An academic environment and the ability to provide full-spectrum medical care to underserved communities are aspects that attract resident physicians and faculty to the UCSF Fresno Department of Family and Community Medicine.
“We can take care of people truly from cradle to grave, that’s why I chose Family Medicine because I wanted to take care of patients before birth all the way to the end of their life,” said Marie Mihara, MD, who graduated in June 2023 from the UCSF Fresno Family and Community Medicine Residency Program and stayed in the department as faculty. Dr. Mihara who cares for patients and supervises residents at Camarena Health’s Sixth Street Health Center in Madera, added, “There aren’t very many places that you can do full spectrum both learning and developing skills on your own and immediately apply them to teaching.”
Full-spectrum care involves prenatal care, delivering babies and ongoing care for patients throughout their lives. As a result of growing interest, mentoring and new training opportunities and increased need, full-spectrum care provided by faculty and Family and Community Medicine residents at UCSF Fresno now includes gender-affirming care, a range of medical treatments and other support that validates and affirms a person’s gender identity.
“The partnership between UCSF Fresno Family and Community Medicine and Camarena Health enhances patient care at the community clinic level by infusing fresh perspectives and updated medical knowledge in order to provide quality and compassionate care,” said Mireya Samaniego, MD, Associate Medical Director, Camarena Health. “Residents’ exposure to diverse medical cases during their training strengthens the clinic’s capacity to address a wide range of health issues in our patient population.”
Diana Howard, MD, who graduated last year from Valley Health Team’s Family Medicine Residency Program and joined the Family and Community Medicine faculty at UCSF Fresno, echoed sentiments about providing full-spectrum care, particularly for transgender patients. Dr. Howard, who was born in Peru and is fluent in Spanish and French, sees patients and supervises residents at Family Health Care Network’s Ambulatory Care Center in Fresno. She also works two days a week at FHCN’s Specialty Services Clinic which houses the Ryan White HIV/AIDS Program.
“Being able to provide gender affirming care and also primary care to my transgender patients makes me feel that we are going to close the gap that we have. The gap not only for access but also the gap that we have in culturally competent physicians. I feel like I can have a double impact because I am also training residents,” said Dr. Howard.
According to Out 4 Mental Health’s Fresno County info sheet, more than 50% of transgender individuals reported their health care providers lacked knowledge specific to them. In addition, 28% of transgender and gender non-conforming people have delayed needed medical care due to concerns of discrimination.
For many years, access to gender-affirming care in the greater Fresno area was limited. But the number of local physicians who are now providing such care is growing. Drs. Mihara and Howard are among them.
“UCSF Fresno Family and Community Medicine prioritizes training in and the delivery of full-spectrum care, including gender-affirming care, to all in our community,” said Ivan Gomez, MD, chief, UCSF Fresno Department of Family and Community Medicine. "That priority includes developing and supporting innovative and relevant medical education training curriculum that is critical to targeting specific interventions for improving gender-affirming health care education for family physicians, particularly in our underserved communities.”
Training physicians to work in multi-disciplinary teams to provide high quality, accessible and culturally appropriate medical care is a priority across UCSF Fresno departments. Both Drs. Howard and Mihara point to Julie Nicole, MD, volunteer clinical faculty member in the UCSF Fresno Department of Obstetrics and Gynecology, as a mentor. Dr. Nicole, a longtime local expert in gender-affirming care, offers elective rotations for residents at her private OB-GYN practice in Clovis.
She is humbled to serve as inspiration for others and acknowledges that there is a purpose to her efforts. “For the longest time I was alone in Fresno providing that care outside of Planned Parenthood. And when you mentor someone, it's a little bit to work yourself out of a job and it's not that I'm planning to retire anytime soon. But it was very important for me to not leave the community behind when I want to retire. I really wanted to work on an infrastructure.”
Dr. Nicole is a certified mentor by the World Professional Association for Transgender Health and encouraged Dr. Howard to complete WPATH certification. Dr. Howard has an additional certification in HIV medicine.
Today, in addition to Drs. Howard, Mihara and Nicole, there are a handful of physicians in and around Fresno who are trained in gender-affirming care. Many of them were mentored by Dr. Nicole. In certain cases when a multi-disciplinary team is needed, patients are referred to UCLA, Stanford or UCSF.
“We're really working on improving access. I strongly believe that gender-affirming care belongs with primary care. I'm a specialist. I'm an OB-GYN, so I am not always in the office. There are some days I'm on labor and delivery. There are some days I'm in the operating room, so that makes it even harder for patients to come and see me,” said Dr. Nicole.
Primary care physicians are vital to the delivery of gender-affirming care and full-scope medicine that addresses patients’ preventive and other health care needs.
“While I do offer medical/hormone therapy, it is important to note that gender affirming care is much more than just medication or surgery. It encompasses a range of social, behavioral, psychological, and medical interventions,” said Dr. Mihara. “Gender affirming care saves lives. Affirming care decreases depression, anxiety, and most importantly decreases suicide risk. Everyone deserves to feel safe with their primary care physician.”
A 2020 California Healthcare Foundation report shows there are 47 primary care physicians in the San Joaquin Valley per 100,000 population. The recommended number is 81 per 100,000. In a region where primary care physicians and specialists are in short supply, the need for physicians who can address the health concerns of transgender patients is crucial. UCSF Fresno is partnering with health systems serving this population and local experts to train culturally competent physicians and expand access to care.
