Central Valley Physicains - Fall 2016

Fall 2016

MEDICINE IN THE MILITARY Propostion 56 Doctors on a Mission Summer Meltdown MACRA: Medicare Payment Reform Being Mortal: What is a Physician’s Role?

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CENTRAL VALLEY PHYSICIANS

Fall 2016

VOLUME 1, NUMBER 4 • FALL 2016

{DEPARTMENTS}

{FEATURES}

20 23 24 31 34

STOP THE BLEED

Reduce Bleeding Deaths

IT’S TIME FOR ACTION

43 SUMMER MELTDOWN 16 IN THE NEWS

New faces and Announcements

34 OBAMACARE

Achieving Consensus

Cost of the Epi-Pen auto-injector

36 MACRA

MEDICINE IN THE MILITARY

40 PUBLIC HEALTH UPDATE:

Fresno doctors U.S. Army veterans

PROPOSITION 56

Raise Tobacco Tax to Save Lives

DOCTORS ON A MISSION

Doctors care beyond our farmlands

Medicare Payment Reforms Painkiller Overdose Epidemic

42 BEING MORTAL

What is the Physician’s Role?

45 CARDIOVASCULAR UPDATE 36th Annual

49 IN MEMORIAM

SUMMER ISSUE CORRECTIONS: The Brave New World of the New-to-Practice Physician had a typo on page 22 – When referencing the Harvard Business Review “Welcome to the Experience Economy” the author is James H. Gilmore In the 2016 Pictorial Directory Supplement Directory pages the photo for Dr. Shankerman was incorrect and will be updated in the 2017 Directory.

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Letter From The Executive Director

SUMMER CHECK MAMMOGRAM CHECK MEMBERSHIP CHECK First and foremost, I wanted to extend a heartfelt thank you to all who attended or contributed in any way to the success of our Summer Meltdown event. I thought the evening was a huge success for the Fresno Madera Medical Society and the Fresno Madera Medical Society Scholarship NICOLE BUTLER Foundation and it looked like everyone had a fantastic time.

The Board of Governors for both the society and foundation agreed that Summer Meltdown will come back next year.

As we get closer to the end of the year the 2017 membership season will begin. The medical society board and staff will be reaching out to doctors for renewals and work towards growing new membership. We are currently offering a “15 for 12” promotion that allows physicians to join the medical society and get 15 months of benefits for the cost of 12. That is a great savings, and will allow members to start utilizing benefits right away.

On Monday, October 17, 2016 we are having a general society meeting at Vino & Friends. This meeting is for all members to get an update of the state of the medical society, review the 2017 slate for Board of Governors, House of Delegates (HOD), and nomination committee positions. During this meeting there will be an opportunity to provide nominations from the floor on any open position board position, committee or HOD seat with the organization. I would encourage everyone to come and bring a potential member. The event starts at 6 pm and you will need to register.

California Medical Association continues to lead the Prop 56 coalition with support of Fresno Madera Medical Society as well as dentists, health plans, labor unions, hospitals, and non-profit health advocate organizations such as the American Heart Association, American Lung Association, and the American Cancer Society to name a few. The California Healthcare, Research and Prevention Tobacco Tax Act of 2016 will increase California’s cigarette tax by $2 per pack, and an equivalent increase will be applied to products containing nicotine derived from tobacco, including e-cigarettes. The majority of funds generated by this tobacco tax will be used to improve existing health care programs, prevent smoking, and fund research into cancer and other tobacco-related diseases.

Prop 56 will not only save lives and reduce youth smoking, but will also generate much-needed revenue for smoking prevention programs, medical research on tobacco-related diseases, and various health care programs, including Medi-Cal. The reason this is so important to Fresno County is that our Medi-cal rates are currently the lowest in the state, therefore restricting healthcare access for the largest Medi-cal recipients: kids. Tobacco remains a deadly, costly problem in California. Tobacco kills 40,000 Californians per year and costs California taxpayers $3.58 billion. That’s $413 per family. Nearly 17,000 kids will get hooked on tobacco this year alone – one-third of them will ultimately die from tobacco-related disease.

Please share this information with your staff, patients, friends, and family, and encourage them all to vote YES on Prop 56.

Last item;, as you know October is Breast Cancer Awareness. Kindly remind your patients to do selfexams and get mammograms. Next April will mark three years cancer-free for me and I am thankful for the fantastic team of doctors, staff, and hospitals that provided my care and continue to monitor my health.

Thank you,

PRESIDENT Hemant Dhingra, MD PRESIDENT-ELECT Alan Kelton, MD VICE PRESIDENT Trilok Puniani, MD SECRETARY-TREASURER Cesar A. Vazquez, MD PAST-PRESIDENT A.M. Aminian, MD BOARD OF GOVERNORS Christine Almon, MD, Alan Birnbaum, MD, Jennifer Davies, MD, Joseph Duflot, MD, William Ebbeling, MD, Don Gaede, MD, David Hadden, MD, Christina Maser, MD, Ranjit Rajpal, MD, Oscar Sablan, MD, Katayoon Shahinfar, MD, Roydon Steinke, MD, Jessica Lee, MD CENTRAL VALLEY PHYSICIANS EDITOR Alan Birnbaum, MD MANAGING EDITORS Nicole Butler and Millie Thao EDITORIAL COMMITTEE Alan Birnbaum, MD - Chair, Don Gaede, MD - Associate Editor, Virgil Airola, MD, Hemant Dhingra, MD, Roydon Steinke, MD, Cesar Vazquez, MD, Nicole Butler, Millie Thao CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Alan Birnbaum, MD, Don Gaede, MD, Ravi Rao, MD, Alex Sherriffs, MD, Roydon Steinke, MD, Jennifer Seita, Millie Thao CONTRIBUTING PHOTOGRAPHERS Nicole Butler, Kelley Nelson CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO: Central Valley Physicians 1040 E. Herndon Ave., Suite 101 Fresno, CA 93720 Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY OFFICE HOURS: Monday through Friday 9 a.m. to 5 p.m.

Closed from 12 to 1 p.m.

MEDICAL SOCIETY STAFF Executive Director Nicole Butler Director, Communications and Physician Relations Millie Thao CMA HOUSE OF DELEGATES REPRESENTATIVES Hemant Dhingra, MD*, A.M. Aminian, MD, Patrick Golden, MD, Brent Kane, MD, Ranjit Rajpal, MD, Oscar Sablan, MD, Roydon Steinke, MD, Toussaint Streat, MD ALTERNATES Alan Kelton, MD*, Naeem Akhtar, MD, Praveen Buddiga, MD, William Carveth, MD, Trilok Puniani, MD, Swarnpal Sekhon, MD *Automatic Delegate

Nicole Butler Executive Director Fresno Madera Medical Society

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Fall 2016

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

Forging the Future for California Medicine

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

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If judged by the number of medical school graduates per state resident, California would only get a D+ in undergraduate medical education.

Our state similarly needs to expand postgraduate medical education. Local physicians should become leaders in making our state self-sufficient in educating new providers.

75% of our physicians, medical and osteopathic, get their basic medical education somewhere other than California. Our state has benefitted from an inf lux of excellent physicians with part or all of their education provided elsewhere. Look no farther than the President of your Medical Society, Hemant Dhingra, M.D., providing superior renal care, or your immediate past President, Alan Aminian, M.D., helping patients combat Valley allergies.

Californians depend on the rest of the United States--really the rest of the world--to turn college graduates into graduating senior medical students ready to enter

a residency. With the pending opening of a private Manipal osteopathic medical college in 2018, and graduating students ready to enter residencies by mid-2022, the Central Valley will positively impact this deficiency.

Already the two California osteopathic schools, Touro with 134 D.O. students and Western with 224, substantially supplement the 1080 M.D. students graduating each year from state-run and private medical schools. The expected addition of about 150 local graduates would increase D.O. graduates to 47% of the M.D. graduate numbers. That would qualify 1,588 new physicians to enter primary care and specialty residencies Yet that would be barely HALF of the new doctors a state of 38 million yearly needs to deal with physician career reorientation, doctor retirement, or the sudden and premature death of actively practicing valuable physicians, such as we have recently

Fall 2016

experienced with the loss of Drs. Charles Smith and we now have and surely will in the future, support from Rabindra Kundu. . local doctors then the highest hurdle of all, adequate The revised ratio of around 32% of students legislative funding. graduating as D.O.’s differs markedly from our current Similarly we need to support the burgeoning ratio of about 4.4% of all practicing physicians educated emergence of the “mid-level” practitioner, those who as D.O.’s. With 55 to 60% of D.O.’s choosing primary become nurse practitioners, building on the core care, we should see a favorable impact on the relative education of an R.N., and physicians’ assistants. Very numbers of physicians providing front-line care. While clearly, not all medical care requires an M.D. or a D.O. the number of physicians overall in California comes Much of the attention patients need can be codified close to meeting statewide needs, Central California into treatment algorithms, where an N.P. or a P.A. can suffers from medical maldistribution, producing a supplement and expand care, while still recognizing the negative impact on access to timely care. As well all exceptions that require direct attention by a physician. know, quality care requires a timely appointment. Care All of us see such individuals, from the Emergency now prevents emergency or even fruitless care in the Department to the primary care clinic to the largest future. specialty clinic, providing care that allows physicians to The process of taking a graduating college senior and serve a larger population. turning them into a practicing physician seven to ten At Fresno’s largest orthopedic clinic, Sierra Pacific years later requires another step, postgraduate years Orthopedics, EACH orthopedist has a dedicated P.A. starting with internship, then residency and frequently fellowship.

As we look at new medical doctors, osteopathic doctors and midSuffice it to say that parallel local interest has emerged level practitioners to improve access to care, we need to also look in creating new residency at new models of delivery, such as “tele-health.” programs, including at private hospitals that have in years past have been only minimally active in this area. Local physicians or N.P. Similarly several of my colleagues in neurology need to support such efforts at all levels, including when utilize a P.A., one in a practice that emphasizes their talents allow becoming instructors and assistant management of headache, another in a setting where clinical professors. Just as we should support expanding close follow-up is mandated by field trials of new undergraduate medical education in California, so must medications. My own private practice by contrast we support broader postgraduate education. probably underutilizes P.A.s or N.P.s, but that may be Providing political support has parallel and powerful an artifact of not planning to have enough space to importance. For years, there has been talk of the accommodate more than our one physician’s assistant.

University of California opening another medical Beyond that, I greatly appreciate my hospital, St. Agnes school, most likely affiliated with U.C. Merced.

Medical Center, for providing a highly skilled and Wouldn’t it be wonderful if that campus when it opens personable Family Nurse Practitioner, Ana Henriques, was actually in Fresno? Might our Governor and R.N., F.N.P., to greatly supplement the time I spend legislators consider that? There is precedent for that directing its Primary Stroke Center program. Surely we since the medical campus for U.C. Berkeley has always need to support any and all programs to train similar been U.C. San Francisco, nearly an hour away in The effective and empathetic mid-level providers.

City, not to mention its local outreach to Fresno with As we look at new medical doctors, osteopathic close affiliation to Community Regional Medical doctors and mid-level practitioners to improve access Center. to care, we need to also look at new models of delivery, Might there be TWO medical schools in one city? Of such as “tele-health.” At Kaiser Permanente locally, my course! Several cities in the Eastern United States have stroke program director counterpart Trilok Puniani, that. Issues include adequate patient numbers, which M.D., incidentally Vice President of our Medical

Fall 2016

CENTRAL VALLEY PHYSICIANS

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

Society, has helped his hospital become part of a twenty-hospital network providing teleneurology for emergent stroke cases, allowing rapid intervention from arrival at the Emergency Department door to the start of clot-busting infusions of tPA in as little as half an hour.

Beyond that, with so much continuing care not requiring direct patient contact, revisit care can expand in particular to video-linked telehealth, where quality will not be compromised by the doctor staying in his or her office and the patient in his or her home. (And with that, as I write, I have a request for a telephone conference with a patient, rather than a revisit; someone whose

frequent migraine has responded to the drug prescribed at the initial Consultation, but the patient’s inf lexible work schedule won’t allow them to make a midafternoon visit!)

Perhaps most of us should have two sessions a week for such contacts facilitated by the widely available Skype or Facetime.

Alas, lagging behind is the reimbursement mechanism for what is otherwise medical care of significant and measurable value.

Assuming we can break down any barriers, financial and otherwise, many of us could be devoting one morning and one afternoon of our office hours to such care.

One further but critical

component to the healthcare person power puzzle in California remains making this state a financially attractive place to practice. It doesn’t matter how many students we graduate with M.D. or D.O. degrees, or how many graduates then finish residencies in primary care or further fellowships in specialty care, if these doctors emerge into a milieu where every third potential patient, due to coverage through the Medi-Cal program, represents a moneylosing proposition to hospitals, multispecialty clinics and private small group offices.

To recapitulate my thoughts from the Summer 2106 issue of Central Valley Physicians, we need to strongly support Proposition 56, tithing tobacco to recover its often hidden health costs. This well-written INC. measure will help underwrite usefully A REGISTRY & PLACEMENT FIRM more equitable levels of reimbursement and with that, expand meaningful access to Nurse Practitioners ~ Physician Assistants quality healthcare.

Today, you are the doctor. Tomorrow, you or your family will be the patient. Make sure that the resources, we all need, will be there.

Become an advocate for your patients and the future of truly quality Locum Tenens ~ Permanent Placement care in California.

Support the expansion Voice: 800-919-9141 or 805-641-9141 of medical education FAX: 805-641-9143 at all levels, and the widening of medical tzweig@tracyzweig.com care delivery options. www.tracyzweig.com

Tracy Zweig Associates Physicians

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Fall 2016

Fall 2016

CENTRAL VALLEY PHYSICIANS

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President Report > Hemant Dhingra, MD

The Year, so far

ABOUT THE AUTHOR ­ ­ ABOUT THE AUTHOR Hemant Dhingra, MD, nephrologist, is Dr. Ronald Morton is a board-certified President and CEO ofwho Thepracticed Nephrology ophthalmologist in Medical Group, Inc. Dr. Dhingra is Bakersfield for over 30 years andPresident is of Fresno Madera Medical Society and a past president of the Kern Countyan Assistant Clinical Professor of Medicine at Medical Society.

He is currently retired UCSF andFresno. enjoys traveling with his wife of 46 years, Ingrid.

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The year, so far has been incredible and very productive. The society has seen very robust growth in the membership. We were able to add 110 new members this year and this was possible by the constant effort by board and staff of Fresno Madera Medical Society to generate enough enthusiasm and add value to membership. This was one of the key goals when I took office as president in January 2016.

I welcome the new members and assure them they will take a pride in the membership and hope they encourage their colleagues and friends to join the membership.

The health industry is going through a lot of changes and to keep our membership upto-date we organized the CEO forum earlier this year which was attended by the chief executive officers of area hospitals and chief

executive officer of California Medical Association. This was very well attended and provided useful information. The Medical society is constantly engaged in educating physicians and their support staff to meet the daily challenges in their practices. This is ref lected by organizing medical managers’ meetings, billing and coding classes on regular basis.

The society also provides the CMA resources for legal questions, billing disputes and helping to collect the aging receivables. This is a free of cost resource available to all the members. I will encourage all the members to use this resource when needed.

One of the missions is to provide the continued education to membership. The medical society has done multiple events this year starting with well

Fall 2016

attended Yosemite post graduate institute, followed by Nephrology update for primary care and few one hour focused programs. There is an upcoming Cardiology update in Madera in October. Altogether, society will provide to close to 30 hrs of free medical education credits to all members, a great value for membership. I encourage all members to use this opportunity. We are planning in July 2017 Alaska cruise with CME program.

We will be announcing the dates very soon.

The Summer Meltdown event with ZDoggMD was attended by six hundred people and was huge success and a very good attempt to involve the members, nonmembers and general community. I want to thank the support of our board and special thanks to Nicole Butler, the executive director for the medical society.

We have actively pursued the legislative agenda for

the society by helping one of our own Dr Arambula to be elected as assembly man. He will be our voice in Sacramento and will protect our interest.

We are planning to update all physicians regarding MIPS and MACRA. This is a complex issue and will affect solo and small practices in future. There will be some webinars and we will use the CMA resources and will try to have an expert to come and address the membership.

My term is coming to an end and there will be installation of new officers in November. The year went fairly fast and I tried my best to keep my promise to enhance the membership. It was honor and privilege to serve you as a president of the society.

Fresno Madera Medical Society

2016 Installation & Awards Gala

Save the Date Friday, November 18, 2016 - 6 pm Fort Washington Golf & Country Club Award Winners Announced & Installation of Alan Kelton, MD

Fall 2016

CENTRAL VALLEY PHYSICIANS

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melt Summer

ltdown Fall 2016

CENTRAL VALLEY PHYSICIANS

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LOCATION & SCOPE OF PRACTICE Understand that telemedicine practice laws vary from state to state.

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Protect PHI with systems specifically designed for the unique security and encryption needs of telemedicine rather than less secure consumer systems.

As with face-to-face encounters, ensure that both the patient and physician are in private rooms to reduce the chances of inadvertent disclosure of PHI.

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In The News

IN THE

NEWS

Providing physicians, office staff, and healthcare executives with relevant and up-to-date information

• FRESNO • Saint Agnes names new Chief Medical Officer W. Eugene Egerton, MD, has been named Saint Agnes Medical Center’s Chief Medical Officer.

Dr. Egerton has served in many health care executive leadership roles and led a W. Eugene Egerton, MD distinguished career in the U.S. Army Medical Command, achieving the rank of colonel before retiring after 23 years of service. He comes to Saint Agnes from Trinity Transition Consultants, LLC, in Maryland, serving as health care executive, independent consultant and chief executive. Dr. Egerton has also held the title of Chief Medical Officer for University of Maryland Medical Center – Midtown Campus and Family Health Centers of Baltimore.

Among his varied assignments, Dr. Egerton’s career culminated as commander of Kirk U.S. Army Health Clinic in Maryland, and inaugural program director for the Population Health Outcomes Program for the Army’s Center for Health Promotion and Preventive Medicine. In this role, he was responsible for the Army’s population health initiatives and most notably for overseeing the Pentagon Post-Disaster Health Assessment after the events of September 11, 2001.

Board-certified in Pediatrics, Dr. Egerton completed fellowship and residency training in Adolescent Medicine at the William

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CENTRAL VALLEY PHYSICIANS

Beaumont Army Medical Center in El Paso, Texas, and earned his medical degree from the University of North Carolina.

UCSF Fresno Launches New Hematology/ Oncology Fellowship Programs UCSF Fresno recently launched two new training programs.

The UCSF Fresno Hematology/Oncology Fellowship is an internal medicine program that launched in July with two fellows. The UCSF Fresno Emergency Medicine Physician Assistant (PA) Residency Program started in August with two residents joining the program this year.

Residency training prepares recently graduated Doctors of Medicine (MD) and Doctors of Osteopathic Medicine (DO) to become specialists, including pediatricians and family practitioners among others, in approximately three to five years.

Fellowships offer specific training beyond residency in an area of expertise. Fellowships generally last one to two years.

The UCSF Fresno Emergency Medicine PA Residency Program is one of only two such programs in the state. The UCSF Fresno program is the first PA residency program in the University of California system and the only state-approved program.

The UCSF Fresno Hematology/Oncology Fellowship is a three-year program headed up by Uzair B. Chaudhary, MD, chief of Hematology/Oncology at UCSF Fresno. Hematology is the study of blood. Oncology is the study of cancer. A hematologist-oncologist is a physician who specializes in the treatment of blood diseases and cancers. Training takes place

Fall 2016

primarily at Community Regional Medical Center (CRMC) and The VA Central California Health Care System with a bone marrow transplant rotation at UCSF.

CONTINUING

The program’s fellows include Greg Gilmore, DO, and Mohamad Barakat, MD.

EDUCATION

Saint Agnes and cCARE partner With a vision of providing the highest standards of cancer care and treatment right here at home, Saint Agnes has chosen to align more closely with California Cancer Associates for Research and Excellence (cCARE), so we can bring the best of our respective resources together to benefit patients. cCARE announced plans to develop a 65,000-square-foot cancer center at Saint Agnes, and of that, plans call for a 31,000-square-foot expansion and renovation of Saint Agnes’ existing Cancer Center, where physicians from cCARE have been practicing for more than 20 years.

Construction, which will take place in stages, is scheduled to break ground in October 2016, with a projected duration of 12 to 15 months.

The new facility will be called ‘cCARE at Saint Agnes’ and will be independently managed and operated by cCARE, a private practice of 25 physicians and 10 nurse practitioners. The staff and operations from cCARE’s two current Fresno locations on East Fir and North Millbrook avenues will merge into one.

Included in the new space will be a high-complexity medical lab, newly renovated state of the art infusion area providing privacy for each patient with oncology certified nursing staff overseeing their care, a physician dispensing program for oral oncolytic providing convenience for patients, expanded radiation oncology suites, and two PET (positron emission tomography) machines.

Outpatient support services, including genetic counseling, social and nutritional services, the sickle cell clinic, nurse navigator program and lymphedema treatment, will continue to be provided by Saint Agnes. All of these Outpatient Services will be provided in one convenient place, located in the Medical Arts Building at 7202 N. Millbrook Avenue, Suite 209.

Fall 2016

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CENTRAL VALLEY PHYSICIANS

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In The News

IN THE

NEWS Saint Agnes Hospitalist Program Grows For the past two years, Saint Agnes Administration and physicians from the HAPP and Reddy groups have been working together to identify a company with expertise in running hospitalist programs at acute care hospitals like Saint Agnes. CEP America, the same company we contract with for our ER physicians, was the unanimous choice.

CEP America is a nationally recognized practice of hospitalists focused on caring for patients with acute medical conditions. It partners with health systems and hospitals across the country, several of which are in the neighboring communities of Madera, Modesto, Selma and Hanford.

Our new CEP relationship officially kicked off August 1. It brings the HAPP and Reddy groups together for the first time, under the umbrella of CEP. Along with many physicians from the former HAPP and Reddy groups, CEP has brought and is actively recruiting even more hospitalists to Saint Agnes.

With these additional resources and CEP’s expertise, we look forward to taking our hospitalist program to the next level.

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Providing physicians, office staff, and healthcare executives with relevant and up-to-date information

Congratulations to Chris Thomson, MD; Alan Birnbaum, MD; Camie Sorensen, MD, Soumya Pai, MD, and Ronaldo Ballecer, MD, for being honored with the Excellence in Patient Care award from the Medical Executive Committee!

Ronald Ballecer, MD

Soumya Pai, MD Soumya Pai, MD - Dr. Pai was recognized for the care she provided to a critically ill patient with a very complex case. During her bedside rounds, Dr. Pai took extra time to explain to staff the patient’s condition and surgical interventions. She drew pictures, changed the dressings and showed how to care for the wounds, incisions and drains.

She went above and beyond in creating a positive relationship with staff, making them feel comfortable to ask questions and was very detailed in her responses. In addition, she took the time to speak with the family to comfort and provide them with thorough updates.

Ronaldo Ballecer, MD - Dr. Ballecer was recognized for his quick and timely actions to retrieve and surgically repair a patient’s nose after it was bitten off in a dog attack. Staff were very appreciative of his speedy efforts to salvage the patient’s nose. He made every attempt to ensure it would heal after surgery through hyperbaric oxygen therapy treatments.

Chris Thomson, MD - Dr. Thomson was recognized for his patience and skill in caring for a patient.

He showed great concern and was very informative in his attempts to care for the patient. While the patient did not survive, Dr. Thomson did all he could in serving the patient and his family through a difficult time.

Fall 2016

they arise. He is firm in his support for everything Saint Agnes stands for and accomplishes.

• KERN • Chris Thomson, MD and Camie Sorensen, MD Camie Sorensen, MD - Dr. Sorensen was recognized for her timely intervention in saving the life of a difficult patient who was refusing medical treatment. Dr. Sorensen was called to speak with the patient in order to convince him to seek treatment for his symptoms.

Eventually, the man agreed and was treated for a dissecting aortic aneurysm through emergency surgery. Dr. Sorensen’s efforts helped save the patient’s life.

Alan Birnbaum, MD Alan Birnbaum, MD - Dr. Birnbaum always goes above and beyond in his dedication to his patients and their families. He is passionate in every aspect of his work, and has been recognized as extraordinarily respectful toward colleagues and physicians. He is able to think quickly to anticipate problems and provide solutions when

Fall 2016

Tehachapi Valley Health Care District Passes Vote The ballot measure to bring the Tehachapi Valley Health Care District under the operation of Adventist Health passed in a community vote by almost 90 percent, allowing Adventist Health to assume management of the hospital under a long-term lease beginning July 1, 2016.

In addition to the operation and management of the current hospital, Adventist Health will provide funding to complete construction of the new hospital and supply ongoing resources to create sustainable and high-quality services.

The new 25-bed critical access hospital will serve the Tehachapi Valley and Southeast Kern County.

The key service areas include emergency services, inpatient, swing bed, laboratory, imaging, inpatient pharmacy and dietary services.

Adventist Health also will operate and manage three rural health clinics located in Tehachapi, Mojave and California City.

Completion of construction is expected by Dec. 2016, and the new hospital plans to open its doors to patients in Feb. 2017.

CLASSIFIEDS If you'd to submit a listing to our Classifieds or purchase an ad, please call 559-224-4224.

FOR SUBLEASE Class A Medical Office Space, approximately 1500 square feet. 1781 East Fir Avenue, Suite 102, available 7/1. Rent: $2250 plus security deposit. Contact Robert at (559) 800-7476 or administration@cvphysiatry.com FOR RENT Medical office space, 1331 square feet. Many new exterior improvements. 1046 and 1060 E. Shields Ave. Contact Shannon Mar, (559) 999-6165 or smar@guarantee.com Central California Available Medical Office BAKERSFIELD - David A Williams, Jason Alexander & Cameron Mahoney 10000 Stockdale Hwy. #102 Bakersfield, CA 93311 | Ph 661 631 3800 For Sale 1921 18th St. - 5,826 sf 3535 San Dimas St. - 4,620 sf 820 34th St. - ±33,000 sf 3941 San Dimas #103 - 3,959 sf Lease 820 34th St. - 20,298 sf 9508 Stockdale Hwy - 2,443 sf 9330 Stockdale Hwy. - 2,665 sf 3535 San Dimas - up to 4,620 sf 3941 San Dimas #103 - 3,959 sf FRESNO - Bobby Fena, Michael Schuh & Beau Plumlee 7485 N. Palm Ave. #110 | Fresno, CA 93711 Ph 559 221 1271 For Lease 560 E. Herndon - up to 15,247 sf 1360 E. Herndon - 16,475 rsf www.colliers.com

CENTRAL VALLEY PHYSICIANS

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Stop the n Ca mpaig

Deaths g n i d e e l educe B R o

BY JAY LEWIS t d e n Desig

Following the mass shooting at the Sandy Hook Elementary School in Newtown, Conn., in December 2012, many Americans wondered if there was something that could be done to prevent similar deaths in the future. Staff at Hartford Hospital, a level-1 trauma center located about 30 miles from Sandy Hook Elementary School, wondered the same thing. Lenworth M. Jacobs, Jr., MD, director of the Trauma Institute at Hartford Hospital, was among thehealthcare providers who were concerned about the victims of the shooting that day. “It was an incredibly distressing situation,” Jacobs said in an interview. “It later prompted us to action.

My colleagues and I wanted to do something; we began to wonder if there was some way to prevent deaths when a tragedy like this occurs.” Jacobs worked with the American College of Surgeons to convene the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooters Events. The Committee met in Hartford and developed the Hartford Consensus, a series of planned initiatives with a goal of reducing mortality from uncontrolled bleeding. This led to the inception of Stop the Bleed, a nationwide campaign to educate people about the risks of uncontrolled bleeding, increase access to care for hemorrhaging victims, and empower the public to offer initial medical aid to someone who is wounded and losing blood. Jacobs, who is also now

the chairman of the Hartford Consensus, said the group believes prevention is a critical factor in reducing injuries and deaths. “We firmly believe that prevention is key,” he said. “But we want people to be educated and prepared if they are in a situation in which someone needs help.”

ANALYZING RISK Jacobs said he and his colleagues began their work with an analysis of factors that contributed to an increased mortality risk among people with uncontrolled bleeding.

“We considered where in the timeline of events the risk of death was most likely to increase,” he said. “Anytime someone has an injury that causes bleeding, the person is losing blood from the moment the injury occurs. The more blood loss, the higher risk of death. It became clear that any delay in treatment could cause people to bleed to death.” As Jacobs noted, in an emergency, the first people on the scene are often law enforcement officials. The goal of law enforcement is typically to stop a crime or to make the area safe. The mission of law enforcement officials is not necessarily to treat injured people and they are not always trained in lifesaving measures. While the mission of law enforcement officials is essential, it could potentially cost vital time for a wounded person who is losing blood. In response, one of the tenets of the Hartford Consensus is to

promote expanding the mission of law enforcement officials, recommending that they be taught lifesaving measures and be encouraged to treat bleeding victims if it is safe to do so.

Jacobs and his colleagues found that a second potential delay is the time it takes emergency medical responders to reach a bleeding victim. As Jacobs noted, in addition to the time it takes for an ambulance to arrive, emergency medical responders are sometimes unable to attend to patients immediately because they are blocked from the scene until it is cleared and safe. The Hartford Consensus now includes recommendations to increase emergency medical responders’ access to the scene and to get help to victims as soon as possible.

ROLE FOR BYSTANDERS Jacobs said he and his colleagues noted that a bystander on the scene is often in a position to provide initial care to someone who is bleeding.

But they questioned whether people lacking a medical background or training would be willing or able to help in such an emergency. To gauge the public’s view on this, a survey was conducted. The results indicated that more than 90 percent of respondents said they would be willing to help stop severe bleeding in an unknown person during an emergency. Jacobs and his colleagues found these results encouraging and began to further develop the Stop the Bleed campaign.

The campaign was expanded to teach simple lifesaving measures to the public. The idea is that the public can and should be taught about basic steps to take to stop hemorrhaging in a wounded person. “Losing excessive blood is the cause of death for many who sustain injuries,” Jacobs said.

“But if a patient can be prevented from

Fall 2016

losing too much blood, they will have a much greater chance of survival.

Emergency medical responders typically arrive within 15 minutes. If a bystander can help stop or reduce bleeding until medical personnel arrive, it could make a significant difference. If a patient is alive when they arrive at the hospital, they have a good chance of surviving.”

A NATIONWIDE CAMPAIGN As part of the campaign, posters and booklets were created and distributed throughout the country; they explain steps bystanders can take to help stop bleeding. People are taught to first identify where someone is bleeding, then to apply firm, steady pressure to the wound with a bandage or clothing. They are taught to then place a tourniquet two to three inches closer to the torso from the bleeding.

Finally, they are taught to repeat these steps if the bleeding continues.

“The steps are simple measures and the posters and booklets use simple language and images,” said Jacobs. “The idea is that even if someone does not know much about medicine, they can still understand what to do in an emergency.” In addition, the campaign is calling for bleeding control kits—which include tourniquets, gauze, dressing and sheers—to be made available in public places. Jacobs said the idea was inspired by the movement to place defibrillators in public places. “People saw there was a public good to place defibrillators in public places,” he said. “We want to do the same thing with bleeding control kits. We want to make sure people understand they are there and know how to use them.” Jacobs and his colleagues have been promoting the Stop the Bleed

campaign through various channels.

The campaign has been endorsed by many political leaders in the United States, including President Obama and Vice President Biden. Various government agencies, including the Department of Homeland Security, the Pentagon and the Federal Bureau of Investigation have become involved in the campaign. In addition, multiple medical and health associations, as well as many local police and fire departments, are supporting the campaign. Jacobs said he and his colleagues will continue to work with government agencies to educate the public and further expand the campaign.

CIVIC RESPONSIBILITY Jacobs said he is pleased by the public’s response to the campaign so far. He also said there are lessons from the past that are encouraging for Stop the Bleed. “Look at the success of previous similar public health ideas,” he said, offering First Aid, CPR, the Heimlich maneuver and defibrillators as examples. “The same thing can happen with Stop the Bleed.” Jacobs said he and his colleagues will continue to promote prevention as the ultimate public health strategy, but want people to be knowledgeable and prepared in the event that an emergency does occur. “We all like to assume that these things won’t happen to us,” he said. “But the reality is that things do happen. And it’s best to be prepared if they do. Yes, it can be scary. But I hope people consider it their civic responsibility to become involved in an emergency and help someone.” Additional information about the Stop the Bleed campaign is available online at www.dhs.gov/ stopthebleed.

CENTRAL VALLEY PHYSICIANS

21

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CENTRAL VALLEY PHYSICIANS

http://www.imq.org/education/caprrc.aspx Fall 2016

R O F E M I T S ’ IT

N O I T AC

BY A.M. AMINIAN, M.D.

As the controversy around the quickly escalating cost of the Epi-Pen auto-injector fails to die down—and rightfully so—I can’t help but have more and more questions.

At first, they were questions of incredulity. “How could a package of two Epi-Pens cost $600 when the amount of epinephrine in each package has an actual value of about $2?”

And, “What justification could there be to raise the cost of medicine from an inflation-adjusted $100 for a package of two Epi-Pens in 2004 to $600 today…a 600% increase?”

Having not found rational answers to either of these, I moved to a line of comparison questions. “It isn’t only the Epi-Pen. Why are asthma medications—well, all medications—so expensive?” “Why can people go across the border, or to Canada, or to Europe and get the same medications much cheaper?”

“Why do insurance companies change their lists of preferred, lower co-pay medicines annually, such as from Symbicort to Dulera for example, only to go back to Symbicort again the next year?” “Where is the consistency; where is the real cost?”

As my questions continued, the faces of my frustrated patients flashed through my mind and my incredulity and comparisons washed away as compassion took over.

The Epi-Pen, the asthma inhalers and all the other medicines we prescribe are essential to the lives of our patients; sometimes having access to them or not can even be a matter of life or death.

“How can we, as a society, place something so essential out of the financial reach of so many?” “Why don’t we have a stable pricing system for medicines in our country?”

But, alas, answers and solutions were nowhere to be found.

So, I went back to the incredulity and started the cycle of questions all over again.

It has to stop! As medical professionals, we need to ask ourselves what can be done about this travesty? We need to be leaders in finding ways to make all medicines more affordable so none of our patients are faced with the difficult decision of deciding whether they purchase an essential medicine for their child or the food they need to prepare their next family meal.

But, we can’t do it alone. All interested stakeholders, from doctors, families, distributors, manufacturers, insurance experts to payers and government agencies like the Food and Drug Administration need to join together to find answers to the questions and, most importantly, to find the solutions that are surely out there to see that all of our patients have access to the medicines they need.

We no longer can sit back quietly and say nothing. Our patients are depending on us to be amongst the leaders in these discussions.

MEDICINE IN THE MILITARY The initial attraction to the military was financial, but three Fresno doctors say the U.S. Army kept them interested by delivering on the promise of adventure.

Where else but in the Army would a neurologist need to check the natural habitat of hyenas before making a diagnosis, or a plastic surgeon get to use her skills on secret service agents, or a pediatrician have the chance to conduct a yearlong health follow up of the Pentagon’s 9-11 survivors?

Listen to these physicians describe the advantages of serving their country while they were learning their craft and you’ll be ready to enlist too: no medical school debt, great benefits, good pay, access to work with top experts, international postings, no worries about billing patients and fascinating, exciting work. >>

by Erin M. Kennedy

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CENTRAL VALLEY PHYSICIANS

Fall 2016

Medicine In The Military > Veterans of the U.S. Army

Fall 2016

CENTRAL VALLEY PHYSICIANS

25

Family Tree > Growing Local Physicians

I’d have to figure out logistics and see where the nearest port was for them to get a certain medication or how we could get someone from Africa to Italy and then finally on a plane to Germany.

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Dr. W. Eugene Egerton, a pediatrician with a specialty in adolescent medicine, was in charge of health care for West Point’s military academy cadets, headed the Army’s population health program and oversaw the “Pentagon Post-Disaster Health Assessment” after Sept. 11, 2001. Dr. Egerton, who was named Saint Agnes Medical Center’s Chief Medical Officer in September, signed up for better residency pay than he could get as a civilian, but stayed 23 years in the Army because he kept getting promoted to more interesting jobs.

Dr. Robin C. Hardiman’s military resume includes trauma surgery for victims of a major earthquake, casualties from the U.S.’s largest mass murder at the time and the crash of a U.S. Secret Service SUV. Hardiman, a plastic and reconstructive surgeon at Fresno’s Kaiser Permanente Hospital, has a special framed commendation from the Secret Service hanging in her office.

The frames hanging on the walls of Dr. Cong Z. Zhao’s University Neurology Associates office on the campus of Community Regional Medical Centers contain a photo of her in fatigues holding a machine gun from her basic training days and an aerial photo of the herringbone architecture of Landstuhl Regional Medical Center in Germany. She calls her time at Landstuhl, the largest military hospital outside of the United States, “a very strange practice” that prepared her for any odd case that could come her way now.

The Army’s web site plugs its military medical corps this way: “You’ll experience greater case diversity and may even have the chance to see and study diseases that are not usually encountered in the private sector.” Dr. Zhao’s Army career certainly corroborates that claim.

Landstuhl Regional serves as the nearest treatment center for wounded soldiers coming from Iraq and Afghanistan and serves all military personnel and their families stationed in the European Union. Between seeing soldiers from war zones, Dr. Zhao would “get weird phone calls from weird places in the world” asking her for medical advice. Often it was a medic on a submarine or ship asking how to treat a patient’s debilitating headaches. “I’d have to figure out logistics and see where the nearest port was for them to get a certain medication or how we could get someone from Africa to Italy and then finally on a plane to Germany,” she says.

Other times she and the infectious disease specialist on base would have to play detective to make a diagnosis. One time, they had to piece together how someone stationed at the Strait of Gibraltar could get Herpes Simian B, a virus only found in macaque monkeys and deadly unless treated early.

“We discovered he had vacationed in Morocco and been scratched by a monkey there,” Dr. Zhao says. “Another guy had something that you get from hyenas and he couldn’t

Fall 2016

tell us where he had been because he was a secret agent. As he’s talking, I’m Googling to see if there are hyenas in Afghanistan. I found out there are,” she says as she shows off a picture on her smart phone of a striped hyena with large pointed ears.

In the military, Dr. Zhao’s patients were younger and mostly male, although she also took care of family of active duty military and retirees from the service as well. “In the military I treated a lot of migraines and seizure disorders and MS (multiple sclerosis) because it’s a disease of the young,” she describes. “And as the war was getting geared up I saw a lot of concussion patients.”

By contrast her patients now are mostly older women since she specializes in movement disorders and is an expert in Parkinson’s disease. After seven years of service, Dr. Zhao left in 2014 for a chance to do a fellowship at the Mayo Clinic in deep brain stimulation used to treat Parkinson’s.

Dr. Zhao’s parents, Chinese immigrants whose idea of the military came from the red army that enforced communism, weren’t happy with her choice to join the U.S. Army. But she says she was a bit of a rebel who liked the challenge it presented, especially the chance to prove herself at basic training.

Basic training for medical officers is easier than for enlisted soldiers, Dr. Zhao says, “because they don’t want us to hurt our delicate little hands.” She found it fun. Mostly it was learning how the Army worked. She described it as a lot of PowerPoint lectures with stints learning to shoot, sprinkled with camping, marching and obstacle course challenges. “Our biggest risk was dehydration” while drilling on how to do medical triage during a mock ambush, she says.

“You automatically outrank people when you show up to basic training as captain, but you’re a complete newbie,” she describes.

“We trained next to the medics. I could hear them getting yelled at and they had their lights out earlier and they were up earlier than we were. We’d get ‘Oh ma’am you can’t do that.’”

Dr. Zhao says some days she misses the order and discipline she found in the military. “I’m glad I did it,” she says of her military experience. “When you leave you don’t have debt and have a way more interesting experience ... Nothing fazes me now.”

Not much fazes Dr. Hardiman either after military experiences that were like treating those in a war zone despite the fact that she was never stationed overseas.

Dr. Hardiman did her residency at the coveted Letterman Army Medical Center in San Francisco’s Presidio. “It was phenomenal because we did our training at San Francisco General and rotated through with UCSF residents with all the really, really experienced surgeons.”

She was there when the Loma Prieta earthquake hit at 5:04 p.m. on Oct. 17, 1989, as Americans watched it live during the televised World Series game between the Oakland A’s and San Francisco Giants at Candlestick Park. The 6.9 magnitude earthquake caused landslides, collapsed double-decker freeway

Fall 2016

I’m glad I did it. When you leave you don’t have debt and have a way more interesting experience ... Nothing fazes me now.

CENTRAL VALLEY PHYSICIANS

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Population Health was sent to the Pentagon for a year to study the survivors.

I had a crack team of epidemiologists to help. That was our first real foray into population health. It was very fascinating but very sobering.

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overpasses and heavily damaged San Francisco’s Marina District, where Hardiman lived. “I just stayed at the hospital for three days and helped where I could because I couldn’t get back to my apartment,” she describes.

Her first posting as an Army medical officer was to Brooke Army Medical Center in Ft. Sam Houston.

“We did all the major trauma for San Antonio. We got all the gunshot wounds, so I got a lot of wartime surgery experience,” Dr. Hardiman says of her time at one of the Army’s largest and busiest medical centers, a 450-bed Level 1 trauma center.

The experience prepared her for what was next – the largest mass murder in U.S. history at the time.

Dr. Hardiman was at Carl R. Darnall Army Medical Center at Fort Hood in Killeen, Texas, when an out-of-work merchant marine crashed his truck into a Luby’s Cafeteria in Killeen and began shooting, taking special aim at the women there. The shooter, a misogynist loner named George Hennard, killed 23 people and wounded 27 others during the Oct. 16, 1991 rampage that came to be known as the Killeen Massacre. He turned his gun on himself during a shootout with police. Most of the wounded were taken to the military base where Dr. Hardiman worked.

Again, Hardiman, with five years of general surgery and two years of plastic surgery experience, was pressed into service as a trauma surgeon, working a few days straight. “It was crazy,” she says. “We didn’t have cell phones back then, so I couldn’t call out to my family.”

After completing specialized training in hand and breast reconstruction and plastic surgery for children with world famous cleft palate surgeons, Hardiman finished her military career as an attending surgeon at William Beaumont Army Medical Center at Fort Bliss in El Paso, Texas. It was there that she got her commendation from the White House.

President Bill Clinton was campaigning in New Mexico before the 1996 election with his usual contingent of secret service officers. “New Mexico has one of the highest drunk driving rates and a drunk driver drove his big SUV into the car full of secret servicemen. The neurosurgeon on the case called me to help close the head of one of the officers,” Dr. Hardiman says. “I put him all back together. He was able to come back to full duty and said his nose looked better than ever. I never saw the president though; he continued on his way.”

Fall 2016

Medicine In The Military > Veterans of the U.S. Army

Dr. Hardiman got out after 10 years of service. “I had two little kids and they were going to send me to Bosnia with no definite return date,” she explains.

What Hardiman loved best about being a military doctor was the way she was able to approach patient care. “In the military you don’t have to worry about costs or billing, you just do what is right for the family.” It’s another one of those points touted on the Army’s web site as a benefit of being an Army doctor.

The Army’s web site and Army recruiters usually start their pitch for the Army Medical Corps with how much money the military pays for medical training – 100% tuition and expenses, plus a generous monthly stipend. The enticements continue with boasts about the opportunities to work in a variety of settings and serve in leadership roles. Dr. Egerton says the chances he got to grow as a leader kept him in more than two decades, but the initial sell didn’t really convince him.

While Drs. Zhao and Hardiman were swayed by the chance to get the Army to pay for medical school, Dr. Egerton says,“I ended up in the military on a whim.”

He was already in his fourth year of medical school in the late 1970s and looking around at residency programs when he encountered an Army recruiter after class one day. “The guy looked really lonely sitting in the hallway. I felt bad for him so I listened to him and filled out an application and forgot all about it,” Dr. Egerton says. “Then the chief of pediatrics from William Beaumont Army Medical Center called me on New Year’s Eve and offered me a place. I did the math and it was double what I would’ve made in another program.”

He was planning to be out and done in five years, but then he was offered a fellowship opportunity in adolescent medicine with a chance to train under one of the preeminent experts at the

time. Dr. Egerton stayed. Then came another “plumb assignment” to run the high school clinic at the base in Augsburg, Germany, and set up the first high school health center at Campbell Barracks in Heidelberg. He also helped care for 60,000 soldiers and their families in the Bavarian base.

Dr. Egerton was thinking it might be time to leave when he returned to the U.S., but he got promoted again and became the brigade commander running the student health services at West Point Military Academy.

“It was the ultimate college health clinic,” Dr. Egerton says. “I had so much

program director for the Population Health Outcomes Program for the Army’s Center for Health Promotion and Preventive Medicine. “That was going to be my terminal assignment,” Dr. Egerton says. “But in 2001, I was attending a conference a block from the White House on Sept. 11th. We got word and turned on the televisions to see the second plane hit the towers. We realized we were under attack.”

He was staying at Crystal City, Virginia, and had to walk back miles to his hotel as roads and cell service shut down. Eventually he made his way to the Pentagon.

I can still remember the looks of the people there and I still remember the smell. It was still fire.

- Dr. Egerton fun there. It taught me how to manage people. There’s no way I would’ve had that kind of experience outside the Army. It was also a research rich environment and I ended up getting published with Stanley Friedman.”

He got a wealth of experience in infectious diseases, did counseling with cadets, handled gynecological cases for the female cadets and worked with a team of orthopedics for the injuries that invariably happened during the cadets’ physical training. “By this time I was too far in with an Army career to get out,” Dr. Egerton says.

He rose through the medical ranks at West Point, eventually becoming Chief Medical Officer at Keller Army Community Hospital there. “From that I got the leadership skills to be selected for command at Aberdeen Proving Ground. It’s a testing and evaluation center and we do stuff we can’t talk about,” Dr. Egerton says.

His last assignment was as commander of Kirk U.S. Army Health Clinic in Maryland, and inaugural

“I can still remember the looks of the people there and I still remember the smell. It was still fire,” Dr. Egerton describes. “Population Health was sent to the Pentagon for a year to study the survivors. I had a crack team of epidemiologists to help. That was our first real foray into population health. It was very fascinating but very sobering.”

Today, population health is very much a part of what hospital medical directors have to become experts in under the era of healthcare reform. Dr. Egerton’s last experience has placed him perfectly for his current role, he says.

Drs. Egerton, Hardiman and Zhao agree that the physicians they are today was shaped by the discipline, the training and the experiences they had serving their country and caring for Army’s soldiers and their families.

“Everything I am professionally,” Dr. Egerton says, “I owe to my time in uniform.”

WEBINARS

EDUCATION •

SEMINARS

DID YOU KNOW?

•

PODCASTS

•

AND MORE

CMA offers free webinars to its members

Through its robust webinar series, the California Medical Association (CMA) gives physicians and their staff have the opportunity to watch live presentations on important topics of interest and learn from industry experts from the comfort of their homes or offices. The webinars are free to CMA members and members’ staff and provide the timely information needed to help run a successful medical practice. What’s more, all webinars are available on-demand immediately following the live airing, providing an ever-growing resource library accessible at any time.

OCT

5

CHPI Physician Quality Rating Program: Navigating the Review and Corrections Process October 5, 2016 | 12:15pm - 1:15pm

With the California Healthcare Performance Information System (CHPI) publishing clinical quality ratings for approximately 13,000 California physicians later this year, physicians will soon begin receiving notices advising of their quality scores along with information on how to access the review and corrections portal to confirm or correct their data.

This webinar will provide an overview of the CHPI quality rating project, along with step-by-step instructions on how physicians can review their data for accuracy before the quality scores are published.

OCT

19

Assembly Bill 72: Out-of-Network Billing: How it Works, Who it Impacts and How to Avoid it October 19, 2016 | 12:15pm - 1:15pm | Members Only

In September, Governor Jerry Brown signed a controversial bill, Assembly Bill 72, into law. This bill will change the billing practices of non-participating physicians practicing in in-network hospitals, ambulatory surgery centers and laboratories.

PRESENTERS: Emily London is a senior manager at the Pacific Business Group on Health (PBGH), where she currently manages the Patient Assessment Survey and communications for the Multi-Payer Claims Database project.

Pete Sikora is a senior manager at the PBGH, where he leads the development of CHPI, one of the first physician-level quality rating systems in the country.

PRESENTER: Janus Norman is CMA’s Senior Vice President for Government Relations and Political Operations, and serves as CMA’s chief lobbyist. He has worked on numerous campaigns during his career, including several ballot measures.

This webinar will present an overview of the new law, providing members with the information to understand the circumstances under which the bill applies, how physicians can continue to charge their usual rate, and the opportunity to improve network adequacy standards.

Is Your Practice at Risk for a HIPAA Security Breach?

NOV

2

November 2, 2016 | 12:15pm - 1:15pm

Medical practices are at increasing risk for HIPAA security breaches such as ransomware, or theft of electronic patient information.

Increased dependency on electronic health records and exchange of data with other providers, or staff turnover can compromise security.

In this webinar, CMA’s HIPAA advisor, David Ginsberg, will discuss common threats and breaches, how to safeguard and strengthen your systems, and what to do if you have a breach.

PRESENTER: David Ginsberg is Co-Founder and President of PrivaPlan Associates, Inc., a leading provider of HIPAA privacy, security and breach notification services, consulting and products for the health care and business associate industry. He also has more than 30 years of experience in the health care industry.

REGISTER ONLINE TODAY! WWW.CMANET.ORG/EVENTS *Webinars are free for CMA members and their staff ($99 for non-members).

YES on

56

California’s Proposition 56 Will Raise Tobacco Tax to Save Lives, Protect Children In November, Californians will have a vital opportunity to stand up to tobacco companies and save lives. Proposition 56 will raise the tax on cigarettes and other tobacco products, including electronic cigarettes containing nicotine, which medical experts warn are creating a major public health threat to children.

Prop. 56 directs additional funds to the University of California for graduate medical education, Denti-Cal, the California Department of Public Health and the California Department of Education for smoking prevention programs, and the University of California for medical research into tobacco-related diseases.

Taxing tobacco saves lives and gets people to quit smoking.

Taxing tobacco is proven to prevent would-be smokers – including youth – from ever starting. And only those who choose to continue or start this deadly and costly habit will pay.

Prop. 56 will protect children. Studies show that 90 percent of smokers start as teens. This year alone, an estimated 16,800 California youth will start smoking, one-third of whom will eventually die from tobacco-related diseases.

The California Medical Association has joined the American Cancer Society Cancer Action Network, American Lung Association in California and American Heart Association in sponsoring Prop. 56, because tobacco hurts all Californians – even those who don’t smoke.

Tobacco companies are aggressively marketing youth-themed, candy-flavored electronic cigarettes containing nicotine to hook a new generation of young consumers. Teen use of e-cigarettes tripled in a single year, and flavored tobacco products are creating a dangerous new public health threat, particularly to youth and minorities. Teens who use e-cigarettes are twice as likely to start smoking traditional cigarettes.

The leading cause of preventable death in our state and the nation, tobacco kills 40,000 Californians annually. Each year, tobacco causes more deaths than guns, car accidents, HIV, alcohol and illegal drugs combined. Meanwhile, Californians spend $3.5 billion dollars each year treating cancer and other tobacco-related diseases through Medi-Cal. Only those who use tobacco products will pay this simple user fee.

The vast majority of funds generated by Prop. 56 (estimated to be up to $1 billion annually with an additional $1 billion in federal matching funds) will go to pay for health care for low income Californians through Medi-Cal. Medi-Cal now serves over 12 million people, almost one third of the state’s population and half of all California children.

Fall 2016

It has been proven that higher tobacco taxes reduce teen smoking, yet California’s tobacco tax is among the lowest in the nation.

Prop. 56 will keep kids from becoming addicted to nicotine.

Prop. 56 will safeguard children and improve California’s communities, economy and health care system. Although we have made some great strides, we cannot stand down from combatting tobacco’s deadly addiction. Learn more at YesOn56.org.

Twitter: @YesOn56 Facebook: @YesOn56 Instagram: @YesOn56

CENTRAL VALLEY PHYSICIANS

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DOCTORS

ON MISSIONS

It’s no secret there are many skilled physicians in the Central Valley, but many may not know their expertise and loving care extends beyond the reach of our farmlands and Sierra Nevada Mountains and into third world countries.

For the last 30 years, Peter D. Witt, MD, Medical Director of Pediatric Plastic Surgery for Valley Children’s Hospital, has been donating his services and time to helping others in need in countries such as Africa, Bangladesh, Bhutan, China, Colombia, Croatia, Mexico, Russia, Vietnam, and North Korea. As a craniofacial and hand surgeon, Dr. Witt mainly repairs cleft lip and cleft palates on mission trips. During his last trip to Vietnam, he performed 54 operations.

Cleft lip and cleft palate are the most common facial and oral malformations that occur early in pregnancy when tissues fail to form properly. A cleft lip is a separation of the two sides of the upper lip and a cleft palate is a split or opening in the roof of the mouth that can lead to speech, dental and feeding problems. Cleft lips are more common among Asian, Latino or Native American children. According to Operation Smile, an international medical charity that hosts surgical missions, every three minutes a child is born with a cleft lip or cleft palate.

Dr. Witt was the first foreigner to perform a cleft lip repair surgery in North Korea in 2008 He and a group of various specialists and surgeons received a direct invitation from the North Korean government to provide much needed clinical services and education there. This was a rare opportunity as the country was ruled by dictator Kim Jong-Il at the time.

After being told cleft lip abnormalities weren’t a problem, Dr. Witt was saddened to discover after just a few days there, the people of North Korea were letting children with cleft lips die of

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starvation.

“It was very sad,” he says. “Cleft lip and cleft palate are the most common congenital anomaly – it’s a very fixable problem with a simple two hour surgery. There’s no reason why these kids can’t live a normal life.”

Pediatric Pediatrician Anesthesiologist Marty Clayman, MD, of Valley Children’s Hospital has had the same experiences on his mission trips to Africa, China, India, Vietnam and the Philippines over the last 18 years.

“Many of these children are abandoned, abused, shunned and all they have is a cosmetic defect,” he says.

During his most recent mission trip, Dr. Clayman administered anesthesia to patients needing cleft lip and cleft palate repair in China. While on mission trips to China with Operation Smile, Dr. Clayman and the medical team screen anywhere from 300 patients and operate on about 120 in multiple operating rooms over the course of several days.

“What’s rewarding is when you see a child with a major defect and they’re fixed and you see the smile on their faces and their family’s faces – you’ve really altered their life,” he says.

Dr. Clayman recalls witnessing a 70-year-old man who had a cleft lip see himself right after surgery with the use of digital cameras in the operating room.

“To see the grin on the face of somebody who has lived with it for years is incredible,” he says.

Fall 2016

INSPIRATION

Dr. Witt was inspired to do mission trips in college after he read the book Daktar: Diplomat in Bangladesh by Viggo Olsen who established a hospital in a Bangledesh jungle. “I was so inspired that I wrote him a letter asking if I could work with him, and he said yes,” Dr. Witt says.

To finance the trip, Dr. Witt applied for a Reader’s Digest international fellowship scholarship and won. After spending three days in the jungle helping others in need, Dr. Witt knew this was what he wanted to continue doing for many years to come.

“The doctor had such a profound influence on me – he was a guy that could do anything – I was going to be a neurosurgeon but after working with him I came back from that experience and applied to general surgery because I wanted to be able to do the kinds of things he did,” he says.

A few years later, in his fourth year of residency, Dr. Witt and his wife went on anther mission trip to Bangladesh that further fueled his passion.

“The physician I assisted there was just a giant of a man,” Dr. Witt says. “What he did in taking care of patients in Bangladesh for 30 years is amazing. He was very skilled, smart and incredibly humble – it called me to a higher level just to be in his presence.”

Out of all of the mission trips he’s been on, Dr. Witt says the most rewarding was time spent in Bhutan, a village at the base of the Himalayas. There was only one general surgeon there to service the entire country. While there, Dr. Witt and the surgeon worked side-by-side repairing cleft lips from sun up to sun down. By the end of his trip, the surgeon had learned a how to repair cleft lips entirely on his own, a valuable skill he would use for a lifetime.

Dr. Clayman was inspired to do medical missions after watching a show on CBS Sunday Morning called Unaccompanied Children, which was about Vietnamese children living in Thailand refugee camps alone. And as fate would have it, he was surprised to see that he actually knew the physician featured on the show, further solidifying his desire to pursue mission trips.

Dr. Clayman goes on one to three missions trips per year has been on about 20 missions trips to China as a visiting professor at the Children’s Hospital of Zheijiang University School of Medicine in Hangzhou.

“The ultimate goal is to teach the medical professionals there so they can learn how to do it on their own,” Dr. Clayman says. “In the U.S., we have a certain way of doing things that are very intensive and expensive, so it is amazing to see what

Fall 2016

can be done with so little. It makes you realize what we’re doing is sometimes more than what needs to be done. You learn you can do with a lot less and it makes you a better physician and healthcare provider.”

WHY MISSIONS

For many physicians, medical mission trips are fully financed by their own means, and oftentimes, they give up their personal vacation time to do them. For both doctors Witt and Clayman, it is just a way of life.

“It makes you feel really good on the inside and you get to travel and see different places and help people that otherwise wouldn’t be helped,” Dr. Clayman says.

Next, Dr. Clayman is headed to Ghana, Africa, in the fall, China in the winter and El Salvador in the beginning of next year.

For Dr. Witt, he is considering going to Armenia next.

“It’s just something that I do,” Dr. Witt says. “It’s doing something for people that don’t have the services and who are grateful – service is the rent we pay for living on this earth.”

PETER D. WITT, MD

Dr. Witt has been in practice for 27 years and has served as the Medical Director of Pediatric Plastic Surgery for Valley Children’s Hospital for 14 years, helping to grow the program into one of the largest plastic surgery pediatric groups in the country.

Before coming to Fresno, Dr. Witt was a tenured professor of 14 years at the University of Kansas School of Medicine, and prior to that, at Washington University in St. Louis. He earned his medical degree from Case Western Reserve University School of Medicine in Cleveland, Ohio, and completed residencies at University of Washington (general surgery) and University of California, Irvine College of Medicine (plastic surgery), where he served as chief resident.

MARTY CLAYMAN, MD

Dr. Clayman has been in practice for 30 years and with Valley Children’s Hospital for 16 years. He’s previously practiced in Hawaii and Michigan and was an assistant professor at the University of Kentucky. He earned his medical degree from the University of Cincinnati College of Medicine, completed a pediatric residency at Cincinnati Children’s Hospital Medical Center and an anesthesia residency at Michael Reese Hospital in Chicago. He also completed a pediatric anesthesia fellowship at Children’s Hospital Colorado.

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ACHIEVING CONSENSUS ON CHANGES TO OBAMACARE WILL NOT BE EASY The Urban Institute recently reported that some 18 million Americans have gained insurance coverage under the Individual mandate, employer mandate and Medicaid expansion of Obamacare, which falls well-short of the expectation in 2010 that the gain would be 30 million of the 45 million then uninsured.

Although a Commonwealth Fund survey recently found majority satisfaction with their insurance, a recent

Kaiser Family Foundation-New York Times survey found that three-fourths of insured people who had medical bills said they could not afford the copays, deductibles and coinsurance; 26 percent received unexpected claim denials; 32 percent received care from an out-of-network provider that their insurance would not cover; and 69 percent were unaware that their provider was out-of-network resulting in

copay sticker shock.

Adopted without broad consensus, subsequent Congresses have sought to repeal and undermine Obamacare.

Viewed as worrisome, expensive extensions of federal power over people’s lives, many object to the Individual mandate to buy insurance or pay a penalty and to the increase in complex administrative regulations and enforcement bureaucracy for that

Obamacare > Achieving Consensus

mandate and the employer mandate (which requires specified group health insurance for “large” employers).

So how might a lasting consensus on healthcare be obtained?

First, a new president should initially seek broad consensus across party lines on what resources are and will be available for and on the ranking of the nation’s spending priorities of national defense; Social Security; replacing/repairing dilapidated bridges, roads, sewer and water lines, aging electrical grid and other infrastructure; education and healthcare.

With budget priorities established, the President should use Theodore Roosevelt’s “bully pulpit” of direct appeal to the public to keep Congress moving quickly to address each priority.

Second, health care presumably will rank high. Many will call for the elimination of the Individual mandate, subsidies, and employer mandate (which the government claims affects only a small percentage of employers).

But most will want to keep the elimination of the insurers’ pre-existing condition exclusion and keep dependent children coverage to age 26.

Third, insurers will protest that without the mandates, people will only sign up when they get sick, causing insurers to go broke, but this might be controlled with a 60-day limited enrollment period each year; by keeping the current ability of insurers to adjust premiums based on certain factors such as age, smoker, and geographic location; and more aggressive government financing of primary care.

The government projects for 2020 a shortage of 20,400 primary care physicians, most severe in high poverty regions where they are needed most.

Fourth, to address this shortage, correct health problems before they become major, and address expensive hospital emergency department overuse, a broad nationwide system of federally owned or contracted primary medical, dental and mental health clinics may be helpful.

Providers today might prefer less stressful set clinic work hours with attractive salaries, medical school loan relief, and high quality equipment and services.

Clinic services open 24/7 could be at no charge to those eligible for Medicaid and on a sliding scale up to 400 percent of the federal poverty level for people 18 to 65 and for Medicare deductibles and copays, or perhaps Medicare could be available to all for clinic services.

Fifth, for freedom of choice, Medicaid and Medicare could continue for primary care outside the government’s clinic system and for hospital and specialty physician care not available at the clinics.

Regulatory impediments (such as HIPAA) could be removed to such innovations as communal and family meetings with doctors to encourage communal healthier

behavior; family and mental health providers’ sharing with each other an individual’s mental health information crucial to treatment and protection of the public; and flexibility for primary care doctors to charge patients directly on a retainer or other basis in place of the administrative burden of billing insurance.

Sixth, for primary, hospital and specialty care not obtained from the clinics, maintain the tax exemption for employer-paid

The government projects for 2020 a shortage of 20,400 primary care physicians. insurance premiums and allow other individuals to deduct up to perhaps $2,000 to $4,000 of the cost of their premiums, which should be lower because of government-financed health care at the primary level.

Achieving consensus on national priorities and how to pay for them, let alone on health care, will not be easy. Enlightened study and leadership are essential.

Daniel O. Jamison is an attorney with Dowling Aaron Incorporated. He can be reached at djamison@dowlingaaron. com. He wrote this for The Fresno Bee.

Q A

I am very confused about Medicare Supplements; what is the BEST plan?

Contact Susan Hatch, PHIAS (Professional Health Insurance Advanced Studies)! She is a renowned specialist on Medicare Supplement Insurance laws, an objective advocate, analyst, and talk radio guest expert on Medicare supplements, Susan is a licensed, 100% Independent Insurance agent who objectively represents ALL Medicare Supplement plan types. She was awarded #1 agent in California and earned The Soaring Eagle Award with NAHU. She is accredited with the BBB and a longtime Fresno resident.

Contact Susan Hatch today!

Phone: (559) 307-2287 License # OF19062 Email: CaMedicarePlans@sbcglobal.net Website: MedicareToday.net

MACRA RESOURCE CENTER Tools and information to help physicians understand the Medicare payment reforms

Learn more at www.cmanet.org/macra

Wondering where to start? There are some critical first steps that physicians should take to prepare for MACRA implementation. The most important step is to get educated about MACRA. Some specific actions to consider include: Learn the basics of MACRA – Under the MACRA proposed rule, there will be two main pathways for physician reimbursement, the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). For an overview on the two pathways, download AMA’s MACRA Action Kit (see page 5), which also includes a checklist (see page 2). Also, watch the California Medical Association (CMA) webinar titled, “What Is MACRA? What Is CMA Doing to Improve It? What Steps Can You Take to Prepare Now?” and the Centers for Medicare & Medicaid Services (CMS) webinar, “MACRA and the Quality Payment Program: An Update on the Recent Proposed Rule.” The webinars will allow you to view at your own pace and will give you the basics of MACRA. Remember that this is a proposed rule and is not final – CMS issued its proposed rule on April 27, 2016, and received many comments from interested stakeholders, including CMA. The final rule is expected this fall. CMA encourages practices to get ready, but to remember that the details are subject to change. To read CMA’s comprehensive comments to CMS outlining constructive improvements to MACRA, visit www. cmanet.org/macra. There you will also find a link to AMA’s extensive comments. >> Determine whether you are exempt from MIPS participation – The proposed rule exempts practices from MIPS if they have a low volume of Medicare patients. This threshold is defined as $10,000 or less in Medicare billed charges and 100 or fewer Medicare patients annually. Physicians in their first year of Medicare participation are also exempt.

Determine whether your practice meets the requirements for small, HPSA, or non-patient facing physician accommodations and exceptions – The proposed rule provides accommodations and additional flexibility for various practice sizes and configurations. See the CMS Small Practices Fact Sheet for more information.

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Fall 2016

MACRA > Medicare Reform

Participate in PQRS for 2016 – Whether your practice ends up participating in MIPS or APMs, there will be a quality reporting component. If you haven’t yet successfully participated in CMS’s Physician Quality Reporting System (PQRS), try again in 2016. CMS has created a 2016 PQRS Implementation Guide that includes a beginner reporter toolkit to help get you started. You’ll gain familiarity with the reporting process and will have access to view your PQRS feedback reports, which can help to guide practice improvements under MACRA. Review QRUR reports to identify where improvements can be made – CMS publishes a mid-year and annual Quality and Resource Use Report (QRUR) to help practices understand their cost and quality assessments under the Value Modifier and quality under PQRS. To access your practice’s QRUR report, visit the CMS Enterprise Portal. One person from the practice will need to obtain an Enterprise Identity Management System (EIDM) account. For more information on setting up an EIDM account, visit the CMS website.

Review proposed measures and determine how you will report – Decide which measures will work for your practice and how you will report the data to CMS. For more information on the proposed individual quality measures for MIPS, see Tables A – G on pages 28,399 – 28,569 of the proposed rule.

Under MIPS there are four reporting categories that allow for different reporting mechanisms: through claims, electronic health records, clinical registry, qualified clinical data registry or the group practice (25+ physicians) reporting option web interface. For more information on reporting mechanisms, see CMS’s “The Merit-Based Incentive Payment System (MIPS)” slide deck (begins on slide 43).

Consider participating in a qualified clinical data registry – If you are not already participating in a qualified clinical data registry, contact your specialty society about participating in theirs. Data registries are a method of reporting that can assist reporting in three of the four MIPS categories.

Evaluate EHR and vendor readiness – Is your EHR considered certified EHR technology (CEHRT)? – Make sure your EHR is certified. To

Fall 2016

see which EHR systems are CEHRT, see the CMS website.

Talk with your EHR vendor about how its product supports transition to MIPS – Find out whether your vendor will meet Medicare MIPS quality reporting requirements or new payment model adoption. Are there any costs associated with needed updates? Ask about timelines for MACRA readiness and interoperability. Document the conversations.

Review CMS’s list of CPIA – Determine which clinical practice improvement activities (CPIA) your practice is already doing and what adjustments need to be made to complete additional activities by 2017. For a list of high weight CPIA categories, see Table 23 on pages 28,263 - 28,265 of the proposed rule. For a complete list of proposed CPIA, see Table H on pages 28,570 - 28,586 of the proposed rul Consider ways your practice can report at least one unique patient for each Advancing Care Information (ACI) measure – ACI will replace the EHR incentive program. Practices should ensure they can report at least one unique patient (or answer “yes”) for each measure of the base score’s six objectives. Ideas (for 2017) include: •

Reach out to existing patients to encourage use of the patient portal.

•

If your EHR allows you to send a secured message through your patient portal to all of your patients at once, you might consider sending an appointment reminder to all of your patients in 2017.

•

For a complete list of the proposed ACI categories, see Table 6 on pages 28,222 – 28,226 of the proposed rule (with additional information in Section II.E.5.g.7).

Conduct a security risk analysis in early 2017 – Failure to do so will result in a score of zero for the ACI category. The risk analysis should comply with the HIPAA Security Rule requirements.

For more information on conducting a HIPAA security risk analysis CMA members have free access to our on-demand webinar, “HIPAA Security Risk Analysis: How to Make Sense of this Requirement” available on our website at www.cmanet.org/webinars. Additional information can be found in CMA On-Call Document #4102, “HIPAA Security Rule,” also free to CMA

CENTRAL VALLEY PHYSICIANS

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MACRA > Medicare Reform

members in the online health law library at www. cmanet.org/cma-on-call. The American Medical Association (AMA) website also has resources to help with this step at www.ama-assn.org/go/hipaa.

View AMA’s STEPS Forward Practice Transformation Series learning module – To help practices make the shift to value-based care, AMA has created the STEPS Forward learning module. The module includes five steps to prepare a practice for value-based health care, answers to common questions and case vignettes describing how physicians can create value-based practices.

Confirm whether you are a participant in any of the advanced APMs already approved by CMS – For a list of the CMS-approved advanced APMs in the proposed rule, see Table 32 on page 28,312.

Stay up-to-date on MACRA related news.

•

Sign up to receive CMS MACRA e-mail updates.

•

Sign up to receive Medicare news directly from CMA through content update alerts. By doing so, you will be notified anytime a new story about MACRA is posted to our website.

To do so, just activate your web account (if you haven’t already done so) and sign up for custom content alerts on the topics that are of interest to you. You will then be notified any time there is new content posted in one of your interest areas.

To do so, 1) Click on “My Account,” 2) In the left sidebar, click on “My Alerts,” 3) Under New Content Alerts, click “Alert Settings,” 4) Type “Medicare” in the search box and hit enter. You can adjust the frequency and format that you receive alerts via the account dashboard. For more information, see www.cmanet.org/customcontent.

Check CMA’s MACRA Resource Center at www. cmanet.org/macra for updates!

For additional information on steps you can take now to prepare, see the AMA MACRA checklist (pages 2-3).

Fresno Madera Medical Society and Dr. Hemant Dhingra invite you to the

2016 General Society Meeting & Social for FMMS Members and Member Prospects

Monday, October 17, 2016 6 pm - Social 7 pm - General Society Meeting 8 pm - Adjournment

R.S.V.P. - (559) 224-4224 ext. 114 Vino & Friends 1560 E Champlain Drive, Fresno, CA 93720

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Fall 2016

MARRIOTT MARQUIS SAN DIEGO MARINA

Join us next year in beautiful San Diego for the 20th Annual Western Health Care Leadership Academy!

(800) 795-2262 westernleadershipacademy.com

Fall 2016

CENTRAL VALLEY PHYSICIANS

39

Public Health

Update

The coalition will be assisting local health care providers in adopting these new pain management guidelines, and utilizing these tools in their practice, by orchestrating an educational series, in three parts, given by recognized subject matter experts. The first of these is Understanding Pain (scheduled for September 21st of this year), followed by Management of Chronic Pain on November 9, 2016, then Safe Prescribing on January 18, 2017.

Prescription pain killer overdose a national epidemic Ken Bird, MD Public Health Officer • Fresno County Department of Public Health

On November 1, 2011 the Centers for Disease Control and Prevention (CDC) declared prescription pain killer overdose a national epidemic. Misinformation with regard to treatment of chronic non-cancer pain, along with aggressive marketing of newer, longer-acting opioids in the management of this pain, led to a quadrupling of sales of these prescription painkillers from 1999 to 2013.

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Fall 2016

Today, the U.S. consumes 83% of the world supply of oxycodone (OxyContin) and 97% of the world supply of hydrocodone (Vicodin), while making up only 4.6% of the world’s population. It is estimated that 14.6% of the U.S. adult population has chronic pain, 3 to 4 % of U.S. adults are being treated with long-term opioid therapy, and 2 million Americans are currently abusing, or are dependent on, opioid pain medications.

enforcement, addiction treatment centers, Fresno County Department of Public Health, Fresno County Department of Behavioral Health, and other community groups. The coalition envisions adopting the three federally sponsored approaches to the opioid overuse epidemic which include: 1) encouraging safe prescribing by providers, 2) increasing access to medication-assisted treatment of addiction, and 3) increasing use and distribution of naloxone (Narcan) in the immediate treatment of overdose.

The more frequent use of these substances (including Vicodin, OxyContin, Percocet, Codeine, and Morphine) The initial emphasis of the coalition will be on the safe over longer periods of time has resulted in a dramatic prescribing of these medications, and will be predicated upon increase in rates of addiction and death due to overdose. recent guidelines, especially those issued by the Medical Because past use of prescription opioids is the strongest Board of California in November of 2014 and those issued risk factor for heroin initiation and use, overuse of these by the CDC in March of this year. Key elements of these prescription opioids has driven an only slightly less dramatic guidelines are the consideration of other pharmaceutical and increase in deaths due to heroin overdose.

Prescription painkiller abuse is now one of the fastest

growing public health concerns in the U.S. and the Annual deaths due to prescription painkiller overdoses currently personal toll that opioid abuse takes on individuals, outnumber deaths from motor their friends, and their families is alarming. vehicle accidents, claiming an average of over 46 lives every day.

Economically, the cost of opioid abuse to this country was non-pharmaceutical options in the treatment of chronic pain, estimated to be $56 billion in 2007. careful assessment of the risk, versus the benefit, of treatment with opioid medication if it is used, and close monitoring of Prescription painkiller abuse is now one of the fastest patient dosage and usage. growing public health concerns in the U.S. and the personal toll that opioid abuse takes on individuals, their friends, and Available to assist with the latter of these is the California their families is alarming.

Prescription Drug Monitoring Program’s (PDMP) Controlled Substance Utilization Review and Evaluation While Fresno County is somewhat less impacted by this System (CURES) tool. Pharmacies and health care providers epidemic than are many areas in the nation and the state, that dispense these medications directly are required to we rank 17th among California counties in deaths related report their dispensing information to the Department to opioid pharmaceuticals with an age-adjusted rate almost of Justice weekly. All California licensed pharmacies and twice the state rate of 3.8/100,000. all California licensed prescribers who are authorized to prescribe opioid (and other scheduled) medications, that are The strongest effort to date at curtailing this epidemic locally registered with CURES, are able to acquire a Patient Activity has been the Lock It Up program which offers outreach Report (PAR) detailing all of a patient’s opioid (or other education to students and their parents on the topic of drugs scheduled) drug prescription activity over the prior year. and alcohol, and the Lock It Up, Clean It Out, Drop It Off program which encourages, and provides information on, The coalition will be assisting local health care providers appropriate disposal of prescription medications. in adopting these new pain management guidelines, and utilizing these tools in their practice, by orchestrating an To further address the epidemic locally a number of educational series, in three parts, given by recognized subject public health partners have come together to form the matter experts. The first of these is Understanding Pain Central Valley Opioid Safety Coalition. This coalition will (scheduled for September 21st of this year), followed by ultimately be comprised of representatives from hospitals, Management of Chronic Pain on November 9, 2016, then clinics, health plans, the medical society, pharmacies, law Safe Prescribing on January 18, 2017.

Fall 2016

CENTRAL VALLEY PHYSICIANS

41

The heart asks pleasure first, And then, excuse from pain; And then, those little anodynes That deaden suffering; And then, to go to sleep; And then, if it should be The will of its Inquisitor, The liberty to die.

Emily Dickinson

BEING

BY DON GAEDE MD

WHAT IS THE PHYSICIAN’S ROLE? The early morning phone call jarred him into consciousness.

“Bill, my dad just killed himself. I just found his body in the garage.”

My friend’s wife was visiting her parents, helping them cope with her father’s advanced bladder cancer. The oncologist had just told him that the chemotherapy was not helping, and that surgery was not an option.

The next day, her father’s mood was changed. He appeared to have given up all hope. For dinner, he asked for his favorite meal of kung pao chicken. Later that evening, he said almost casually to his wife, “We’ve had a pretty good life together, haven’t we?” In the wee hours of the next morning, he slipped out of bed and put a bullet through his head.

Her father was an 83-year-old veteran of the Vietnam and Korean wars, a highly-decorated colonel, a “take-charge” kind of a guy. But before ending his life, he did not take the time to say goodbye to his wife and children. And he left a long wake of shock and sorrow behind him.

Since that day 3 years ago, my friend and his wife have often wondered how things might have gone differently. Might a palliative care consultation have averted his decision? If there had been a physician aid-in-dying law, could he have ended his life without causing so much emotional trauma to his family?

Atul Gawande, author of the best-selling “Being Mortal,” spoke on this issue at CMA’s leadership academy in May. He highlighted a 2010 Harvard study of metastatic non–small-cell lung cancer patients in which half of them were randomized to receive early palliative care. This intervention led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving palliative care had less aggressive care at the end of life, but surprisingly, longer survival.

Gawande believes that a palliative care consultation can be key to helping people with terminal illness live the

last days of their lives with better quality. Palliative care is sometimes confused with hospice. That’s understandable--it’s an important part of hospice care. But while hospice offers comfort during the last months of life, palliative care can be given at any point in a serious illness, and can be combined with curative treatment.

In June, California became the 5th state in America where it is legal for physicians to assist a terminal patient in dying.

A Gallup poll last year revealed growing support among the public for physician aid-in-dying: almost 70% of Americans supported the idea. Among us physicians, the subject remains more controversial; only about 50% of us support it, according to a 2014 Medscape survey.

Last year, the CMA changed its position on physicianassisted dying from “opposed” to “neutral,” stating that they “believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage.”

A recent editorial in JAMA entitled “The Liberty to Die” by Drs. Adashi and Clodfelter described the controversy well: “To its proponents, physician aid-in-dying represents compassion and beneficence in the face of terminal physical pain and disability, and the right to exercise free choice and autonomy of will. To its opponents, physician aid-in-dying violates deeply held views on the sanctity of life, distorts the imperative of the healing mission, devalues the role of palliation, and risks coercion of the elderly, disabled, destitute, and despondent.”

I have a lot to learn about end-of-life issues. Depending on the situation, and after a palliative care consultation, I might consider assisting a patient in ending his or her life. But however we physicians feel, we need to become more familiar with this difficult topic, turn it over in our minds, discuss it among ourselves, and most importantly, listen carefully to our patients’ concerns.

Save the

Date

36th Annual Central Valley Cardiology Symposium Saturday, October 29, 2016 - 8 am Madera County Office of Education, Madera CA

Feature Topics:

- Pulmonary Hypertension in the Heart Failure Patient – Distinguishing Primary from Secondary and How to Best Treat It - Update on Sleep Disorders and Heart Disease - Angiotensin Receptor – Neprilysine Inhibition: The Role in the Management of Heart Failure - An Update on New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: Assessing Risks and Individualizing NOAC Therapy - Open, Endovascular, and Hybrid Techniques for Treatment of Thoracic Aortic Aneurysms and Complicated Dissections - A Comparative Overview and Update on the Evolving Aortic and Mitral Valve Surgical and Transcatheter Therapies – (TVAR, Mitral Clip)

Speakers:

Jay D. Pal, MD, PhD Assistant Professor, Division of Cardiothoracic Surgery, University of Washington Preregistration required - No charge Richard F. Wright, MD, FACC Chairman of the Board, Pacific Heart Institute, Research Director, Pacific Heart Institute, Director, Heart Failure Center, Pacific Heart Institute Roblee Allen, MD Medical Director, Advanced Lung Disease/Lung Transplant Service, University of California Davis Medical Center

For more information or to register visit www.fmms.org or call (559) 224-4224 ext. 118 $75 registeration free for Physicians, Fresno Madera Medical Society members are free.

CME 6.0 Applied for, invitaton to follow

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CENTRAL VALLEY PHYSICIANS

Fall 2016

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

On behalf of Fresno Madera Medical Society, I would like to take this opportunity to invite all of you to Cardiovascular Update 2016--our Medical Society’s 36th Annual Central Valley Cardiology Symposium. Since its commencement in Madera over three decades ago, the objective of Cardiovascular Update has been to create an inter-professional forum for physicians, nurses, students and other allied health professionals to come together to imagine, share and create solutions to advance the heart health of our Central Valley communities through education and dialogue on cutting edge developments in clinical and translational “Bench-to-Bedside” cardiovascular research, technology and innovation.

We are deeply honored to have an extraordinary panel of distinguished experts and physician leaders who are renowned for their scholarship and dedication

Fall 2016

to community engagement. Each of our speakers have published extensively on a wide range of issues in cardiovascular medicine and have demonstrated a profound commitment to educating and training the next generation of physician leaders.

Dr. Roblee P. Allen, is a Professor of Medicine and serves as the Director of the Medical/Surgical Intensive Care Unit, and Director of the Invasive Procedures in the Pulmonary Services Laboratory at UC Davis Medical Center. Dr. Allen is a preeminent scholar and educator distinguished for his expertise in the field of advanced-stage lung disease and lung transplantation. He serves as a research fellow sponsored by the American Lung Association and the NIH. His clinical interests include functionality of lung volume reduction surgery, effects of anti-rejection drugs following lung transplantation, chronic obstructive pulmonary

CENTRAL VALLEY PHYSICIANS

45

Cardiovascular Update 2016 > 36th Annual

disease, acute respiratory distress syndrome, and cystic fibrosis. Dr. Allen’s extensive research studies include effects of high-carbohydrate diet on acute mountain sickness and circulating cytokines, effects of

overview of optimum treatment plans and methodologies for distinguishing primary from secondary pulmonary hypertension in the heart failure patient and an update on sleep disorders and heart disease.

Our reputable panel of physician leaders will engage with some of the most pressing and critical issues impacting the cardiovascular health and wellness of central San Joaquin Valley communities. therapeutic drugs on communityacquired pneumonia, cellular responses of bronchial and esophageal carcinomas to photodynamic therapy, treatments for gram-negative septic shock, and pharmacokinetics and iatrogenic drug toxicities in intensivecare units. His lectures will provide an

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CENTRAL VALLEY PHYSICIANS

Dr. Dipanjan Banerjee, is a Clinical Assistant Professor of Medicine and serves as the Medical Director of the mechanical circulatory support program and as physician lead of the heart failure readmission reduction program at Stanford Medicine. Dr. Banerjee is a dynamic

and accomplished expert in the fields of advanced heart failure and cardiac transplantation, with a primary interest in patients with end stage heart failure. His research interests primarily involve improving outcomes in patients with left ventricular assist devices (LVAD), including conducting clinical trials.

In particular, he is interested in the hemodynamic evaluation of patients receiving LVADs, and is part of a national multi-center trial investigating the use of protocolized ramp right heart catheterization in these patients. His presentations will focus on the role of Angiotensin Receptor—Neprilysine Inhibition in the management of heart failure and on the intricacies of patient selection and management for Left Ventricular Assist Devices (LVADS) for bridge to cardiac transplantation and

Fall 2016

destination therapy.

Dr. Jay D. Pal, is an Assistant Professor in the Department of Surgery in the Division of Cardiothoracic Surgery at the University of Washington and will serve as the Chief of Cardiac Surgery at the Puget Sound Veterans’ Administration Hospital. Dr. Pal is a prominent and gifted surgeon recognized for his expertise in the field of thoracic and cardiac surgery.

His clinical interests focus in the areas of mechanical circulatory support; heart transplantation; aortic surgery and adult cardiac surgery. Dr. Pal’s primary research interests are directed towards ischemia-reperfusion injury; mechanical circulatory support and outcomes after cardiac surgery. Dr. Pal’s first discussion will explore open, endovascular and hybrid techniques for the treatment of thoracic

aortic aneurysms and complicated dissections. The latter portion of his presentation will provide a comparative overview and update on evolving aortic and mitral valve surgical and transcatheter therapies— (TVAR, mitral clip).

Our reputable panel of physician leaders will engage with some of the most pressing and critical issues impacting the cardiovascular health and wellness of central San Joaquin Valley communities. Our Valley is afflicted with some of the highest rates of cardiovascular disease in California and all of us in the medical community must come together to imagine and create solutions to address this epidemic. I encourage all FMMS members and the greater Central Valley medical community to attend and engage Cardiovascular Update 2016, for what promises to be

a highly informative and stimulating learning experience.

I would like to give special thanks to all of our guest faculty speakers, to the dedicated members of our symposium committee, and to the entire FMMS staff for all of your tremendous efforts in making this CME initiative possible.

Yours collegially, Ranjit S. Rajpal MD Program Director Please join us for Cardiovascular Update 2016 on Saturday, October 29th, 2016 at the Madera County Office of Education in Madera, CA. Registration begins at 8:00 a.m.

To RSVP call 559-224-4224 or email nbutler@fmms.org

Management of Chronic Pain The healthcare community in Central Valley has seen an increase in problems arising from the use of prescription pain management medications.

The Central Valley Opioid Safety Coalition has planned a lecture series that will raise the level of understanding of this critical issue. The 3-part lecture series includes topics about Understanding Pain, the Management of Chronic Pain, and Safe Prescribing.

September 21, 2016 - Understanding Pain - Completed November 9, 2016 - Management of Chronic Pain January 18, 2017 - Safe Prescribing

Wednesday, November 9, 2016

Samir Sheth, M.D. Pain Medicine

Assistant Professor, Pain Medicine Co-Director of Neuromodulation, UC Davis Health System Additional speaker to be announced

CME Dinner Event

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2.0 Applied for - Email Invitation to Follow

November 9, 2016 - 6 PM to 9 PM Fort Washington Country Club 10272 N Millbrook Ave., Fresno, CA

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the number of people who die everyday from prescription opioid overdose

Preregistration is required - No charge Please register online at www.fmms.org or by calling (559) 224-4224. Registration must be received by November 4 to be a guarantee participant.

Fall 2016

In Memoriam

In Memoriam

Rabindra N Kundu • J. Charles Smith, MD • Maurice “Moe” Gillespie • Myron “Mike” William Joseph • Victor Medrano, MD

RABINDRA N KUNDU September 3, 1968 - August 31, 2016

Rabi as he was known to his friends, family and colleagues was born in Kolkata, Eastern India to Mr. N. G. Kundu and his wife Sandhya Kundu. During his early years of life, he travelled across the Indian subcontinent along with his parents and gained valuable experience in adapting to different systems of education. He was always a prodigiously talented student who rarely failed to excel in any and all subjects that happened to challenge his interests. As expected, he was accepted to the Armed Forces Medical College, Pune India one of the premier medical schools of India that went on to shape his future medical career. Following completion of his medical school, he was selected to join Surgical Residency at Post Graduate Institute of Medical Education & Research, Chandigarh, India and graduated with top honors as well as numerous commendations and accolades.

He subsequently decided to pursue minimally invasive GI surgical training in United Kingdom and towards that end acquired the prestigious Fellowship of the Royal College of United Kingdom (FRCS).

During the course of his training as Senior Registrar at Manchester, United Kingdom, the uniqueness of Gastrointestinal endoscopy started to fascinate him and led him across the ocean to Graduate Hospital Philadelphia, PA. Here he completed a few years of Internal Medicine Residency while simultaneously pursuing a very productive stint as an outcome

Fall 2016

researcher on Inflammatory Bowel disease at University of Pennsylvania. His skills as an endoscopist and brilliant clinician were soon noticed by multiple individuals at various Ivy League institutions leading to his acceptance at Beth Israel Medical Centre, Harvard Medical School, Boston MA for a dedicated two year advanced endoscopy Fellowship. He made his mark during his training with all his mentors and colleagues to the point of being offered a faculty position at Harvard Medical School. He declined that offer in the greater interest of pursuing the challenge of creating a new advanced endoscopy practice and gastrointestinal fellowship program at UCSF Fresno.

At Community Regional Medical Center (CRMC), Fresno, CA he was instrumental in creating a center of excellence for both Gastrointestinal Endoscopy and GI Oncology. He spearheaded the process of creating a state of the art endoscopy suite at CRMC Fresno.

He conceptualized, designed and helped to integrate endoscopy training and education into everyday gastroenterology practice. He was currently holding multiple hats as the Director of endoscopy at CRMC and the Program Director of the GI Fellowship at UCSF Fresno. He has inspired many of his trainees to either follow his career path or to continue to provide GI care locally in the Central Valley. His vision for Digestive Disease Health has led to the creation of a center of excellence at CRMC, Fresno CA providing much needed support for patients and their families in getting advanced GI care locally at Fresno rather than traveling out of the Central Valley.

CENTRAL VALLEY PHYSICIANS

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JOIN NOW AND RECEIVE

15 MONTHS OF MEMBERSHIP FOR THE PRICE OF 12.* *Starting October 1, 2016, new members who join, paying full 2017 dues up front, will receive the remaining months of 2016 membership for free.

When you join the California Medical Association and your local county medical society, you join more than 42,000 members statewide who are actively protecting the practice of medicine and defending public health. Together, we are stronger.

JOIN TODAY TO START RECEIVING YOUR BENEFITS! TOGETHER, WE ARE STRONGER. It’s through a strong membership foundation that CMA remains a dominant force in health care, leading the charge on several fronts, including the following: Continuously defending the Medical Injury Compensation Reform Act (MICRA) Advocating for specialty scope of practice that protects patients Leading public health efforts, including decreasing youth smoking and passing a landmark immunization law Other benefits of membership include professional, personal and practice resources, which commonly offset the price of dues. Learn more at www.cmanet.org/groupdiscounts.

COMPLETE THE APPLICATION ON THE BACK AND FAX OR MAIL TO: FAX: (916) 596-1128 MAIL: California Medical Association, 1201 J Street, Suite 275, Sacramento CA 95814

OR SIGN UP AT: WEB: www.cmanet.org/join • PHONE: 1 (800) 786-4262

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Fall 2016

In Memoriam

In Memoriam

Rabindra N Kundu • J. Charles Smith, MD • Maurice “Moe” Gillespie • Myron “Mike” William Joseph • Victor Medrano, MD

In his leisure time, he loved photography, traveling all over the world to exotic destinations and above all spending quality time with family and friends.

He leaves behind his wife of 17 years Sudeshna Kundu, two children Rishi and Roma and a whole legion of friends, colleagues and patients. He continued to be an inspiring educator, brilliant clinician and an ace endoscopist till the last moment of his life. His role as a father, husband and friend will be cherished and the loss so monumental that absolutely cannot be replaced.

Dr. Kundu was a member of the Fresno Madera Medical Society for 9 years.

J. CHARLES SMITH, MD February 17, 1949 – August 12, 2016

Dr. Smith was born on February 17, 1949, in Fort Worth, TX. Charlie passed away suddenly on Friday, August 12, 2016.

Charlie attended Austin College majoring in psychology.

He completed his premedical studies at University of California, San Diego, and then returned to the University of Texas for medical school. He then completed an Internship in Internal Medicine at University of Southern California, Los Angeles County Medical Center and stayed on at USC-LA County for residency in diagnostic radiology, followed by fellowships in both nuclear medicine and pediatric radiology at Los Angeles Children’s Hospital.

Charlie served San Joaquin Valley families for more than 35 years. First as a pediatric radiologist and department head, later as Chief of Staff at Valley Children’s Hospital, and as a member of the Board of Trustees for the past 20 years.

Fall 2016

Having already surpassed the career goals of his youth, Charlie was honored to have been named Chairman of the Board for the term commencing in January of 2017. In addition, he recently took on the role of Medical Director of Imaging at Saint Agnes Medical Center.

Whether Charlie was a mentor, a caregiver, a father figure, or a friend, each day brings yet another round of stories about how Charlie touched people’s lives. For his family, beyond simply being an amazing husband, father, and grandfather, Charlie was the best teacher they ever had, their favorite drinking buddy, and above all, the family prankster in chief.

Charlie is survived by his wife of 46 years, Susan Smith; his daughter, Ali Jordan and her husband Brett; and his son, Brenden Smith and his wife Laura. Charlie is also survived by his sister, Kay Stowell and her family in Austin, TX. Charlie had two grandchildren, Carter and Caroline.

Dr. Smith was a member of the Fresno Madera Medical Society for 39 years.

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In Memoriam

In Memoriam

Rabindra N Kundu • J. Charles Smith, MD • Maurice “Moe” Gillespie • Myron “Mike” William Joseph • Victor Medrano, MD

MAURICE “MOE” GILLESPIE May 2, 1941 – June 23, 2016

Dr. Maurice “Moe” Gillespie passed peacefully at his home in Monterey, CA, on Thursday, June 23, 2016, at the age of 75. Maurice was born on May 2, 1941, in Somerville, MA, to Maurice Sr. and Margaret Gillespie.

He graduated from the University of Notre Dame in 1963, then from Tufts University School of Medicine in 1967, and completed his internship at University of Washington, Harborview Medical Center in Seattle, WA. He served as a Battalion Surgeon in the United States Navy with the Third Marine Division in Vietnam where he was awarded the United States Bronze Star with Valor and the Vietnamese Cross of Gallantry in August 1968.

While volunteering his time at the Third Marine Division, Memorial Children’s Hospital in Dong Ha, Vietnam, Maurice decided to choose Pediatrics as a career.

He married Patricia in 1969, after they both returned from service in Vietnam and the couple then spent two years living in Italy where he was stationed with the United States Sixth Fleet. Moe and Pat moved back to the United States and settled in Fresno, CA, where he did his Pediatric residency at Valley Medical Center. He then joined the Fresno Children’s Medical Group where he practiced Pediatric Medicine for the next 40 years, serving for a time as the Chief of Medical Staff at Valley Children’s Hospital and working with California Children’s Services of Fresno County for 44 years.

In 2013, Maurice retired with Patricia to Monterey, CA. He was an active and dedicated member of the San Carlos Cathedral community where he was the Secretary of the

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Knight’s of Columbus, Council 1645. He was a Guide at the Monterey Bay Aquarium, a Docent at San Carlos Cathedral Heritage Center Museum, and a volunteer for the Loaves and Fishes Ministry.

Maurice is survived by Patricia, his wife of 46 years; children, Michael Gillespie and wife Ranee of Oakland, CA, David Gillespie of San Ramon, CA, Lynn Kragelund and husband Sean of Monterey, CA, James Gillespie and wife Katherine of San Francisco, CA, and Catherine Gillespie and wife Melissa of San Francisco, CA; siblings, Ellen Gillespie and husband Bruce Henry of Pittsfield, MA, and Jeanne Gillespie and husband David Pitton of San Jose, CA; and ten grandchildren.

Dr. Gillespie was a member of the Fresno Madera Medical Society for 34 years.

MYRON “MIKE” WILLIAM JOSEPH March 28, 1931 – July 18, 2016

Dr. Joseph passed away on Monday, July 18, 2016, in Fresno, CA. Mike was born to Glenn and Loleta Joseph on March 28, 1931, in Upland, CA. An only child, he grew up interested in many things including stamps and coins. As an Eagle Scout he earned a Dofflemyer Scholarship to Stanford University.

After graduating with a Bachelor of Science degree in Biological Sciences, he attended Stanford Medical School where he earned his MD in 1956.

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Dr. Joseph moved to Fresno for a year of internship at Fresno County General Hospital. Myron was a Captain in the 101st Airborne for two years returning to Fresno to complete his residency in Internal Medicine at the County Hospital. In 1962, Mike opened his first practice in Fresno.

Two years later, helping to establish an eight doctor practice on Fruit and McKinley. In 1975, when St. Agnes Hospital moved to its current location on Herndon, Myron moved his office to a nearby complex. During his career, Dr. Joseph served as Chief of Medical Staff at Sierra Hospital and at St. Agnes. For 32 years, he served as head of the ByLaws Committee at St. Agnes Hospital. Myron retired in December of 1999.

Following retirement, Mike, his wife Brenda, and a friend founded “Things Remembered” buying and selling collectibles and antiques. Mike greatly enjoyed the research involved, attending auctions and sales and establishing friendships with other dealers and customers. He also stayed busy helping Brenda with her estate sale business.

Mike was a man of many talents and interests. Over the years he enjoyed backpacking, camping, hiking, rock hunting and traveling, all recorded on thousands of photos. For almost 50 years many friends and family enjoyed celebrating life and holidays in their cabin at Dinkey Creek. Mike found joy in working in his large yard and was very proud of the front hedge which

he trimmed with great affection and enthusiasm until his health prevented him from doing so. Mike was an avid bridge player, enjoyed music of many kinds and supported the local arts community. He and Brenda supported the Bulldog Foundation attending Fresno State home games as often as possible.

Dr. Joseph was beloved by his patients because of his conscientious consideration not only of their symptoms and diseases, but their personal lives. Mike delighted family and friends with his quirky sense of humor, his intelligent interest Assisted Living • Memory Care in a multitude of subjects and his humble willingness to listen to their problems and lend a helping hand. Words cannot express the loss his wife and companion of 52 years is feeling. Mikey was a unique individual whose very existence has made the world a better place.

He is survived by his Resident focused care that you will be proud to recommend. wife Brenda; sons, Mark, Matthew and Ian; Brenda’s Personalized care plan • Incontinence Program sister, Janet and husband Medication management including injections • Purposeful activity programs Richard; granddaughters, Nurse on-site 7 days a week • Diabetic Wellness Program Rowan and Brooklyn; along with extended family and 5605 N Gates Ave • Fresno, CA 93722 close friends.

559-682-3114 Dr. Joseph was a member oakmontoffresno.com of the Fresno Madera Medical Society for 46 years.

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Fall 2016

CENTRAL VALLEY PHYSICIANS

53

In Memoriam

In Memoriam

Victor Medrano, MD

BY ALAN BIRNBAUM, MD

I met Vic Medrano, MD, perhaps in 1973, when he came to our house to call on my late mother, Dr. Nathalie Wolfe Birnbaum.

She had come under his care for her breast cancer that had been diagnosed and treated, first with surgical resection, then radiotherapy, some use of interferon radiotherapy but finally under Vic’s direction, the crucible of chemotherapy. What I recall of that visit are not any medical details but instead Dr. Medrano’s positive attitude.

In fact Vic was Fresno’s first true medical oncologist, in an era more than forty years ago when options were far fewer than the armamentarium now available. 5-FU. Vincristine.

Adriamycin, the orange infusion so irksome that my mother could not tolerate my drinking a Nehi orange soda in front of her. Ultimately the potions failed as of August 1975. Now this August of 2016 we have also lost Vic, like my own mother a victim of the great relentless voracious crab that is cancer. But we have not lost the human lessons of knowledge, judgment, empathy and integrity that marks the great doctors of each generation. These gird our medical skills every time we face a difficult situation, a patient in distress or a family in crisis.

Many reading this piece knew Vic well. He had a rewarding career advancing his specialty in the Fresno area through his retirement in 1998. The recent well-written death notice in the Fresno Bee, prepared by his daughter Victoria, can be readily found in-line. I suggest reading it slowly, like sipping any of the fine wines Vic enjoyed. Victoria beyond that was kind enough to share additional sources from family and close friends. The common thread among these was not just respect for the man as a doctor but deep affection for him as a human being.

Vic possessed leadership skills but especially people skills under the most difficult of situations. I still recall more than forty years later his gently letting a young intern, myself, know

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that he had come to the end of his skills in dealing with my mother’s final chapter, bony metastases that had scourged my her body until the final hypercalcemia took over. But as I was comforted, at the same time I became Vic’s student, in that art of medicine that goes beyond the diagnostic facts or the procedures, or the operations and the pharmacopoeia. If a doctor cannot help his or her patients deal with the painful reality and often finality of terminal disease they cannot be a complete physician.

To the extent after more than forty years I have become a complete physician I owe that to a few special teachers. Vic Medrano, surely was such a mentor for me and many others, who knew and learned from him. May he rest in peace as we serve his memory by using our skills as complete physicians.

Fall 2016

CMA/Fresno-Madera Medical Society/ Kern County Medical Society sponsored Health Insurance Program

Is your health insurance open enrollment soon?

Are your rates going up?

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Whether you are an individual policyholder or a member of a group health plan, it’s time to think about your health coverage for 2017. The open enrollment period for individual and family plans starts on November 1, 2016. Many practices have open enrollment periods for small groups on December 1 or January 1.

Did you know that you can get the right insurance though the CMA/Fresno-Madera Medical Society/ Kern County Medical Society sponsored Health Insurance program with Mercer? If you are covering yourself, or if you’re responsible for providing coverage for your family or employees, working with Mercer online or in person with a licensed agent, can get you the benefits you need, utilizing the physicians you want to see, at a price that fits your budget.

Working with the largest insurers in California, Mercer can help you determine what’s best for you.

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75541 (10/16) • Copyright 2016 Mercer LLC. All rights reserved. 777 South Figueroa Street, Los Angeles, CA 90017 800-842-3761 • www.CountyCMAMemberInsurance.com • CMACounty.Insurance.service@mercer.com Fall 2016

CENTRAL VALLEY PHYSICIANS

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Fresno Madera Medical Society 1040 E. Herndon Ave., Suite 101 Fresno, CA 93720

PRSRT STD. U.S. POSTAGE

PAID

Permit No. 30 Fresno, CA

State of the Heart SAINT AGNES CARDIOLOGY SYMPOSIUM 2016 MORE CENTRAL VALLEY

‘FIRSTS’ FROM SAINT AGNES Saturday, April 23 • 8 a.m.-2 p.m.

Opened the Valley’s first Saint Agnes Medical Center, Shehadey Pavilion cardiac rehab program.

1303 East Herndon Avenue • Fresno, California Introduced coronary stent technology.

Doctors perform THE FIRST Opened accredited, noninvasive and This symposium focuses on cardiovascular disease management OPEN-HEART SURGERY vascular lab. emerging paradigms in treating coronary and structural heart disease. at Saint Agnes First to study hearts with Medical Center It will address practice gaps in disease management and provide education 3-D color mapping.

to improve patient outcomes.

RVETTE STIN Speakers GR CO

COST OF A

Performed coronary bypass using robotic technology.

Used catheter closure procedure to fix heart defects.

AY

Performed first transcatheter aortic

replacement.Artery Disease Paradigms of Revascularization for Chronicvalve Coronary Verghese Mathew, MD, FACC, FSCAI A Healthgrades Five-Star recipient for heart attack treatment two years in of a row.

Consultant, Division of Cardiovascular Diseases and Department Radiology Professor of Medicine, Mayo Clinic College of Medicine

$8,000

Protected PCI: Treating Complex Coronary Artery Disease in 2016

apple Anthony A. Hilliard, MD computer Assistant Professor of Medicine was launched Director, Adult Cardiovascular Lab in a garage

ROCKY

Loma Linda University International Heart Institute

ruled the

box office at

Invasive Management of Intractable Angina Gurpreet S. Sandhu MD, PhD Director, Dr. Earl Wood Cardiac Cath Lab, Mayo Clinic

per ticket

Transcatheter MitralbyValve a pop single BritishTherapies duo 10cc Oluseun O. Alli, MD Assistant Professor of Medicine University of Alabama at Birmingham School of Medicine

Preregistration is required • No charge Please register online at www.samc.com. Registration must be received by April 16, 2016, to be guaranteedqueen's a participantBOHEMIAN syllabus. If you have questions or problems registering online, RHAPSODY went gold email medicaleducation@samc.com or call (559) 450-7566. samc.com Registration at the door is dependent on space availability.

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5 AMA PRA Category 1 Credits to be awarded