Fall 2011
The Residents Report Newsletter of the Office of Graduate Medical Education I University of California, San Francisco
Self-Care During Residency: You Can’t Take Care of Others if You Can’t Take Care of Yourself Rob Starkey, Psy.D. Faculty & Staff Assistance Program (FSAP)
in this issue Self-Care in Residency 1 News from SFGH 3 News from the Library 4 New Vice Dean for Education 5 Transforming Primary Care 6 Quality & Safety Update 7 Out & About 8 Simulation in GME 11 The Patient Experience 14 Resident/Fellow’s Council 15 AIDS Walk Update 16 GME Diversity 18 GME Events Gallery 19 GME Cypher 20
The stresses of residency are numerous, including being overworked and underpaid; receiving more criticism than praise; having too much to do with too little time; having to neglect your personal life, and working in a high pace, high stakes environment that maintains the idea of a shared goal, while continuing to have an undercurrent of competition. In addition, the transition from student to resident can be a challenging one due to the abrupt change in status. As residents at UCSF, you are among the most driven, intelligent individuals in the world. Many of you were the academic superstars of your high school, college, and medical school classes. Now, you may find yourself struggling in your work and having difficulty maintaining your confidence. Feeling stressed and overwhelmed is perfectly natural but the good news is that there are ways of ameliorating your stress through selfcare. It is all too easy to neglect yourself in the process of trying to complete the multitude of tasks before you, but there are things you can do. Here are several ideas to help you cope with and reduce stress in the workplace: 1. Decrease or discontinue your caffeine consumption. Caffeine can mimic and exacerbate the effects of stress on the body. 2. Exercise regularly. Exercise can help reduce built up tension and reduce stress.
UCSF School of Medicine Graduate Medical Education 500 Parnassus Avenue MU 250 East, # 0474 San Francisco, CA 94143 tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme
3. Engage in relaxation/meditation techniques. Take a few deep breaths periodically during the day and try to let some of the tension out. Breathe in for two to three seconds and out for five to six seconds. Try to notice any tension in your body and breathe out the tension. 4. Get sufficient sleep. Sufficient sleep relaxes the body and mind. Practice good sleep hygiene if you are having difficulty falling or staying asleep. Furthermore, studies indicate that having a TV in your room negatively affects sleep, so you might want to consider removing the TV from your bedroom. Also, reducing the brightness (continued on page 2)
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Self Care During Residency... (continued from page 1)
of your lights before you go to sleep can improve your ability to fall asleep. 5. Allow for time-outs and leisure. Allow yourself to have fun or just get away from the stresses of work sometimes. 6. Set realistic expectations. Mistakes will be made, so try to give yourself a little compassion when you do make a mistake. 7. Try to reframe or reinterpret stressful situations. Situations can be interpreted in many different ways and your attribution can make a big difference in how it makes you feel. For instance, by framing the attending giving you a hard time as her having a bad day or that she is trying to help you become a better physician can be a better way of understanding the situation rather than taking it personally. 8. Keep a journal. Journaling can provide a good outlet for your feelings and thoughts as well as provide clarity on issues. 9. Have a support system. Maintain or develop a good support network. It’s okay to lean on other people sometimes. 10. Maintain a sense of humor. Try to find the humor in things and appreciate the positive moments during your day. Savor those moments when you are talking to the interesting patient or the funny exchange between colleagues. 11. Ensure a balanced diet. Maintain a healthy diet and watch your intake of sugars, fats, salt, and alcohol, which can all exacerbate stress. Many of you are under extraordinary amounts of stress and the demands on you can be overwhelming. Physicians are often held in an exalted position in our society, which can have as a side effect an internalized expectation that physicians don’t have problems. You must have extraordinary internal resources in order to have attained your academic success, but that doesn’t mean that you can’t have problems. If life starts to feel like
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it’s too much reach out to someone. We at the Faculty and Staff Assistance Program can provide you with counseling services as well as referrals to therapists in the community. FSAP services are free, confidential, and available for both personal and work-related issues. Please contact us at 476-8279 or visit our web site at http://www.ucsfhr.ucsf.edu/assist for more information.
Upcoming Events GME GRAND ROUNDS Third Tuesday of each month from noon to 1 pm Making Believe in Medicine: The Role of Simulation in Graduate Medical Education Sandrijn van Schaik, MD, PhD November 17, 2011 N-225
RESIDENT AND FELLOWS COUNCIL Third Monday of each month from 5:30pm to 7:30 pm
DEAN HAWGOOD’S DIVERSITY RECEPTION November 17, 2011 6:30 pm to 8:30 pm
NEWS FROM SFGH Doug Eckman, MBA Operations Manager, SFGH Dean’s Offfice
SFGH REBUILD HITTING MAJOR MILESTONES The SFGH rebuild has hit several major milestones recently. The digging and excavation of 120,000 cubic yards of dirt was completed in May, creating a hole deep enough for the two below-ground stories of the new hospital. In July a 175-foot tall crane with a 200-foot long boom arm was assembled and will remain on site to load equipment and materials down into the pit and help with steel frame construction beginning this winter. The first major concrete pour took place in September. Over the course of 20 hours, more than 600 truckloads of concrete were delivered and pumped onto the site to create the first section of the four-foot thick foundation for the new hospital. The second concrete pour is scheduled for late October, after which the base-isolators that will allow the building to withstand seismic activity will be installed. After that the steel frame will start to go up, providing a glimpse at what our new hospital will look like. Construction is scheduled to be complete in 2015. NEW REBUILD VIEWING AREA ON CAMPUS Have you wondered what a base isolator looks like? Come see the rebuild project’s new public viewing area just north of the SFGH outpatient pharmacy lobby entrance. Visitors are welcome during daylight hours to check out four massive metal base isolators and learn how they will protect our new hospital building in the case of an earthquake. Also, a large viewing window provides a front row glimpse of how the new hospital is progressing. NEW BIKE STORAGE AT SFGH A new double-deck bike enclosure is nearly complete for SFGH residents, clinical fellows, and employees to safely store their bicycles. Located south of the main hospital entrance, it has two levels of racks that will expand the capacity for secure bike storage at SFGH. The area will be well-lit and electronic access will allow employees with a hospital ID badge to open the bike enclosure gate. Housestaff should contact their SFGH site coordinator if they need a SFGH ID badge.
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News from the UCSF Library Josephine Tan, MLIS Education and Information Consultant
Short on time, but need to find some targeted research papers in PubMed? Try out these search tips the next time you are searching PubMed. • • •
Need to find a specific article? Try Single Citation Matcher. Need to find an evidence-based medicine (EBM) paper quickly? Try Clinical Queries. Connect to either of these features in the lower portion of PubMed’s homepage, under the PubMed Tools section.
Use Single Citation Matcher when you are trying to locate an exact article. The fastest way to locate an article for which you have most or all of the citation information is to search on the journal title, year, and first page of the article. Use Clinical Queries when you need to find an EBM article. Once you type in and run your search in Clinical Queries, choose one of the options to find specific types of clinical articles (ie, etiology, diagnosis, therapy, prognosis, clinical prediction, guidelines.)
Click on the See all link at the bottom right of the results column to see a full list of results. Also included in the results window of your Clinical Queries search are links to Systematic Reviews and Medical Genetics articles relating to your search terms. Some other quick tips useful for cutting through a large set of not fully relevant PubMed results is to try some of these options: • • • • • •
Use AND to combine different concepts Use OR to combine similar concepts Use [ti] to find a word/phrase in the title of an article Use [tiab] to find a word/phrase in the title/abstract of an article Use “quotation marks” to find an exact phrase Use an * to find variations to a word (ie, effective* finds effective, effectiveness, effectively, etc)
Putting these tips all together, here’s an example of how you might run a search in PubMed’s simple search box: (continued on page 5)
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Library... (continued from page 4)
This search phrase will look for either the phrase “otitis media” or “ear infection” to appear in the title of the paper, mention antibiotics in the title/abstract, and find wording relating to effectiveness. • •
By using these restrictions, our hope is to quickly find a set of highly relevant papers on our topic. This is NOT meant to find a comprehensive set of results, but is an excellent way to find a first set of on target papers for you to review.
For more helpful tips on how to research and manage your information, check out the In Plain Sight blog at http://tiny.ucsf.edu/inplainsight , or contact Josephine Tan, josephine.tan@ucsf.edu, 415-476-2534, for more information.
New Vice Dean for Education, Catherine Reinus Lucey, MD Lisa Cisneros Editor-in-Chief, Web Communications
Catherine Reinis Lucey, MD, joined UCSF as the new Vice Dean for Education in the School of Medicine on September 1. Prior to her appointment, Lucey served as the Interim Dean and Vice Dean for Education at The Ohio State University (OSU) College of Medicine where she directed undergraduate medical education, graduate medical education, and continuing medical education, as well as the schools of allied health and biomedical sciences. Lucey earned her medical degree from the Northwestern University School of Medicine and completed her residency in Internal Medicine, including service as chief resident at San Francisco General Hospital. “I am excited about returning to UCSF because I honestly believe that this institution has developed the best medical education system in the country,”
Lucey said. “This is the institution that will be able to develop educational innovations that help our students and trainees become the types of physicians who will solve our current and future health care challenges.” Lucey’s areas of expertise include professionalism, clinical problem solving, and learner remediation. She has been a passionate advocate for using education to advance the quality and safety of patient care and to prepare leaders capable of solving current problems in health care and health care delivery. Under Lucey’s leadership, OSU employed a novel model of professionalism across the medical center. Lucey has won numerous honors and awards during her career, including several teacher of the year awards, a mentor of the year award and the faculty teaching award in 2009. As Vice Dean, Lucey’s top priorities include the continued support of students, trainees, and faculty to advance interprofessional education; identifying strategies to build a more seamless continuum of medical education; and to build collaborations with leaders in biomedical science and clinical care to engage students and residents.
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Transforming Primary Care and Clinical Education in the VA: Education in Patient Aligned Care Teams (EdPact) Bridget O’Brien, PhD; Rebecca Shunk, MD; Susan Janson, DNSc, RN, ANP-BC, CNS, AE-C, FAAN; Maya Dulay, MD; Shalini Patel, MD; Jessie Coty
Mr. Parks is a Vietnam War veteran who was diagnosed with diabetes five years ago. On a Thursday morning at 10am, he receives a call from his nurse, Debbie. She knows this is the best time to catch him and she keeps him accountable for checking his glucose and taking his insulin regularly. Today she also orders his HGA1C and fasting lipids and reminds him about his appointment in three weeks with Dr. Alvarez, his resident physician, and Gary, the clinic dietician. One week prior to his appointment Mr. Parks receives a call from Ella, his LVN, who asks his agenda for the visit and reminds him to get his fasting labs beforehand. The day of the visit the teamlets briefs Dr. Alvarez about Mr. Parks’ agenda at the morning huddle. Mr. Parks’ experience may sound unusual to you if you are accustomed to “traditional” primary care practices; his example reveals a whole new way of doing primary care in the VA. In less than one year the VA Medical System has embraced the patientcentered medical home (PCMH) as both a concept and, more impressively, as an up-and-running system of patient care in its primary care clinics nationwide. By the summer of 2011, patient aligned care teams (PACTs) and teamlets were ‘huddling’ on a regular basis to improve coordination and continuity of care for their assigned panels of patients. These teamlets consist of primary providers (MDs and NPs), registered nurses (RNs), clinical associates (LVNs, LPNs), and clerical associates. In addition, teams of associated health professionals (social workers, mental health providers, nutritionists/dieticians, podiatrists, clinical pharmacists) provide integrated services in VA primary care clinics and work closely with teamlets to support patient care.
Often major system redesign efforts such as PCMH and PACT have implications for the education of trainees in the health professions, but rarely is there an explicit effort to incorporate the trainees into the change process. For example, it would not be uncommon in a VA primary care clinic for teamlets to huddle every morning with attending physicians and nurse practitioner primary care providers to review the schedule for the day and discuss any important patient concerns or needs. Although residents and NP students are the primary providers for their panel patients, they would not be asked to huddle with a teamlet because the process is new and changing, trainee panels are small, and the trainees and teamlets are pressed for time. This is a missed opportunity for the residents to learn experientially about systems-changes and practice-based improvement. Fortunately, VA leadership recognized PACT as a golden educational opportunity. VA primary care clinics around the country provide training sites for a substantial number of residents, NP students, and trainees from associated health professions. Rather than allowing these trainees to be bystanders or passive recipients of PACT, the VA envisioned new models of education aligned with the goals of PACT/PCMH that would engage trainees as active participants in the change effort. One example of the VA’s commitment to aligning excellence in primary care and excellence in ambulatory education occurred in January of this year. Through a competitive process, the VA Office of Academic Affiliations selected five Centers of Excellence for Primary Care Education (Boise, Cleveland, Puget Sound/Seattle, San Francisco, and West Haven). At the San Francisco VA we have created an educational program called EdPACT (Education in Patient Aligned Care Teams) in which teams of NP students and internal medicine residents work collaboratively within a teamlet to provide care for a panel of patients. The NP students and medical residents also cover each other’s patients when absent from clinic due to university breaks, inpatient rotations, and vacations. In addition to immersion (continued on page 17)
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GME Quality & Safety Program Update Glenn Rosenbluth, MD Director, Quality and Safety Programs GME
The GME quality and safety program continues to grow this year and the centerpiece of our activities continues to be the Housestaff Incentive Program. This past year, we were thrilled that we met all three of the shared Housestaff Quality Improvement Goals (increased patient satisfaction, increased hand hygiene, and decreased lab test utilization). All housestaff who worked at Parnassus for at least 12 weeks earned an extra $1200! Congratulations to all involved. In addition, nine out of twelve programs ALSO met their program-specific incentive goals! The program will continue in the 2011-2012 academic year, and housestaff will again be eligible for up to $1200 in incentive payments. Goal #1: Patient Satisfaction On the patient satisfaction survey likelihood of recommending question, maintain an annual average (July ‘11 – June ‘12) mean score of 90.6. This goal is the same as the target patient satisfaction goal that has been set for Medical Center staff. Goal # 2: Patient Quality and Safety Achieve 85% hand hygiene compliance for at least six of 12 months. This goal is the same as the hand hygiene goal that has been set for Medical Center Staff and includes data for all providers. Goal #3: Laboratory Test Utilization By June 2012 residents will decrease by 5% the aggregated utilization of common laboratory tests (defined as tests/inpatient day). Common tests will include, CBC, CBC with differential, electrolytes (Na, K, Cl, CO2), HCO3, Mg, Ca, Phos, BUN, Cr, AST, ALT, total bilirubin, alkaline phosphatase, PTT, LDH, GGT, Ionized Calcium, and albumin. Reduction will be calculated in comparison with January-June 2011 as a baseline. Patients on transplant services will be excluded.
• Lab Medicine • Neurology • Neurological Surgery • Obstetrics and Gynecology • Ophthalmology • Otolaryngology • Pathology • Pediatrics • Radiation Oncology • Urology For a complete list of the program/department specific incentive goals please follow this link: http://bit.ly/oqY2q9 All of these programs came together on August 18 for a kickoff symposium. Glenn Rosenbluth, MD, Director of Quality and Safety Programs for GME facilitated this event. Trainee champions, QI champions, and program directors from all sixteen programs/ departments worked together to learn skills and progress their projects. If you aren’t participating this year, it isn’t too early to start thinking about a program/department specific incentive for next year! What would you and your peers like to improve? Other ways to contribute: • Tell your chief residents now about relevant quality and safety issues. We meet with them monthly for dinner and your concerns will be heard at the highest levels! • The Patient Care Fund is back in business! Keep an eye out for upcoming announcements. This fund is a great way to help get your improvement ideas funded!
Program Specific Incentive Goals: This year we also have 16 programs participating in department-specific QI incentive programs: • Anesthesia • Dermatology • Department of Medicine Fellowships • Emergency Medicine • Internal Medicine
(l - r) Matthew Russell, MD and Gerald Kangelaris, MD discuss Otolaryngology’s incentive proposal
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OUT & ABOUT from the Resident and Fellow Affairs Committee Where members of the Resident and Fellow Affairs Committee recommend their favorite scenes outside UCSF.
Sausalito Bound! Laura Tabatabai, MD Associate Professor, Pathology San Francisco Veteran’s Affairs Medical Center For a break from the city, try a quick taste of the loveliest New England villages outside of New England…a journey through Sausalito and Tiburon. While you could drive to these towns, why would you if you can take a beautiful ferry ride from the Ferry Building/pier through the beautiful San Francisco Bay to these quaint villages. The day must begin, of course, with a glass of rose or champagne at The Ferry Plaza Wine Merchant at the Ferry Building. A bottle of Domaine Allimant-Laugner Brut Rosé Crémant d’Alsace will satisfy both requirements and trust me - the ferry ride will be so much more beautiful after a glass. Once in Sausalito, you have multiple choices for lunch - Poggio (or “hill” in Italian) is right on Bridgeway as you get off the boat. It’s a classic Tuscan-style Italian trattoria with comfortable neighborhood charm and destination-caliber cuisine using local ingredients as well as organic herbs and vegetables. Start off with a glass of Prosecco and fresh burrata with roasted cherry tomatoes and fragola salad with goat cheese and hazelnuts. The Napolitano style pizza or pasta with roasted eggplant, chili, and ricotta are good choices topped off with tiramisu and capuccino as you sit outside and indulge in some people watching while enjoying the open air dining. After an easy stroll along the water or climbing the many hidden staircases along Bridgway, island hop over to Tiburon by getting back on the ferry. Once off the boat, take a walk along the historic Ark Row shops. As the street curves around there’s a quiet staircase which discretely invites locals away from the tourists for a climb up to Corinthian Island. Once up the stairs a bench awaits at the hilltop with spectacular views of the city, Sausalito, and Angel Island. Sit back
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and relax for a few minutes. Take a few deep breaths, close your eyes, and quiet your thoughts. Time and space aren’t limited and you don’t have to go places, to go places. We’re out and about, just by being here now. A walk westward will eventually find a path along Belvedere and the southern portion of Tiburon along the northern edge of Richardson Bay to Blackie’s Pasture, where a grassy lawn can be enjoyed with full-face views of Mt. Tam and the sounds and sights of migrating birds of various morphologies and staining patterns. If you really want to burn more calories, you can climb up to Ring Mountain where more spectacular views await. After the hike, when hunger strikes, head over to waterfront dining and gorgeous views of the San Francisco skyline from the outside patio at Servino. Order a bottle of your favorite Barolo or super Tuscan and enjoy food from a wide selection of caprese salad, pizza verdura and capellini. Once the Barolo is poured, the slow service won’t be as bothersome. Finish off with a capuccino, then plan your next trip hiking and cycling Angel Island while heading back on the last ferry to San Francisco. As always, remember to enjoy the ride (including its ups and downs)!
OUT & ABOUT from the Resident and Fellow Affairs Committee Out with Shasta and Sierra Sue Sheehan Division Administrator, Education Department of Medicine One of the best ways to get out and about is a hike with woman and man’s best friend. Shasta, my three year old golden retriever, and Sierra, her 8 month old sister, get me out and about to explore new places. San Francisco and the Bay Area have many venues that are dog-friendly. Here are some of my favorite places to take them. Golden Gate Park requires dogs to be on leash in most areas. For a quiet morning walk I often take them to the Aids Memorial Grove. Although dogs must be on leash it is a picturesque, quick walk that’s very close to the Parnassus campus. Golden Gate Park also has four off-leash areas for dogs: • • • •
The northeast corner - between Stanyan Street, Fulton Street, and Conservatory Drive East. The southeast section of the park bound by Lincoln Way, Martin Luther King Jr. Drive, and 5th and 7th Avenues. The western half of the park between Martin Luther King Jr. Drive, Middle Drive West, and 34th and 38th Avenues. A fenced dog training area located at 38th Avenue and Fulton.
Crissy Field lies in the shadows of the Golden Gate Bridge offering great views of the Marin Headlands, Alcatraz, the downtown skyline, and the East Bay. As a popular spot for city dog walkers Crissy Field has abundant parking, and easy access to a large lawn area as well as an off-leash beach area. This was a great introduction to the ocean for my dogs without the worry of them getting hit by large waves or being pulled into the ocean by an undertow. My dogs had only experienced swimming in a lake before coming to Crissy Field and were a bit cautious when the waves started moving toward them. Bernal Heights Dog Park is at the end of Folsom Street high above the city. The park, a former rock quarry, is now an off-leash area for dogs. The park has incredible 360 degree views of the city, the East Bay, and Marin (on a clear day). Looking northeast, the San Francisco General Hospital brick buildings stand out against the city skyline. At the top entrance to the park there are dog bags, an information board, and a drinking fountain especially for dogs. One main paved trail goes from the upper to the lower parking area and there are numerous unpaved trails that take you to the upper areas of the park. The hiking trails can be steep and chilly in the afternoons, so always bring a jacket. Fort Funston is located off of Skyline just south of Ocean Beach and is a very popular off-leash dog area for dog owners and dog walkers. The park has a large parking area and a water fountain with dog bowls. The main trail is paved and winds northwest through sand dunes and ice plant toward the ocean. The ocean access at the bottom of the trail is steep so be prepared. Also, the surf here can be rough as this park is on the ocean. In addition to its draw for dog owners, Fort Funston is also very popular with hang-gliders who fly up and down the cliffs overlooking the beach. Although there were lots of dogs and large dog walking groups when we visited, all the dog owners were very responsible and the dogs were friendly and under control. (continued on page 10)
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Out with Shasta and Sierra... (continued from page 9)
If you have a day off and are interested in seeing the sun, try some of the parks in the East Bay/Oakland. Sibley and Redwood Regional Parks both have off-leash areas for dogs. Since I live in the Oakland hills, Sibley Park is a quick drive for me, located just off of Grizzly Peak Boulevard. The views of San Francisco and the bay on the drive up to the park are spectacular. Sibley has a parking area, dog water fountain, and bathrooms at the main trail head. There are numerous hiking trails and the majority of the park is off-leash for dogs. Redwood Regional Park is just south of Sibley on Skyline Boulevard. Redwood also has miles of hiking trails that are mostly off-leash. The Skyline gate staging area is a favorite and has a parking lot, dog water fountain, and new bathrooms. Be prepared to share some areas of these parks with hikers, bicycles, cattle, and horses. During the summer and fall keeping your dog on the trail is a good idea if you are allergic to poison oak. To minimize that possibility I wipe my dogs down with a towel after their run. Be a responsible guardian and always carry a leash, dog pickup bags, treats, and water.
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Simulation in Graduate Medical Education: Are Plastic Mannequins Replacing Real Patients? Sandrijn van Schaik, MD, PhD Education Director, Kanbar Center for Simulation, Clinical Skills, and Telemedicine Education
One of the questions I hear most frequently when talking about simulation-based medical education is whether I believe that simulation can replace clinical experience. My answer is simple: no. UCSF’s Kanbar Center for Simulation, Clinical Skills, and Telemedicine Education has state-of-the-art simulation equipment including the newest generation of mannequins, but there is no doubt about it there is not a single member in our “sim family” that truly resembles a real patient. But that is, in my mind, not the intent of simulation-based education. Simulation offers opportunities to practice, then reflect back on your practice, listen to feedback, and think about how you can improve and try it again. This is the concept of Sandrijn van Schaik, MD, PhD supervises students intubating a high fidelity simulation mannequin in the Kanbar Center “deliberate practice,” described in the education literature as the way in which experts become experts, whether in the operating room, on the tennis court, or in a concert hall. In the Kanbar Center you can fumble with a central line kit and practice your eye-hand coordination using ultrasound to locate the vessel on a task trainer, or hone your resuscitation skills with one of our mannequins. It’s a way to prepare yourself for clinical encounters (that first central line on a real patient, that first code that you need to run) and to repeat your experiences on clinical rotations in a more controlled setting and fashion. The Accreditation Council for Graduate Medical Education (ACGME) really encourages GME programs to use simulation, not only because it is a safe way to learn procedures and how to deal with rare and high stakes events, but also because it creates an opportunity for standardized assessment of such skills. The Kanbar Center has AV-recording equipment to capture simulations and a software system called B-line Medical SimBridge that allows for annotation and evaluation of simulated activities. So can you just come over at any time to practice on our simulators? Not quite. The simulation literature suggests that effective simulation-based education is integrated into a residency curriculum, has clear objectives and benchmarks for performance, and includes ongoing feedback on performance. We therefore require faculty involvement in all simulation programs at Kanbar, but housestaff can certainly help design curriculum. Want to know more? Check out our website: http://medschool.ucsf.edu/kanbar/ or email me at vanschaiks@peds.ucsf.edu.
CTSI Research Funding Opportunity for Residents Christian Leiva, CTST Coordinator
The Resident Research Funding (RRF) Program of the Resident Research Training Program (RRTP) provides up to $2000 per academic year to residents for qualified clinical and translational research expenses not covered by their mentor or other sources. Funds may be used for qualified research expenses as defined by official UCSF policy, including materials, tuition, design and bio-statistics consultation, analytic support, and study-related travel. The deadline for the fall 2011 cycle is October 31, 2011. For more information please go to http://ctsi.ucsf.edu/funding/funding-for-residents#funding. RRTP also offers many other opportunities for residents interested in careers in clinical and translational research. For information on all our opportunities please go to http://ctsi.ucsf.edu/training/resident.
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10 QUESTIONS FROM THE RESIDENT AND FELLOW AFFAIRS COMMITTEE healthcare environment. They see where the cracks are in the system and what kinds of work-arounds are necessary and how to implement them. If we could tap into their insight and expand on best practices they have discovered through their work with patients, our medical center would be better off for it. One of my goals is to work closely with medical center administration because residents and clinical fellows, who are delivering the type of care our patients want and are measurably excellent, are the route to a better, more effective medical center.
Catherine Reinis Lucey, MD, was appointed Vice Dean for Education in the School of Medicine, effective September 1, and answers resident and clinical fellow questions about her priorities and plans in her new position here at UCSF.
1) As the new Vice Dean for Education, how do you plan to interact with the residents and clinical fellows at UCSF? I got my start in medical education as a residency program director in internal medicine so I have always had a great deal of fondness for learners at that level. I am also very appreciative of the amount of energy and effort residents and clinical fellows put into teaching our medical students. They are the core of much of our educational programs and my hope is I am able to interact with them as much as possible.
3) Do you think our current model of residency training will be economically sustainable under new health care systems? The future is unclear, but I believe that wherever our new system ends up we have to find a way to make residency training and medical student education a core part of the academic medical center. I think what will change over time is the way we use our faculty and the way we deploy our residents and students on rotations. We cannot keep running residency programs the way they were back before there were DRGs and the current focus on quality measures and the economics of healthcare. The people in medical education including the great faculty and trainees that we have here at UCSF need to recreate it so it is economically sustainable. It is up to us.
4) How do you feel about resident work hour restrictions, especially the newer requirements put into place last July? The days of working 100-120 hours were probably not best for patient safety. On the other hand, patient safety I am in the process right now of setting up and quality are complex problems. It’s simplistic to think opportunities to round with different teams from that simply decreasing the hours that residents work will different departments. My hope is to get a better dramatically increase the safety and quality of our patient understanding of how the residents work with our medical students and watch our faculty interact with care. Actually, it’s possible that there is a work hour limit that is too low - a point at which the risk of errors might the residents, so I can get a good sense of how increase due to more hand-offs and less experience people are advancing education here at UCSF. for residents. They may make mistakes going out into 2) What are your thoughts about the interface practice because they did not have the opportunity of the medical school and the medical center? to train and achieve a level of expertise under the They are partners in the UCSF mission of patient supervision of a watchful faculty during their training. care, education, and research. Medical centers I am a big supporter of paying attention to resident benefit from having a bright, energetic faculty and fatigue. I think again this is another situation where residents innovate about what our patients need residents and fellows at UCSF working with their faculty us to do, which is to provide them with the best can come up with multi-facetted programmatic solutions care available. I’m not convinced we leverage that both enhance patient safety and quality and optimize the innovative thoughts and problem-solving capabilities of our residents and students in our (continued on page 13)
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10 Questions.....from the RFA Committee (continued from page 12)
resident education. The ACGME is in a tough position and did its best to navigate in stormy political waters. It’s very easy to say that doctors should be like truck drivers or airline pilots with regard to fatigue and work hours. However, I would hope that we could come up with a logical comprehensive system that pays attention to fatigue as an element of a resident’s work life as well as pays attention to adequate training and appropriate transitions. We may be able to convince the public that our approach is better. 5) With heightened expectations for clinical productivity, how is the role of clinical faculty changing and how is this affecting residency training? Clinical faculty are critically important to the success of GME training programs. This is where our residents learn hands-on patient care and to be the types of doctors that patients expect them to be. We are blessed here at UCSF to have some of the finest clinical faculty I’ve seen in my career that spans five academic medical centers. That being said, we have not been innovative about the role of the clinical faculty. We have asked our faculty to accept an increasing amount of work without stepping back and asking what aspects of medical education have to be delivered by clinical faculty. Does a certain learning experience require faculty with a learner in a room with a patient? Or, can another technological approach be just as effective? This is an area ripe for discovery. I want people to view medical education as a sustainable healthcare career choice. 6) The specialty Boards and the ACGME are engaged in developing milestones for residency training. How will this affect how we are trained? The ACGME Milestones Project is very interesting because it could usher in a future where training is not time-linked, but limited only by the expertise that one develops. Rather than promoting people every year to the next level of responsibility, we might promote them in the middle of the year if their demonstrated level of expertise were such that they could do the next level of the job. Entry skills vary and the rate of skill acquisition varies. The Milestones Project is aiming to develop a commonset of expectations for each specialty and to develop
tools that would allow us to accurately assess a given individual’s skill development and competency. There is a unique project at the University of Toronto where orthopedic residents advance when they demonstrate the skills they need to be successful at the next level. Their training is tailored to helping them achieve those skills in as efficient a way as possible -- which means spending time in the simulation center perfecting psychomotor skills and concentrating operative experiences on one type of procedure until they master that procedure, rather than operating on whatever patients come through the door. This type of program is educationally interesting, but may not be feasible. We need to find a balance between individualized education and care for patients. 7) While there is much interest in interprofessional education, are there any good models of how this can be accomplished successfully? There are pilots across the country for interprofessional education incorporating aspects of crew resource management training in the operation room and team training in the emergency room. Is there comprehensive interprofessional education that has been successfully implemented in undergraduate and graduate medical education? I would have to say that I am not aware of one. Some reasons why this has not been successfully implemented include imperfect understanding of how to work together, age or status differentials among practitioners, and different accreditation structures. We are lucky at UCSF because the Chancellor and deans of all of the schools of health sciences have pooled their resources to develop a new center for interprofessional education. Scott Reeves, PhD, an internationally renowned expert in interprofessional education will direct the new center beginning in November. UCSF is very well situated to make advances in interprofessional education and develop a national reputation for leading in this field. 8) It is said that CMS pays for “educational waste” in medical training. What do you think about this? IME (indirect medical education) payments are based on the premise that medical care delivered in an educational system has a certain amount of waste associated with it. These are said to include extra studies that learners order, extra procedures, and complications that result when trainees are involved. (continued on page 14)
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10 Questions....from the RFA Committee (continued from page 13)
Interestingly enough, when experts look into this, they can show that the costs associated with training add up to only a portion about 2/3, of the IME payments. I’m not sure that education has to result in excess testing and increased complications. I believe most data suggest that care delivered at academic medical centers in the setting of residency training programs is the highest quality care around. The monies that we get from Medicare should not come to us because of what they see as waste in the system, but instead because we add value to the care that our patients receive. 9) How do you see us using educational technology in the future? This is a great horizon for us! Being in northern California around so many high tech companies can be beneficial to us in this venture. Up until now, I think educational technology has provided a way for learners to access huge amounts of information. This has been the first step, but now we need to help learners figure out how to sort through those vast amounts of information. The next set of educational technology tools should help learners sift through and understand what they need to learn and make it easier for them to learn. We need to configure software and develop applications that will advance actual learning. 10) In the past, you have taught a course for residents about leadership. Why do you think this is important? All physicians need leadership skills in the career they have chosen whether it’s conscious in their mind or not. The work we do on a daily basis in our practice environments calls for leadership qualities in interactions with patients and colleagues, and requires skills in negotiation, conflict resolution, and change management visioning. These are universally needed when dealing with people successfully. I truly believe the residents at UCSF will be end up being the leaders of the future in American medicine. When I look back at my residency group here at UCSF, one of my co-residents is now chancellor of UCSF. Helping our residents think about their style of leadership and the difficult challenges that leaders face is an investment worth making.
The Patient & Family Experience: Moving Beyond the Status Quo Catherine Lau, MD, Assistant Clinical Professor, Medicine Diane Sliwka, MD, Associate Clinical Professor, Medicine
The Institute of Medicine defines quality medical care as “patient centered” in addition to safe, equitable, timely, effective, and efficient. Improved healthcare provider communication with patients has been shown to improve many facets of care, including patient safety, compliance with plan of care, patient anxiety, readmissions to the hospital, malpractice claims, and clinical outcomes. Although the patient experience has been publically reported using the HCAHPS (Healthcare Consumer Assessment of Providers and Systems) patient survey since 2008, this data will now be used to determine Medicare reimbursement to hospitals as part of a greater “value based purchasing” program, further compelling improvement in this area. As healthcare providers, we play an integral role in the patient and family experience. What are patient’s asked? Patients give feedback about physician care through a survey that is mailed following any medical encounter. Currently, inpatient physician care is rated based on what percentage of patients answer “Always” to the (continued on page 16)
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Resident and Fellow’s Council Robin Horak, MD and Elizabeth (Lisa) Le, MD Resident and Fellow’s Council Co-Chairs
Welcome to the start of another exciting year. For those of you new to San Francisco, welcome to UCSF! The Resident and Fellow’s Council (RFC) is busy advocating for UCSF housestaff on issues ranging from quality of life to training and education. This year is shaping up to be a particularly busy one! Our 2010 - 2011 hospital-wide housestaff incentive goals to improve patient satisfaction, achieve greater hand hygiene compliance, and decrease unnecessary laboratory utilization were all reached successfully, resulting in an extra $1200 bonus for all eligible housestaff. In addition, many departments we are able to achieve their own individual department-specific goals. For 2011-2012, the UCSF Medical Center will be pursing the same incentives but with higher set goals, and we now have 15 programs/departments, including all department of medicine fellowships, participating in the department-specific incentive programs. We eagerly anticipate the results of the these wonderful resident and clinical fellow created and led programs. This year, we have renewed our strong commitment to resident representation and leadership throughout the Medical Center and UCSF campus. To support this goal, we have been hard at work placing residents and clinical fellows on various committees throughout UCSF and have succeeded in matching residents and clinical fellows to over 15 committees. Current RFC specific projects include creating an algorithm for contacting medicine fellows, facilitating better real-time communication between radiology and ordering providers, working with nurses to create a paging etiquette, and facilitating the creation of an ICU central line cart. Fortunately, resources also continue to be available in the UCSF Patient Care Fund with $50,000 allocated for resident and clinical fellow designed projects to improve the patient experience. Applications will be accepted until December 1st, 2011. For more details, please go to http://medschool.ucsf.edu/gme/residents/pcfund.html. We are always looking for new thoughts on how to improve the resident and clinical fellow experience at UCSF. If you have ideas for projects or would like to get involved, please contact us, your department representative… or come to a meeting!!! New members are always welcome. Wishing you all the best, Robin and Lisa
Too Tired to Drive Home after a Long Shift?! Residents and clinical fellows may obtain a taxi voucher card from the UCSF Medical Center Security Office on the first floor of Moffitt Hospital (room 192). Please note: this is only to be used in the event a trainee is unfit to drive home. Location of Voucher Pick-Up: 505 Parnassus Ave Moffitt Hospital, Room 192 (415) 885-7890 Trainees will be asked to show their UCSF ID badge (that must have a title of either “Resident” or “Clinical Fellow”), sign a log-sheet and provide their program name, number of hours worked, and provider ID. Schedule a Taxi: The voucher/card is good for a one-way, one-time ride home with Yellow Cab. To schedule a pick-up, residents and clinical fellows should call Yellow Cab at (415) 333-3333.
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UCSF GME Resident & Fellow AIDS Walk Team Update Paul Day, Communications & Events Analyst, GME
On a beautiful Sunday morning in July, 25,000 people gathered in Sharon Meadows to participate in the 25th Annual San Francisco AIDS Walk. The day was full of food, music, and of course, 6.1 miles of power walking through Golden Gate Park! Feet were tired, but spirits were up as we all came together for one purpose; supporting the San Francisco AIDS Foundation. The final fundraising tallies are in and the UCSF GME Resident & Fellow team had a very strong showing this year! We raised a whopping $4865!
(l-r) James Thomas, MD, Internal Medicine; Elizabeth Le, MD, Internal Medicine; Janina Patsch, MD, Radiology; Robin Horak, MD, Pediatrics; Mark Appelbaum, MD, Pediatrics
Congratulations to everyone who participated and thank you to all those who supported friends and colleagues.
Here’s a breakdown of how well our team did: • •
Ranked 87 out of 611 teams for overall fundraising Ranked 4 out of 13 within UCSF for fundraising
Great job everyone! Everyone should be commended for their efforts. The money we raised pushed UCSF over its goal of $50,000 by $5,000 and put UCSF in third place, right after the GAP and Levis. I believe this is our best showing yet! Congratulations everyone! See you all next year! Patient Experience... (continued from page 14)
following questions: How often did doctors 1) treat you with courtesy and respect?; 2) listen carefully to you?; and 3) explain things in a way you could understand? Improvement depends largely on moving the answer from “Usually” to “Always”. What works? Improvement is not rocket science, but it does require the conscious effort of every person who interacts with the patient. Evidence has shown the following to be highly effective. 1. Knock and ask to enter a patient’s room. 2. Introduce yourself by first and last name and your role. Write your name on the white board. 3. Acknowledge the patient and family. Use patient’s preferred name. 4. Sit down - this can double the perception of time 16
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spent. 5. Ask open ended questions and listen. 6. Elicit patient and family concerns and repeat them back. 7. Avoid jargon. Offer interpreters. 8. Duration: How long fasting? In the hospital? In a procedure? 9. Explain and check for understanding. 10. Thank the patient and family. Maya Angelou said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” For more detailed examples, read the extended version of this article on the GME website: http://medschool.ucsf.edu/gme/GRounds/GR%202011/gr081611.html
Transforming Primary Care... (continued from page 6)
in this interprofessional, team-based model of care, trainees participate in weekly educational sessions addressing core topics of PACT/PCMH such as patient-centered communication, interprofessional collaboration and teamwork, performance improvement, and continuity of care. Activities range from video tape review and discussion of communication skills during patient visits; a day long team-building retreat for teamlets; complex case conferences with a multidisciplinary team of professionals; and dedicated time to work on panel management and performance improvement projects. For residents and NP students, this explicit attention to and participation in interprofessional, team-based care, performance improvement, and engagement in systems redesign is typically not a major component of clinical training. Several positive reports on EdPACT have been received within the first few months. From a sub-specialist: During the first week of the program Dr. Pat Cornett, an attending in hematology/oncology, sent a note about one of our EdPACT NP student-providers. Dr. Cornett stated... “I saw a new oncology patient who must have been one of the first new patients in the COE seen by an NP student. He (the patient) couldn’t have been more effusive with praise and was quite complimentary towards the care provided by the student.” From an EdPACT preceptor: Dr. Maya Dulay shared her observations of team huddles, noting that the huddles allow her to do “anticipatory precepting.” Knowing what patients the trainees would see allowed her to suggest skills for trainees to work on during the visit and ways they can utilize their team better. By the end of the first two months she was very pleased to see the residents appropriately delegating tasks to other members of the teamlet rather than doing everything themselves as well as the NP students suggesting ways to improve team-based care by proposing improvements in the LVN’s pre-visit planning phone calls and other changes to make the huddle run more smoothly.
Observations from learners: “I wish I could recount that my first interaction with a patient started doubtfully, yet ended with an approving nod and touch from the patient. That would be a moving EDPACT story. Yet, truly, my first weeks seem a blur without any definite form rather a collage of many images. My memory holds the grainy silhouettes of charismatic patients with heart wrenching military stories and their lives since unfolded for me. Mental snapshots mark lightening-paced introductions to a diverse set of care providers. Yet, these introductions then needed a slow and more deliberate untangling of how to best work together. Add to this collage, my own (highly flawed) process diagrams of how to best wrestle with (and win!) the electronic health record, CPRS, never mind learn and negotiate many administrative procedures. Yet, in the end, perhaps the blur is more a result of the pace of the clinic for me. Surely the pace would be slow for a longexperienced practitioner, or even my resident partner, yet it had me run regularly for the finish line well after all others had left the clinic! Yet, if I take a breath and a few steps back, a very definite and singular theme appears. I absolutely love this program! I see where it is going and I understand its vision. My immediate immersion smack dab into the “thick” of providing patient-centered primary care, along with a team of bright and passionate professionals, moves me despite tiring weeks. I hope it moves my patients too.” This article was adapted from Primary Care Progress Notes, the original article is found at http://www.primarycareprogress.org If you would like more information about this program, please contact or visit our website at http://www.sanfrancisco.va.gov/education/edpact.asp Rebecca Shunk, Director of the SFVA Center of Excellence for Primary Care Education (EdPACT) Rebecca.shunk@va.gov Susan Janson, Co-Director of the SFVA Center of Excellence for Primary Care Education (EdPACT) Susan.janson@nursing.ucsf.edu Bridget O’Brien, Director of Evaluation for the EdPACT bridget.obrien@ucsf.edu
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GME Diversity Rene Salazar, MD GME Director of Diversity
The Office of Graduate Medical Education is committed to training physicians from all backgrounds and cultures and has an interest in developing a diverse community among residents and clinical fellows from all training programs. Several events are planned for this year including many social events, recruitment activities, volunteering at student-run clinics, and opportunities to represent UCSF at various annual meetings of national medical organizations. There are also opportunities to serve on diversity committees within the School of Medicine and the UCSF campus. UIM Dinner Program: The UCSF School of Medicine Mentorship Program for Underrepresented in Medicine (UIM) Students held it’s first dinner on September 21, 2011. This year’s welcome dinner was one of it’s largest ever with postbac students, medical students, residents, clinical fellows, and faculty in attendance. Now in its 13th year, this program aims to introduce and foster mentoring relationships between students and physicians, and residents and clinical fellows. The UIM dinners are themed around topics of interest to students. Previous topics have included: “Community Service and Mentoring” and “Impact of Finances on Physician Careers.” The dinners are held monthly during the fall and winter quarters. For more information, please contact Irma L Moreno at 514-1390. Save the Date-Dean’s Diversity Event: Dr. Sam Hawgood, Dean of the UCSF School of Medicine, is hosting his annual UCSF Resident and Fellow Diversity Celebration Reception from 6:30-8:30 PM on November 17, 2011. All SOM residents, clinical fellows and faculty interested in increasing and supporting diversity at UCSF are welcome. Rene Salazar, GME Director of Diversity will present an update on activities to promote diversity in GME. Dr. Renee Navarro, UCSF Director of Academic Diversity, will also present a brief update on campus-wide diversity efforts. Recruitment Events: GME is planning a diversity holiday reception on December 14, 2011 for residency applicants, residents, clinical fellows, and faculty. This event is an opportunity for applicants to meet current residents and clinical fellows and learn more about diversity at UCSF. Our fourth annual Second Look Diversity Event for residency program applicants will be on January 20, 2012. In addition to learning more about our training programs, the program provides applicants with the opportunity to meet campus leaders committed to promoting diversity at UCSF. A panel discussion with housestaff and clinical fellows will be held in the afternoon followed by an evening reception. Volunteer Opportunities: UCSF sponsors several student-run clinics in the city. Volunteer preceptor opportunities for residents and clinical fellows are available year-round at the following clinics: Homeless Clinic (provides care to the homeless), Hepatitis B Clinic (focuses on hepatitis B screening in Asian communities), and Clinica Martin Baro (provides free primary care services for Latino day laborers in the Mission). In addition to providing free screening and health care to underserved populations, the clinics also provide a chance to work with first and second year UCSF medical students and undergraduate students from UC Berkeley and San Francisco State University. Contact Dr. Rene Salazar to learn more. National Meetings: Opportunities to represent UCSF at annual and regional meetings for various organizations are also available. Upcoming meetings include the SNMA annual meeting in Atlanta, GA (April 4-8, 2012). Residents or clinical fellows interested in attending or participating should contact Dr. René Salazar, GME Director of Diversity, salazarr@medicine.ucsf.edu.
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GME EVENTS GALLERY 2011 New Resident & Clinical Fellow Orientation
Interns being fit-tested at the Skills Lab.
Incentive Program Fall Symposium August 18, 2011 Faculty Alumni House
Kathryn Crozier, MD, Neurology discusses her incentive goal with fellow program participants
New Interns deciding which lab coat fits best. (l - r) Naama Neeman, MS, Internal Medicine; Krishan Soni, MD, Internal Medicine; Elizabeth Le, MD, Internal Medicine; Francis Wolf, MD, Anesthesia
New interns learning how to collect blood cultures.
Photos by Susan Merrell, University Relations
(l - r) Melissa Catenacci, MD, Pediatrics; Esther Le, MD, Pediatrics; Enrique Terrazas, MD, Laboratory Medicine
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THE OFFICE OF GRADUATE MEDICAL EDUCATION
Fall 2011
G M E
•
S. Claiborne Johnston, MD Vascular Neurology
•
Eric Widera, MD Geriatric Medicine (IM)
Program Coordinators •
Melissa Benson Orthopaedic Sports Medicine
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Kathy Kojimoto Ophthalmology
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Kate Shimshock Medical Genetics, Neonatalperinatal medicine, & Pediatric Cardiology
• •
Hugo Sosa Child & Adolescent Psychiatry Sharlene Thompson Critical Care Medicine (AN) & Pain Medicine Happy retirement to Carol Gould and Elizabeth Settel!
Solve the Summer 2 0 1 0
C y p h e r
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Residents Report
Editorial Staff: Amy Day Paul Day
Many Thanks The Office of Graduate Medical Education would like to thank the following contributors for
Instructions: The above is an encoded quote from a famous person. Solve the cypher by substituting letters. Send your answers to Paul Day in OGME daypw@medsch.ucsf.edu. Correct answers will be entered into a drawing to win a $50 gift certificate!
The Summer 2011 Cypher answer was: Prejudices, it is well known, are most difficult to eradicate from the heart whose soil has never been loosened or fertilised by education: they grow there, firm as weeds among stones. Charlotte Brontë
Congratulations, Charles Stout, Neurointerventional Radiology Fellow, PGY7!!
Important GME Contact Information Office of GME
(415) 476-4562
GME Confidential Help Line
(415) 502-9400
Director, GME Associate Dean, GME UCSF Faculty & Staff Assistance Program (FSAP) GME Website
The
Robert B. Baron, MD, MS
Welcomes New Program Directors And Program Coordinators Program Directors
C Y P H E R
(415) 514-0146 daya@medsch.ucsf.edu (415) 476-3414 baron@medicine.ucsf.edu (415) 476-8279
submitting articles.
Contributors Lisa Cisneros Pat Cornett Jessie Coty Paul Day Maya Dulay Doug Eckman Robin Horak Susan Janson Catherine Lau Elizabeth Le Mary McGrath Susan Merrell Bridget O’Brien Shalini Patel Glenn Rosenbluth Rene Salazar Sue Sheehan Rebecca Shunk Diane Sliwka Rob Starkey Laura Tabatabai Josephine Tan Sandrijn van Schaik
UCSF School of Medicine Graduate Medical Education 500 Parnassus Avenue MU 250 East, # 0474 San Francisco, CA 94143 tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme
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