Focus on UCSF Fresno Newsletter, November 2021

Teach

Unique Dermatology Rotation Provides Education and Training to Multidisciplinary Groups of Learners
 
Gregory Simpson, MD instructing residents

 

Gregory Simpson, MD, instructing residents

By Barbara Anderson

At UCSF Fresno, physicians-in training – from Emergency Medicine to Psychiatry – are afforded a unique clinical rotation in Dermatology providing education and training in skin diseases that affect one in four Americans each year.

Skin diseases send many patients to physicians every year, but medical residents can receive limited exposure to Dermatology, says Gregory L. Simpson, MD, UCSF associate clinical professor of Dermatology and medical director of Dermatology at UCSF Fresno. “A lot of people get zero Dermatology exposure,” he says. “It’s because in Dermatology, there’s not a lot of academic dermatologists.”

Dermatology is a division within the Department of Internal Medicine at UCSF Fresno, but Dr. Simpson teaches multidisciplinary groups of learners at clinics at Family Health Care Network in downtown Fresno. At the adult clinic, he trains Internal Medicine residents alongside residents in Emergency Medicine, Psychiatry, Family and Community Medicine, Emergency Medicine physician assistant residents, and Dental residents who are in the FHCN Dental residency program. San Joaquin Valley Program in Medical Education (SJV PRIME) medical students also participate. The Dermatology clinical rotation at the pediatric clinic includes UCSF Fresno residents in Pediatrics, Internal Medicine, Family and Community Medicine, as well as SJV PRIME students.

Residents from different medical disciplines rotating together at a Dermatology clinic is rare. “Internal Medicine, Family Medicine, Emergency Medicine – there might be situations where all of those are together – but having Psychiatry and Pediatrics, I think that is pretty unique,” Dr. Simpson says. “And adding in the dental resident – is incredibly rare.

Multidisciplinary training in Dermatology provides medical residents with a well-rounded and useful education. According to the American Academy of Dermatology’s 2016 Burden of Skin Disease report, nearly 25 percent of the population from 0-17 years had a diagnosed skin condition; and nearly 50 percent of people over age 65 have skin disease. On top of that, two-thirds of all patients with skin diseases are treated by non-dermatologists, the report says. And Dr. Simpson adds that some studies say skin conditions in a hospital inpatient ward are diagnosed incorrectly 40 % to 50% percent of the time if a dermatologist is not involved.

Dr. Simpson’s Dermatology clinic at FHCN has expanded patient access to specialty care for new patients and existing patients. “The residents have an opportunity to learn, recognize and treat acute and chronic skin conditions,” says Seema Policepatil, MD, UCSF assistant clinical professor at UCSF Fresno and FHCN clinic medical director. “The learning experience and the gratitude they find in treating these patients is invaluable. This helps recruit and train physicians from diverse backgrounds who are interested in providing care to the underserved communities of Fresno, while providing high-quality, broad-based clinical education and experience.”

At a recent FHCN clinic, Dr. Simpson gave a one-hour didactic lecture before assigning clinic patients to a second-year Internal Medicine resident, a third-year Internal Medicine resident, a first-year Emergency Medicine physician assistant, a second-year Family and Community Medicine resident and an FHCN Dental resident. The multidisciplinary nature of the group pleased Dr. Simpson. “This is nice, because Dermatology hits every discipline,” he says. “Everybody has skin and everybody has some skin problem.”

Internal Medicine and Family and Community Medicine physicians can see a lot of skin disorders in their careers. They are often called upon to diagnose skin cancers and skin rashes in hospitals and in private practice they see skin cancers as well as common skin diseases, such as eczema and psoriasis, that have been associated with heart disease and diabetes. At UCSF Fresno, residents in both disciplines get the most training in Dermatology, rotating with Dr. Simpson at FHCN as well as at the VA Central California Health Care System in Fresno and at University Dermatology Associates, his faculty medical office in Fresno.

“As Internal Medicine physicians, we see everything. We’re responsible for everything in our patients and skin lesions are one of those that are easy to be dismissive of but also can have serious implications for patients,” says Neetu Mahli, MD, a third-year Internal Medicine resident and SJV PRIME alum who is rotating with Dr. Simpson at FHCN. “This experience here with Dr. Simpson, seeing what is scary, what is not scary, helps find that balance between over-treatment and appropriate treatment,” she says, recalling the case of a young man who died from metastatic melanoma. “If only someone had recognized that earlier it could possibly have been prevented by a simple excision.”

Rahul Chug, DO, a third-year Internal Medicine resident, says the Dermatology clinical rotation “helps us a lot in the real world.” After two rotations with Dr. Simpson, he has become alert to skin diseases. Recently, he snapped a photo of a lesion on a hospital patient and sent it to Dr. Simpson for his opinion. “It ended up being a melanoma,” Dr. Chug says.

At some time or another, Dermatology bridges across a medical discipline. For example, residents in Pediatrics see a gamut of skin conditions. “Kids have so many rashes and such variable skin conditions – eczema, viral rash, foot and mouth disease – and for all of this, the pediatrician really needs to know Dermatology quite well,” Dr. Simpson says.

Emergency Medicine residents and physician assistant residents see patients of all ages who have skin conditions requiring assessment. In the Emergency Department at Community Regional Medical Center residents and physician assistants see a lot of rashes and lesions. “Dr. Simpson is really good at teaching and so it’s helpful to know what scary things to look out for that come through the ER or what looks scary but may not necessarily be scary based on certain findings,” says Haylee DeGrood, PA-C, a physician assistant resident who is rotating in the adult Dermatology clinic at FHCN.

While inclusion of a dental resident in the Dermatology clinic may seem random, it is not. “It’s great with the dental resident because a lot of times we’ll have intra-oral pathology; and dental residents also will have something we’ve never heard of, and they’ll talk about that. So, it’s a very collaborative atmosphere,” Dr. Simpson says.

Brandon Adams, DDS, an FHCN Dental resident who is rotating with Dr. Simpson, hopes he can be of use in diagnosing patients with conditions in the oral cavity. Likewise, being able to detect other skin conditions is key to early diagnosis and proper treatment. “Learning whatever I can about Dermatology I can translate into my practice in the future,” he says.

Psychiatry residents benefit from the Dermatology clinical rotation at FHCN too. Psychiatry issues can present as dermatology problems, such as Morgellons Disease, a delusional disorder that leads to the belief that parasites or bugs are crawling underneath the skin, Dr. Simpson says. “These sort of issues we see kind of on a regular basis.”

Interacting with residents from different medical disciplines is one of the attractions of the Dermatology clinical rotation for Rey Berry, a third-year SJV PRIME student. SJV PRIME students spend the first 18 months of their four-year education at UCSF and spend the remaining two and a half years of medical school completing clinical rotations at UCSF Fresno. “Working with different people that also means different skill sets so you learn a lot from them through that,” Berry says.

Improving communication among providers is a welcome offshoot of the multidisciplinary Dermatology clinic, Dr. Simpson says. “I’m a firm believer that the best patient care is when the doctors are talking to each other,” he says. “Over the years, I’ve just added new disciplines because I thought this is great. This way we’re all talking. All these residents know each other. They’re becoming better colleagues just by being in this clinic together. Outside of just learning more Dermatology, they become better at communicating with each other.”

UCSF Fresno strives to provide learners with a unique, well-rounded education that is not available in many places and that produces clinicians who will provide outstanding patient care. Expanding access to Dermatology across medical disciplines is an effort to ensure that goal is met, Dr. Simpson says.

 

UCSF Fresno Mobile HeaLCOVID-19 Equity Project

Care

UCSF Fresno COVID-19 Equity Project Is First in Area to Provide Free, Accessible and Early Treatment for Mild to Moderate COVID-19 

UCSF Fresno Mobile HeaLCOVID-19 Equity Project.

By Brandy Ramos Nikaido 

UCSF Fresno’s Mobile HeaL COVID-19 Equity Project (CEP) now offers an early treatment for COVID-19. Monoclonal antibody therapy or mAb reduces the need for hospitalization in higher- risk patients with mild to moderate COVID-19 and reduces progression to severe illness by as much as 70%, according to information from the U.S. Department of Health and Human Services.  UCSF Fresno CEP was the first in the San Joaquin Valley to offer the treatment for free without requiring an appointment or referral at its drive-through clinic on Shaw Avenue across from Fashion Fair Mall in Fresno.

Monoclonal antibody therapy has Emergency Use Authorization from the Food and Drug Administration to treat mild to moderate COVID-19 positive patients within the first 10 days of symptom onset and who are at higher risk of severe illness, hospitalization or death due to COVID-19. Currently, there are three mAb treatments available in the United States. The UCSF Fresno COVID-19 Equity Project administers REGEN-COV™ (casirivimab and imdevimab). 

Mayra Arana, lifelong Firebaugh resident and leukemia survivor, was the first person to receive monoclonal antibody therapy at UCSF Fresno CEP. Her husband Michael Rodriguez was the second. Arana is a UCSF patient and was referred to UCSF Fresno CEP by her oncologist in San Francisco.

Arana received the monoclonal antibody therapy on Sept. 17, 2021. “COVID is very bad – headaches, the chills, body aches, and congestion, feeling like I can’t breathe. That’s been the worst for me. I have issues with my lungs since when I had leukemia. It’s like I’m choking,” Arana said.

Arana was diagnosed with leukemia in 2015. She had chemotherapy and a bone marrow transplant in 2016. She is in remission now but is dealing with the aftermath of battling leukemia that includes health problems such as lung issues and Graft versus host disease (GVHD), which can occur after a transplant when donor bone marrow or stem cells attack the recipient. Symptoms vary but in Arana’s case, GVHD caused painful blisters in her mouth and throat.

Because of her immunocompromised condition, despite being fully vaccinated, Arana got sick with COVID-19 and so did her entire family. An ideal candidate for mAb, she was offered the opportunity to receive the treatment at UCSF in San Francisco but there were logistical issues.

“Everyone in my family had it (COVID-19). We would have to take our kids,” she said. “I can’t take them to a safe spot like in a hotel room. I don’t want to expose anyone in the hotel or hotel employees.” And having her children stay in the car in a garage during treatment would not work. A local option was very beneficial. “Forty-five minutes away from my home is better than having to do a three-hour drive and still have to wait at the clinic and then come back at late hours in the night. This is definitely good,” said Arana.

Monoclonal antibodies are synthetic (laboratory-made) antibodies given to patients through intravenous transfusion or under the skin via injections. The synthetic antibodies help patients develop an immune response or a stronger response. At UCSF Fresno’s CEP, four injections are administered, followed by an hour observation period.

“Monoclonal antibody therapy is not a substitute for vaccines. The best way to prevent severe COVID-19 illness is to get vaccinated,” said Kenny Banh, MD, an emergency medicine physician, medical director of the UCSF Fresno Mobile HeaL COVID-19 and assistant dean for Undergraduate Medical Education at UCSF Fresno. “Vaccines are administered when people are well. They help them develop their own immune response to COVID-19. Monoclonal antibodies are given via injections to help prevent people who are already sick from getting worse or who have had a recent exposure.  Vaccines are preventative. Monoclonal antibody therapy is therapeutic. MAb is available for higher-risk patients whether they are vaccinated or unvaccinated.”

Five weeks out from the mAb injections, Arana said she’s feeling great.

“I started feeling better in about 24 hours. I haven’t gotten sick. I haven’t felt weak or any different. I actually feel a little more energetic,” she said. “I kind of feel like the injections may have given me a little boost.”

While the whole family has recovered from COVID-19, her daughter got sick with a cold recently but so far, Arana has remained well.

“If you have a pre-existing condition or your immune system is low, I definitely recommend mAb,” Arana said.

It’s not for everyone, Dr. Banh emphasized. This treatment is for people with significant comorbidities and people who have weakened immune responses that put them at risk for developing severe COVID-19.

Despite having EUA and being recognized as a proven treatment, there isn’t a lot of awareness or availability of monoclonal antibody therapy, according to a CNN report

Dr. Banh is hopeful that will change.

“I hope this is a really significant proactive treatment for COVID,” said Dr. Banh. “We are starting small and ramping up as much as possible.”

In addition to mAb therapy, UCSF Fresno’s CEP clinic also administers free COVID-19 vaccines, COVID-19 testing and flu vaccines to the community, especially people from underserved and under-resourced communities. For more information, visit www.fresno.ucsf.edu/cep and follow @UCSFFresno on Facebook, Instagram, LinkedIn and Twitter.

 

Research

UCSF Fresno Vascular Surgeon Leads
Multi-Centered Study on Need for New Scoring System to Assess Risk of
Lower-Extremity Amputations in Trauma Patients
Leigh Ann O'Banion, MD

 

Leigh Ann O’Banion, MD

By Barbara Anderson

A multi-centered study of patients with traumatic popliteal vascular injuries led by UCSF Fresno Vascular Surgeon Leigh Ann O’Banion, MD, validates the need for a new, simple scoring system to preoperatively assess the risk of lower-extremity amputations in trauma patients.

X-ray Photo (courtesy of Gurinder S. Dhaliwal)

Photo courtesy of Gurinder S. Dhaliwal

Traumatic Injuries to the popliteal (artery behind the leg) that occur from car wrecks, sporting activities, farming and other accidents are associated with a high risk of amputation (10-15 percent). Traumatic injuries are the second cause of lower-extremity amputations in the United States, behind vascular diseases such as diabetes and peripheral arterial disease. But it has been more than 20 years since the Mangled Extremity Severity Score (MESS) was created.  Its complexity and inability to be validated led to the conclusion that a significant need remains to evaluate predictors of amputation after severe lower extremity injury. Dr. O’Banion and colleagues aimed to provide an “easy to use scoring system that risk stratified patients,” which differed from prior scores whose aim was to “determine a threshold of futility”.

Older scoring systems are more complicated to use and determine only if a limb can be saved or if there is no chance of limb salvage. The study of the POPliteal Scoring Assessment for Vascular Extremity Injuries in Trauma (POPSAVEIT) shows the need for a new scoring system that provides a straightforward assessment of the percent of risk for amputation in a traumatic injury.

UCSF Fresno was the lead research institution for the POPSAVEIT study, which evaluated about 500 patients from 14 institutions across the West Coast. A total of 355 patients were included in the study, with an amputation rate of 16 percent. This was the first multi-institutional study led by a faculty in the Department of Surgery at UCSF Fresno, Dr. O’Banion said. The project began about four years ago when she and Gregory A. Magee, MD, a vascular surgeon at USC, began chatting about the high number of lower-extremity trauma patients seen in Central and Southern California.

UCSF Fresno surgeons provide trauma care at Community Regional Medical Center, which houses the only Level 1 Trauma Center between Los Angeles and Sacramento. “We treat patients from a large catchment area,” Dr. O’Banion said. “If someone is injured playing football in Bakersfield, for example, and has a lower-extremity injury, it’s a long way to come; we want to risk stratify the patient so that we can better communicate about the injury and the urgency for need of revascularization.”

As reported in the September 2021 issue of the Journal of Vascular Surgery, POPSAVEIT derives an amputation risk by applying scores to systolic blood pressure (one point), orthopaedic injury (two points), lack of pedal Doppler (ultrasound) signals (two points), or (one point) for lack of palpable pedal pulses if Doppler unavailable. The higher the overall score, the greater the assessment risk for amputation.

“This can help us communicate better with patients and help with communication between physicians about this devastating injury,” Dr. O’Banion said. For patients, the preoperative scoring system provides a risk level for limb loss, regardless of the best efforts of surgeons. “It is important, for any surgery that you know the risk of the surgery and that you know the percent of successful outcomes.” Also, trauma surgeons responding to calls will know by the POPSAVEIT how severe the injury is and the urgency for their response.

The POPSAVEIT system is practical, too. It can be in any environment no matter how austere. “If you are in the military at war, you can use this scoring system or if you’re at a Level 1 trauma center, you can use it, because all it requires is a blood pressure cuff and a physician,” Dr. O’Banion said.

The research has been rewarding, she said.  “It’s been a labor of love over the last four years for Dr. Magee and me.  We hope to have a tool that will be used across U.S. institutions and eventually in all environments on a global level.”

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Shabnam Pooya, PhD, Fresno State assistant professor in the Department of Food Science and Nutrition with student

Partner

UCSF Fresno Partners with Fresno State and Community Cancer Institute on Nutrition-Cancer Study

 

Shabnam Pooya, PhD, Fresno State assistant professor in the Department of Food Science and Nutrition with student. Photo courtesy of Geoff Thurner, Fresno State

By Barbara Anderson

UCSF Fresno is collaborating with Fresno State and the Community Cancer Institute (CCI) on a retrospective study to determine the effects of nutrition on outcomes and survival for patients with different types of cancer.

Amir Fathi, MD

Amir Fathi, MD

“We realize one of the most important things that affects the outcome of cancer is the nutritional status of the patient during cancer treatment,” said Amir Fathi, MD, a UCSF Fresno surgeon, hepatopancreaticobiliary specialist and principal investigator in the study.

Preliminary results of the nutrition-cancer study showed 74 percent of breast cancer patients were either obese or overweight based on their body mass index (BMI), said Shabnam Pooya, PhD, Fresno State assistant professor in the Department of Food Science and Nutrition. Dr. Pooya supervises undergraduate Human Nutritional Sciences students who review patient medical charts at CCI. The medical records are of randomly selected cancer patients from 2009 to 2019 who consented to have their patient data used for research.

“We want to know the effect of nutrition related factors on the survival of these type of patients,” Dr. Pooya said. “What was the effect of the food they eat? How does that affect their survival or how does it delay the spreading of their cancer or improve their treatment? What about the percentage of their muscle to their fat or some other markers for body composition? What about inflammatory markers affected by their diet and by their disease. We want to look at all these nutritional factors and find the relationship of these factors and the patients’ survival and the cancer patients’ outcomes.”

The study began as a small pilot project at Fresno State in 2020 that analyzed nutritional data on 250 patients (50 patients each with breast, liver, pancreatic, stomach and colorectal cancers). The most promising results from the pilot project were for breast and liver cancers and more information is now being collected on 250 breast cancer and 250 liver cancer patients. Results from the pilot project showed, for example, that in breast cancer, when the BMI is high, when the patient is obese or morbidly obese, the chance of metastasis (cancer spreading outside the breast) is higher, Dr. Fathi said. The results, however, are from a sample size that was limited to 50 patients. Therefore, the current study of a bigger sample size, may show different results, Dr. Pooya said.

This is the first time that UCSF Fresno, CCI and Fresno State have collaborated on a research project. “It is a teamwork on a multi-disciplinary path,” Dr. Pooya said.

Dr. Fathi said partnering with Fresno State and CCI on the cancer nutrition study has been beneficial for all. He is chair of the Cancer Committee at Community Health System, which operates CCI. “When CCI opened in Clovis in 2018, we were really focused on building the best possible treatment platform for our patients in the San Joaquin Valley,” Dr. Fathi said. “After achieving this goal, we decided to not only provide the best care, but to produce knowledge – to do research – to be an institution that touches multiple aspects of the cancer care, including research. So rather than reinventing the wheel, we wanted to collaborate with the powerhouses in the town, and Fresno State is a great place. They have wonderful teaching programs, and they know a lot about food because we’re in an agricultural area.”

Having the opportunity for CCI to participate in research has been exciting, said Lynette Smiley, vice president of cancer services and diagnostic services for Community Health System. “It’s great to be a part of partnership within the community, with students and with our own staff as well. It gives us an opportunity to show our young people what they can do, not only in nutrition, but in research and having that inquisitiveness to find solutions and find out how to achieve good outcomes.”

Vanessa Ramos is one of the Fresno State nutrition students who is working on the study as part of her Jordan Collage Honor research program. A junior and Human-Nutritional Sciences, Dietetics major, Ramos goes to CCI sometimes several days a week to review patients’ medical charts. “I look for past medical history, BMI, blood work and lipid panels for every patient,” she said. Drs. Pooya and Fathi use information from the medical records for a multi-regression analysis to associate the findings with medical outcomes, including patient survival rates after five years.

Part of Ramos’ time includes reading registered dietitian’s notes, which she finds intriguing. “It was great to see how they take their notes so when I’m in a clinical setting I will know the acronyms they use and the type of information they put in a nutrition assessment.” Ramos, who grew up in Porterville, said the research experience has solidified an interest in becoming a registered dietitian. And she wants to stay in the Valley. “I see myself working in oncology because of the research I’ve done already. It’s been very interesting.”

Dr. Pooya enjoys working with the Fresno State students. “We’re here to provide the best education and hands-on experience to better prepare students for the job market competition and encourage them to stay in the Valley. That’s a main goal here to inspire them to find their future job here and be ready for it by all of these skills sets that they learn during their years of education here.”

The involvement of Fresno State students in the study is a pathway for future health care workers, Dr. Fathi said. “We want to excite the students about the Valley and what is going on and promote staying in the Valley. We really want them to get trained in the Valley and stay in the Valley, because we have a huge shortage of health care providers.”

UCSF Fresno’s collaboration with CCI and Fresno State also provides opportunities to improve patient health now – and in the future. “We realize how important nutrition is in cancer treatment and that surgery or chemotherapy is not enough,” Dr. Fathi said. “We need to look at the other aspects of the treatment to have the best possible results.”

 

Inspire

UCSF Fresno
People Spotlight
 

Monique Kaur Atwal, MD, and Enid Picart, MD

 

Monique Kaur Atwal, MD, and Enid Picart, MD (left to right)

UCSF Fresno’s success and growth are a direct result of the dedication and inspiration of our faculty, staff, residents, fellows, students, alumni, partners, donors and friends. In each issue of Focus, we introduce you to the people who contribute to the greatness of UCSF Fresno through informal interviews.  

This month, we are featuring two UCSF Fresno resident physicians and SJV PRIME alumnae: Monique Kaur Atwal, MD, and Enid Picart, MD. 


Please meet Monique Kaur Atwal:

What is your name? Nickname? 

Monique Kaur Atwal, MD

In what program are you training? What year are you? How many years is the training program? 

I’m a third-year resident in the UCSF Fresno Department of Psychiatry Residency. It’s a four-year program.

Where did you grow up and where did you go to school (high school, college, graduate school, any other certifications)? 

I grew up in Selma, California. I attended Sunnyside High School and was part of the Sunnyside High School Doctors Academy. I graduated from UCLA with a Bachelor of Science. I graduated from the UC Davis School of Medicine Postbaccalaureate Program. I earned my medical degree from the UC Davis School of Medicine in the San Joaquin Valley Program in Medical Education (SJV PRIME).

 What inspired you to pursue your specialty? 

While on clinical rotations in medical school, I found that I was more drawn to conversing with patients than monitoring clinical data. Psychiatry was the field that allowed me the most patient interaction and time to truly understand my patients, their past, their current struggles, and to build a therapeutic relationship.

Growing up in the San Joaquin Valley, I am also aware of the physician shortages highly prevalent here, and in mental health particularly with there being a large deficit in a population highly vulnerable to such issues. My goal has always been to give back to my community and now I plan to raise awareness for mental health in our local minority populations and attempt to make mental health care more accessible. 

 In what way did SJV PRIME influence your path to becoming a physician?  

SJV PRIME allowed me to complete my third- and fourth-year medical school clinical rotations in Fresno, which exposed me to the unique issues our community faces today. With this exposure, I was able to truly see how my future career choice would impact the community I planned to stay in post training. Through SJV PRIME, I also was able to further my education on cultural competency, socioeconomic determinants of health, and build relations with local resources and minority organizations. 

What is the best part of your job? What is the hardest?  

The best part of my job is seeing patients improve and gain better quality of life with your help. The hardest part is working with certain patients who struggle to maintain a stable mental state due to noncompliance, substance use, or socioeconomic issues. It is difficult to see your efforts fall short but as a psychiatrist, we must understand the external and internal factors of each person that influence who they are and the decisions they choose to make.

What do you think is needed to normalize mental health?  

To normalize mental health, more community awareness is needed in schools, churches, local organizations, etc., and more and easier access to resources is important.

 What do you like to do in your off time? 

I enjoy cooking, playing with my dog Mylo, wine tasting, DIY projects, and attending sports games.

What is the most important thing you would like people to know about you? Or what else would you like to add about you, your background, family or career? 

Like most, I have overcome my personal struggles to get to where I am today. With the help of the Doctors Academy program, the Latino Center for Medical Education and Research, and UCSF Fresno, I have been fortunate to gain a community of professionals who have supported me immensely on this path. I hope to continue this by giving back to my community both professionally and educationally as a mentor and support for future health professionals to continue addressing the needs of the SJV.


Please meet Enid Picart, MD:

What is your name? Nickname? 

My name is Enid Picart, MD. Nickname Pica, nickname given to me by one of my good friends, Fatima, in the UCSF Fresno Pediatrics Residency Program.

In what program are you training? What year are you? How many years is the training program? 

I am currently a second-year resident at the UCSF Fresno Department of Emergency Medicine Residency Program. This program is four-years. I am half-way through! 

Where did you grow up and where did you go to school (high school, college, graduate school, any other certifications)? 

As a kid we moved around A LOT.  I was born in San Mateo, California, and I lived in Sparks, Nevada, until the fifth grade then we moved to Modesto, California, which I identify as my hometown. I went to Peter Johansen High School then went to UC Merced for my undergraduate education in Human Biology with an emphasis in Biochemistry. After graduating, I took several years off to pursue community-based work, which I still enjoy and do now when residency training permits. 

What inspired you to pursue your specialty? 

As a child my family was uninsured. Both my parents are self-employed house cleaners so the emergency room was all we really knew as a go-to location for health care. It was not until I got older and started to understand the difference between emergency care and primary care that eventually we were able to qualify for primary health care services on a sliding-scale through a Federally Qualified Health Center (FQHC). However, being in the emergency room for various ailments that affected both my father and mother and seeing the lack of diversity as well as bilingual physicians in the emergency room really stuck with me as a child. At the age of seven, I was my parents’ interpreter doing my best to translate when my mother would tell me “que tengo aire en la espalda,” which directly translates to “I have air in my back.” The medical translation is “I have back pain (likely due to cramping).”  I saw then that I could make a difference as a physician and not just one a patient at a time. As an ED provider, I work with an amazing team that also helps to connect patients with the resources they need. I also have time to continue working in the community such as with the UCSF Fresno Mobile HeaL Clinic whenever possible.  

In what way did SJV PRIME influence your path to becoming a physician?

I knew while at UC Merced when I learned about the SJV PRIME program, that it was the program for me. I was raised in the Central Valley and wanted to stay, live, train and work in the Valley so the program was the perfect fit. The SJV PRIME is a spectacular program that focuses on training students with a passion and drive to serve the region. I knew that I wanted to continue serving the Valley community well after medical school and residency and I focused my efforts on getting in. I knew that not only would I get an awesome medical education but also the opportunity to train directly in the population I want to serve and to learn more about the various communities in the region. 

What is the best part of your job? What is the hardest?  

The best part of my job is when I am asked by a patient to be their primary doctor or when I am thanked for taking the time to listen and address a patient’s concern. The hardest part of my job is balancing everything – continuing to stay on top of current medical information and procedures while also finishing patient notes on time and importantly, providing excellent medical care. 

What is at the top of your personal or professional to-do list?

At the top of my personal to-do list at this moment is to deliver my husband’s and my first child. We are expecting our first baby and we are super excited. It has been tough during residency, but I have had so much support from the ED staff, my fellow residents and the Emergency Medicine Program faculty and staff.

Professionally, I am looking into possible options for fellowship as I want to continue teaching but also critical care intrigues me greatly. In addition, my goal always is to continue to expand my knowledge base so that I can be an excellent emergency physician for Central Valley residents.   

What do you think is needed to normalize mental health? 

This is a tough question. I think there may be cultural misconceptions about mental health that at times does not allow people to seek mental health services. As a Latina, I know that culturally, mental health is not usually taken seriously in our community. There is a negative connotation to needing mental health services. I think that if more people who have sought mental health services share their experience this can also be very helpful to others who may not know or understand what services exists.

As a medical provider, student and individual who has personally benefited from mental health services, I recommend these services to my patients and provide my own experience with these services as a steppingstone into the conversation.

In addition to sharing and even offering mental health resources, I think that improved access to mental health services will help to normalize mental health. Unfortunately, there is a limitation of all medical services in the Valley, especially mental health services. If there is an improved effort to bring in mental health providers that take MediCal and Medicare this would allow our low-income patients a much needed resource.  Waiting periods to seek mental health services can take up to six months to a year to gain access to and also the number of visits are usually limited to one visit per month, at least this is what my patients who are actively seeking mental health services tell me.  

The zombie apocalypse is coming. Which three people from UCSF Fresno would you pick to be on your team and why? 

Dr. Sue Spano, Emergency Medicine faculty because she is one the best wilderness medicine faculty that I know and I think her skills would be ideal in said situation. Dr. Kenny Banh, Emergency Medicine faculty, UCSF Fresno Mobile HeaL Clinic director among other titles, because I think that he can likely talk himself out of any situation with his awesome negotiating skills. And Dr. Betty Liao, director of Wellness and Mental Health Support Services at UCSF Fresno. I know that during an apocalypse I am going to need some mental health pep talks.

What do you like to do in your off time? 

I really enjoy spending time with my family and friends that means either staying at home or going for walks and hikes around the area. I enjoy exercising, yoga is my jam. Currently, I’m also on an audiobook kick, listening to everything from fantasy/fiction to financial to-do books.  

What is the most important thing you would like people to know about you? Or what else would you like to add about you, your background, family or career? 

As I begin my journey into motherhood as a resident, I just want my patients to know that I will continue to advocate for their health to the best of my ability regardless of how sleep deprived I may be. I come from humble roots and with a passion to help others and I want to continue to instill this in our son, Panchito.  As he continues to grow, I want him, as well as others, to see the wonderful offerings that the vibrant Central Valley community has to offer its residents and this is a wonderful place to raise a family, be part of a community and flourish as a medical professional. I am hoping to stay in the Central Valley for the long haul as a physician but most importantly as an educator and mentor to those from this community who are aspiring to be medical professionals themselves. Si se puede!

 

Residents at Boot Camp

Supporting UCSF Fresno

Isnardi Foundation Gift to UCSF Fresno Promotes Learning and Discovery

By Kathleen Smith, Development and Alumni Relations, UCSF Fresno  

Thanks to a gift from the Isnardi Foundation, the UCSF Fresno Clinical Skills Lab and Simulation Center added a new childbirth simulator mannequin and with other funding the center was expanded into adjacent space, nearly doubling in size and allowing for dedicated simulation rooms by specialty. In addition, a state-of-the-art learning management and audio-visual system was installed to record each training session from multiple camera angles, including data from patient monitors to provide valuable feedback to assess the learner’s performance. These much-needed additions represent Phase One of upgrades to the Skills Lab and Simulation Center. Additional renovations are needed to continue to meet the demands of our growing regional campus.

 Each year, UCSF Fresno trains nearly 300 residents, fellows and physician assistants. Roughly 50% of our graduates remain in the Central Valley and about 70% stay in California to care for patients, teach future physicians or continue their medical education.

As a regional campus of the UCSF School of Medicine, students in the San Joaquin Valley Program in Medical Education (SJV PRIME) live and train in Fresno for the final two and a half years of medical school. We also host medical students from other medical schools for rotations, and help prepare middle, high school and college students for careers in health and medicine through a variety of career pathway programs.

Medical simulation is an integral component of medical education for all groups of learners. The UCSF Fresno Clinical Skills Lab and Simulation Center provides students and physicians with hands-on experience in a simulated clinical environment so they can safely acquire the knowledge, skills and attitudes needed to care for patients in the real world.

During simulations, learners practice responding to common medical procedures, complex medical conditions and life-threatening emergencies through a combination of role play, low and high-tech tools in a variety of settings including mock examination and operating rooms. Simulation tools include task trainers to practice specific skills such as lumbar punctures, intubation and suturing, as well as realistic interactive patient mannequins.

The Isnardi Foundation was established in 2006 by Fresno native and graduate of the University of California, San Francisco School of Pharmacy (1943) Vince Isnardi. Dr. Isnardi dedicated his life to helping improve the health of his patients as well as the broader community where he was born and raised. He passed away in 2011, but his life of giving and caring continues through the work of the Isnardi Foundation.

The Isnardi Foundation gift also enabled the purchase of a new childbirth simulator mannequin. Known as Victoria, this high-fidelity training tool simulates a full range of obstetrical events to mimic human anatomy and physiology and create more realistic clinical scenarios. For example, her eye movements can illustrate signs of stress, stroke, head trauma, and many other diseases and conditions. With a fully programmable airway, she can be connected to a ventilator just as you would a real patient.

The UCSF Fresno Department of Obstetrics and Gynecology (OB/GYN) holds regular training sessions for its residents with Victoria as their patient. Using the dedicated OB/GYN/Pediatric simulation suite, they practice true-to-life delivery and other OB/GYN scenarios while an integrated array of sensors tracks their performance for review and debriefing later with their team and faculty – leading to the best care for the patients we serve.

“Our faculty and residents tell us how realistic the exercises are with Victoria,” said Lee Hagerty, Medical Simulation Educator for the Simulation Center. “The attention to detail when performing a C-section is incredibly true-to-life. She is by far the highest-fidelity human patient simulator we have in the Center.”

Victoria and other mannequins in the Simulation Center have also been used in community outreach, helping educate Emergency Medical Services (EMS) community partners at American Ambulance, to educate local high school students in the Doctors Academy program and illustrate the teamwork involved in a Code Blue scenario during a session of the 2021 Mini Med School series.

We are grateful for the support of the Isnardi Foundation and their commitment to carry on the legacy of their founder to help improve health in the community Vince Isnardi was proud to call home. With additional support, we can continue to expand and improve this state-of-the art facility to keep pace with the growing number of residents, fellows and medical students training at UCSF Fresno.

Please consider making a gift to the UCSF Fresno Clinical Skills Lab and Simulation Center to help us continue to provide the highest caliber of teaching and education for our learners and future physicians. For information about other ways to give, please contact Kathleen Smith, Assistant Director of Development for UCSF Fresno, at (559) 499-6426 or kathleen.smith@ucsf.edu.

Kudos

UCSF Fresno
Recognition

Applause
Patil Armenian, MD; Brian Chinnock, MD; Jessica Fujimoto, MD; Lily Hitchner, MD; and Xian Li, MD (left to right)

Patil Armenian, MD; Brian Chinnock, MD; Jessica Fujimoto, MD; Lily Hitchner, MD; and Xian Li, MD (clockwise from top left)

Congratulations to the five Emergency Medicine (EM) faculty members at UCSF Fresno who were recognized among the recipients of this year’s Excellence in Teaching Awards from the UCSF Haile T. Debas Academy of Medical Educators. EM faculty include: Patil Armenian, MD; Brian Chinnock, MD; Jessica Fujimoto, MD; Lily Hitchner, MD; and Xian Li, MD. Program Director Stacy Sawtelle-Vohra, MD, made the announcement.

 

 

 

 

Candice Reyes (Yuvienco), MD

Candice Reyes (Yuvienco), MD

Kudos to UCSF Associate Clinical Professor of Medicine at UCSF Fresno and VA Central California Health Care in Fresno, who also received a 2021 Haile T. Debas Academy of Medical Educators Excellence in Teaching Award. Vipul Jain, MD, executive vice chair, UCSF Fresno Department of Internal Medicine, made the announcement and praised Dr. Reyes (Yuvienco), “You have been a model clinician educator and contributed significantly in keeping the Rheumatology Division successful along the years.”

The Excellence in Teaching Awards are peer-nominated awards that highlight outstanding frontline teachers at UCSF.  These frontline teachers are ‘unsung heroes’ who demonstrate daily their dedication to education and teach in a manner that creates an encouraging and intellectually stimulating environment that promotes critical thinking and learning.

Motasem Refaat, MD, Lily Hitchner, MD, and Richard Kiel, MD (left to right)

Motasem Refaat, MD, Lily Hitchner, MD, and Richard Kiel, MD (left to right)

Congrats to the new coaches for the UCSF San Joaquin Valley Program in Medical Education including Motasem Refaat, MD, with the UCSF Fresno Department of Orthopaedic Surgery, and Lily Hitchner, MD, in the UCSF Fresno Department of Emergency Medicine.  They join Richard Kiel, MD, from the Division of Cardiology in the UCSF Fresno Department of Internal Medicine, in expanding our student coaching cohort locally.

katherine flores, MD

Katherine Flores, MD

Congratulations to Katherine A. Flores, MD, who was appointed by Assembly Speaker Anthony Rendon to serve on the California Health Workforce Education and Training Council. Dr. Flores is a leading expert on health care workforce issues. She director of the UCSF Fresno Latino Center for Medical Education and Research and founder of UCSF Fresno’s Doctors Academy.