A MEDICAL & MARRIAGE PARTNERSHIP
Fowler Community Health Center

Fowler, California
Primary Contacts: Alex Sherriffs, MD and Joan Rubinstein, MD
Ages: Early 50s
Years in Practice: 24 years
Medical School: University of California, Davis
Residency: University of California, San Francisco-Fresno

The Fowler Community Health Center (FCHC) is a three-physician practice in Fowler, California — a rural, agribusiness community of about 4,000 located in the geographic center of California. Fowler community leaders were recruiting for a new physician when Dr. Joan Rubinstein visited and expressed an interest in opening a practice with her husband, Dr. Alexander Sherriffs. The leaders were thrilled to have a husband-and-wife team and immediately began building a clinic to their specifications. Since then, the Sherriffs-Rubinstein family has made Fowler its personal and professional home. As they explain: "We  wouldn't have been able to come here if not for the support our community leaders provided. They built our offices to our specifications, leased them to us, and provided all kinds of business advice."

Two years ago, the husband-and-wife practice merged with Selma Community Hospital (SCH) and became one of its rural health centers. The "mom and pop" operation is now managed by the hospital in an affiliation that seems to be beneficial to all involved. For Drs. Sherriffs and Rubinstein, the merger provides:

• Higher per patient compensation for Medi-Cal patients;
• Freedom from some of the organizational tasks of practice management;
• A longer-term perspective that ensures a continued physician practice in Fowler;
• An increased ability to take time away from the practice for vacations and professional meetings; and,
• Payment for Dr. Rubenstein's administrative services and for serving as Medical Director.

For SCH, the merger provides:
• A source of referrals to the sub-specialists who practice at the hospital;
• increased services for Medi-Cal patients; and,
• A longer term commitment to providing physicians for the community.

Alexander Sherriffs and Joan Rubinstein both grew up in California. After under-graduate years at Yale and Swarthmore respectively, they attended medical school at the University of California at Davis and married when they were both residents in the UC Fresno Residency Program. Drs. Sherriffs and Rubinstein then spent two years with the Public Health Service in northern Michigan. While they agreed with the mission and values of the Public Health Service, they did not see their future as being part of a bureaucracy. Most of all, they knew that they really wanted a rural practice and they wanted to be closer to their families. They selected Fowler because they:

• Respected the medical community in the area;
• Liked the values and local pride of the community;
• Had the ability to establish an office close to their home and hospital;
• Could affiliate with a medical school and teach;
• Could afford to live there; and,
• Liked the fact that although Fowler is rural, it is not isolated since it is only 15 miles from Fresno.

They were particularly pleased that their "mission," to take care of a whole community regardless of economic station and ethnicity, agreed with the needs of Fowler. "We would be able to do the whole scope of family medicine practice, including obstetrics, assisting at surgery, and geriatrics," explains Dr. Sherriffs.

Kenny Bedrosian, head of the community committee that recruited them, says, "They interviewed us, and we saw that they had a vision for the future that we agreed with." High on the Sherriffs/Rubinstein list of values is a devotion to caring for the entire community, regardless of economic circumstances. They participate in all major civic events from the Fourth of July parade, to blood drives, to school activities with their two daughters. As Dr. Rubinstein says, "Our kids have kept us honest about ourselves as parents and physicians."

Making their marriage and medical partnership work has not always been easy, but the secret is being inter-dependent and independent at the same time. While Drs. Sherriffs and Rubinstein share their office practice hours and make mutual decisions about the practice, they each have an area of independence. For example, only Dr. Rubinstein did OB and delivered babies because that was one of her great joys. "Doing obstetrics keeps our practice young. I used to see literally five generations in our practice. I got to exercise my technical skills, collaborate with skilled nurses and consultants and see families through a major life event." When their own children were young, her husband was the one who made sure he was home when she was at the hospital with a delivery.

Dr. Sherriffs spends approximately half his time with the residency program at UC Fresno and as Medical Director of the Alzheimer's & Memory Center of Fresno. He has a certificate of added qualification in geriatrics and sees most of the nursing home patients.

FCHC patients span a wide range of ages from newborn to geriatric. Farm workers, businessmen and homemakers all appear equally comfortable in the reception area. Spanish-speaking patients are greeted in Spanish and all signs are bilingual. About half of the patients are Hispanic. The rest of the patients are a mixture of Caucasian, Armenian, African-American, Japanese, Punjabi and Arab.

When the practice reorganized to become part of SCH, the physicians were concerned that some of the current patients might not want to fill out the new forms, but few complained. "Most patients just wanted to do what was best for the doctors, "explained one long-time employee. As one front office employee says, "We all know these families really well. They have been coming here for years, and they are like family to us now."

Dr. Rubinstein explains that it is humbling to be a family physician and to "be in the presence of patients' most intimate desires, fears, and dreams. We really learn so much when entire families come to see us. Often the children say something that gives us a window into family life and a health issue that another family member may be struggling with."

The practice encompasses the complete scope of family medicine, including obstetrics and prenatal care. Each member of the group sees pediatric, adult, and geriatric patients as well as injured workmen. Outpatient procedures, including vasectomy, colposcopy, sigmoidoscopy, endometrial biopsies, and excision of skin lesions are done in the office. Each of the physicians assists at surgery in a nearby hospital. They all make occasional house calls and, together, they make about 200 nursing home visits each month.

Recently, Dr. Rubinstein decided to stop delivering babies. "My sister is seriously ill," she explains, "and I want to be able to spend more time with her. Also, as I age, I find that I just cannot recover as quickly from the long and erratic hours that OB demands. It was a really hard decision because I have delivered so many patients who want me for their next pregnancies, but it is the best decision," says Dr. Rubinstein somewhat regretfully. Dr. Chen will continue to do OB for the practice.

Compensation and Benefits

The three FCHC physicians are contracted fee-for-service and all staff are employees of SCH. The physicians are responsible for their own malpractice, health insurance and other benefits, but their hours are much more flexible and vacation is at physician discretion. Salary ranges from $110,000 to $150,000 per year, depending upon hours worked and productivity.

Hours/Practice Flexibility

Drs. Rubinstein and Chen work a full-time schedule at FCHC. Dr. Sherriffs devotes half of his time to private practice, and the other half to the UCSF Residency Program in Fresno.

The practice shares call with another family medicine practice, which means that each member of the practice is on-call one weekend in six, although Dr. Chen handles his own deliveries.

Employees

Most of the employees of FCHC are long-term and devoted to the practice and the patients. Following the affiliation with the hospital, some roles changed, and there is now an administrator who had prior experience with the hospital's rural health clinic program.

When staff were employed by Drs. Sherriffs and Rubinstein, they received benefits, including health insurance, paid vacation and retirement. As hospital employees, they have the same benefits with lower deductibles, but employees sometimes miss some of the flexibility of a small office. Being hospital employees has afforded more opportunities for professional advancement, however.

Balance

Although Drs. Sherriffs and Rubinstein are satisfied with the balance they have achieved between their personal and professional lives, they readily admit that their daughters would probably say that work sometimes interfered with the family when the children were younger. As physicians immersed in small

town life, it is difficult to completely escape their professional responsibilities. As community leader Kenny Bedrosian says, "A lot of people in Fowler have their home phone number." The physician couple believes, however, that their patients are remarkably respectful of their time and contact them only in truly appropriate circumstances.

Their daughters' day care provider was an extremely important element in terms of maintaining "balance," especially when the girls were young; Dr. Rubinstein especially seems to appreciate the flexibility the child care provider offered when late appointments and hospital rounds sometimes necessitated longer child care hours than usual. "What made this work for us when our girls were small was excellent neighborhood day care, bus schedules that allowed them to be dropped off at the office after school, and a supportive staff and community," explains Dr. Rubinstein.

The Sherriffs/Rubinsteins display pictures taken at nearby Yosemite and Kings Canyon and point out the proximity of these wonderful parks is a real advantage of their location. "We can go cross-country skiing or hiking over a weekend and completely escape very quickly," says Dr. Rubinstein. Taking time off has become easier with the addition of Dr. Chen; both realize the work/life balance advantages of Dr. Rubinstein's decision to give up OB.

Seeking to add a new associate to their rural practice, Drs. Rubinstein and Sherriffs said that it took some time to find a younger physician who was a good fit with the community. For the past two years, however, Dr. Chen has been a part of the clinic, although he and his family live in Fresno. Dr. Chen very much enjoys his relationships with other physicians at the hospital, and he is pleased to offer Saturday office hours. He believes that he brings additional energy to the practice and allows Drs. Sherriffs and Rubinstein to "take a break on occasion."

As part of their search for an associate at FCHC, Drs. Sherriffs and Rubinstein identified the following characteristics they believed necessary for "a good fit":

• A physician who shares the same philosophy and values;
• A physician who is eager to be part of a rural community; and,
• Outstanding training and experience.

They have a strong commitment to continuity of care, which was an important part of the agreement with SCH. With the addition of Dr. Chen, the practice can accommodate more patients, while Drs. Sherriffs and Rubinstein can remain committed to their own patients. Moreover, with the merger Dr. Chen has the security of a guarantee, and there is a longer term commitment to capital and upgrading the Fowler office.
 

The community of Fowler is a true microcosm, with people of all economic strata and educational backgrounds, including farm workers, agri-businessmen, professionals, and homemakers. Approximately half of the Health Center's patients are Hispanic, and many of the staff are bilingual.

Both Drs. Sherriffs and Rubinstein are very connected to the community. As the Mayor of Fowler says, "They have had a huge impact. I don't know what we would have done without them. They are involved in everything in this town." Some of their community activities include:

• Preparing high school students for the Academic Decathalon and Science Olympiad
• Identifying the need and then continuously volunteering at the twice-a-year community blood drive
• Participating in local service organizations
• Coaching youth soccer and serving as team physician at the high school

One of their colleagues describes the physicians' community involvement: "They have immersed themselves so completely in the community that their practice is completely integrated with community life. They really take care of everyone and don't ‘turn it off' at 5 pm. They are our model preceptors," says Dr. Alex Moir, of the Family Medicine Residency Program at UC Fresno.

Another passion for Dr. Sherriffs is involvement with the county and state medical society. As President of the Fresno-Madera Medical Society, Dr. Sherriffs launched a multi-front campaign to attack air pollution in the San Joaquin Valley, which has some of the worst air in the state and the nation. "I got tired of the air quality and decided it was time to get the medical society involved in this," says Dr. Sherriffs. A bilingual brochure, "What Your Doctor Wants You To Know About Air Pollution," was produced by the society and has been widely used to elevate the issue in this huge county. He is proud of the local medical society collaborative efforts to persuade the Fresno City Council to require changes in planning and growth for developments.

Dr. Rubinstein summarized her approach to continuing medical education by saying, "It is an ongoing commitment. I read the journals. We try to attend an out of town meeting every year, and also the AAFP meeting at least every five years." Dr. Sherriffs is most likely to use the internet, and he is an enthusiastic subscriber to Audio Digest, an audio CME tool that he can pop in the tape player as he travels between office, hospital, the Alzheimer's Center and the residency program. Both Drs. Sherriffs and Rubinstein annually attend the California Academy of Family Physicians Scientific Assembly. As Dr. Sherriffs explains, "It's a great value." At least twice a month, they attend a hospital program or CME program in Fresno.

For FCHC, another advantage of being part of a larger system of care is proficiency in quality assurance. Their IPA regularly gives them data about their HMO patients and pays bonuses for exceeding certain quality measures. The Medical Directors in the Adventist Health System meet regularly and are sharing the development of chronic disease management programs.

Relationships with Other Specialists

Drs. Sherriffs, Rubinstein and Chen routinely refer patients to specialists at SCH and in Fresno. They selected Fowler, in part, because they knew the consulting physicians with whom they would be working. They are very knowledgeable about these physicians and their skills. In referrals as well as prescribing, they must consider the patients' insurance coverage.

Hospital Relationships

Each member of the group has privileges at SCH, a rural 57-bed acute care community hospital in the heart of the San Joaquin Valley. Hospital services include a 24-hour emergency department, a birthing center, laboratory, pharmacy, CT and MRI equipment, industrial health services, and a skilled nursing facility, in addition to the rural health clinic.

SCH is a member of Adventist Health, a 20-hospital health care system headquartered in Roseville, CA, with facilities in Hawaii, Oregon, and Washington, in addition to California.

Relationships with University/Other Educational Settings

As previously noted, Dr. Sherriffs teaches half-time in the residency program at UC Fresno, where he focuses particularly on mentoring residents in geriatrics. He is also the Medical Director of the UCSF Fresno Alzheimer's and Memory Center, a consultation/ research/ teaching facility.

As Director, Dr. Sherriffs also collaborates on many clinical research studies. Some examples include:

• Depression in Alzheimer's Disease and Other Dementias
• Caregiver Perception of Change in Intimacy When a Spouse has Dementia
• Frontotemporal Dementia: A Collaborative of the 10 State ARCC Centers

Relationships with Medical Students and Residents

Dr. Sherriffs really enjoys teaching because "it allows me to keep learning. "As Linda Hewett, Psy.D. of the Alzheimer's and Memory Center says of Dr. Sherriffs, "He always tells the residents that 'we are all learners here.' His face lights up when he is working with medical students and residents," says Joy Grado, the Director of the Center.

In addition, FCHC serves as a fellowship site for the Huffman Fellow in Family Practice Program, a month-long program for a newly minted medical student to live with Drs. Sherriffs and Rubinstein. As guests in their home and their practice, the students receive a holistic view of life as family medicine specialists in rural California. They experience the joy of fresh fruit and vegetables from the doctors' garden, the delicate balance of family and work life, and the high expectations of delivering the best medical care. As Sabrina Villalba, a recent student, describes, "This was the kind of medicine I had always visualized. The doctors embody everything that I ever expected family medicine to be."

Purchasing

Currently, technology purchase decisions are made in consultation with the hospital. The hospital has made a significant investment in computers so that the practice is Health Insurance Portability and Accountability Act (HIPAA) compliant and on the same information technology system as the other rural health clinics in the health care system.

Knowledge Management Technology

As a first step toward an electronic health record, laboratory and x-ray reports from the hospital are available online. In addition, Dr. Sherriffs reports that "the computer is on my desk, and I am stopping a couple of times a day to look to the internet to answer clinical questions about patients I am seeing right then."

Patient Communication

Most patient communication is done face-to-face and with a large array of brochures about various diseases and conditions. Physicians review all lab reports with home communication to patients by the office staff. Physicians call patients everyday to review abnormal test results.

Practice Management Technology

When Drs. Sherriffs and Rubinstein first started their practice, the receptionist could handle all of the billing, collections and appointments on a paper-based system. Then they converted to the Medical Manager system for billing, accounts receivable and reconciliation of bank statements. Now the hospital IT system handles everything. The hospital has committed to a paperless office in the next two years.

Financial Management

For their personal (and former practice) accounts, early in their practices, Drs. Sherriffs and Rubinstein secured the services of an excellent CPA and use her still. "The continuity has been wonderful, and we couldn't have done it without her," says Dr. Sherriffs. They have invested consistently and feel confident about their ability to retire in the future. The couple invested in several limited partnerships, which they report is "a very bad idea unless you have the time to 'dog' them." Practice, legal, tax and audit issues are handled by the hospital.

Marketing

Since the clinic has become part of the rural health efforts of SCH, more marketing has been done. There is a bilingual brochure that describes the services provided by the four rural health centers affiliated with the hospital. When the clinic was remodeled, the hospital held an open house as part of its marketing program. "Small town marketing is about involvement in the local scene," says Dr. Sherriffs.

Coverage/Relations with Payers

The percentage of the practice covered by various payers can be broken down approximately as follows: 10% private health plans; 20% Medicare; 30%, Medi-Cal; 10% self-pay/no insurance; 30% HMO.

Reimbursement

FCHC recently enacted a flat $20 payment per visit, for uninsured patients. According to Dr. Sherriffs, this has not decreased the number of self-pay patients, and it has eliminated any ambiguity about qualifications for the sliding scale rate.

 

Primary Contact:	Alexander Sherriffs, MD and Joan Rubinstein, MD
	Fowler Community Health Center
	Fowler, California

Dr. Gregory Chen, Fowler Community Health Center, Fowler, California
Christina Pittman, PA, Fowler Community Health Center, Fowler, California

Practice Staff:

• Akiko Julian, Medical Biller and former Office Manager, Fowler Community Health Center, Fowler, California
• Sara Santillan, Administrator, Fowler Community Health Center, Fowler, California
• Nita Velareal, Officer Manager, Fowler Community Health Center, Fowler, California

Others contacted for this profile:

• Kristine Aubry, RN, Vice President, Patient Care Services, Selma Community Hospital, Selma, California
• Kenny Bedrosian, President of United Fruit Farms and former President of the Foundation, Fowler, California
• Jerry Bodily, Science teacher, Fowler, California
• Belinda Cano, Director Rural Health, Selma Community Rural Health Administration Office, Selma, California
• Joy Grado, Administrator, Alzheimer's & Memory Center, Fresno, California
• Linda Hewitt, Psy.D, Co-Director, Assistant Clinical Professor, Neuropsychology, Alzheimer's & Memory Center,Fresno, California
• Alex Moir, MD, Associate Clinical Professor, Family Practice Residency Program, UCSF Fresno, Selma Community Health Center, Selma, California
• Richard Rawson, President, Selma Community Hospital, Selma, California
• Jim Simonian, Mayor of Fowler, Fowler, California
• Sabrina Villalba, former student intern, Fowler Community Health Center, Fowler, California

Other Resources:

• www.selma.ah.org
• www.ucsfresno.edu/alzheimer
• "What Your Doctor Wants You to Know about Air Pollution," brochure from Fresno-Madera Medical Society, Fresno, California
• "Selma Community Hospital Rural Health Centers," brochure from Selma Community Hospital, Selma, California
• "UCSF Fresno Alzheimer's & Memory Center Research Studies," two page description from UCSF Alzheimer's & Memory Center, Fresno, California