Central Valley Physicians - Summer 2021

INSIDE: 3 Valley Programs Graduate Residents 2021 Writing Competition Results Advancing Sickle Cell Care Saint Agnes Graduates Inaugural Class Summer 2021

Kids & COVID-19

CENTRAL VALLEY PHYSICIANS 1

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.

FMMS sponsors up to four (4) annual sessions with approved and ve�ed providers confiden�ally, conveniently and FREE to physicians living and prac�cing in Fresno and Madera Coun�es.

Par�cipa�ng in a Joy of Medicine Resiliency Consulta�on is completely confiden�al. Neither FMMS, your employer, nor the California Board of Medicine will be no�fied if you choose to par�cipate.

Par�cipa�ng providers offer a wide range of appointment �mes that strive to accommodate the unique and busy schedules of physicians.

Providers are paid by FMMS directly, discreetly and anonymously. Insurance will not be asked for or billed.

Physicians have the op�on of extending their par�cipa�on at their own expense a�er the fourth visit.

It’s OK to ask for help! Call today to schedule a free Resiliency Consulta�on and begin the process of reconnec�ng to your Joy of Medicine.

RECONNECT TO YOUR

Joy of Medicine

SCHEDULE ROUBICEK and THACKER 559-323-8484

2 CENTRAL VALLEY PHYSICIANS 2021 Call and identify yourself as a physician practicing in Fresno Summer or Madera County AN APPOINTMENT

VOLUME 6, NUMBER 2 • SUMMER 2021

{FEATURES}

10 26 29 34 37 42

RESIDENCY GRADUATIONS LEADERSHIP AWARDS WRITING CONTEST WINNERS

SICKLE CELL CARE

KIDS AND COVID 19

CAMARENA HEALTH: CONVENIENT CARE

Summer 2021

{DEPARTMENTS} 5 MESSAGE FROM THE EDITOR 7 MESSAGE FROM THE PRESIDENT JOY OF MEDICINE: 46 WHEN TAKING A BREAK MAKES US SICK

49 FINANCIAL WELLNESS 54 IN MEMORIUM

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From the Executive Director

PRESIDENT – Don H. Gaede, MD PRESIDENT-ELECT – 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 Assistant Editor – Karen Dahl, MD Managing Editor – Stacy Woods 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 Farin Jacobson, Russell Maltes, Reshma Patel, MD Catherine Heaney, MA, MSW CONTRIBUTING PHOTOGRAPHERS Anthony Imirian CENTRAL VALLEY PHYSICIANS is produced by Fresno Madera Medical Society PLEASE DIRECT ALL INQUIRIES AND SUBMISSIONS TO Central Valley Physicians 255 W Fallbrook Avenue Suite 104; Fresno, CA 93711 Phone: 559-224-4224 | Fax: 559-224-0276 Email address: swoods@fmms.org MEDICAL SOCIETY STAFF Executive Director – Stacy Woods Marketing Coordinator – Casey Nagle

Summer 2021

A message from our Editor > Farah Karipineni, MD

True North

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.

Summer 2021

As if things were not challenging enough with COVID, practicing medicine in the Valley has the added strain of difficult relationships between major stakeholders in town. Many physicians find themselves caught in the middle, unsure of where allegiances should lie and how the outcome of this fight will affect our practices, our communities and our own lives. I’m relatively new to the area, and don’t pretend to understand the nuances of the tension, but it is clear that key relationships are strained. In times like these, supporting each other is even more tantamount. A word of concern, going the extra mile for a colleague, or lending an ear, can make a world of difference. I have been on both the giving and receiving end of such kindness, and in the current milieu, it means so much when it comes from colleagues embroiled in the same battle.

“I just always follow my true north.”

In one such moment, an esteemed colleague recently told me the recipe of her career success, saying, “I just always follow my true north.” Of course, advice like this never steers us wrong, yet can often seem difficult to follow. Perhaps as we advance in our careers, motives like finances, power, or social or political allegiances alter the course of our ship. Or maybe it is the unforeseen obstacles that shake us, which the past year has thrown out in abundance. Either way, as we steer our course, we may find ourselves at risk of losing our true north.

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This is a well-known phenomenon; life promises to throw each of us our fair share of tumult. But to quote A League of Their Own, “If it was easy, everyone would do it.” Staying true to one’s deeply held beliefs, core values and principles throughout the storm is such a prized leadership skill in part because it is so rare.

The model of leadership that rests on bureaucracy, paternalism, hierarchy, self-interest, and charisma is antiquated. This model has passed on an insidious inheritance of things like systemic racism, sexism, nepotism, and groupthink to our collective experience.

It is a culture so deeply embedded that it is almost invisible, though we face its myriad effects daily. As physicians in the Valley, we need only to consider our patient population to demonstrate abundant examples of these effects.

But just like Mr. Rogers’ mother told him, “You will always find people who are helping.” Leadership in the name of service is not a new phenomenon, either, and we also have many illustrious examples of it, both in our community and at large. These leaders know that authenticity, strength of character, honesty,

day, whether with our staff, our patients, health care administration, or our families. With all the challenges we face both personally and as a community, defining our true north and thoughtfully (re)directing our course is as crucial as ever. We owe it to ourselves, to each other, and to the communities who need us.

And to the beloved colleague who reminded me of this—the one and only Dr. Christina Maser—thank you.

“If it was easy, everyone would do it.”

humility and service are of far more value—priceless, in fact—and pay dividends not only in their leadership roles but also in their personal satisfaction. Research has proven this.

Dr. Albert Schweitzer, renowned Nobel Peace Prize winner, humanitarian, and musician, said it well: “The only ones among you who will be truly happy are those who will have sought and found how to serve.”

And what could be more important than our own happiness?

As physicians, we both lead and serve every

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Summer 2021

A message from our President > Don Gaede, MD

Celebrating the Practice of Medicine

ABOUT THE AUTHOR 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.

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To all the medical students and residents graduating this year, “Welcome to our profession!” The profession of physician, as I’m sure you already know, is much more than a job where you punch a time clock and put in your 8 hours. It is a calling. A calling that you now have the honor of pursuing for the next few years. Treasure these years, because they will fly by much too fast.

In the course of your career, you will have the chance to use your scientific, social, emotional, and even spiritual skills to improve the health of countless persons. You will receive heartfelt thanks from many of your patients, and unspoken thanks and respect from many others. You will be paid well for your services, but the best reward is not the money. In spite of the undeniable frustrations of practicing medicine in this day and age, a tremendous sense of joy often comes from your interactions with your patients, your colleagues, and your assistants.

In fact, practicing medicine is so rewarding that a good number of us have a hard time giving it up.

It is with tremendously mixed feelings that we hang up the stethoscope. A few years ago, I heard through the grapevine that a long-time colleague was retiring, so I called him up on the phone. “Hey Pete, I just heard you’re retiring—congratulations!!” Dead silence on the other end.

Then finally, “Yeah...thanks.”

Surveys show that we physicians work longer years than average mainly because we enjoy what we do. I’m 71 years old and have been practicing for (OMG!) 42 years. I’ve cut back on my work schedule, but still enjoy the challenge of my vascular medicine practice. Long-time orthopedic surgeon Charles Touton retired this year at the age of 74, after practicing for 44 years. Norman Siegel has been practicing internal medicine since 1964, but at the age of 86, he still relishes full-time work.

But I digress. This issue of CVP magazine is mainly devoted to CENTRAL VALLEY PHYSICIANS 7

celebrating the graduation of many of our Central Valley residents and fellows. We have a lot to celebrate: there are a total of ­­122 residents and fellows graduating: 13 from Valley Children’s Hospital, 100 from UCSF-Fresno, and 9 from St. Agnes Medical Center’s inaugural group. This year our medical society was very pleased to present the FMMS Leadership Award to an outstanding resident at of each of the 3 programs: pediatrician Kevin Nguyen at Valley Children’s Hospital, ER physician Mackensie Yore at UCSF-Fresno/Community Medical Center, and internist Keerat Dhatt at St. Agnes Medical Center. Congratulations to all of you!

It is especially heartening to see this bounty of graduates in light of our Valley’s long-standing physician shortage. Historically, about 50% of our GME graduates stay to practice here in the Central Valley, so we can realistically hope that many of these recent grads will put down roots and practice their craft right here in the Central Valley.

I sure hope they do. Compared to our entire state, the San Joaquin Valley has just 60% of the average number of physicians per capita. And it’s likely to get worse before it gets better--one third of our physicians are within 5 years of retirement, and I am one of them.

Not only do our Valley physicians skew to the older end of the spectrum; our ethnic makeup is also skewed.

For example, although 40% of California’s population are Latinx, only 6% of our physicians come from that heritage.

And people tend to be sicker here than elsewhere in the state. Due in part to the high incidence of diabetes, obesity, and asthma, Fresno County’s medical outcomes rank 52 out of 58 counties in the state.

Fortunately, help is on the way. The past few years have seen the development of new GME programs at Valley Children’s Hospital and St. Agnes Medical Center, as well as new residencies and fellowships at UCSF-Fresno. What’s more, as of last year, we finally have a new medical school in town: CHSU’s College of Osteopathic Medicine.

I would be remiss if I didn’t point out that many of these new residency slots were funded by the Proposition 56 cigarette tax. Who played an important role in getting it to pass? None other than our medical society, together with the other medical societies comprising the California Medical Association. The Central Valley received a big share of that $40 million funding for GME programs,

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because it is an underserved area of the state. Who played a key role in Sacramento to make sure that happened?

Assemblyman and FMMS member Dr. Joaquin Arambula.

Another way to bring more docs to our Valley is to recruit home-grown undergraduate students into medical school. That’s a main focus of the 10-year-old program at UCSF Fresno called San Joaquin Valley PRIME. It offers students with roots in our Valley a chance to get a medical education from faculty at UCSF, UC Merced, and UCSF Fresno, while learning about the special health needs of our local communities. Currently 36 students are enrolled in the program. The Doctor’s Academy and the new Premedical Surgical Internship program at UCSF Fresno are 2 other programs attempting to bring local ethnically diverse high school and college students into the field of medicine.

Finally, our medical society is endorsing Senator Melissa Hurtado’s bill “SB-40” which would create the California Medical Scholars pilot program. This program would encourage local students throughout the state—especially rural minority students—to enter the pre-medical school pipeline at the community college level. This would significantly increase the chance that they would then go on to medical school and residency, and eventually join the ranks of our Valley’s primary care physicians.

We must stay vigilant to ensure that the pipelines bringing more physicians into our Valley are well-funded and growing. We are very proud of the medical students and residents that graduate from our Valley programs, and look forward to seeing all that they will contribute in the years to come.

Family Practitioner/Internist Wanted

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

10 CENTRAL VALLEY PHYSICIANS

Summer 2021

One hundred medical residents and fellows along with four oral and maxillofacial surgery dental residents and five physician assistants completed training at UCSF Fresno this year for a total of 109 graduates.

Due to the COVID-19 pandemic, UCSF Fresno celebrated the occasion for the second year in a row with a virtual commencement on June 10th.

Many of the graduates will stay in the Central Valley to care for patients, teach future physicians or continue their medical education.

UCSF Fresno is the largest academic physician-training program between San Francisco and Sacramento in the north and Los Angeles to the south. Faculty at UCSF Fresno along with residents and fellows provide care to thousands of patients each year. UCSF Fresno was established in 1975 to address the severe shortage of physicians in California’s San Joaquin Valley.

“Under the leadership of our faculty, trainees pivoted and persevered during the height of the COVID-19 pandemic and subsequent surge,” said Michael W. Peterson, MD, associate dean at UCSF Fresno. “They continued their critical work in learning environments, at bedsides and in the community, while addressing the renewed movement for social justice that calls on each of us to recognize, reject and break down systemic barriers and racism. We are pleased to have helped them fine tune their skills. We are incredibly proud of the health professionals they are today and particularly delighted that so many are staying in the Central Valley.”

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UCSF Fresno 2021 Graduation Highlights: • • • • • • • •

60% of residents and fellows completing training in the Department of Emergency Medicine are staying in the Central Valley to provide care.

47% of residents and fellows completing training in the Department of Family and Community Medicine are staying in the region to provide much needed primary care.

50% of Internal Medicine residents are staying in the Valley.

Both fellows in the Infectious Diseases Program are staying in Fresno as faculty at UCSF Fresno to train physicians and provide desperately needed expertise in the community to address COVID-19 and other infectious diseases.

46% of residents completing training in the Department of Pediatrics are staying in the region.

25% of residents completing Psychiatry training are staying in the Valley and 75% are staying in California or 1 out of 4 graduating Psychiatry residents is staying in the Valley and 3 are staying in California.

40% of all UCSF Fresno 2021 graduates are staying in the Central Valley.

75% of all graduates are staying in California to provide care, teach or continue their education.

The 2021 graduating class includes: Hebah Ghanem, MD,

is completing a two-year fellowship in Infectious Diseases at UCSF Fresno. Fellowships are advanced training in a sub-specialty after residency. After graduation, Dr. Ghanem is staying in Fresno as faculty at UCSF Fresno to provide care and teach residents and fellows. Her co-fellow in the Infectious Diseases program also is staying in Fresno, where the medical expertise is desperately needed.

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Dr. Ghanem, who is Jordanian, was born in Kuwait and lived in various countries. After the Gulf War, she moved to Jordan where she went to medical school, completed residency training and became board certified in Dermatology. She and her husband moved to the United States in 2013 for her husband to finish his nurse practitioner degree. They moved to Orange County in California to be near family. At that time, she decided to shift her focus from Dermatology to Internal Medicine.

Even though she had scored the highest rank, earning her a spot in Dermatology, which was considered the most prestigious specialty in her country, coming to the U.S. as a foreign graduate was challenging. “My four years of experience was not considered. It was hard for me to stay in medicine.”

As the wife of a student, her visa did not allow her to work. She stayed home for two years and wondered during that time whether she should stay in medicine. “I think I wanted to be a role model for my daughters,” she said. “I watched Gray’s Anatomy and would cry. Friends wrote in my yearbook that I was going to be at WHO (World Health Organization) one day. That was my lowest point, and I didn’t want my daughters to feel like it’s OK to quit.”

When her husband finished his nursing program, it was time to decide whether to go back to Jordan or stay in the U.S. They decided to stay and applied for Permanent

Summer 2021

Resident Cards. Meanwhile, Dr. Ghanem applied to Internal Medicine residency training programs and matched with Trinitas in New Jersey. Following residency, her plan was to go back to Orange County, but an interview at UCSF Fresno would change her course.

“I like the people at UCSF Fresno the best. The staff are very friendly and make me feel at home,” she said. “My co-fellow, Dr. Michele Maison-Fomotar, it felt like we knew each other for a long time. Dr. Naiel Nassar, our program director, we can go to him with any concerns. And Lorna Tahan (program coordinator), emailing her was one reason I chose this program. She was so friendly, so great. When I came here for the interview, I felt like ‘yes, I want to be here’ from day one when I did my interview.”

Dr. Ghanem looks forward to joining the faculty at UCSF Fresno, teaching and being an Infectious Diseases attending physician and expanding the program. Infectious Diseases is an important sub-specialty in Fresno, especially with valley fever, sexually transmitted illness rates that are high, and with COVID-19, she said. “It’s been very important to have the ID expertise here.”

When not working, Dr. Ghanem spends time with family, taking her three kids to gymnastics, swimming and horse riding. After graduation, she is going back to Jordan to see her parents. It’s been three years.

Her advice for new interns coming to UCSF Fresno in late June is to like what you do, love what you do, and you will feel connected. “Even at moments when you feel down, you have this inside you and that will make you feel right again. I think anyone who loves what they do, they can do it, too. I’m proud of myself.”

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Fresno native Walid Hamud-

Ahmed, MD,

is completing a four-year emergency medicine residency program at UCSF Fresno, fulfilling a childhood dream.

“As a kid, my dad was a big influence in my life and he would always joke, ‘My son, when I get old and sick, I need you to be my doctor and take care of me,’” said Dr. HamudAhmed. “It really stuck with me.”

His father died tragically in a car accident when Hamud-Ahmed was 11. His mom, Nor, was left to raise six boys alone, including Dr. Hamud-Ahmed, who was third oldest. “No one gets anywhere in life alone,” Dr. HamudAhmed said. “There were definitely moments where things were brought into question, ‘like is school the most important thing?’”

His family ran a small grocery store in Fresno County that served many migrant farmworkers. They sold food and cashed checks. Ghasan, Dr. Hamud-Ahmed’s brother, the oldest of the six boys, stepped up to run the family business. Ghasan was just 19 years old at the time.

“At certain points in my teenage years, I saw my brother struggling and it made me feel guilty because I was able to go to school and he wasn’t. I know he could see a brighter future ahead of me and his support was what changed the world for me. Certainly, without him, I would not be where I am today.” A graduate of Central East High School, Dr.

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Hamud-Ahmed graduated from Fresno State as part of the Smittcamp Family Honors Program.

Attracted by its Program in Medical Education for the Urban Underserved (PRIME-US), Dr. Hamud-Ahmed was admitted to the UCSF School of Medicine. PRIMEUS is designed to nurture, support and equip medical students to effectively promote health equity and provide health care to urban underserved communities.

While at UCSF, Hamud-Ahmed was involved in a violence prevention program that studied people who were injured from gun violence and ways to prevent further injury. With the American Association of Yemeni Students and Professionals, he also worked with students from Yemen, first-generation Yemeni boys and girls who didn’t get the encouragement to go to college due to cultural pressures. He hopes to continue these efforts in the Central Valley following residency. “Residency is so busy, it will be nice to have some free time to give back again.”

“A lot of us went into medicine to give back to those most in need. Medicine alone will not fix societies. We need to address issues in education, financial health and literacy, safe neighborhoods, pipeline programs-- all very much are tied to your health and wellbeing. I saw firsthand how your ZIP code can affect your health and safety. These are things that will take grassroots efforts to change. I always had that kind of outlook in life.”

At UCSF Fresno, he loves the faculty, residents, and patients. “Our patients are some of the most generous and grateful patients that you can take care of. The need is so great. They really do appreciate our care and our service. The gratitude they share is unlike anything I’ve experienced at other hospitals, and I’ve worked in many.”

Dr. Hamud-Ahmed is grateful to the people who encouraged him to become a physician, including Kenny Banh, MD, emergency medicine physician and assistant dean for Undergraduate Medical Education at UCSF Fresno. He met Dr. Banh when Hamud-Ahmed was a premedical student. Part of the UCSF Fresno Academic Research Associates Program while at Fresno State, Dr. Hamud-Ahmed calls himself a product of UCSF Fresno pathway programs.

He is most proud of being a husband to wife Haleema and father to Ismael and Noora. “They changed my life for the better and gave me perspective on what really is

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important. I’m proud of them and lucky to have them in my life.”

After graduation, Dr. Hamud-Ahmed will work in the Emergency Department at Clovis Community Medical Center and will stay at UCSF Fresno as part-time faculty.

“I don’t want to stop being a resident in a way. I want to continue learning. I want to stay on the cutting-edge,” he said. “I’m very grateful for UCSF Fresno, for the support and encouragement, and my family, especially my mom Nor and my brother Ghasan.”

Leslie Littlefield, MD,

is completing a three-year fellowship in Pulmonary and Critical Care (PCC), a division within the UCSF Fresno Department of Internal Medicine. Fellowships are advanced training in a sub-specialty following residency.

PCC fellows receive extensive training in pulmonary medicine with dedicated faculty in all subspecialties in pulmonary medicine such as cystic fibrosis, pulmonary hypertension, interstitial lung disease, asthma/COPD, lung infection, lung cancer, interventional pulmonary and general pulmonary medicine.

Dr. Littlefield, a self-described first-generation Mexican American, grew up all over California, moving with her mother about 20 times before she was 16 to escape Summer 2021

an abusive background. They settled in Orangevale near Sacramento, where she graduated from Casa Roble High School at age 16 and became a certified nurse’s aide. With the goal of becoming a doctor, she became a licensed vocational nurse and took courses at nearby community colleges – wherever she could find classes that fit her schedule. When a chance came up to go to medical school in Mexico, she seized the opportunity.

“It was another world,” she said. “Speaking Spanish at home was different than being fluent and speaking with (medical school) peers.” Six years later, she graduated at the top of her class and completed the customary internship year as well as a year of community service in Mexico.

There were times when she thought about giving up.

Pit bulls attacked her beloved Chihuahua. Her husband could not find a job. Her car was stolen, and family belongings were stolen back in the United States.

A tale she heard in Mexico kept her going. It was a story of two frogs stuck in a bucket of cream. Unable to get out, one frog gives up. The other, determined to survive, keeps going, keeps churning away. The cream begins to solidify and eventually turns to butter, and the frog climbs out of the bucket.

Dr. Littlefield returned to the U.S. and completed residency training in Internal Medicine at Alameda Health System in Oakland. There, she developed an interest and passion for Pulmonary and Critical Care. She did an elective at UCSF Fresno and fell in love.

“I love the people, the culture, the patients, everyone is humble here,” she said. “There is high acuity seen here that you don’t see anywhere else and my program prides itself on teaching autonomy and critical decision making.

The Pulmonary and Critical Care Division was on the front lines during the height of the COVID-19 pandemic and the subsequent surge in 2020.

“COVID gave a whole new meaning to intensive care,” she said. “We worked around the clock, 24 hours a day in shifts. There were so many unknowns brought on by COVID. You don’t know if you’re going to get infected, but you have a moral responsibility to do right by the patients.”

Looking back as training ends, Dr. Littlefield said, “I am proud that I got here. I could have stopped many, many times but didn’t. I think about the underprivileged part, coming from a background like that could have led me

Summer 2021

down a very different path.

“I would like to tell every impoverished person from every ethnicity, if I can do it, if one person can do it. They can all do it. Never give up.

Whatever your dreams are – go for it.”

Oh, and thank you, mommy, she added, grinning widely.

After graduation, she looks forward to spending time with her family in Sacramento, paying off some student loans and finding work-life balance that may include belly dancing, which she enjoyed so much in her life before residency and fellowship training.

Michele Meime Maison-Fomotar, MD,

is completing a two-year fellowship in Infectious Diseases (ID) at UCSF Fresno and will stay as Internal Medicine faculty.

Dr. Maison-Fomotar completed a three-year residency in Internal Medicine at UCSF Fresno before continuing as an Infectious Diseases Fellow. “I am happy to have been a part of the UCSF Fresno family since 2016, and I look forward to staying on as ID faculty,” she said. “I hope I can inspire people to love ID as I do.”

Dr. Maison-Fomotar grew up in Cameroon, Africa, where she went straight to medical school from high school for a seven-year program at the Faculte de Medecine et des Sciences Biomedicales Universite de Yaoundé. Her biggest challenge, as an immigrant, was getting into residency and “learning how to adapt in a new educational system here in the United States, especially since I learned medicine

CENTRAL VALLEY PHYSICIANS 15

mostly in French,” she said. But at UCSF Fresno, she felt a sense of belonging to a large family, and the best part of her training experience has been the collegiality of her coresidents, fellows and faculty, she said.

She drew inspiration to become a physician from the strong women in her life. Her godmother was a midwife, one of her close family friends is a physician and her older sister is a physician. Watching her mother struggle with diabetes inspired her to become an internist, she said. She also found Internal Medicine fascinating. “The complexity of dealing with the adult patient has always called to me.

As a physician in Cameroon, I worked mostly with adult patients, especially patients with HIV, tuberculosis, and malaria.

Dr, Maison-Fomotar and her co-fellow in the Infectious Diseases program are staying in Fresno, where medical expertise is desperately needed for valley fever, increasing rates of sexually transmitted diseases and for COVID-19.

“I have always wanted to do Infectious Diseases, especially after my experiences in Cameroon.” The pathology she has seen in Fresno is unparalleled as well, she said.

“And I have a healthy respect for microorganisms and the havoc they can wreak. The world of ID continues to enlighten, challenge and fascinate me daily.”

COVID-19 was a new experience, she said. “I don’t think many of us were prepared for the magnitude this pandemic would take and it was daunting to be in the middle of it. However, it highlighted the resilience and solidarity we can have in the face of adversity, opened us to new ways of working, exciting new research and vaccines, and has forever changed the way we learn, work, and relate with others.”

Her advice for incoming interns arriving at the end of June? “Enjoy the ride! It will be challenging but these years are the ones where you will learn the most.”

In her spare time, Dr. Maison-Fomotar enjoys cooking, traveling, dancing, playing the piano, event planning and décor – and just spending time with family.

Her plans after graduation include taking a vacation before she joins the Infectious Diseases team at UCSF Fresno. “I am so excited!”

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Monika Thomas-Uribe, MD, MPH,

is completing a three-year residency training program in Pediatrics at UCSF Fresno. After graduation, Dr. ThomasUribe will stay in Fresno to care for patients at Kaiser Permanente’s Fresno Medical Center.

The patients she serves in Fresno remind her of the patient population in Valle de Bravo, the small town in Mexico where she grew up. “My father is a surgeon. He did surgeries, but also delivered babies, cared for patients of all ages and was often paid with chickens and pigs. That’s what I thought it meant to be a doctor, she said. I always wanted to be a doctor.”

Her family moved to Toluca, the capital of Mexico’s central State of Mexico so she could attend high school.

She attended medical school at the Universidad Anáhuac in Huixquilucan, State of Mexico, Mexico.

“In Mexico, students go to medical school for six years. The fifth year is an internship. The sixth year is a social service year,” said Dr. Thomas-Uribe. “You spend time providing medical care in remote areas of the country.”

During medical school, she volunteered to go to Haiti after the 2010 earthquake. After medical school, she did visiting rotations at Oxford in England and in Germany.

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Her passion for public health led her to Emory University where she earned a master’s in public health. It was then she decided to stay in the United States, moving to California for a job as a research assistant at Stanford University.

There, she met her husband.

While applying to residency programs, mentors at Stanford and a colleague both recommended UCSF Fresno. She applied and matched. The colleague who recommended UCSF Fresno – Mackenzie Yore, MD – is completing residency training in the UCSF Fresno Department of Emergency Medicine.

“Being here and about to finish residency training is a dream come true, said Dr. Thomas-Uribe. The patient population is what I like best. I was nervous at first that I wasn’t going to help people I am passionate about. But I speak Spanish every day and I understand the culture and that’s something I love about being here.”

The end of training comes with bittersweet moments, too. She had her final medical visit recently with the very first pediatric patient she saw in residency. He’s almost three years old now. And looking back, she is reminded that the path wasn’t always easy. It was hard to get into medical school. It was expensive and it was emotionally draining, she said.

“It’s difficult in the United States for international medical graduates, trying to understand everything again in English and trying to prove that you are good enough,” she said. “I don’t know if it was my own insecurities or if it was real, probably a combination of both.”

She acknowledges the help of family, her husband, mentors and friends and is grateful for everyone who supported her along the way.

She is proud of a pesticide project she has been working on. Latinos make up the majority of people working in the fields. They deserve help with education about exposure to pesticides, she said. “We need to make sure they understand with information in Spanish, Mixteco or the language they speak. They need personal protective equipment and vaccines. This is something I’m going to continue to work on.”

In her spare time, she enjoys running, participating in triathlons, working out, being outdoors, practicing capoeira (a Brazilian martial art) with her husband, relaxing and reading. She is looking forward to more spare time after

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residency and caring for patients at Kaiser. “I love working with children.

It is the best,” said Dr. Thomas-Uribe.

“Children teach you so much.”

Some of her patients even bring her whatever fruit is in season, a fond reminder of the special bonds she recalls her father having with patients when she was growing up.

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CENTRAL VALLEY PHYSICIANS 17

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Class of 2021

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CENTRAL VALLEY PHYSICIANS 19

Pediatric Persuits

Appreciative patients and supportive colleagues are just two reasons Valley Children’s newest Chief Residents plan to stay in or return to the Valley to pursue careers in pediatrics.

Chloe Kupelian, DO, and Keenia Tappin, MD, were drawn to because of its mission to provide the best care to children and the best training for physician leaders and scholars.

“Their ultimate goal is for every resident to succeed and achieve their optimal potential and it was very evident on interview day. I wanted to be a part of that,” said Kupelian, who hails from Santa Clarita and graduated from Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania.

Tappin, who is from Glendale and graduated from Keck School of Medicine at USC, was also attracted to the Valley and VCH specifically because it is important to her to serve children who come from lower socioeconomic backgrounds.

“We care for 1.3 million kids,” she said. “It's a huge catchment area, right between like two big areas [the Bay Area and Southern California], and we kind of take over and take care of all the kids that need us.”

Each year, two Chief Residents from each graduating class of residents are nominated and selected by the program to serve as clinicians, educators and liaisons between the program and the residents.

Kupelian and Tappin were nominated by their peers as well as hospital faculty and selected as VCH’s Chief Residents out of 13 in their graduating class.

The Chief Residents are in an ideal position to help because they have freshly graduated from the program the residents are going through.

“A huge part of my job is teaching medical knowledge, preparation for boards and teaching the art of medicine.

That’s massive,” Tappin said. “Because we’re close enough to it where we don't have amnesia. We know where they’re at and where they’re trying to go, so we can help bridge that gap of support.”

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KUPELIAN PLANS TO PURSUE TRAINING AS PEDIATRIC HOSPITALIST Kupelian’s interest in becoming a physician was rooted in her family.

“I had a grandfather in Lebanon where my family's from,” she said. “He was the only physician in our family and he served a pretty similar patient population, one that was in dire need of medical care and there was a lot of poverty in the country as well. His work really inspired me to pursue that.”As a pediatric resident at VCH, Kupelian loved that she and her colleagues were welcomed and involved in the local community.

“It was very evident throughout my training and even now that this hospital is a really integral part of the Central Valley,” she said. “A lot of families really value the care their children receive here and I'm really glad that I could have been a part of that during my training.”

While Kupelian said she would love to come back to work at Valley Children’s Hospital in the future, she is pursuing two years of additional training in hospital medicine that isn’t available in this area.

“I would like to be a Pediatric Hospitalist, so I will be taking care of hospitalized children, and there is a movement in the American Board of Pediatrics and the American Academy of Pediatrics to create a board-certified subspecialty called pediatric hospital medicine,” she explained.

After two years of training in that subspecialty, Kuplian wants to work with residents and fellows at an academic center.

“I'm also interested in simulation, which is a multidisciplinary specialty in which you essentially try to enhance the skills of trainees so that they are prepared for real-life situations when it comes to pediatric codes or rapid responses, any sort of emergent situation, prepping them prior to actually being in real life and dealing with these situations.”

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TAPPIN PLANS TO OPEN A FOSTER YOUTH CLINIC IN THE VALLEY Family was also an inspiration for Tappin to pursue medicine — but not because there were doctors in her family.

Her sister, who is nine years younger, was born with WolffParkinson-White (WPW) syndrome, a heart condition in which an extra electrical pathway in the heart causes a rapid heartbeat.

“A cardiologist was able to help her out and … get rid of that extra tissue,” she explained. “She was able to be returned to our family and returned to her life and the ability to achieve her dreams. Whatever she wanted to do, she could do it.”

That’s the moment she realized she wanted to be a pediatrician.

“I want to get kids back to their families, get them back to their health, so that they can go be amazing people,” she said.

As a resident, Tappin enjoyed being able to connect with patient families as a member of a minority: an African American woman healthcare provider.

“The population we care for are very grateful and appreciative for our care,” she said. “Sometimes we walk into the room of an African American family or even another minority, and they are genuinely so happy to see you. They’re like, ‘we’re so glad that you’re here!’ It’s that appreciation that is really nice and rewarding.”

After serving as a Chief Resident, Tappin wants to stay in the area and work in general pediatrics in Madera.

“Ultimately, I want to open up a foster youth clinic,” she said. “So, I still want to stay in the Central Valley, and I think Valley Children’s especially, because we have a lot of sites around the Valley. I think it would be a great avenue to stay with.”

She enjoys Valley life, including the close-knit community and the cost of living.

“I feel like all the things that I need, I can get to here,” she Summer 2021

said. “Yosemite is not too far, there are beautiful walking trails, there’s an airport. If you want to go somewhere it's pretty close and convenient.”

When she came to Fresno three years ago, it was during the midst of the Fres-yes movement, which aimed at bringing economic opportunities to the Valley, Tappin explained.

“Seeing communities come together for change and be on the same page is something exciting to me,” she said. “To be a part of that change is also really exciting and another thing that makes me want to stay and attracted me to Fresno.”

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Graduates Inderbir Baadh, MD Neilinder S. Behniwal, MD Mehrab Devani, MD Jasmeet Kaur Dhaliwal, MD Keerat Dhatt, MD Hannah A. Knox, MD Gagandeep Rajpal, MD Parisa Rezapoor, MD Alejandro Torres Cortes, MD

Priliminary Paul A. Kohanteb, MD Diagnostic Radiology: Akash Lohia, DO Physical Medicine & Rehabilitation: Anand Shivaprasad, DO Diagnostic Radiology: Thotsophon Taechariyakul, MD

On Friday evening June 11th Nancy Hollingsworth, RN, MSN, MBA President and Chief Executive Officer, Saint Agnes Medical Center welcomed program administration, faculty and staff from the hospital’s Graduate Medical Education program and the small group of parents and close friends who gathered to celebrate 9 graduating residents in the program’s inaugural class. The program began in June of 2018 when it welcomed these same students.

After three years of training, nine of those residents officially graduated from the program in an intimate outdoor ceremony.

Special guests for the evening included City of Fresno Mayor Jerry Dyer, Congressman Jim Costa, Assemblymember Joaquin Arambula, MD and California Medical Association CEO Dustin Corcoran.

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In addition to the diplomas several awards of distinction were presented including: • Certificate of Recognition for highest Inservice Training Examination Score for PGY-1 -2020 sponsored by American College of Physicians: Maryam Moradi, MD • Certificate of Recognition for highest Inservice Training Examination Score for PGY-2- 2020 sponsored by American College of Physicians: Kevin Orita, MD • Certificate of Recognition for highest Inservice Training Examination Score for PGY-3- 2020 sponsored by American College of Physicians: Parisa Rezapoor, MD • Exceptional Service Award for dedicated service as founding Designated Institution Official: Charles M. Farr, MD • Exceptional Service Award for Founding GME Director: Dana Z. Lucka, Ed.D. • Chief Resident Award: Keerat Dhatt, MD (graduatePGY-3) • Chief Resident Award: Alejandro Cortes Torres, MD (graduate-PGY-3)

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• • • •

Faculty Award of Excellence: Mohammed Elhassan, MD Program Coordinator Award of Excellence: Kelley Montgomery Excellence in Academic Leadership: Hemant Dhingra, MD, Program Director Excellence in Academic Leadership: Kiran Reddy, MD, Associate Program Director

Dr. Keerat Dhatt, MD received the Devi and Ram Resident Scholarship Award in the amount of $1,000.

Additional awards and recognition went to: • Faculty of the Year, Mohammed Elhassan, MD • Exceptional Service Award, Dana Lucka, Ed.D., Kiran Reddy, MD and Charles Farr, MD. • Program Director Award, Hemant Dhingra, MD Hemant Dhingra, MD assisted by Kiran Reddy, MD and Pedram Ansari, MD distributed the diplomas to the graduates.

W. Eugene Egerton, MD, FAAP, Chief Medical Officer Saint Agnes Medical Center provided closing remarks.

UPCOMING CME 41st ANNUAL CENTRAL VALLEY CARDIOLOGY SYMPOSIUM

SAVE THE DATES GENERAL SOCIETY MEETING Wednesday, September 22, 2021 Virtual 6:00pm INSTALLATION & AWARDS GALA Friday, November 19, 2021 Virtual 6:00pm

www.fmms.org 559-224-4224

Summer 2021

Saturday, September 18, 2021 8:00 am Madera County Office of Education

HEPATOLOGY & GASTROENTEROLOGY UPDATES 2021 Thursday, October 7, 2021 6:00 pm Fort Washington Golf and Country Club

NEPHROLOGY SYMPOSIUM

Saturday, October 16, 2021 8 am Nickerson Auditorium, Saint Agnes Medical Center

DIABETES SYMPOSIUM

Saturday, November 13, 2021 8:00 am Nickerson Auditorium, Saint Agnes Medical Center

JOY OF MEDICINE SUMMIT

Saturday, December 3, 2021 9:00 am Tenaya Lodge, Fish Camp

CENTRAL VALLEY PHYSICIANS 25

KEERAT DHATT, MD Dr. Keerat Dhatt, MD, is a first-generation American whose parents immigrated from India. She grew up in Stockton and graduated from St. George’s University School of Medicine in Grenada in 2017.

After staying in Stockton for a year, Dr. Dhatt became part of the inaugural residency program at St. Agnes Medical Center in Fresno.

“It was really important to me to come back to the Central Valley,” she said, “because this is a very underserved area and part of the reason why I went into medicine was to come back and serve my community.”

Dr. Dhatt was nominated by St. Agnes Graduate Medical Education (GME) program directors for the Fresno Madera Medical Society Leadership Award for 2021.

She served in leadership roles throughout her residency to help build the program from the ground up. She was one of two residents to serve on the GME committee in her first year.

“We were the first class, so from the very beginning we were really involved in the structure of the program and 26 CENTRAL VALLEY PHYSICIANS

education for the program, and the way the program would interact with the rest of the hospital,” she said.

Her experience as part of the GME committee prepared her for her role last year as one of two Chief Residents, who serve as leaders and liaisons between residents and hospital staff and administration.

“By the time third year came around, I had a good idea about how to address things and how to write protocols,” she said. “We make the schedule for the year; we help with lectures. Education is really a big part of residency. It's a really good balance between actual clinical work and still learning and improving your medical knowledge.”

The number of residents at St. Agnes grew from 12 to more than 40 since the program’s inception, Dr. Dhatt said.

“We’ve kind of opened the door for that and now we have a lot more teaching in the hospital,” she said. “We have medical students coming in and it’s really changed the culture of the hospital a lot.”

Dr. Dhatt was excited to be a pioneer in St. Agnes’ residency program because of the opportunity to provide input and shape the program.

“With the newer programs, it seems like a lot more focus now is being geared towards resident wellness to help with burnout and work-life balance and work-education balance,” she described. “St. Agnes really wanted to be on top of that and to be a leader in those aspects, so it was really exciting. Throughout the years they did take a lot of Summer 2021

our feedback.”

In August, Dr. Dhatt will start a two-year nephrology fellowship at UC Davis, after which she plans to settle in the Central Valley to practice kidney medicine.

“One of the reasons I went into medicine to begin with was growing up, I'm the oldest of three siblings, and my youngest sibling, my brother, developed kidney problems as an infant,” Dr. Dhatt explained. “Even as a toddler, he was going in and out of the hospital and it was a very stressful situation. We were lucky to have a really good team of doctors and that really inspired me.

“Luckily enough I ended up at St. Agnes and our program director here is also a nephrologist. So our nephrology rotations and our nephrology education and experiences were really, really strong. I felt like it was able to give me a lot more background than a lot of people get in the field. It really helps when you're looking for fellowship, to have those experiences.”

KEVIN NGUYEN, MD As a Valley Children’s Hospital resident, Dr. Kevin Nguyen had a huge impact on the culture of the hospital and the education of its staff surrounding sexual orientation and gender identity, especially in caring for transgender patients.

Valley Children’s Hospital Residency Program directors nominated Dr. Nguyen for the Fresno Madera Medical Society Leadership Award for 2021 for his work and advocacy for the LGBTQ+ community.

Dr. Nguyen said it was a continuation of the work he focused on during medical school at UC Davis School of Medicine, where he worked a lot with transgender teenagers and adults.

“There’s a huge need for people who can provide respectful and affirming and welcoming spaces, especially in healthcare. I knew I wanted to bring that no matter where I was,” he said. “When I came to Fresno and Madera, it wasn’t a topic on people’s radar. There’s a lot of opportunity to grow that, so I just took it and started whatever opportunities I could to create changes that Summer 2021

would last.”

Dr. Nguyen worked on updating the electronic medical record, policy work in the hospital, and leading education sessions for doctors on treatments and medications such as gender-affirming hormone therapy.

There were tools already available in the new electronic medical record system that VCH switched to in spring of 2020 that allowed nurses and doctors to ask and record a patient’s sexual orientation, gender identity, gender assigned at birth, and preferred name, Dr. Nguyen said.

“That way anyone who pulls it up can say, ‘I see your legal name, but I also see the name you go by and so, to be respectful, I’ll call you by whatever you want us to call you,” he said. “So that’s not just an LGBT thing, that’s a common sense, respectful thing.”

But it was Dr. Nguyen’s championing for these changes that made a lasting difference, said Chief of Pediatrics Jolie A. Limon, MD, in Dr. Nguyen’s nomination letter.

“This could have easily been overlooked without his advocacy and diligence,” she said.

Dr. Nguyen was also nominated for Valley Children’s Patient Experience Award for his work on ensuring that patients and their pronouns are respected and used, Dr. Limon wrote.

Continually getting feedback from patients, families, and staff motivated Dr. Nguyen to continue his advocacy work within the medical community.

“When people tell you ‘Hey, it’s been years and no one’s ever treated me this way and it’s amazing that now I feel respected and I feel welcomed,’ that for me is a very, very affirming thing,” he said. “That’s why I kept doing what I was doing because I found it so rewarding and enjoyable.”

The impact Dr. Nguyen made wasn’t limited to patients and their families, but also made a difference among Valley Children’s staff and administration.

“One employee publicly recognized the impact of this work in our internal communication, stating that they feel accepted and acknowledged for whom they truly are for the first time at our organization.” Dr. Limon wrote.

Dr. Nguyen, who hails from El Dorado Hills near Sacramento, recently graduated from the VCH residency program and moved across the country to start a three-year child and adolescent psychiatry fellowship at Children’s

CENTRAL VALLEY PHYSICIANS 27

Hospital of Philadelphia.

Dr. Nguyen hopes his fellowship will prepare him to integrate his medical pediatrics training with psychiatric training so he can serve young people who have overlap between their medical illness and psychiatric illness, he said.

“Transgender medicine was the original reason I started doing this. A lot of people who identify as transgender or non-binary end up having a lot of internal distress, whether it’s substance use, addiction, depression, anxiety, eating disorders,” he explained. “I want to take care of the medical stuff and the mental health stuff at the same time, because in my mind that seems more holistic, where you see a person as a complete whole. In the medical field, they kind of separate them out, like mental health is for psychiatrists and therapists. I want them to come together

MACKENZIE YORE, MD Dr. Christina Maser, President-elect of the Fresno Madera Medical Society virtually presented the Steven N. Parks, MD Leadership Award to Mackenzie Yore, MD. in recognition of her efforts on health equity during her residency at UCSF Fresno. Dr Yore was nominated by the Emergency Medicine Residency Program Leadership Team who stated “Dr. Yore is a graduating resident in Emergency Medicine who embodies the leadership and vision of Dr. Parks. Her efforts and leadership over her four years in Fresno have contributed greatly not only to the Emergency Medicine Department, but to UCSF Fresno and the greater Fresno community as a whole.”

Dr. Yore holds an M.D. from Stanford with a concentration in Medical Education and Global Health and a Masters in Global Health Sciences from UCSF. Building on her graduate education experience, Dr. Yore founded the UCSF Fresno Health Equity Action Lab in April 2019.

Her goal was to form a community of residents and faculty from all departments interested in learning about and addressing socio- economic barriers to health equity for

28 CENTRAL VALLEY PHYSICIANS

our patients at CRMC and the greater Fresno area. She organized and led monthly meetings, at first volunteering space in her home, and later via zoom. These monthly meetings discussed current events and journal articles and brought together colleagues from different departments to present and collaborate on health equity-related research and group projects. She volunteered her time to mentor fellow residents and local college and high-school students interested in health equity through this platform. She hosted a round table discussion bringing local communitybased organizations that focus on mental health together in May and a workshop on structural competency for the UCSF Fresno community in July 2021.

As a chief resident in Emergency Medicine during the Covid19 pandemic, Dr. Yore led efforts to build a sense of community among incoming interns and the residency over a largely and challenging virtual platform.

She dedicated much time to problem-solve with residents on personal and professional issues, becoming a go-to mentor for junior residents seeking connection during this time. She also participated in monthly program, faculty, and ED operations meetings to serve as a liaison to best represent resident interests. Dr. Yore recognized a critical need for increased connectivity between residents and co-led and developed a series entitled “Chicken Soup for the Residency Soul,” a monthly curriculum for residents on wellbeing, personal reflection, and growth.

Dr. Yore also served on the Graduate Medical Education Committee (GMEC) from August 2019 to July 2020 and is currently serving on the GMEC subcommittee on the Covid-19 pandemic to represent the resident perspective and serve as a liaison for UCSF Fresno residents. At the national level, Dr. Yore is a subgroup coleader for the Society of Academic Emergency Medicine (SAEM) consensus conference in May 2021 entitled “From Bedside to Policy: Advancing Social Emergency Medicine and Population Health Through Research, Collaboration, and Education.” She also volunteered her time to lead a session on Health Equity at UCSF Fresno for all incoming interns in June of 2020.

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All names have been changed to protect the privacy of the patients.

Learning Selflessness from a Patient Who Lost His Voice Annee Rempel, Medical student, University of Iowa Medical School

While on an Otolaryngology rotation, I cared for a patient who shifted my perspective on what it means to give even when everything has seemingly been taken away. He had laryngeal squamous cell carcinoma that was compromising his airway. I remember how calm he was as anesthesia rolled him into the OR. Did he fully grasp what it might feel like to never again move air freely between his lips? To never again speak effortlessly or sing?

The total laryngectomy went well, intraoperative margins were negative, the surgical team was happy with the outcome and chatted freely as they allowed me, the med student, to close the skin. I remember focusing on the suturing, willing myself to be happy that we’d taken out the cancer (a small miracle, in my mind, with all the delicate neck structures we’d successfully navigated in the preceding hours), and trying not to think about all that had been taken away.

I pre-rounded on him the following morning, the first morning he woke up without a voice. He was wide awake and had a small white board and pen at the ready. I asked him the normal questions and he took the time to write out every answer.

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His handwriting was clear and he used all capital letters. After inspecting the surgical site and drain output, I asked him what I ask most patients before I leave the room: Is there anything else you want me to share with the team this morning before we come back as a group? He lifted a finger as if to say Wait one moment. He got out his phone and scrolled before turning the screen towards me. The photo showed a small wooden gazebo with a collection of aspen trees in the foreground and mountains in the background. He lifted his finger again then started writing on the whiteboard: I HAVE A BEAUTIFUL CABIN ON THE SALMON RIVER IN IDAHO. YOU ARE ALL INVITED. When he turned the white board towards me, I was overcome. I had to work to keep tears from coming and I’m sure he could see my eyes change above my mask, behind my shield.

He reached for my hand. I squeezed it. After a moment of silence, a sound he will become all too familiar with, I told him: Thank you. I will tell the team.

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2nd Place

Yasamin Mohammadi, 4th Year Medical Student, Kansas City University, rotating at hospitals in the Central Valley through California Health Sciences University

I’ll never forget my first rotation of my third-year of medical school. I was that perfectly caffeinated combination of nervous, excited, and eager to learn. My attending was quick to rip the metaphorical bandaid off, and she urged us to enter the patient rooms at a spritely pace. I was overwhelmed, to say the least. The electronic medical record was an enigma, and I was furiously typing and racking my brain to make sure I asked every single last question. I found myself caught up in my own anxiety about doing everything right, and I was scurrying through the typical questions for the annual physical: “Any allergies?” “Do you drink alcohol?” I didn’t look up from the screen as I was already anticipating the next three patients I needed to see. I defied my own rules about the physician-patient interview and asked several questions back to back, “Are you pregnant? Have you ever been pregnant? If so, how many times? Any complications?” A sniffle. I looked up. In front of me was a human being. She was 24 years old with bright, tearful eyes. Once our eyes made contact she began to sob. She painstakingly told me of how she had lost her second child within minutes of delivery. How she watched

in agony as his limp body was taken by the NICU team, how he didn’t respond, how she broke apart, how she has attempted to mend, how she has succeeded and failed. I sat there, absorbing the pain, allowing the difficulties of another to wash over me.

A refreshing reminder of why I was there in the first place. The computer, running low on battery as ever, shut off. There were two separate knocks on the door (not-so-subtle reminders to finish the visit). I didn’t pay them any mind. I just listened. I recognized at that moment that efficiency in electronic records, asking the right questions, and performing and detailing the exam all matter; however, there is no substitute for the raw humanism in medicine. There is no replacement for face-toface visits and a willingness to make space to momentarily hold another person’s load. To provide a listening ear, undivided attention, and an open heart. To the brave soul who I met that day, this patient who has forever touched my heart, I thank you for your patience with me as I humbly learned medicine is an art.

3rd Place “This is for you, Doctor” Pritha Dewanjee, DO PGY-2, Valley Children’s Hospital I was dreading my oncology rotation. One of the reasons I chose pediatrics was because kids had proven to be resilient in my experience so far; I had seen far less deaths in pediatrics than I had in the adult world. Unfortunately, oncology did not fit that generalization. The very idea of pediatric oncology was daunting to me: putting children through living torture with chemotherapeutics in the hope that they would not succumb to their own bodies self-destructing.

One of my first patients was eight and had a squeaky voice.

She was timid but had also matured beyond her years in that way that pediatric oncology patients often do after all they endure with their therapy. After I had finished my tasks for the day, I 30 CENTRAL VALLEY PHYSICIANS

would go to her room and talk to her grandmother who would show me bouquets of her grandchild’s hair as my patient would silently draw. She seemed even more timid when it came time for her to return back home. I tried to comfort her with words of encouragement, but I knew I could not possibly fathom the concerns of a child who had gone through so much in such a short time and was about to return home to loved ones who did not know her new self. She would silently listen to my attempts to soothe her with wide eyes and I would eventually trail off uncertainly. On the last day of her admission, with her mother’s prompting, she handed me a piece of paper with a quiet, “This is for you, doctor.”

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My first gift from a patient. I had longed for this moment ever since I had entered pediatrics but I had always imagined it to be a stick figure from a happy, healthy patient whimsically drawn before a well-child visit. Instead, I had received the product of what I had watched my patient painstakingly create with glittery gel pens on lined pieces of notebook paper. She had written a message thanking me and adorned the note with flowers. In that moment, I felt something that had become foreign to me since

pursuing medicine. I had received validation from my faculty mentors, colleagues, and loved ones but nothing had been able to shake me from the grips of imposter syndrome. But with that single note, I finally felt certain that I was in the right career.

Additional Submissions Brandon J. Croft, MD,

The Double Blind Trial

PGY-2 UCSF Fresno

Dinithi Ketagoda Iddawela, MD,

This situation was different from every other time. This would be my patient’s last paracentesis. This was not because we had optimized his treatment with pharmacotherapy and nor was it because we had miraculously cured his liver. He was not a liver transplant candidate, he did not qualify for TIPS placement, and symptomatic management was no longer working. Prior to the procedure I waited outside the door allowing him to share a moment with his wife on a virtual call. Unfortunately, this was a time in the where facial expressions were hidden by masks and family members were unable to be present at the patient’s bedside. While placing the paracentesis catheter, I felt a sense of peace in the room. He had finally taken control of his medical condition for the first time since he had been diagnosed with liver cirrhosis, and had chosen to go home on hospice.

For the first time in three months, he would be able to leave the hospital setting for longer than three days and spend time with his loved ones. He would have the freedom to be around his family and friends and eat any type of diet that he wished.

His eyes lit up with joy when he informed me that his next meal after his hospital discharge would be his wife’s famous steak and mashed potatoes. He would consume that meal with a side of cherry cola which was a drink that he frequented as a child, but was forbidden since his diagnosis of liver disease. He would be liberated from the pain of intravenous catheters and free of the irritation from cardiac monitoring devices. The beeping of monitors and moans of patients in pain would be a thing of the past. He would finally close this chapter of his story. After draining the peritoneal fluid, he looked around the room and told the entire medical team that he loved us and was thankful for how relentless we were in fighting for him this entire time. It was at that time that I learned healing goes beyond reversing medical issues, but also encompasses giving people control of their life back during the irreversible issues. I was thankful to be part of his story, and he will always be part of mine.

Chief Resident, Department of Internal Medicine

Summer 2021

UCSF Fresno

During my IM residency training in the Central Valley, a medically underserved area with a diverse patient population coming from immigrant and refugee backgrounds, I had exposure to a wide range of pathologies, frequently in the setting of clinically complex presentations and advanced disease processes. The holistic experience of managing multisystemic disease-related complications in conjunction with challenging social determinants of health significantly influenced my career aspirations of improving healthcare access to vulnerable populations, providing youth mentorship in medical education to disadvantaged communities, advocating for equal opportunity irrespective of demographic characteristics and addressing unconscious biases.

It was during my first month of an outpatient block in Intern year that I met the memorable Mr. X, a Spanish-speaking Hispanic patient in his late 40s with type 2 diabetes already complicated by coronary artery disease, chronic kidney disease, peripheral neuropathy and proliferative retinopathy resulting in vision loss. He was presenting for a follow-up visit after a hospital discharge for diabetic ketoacidosis and his point-of-care glucose in clinic was in the 400s that day. Browsing through the EMR, I can still remember feeling frustrated about his poor glycemic control despite recurrent inpatient admissions with extensive counseling along with rapidly progressive macrovascular and microvascular end-organ damage indicative of poor long-term prognosis. When I inquired about his treatment compliance, he mentioned that his wife helps him administer medications since he is legally blind so we agreed for her to accompany him to the next visit. I met Mrs. X a month later and gave detailed instructions with the assistance of a Spanish interpreter and she nodded in agreement with an innocent smile. I remained hopeful

CENTRAL VALLEY PHYSICIANS 31

that his glucose log would have better numbers at the subsequent encounter but that was not the case unfortunately. I questioned the wife sternly this time and it was then that she admitted that she struggled with the prescription labels due to her illiteracy. My heart sank at that moment and I felt so disappointed by my own blindness towards the psychosocial factors that were apparent barriers to this patient’s optimal care. I ended up taking the time to teach the numbers 1-3 to her and wrote them on each vial for her reference. This was the beginning of significantly improved diabetic management for him and the rewarding lifelong practice of “treating the patient who has the disease not just the disease” as affirmed by Dr. Osler for me.

Tyler Ky. PGY-3 Kansas City University Medical School completing rotations through California Health Sciences University The third year of medical school is traditionally the year where we, as future physicians, attempt to make sense of what medicine is in practice and which specialty we all hope to match into.

Although each of the patients I’ve had the pleasure of meeting throughout the last year have helped shape my learning, a young man hospitalized for persisting pneumothorax really helped me stay grounded to what medicine really is to me. A young man, not many years younger than myself was already hospitalized for over a week when I joined his care team during my surgical service. A persisting pneumothorax complicated by a bronchopleural fistula kept this patient in the hospital for much longer than he ever anticipated. The ebb and flow of news detailing progress, only for recurrence soon began to wear him down. Coupled with visitation restrictions and hospital closed-door policies, it was not easy to see this young man cope alone. Our daily chest tube checks turned into conversations about medicine, sports, and even marching band from our younger years. Rather than adhering to the daily repetition, he allowed me the opportunity to help his mind, body, and spirit heal cohesively. In a turn of events, his condition improved in the coming days and was discharged on my last day of surgery service. This young man’s outpatient follow-up was subsequently met with non-recurrence and healthy spirits – and even a desire to pursue healthcare.

When we start medical school all our focus is buried in our textbooks, rubrics, and examinations, but transitioning to clinical rotations provides a stark reminder for our why.

Although this patient was, in all regards, trying to physically heal, I hoped to jump-charge healing for his mind and spirit as well. Being hospitalized for over three weeks in total is hard enough at a young age, but coupled with the restrictions in place 32 CENTRAL VALLEY PHYSICIANS

due to the on-going pandemic – it was not surprising to see the mental fatigue he experienced. I will likely remember this patient for the rest of my career, not because of his positive outcome or his textbook diagnosis, but because our interactions will serve as a reminder for why I pursued medicine. Despite the incredible advancements in medicine and technology, I hope to continue to help patients holistically in all facets of health – in mind, body, and spirit.

Tyler Laws-Mahe, California Health Sciences University College of Osteopathic Medicine Thus far, nothing has impacted me as strongly as my time at the nursing home. It was one of my first experiences as a healthcare professional as I was preparing for medical school, and the longterm care environment allowed me to get to know my patients intimately. Working with a geriatric population allowed me to see the wonderful, healthy lives my patients once lived, and the burden and destruction wreaked by chronic disease.

One of my most memorable patients was Ethel*. From information from my co-workers, I learned that Ethel had lived at the nursing home for a decade, and was very active and happy when she first came. However, by the time I started, Ethel was non-verbal and had severe spastic paralysis. From my perspective, there was very little that she could enjoy.

She couldn’t speak, so she couldn’t communicate her wants and interact with others. She couldn’t move, and so couldn’t participate in nursing home activities and was confined to a wheelchair. She could only move between her bed and wheelchair, and how she spent her day was completely up to me as her caregiver. I was humbled by the incredible amount of responsibility placed on me as a new nursing assistant.

None of Ethel’s activities of daily living were easy. Getting her dressed in the morning was a daily battle of Ethel and I against her condition. Mealtime was a fine walk between giving Ethel her pureed food at a pace she was comfortable with and dealing with the demands on my time and my other patients.

She was entirely incontinent, and the only way to do a brief change was in her bed. Frequently as I would do her brief change, she would urinate on the fresh brief I had supplied. This was incredibly frustrating on my end, until I realized she probably didn’t enjoy spending time in her wheelchair in a wet brief.

Ethel was an early introduction to a lot of questions I still haven’t answered. What must it be like to have so little control over your daily life? Was the way our medical system treated someone without volition truly the best that it could be? What could I have done better to make her feel like a person? She was an early introduction to the human side of healthcare, and she Summer 2021

will impact the way I treat patients for my entire life.

Speaking Without Words Leah Lucero UCSF Fresno Resident, Dept of Surgery During medical school, every physician must learn an endless amount of new information and skills: complex biochemical pathways, how to listen to lungs with a stethoscope, and even how to properly deliver a baby. Something that is not taught, however, is how to connect with the family of a dying patient.

Lectures and review questions can never convey or prepare us for how difficult this can be.

I was working nights in the Intensive Care Unit when I first met Mr. Lee. He was an immigrant from Southeast Asia with a perforated stomach ulcer. Despite emergent surgery, his body had suffered an unsurvivable blow, and after months of ICU care it was clear that he was not getting better. His wife, Paj, was a constant fixture at his bedside. The day came when his kidneys failed and his ventilator requirements increased. Paj asked for my honest thoughts about her husband’s prognosis. I was at a loss - there was nothing positive to say, no magic wand to wave to make everything better. We stood facing one another, and before I knew it I found myself moving forward with my arms open. To my surprise, she stepped into my embrace, and held me back. We stood there for a long time without speaking. Our hug expressed all of the feelings words failed to describe: our determination to be there for Mr. Lee, our frustration with the limits of modern medicine, and our deep mutual sorrow.

New physicians often have a self-set expectation to be in control of our emotions at all times. But from what I’ve found, it is not only acceptable to express sadness and vulnerability - it can be the best way to connect with our patients and their families.

Humans have innumerable differences in backgrounds, beliefs, and upbringings, but emotion is something we all share. It’s an unspoken language that can bond two individuals even in the darkest of times. While it’s important to exude confidence during patient care, it’s even more important to remember that at the end of the day, physicians are people with thoughts, emotions, and worries just like their patients. I don’t think I’ve ever related more to a patient than in that moment of open vulnerability. I couldn’t save Mr. Lee, but he and Paj taught me one of the most important lessons I’ve learned in my 7 years of medicine.

Surgery Residency, this happened to me. My most profound encounter happened when the roles were reversed, and I became the patient.

In December 2020, during the peak of the pandemic, I tested positive for COVID-19. After eight miserable days of cyclic fevers, intense body aches, and a steadily decreasing oxygen saturation, I conceded to my stubbornness and sought help. I was diagnosed with COVID pneumonia and admitted to my home training hospital for a five-day course of Remdesivir.

As someone who has dedicated his life to living a healthy lifestyle and helping others do the same, it was an incomprehensible position to be in.

It’s a strange feeling walking the hospital halls freely as a doctor one day and as a patient the next. I was confined to a bed in a pod with three other COVID patients on the impromptu COVID unit. Our “rooms” were separated by curtains, had one common bathroom without a shower, and an industrial filter providing “white noise.” My colleagues were in the same building but could not feel further away. I felt scared and alone. Amidst the pain and uncertainty of my diagnosis, I became aware of the challenges that all patients face. Occurrences that were once commonplace such as IVs, regular vital checks, delayed food delivery, and ceaseless beeping noises created a stressful, uncomfortable experience for me.

As my symptoms subsided and my morale improved, I realized the tremendous growth opportunity this experience provided for me as both a patient and physician. Observing the other patients around me, I gained a greater appreciation of my own mortality, and the fact things could always be worse.

It was revealing how simple gestures from staff and loved ones influenced how I was feeling. Some provided me with hope and comfort while others made me frustrated and confused.

Ultimately, it was less about the specific therapies or services given, but the way they were given. Taking a few more minutes to explain the current treatment plan, ensuring my questions were answered, occasional unprompted check-ins, and food deliveries, proved to be the real cures to lifting my spirits.

The healing power of human dignity is what I ultimately wish to convey with my story. The best care comes from those who can put themselves in their patients’ shoes.

Philip Locker, MD UCSF Fresno Orthopaedics Certain patient encounters can have a lasting impact on the lives of healthcare professionals. Three years into my Orthopedic

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© Can Stock Photo / ezumeimages

Forty-one.

That’s the life expectancy of a person with Sickle Cell Disease in California.

Elsewhere in the country, Sickle Cell Disease (SCD) patients are expected to live to age 67.

Several factors contribute to this discrepancy, including lack of outpatient SCD care, a shortage of providers and lack of interest in specializing in sickle cell, socio-economic barriers, and systemic and institutionalized racism, as a majority of SCD patients are African American, explained UCSF Fresno assistant clinical professor Dr. Mohammed Bukari.

“A dedicated facility for sickle cell patients is not very common,” said Dr. Bukari, who is also the director of the Sickle Cell Program at Community Cancer Institute. “This leaves a lot of patients with the only option of going to the ER. And as if that is not enough, there’s poverty, socioeconomic problems, homelessness, lack of transportation.”

Dr. Bukari, along with Dr. Patrick Macmillan, UCSF Fresno Chief of the Division of Palliative Medicine, is 34 CENTRAL VALLEY PHYSICIANS

working to change the outcomes for sickle cell patients, beginning in the Central Valley.

“There are a whole lot of patients out there really without anywhere to go,” Dr. Bukari said. “These patients have had this disease all their life. They are in chronic pain, they are always in the hospital, in the ER, or physicians’ offices, and unfortunately, they are also either marginalized, looked down upon, there’s a high extent of biases.

“They don’t feel like people really care about them.

Being a provider who identifies myself as a sickle cell provider, I make sure that I make them feel welcome, heard, and make them feel part of the team.”

A STATEWIDE EFFORT The first step to helping these patients was establishing a dedicated outpatient sickle cell clinic at Community Cancer Institute in Clovis, which was grant-funded beginning in July 2020.

“Then the other side of it is just looking at the

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overall picture of (sickle cell patients) and also developing awareness in healthcare delivery systems, healthcare protocols and pathways so that when they do go to the provider training programs, and community-based hospital to get the care, they are more streamlined or organizations. standardized,” Dr. Macmillan said.

A DEDICATED OUTPATIENT CLINIC This surveying process and development of protocols Dr. Bukari currently serves 32 patients at the dedicated will be funded by a $75,000 grant to be awarded beginning SCD clinic at CCI two days out of the month. He is July 1. working to expand the clinic to weekly service by using These grants are part of the California Sickle Cell Networking California Sickle Cell Care funds to recruit a Action Plan, a statewide effort established in 2018 to mid-level provider. improve healthcare systems and the quality of life and Sickle cell patients are referred by their primary care longevity of those living with sickle cell disorders. doctor. There are also between 200 and 300 young sickle Patients with SCD have inherited a genetic variant in cell patients under the care of Valley Children’s Hospital, both of their hemoglobin A genes which results in the red and a few of those patients have transitioned to Dr. blood cells becoming Bukari as they reached irreversibly distorted in a adulthood, he said. sickle-like shape.

People with SCD have serious The sickle cell In the U.S., SCD health problems throughout outpatient clinic occurs most commonly their lifespan, can suffer pain specifically screens in African Americans episodes that land them patients for organ (one in 365 African frequently in the emergency damage or complications, American births), and department, and have a and manages diseaseHispanics (1 in 16,3000 shorter life expectancy. modifying medications births), according to such as hydroxyurea, the CDC. Additionally, crizanlizumab, voxelotor, some people are born and L-glutamine, Dr. with Sickle Cell Trait, Bukari said. where only one of two hemoglobin genes carry the sickle Having a dedicated sickle cell doctor can make a huge cell variant. difference for patients and the way they are treated by other People with SCD have serious health problems providers, Dr. Bukari said. throughout their lifespan, can suffer pain episodes that land “Every now and then when they have problems when them frequently in the emergency department, and have a they go to the hospital, they call me, and I am a very strong shorter life expectancy. advocate for them,” he said. “I tell people, ‘look, forget your “And that is why the advocacy group actually came misconceptions about them and just listen to what they together and created a call for action to try and change say.’ That’s the one advantage of having a clinic. Generally, that,” Dr. Bukari said. when you go to the ER and you can identify, ‘I have a The Center for Inherited Blood Disorders, sickle cell doctor and this is their name,’ you are treated, community-based organizations, and government agencies unfortunately, different, compared to someone who interested in minority health came together in 2018 to (doesn’t), and people think you are just jumping from ER advocate for sickle cell treatment and research funding, Dr. to ER for pain medication. It’s really important to me that Bukari explained. these patients have access to outpatient care.”

In 2019 funding was added to the state budget. In 2020, Dr. Bukari was awarded a grant from Networking California Sickle Cell Care to expand access to Sickle Cell Disease care in California through education and

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FIGHTING A STIGMA AGAINST SICKLE CELL PAIN PATIENTS Opioids are the mainstay of treatment for sickle cell disease

CENTRAL VALLEY PHYSICIANS 35

pain, said Dr. Macmillan, who treats some of Dr. Bukari’s patients specifically for pain management. He said the opioid crisis is a factor in how patients are treated in the emergency department.

fluids, Dr. Macmillan said.

“They get a bunch of fluids and they get hydrated, which makes sense,” he said. “You’re trying to flood the intravascular space so those cells can actually move through because when they get stuck it’s like a traffic jam.

“I think there’s a bias, there’s a judgment when a sickle So you hydrate people and that allows things to kind of get cell patient comes to the emergency department, there’s into motion again. Then obviously you have to treat the an automatic assumption they’re drug addicts, they’re pain because the pain really is the lack of oxygen at the site.” drug-seeking,” he said. “I've certainly had patients that The goal is to develop a master template each have substance abuse problems, but they also have sickle institution can use to design their own ER procedures that cell disease and we need to find a way to balance those two work for them, Dr. Bukari said. things and treat people humanely.”

“We know not all ERs are created the same with the Understanding the pain and believing in patients is same resources, so the idea is you use the template to meet also a factor, Dr. Macmillan said. Not all sickle cell patients your needs,” he said. have pain episodes, The second part because the disease can is inpatient care, where present differently in “I think there’s a bias, there’s Dr. Bukari and his team each individual. a judgment when a sickle will develop similar A sickle cell crisis cell patient comes to the sickle cell protocols and occurs when the sickleemergency department, pathways for inpatient shaped red blood cells there’s an automatic management. clump together and block assumption they’re drug “The overall goal small blood vessels. addicts, they’re drug-seeking,” is once we have a really “This creates a good system for our ER situation where there and the hospital we can is a lack of oxygen to share this with other that part of the body, and when that happens, they have hospitals in the Central Valley,” Dr. Bukari said. “The these pain crises,” Dr. Macmillan explained. “One of the protocols are not going to be restricted to us. Whoever problems that we have is that I think some folks might needs it can have it.” think ‘well maybe it’s not that bad. Maybe people are just The third part of the grant will fund surveys with faking it or are not really accurately describing how severe patients about their quality of life and emotional health, Dr. the pain is.’ ” Macmillan said.

DEVELOPING INPATIENT PROTOCOLS “It's not just a physical thing that they go through, The first grant from Networking California Sickle Cell but they also go through stigmatization when it comes to Care funded the dedicated outpatient clinic for sickle their care, so there's a lot of emotional, mental distress, cell patients. The second grant, which will be put to use spiritual distress even, and depression and anxiety become beginning July 1, will be focused on sickle cell emergency co-morbid.” care, inpatient care, and quality of life.

“We want to know how these patients are doing over time and are we really making any difference in their life,” “Essentially what we're trying to do is provide better Dr. Bukari added. care for sickle cell patients when they go into the emergency department, so we're developing protocols and pathways so that there's a standardization of care,” Dr. Macmillan said.

Currently, sickle cell patients who go to the emergency department for pain episodes are given IV

36 CENTRAL VALLEY PHYSICIANS

Summer 2021

© Can Stock Photo / paulshuang

MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN Multisystem inflammatory syndrome in children (MIS-C) was first identified in April 2020. The condition has also been called pediatric inflammatory multisystem syndrome (PIMS).

ABOUT THE AUTHOR Reshma Patel, MD - Pediatric Rheumatologist, Clinical Assistant Professor (affiliated), Stanford University School of Medicine, Rheumatology Academic Chief, Pediatric Core Faculty, and Faculty Coach Valley Children’s Pediatric Residency Program affiliated with Stanford School of Medicine

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Multisystem inflammatory syndrome in children is a serious condition that appears to be linked to coronavirus disease 2019 (COVID-19) that occurs in children under 21 years of age. The syndrome is due to the body’s immune response to the presence of the SARS-CoV-2 coronavirus and many children with MIS-C have a positive antibody test (COVID IgG). The presenting inflammation seems to present in many children who may have had asymptomatic or symptomatic COVID infection even weeks prior. It has also been seen during active COVID pneumonia.

The syndrome causes severe inflammation of the blood vessels in the heart, kidneys, digestive system, brain, skin, eyes and other organs. It is also thought to affect the coagulation pathway leading to increased risk of blood clots. MIS-C or PIMS has features in common with an illness called Kawasaki disease as well as sepsis, which also causes inflammation of the blood vessels throughout the body.

We have seen more than a fourth of the state’s MIS-C cases in the Central Valley, many of which required ICU admission.

In the U.S., more Black and Hispanic children have been diagnosed with MIS-C compared with children of other races and ethnic groups. This, in part, may explain the large number of cases in the Central Valley where there is a large Hispanic population. Studies are needed to help determine why MIS-C affects these children more often than others.

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SYMPTOMS OF MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN Patients have many of the below signs and symptoms that acutely present and worsen rapidly.

• • • • • • • • • • • • •

Fever > 24 hours or longer, usually >101 Vomiting Diarrhea Abdominal Pain Skin rash Feeling unusually tired Tachycardia and Tachypnea Red eyes Redness or swelling of the lips and tongue Redness or swelling of the hands or feet Headache, dizziness or lightheadedness Enlarged lymph nodes Bodyaches and neck pain

Early diagnosis and treatment of patients with MIS-C is critical to prevent long-term complications.

If a child has signs of MIS-C, it is recommended that they contact their pediatrician, and depending on clinical status they may be directed to the emergency department for further care. Early labwork has revealed markedly elevated inflammatory markers such as CRP, ESR, Ferritin, D-dimer and abnormal electrolytes, such as low sodium or albumin levels in the blood. These patients should have both COVID PCR and COVID IgG testing performed.

Many patients have rapid hemodynamic instability and require intravenous fluid boluses as well as vasopressors for cardiogenic support. Additional treatments used include intravenous Immunoglobulin (IVIG), systemic corticosteroids, as well as immunomodulatory drugs, such as anakinra and tocilizumab.

AS CHILDREN RETURN BACK TO SCHOOLS The health and safety of our children, school staff, and communities remain our top priorities Below are some common questions and answers that will

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be useful for school staff and parents.

What is the treatment for MIS-C? • A patient with MIS-C can be categorized in to mild, moderate, and severe. If the child is moderate or severe, they need treatments such as intravenous Immunoglobulin (IVIG), systemic corticosteroids, or even immunomodulatory drugs to calm the overactive immune system. Treatment usually is a few days to over a week.

Do children with MIS-C need to be in isolation?

• MIS-C is a rare condition that is NOT contagious. It is a separate illness from active COVID-19 infection.

But because it can occur in children that may still have active COVID-19 virus, those children would need to be in isolation if in the hospital. It seems to be affecting children in a random way and have not seen siblings in the same household have MIS-C. Typically the recovery and or treatment for MIS-C is 1-2 weeks, they do not need to quarantine for MIS-C itself.

How to ease anxiety about a new syndrome?

• MIS-C is still rare. While we have seen and increased amount of children at VCH and surrounding hospitals, the majority of COVID exposed children are not having this complication.

• Children are responding well to treatment • MIS-C is not subtle. Parent or school staff will notice the child behaving differently. While symptoms are similar to a common cold, a “stomach bug”, or bacterial infections, they will feel much worse. With other viral infections, children still look pretty healthy. But kids with MIS-C can really truly be “lethargic” and want to sleep, and don’t want to eat. It is important to have high level of suspicion for MIS-C in our endemic area and recognize patients with MIS-C will clinically deteriorate fast and go into shock.

• There is ongoing research throughout the country, including VCH, to follow-up patients with moderatesevere MIS-C at least 6-12 months in order to

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determine if there are more long term complications that develop What else can help to prevent MIS-C or catch it “early”?

• Awareness of previous COVID infection, COVID exposure, or positive test may help with higher level of suspicion of MIS-C in children that present with above symptoms and get them evaluated sooner • Really encourage good water and electrolyte intake to try to prevent shock like low blood pressure • Continuing frequent hand washing as well as following masking and social distancing guidelines to help prevent asymptomatic spread CHILDHOOD VACCINATIONS POST IVIG Children who receive Intravenous Immunoglobulin (IVIG) will need modification in certain school required vaccinations.

IDENTIFYING AND REPORTING OF (MIS-C) MIS-C is a reportable disease. For more information on how to report cases, please refer to https://www.co.fresno.ca.us/departments/public-health/ community-health/epidemiology/reporting-diseases-3691 Primary care providers can reduce the incidence of MIS-C by reminding children and families to take extra precautions: disinfect, wear masks and socially distance and encouraging eligible children to get vaccinated against COVID. For more information about MIS-C please visit the following links: • https://services.aap.org/en/pages/2019-novelcoronavirus-covid-19-infections/clinical-guidance/ multisystem-inflammatory-syndrome-in-childrenmis-c-interim-guidance/ • https://www.cdc.gov/mis-c/hcp/

© Can Stock Photo / tommyandone

The efficiency of live virus vaccines may decrease, if administered 2 weeks before administration of IVIG or in 1–2 months after administration of IVIG. • MMR and varicella vaccines should be administered 11 months after administration of IVIG. • If MMR and varicella vaccines have been administered within 14 days before IVIG, they should be repeated 8 months after IVIG

Oral polio vaccine, rotavirus, live influenza virus, and all inactive vaccines are not affected by blood and blood product transfusions, so they can be administered in accordance with typical vaccination schedule

Summer 39 CENTRAL 2021 VALLEY PHYSICIANS

CENTRAL VALLEY PHYSICIANS Spring 39 2021

The effort to eradicate COVID-19 has been one of community collaboration, often resulting in health centers and staff working outside their normal scope of care.

“Many hands make work light,” explained May Cha, The Nephrology Group, Inc.’s Ambulatory Surgical Center Manager. “How can we contribute to our local community’s effort to combat Covid-19? We can’t have the mindset that ‘it’s not what we do’, or ‘it’s not within our scope of practice’. At the urging and direction of our organizational leaders; Drs. Hemant Dhingra and Joseph Duflot, we answered the call to action from our local public health officials.”

The Nephrology Group, already equipped to provide IV infusion treatments, was instrumental in assisting the Fresno County Department of Public Health with monoclonal and polyclonal antibody treatments during the pandemic.

The center became one of the first in Fresno County to provide outpatient early-onset COVID-19 patients with monoclonal and polyclonal antibodies, laboratory-made proteins that mimic the immune system’s ability to fight off harmful antigens such as viruses.

Poly/Monoclonal antibody treatments were effective in treating COVID-19 within the first 10 days of test positivity. With early treatment, we give the patients the

very best chances of beating back the virus. With the emerging variant strains, the IV infusion treatments have changed. The monoclonal therapy is no longer effective.

Casirivimab and Imdevimab with polyclonal therapies are drugs being administered now.

The therapy is not hard to administer. Patients are infused 60-minutes, and then monitored for the next 60 minutes for any allergic reactions, Cha said. “The challenge is finishing up our non-Covid patients timely so we can start the therapies”.

“We’ve experienced patients who present with fevers, body aches and generally not feeling well,” Cha explained.

“And feel better upon completion of the infusion therapy.”

It is overwhelming and exciting to be able to partner with our Fresno County Health Department; Dr. Rais Vohra and Dr. John Zweifler to offer these services toward the peak of our second and third wave. Hospitals were overwhelmed managing critically ill Covid-19 patients.

These Polyclonal therapies are indicated for outpatient, early onset to avoid hospitalization.

Centers that offer IV infusion therapies may have the equipment to treat COVID-19 patients with the polyclonal antibodies, but faced logistical challenges. “COVID-19 and non-COVID-19 patients couldn’t be treated at the same time. The infection control measures required to mitigate risk and terminal clean in between each set of patients was a challenge for us”, Cha said.

“In November 2020 we worked diligently to procure COVID vaccine for our most vulnerable population, which is the end-stage renal disease patients on dialysis, and our immunocompromised patients,” she said.

Cha continued, “Covid-19 has ravaged our community, state and country. The patients that we treat are some of the most frail and vulnerable. The Nephrology Group and their leaders wanted to advocate for those patients to ensure that they were included and prioritized to have access to treatment therapies such as Polyclonal antibody infusion and Covid-19 vaccines.”

The Nephrology Group began offering drive-up vaccination clinics for their patients in January 2021.

Beyond treatments and vaccinations, The Nephrology Group’s nonprofit charity arm, Fresno Nephrology Kidney Foundation (FNKF), also contributed to easing pandemic woes.

The Foundation sponsored meals for frontline health Summer 2021

workers at Clovis Community Hospital, and for residents at Terry’s House, a nonprofit that provides lodging and food for families of patients being treated at Community Medical Centers.

FNKF volunteers also made homemade face masks, which were donated to Community Regional Medical Center, Valley Children’s Hospital, and dialysis centers around the county, Cha said.

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42 CENTRAL VALLEY PHYSICIANS

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Imagine, as a student, not having to miss a half- or full-day of school for a doctor or dentist appointment.

Imagine, as a parent, not having to miss work to take your teenager to such appointments.

Imagine as a student feeling like you can access care, nutrition, health education, behavioral health and counseling services on your school campus if needed.

Camarena Health has made this possible for high school students in Madera with two on-campus clinics that provide medical, dental, and behavioral health services during school hours. By offering these services on campus, Camarena Health has been able to increase access to care, address healthcare needs of students and improve learning and seat time that was often lost because kids would miss school or couldn’t focus because they had an unaddressed medical need.

“I wish we had something like that when we were in high school,” said Sandra Huizar-Herrera, FNP. “Because you don’t want to talk to your mom about a lot of stuff. That would have been so nice to have had a health center [on campus].”

Huizar-Herrera has been at Camarena’s School-Based Health Center on the Madera South High School campus since the clinic opened in 2018. A second School-Based Health Center was part of the blueprint for Matilda Torres High School, which opened in Fall 2020.

There are 18 Camarena Health centers spread across Madera and Fresno counties, but the two school-based centers are unique in the access and opportunities they provide students and their parents, said Camarena Health Centers Chief Medical Officer Joel Ramirez, MD MBA. “Being positioned on the campus, they do lend themselves well to providing these students access [to

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care],” he said. “And it also gives us opportunities to do things like student presentations, school physicals, even teaching opportunities for students who are interested in healthcare fields.”

CONVENIENCE FOR STUDENTS, PARENTS Camarena Health’s School-Based Health Centers offer everything from routine to acute care, managing chronic illnesses to providing splints or suturing for any accident that may occur, said Huizar-Herrera.

Services include medical, dental, behavioral health, vision screenings, and immunizations, including the COVID-19 vaccine. When the Pfizer COVID-19 vaccine was approved for ages 12 and older.

The School-Based Health Centers have three exam rooms for medical services, and three to four dental chairs, along with separate offices for behavioral health and a health educator. Huizar-Herrera said “Camarena Health built the nurses office into Madera Souths’ School Based Health Center for the sole purpose of coordinating care with the school nurse and our care teams on campus. Both the school Health services staff and our Camarena Health care teams work closely together to ensure kids access care they need and are able to get back to class timely.”

“We see people from the community and we also see high school students. We do basic care, checkups, anything from sports physicals to getting flu shots to doing scoliosis screenings,” she said.

Like all of the other Camarena Health centers, the school-based center provides access to health services for anyone in the community, not just students. Most medical insurance is accepted, and there is a sliding fee scale based on income for those without insurance, Dr. Ramirez said.

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The clinics are open during school hours, from 7:15 a.m. to 4:30 p.m. Monday through Friday.

“Even if we have patients from the community, our first priority is the students,” Huizar-Herrera said.

“Through Camarena Health’s partnership with MUSD we are able to collaborate and prioritize student’s needs and access care during the school day while being able to support their families, administration and the surrounding community with care.”

Having an on-campus clinic means less school is missed, which helps students and their families, said Dr. Humberto Avila, MD, who started in September 2020 at the Matilda Torres center.

He noted that many parents work the same hours that doctors’ offices are open, which makes it difficult to take time off to get their child to an appointment.

Students can schedule their medical and dental appointments during school hours and go by themselves, eliminating the need for parents to miss work. “[Students] usually tend to only miss one period to come to an appointment, compared to if they went to a doctor’s appointment [off-campus] they would miss half a day, or if they’re going to Fresno they might miss an entire day of school,” Dr. Avila said.

FOSTERING INDEPENDENCE Besides seeking confidential care, it is important for adolescents, including patients who already have chronic illnesses, to get used to going to their doctors’ appointments unaccompanied, Dr. Avila said.

“I have a lot of young patients who are in their 20s or even 30s and 40s and they don’t know they’re supposed to go to the doctor every once in a while to get checked, or they don’t know how to get their labs drawn,” he said. “It’s important that people get that exposure early on to get that routine care.”

This is even more important now that obesity rates among adolescents are rising, Dr. Avila said.

“We’re getting 16-year-olds now who weigh 300 pounds and are developing Type 2 diabetes and things like that, so I think it’s more and more important now than ever that we are seeing these patients earlier and hoping that we can make these interventions sooner,” he said.

Even students who are used to going to the doctor 44 CENTRAL VALLEY PHYSICIANS

may find themselves at a loss when they’re expected to go to the doctor alone, Dr. Avila said.

“Say a Type I diabetic who has had diabetes since they were 10, they’re used to going to their appointments with their parents; but now they’re 18 or 20 and now they don’t know what questions to ask their doctors, or how to have a follow-up,” he explained. “What we see often, especially with Type I diabetics, is that they’re really controlled when they’re 17 years old, but now they’re 21 or 22, and [their disease] is completely out of control because they’re in charge of their medical and not their parent.”

By visiting the School-Based Health Center for their appointments alone, teens can gain independence and have better health outcomes as they reach adulthood, Avila said.

ENCOURAGING EXPOSURE TO CAREERS IN THE MEDICAL FIELD Early exposure to the medical field, with opportunities to shadow healthcare workers at School-Based Health Centers, can help build the healthcare workforce in the Central Valley, said Dr. Ramirez.

“Healthcare, in general, is facing a real shortage here in the Central Valley, not only in specialty services but also primary care,” he said. “We do not have a good ratio of medical providers to citizens of the area. One way to encourage that is by creating opportunities for learning and exposure to the healthcare fields.”

Camarena Health hosted its 6th Annual Health Career Starts Here Youth Conference in May for Health Science CTE students at Madera Technical Exploration Center (MadTEC). Students heard from Camarena Health providers about their experience becoming medical professionals and participated in hands-on workshops with Camarena Health staff.

This annual conference, combined with year-round access to School-Based Health Centers, increases students’ interest in healthcare fields, Dr. Ramirez said.

“Since we’re right on campus and students are able to easily access our health services and the professionals that work there, they can understand and see what it is they do for us,” he said. “Our goal is that by way of these exposures, and opportunities for job shadowing, we can build up our workforce here locally.”

Summer 2021

The value of perspective Advice. Beyond investing.

With so much at stake when it comes to protecting all that you’ve worked so hard to achieve, it may be a good time to review your financial plan. At Litle Wealth Management, our approach starts by understanding your life and what you want to accomplish. Then we work together to create a framework designed to give you the confidence to do what matters most, no matter what the markets are doing.

We want to help ensure you have all you need for today, tomorrow, and for generations to come. Let’s start the conversation.

Troy A. Litle Senior Vice President - Wealth Management 559-248-4022 troy.litle@ubs.com Lisa Ann Tadich Financial Advisor 559-248-4007 lisaann.tadich@ubs.com

Litle Wealth Management UBS Financial Services Inc. Fig Garden Financial Center 5200 N Palm - Suite 101 Fresno, CA 93704-2225 559-226-2800 800-423-8797

Kenneth Rollins Registered CSA 559-248-4009 kenneth.rollins@ubs.com

ubs.com/team/litlewealthmanagement As a firm providing wealth management services to clients, UBS Financial Services Inc. offers investment advisory services in its capacity as an SEC-registered investment adviser and brokerage services in its capacity as an SEC-registered broker-dealer. Investment advisory services and brokerage services are separate and distinct, differ in material ways and are governed by different laws and separate arrangements. It is important that clients understand the ways in which we conduct business, that they carefully read the agreements and disclosures that we provide to them about the products or services we offer. For more information, please review the PDF document at ubs.com/relationshipsummary. ©UBS 2021. All rights reserved. UBS Financial Services Inc. is a subsidiary of UBS AG. Member FINRA/SIPC. D-UBS38805F6F

Summer 2021

CENTRAL VALLEY PHYSICIANS 45

© Can Stock Photo / galitskaya

ABOUT THE AUTHOR Catherine Heaney, MA, MSW, ACSW Registered Associate Clinical Social Worker, ACSW #70738 Catherine specializes in working with adults struggling with: anxiety, depression, and coping skills. Through counseling and cognitive behavioral goal setting, Catherine helps clients implement a plan to help them understand what motivates our actions and reactions to the world.

In addition to her education in social work, Catherine brings with her a strong entrepreneurial background. She has owned and operated several restaurants in the Central Valley, giving her a unique perspective of the ebbs and flows of owning businesses. With her experience, Catherine hopes to encourage her clients to take charge of their lives and see life’s challenges as opportunities.

46 CENTRAL VALLEY PHYSICIANS

The first thought that might come to mind upon hearing the term "Leisure Sickness" is getting a little seasick while aboard a 7-day Caribbean cruise.

However, leisure sickness is a very real and frustrating infliction that impacts many individuals – especially professionals with demanding, high-stress jobs. In fact, you may start emphatically shaking your head up and down and feeling an overwhelming sense of, "Wow, there's a term for this!" as you discover that you’ve previously experienced leisure sickness yourself.

Stress can take on many shapes, and while there is a positive form of stress (eustress), it is typically something that wreaks havoc on our physical and mental health. When we are consistently under immense pressure, even low-grade stress can change how our minds and bodies respond to what is happening around us.

So let me ask you this: have you ever planned a trip only to be sick for part – if not the entire – time? If you're doing that aforementioned head shaking, don't worry, you're not alone and there’s a term for that… that's leisure sickness.

According to an article in the Wall Street Journal, Why Relaxing is Hard Work (2010)1, there was a study done in the Netherlands in 2002 on this very topic. Their findings demonstrate that 3% of the population suffer from leisure sickness that presents as flu-like symptoms. Furthermore, “weekend headaches” can account for, “one-third of all migraines and one-sixth of tension headaches.”

When we condition ourselves to operate under stress to the point that it becomes the norm, it can be challenging for us to say, "Hey, it's Pina Colada time, let's shift gears and relax!" This is because that low-stress gear is no longer our normal state. Quickly, our brains learn that we exist in a stressful

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environment, and to survive, it must habituate. Plainly speaking, if we then flip it upside down and now we’re in a place of calm, this feels almost like an attack on our senses because it's now novel and foreign. This causes physical symptoms like headaches, migraines, nausea, and other ailments to develop.

Esther Sternberg, a researcher of neuroendocrine immunology at the National Institutes of Health, states “stress hormones go a long way toward explaining why most people who suffer from leisure sickness on vacation experience their symptoms within the first couple of days after they stop work. ” (Los Angeles Times, Perhaps it’s a case of ‘leisure sickness’, 2007).

This phenomenon is not only seen in high stress positions such as medicine, but also in students heading home for a much needed break during college. The very act of slowing down can make some individuals physically ill. So instead of spending time regrouping and relaxing, they're curled in a ball on their bed, wishing their head would stop throbbing.

Now more than ever, you are likely feeling stressed. COVID-19 has changed the landscape of our mental health and our environments. For the last year, we've been social distancing, wearing masks, washing our hands obsessively, and using hand sanitizer to the point that it became hard to find. This isn't "normal" by any means, but over time, we do adapt. You can recognize this by the sense that wearing a mask today isn't nearly as awkward as it was a year ago. It's a fantastic thing we do, how we can learn, without trying, to adapt to our environments.

Regrettably, this adaptation to our environment doesn't mean that our stress hormones aren't having a party—they are. This additional layer of stress has created the perfect storm for leisure sickness to develop as we begin to take time off and visit far-off places once again..

To offset this, there are a few techniques you can try. These strategies are mainly mindfulness based. The very act of being aware that leisure sickness might occur can provide you with a sense of control, and planning accordingly might even save your vacation.

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1. Instead of jumping into your vacation after going 100 mph at work, dial back your work incrementally before your vacation, if you can. For example, rather than seeing your usual number of patients, start cutting back a bit before you take off. This way, your body can learn how to not be in such a heightened state when you hit the sand. Also, consider leaning into work when you get back rather than jumping right in.

2. Take care of yourself throughout your work/life (or lack thereof) balance. By sleeping more, taking breaks, managing stress, and nourishing yourself consistently with a balanced diet, you're helping your current and future self.

3. Try meditation. Often, meditation is misunderstood.

Some people may think that you need to clear your day, buy a robe and climb up a mountain to achieve this new level of being but really, all you need is some free time and the right mindset. Meditation isn't to clear your mind but to change your relationship with your thoughts. Instead of fighting them, you can learn how to acknowledge them, gain distance from them and not have them take over every waking second.

4. Talk to someone. One of the most powerful tools we have is one we may not always use, especially when we need to the most. Rather than trying to power through this alone, opening up to someone will significantly benefit your current and future health. Addressing your symptoms and stressors with a professional, you're taking back control and processing stress consistently, not only when you have some time off.

Minor tweaks in the present can change your relationship with your trips and how you process and respond to stress. By taking care of yourself now, you're also taking care of “vacation you” so that you can enjoy sipping that Pina Colada with your toes in the sand – not a single leisure sickness symptom in sight. Bon voyage!

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© Can Stock Photo / viscorp

ABOUT THE AUTHOR Russell Maltes is a client adviser at Regency Investment Advisers. He works with individuals, families, and businesses to address the broad spectrum of financial planning and investing. His entire 20 plus year career has been in financial services.

Starting in banking in the late ‘90s, Russell has worked for Merrill Lynch, Charles Schwab, Transamerica, and now Regency.

Russell and wife Taryn are both Fresno State alums and children of retired U.S. Navy veterans. They live in Clovis and share two children.

48 CENTRAL VALLEY PHYSICIANS

Summer 2021

The older I get, the more I love a good analogy. There is something special about someone who can help you relate difficult material to something familiar. Done well, there is an “Aha!” moment. It is as if someone flipped the light switch on in a dark room and now you can see! When I try to imagine what medical school must be like, I akin it to drinking from a firehose. You are constantly being fed a huge volume of information with the hope that you process and retain as much as possible. On a smaller scale, personal finance can be similar. The good news is you do not have to master it all at one time. Quite the contrary. There are key concepts that will help you hit the ground running while others can certainly wait as you gain experience and better define your career path.

Let us start with one of the most important concepts in investing and financial planning: compound interest.

Compound interest is the result of earning a return on an investment, but instead of collecting and spending that return on investment, it is combined with the initial investment and goes back to work for you. Going forward, you are now earning interest on your interest. Imagine forming a snowball with your hands and rolling it down the mountain side. At first, the ball is small and rolling slowly.

In a moment, it begins to pick up speed and pack on snow on all sides. Soon it is moving and growing at a pace far beyond where it started. By the time it nears the bottom, it is so big and powerful it becomes unstoppable. That’s compound interest.

Another compelling example of compound interest is the choice between being given a million dollars one time or a penny doubled every day for 30 days. While a million dollars up front sounds appealing, taking the penny and doubling it every day for a month will yield well over five million dollars! Like the snowball analogy, the growth of the penny will start slow. By taking the penny option, you will only have $0.16 on day 5. It is not until day 21 when you reach $10,000. From here, things begin to take off.

From day 21, it is only four more days to get to $167,772.

Just three days after that, you finally reach the million dollars you initially bypassed. Just two days later, your initial penny now eclipses the five-million-dollar mark!

As you can see, the most important factor of compound interest is time. Growth is very slow in the beginning. It is at the tail end where compound

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interest really shines. What does that mean for young professionals? Time is on your side, so don’t wait to get started! The sooner you start, the more likely you will hit, or exceed, your goal. It is easy to rationalize waiting to invest and instead prioritize other spending. However, the number one comment I hear as clients near their investment or retirement goals is “I wish I had started sooner.” Planting investment seeds now will yield dramatically more down road.

But what about debt? Why should I begin to look at investing when I owe six figures in student loans? A plan to address your debt can be as important as investing early. Types of loans, interest rates, penalties, and loan forgiveness are all important aspects to understand. A good place to start is deciding whether to explore loan forgiveness (or sponsored loan repayment) or to pay your student loans in full. This decision may drive where you choose to pursue employment. It also helps determine if it is wise to make additional principal payments.

There are several programs out there that provide loan forgiveness or will make your student loan payments in exchange for service time. Public Service Loan Forgiveness (PSLF) is a program through the U.S. Department of Education that will erase any remaining federal student loan debt after you make ten years of payments while working for the government or a nonprofit. The forgiveness will likely be tax free. Many states will repay some or even all a physician’s student loans if they are willing to work in underserved or rural areas. There is usually an associated minimum time commitment. Websites like the Association of American Medical Colleges maintain information on state and federal repayment programs. The National Health Service Corps offers a loan repayment program for working in HPSAs (Health Professional Shortage Areas). Your loan provider can often help with up-to-date loan forgiveness and payment assistance resources.

Instead of assistance, you may be considering going the private employment route and paying your loans back in full. Amortization is a term used in the loan industry to describe the repayment schedule of a loan. Here is where an adviser can assist with developing an accelerated amortization schedule that fits your budget and reduces the interest costs over the life of the loan. Additional

CENTRAL VALLEY PHYSICIANS 49

principal payments can drastically reduce the total cost of borrowing. For example, take a typical $200,000 10-year student loan at an 8% interest rate. Making the minimum payments will result in a total cost of borrowing of just over $291,000. Paying an additional $1000 per month would pay that loan off more than 3.5 years sooner and save over $36,000 in interest. The interest savings only get better with the more you are willing to prepay.

The compound interest and debt reduction concepts raise an interesting question: do I invest or pay down debt?

Perhaps do both at the same time? The answer may not be so simple. This is where working with a financial adviser can help. He or she can help you articulate your priorities and goals. They can help you establish a budget that determines your ability to invest or prepay debt. They can map out how different action plans will play out, getting you to your goal in the most efficient way possible. In addition, your adviser can help you stay on track along the way.

That leaves us with a short tutorial on credit reports and scores. Credit is an integral part of our financial system. Your credit report is the history of your credit usage. It contains the vendors you borrowed from, the amounts, credit limits, and payment timeliness. A credit score is a calculation taking those factors into account.

Higher credit scores often equate to better rates and terms.

There are three major credit bureaus: Equifax, Experian, and Trans Union. Each collects credit information from vendors and formulates a score. They all use slightly different algorithms, but their scores should be within a similar range. However, the predominant credit scoring system is provided by the Fair Isaac Corporation.

Referred to as your FICO score, it ranges from 300 to 850.

Generally, scores in the 670 to 739 range reflect good credit while a score of 740 or more is considered excellent credit.

Each of the bureaus and FICO use similar criteria for determining your score. For FICO specifically, it looks at five weighted factors:

50 CENTRAL VALLEY PHYSICIANS

•

Payment history (35%): This measures your ability to pay things on time. The fewer the delinquent payments on record, the better your score.

• Amount owed (30%): This looks at your total amount owed as well as your credit utilization ratio. Utilization analyzes how much you have borrowed in respect to the amount you have available to borrow. The lower your revolving credit balances relative to their limits, the better your score.

• Length of credit history (15%): This describes how long you have been using credit in general and the average age of all your accounts. Longer standing credit relationships, especially those in good standing, are more valuable than newer credit accounts.

• Credit mix (10%): The types of credit accounts you have matters. A good mix of credit cards, student loans, mortgage loans, and auto loans is helpful. In general, though, your credit mix only really matters if your credit history is very limited.

• New credit (10%): When you apply for credit, a credit inquiry is recorded. Your history of inquiries plays a role in your score. Lenders are cautious of borrowers applying for a lot of different credit accounts in a short period.

We have just scratched the surface of these topics.

The concept of compound interest is the cornerstone of investing. A dedicated debt reduction plan, specifically for student loans, can lower the overall cost of borrowing and open the door to building wealth. Lastly, a cursory understanding of how credit works may lead you to better borrowing decisions. These decisions can have ripples down the road when it is time to buy a home or start a practice. There are several other important financial concepts that can help get your career and adult life off on the right foot. Working with a financial adviser to create a customized plan for you can be the ticket to financial success later in life.

Summer 2021

Doctors Day Honor Roll In Honor ofof Doctor’s Doctors Day - March 30,honored 2021,colleagues thesewith doctors recognized by their theirThese dedication In celebration Day, many of our local physicians a donationwere in their name to the Fresno Madera Medical colleagues Society Scholarshipfor Foundation. physicians were honored for their dedication to the health of our community and the practice of medicine. and The contributions toSociety society andFoundation the community.

Their to putting patients first, especially in these times Fresno Madera Medical Scholarship is a 501(c)(6) nonprofit createddedication to administer a perpetual and revolving scholarship fund for deserving medical students from Fresno and Madera counties. The Scholarship Foundation was made possible by the excess funds realized from the Sabin Oral Polio Sunday Clinics in 1962-63. With efforts of the citizens ofofCOVID isthese something to commemorate.

This National Doctors Day, friends, family, and patients both counties, clinics were organized and sponsored by FMMS to immunize the population of Fresno and Maderacolleagues, counties against poliomyelitis.

Throughout the years, additional funds have been generated through contributions, memorial gifts and repayments on would recognize the following doctors for fmms.org their care and support. monies from former recipients.

Donationslike to the to FMMS Scholarship Foundation can be made year round by visiting or calling 559-224-4224.

In Honor of

BONNA ROGERS-NEUFELD, MD, FACR, CCD "Dr. Rogers-Neufeld has gone above and beyond for the women of the Central Valley for over 30 years while acting as the longest serving lead mammographer in our region."

MARK ALSON, MD SIERRA IMAGING ASSOCIATES

In Honor of

Pravachan Hegde, MD "Thank you, Dr. Hegde, for working so hard to ensure patients receive the care they need."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

Eyad Almasri, MD "Thank you, Dr. Almasri, for spearheading cutting-edge research to ensure patients have access to the latest clinical trials and treatment options. Your tireless work caring for critically ill patients is appreciated."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

Mohamed Fayed, MD "Thank you, Dr. Fayed, for your tireless work caring for critically-ill patients and for all you do for our community."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

Jonathan Terry, MD "Thank you for your dedication to the people of the Central Valley!"

In Honor of

DR. MICHAEL MOYA "Words cannot begin to describe how thankful we are for all that you do- your encouragement, guidance, friendship, and unwavering dedication to making sure we remained safe and protected during this global pandemic. We are honored and humbled to call you our APD. " SAMC FAMILY MEDICINE RESIDENCY

In Honor of

Dr. Ji Young Park "Thank you Dr. Park for helping us spread our wings.

You are a phenomenal teacher, and we appreciate that you always allow us to learn by doing. Thank you for your support and for being our strength. Your words of encouragement continue to inspire us to be the best versions of ourselves."

SAMC FAMILY MEDICINE RESIDENCY

In Honor of

Vijay Balasubramanian, MD, FCCP, MRCP "Thank you, Dr. Balasubramanian, for all that you do for your patients and community."

In Honor of

"Thank you, Dr. Ghimire, for your unwavering commitment to your patient's health and your community. " CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

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"Thank you, Dr. Lee, for your commitment to high-quality care for your patients and community. " CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

Vipul Jain, MD, MS "Thank you, Dr. Jain, for your continued leadership during this time and your commitment to providing high-quality care for patients in need."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

Leslie Storey, MD "For your hard work in providing dermatology care to the underserved of the Central Valley"

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

Karl Van Gundy, MD "Thank you, Dr. Van Gundy! Your steadfast work caring for Central Valley patients is appreciated."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

DR. Luis Dehesa "For your hard work in providing dermatology care to the underserved of the Central Valley" GREGORY SIMPSON, MD UCSF - FRESNO

MARINA ROYTMAN, MD UCSF - Fresno

Anil Ghimire, MD

In Honor of

David Lee, MD, FCCP

In Honor of

Timothy Evans, MD, PhD "Thank you, Dr. Evans, for providing such excellent care to your patients and community."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

GREGORY SIMPSON, MD UCSF - FRESNO

In Honor of

Kathryn Bilello, MD "Thank you, Dr. Bilello, for ensuring patients have access to the highquality care they need and deserve."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

Michael Peterson, MD "Thank you, Dr. Peterson, for your commitment to Central Valley patients through high-quality care and teaching the next generation of physicians."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

In Honor of

Waqas Aslam, MD "Thank you, Dr. Jain, for your continued leadership during this time and your commitment to providing high-quality care for patients in need."

CENTRAL CALIFORNIA FACULTY MEDICAL GROUP

CENTRAL VALLEY PHYSICIANS 51

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

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

Your annual dues can be more than offset when using membership services and discounts, and you get personal assistance with practice management and payment recovery issues to improve your bottom line. Join the FMMS to be a better leader for your staff and patients, and to amplify your voice to influence policy and legislation. The FMMS brings together an active community of physicians in order to improve the larger community. Our mission is physician-driven, and we want to help you solve your biggest practice management issue. Join the FMMS today!

BENEFIT Automobile & Homeowners Insurance CAP Cooperative of American Physicians

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Save up to 8% more.

CONTACT Mercury Insurance Group (866) 602-5259 www.mercuryinsurance.com/cma

Member discounts on malpractice protection, risk management and practice management.

Albert Malasig (650) 543-2185 www.CAPphysicians.com

Save up to 25% on car rentals for business or personal travel.

Avis (800) 786-4262 www.cmanet.org/groupdiscounts

Classified Ads

Free classified ads in Central Valley Physicians Magazine

Resiliency Consultations

3 Free, anonymous resiliency consultations yearly through Joy of Medicine Program

Roubicek and Thacker 559-323-8484

FMMS is an accredited provider for Continuing Medical Education providing free and low cost seminars for members.

FMMS: (559) 224-4224 www.fmms.org

Confidential support and assistance to physicians affected by substance abuse, or an emotional or physical problem.

CMA: (650) 756-7787 https://www.cmadocs.org/confidential-line

Discount on hourly consulting fee for practice assessments, valuation, brokerage, partnerships, etc.

Practice & Liability Consultants (415) 764-4800 www.practiceconsultants.net

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CHP approved emblem provides physicians expemption from speeding laws when en route to an emergency

FMMS (559) 224-4224

Human Resource Services

20% discount plus free consulting calls with HR Business Partner package

Sierra HR Partners, Inc. (559) 431-8090 www.sierrahr.com

Discounts on medical, workers’ comp, dental, disability, long-term care, level term life & business overhead expense.

Mercer (800) 842-3761 www.mercer.com

Free tool kit on quality measures & online tool to create custom MIPS plan.

FMMS (559) 224-4224

CME Seminars

Confidential Hotline

Consultancy Services

Insurance MACRA Assistance

52 CENTRAL VALLEY PHYSICIANS

FMMS: (559) 224-4224

Summer 2021

BENEFIT

CONTACT

Up to 89% off the cover price of hundreds of magazines for your home, office, and waiting and patient rooms.

Consumer Subscription Services (800) 289-6247 www.cmanet.org/magazines

Medical IDs

Discounts on 24-hour emergency identification and family notification services.

MedicAlert Foundation (800) 253-7880 www.medicalert.org/cma

Medical Office Services

Discounts on medical billing. No upfront costs. 1st month free and 2nd month 1/2 price.

Rita Nye (559) 359-6170 www.medicalbillingmos.com

Messaging App

Free secure messaging app for physician-to-physician/care team communication.

DocBookMD www.cmanet.org/docbookmd

Notary Services

Need a document notarized? Members can receive free Notary Services at the FMMS office.

FMMS 255 W Fallbrook Ave Suite 104 (559) 224-4224

Save up to 80% on office supplies and more.

Staples Advantage (800) 786-4262 www.cmanet.org/staples

CMA’s 24-hour Physicians Confidential Assistance hotline. Free and will not result in any form of disciplinary action.

Completely Confidential Doctor - Doctor Assistance (650)756-7787

Help for practices of all sizes: legal handbooks, practice mgmt. guides, patient education materials, etc.

CMA Resource Library www.cmanet.org/resource-library

Magazine Subscriptions

Office Supplies

Physician Assistance

Practice Resources

Premier Valley Bank

Local bank offering comprehensive banking solutions that help make the job of managing finances easier

Premier Valley Bank www.premiervalleybank.com

Regency Investment Advisers

Financial advisors offering services in investment management, financial planning and retirement plans.

Chris Comstock (559) 438-2640 www.regencyinvests.com

Get paid: members receive one-on-one assistance. We have recouped $16 million from payors in the last 10 years.

FMMS: (559) 224-4224 CMA: (888) 401-5911

15% discount on tamper-resistant security prescription pads and printer paper.

RxSecurity (800) 667-9723 www.rxsecurity.com/cma-order

Discounts on website design packages, including mobile-friendly design.

Mayaco (209) 957-8629 www.mayaco.com/physicians

Reimbursement Assistance Security Prescription Pads Website

For information on becoming an FMMS Business Partner call 559-224-4224 Summer 2021

CENTRAL VALLEY PHYSICIANS 53

In Memoriam

Donald E. Roy April 15, 1935 – May 09, 2020

Donald E. Roy MD, age 85, of Fresno, California passed away on Saturday May 9, 2020. Donald was born April 15, 1935 in Hamden, Missouri.

Donald is survived by his wife, Linda Roy; daughter LaDonna Bush; son Robert Roy; daughter Charisse Jimenez (David); son Karl Roy (Bev); and son Jerry Lee Hudson; brother Charles Roy and brother John Roy. Donald will also be lovingly remembered by his 9 grandchildren and 15 great grandchildren.

Serving as pallbearers are Robert Roy, Karl Roy, Jerry Hudson, Jeff Dakin and David Jimenez.

A Memorial Service is being planned to honor Donald Roy MD, which will include military honors (date to be determined).

Dr. Roy was a member of the California Medical Association/Fresno Madera Medical Association for 48 years.

Horst Weinberg February 28, 1928 – June 14, 2021

Davis , California - Dr. Horst Weinberg, age 93, passed away peacefully on June 14, 2021 in Davis, California. Born in Germany, he spent much of his childhood in Bombay, India before coming to America at age 16. Horst studied at Park College and the University of Michigan where he received his Bachelor's degree. He received his Doctor of Medicine from the University of Chicago in 1953. Following an internship at the University of Cincinnati, a tour in the USAF as a flight surgeon, and pediatric training in Philadelphia and Oakland, Horst practiced pediatrics in Fresno, California for almost 40 years. He was active at Valley Children's Hospital, published more than 25 papers on pediatrics, and published a book for parents on how to take care of their children.

For 6 years he appeared weekly on KSEE-24, a Central California TV station, doing a segment called "The Doctor is In", answering questions phoned in by parents.

After retirement, he donated his time to work in New Jersey at a Free Clinic seeing children. In 2005, he moved with wife Carol to Sacramento, California where he volunteered 1 day weekly seeing children at the Oak Park Free Clinic and Salud Clinic for many years. After the loss of his wife of 60 years, he relocated to Davis, California where he walked the Greenbelt daily and was active in his Assisted Living facility up until his death. He is survived by 3 children, 7 grandchildren and 1 great-granddaughter. Dr. Weinberg was a member of the California Medical Association/Fresno Madera Medical Society for 51 years.

54 CENTRAL VALLEY PHYSICIANS

Summer 2021

From the most delicate robotic and catheter procedures to the latest precision therapeutics, we’re proud to offer up-to-the-minute diagnostic and treatment options for both adult and pediatric referring providers across Northern California and the Central Valley.

Your referred patients benefit from shorter drives, less traffic gridlock, affordable lodging, and more support from local family and friends. We also offer robust telehealth and telemedicine options, for both initial consultations and follow up care.

Referring your patients to UC Davis Health specialty and subspecialty care is now easier than ever. Our physician referral liaison team is here to serve as direct lines of communication — helping to navigate and expedite referrals, obtain information, resolve process questions, and more.

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Our liaisons can also help to: ■

■

■

■

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Facilitate access to our secure EMR system, PhysicianConnect Arrange meetings and/or webinars with our clinicians Assist with UC Davis Health clinical trials and telemedicine Keep you abreast of new services, providers and research programs Share information about CME and events such as tumor boards, grand rounds, lunch-and-learns and symposiums

We welcome you to reach out to your local UC Davis Health Physician Referral Liaison today: Stacy Hall | 916-882-1606 | stlhall@ucdavis.edu

CENTRAL VALLEY PHYSICIANS 55

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Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code. Members pay tax-deductible assessments, based on risk classifications, for the amount necessary to pay claims and administrative costs.

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