Central Valley Physicians Winter 2018

Winter 2018

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VOLUME 2, NUMBER 4 • WINTER 2018

{FEATURES}

8 5 24 28 38 44 48 Winter 2018

NEW OFFICERS WRITING CONTEST PHYSICIAN BURNOUT FMMS LIFETIME ACHIEVEMENT AWARDS LEGACY OF MEDICINE

{DEPARTMENTS} 6 EDITORIAL 16 PRESIDENT’S REPORT 18 PHOTO SPREAD - GOLF EVENT 22 MOVIE REVIEW 36 PHOTO SPREAD - HOLIDAY PARTY 46 PUBLIC HEALTH

LIFECYCLE OF LEGISLATION UNWAVERING DEFENSE

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From The Executive Director

HAPPY NEW YEAR!

This year seemed to fly by, and with every New Year I take some time to reflect on everything I am grateful for in my life.

Personally, I am grateful for my wonderful family, my husband who has the amazing ability to remain calm and grounded when I am not, my oldest daughter who moved to Dublin, Ireland to start her post-graduate NICOLE BUTLER training to become a veterinarian, and my youngest daughter started pre-school. For those of you wondering: yes, my two daughters are 20 years apart in age.

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

I am also grateful for another successful year at the Medical Society. We had a fantastic board of governors led by Dr. Alan Kelton. With his leadership, we were able meet our membership goals, hosted over 50 hours of Continuing Medical Education including our first ever CME cruise, and held another successful fundraiser supporting the Fresno Madera Medical Society Scholarship Foundation. In addition, the medical society moved the office to the Riverpark area, launched Central Valley Physician podcast and started expanding benefits locally for our members.

2018 will be another great year. We have a new president, Dr. Trilok Puniani, neurologist at Kaiser and some new board members that include Drs. Khwaja, Visveshwara, Barker, Golden, Jajodia and Anaya.

CENTRAL VALLEY PHYSICIANS EDITOR Don Gaede, MD MANAGING EDITOR Nicole Butler EDITORIAL COMMITTEE Don Gaede, MD - Chair, Alan Birnbaum, MD - Associate Editor, Roydon Steinke, MD, Cesar Vazquez, MD, Nicole Butler, Trilok Puniani, MD CREATIVE DIRECTOR www.sherrylavonedesign.com CONTRIBUTING WRITERS Don Gaede, MD, Roydon Steinke, MD, Erin Kennedy, Malissa Rose, Ken Bird, MD and Nicole Butler CONTRIBUTING PHOTOGRAPHERS

As we start working on our goal for year, Dr. Puniani and the Board of Governors will be busy with membership growth and retention, new membership benefits and developing a new program for physician wellness.

Nicole Butler, Derek Martin, Rogelio Rojo CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO:

January and February are membership renewal months. As a reminder, please renew your membership, and if you are interested in becoming a member, please go online at fmms.org to apply. Your membership cost covers membership to both Fresno Madera Medical Society (FMMS) and the California Medical Association (CMA).

Central Valley Physicians 255 W. Fallbrook, Suite 104 Fresno CA 93711 Phone: 559-224-4224 • Fax: 559-224-0276 Email Address: nbutler@fmms.org MEDICAL SOCIETY STAFF Executive Director, Nicole Butler Marketing and Events Coordinator, Kailey Fontes

Happy New Year!

Receptionist, Becky Gentry

Nicole Butler

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Winter 2018

1,000 Writing Contest! $

Do you have an inspiring or interesting story to tell? Do you have a particular ax to grind? Do you secretly yearn to become the next Oliver Sacks, Robin Cook, or Atul Gawande? Great—we want to hear from you!

Whether we physicians are communicating with each other, our patients, our political representatives, or the public at large, good writing skills are invaluable. The Fresno-Madera Medical Society would like to encourage these skills. Hence, we are launching this writing contest.

Here are the rules: 1. $1,000 will be awarded to the physician who submits the best piece of writing by April 1, 2018.

2. The physician must be a member of FMMS in active practice.

3. The article should be 400 to 1,000 words long. It may be subject to minor editing.

4. The subject matter must relate to the medical field.

5. A panel of 3 physicians on the FMMS executive board will judge the contest. The articles will be evaluated anonymously; in other words, the names of the authors will not be revealed to the judges until they have chosen a winner.

You can email your article to our executive director Nicole Butler at nbutler@fmms.org, or send by mail to: Nicole Butler, Executive Director 255 W. Fallbrook Ave., Suite 104 Fresno, CA 93711 Winter 2018

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

Taking Ownership

ABOUT THE AUTHOR Dr. Gaede, a Fresno native, is board-certified in Internal Medicine and specializes in Vascular Medicine, with an expertise in the treatment of varicose veins, circulation problems, blood clots, and advanced techniques using ultrasound and sclerotherapy.

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Dr. Terry “Hutch” Hutchison says we physicians need to take ownership of our patients. I was intrigued when I heard him use this phrase while accepting the FMMS Lifetime Achievement Award in November (see page 28) Here is a man who, at age 78, is still practicing and teaching neurology.

He’s widely respected, and dare I say loved, by his patients, residents, and colleagues. So I said to myself, this is a man to whom I probably should pay close attention.

A few weeks later I asked him to elaborate a bit on what he had said. “Ownership” of our patients has a number of facets, he said, but an important part is establishing a personal, caring relationship with them.

To illustrate the concept, he told me about something he did while teaching and practicing neurology in

San Francisco. It began concerning him that the people taking the incoming calls from patients and families were not always the most cordial and patient. He thought that maybe this was because they were housed in a building entirely separate from the medical clinic. They never saw the patients they were dealing with.

So he took some photos of his patients and families, and brought them over to show to the people answering the phones. Then he asked them, if these were your children, how would you feel toward them? How would you speak to them?

I get the feeling that every time Dr. “Hutch” sees a patient, he asks himself the very same question: “What if this patient were my child--how would I speak to him or her?”

Some of this caring attitude toward patients may also stem from the fact

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that his 16-year-old son was involved in a very serious car accident; it resulted in significant brain injury and epilepsy.

His son now leads an epilepsy support group.

Fragmentation of care: Dr. Hutchison said that over his many years of practice, he’s seen more and more of this issue.

Specialists often focus their sole attention on their particular slice of the patient’s problems; the rest of the patient’s issues may be ignored, or perfunctorily noted on the Problem List.

He said that for primary care physicians, taking ownership of the whole patient is even more important. How true, I thought. I experience this issue from both sides, since I practice both as a primary care internist and a vascular medicine specialist.

In my role as primary care internist, I try to be my patient’s advocate and consultant. Sometimes my sicker patients’ care seems to be “taken over” by numerous specialist physicians.

But it is my role as primary care physician to stay involved, and help them navigate the murky medical waters.

Abraham Maslow famously wrote, “I suppose it is

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tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” As specialty physicians, it is essential to not only evaluate the patient through the lens of our specialties, but to also look at the entire patient. So let us specialists lay our hammers down for a minute, to really get to know our patients, before we proceed to the next nail.

An emphasis on “ownership” might benefit our patients as well. It may seem obvious to us physicians, but perhaps we should tell them explicitly that we are simply their consultants. We can educate them about their health issues, give them drugs, and perform surgeries, but their overall health​is much more dependent on ​t heir own lifestyle ​choices than ​on ​our interventions​.

Dr. Hutchison told me that practicing medicine is still very rewarding for him. Taking ownership of his patients probably explains why he’s still practicing medicine well past the usual retirement age. In this era of increasing physician dissatisfaction and burnout, his approach to patients is one we might all try to emulate.

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Fresno Madera Medical Society

ELECTS NEW OFFICERS Fresno Madera Medical Society announced the appointment of new officers for 2018. The Board of Governors and the new officers started their term beginning January 1.

PHOTOGRAPHER: DEREK MARTIN

Incoming president Trilok Puniani, MD, Neurologist at Kaiser Permanente, Fresno, has been a member of the medical society for 30 years and has served on the Board for the past 5 years.

Dr. Puniani has been a rising leader within the Medical Society, having previous experience serving in all of the officer positions as President-Elect and Vice President. He also serves in various leadership roles within Kaiser. >>

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Officers: PRESIDENT – Trilok Puniani, MD Neurology, Kaiser Permanente PRESIDENT-ELECT – Cesar Vazquez, MD Pediatrics, Cesar Vazquez, MD, Inc. VICE PRESIDENT – Alan Birnbaum, MD Neurology, Spruce Multi-Specialty SECRETARY-TREASURER – Don Gaede, MD Internal Medicine and Vascular Medicine PAST PRESIDENT – Alan Kelton, MD Internal Medicine, CCFMG Christine Almon, MD Janae Barker, DO Jennifer Davies, MD Joseph Duflot, MD Patrick Golden, MD David Hadden, MD Prahalad Jajodia, MD Brent Kane, MD Shamsuddin Khwaja, MD Christine Maser, MD Katayoon Shahinfar, MD Nadarasa Visveshwara, MD Andres Anaya, MD (Resident Board Member) CMA TRUSTEE: Ranjit Rajpal, MD

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In 2018, Fresno Madera Medical Society will focus on Physician Wellness. As your colleagues, the physician leadership at FMMS, understands the struggles physicians face on a daily basis.

As your professional organization, FMMS is determined to help physicians in the Central Valley find happiness and fulfillment in your profession. Our goal is to engage physicians in the region in a long-term conversation that will help physicians recognize the signs of burnout, build meaningful resiliency, and help physicians thrive.

We will continue our efforts to raise funds for the FMMS Scholarship Foundation. For over 50 years we have distributed scholarships to hundreds medical students from the Valley.

In 2016 we granted $25,000 and this year that amount increased to over $35,000. Funding for those scholarships came from generous donations of physicians and from our annual fundraiser “Summer Meltdown.”

In 2018 FMMS will continue to expand our Continue Medical Education program, adding additional educational seminars throughout the central valley. In 2017 we provided over 40 CME hours covering topics in cardiac, nephrology, pain management, asthma and diabetes. We also hosted our first CME Cruise to Alaska, and planning another cruise in 2019 to the French Riviera.

For the past two years the Medical Society has been a major stakeholder with the Central Valley Opioid Safety Coalition (CVOSC) with the goal of educating the medical community on improved methods for pain management and safe prescribing. In 2018 CVOSC will expanding its efforts with more community messaging in order to decrease deaths in the valley due to overdose.

Fresno Madera Medical Society will also continue to work with the California Medical Association (CMA) in 2018 to sustained malpractice protection law. MICRA will always be a fight for us as trial attorneys continue to try and pass a proposition that will radically change our practices and malpractice risk.

Winter 2018

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MEMBERSHIP

Becoming a Member Top 10 reasons why you should join today.

When you become a member, you support your local medical society and hire CMA, a powerful professional staff to protect your profession from legal, legislative, and regulatory intrusions. Below are the top 10 reasons to be a member of Fresno Madera Medical Society (FMMS) and the California Medical Association (CMA).

1. Protect MICRA

3. Stay in the Know

CMA staunchly defends the landmark Medical Injury Compensation Reform Act (MICRA) year after year, saving each California physician an average of $75,000 per year in professional liability insurance premiums.

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

2. Collaborate with Colleagues FMMS bring together physicians from all over the Valley, from different specialties and modes of practice to develop strong unity through leadership, collaboration, socials, educational events, and community service.

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4. Shape the Future of Medicine Through aggressive political and regulatory advocacy, CMA and its county medical societies

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MEMBERSHIP

CMA was founded in 1856 by a small group of physicians who knew it was their duty to fight for their patients and for their profession.

are positioned among the most influential stakeholders in the development and implementation of health policy. In addition, members receive direct access to our state and national legislative leaders to influence how medical care is provide today and in the future.

5. Save Money There are several ways to save money when you are a member. Discounted health insurance for you and your staff, automatic 5% savings on workers’ comp insurance, CME and Online educational courses, auto and home insurance, car rental, office supplies and much more. >>

NEW! New Monthly Membership!

Fresno Madera Medical Society and California Medical Association membership is easy to maintain and hassle-free with automatically recurring monthly payments at an affordable price. If you are not a member, enroll today at www.cmanet.org/monthly to start receiving your benefits! If you’re a current member, and would like to switch to monthly payments keep an eye out for your renewal invoices and choose the monthly payments.

QUESTIONS? Contact CMA’s Member Service Center at (800) 786-4262 or memberservice@cmanet.org.

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MEMBERSHIP

Ask yourself who will have the most impact on the way you practice “medicine - the government, or physicians in organized medicine through CMA? Be involved or be left behind. ” - J. Brennan Cassidy, M.D.

6. Get Paid Members receive one-on-one assistance from CMA’s reimbursement experts, who have recouped $15.5 million from payors on behalf of CMA physicians in the past nine years.

7. Continue Medical Education FMMS provides opportunities to further your knowledge with Continuing Medical Education. CME symposiums and dinner events are provided throughout the year with current topics that relate directly to your patient care. Learn from the experts and hear from recognized speakers.

8. Education and Training for Your Practice FMMS provides monthly Medical Managers Forum to arm your office staff with practical information and tools to overcome new challenges in

healthcare, run the office successfully and move your practice forward.

9. Lead by Example FMMS and CMA provide many opportunities to get involved, including opportunities to volunteer; serve on a committee, council or board; and shape the future of the medical profession and giving back.

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

Fresno Madera Medical Society was founded in 1883, as the first professional organization in Fresno County. Chester Rowell, MD, and a small group of physicians created the organization two years before the city of Fresno was incorporated, and formed the cornerstone of organized medicine in the area. Today, Fresno Madera Medical Society has over 1200 physician members working together to provide care to Valley residents.

Christina Maser, MD, FACS Associate Clinical Professor, UCSF Medical Director, University Surgical Associates • Member since 2006

QUESTIONS? Contact FMMS at (559) 224-4224 ext 118 or CMA’s Member Service Center at (800) 786-4262.

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Winter 2018

CALIFORNIA MEDICAL ASSOCIATION

SEE JANE SAVE WITH CMA Purchased health insurance for her

Purchased workers’ comp insurance

8-person staff through Mercer.

through the Mercer/Preferred

SAVED: $12,120

Employers program.

SAVE: $750

Called CMA’s legal information line and accessed documents from CMA’s online

Earned 16.75 CME by attending

health law library, instead of calling an

CMA’s Western Health Care

attorney for that same information.

Leadership Academy.

SAVED: $2,660

SAVED: $400

Used EnviroMerica to manage

Participated in 3 online webinars.

her practice’s medical waste and

SAVED: $297

regulatory compliance.

SAVED: $1,200

Used CMA’s magazine discount program to subscribe to 10 magazines

Hired CMA partner Mayaco Internet

for her waiting room and exam rooms.

and Marketing to design a new

SAVED: $250

mobile-friendly website.

SAVED: $1,000

Bundled her auto and home insurance through Mercury Insurance.

Called CMA’s reimbursement helpline.

RECOVERED: $800

SAVED: $230 Kept track of her CME credits through

Sent her billing staff to CMA’s

IMQ’s online CME certification portal.

ICD-10 boot camp.

SAVED: $24

SAVED: $800

Bought security prescription EMR Purchased office supplies through

sheets from RxSecurity.

CMA’s Staples Advantage program.

SAVED: $10

SAVED: $750

TOTAL SAVINGS: $21,291 Saving money, having access to unique services, knowing her dues support the California Medical Association’s efforts to Winter 2018 CENTRAL VALLEY PHYSICIANS 15 protect the viability of her practice, so she can focus on providing her patients with excellent care: PRICELESS

President Report > Trilok Puniani, MD

I Ran for President Because...

ABOUT THE AUTHOR Dr. Trilok Puniani is a board certified in Neurology and Vascular Neurology, he completed is residency training at New York Medical College and Westchester County Medical Center, in Valhalla, NY and his fellowship training at Methodist Hospital and Baptist Memorial Hospital in Memphis, TN. Upon completion of residency and fellowship in Neurology, Puniani moved to Fresno in 1989 and started a private practice later joining Kaiser Permanente in 1997 where he is currently Chief of the Neurology Department.

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I ran for President because this is a great organization with a mission, and it provides me with an opportunity to interact and serve my colleagues.

As physicians, we are always faced with the challenges of everyday life and providing the best care to our patients, and we need to be valued for the sacrifices we have made to earn our professional titles.

A major consequence of our current healthcare system is physician burnout.

Burnout occurs when a physician experiences one or more of these symptoms: depersonalization, emotional exhaustion, or a low sense of accomplishment.

We physicians spend endless hours performing clerical work, frustrated dealing with health insurance companies, obtaining authorization for ongoing care of patients and Electronic Health Record (EHR); although EHR is a necessary technology for safe and efficient patient care.

One study found that physicians spent 27% of their work day on direct patient care and 49% on EHR and desk work.

We need to recognize physician burnout and provide our colleagues with the appropriate support. Our Medical Society will be actively involved in bolstering the physician wellness and wellbeing programs to help our physicians achieve a better work-life balance.

Now let me briefly talk about Health Care: Health care reform is in political turmoil.

Last month I attended the California Medical Association (CMA)-House of Delegates (HOD) 146th Annual session in Anaheim. There were several great speakers, including politicians like House Majority Leader Kevin McCarthy and Congressman/physician Raul Ruiz. There was an extensive discussion about health care reform and whether the single payer system should be law of the land.

What struck me the most was that none of the speakers could furnish a plausible explanation for the exorbitant cost of health care.

I firmly believe that the epidemic of escalating health insurance premiums is deeply rooted in three major contributing factors:

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We have the voices of our physicians through Advocacy and unified support.

We can revive our Political Action Committee locally.

1. The pharmaceutical companies.

All of us are quite familiar with the exponential increase in the cost of the drugs every year. In Neurology, I can give you an example of some the drugs used in multiple sclerosis that 1990’s cost about $18,000 a year. The same drugs in 2017 cost upwards of $55,000 a year. All the other specialists have seen similar trends. Some of the newer drugs for treatment of cancer, AIDS, and other chronic conditions cost upwards of $100,000 a year.

2. The generous rewards of the CEOs of health insurance and pharmaceutical companies.

In 2016, the CEOs of the eight largest publicly traded health insurance companies made $171.8 million in total compensation, based on stock gains.

The CEOs’ combined 2016 compensation would be enough to cover the average annual premium for almost 60,000 people.

Since 2010, when the Affordable Care Act was passed, compensation packages for CEOs of U.S. health care insurance and pharmaceutical companies totaled $9.8 billion.

The top earner was John Martin, the former CEO of pharmaceutical company, Gilead Sciences, who took home nearly $900 million.

3. Cost of malpractice insurance.

Nationwide, the cost of malpractice insurance is escalating.

Fortunately, in California, we do have a safety net: MICRA (Medical Injury Compensation Reform Act of 1975). As most of you may recall, on November 4, 2014, Proposition 46 failed, which otherwise would have raised the MICRA cap to current inflation standards (approximately $1.1 million).

This is a direct result of advocacy by the CMA including the support of all the physicians in the Medical Society.

How can we move forward?

We have the voices of our physicians through advocacy and unified support.We can revive our Political Action Committee locally.

As physicians we need to show true leadership by working together in:

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•A dvocating for health care reform in today’s uncertain political environment, in collaboration with CMA and other medical societies.

• S hape the future of health care and position ourselves in implementing health care policy.

• E nsuring access to quality medical care for our patients.

• P romoting physicians’ wellness.

Like most of you, I strongly believe that every US citizen is entitled to health care coverage.

In order to mitigate the cost: • Our Health care system should be a nonprofit organization.

•L imit the compensation of the CEOs. •C ap the escalating cost of pharmaceutical drugs and malpractice insurance.

• E xplore an alternative model of health care system such as Cleveland Clinic, Mayo Clinic and Kaiser Permanente.

In conclusion, I would like to thank the Board of directors of FMMS, and the past presidents of the Medical Society, Drs Ilic, Rajpal, Jajodia, Aminian and Dhingra, for their unfaltering support.

Every year, the bar is raised higher, and I intend to continue that trend.

I would also like to thank Nicole Butler and her amazing staff, who have been instrumental in running the daily activities of this Medical Society.

I thank my colleagues in Kaiser Permanente for their support.

Last but not least, I am thankful to my supportive family, my wife Navjit and our 3 sons, Arjan, Angad, and Gobind.

I am looking forward to a bright and successful year.

Trilok Puniani, MD

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GO LOCAL ORGANIZATIONS GIVING BACK TO HEALTH CARE IN THE VALLEY

GL Bruno Family Foundation hosted its 21st annual golf tournament at San Joaquin Golf Club, raising a record $123,000.

PHOTOGRAPHER: ROGELIO ROJO & NICOLE BUTLER

This year’s event hosted 140 golfers from 30 organizations and distributed funds to the following beneficiaries; Saint Agnes Foundation, Valley Children’s Hospital, Connecting the Cure to Crohn’s and Colitis, America Cancer Society, Community Regional Medical Center Terry’s House, Alzheimer’s Association, and two new organizations, United Cerebral Palsy of Central California and the Poverello House.

At the tournament Gary L. Bruno, Foundation founder and President and Chief Executive Officer of G. L. Bruno Associates, Inc., cited the generosity of over 20 tournament sponsors that supported the event stating that their commitment is the major factors in the tournament’s ongoing success. With this year’s gifts, the Foundation has donated over $870,000 to medical-related charities within the Central Valley. >>

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OLF Winter 2018

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GOLF

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Movie Review Kings Row • By Roydon Steinke, MD

“Kings Row”, 1942, starring Ann Sheridan, Robert Young, Ronald Reagan and Betty Field, was nominated for 3 Academy Awards. It was produced by Hal Wallace who went on to produce many Elvis movies. Ronald Reagan was a registered Democrat when he gave this performance.

This movie, simply, is about doctors and the practice of medicine. The venue, Kings Row, is a town of about 5,000 people established in 1890 and the time depicted was the late 1800s and 1900. Two doctors, Dr. Alexander Q. Tower and Dr. Henry Gordon, practiced in this community. Dr. Tower, trained in Vienna which was considered a superior center for medical education, like Berlin or the Sorbonne at that time; Dr. Gordon was trained in America. Early in the movie, Dr. Tower is described as “a doctor who says he is a doctor but never has any patients and has a wife who stays in an upstairs bedroom all the time.” Dr. Gordon’s entrance has him surgically treating ulcers without chloroform anesthesia, apparently, available at that time. The screams are palpable!

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Young Parris Mitchell (Robert Young) wants to be a legendary doctor and studies with Dr. Tower to prepare for entrance into medical school in Vienna.

His friend, Drake McHugh (Ronald Reagan) is “wild” and irresponsible.

While in Vienna, Dr. Mitchell, who has aspirations for a career in psychiatry, learns that his friend, McHugh, suffered a bilateral leg amputation after an accident that was performed by Dr. Gordon. Mitchell returns home to some severe tragedies and psychiatric problems that needed attention.

The topics illustrated in this movie include class distinction and melding of people of different classes; the relationship of daughters with their physician-fathers; good well-trained doctors verses doctors who are “country quacks”, “bedside manners” doctors, “eminent carpenters with a knife, chisel and scalpel” or who “punish transgressions.”

The young Dr. Mitchell shows incredible compassion in lieu of the sangfroid approach of the older two doctors and in the end learns about the importance of frank honesty with the patient.

The acting was superb and one got the feeling that one was watching real people and not movie stars. In addition the cinematography was brilliant providing excellent display of real town America.

On a personal level, this movie allowed me to reminisce about my youth reading to my mother by a coal-oil lamp, cooking on a wood stove, pumping water with a hand pump, and driving a team of horses hitched to a wagon. Also, this movie whetted my interest in medicine as a youth.

Quotes from the movie: “Some people grow up and some people just grow older.” “Medicine is a game in which man pits his brain against the forces of destruction and disease.”

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Burnou

Physician Burnout

CMA Doc: Edward Ellison, M.D. Southern California physician sets out to teach physicians that their wellness matters

“Physicians are ailing,” says Edward Ellison, M.D. He wants the public to know about it and to thank their physicians, he wants governing bodies to understand the toll their reporting and oversight requirements are taking on physicians, and he wants the physicians who lead medical schools, residency programs and medical groups to change the nature of being a physician from one of suffering to one of health and well-being.

Dr. Ellison is in a position—or more accurately, many positions—to effect that change. Since 2012, he has been Executive Medical Director and board chair of the Southern California Permanente Medical Group. He is also board chair and CEO of the Southeast Permanente Medical Group, comprised of 500 physicians in the cities of Atlanta and Athens, GA, and surrounding areas. >>

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Dr. Ellison is so concerned about physicians’ unhappiness in a profession they once loved that he presented the grim picture to a public, nonmedical forum, the 2017 TEDxNaperville conference in the Chicago area this November.”

He is co-CEO of the nationwide Permanente Federation. And he is a member of the board of directors of the soon-to-be Kaiser Permanente School of Medicine, under construction in Pasadena.

He was also part of an AMA consortium of 10 physician leaders of major medical groups, including the Mayo and Cleveland clinics and several academic medical centers, drawn together in 2016 to propose solutions to the physician burnout crisis, which jeopardizes the quality of care and is pushing more and more physicians to leave the profession.

Dr. Ellison is so concerned about physicians’ unhappiness in a profession they once loved that he presented the grim picture to a public, nonmedical forum, the 2017 TEDxNaperville conference in the Chicago area this November. Among the causes of burnout, Dr. Ellison, said are that physicians, who are by nature perfectionists, feel they have lost control over their work and are “being measured on everything they do.” The electronic health care records and reporting requirements have created inefficient workf lows and less time for patients, which “feel like a gigantic pile-on.” He noted that surveys of physicians conducted in 2011 and again in 2014 showed that numbers of physicians experiencing at least one symptom of burnout rose to 54.4 percent from 45.5 percent.

“But it gets darker,” Dr. Ellison said. “In the last two years data show that the rate of suicide among male physicians is 40 percent higher than that of the general public,” with female physicians’ suicide rate “130 percent greater than the general public.” In fact, he said, “The rate of suicide among physicians is similar to that of combat veterans.”

Much of the problem, too, begins in medical school with many physicians entering practice after residency training already “broken and beaten,” Dr. Ellison said. He noted that two of his medical school classmates killed themselves before beginning their internships. He described his early career within the traditional “lockstep” regimen of American medical education: “I did the

Winter 2018

In a first for U.S. academic medical center, Stanford Medicine hires chief physician wellness officer

BY RUTHANN RICHTER, STANFORD UNIVERSITY

Tait Shanafelt, M.D., a pioneer and nationally recognized expert in physician burnout, recently joined Stanford Medicine as its first chief wellness officer, leading the medical center’s pioneering physician wellness program.

His appointment makes Stanford the first academic medical center in the country to create a position of chief wellness officer at a time when physician burnout nationally has reached an all-time high. Dr. Shanafelt, whose clinical work and research focus on the treatment of patients with chronic lymphocytic leukemia, will direct the WellMD Center at Stanford Medicine and serve as associate dean of the School of Medicine.

Leading the way Since 2008, Dr. Shanafelt has overseen multiple national surveys that included more than 30,000 U.S. physicians and about 9,000 U.S. workers in other fields. These found increasing rates of burnout among doctors; in 2014, more than half of those surveyed were suffering from emotional exhaustion, loss of meaning in work or a sense of ineffectiveness and a lack of engagement with patients. Moreover, his studies have found that as physicians suffer, so do patients: Burnout has been found to contribute to physician errors, higher mortality among hospitalized patients and less compassionate care.

“I think most health care leaders now realize this is a threat to their organization, but there is also uncertainty that they can do anything effective to address it,” Dr. Shanafelt said. “They say, ‘It’s a national

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epidemic, what can we do?’ My experience has shown that an individual organization that is committed to this at the highest level of leadership and that invests in well-designed interventions can move the needle and run counter to the national trend of physician distress and burnout. I hope that the Stanford WellMD Center becomes a paragon that other medical centers want to emulate.”

Declining burnout rates at Mayo In 2008, Dr. Shanafelt became the Mayo Clinic’s director of the Department of Medicine Program on Physician Well-Being and launched an effort to address physician distress through programs promoting physician autonomy, efficiency, collegiality and a sense of community. While many were focused on strategies to make individual physicians more resilient, Dr. Shanafelt and his team focused on systems, the practice environment, organizational culture, and leadership.

As a result, the absolute burnout rates among Mayo physicians declined 7 percent over two years, despite an 11 percent rise in the rate among physicians nationally.

Dr. Shanafelt will work in collaboration with his new colleagues at Stanford in building on its innovative WellMD Center, which was established in 2016. The center has engaged more than 200 physicians through programs focusing on peer support, stress reduction and ways to cultivate compassion and resilience, as well as a literature and a dinner series in which physicians explore the challenges and rewards of being a doctor.

Bryan Bohman, M.D., who served as WellMD’s interim director, said the WellMD team has worked closely with Dr. Shanafelt over the past year on projects of mutual interest.

“All of us at the center have been struck by Tait’s collaborative nature, his integrity, his warmth, his generosity of spirit and his work ethic,” said Dr. Bohman, who also serves as chief medical officer for Stanford’s University Healthcare Alliance. “Both at Mayo and nationally — in the physician wellness community — Tait is seen as an inspiring and strong leader. We couldn’t be happier that he will be guiding our future wellness work at Stanford.”

This article was excerpted with permission from Stanford Medicine News. Ruthann Richter is the director of media relations for the Stanford University School of Medicine Office of Communication & Public Affairs.

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I have gained perspective. I have heard the cries. it is time that society recognize and care about the lives of those who save lives.”

training. I went without sleep. I ate junk. And I learned and I suffered. But I was also inspired by the gratitude of my patients and the satisfaction of knowing I was making a difference in people’s lives. So I did more and I asked for more and took on more, as my colleagues do.”

Now, however, having been “called to leadership,” and being a “co-leader of one of the largest groups of physicians in the world—21,000 doctors taking care of almost 12 million patients,” he said, “I have gained perspective. I have heard the cries.” He said it is time that society “recognize and care about the lives of those who save lives.”

Within SCPMG, he spearheaded a physician wellness program focusing on physicians’ health and on burnout prevention. For the physicians of the future he wants a total transformation of the American medical culture.

“We need to change our thinking,” Dr. Ellison says, “and change our culture inside and outside of the medical profession across society…We have to declare our physicians’ humanity.”

Permanente, he says, has a “path forward” beginning with its new medical school. As well as teaching students to be exceptional physicians, which is “nonnegotiable,” he says, “We are going to teach them that their wellness matters. We are going to provide support for them and connect them with each other and resources. We are going to teach them how to set healthy boundaries for their own wellness and about how prevention and nutrition work not just for their patients but for themselves.”

For whatever kind of medical system—small practice, large practice, academic institutions—that the students set their sights on, he says, ““We’re going to teach them how to work within theses systems to change these systems so they’re not buffeted about [and] they can be advocates for change.”

“I still love my profession,” Dr. Ellison says, and he hopes young people, “those bright shining stars,” will continue to seek it out.

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The California The California Medical Medical Association Association and the andSierra the Fresno Sacramento Madera Valley Medical Medical Society Society

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Medical Mentors

LIFETIME

Mentor – it’s who they are and it’s what they do.

Look up the word and the synonyms abound: educator, master, counselor, motivator, orienter, but also trailblazer, expert, and sage. In the verb form they pave the way, make another ready, encourage, direct, demonstrate, edify and illuminate.”

By Erin M. Kennedy Photography by Derrek Martin

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ll of this year’s Fresno Madera Medical Society Lifetime Achievement honorees do that and more. All University of California, San Francisco, faculty members in Fresno, they’ve made a mark through mentoring others to follow in their footsteps.

And in keeping with the mentoring theme, this year’s Special Project Award went to a family practice physician who partnered with local schools to encourage disadvantaged students to pursue healthcare careers. That’s especially crucial in the central San Joaquin Valley which has one of the lowest doctor-to-patient ratios in California.

“Mentor” does not fully do justice to the legacy of

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Honored for their

OF SERVICE

these physicians. One was an always on-call surgeon and hand expert with a signature dressing method named for him. Another helped rebuild and restart the UCSF Fresno cardiology fellowship program.

The third is known for his tender heart, handing out his cell phone number to patients and moving mountains to get rare treatments for his pediatric patients. >>

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THE 2017 LIFETIME ACHIEVEMENT HONOREES ARE:

•K ent Yamaguchi, M.D., FACS, a recently retired UCSF Fresno clinical professor specializing in reconstructive plastic and hand surgery • R alph Wessel, M.D., assistant clinical professor for UCSF Fresno’s cardiovascular fellowship and former Chief of Cardiology at Kaiser Permanente Fresno • H. Terry “Hutch” Hutchison, M.D., Ph.D., a UCSF Fresno clinical professor board certified in child neurology, pediatrics and genetics

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The 2017 Special Project Award went to Katherine Flores, M.D., director of UCSF Fresno’s Latino Center for Medical Education and Research, for her work creating The Doctors Academy at local high schools and expanding the program to junior highs and California State University, Fresno.

No better place than Fresno

I think he’s spent a lifetime giving back to his community.” - Dr. Sian

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A native of Fresno, Plastic Surgeon Kent Yamaguchi is also exceedingly proud of local institutions say his friends. “He always asks every resident he meets where they went to school,” said Krista Kaups, M.D., MSc, FACS, who has worked beside him for 23 years at Community Regional Medical Center in her roles as director of the surgical intensive care unit and program director of the Surgical Critical Care Fellowship at UCSF Fresno. “When they tell him some Ivy League school or another prestigious university, he’ll tell them, ‘That’s too bad you couldn’t go to Fresno State.’”

His advocacy for his hometown convinced Kenty U. Sian, M.D., to come to the Valley after they met at Indiana University Medical Center where Dr. Yamaguchi did his plastic surgery residency. “He’s responsible for bringing me to Fresno,” said Dr. Sian, estimating that half the Valley’s plastic surgeons are here because Dr. Yamaguchi trained or recruited them. Besides UCSF residents, Dr. Yamaguchi also mentored local college and high school students, encouraging them to go into medicine.

“I think he’s spent a lifetime giving back to his community,” Dr. Sian said.

Dr. Yamaguchi says he always knew he’d come back to the Valley to care for his community after going to UCSF and then University of California, Irvine, for his otolaryngology residency and Indiana for a plastic surgery residency. He did one more stint out of state to complete a fellowship in head and neck surgery at Boston University before coming back to Fresno more than four decades ago.

In those early years he was the sole doctor on call for reconstructive plastic and hand surgery in Fresno say his colleagues at Community Regional’s Level 1 trauma center. “If I had a tendon laceration, he’d come in the middle of the night to fix it” said Gene Kallsen, M.D., chief of Emergency Medicine at Community Regional and a UCSF clinical professor. “Other specialists might say things can be done electively later, but we ER doctors so appreciated it when he came in and took care of the issue right away … He’s one of the most hard-working doctors I know.”

Dr. Kaups estimated that Dr. Yamaguchi has cared for thousands of trauma patients, returning hand function to normalcy for the vast majority.

“He set a standard for hand surgery that is extremely high,” agreed Dr. Kallsen. “Everyone he’s taught and worked with knows the

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‘Yamaguchi hand dressing.’”

Ask Dr. Yamaguchi about the bandaging method named after him and he shrugs in his usual humble fashion. He explains, “Oh that’s just a way of splinting the hand so it’s in the most natural, functional position” as if anyone would’ve done it that way, curving fingers over a softball-sized wad of gauze before wrapping the hand.

“His teaching style was very hands on and he was a good lecturer. He really does it all,” Kallsen said. Besides teaching hundreds of emergency medicine and surgical residents, Dr. Yamaguchi also did research, publishing about 30 peer-reviewed articles before his retirement in 2017, said Dr. Kallsen. Even though he’s retired, his colleagues expect they’ll see him continuing to give back to his hometown.

“I’m going to miss a number of things about him. I’ll miss

his curiosity and the way he’s always thinking of how to make processes and procedures better,” Dr. Kaups said. “We’re going to have a very hard time finding someone to replace him.”

In presenting the award at the Medical Society’s annual awards gala, Carlos Sueldo, M.D., summed up Dr. Yamaguchi’s impact simply: “He represents expertise in medicine, excellence in teaching and education, excellence in research and excellence in patient care. And I’m really, really proud to call him my friend.”

Dr. Yamaguchi was characteristically humble as he accepted the award: “I hope when I grow up I can be whoever they’re talking about. I’m most grateful for this award. I certainly didn’t expect it. I think all three of us were surprised and humbled by this honor.”

Elevating heart care in the Valley

He’s had a profound influence on the Valley.” - Dr. Peterson

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Cardiologist Ralph Wessel expressed those same sentiments when he heard of his honor. “I’m very humbled to be up here. I was really surprised. I came to Fresno after I finished medical school in 1970 and have pretty much been here ever since.

I’ve seen lots of changes and developments in Fresno and it’s all been in a positive direction.”

Michael W. Peterson, MD, associate dean of the UCSF Fresno Medical Education Program, presented Dr. Wessel his Lifetime Achievement Award and praised his commitment to bringing along the next generation of Valley cardiologists and his work with countless medical residents.

“He’s had a profound influence on the Valley,” said Dr. Peterson, who estimates Dr. Wessel has trained more than a 100 cardiovascular fellows.

Dr. Wessel, who is board certified in internal medicine and cardiovascular disease, has taught hundreds of primary care and emergency doctors the basics of heart disease and cardiac abnormalities as one of two or three cardiology professors for UCSF Fresno in the 1970s. “He taught me the cardiology I know,” said Dr. Kallsen, who characterized Dr. Wessel’s teaching style as instructing through demonstration, modeling how to be a great cardiologist.

“He’s the lead in teaching EKG here in the region,” added Dr. Peterson. “He’s the go-to

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cardiologist for questions. He has an evidence-based approach but it’s very common sense.”

A year after he joined the UCSF Fresno faculty, Dr. Wessel earned the Kaiser Award for Excellence in Teaching in 1971.

He won those same accolades for teaching another two times.

“He’s just a doctor’s doctor and he’s a fabulous teacher,” Dr. Peterson praised.

As one of the most beloved and respected teacher’s in the UCSF Fresno Medical Education program, Dr. Wessel has been called a “do-it-all” cardiologist. He has expertise in interventional cardiology, myocardial pathology, congestive heart failure, pacemakers, and pulmonary hypertension.

His published articles and book chapters range from outlining when ablation should be considered to treat atrial fibrillation to looking at the effects of cigarette smoke exposure on clotting and pharmacology in the cath lab.

Dr. Wessel left teaching to join Kaiser Permanente Fresno as a cardiologist, eventually becoming Chief of Cardiology there.

When he retired he came back to teaching helping re-establish

a UCSF cardiovascular fellowship in 2007. Dr. Wessel said he’s grateful he’s been able to continue in a role he relishes – “teaching the residents which I love. I really enjoy watching them grow.”

In his spare time Dr. Wessel takes to open water seeking the thrill of heeling his craft with the wind. “I was a sailor but not a racer when I met him,” said Dr. Kallsen, who learned to be one joining Dr. Wessel for the High Sierra Regatta on Huntington Lake.

Dr. Wessel sailed on large vessels before his Fresno medical career, most notably the USS Tripoli (LPH-10), which served three deployments in Vietnam starting in 1967. Dr. Wessel was awarded a U.S. Navy commendation medical with combat distinction for Meritorious Achievement as a Medical Officer.

Despite the long list of accomplishments, colleagues say Dr. Wessel comes across as humble and approachable. “He’s confident, but really low-key,” described Dr. Peterson. “And he comes across the same way to patients. He really listens and when he’s with you. He’s engaged with you.”

Bringing rare care to Central California

His engagement with patients is what families and his students also rave about with Dr. H. Terry “Hutch” Hutchison.

The pediatric neurologist made news headlines this year when he became the first to commercially administer Spinraza for Spinal Muscular Atrophy (SMA) to one of his longtime patients, 8-year-old Hayden Calafiore.

Touted as a miracle drug that can prolong life and even stop symptoms if given early enough, the drug also was also part of political rhetoric about why healthcare costs are skyrocketing because of drug prices. It costs nearly $20,000 a dose.

While other hospitals were struggling with insurance companies to figure out how to make the drug available, Dr. Hutchison moved mountains and worked with Community Regional pharmacists to speed the process up. Patients like Hayden have little time to waste as the disease destroys the nerves that send signals to muscles, robbing them of the power to walk and breathe on their own. She wasn’t supposed to live past 2 years, her mother Jennifer Calafiore said.

“Fresno has become a light for the entire world with this

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drug,” said Serena Yang, M.D., UCSF Fresno Interim Chief of Pediatrics. She’s known Dr. Hutchison for 10 years and said she never ceases to be amazed by the lengths he goes to rescue people.

Staff at the hospital where Dr. Hutchison, a UCSF Fresno assistant professor in neurology, sees pediatric patients in the monthly neurology clinic, know him to be a persistent advocate for his patients. “He’s 200% always there for everyone in the community,” Dr. Yang said.

With his bushy brows and gravelly voice he can seem fierce at first, but it hides a tender heart. In every media interview he had in January 2017 about Hayden’s chance at the miracle drug, Dr. Hutchison cried. He’s famous for that – and for group hugs and giving his cell phone out to the families he sees. He considers the accessibility a matter of “ownership.”

He explained, “That means when I see a patient, it’s my patient. Others may see them, of course. But I give them my cell phone and tell them I’ll always respond as I can.”

Dr. Christian Faulkenberry-Miranda, a UCSF Fresno pediatric faculty member, is in awe of the rapport her mentor has with patients. “I’ve never seen a doctor where parents thank him after he gives them a devastating diagnosis about

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their child. He’s there for them every minute. He cries with families and laughs with them,” she said. “And he tolerates calls at dinner and he runs out to the hospital in the middle of the night.”

She was a bit afraid of the big-hearted doctor before she met him. “I knew Dr. Hutch long before I arrived here,” said Dr. Faulkenberry-Miranda, who was a resident under Dr.

He’s 200% always there for everyone in the community.” - Dr. Yang Hutchison. “He’s famous. He’s a character in a book residents read, ‘The Spirit Catches You and You Fall Down.’ I was terrified when I had to do my first consultation with him.”

Dr. Hutch talked with her by phone before the meeting.

He gruffly asked if she wanted to learn about neurology. She responded yes. “Okay, I’ll be right there” Dr. Hutchison told her. Ten minutes later he was and peppered her with questions about what she wanted to know first.

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“The really great thing about Hutch is he lets you have all the experience. He’s quick to push you out of the nest and let you do stuff,” said Emily Bahne, a pediatric nurse practioner who has worked with Dr. Hutchison for the past four years. His students say they’ve learned the most by watching him with patients.

“He sees the whole kid and he has such a humane and compassionate way,” Bahne explained. “He gets joy from working with families and connecting with them, especially special needs children.”

Dr. Yang agreed, “He has the most incredible bedside manner.” Dr. Hutch crouches down to eye level with his child patients confined to beds and wheelchairs, holds their hands and tells them how special and smart and beautiful they are before he explains what procedure they’ll undergo.

And he finds time to make medical mission trips to Mexico annually to care for more special needs children there. Some of the phone calls that constantly interrupt his days are from

Mexico and patients he saw just once, said Bahne.

In addition to his generosity and big heart, Dr. Hutchison’s keen intellect amazes colleagues. He’s triple board certified in pediatrics, neurology and genetics and has a PhD in molecular biology. Before getting those degrees he was a rocket engineer.

Dr. Yang said he often brings in the latest gene discovery to share with her.

“Hutch is on his third career I think,” joked Dr. Peterson.

“He was going to retire, but the ink wasn’t even dried when he called and asked if he could come back. He’s one of those people we have to say ‘Go home!’ to because he’d work 24 hours a day if he could.”

Dr. Hutchison sheepishly admitted it’s true: “I told my wife I’ll probably retire when I can’t find my way to the office anymore. She said, ‘Oh no, I’ll drive you!’ We’ve lived together 67 years.” And like his patients and staff, Dr. Hutchinson’s wife, knows he’s hopelessly devoted to making a difference – especially in those difficult cases.

Creating the physician pipeline back to the Valley

Dr. Katherine Flores, a family practice physician who is the 2017 recipient of the Special Project Award, knew early she too wanted to change lives – not just for patients, but for others like her who might feel the calling to be medical practitioners but did not have the means or the support to get there.

“Dr. Flores has been a ground breaker,” praised Dr. Peterson. “Twenty years before the rest of us were talking about pathways and pipelines and helping bring kids from this region into healthcare, she was doing something about it.”

Dr. Katherine Flores started the Sunnyside High School Doctors Academy in 1999 to help students from backgrounds like hers get the skills and mentoring needed to eventually enter healthcare careers and hopefully medical school. Dr. Flores was raised by her immigrant grandparents after her mother died and grew up working in fields and orchards, picking fruit alongside her family starting at age 4. A year after the Doctors Academy started, Fresno Unified expanded the concept to a Junior Doctors Academy to encourage students at earlier grades at Terronez, Sequoia and Kings Canyon middle schools.

The Doctors Academy program has now expanded to Caruthers High School and Selma High School and graduates 60 to 70 students a year.

Dr. Flores has described how difficult it was to go away from family to Stanford University and then medical school at UC Davis. She wanted to

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provide a support system at colleges for students with backgrounds like hers. She partnered with Fresno State in a Health Careers Opportunities Program that provides study skills, financial help, counseling, and mentors to about 100 participants annually.

Dr. Peterson called Dr. Flores impact “incredible.”

The statistics speak for themselves: • 1 00% of her Doctors Academy students graduate from high school in schools where graduation rates are far below state averages • 1 00% of Doctors Academy graduates are been accepted at four-year universities

M.D. She’s the rare Hmong-speaking family practice doctor in a region with the second largest Hmong population in the U.S. After following cultural norms into marriage at 14 and becoming a single mother of two before other girls her age were out of high school, Dr. Her got the same encouragement, support and nudge Ramirez did from the Fresno State program Flores established.

“A lot of people were pushing my wife to go into surgical services after medical school in Philadelphia,” Ramirez said, “but because of Dr. Flores’ message of giving back she decided to work with Hmong patients in her own community.”

•M ore than 41% go to University of California campus after high school •D octors Academy graduates have become physicians, pharmacists, physician assistants, nurses For Valley residents the result of having home-grown physicians is powerful. “The evidence is clear,” said Dr. Peterson. “When patients see a doctor that looks like them, sounds like them and shares their culture the outcomes are better.”

But physicians aren’t the only ones Dr. Flores encouraged to reach their potential and then persuaded to come back.

Growing up in tiny, rural Firebaugh working the surrounding farm fields during the summer, Patrick Ramirez didn’t have many healthcare role models. He know the town’s one doctor but couldn’t envision a career in healthcare. “I wasn’t sure I was even going to go to college,” he said.

Now a vice president of corporate services at Community Medical Centers and recently named to the Fresno State University Advisory Board by Fresno State President Joseph I. Castro, Ramirez credits where is now to Dr. Flores. It was her mentoring and his involvement in the Health Careers Opportunities Program at Fresno State that set his life path.

“She inspired me. Because of her, I started to believe in myself,” said Ramirez. “It’s scary to think where I’d be without her … I went from being almost kicked out of college to being on the president’s honors list.”

Dr. Flores also mentored Ramirez’s wife, Bonnie Her,

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She inspired me. Because of her, I started to believe in myself. It’s scary to think where I’d be without her … I went from being almost kicked out of college to being on the president’s honors list.” - Patrick Ramirez

It was that same message that pulled Ramirez back to the Valley. After earning his master’s in public health policy and management for UC Berkeley, he had the opportunity to stay in the Bay Area and continue population health work. But he said, “I heard Dr. Flores’ voice talking about the ‘importance of giving back and coming back’.”

In accepting the Special Program Award by video, Dr. Flores praised her Valley colleagues for the countless hours they spend mentoring her students in summer programs that are part of the Doctors Academy.

This year’s Medical Society honorees all share a special commitment to growing doctors and surgeons for a region that has long struggled to reach parity with the rest of California on health access.

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the Ultimate

Holiday Party

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Winter 2018

Thank You Fresno BMW sponsored by Mercer

Winter 2018

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A

LEGACY

of

MEDICINE

The inspiration behind three generations of physicians

By Malissa Trenholm Practicing medicine is the Sosa family’s tradition – one that spans three generations.

Their legacy began with Vascular Surgeon Francisco T. Unguez, MD, who practiced in Fresno for more than 30 years; followed by his daughter, Pediatrician Carmela Sosa, MD, of Valley Children’s Healthcare; and succeeded by her daughter Eliana Sosa, who is currently in medical school. In addition, Carmela’s husband, Luis Sosa, MD, is an occupational medicine physician at Kaiser Permanente Fresno.

It is evident this family has, and will continue to impact the lives of many in the Central Valley. Although it is rare to come across a lineage of physicians, one actually exists in Fresno.

Their story began with Francisco, who came to the United States from Mexico at just 15 years old. His mother wanted him to amount to something, Francisco says, so they encouraged him to go to school in the United States. He and his father traveled to Gardena, Calif., where they had distant relatives attending The Spanish American Institute. >>

“He dropped me at the school and that was it,” Francisco says. “He told me to stay here and learn some English.”

Aside from being influenced by American movies and books, and his favorite actor Vincent Price, Francisco realized he wanted to become a physician at age 19 when his father fell ill and passed away. He didn’t understand why the doctors couldn’t save him.

“You kind of vacillate, when you’re choosing a school, but I think that was the deciding factor when I saw him ill,” he says.”I knew I wanted to be a physician.”

Francisco attended Compton Junior College, Pepperdine University for pre-medical, and then the University of Southern California School of Medicine. He underwent general surgical residency training at General Hospital of Fresno County, which included time at Pacific Presbyterian Hospital in San Francisco.

“I liked it here,” he says. “I liked that the hospital was brand new and it had all the things us residents wanted. I met my wife here, then kids came, and that was it.”

THE INSPIRATION

“For as long as I could remember, I wanted to go into medicine, and I can say that was because of my dad,” Carmela says. “When I was younger, people would recognize him around town and thank him for saving their loved one’s lives. I remember in high school, people would recognize my last name and I would get so many thanks. His passion for what he did and the impact he had on so many people in this community inspired me.”

In fact, their unique last name is actually made-up, Carmela

Francisco became well-known within the community, touching the lives of thousands throughout his career. He initially was a general surgeon then specialized in vascular surgery. Due to the nature of his complicated cases, it was his very hands that saved many lives. This is what inspired his second child, Carmela, to follow in his footsteps and pursue a career in medicine.

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explains. Francisco’s parents left Canton, China in the 1920s. Due to anti-immigrant sentiment, many ports were closed to the Chinese along the United States Pacific coastline. Francisco’s father had intended to land in San Francisco, but continued down the coastline until a port in Mexico allowed them to disembark. In order for them to assimilate to their new culture, they changed their last name from Ng to Unguez, and all four of their Mexican-born children were given Hispanic first names.

Carmela completed pre-medical coursework at California State University, Fresno; and both she and Luis attended Case Western Reserve University School of Medicine in Ohio.

Knowing first-hand the struggles of schooling and the long hours required during residency, Francisco retired and he and his wife, Eilene, moved to Ohio to help the young family.

After 11 years, the Sosa family returned to California to raise their family of four children.

“We decided to come back to the Valley because it is big enough but still like a small community,” Carmela says. “It’s a wonderful place to have a family.”

CONTINUING THE LEGACY

Eliana, the oldest of four, remembers her mother reading her the “baby ouch book” (Fitzpatrick’s Dermatology in General Medicine). Although she was fascinated by all the “ouches” a baby could get, she still insisted she would never be a physician. Eliana studied Biology in college with hopes to become a veterinarian, but what changed her mind was the many people she was able to help as an English tutor at the Clovis Community College Tutorial Center.

“I think it was being able to interface with people from so many incredible different backgrounds and getting to know them and help them through their difficulties no matter how big or small they were – I loved having that academic and personal impact on people,” she says. “I came to the realization my sophomore year that I could combine that with the science I really enjoyed into one profession and career, which was medicine.”

Eliana completed her pre-medicine coursework at California State University, Fresno, and volunteered at

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“I think it was being able to interface with people from so many incredible different backgrounds and getting to know them and help them through their difficulties no matter how big or small they were – I loved having that academic and personal impact on people.” - Eliana

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free clinics throughout Fresno and Clovis.

“I absolutely loved my experiences,” she says. “I loved the things I got to do and the people I got to meet and impact.”

As to be expected, Eliana met many people who benefitted from her physician predecessors – one of them being her favorite Fresno State professor.

“He told me that he was so grateful he has no scar from his thyroid surgery because his surgeon was such a fabulous surgeon, by the name of Francisco Unguez,” Eliana says. “I was so happy to tell him that it was my grandfather that operated on him!”

As it turns out, that same professor also taught Carmela.

“He kind of touched our family in all three generations of medicine,” Eliana says.

Eliana is currently a first-year student at the Medical College of Wisconsin.

“I never felt pressure to continue the tradition of medicine we have, it was actively my decision,” she says.”It is so wonderful to be able to keep our tradition and passion for science and people alive. It’s great to be able to see that from generation to generation reflected in our family. To me, that is what I think is really fascinating and important – I do carry it on with a great deal of pride.”

Eliana isn’t opposed to return to Fresno to practice medicine once she graduates.

“I am very open to where life takes me,” she says. “They say everyone comes back to Fresno, so I wouldn’t be surprised if I did!”

“I came back,” Carmela adds, laughing.

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CENTRAL VALLEY PHYSICIANS

FAMILY TRADITIONS

Aside from practicing medicine, this family has another long-standing tradition – crafting. As a self-proclaimed closet-crafter, Carmela loves to bring her family together during the holidays – whether to make tamales, decorate sugar skulls for Halloween or assemble gingerbread houses at Tenaya Lodge – a fun family activity they all enjoyed together this past Christmas.

Although this family is like any other, one thing will always stay the same – their rich heritage and tradition of helping others here in the Central Valley.

Winter 2018

CL

DS

F I S IE S A

FOR SUBLEASE

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

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

Medical Consultants Needed for Fresno Field Office This is an excellent opportunity to help your community and to obtain valuable experience. The Department of Consumer Affairs, Division of Investigation, and Health Quality Investigation Unit is seeking well-qualified individuals to be a Medical Consultant for the Fresno Field Office.

Winter 2018

Are you interested in being an integral part of the Medical Board of California enforcement process? Do you have the ability to conduct interviews, exercise sound judgment in reviewing conflicting medical reports and preparing opinions, analyzing problems, and taking appropriate action?

Interested individuals must submit an application for examination.

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

If you have any questions please contact Herbert Boro, MD, F.A.C.P. with the Health Quality Investigation Unit in Fresno at (559) 447-3045 or by email at herbert.boro@mbc.ca.gov.

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

Class A Medical Office Space, approximately 1500 square feet. 1781 East Fir Avenue, Suite 102, available 7/1. Rent: $2250 plus security deposit.

Contact Robert at (559) 800-7476 or administration@cvphysiatry.com.

Premiere medical office space for sublet.

The entire facility is 5000 square feet with modern aesthetic furnishings.

Can include access to accredited ambulatory surgical facility with ability to perform procedures under general anesthesia or sedation as part of an office-based procedure. There are 4 exam rooms and nursing station, well suited for ophthalmology, gynecology, dermatology, plastic surgery or ENT practices. Support staff can be provided on request. Please inquire at 559 7979000 or email hedi@wpsfresno.com

If you would like to submit a listing to our Classifieds, contact nbutler@fmms.org. Listings are free for members with reasonable rates for nonmembers.

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HOW A BILL BECOMES A LAW Change is happening, and change will always happen. CMA remains focused on the future and will act boldly to shape the world of health care to support physicians and patients.

BILL IS INTRODUCED

Ruth Haskins, MD, CMA PRESIDENT

COMMITTEE HEARINGS COMMITTEE HEARINGS IF PASSED (SENT TO OTHER HOUSE)

FLOOR ACTION

FLOOR ACTION RETURNED TO ORIGINAL HOUSE

IF PASSED WITH AMMENDMENTS IF PASSED WITHOUT AMMENDMENTS

BILL GOES TO GOVERNOR IF ORIGINAL HOUSE CONCURRS

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CENTRAL VALLEY PHYSICIANS

IF NOT VETOED

MOST BILLS BECOME LAW JAN. 1 OF THE NEXT YEAR

Winter 2018

THE LIFECYCLE OF

Legislation

FROM IDEA INTO L AW

The California Medical Association (CMA) is the largest, most influential medical organization in California, and an aggressive advocate for doctors and patients. CMA relies on the involvement of its members to communicate the physician vision of medical care to the public, to lawmakers and to the regulators who determine how medicine is practiced.

An idea is born: Ideas for new health policy are born in a number of places. One of them is in the hearts and minds of the physicians of California. CMA members can directly influence the association’s health care advocacy agenda by submitting a resolution for consideration to the CMA House of Delegates.

CMA policy is established: Resolutions are assigned to councils and subcommittees for study and development, then opened up for discussion by your physician colleagues before recommendations are developed for action by the CMA Board of Trustees. Many of CMA’s sponsored bills have their genesis in an idea submitted by our physician members. While not all CMA policies result in direct legislative action, they are used to guide CMA’s positions on the hundreds of health care bills that are introduced into the State Legislature each year.

Bills are introduced: The California Legislature operates on a two‐year session. Each year, primarily in January and February, bills are introduced by lawmakers for consideration. The governor may also call a special session of the Legislature to deal with specific subjects.

CMA takes a position: Each year, with physician input, CMA monitors more than 500 bills and takes a public position on around 200 bills. Those positions include watch, support, oppose, support if amended and oppose unless amended.

CMA also may choose to sponsor or co-sponsor legislation that is of critical importance to the physicians of California.

Bills move through the process: If a bill is to become law, it must be passed out of one or more committees, approved by a simple majority of both houses, and signed by the governor. Laws ordinarily take effect on January 1 of the following year. Briefly, a bill progresses through the following steps: 1. A bill is introduced. 2. The bill is heard in one or more committees in its house of origin (either Senate or Assembly), including public testimony. 3. If the bill passes out of committee(s), it goes to the house floor for a vote. If it passes out of the house, it is sent to the other house for consideration following the same process described above. 4. If approved by both houses, the bill goes to the governor for signing. 5. The governor has three choices: sign the bill into law, allow it to become law without his or her signature, or veto it. A governor’s veto can be overridden by a two-thirds vote in both houses.

CMA monitors and protects physician interests: CMA’s powerful government relations team works tirelessly with legislators to educate them on how legislation could enhance or threaten patients’ health or physicians’ ability to practice medicine. Their activities include reading and tracking bills and amendments, shaping bill language, meeting with legislators, testifying in committee, conducting research, and preparing policy papers and position letters. Every year, CMA not only supports and shapes the development of valuable health care policy, but the association also stops a number of harmful legislative proposals.

For more information on CMA’s legislative advocacy, and how you can get involved, visit www.cmanet.org.

Winter 2018

CENTRAL VALLEY PHYSICIANS

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Public Health

Update

Public Health Opiod Crisis Ken Bird, MD Public Health Officer • Fresno County Department of Public Health

The national opioid overdose crisis is not news to any of you. As you know, the Centers for Disease Control and Prevention (CDC) declared prescription painkiller overdose a national epidemic on November 1, 2011. The White House declared this epidemic a public health emergency on October 26 of this year (2017).

From 1999 to 2013, sales of these prescription painkillers quadrupled secondary to: • The prior perception that pain was being inadequately treated by the medical community • Misinformation with regard to treatment of chronic non-cancer pain AND • Aggressive marketing of newer, longer-acting opioids in the management of this pain

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CENTRAL VALLEY PHYSICIANS

Winter 2018

Today, the U.S. consumes 83% of the world supply of oxycodone and 97% of the world supply of hydrocodone, 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, that 3 to 4 % of U.S. adults are being treated with long-term opioid therapy, and that 2 million Americans are currently abusing, or are dependent on, opioid pain medications.

The more frequent use of these substances over longer periods of time has resulted in a dramatic increase in rates of addiction and death due to overdose. Because past use of prescription opioids is the strongest risk factor for heroin initiation and use, overuse of these prescription opioids has driven an only slightly less dramatic 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 personal toll that opioid abuse takes on individuals, their friends, and their families is alarming.

The Council of Economic Advisors estimates that in 2015, the economic cost of the opioid crisis was $504 billion (2.8% of GDP).

Fresno County is somewhat less impacted by this epidemic than are many areas in the nation and the state, yet we rank 17th among California counties in deaths related to opioid pharmaceuticals with an age-adjusted rate almost twice the state rate of 3.8/100,000. In 2016 there were 63 premature deaths in Fresno County from opioid overdose.

I have watched the call for national and local efforts to bring this epidemic under control through 1) increased public awareness of the dangers of these medications, 2) increased access to naloxone to those at risk of overdose, 3) increased access to medication-assisted treatment for those addicted, but most especially by 4) emphasizing safe prescribing for pain by clinicians.

As I watch this mounting demand for safe prescribing, I begin to realize that many of you probably feel like the unnamed narrator in Edgar Allen Poe’s short story The Pit and the Pendulum. You are stuck agonizingly watching the pendulum that is going to eventually spell your doom swing from the extreme of the liability of not treating pain sufficiently (or worse, abruptly stopping opioids for patients that have been taking them for months) to the other extreme of over treating that pain with opioid medication which can lead to subsequent addiction and/or overdose death.

Safe management of both acute and chronic pain and safe

Winter 2018

prescribing are, of course, essential in the reversal of the current epidemic. It is best practice, and not exceedingly difficult.

Safe prescribing of these medications is predicated upon recent guidelines, especially those issued by the Medical Board of California in November of 2014 and those issued by the CDC in March 2016. Key elements of these guidelines are: • The consideration of other pharmaceutical and nonpharmaceutical options in the treatment of chronic pain • Careful assessment of the risk, versus the benefit of treatment with opioid medication, if it is used • Starting with the lowest possible dose of short-acting agents for the shortest possible time • Close monitoring of patient dosage and usage, especially through the California Prescription Drug Monitoring Program’s (PDMP) Controlled Substance Utilization Review and Evaluation System (CURES) • Frequent reassessment of patient function • Having a plan to terminate treatment • Co-prescribing naloxone for those on high morphine milligram equivalents • Avoidance of opioids and benzodiazepines concurrently • Referral for treatment of identified opioid use disorder In a recent letter to California healthcare providers the state public health officer, Dr. Karen Smith, offered a variety of resources to assist you in addressing these issues with your patients. These resources are available at http://www.cdph.ca.gov/PrescriberResources .

As a final note, and as noted above, safe prescribing mandates treatment for your patients with opioid use disorder, and there remains a paucity of medication-assisted treatment programs in our area. If you are interested in providing such needed treatment the Medication Assisted Treatment (MAT) Expansion Project has been implemented locally with MedMark Treatment Centers, whereby MedMark will work collaboratively with community providers by serving as a supporting “hub” to “spoke” providers. These providers must have a waivered physician on staff who have completed eight hours of required buprenorphine training, and applied for a waiver that allows them to prescribe or dispense this medication in settings other than an opioid treatment program (OTP). Details regarding this can be found at https://www. samhsa.gov/medication-assisted-treatment/buprenorphinewaiver-management.

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In modern California politics, there is no more imposing figure than Governor Jerry Brown. Since his return to the Governor’s office, Brown and his administration have been able to develop and implement his policy agenda in a nearly flawless manner, overcoming every political obstacle in his pathway. Nowhere has Governor Brown’s dominance been more evident than in the crafting of the state budget.

Prior to Governor Brown’s return and the passage of the majority-vote budget, the enactment of the state budget was a clash of political wills, a battle of ideals and priorities.

The governor would present his vision in January. The

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Legislature would take months re-shaping and re-focusing the governor’s budget proposal. Tense negotiations would yield significant legislative changes in the budget and a handful of gubernatorial line-item vetoes. During his second tenure, Governor Brown has worked to deliver on-time budgets that do not significantly differ from his January proposals.

This year, the state budget process was more critical than ever to the California Medical Association (CMA). The November 2016 election yielded another ballot measure victory for CMA and public health advocates across the Golden State with the passage of Proposition 56.

Winter 2018

CMA took on Big Tobacco and passed Prop. 56, which increased the tax on tobacco products by $2 per pack and stipulated that the new tobacco tax funds should increase access by improving provider payments.

Brown signed, provides over $1 billion ($546 million in state funds, with a federal match) to improve provider payments, and nearly $750 million ($375 million in state funds, with a federal match) will be available to physicians.

This victory was a collective effort of the entire Restoring Prop. 56 funds was CMA’s top budget priority, and we CMA. A budget team was engaged the Legislature through earned media, digital advertising, assembled, comprised of grassroots outreach and direct advocacy. members of the Centers for Government Relations, Despite being outspent, CMA and its partners in support of Health Policy, Communications and Political Operations. the measure got Prop. 56 passed overwhelmingly, providing Working in concert, this team successfully pushed the budget an influx of new revenue to increase payments to Medi-Cal as CMA’s top legislative priority. providers. Governor Brown, however, seeking to secure his Media coverage of the budget is always competitive, but the legacy of fiscal prudence, sought to re-interpret the provisions issue of Prop. 56 funding garnered a significant amount of of Prop. 56 to redirect the tobacco tax proceeds from Medi-Cal attention, even among the sea of other budget fights, thanks providers to the State General Fund. to the persistence of the CMA communications team. Local In his January budget proposal, Governor Brown didn’t physicians and county medical society executives were include a rate increase for Medi-Cal providers. While there was engaged in the fight, bringing the issue to the attention of their an initial thought that the Governor was utilizing this proposal legislators at in-district meetings and to the Capitol on our as a negotiation tactic to help shape the overarching discussion Legislative Advocacy Day in April. The CMA Government of the architecture for the state budget, it quickly became apparent that the Amid the budget battle, the quotidian legislative work continued Governor did not intend to ever – as always. However, the routine was not without intensity. support a rate increase for Medi-Cal providers. Thus, the battle began!

The Governor’s intentions became more evident with the Relations team, the face of the fight, came armed to each release of the Department of Finance’s May Revision. Just hearing and meeting with the expertise of the CMA Health weeks before the constitutional deadline for the Legislature Policy team. to pass the budget, the Governor doubled down on this earlier Although this fight will no doubt play out again in some proposal and once again proposed no funding to support a future years and we will need to be vigilant to ensure Medi-Cal rate increase for providers. continued funding, this year’s budget success seals the intent of Restoring Prop. 56 funds was CMA’s top budget priority, the voters and will provide relief for California’s shamefully low and we engaged the Legislature through earned media, digital Medi-Cal reimbursement rates. advertising, grassroots outreach and direct advocacy. CMA Amid the budget battle, the quotidian legislative work and its coalition partners, specifically the California Dental continued – as always. However, the routine was not without Association and Planned Parenthood, devoted the necessary intensity. CMA this year pushed an aggressive legislative resources to make sure that the Legislature followed the will agenda through our package of sponsored bills, seeking to of the voters and used the tobacco tax money to improve address a wide variety of our members’ issues. access to care in our state. CMA’s county medical societies Two of our sponsored bills this year pertained to different and individual physician members made calls, wrote letters aspects of the opioid crisis. SB 641 (Lara), which was put on and conducted in-person legislative lobbying visits. Our hold for further discussion in the 2018 legislative session, legislative champions, led by Senator Richard Pan, M.D., and is a supplement to Senator Lara’s SB 482 from last session, Assemblymembers Joaquin Arambula, M.D., and Jim Wood, requiring use of the Controlled Substance Utilization D.D.S., pushed both the State Senate and Assembly to reject Review and Evaluation System (CURES) for Schedule II-IV the Governor’s budget. The final budget, which Governor controlled substance prescriptions. Our bill would improve

Winter 2018

CENTRAL VALLEY PHYSICIANS

49

privacy protections in the mandated use of CURES. To deal with how opioids are prescribed, Assembly member Joaquin Arambula, M.D., introduced AB 1048, which allowed for partial fill of Schedule II prescriptions and removed the requirement for evaluating pain as the fifth vital sign. These changes will alleviate some of the pressure on physicians to

the workers’ compensation coverage requirement established

by AB 2883, provided they have health insurance coverage.

SB 189 will dramatically reduce the administrative cost of running a medical practice.

Our highest profile legislative fight was over the Medical Board of California sunset review. This was the Legislature’s scheduled review of the medical board, during As ever with the two-year legislative cycle, the bulk of the first year’s which it can make changes work sets the stage for the second year’s. Discussions will resume to the board’s policies and in January over a host of issues, and CMA is well positioned in those procedures and, crucially, conversations to protect the interests of physicians and their patients. extends the board past its “sunset” – that is, dissolution prescribe and reduce the number of opioids given to patients.

– date. What should have been an uneventful, perfunctory bill CMA also successfully pushed a clean-up bill for last year’s became a fight for CMA because of the inclusion of several AB 2883, a workers’ compensation bill that inadvertently provisions eroding physicians’ rights. We secured amendments created hundreds of thousands of dollars new, burdensome to remove harmful provisions from the bill, including ones costs to physician practices. CMA’s bill—SB 189 that would have reestablished a cost recovery program for (Bradford)—completely exempted physician practices from the board, provided the board with new authority to issue cease practice orders and required certain physicians to notify their patients of their probation status..

INC. As ever with the A REGISTRY & PLACEMENT FIRM two-year legislative cycle, the bulk of the first year’s work sets the stage for the second Nurse Practitioners ~ Physician Assistants year’s. Discussions will resume in January over a host of issues, and CMA is well positioned in those conversations to protect the interests of physicians and their patients. Our strength this year builds our strength for next year.

Tracy Zweig Associates Physicians

Locum Tenens ~ Permanent Placement Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143

In Unity, Janus L. Norman

tzweig@tracyzweig.com www.tracyzweig.com

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CENTRAL VALLEY PHYSICIANS

Winter 2018

Funding For

medical

professionals

by those who understand

the industry Credit lines and loans, tailored to the medical industry, with rates starting as low as *6% and 24-hour underwriting.

Need funding?

Ask us about our options and services by contacting Dr. Mark Scoffield: mark@vettedfunding.com | 559-281-4699 | WWW.VETTEDFUNDING.COM Vetted Partners is a nontraditional consulting company focused on the funding and strategic growth of businesses. *for eligible applicants Winter 2018

CENTRAL VALLEY PHYSICIANS

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

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

Need a physical? We’ll get you one within the week.

It’s primary care on your schedule – available right here in Fresno and Clovis.

Call (559) 450-7267 to schedule an appointment with a physician at one of our Saint Agnes Care sites.

And for those unexpected illnesses and accidents that happen after-hours and on weekends, we offer urgent care When you’re confident you’ve chosen the right at two convenient locations. hospital for your maternity care, you’re free to think of just For about anything.

It’s why so many more information, visit samc.com/urgent-care. women choose Saint Agnes Medical Center.

Along with all-private rooms, we partner with more convenient.

Medical care has never been Valley Children’s Healthcare to give you and your baby access to a Level III NICU and one of the top maternal fetal medicine programs around.

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

Saint Agnes Care

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CENTRAL VALLEY PHYSICIANS

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

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

Winter 2018