Herb held many leadership positions including Chief of Infectious Disease, Administrative Chief of Hematology Oncology, Assistant Physician in Chief for Service and Access, Assistant Physician in Chief for Quality, Chief of Quality and Director of the Ambulatory Infusion Center. In his retirement in 2011, Herb worked for the State of California, Department of Consumer Affairs, Health Quality Investigation Unit as a Medical Consultant. He was Program Director for the Annual Scientific Meetings of the Coccidioidomycosis Study Group from 2013-2018. Herb was a well-respected physician and was recognized with many awards including UC


Davis Undergraduate Research Award Dept of Bacteriology in 1970, Kern Medical Center Intern of the Year 1975, Central Valley AIDS Team, Fresno Professional Assistance Award 1987, Kaiser Foundation Hospital and Medical Center Extra Mile Hero 2000, Everyday Hero 2003, 2008 The Permanante Medical Group 60th Anniversary Fresno Medical Center Honoree, 2011 Fresno AIDS Day Enrique Lopez Provider of the Year Award for Lifetime Achievement, 2017 Coccidioidomycosis Study Group President’s Award for Achievement, Fresno Madera Medical Society Lifetime Achievement Award, Nov 2018. Herb’s many joys in life were spending time with his wife, daughters and granddaughters. He had a wide circle of friends, was loved and appreciated as a man of great intelligence, generosity, honesty and mentor who was a compassionate healer. He had a strong passion for hiking and spending time in the outdoors. He was very physically active jogging, cycling, hiking and backpacking. He had a love for travel with his wife and friends. He loved to play games including poker, chess and billiards. He was preceded in death by his parents Leon and Barbara Boro. He is survived by his wife of 48 years, Judith Boro, daughters Susan Affleck (Jared) and Jennifer Golove (Steven), granddaughters Ashley and Michelle Affleck, Sascha and Marlo Golove, and his loving brother Robert Boro. Uncle to Anya Davitiashvili (Michael), Nadia Baskett (Andrew) and Uncle to David Wasserman (Lynn).

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In Memoriam JOHN T. BONNER, MD December 7, 1936 – November 21, 2018

John strived for excellence in everything he did and he appreciated the finer things in life, including travel, good wine, his BMW automobile, anything by Barbra Streisand, and his five German Shorthaired Pointers.

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John T. Bonner, M.D., husband, father and neurosurgeon, passed away after the recurrence of a malignant brain tumor. Born on December 7, 1936, in Havre, Montana, John was raised in Butte, Montana by his mother, Isobel, after his father passed away in 1938. John’s mother was a public school teacher who impressed upon her son the importance of education. Consequently, John was his high school valedictorian and Boys State representative. He then graduated maxima cum laude from Carroll College in Helena, Montana, before attending medical school on scholarship at the University of Chicago Pritzker School of Medicine. He did his surgical internship at Duke University and his neurosurgical residency at the University of Washington. From 1969 to 1972, he taught neurosurgery at the University of Missouri at Columbia. John came to Fresno in 1972 to enter private practice neurosurgery. He also worked as a medical consultant for the State of California, Disability Determination Service. John loved being a neurosurgeon, and he was active in many medical organizations and activities. He was a longtime medical ethics consultant at Community Regional Medical Center and he was also a dedicated member of the St. Agnes Hospital Institutional Review Board. John served as President of the Fresno Madera Medical Society and was for many years a local delegate to the California Medical

Association (CMA). He was President of the California Association of Neurological Surgeons (CANS), and President of the Western Neurosurgical Society (WNS). For his service, John was honored with the Fresno Madera Medical Society Lifetime Achievement Award and the California Association of Neurological Surgeons’ Byron Cone Pevehouse Service Award , which is conferred upon a neurosurgeon in California who has served both the community of neurosurgery and medicine in general in an effective and distinguished manner. John strived for excellence in everything he did and he appreciated the finer things in life, including travel, good wine, his BMW automobile, anything by Barbra Streisand, and his five German Shorthaired Pointers. John and his wife, Romona, particularly enjoyed their forty some year participation in a theme dinner party gourmet group. John was an avid follower of sports, and ran several marathons. John was preceded in death by his wife of 52 years, Romona, as well as his mother, Isobel, and father Thomas. He is survived by his three children, Kerry, Cheryl and David, and his German Shorthaired Pointer, Liesl. Dr. Bonner was a member of the Fresno Madera Medical Society for 46 years and what the recipient of the FMMS Lifetime Achievement Award in 2012.









“You won’t be able to turn your head away, until you come see us.”

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. Fortunately, we offer same- or next-day appointments, extended hours and a range of services to address your needs. Need a physical? We’ll get you one within the week. It’s primary care on your schedule – available right here in Fresno and Clovis. Call (559) 450-7267 to schedule an appointment with a physician at one of our Saint Agnes Care sites.

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

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Saint Agnes Care



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

Cplans accepted Most insurance


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