Medical migration

Dr. Zeljka Chobanov, like every resident of the Ridge, had her life irreversibly altered Nov. 8 when the Camp Fire devastated the region. She, her husband and two young children survived with their house intact. Her primary place of practice, however, turned to ash.

A neurologist, Chobanov saw patients at two facilities operated by Adventist Health—the Canyon View Clinic and Feather River Specialty Services—and performed procedures at Feather River Hospital. The firestorm consumed lower-elevation buildings of the main campus, including the Canyon View Clinic, and damaged portions of the hospital to the extent that its future remains uncertain.

Her office, across Pentz Road within Feather River Specialty Services, burned to the ground; “absolutely gone,” she said. Chobanov lost her medical library, diplomas and all practice documents that weren’t digitally preserved in the electronic medical record system. She had stored her most important paperwork in two safes rated fireproof.

“When I got to the office, I looked at the foundation and I actually saw the resemblance of the two safes that actually melted,” Chobanov recalled. “[The residue], you take it and it just crumbles.”

She couldn’t afford to crumble.

Besides her family, she had patients to consider. Many evacuated in such haste that they left medications behind. Some suffered adverse effects from the disaster. Some simply needed the reassurance that their doctor-patient connection remained when so much else did not.

In the immediate aftermath, Chobanov stayed in contact by phone. Her family returned home shortly after Thanksgiving, which also is when she began taking in-person appointments. Adventist Health, the faith-based nonprofit that owns Feather River Hospital, found her a location in Chico until resettling her practice into the Feather River Health Center, the rural health clinic on the Skyway, which reopened the day after Christmas.

Long-term, she faced a professional decision. Adventist Health had not definitively stated it would reopen the hospital—and still hasn’t. Behind the scenes, Chobanov and other Ridge physicians got no such assurance, either.

So, effective Feb. 1, Chobanov switched her affiliation to Oroville Hospital. She’s joined Dr. Lynne Pappas, a psychiatrist who’d been based at the Feather River Health Center; Dr. Damien Pestana, previously with Feather River Gastroenterology; and audiologist Deborah Touchette, who moved her practice—Paradise Hearing & Balance Clinics—into Oroville Ear, Nose and Throat.

Other physicians, most notably the pediatricians and general practitioners of Paradise Medical Group, set up shop in Chico. Others, predominantly specialists, left the area altogether.

With Paradise already classified by the federal government as a medically underserved area, and the North State among the rural California regions suffering a chronic shortage of physicians, the exodus off the Ridge has compounded an existing problem.

“Big picture, I think [the area has] lost more physician services than we’ve lost population,” said Mike Wiltermood, CEO of Enloe Medical Center in Chico, where the largest share of refugees has resettled. “You really see it in the emergency room. …

“What we see and what we believe, simply because of the rush of people coming into the emergency room and urgent care centers, is that we’re still woefully under the community requirement for primary care.”

Most every local primary care doctor—family medicine, internal medicine, pediatrics—in private practice has a waiting list for new patients. Low-income adults and families on government-subsidized insurance plans, namely Medi-Cal, must go to clinics such as Ampla Health, Northern Valley Indian Health and, yes, the Feather River Health Center. Those facilities are impacted as well.

More and more, hospitals and clinics have turned to midlevel providers to fill the gap. Nurse practitioners and physician assistants treat patients in primary care and specialty practices. (See “The ‘doctor’ will see you,” Healthlines, Oct. 23, 2014.) But if a midlevel’s hospital, clinic or medical office closes, they—and their patients—must deal with displacement.

Chobanov’s practice requires hospital affiliation. She has patients with multiple sclerosis who receive infusion therapies she can’t provide in an outpatient facility without special licensing. She orders procedures, such as lumbar punctures, which she needs colleagues to perform. She does electro-diagnostic testing, which takes specialized equipment.

“After a lot of communication back and forth,” Chobanov said, “I came to a conclusion that, actually, even if certain services are coming back to the Paradise area, it’s going to take quite some time—and I was not really in a situation to stand by and wait until then.”

Delicate balance

Adventist Health Feather River, known as Feather River Hospital until 2017, long comprised sites and services nestled around Paradise, plus a few satellites off the Ridge. That network included a house for hospice care, offices for specialty practices, clinics for primary care and rehabilitation, a pharmacy and, as of two years ago, a center promoting wellness (see “Preventative measures,” Healthlines, Sept. 30, 2018).

The hospital itself—the centerpiece of the main campus, overlooking clinic buildings and senior housing that, in turn, overlooked Feather River Canyon—closed for just the second time in its 68-year history after the Camp Fire wreaked its havoc.

The first closure, following evacuations for the 2008 Humboldt Fire, lasted a matter of months once Feather River cleaned facilities and passed inspections. This closure could persist for years. Along with claiming whole buildings, the fire caused damage to structures that on superficial view appeared untouched or relatively unaffected.

The parent organization, based in Roseville, stated publicly it would need a comprehensive inspection and assessment before determining the hospital's future, but cited 2020 as the earliest it could reopen. Adventist Health retained or job-placed 407 of 1,205 Feather River employees. Last month, the remaining 798 were issued final paychecks.

Adventist Health did not provide specific information for this article by deadline. Instead, the organization sent a statement. It reads, in part:

“Just like our patients, health care providers based in Paradise are having to make difficult decisions about their future due to destroyed businesses and homes. Paradise has been blessed to have excellent providers, although several of them, like others in the community, have decided that leaving the area is what is best for their families.

“Even with some providers leaving the area, Adventist Health has a great network of providers that is helping us to ensure we do have a wide range of healthcare specialties available at our clinics in Chico and at the Feather River Health Center in Paradise…. We are working on strategies to partner with providers that will help us expand our services and increase patient capacity.”

The bulk of those services cluster at the 41,000-square-foot health center in lower Paradise, plus existing offices in Chico. Enloe and Oroville Hospital have faced a delicate balance between supporting and poaching. In a sense, they're competitors—yet they, with Orchard Hospital in Gridley, compose a countywide health system that responds collectively to emergencies.

There were 69 patients at Feather River when the Camp Fire reached Paradise. Hospital staff used their own vehicles to supplement ambulances evacuating them to Enloe and Oroville Hospital. Enloe welcomed Adventist Health officials into its conference center, across The Esplanade from the hospital, to use as a command center while granting medical personnel emergency credentials to treat patients.

Oroville Hospital CEO Robert Wentz told the CN&R days after the fire that his facilities had room for additional doctors. (See “Uncertain prognosis,” cover story, Nov. 15.) In the intervening months, he says he's taken a strategic approach to courting providers from the Ridge, looking only for those who mesh with his hospital and its needs.

“We knew them because they were in the area, and then we got an insight into how professional they really are under some of the most dire of circumstances,” Wentz said. “That kind of a window isn't something you usually get to see.”

Brady Haynes, Enloe's vice president of physician engagement, continues to focus on collaboration with Adventist Health and Paradise doctors. Notably, he placed Paradise Medical Group (PMG), a primary care practice that lost its facility to the fire, into a vacant clinic next to the Enloe Regional Cancer Center. The group remains independent from Chico's hospital, though its pediatricians have privileges to admit and treat patients there. In any case, Enloe dispatched three trucks and eight workers to bring down unscathed equipment from PMG's old location.

Several other Ridge doctors shifted their shingles to Chico. Dr. Arthur Silverstein joined Northstate Cardiology Consultants and Enloe's medical staff. Dr. Gregory Davis, affiliated with Feather River and Enloe, set up a new gynecology practice, Mangrove Women's Health. The Chico VA Clinic hired primary care providers Drs. Courtney Badour and Joseph Lee ahead of its expansion at Meriam Park.

Mainly, Enloe is bolstering its capacity to handle loads that have increased since the fire. For instance, in the absence of Feather River, births at the Nettleton Mother & Baby Center jumped 40 percent. Haynes said the obstetrics department will add comprehensive midwifery services, including deliveries by certified nurse midwives, in the near future.

“Babies don't stop,” he said.

Going mobile

The morning of the fire, about 7:30, Dr. Richard Thorp looked out a window and “noticed something wasn't right.” He recalls an odd color to the sky; when he stepped outside his home, on the east side of Paradise, he smelled smoke and saw it plume.

That prompted him to head west to the Feather River Health Center, which he thought was in immediate jeopardy. An internal medicine practitioner who's president and CEO of PMG, he also served as medical director for the rural health clinic. A call from Lorretta Sarmento, PMG's operations manager, redirected him to their Pentz Road office complex uphill from the hospital.

“By this time, there was ash falling in the parking lot [and] you could hear the fire coming down the canyon,” Thorp said. “It was just was this huge roar, like a steam locomotive—it was just an amazing sound—[and] things exploding in the background; whether it was propane tanks or trees, I don't know. But it was pretty intense.”

Due to the early hour, around 8 a.m., only Dr. Jason Vance had patients in the office. Those few, along with the staff, evacuated. The fire wound up destroying one of the three buildings PMG occupied, the northern one that housed Vance (family medicine), the pediatricians and two specialty practices. The sister structures, which housed the remaining PMG providers, sustained damage but survived.

As with Chobanov, PMG providers faced immediate needs—personal and professional. Thorp and Vance were among the practice's 34 displaced employees, two-thirds of the staff; among them, 27 lost their homes. Thirteen employees were so affected by the traumatic events that they couldn't return to work, though three subsequently came back and two may come next month.

Practitioners began connecting with patients the next day. PMG uses a digital phone system, Thorp explained, so the company simply transferred calls to cellphones. Doctors used the electronic medical record system, or EMR, to fill prescriptions.

“The EMR was really a blessing,” said Dr. James Logan, a pediatrician and PMG's chief operating officer.

Meanwhile, Vance got a call from Dr. Randall Williams at Mangrove Medical Group, offering space to treat patients. By Monday, Nov. 12, “two business days after the fire,” Vance said, “we had our patients getting emails, texts and phone calls saying we were ready for them.”

PMG also shared space in the Chico branch of a pediatric cardiology practice based in Sacramento until consolidating into the clinic on Cohasset Road. Formerly a children's health clinic, the Enloe-owned building is a compact single story of 5,600 square feet—“definitely a change,” Logan said, from the 20,000 square feet spanning the trio of buildings the 10 providers had in Paradise.

Regardless, PMG will situate here for the foreseeable future. The practice will reopen its surviving Paradise offices as soon as possible so family practice and internal medicine providers can see Ridge patients closer to home. These practitioners and the pediatricians will continue taking appointments in the Chico clinic in what Thorp described as a “dual presence” in the communities.

Newly expanding their reach is telemedicine. Last Wednesday (March 6), the practice launched a partnership with Blue Shield of California, an insurer Thorp said is helping fund PMG's recovery, and Teledoc, a firm that offers online consultations with physicians.

Patients, regardless of their location, can “see” their PMG provider via smartphone, tablet or computer. (They can speak by phone as well.)The practice utilizes Teledoc's technology, such as a mobile app, for these virtual visits.

Eventually, Thorp said, the platform could bring specialists remotely to the Ridge.

“Everything is kind of fluid,” he added. “We're kind of making this plan up as we go.”

Best estimates

When, or if, Adventist Health reopens Feather River Hospital, it will need to deal with the loss of physicians who staff a medical center. The organization did not respond to multiple requests for a count; the CN&R estimates, based on reporting, at least 28 doctors from Paradise no longer practice in Butte County. Not even considering those practicing off the Ridge who lost homes, that figure could be twice as high—representing 60 percent of the Ridge's physicians—if, as PMG doctors say, the network of specialists established by Adventist Health has vanished.

“Building that kind of specialty infrastructure takes time,” said Thorp, a former Feather River board member and past president of the California Medical Association. “Many of the specialties that were there six months ago weren't there when I came to Paradise in 1981. We didn't have oncology, we didn't have cardiology, we didn't have GI, we didn't have pulmonary medicine, we didn't have psychiatry …

“And without primary care, you can't build a specialty network.”

That's because primary care is the entry point of the health care system. Those doctors' referrals direct patients to specialists. Without them, insurers rarely pay for care.

PMG managed to keep all eight of its physicians, plus its nurse practitioner and physician assistant. Logan, Thorp and Vance each said the doctors never questioned staying locally—together. Their practice formed in 2001; all six founders remain active. (Besides those three, there's Dr. Arthur Brinckerhoff, internal medicine; Dr. Susan Mallory, pediatrics; and Dr. Richard Turner, family medicine.)

Overall, though, the Paradise medical community has fractured. Every obstetrician who delivered babies at the Birth Day Place had left the area by March 1. PMG doctors also cited the loss of three general surgeons, three primary care physicians, two gastroenterologists, a pulmonologist, a neurologist and an oncologist.

Feather River's closure left emergency room doctors and hospitalists without a workplace; anesthesiologists, surgeons and others without privileges at another hospital faced the same predicament.

Then there's the human element.

“Any of the people that went through the fire went through the trauma,” said Haynes, of Enloe. “So for some of them, [the decision to leave] was the effects of what they went through—rightly so.

“And it's no different than any other of the population: A lot of them lost everything, their houses, and with the housing shortage, they can't find homes. Like anybody else, they have to make the decision whether they want to rebuild.

“Since across the nation there's a [doctor] shortage, they can move anywhere they choose,” he added. “Even if we could retain them, for some of these services, you have to be close by a hospital either for [being on] call or to handle their patients.”

That was the case with Chobanov. She said she never thought of leaving the area—she didn't want to uproot her children, and with her house standing, she didn't face the dilemma of whether to rebuild. The offer from Oroville Hospital meant she still could care for her current patients after a minimal transition. She rotates between two offices: Dove's Landing Neurology, on Oro Dam Boulevard, and Oroville Hospital Neurology, on the main campus.

“I really don't like changes,” she said, laughing softly. “Whether it was Oroville, whether it was any other location, I couldn't be spared … but I'm surrounded by a great group of people that made it easier.”

Room to grow

Dr. Lynne Pappas doesn't live in the burn zone and didn't lose her office to the fire. Her psychiatry practice—for children, adolescents and adults, from as far away as Yreka—resided in the Feather River Health Center.

Still, Nov. 8 and the days that followed proved trying. After almost 11 years in Paradise, and 16 years prior working around the North State, she has a large pool of patients. Pappas also was part of a team, working with therapists and other psychiatrists at Adventist Health Feather River.

They had many patients in crisis, amid a crisis. With their building closed, the team turned a Chico Starbucks into their command center. Each morning, they'd meet, formulate an action plan, then disperse to homes, shelters and camps to give care. Cellphones and computers kept everyone connected.

“It was a series of very long days—20-hour days sometimes—of being on the phone, contacting all patients, trying to find them … reaching out to make sure they were OK,” Pappas said. “We were doing what we could to facilitate whatever we could for their needs, because in the moment obviously it was just mayhem.

“But more than anything, I think the people that we work with, we were a grounding for them, and so it was a blessing for everyone.”

She secured space in a church through the end of December, when the Feather River Health Center reopened. She came back to find cramped quarters.

Pappas no longer had her allotment of rooms in which to see patients. Because her case load is so full and varied, she requires two; with added providers to accommodate, Feather River would spare only one.

“I needed to find a facility with a space to work where I could continue seeing all of my patients,” Pappas said. “Oroville Hospital had reached out to me at that time and was wanting to embrace that, provide whatever space I needed to continue practicing and to build the practice.”

She, like Chobanov, started Feb. 1. The hospital set her up in a facility by Highway 70, the Mental Well-Being Clinic, with three therapists. Pappas brought along Jacquie Lynn Donadio, her psychiatric nurse the past 12 years.

“When I came on with my nurse specialist, the idea was to grow the department,” Pappas said. Among the initiatives: consultations for hospital patients “who are suffering and have psychiatric needs.”

She added: “The hope is to continue growing through recruitment … because the need is obviously so great.”

What's ahead?

The future of health care in Paradise is like the future of the town itself. Much will depend on how many residents return and the extent to which their community rebuilds.

“Nobody will know for years,” Haynes said. “As we get farther away from the event, we will understand more. But I think it will take two years to understand what the new norm is.”

With communities co-mingled—Chico, Oroville and Gridley housing fire refugees and providing services, including health care—Haynes noted a ripple effect. Long-term, might the population decrease from those choosing to move away, instead of rebuild, offset the loss of providers? Haynes considers that a possibility.

Wentz isn't convinced. He asserted that the loss of physicians from the Ridge “has an effect on the entire region”—already facing a provider shortage, “this obviously didn't make that better. It just adds some additional challenges to recruiting, to assure we have the right number of physicians to care for the people. And we will take care of them.”

Pappas said her professional move to Oroville is permanent. Chobanov said the same thing. A full-service hospital in Paradise won't bring them back.

“I really loved my prior position, and the hospital,” Chobanov said. “I had a perfect 6 1/2 years there. I really enjoyed it very much.

“However, realistically, I don't see it coming back as it was—at least in the near future. And I cannot sit in two chairs at the same time. I have to take care of my professional life, my patients, my family. So, I'm here for good.”