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Winter 2020


Trailblazers Honored

House of Delegates • Doctors that Made a Difference • 2019 Legislative Wrap-Up

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There is such a place Medical Malpractice Coverage and So Much More CAPphysicians.com Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code.



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14 22 39 43 46 52 Winter 2020








From The Executive Director

I CAN’T BELIEVE THAT IT IS 2020. The years just continue to fly by, and just like that we are celebrating 2020. This year I am grateful for all of the members that continue to support me and the medical society, insuring its standability and growth. I have been with the medical society 5 years and am proud of our growth and continued support that the physicians of the valley have provided the organization, which by the year will be our 137th year of existence and providing services to physicians in Fresno and Madera. When I started in 2015 membership had an 8-year decline. Today, I am thrilled to share we continue to grow and we have more physician members than in the history of the medical society. Personally, I am grateful for my wonderful family. Tim my husband of almost 8 years, who has the amazing ability to remain calm and grounded when I am not, my oldest daughter Taylor, who is on her third year of veterinarian school Dublin, Ireland, my 6 year old daughter, Scarlet who is the sweetest most independent 6 year old I have ever met and Chandler our almost 2 year old that is officially ours with the completion of her adoption last August. She is our firecracker that makes us question ourselves every day how we keep these small children alive, and maintain our full-time careers. I am so excited for our leadership team for 2020 being led by Dr. Alan Birnbaum. With his leadership, I am sure it will be a busy and rewarding year. 2019 was very successful. We met our membership goals, hosted over 60 hours of Continuing Medical Education including our second CME cruise, and held another successful fundraiser supporting the Fresno Madera Medical Society Scholarship Foundation. As always, at the beginning of every new year we focus on membership renewal. As a reminder, please renew your membership and if you are interested in becoming a member please go online at fmms.org to apply. Your membership cost covers membership to both Fresno Madera Medical Society (FMMS) and the California Medical Association (CMA).

PRESIDENT Alan Birnbaum, MD PRESIDENT-ELECT Don Gaede, MD VICE PRESIDENT Christina Maser, MD TREASURER Jennifer Davies, MD PAST-PRESIDENT Cesar A. Vazquez, MD BOARD OF GOVERNORS Janae Barker, DO, Shamsuddin Khwaja, MD, Katayoon Shahinfar, MD, John Moua, MD, Pamela Kammen, MD, Ravi Rao, MD, Sonia Shah, MD, Marina Roytman, MD, Jesus Rodriguez, MD, Greg Simpson, MD, Brent Kane, MD, Jai Uttam, MD, Jessica Vaughn, DO (Resident Board Member) CMA Trustee; Ranjit Rajpal, MD CENTRAL VALLEY PHYSICIANS EDITOR Farah Karipineni, MD MANAGING EDITOR Nicole Butler ASSISTANT EDITOR Don Gaede, MD EDITORIAL COMMITTEE Farah Karipineni, MD - Chair, Chang Na, MD Roydon Steinke, MD, Cesar Vazquez, MD Hemant Dhingra, MD, Nicole Butler, Trilok Puniani, MD Alan Birnbaum, MD, Alya Ahmad, MD FAAP CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Cesar Vazquez, MD, Alan Birnbaum, Don Gaede, MD, Alya Ahmad, MD FAAP, Richele Kleiser, Malissa Trenholm, Stacy Woods, Erin Kennedy, Nicole Butler, CONTRIBUTING PHOTOGRAPHERS Anthony Imirian, CHSU Staff CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711 Phone: 559-224-4224 • Fax: 559-224-0276

Happy New Year!

Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler Membership and Events Manager, Stacy Woods

Nicole Butler PS- I thought I would share our Christmas Card so you can see my family. We try and mix it up every year and this is what we came up with for 2019, we started planning the idea after this year’s Summer Meltdown event… can you tell?



Winter 2020

Fresno Madera Medical Society

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

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

16.0 CME

Applied For

Registration is now open - Call (559) 224-4224 ext. 118 for more information or visit www.FMMS.org Winter 2020



A message from our outgoing President > Cesar Vazquez, MD FAAP

Gun Violence The history of gun rights speaks differently to different people.

The 6.5×52mm Carcano Model 91/38 infantry rifle that was used to assassinate president John F. Kennedy in 1968 was purchased via….mail order for $12.78. This seminal event together with the assassination of Dr. Martin Luther King that same year triggered a national ground swell against our gun culture, and the sheer volume of correspondence reaching senators and congressman overwhelmed even the organized and robust NRA lobbyists. Disappointingly, all that came out of this public outcry was restricting the mail-order sales of guns. Senator Joseph Tydings of Maryland, appealing in the summer of 1968 for an effective gun-control law, lamented, “It is just tragic that in all of Western civilization the United States is the one country with an insane gun policy.” ABOUT THE AUTHOR Dr. Cesar Vazquez is board certified in General Pediatrics. He earned his Bachelors of Science in Electrical Engineering and after working in the aerospace industry for a few years, he decided to pursue his dream of becoming a doctor. He attended the University of California Irvine Medical School followed by a General Surgery Internship at Cedars-Sinai Medical Center in Los Angeles. He then completed a Pediatric residency through the University of California San Francisco-Fresno and spent an additional year at Stanford University as a fellow in Pediatric Cardiology. Dr. Vazquez practiced for 18 years before transitioning to his current position as a physician advisor at St. Agnes Medical Center where he’s involved with utilization review, commercial denials, and clinical documentation improvement. Cesar Vazquez, MD FMMS Past-President



Perhaps the debate of how the Second Amendment should be interpreted has been settled. Regardless of interpretation, at this pivotal moment in our history, we have a problem: An availability of guns that is unseen across the world. According to Patrick J. Charles a constitutional scholar and author of numerous articles and books on gun control, “The history of gun rights speaks differently to different people. There is not one historical narrative of gun rights, but many. The Founding Fathers’ conception of the Second Amendment had little to do with a right to own, maintain, and use firearms for hunting, shooting, and self-defense. Rather, the heart of the Second Amendment related to a well-regulated militia, which had political, societal, constitutional, and ideological significance for the Founding Fathers.” He goes on, “The history of gun rights was not based on adhering to accepted historical principles, such as historical objectivity, the search for the historical truth, or a scholarly exchange of ideas. Rather, the history

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of gun rights was principled on legal advocacy, political activism, and in the process expanding the meaning and scope of the Second Amendment as broadly as possible.”1 His in-depth scholarly work, upon reading primary and secondary sources, the term “bear arms” was used in a distinctively military context. While there were indeed a few outliers that used the term “bear arms” broadly, there was nothing in them to firmly suggest that “bear arms” was referring to the general carrying of arms for non-militaryrelated purposes. As Richard Hofstadter, the Pulitzer Prize winner for history and professor at Columbia University wrote in his 1970 article “America as a Gun Culture”, “the urban population of the nation is probably more heavily armed than at any time in history, largely because the close of World War II left the participating countries with a huge surplus of militarily obsolescent but still quite usable guns. These could be sold nowhere in the world but in the United States, since no other country large enough and wealthy enough to provide a good

market would have them.” It has been estimated that between five and seven million foreign weapons were imported into the United States between 1959 and 1963. Between 1965 and 1968 handgun imports rose from 346,000 to 1,155,000. There is no disputing that the US is the civilian gun capital of the world. Today there are more than 393 million civilianowned firearms in the United States, or enough for every man, woman and child to own one and still have 67 million guns left over. Those numbers come from the latest edition of the global Small Arms Survey, a project of the Graduate Institute of International and Development Studies in Geneva.2 This means that even though the US makes up 4% of the population, we own 46% of the world’s firearms. One can postulate a variety of reason for this current state, giving blame or credit to the frontier expansion during the first 250 years of American history. Guns were an essential part for hunting edible game, controlling wild vermin and predators. Furthermore, as a colonizing people, the Native Americans were considered a formidable force to reckon with, and guns

1 https://www.americanheritage.com/history-gun-rights-america. 2 https://www.washingtonpost.com/news/wonk/wp/2018/06/19/there-are-more-guns-than-people-in-the-united-states-according-toa-new-study-of-global-firearm-ownership/

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A message from our outgoing President > Cesar Vazquez, MD FAAP

were a deciding factor in their conquest. The gun, being an icon in the South’s outdoor culture, as well as a necessary tool in the work of slave patrols, was also an important symbol of white male status. “What began as a necessity of agriculture and the frontier took hold as a sport and as an ingredient in the American imagination” says Mr. Hofstadter. At a time when only 1.3% of the US workers make their living in farming, why is the gun still so prevalent in our culture? A culture that for the last century and a half only a trivial

By its inclusion in the Bill of Rights, the right to bear arms became sanctioned and regarded as an item on the basic list of guarantees of individual liberties. According to Hofstadter, plainly it was not meant as such. “The right to bear arms was a collective, not an individual, right, closely linked to the civic need (especially keen in the absence of a sufficient national army) for “a well-regulated Militia.” It was, in effect, a promise that Congress would not be able to bar the states from doing whatever was necessary to maintain well-regulated militias.

In all societies the presence of The fact is that no other democracy in the world observes small groups of uncontrolled and any such “right,” and in other major democracies in which unauthorized citizens’ rights are better protected than in ours, such as men and women in unregulated England and the Scandinavian countries, our arms control possession of arms polices are considered absurd. is recognized to be dangerous. The fragment of its population comes in contact with a frontier, tremendous lobbying power of the NRA has caused legislators and, in fact, has not known a true frontier for three generations? to yield and become responsive to their demands as well as Moreover, why did the United States alone among industrial to those of gunmakers, importers, military sympathizers, and societies cling to the idea that a substantially unregulated far-right organizations. supply of guns among its city populations is a safe and acceptable thing? The fact is that no other democracy in the world observes any such “right,” and in other major democracies in which citizens’ One answer that lives in myth is that the freedom of America rights are better protected than in ours, such as England and had been won by the armed yeoman and the militia system. the Scandinavian countries, our arms control polices are Washington, who had to command militiamen, was not considered absurd. impressed with them. He had seen not a single instance, he once wrote, that would justify “an opinion of Militia or According to the Giffords law website: https://lawcenter. raw Troops being fit for the real business of fighting. I have giffords.org/scorecard/#CA, our country has more guns per found them useful as light Parties to skirmish in the woods, capita than any other nation and a higher gun death rate than but incapable of making or sustaining a serious attack.” any other developed nation. The United States is the only Despite the poor record of militia troops in the Revolution, as modern industrial urban nation that persists in maintaining compared with the courage and persistence of Washington’s a gun culture. It is the only industrial nation in which the small and fluctuating Continental Army, the myth has possession of rifles, shotguns, and handguns is lawfully persisted. In sum, other societies, in the course of industrial prevalent among large numbers of its population. Yet it remains and urban development, have succeeded in modifying their the most passive of all the major countries in the matter of gun old gun habits, and we have not. After all, the US is not the control. “After decades of gridlock at the federal level, state only nation with a frontier history. Canada and Australia have legislators have taken it into their own hands to address the had theirs, and yet their gun control measures are far more gun violence crisis, passing laws to protect their constituents satisfactory than ours. and save lives. And it’s working—of the 10 states with the strongest gun laws, seven of them have the lowest gun death rates.”, according to the Giffords Law Center.



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As they do every year, the attorneys at Giffords Law Center graded the states on the relative strength of their gun laws and found an undeniable correlation between strong gun laws and low gun death rates. “Year after year, our findings remain the same: gun safety laws save lives.” More states should listen to the American people, who are calling for an end to this epidemic, and show the courage to pass the laws and policies proven to prevent gun violence.

reverend Martin Luther King once said: “Our lives begin to end the day we become silent about things that matter.’” On July, 2017, the CMAs Firearm Violence Prevention Technical Advisory Committee (TAC) composed of physician experts, performed a comprehensive review and analysis of existing CMA policy, epidemiological data and current scientific research, and developed a CMA position statement. The policy statement entitled “Firearm Violence Prevention and the Physician” should be considered required reading for any physician regardless of specialty. To quote from the paper: “CMA recognizes that fundamentally,

The gun violence prevention movement experienced unprecedented progress in 2018. After the mass shooting in Parkland, Florida, high school activists stepped up and spoke out, urging our leaders to confront this unconscionable As of December 11th, 2019 there were 395 mass public health crisis. Twentysix states and DC passed shootings in the US compared to 337 in 2018. 67 new gun safety laws in 2018 ref lecting strong firearm violence is a human and civil rights matter, it violates public interest in the decades-long work of gun safety. In the fundamental human right to life, liberty, and security November’s midterm elections, voters overwhelmingly of person - the right to live safely without fear in a free rejected gun lobby–backed candidates and elected a new gun society”. Please see: https://www.cmadocs.org/LinkClick. safety majority to Congress. aspx?fileticket=P6rNFVs3ZcY%3d&portalid=53. California continued to strengthen its already strong gun FMMS took this call to action initiative one step further laws in 2018 by, among other things, raising the minimum and sponsored its own Violence Prevention CME dinner age to purchase and manufacture guns and broadening its in the fall of 2019 that featured two prominent experts in domestic violence laws. To uphold its role as a leader in gun the field of firearm and violence research. Dr. James Davis, violence prevention, California should also substantially trauma surgeon from UCSF-Fresno and co-author of the increase its investment in violence intervention programs, Firearm Strategy Team (FAST) workgroup and Dr. Amy restrict bulk firearm purchases, and regulate the sale of Barnhorst from the UC Davis Violence Prevention Program. homemade “ghost gun” components. The talks were designed to provide background information based on the latest research and teach important principles As of December 11th, 2019 there were 395 mass shootings that physicians could apply to their daily practices. The in the US compared to 337 in 2018, according to AMA and CMA have declared gun violence a public health gunviolencearchive.com, an online archive of gun violence crisis with CMA endorsing a ballot initiative - proposition incidents, with a total of 37,179 gun violence related deaths 63 - that passed on the November, 2016 ballot. It requires - all causes. On December 12th, another mass shooting in a background check and California Department of Justice a small Jersey City Jewish community took place where 4 authorization to purchase ammunition, prohibits possession people were killed in what’s being considered a targeted of large–capacity ammunition magazines, levies fines for racially motivated attack. While the California Medical failing to report when guns are stolen or lost, establishes Association (CMA) and its members are not a in position procedures for enforcing laws prohibiting firearm possession to change current laws, we physicians do have the inf luence by specified persons, and requires California Department to assess risk, provide education and change behaviors of Justice’s participation in the federal National Instant related to firearm violence. Moreover, when the protection Criminal Background Check System. of our citizen’s demands changes in policy against the will of politicians and lobbying groups we must remember what

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A message from our outgoing President > Cesar Vazquez, MD FAAP

 onversely, state laws most strongly correlated with increased overall C firearm mortality: “Stand Your Ground” associated with 32% increase in homicide in Florida since enacted.

Some of the noteworthy points taken from Dr. Davis’ talk include: • 3% of the US population owns 50% of the guns, which leads to the conclusion that the NRA does not represent the majority of Americans. • The argument that more guns equal less crime was debunked by a major study from Stanford Law school. According to the national bureau of economic research: violent crime is 10-15% higher in states with “right to carry” than without RTC, and the murder rate was propped up by RTC, Stand Your Ground laws. • One example the power of legislation can have on society is documented by: • Port Arthur Australia, 1996: • 28-year-old man, armed with a Colt AR 15 opened fire • 35 dead and 18 wounded • Within weeks, national political effort led to banning semi-automatic and military-style weapons across the country plus National Gun Buy Back Program • By 2014, murder rate < 1/100,000

• National Projections based on these rates: • U  niversal background: reduce mortality from 10.35 to 4.46/100k •Background checks for ammo: reduce mortality to 1.99/ 100k • Firearm identification: reduce mortality to 1.81/100k •C  onversely, state laws most strongly correlated with increased overall firearm mortality:

• “Stand Your Ground” - 32% increase in homicide in Florida since enacted

•D  r. Klaveras, 2016, Rampage Nation • During the assault weapons ban, there was a ban on high-capacity magazines capable of holding more than 10 rounds.

• “ We have found that when large capacity mags are regulated, you get drastic drops in both the incidence of gun massacres and the fatality rate of gun massacres.”

•W  e know states with strong gun safety laws have fewer gun deaths per capita than states with weak laws In short, gun laws work.

• A n article in the Lancet 2016; 387: 1847-55:

• S tate laws most strongly correlated with reduced overall firearm mortality (incidence rate ratios IRR): •Universal background checks: IRR 0.39, p = 0.001 • A mmunition background checks: IRR 0.18, p < 0.001 • Firearm identification (microstamping): IRR 0.16, p < 0.001



California has a death rate of 7.9/100,000 population and a rating of A according to Giffords Law Center compared to F ratings from states such as Texas, Louisiana, Alaska, Arizona, Missouri, Arkansas, Kentucky, and Wyoming with death rates ranging from 12-21. A more sobering statistic is that during the assault weapons ban from 1994 until its expiration in 2004 death rates from gun massacres fell by 43%. Following its lapse, there was a 239% increase in massacre deaths.

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The following organizations support ban on assault style weapons: • American College of Surgeons • Western Trauma Association • American Association for the Surgery of Trauma The article from the Firearm Strategy Team (FAST) Workgroup presents 13 recommendations from a workgroup of 22 surgeons (median experience of 28 years caring for trauma patients), 18 of whom are passionate firearm owners themselves, representing a broad range of experience with firearm ownership and use. These recommendations are put forth in an advisory capacity and include, “Strategies and tactics to increase firearm safety, reduce the probability of mass shootings, reduce firearm-associated violence, address mental health factors, and encourage federally funded firearm injury research while preserving the right to own and use a firearm.”

consequential subject our society should focus on as this one. Doctors see the unthinkable fallout caused by gun violence on a daily bases and are in a unique position to apply their training and background to help de-escalate a potentially violent situation as well as when and how to report to authorities. Doctors also carry the credentials and leadership skills to partner with their colleagues in the CMA to support lobbying efforts or author new resolutions that improve existing gun laws or create new ones. Ultimately, in the not too distant future, we should all look forward to a safer, more peaceful California where gun violence incidents are as rare a singleparty rule in the United States. Cesar Vazquez, MD

Finally, as we near closer to our next presidential election, it is clear that all 2020 presidential candidates see the gun violence crisis as a national emergency and many promise that gun safety will be a top priority. For example, information on his website states that Mike Bloomberg co-founded Mayors Against Illegal Guns, a coalition that grew to 1,000 mayors. During Mr. Bloomberg’s time as mayor, firearm deaths decreased by 46% and the firearm death rate was less than a third the rate in the rest of the country. After leaving City Hall, he got even more involved. Having merged Mayors Against Illegal Guns with the grassroots group Moms Demand Action for Gun Sense in America, he helped launch Every-town for Gun Safety – which has six million supporters and is the country’s most powerful grass-roots force for gun safety. As I wind down my term as president of FMMS, I can’t imagine a more

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CHSU Offers Local Valley Students More Opportunities to Pursue Health Care Education California Health Sciences University (CHSU), the private institution founded in 2012 by the Assemi family and located in Clovis, CA continues to make strides with fulfilling its mission to educate students and health care professionals to improve access to quality health care in the San Joaquin Valley. CHSU’s College of Pharmacy has recently announced their students are eligible to apply for federal loan programs. Until recently, pharmacy students at the University had to rely on private loans to finance their education. This critical and important milestone will provide more opportunities for pharmacy students, by providing an additional option for funding their education and making a career in pharmacy more attainable. “Historically, 84% of our CHSU pharmacy students have



utilized available private loan programs to help pay for their education. Providing our pharmacy students access to the Federal loan programs will significantly help to make their higher education more attainable,” stated Florence T. Dunn, President at California Health Sciences University. Current, incoming and prospective pharmacy students can apply through the Free Application for Federal Student Aid or FAFSA using the California Health Sciences University school code 042814. Officials at the University plan to work with the U.S. Department of Education to determine eligibility for their new medical school students in their CHSU College of Osteopathic Medicine and plan to apply at the earliest possible time. Excitement for their launch of the College of Osteopathic

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Medicine is growing as the grand opening of the new building is just a few short months away! CHSUâ&#x20AC;&#x2122;s College of Osteopathic Medicine building at the Universityâ&#x20AC;&#x2122;s new campus is nearly complete. Located at 2500 Alluvial Avenue in Clovis, the brand new, state-of-the-art building features a simulation center, osteopathic skills lab, and large classrooms with capacity for 200-300 students. The new building also includes a library, student lounge, ample study spaces, faculty offices, and a teaching kitchen for educating students and the community about healthy meal preparation. The first class of seventy-five (75) medical students will matriculate in July 2020, with the class size growing to 150 within two years. Aligned with the University mission, the College hopes to recruit, train and retain physicians for the underserved population in the Central Valley under the leadership of John Graneto, DO, MEd, Dean for the College of Osteopathic Medicine. The University will be hosting a Ribbon Cutting Ceremony to celebrate the opening of the College of Osteopathic Medicine on Wednesday, April 1, 2020 at 9:00 am. All are invited to celebrate this historic milestone, which would not be possible without the support of our community partners, physicians and preceptors. Through the continued growth of their pharmacy and medical schools, and future plan to construct up to eight (8) additional Colleges, the University will progress towards achieving their mission of helping remedy the shortage of health care providers in the Central Valley. For more information about CHSU programs, employment or preceptor opportunities or to schedule a campus tour, visit chsu.edu or call (559) 325 3600.

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The California Medical Association (CMA) recently convened its 148th annual House of Delegates (HOD) meeting in Anaheim. Over 500 California physicians debated and outlined a policy agenda on major issues that have been determined to be the most important issues affecting members, the association and the practice of medicine. The association also installed its new officers, including new CMA President Peter N. Bretan, Jr., M.D., a urologist and transplant surgeon who gave up his Bay Area practice to serve patients at a safety net hospital in Watsonville. The major issues the delegates focused on this year were: +

Augmented Intelligence (A.I.): The delegates explored pragmatic solutions that address medical decision-making, new liabilities and privacy concerns inherent with augmented and artificial intelligence in health care, with a focus on keeping physicians at the center of health care delivery. >>

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Homelessness: Physicians witness the

The final actions of the House of Delegates, including

homelessness crisis in emergency rooms, clinics

newly established policies, are now posted at

and on the streets of our communities. The


delegates declared that stable and affordable housing is an essential community priority and


an important social determinant of health. They

Watsonville Urologist and Transplant Surgeon

also discussed evidence-based solutions that

Installed as CMA President

address the health care and social needs of those at risk of or experiencing homelessness.

Peter N. Bretan, Jr., M.D., a urologist and kidney transplant surgeon who gave up his Bay Area


Cannabis: The delegates weighed in on pressing

practice to serve patients at a safety net hospital

issues, including health impacts associated with

in Watsonville., was elected as the 152nd president

cannabis use, public health protections, federal

of the California Medical Association. Dr. Bretan

legalization, data and surveillance efforts, high-

is the first Filipino-American physician to serve as

quality research, marketing and advertising


practices, cannabis equity programs and more. “The most important goal, not just in this year of my +

Adverse Childhood Experiences (ACE):

presidency, but always, is to take back our profession

Recognizing that ACEs have a strong and life-

by enabling physicians to lead the struggle to

long correlation to numerous health, social and

protect, expand and make universal access to health

behavioral problems, the delegates learned more

care for all of our patients in California,” said Dr.

about data collection, research and incorporating

Bretan. “If we are successful in this state, it will lead

ACE screening practices into routine care.

the way for sustainable universal health care for all of America.”



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Dr. Bretan is the founder and CEO of LifePlant International, a charitable organization that furnishes lifesaving transplants in developing countries, for which he was recognized by the American Medical Association with the Benjamin Rush Award for Citizenship and Community Service. Dr. Bretan has also provided care around the world on medical missions. “I grew up as a child farm laborer, and I know what it is to be without adequate health care. My greatest motivation is in service to give back to society for my good fortune,” said Dr. Bretan. After years of practice in Marin and Sonoma counties, Dr. Bretan now provides urologic and laparoscopic surgical care at a safety net hospital in Santa Cruz County. Most of his patients speak no English and have no medical insurance. “My presidency will be dedicated to giving these patients, and the millions of hard-working Californians like them, a voice,” said Dr. Bretan. “We have an incredible opportunity to boldly change the way health care is delivered. We know that to best serve patients, health care must be physician-led.” Dr. Bretan has served as a CMA trustee and delegate, and is a three-time county medical society president. He is the current president of the California Urological Association and serves as an adjunct clinical professor at Touro University, where he has taught classes in health care policy for the past 16 years. Dr. Bretan earned his B.S. degree in physiology from UC Berkeley and his medical degree from UC San Francisco, where he completed residencies in general surgery and urology, as well as a fellowship in radiology. He also completed a fellowship at The Cleveland Clinic Foundation in transplantation and renovascular surgery. Dr. Bretan is a member of the San Francisco Marin Medical Society and the Mendocino-Lake County Medical Society.

STAYI NG I NVOLVED Already have ideas for next year’s House of Delegates or want to continue the fight to support CMA? Even though HOD might be over, there are plenty of ways to stay involved and dedicated to CMA. Grassroots Action Center CMA boasts some of the best advocates and lawyers in the capital - but YOU are the most powerful advocate. As someone who serves on the front lines of health care delivery, elected officials and policymakers need to hear your voice to make informed policy, legislation and regulations. Visit cmadocs.org/grassroots to see how you can get involved. Submit a Resolution CMA is proud of its resolutions process because it preserves the value of each member’s perspectives and experiences, and empowers physicians to shape the ever-changing health care landscape and ensure that CMA is speaking with its members’ voices in its advocacy. From internal governance to ambitious statewide advocacy, every policy is crafted, reviewed and approved by the dedicated team of physician leaders that make up CMA’s organizational structure. Visit cmadocs.org/resolutions to submit a resolution. Nominate Yourself or a Colleague Members of CMA councils and subcommittees play crucial roles in

Sacramento Pain Specialist Named CMA President-Elect Sacramento pain specialist Lee T. Snook, Jr., M.D., was

shaping health care policy. You can find out more about available opportunities and awards at cmadocs.org/nominations.

named president-elect of CMA. He will serve on the

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Executive Committee as president-elect for one year.

medical review officer and a qualified medical

Dr. Snook will be installed as president following next


year’s House of Delegates. Dr. Snook graduated from the University of Nevada A CMA member since 1985, Dr. Snook has served

School of Medicine in Reno, NV. He did his internal

as speaker and vice speaker of the CMA House

medicine and anesthesiology residencies at the

of Delegates. He has also served as chair of the

University of Wisconsin Hospitals and Clinics in

CMA Worker’s Compensation Technical Advisory

Madison, WI.

Committee for the past eight years and as a member of CMA’s Board of Trustees for the past 10 years. Dr.

He is an American Medical Association delegate

Snook is a member of the Sierra Sacramento Valley

for the American Society of Interventional Pain

Medical Society.

Physicians and an alternate delegate for the California Society of Anesthesiologists. He is also a board

Dr. Snook is an outspoken advocate for physician

member at California Public Protection and Physician

wellness and was an advocate for approaches to

Health, Inc.

preventing physician burnout long before it became a popular thing to talk about. He has spent the past


25 years working to develop policies and programs

San Bernardino Anesthesiologist Receives CMA

that have achieved positive results for the health

Speaker’s Award

and wellness of all physicians and for the practice of

San Bernardino anesthesiologist Thelma Z. Korpman,


M.D., received the 2019 Gary Krieger Speaker’s Recognition Award. The recipient of this award

Dr. Snook is a medical director, president and founder

is hand-selected by the Speaker of the House for

of the Metropolitan Pain Management Consultants,

remarkable contributions to CMA and its House of

Inc., in Sacramento. He is board-certified in


anesthesiology, internal medicine, addiction medicine


and pain medicine. He is a fellow of the American

“The recipient of this year’s Krieger Award is a woman

College of Physicians and the American Society of

whose dedication and service has been nothing short

Addiction Medicine. Dr. Snook is also a certified

of incredible and inspirational,” said Speaker Lee T.


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Snook, Jr., M.D. “A true role model and prolific leader

Dr. Soper has an impeccable reputation for

she has contributed to organized medicine since she

providing first-rate, and sometimes life changing,

started practicing anesthesia in 1977. As a member of

care for many of Humboldt and Del Norte

her beloved San Bernardino County Medical Society

counties’ most mentally ill clients. He will see

(SBCMS), she has led the way, over and over again.”

patients regardless of their insurance, including Medi-Cal and Medicare.

Dr. Korpman has been a member of CMA since 1978 and of SBCMS since 1977. She has been a member of

“I keep reminding myself that I am very lucky

the House of Delegates for 11 years. She has served as

to do this,” said Dr. Soper. “People keep inviting

Chair of the District 2 Delegation to the CMA and is the

me into their very personal lives. And when you

current Chair of the HOD Rules Committee.

watch people get better, it’s very gratifying.”

The full 2019-2020 CMA Executive Committee includes:

For 15 years, Dr. Soper has also served as chair of


President: Peter N. Bretan, Jr., M.D., Watsonville

his local physician well-being committee, which


President-Elect: Lee T. Snook, Jr., M.D., Sacramento

aids physicians who may have health problems


Chair of the Board: Robert E. Wailes, M.D.,

that could impair their ability to practice




Vice-Chair of the Board: Shannon L. UdovicConstant, M.D., San Francisco


Speaker of the House: Tanya W. Spirtos, M.D., Redwood City


Vice-Speaker of the House: Jack Chou, M.D., Baldwin Park


Immediate Past President: David H. Aizuss, M.D., Los Angeles


Eureka Psychiatrist Honored with CMA’s Prestigious

The CMA Political Action Committee (CALPAC)

Plessner Award

raised over $170,000 during CMA’s annual House

Eureka psychiatrist Robert Soper, M.D., received CMA’s

of Delegates meeting. Donations to CALPAC are

most prestigious award, the Frederick K.M. Plessner

used to support candidates for office who share

Memorial Award. The award honors a California

medicine’s priorities.

physician who best exemplifies the ethics and practice of a rural country practitioner.

Join CALPAC Today! Please join your colleagues in supporting

For the past 30 years, Dr. Soper has been practicing

CALPAC and help strengthen our political voice.

psychiatry in rural Humboldt and Del Norte counties,

Please visit calpac.org/donate to contribute

where there are very few psychiatrists. He would

to CALPAC. Different levels of support are

regularly drive 90 minutes over curvy winding roads to

available along with monthly options that make

provide psychiatric services in Del Norte county, where

supporting the House of Medicine easier than

there were no other practicing psychiatrists.


“As a physician who needs to refer some difficult

To mail a check, please make payable to CALPAC

psychiatric patients, there wasn’t a single, solitary time,

and send to: CALPAC, 1201 K Street, Ste 800,

that he told me I cannot see a patient,” said Caroline

Sacramento, CA 95814.

Connor, M.D. “He was open, he always called me back if he didn’t answer immediately, and he always accepted

For more information about CALPAC,

everyone. For family physicians on the firing line, that

visit calpac.org.

was unbelievably comforting.”

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“His commitment to keep his practice open shows

commitment to the San Diego community. Dr.

a true dedication to serving the more complex

Bazzo is the immediate past-president and a current

psychiatric patients in the community who

member of the San Diego County Medical Society;

would otherwise have to travel out of the area for

he was president of the San Diego Academy of

treatment,” said Corinne Frugoni, M.D., a family

Family Physicians in 2005 and currently serves as

physician in Arcata who has worked with Dr. Soper on

president-elect of the California Academy of Family

the local physician well-being committee.

Physicians. He serves as Head Team Physician for the San Diego Seals (professional indoor lacrosse) and is

Dr. Soper has been a member of CMA and Humboldt-

team physician or consulting physician for numerous

Del Norte County Medical Society since 1991.

other sports teams in the San Diego area including professional level teams like the San Diego Chargers

San Diego Physician Receives CMA’s Physician

and the San Diego Sockers (professional indoor

Health and Well-Being Award

soccer) and other Olympic, collegiate, and high school

San Diego family medicine physician David Bazzo,

level teams. His peers voted him one of San Diego’s

M.D., was awarded the 2019 Gary S. Nye Award for

“Top Doctors” for the last 14 years in family medicine

Physician Health and Well-Being. This annual award

and/or sports medicine.

honors a CMA member who has made significant contributions toward improving physician health and

Dr. Bazzo has been a member of the California


Medical Association since 1990. He has served on CMA’s Council for Ethical, Legal and Judicial Affairs

Dr. Bazzo is honored with this award for his

and serves in CMA’s House of Delegates representing

commitment to the Physician Assessment and

District 1.

Clinical Education (PACE) program at UC San Diego. Since 1996, the PACE program has promoted a culture

CMA Recognizes Two Recipients with

of ongoing quality improvement and professional

Compassionate Service Award

development in the medical field. The mission of the

This year, CMA named two recipients deserving of

PACE program is to better the quality of health care

the Compassionate Service Award, created in 2015 to

throughout the nation by offering assessment and

honor CMA member physicians who best illustrate

remediation services to medical professionals. This

the association’s commitment to community and

nationally recognized program is a model for how

charity care.

practicing physicians can get assessment, education and assistance.

The first recipient is family medicine physician Melissa Bishop, M.D. Dr. Bishop is a family medicine physician


For the last 20 years, Dr. Bazzo has helped physicians

who has worked with medically underserved patients

who enter the PACE program. Through his

since completing her residency in 1997. For 17 years,

involvement with organized medicine, he has worked

she worked with Piedmont Health Services (PHS), a

to study risk factors and develop interventions to

group of federally qualified health centers in central

benefit physicians and help them overcome burnout

North Carolina. While at PHS, she cared for a rural,

and remediation. As it currently exists, the PACE

low-income population, many of whom were recent

program intervenes at the end of a physician’s

immigrants from Latin America. In addition to patient

disciplinary process, but Dr. Bazzo understands

care, she wrote a weekly “Ask the Doctor” column

that interventions earlier in the process might help

for the Spanish language newspaper, served on

prevent remediation and burnout in the first place

the board of the North Carolina Community Health

and is actively developing ways to promote early

Center Association and conducted numerous quality

intervention practices.

improvement initiatives.

In addition to his commitment to physician wellness,

In 2015, she relocated to Escondido and joined

Dr. Bazzo is well decorated and recognized for his

Neighborhood Healthcare (NHC), another federally


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qualified health center providing care for low-

Riverside County Medical Association started Project

income, medically and socially complex patients in

K.I.N.D. to address the acute health care needs of

San Diego and Riverside counties. NHC is frequently

elementary, middle and high school age children

spotlighted as an organization that has achieved

who would otherwise “fall through the cracks” of

excellent quality outcomes despite the challenges of

the health care system. Today, Project K.I.N.D. works

caring for patients with limited resources.

with school districts throughout Riverside County to screen low income students for health needs. These

Dr. Bishop currently serves as NHC’s Medical Director

children are then referred to Project K.I.N.D. to treat

of Quality and she has worked tirelessly to make it

acute health care needs through a network of over

easier to take good care of patients by spearheading

140 volunteer physicians, dentists and optometrists.

numerous quality improvement projects including

All Project K.I.N.D. services offered by the treating

provider education, system redesign and team-based

providers are at no cost to the families.

care. Project K.I.N.D. is 100% grant funded and currently Dr. Bishop has provided care to asylum seekers at

serves the Alvord, Beaumont, Corona-Norco, Moreno

the various shelters in San Diego and Tijuana since

Valley and Riverside school districts. These five

the arrival of the migrant caravan last fall. Since

districts represent 167 schools and 158,000+ students.

November 2018 she has screened over 500 people in migrant shelters. In addition, she has volunteered as

Accepting the award was Project K.I.N.D. Medical

a medical provider with the Refugee Health Alliance

Director Harold Jackson, M.D.

at several migrant shelters located in Tijuana.

Reliving House of Delegates 2019 The award’s second recipient was Project K.I.N.D.

Couldn’t get enough of HOD? Check out our Flickr

(Kids in Need of Doctors). Project K.I.N.D. has been

page for photos of HOD 2019 and relive all the glory

addressing the acute health care needs of low-

and memories!

income, immigrant, single-parent and Spanish-


speaking families in Riverside County for the last 25 years.

Winter 2020




Itâ&#x20AC;&#x2122;s amazing to think that just a few decades ago, health care services in the Central Valley were sparse. In the earlier part of the century, some of the existing medical practices here were even downright strange â&#x20AC;&#x201C; like a hearse arriving to the scene of an accident rather than trained emergency personnel, open heart surgeries performed without pumps or equipment, or paper log books to document procedures. >>



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Dr. Marius performing heart surgery in Fresno CA If it weren’t for these bright, brave and determined physicians who paved the way by creating, molding and advancing medical services in our community, health care in Fresno would look a lot different today. Drs. David Hodge, Gene Kallsen and Fitzalbert Marius have made a difference in thousands of lives by advancing services in the areas of pediatrics, emergency medicine and cardiology. Here are their stories.

DAVID HODGE, MD Pediatric Surgery

Surprisingly, when David Hodge, MD, came to Fresno in the late 1970s, all adult heart cases were performed at the former Children’s Hospital on Shields and Millbrook. With only one pediatric surgeon serving the community (Ernest Haws, MD), and surgery subspecialties not yet in existence, there was a huge need for more pediatric surgeons. Recognizing this need, Dr. Haws placed an ad in the American Pediatric Surgery Association’s clearinghouse as a call for help. Dr. Hodge answered it. “Fresno gave me the opportunity to do exactly what I really wanted to do,” he says. “It was nice here because as a pediatric surgeon, you need a large volume of patients in order to practice, so most pediatric surgeons – at least at that point in time, and even to this day – can only exist in either academic research or major metropolitan areas. One of the things I actually liked about Fresno was that it was kind of a big farm town in some respects, and one thing that was unique about this community was the fact that there was a children’s

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hospital.” In the late 1970s, Dr. Hodge says Fresno was considerably smaller than what it is today. With only four small operating rooms, the Children’s Hospital had two pediatric surgeons, two pediatric cardiologists, four neonatologists and one anesthesiologist at that time. There was a NICU but no Pediatric Intensive Care services. Surgeons from University of California, San Francisco, would visit once a month to provide specialty care on designated clinic days. “Today, very few kids have to actually leave the Valley in order to get that kind of care,” Dr. Hodge says. “It is light-years ahead of what it was in 1979. If you had anything seriously wrong with you then you had no choice but to go to San Francisco or travel in the Bay Area.” In addition to having his own private practice, most of Dr. Hodge’s career was spent at Children’s Hospital. He also served as a member of the Children’s Specialty Medical Group. Furthermore, in order for Community Regional Medical



Centers to have a third-level NICU in 2007, Dr. Hodge agreed to serve as the certified unit’s California Children’s Services (CCS) physician. Aside from his professional career, Dr. Hodge is known as a dedicated Rotarian and compassionate public servant. For the past 31 years, the Fresno Rotary has sponsored Dr. Hodge’s medical missions project, Project Nino, comprised of serviceminded physicians, dentists and pharmacists who provide basic medical care to children in rural Mexico. Dr. Hodge originally initiated the project in response to the 1985 Mexico City earthquake. “This last year we treated fifteen hundred kids,” says Dr. Hodge. “In years past we have seen as many as 3,000 to 4,000. Initially, we mainly treated worms, parasites and lice because practically every kid had it. In almost thirty years, we rarely see these cases anymore so we really changed the whole complexion of their wellbeing. It has been a rewarding trip over the years.” As Fresno’s second pediatric surgeon, Dr. Hodge has surely changed the lives of thousands of Valley children. He initially wasn’t exposed to pediatrics until he was placed in a pediatric surgery clerkship during his third year at Kansas University Medical School. “At that point in time, I decided that is what I wanted to do,” he says. “It is nice to think about the fact that you can operate on somebody that would have a 65-year period adult life span. You can change a life that would not have a life due to an abnormality. Once you have corrected it, then those children can live a thriving adult life. That is why I chose pediatrics.”


Trauma/Emergency Medicine

Gene Kallsen, MD, came to Fresno in 1977 to complete his Emergency Medicine residency after graduating from the University of Minnesota in 1972 and completing a rotating internship in Seattle. He expected to go straight to Vietnam after his internship, but the draft ended the same week he finished his internship at Harborview.   He then spent four years at Group Health Cooperative as a primary care doctor, when Family Practice was an early specialty. The “grandfather clause” allowed him to become board-certified in Family Medicine by passing a test. During those four years, he discovered the new field of Emergency Medicine (EM). “It was a pivotal time for Emergency Medicine because it officially became a specialty in 1979,”Dr. Kallsen says. “The



specialty was developing and Fresno was lucky enough to have one of the earlier programs. It was an exciting time in the evolution of Emergency Medicine. Coincidentally, it was the same year I finished my residency at the old Valley Medical Center (VCM).” In 1974, VMC’s EM residency was started by Robert Dailey, MD. Dr. Dailey had been the first program director of California’s first EM residency at the University Southern California in 1972. Loren Grayson, MD, and Robert Peters, MD, were instrumental in bringing Dr. Dailey to Fresno as they both realized the importance of the growing new field and its relationship to EMS systems. As a senior resident, Dr. Kallsen’s project was to write the original paramedic protocols for Fresno County. “They’re still in use here in Fresno, though they have been modified a bit over the years,” he says. “I was fortunate enough to be here when it all started.” In 1980, Dr. Kallsen was named Fresno County’s first EMS Medical Director. During his 10-year tenure in that role, he helped to create Fresno County’s trauma system. Dr. Kallsen says the new EMS standards and implementation were largely evolving in the U.S. due to the  Vietnamese War. “The care was so advanced there that the trauma victims received better care than here,” he says. “Up until the late 1970s, you would often get a hearse to arrive at the scene of a car accident in the U.S. – the driver knew how to embalm but they may or may not have known first aid or basic life support.” Back then, Dr. Kallsen says typical coverage for emergency “rooms” in hospitals involved a nurse on duty in the ED that would call in the appropriate doctor depending on the case, or only interns and residents would provide emergency care with little supervision. “Hospital EDs were not manned very well,” he says. “There was no special training for people who worked in them and there was no real agreement about what Emergency Medicine doctors should know.” Meanwhile, paramedic programs were starting all over the country with a need for training, coordination and medical oversight. “Between the 1950s and 1970s, the number of U.S. Emergency room visits went from 10 to 60 million within 15 years,” he says. “There was incredible growth and the need for ED doctors as the requirements grew. Emergency Medicine physicians now have to complete special training and achieve board-certification before practicing.”

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Dr. Robert Stewart: main surgeon, Dr. Leonardo Thompson & Fitzalbert Marius are assistants, R.N. Lana is the nurse. At ST. Agnes Hospital in 1992

Drs. Marius, Stewart and Thompson Open heart surgery at Valley Children’s Hospital performing open heart surgery in 1972 with Dr. Yenching Wu, Dr. Fitzalbert Marius, and

Shamin Khan R.N. Around 1980.

With a career in Emergency Medicine spanning a total of 40 years, Dr. Kallsen has deeply impacted the medical field in Fresno and beyond. “I got to play a role in California to some degree because I was a founding member and second president of the EMS Medical Directors of California (EMDAC) when a new law was passed (The California EMS Act in 1980), requiring every county to have an EMS Medical Director,” he says. “I got to do a lot of fun stuff as second president of EMDAC and later as Chairman of the California EMS Commission.”   Most importantly, Dr. Kallsen got the opportunity to teach EM to residents at VMC, then University Medical Centers, and now Community Regional Medical Centers. He served as Chief of EM for the University of California, San FranciscoFresno from 1990 to 2012. During that time, the faculty grew

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D ! !

Open heart surgery at Valley Children’s Hospital with Dr. Yenching Wu, Dr. Fitzalbert Marius, and Shamin Khan R.N. Around 1980.




!!!!!!!!!!!!!!!!!!!!!!Bryron!Evans!1963!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Ernest!Haws!!!1972! !!!!!!!!!!!!!!!!!Thoracic!&!Cardiac!Surgeon!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Pediatric!Cardiac!Surgeon! ! ! ! ! ! ! ! ! ! ! ! ! !!!!!!! ! ! ! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!!!Richard!Hoffman!!1963!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Thomas!Eliason!!1969!!!! !!!!!!!!!!!!!!!!!Thoracic!&!Cardiac!Surgeon!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Cardiologist! !

from 12 to 45 members, and the number of residents increased from 18 to 40. Looking back, when Dr. Kallsen began his EM career in 1979, his goal was simple: to train doctors in the new specialty of Emergency Medicine. “Now, at any given time, we have 40 Emergency Medicine residents training to complete their four-year requirement,” he says. “The goal was to produce many well-trained Emergency doctors – many of whom would stay locally or go out to be leaders elsewhere – and I think we have accomplished that with training well over 300 EM physicians since the program’s inception. Thanks to all the EM faculty and physicians from many other specialties who supported our growth and development.”


In 1958, Fitzalbert Marius, MD, and Thoracic Surgeon Byron Evans, MD, performed the first open heart surgery in Fresno. They are acclaimed as heart surgery pioneers because they bravely performed the risky procedures without advanced equipment or stabilizing pumps. After graduating from Howard Medical School in



pumps to assist the patients during this type of procedure, but no one knew how to use them, so they didn’t want to risk placing patients on pumps manned by untrained clinicians. “We were thinking that maybe we could find a way to do some open-heart cases without the pump,” he says. “We discussed the Secundum Atrium defect in children, which is essentially a hole that needs to be closed between the right and left atrium. We didn’t have electric saws or none of that stuff – we had to use scissors and a cleaver to open the sternum.”

Washington, D.C., Dr. Marius was one of the first AfricanAmerican physicians to complete a General Surgery residency at Fresno County General Hospital. During a year-long partial fellowship with Stanford University’s Cardiac Surgery Program at Stanford Lane Hospital in San Francisco, Dr. Marius trained with Norman Shumway, MD, (the first open heart surgeon and heart transplant inventor), and Frank Gerbode, MD. Knowing this, Dr. Evans asked Dr. Marius if he’d be interested in performing open heart surgeries in Fresno. The two then traveled to Los Angeles to learn from other like-minded physicians and study and watch these procedures. Once ready, they were tasked to complete 10 successful cases in order to receive accreditation from the state. “We had none of the state-of-the-art equipment; all we had was X-ray and our guts!” Dr. Marius says. The duo decided to perform 10 Secundum Atrium defect correction cases at the former Valley Children’s Hospital on Shields and Millbrook. Dr. Marius says the hospital had heart



Because the brain begins to die after three minutes of non-oxygenation, Drs. Evans and Marius invented a way to allow for a seven-minute window to correct the defect without utilizing pumps. By placing the unconscious patient in a tub of ice water, the physicians lowered the patient’s temperature to slow the heart beat. Once the sternum was opened, they then carefully placed tourniquets on the two major heart input veins and the two major heart output arteries, and began a silk suture at the top of the right atrium with clamps on either side. One would suck the blood down until the hole was visible and the other would start suturing, while carefully filling the heart with saline to prevent air from entering. “We had gotten to where we were doing the atrial closure part of those procedures in three to four minutes, averaging about three and one-half minutes,” says Dr. Marius. “We did 10 of those and all 10 patients came out beautifully and grew up without problems.” As a natural-born artist and skilled tailor with a steady hand, surgical medicine was a good fit for Dr. Marius, even if he didn’t realize it until later in life. During World War II, Dr. Marius served in the Armed Forces from 1942 to 1946, benefitting from its concentrated four-year medical program. He then finished his education at Lincoln

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Gene Kallsen, MD with his wife Pam Kallsen University in 1948. Torn between his love of art and medicine, he simultaneously applied to the prestigious Ecole des BeauxArts school in France and Howard Medical School in Washington, D.C. When he was accepted to both schools, he decided his fate would be determined by the flip of a coin. Although by chance, thousands of Valley residents have surely benefited from Dr. Marius’ skilled hands. He is the city’s first African American surgeon; has dedicated over 50 years to heart surgery teams at Saint Agnes Medical Center and Fresno Heart and Surgical Hospital; and has conducted many religious motivational seminars and workshops to inspire the youth. “I simply wanted to see patients and take care of people,” he says. “I came here to take care of patients and make them physically better and to think positively through a face-toface contact and relationship. That is why people remember me – the whole 50-plus, 60 years that I was practicing – I always stayed positive.”

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Trailblazers Honored

Known for being the first in our region to create a new model of cancer care for women, establish a women-centric medical group and be a female leader emergency and academic medicine, this year’s Fresno Madera Medical Society honorees are also remarkable for being the second, third and fourth women ever chosen by their peers for their lifetime achievements. Colleagues call them “pioneers” and praise these three for their calm grace, hard work, and compassion – and for paving the way for other women. And all three came to Fresno at the beginning of their careers not intending to stay long, but fell in love with the Valley’s diversity and unique health challenges. And this was a place, they said, where they could make a real difference. All three have. >> BY ERIN M. KENNEDY

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The 2019 Lifetime Achievement honorees are:

• Margaret Hadcock, M.D., the region’s first breast surgeon who founded the multi-disciplinary conference model of care locally,

• Jean Linder, M.D., an internal medicine physician who built the area’s first all-female medical group and served as the medical society president, • And Lori Weichenthal, M.D., the first female leader in the UCSF Fresno emergency medicine department and now the associate dean of graduate medical education for UCSF Fresno, who helped create the wilderness medicine fellowship. The 2019 Special Project Award went to The Fresno Nephrology Kidney Foundation, for its work in educating the community on kidney disease and for support patients on dialysis.



Forging the way for other women in academics

Dr. Lori Weichenthal’s colleagues see her as their torchbearer, the type of leader they strive to be – not just because she was first, but because she forged new paths for residents, established unique expertise, and has done it all with quiet efficiency, kindness and Buddha-like calmness. “She exemplifies what a female role model in medicine should be,” said Suzanne Spano, M.D., UCSF associate clinical professor in emergency medicine and the Wilderness Fellowship director for UCSF Fresno, who was mentored by Dr. Weichenthal since she was a resident. “She’s a true pioneer. “She’s really a foundational member of not just emergency medicine here,” Dr. Spano continued, “but the first female leader in the emergency medicine department as an associate program director, now she’s the associate dean of graduate medical education. But if you’re the associate program director for emergency medicine at UCSF Fresno, one of the oldest emergency medicine residencies in the country, that makes you a leader nationally.”

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Dr. Weichenthal has also served regionally and nationally on the American College of Emergency Physicians board and committees. There was only one other woman in the emergency department at UCSF in 1995 when Dr. Weichenthal started. Women in medical leadership positions are still rare. Although women have comprised at least 40% of medical school enrollment since the 1990s, just 22% become full professors at academic medical centers and only 16% hold leadership positions in administration or department levels. “There’s still a glass ceiling in academic medicine,” Dr. Weichenthal said. She set out to change those odds in Fresno. She surveyed UCSF Fresno’s women residents and interviewed medical students and then started a women in academic medicine organization to create more collaboration and an infrastructure of support. She also worked with colleagues, she said, to build a training program “that allows physicians to maintain their humanity and compassion.” “I think Lori realized being a woman in academic medicine in academic leadership is hard, it’s kind of a man’s world,” said Nicole Campagne, M.D. “A lot of us are moms juggling kids and juggling lots of outside things. The retention of woman in academic medicine is very small.” Dr. Campagne started as a resident under Dr. Weichenthal and has followed her into academic leadership as associate professor of emergency medicine at UCSF Fresno and vice medical chief of the Community Regional Medical Center emergency department. “Lori is what we all strive to be,” she said. “She sees a need in the community, in the emergency department, in academics and always strives to fix that need. All these things she does with a quiet elegance. Things just magically get done when Lori’s around. Her magic pixie dust, we’d all like some of it.”



Dr. Spano agreed: “She’s the person who go to when you need to get a thing done. “She’s really like a beacon for all the women who follow on how to be a leader in medicine,” Dr. Spano praised. “I believe our medical staff leadership will continue to have more than one token female because of Lori Weichenthal.”

National expertise in wilderness medicine and physician wellness

Dr. Weichenthal also saw a need for expanding options in emergency

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medicine so helped create one of the first wilderness medicine fellowship programs in the nation. “We have opportunities in Fresno that are unique and we already had a national parks medic program,” Dr. Weichenthal explained. “We started building our curriculum and it just slowly came to be one of the top five wilderness medicine fellowships in the U.S. 12 years ago. Many of the fellows have stayed on as faculty. That has been a positive, positive result.” DRS. JEAN LINDER AND ROYDON STEINKE

Dr. Spano is one of them. She was the second fellow in the program and says it was a life-changing, if sometimes harrowing, experience. “Dr. Weichenthal saved me at least 10 times from drowning and saved me from hypothermia,” she described. Besides teaching survival skills and how to care for others in the wilds, Dr. Weichenthal used the opportunity to give lessons on wellness – another of her passions. “She showed that practicing and caring for people in an austere environment really replenishes who we are,” said Dr. Spano. Her colleagues said just watching her work often replenishes and inspires them. “No matter what was happening, Dr. Weichenthal would be serene, composed, everything under control,” described Dr. Spano. “She’s elegant under fire,” agreed Dr. Campagne.


Jim Comes, M.D., chief of emergency medicine at Community Regional, characterized Dr. Weichenthal’s work style as seemingly effortless: “What I admire about her is her kindness, her integrity, her high standards, her professionalism, her Zen-like quality. The department could be falling apart, it could be pandemonium and she just seems to be just gliding through. And that calm is very comforting.” For the past two decades, Dr. Comes, who is also chair of UCSF Fresno emergency medicine department and vice chair of emergency medicine at UCSF’s main campus, has come to depend on Dr. Weichenthal’s calm support: “She was my confidante. She was the person who could tell me the truth and tell me things I needed to hear and not what I wanted to hear. She’s the type of person you lean on during tragedy.” When Melissa Dowd, a 30-year-old UCSF Fresno emergency medicine resident was struck by a car and killed in 2012 while crossing a street, Dr. Weichenthal was the first person Dr. Comes called after he was notified. It was 2:30 a.m. and she came immediately to pick him up. “Her husband drove us to the hospital where Melissa Dowd was cared for by a former resident at St. Agnes hospital,” Dr. Comes said. “And she was there for me and with me when I broke the news to our residents that Saturday morning.”



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Dr. Weichenthal has taken these kinds of tragedy and personal losses and turned the experiences outward to help others, said Dr. Spano. She’s become a huge support locally to those who are survivors of suicide loss, using her own experiences to help guide people through grief.

was the first female physician in town who developed a female medical group or a group around the nidus of female physicians with Dr. (Mary Ann) Quann and Dr. Helen Jones,” said her longtime friend Roy Stienke, M.D. “And that was pioneering.”

Dr. Weichenthal has led the way locally and nationally on physician wellness efforts. Finding ways to maintain wellness and work-like balance are critical, she’s said, for those in healthcare who work with people in crisis and are responsible in often life or death situations. She leads free yoga classes for UCSF residents and hospital employees on the Community Regional campus and established an annual wellness day at UCSF Fresno for physicians, therapists and nurses. “We have a national expert on physician wellness, that’s got national recognition right here in Fresno. That’s something to be proud of,” said Dr. Comes.

John Monteleone, M.D., a Community Medical Providers family medicine physician, said he was amazed when she started the practice right after her UCSF Fresno residency. “I think of all the years that LQMG has been around, it’s really unique.”

Creating a medical practice of women for women

The Linder Quann Medical Group has also been a source of Fresno pride and considered groundbreaking. “Dr. Linder

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What made the medical group special was Dr. Linder’s leadership, said Eric Hanson, M.D., an orthopedic surgeon who has worked with her on the California State University, Fresno, sports medicine team for 25 years. “I think Jean is unique in that she has a phenomenal empathy and she truly, truly cares for each person she interacts with,” he said. “She’s going to take care of business and do it a way that’s thorough, that’s compassionate and in such a unique way. There’s not that many people who have that gift and that desire and that relentless energy to do things right in such a holistic way.”





Colleagues marvel at her boundless energy and all she does outside her regular medical practice. “How and why Dr. Linder devotes her energy to so many different things, I don’t think she questions it,” said Dr. Hanson, “I think it’s just intuitive, it’s her nature. Her daughters also have that relentless energy and curiosity. If it’s going to be of service, then for Jean that’s the right thing to do.” Dr. Linder said that idea of service and trying whatever new opportunity was put in front her started at early age. “I was fortunate to grow up in a small (Iowa) town of 1,800 that just had an incredible can-do spirit.” She tried her hand at music, drama and every sport, even starting a golf team. “That instilled in me that you work 105%, but you also find time to play and to contribute to your community and those around you and to your family 110%. It doesn’t matter that the math doesn’t add up. It works,” she said.

Serving outside her practice wherever there’s a need

Colleagues said Dr. Linder could always be counted on to be there whenever anyone asked, whether it was serving the homeless at the Poverello House, sitting on the medical society’s CME committee, flying across the world to bring medicine to remote areas or to players on the sidelines of Fresno State games. For 25 years she had Dr. Hanson have worked to support Fresno State athletes and care for players injured at football games. Dr. Hanson praised the compassion she showed for players going through a rough time. And when Dr. Hanson needed another hand to help on mission trips to northern Thailand to work with remote hill tribe villagers, Dr. Linder readily volunteered.

Her father was the only physician in their tiny town so people depended on them. Their station wagon was the ambulance to take people to the hospital miles away. “Our doors were always open. Our keys were always under the mat in our cars if someone needed a car,” Dr. Linder described.

“I’ve seen so many sides of Jean,” Dr. Hanson said. “In a muddy, dirty village with no toilet taking care of people she can’t communicate well with I’ve seen her compassionate side and patient side. I’ve seen her rooting for the team. And I’ve seen how engaging she is on a personal level. She’s impacted so many people.”

That kind of generosity and service has been a hallmark of her time in Fresno – a place she never expected to stay. “I thought I was going to be here for a year and go off and serve on a Hopi Indian reservation in Arizona…this San Joaquin Valley is so unique of an environment and such a great place to live and practice medicine,” Dr. Linder said, adding she was drawn to the health challenges and the diversity of her patients.

She’s had huge impact on UCSF Fresno residents through the years said Dr. Monteleone. “Both Jean and I were part of a residency program where our professors who were downto-earth and would come and put their arm around you and tell us to take some time off and go to Yosemite, have a meal, take a hike and learn some things. That was the post-graduate institute and Yosemite Conference. Jean and I have been



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involved since we went the first time. This is Jean at her best.” Dr. Steinke said the Yosemite Conference, sponsored by the society and marking its 69th year this February, wouldn’t be what it is today without Dr. Linder’s efforts. “I wish she would continue to practice for a number of years because she really is an asset to our community. We have a real lack of primary care physicians and she fills a gap. And particularly a lack of women physicians that women can gravitate towards,” said Dr. Steinke, an obstetrician who has been referring patients back and forth to Dr. Linder for more than 35 years. The two doctors really bonded, however, serving together on the medical society board during what they both describe as a “tumultuous time.” Dr. Steinke, who was president when Dr. Linder was president elect, praised her service: “She was very stalwart and stuck to her principles and would not be moved when people were trying to cajole her to do things against her principles.”

community,” said Bonna Rogers-Neufeld, M.D., a radiologist who has worked with Dr. Hadcock 35 years. Oncologist Christopher Perkins, M.D., agreed, “Dr. Hadcock has always been intensely passionate about her work, intensely passionate about her patients and a forward thinker when it comes to how we can improve the quality of care.” Breast cancer was one of the first cancers that used this collaborative model with great success. “Treating breast cancer patients requires a team,” explained Dr. Perkins. “It’s not just one doctor. It requires a team from the mammographer, to the pathologist that reads the pathology report, to the medical oncologists, to the surgeon, to the radiation oncologist and the support team of nurses and social workers. So it really requires a village.” Dr. Hadcock humbly said she didn’t do it alone: “I didn’t just create something. I worked with excellent physicians to create something for the care of breast cancer patients. It’s been a total joy.”

Both joke that it may be the only time that the medical society’s president delivered the baby of the president elect of the medical society. “Dr. Steinke said to me after delivering my baby, ‘I don’t want to even see you step foot in your office for at least two weeks,’” Dr. Linder recounted. “And in the next breath he said, ‘But you have to be at the medical society meeting with me tomorrow night.’ The challenge that was facing the medical society at that time was really important and we were both there to make a difference. And there really were some things that needed to be done that night.”

Pioneering breast cancer care in Fresno

The big difference that Dr. Meg Hadcock has made in Fresno colleagues say has been creating the model of a weekly multi-disciplinary conference to tailor and coordinate care for each breast cancer patient. “She really had the first idea to do that. So many people have followed and built upon that in our

Winter 2020



She didn’t plan to become a breast surgeon or even a doctor. “I came from a little town in Montana and grew up not expecting to do medicine. It wasn’t in my family, but there must have been some little hungry part because I used to scrub in with my local GP in surgery with two other students from my high school class of 80.” Her women colleagues call her a role model and admire her professional tenacity and focus. “Meg Hadcock comes from very humble beginnings,” said Dr. Rogers-Neufeld. “She’s had to work her way, really slug her way through medicine back in a time in the 80s when it was very, very hard to be a woman in medicine, but especially in surgery.” Dr. Hadcock ascribes that tenacity to her upbringing: “When you grow up on the plains of Montana you have a certain grit about you and you have a certain durability to last through things.” After finishing her general surgery residence in Chicago, Dr. Hadcock and her husband, a vascular surgeon, came to Fresno in the mid-1980s. A year into her practice, she decided to specialize. “As more and more cases of breast cancer came to me my practice evolved,” she explained. “My last year of residency was when lumpectomies started being done. You can see how many things have changed in 35 years. It’s my joy to see we have the depth and breadth of multi-disciplinary care to provide an unparalleled way to care for women in the Valley with breast cancer. They can see a geneticist, they can see a nutritionist.” Since deciding to specialize, Dr. Hadcock has served in leadership on women’s health and cancer committees at two local hospitals and given extensive lectures to her colleagues and the public about early detection, screening, prevention and treatments of breast cancer. She’s continually educating other physicians how to enhance cancer care for their patients, promoting the development of lymphedema services and ways to prevent lymphedema by adjusting treatments. Simplifying and humanizing the medical process for patients from diagnosis through surgery and sometimes radiation and chemotherapy has been Dr. Hadcock’s aim for patients. She writes a blog to demystify one of the leading causes of death for women in America, covering topics like when to start mammogram screening, what “multi-disciplinary care” is exactly, and what the risk factors are for breast cancer. And she writes in a down-to-earth way, sometimes using cartoon characters and comical photos to illustrate points. Plastic Surgeon Carl Askren, M.D., F.A.C.S., said Dr. Hadcock



has continued to push for new ways to improve care, pointing to the ERAS (Enhanced Recovery After Surgery) protocols she implemented. The two have performed surgeries together over the years, he said. “We’re apparently known as the ‘A team’ at St. Agnes (Medical Center) and that’s really due to her. I’m kind of riding on her coat tails. She has impeccable patient care. I admire the compassion she has for patients and the way she advocates for them.” Her advocacy extends, Dr. Askren said, to “training pathologists to phone her first after examining tissue from her surgeries so she can promptly call the patient and family and let them know as soon as the information is hot off the press about what happened with surgery and what their outlook may be.” Dr. Hadcock cares for her patients as if they were her neighbors say colleagues. “Her notes and her record keeping are impeccable. Anything I wanted to know about the patient I could just look at the references and see,” said Dr. RogersNeufeld. “But it also wouldn’t be surprising to read the patient was an avid quilter or had just taken up golf or was stressed because they were a caregiver. She always tried to find little details to learn about the patient and their lives and what they were going through.” And it’s this personal connection that has really marked Dr. Hadcock’s career. “She’s done lots of surgeries and saved many lives and she’s done it with grace and dignity and preserving the body image of the patient,” Dr. Rogers-Neufeld said.

Tender heart, tears prompt start of kidney disease foundation

A local patient advocacy organization was born out of a deep sense of personal connection and empathy. As Janie Holland was crying a river of tears for her fellow patients on dialysis, Dr. Hemant Dhingra gently chided her to do something instead of feeling sorry for everyone. “Dr. Dhingra said you can either cry of think about what you can do,” she said. Holland explained that she wasn’t crying for herself, she was crying for others, “I knew I had a kidney waiting for me, but I wasn’t sure about everyone else.” During that first nearly 4-hour dialysis session, Holland said she watched the people in the room change over twice and realized there was a huge need in our region. “Kidney disease is an epidemic around the world. But the Central Valley has more kidney disease than other areas,” said

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Dr. Dhingra. “We have especially high incidence of diabetes and hypertension and obesity in the Central Valley which are precursors to kidney disease. And the Valley is so underserved, people don’t have the access to healthcare and when we see them they are fairly advanced.”

supporters. The foundation is funded primarily through donations and events, and is run by a board of local physicians, donors and patients. The foundation has plans over the next five years to start a mobile clinic to take education to underserved communities and bring awareness to the disease through school essay contests and scholarships, said Dr. Dhingra. “We want to be the leading force on education and support,” he added.

Holland saw all that during her time in the dialysis chair: “I thought some of these people look like they could use some help financially or other things like rides. No one in the room looked like they had hope in their eyes. I don’t have a kidney to give. But I knew I could help in some way.”

“I think it would be nice if we could find kidneys for everyone,” said Holland whose kidney disease was a result of a congenital condition. A longtime girlfriend readily offered up her kidney and in a three-way swap, a perfect donor kidney was found for Holland and others got kidneys too.

She took up Dr. Dhingra’s suggestion and created the Fresno Nephrology Kidney Foundation with the friend who eventually gave up a kidney to help her.

“In reality people aren’t so willing to give up a kidney,” Holland continued. “If people saw the real need and saw it firsthand, they would think differently.”

May Cha, executive director of the kidney foundation, outlined the mission as basically improving the lives of those who are on dialysis or who have received kidney transplants. Additionally the foundation aims to educate the community about the risk factors and the need for early screening and detection.

Tracy Zweig Associates

“The disease is so profound and really silent. By the time people show symptoms of the disease it’s too late,” Cha explained. “That is part of the challenge. And when you are told your kidneys are no longer working and you have to go on dialysis your world falls apart. We hope to hold people’s hand and carry them through what can really be a bleak time.” The foundation helps offer educational resources and partner new dialysis patients with mentors/

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Negotiating your First physician Employment contract Wednesday, January 29, 2020 6:00 PM

Cosmopolitan Tavern & Grill 625 O Street Fresno, CA 93721

Special Dinner Presentation A physician employment contract is one of the most important documents a doctor will sign in his or her career The contract will be the guiding document for the physicianâ&#x20AC;&#x2122;s tenure at whatever office or institution with which he/she will affiliate, and can set the expectations and parameters for a physician to achieve shareholder status in the future. For physicians joining groups and receiving income guarantees from hospitals, the employment agreement and other documents define the physicianâ&#x20AC;&#x2122;s rights and obligations in the three-way relationship. Its importance cannot be overemphasized and therefore care must be taken to ensure that the doctor is aware of the potential pitfalls and minefields which surround the employment agreement. It is with this in mind that the physician retain proper and experienced legal representation to assist in explaining all of the specifics of the particular contract and recommend changes and raise issues which are contained within it. We will discuss some of the common issues arising in such agreements and recommending the retention of an attorney to explain the specifics of each contract with the doctor.

Todd Wynkoop, J.D.


Todd Wynkoop earned his Juris Doctor degree from Georgetown University where he served as Editor in Chief, American Criminal Law Review. Prior to his present position with McCormick Barstow, LLC, Mr. Wynkoop served as Vice President of Development for a regional medical specialty development and construction firm where he dealt extensively in matters related to real estate, land use, entitlements, California Environmental Quality Act compliance and business transactions, including corporate formation syndication and private placement offerings. Mr. Wynkoop began his legal career as a Navy Judge Advocate, then practiced at an international law firm in Washington D.C. where he represented corporate clients in regulatory investigations, compliance reviews and complex civil litigation with a a particular emphasis on banking and healthcare law.





or call

559-224-4224 Winter 2020





Fresno Madera Medical Society over 137 years from 1883 to 2020 has had as many Presidents; I have met almost all FMMS Presidents since 1951. Allow me to mention first five of personal importance, now deceased:

1. Hugh Awtrey 1951; ophthalmologist, he interviewed me for Vanderbilt, despite the severe hearing loss that drove him from practice; he would be the most remote President I met.

2. Robb Smith, Sr. 1959; GP; I drove fifty years ago to Orange Cove, to discuss a career with him prior to applying to medical school; I recall also his son, Robb Jr., sadly lost in an MVA before he could also serve.

3. Theodore Steinberg, 1967; treated my myopia for 3 decades age 3 to 1983; he also served as a Temple Beth Israel President.

4. Hy Ginsburg, 1968; surgeon, cosigned my late mother’s office opening loan, later did my med school PE; he was also a TBI President; “If you need something done, get a busy person to do it!”

5. Jerome Radding, 1980; internist, my parents’ personal physician; I shall always recall him the day of the Challenger tragedy.

May I mention five still with us, three here tonight:

6. John Telles, 1989; cardiologist; interviewed by FMMS same day as me, John represents the high quality of Fresno area heart care.

7. Royden Steinke, 1992; ob-gyn; he has been a continuing mentor for my FMMS activity, and an informant on the Canadian health system.

8. Ranjit Rajpal, 2013; Madera cardiologist; he recruited me to FMMS Board, following a Woodward Park Walk with a Doc, to replace a physician who seemed unable to attend Board meetings.

9. Alan Aminian, 2015; allergist; now current St. Agnes Medical Center Staff Medical President; he redirected and straightened the course of FMMS at a troubled time.

10. Trilok Puniani, 2018; fellow neurologist & stroke program advocate, now moving his talents and experience from Kaiser Permanente to Community Regional Medical Center.

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I should mention also Drs. Snyder, Tostenson, Millar, Wilde, Packer, Quinn, Whitworth, Knapp, Barg, Rife, Beil, Nix, Chandler, Pardini, Lattin, Touton, O’Brien, Linder, Shishmanian, Sherrifs, Jones, Airola, Hadden, Chann, Ilic, Dhingra, and Vazquez. Of these Dr. Donald Knapp is our oldest living President, and of course, Dr. Jean Linder we shall honor tonight. In fact we honor THREE women for career achievement, on a night when we bring onto our Executive Board two women, Drs. Jennifer Davies as Secretary-Treasurer and Christina Maser as Vice President. As we mention women who lead, allow me to memorialize my most important medical mentor, likely in her time a pediatrician to several in this audience, my late mother, Dr. Nathalie Wolfe Birnbaum. Cancer cut her medical and community service career sadly far too short, but her loving imprint has guided me for forty-four further years. She would have been so pleased not to just see my installation, but equally happy to have seen our trio of career honorees, and our new officers. I know that tonight I lack the time to discuss either national or local medical issues policies, so many active and unresolved, for which we as physicians need to provide leadership. But I can provide my view as to why any and all medical doctors, both M.D. and D.O., need to become and continue as LEADERS. Perhaps some of you recall the line from “Fiddler On The Roof,” as Tevye the Milkman, prior to a rollicking Bock and Harnick song, bemoans to his bovines that: “It’s no sin to be poor, but it’s no great honor either!” I first heard that line on Broadway from the lips of the late Zero Mostel, when my parents took us New York City fifty-five years ago. Later I heard it locally when our beloved Cantor Michel Loring did the role for a Fresno theater. So, apologizing to Shalom Aleichem, let me bend Tevye’s plaint to remind us that we ALL need to lead: “It’s no sin to be a follower, but it’s no great honor either!” Look inside yourself, even if you are BUSY, and ask this critical question: “Am I a leader, and if so, how?” Then recall Dr. Ginsburg’s sage advice, “If you need something done, get a BUSY person to do it!” Hopefully your answer will be, as it continues to be for our active recent Presidents, Drs. Dhingra, Kelton and Vazquez, and our new President-Elect Dr. Don Gaede, “YES!” Yet on the other hand, if your answer is NO, stop and ask yourself: “What can I do, what should I do, to BECOME a leader, for the benefit of my fellow physicians, patients and community?” Most of you will know what you need to do, VOLUNTEER for at least one medical society committee, take on a special project, or consider for next year considering coming onto our Board of Governors. One of those might be the right first step, along what could be a long career of service, continuing into the California Medical Association. Such would follow the example of Dr. Ranjit Rajpal, who has become so active in CMA matters, or similarly, Dr. Virgil Airola, with now over twenty years of active, skillful and enthusiastic involvement in those legislative matters that impact how we practice medicine.



Perhaps you already know where you would start. If not, don’t worry, as our very capable FMMS Executive Director Nicole Butler can assist you, to find where your interests and the Society’s needs best mesh. Let me emphasize that while tonight’s joyful event is county-based, for the creative leadership we generate to gain traction towards positive action, we must operate at a statewide level. Membership concurrently in Fresno Madera Medical Society and the California Medical Association has never been just a random link or an accounting convenience. Instead such has always been intentional and proactive, in good measure to DEVELOP LEADERS, who can deal with statewide if not national issues impacting the practice of medicine and public health. What are the TRAITS and habits that leaders, need? Likely you can answer mentally as I outline ten of the more obvious concepts: Read, become informed; beyond our own much-improved quarterly Central Valley Physicians magazine, every month one needs to read periodicals, E-mail journals and even watch some selected television. Remember tomorrow is NOT a cut and paste of yesterday, unlike much of the Electronic Medical Record I read on hospital rounds. Listen to your patients; hear their concerns, including access, cost and quality of care; we need to lead for their benefit! Share your ideas with colleagues, in all areas; wisdom and new ideas steep like a good cup of tea, when the leaves of one person’s thought mix with the hot water of another’s responses. Do not fear to disagree; debate seasons ideas, just as in the Doctors’ Lounge, Sriracha sauce flavors our food. Attend meetings even when you are tired; absenteeism kills a quorum letting decisions lapse. Again I am here today in part because Dr. Rajpal asked to replace a Board member who never attended! Leave your personal political views at home when you attend Society meetings. Very few issues we need to consider as physicians follow any Republican-Democrat pattern. Consider community and statewide issues beyond or greater than those of personal financial gain, to support and promote the overall health of our entire nation. Cooperation with hospital entities has become essential; local medical societies need to concentrate upon any and all interface areas and activities; we should facilitate cooperation between different systems, and mitigate competition for competition’s sake. FINALLY, “organized medicine” is NOT an epithet! We should be proud to be FMMS and CMA members. To lead especially means that every year we must reconsider, reinvent and expand our role within our community and state. Beyond that, I appreciate the support and advice from my wife Kathy, as I face a year of Society activity, and at the same time, applaud her own activity in both the St. Agnes and Medical Society Alliances. To conclude, THANK YOU, not so much for the honor of becoming the 2020 President of Fresno Madera Medical Society, as for the opportunity to LEAD and in turn join others in leadership. Alan M. Birnbaum, M.D.

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FRESNO MADERA MEDICAL SOCIETY ELECTS NEW OFFICERS Fresno Madera Medical Society announced the appointment of new officers for 2020. The Board of Governors and the following new officers started their term beginning January 1.


PRESIDENT – Alan Birnbaum, MD Neurology, Spruce Multi-Specialty PRESIDENT-ELECT - Don Gaede, MD Internal and Vascular Medicine, Vein Pros Medical Group VICE PRESIDENT – Christine Maser, MD Surgery, CCFMG SECRETARY-TREASURER – Jennifer Davies, MD Otolaryngology-Head and Neck Surgery, CCENT PAST PRESIDENT – – Cesar Vazquez, MD Administrative Medicine, Optum360 BOARD OF GOVERNORS Janae Barker, DO- Camarena Health Pamela Kammen, MD- California Health Sciences University Brent Kane, MD- Community Cancer Institute Shamsuddin Khwaja, MD- Central California Heart and Lung Surgery John Moua, MD- CCFMG Ravi Rao, MD- CCare Jesus Rodriguez, MD- Kaiser Marina Roytman, MD- CCFMG Sonia Shah, MD- Kaiser Katayoon Shahinfar, MD- ABC Pediatrics Greg Simpson, MD, CCFMG Jai Uttam, MD- Community Anesthesia Group Jessica Vaughn, MD (Resident Board Member, Valley Children’s) CMA TRUSTEE: Ranjit Rajpal, MD

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Fresno Madera Medical Society’s incoming president Alan Birnbaum, MD is a Neurologist at Spruce Multi-Specialty and Director of the Stroke Program at Saint Agnes Medical Center. He has been a member of the medical society for 40 years and has served on the Board for the past 6 years. Dr. Birnbaum has been a rising leader within the Medical Society, having previous experience serving in all of the officer positions leading to the 2020 President. In 2020 FMMS will start the new year developing the organizations strategic plan that will provide a vision for the Society and define the business the organization will focus on for the coming years. The Joy of Medicine Program will expand on services to physicians in the valley. As your colleagues, the physician leadership at FMMS, understand the struggles physicians face on a daily basis. As you professional organization, FMMS is determined to help physicians in the Central Valley find happiness and fulfillment in your profession. Our goal is to engage physicians in the region in a long-term conversation that will help physicians recognize the signs of burnout build meaningful resiliency and help physicians thrive. We will continue our efforts to raise funds for the Fresno Madera Medical Society Scholarship Foundation. For over 50 years we have distributed scholarships to hundreds medical students from the Valley. In 2018 we granted $35,000 and this year that amount increased to over $45,000. Funding for those scholarships came from generous donations of physicians and from our annual fundraiser “Summer Meltdown.”   Our thriving Continue Medical Education program will continue to grow, offering additional educational seminars throughout the central Valley. In 2019 we provided over 60 CME hours covering topics in cardiac, nephrology, pain management and diabetes. We also hosted our second CME Cruise from Rome to Venice. The 2021 CME Cruise is in the planning phase now, and should be announced shortly. For the past four years the Medical Society has been a major stakeholder with the Central Valley Opioid Safety Coalition (CVOSC) with the goal of educating the medical community on improved methods for pain management and safe prescribing. In 2020 the Medical Society has been awarded a 3-year grant to continue these efforts therefore will continue working with the physicians and community in order to decrease deaths in the valley due to overdose.  Fresno Madera Medical Society will also continue to work with the California Medical Association (CMA) in 2020 to sustained malpractice protection law. MICRA will always be a fight for us as trial attorneys continue to try and pass a proposition that will radically change our practices and malpractice risk.  If you are not a member of the Medical Society and would like to join today you can by calling (559) 224-4224 ext 114 or visit www.fmms.org



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Winter 2020

California Medical Associationâ&#x20AC;&#x2122;s 2019 Legislative Wrap-Up In January, California witnessed something completely new. The swearing in of Governor Gavin Newson marked the first time in state history that a Democratic governor was succeeded by another Democratic governor. Political history is flush with examples of challenges facing the incumbent party attempting to hold on to statewide power. Typically, voters seize the opportunity for change by electing a leader of a different party. But this time, voters chose to move from a moderate Democrat (Jerry Brown) to a progressive Democrat (Gavin Newsom). The transition from Brown, who retained tight control of the stateâ&#x20AC;&#x2122;s budget and legislative process, to a first-time governor provided the legislature with an opportunity to reshape Californiaâ&#x20AC;&#x2122;s policy landscape.

Discussion, debate, dialogue and compromise were the overwhelming themes of the 2019 session. Since Governor Newsom did not have a public veto or signing history, his

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policy perspective was not yet set in stone. Legislators saw this as an opportunity to bring nearly every recycled and newly minted policy idea to the proverbial table.

The tone of the 2019 legislative session was overall one of unbridled optimism. Such political environments pose many risks and opportunities, with many competing interest groups jockeying to raise their priorities.

The California Medical Association (CMA) successfully collaborated with the legislature on proactive efforts to expand public health initiatives, reduce administrative burdens, increase physician reimbursements and strengthen the physician workforce. However, over the course of the legislative year, additional reactive efforts emerged as various stakeholders launched unmerited attacks against the profession.

CENTRAL VALLEY PHYSICIANS 431 cmadocs.org | Page

RELIEVING ADMINISTRATION BURDENS In January 2019, CMA was faced with an immediate crisis: flawed implementation of a new state law—intended to improve the security of physician prescription pads as a solution to the opioid crisis—left pharmacies unable to fill prescriptions and patients being refused necessary medications.

DEFEATED an attempt to dramatically increase

DEFEATED multiple attempts to publicly disclose

During the last weeks of the legislative session, the United Healthcare Workers Union went after the physician community and sought to shame physicians for the compensation they receive. CMA successfully stopped the union’s sponsored bill, AB 1404 (SANTIAGO), which would have required targeted physician groups to disclose the total compensation of their physician partners as a means of creating leverage in union contract negotiations. Such attacks don’t belong in the health care legislative space; they increase the difficulty of recruiting the quantity of physicians needed to serve patients and negatively impact efforts to constrain health care costs. In addition to the above, CMA took the following actions to either relieve existing administrative burdens or stop the creation of new burdens:

PASSED legislation to alleviate burdens associated with mandatory use of the CURES database

DEFEATED legislation to change prescription labeling requirements

DEFEATED legislation to require referral to alternative medicine practitioners prior to prescribing an opioid



physician reimbursement and contracted rates

This year’s budget contained $120 MILLION to support loan repayment programs for physicians and dentists (administered by Physicians for a Healthy California)

CMA quickly worked with the Newsom Administration, the California Department of Justice and the legislature to resolve the matter. The result was the swift approval and enactment of CMA-sponsored AB 149 (COOPER), which allowed patients to immediately start receiving their prescriptions and physicians to utilize their existing prescription pads until July 2021.

CMA also sponsored AB 744 (AGUIAR-CURRY) to revamp the rules regarding the payment of health care services provided via telehealth in order to increase access to care. Under existing law, physicians are incentivized to require patients to physically enter medical offices for services that could otherwise be delivered utilizing telehealth. Health plans sought to maintain existing law as a means of creating barriers to care. However, CMA worked with legislators from both rural and urban areas, showcasing the benefits of telehealth and the necessity for plans to pay for physician expertise regardless of the modality under which it is delivered. Despite the opposition of the health insurer lobby, the measure received only one “no” vote throughout the entire process.

physician licensing fees

ACCESS TO CARE In June, Governor Newsom signed his first state budget. The process for the 2019-2020 budget was dramatically different than prior years. Consistent with his campaign promises, Newsom prioritized health care. Not only did he expand health care insurance coverage, he was equally committed to funding access to care. This year’s budget contained: •

$2.2 BILLION for provider rate increases funded by

$120 MILLION to support loan repayment

$250 MILLION for the creation of a Value-Based

$150 MILLION for developmental and trauma



the Proposition 56 tobacco tax

programs for physicians and dentists (administered by Physicians for a Healthy California)

Payment Program within Medi-Cal screening supplemental payments

now includes all young adults aged 19-25, regardless of their immigration status

obtain health coverage

Winter 20202 cmadocs.org | Page

PUBLIC HEALTH AND POLICING THE PROFESSION The physician members of CMA hold sacred the trust patients and communities have in the medical profession. On countless occasions, the leaders of state, county and specialty societies wrestle with a variety of policy questions. And while there are many perspectives from which a policy can be debated, inevitably the question will be asked: how will this impact our patients and the trust the public places in physicians to look after their best interest and health? In 2015, CMA sponsored SENATOR RICHARD PAN, M.D.’S SB 277 to eliminate the personal belief exemption from the statutory requirements for childhood vaccinations.

The fight to enact SB 277 was fierce. Thousands of anti-vaxxers flooded the hallways of the Capitol. New security protocols were required for Senator Pan and CMA headquarters. The bill was heavily protested at the Capitol and in local districts; thousands of rabid anti-vaxxers spewed inflammatory rhetoric and threats of bodily harm. When Governor Jerry Brown signed that measure into law, Sacramento assumed the chapter on vaccines was closed.

The result of SB 277 was positive overall, and statewide vaccination rates improved. However, a number of geographic pockets of unvaccinated children emerged due to vaccine hesitancy and a few physicians willing to inappropriately monetize the moment by providing vaccine exemptions with questionable medical rationales. While some abuse was anticipated, the quantity of exemptions issued by a few physicians was alarming. On social media, parents openly discussed how to purchase exemptions, which physicians were open to such transactions and what medical symptoms to highlight in the visit. As such behavior persisted, Senator Pan and CMA faced a dilemma: how to respond to physicians whose actions threaten to erode public trust in the physician community?

CMA’s obligation to protect the integrity of the profession and the public trust in the physician community outweighed the fear of facing fierce, threatening opposition.

Similar courage was necessary on other fronts, including the legislature’s response to the sexual misconduct of gynecologist George Tyndall in student health centers at the University of Southern California. CMA ensured important due process protections for physicians remained, while not protecting the deplorable behavior of a specific physician. Navigating such troubling matters is complex, and CMA successfully preserved fundamental protections, while building our creditability with the legislature that CMA is an association that stands for quality physicians with the ability to self-police the profession. Courage to fight for patients, courage to fight for the betterment of the profession and courage to fight for the public’s health is why CMA is the most effective advocacy organization in the Golden State! In unity,

Janus L. Norman CMA Senior Vice President Centers for Government Relations and Political Operations For more details on the major bills that CMA followed this year, visit cmadocs.org/leg-wrap-2019. Subscribe to CMA’s free biweekly Newswire and stay informed on CMA’s legislative efforts and other issues critical to the practice of medicine at cmadocs.org/subscribe.

Courage! CMA and Dr. Pan chose to once again brave the turbulence and introduced legislation (SB 276) to increase vaccination rates by cracking down on inappropriate physician behavior. The reaction of the opposition exceeded our expectations. We knew there would be threats and a high number of anti-vaxxers protesting at the State Capitol and in the districts. We did not expect blood to be thrown onto the Senate floor from the gallery or parents forming chains to block the entrance of the Capitol.

Winter 2020

CENTRAL VALLEY PHYSICIANS 453 cmadocs.org | Page

Installation & Awards Gala

Public Health


The Social Context and Vulnerabilities that Challenge Health Care in the San Joaquin Valley of California BY ALYA AHMAD

Call it white privilege or health disparity, it appears to be two sides of the same coin. We used to consider ethnic or genetic variants as risk factors and prognostic to health conditions. Yet what has become more relevant is the Social Determinants of Health (SDH) as causal to disease prevalence and complexity to health care. This is was made more evident, in one of the many examples of care I encounter daily as a pediatric hospitalist in the San Joaquin Valley region. A 12-year-old Hispanic boy is admitted with a ruptured appendix and develops a complicated abscess with an extensive hospitalization due to his complication. Why? Did he have the genetic propensity for this adverse outcome? Was it because he was noncompliant with his antibiotic regimen? No. Rather it is the social construct and circumstance that hurdles his care. First, he had trouble getting to a hospital or



clinic. Both his parents are migrant workers with erratic long hours. Despite intense pain, he did not want to burden his family and further delays evaluation. In silent desperation, his mother is bounced around from clinic to emergency room and back to their rural based clinic then referred back to the same emergency room more than 20 miles from their home. By the time he is admitted 2 days later, he is profoundly ill. The surgeon is called in the middle of night for his emergent open surgical appendectomy and drainage. Even after his post-operative care while on broad spectrum intravenous antibiotics, his conditions persists with fevers, chills, and pain. Yet, he continues to deny his symptoms to avoid worrying his mother. His Spanish speaking mother never asserts or doubts why even despite surgery and drainage he was not healing per the usual expectation. Five days post-operative he requires another procedure for

Winter 2020

Farmersville and Madera in which community PHPEHUVUHYLHZHGSUHOLPLQDU\Ĺ&#x201E;QGLQJVDQG SURYLGHGDGGLWLRQDOUHĹ&#x201E;QHPHQWDQG Analysis of secondary data from multiple public sources and published reports.

Not only do many of the regionâ&#x20AC;&#x2122;s children live in areas of persistent poverty, they live in areas of concentrated â&#x20AC;˘ poverty. These are places where more than 30% of the residents have incomes below the FPL. The percentage of children living in concentrated poverty is higher in the San Joaquin Valley than the statewide average, and Regional Background: A Place of complex abscess drainage. What are the true determinants to Even more, California a large (Gross(Figure Domestic is still increasing in has some counties 2).Product) A survey his Contradictions complicated outcome? in terms of agriculture production in the country. When respondent from Fresno County described areas of The San Joaquin Valley is the economic heartland of you break it down by county, crop value in the valley ranks concentrated poverty as places â&#x20AC;&#x153;â&#x20AC;Śthat are completely state, agriculture, oil and landthe development In athe 2007 study,where â&#x20AC;&#x153;We Can Do Better-Improving Health of high. Yet, the valley with the largest crop production also impoverished, and within those sections the families theJHQHUDWHVLJQLĹ&#x201E;FDQWZHDOWK(LJKWRIWKHQLQH6DQ-RDTXLQ American People, The New England Journal of Medicine, paradoxically the highest poverty in theconcentrated state. Even face multiplehas barriers suchchild as food deserts, counties featuredtoinpremature this report were theValley proportional contributors death areamong the with stability,high poverty remains rampant in theand areaseconomic of high crime, poverty neighborhoods, top 10 agricultural producers in the state in terms of described, and behavioral and social patterns dominate: central valley. The racism. rates of concentrated poverty, more institutionalized Where families live where determine total crop value in 2014. And yet, seven of these counties their30% opportunities.â&#x20AC;? â&#x20AC;˘ 40% Behavioral Patters than of population are below the Federal Poverty Level appear in another â&#x20AC;&#x2DC;top 10â&#x20AC;&#x2122; list: a ranking of the California â&#x20AC;˘ 30% Genetic Predisposition (FPL), are greatest in SJV areas and are increasing over time: counties with the highest percentage of children in â&#x20AC;˘ 15% Social Circumstances Californiaâ&#x20AC;&#x2122;s San Joaquin Valley: A Region and Its Children Under Stress poverty (Figure 1). More than one out of three children â&#x20AC;˘ 10% Health Care Percentage of children under 18 living in areasJanuary of 2017 in the region lives below the Federal Poverty Level Figure 2. Percentage of children under 18 living in areas of â&#x20AC;˘ 5% Environmental Exposure concentrated poverty concentrated poverty (FPL), which was $24,008 for a family of four in 2014. In Fresno, Tulare and Kings counties, child poverty rates lobbyists, policymakers medical professionals; have50.0% remained more than 20% since 1980, putting them More recently there appears to and be a paradigm shift in how 45.0% â&#x20AC;˘ health Interviews withand 28County individuals from these â&#x20AC;&#x153;persistent povertyâ&#x20AC;? category.2 As described in Figure California Agricultural crop value in the care1.systems access isrankings: viewed. Health caresame delivery and child poverty, sectors; more40.0% detail below, researchers and community advocates plays a relatively minor2014 role in its impact to premature death. California â&#x20AC;˘ What Tengoverns meetings throughout the region that engaged have drawn connections between the dependence Fresno 35.0% individual behavior of the patient is a result of Cropmembers (billions) from diverse racial Child poverty (percent) community and on low-wage agricultural labor and poverty, while the Kern SDH, which are a value product of: 30.0% Kings Fresno, 38.9% (1) Tulare, $8.1 (1) in discussion activities to elicit ethnic groups their dominance of industrial interests in local and regional Madera â&#x20AC;˘ Barriers to appropriate health care 25.0% Kings, 38.5% (2) Kern, $7.6 (2) Merced, 38.1% (3) knowledge and opinions; politics has led to policies that further disadvantage theMariposa Fresno, $7.0 (3) â&#x20AC;˘ Economic instability 20.0% Tulare, 38.0% (4) Merced â&#x20AC;˘ Town hallenvironment meetings in Merced, Stockton, Kern, 33.6% (5) regionâ&#x20AC;&#x2122;s most vulnerable populations.3 Merced, $4.4 (5) â&#x20AC;˘ Unsafe San Joaquin 15.0% Madera, 30.7% (6) Stanislaus, $4.4 (6) Stanislaus Farmersville and Madera in which community Joaquin, $3.2 (7) â&#x20AC;˘San Poor health literacy and education 10.0% Tulare Kings, $2.5 (8) PHPEHUVUHYLHZHGSUHOLPLQDU\Ĺ&#x201E;QGLQJVDQG Not only do many of the regionâ&#x20AC;&#x2122;s children live in areas San Joaquin, 28.3% (9) â&#x20AC;˘ Limited social Madera, $2.3 (9) and community support 5.0% SURYLGHGDGGLWLRQDOUHĹ&#x201E;QHPHQWDQG of persistent poverty, they live in areas of concentrated â&#x20AC;˘ Food scarcity 0.0% â&#x20AC;˘ Analysis of secondary data from multiple public poverty. These are places than 30% of the 2006-10 2007-11 where 2008-12more 2009-13 2009-14 â&#x20AC;˘ Social discrimination and language barriers sources and published reports. residents have incomes below the FPL. The percentage These are just a few of the factors that part represent and Source: As cited on kidsdata.org, American Community Survey and Annie E. of children living in concentrated poverty is higher in 23.7% (16) Casey Foundation, KIDS COUNT Data Center (Jan. 2016) challenge patient care and health inequities. GeneticsStanislaus, is the San Joaquin Valley than the statewide average, and Regional Background: Place of Reports, Source:a California County Agricultural Commissionersâ&#x20AC;&#x2122; 2013relatively minimal risk factor toA disease condition. We cannot is still increasing inSan some counties A survey Californiaâ&#x20AC;&#x2122;s2015; SanAmerican Joaquin Valley: A Region and Its Children Under Stress One-third of all Joaquin Valley(Figure children2). (excluding Mariposa Survey one-year estimates of the percentage Contradictions just say that BlacksCommunity have a greater risk of heart disease, diabetes, Furthermore, poverty rates are highest among children of of children under 18 living in households with incomes below the Federal County, from for which dataCounty were notdescribed available) live in neighborhoods respondent Fresno areas of January 2017 The San Joaquin Valley is to theascertain economic heartland of hypertension etc.2014. We4 need the social context color. The ethnic gap in poverty is 10 to 35%. Poverty Level, where more than 30% residents are poor, twice the state concentrated poverty as of places â&#x20AC;&#x153;â&#x20AC;Śthat are completely the state, where agriculture, oil and land development of our diverse populations in order to address incidence of average. After forthose severalsections years, rates off or declined impoverished, andrising within theleveled families in many counties in 2014. Tulare Countychildren and San Joaquin County JHQHUDWHVLJQLĹ&#x201E;FDQWZHDOWK(LJKWRIWKHQLQH6DQ-RDTXLQ Eight of the SanitsJoaquin counties aregenetics among of the top chronic disease and effects. Valley It cannot be just Percentage of San Joaquin Valley under 6 in faceFigure multiple barriers such as food deserts, concentrated to approximately 310,000 people, two-thirds ofofthe them 6.exceptions, Percentage ofsignificant San Joaquin Valley children under 6 are the with increases in the percentage nine agricultural producers in the state, and seven these Valley counties featured in this report were among the immigrant, the refugee, the homeless, or impoverished poverty, race/ethnicity of high by crime, high poverty neighborhoods, and inof poverty, by race/ethnicity with incomes below People ofwith children living in areas of concentrated poverty between 2013 same counties are$34,999. in the topin10 counties the are highest child areas top 10 agricultural producers the state incolor terms ofoverpopulation that lead to the greater morbidity and mortality. institutionalized racism. Where families live determine and 2014. poverty rates. represented in these communities, where theycounties make up total value in 2014. And seven of these 60% As a crop pediatrician practicing in theyet, central valley, I see the their opportunities.â&#x20AC;? 65% of the population, compared to 54% of the regionâ&#x20AC;&#x2122;s appear in another â&#x20AC;&#x2DC;top 10â&#x20AC;&#x2122; list: ainranking thedelivery, California consequence of social complexity pediatricofcare 15 50% total population. counties with the highest percentage of children in daily. In a recent 2017 report by Center for Regional Change poverty 1). MoreCalifornia than oneSan out of three children and Pan(Figure Valley Institute, Joaquin Valley, 40% in the region lives below the Federal Poverty Level Limited Opportunities children areEconomic â&#x20AC;&#x153;living under stressâ&#x20AC;?. They are not only born under Figure 2. Percentage of children under 18 living in areas of concentrated poverty (FPL), which was $24,008 for a family of four in 2014. 30% duress but face lifelong barricades to better health, physical and Contribute to Poverty In Fresno, Tulare and Kings counties, child poverty rates mental. The occurrenceprocessing of child poverty level in counties of the to 50.0% The agriculture/food industry is expected 20% SJV are profound. The graph exhibits poverty levels of 28 tofor 38 45.0% be the primary employer in the San Joaquin Valley Figure 1. California County rankings: Agricultural crop value 16 2014 % inchild the valley: and poverty, 40.0% years to come, but other growing industries include 10% California Fresno 35.0% retail, health care services, hospitality and tourism, Kern value (billions) Child poverty (percent) educationCrop and training, business services, construction, 30.0% 0% Kings White LaĆ&#x;no Black Asian MulĆ&#x;racial All Fresno, 38.9% (1) Tulare, $8.1 (1) Madera VRFLDOVHUYLFHVWUDQVSRUWDWLRQDQGĹ&#x201E;QDQFLDOVHUYLFHV 25.0% Kings, 38.5% (2) Kern, $7.6 (2) Source: American Community Survey, 2010-14 Mariposa Fresno, $7.0 (3) 17 and real estate. Many of these industriesMerced, rely38.1% (3) 20.0% Tulare, 38.0% (4) Merced Kern, 33.6% (5) Merced, (5) Sanchildren Joaquin heavily on$4.4 low-wage and seasonal laborers, including 15.0% In the nine-county region, approximately 1 in 5 white Madera, 30.7% (6) Stanislaus, $4.4 (6) Stanislaus San Joaquin, $3.2 (7) under the age of 6 are poor. In comparison, the poverty rate for undocumented immigrants, who often face poor 10.0% Tulare Kings, $2.5 (8) Asian and multiracial children is 30%, doubles to 40% among San Joaquin, 28.3% (9) Madera, $2.3 (9) working conditions and workplace violations such as 5.0% Latino children, and triples to 60% for African American children. wage theft.18 0.0% 2006-10

As a result, poverty remains an acute problem in the 23.7% (16) Winter 2020 region, where 1 in 3 families with childrenStanislaus, under 18 19 Source: California County Agricultural Commissionersâ&#x20AC;&#x2122; have incomes below the FPL. PovertyReports, rates2013are even





Source: As cited on kidsdata.org, below 150% of the American FPL.20 Community Survey and Annie E. VALLEY Casey Foundation, KIDS COUNTCENTRAL Data Center (Jan. 2016) PHYSICIANS


Page 5

Californiaâ&#x20AC;&#x2122;s San Joaquin Valley: A Region and Its Children Under Stress January 2017

Joaquin Valley, it remains higher than the state Given the high rate of poverty in the San Joaquin Valley average (Figure 12). Since poverty is more prevalent and the central role that schools play in childrenâ&#x20AC;&#x2122;s among non-white populations, people of color are lives, the FRPM is an important source of nutrition for Despite economic potential, health care access and resources GLVSURSRUWLRQDWHO\DĹ&#x192;HFWHGE\IRRGLQVHFXULW\7KH children poornow families. TheAdverse percentage of children Scientificfrom literature highlights Childhood also operate at crisis levels. Rural communities with geographic United States Department of Agriculture (USDA) reports who are eligible for FRPM is much higher than the Californiaâ&#x20AC;&#x2122;s San Joaquin Valley: A Region and Its Children Under Stress Experience (ACE) in which the number of exposures of toxic obstacles face shortages in provider availability and health care that food insecurity nationwide is more than twice as statewide average in every county except Mariposa January 2017 stress and trauma: child abuse, neglect, domestic violence, systems. The same fertile communities of SJV producing the common in Latino (22.4%) and black (26.1%) households (Table 3),drug/ but the participation rate amongseparation, eligible and parental alcohol exposure, incarceration, food source of the nation, ironically have the larger limitations of compared to white households (10.5%). Of children who children is lower than it could be for lunch, breakfast or stress, is scored. The greater number of ACEâ&#x20AC;&#x2122;s, the greater access to food. Food scarcity, where food and especially healthy experience very low food security in the United States, and summer meals. An informant with expertise eryday to address thelimited problem. As expressed by a 26 local public degree of maladaptive physiological, neuro-architectural,on food is either or uncertain, remain above to 29% 42 40% have a foreign-born parent. These conditions supplemental programseffects noted reasons enge in KHDOWKRĹ&#x2020;FLDOIURP0HUFHG&RXQW\â&#x20AC;&#x153;There are strides immunological,food and epigenetic onthat the fetal and for low when compared to food shortage for whole of California at are 23%. UHĹ&#x2026;HFWHGLQWKH6DQ-RDTXLQ9DOOH\ participation in the The breakfast includehealth thatand not amilies that have been made over the last 20 years in regards to developing children. effect ofprogram ACEâ&#x20AC;&#x2122;s on mental all schools participate, awareness of the program is reducing poor air quality here in the valleyâ&#x20AC;Śbut we still chronic medical conditions, (asthma, diabetes, Cancer, heartlow, Estimated percentage of children under 18 living Figure 12. Estimated percentage of children under 18 living in DQGLWFDQEHGLĹ&#x2020;FXOWWRJHW\RXQJFKLOGUHQWRVFKRRO have ways to gowith and itâ&#x20AC;&#x2122;s still impacting ouraccess children.â&#x20AC;? disease, obesity, etc.) correlates exponentially with the number in ahouseholds limited or uncertain to households with limited or uncertain access to HDUO\HQRXJKIRUEUHDNIDVWVHUYHGEHIRUHVFKRRO(Ĺ&#x192;RUWV Ĺ&#x192;HFW Major sources of air pollution in the region include the of ACE exposures. Such that, if a child has more than 4 ACE adequate food, 2014 adequate food, 2014 toexposures increasethe participation include â&#x20AC;&#x153;innovative programs he petrochemical industry, agriculture-related sources risk of developing COPD (Chronic Obstructive such as breakfast in the classroom and second-chance 29% 29% 29% o (such as diesel irrigation pumps, dust from tilling and Pulmonary disease) as an adult increase by 260%; for 28% 27% breakfast. programs areIn great ways the to overcome 27% 27% 26% 26% nt SHVWLFLGHV DQGYHKLFOHWUDĹ&#x2020;FDORQJLWVKLJKYROXPH depressionThese it increases by 460%. California prevalence of some of the traditional barriers â&#x20AC;&#x201C; they increase awareness, transportation corridors for autos, California, 23%trucks and rail the number of ACE with 2 or more toxic level stress exposures GRQáWUHTXLUHDQDOWHUDWLRQRIGURSRĹ&#x192;RUEXVVFKHGXOHVDQG lines. Communities located near these sources face early in the childâ&#x20AC;&#x2122;s life is at 16.7%. Per kidsdata.org, a Population are seamlessly integrated into school day,â&#x20AC;? according disproportionately high exposure to air pollution. Reference Bureau, analysis of datathe from the National Survey toofthis informant. Childrenâ&#x20AC;&#x2122;s Health and the American Community Survey he (Mar. 2018) the incidence of parent reported of ACE scores Families that live in homes lacking adequate air med The summer program is evenFresno, less well-utilized, >2 for the SJVmeal counties is even higher: Tulare, Madera, conditioning and weatherization, coupled with close essed primarily because fewfrom schools participate. Additional and Merced cities range 17.9 to 19.3% of the population. proximity to pollution sources, are at the highest risks E\ barriers include lack of awareness, transportation to Such that 1 out of 5 children are exposed to toxic level stress. for air pollution-related illness. Asthma is one of the es distribution sites and age limits. Although all children The consequences of that same child becoming an adult with a most prevalent childhood diseases associated with HDUFK ages 0-18 are eligible to participate in summer chronic medical and or mental condition cannot be discounted. outdoor air pollution. (It is important to note that meals, this USDA-funded program does not provide asthma is also caused by a number of other causes RQ reimbursement for meals provided to parents, making Source: Feeding America, the Meal Gap. Health vulnerabilities in the valley are extreme and burden including indoor air Map quality, household pets and pests.) LWGLĹ&#x2020;FXOWIRUIDPLOLHVWRHDWWRJHWKHU,QVRPHSODFHV the limited health care systems servicing the community in Asthma children ages 1-17 the region The ratediagnoses of childhoodof food insecurity in the Sanin Joaquin Valley private contributions (e.g. from hospitals and health SJV. The current California governorâ&#x20AC;&#x2122;s administration has is higher than the state as a whole. In 2014, the highest rates of range from 7.7% to 32.5% compared to 15.4% for the l V\VWHPV KHOSĹ&#x201E;OOWKHJDS 50 Theas overall pollution which represents potential acknowledged this fact. Support to implement and maintain food insecurity were inburden, Fresno, Merced andthe Tulare counties, Due to the variation in state a whole (Figure 15).Kings, where 29% of children under 18 experienced limited or uncertain exposures to pollutants and adverse environmental conditions education and training programs with retention of how asthma is diagnosed, a better indicator of the scope Inmedical oor addition to government-funded supplemental access tobyfood, compared togreater 23% ofthan children statewide. caused pollutants, is the 8 to 10% in the Valley. providers in SJV is necessary. Specific funding allotments for of this problem may be in the number of emergency s and food programs, other resources such as food banks Notvisits surprisingly, asthmaamong and lungchildren. diseases inBy SJVthis districts are improving mental health, air quality, homelessness among many room for asthma metric, ed risk DQGHPHUJHQF\DLGSURJUDPVDWWHPSWWRĹ&#x201E;OOWKHJDSV highest in central California. other SDHâ&#x20AC;&#x2122;s in the region is vital. 8QWLODOOIDPLOLHVKDYHDGHTXDWHĹ&#x201E;QDQFLDOUHVRXUFHV but they cannot keep pace with demand, especially us Figure 15. Percentage of children diagnosed with asthma during economic downturns such as that caused by Poor air emergency relief programs like CalFresh (Californiaâ&#x20AC;&#x2122;s Percentage of children diagnosed with asthma Dr Nadine Burke-Harris, California first female Surgeon Supplemental Nutrition Assistance Program), the the continued drought.43 Additionally, donated food is WHVWR General, who recently visited the Valley, announced an ACEs Tulare Nutrition Program 10.3% for Women, Special Supplemental not always healthy or what families would choose for -term Aware campaign. The ACEs Aware initiative is a first-in-theInfants, and Children (WIC), Free7.7% and Reduced Price themselves. According to one community member, â&#x20AC;&#x153;Many U.S. Stanislaus nation statewide effort to screen for childhood trauma and school meals (FRPM), and food banks will remain times foods are expired and other times it is not expired zone treat the impacts of toxic stress. The bold goal of this stateSan Joaquin 22.9% a necessity. These programs help impoverished but it is not fresh fruit or produce. It includes processed HGWKH wide initiative is to reduce Adverse Childhood Experiences families put Merced food on the table, yet many people across food.â&#x20AC;? Some parents expressed similar dissatisfaction 32.5% and toxic stress by half in a single generation, and to launch a California who are eligible for these programs do not with food provided by schools, commenting that schools national movement to ensure everyone is ACEs Aware. ACEâ&#x20AC;&#x2122;s Mariposa n/a use them. The same holds true in the San Joaquin should serve healthier food and beverages, and take into ith Aware is not only a complete program with training and readily Valley. Community consideration the cultural backgrounds of their students. Maderamembers involved 11.5%in this research ies) available tools to implement screening, it is fully reimbursed in expressed that stigma prevents many people from 7KHVHVHQWLPHQWVUHĹ&#x2026;HFWWKHOLPLWHGFKRLFHVDYDLODEOHWR e levels Kings preventative pediatric care setting. 22.3% applying, as do restrictive eligibility criteria, lack of low-income parents who often rely on supplemental food e. XQGHUVWDQGLQJRIWKHHOLJLELOLW\FULWHULDDQGWKHGLĹ&#x2020;FXOW\ SURJUDPVDQGFDQáWDĹ&#x192;RUGWREX\WKHIUHVKSHVWLFLGHIUHH Kern 10.3% red as they pediatricians we can Identify exposed of applying. orStarting organicearly, food would prefer to feedkids their children. e Fresno 21.3% to ACEs through routine screenings and establish prevention o its programs in healthcare, schools and youth-serving Page 17 California 15.4% stice Source: California Health Interview Survey (2011-2012) f the Several counties have high rates of childhood asthma diagnoses, o relative to the state as a whole, including Merced, where 1 of â&#x20AC;&#x201C;a 50 CENTRAL VALLEY PHYSICIANS Winter 2020 3 children has received a diagnosis of asthma. In some San on as a Joaquin Valley counties, rates are lower than the statewide

By Dr Alya Ahmad MD FAAP Pediatric Hospitalist www.thecontextofcare.com

Schroeder, Steven MD, N Engl J Med 2007: 357:1221-1228, DOI: 10.10067/NEJMsa073350 Data Source: kidsdata.org, Population Reference Bureau, analysis of data from the National Survey of Children’s Health and the American Community Survey (Mar. 2018). “The Relationship of Adverse Childhood Experiences to Adult Health: Turning gold into lead” Felitti, VJ “Adverse Childhood Experiences and Chronic Obstructive Pulmonary Disease in Adults” Anda et al, Am J Prev Med. 2008 May; 34(5):396-403

References: “California’s San Joaquin Valley: A Regional and Its Children Under Stress”, Center for Regional Change and Pan Valley Institute, 2017 Data 2010-14 American Community Survey “We Can Do Better-Improving the Health of the American People”,

California’s San Joaquin Valley: A Region and Its Children Under Stress January 2017 California’s San Joaquin Valley: A Region and Its Children Under Stress January 2017 California’s San Joaquin Valley: A Region and Its Children Under Stress January 2017

organizations. In their critical and early developmental stages, resources allocation of health services can be provided. It is also imperative to know and stay engaged with our region’s leaders, telling our stories in health care, enlist our community partners, schools, regulatory agencies, and empower our patients and families to advocate for social and health equity.

Advanced Treatment for Major Depressive Disorder

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Phone (559) 433-1TMS

Winter 2020

Edgar Castillo-Armas, MD Psychiatrist

Transcranial Magnetic Stimulation (rTMS) delivers repetitive magnetic pulses to stimulate nerve cells in the area of the brain that controls mood. Rapid change in the magnetic field induces a current of sufficient amplitude and duration which in turn will excite the neurons.




Joy of Medicine




ttendance nearly doubled for the Joy of Medicine Summit during the second annual event December 6-7, 2019 and over 80 percent of physicians attending brought their families to enjoy the weekend at the magnificent Tenaya Lodge located just an hour north of Fresno in Fish Camp. Offering an idyllic winter setting, Tenaya Lodge boasts an abundance of activities and amenities to make for a perfect mountain getaway. Festivities kicked off Friday evening with the Fireside Family Social. The social was a special addition to this year’s conference including s’mores, hot chocolate and ice skating at the lodge. All ages and skill levels enjoyed time on the ice and there was enough snow from the previous storm to allow for snowman building and the occasional snowball exchange rink-side. A cooking demonstration on Saturday morning – Delicious, Healthy, Plant-based Breakfast with Rajiv Misquitta, MD - began the 4 hours of CME which also included Physician Health and Wellbeing: Practical Solutions (Misquitta), Joy and Meaning in Medicine: A Comprehensive Organizational Approach (Amanjot Sethi, MD), Joyful Together: Finding Ways to Enhance Joy In Relationships (Jeff Crane, PhD) and How to Find Joy In Your Current Practice When Joy Has A Different Look Than You Expected (Michael Allshouse, DO). The Joy of Medicine Summit is an annual event designed to engage physicians, residents and spouses in a conversation that will assist in recognizing the signs of burnout, offer strategies to build resilience and the means to thrive both professionally and personally. Physicians are encouraged to involve the entire family with activities over the weekend. In addition to the Fireside S’mores, a Kid’s Lunch and Activity provided fun for the younger participants while the physicians and spouses attended lunch with the keynote exploring building joy in relationships. Special activities to help promote wellbeing included chair massage courtesy of National Holistic Institute (Clovis) for both attendees and spouses and a guided Nature Walk to explore the beautiful mountain location.



Winter 2020

The Summit closed with a family dinner and gingerbread decorating. 10” Gingerbread men were the canvas and candy in all shapes, colors and sizes provided the medium for a little friendly and creative artistic competition for best of show for kids, teens and adults. Weather ranged from sunshine Friday afternoon to showers on Saturday with the highly anticipated snowfall finally making an appearance on Sunday morning adding the final missing element to a perfect winter wonderland setting for the weekend. While the Summit lasts for only one weekend, the Joy of Medicine program is available for physicians throughout the year. Any physician from Fresno or Madera County can take advantage of Resiliency Consultations or participate in Peer Groups and socials all year long. As your professional organization, FMMS is committed to helping physicians in the Central Valley find happiness and fulfillment in their profession. The vision of the Joy of Medicine is to empower our members to achieve the highest level of professional and personal well-being. By education and advocacy, we promote camaraderie, compassion and healthy lifestyle to produce work-life balance and systems change. FMMS recognizes the overwhelming stresses and immense workloads that physicians face today. Stress, anxiety, depression and grief are common, but they can be managed. Resiliency Consultations can provide relief, an increased ability to cope, healing and an opportunity for personal growth.

Participating in a Joy of Medicine Resiliency Consultation is completely confidential. No one is notified if a physician chooses to participate. Participating providers offer a wide range of appointment times that strive to accommodate the unique and busy schedules of physicians. Providers are paid by FMMS directly, discreetly and anonymously. Insurance will not be asked for or billed. Physicians can book a Resiliency Consultation by calling 559-323-8484 and identifying themselves as a participant in the Joy of Medicine. Physicians can also reconnect to their Joy of Medicine through Peer Groups. Peer Groups are small groups of physicians who gather around a common interest, activity or geographic area. Peer Groups meet monthly and offer the opportunity to connect with colleagues on a deeper level and explore the challenges and triumphs of practicing medicine. The groups are hosted by physicians eligible to participate in the Joy of Medicine. The host provides a location for the group to meet and the Joy of Medicine provides light refreshments and a wellness coach to help facilitate the conversation. If you are interested in starting a Peer Group, contact the Fresno Madera Medical Society at 559-224-4224. The Joy of Medicine committee is chaired by Don Yoshimura, MD and the program receives financial support from Cooperative of American Physicians, Community Medical Centers, Fresno Madera Medical Society Foundation, NorCal Mutual, Fresno Madera Medical Society Alliance and Saint Agnes Medical Center.

FMMS sponsors up to four annual sessions with approved and vetted providers, confidentially, conveniently and free to physicians living and practicing in Fresno or Madera County.

Winter 2020



I WOULD LIKE TO GIVE A BIG THANK YOU to all those who helped organize this year’s Joy of Medicine Summit at Tenaya Lodge. I learned a lot of great things at the Summit; let me just mention 6 of them: We physicians all need to learn how to cook like Rajiv Misquitta MD. To introduce his talk on Saturday morning, Dr. Misquitta made all of us a delicious breakfast of curried tofu, greens, onions, and crackers. He advocates a vegan diet as the best way to avoid heart disease. He should know—10 years ago he suffered a heart attack, followed 4 months later by cardiac bypass surgery. He determined that this was not going to happen again, and embarked on a journey that led him to embrace a plant-based diet. And not just any plants. French fries, he points out, are plant-based; so are Twinkies. To avoid coronary disease, he recommends a low-fat vegan diet, and along with his wife has written a book entitled Health Heart, Healthy Planet (available on Amazon). We doctors preach to our patients about healthy diets and staying away from fast foods, but if they don’t know how to cook, that advice may fall on deaf ears. Bon Appetit, Dr. Misquitta! Coloring with crayons isn’t just for kids; it can be both fun and revealing. Dr. Amanjot Sethi, urologist and Director of Wellness Operations at the Permanente Medical Group in Walnut Creek, asked all of us to pick up some crayons and draw a picture (more honestly, a caricature) of the people who influenced us on the path of becoming a physician. Christina Maser MD, medical director of University Surgical Associates, drew a picture of her mother in the OR. Her mother was an OR nurse who occasionally brought her daughter to work to see what mom was up to. So Christina was quite comfortable in that environment before she ever became a surgeon. I crayoned 2 pictures; one of my uncle Elmer Gaede who practiced family medicine in the Kenai Peninsula of Alaska, and one of my great uncle Menno Gaede who practiced as a GP in Reedley for many years. When I turned 10 or 11, my parents said to me, “Why don’t you become a doctor like Uncle Elmer or Uncle Menno?” Those uncles were already my heroes, so that decision wasn’t hard for me to make. Finding joy in medicine is not just about the absence of burnout; it’s more about finding meaning and purpose in your work. Meaning is enhanced by something increasingly rare in our busy lives: connecting with our colleagues. So Misquitta and Sethi have been encouraging the return of the physician lounge, as well as facilitating monthly peer groups where physicians can share their stresses and successes. To connect with your peers, try taking a hike. Dr. Wenbiao



Zhang has an office a stone’s throw from my office, but we haven’t had a chance to talk for over 3 years. It was a great pleasure to go on a guided nature walk with him and his wife, and catch up with each other along the trail. We hiked along with a number of other hardy docs and their families, even though some rain sent several of our group back to the lodge. For those of us that persevered, the hike was well worth the effort and a great chance to re-connect with each other and with nature. We have our own Patch Adams right here in Fresno--his name is Michael Allshouse, DO. He is head of pediatric surgery at Valley Children’s Hospital, and has a wonderful way of putting a smile on your face, whether he’s talking to doctors or speaking with his young patients. He showed us a photo of an autistic patient of his who can’t speak a word, but is able to text on his smartphone that Dr. Allshouse is his favorite doctor. Allshouse has a big happy family of 5 children which includes a son with Down syndrome and an adopted son with the same condition. He reminds doctors and parents that “You don’t have a Down syndrome kid; you have a child who happens to have Down syndrome.” And he points out that kids with Down syndrome are possibly the happiest humans on this planet. Attend “Lunch with Spouses” even if your spouse can’t be with you. I experienced some trepidation about attending this event as I looked around and saw all the couples. But at my age, I tend to ignore trepidations. The lunch was delicious, but then came the hard part. The speaker (Jeff Crane LMFTI) gave some opening remarks, and then asked us all to turn to our spouses and discuss who in our relationship was the Pursuer, and who was the Avoider. I heard a voice behind me say, “Well, since we’re both here alone, maybe we can just discuss this between ourselves.” The friendly voice came from the chair of the event, Don Yoshimura. As Don and I shared a bit about our marriages, we found out that not only do he and I share the same first name, we are both part of that select 1% of people that have perfect marriages. I jest. We did learn from Mr. Crane that after working a full day at the office and being super-empathetic to our patients, it’s ok if our empathy tank if on empty by the time we get home. We just need to be present and connected with our wives as they share their day with us. I think I can do that. Don Gaede, M.D.

Winter 2020

In Memoriam

In Memoriam RICHARD H. THORP, M.D.

06/19/1937 – 10/27/2019 Richard H. Thorp, M.D. was born in Boston, MA, on June 19, 1934 to Dr. And Mrs. Edward G. Thorp of Melrose, MA. Dick passed away in his sleep on October 27, 2019 in Fresno, CA. He is survived by his loving wife, of 62 years, Roz; his sister Martha Brightman; his daughter Rosamond Thorp Herling and her daughters Rosamond, Caroline, and Elizabeth; his son Chip and his wife Cheryl; his son Edward; and his son David, wife Karin, and their sons Liam and Landon. Dr. Thorp was a member of Fresno Madera Medical Society for 45 years.


James Edward Walters M.D., long time Madera Physician and Surgeon, passed away on Thursday, October 17, 2019 at Madera Community Hospital. Dr. Walters was born in 1937 in New York City to James and Geraldine Walters. A strong value of education was instilled by his parents during his early years. He received his undergraduate degree at Iona College in New Rochelle, New York and graduated with honors from Howard University College of Medicine in 1964.Dr. Walters later completed his Residency in Cleveland, Ohio. After Residency he moved to the Central Valley where he began his medical career at Valley Medical Center. A few years later, he began working at the former Madera County Hospital, which later merged with Dearborn Hospital to become Madera Community Hospital at the new facility on Almond Avenue. Dr. Walters was an integral part of the medical community here in Madera with his General Surgery and Family Practice. He volunteered his time at the Madera High School Coyote football games and spent time facilitating sports physicals for Madera High School athletes. His medical career spanned nearly 50 years before his retirement.

Winter 2020

He met and later married Maureen Urrutia in 1972 and they have made Madera their home where Doctor was a member of St. Joachim’s Catholic Church and a former member of the Knights of Columbus Council of the Parish, as well as a member of the Young Men’s Institute. In the winter seasons he was an avid snow skier enjoying the thrill of the mountain slopes of the Sierras. His love of skiing was a dominating passion and a source of joy. In addition to his parents, Doctor was preceded in death by a sister Barbara Regina Walters. He is survived by his wife of 46 years Maureen Walters of Madera, his daughter Tiffany Walters of Palo Alto, CA, his brothers Clarence Jones of Delaware and Charles Jones and his wife Jean of Florida and by their children. Dr. Walters graduated in the Class of 1964 from the Howard University College of Medicine. Dr. Walters was a member of Fresno Madera Medical Society for 47 years.



When you’re confident you’ve chosen the right hospital for your maternity care, you’re free to think of just about anything. It’s why so many women choose Saint Agnes Medical Center. Along with all-private rooms, we partner with Valley Children’s Healthcare to give you and your baby access to a Level III NICU and one of the top maternal fetal medicine programs around. As our surgeons’ skilled hands control innovative treatments in our Visit www.samc.com to learn how of with our highest goal: operating rooms, Saint Agnes stayspeace in touch mind is just one of the many things we deliver. protecting every blessing that walks through our doors.

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