Central Valley Physicians Winter 2021

Winter 2021

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CalHealthCares offers up to $300,000 in loan repayment for eligible physicians.

The next application cycle for CalHealthCares is coming up January 18, 2021 - February 12, 2021!

We are holding an early review period where the CalHealthCares team will review applications, provide feedback, and applicants will have 1 opportunity to fix any inconsistencies discovered. This is a great opportunity for applicants to apply as early as January 29 at 5 pm (PST)!

Webinars available on the website on how to improve your chances to receive a loan repayment: Live Webinar: CalHealthCares Loan Repayment Application February, 9 2021 12:00 PM PST

More information at CalHealthCares.org

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Winter 2021

VOLUME 5, NUMBER 4 • WINTER 2021

{FEATURES}

12 20 24 26 28 33 37

COVID CRISIS SPURS HEALTHCARE INNOVATIONS

COVID-19 VACCINE: OUR BEST SHOT

2021 INSTALLATION OF OFFICERS

THE PANDEMIC WITHIN THE PANDEMIC

COVID AND THE ELDERLY

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{DEPARTMENTS} 4 FROM THE EXECUTIVE DIRECTOR 6 MESSAGE FROM THE PRESIDENT 10 MESSAGE FROM THE EDITOR 31 NEW LIFE FOR MEASURE P 32 KEY 2021 EMPLOYMENT LAW CHANGES

TAX-FUNDED PROGRAM 42 TOBACCO AWARDS

CMA’S 2020 LEGISLATIVE WRAP-UP

TO ADDRESS VACCINE 44 HOW HESITANCY

MANAGING THE COMMUNITY BLOOD SUPPLY

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From the Executive Director

PRESIDENT – Don H. Gaede, MD

Nearly a year ago, while most of the world focused on the news, watching the pandemic unfold, physicians faced the aggressor head on, providing exceptional care for the sick, studying the virus and working tirelessly to protect the community.

As the number of cases and death toll rose, remarkable stories of community began filtering through the despair. Here in the Central Valley our physicians, the superheroes of 2020, were strengthened by a vast network of support groups. At FMMS, we are so proud of the way our physicians have met the challenges of STACY WOODS this crisis and equally proud of the way our community has risen to the occasion in support. When PPE inventory ran low, makerspaces across the country shared ideas that led to thousands of protective shields printed on local 3D printers and laser cut in workshops, garages and high school classrooms. Sewing machines hummed as hundreds of volunteers sewed cloth masks and breweries and wineries began bottling batches of hand sanitizer. Businesses delivered groceries, meals and personal care items to seniors unable to venture out even for essentials. It was truly a beautiful thing to see our community band together and support one another.

2021 has arrived with a sense of hope. The Public Health Departments in both Fresno County and Madera County have worked long hours preparing for and distributing the much-anticipated COVID-19 vaccine giving us our best shot at returning to normal.

While masks and hand sanitizer will be with us for a while, we can visualize brighter days ahead.

At FMMS it is full steam ahead. We have added a new staff member, Casey Nagle and we are planning a year filled with familiar events including a Nephrology Symposium, Hepatology and Gastroenterology Updates, Diabetes Symposium and the 41st Annual Central Valley Cardiology Symposium. The date is reserved for our Installation Gala in November and we are hopeful Summer Meltdown will once again benefit our Scholarship Foundation.

PRESIDENT-ELECT – Christina Maser, MD VICE PRESIDENT – John Moua, MD TREASURER – Marina Roytman, MD PAST-PRESIDENT – Alan Birnbaum, MD BOARD OF GOVERNORS Mark Alson, MD Pamela Kammen, MD Brent Kane, MD Farah Karipineni, MD Anne Prentice, MD Jesus Rodriguez, MD Sonia Shah, MD Katayoon Shahinfar, MD Greg Simpson, MD Toussaint Streat, MD Benjamin Teitelbaum, MD Jai Uttam, MD CMA Trustee – Ranjit S. Rajpal, MD CENTRAL VALLEY PHYSICIANS Editor – Farah Karipineni, MD Managing Editor – Stacy Woods Assistant Editor – Karen Dahl, MD EDITORIAL COMMITTEE Farah Karipineni, MD, Chair Don Gaede MD Karen Dahl, MD Roydon Steinke, MD Michael Mcmillon, MD Manisha Mittal, MD CREATIVE DIRECTOR prime42: DESIGN | MARKET | HOST prime42.com CONTRIBUTING WRITERS Erin Kennedy, Farah Karipineni, MD, MPH, Marina Roytman, MD, Chris Staub CONTRIBUTING PHOTOGRAPHERS Anthony Imirian

For now, we will remain masked and socially distanced, yet eager to support our many members and their practices through all of the challenges and victories of 2021.

Wishing each of you a joyous new year.

CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO Central Valley Physicians 255 W Fallbrook Avenue Suite 104; Fresno, CA 93711 Phone: 559-224-4224 | Fax: 559-224-0276 Email address: swoods@fmms.org MEDICAL SOCIETY STAFF

Stacy Woods

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Executive Director – Stacy Woods Marketing Coordinator – Casey Nagle

Winter 2021

We Help You Get Paid CMA’s reimbursement experts have recouped more than $30 million from payors on behalf of member physicians in the past 11 years.

PRACTICE MANAGEMENT ASSISTANCE CMA’s practice management experts provide free assistance to members and their staff on reimbursement, contracting and practice management related issues.

DIRECT PAYOR INTERVENTION CMA has recouped more than $30 million from payors on behalf of CMA member physicians in the past 11 years. These monies represent actual physician reimbursements that would have likely gone unpaid without CMA intervention.

EDUCATION CMA offers timely, high-quality education programs for physicians and their staff. From interactive in-person seminars to live and on-demand webinars, CMA provides the information needed to help run a successful medical practice.

PRACTICE MANAGEMENT NEWSLETTER CMA Practice Resources—known as CPR—is a monthly email bulletin that includes tips and tools to help physicians and their office staff improve practice efficiency and viability.

PAYOR CONTRACT ANALYSIS CMA members have free access to objective written analyses of major health plan contracts designed to help physicians understand their rights and options when contracting with a third-party payor, as well as which contract provisions are prohibited by California law.

“The value that CMA brings to physician practices cannot be understated. Membership is not a cost to my practice – it is an investment. I couldn’t run my practice without it.”

–Tom McKenzie, M.D., member since 1991

Need Help?

Contact CMA’s Reimbursement Help Line at (888) 401-5911 or economicservices@cmadocs.org

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A message from our President > Don Gaede, MD

Compassion, Science and Fun

Don Gaede, MD is board certified in Internal Medicine and fellowship trained in vascular medicine. He is a varicose vein specialist with extensive training and years of experience practicing vascular medicine.

Dr. Gaede earned his medical degree from Loma Linda University School of Medicine. His residency was completed at University of California, San Francisco, Fresno and his fellowship at Cleveland Clinic in Ohio.

Greetings from your new medical society president! Because of COVID-19, lots of things are different. In November, we had a “virtual” installation of medical society officers at Woodward Park. I gave my installation speech--to an audience I estimated at about 8 people. So Stacy Woods, our new and very astute executive director, suggested I reprint it here: I am very honored to serve as your incoming medical society president. My vision for this next year can be summarized in just 3 letters: C. S. F. No--I’m not talking about cerebrospinal fluid. I am talking about Compassion, Science, and Fun. Let’s first talk about compassion.

At our board of governors retreat in January, pre-COVID 19, we talked at length (without masks or social distancing) about our vision for our medical society, and asked ourselves, what are our top priorities for the coming years. We took votes.

The idea that got some of the most votes was the concept of starting a mentorship program. I don’t know about the rest of you, but I was pretty much “mentor-less” during medical school and residency, even though I could have greatly benefitted from having a mentor. I suppose that if I had been sufficiently bold and extroverted, I could have figured out how to find my own mentor. But bold and extroverted did not describe my personality in my late 20s. I’ve spoken with others such as Marina Roytman, our incoming secretary-treasurer, who told me she received invaluable help on her way to becoming a hepatologist by having a mentor.

So, our board is in the process of creating a mentorship program that we

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ABOUT THE AUTHOR

hope will facilitate the pairing up of mentors and mentees, and I hope a number of you will volunteer your valuable time and expertise. Keep in mind that mentoring can be valuable not just in the beginning of your career, but later on too. For example, how do you transition from clinical to non-clinical medicine? How does an older physician start cutting back on his or her work hours? How do you transition into retirement?

All of these situations might benefit from having a mentor. A mentorship program is also a way to connect medical society members with each other, in a time when we increasingly live in our own silos.

We physicians have always had stressful jobs, but the COVID-19 pandemic has put many of us under even more stress, as we try to care for our patients without getting sick ourselves, try not to bring the disease home to our loved ones, and try to cope financially in uncertain times. I read one study that said the pandemic was likely to cut the average primary care physician’s annual income by over 65K. Fortunately, our medical society will continue to bring compassion to our members through our resiliency consultations. Thanks to a grant from the Cooperative of American Physicians and Norcal, as well as contributions from St. Agnes and Community hospitals, a number of our member physicians have taken advantage of these free consultations and received invaluable help as they try to cope during these difficult times. Any member can receive up to 4 sessions at Roubicek and Thacker Counseling. And of course, the consults are completely confidential--no one at the medical society is told who signs up.

The idea that got some of the most votes was the concept of starting a mentorship program.

What about compassion for our patients? We physicians are sometimes criticized for our lack of compassion and empathy, and I’m very sure I could improve my skills in this area. Studies show that practicing more empathy might address 3 important issues at the same time: 1) higher patient satisfaction, 2) lower physician burnout rates, and 3) lower risk of malpractice suits.

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Our risk of being sued goes down significantly if we empathize with our patients and their families, and simply tell them we’re sorry for what happened. Remember, saying you’re sorry for what happened is not the same thing as apologizing and admitting fault. It’s simply showing compassion for another human being who is hurting.

Science Our Fresno-Madera medical society was formed over 135 years ago, and has been supporting scientifically-based public health initiatives from its very inception. At that time, small pox was a world-wide scourge with a high mortality rate. So our medical society sponsored one of the first large scale programs to make sure everyone received the small pox vaccine.

But today, science is under attack. Recently, the New England Journal of Medicine editors put it this way “Today more than ever, science is being manipulated and disregarded.

Truth may be difficult to know, but the scientific process is our best path to knowing it.”

For example, California public health officers have been the target of harassment and even death threats by people upset about directives to stem the pandemic, such as wearing masks. A total of 10 county health officers have resigned or left their positions since COVID-19 appeared in March of this year.

It has reached the point that Gov. Newsom recently issued an executive order protecting the home addresses of public health officers.

We physicians are “trusted messengers” when it comes

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to scientific and medical matters, whether it’s about wearing “Seriousness has no healing qualities at all.” masks, taking vaccines, or the threat to the health of our valley Dr. Zubin Damania, also known as ZdoggMD, grew up residents posed by global warming. We need be ready and here in Clovis, the child of 2 physician parents. He performed willing to raise our voices, and inform the public about what some of his famous medical rap songs at our medical society’s medical science says about these issues, and how they are “Summer Meltdown” several years ago. Damania obviously affecting our patients and our community. knows the value of a good sense of humor. He once said, “I am Dr. Alex Sherriffs, former president of our medical the oldest of three children, but sometimes my parents consider society, serves on the board of our Valley Air District as well as me the only child, because the other two are not doctors.” the California Air Resources Board. He told me that he’d love Once this pandemic ends, and we can finally laugh out to see more physicians show up and voice their opinions at the loud in public without fear of giving someone a deadly virus, our monthly Valley Air District meetings. I encourage any of you to medical society intends to bring Dr. Damania back. contact me if you’re interested in joining me in this effort.

Very soon, several COVID-19 vaccines are What about compassion for our patients? We going to hit the market. But polls indicate that only physicians are sometimes criticized for our about half of Americans plan to take it, mainly because they’re concerned that they may have been lack of compassion and empathy, and I’m very rushed to production without good scientific testing. sure I could improve my skills in this area.

So just like back during the days of small pox epidemics, it will be up to us physicians to assess the scientific evidence, and if it passes muster, to help Dr. Vohra and our Fresno County Public Health Department Finally, I’m very much looking forward to working with and Dr. Paul and our Madera County Public Health our new board of governors—possibly the most diverse board Department to encourage our patients to get vaccinated. A we have ever had. We have physicians representing both “vaccination acceptance” committee has been formed to help in academic medicine and private practice, solo practice and large this effort. Please let me or Stacy Woods know if you would like group practice, wide ethnic diversity, younger age to . . . (ahem) to join this effort. a more mature age, and a balanced male/female mix. And we The final letter of “C.S.F.” stands for funnnnn! are very lucky to have a new but very experienced executive My friend Dr. Stephen Davis used to have an answering director in the person of Stacy Woods. machine that said: “So sorry I can’t answer the phone right So that’s my speech! I’m looking forward to working now--I’m off saving lives.” He was right--we physicians are with all of you, our members. Membership in the Fresnotasked with the most serious of duties, to hold people’s lives in Madera Medical Society and the California Medical our hands, to try to bring them back to health, and when that’s Association has never been more important, so thank not possible, to help them leave this earth without too much you for joining our team. Let’s work together as we try to suffering. But at the same time, we have got to find a way to bring compassion, science, and fun to these interesting and bring a little fun and relaxation into our lives. Life is too short challenging times. not to!

Humor and health expert Dr. Shayne Yates states, “Too many people equate seriousness with professionalism, and put a lid on their sense of humor.” Saving lives is very serious business, but a sense of humor enables us to separate who we are from what we do.

Studies show that laughter lowers our stress hormones and stimulates our immune system. By comparison, according to Patch Adams, founder of the Gesundheit! Institute, 8 CENTRAL VALLEY PHYSICIANS

Winter 2021

Office

Manager

Forum

FREE to FMMS/CMA Members

Medicare Changes: 2021 and Beyond Online Webinar

Wednesday, February 17, 2021

12 :00 pm - 1:15 pm

This 60-minute virtual training will provide your practice with an overview of the Final Rule that includes updated on Policy, Payment and Quality Provisions Changes for Medicare under the Physician Fee Schedule (MPFS) for Calendar Year 2021 and beyond.

Subjects highlighted in this workshop include: -

Telehealth and other Communications Technology New CMS E/M 2021 Guidelines The Quality Payment Program (MACRA) Year 5 Compliance with the current MAC Other Medicare Part B issues

You will walk away with resources you can use throughout the coming year to maximize your reimbursement.

In her capacity as Associate Director of CMA's Center for Economic Services, Cheryl provides support to CMA member physicians on Medicare issues. Cheryl has more than 20 years of experience in the Medicare Program, having worked as an Education and Training Specialist, Medical Review Analyst and as a Customer Service Representative across all the CA Medicare contractors including Noridian Healthcare Solutions. Over the years, Cheryl has provided problem solving assistance to physicians, specialty organizations, billing staff and other Cheryl Bradley

healthcare professionals throughout California, Hawaii and Nevada.

Registration Required: www.FMMS.org The FMMS Office Manager Forum empowers physicians and their medical staff with valuable tools via expert led education sessions from industry professionals who are committed to delivering quality healthcare. Monthly meetings will be offered via ZOOM until further notice.

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A message from our Editor > Farah Karipineni, MD

20 wonderful things that happened in 2020, in case you missed them

ABOUT THE AUTHOR Farah Karipineni, MD, MPH, is board certified in General Surgery and fellowship trained in Endocrine Surgery. She is currently practicing in Fresno as an Assistant Clinical Professor for UCSF. Dr. Karipineni earned her medical degree from University of California, Irvine School of Medicine. Her residency in General Surgery was completed at Albert Einstein Medical Center, and she completed her fellowship in Endocrine Surgery at Johns Hopkins School of Medicine.

Dr Karipineni has been published in journals including The American Surgeon, the International Journal of Surgery and the Journal of Surgical Education.

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At the time of this writing, we are at a critical juncture in the pandemic.

According to the New York Times, Fresno County ranked highest in the country among U.S. metro areas for COVID spread this holiday season. This chilling news came in the same days as thousands of Fresnans received the first dose of the Pfizer vaccine. Along with the usual hope of a new year’s turning point comes the longing anticipation that the particular struggles of 2020 will be left behind.

Yet, with 2020 in our rear view, even with so much strife, there was much to be celebrated. Some of it we heard, some of it we didn’t, but I believe it all deserves to be commemorated. For in our darkest moments there is still light, and it is often the most poignant light. Below, for an indulgence of grateful reflection, I have included some of those shining moments.

1. More people voted than ever in American history, and the highest percentage (66.2%) of the eligible voting population since 1900, when 73.7% of eligible Americans cast their vote.

2. Black Lives Matter became a movement, rather than a moment, in large part due to high profile racial atrocities this year (and beyond).

3. Neighborhoods across the world came together to spread joy with chalk messages, socially distanced Easter egg hunts, and coordinated living room, doorway and window symphonies.

4. The first half of 2020 saw an unprecedented decline in carbon and nitrogen emissions. While the reason for this was obviously unfavorable and unsustainable (lockdown and social isolation), it was undeniably beneficial for our environment.

5. Appreciation of healthcare workers is at an unprecedented high.

6. The exclusive theater production Hamilton, previously averaging about $300 per ticket (and as high as $1,000) according to

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Broadway League, surprised the world with an Washington, D.C. after Mary W. Jackson, the early release of the movie. Its original release, agency’s first African American female engineer. scheduled for October 15, 2021, was moved up 15. Under significant social pressure, Confederate by 15 months. According to Disney executive symbols across the country were replaced with chairman Robert Iger on Twitter, “In this very more inclusive entities, as America was forced to difficult time, this story of leadership, tenacity, reckon with its racist history. hope, love & the power of people to unite against 16. Fresno City Council is funding Advance Peace, adversity is both relevant and inspiring.” as part of its community-based strategy to reduce 7. Plastic-eating particles were developed to make gun violence and transform lives in Fresno. plastic infinitely reusable. Tech startup company 17. Distance learning is at an all-time high.

Carbios, based in France, identified a bacterial MasterClass, for instance, brings lessons about enzyme that digests plastic for indefinite recycling. cooking from Gordon Ramsay, filmmaking from 8. The novel mRNA mechanism for the COVID Martin Scorsese, and songwriting from Alicia vaccine, the unprecedented accelerated timeline Keyes right into your home. for its development, and its successful initial 18. The Fresno Chaffee Zoo welcomed their first administration across the world, were a testament female southern white rhino ever born at the zoo to science and technology and global cooperation. in October 2020.

9. Biodiversity is benefitting from reduced human 19. Measure P finally passed, and culminates a longactivities. As a society, our priority is undoubtedly running attempt to fund city parks and recreation. human health, but a surge in wildlife is certainly 20. Domestic pets appeared to benefit from the effects a good sign for the health of our planet. As of social isolation. Their humans spent more Yosemite’s Ranger Katie Patrick said, “For the time at home, a fact that one expert dog trainer in most part, I think they’re having a party.”

Oakland, CA “suspect[s] our pets are absolutely 10. Good news on the infectious disease front? Yes, even in 2020: Africa was declared free of polio Yet, with 2020 in our rear view, even with so much on August 25, 2020. strife, there was much to be celebrated.

11. A world first, CRISPR-Cas9 gene therapy was used in a human to deliver DNA fragments directly into a patient’s eyeball in an attempt to reverse tickled to death” about. Some reports also suggest congenital blindness. an uptick in household pet adoptions from local 12. Elon Musk’s SpaceX launched two Americans, animal shelters.

Dough Hurley and Bob Behnken, into orbit from US. Soil for the first time in nearly a decade. Some believe this successful launch may herald a new era of commercial spaceflight.

13. Hundreds of new species were discovered in 2020. A rare iridescent snake discovered in the Ha Giang province of Vietnam, a new species of beaked whale off the coast of Mexico, and a new spider species called the Loureedia phoenixi found in Iran are among these fascinating discoveries.

14. NASA named its headquarters building in

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“

UCSF Fresno, as a pioneering institution, we asked how we could help in contributing to the science and most importantly by being advocates for the Central Valley and giving patients here early access to treatments that might not be available anywhere else

”

Eyad Almasri, M.D.

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COVID Crisis Spurs Healthcare Innovations

BY ERIN M. KENNEDY

W

hen the human immune system encounters a new pathogen it triggers a response that makes the body faster and more adept in dispatching the threat the next time it arises. External pressure helps muscles and bones grow and strengthen.

After mild trauma, brains compensate with functional hyperconnectivity.

Healthcare has reacted similarly to the coronavirus crisis, becoming smarter, stronger, more resilient and connected. Local hospitals and medical practitioners have responded to the unprecedented stress and challenges with collaboration and innovation, finding new efficiencies, treatments and ways to reach patients. Telehealth visits exploded, more than 15 clinical trials with area patients helped speed science and local COVID recoveries, and physicians became Central Valley PPE pioneers.

“The amount of work that our organization accomplished in (the first) three months is stunning,” said Thomas Utecht, M.D., Community Medical Centers’ Chief Medical & Quality.

“In this crisis, things move at hyper speed,” agreed Dr. Jeffrey Thomas, Vice President and Chief Medical & Quality Officer for Community Regional Medical Center.

“Things that can take six to seven months normally have come to fruition in weeks. I think any time there’s a crisis, it tends to bring people together to work for the common good.”

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Shahzad Jahromi, M.D. Kaiser Permanente Fresno’s Physician in Chief, observed that the pandemic also forced normally bureaucratic organizations to speed up their processes and decision making: “A lot of organizations, including ourselves, can get rid of a lot of red tape.” He marveled at “seeing the collaboration between the hospitals that are typically in competition.”

Kaiser Permanente Fresno reached out in early March to Fresno area hospitals to share a COVID-19 treatment booklet developed by Kaiser Permanente’s regional medical group. Valley Children’s Hospital extended its laboratory resources to Community until it could acquire testing technology in-house during the pandemic’s early days. More recently, California State University Fresno provided sub-zero freezer space until Community could acquire special storage for the COVID-19 vaccine. The university’s freezer, used by the Department of Chemistry and Biochemistry, can reach temperatures of -86 degrees and holds 95,000 vaccine doses.

Hospital staff also noted how great coordination has been with the Fresno County Department of Public Health in tackling the pandemic collaboratively across the region.

“The partnerships and relationship between our public health department has been something we should be really proud of and something that’s the silver lining for me,” Dr. Utecht said. “Hopefully that working relationship will continue whenever the pandemic is over.”

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LOCAL RESEARCH HELPED VALLEY PATIENTS GET NEW TREATMENTS EARLY Relationships forged over decades with the University of California, San Francisco, and the long history of research in the Valley put local patients at the forefront of the newest COVID-19 treatments.

“Between March and the month of May no one had access to remdesivir, but our patients did,” said Eyad Almasri, M.D., who is board certified in Internal Medicine, Pulmonary, Critical Care and Sleep Medicine, and has been on the forefront of COVID-19 treatment research locally. “People in this hospital (Community Regional) had

© Can Stock Photo / crampinini

patients, I was already six weeks into talks with Gilead” Dr. Almasri continued. Gilead Sciences is the inventor of the antiviral remdesivir, which was created as a possible treatment for hepatitis and later studied as an Ebola treatment. Dr. Almasri was too late to get into the early phases of the clinical trials, which were double-blinded with patients and doctors not knowing if they were receiving or administering a placebo.

“Gilead called me and said, ‘We have something that is better. We have this Phase 3 Expanded Access program.

We think it works and it’s safe so we’re going to give you something right away for your patients,’” Dr. Almasri described how the Community Regional was able to get remdesivir even before it was approved for use by the FDA. “It was a 10 days’ course and we started realizing early that the mortality of COVID was not 70% like in Italy or New York, but probably about 20% or lower.”

Gilead and other pharmaceutical companies have been keen to conduct trials with institutions who have a history of conducting clinical trials and to find ways to involve more Black and Latino patients. “Our diversity was really a big asset,” said Dr. Almasri.

“Our success (with remdesivir) started raising our name within a lot of medical research institutions and they started reaching out to us,” Dr. Almasri said. “Because of that, we now have 15 ongoing clinical trials, most of them well respected double-blind trials.”

Anna Kazaryan, M.D., a rheumatologist and UCSF Fresno faculty member, has been conducting other kinds of research with COVID-19 patients, looking at the connection between Vitamin D levels and who gets sick with COVID-19. “Those who were deficient in Vitamin D ended up in the ICU. The level of Vitamin D correlated with the severity of COVID and predicted outcomes,” she explained her findings. “Nearly 80% of those with deficient levels ended up in the ICU.” Dr. Kazaryan said she’s been fascinated since medical school with the immune system, the concept of

access to a drug that was later found to help.”

Dr. Almasri, who is Community Regional’s critical care medical director and a UCSF associate clinical professor of medicine, said he had been paying attention to emerging diseases after being involved in 2014 with preparations for possible Ebola patients.

“UCSF Fresno, as a pioneering institution, we asked how we could help in contributing to the science and most importantly by being advocates for the Central Valley and giving patients here early access to treatments that might not be available anywhere else,” Dr. Almasri said.

“So late in March when we saw our first COVID 14 CENTRAL VALLEY PHYSICIANS

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© Can Stock Photo / AndreyPopov

autoimmunity and the complexity of diseases as a consequence of lack of immune control.

She noticed that her autoimmune patients had flare ups their chronic conditions and were more prone to infections when their Vitamin D levels dropped. That made her wonder if she’d see the same with COVID-19. Dr. Kazaryan looked at both outpatient and inpatient data to see if Vitamin D levels made a difference with who got COVID and who got really sick with it. She said her findings made sense: “Vitamin D plays such an important role in the immune system by regulating the immune cells to help fight off infections and reduce inflammation. If you are deficient in Vitamin D, you don’t have that key player.”

of UCSF residents “working tirelessly” and skilled hospital staff.

Fresno’s also had access to the ECMO team (extracorporeal membrane oxygenation) at Community Regional. Mohamed Fayed, M.D., a UCSF colleague of Dr. Almasri’s who is certified in If you do the math, we’re at less than 2% (mortality Internal Medicine, Pulmonary rate). “We’re in line with the rest of California, which is Disease and Critical Care a little bit higher.

Medicine, has been overseeing ECMO use with COVID patients who seemed nearly beyond hope, helping them be discharged back to their families and their Next Dr. Kazaryan’s seeking approvals to start a phase previous lives.

2 study exploring if Vitamin D can be used as a preventative REMOTE MEDICAL CARE BECAME and a therapeutic for COVID-19.

While local infection rates have been skyrocketing, ROUTINE mortality rates have remained low, said Dr. Almasri, The pandemic prompted innovation and fast adoption crediting colleagues like Dr. Kazaryan for helping advance of new ways of treating patients. “We had planned before knowledge about the disease and treatment. “If you do the COVID to do some video visits,” Dr. Jahromi said of math, we’re at less than 2% (mortality rate),” he said in midKaiser Permanente. “COVID has pushed that forward December about Fresno County. “We’re in line with the by a magnitude of years. Initially there was a goal of 20% rest of California, which is a little bit higher.” telehealth and that quickly went up to 80%.”

With lower than national average numbers of ICU Having such a highly contagious and potentially beds per capita and pulmonologists per capita in California deadly disease compelled medical professionals to quickly and big physician shortages in the Valley, Dr. Almasri learn tele-medicine technology, Dr. Almasri said. marveled at the region’s outcomes. He attributed the high “We use Zoom, Ring Central, Go-to-Meeting, COVID-19 recovery rate to access to early clinical trials, whatever now. Honestly without COVID you could not collaboration among physician experts locally, the presence force busy physicians to learn this,” he said. “I just finished

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a full half-day of telehealth visits. I asked every single patient if they wanted to continue this after COVID and only one out of nine said they would rather come back into the office.”

For his patients in Coalinga or Mariposa being able to connect virtually and feel like they received the same quality care has been a welcome convenience and timesaver, said Dr. Almasri.

“It has been wonderful for our complex children who we wanted to just protect and be able to keep them in their homes. I’ve been able to triage to actually see who I need to see in the office and manage the rest remotely,” said Hailey Nelson, M.D., a pediatrician at the Charley Mitchel Clinic at Valley Children’s Hospital. She finds it an advantage to be able to see her pediatric patients in their home setting.

“That really has added value to see them in their homes,” Dr. Nelson said. “Kids love it too. They can show me their favorite toy and you get to interact with them in a different way. In the office, I’m wearing a mask and goggles and you can’t see my face. With a little kid during an exam you would say ‘Open your mouth’ and typically you would open your mouth and show them what to do. They can’t tell that anymore because of the mask.”

Dr. Nelson said she’s had to become more creative in how she examines her patients virtually: We’ve been singing ‘Head, Shoulders, Knees and Toes’ so I can tell how they are moving their body and how everything is working.”

Karen Dahl, M.D., Vice President of Quality, Patient Safety and Medical Affairs at Valley Children’s Hospital, said she’s found tele-medicine benefits both physicians and patients. “We can reach so many more people.”

NEW HOPE WITH A VACCINE AND OUTPATIENT TREATMENT After months of scrambling for resources, and shifting protocols and treatments as there were new discoveries about this novel virus, physicians said they’ve felt worn down. But December brought new hope with deliveries of COVID-19 vaccines to Central Valley hospitals and approval of new treatments.

“The entire month I’ve been energized by the news,” said Dr. Dahl, who also is Medical Director of Employee Health at Valley Children’s Hospital. “Bad as the surge

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has been, the availability of monoclonal antibody therapy for outpatients and the vaccine delivery has really been the best news we’ve had all year.”

Dr. Dahl has been listening to the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices live meetings and said she’s been encouraged by the experiences of patients in Pfizer’s and Moderna’s clinical trials: “This is in line with other vaccines for the kind of side effects and the percentage getting side effects. I’m really confident in this vaccine and the process it went through to evaluate its efficacy and its safety.”

The administration of a COVID-19 vaccine, however, is a bit more involved than the flu shot, she said. “It’s taken a week to do all the prioritization and planning for this. It’s not like you can line everybody up and run them through.

There is extra paper work because of the EUA status and social distancing limits the number we can get through a clinic during a single session.”

The Advisory Committee on Immunization Practices is recommending that hospitals stagger administration among doctors and clinical staff in a department, Dr. Dahl said. In addition, Pfizer and Moderna vaccines need to be stored in specialized freezers and once taken out must be administered within a short time period. And both require a second dose 21 or 28 days after the first in order to be effective.

Valley Children’s was chosen to be Central California’s storage and distribution site of the COVID-19 vaccine because it has enough ultra-low freezer capacity for 200,000 doses. It’s one of 33 pre-positioning sites chosen by the California Department of Public Health to store and help distribute the vaccine.

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Dr. Dahl said this offers a lot hope for preserving the resources and beds in crowded hospitals for only the sickest COVID patients.

DOCTORS BECAME SUPPLY CHAIN AND PPE INNOVATORS COVID-19 has forged connections and collaboration between healthcare and the greater community, as people stepped up to help during early shortages of protective equipment. Dr. Nelson, a pediatrician at Valley Childrens Hospital, helped organize Clovis Unified School District teachers and students to make N95 respirator masks and face shields.

“I knew my son’s second-grade teacher did robotics and he got me connected to the high school robotics team just as the schools were shutting down,” explained Dr. Nelson. “I was able to coordinate with all the teachers to take home their 3-D printers. We went through various prototypes to figure out the right mask and how to make them fit and went to work on production.”

Parents and students helped sterilize and package PPE for shipping to whoever needed it. All the materials and labor was donated. In the span of two months, the group had produced 2,000 face shields, and 800 3-D printed masks Next Dr. Nelson became a fabric broker, coordinating drop offs to students all over Fresno who cut out mask patterns and put them together in kits for home sewers who turned out nearly 500 masks for the public. She managed all this, her busy practice seeing children with complex conditions and three children at home, she said, because

Valley Children’s began vaccinating staff on Dec. 16, Kaiser Permanente Fresno followed on Dec. 17, and Community Medical Centers began vaccinations Dec. 18.

St. Agnes Medical Center and Adventist Health Hanford began providing immunizations to their direct patient care staff on Dec. 21. Valley Children’s vaccinated only its employees at highest risk for COVID complications with its first shipment.

As healthcare providers and staff lined up for their first shot, hospitals were also working out details to provide outpatient IV therapy to patients with mild to moderate COVID-19 I knew my son’s second-grade teacher did robotics and he got symptoms. “Most of the public will recognize me connected to the high school robotics team just as the monoclonal antibody schools were shutting down therapy as what was given to President Trump,” said Dr. Dahl. “It’s received her toddler wasn’t sleeping through the night when the Emergency Use Authorization from the FDA because of its pandemic started. “I would snuggle her and learn about efficacy in reducing the need for an emergency room visit or filtration for PPE. Or I would send out these coordination hospitalization. There is data to show it can alter the course emails at 2 a.m.,” she said. early in the disease and keep people out of the hospital.”

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© Can Stock Photo / crampinini

to use in Community Regional’s emergency department.

Besides becoming innovators outside their realm because of PPE shortages, Dr. Jahromi noted healthcare was forced to become much more efficient: “As a country we’re a country of one-time use. But now this shows us that we can reuse things.”

MARATHON CRISIS TESTED ENERGY, RESOURCES, BUT ALSO BROUGHT POSITIVE CHANGE Patrick MacMillan, M.D., Director of Palliative Care at Community, hopes those new efficiencies and discoveries serve healthcare well into the future, but worries about the pandemic’s lingering effects on his colleagues and hospital staff.

“What’s going to be the long-term cost to the health industry in terms of what people have seen and experienced?” he wondered. “This is not like anything I imagined living through. COVID-19 has been the most unpredictable disease. Everything is different. Everything has changed. I’m hopeful In my neighborhood the number of people I see things will recalibrate in a way that is helpful outdoors walking, roller-blading, cycling has to healthcare and to humans.” really increased because there’s nothing else to Dr. Dahl has the same hopes: “In my do. I hope those habits will persist and I hope neighborhood the number of people I see outdoors walking, roller-blading, cycling has that’s a long-standing benefit from this. really increased because there’s nothing else to do. I hope those habits will persist and I hope that’s a long-standing benefit from this.” over patients to protect caregivers from the COVID-19 She’s been excited to see more families being outside virus, she thought something similar might help protect her together – and also rediscovering family meals. “This has Community Regional colleagues if she should figure out brought back family dinners. We’re spending time together how to make it. as a family so that’s a positive,” she said.

She enlisted her next-door neighbor Jay Russell to Dr. Almasri observed that the pandemic has definitely help. After a few tries he figured out how to make a lightpulled the community together to work toward a common weight Plexiglas box with armholes that can be placed enemy. “The silver lining for me is that COVID has shown over a patient’s upper body and that physicians can reach society how valuable we are,” he added. “I’ve been a doctor through during procedures and examinations. Droplets 25 years and I’ve never felt so proud to be a doctor, nor felt breathed out are trapped in the box. Early in the pandemic, so valued, as I did this year.” during the height of mask shortages, the boxes were put “I’ve never done anything in this realm, but it’s all about connections,” Dr. Nelson said. “You don’t have to have the full answer you just have to go for that next step.”

It was connections to her handyman neighbor and creative thinking spurred by necessity that turned Athira Nair, M.D, a UCSF pediatric cardiologist, into a PPE innovator. After seeing how a Taiwanese doctor used a box

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Winter 2021

FMMS Joy of Medicine www.FMMSJoy.org

It’s Ok To Ask For

Help RESILIENCY CONSULTATIONS The Fresno Madera Medical Society recognizes the overwhelming stresses and immense workloads that physicians face today. Stress, anxiety, depression and grief are common, but they can be managed. Resiliency Consulta�ons can provide relief, an increased ability to cope, healing and an opportunity for personal growth.

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RECONNECT TO YOUR

Joy of Medicine

SCHEDULE ROUBICEK and THACKER 559-323-8484 Winter 2021 AN APPOINTMENT

VALLEY PHYSICIANS 19 Call and identify yourself as a physicianCENTRAL practicing in Fresno or Madera County

DR. RAIS VOHRA, INTERIM PUBLIC HEALTH OFFICER AND DR. JOHN ZWEIFLER, PUBLIC HEALTH PHYSICIAN

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Winter 2021

The ongoing toll of the COVID-19 we can look forward to adding bioengineering, and equally a symbol pandemic has included economic another powerful tool, because of humane scientific research in its shutdowns, job losses, substance COVID-19 vaccines are coming, and finest hour. Many other vaccines and addictions, illnesses, hospitalizations, not a day too soon. therapeutics are also in the pipeline, and hundreds of thousands of deaths COVID-19 vaccines offer and we are hoping that they can all nationwide. COVID-19 has haunted the hope for a return to normalcy; help us wake from the nightmare of our neighborhoods in Fresno County they represent the one scientific this pandemic. and throughout the Central Valley, breakthrough which, if adopted Operation Warp Speed was affecting virtually every a federal initiative hour of our days for involving the many months. Despite Departments of Health The Fresno County Department of Public the grim statistics and and Human Services, Health (FCDPH) needs all clinicians to many losses, we are and Defense to produce help win this fight grateful that so many and deliver 300 Valley residents have million doses of safe helped to flatten the and effective vaccines curve by supporting safe health broadly, promises to transform with the initial doses available by practices, and enduring many COVID-19 from a perpetual headline January 2021. Operation Warp hardships related to restricting our to a medical footnote, similar to Speed has partnered with several social activities, wearing masks, and polio and hopefully just as rare. Two pharmaceutical companies and maintaining strict precautions around mRNA-based vaccines, developed manufacturers to develop an array our elderly and frail neighbors and in record time, are a testament of strategies including vaccines and friends. To these layers of protection, to advances in genomics and other therapeutics, in some ways

Winter 2021

CENTRAL VALLEY PHYSICIANS 21

parallel to the Manhattan Project in Control and Prevention (CDC) Pharmacy Partnership for Long Term WW2, in order to combine and unite advisory committee recommended Care Program. When more vaccine resources and information against a that the first doses be given to the doses become available in early 2021, common enemy. Interestingly, Pfizer, approximately 21 million health other high-risk groups are next in which was not part of Operation care personnel in the U.S., with line, including health care workers Warp Speed, was the first vaccine to another 3 million going to residents in ambulatory settings, essential be approved by the FDA. of long-term care facilities. In workers, and persons who are elderly With COVID-19 cases and Fresno County, the first 7800 or have chronic conditions. In all of deaths surging, there is urgency to doses of the Pfizer vaccine have these phases and plans, a focus on distribute the COVID-19 vaccine, been allocated to area hospitals equity and transparency has been and federal and state agencies are to administer to their highest risk paramount. working feverishly even now to employees—not just physicians and There are challenges with make sure these products are able nurses but also therapists, ancillary storing and distributing COVID-19 to immunize the public vaccines. The Pfizer as soon as possible. Pfizer vaccine must be stored at and Moderna are expected an ultra-cold temperature In Fresno County, the first 7800 to provide a total of of -70 degrees Celsius, doses of the Pfizer vaccine have been about 40 million doses of which requires a special their respective vaccines freezer or dry ice, while allocated to hospitals to administer to nationwide by the end of the Moderna vaccine must their highest risk employees the year, enough to give up be stored at -20 degrees to 20 million people the Celsius, which can be required two doses. achieved in most freezers.

However, once “WHO GETS IT FIRST?” and administrative staff. Skilled thawed, the Pfizer vaccine can be It’s not just a dry theoretical nursing facilities and assisted living stored in a refrigerator for up to five exercise for a medical school ethics facilities will be able to receive onsite days, and the Moderna vaccine for course, it is a real-life dilemma immunizations for patients and staff up to 30 days. Both the Pfizer and that demands practical solutions, from pharmacies including CVS Moderna vaccines require two doses, and quickly. A Centers for Disease and Walgreens through the Federal 21 days apart for Pfizer, and 28 days

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Winter 2021

for Moderna. administer the vaccine. phase of the vaccine experience is that Despite the challenges, the All health care providers COVID-19 vaccines now available COVID-19 vaccines have been shown administering the COVID-19 vaccine offer the quickest and surest way to to be highly effective- over 90% in will need to enter vaccine-related escape the pandemic. adult patients including the elderly. information into the California ADMINISTERING THE Because the vaccine is designed to Immunization Registry (CAIR) VACCINE stimulate an immune response side database. If your office is not already effects from the immunizations, are registered with or entering data The Fresno County Department fatigue, muscle aches, fever, joint pain, into CAIR or for more information of Public Health (FCDPH) needs headache, pain and redness at the on the information registry, go to all clinicians to help win this fight. injection site. www.cairweb.org/covid. If you are As is the case for influenza vaccines In clinical trials, these side planning to vaccinate healthcare and childhood immunizations, effects were reported in less than 10% personnel and are willing to vaccinate medical offices will play a key role of patients, mainly in those healthcare personnel that under 55 years of age, and are not your staff, please no serious long-term side contact the FCDPH Despite the challenges, the effects have been noted yet. at covidvaccine@ Important questions fresnocountyca.govand COVID-19 vaccines have been shown about the COVID-19 include those details that in to be highly effective- over 90% in vaccine remain to be the email. adult patients including the elderly. answered, including how In summary— long vaccine immunity vaccines have saved lasts, and whether you can countless lives and promise transmit the virus even to do so with this viral if you yourself are protected from pandemic as well. This is a time to in immunizing our communities. illness. We will continue to learn show leadership, courage, ingenuity, The FCDPH is looking to medical much more about the virus, and the and lead our patients by the examples professionals to support its efforts weapons we have developed to defeat we set as we forge ahead in the fight to communicate the value and it, in the weeks and months ahead. against COVID-19. Let’s all give this importance of the COVID-19 What we do know even in this early fight out best SHOT! vaccines to the public, as well as to

Winter 2021

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Winter 2021

2021 Installation of Officers

For the first time in 137 years, the Fresno Madera Medical Society held a virtual installation. On a breezy afternoon in Woodward Park, our 2021 Officers gathered to take the oath of office. Outgoing President Alan Birnbaum, MD officiated over the installation of President Don H. Gaede, MD, President-Elect Christina Maser, MD, Vice President John Moua, MD and Treasurer Marina Roytman, MD. In addition to the officers, the 2021 Board of Governors includes: Mark Alson, MD, Pamela Kammen, MD, Brent Kane, MD, Farah Karipineni, MD, Anne Prentice, MD, Jesus Rodriguez, MD, Sonia Shah, MD, Katayoon Shahinfar, MD, Greg Simpson, MD, Toussaint Streat, MD, Benjamin Teitelbaum, MD and Jai Uttam, MD. Winter 2021

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Pandemic Pandemic THE

WITHIN THE

MARINA ROYTMAN MD

…NOVEMBER 18, 2020...

UCSF FRESNO HEPATOLOGY INPATIENT ROUNDS… “28-year-old, Caucasian woman presented to the ED with abdominal distension, yellowing of her eyes and skin and poor appetite for 1 week. Patient reports drastically increasing her alcohol intake over the previous few months which she attributes to multiple life stressors: loss of work/income, concern for ability to pay rent, having to direct distance learning for her 3 young children, all in the setting of COVID-19 pandemic.

Patient previously consumed 1-2 glasses of wine a week which escalated to 1-2 bottles of wine a day beginning in late July. Patient began feeling unwell (nausea, vomiting, low grade fever, right upper quadrant discomfort) in the end of October which led her to stop drinking alcohol in the beginning of November. Physical exam reveals an anxious woman with jaundice, scleral icterus and large volume ascites. Spider angiomas are notably absent.

Labs include total bilirubin of 24 mg/dL, AST 89 IU/L, ALT 37 IU/L, albumin 3.1 g/dL, INR 2.4, Hg 9.0 g/dL, platelets 97,000/πL. Imaging reveals large volume ascites as well as massively enlarged liver with smooth contour”.

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As a resident will astutely point out, this patient has acute alcoholic hepatitis (AH). It is characterized by onset of jaundice within prior 8 weeks, mild transaminitis (AST/ ALT > 1.5, both values <400 IU/L), total bilirubin >3.0 mg/dL in the setting of excessive alcohol consumption with less than 60 days of abstinence before the onset of jaundice1. Clinical presentation can be indistinguishable from decompensated cirrhosis with severe cases exhibiting ascites, hepatic encephalopathy, coagulopathy and decreased platelet count2. It is common for the patients to experience malaise, anorexia, low grade fever and right upper quadrant discomfort at the onset of the AH that lead them to discontinue alcohol consumption a few days to weeks prior to seeking medical care.

AH was a rare diagnosis prior to COVID-19 pandemic. Its incidence has exploded in the Central Valley as well as in the other parts of the country most likely due to massive social instability resulting from the months of pandemic-related disruptions. Our patients are losing their jobs, their homes, their loved ones and are coping by increasing their alcohol consumption. Parents (frequently mothers) are experiencing unprecedented levels of stress by having to cope with distance learning, lack of day care in addition to working from home and running the households. Daily, excessive drinking has been normalized in social media leading to witty memes and, tragically, to half of my service being dedicated to young patients with AH.

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It is critical to make the diagnosis of AH and to distinguish it from the decompensated cirrhosis as the treatment and prognosis vary significantly. First, high index of suspicion for AH is needed while evaluating a patient with a concerning clinical syndrome, keeping in mind that patients may have stopped drinking a few days to a few weeks ago and may not readily volunteer their drinking history. Second, we must not immediately jump to the diagnosis of cirrhosis while evaluating a patient with features of hepatic decompensation as those can be seen in AH. Presence of massive hepatomegaly with smooth hepatic contours is one of the clues to the diagnosis of AH. Third, we must explain to the patients that the liver function can recover with abstinence from alcohol and proper care as many patients are terrified of dying given their very disturbing and rapidly progressing symptoms.

Liver biopsy is not needed in the vast majority of patients presenting with classic signs and symptoms of AH. It is reserved for a fraction of patients in whom the diagnosis is unclear. Treatment includes abstinence from alcohol, aggressive nutritional support (high calorie and high protein diet) and in selected cases, steroid therapy (prednisolone preferred). Severity of the AH and the need for steroid therapy is determined by calculating lab-based prognostic scores (MELD-NA and Maddrey discriminant function scores are most commonly used). Steroid therapy is shown to only improve 28-day mortality3, while high quality nutrition, and most importantly abstinence have been shown to be beneficial for long term survival. Steroid therapy should not be offered in the setting of uncontrolled infection, active bleeding and, arguably, acute kidney injury. Steroid therapy is not a panacea and should be offered to carefully selected patients who meet the selection criteria and in whom close follow up can be assured. Lille score should to be calculated on day 4 (previously day 7) of steroid therapy to determine response and the need to continue treatment for full 28-day course4. Steroids should be stopped in non-responders to avoid steroid related complications as soon as Lille score results are available.

Steroids can be safely stopped after the completion of 28day course without taper.

Many patients show dramatic recovery over weeks

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to months of abstinence with resolution of all signs and symptoms of hepatic decompensation. Some patients may need aggressive diuretic therapy and/or scheduled large volume paracentesis during the recovery process.

Improving INR is the best prognostic indicator of recovery.

Some patients who do not recover may need to be referred for liver transplant evaluation even prior to achieving a specific period of sobriety (previously 6 months). Larger transplant centers are now considering patients with alcohol-related liver disease for early transplantation if they are critically ill and meet criteria predictive of posttransplant sobriety (e.g. good support system, commitment to sobriety, insight into current condition). Counseling patients to engage in substance abuse treatment program is critical to patients’ long term ability to maintain sobriety.

COVID-19 has made a previously uncommon condition of AH a daily occurrence on our inpatient wards further staining the medical system that is already on the brink of collapse. As clinicians, not only do we need to be familiar with the diagnosis and treatment of this condition, but we need to actively work on preventing it by educating our patients about the danger of excessive alcohol consumption. Asking the patients about their alcohol consumption may feel like an additional burden to the already overloaded virtual visits, but it may save their livers and their lives.

REFERENCES: 1. Diagnosis and Treatment of Alcohol‐Associated Liver Diseases: 2019 Practice Guidance from the American Association for the Study of Liver Diseases. David W. Crabb, Gene Y. Im, Gyongyi Szabo, Jessica L. Mellinger, Michael R. Lucey. https://doi.org/10.1002/hep.30866 2. EASL Clinical Practice Guidelines: Management of alcohol-related liver disease. PMID: 29628280, DOI: 10.1016/j.jhep.2018.03.018 3. Prednisolone or Pentoxifylline for Alcoholic Hepatitis.

Mark R. Thursz et al. N Engl J Med 2015; 372:1619-1628, DOI: 10.1056/NEJMoa1412278 4. A Day-4 Lille Model Predicts Response to Corticosteroids and Mortality in Severe Alcoholic Hepatitis. Mauricio Garcia-Saenz-de-Sicilia et al. Am J Gastroenterol, 2017 Feb;112(2):306-315. DOI: 10.1038/ajg.2016.539

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© Can Stock Photo / Zinkevych

“

Keeping our older patients informed, connected and cared for will demand creative and dedicated solutions, and our role as physicians is crucial.

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FARAH KARIPINENI, MD One of the very first things we learned about COVID-19 Lynch has already seen one suicide in his elderly patient was how crippling the virus is for our elderly population. population since the pandemic, and recalls two other Nursing homes across the world were one of the first and patients who are so depressed isolating from family that most vulnerable places in the pandemic’s devastating they want to die. path, and the medical community quickly rallied to try Dr Jyothi Patri, a family medicine physician at UCSF to understand and mitigate its havoc. Myriad articles Fresno, has also struggled with helping her elderly patients researching risk factors for predicting pathogenesis, survive isolation. On the one hand, she has seen firsthand cytokine storms, the contribution of “inflame-aging” and the effects of holiday family gatherings on COVID respiratory rehabilitation in the elderly immediately surged infections—four of her older patients were infected by on Pubmed. family members in the week after Thanksgiving. While she But as we enter the new year still battling the has discouraged family visits in her high risk older patients, pandemic, another insidious pandemic has also been she wants patients to know that primary care in person ravaging our fragile elderly community, one which we are visits are still very important. Many older patients struggle similarly ill-equipped to battle: isolation. As physicians, to do telehealth, and telephone visits are insufficient to many of us have likely experienced the downstream discuss multiple medical issues in chronically ill, comorbid effects of this struggle in the patients. “We are seeing more form of our older patients exacerbations of chronic missing important follow up diseases,” Dr. Patri says.

Extra patience from office staff appointments, labs, or imaging Because they are afraid to may be required for navigating a studies; displaying anxiety or go out, they refuse lab work. telehealth visit with the elderly. depression at visits; presenting “They are afraid to come to with more severe forms of the office. But a lot of physical non-COVID disease; and exam is done just by looking unable to do telehealth appointments. These issues are a at people.” She also notices that the patient-physician small manifestation of a much larger struggle that has been relationship has suffered during the pandemic, which may almost unbearable for the elderly in the past several months portend COVID vaccination refusal in the future: “Our of the pandemic, many of which stem from isolation. relationship with patients is suffering due to minimal For Dr. Michael Lynch, an internal medicine contact. Elderly patients are leaning more on family than specialist in Fresno, this sobering trend has hit close to evidence-based information.” Dr. Patri urges physicians home. As the pandemic hit the valley, the local medical to encourage their healthy elderly patients to maintain in community rushed to set up resources to care for the person PCP visits, get the COVID vaccine when possible, elderly’s health care, but not their emotional needs. and avoid high risk family interactions.

“Facilities like nursing homes need to be able to provide Indeed, while social isolation appears to be our best emotional support”, he states. One of the most important hope for preventing the spread of the pandemic among our ways of doing this is helping patients connect with their most vulnerable, it has also been linked to other diseases. families during isolation. “As people get older, their social Social exclusion has been associated with higher rates of contacts are more important. That’s all they exist for. When vascular disease, cognitive impairment, emotional distress, that is cut off, their purpose for existence goes away.” Dr. reduced physical activity, and even premature mortality. As Winter 2021

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© Can Stock Photo / imtmphoto

Plagg et al write in a recent study on prolonged social isolation during COVID-19, “The sad climax of isolation is the lonely dying and the impossibility of an accompanied, palliative situation — a human as well as medical-ethical debacle.”

Fortunately, there are many ways that physicians can help. Telehealth and telephone calls (for those who cannot do telehealth) can keep physicians in touch with their elderly patients, and may serve as virtual check-ins that are important not only for their physical conditions but for their mental health, as well. Extra patience from office staff may be required for navigating a telehealth visit with the elderly. When a telehealth visit is not possible due to technological barriers, offering a telephone call instead of postponing a visit entirely until safer times may also help patients feel less isolated. More frequent contact may also be needed; Dr. Patri has begun to offer 6-week telehealth follow-ups instead of the regular 3-month follow-ups for some of her elderly patients. During in-person office visits where no family is allowed, offering to put family members on speakerphone can be another resource.

Ensuring a safe environment in the office by avoiding waiting room crowding, encouraging patients to make appointments for lab draws to reduce wait times can also make a big difference. And of course, screening staff plays an important role; some centers like Central Valley Indian Health are implementing random asymptomatic 2-4 week COVID testing for all staff in addition to temperature checks and daily questionnaires.

Another tremendous resource for the elderly, both in the face of the pandemic and otherwise, is the Valley Caregiver Resource Center. Michele Dibuduo, the Executive Director of the center, has worked tirelessly to increase their resources for the elderly and their caregivers during this critical time. Their services include support groups and a wealth of virtual classes on mental health, understanding the language of dementia, and the use of technology during isolation. They are willing and able to help connect patients to telehealth visits with contactless

tech support. They even offer in-home respite visits to relieve caregivers, a program which is continuing during the pandemic. As some of their seniors don’t have internet or computers, they are purchasing iPads for families who do not have them. Most of their services are free, and a referral is as simple as giving the center’s contact information to patients or caregivers. More information on their services is available at valleycrc.org.

Another valley institution for comprehensive elderly care worth noting is the Program of All-Inclusive Care for the Elderly (PACE) for Fresno residents age 55 and over who need considerable assistance with daily living. Most patients need insurance to participate, but private pay patients may also qualify. A physician referral is needed, and a series of assessments affirms the need for services.

Nicole Butler, Director of Operations at PACE, has noted worsening social isolation in their community as well: “It is the #1 issue when we talk to seniors, they are grossly alone, and saddened by that.” To combat this, all PACE participants receive a device called a Grand Pad when they become members. All the costs are covered by PACE, and home internet is not required. The user-friendly devices allow the elderly to participate in daily activities like bingo, history trivia, and chair yoga. They can also use them to call their PACE care providers. Find more information at fresnopace.org.

In the months ahead, COVID challenges abound.

Keeping our older patients informed, connected and cared for will demand creative and dedicated solutions, and our role as physicians is crucial. Referring patients and caregivers to the resources in this article; urging patients to get the COVID vaccine; advocating for social distancing when necessary and safe family visits when possible; utilizing frequent telehealth and telephone visits to stay connected; and ensuring a safe office visit are just some of the ways we can help our vulnerable elderly survive isolation during the pandemic.

Winter 2021

Finally—a bit of good news to finish off a horrendous year.

Measure P, the city parks initiative that was backed by many physicians including our medical society, appears to be getting a second life. Although 52% of Fresnans voted for it in 2018, it didn’t make the 2/3 majority required

by Prop 13 for any tax measures. But California’s Fifth District Court of Appeal decided that a 2/3 majority was not needed for this measure, and therefore the proposition passed. Fortunately, the city of Fresno said it won’t fight the ruling (the Howard Jarvis Taxpayers Assn. may appeal it to the state supreme court).

This is good news for Fresno, and good news for the health of our citizens, particularly our youth. Our young people have told us there is a dearth of places for them to get fresh air and exercise. And if this pandemic has taught us anything, we’ve learned that when you’re cooped up, outdoor exercise is just what the doctor ordered to maintain a healthy body and mind. But without safe,

well-maintained parks, that type of exercise is difficult to obtain, especially for residents in the south part of town, whose neighborhoods have suffered from neglect for many years.

The Trust for Public Land annually ranks the nation’s top 100 cities for park access; Fresno recently ranked an embarrassing 94th out of 100 cities for park space. Now there is a chance we Fresnans can start bragging about our plentiful and safe green space, both north and south of Shaw Avenue.

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

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www.depressionfresno.com CENTRAL VALLEY PHYSICIANS 31

PRACTICE NEWS AND RESOURCES

New Life for Measure P

PRACTICE NEWS AND RESOURCES

BY JAMIE M. BOSSSUAT, ESQ California employment laws are always changing, but employers in 2021 will face some significant changes and challenges ranging from COVID-19 safety and notification requirements to expansion of the California Family Rights Act. This article addresses a few key changes that employers should prepare for.

COVID-19 REQUIREMENTS

© Can Stock Photo / putilich

Cal/OSHA and OSHA have begun citing employers for COVID-19 safety violations. They have issued a total of more than $2.5 million in penalties through the end of October. To prevent citations and penalties, employers should have a written Injury and Illness Prevention Plan in place and should have a specific COVID-19 safety plan in place that employees have been trained on and that complies with both state and local guidelines.

Also, California law now has very strict notification requirements for COVID-19 exposure in the workplace.

Employers must provide written notice to all employees who may have been exposed within one business day.

This notice must also include notice of COVID-19 related benefits and the company’s anti-discrimination, antiharassment and anti-retaliation policies and the company’s disinfection protocols and safety plan.

Due to the short-timeframe for providing notice it is recommended that employers consult counsel and have a plan in place to respond to a COVID-19 exposure and have draft notices ready to be distributed quickly.

SEXUAL HARASSMENT TRAINING All employees must have completed a compliant sexual harassment training by January 1, 2021. Supervisory 32 CENTRAL VALLEY PHYSICIANS

employees must receive 2 hours of training and nonsupervisory employees must receive 1 hour of training.

New hires must receive training within 6 months of their start date.

CALIFORNIA FAMILY RIGHTS ACT EXPANSION California has significantly expanded the California Family Rights Act, which provides employees the opportunity to take up to 12 weeks of job-protected leave for their own serious health condition, the serious health condition of a family member or a birth or foster or adoption placement. The law, which previously only applied to employers with 50 or more employees now applies to all employers with more than 5 employees. The definition of “family member” has also been expanded.

All employers must update their employee handbooks to reflect this change and should familiarize themselves with the requirements of CFRA so they are prepared to implement the new law at the beginning of January.

MINIMUM WAGE INCREASE Also, employers should keep in mind that the minimum wage increases each year in California. For 2021 the minimum wage will be $13 per hour for employers with 25 employees or less and $14 per hour for employers with 26 employees or more. This also increases the salary threshold for exempt employees who fall under the professional, administrative or executive exemptions.

The salary minimum will be $54,080 for employers with 25 employees or less and $58,240 for employers with 26 employees or more.

Winter 2021

CALIFORNIA’S COMPLETELY UNPREDICTABLE,

TOTALLY CHAOTIC LEGISLATIVE YEAR

As 2019 concluded, reasonable assumptions about 2020 began to emerge. The year was expected to be busy and more polarizing due to the presidential election occurring in November. Large-scale issue-based campaigns calling for new state programs supported by the expected state budget surplus were being announced. State legislators were finalizing their legislative packages. And lastly, the California Medical Association (CMA) was preparing to defeat yet another attempt to eliminate the cap on noneconomic damages incorporated in California’s longstanding professional liability reform law, the Medical Injury Compensation Reform Act (MICRA).

In March, the world changed, and California politics and the legislative process went through an unprecedented transformation.

On March 19 Governor Gavin Newsom issued the nation’s first statewide stay-at-home order in response to the arrival

Winter 2021

of the novel coronavirus (SARS-coV2) in California. All nonessential businesses, such as restaurants, entertainment centers/activities, etc., were immediately shut down until further notice. The State Legislature was forced to take multiple extended recesses, and all in-person lobbying was prohibited, leading to the cancellation of CMA’s annual Legislative Advocacy Day. The legislative process was completely upended. CMA staff worked diligently to adjust to ever-changing dynamics, as both houses of the Legislature scrambled to implement social distancing guidelines and condense their calendars.

In the end, CMA successfully maintained state funding for physician services, defeated proposals to increase or add new administrative burdens onto physicians, and secured a number of Executive Orders to protect medical practices as they faced a pandemic unlike any seen in the past century.

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However, CMA did not escape the legislative session unscathed. The legislature passed, and the governor signed AB 890 (WOOD), which created two new classifications for nurse practitioners (NP). While this measure was passed into law, this matter is far from settled, as the fight to ensure patient safety now moves into the regulatory process. All of CMA’s advocacy centers have prioritized this issue, developed an action plan, and are coordinating with the American Medical Association (AMA) as well as various specialty associations to ensure the bill is implemented in a manner that protects patients and physician practices.

BUDGET – ACCESS TO CARE California began this year with a strong economy, historic reserves and a projected surplus of $5.6 billion. Due to the COVID-19 pandemic, the state’s economy took a significant hit, which meant the Governor had to make several difficult decisions when revising his proposed budget in May. The Governor’s May Revision was a complete redrafting of the state budget proposal released on January 10, 2020.

In January, the budget proposal increased our state’s investment in health care, which included growing California’s physician workforce. The May Budget Revision, however, sought to reverse course, proposing to cut Proposition 56 funding for increased physician reimbursements, reduce patient benefits in Medi-Cal and strike all investments seeking to expand the physician workforce. Through the budget process in the Legislature, CMA was able to protect: •

$1.2 BILLION in Proposition 56 (tobacco tax) funding, which provides supplemental payments for physician and dental services, family health services, developmental screenings, non-emergency medical transportation and value-based payments. This includes the continuation of all future cohorts of the Proposition 56 Physician and Dentist Loan Repayment Program (years 2-5 of the 5-year program).

•

$1.5 MILLION in General Fund monies to maintain the Proposition 56 Graduate Medical Education program at an ongoing total of $40 million.

•

$33.3 MILLION in ongoing General Fund monies for the continuation of the Song-Brown Healthcare Workforce Training Program.

•

THE EXPANSION OF POST-PARTUM MENTAL HEALTH SERVICES for individuals diagnosed with a maternal mental health condition.

34 CENTRAL VALLEY PHYSICIANS

Through the budget process in the Legislature, CMA was able to protect $1.2 billion in Proposition 56 (tobacco tax) funding, which provides supplemental payments for physician and dental services, family health services, developmental screenings, nonemergency medical transportation and value-based payments.

In addition, the revised budget proposal included a 47% increase to the Medical Board of California’s physician and surgeon licensing fee. Through CMA’s advocacy, the Legislature rejected that proposal. Still, the Legislature could revisit the discussion in 2021 when the Medical Board is subject to a review of all of its operations through the Sunset Review process. It is anticipated that the Medical Board will seek a license fee increase in the context of that process.

SURPRISE BILLING – AB 72 FIX Since the implementation of AB 72 (Bonta) related to surprise billing, CMA has been working with the Legislature to mitigate the negative impacts on the physician community. This year, AB 2157 (WOOD) was introduced to address the issues surrounding the independent dispute resolution process (IDRP). Along with several specialty societies, CMA was able to secure amendments that allowed physicians to provide more substantial evidence to better defend their claims during an AB 72 payment dispute. Through CMA’s advocacy in the legislative process and with the Department of Managed Health Care (DMHC) directly, an IDRP determination has been in the physician’s favor, a first since the law became effective. However, our work on this issue does not end there. CMA continues to work with regulators and legislators to further ensure a process that is fair and accessible to any physician needing to use it.

PUBLIC HEALTH Flavored tobacco products are often the entry point for young people who use tobacco. Over the last several years, a spike in e-cigarette use among the nation’s youth

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has been linked to targeted advertisements of flavored tobacco. Menthol cigarettes, sweet cigars, candy vapes and other flavored tobacco products serve one purpose: to mask tobacco’s harshness and get users hooked to a dangerous life-long addiction. In 2020, CMA combined forces with a large coalition of health care, youth and community organizations to support SB 793 (HILL), which prohibits tobacco retailers, or any tobacco retailers’ agents or employees, from selling, offering for sale, or possessing with the intent to sell or offer for sale, a flavored tobacco product or a tobacco product flavor enhancer. This ban includes e-cigarettes and vaping products, as well as traditional tobacco products. SB 793 crossed the legislative finish line and was quickly signed by Governor Newsom once it reached his desk. The new law will take effect on January 1, 2021.

DECREASING ADMINISTRATIVE BURDENS CMA worked with ASSEMBLYMEMBER LORENA GONZALEZ ON AB 2257 to further address challenges for physician practices resulting from a bill passed last year (AB 5) that made significant changes to the definitions of independent contractors and employees, in an attempt to be consistent with the court decision in the Dynamex case. Last year, AB 5 included an exemption for physicians, but there continued to be a need to address business-to-business and referral agency arrangements.

CMA successfully secured amendments to address those outstanding concerns, and the bill was signed into law.

CMA also helped lead a coalition to defeat SB 977 (MONNING), which sought to expand the California Attorney General’s existing authority related to mergers and acquisitions in the health care industry. Although CMA policy supports governmental actions designed to ensure hospital market competition, this broadly drafted legislation established a wide definition of health care transactions, which included leasing and other medical contracting arrangements. SB 977 ultimately failed to move off the Assembly floor.

CMA worked with Senator Dr. Richard Pan to exempt independent medical practices from the mandate, and secured physician involvement in future rulemaking and guidance on this issue and supply chain sustainability.

Winter 2021

In addition to the above, CMA worked with multiple legislative offices to stop the creation of new administrative burdens related to the COVID-19 pandemic. AB 685 (REYES) requires employers to provide written notification within 24 hours to their employees if they were potentially exposed, at the workplace, to a person who has COVID-19.

As this would have required physician practices to report this information daily, CMA secured amendments that exempted employees who conduct COVID-19 testing or screening or that provide direct care to individuals known to have tested positive for COVID-19. This approach balanced CMA’s support for notifying employees of possible exposure and protecting physician practices from being overburdened.

Senator Richard Pan, M.D., introduced legislation requiring the state and health care employers to procure a stockpile of personal protective equipment (PPE) as a means of addressing future equipment shortages like the one experienced at the outset of the pandemic. As introduced, the bill would have created a significant burden on independent physician practices. CMA worked with Dr. Pan to exempt independent medical practices from the mandate, and secured physician involvement in future rulemaking and guidance on this issue and supply chain sustainability.

IMPLEMENTING TELEHEALTH At the onset of the statewide public health emergency, CMA worked to build upon AB 744 (AGUIAR-CURRY, 2019), which required commercial health plans to implement payment parity for services provided via telehealth. An association-wide advocacy effort allowed CMA to secure widespread payor coverage across the entire health care system that required all commercial, Medi-Cal and workers’ compensation payors to immediately cover telehealth services at the same rate as in-person services. To achieve this outcome, CMA worked with each independent agency and department to ensure consistency between the DMHC and the Department of Health Care Services (DHCS) as well as the California Department of Insurance (CDI) and employers under the Department of Workers’ Compensation (DWC). Each agency continued to post updated guidance consistent with CMA’s input, and often referenced CMA’s sponsored telehealth legislation (AB 744) as their models.

CMA also advocated for the Governor to waive existing laws requiring consent prior to providing telehealth services. During the COVID-19 state of emergency, these waivers ensure that no enforcement action would be authorized against covered health care providers providing telehealth services via remote communication technologies that may not fully comply with these privacy laws. CMA was successful in receiving these waivers at the state and federal levels.

CENTRAL VALLEY PHYSICIANS 35

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DECREASING LIABILITY FOR MEDICAL PRACTICES CMA worked with a coalition of health care and other business organizations to defeat AB 2570 (STONE). This bill would have exposed physicians and their practices to frivolous lawsuits, making it more difficult for physicians to maintain the viability of their practices.

SCOPE OF PRACTICE As discussed earlier, ASSEMBLYMEMBER JIM WOOD’S AB 890 creates two new categories of nurse practitioners, who would be allowed to provide services without standardized procedures. Despite the fervent work of CMA, the AMA and numerous specialty societies, the bill passed the legislature and was enacted in law. The bill does not eliminate physician supervision and leaves room for interpretation regarding the role supervision can still play in the physician-NP relationship. It should also be noted that existing NPs are not impacted by AB 890 and must continue practicing under standardized procedures. In addition, the measure includes a delayed implementation of three years to allow for the completion of the regulatory process. A detailed factsheet on this bill can be found on the CMA website at cmadocs.org.

UNCERTAINTY CONTINUES Although the 2019-2020 legislative session has finally concluded, uncertainty continues. In November, a new fiscal outlook will reveal whether the state budget is still facing a multi-billion shortfall. December will provide an idea of whether the Legislature will reopen the Capitol and allow for in-person lobbying. The political process will continue to be uncertain. However, there will be a consistent truth among all the unpredictable chaos: CMA will always be in the midst of every critical political and legislative battle, utilizing our resources to advance an agenda that protects physician practices and empowers the physician voice.

For more details on the major bills that CMA followed this year, visit cmadocs.org/leg-wrap-2020. Subscribe to CMA’s free biweekly Newswire and stay informed on CMA’s legislative efforts and other issues critical to the practice of medicine at cmadocs.org/subscribe.

Despite this setback, the fight to protect patient safety will now roll into the regulatory process. CMA will continue to work in tandem with AMA and our grassroots network to keep physicians engaged on this issue.

CMA will always be in the midst of every critical political and legislative battle, utilizing our resources to advance an agenda that protects physician practices and empowers the physician voice.

In other scope developments, CMA and the American College of Obstetricians and Gynecologists (ACOG) resolved a long-standing issue with the certified nursemidwives (CNM) through SB 1237 (DODD). This bill creates a framework for CNMs to perform certain functions within the scope of midwifery independently while maintaining a collaborative relationship with a physician and surgeon. The measure also includes a requirement for informed patient consent as well as patient outcome reporting requirements.

36 CENTRAL VALLEY PHYSICIANS

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MANAGING THE COMMUNITY BLOOD SUPPLY THROUGH THE PANDEMIC Central California Blood Center’s Never-Ending Mission

C

onvincing enough healthy people to donate blood has always been a challenge. It’s tough, even in a normal year. In 2020, the COVID-19 pandemic adversely affected countless ordinary activities in our world, including blood donation. When the SARSCoV2 virus reached the Central Valley last March, high schools and colleges began closing their doors. With school closures, many blood donations vanished. In addition, pandemic anxieties lead some businesses to postpone hosting blood drives, despite health officials at all levels of government advising that blood donation was safe and essential. Consequently, many mobile blood drives, which historically comprised 50% of all donated blood,

CHRISTOPHER STAUB, CEO CENTRAL CALIFORNIA BLOOD CENTER

Winter 2021

CENTRAL VALLEY PHYSICIANS 37

Had COVID?

YOU HAVE IT IN YOU TO HELP OTHERS BEAT COVID.

VISIT DONATEBLOOD.ORG FOR MORE INFORMATION.

were canceled.

The Central California Blood Center (CCBC), the Valley’s nonprofit provider of blood products and services, proactively recognized the need to convince increased numbers of people to donate blood at “brick and mortar” collection locations to make up for mobile blood drive cancelations. In many parts of the nation, blood collection fell overall by about 10-20%. Today, nearly ten months into the pandemic, CCBC has received outstanding support from our local community. Waves of blood donors, many first-time donors, heroically stepped up to enable CCBC to keep our hospitals supplied with blood. Through August, local blood collection was only down about 2.5% from our goal and remarkably, since September, blood donor collections have been above goal. Data through November 2020 shows that despite the hit to the blood supply from loss of mobile blood drives, CCBC adjusted quickly, implementing effective and innovative strategies to collect blood.

We thank our community leaders, blood donors and dedicated staff. Together they allowed us to collect whole blood and platelets above goals set prior to the pandemic.

Like any supply chain, there must be a balance between supply and demand. Generally, a community’s projected need for blood products determines goals as to how much blood must be recruited, collected and processed. Throughout most of the pandemic, hospitals across the nation had limited the number of elective surgeries, reducing some of the demand for blood. Locally, however, the effects of elective surgery reductions were offset by unexpected surges in demand and use of type O blood, particularly for trauma patients. Reoccurring medical and surgical needs for blood, platelet and plasma transfusion continue unabated, even during a pandemic. So with demand for local blood surging, particularly type O, from September through the Fall, it sometimes wasn’t enough that we hit our collection goals. Like the rest of the country, we experienced some tense days with blood shortages.

Any blood shortage, whether the cause is supply- side or demandside, is equally scary if you are the person who needs the blood.

Winter 2021

Primarily because of loss of high school and college blood drives, the age mix of blood donors has shifted remarkably. Before the pandemic, young donors ages 16-21 provided up to 32% of the blood supply. During the pandemic, blood donations from this young demographic dropped to only 4%. While older donors have stepped in to answer the call, CCBC and blood centers across the nation must find new ways to re-engage young blood donors, even as schools may not soon return to normal, to sustain adequate blood resources for all patients.

Looking ahead to the next six months and beyond, CCBC and our Central Valley community need your help. Become a blood donor. Visit DonateBlood.org to find out where/when/how. (Getting

the FDA authorized COVID vaccine will not make you ineligible to donate blood or platelets). Come to one of our fixed sites and donate blood today. All blood types, particularly type O needed!

If you have healthy family members in your household, ages 16 and over, bring them along. Encourage others to donate. Physicians should encourage patients’ family members to donate blood.

Donating blood is safe. Blood Centers practice universal masking, ample distancing, and all other CDC safety standards to assure safety for donors and staff. Physicians, community leaders, elected officials, and healthy people, young and oldWe need you today. Valley People Need Valley Blood.

The Fresno Madera Medical Society is working to establish a program that brings mentors and mentees together. When looking back over their careers, some physicians attribute much of their success to the help and advice they received from another physician. Other physicians regret the fact that they did not have anyone to talk to when they needed to make an important decision.

Having a seasoned physician - a mentor - can be essential to achieving one’s career goals or in simply finding the right work-life balance.

Interested in becoming a mentor, or mentee? Contact Stacy Woods at swoods@fmms.org.

Winter 2021

CENTRAL VALLEY PHYSICIANS 39

PUT YOUR MEMBERSHIP TO WORK! When you join the Fresno Madera Medical Society, you join the California Medical Association as well.

When you join the Fresno Madera Medical Society, you join the California Medical Association as well.

Together FMMS-CMA can help with the success of your practice.

Together FMMS-CMA can help with the success of your practice.

Your annual dues can be more than offset when using membership services and discounts, and you get personal assistance with Your annual dues can be more than offset when using and you geta personal assistance with practice management and payment recovery issues to membership improve yourservices bottomand line.discounts, Join the FMMS to be better leader for your practice management and payment recovery issues to improve your bottom line.

Join the FMMS to be a better leader for your staff and patients, and to amplify your voice to influence policy and legislation. The FMMS brings together an active community staff and patients, andtotoimprove amplify the yourlarger voicecommunity. to influenceOur policy and legislation.

The FMMSand brings together an active community of physicians in order mission is physician-driven, we want to help you solve your of physicians in order to improve the larger community.

Our mission is physician-driven, and we want to help you solve your biggest practice management issue. Join the FMMS today! biggest practice management issue. Join the FMMS today!

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40 CENTRAL VALLEY PHYSICIANS

Winter 2021

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CENTRAL VALLEY PHYSICIANS 41

PRACTICE NEWS AND RESOURCES

Your CMA Dues at Work: Over $5 Million of Prop 56 Tobacco Tax Money Awarded to Valley Residency Programs 101 awardees will help address physician shortage, increase access to care Largest CalMedForce applicant pool, so far, with over $95M requested Physicians for a Healthy California (PHC) announced more than $38 million in CalMedForce awards across the state to support medical training and residency programs and help grow the physician workforce.

The third round of CalMedForce funding, released by PHC and generated by the voter-approved Proposition 56 tobacco tax in 2016, will support 202 residency positions in 101 graduate medical education (GME) programs at hospitals and clinics, with an emphasis on those serving

medically underserved groups and communities. This cycle represented the largest applicant pool: 541 residents and 122 applications requesting over $95 million in funding.

The California Future Health Workforce Commission estimated that California will need 4,700 additional primary care clinicians by 2025 and approximately 4,100 more by 2030 to meet demand.

PHC, in partnership with the University of California (UC), established the CalMedForce grant program to

Fresno and Madera County Residency Programs Awarded Saint Agnes Medical Center Emergency Medicine Residency Program Saint Agnes Medical Center Family Medicine Residency Program Saint Agnes Medical Center Internal Medicine Residency Program University of California (San Francisco)/Fresno Pediatric Residency Program University of California (San Francisco)/Fresno Emergency Medicine Residency Program University of California (San Francisco)/Fresno Family Medicine Residency Program University of California (San Francisco)/Fresno Obstetrics and Gynecology Residency Valley Children’s Healthcare Pediatric Residency Program Total Local Awards

42 CENTRAL VALLEY PHYSICIANS

Amount $1,125,000.00 $ 225,000.00 $ 675,000.00 $ 750,000.00 $ 480,000.00 $ 150,000.00 $1,000,000.00 $ 750,000.00 $5,155,000.00

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help address California’s looming physician shortage because medical school graduates must continue training in an accredited, specialty-specific GME residency program to obtain a medical license and care for patients independently.

“CalMedForce continues to demonstrate the high demand and need for GME opportunities,” said Lupe Alonzo-Diaz, MPA, PHC president and CEO. “The lack of sufficient residency spots contributes to California’s physician shortage and limits the number of new doctors entering the workforce. With COVID 19 impacting life for the foreseeable future, programs like CalMedForce are even more essential to protect access to care for all Californians.”

The UC is the designated recipient of Proposition 56 funding and has contracted with PHC to administer CalMedForce. All accredited residency programs in the state that meet guidelines are eligible to apply for funding.

Of this year’s CalMedForce awardees, approximately 14% of GME programs are sponsored by the University.

To date, CalMedForce has released over $114 million for 261 awards to 121 GME programs across California to retain and expand GME programs in primary care (family medicine, internal medicine, pediatrics, and obstetrics and gynecology) and emergency medicine. However, even with the additional funding, the shortage of California residency programs poses an ongoing challenge for expanding the physician workforce.

“We understand the vital statewide need for this program and the funding it provides to support California’s future physicians,” said Cathryn Nation, M.D., Vice President for Health Sciences at UC Office of the President.

“The annual demand for funding reflects the importance of this program and its focus on the needs of medically underserved groups and communities.”

Tracy Zweig Associates A

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Winter 2021

CENTRAL VALLEY PHYSICIANS 43

PRACTICE NEWS AND RESOURCES

© Can Stock Photo / garnazarina

How to Address Vaccine Hesitancy DON GAEDE, MD, FMMS PRESIDENT ALEX SHERRIFFS, MD, FORMER FMMS PRESIDENT (1999) The good news: Vaccines against COVID-19 are now available, and most of us have been able to get our first vaccinations! One small ouch for man; one great leap for public health.

The bad news: Many people are hesitant to take the vaccine; this includes health care providers. Multiple health care facilities report only 30-40% of their staff consenting for the first round of vaccination. Alas, fake news travels faster than facts.

Our medical society is looking for ways to address the problem. We’ve teamed up with the Fresno County Dept. of Public Health to produce PSAs, and we’re going to be airing interviews of prominent individuals talking about the vaccine. Meantime, there is a more immediate way to address vaccine hesitancy. How? By having a brief conversation with each of your patients about the vaccine.

Consider this: At every patient encounter, ask, “What questions do you have about the COVID-19 vaccine?” If they have any concerns, respond in a positive way, such as, “Great question!” Then proceed to reassure them by giving them accurate information about their concerns.

One physician quipped that the most common side 44 CENTRAL VALLEY PHYSICIANS

effect from the vaccine is—relief! Questions we’ve heard include: 1) Fast vaccine development has meant safety shortcuts. Response? Every vaccine raises safety issues, and COVID vaccines have been rigorously evaluated for safety. Not all the answers are in, but we know enough that I got vaccinated. 2) The vaccine might cause infertility.

Response? Side effects like fertility have been looked for, and in over 2 million doses administered, no evidence of such a problem has been found.

This conversation doesn’t even take 2 minutes, but can greatly improve our community’s vaccine acceptance rate. If the discussion is getting too lengthy, refer the patient to www.CDC.gov for up-to-date information you trust, and offer to schedule a follow up discussion.

By the way, having a vaccine discussion can get you paid more for the visit, since it increases its complexity. No pesky boxes to check! That’s a win-win situation for all of us.

PS: An informative and entertaining discussion of vaccination hesitancy featuring Dr. Anthony Fauci talking with The Try Guys can be found at: https://youtu.be/NDuaiYf8WD Winter 2021

Fresno, California - Helen was born on November 6, 1933 to Andreas Rotous and Georgia Zaniakou Rotous in Aberdeen, Washington. Helen’s parents were both Greek immigrants from Limni, Evia who wanted only the best for Helen and her older sister, Cordelia. Much of the sisters’ childhood was spent working at the Thriftway Market grocery store their parents owned, and participating in music lessons, dance lessons, and other studies. Helen was an exceptional student. After graduating from Weatherwax High School in 1951, she attended the University of Washington and graduated three years later with a degree in medical science.

Helen then attended and obtained her medical degree at the University of Washington School of Medicine. She was one of only five women in the Class of ‘58. Helen then moved to Sacramento, California to perform her internship at Sacramento County Hospital, after which she worked as a physician at McClellan Air Force Base. Helen was active in the Annunciation Greek Orthodox Church and made many lifelong friends as president of the youth group and as a member of the church choir.

In 1960, Helen met her future husband, Chris Evangelos Rockas, an attorney from Fresno, California. They were married on April 16, 1961. Helen then moved to Fresno where she completed her residency at Fresno County Hospital, followed by nearly a decade as a private-practice pediatrician.

Helen spent the next 29 years of her career working to improve the lives of children and adults with special needs at Central Valley Regional Center. She served as CVRC’s medical director during the latter half of her time there.

Helen was a dedicated, curious, and caring physician who also served as the Chairperson of the Fresno-Madera Women Physicians and the Regional Center Physicians Organization.

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After retirement, she enjoyed volunteering at the 2004 Olympics and Para-Olympics in Athens, Greece, where she used her ability to speak Greek and English to assist attendees.

Helen was always busy, whether being a fantastic mom to her two children, Panayiota and Andreas, or participating in the many activities at St. George Greek Orthodox Church where she worshipped for nearly six decades. She was President of the Daughters of Penelope, a Greek-American service organization, and Founder and District Chair of Penelope’s Library Project, which supported women’s shelters across the United States.

In retirement, Helen was also an active member of the Fresno Community Chorus for 19 years. With her husband, she toured the world with the group, singing in France, Norway, Sweden, Denmark, Israel, Italy, and China. All who knew Helen were aware of the deep pride she had for her Greek heritage – and her love of dance and song. She had many wonderful friendships over the years and the family thanks all who were so kind to her in her final years.

Helen is survived by her loving husband of 59 years, Chris Rockas, daughter Panayiota (Patti) McCloskey, son Andreas (Andy) Rockas and his wife Danielle Guard, and three grandchildren, Grant McCloskey, Nicole McCloskey, and William Rockas.

Due to these challenging times, no public memorial service will be held at this time. In lieu of flowers, remembrances may be made to St. George Greek Orthodox Church located at 2219 N. Orchard St., Fresno, CA 93703.

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Fresno, California - Dr. Mayur Amin progressed to his next journey on Jan 3rd after a battle with COVID-19.

Dr. Amin was born and raised in Nairobi, Kenya where he cultivated his love for nature. He completed medical school in Baroda, India, psychiatry residency in Oshkosh, WI and afterwards moved to Fresno, CA. Over his illustrious career he compassionately cared for thousands of vulnerable mental health patients in Fresno and surrounding communities. He lived for his family and is survived by his wife Mrudula, daughter Amee, son-in-law Kunal, son Raj, brother Milan and family, late brother Samir’s family, and countless friends and colleagues. He always took respite in the great outdoors and was known for his love of animals, gardening, landscapes, and Costco.

Undoubtedly, he left the world a better place in his tireless quest for humanity and tranquility.

The Amin Children have made a charitable account to create a lasting legacy on their fathers behalf. The Mayur Admin MD Foundation is accepting donations through the website GoFundMe, funds will go to local institutions and scholarships that support exemplary and compassionate patient care. Additionally, the family looks forward to supporting mental health causes in honor of their Dad’s 29 years of service as a psychiatrist to the people of the Fresno County.

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Walnut Creek, California - Constantine Alexander Michas died peacefully on Tuesday, November 3rd, 2020 at the age of 79. Con was a resident of Fresno, California for 38 years.

He moved to Walnut Creek, California three years ago.

At the time of his death, he resided at Carnelian Assisted Living, a memory care provider there.

Con was born in Vancouver, British Columbia on May 21st, 1941 to John and Catherine Michas. The older of two sons, he attended General Gordon Elementary School and Kitsilano Secondary School. He attended the University of British Columbia, graduating in three years, and directly entered UBC’s Faculty of Medicine, class of 1966. He was an intern at Cook County Hospital in Chicago and a surgical resident at the University of Michigan where he met his wife of 51 years, Justine Taylor of Mt. Clemens, Michigan. They settled in Sacramento where he completed the last year of his residency at the University of California at Davis. He stayed on as associate professor, developing the first burn unit there. In 1979, he joined Surgical Associates of Fresno and practiced general and vascular surgery for 30 years. Con was a Fellow of the American College of Surgeons and was active in the medical community of Fresno. He was devoted to his Winter 2021

patients, to his office staff, and to the staff, nurses and doctors at Fresno Community, Clovis Community and Saint Agnes Hospitals.

In addition to Justine and his brother John Michas of Vancouver, BC, Con is survived by his four children: Christina, Alex, Andreas and Gregory; their spouses: Jimmy Wallenstein, Ariane Michas, Sara Michas-Martin and Tyla Michas; six grandchildren: Oscar and Sylvie Wallenstein, Ophelia and Soren Michas, Jonah MichasMartin, and Ethan Michas; and a large extended family.

All of his children and their families returned to reside in California, satisfying his greatest wish that they be near one another.

Con traveled widely, grew fruit and vegetables in his garden, and played poker with friends. He loved a beautiful landscape, skiing and hiking in Tahoe, and his home in Carmel-by-the-Sea. He was proud of his Greek heritage, loyal to his Canadian roots, and became a US citizen in 2012. He had a wonderful positive spirit. He was generous and kind. He loved to hug. Above all, Con loved to be surrounded by his family and friends. He will be dearly missed.

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