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VOL.90 NO.6 July/August 2017

“ For more than 40 years, MIEC has been a valued partner of the SFMS and an invaluable resource for our members.”

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SAN FRANCISCO MARIN MEDICINE July/August 2017 Volume 90, Number 6

Medical Education FEATURE ARTICLES 10 Preparing Students for the Future: The Bridges Program at UCSF Catherine Lucey, MD, and Susan Masters, PhD 13 A New Way Forward: First Year of Medical School in a Brand New Curriculum Sarah W. Takimoto

14 Combining Theory and Practice: UCSF's Coaching Program and Clinical Microsystems Clerkship Tenessa MacKenzie, MD; Stephanie Rennke, MD; Nilika Singhal, MD; Edward Cruz, MD, MPH 16 The Bridges Experience: Total Immersion From Day One Emily C. Wong 17 The UCSF Coda Program: The Finishing Touches of Medical School Hueylan Chern, MD, Bradley Monash, MD, and Courtney Green, MD

18 New School: Christine K. Cassel, MD, on Kaiser's Effort for a New Model of Education Steve Heilig, MPH 20 High-Tech Learning: Leveraging Technology to Improve Education Kimberly TOPP, PnD, PT

22 PRIME-US: Program in Medical Education for the Urban Underserved Leigh Kimberg, MD 24 Treating and Teaching: The San Francisco Free Clinic Emily Hurstak, MD, MPH, MAS

25 Pain Beneath the White Coat: Experience is the Greatest Teacher Joanna Jacobs 26 Vital Talk: Mastering Clinical Conversations About Serious Illness Monique Schaulis, MD


Membership Matters


President’s Message Man-Kit Leung, MD


Editorial Gordon Fung, MD, PhD

29 Medical Community News 30 Upcoming Events

OF INTEREST 12 CMA Advocacy Pays Off For Tobacco Tax Funding 27 Health Policy Perspective: Evidence-Based Politics? Steve Heilig, MPH

SFMMS 2017 General Membership Meeting September 11, 6:00 to 7:30 p.m. | Golden Gate Yacht Club Calling all SFMMS members: Join us at our General Meeting on September 11, 2017. Members are welcome to stay for the board meeting immediately following the General Meeting. This is a good opportunity to meet with SFMMS leadership and to learn firsthand the issues SFMMS and CMA are advocating for on behalf of physicians and their patients in San Francisco, Marin and California. Details will be available soon at

Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web:



MEMBERSHIP MATTERS Activities and Actions of Interest to SFMMS Members

Featured Member – J. Nwando Olayiwola, MD Dr. Nwando Olayiwola is a family physician and Chief Clinical Transformation Officer for RubiconMD, a leading provider of electronic consultations between primary care and specialty care providers. She is also currently an Associate Clinical Professor in the Department of Family and Community Medicine at UCSF, where she served as the Director of the Center for Excellence in Primary Care until February 2017. Dr. Olayiwola founded the Association of Minority Women Professionals (AMWP) in 2016. Headquartered in Northern California, AMWP is a women's empowerment organization focusing on supporting, mentoring, motivating and developing women of diverse backgrounds, beliefs and orientations to not only to survive, but to thrive in their professional environments. SFMMS is pleased to welcome Dr. Olayiwola as a new member! Read more about Dr. Olayiwola at

2017 SF Pride Parade

SFMMS was proud to be a part of the San Francisco Department of Public Health (SFDPH) contingent at the 2017 SF Pride Parade. SFDPH broke a contingent record with over one hundred marchers and managed to earn a ribbon for "Absolutely Fabulous Marching Contingent." Special thanks to SFMMS President Man-Kit Leung, SFMMS President-Elect John Maa, MD, and SFMMS Board Member Michael Shrader, MD for participating!

SFMMS Welcomes the Hiroshima Prefectural Medical Association

In July, SFMMS enjoyed its biennial visit from the Hiroshima Prefectural Medical Association. Since 1977, the Hiroshima Prefectural Medical Association (HMA) has conducted health checkups for atomic bomb survivors in North America. As the sister society to HMA since 1981, SFMMS has regularly provided the local affiliation necessary for the team of HMA physicians to conduct these medical examinations. In addition this year, the Hiroshima International Council for 4

Health Care of the Radiation-Exposed (HICARE) hosted a seminar at St. Mary's Medical Center to educate medical personnel about treating atomic bomb survivors throughout the world.

New Video Shows Physicians How to Avoid Medicare Payment Penalties

The AMA has published a short instructional video to help physicians avoid being penalized under the new Medicare Quality Payment Program (QPP). The video, “One patient, one measure, no penalty: How to avoid a Medicare payment penalty with basic reporting,” offers step-by-step instructions on how to report so physicians can avoid a negative four percent payment adjustment in 2019. View the video at To help physicians understand the payment reforms and prepare for the transition, SFMMS has a MACRA resources page at www.sfmms. org/for-physicians/macra-resources-for-physicians.aspx.

Reminder: New Out-of-Network Billing and Payment Law Took Effect July 1

On July 1, 2017, a new law (AB 72) took effect that changes the billing practices of non-participating physicians providing covered, non-emergent care at in-network facilities including hospitals, ambulatory surgery centers and laboratories. The law, signed in 2016, was designed to reduce unexpected medical bills when patients go to an in-network facility but receive care from an out-of-network doctor. Learn more at

Final Budget Agreement Provides Over $1 Billion to Improve Medi-Cal Provider Payments

Last November, the California Medical Association (CMA) took on Big Tobacco to improve access throughout the Medi-Cal program. California voters overwhelmingly approved Proposition 56, which added a $2 tax on tobacco products and stipulated that funds should increase access by improving provider payments. The Governor’s budget proposal redirected all tobacco tax revenues to support the state’s General Fund obligations. Restoring Prop 56 funds was CMA’s #1 budget priority, and we engaged the legislature through earned media, digital advertising, grassroots outreach and direct advocacy. The legislature heeded CMA’s leadership and efforts and the Senate and Assembly approved the state budget, which includes a Prop 56 appropriation bill that provides over $1 billion ($546 million in state funds plus a federal match) for the 2017-2018 fiscal year to improve provider payments. Read more at

CMA To Tackle Three Major Issues at 2017 Annual Meeting

The 146th Annual Session of the CMA House of Delegates (HOD) will tackle three major issues when it convenes October 21-


22, 2017, at the Disneyland Hotel in Anaheim – Health Care Reform, Physician Workforce and Mental Health. The HOD establishes broad policy on current major issues that have been determined to be the most important issues affecting members, the association, and the practice of medicine. Discussions on these major issues are now available for comment. All members are welcome to submit comments online at Contact: Michelle Chapanian, (800) 786-4262 or

Free CME: Child Abuse Prevention, Recognition, Reporting

The Institute for Medical Quality (IMQ) is offering a free online course on child abuse prevention, recognition and reporting. This seventy-five-minute course, created by the Child Abuse Prevention Center in Sacramento, is designed for physicians, nurses and other health care professionals who are mandated by law to report suspected child abuse and neglect, but who may not be familiar with the signs and symptoms. This course will also explain what, when, and to whom to properly report findings. The course is offered free of charge through a grant from the California Governor's Office of Emergency Services. The governor's office hopes that ALL licensed California physicians, nurses and other health care professionals will take this course. Pre-register for the course at

Volunteers for Medical Mission Needed

The PMSNC medical and surgical mission team will be traveling to Santa Barbara, Iloilo, Philippines from January 18-29, 2018. The PMSNC mission team includes a mix of physicians, dentists, optometrists, nurses, students and other allied health professionals. Medical services are composed of primary care, various surgical specialties, ophthalmology and dentistry. Because of the credentialing process, the medical mission team needs completed applications and fee payments by the end of July, but the earlier the better. They are expecting over two-hundred volunteers for this mission. Learn more or apply at www.

2017-2018 SFMMS Membership Desktop Reference




The 2017-2018 SFMMS Membership Directory and Physician Desk Reference has been mailed out to all active physician members. The annual Directory is one of the most valued benefits of membership, and is the only pictorial directory of physicians in San Francisco and Marin. For questions or information about the directory, please contact the membership department at (415) 561-0850 extension 200 or at

CMA’s Practice Manager Tip of the Month Develop a marketing strategy to keep your practice competitive. In today’s constantly changing health care environment, physicians in small and solo practices find themselves at a disadvantage when competing against large groups and large health care systems for access to patients. While a solo or small group physician’s reputation for providing accessible quality of care should go a long way in assuring a stable patient base, the development of a marketing strategy or plan can certainly aid a physician in building and/or maintaining a viable practice. For more information, see “Practice Check-Up: Marketing Your Practice” at and CMA On-Call document #0100, “Accessing Patients: Marketing and Other Steps Physicians Can Take” at WWW.SFMMS.ORG

July/August 2017 Volume 90, Number 6 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Toni Brayer, MD Arthur Lyons, MD Chunbo Cai, MD John Maa, MD Linda Hawes Clever, MD David Pating, MD SFMS OFFICERS President Man-Kit Leung, MD President-Elect John Maa, MD Secretary Brian Grady, MD Treasurer Kimberly L. Newell, MD Immediate Past President Richard A. Podolin, MD MMS Officers President Peter Bretan, MD President-Elect Michael Kwok, MD Secretary/Treasurer Naveen Kumar, MD Immediate Past President Jeffrey Stevenson, MD SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Director of Administration Posi Lyon Membership Coordinator Ariel Young SFMMS BOARD OF DIRECTORS Larry Bedard, MD Charles E. Binkley, MD Peter Bretan, MD Irina deFischer, MD Nida Degesys, MD David T. Duong, MD Benjamin L. Franc, MD Steven H. Fugaro, MD Robert A. Harvey, MD Imran Junaid, MD Naveen Kumar, MD Michael Kwok, MD Raymond Liu, MD Todd A. May, MD Jason Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Ray Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD

Monique D. Schaulis, MD Michael C. Schrader, MD Lori Selleck, MD Dennis Song, MD Jeff Stevenson, MD Winnie Tong, MD Matt Willis, MD Joseph W. Woo, MD Albert Y. Yu, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD








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Medical Education: Training the Model Physician It used to be known as the triple threat—the model physician who was a keen diagnostician, a wise teacher, and a clever scientist. As a clinician, s/he would be shrewd and astute, sleuthing clues from the patient’s history and physical exam findings to arrive at even the most esoteric of diagnoses. As an educator, s/he would be erudite and scholarly, capable of reciting tomes of medical knowledge. As a researcher, s/he would be methodical and logical, conducting experiments that would uncover immutable truths of nature and human biology. Most importantly, the model physician would possess a masterful understanding of the internal workings of the human body. After all, disease, I was taught as a medical student, arises from dysfunction of an individual’s anatomy or physiology and is treated by correcting these internal disordered processes. Nearly fifteen years after medical school, I have come to learn that extrinsic social forces can be as important as intrinsic host factors in the development of disease. Dubbed the social determinants of health, factors such as socioeconomic status, education, employment, social support networks, and access to health care are now recognized as important drivers of health outcomes. For example, based on a meta-analysis of nearly fifty studies, researchers found that social factors, including education, racial segregation, social supports, poverty, and income inequality accounted for over a third of total deaths in the United States in the year 2000.1 Similarly, lower education levels are directly correlated with lower income, higher likelihood of smoking, and shorter life expectancy.2 In fact, the likelihood of premature death in the U.S. increases as income decreases. Medicine is not practiced devoid of social context. Indeed, policy and politics have significant influence on health outcomes. To combat disease, physicians must also master skills needed in political advocacy. Fortunately, medical education has evolved since my medical school days. An increasing number of medical schools and residency programs across the country have incorporated health advocacy as part of their curricula. One pioneering example is Montefiore Medical Center in Bronx, New York. In 2006 the medical center published results of a one-month research-based health activism program for medical students and demonstrated a model for training physician activists to engage in health systems reform.3 A subsequent example is the University of Colorado School of Medicine’s Leadership Education Advocacy Development Scholarship (LEADS) program which provides training to promote community health. Locally, the UCSF Department of Pediatrics residency program offers the Pediatric Leadership for the Underserved (PLUS) track which includes extensive political advocacy education. In fact, residents from the PLUS program WWW.SFMMS.ORG

have been members of the Board of Directors of the San Francisco Marin Medical Society. The adoption of advocacy curricula in medical education has led to a new generation of physicians who are more engaged in the political process and more facile at health activism. One shining example is our own resident member Elizabeth Griffiths, M.D., M.P.H., who recently authored an impressive piece in the New England Journal of Medicine on effective legislative advocacy by medical trainees.4 Her article articulately summarizes lessons learned from campaigns during her medical school and residency training and gives sage advice on how medical trainees can become successful health policy advocates. There are certainly those unique individuals who possess the combination of traits to be the traditional triple threat. They are observant clinicians, insightful teachers, and inventive scientists all in one. However, any definition of a model physician that does not include health activist is outdated. Physicians who eschew political controversy or become inured to politics fail to appreciate the extensive involvement of the social determinants of health on the development and treatment of disease. Moreover, as respected members of the community, doctors have a moral obligation to safeguard the welfare of the infirm and the less fortunate. While intelligence, perceptiveness, and resourcefulness are important characteristics, the model physician, above all, is driven by compassion to advocate for the disadvantaged and the vulnerable. Man-Kit Leung, MD, is an otolaryngologist—head and neck surgeon in private practice and president of the San Francisco Marin Medical Society. He welcomes correspondence at mleung@

References 1. Galea, Sandro et al. “Estimated Deaths Attributable to Social Factors in the United States.” American Journal of Public Health 101, no. 8 (August 2011):1456–1465. 2. Heiman, Harry J. et al. “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity.” The Henry J. Kaiser Family Foundation. 04 Nov. 2015. Web. 16 Jul. 2017. 3. Cha, Steven S. et al. “Description of a Research-based Health Activism Curriculum for Medical Students.” Journal of General Internal Medicine 21, no. 12 (December 2006):1325-1328. 4. Griffiths, Elizabeth P. “Effective Legislative Advocacy— Lessons from Successful Medical Trainee Campaigns.” New England Journal of Medicine 376, no. 25 (June 2017):2409-2411. JULY/AUGUST 2017 SAN FRANCISCO MARIN MEDICINE


Free MACRA Assistance Program SFMMS and MIEC, the doctor-owned professional liability insurance carrier endorsed by SFMMS, have teamed up with nationally recognized subject-matter experts to develop a free program to help physicians maximize reimbursement under MACRA. Half-Day In-Person Seminar: Deep-dive session for physicians, practice managers, and billers to begin developing a plan to earn incentives and maximize reimbursement. Please indicate which session you can attend. • Wednesday, September 6 from 12:00pm – 4:00pm in San Francisco • Thursday, September 7 from 12:30pm – 4:30pm in Marin Online Tutorials and Webinars: Topics covered in the online library of tutorials and recorded webinars include: • Reviewing QRUR reports • Choosing measures strategically • In-depth overviews of each MIPS component MIPS Navigator Online Measure Selection Tool: Free license for online tool that helps you create a customized MIPS plan for your practice. Submit your registration in the following link: For more information, contact SFMMS at (415) 561-0850


Medical Education: What’s New? Everything! Since the landmark Flexner Report back in 1910, medical education has been pretty much taught in a template format. Every U.S.-trained physician remembers making sure that they completed his/her undergraduate pre-medical school requirements and the MCAT. Then four years of formal medical school curriculum, with the first years mainly in lectures and laboratories. During these first two years, we learned some aspects of professionalism, patientphysician interactions and communications by initially shadowing physicians in clinical settings and practicing our patient interviewing skills and diagnostic skills. All these was in preparation for the “best” of medical school with the third year when we were assigned to groups to perform as clerks on clinical rotations that would cover the basics of clinical practice. The fourth year was mainly one of electives that would help to focus further study on a chosen specialty or areas of interest. The goals of this curriculum were to provide physicians with the necessary basic skills and knowledge to diagnose and treat disease. Over the past century, many forces and demands overwhelmed this structured template and made it obvious that the process and content of medical education needed an overhaul. Among the main demands was the sheer volume of new knowledge in basic and clinical sciences. With continued expansion of knowledge of human biology and development of technology to reveal the entire human genome and specific pathways of regulation, metabolism and much more, there seemed to be insufficient time to keep up with providing this “basic knowledge base” to physicians. Thus came calls to add more time to include nutrition, ethics, obesity, pain, and other topics. Additionally, there was significant new knowledge regarding better adult learning methods. It became increasingly clear that attending lectures in large groups was among the most ineffective means of education. A major force was also that healthcare was focusing more on populations and groups with a team approach rather than single physician-patient interaction. There was an evolving science of health systems that needed to be part of the main pillars of medical education —all things that needed to be learned in order to become a successful physician/clinician in healthcare today. In 2013, the American Medical Association set out to transform and modernize medical education in this country by creating and funding a diverse network of medical schools to innovate, share practices, and push the boundaries of traditional medical education. Of the 119 schools that submitted applications to form this network, nine were chosen, including UCSF. This core group was known as the Accelerating Change in Medical Education Consortium and continues to meet regularly since then. The goals of the group were clarified at the outset. They defined the ideal physician as a lifelong student of medicine with a commitWWW.SFMMS.ORG

ment to continuous inquiry, discovery and innovation. They added, in addition to basic sciences and clinical sciences, the third pillar of “Health System science” to the basic core of knowledge for physicians. The ACMEC continues to evaluate approaches that must have measurable outcomes. Evaluation of the learner with specific competencies and milestones rather than just performance on memory based tests is also critical to the changes made in educating physician. Technology advances are here to stay. Medical education needs to continue to utilize and integrate these tools to best utilize them. UCSF has been a leader in this transformation of medical education and in 2016 formally introduced the Bridges Curriculum to the Class of 2020 that restructured the entire four years of medical education from day one. It is definitely true that if any veteran physician came to UCSF or any of the other medical schools in the ACMEC, they would not recognize much of what is now being taught and how it is being taught. There very few large lectures with multiple small group meetings with facilitators. The students as early as first year are presented with clinical cases. The health systems science curriculum is being taught to the first year medical students in Clinical Microsystem clerkships. I had the experience of facilitating a small group with MS1; and the breadth and depth of the discussion and research skills of the students was humbling and inspiring to me. Hopefully, in reading the articles in this issue, you can gain an understanding of the new educational process from the basic premise driving the change, the faculty development involved, the specific courses that continue to provide basic physician skills, and some students’ responses to this new program. The final answer of whether this was a good change can only be seen in the qualities of the physicians in training and when they graduate. We watch with interest as to how this program unfolds. These are the physicians that will be taking care of us. Editor and cardiologist Gordon Fung, MD, PhD, is clinical professor of medicine at UCSF with a practice in consultative general clinical cardiology, and is medical director of the Electrocardiography Lab at Moffit/Long Hospitals and of the nation’s first UCSF Asian Heart & Vascular Center located on the Mount Zion Campus. He is a former SFMS President.



Medical Education

PREPARING STUDENTS FOR THE FUTURE The Bridges Program at UCSF Catherine Lucey, MD, and Susan Masters, PhD The University of California, San Francisco (UCSF) Bridges Curriculum launched in August 2016, representing the culmination of four years of work involving over three hundred faculty, staff, and students. The medical school’s most ambitious curriculum

modification in fifteen years, Bridges will better prepare students for a changing healthcare environment of rapidly expanding knowledge, new science domains, and novel technologies. Bridges moves beyond the one hundred-year-old model of two years of basic science followed by two years of clinical application. In this new curriculum, education on foundational scientific concepts is integrated with teaching about clinical skills and scientific methods throughout the four years. With this strategy, the art and science of medicine continuously reinforce one another. San Francisco is blessed to be a city full of remarkably talented physicians delivering compassionate, patient-centered, high quality care every day. Many of our city’s physicians trained in Northern California institutions. Given the success of medical education systems that trained these wonderful physicians, why change? This is a common question posed when educators nationwide talk about the need to redesign the ecosystem in which our students and residents learn. A close second is a demand for data: prove that this new curriculum will be better than the old one. In 2010, Julio Frenk, then Dean of the Harvard School of Public Health, wrote in an article summarizing the work of a Lancet Commission on Health Professions for the 21st Century, reminding us that the purpose of medical education is to improve the health of our communities and to alleviate suffering from illness and disease. Why change? Because achieving this goal means that we, as leaders in education, must continuously surveil the environment and adapt our teaching to ensure that physician graduates are fully prepared to address and eliminate the health care challenges of the 21st century. How to prove that this is better than the curriculum of yore? Our goal is not to prove that this is better than the education system in place when we were students and residents. The goal is to prove that our physician graduates are perfectly prepared to lead, serve, learn and thrive in the world of medicine that will exist when they are ready to enter practice eight to ten years down the road. “Our new curriculum was designed to amplify the enduring qualities of the very best of San Francisco’s practicing physicians: compassionate, accountable, and expert. In addition, Bridges was created to help physicians master emerg10

ing competencies in interprofessional team-based care, measurement and continuous improvement, and continuous learning through inquiry. These new competencies will help our physicians meet the health care needs of our increasingly diverse patients,” says Catherine Lucey, MD, UCSF’s Vice Dean for Medical Education, Executive Vice Dean for the School of Medicine, Professor of Medicine, The Faustino and Martha Molina Bernadett Presidential Chair in Medical Education, and overall lead for the curriculum redesign.

A Uniquely UCSF Medical School Curriculum

“UCSF was ideally positioned to develop and launch Bridges with its culture of inquiry, continuous improvement, adaptive leadership, and health equity,” says Susan Masters, PhD, Associate Dean for Curriculum who was instrumental to the development and implementation of the Bridges Curriculum. Dr. Masters cites organizational and leadership support that enabled roll-out of the new curriculum, as well as partnerships with health systems (creating and improving high-value patient care through quality and systems improvement work), a focus on systems science (where students are embedded in clinical teams from the start of medical school to understand and improve the patient experience), and the integration of science and clinical skills. “Because of this confluence, the climate here was ‘just right’ for Bridges,” says Dr. Masters. “As a result, our medical school graduates can be recognized by the way they tackle problems, champion inquiry, work in teams, and embrace measurement and improvement.”

A National Movement to Create Medical Schools of the Future

The traditional medical school curriculum launched in 1910 when the Flexner Report resulted in closure of one third of U.S. medical schools. In 2002, the Institute of Medicine released its Health Professions Education: A Bridge to Quality report, which offered a new approach: all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics. The traditional approach to medical education was further challenged by the 2010 Carnegie Foundation-sponsored report titled Educating Physicians: A Call for Reform of Medical School and Residency by UCSF’s Molly Cooke, MD, David Irby, PhD, Bridget O’Brien, PhD, and Lee Shulman, MD. In 2013, UCSF was among the first eleven medical schools funded by the American Medical Association’s Accelerating Change in Medical Education initiative to create the medical


school of the future, in which medical education keeps pace with and adapts to rapid advances in scientific and healthcare knowledge, delivery, and technologies. The American Medical Association further connected these medical schools as a consortium focused on: • Creating virtual healthcare learning systems with authentic clinical data sets, electronic medical records, and interactive ePortfolios; • Developing curricular models and real-world learning experiences; • Conducting a faculty development needs assessment survey ; • Drafting a conceptual model of the ‘master adaptive learner’—an expert, self-directed, self-regulated and lifelong workplace learner—to serve as a roadmap for medical students and schools; and • Establishing a collaborative evaluation and learner assessment approach.

One Year After Bridges Implementation

The Class of 2020 Bridges Curriculum students have completed their first year and are enjoying a summer break. During their first year, they helped pioneer the Foundations 1 phase of the curriculum, which is comprised of four elements:

The Clinical Microsystems Clerkship (CMC): In the CMC, first-year students joined a clinical microsystem ’home’ within their month of school to gain practical experience working in complex health systems to improve the patient experience and overall health care quality. To optimize students’ experience in the CMCs, UCSF’s School of Medicine has partnered with UCSF Health and with its two primary affiliated hospitals—Zuckerberg San Francisco General Hospital and Trauma Center and the San Francisco Veterans Administration Medical Center—to provide these training experiences. “In designing this curriculum, the medical education community sought to ensure that students in the clinics would be prepared to contribute to high-quality care, and not just use the clinical environment to advance their education,” says Dr. Lucey. In the CMC, groups of five or six students are assigned to a physician coach and work within a clinical site one day per week. The microsystem sites are diverse, ranging from family medicine clinics to emergency rooms to in-patient centers. There, groups integrate with clinical teams to tackle quality improvement projects that align with the identified needs of the microsystem. For example, microsystem projects implemented to date are helping students: • Develop a better understanding of barriers that prevent physicians and patients from completing advanced care planning; • Assess the outcomes of patients who have undergone a procedure for back pain according to benchmarks for pain and quality of life measures; • Generate tools to help providers consistently discuss HIV pre-exposure prophylaxis medication with their patients; and • Craft multilingual tutorials to increase non-EnglishWWW.SFMMS.ORG

speaking patients’ access to UCSF’s electronic patient portal. “These projects are a key defining feature of the CMC,” says Dr. Masters. “By offering formalized education around health systems improvement work, UCSF is showing its commitment to broadening the view of medical students regarding factors that affect a patient’s healthcare experience.”

Core Inquiry Curriculum (CIC) & Inquiry Immersion: The Inquiry element of Bridges is a longitudinal thread that provides students the skills to explore the limits of current knowledge and develop an appreciation for the methods of discovery in a diverse set of scientific disciplines. The Core Inquiry Curriculum (CIC) and the Inquiry Immersion course are the first phases of this longitudinal thread. The CIC engages students in weekly clinical cases that present current approaches and issues relevant to the established foundational science students are concurrently learning. Students learn to apply the tools of epidemiology and evidencebased medicine to their inquiry exploration. In the Inquiry Immersion course, small groups of students and a UCSF expert spend two weeks in a ’mini-course’ delving into cutting-edge topics such as academic health and health reform, cancer immunology, climate change, gender and illness, next generation sequencing, and mindfulness. “Inquiry—as we are envisioning it in the Bridges Curriculum—represents a habit of mind for always being curious and interested in the world around us, and having the skills and tools to seek answers in an effective, efficient way,” says Dr. Masters. Foundational Sciences (FS) Blocks: Through a series of foundational science blocks, students learn the core scientific knowledge needed to provide the most effective medical care to future patients. Normal human structure and function are integrated abnormal processes so that students formulate an integrated view of health and illness. Two new FS blocks—Health & the Individual and Health & Society—provide a focused study of social, behavioral, health systems, and population sciences. The learning strategies in the FS are based on modern adult learning principles, with protected time for independent study, a preponderance of active learning sessions, and an assessment system that emphasizes formative assessment for learning. ARCH Weeks: The Assessment, Reflection, Coaching, and Health (ARCH) component of the curriculum—occurring four times throughout Foundations 1—includes activities designed to help evaluate students’ progress, provide a time for personal wellbeing, and allow opportunities to identify new areas of career growth.

Looking Ahead: Bridges in 2018 and Beyond

Next winter, the Class of 2020 students will begin the Foundations 2 (F2) phase of Bridges. This phase advances students’ patient care skills, and builds core concepts in foundational science in a spiral learning education method. In addition to completing their core clerkships, students in F2 will have time to take several Clinical Immersion Experience clinical electives—

Continued on page 12 . . .



The Bridges Program Continued from page 11 . . . two- or four-week electives that provide opportunities for career exploration in areas other than the core clerkships (e.g., apprenticeship, clinical skills building, and sub-specialties), or a deeper exploration of a core clerkship specialty. To conclude F2, students will have time to prepare for and take the USMLE Step 1 exam. The final phase of Bridges, Career Launch—beginning for Class of 2020 students in spring 2019—has fifty-three weeks of dedicated time for students to complete a required Inquiry Deep Explore scholarly project, while also pursuing advanced clinical training that prepares them for their chosen career paths. In Career Launch, students will complete a longitudinal Ambulatory Clinical Experience (ACE), for focused clinical work and preparation related to their residency specialty. “I am so proud of the impact our students immersed in

Bridges have already had on our institution and look forward with great excitement to all that they will accomplish as they launch their careers as UCSF-educated physicians,” says Dr. Lucey. “I know the profession of medicine will be enriched by these remarkable graduates. I am deeply grateful that they chose UCSF to start their careers.” Catherine R. Lucey, MD, is Executive Vice Dean for the School of Medicine, Vice Dean for Education, the Faustino and Martha Molina Bernadett Presidential Chair in Medical Education, and Professor of Medicine. Susan Masters, PhD, is former Associate Dean for Curriculum

CMA ADVOCACY PAYS OFF FOR TOBACCO TAX FUNDING The Department of Health Care Services (DHCS) has released its plan to allocate Proposition 56 funding approved in the recently enacted state budget for supplemental payments to physicians. The Department’s intent is to allocate the funds by CPT Code for certain physician services as part of a one-year supplemental payment program. The program will cover both Medi-Cal fee-for-service and managed care; however, the total dollar amount in the notice reflects only the fee-for-service portion of the funding. CMA’s advocacy efforts surrounding the allocation of Proposition 56 dollars focused on a broader supplemental payment program based on the number of Medi-Cal patients seen. DHCS’s intent in targeting specific CPT Codes is to get funds to physicians as quickly as possible, while ensuring that payments are retroactive to July 1, 2017. As illustrated below, DHCS’s proposal includes significant increases for a number of physician services, including increases of more than fifty percent and in some cases almost double, for most new and established patient office visits. Overall, each one of the selected services in DHCS’s proposal reflects percentage increases in the double digits. CPT Code


2017 Medi-Cal Rates DHCS Proposed % Increase from with 10% cut Rate current rates to proposed rate

90863 Pharm Mgmt w/PSYTX




99202 Level II new pt visit




99201 Level I new pt visit

99203 Level III new pt visit 99204 Level IV new pt visit 99205 Level V new pt visit

99211 Office/Outpatient Visit Est 99212 Office/Outpatient visit Est 99213 Office/Outpatient visit Est 99214 Office/Outpatient visit Est 99215 Office/Outpatient visit Est

90791 Psych diagnostic evaluation 90792 Psych diag w/medical svcs

$20.61 $51.48 $62.01 $74.43 $10.80 $16.29 $21.60 $33.75 $51.48

$115.27 $92.93

*Based on rates as of 1/26/17, California, Area 63 (Sacramento/Placer Counties) From the California Medical Association 12

$35.61 $76.48 $87.01

$124.43 $20.80 $31.29 $36.60 $58.75 $76.48

$150.27 $127.93

73% 49% 40% 67% 93% 92% 69% 74% 49% 30% 38%


Medical Education

A NEW WAY FORWARD First Year of Medical School in a Brand New Curriculum Sarah W. Takimoto The meaning of health and health care is evolving. Practicing physicians have adapted to the electronic medical record, rapid advances in genomic technologies, new data on the social determinants of health, and sweeping changes to health care legislation at both the national and state level. We, the physicians of the future, are entering a field that constantly changes, advances, and transforms. Last year, the University of California, San Francisco (UCSF) introduced the Bridges Curriculum, a new medical school curriculum to educate physicians of the 21st century. It shortens the time before core clerkships and structures this initial time around three curricular elements: foundational sciences blocks, a longitudinal clinical experience, and a research-oriented inquiry program. The transition to a new curriculum is not without its challenges. As exciting as it is to pioneer the next wave of medical education, there is a simultaneous realization that we operate within the greater medical education system, a system that is slow to take up change with us. Standardized tests highly influence our entrance into coveted residency spots, and there is no formal evaluation for components such as advocacy and cultural humility. As institutions work to redesign our education, they must also recognize that medical students come in with our own expectations of what we should learn and experience. This hits at the key fact for all students pioneering a new curriculum. This, the Bridges Curriculum, is all we know. While it is common knowledge that medical school is challenging, we have no reference for what is the norm versus difficulties that come from curricular transition. We depend on supportive faculty and staff to guide us. Through these strong relationships, we are able to experience all that UCSF and the new curriculum have to offer. Bridges captures the essence of the UCSF community and formalizes it into medical education. It starts with a strong foundation of medical knowledge. Instead of descriptions of diseases, our lectures have a clear focus on clinical reasoning. Exams test our understanding using open-ended questions instead of multiple choice. We are asked to go beyond recognition and explain our thought processes to support our answers. This exercise encourages us to dig deeper—to ask why. The inquiry program attempts to further our probing through case-based learning. We independently research learning objectives or gaps in our knowledge that are identified during sessions. Inquiry’s strongest component during the first year was an immersion course that matched students with UCSF faculty who are leaders in their respective fields. Topics ranged from academic health policy to cancer immunotherapy to working with vulnerable populations. Unlike the previous core inquiry WWW.SFMMS.ORG

curriculum, the immersion course appreciated the diversity of my classes’ backgrounds and interests by fostering personalized exploration. In line with the diversity of my peers, the diversity of the larger San Francisco public is an important component of our medical education. We are a public institution with a commitment to care for our quite unique community. Therefore, the start of our clinical training took a step back from taking a history or the basics of a physical exam. Bridges emphasized communication as a foundational clinical skill by giving us techniques to discover patients’ ideas, concerns, and expectations. It is with this foundation that we entered preceptorships in the Spring. Under the watchful eye of a faculty coach and mentor, we became integrated in microsystems and patient populations across San Francisco. Finally, Bridges introduced two new foundational science blocks into the curriculum: Health & The Individual and Health & Society. Here we engaged with topics such as race, identity, and advocacy. We learned about the impacts of social factors on patient outcome and how health is far more than health care. During this time, I developed an incredible gratitude for my peers. Their patience during difficult and awkward conversations was instrumental to creating a safe space. When learning about these topics, there is no perfect assignment; instead, there must be a willingness to listen and share. One strength of Bridges has been the open dialogue between students, deans, and course directors. From multiple inperson meetings and town halls, our feedback has already led to changes for the second Bridges cohort starting in August 2017. My hope is that this will develop into a culture of change. As the practice of medicine continues to evolve, so should our medical education. Improvement that comes through partnering with students, continuing to set new goals, and being open to adaptation will be the new way forward. The Bridges Curriculum spans more than a series of programs or elements; it encapsulates the values of a community. It is these values that equip us to become physicians of the 21st century. Sarah W. Takimoto is a UCSF Class of 2020 Medical Student.



Medical Education

COMBINING THEORY AND PRACTICE UCSF's Coaching Program and Clinical Microsystems Clerkship Tenessa MacKenzie, MD; Stephanie Rennke, MD; Nilika Singhal, MD; Edward Cruz, MD, MPH School’s out for summer break for University of California, San Francisco’s (UCSF) class of 2020 medical students who just completed their first year. Though the faculty aren’t all sitting poolside or vacationing with their families, we are enjoying some well-deserved relaxation after a busy year rolling out the new Bridges Curriculum. Key to the new curriculum is the School of Medicine (SOM) Coaching Program, in which every medical student of the firstyear class is placed in groups of five or six, and each small group is assigned a faculty coach from a diverse range of specialties, clinical sites, and medical education experiences. The inaugural group of twenty-eight coaches met their group of students during orientation week last August, and have continued to work with their students for a full day almost every week since then. Our coaching role is to “provide longitudinal academic guidance and support the students’ professional and personal development,” though in simpler terms, a coach is a combination of mentor, guide, observer, teacher, counselor, advocate, and friend. Unlike some mentorships where the mentor and mentee connect over shared interests or professional goals, the faculty coach-medical student relationship is assigned by the SOM seemingly at random, and we are thrust into an intense immersive experience in the longitudinal Clinical Microsystems Clerkship. The Clinical Microsystems Clerkship (CMC) is an innovative longitudinal clinical skills course based at a variety of clinical sites known as “microsystems.” These microsystems essentially serve as small microcosms of the much larger health systems of UCSF Health, Zuckerberg San Francisco General Hospital, and the San Francisco Veterans Affairs Medical Center. Early learners are embedded in a microsystem where they spend several hours each week developing proficiency working in interprofessional teams, actively practicing systems quality improvement, and learning clinical skills. The CMC sites span a huge array of clinical environments, each overseen by a faculty coach. Students don’t choose their microsystems, so many are placed with their coaches in fields in which they may not have a career interest or even know much about. However, the purpose of the CMC isn’t meant to be an immersive experience in a particular discipline, but rather an environment to train the next generation of physicians through workplace-based learning in health systems science, interprofessional teamwork, and patient experience, safety, and quality. For example, at UCSF Family Medicine Center at Lakeshore, students focused on improving vaccination rates. Jason Parad, a first-year medical student, commented, “Our Quality Improvement (QI) project aimed to increase vaccine uptake through a 14

range of solutions, from electronic messaging to a student-run clinic. It was especially exciting to see our work take root and begin having an impact.” Other students at the same CMC site at Lakeshore worked to improve the integration of oral health care and preventive medical care by surveying staff and providers about gaps and areas for improvement, collaborating with UCSF dental providers to learn a focused oral exam, and working with UCSF Information Technology to create a tool for documenting oral health screens and follow up plans in the electronic medical record. Students working at UCSF Benioff Children’s Hospital focused on learning about the delivery of health care to children admitted to the hospital, and found that sometimes, on transitioning back to the outpatient world, medical plans of action developed on the inpatient side fall through the cracks. These students developed a project aimed at improving the inpatient to outpatient transition of care. Sacha Finn, a medical student assigned to an Infectious Diseases clinic at UCSF Parnassus commented, “My CMC QI project was to make providers more aware of their patients who are on chronic opioids. We put physician-patient pain contracts in place, ordered urine toxicology screens, and trained patients in using naloxone.” Another group of CMC students at UCSF Benioff Children’s Hospital observed instances of unequal access to care for outpatient pediatric patients, citing language barriers as a chief cause. To this end, the student group worked toward improving access to the electronic health record for Spanish-speaking patients. A CMC group working at the 6M Children’s Health Center at Zuckerberg San Francisco General identified that adolescents


seen in the pediatric urgent care clinic had low testing rates for sexually transmitted infections (STIs). The medical students worked with clinic staff to implement a universal testing protocol for all teenagers aged fifteen and older, and consequently were able to more than double testing rates within two months of instituting the protocol. As a result of the project, teens with asymptomatic STIs who would not typically have been tested were identified and treated. Experiences within the twenty-eight different clinical microsystems vary, though all students have made systems improvement efforts and become well-versed in the lean quality improvement framework through creation of an A3 systematic problem solving approach, known within the CMC as a Systems Improvement Template. Many student groups have presented their work at conferences and have plans to submit publications. Students were also encouraged to consider how to make their efforts sustainable, such as turning over their projects to the incoming groups of first-year medical students or handing off their work to other members of the interprofessional teams. Throughout their first year, medical students acquired and practiced other doctoring skills, including taking patient histories, performing physical examinations, and applying clinical reasoning. These skills sessions were made up of the same tight-knit group of CMC students along with their faculty coach and took place during the other half of the CMC day, making for intensive days with robust clinical learning. Students spent the first half of the year learning and practicing direct patient care skills with standardized patients in UCSF’s Kanbar Center for Simulation and Clinical Skills. Working with standardized patients provided a safe space for students to practice such skills as empathizing with depressed patients while keeping composure, visualizing tympanic membranes, learning the basics of abdominal ultrasound, and figuring out a pertinent history and exam for a patient presenting with a vague chief complaint. The Bridges Curriculum design teams thoughtfully scheduled clinical skills sessions to align with what the students were learning in their foundational sciences classes, so the students were able to learn the cardiovascular exam in the same week that they studied the anatomy and physiology of the heart. Later in the year, students progressed to applying their clinical skills with direct patient care in their microsystems, always with the support of their peers and coach. Coach Descartes Li, Clinical Professor in the Department of Psychiatry, commented, “The CMC is a great opportunity to develop a one-to-one mentoring relationship with several UCSF medical students, which gives you a different perspective. Watching them start the journey of medicine reminds me of all the great (and challenging) parts of being a physician. These are the parts that you forget in the business of your day-to-day existence.” A fundamental component of the CMC and coaching program is the creation of a safe and supportive environment in which early learners can test their knowledge and skills and increase student roles and responsibilities over time. Rather than silently wondering if “cellulite” and “cellulitis” is the same thing, as came up during a recent clinical reasoning session involving “the red leg,” the students just ask! WWW.SFMMS.ORG

Conversely, many faculty coaches rarely use their stethoscope at this point in their careers, and have had to brush up on their own clinical skills and acknowledge their limitations. A huge strength of the program is encouraging learners to solicit and incorporate feedback in their practice of professional identity formation. The students and their coaches regularly practice giving and receiving feedback, engaging in critical reflection, and developing individualized goals. Atul Gawande described the idea of a coach for physicians in his piece “The Coach in the Operating Room.” He commented, “the coaching model is different from the traditional conception of pedagogy, where there’s a presumption that, after a certain point, the student no longer needs instruction. You graduate. You’re done. You can go the rest of the way yourself.” The premise of a coach rests on the knowledge that, despite years of intense studying, no physician can ever “be done.” Though this lesson may be obvious to some, the concept of lifelong learning and the potential benefits of coaching for future physicians are boundless. Just as health coaching helps patients build the knowledge, skills, and confidence to manage their chronic medical conditions, at UCSF, we hope to train a generation of physicians who are similarly empowered to transform their professional goals into action. Drs. Tenessa MacKenzie, Stephanie Rennke, Nilika Singhal, and Edward Cruz (clockwise below) are UCSF faculty physicians and inaugural coaches in the UCSF SOM Coaching Program. Dr. MacKenzie is an Assistant Clinical Professor of Family Medicine; Dr. Rennke is an Associate Clinical Professor of Medicine and a UCSF Bridges Curriculum Clinical Microsystems Clerkship Site Director for UCSF Health; Dr. Singhal is an Assistant Professor of Neurology & Pediatrics; and Dr. Cruz is an Assistant Professor of Pediatrics.



Medical Education

THE BRIDGES EXPERIENCE Total Immersion From Day One Emily C. Wong On my first day in the hospital as a medical student, I saw a man falter in the hospital lobby and get rushed into the Emergency Room. He had been picking

up his wife from work at the Zuckerberg San Francisco General Hospital when he felt a sudden tightness in his chest. Within minutes, the medical team mounted an impressive response, orchestrating a quick and coordinated effort to get him the care he needed—first, a firestorm of providers buzzing purposefully around him in the Emergency Room, and then a team of four working quietly to restore blood flow through his blocked coronary artery. As a first-year student in the inaugural year of the Bridges Curriculum at University of California, San Francisco, I witnessed these events through the lens of systems improvement. It was a Thursday afternoon in September, and I was observing the clinical environment in which I would be implementing a quality improvement project through the Clinical Microsystems Clerkship (CMC). As I debriefed my observations from the day with my medical school coach, Dr. Andrea Marmor, I felt energized knowing that this system, complete with effective protocols and good communication, had served its purpose that day: saving a man’s life. In the months since, I have learned many things through the Bridges Curriculum that give context to what I saw that day. Through our Foundational Sciences curriculum, I learned how ST-Segment Elevation Myocardial Infarctions (STEMIs, or heart attacks) are diagnosed, which medications were likely given to this patient upon his arrival, and the name of the artery that was blocked. Through my CMC systems improvement work, I discovered that those seamless protocols I witnessed did not come into place overnight; and that effective communication between team members and departments requires sustained effort. In the Health and the Individual and Health and Society curricular blocks, we discussed structural determinants of health, and I learned to recognize the forces outside of the man’s acute diagnosis—including personal identity, politics, language, and wealth—that played instrumental roles in shaping his access to and interactions with health care. And through the Coaching Program, in which a physician coach spends one day per week with five to six medical students working on clinical skills, I gained an appreciation for the open communication and compassion that the medical team showed the patient’s wife in the Emergency Room as she looked on nervously from a corner of the room. Still, I have at times felt overwhelmed by the magnitude of things we encounter in medicine. I was overcome with grief after scrubbing in on an organ procurement operation, in which the organ donor was exactly my age, with a family that delayed 16

the procedure by a few hours because they were having a hard time saying good-bye. And I was infuriated by Congressional attempts to repeal the Affordable Care Act, knowing that access to routine preventive care was a major reason that a patient with chronic pancreatitis and diabetes was able to stay out of the hospital. Through our curriculum, I have learned about the process for placing individuals on the organ transplant list, engaged in conversations with classmates about the interplay between policy and medicine, and even attended classes dedicated to critiquing and writing op-eds to advocate for our patients. But I’m still figuring out how to bring what I’ve learned into practice; how to make sense of these broad concepts in the context of real-world patients, hospitals, and clinical settings. Luckily, I have a wonderful partner in this journey—my coach, Dr. Marmor. Our coaches serve dual roles as instructors and mentors throughout medical school, and Dr. Marmor has enthusiastically cheered alongside me after small successes while being a generous listener when I’ve needed to process more difficult days. Having a coach with whom to debrief difficult clinical encounters, discuss my academic progress, and develop a plan to get me from first year to residency has been a major highlight of the Bridges Curriculum. As I continue to grapple with the practical and emotional challenges that come with being a clinical care provider in the context of an immensely complex social environment, I take comfort in knowing that the Bridges curriculum has given me exposure to some of these things already—and that my coach will be there to help guide me through the rest. Emily C. Wong just completed her first year of medical school at UCSF. She is the advocacy chair of UCSF’s Students for Organized Medicine, a student group dedicated to promoting activism through policy, advocacy, and service.


Medical Education

THE UCSF CODA PROGRAM The Finishing Touches of Medical School Hueylan Chern, MD, Bradley Monash, MD, and Courtney Green, MD Among the numerous milestones in the life of a physician, for many the transition from medical student to resident physician perhaps remains the most daunting. Patients replace textbooks, treatment

plans supplant examinations, and patient outcomes supersede grades. This challenging and stressful transition can be physically and emotionally exhausting. Filled with uncertainty and many new responsibilities, new interns experience a steep learning curve—from day one they need to navigate complex health systems and deliver competent, appropriate, and highvalue patient care. The “July phenomenon,” a perceived increase in the risk of medical errors that occurs in association with the beginning of residency, has been widely publicized and described in the medical literature. Educators have attempted to address many of these challenges by developing preparatory courses for the fourth year of medical school, aiming to bridge the gap between the clinical, professional, psychological and emotional demands of medical school and residency. Preparatory courses run the instructional design gamut, from boot camp experiences focusing on specific specialty training to more all-inclusive courses that cover more generic transition principles applicable to all specialties. In 2001, the University of California, San Francisco (UCSF) School of Medicine responded to these needs with the development and implementation of a multidisciplinary, integrated, capstone course for all graduating medical students. Coda (as in the concluding passage of a piece or movement) takes place during the last three weeks of medical school. Designed to prepare students for residency and the demands of physician-hood, Coda cultivates a sophisticated, purposeful and holistic educational experience that consolidates core clinical and systemsbased knowledge, hones critical resuscitative and procedural skills, and fosters innovative strategies to enhance personal well-being. Insights from residency program directors, recent medical school graduates, and respected leaders in medical education formed the basis of a comprehensive list of competencies necessary for the successful transition to internship. These were further honed through cross-referencing with the six Accreditation Council for Graduate Medical Education (ACGME) core competencies, and more recently the ACMGE milestones. Through ongoing student feedback and bi-annual review from UCSF’s educational oversight committees, Coda has evolved into a celebrated and highly anticipated foundational component of UCSF medical student training. The schedule consists of morning large group didactics and individualized afternoon small group sessions. Lectures cover WWW.SFMMS.ORG

high-yield topics relevant to all providers, including clinical reasoning, medical liability, resident well-being, and the management of common and emergent medical conditions. The small group sessions consist of workshops, panel discussions, and simulation exercises that focus on clinical processes (e.g., medication reconciliation, family-centered rounds), procedural skills (e.g., central line placement, chest tube management), and anxiety provoking topics (e.g., making mistakes as an intern, top ten overnight calls for various disciplines). There are also sessions that focus on work-life balance, the political challenges of working in a hierarchy, planning and managing finances, and professional development in residency. The success of Coda is an exploratory analysis published in Academic Medicine, co-authored by the course originators.1 Coda increasingly offers opportunities for individualized, specialty-focused content review and skills training. The small group sessions are offered as “selectives,” with student interest and participation based on their future residency training. The curriculum houses a parallel track for pediatrics-bound students. Students headed into the more procedurally oriented fields of obstetrics and gynecology, emergency medicine and surgery may enroll in their respective competency-based immersion experience (COBIE). These longitudinal “courses within a course” offer closely mentored break-out sessions hone the requisite knowledge and skills for students to hit the ground running on their first day of internship. The educational system has recognized the importance of such training, as demonstrated through a statement released by joint surgical organizations (American Board of Surgery; American College of Surgeons; Association of Program Directors in Surgery; Association for Surgical Education) that “all matriculates to surgery residency successfully complete a preparatory course . . . before the start of their training.” Specialist medical educators developed their respective COBIEs with detailed attention to the core cognitive and technical skills required by trainees. Students receive focused instruction with close supervision and engagement from faculty mentors. For the surgery COBIE, interactive sessions cover an intensive review of technical skills, ward management and communication skills. Course facilitators teach ward management content through hands-on instruction involving mock pages that reflect common post-operative conditions. These practical scenarios simulate urgent, potentially life threatening post-operative ward issues that the interns may face alone while other residents are scrubbed in the Operating Room and not readily available. They aim to highlight early recognition, immediate actions, when to request assistance, and how to

Continued on page 19 . . .



Medical Education

NEW SCHOOL Christine K. Cassel, MD, on Kaiser's Effort for a New Model of Education Steve Heilig, MPH Christine Cassel, MD, is a leading figure in geriatric medicine, medical ethics and quality of care and has been President of the National Quality Forum, American Board of Internal Medicine and American College of Physicians. She chaired Institute of Medicine reports on end-of-life care and public health and is author or co-author of fourteen books and more than two hundred journal articles. She edited four editions of Geriatric Medicine, a leading textbook, and completed a bioethics health policy fellowship program at the University of California, San Francisco (UCSF). Cassel is the Planning Dean for a new Kaiser Permanente School of Medicine opening in Los Angeles in 2019 and we asked her for a summary of this effort.

What was the impetus for this new medical school? Kaiser Permanente (KP) has been training residents for over forty years, in many specialties, with collaborative relationships with medical schools. It's a different kind of experience here for residents because of our distinct system. The Kaiser board considered creating a medical school for some time, starting with the vision of a group of Kaiser physicians who worked on the idea for eight years. It's an organization devoted to delivering affordable quality care to members, and for some the idea of a medical school seemed a bit of a stretch. But as the country moves towards new models and using data to improve such care, the leadership saw the medical school as another way to create a useful model for our country when so much is changing.

Let's get this up front—some have surmised Kaiser is doing this mainly because they need more doctors trained in the Kaiser model and the school is to be a kind of "feeder" for KP.

Yes, that has been questioned. It does take time for new physicians to work best in our system and I could see how it might seem we are hoping to train our own. But that's not the case; it's actually to be a very small school, starting with 48 students per class for the first four years at least, and we have 22,000 Permanente physicians now, so this is a drop in the bucket and it would hardly be efficient to start a whole school for that reason. What we are doing is testing a hypothesis that we can improve care by embedding students in an integrated system of care.

There have been so many high-level efforts to reform and improve medical training, going back a century to Flexner and onward; are you using such reports to guide your new school?

We're part of the group called Beyond Flexner (; their focus is on social missions in health professional education. We do want to be very respectful of the tra18

ditional Flexnerian model, which was that students should be taught in a research university with more evidence-based focus than before, with students taught by those at the cutting edge of all areas of science and medicine, and multiple clinical relationships. The message students get is often dependent on where they are rotating, with varied strengths and frustrations, and with education competing with other missions such as research. So we join those who want to give more attention to best teaching, and elevate faculty who are the best teachers. That has been difficult in an NIH-funded research culture. Our students will be embedded in a clinical system where they have all the data available on each patient, where specialists are highly dependent on primary care and the patient also has electronic access to all their data—52 percent of KP interactions with members are done electronically already, so that is much more efficient for the patients who have to come into the office less. Teamwork is paramount too, with interdisciplinary teams of doctors, nurses, social workers, pharmacists involved in teaching as well.

So is this a refocus on primary care as so many have recommended?

This school will be focused entirely on primary care physicians. The training and system will be built on respect and the integral importance of primary care. Students who want to to focus on molecular biology research should go to another school and we will make that clear. The research these students will do will be based on population data, as we have a very rich database there. Of course we will teach basic science, anatomy, physiology, etc, but we are hiring faculty there based mostly on their teaching expertise. Much will be done in small-group settings rather than large lectures. It is being shown that students learn better that way—in fact, it's harder to re-train faculty in some of these curriculum changes!

Do you see this as also an attempt to address future physician supply problems?

There is debate about exactly how many and what kind of new doctors are going to be needed, of course. I think nobody debates that we need new physicians equipped to practice in the rapidly-changing medicine we now live in. Our students are going to just be starting practice in 2030—how in the world can we know just what that will be like? So we need to equip them with the best understanding of technology, their communities. and the evolving roles of physicians and practice, especially as part of a team. That's what this effort is all about.

How about diversity concerns, voiced by so many?

Diversity in terms of social, ethnic and racial diversity but


The UCSF Coda Program Continued from page 17 . . .

also economic diversity, is something we are committed to addressing. Right now 60 percent of U.S. medical students come from the top 20 percent of income, and 3 percent from the bottom 20 percent. We will have not only scholarships but look at better pipelines for disadvantaged students.

Will the school seek to address high medical school debt?

We are opening in 2019, and the first two classes, for their whole four years, will be tuition-free. After that it will average 50 percent support and I suspect it will be more, as we haven't begun fundraising for these purposes.

This is a kind of a temporary, "consultant" role for you, correct?

Yes. I am not a Permanente physician, although I was on their board for over a decade and have long been an admirer of their system. I've been in academic medicine and was a Dean at Oregon Health and Sciences University. We'll be hiring a new founding Dean and board, and so forth. So credit should go to Kaiser leaders who conceived and will be following through on this very large project. The last time a medical school was developed without an affiliated university was Mayo over forty years ago, and their concept was similar, in that they wanted it to not be a university, research-oriented culture, but with a clinical focus and culture. Right after Kaiser made it's announcement in 2015, Geisinger announced it was merging with or acquiring a struggling medical school to train students in their model of care. So it's kind of interesting that with more integrated systems now, we may see other schools along these lines developing in the future. For more information, see: WWW.SFMMS.ORG

accurately present patients in a concise manner. The technical sessions review preparation for operations, obtaining surgical consents, core operative principles, and basic surgical skills such as knot tying and suturing. These skills are further reinforced by an innovative home video curriculum made possible through shared research development and curricular collaboration between the UCSF Surgical Skills Center and Practice, an innovative technology company. The curriculum uses a mobile application with video capture to foster deliberate practice and self-reflection. Completed home video assignments are uploaded and reviewed by peers and faculty for individualized feedback. Early experience with the surgery COBIE has revealed improved student confidence and technical performance.2 As medical educators, we need to continue to innovate and creatively revise and revamp undergraduate medical curricula to meet the changing demands of medical education. The UCSF Coda course with its embedded flexible, individualized, and competency-based educational opportunities exemplifies such effort, and may serve as a template for other institutions. Through providing students with didactics and small-group sessions applicable to professional development and clinical training across disciplines, and further offering tailored longitudinal curricular experiences, we are able to deliver a compact and high-yield preparatory course and capstone medical school experience for all. Hueylan Chern, MD, is a colorectal surgeon at UCSF Medical Center. She specializes in laparoscopic procedures for conditions such as colorectal cancer, inflammatory bowel disease and diverticular disease. Bradley Monash, MD, is Associate Chief of the Medicine Service, and Assistant Clinical Professor of Internal Medicine and Pediatrics at UCSF school of medicine. He also serves as the Site Director at Moffitt-Long Hospital for the UCSF Internal Medicine Residency, and as Co-Director of Coda. Courtney Green, MD, is a Resident Research Fellow in General Surgery at UCSF.

References 1. Teo AR, Harleman E, O’Sullivan PS, Maa J. The Key Role of a Transition Course in Preparing Medical Students for Internship. Academic medicine: Journal of the Association of American Medical Colleges. 2011;86(7):860-865. 2. Green CA, Vaughn CJ, Wyles SM, O’Sullivan PS, Kim EH, Chern H. Evaluation of a Surgery-Based Adjunct Course for Senior Medical Students Entering Surgical Residencies. J Surg Educ. 2016 Jul-Aug;73(4):631-8.



Medical Education

HIGH-TECH LEARNING Leveraging Technology to Improve Education Kimberly TOPP, PnD, PT When I enrolled in graduate school thirty years ago, PhD students were placed in anatomy classes with the first-year medical students, but we did not “mix” professionally. We took gross anatomy, histology

and embryology as individual, quarter-length courses. We took paper-based tests and recounted anatomical facts. It was in the research lab that I learned to think critically. Today, technology, amazing scientific developments and novel clinical approaches are compelling curricular reform. Today’s medical curriculum is significantly different from my experience, and comprises systems-based, multidisciplinary courses of a few weeks’ duration. At UCSF, like other schools, the discipline of anatomy is dispersed and integrated throughout the four years of medical school, and beyond. And interprofessional practice and education are emerging necessities. Cognizant of the importance of the educational environment for learning, we sought to enhance the learning of anatomy by designing a comfortable space for learners and educators, a space that facilitated group interaction and peer- and near-peer teaching and learning, and a “safe” environment to err, improve and discover. We brought together PhD and DSc faculty, well versed in educational scholarship, clinical care and the anatomical sciences. In the footprint of the original anatomy lab on the 13th floor of the Medical Sciences building, we developed the Anatomy Learning Center, a technology-enabled, state of the art facility for interprofessional education in the anatomical sciences. With views of the Golden Gate Bridge, medical students learn foundational anatomical terminology, structural relationships, and anatomical variation through dissection and exploration of pre-dissected cadavers, which were donated for education and science to the UCSF Willed Body Program. Health professions education is evolving and UCSF is advancing apace, preparing learners for early and evolving clinical practice. Carefully designed facilities and controlled air flow in the Anatomy Learning Center has allowed for the use of unembalmed cadavers, enabling medical students to practice emergency procedures, such as endotracheal intubation and intraosseous infusion, and office procedures, such as synovial joint infusion and aspiration. Interns, residents and fellows practice surgical procedures, such as laparoscopic cholecystectomy and hysterectomy, and ultrasound-guided local anesthesia. Clinical faculty teach alongside core anatomy faculty in the Anatomy Learning Center, introducing early career students to various specialty areas and teaching them about the clinical relevance of anatomical variation and detail. Interest is piqued as residents learn procedures directly from fellows and attending physicians in a “safe” environment, and early career students observe the culture of life long learning and improvement. 20

Technology is changing how we learn and practice health care, and UCSF is leveraging the movement. The Anatomy Learning Center is equipped with wireless technology and 100 iPads, enabling students to download faculty-designed lab guides and conduct real-time searches for primary literature and anatomical images. Faculty instructors carry in the lab iPads with atlas images that can be rotated and expanded to increase students’ understanding of key concepts. Faculty and students project images and video, as well as dissection and laparoscopic demonstrations, from their iPads to 72-inch high-definition wall displays in the laboratory and the adjacent high-tech classroom. Wireless technology and image and video projection allow for integrated learning of gross anatomy and the related fields of histology, embryology, and anatomical imaging. Moreover, 3-D printing of anatomical structures will be introduced this year. Students’ spatial awareness is improved by observing the details necessary for 3-D printing, as well as by observing sectional images, rotatable models and laparoscopic views concurrent with dissected cadavers. Clinical practice is advancing rapidly, and we are driving change in education to improve the patient care provided by students and graduates. As an example, ultrasound imaging is now a bedside or clinic procedure and the Anatomy Learning Center houses three mobile ultrasound machines. Medical students now become proficient in FAST (focused assessment with sonography in trauma) exams, and physical therapy students observe in real-time the contraction of skeletal muscles and gliding of nerves that occurs during limb movement. Often these health professions students learn together, facilitating their understanding of team members’ abilities in interprofessional practice. A second example of anatomy helping to advance clinical practice of health professions students may be seen in the incorporation of “trans-anatomy” education in the medical school curriculum. UCSF led the field with the first national course on the “Anatomy of Gender Transition,” incorporating not only demonstrations of surgical procedures, but importantly, patient experience and guidance on inclusive, patient-centered care. This course was developed to facilitate dialogue and diversity in medical schools across the country, and the educational content will be incorporated this year into the Foundations 1 curriculum for the UCSF medical school. A large component of higher education is learner assessment, and there has been significant change here, as well. Within the integrated, systems-based curriculum, students are provided formative self-assessment questions and group-based quizzes in the anatomy lab. Students are accountable for each other’s learning and work together to reason through difficult


questions, just as they will in the clinical environment. In the past, course examinations were focused on factual knowledge. Today’s summative assessments acknowledge that facts are readily available through reputable sources. Thus, course assessments examine a student’s ability to locate and utilize available resources, synthesize and prioritize important information, and demonstrate clinical reasoning in narrative format. A personalized and detailed “dashboard” of one’s progress through the curriculum is made available to each student. The ability to explain one’s clinical rationale and to self-assess in professional development are skills that will serve students well in the challenging environment of clinical inquiry and practice. It is our responsibility to ensure that our graduates are well prepared to lead and participate in highly effective interprofessional teams to provide for our patients and populations. As such, the UCSF Program in Interprofessional Practice and Education has developed coursework, a documentation system, and competency guidance to facilitate interprofessional practice and education. Acknowledging that each school has professionspecific competencies and collectively the professions have common competencies that facilitate team-based patient care, the Program in Interprofessional Practice and Education has focused on interprofessional competencies that must be taught and learned in an interprofessional setting. These include understanding teams, knowledge of roles and responsibilities, effective delegation and follow-up, usual and crisis communication, conflict management and continuous learning. UCSF students from all schools participate in the Core Principles of Interprofessional Practice course, which includes modules on introductory concepts, team member roles and responsibilities, communication and accountability, conflict management and negotiation, and leadership and membership, and students then work together to apply these skills in the care of a standardized patient. Throughout their education, students engage in interprofessional learning and practice in areas of interest, and will soon track their participation in the new UCSF IPE Passport system. It is clear that UCSF is at the forefront of education for our health professions students! Kimberly S. Topp, PT, PhD, FAAA, is Professor and Chair, Department of Physical Therapy and Rehabilitation Science, and Professor, Department of Anatomy, UCSF School of Medicine.


Presented by the Asian Health Institute Department of Medicine University of California, San Francisco


Asian Health Symposium Laurel Heights Conference Center • 3333 California Street • San Francisco, California


Gordon Fung, MD, MPH, PhD Professor of Medicine, UCSF Diana Lau, PhD, RN, CNS Assistant Professor School of Nursing, UCSF STEERING COMMITTEE

Peter Chin-Hong, MD John Inadomi, MD Andrew Ko, MD Gene Lau, MD Byron Lee, MD Don Ng, MD Eugene Yang, MD

October 6-7, 2017


October 6 -7, 2017




Medical Education

PRIME-US Program in Medical Education for the Urban Underserved Leigh Kimberg, MD Achieving health equity for individuals and communities in California, the most diverse and populous state in our country, requires a diverse healthcare workforce equipped to provide culturally accountable healthcare and public health leadership. In 2006, a California legislative initiative (Prop 1D) was

used to support the expansion of medical school classes in the University of California (UC) system to create a diverse workforce trained to eliminate health disparities.1 Benefiting from state, foundation, and individual donor support, Program in Medical Education for the Urban Underserved (PRIME-US) was piloted in 2006 and launched in 2007 at the University of California, San Francisco (UCSF) and the UCSF-University of California, Berkeley Joint Medical Program (JMP) with the mission to, “nurture, support and equip participating medical students to become leaders in underserved care.” PRIME-US is a highly selective five year curricular program which admits students, after admission to UCSF or the JMP, who have already demonstrated a commitment to serving underresourced communities and promoting health equity. Each PRIME-US cohort is remarkably diverse; over the past decade, PRIME-US students self-identify as coming from the following backgrounds: 59 percent “under-represented in medicine” or “UIM” (as defined by UC as: Black/African American, Latino/ Hispanic/Chicano, Native American/American Indian, or Asian Pacific Islander), 86 percent racial/ethnic minority, 52 percent socio-economically disadvantaged, and other aspects of diversity including sexual orientation and gender identity minorities, first-generation to college, first language other than English, first and second generation immigrants, and more. These remarkable PRIME-US students participate in a robust curricular program, in addition to the medical school curriculum, that includes: a summer Introduction immersion experience, a seminar series and site visits, a community engagement program, clinical placements in underserved settings, a Capstone course, a leadership program, a master’s degree or research fellowship, a mentorship and support program, and an outreach program. The PRIME-US curriculum is based upon community engagement and leadership competencies developed by PRIME-US stakeholders and health equity competencies developed by UCSF and community stakeholders through STEP UP. PRIME-US is grounded in a health equity perspective2 and draws upon the concepts of “cultural humility”3 and asset-based health promotion to guide our work. The process of reflection is incorporated into each learning experience to deepen the students’ engagement and understanding. The curriculum is highly dynamic; our seminar series and site visits are designed each year to reflect the interests of each student co22

hort, trends in health disparities and equity, and the input of our community partners. Rather than sitting in a classroom, PRIME-US students can be found in the Tenderloin assisting the ‘corner captains’ from Tenderloin Safe Passage, interviewing stakeholders for the ‘Roadmap to Peace’ community initiative, surveying patients about healthy food access at Southeast Health Center, learning about the community health worker program at the Women’s Community Clinic, preparing a policy brief about neighborhood drinking water access in partnership with UCSF and the San Francisco Health Improvement Partnership (SFHIP), or teaching middle school students about lung physiology, asthma, and air pollution at the Junior Doctor’s Academy in Fresno, California. By the time the PRIME-US students participate in the final-year Capstone course they are able to make substantive contributions to the work of our community partners. Throughout their participation in PRIME-US, students are encouraged to apply for small PRIME-US grants to support their required community engagement projects. Students work individually or in groups to practice community engagement principles through partnerships with community organizations. Many of our students’ community engagement projects include mentoring of diverse young students from minority and underresourced backgrounds. Each year, PRIME-US students, staff, and faculty provide outreach and mentorship to approximately 1,000 students, from elementary school to post-baccalaureate programs. PRIME-US is now fulfilling its promise to diversify the workforce and promote health equity. PRIME-US has matriculated 157 students and graduated 95 students. During their participation in PRIME-US, 69 percent of students complete a masters’ degree or research year in order to gain additional key public


health leadership skills. While most PRIME-US graduates are still in post-graduate training, we know that 51 percent have chosen primary care fields (pediatrics, family medicine, medicine) and an additional 38 percent have chosen fields (med-peds, emergency medicine, Ob/gyn, psychiatry) that are under-subscribed, especially in underserved communities. All PRIME-US graduates who have completed their training are serving underserved communities in academic institutions or non-profit healthcare organizations that have a social mission or in community health centers. PRIME-US has come ‘full-circle’; Dr. Monica Hahn, a member of the first PRIME-US cohort, is now a PRIME-US faculty member. And, led by the PRIME-US Administrative Program Director, Aisha Queen-Johnson, MSW, aspects of the PRIME-US community engagement curriculum are now being adopted by UCSF for all incoming medical students. PRIME-US’s success is articulated most beautifully by our students who have described PRIME-US as “an eco-system for creating health equity” (S. Noori) and remarked that “…everyone has ‘an activated social justice nerve’ . . . PRIME –US is a vehicle for keeping that activist/advocate spirit alive and shining brightly through the sense of community, the community partnerships, and the support.” (D. Kim) PRIME-US students value the mentorship and support from their student peers, staff, and faculty and feel that they are able to learn deeply through their participation in a trusted community in which “[we] can be vulnerable. [We] can share our stories.” (S. Noori) In the highly diverse PRIME-US learning community there is a constant interplay between the provision of respectful, trustworthy support and active engagement in the reflection process. This interplay is critical in the development of PRIME-US students’ leadership skills. After a decade of experience, PRIME-US has demonstrated that a mission-driven curricular, mentorship, and support program can graduate physician-leaders who will make significant contributions to health equity in California and beyond. Leigh Kimberg, MD, is a Professor of Medicine in the Division of General Internal Medicine at SFGH, UCSF and the Program Director of PRIME-US. For the past two decades, she has been a primary care provider at Maxine Hall Health Center and the Richard Fine People’s Clinic and has done violence prevention work for the San Francisco Department of Public Health.

An Appeal to Senators’ Consciences and Oaths on the Health Bill A health care ethicist says that senators, like doctors, should be guided by their sense of human decency and professional oaths. To the Editor: Re “Official Estimate Imperils Support for Health Bill” (front page, June 27): As a health care ethicist, I am often called upon to help doctors and others make tough decisions for people who are very ill. I regularly see medical professionals do all they can for such patients, regardless of their finances or insurance status. Beyond their sense of human decency, these professionals have taken oaths that compel them to do this. As elected officials, senators also take oaths to serve the American people—not corporations, or some ideology or even the president. Given that virtually every relevant professional group opposes the Republican repeal bill, and that it will demonstrably hurt millions of people, any senators voting for it would clearly be violating their own oath of office. As they consider their vote, which has now been postponed, I hope they will remember that. Future historians—and voters—certainly will. —STEVE HEILIG, SAN FRANCISCO This letter was reprinted from the New York Times, June 27, 2017

Tracy Zweig Associates INC.






~ Physicians ~ Nurse Practitioners Physician Assistants

References 1. Nation, C., Preparing for Change: The Plan, the Promise and the Parachute. 2. Braveman, P., What Are Health Disparities and Health Equity? We Need to Be Clear. Public Health Reports, 2014. 129(Suppl 2): p. 5-8. 3. Tervalon, M.a.M.-G., Jann, Cultural Humility Versus Cultural Competence - A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. J. Health Care Poor Underserved., 1998. 9(2): p. 117-25.


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Medical Education

TREATING AND TEACHING The San Francisco Free Clinic Emily Hurstak, MD, MPH, MAS

The San Francisco Free Clinic (SFFC) is a primary care clinic founded in 1993 by two family medicine physicians committed to care for underserved patients. The clinic’s mission is twofold: to provide medical

care to individuals without health insurance AND help train future providers of medical care through an established community medicine rotation. The clinic treats the full range of acute and chronic illnesses, but places a special emphasis on preventive/primary care. Each of the clinic’s six attending physicians has academic appointments at University of California, San Francisco (UCSF) and Yale School of Medicine and share a commitment to teaching. Apart from the two founding physicians, Drs. Richard and Patricia Gibbs, our current attending physicians chose careers at SFFC after having positive experiences working at SFFC during their own clinical training. As a sub-internship in community medicine, the SFFC serves as a training site for third and fourth year medical students. Medical students complete a four-week rotation at the clinic; approximately twenty students complete the rotation each year. Students focus on mastering advanced history taking and physical exam skills, as well as concise and wellreasoned patient case presentations. Students often present clinical cases and learn nuanced exam skills and differential diagnoses at the patient’s bedside. Medical students are expected to function at the level of an intern (R1) to prepare them for their next step in clinical training. Over the years, SFFC has received overwhelmingly positive feedback from students rating their time at SFFC as one of the best clinical rotations. Initially, UCSF School of Medicine asked the clinic to act as a training site for the community medicine rotation, and for the past twenty-four years the clinic has served as a training site for Yale and University of Southern California in addition to UCSF. Stanford Medical School began sending students to the clinic in 2017. SFFC also provides a clinical training site for residents in the fields of internal medicine (UCSF) and psychiatry (California Pacific Medical Center). Residents participate in clinics one to two times a week (or more in the case of psychiatry trainees) during their outpatient training time—usually for a period of two to four weeks at a time. Approximately thirty residents participate in clinical opportunities at SFFC each year. SFFC’s teaching commitment is global—to expose trainees to the reality of caring for patients in a safety-net clinical setting and to nurture interest in careers serving undeserved patient populations. Students and trainees are not only exposed to primary care medicine, but they also have the oppor24

tunity to learn sports medicine orthopedics skills by joining Dr. Richard Gibbs in his sessions as the supervising physician for the San Francisco Ballet. Finally, SFFC provides a training pipeline for premedical students and students interested in pursuing careers in the health sciences. Volunteers help with clinic operation—they are trained in medical assistant skills, front desk and scheduling skills, assist patients with new patient surveys, and other related activities. Many volunteers go on to successful careers in medicine. For example, six of the clinic’s volunteers were accepted to medical school in 2016. A premedical student from Williams College in Massachusetts joins SFFC each summer for several months as part of the Williams Alumni Sponsored Internship Program. This student learns clinical skills and is required to write a thesis on an aspect of healthcare which is presented to the clinic staff at he end of the summer. Finally, SFFC offers a paid summer internship to two local Washington High students—a unique opportunity to introduce young teens to a possible career in healthcare. The array of motivated students and trainees involved in SFFC clinical activities invigorates the clinic with obvious benefits in clinic functioning and patient care. A patient receiving care at SFFC has the opportunity for more one-on-one attention than is available in most primary care settings. Furthermore, patients often appreciate the opportunity to train future healthcare providers, offering feedback about patientcentered empathic care. At SFFC, we are incredibly lucky to receive tremendous support of the local Bay Area medical community who support us through physician volunteerism and the provision of free medical services to our patients. We are also highly fortunate to be involved in training future healthcare providers. For more information please visit our website:


Medical Education

PAIN BENEATH THE WHITE COAT Experience is the Greatest Teacher Joanna Jacobs

I peel the pads off the plastic cover and place them carefully on my stomach. I turn the device on. What level

will I go up to today? I’m going to be walking in the hospital today, so I need to control my pain. Up to level nine, no not enough. Level ten. Today, instead of the patient’s gown, I put on the white coat. I have the wire from the TENS machine wrapped around my body and the remote in my pocket so that I don’t offend anyone with my double status. I feel like a secret agent, the patient in doctor’s shoes. I am a third year medical student just starting rotations. I carry my pain with me every day, just another lens I live through. I see patients suffering and I see their care team trying to determine treatment. The providers I work with deliver generations worth of knowledge and a striking amount of compassion to each patient interaction. While their intention and expertise are inspiring, practitioners at all levels can gain insight from hearing descriptions of chronic pain. After my relationship with pain, I can’t help but analyze it, pull it apart, and learn from it. We rarely talk about pain and we have very little training in what pain truly means for the patient. If we dove deeper into the subject as medical students and as practicing physicians, in addition to learning how to treat chronic pain with medication, we might begin to understand that from patients’ vulnerability comes resilience and strength. By understanding what this sensation does to the body and mind, we can offer assistance and heal in a more tailored way. We can honor and destigmatize suffering. I will try to explain part of my experience to you, and while it is a study with an “N” of one, I hope it can begin a dialogue. Analysis of my pain has led to the observation that each painful experience is unique. Even after years of this sensation, ask me what my pain was like yesterday and I can only give you vague recollections and unhelpful descriptions such as “bad” or “not too bad.” Pain plays with memory and the mind. It has power as a separate entity in my life, asserting itself at will. It can persist quietly at the back of my mind, or it can insist on attention, pulling my mind from being truly present. You may not know when I’m in pain if you haven't been trained to see the glaze in my eyes when I’m not operating at full speed. At times the sensation becomes all consuming, forcing me horizontal for a time. The sensation becomes more complex when lying in bed, vulnerable, in the gown that identifies me as just one of the slew of patients you will see today. Ask me to numerically quantify my pain, and I may laugh at the absurdity of the thought. My pain varies with my coping strategies, and the same level may fall in a different place on the scale if I have a hand to hold or a pet to cuddle up against. WWW.SFMMS.ORG

Instead of asking how much pain I’m in, ask how my pain is affecting me that day. That I can answer because my functional status for the day takes into account my emotions and coping strategies. How do we make space for pain in medicine? In our didactic curriculum, we learn about different processes that cause pain, creating a dichotomy between absence and presence of physical suffering. We learn adjectives like colicky, stabbing, dull, diffuse, shooting, and burning, and associate each term with a particular diagnosis. I wonder if we can train ourselves to converse in a way that functions beyond narrowing a differential, beyond the scripted empathetic statements we are taught, to a place where we can heal with our questions and responses. We can learn how to help our patients see their own strength and find their coping strategies as well as gain a more nuanced understanding of what is causing their suffering beyond their pain. To get there, we must first understand pain—a deep dive into what it is, how it functions in our lives, and how we can weave that knowledge into our empathy. When I talk about my pain to others, whether classmates or faculty members, I am usually met with pity and sympathy. This attitude doesn't take into account my perspective. From my pain, I find my strength, resilience, and character. I find my drive and motivations. Each decision I make carries more weight when made through the gauzy layer of pain, even a simple decision to arrive at the hospital half an hour earlier to spend more time with a patient. I find pride and confidence in my pain, whether my suffering is visible to you or not. I respect myself for it. There is strength in the vulnerability that, as a patient, I've learned to accept. When you hear me talk of that pain, I want you to see my fortitude. Admitting to pain requires a combination of courage and humility, and I am amazed and honored when a patient trusts me enough to share their pain with me. I am fortunate because I have had over eight years of experience with pain, whereas many of my classmates have not experienced chronic pain at all. We are entering the lives of individuals at their most painful moments, physically or emotionally, without exploring the underbelly of suffering. An intimate conversation among friends and peers, pulling from collective human experience with pain in all its forms, can propel us all into a higher level of understanding and help us bring awe to the pain we see hiding in a patient’s gown. Joanna Jacobs is a third year medical student at the University of California, San Francisco School of Medicine and faculty for "The Healer's Art," a course that explores the values of service, healing relationship, and compassionate care. JULY/AUGUST 2017 SAN FRANCISCO MARIN MEDICINE


Medical Education

VITAL TALK Mastering Clinical Conversations About Serious Illness Monique Schaulis, MD VitalTalk is a nonprofit specializing in developing and facilitating advanced communication skills courses and faculty training courses to promote honest and compassionate communication in the setting of serious illness. Co-founded by Drs. Anthony

Back, James Tulsky and Robert Arnold, VitalTalk has supported thousands of physicians across the country over the last ten years. Monique Schaulis, of the SFMMS board, can vouch for its practice changing benefits and will be faculty at an upcoming Bay Area course. Details can be found below for registration. VitalTalk offers one-day Mastering Tough Conversations courses that give clinicians the opportunity to learn easy to remember conversation maps and role-play the experience with trained actors as simulated patients. The course is designed to give providers, including physicians, advanced practice nurses, and physicians assistants, tools to lead honest discussions with seriously ill patients and their families about prognosis & goals of care. Years of research and practice have resulted in an evidence-based teaching method that uses a combination of small group break-out sessions with intensive skills practice and feedback, simulated patients who create a real-world atmosphere, cognitive mapping, deliberate practice and just-in-time feedback. Training results in immediate, significant and lasting improvement to the medical practitioner’s ability to address patient and family needs for serious illness care. Providers from a range of practice settings and specialties are encouraged to attend, including primary care, hospital medicine, cardiology, oncology, geriatrics, neurology, critical care,

Stories and Strategies to Engage Providers and Address Burnout: Top Leaders in the Field Show What You Can Do Within Your Organization

and palliative care. In this unique, hands-on, intensive course, clinicians will learn and practice in a community of peers, led by facilitators experienced in the VitalTalk evidence-based learning method. The topics covered include: talking about prognosis and goals of care. To maximize the learning experience, the course is limited to twenty-four participants. The cases will involve cancer and non-cancer adult diagnoses. The San Francisco Bay Area is currently the pilot region for VitalTalk’s first regional training hub in the country, and registration is now open for their first eight-hour Mastering Tough Conversations course. The course will take place on October 4, 2017 at Preservation Park in Oakland. To register for this course, visit There are only twentyfour slots available in the course, so we recommend registering soon to reserve a spot. If you can’t get a spot, let us know and we can update you on future courses.

August 24, 2017 - San Francisco, CA. 8:30 am to 4:30 pm (7 hours CME) Hilton San Francisco Union Square

SFMS Vaccination Public Service Announcement Featuring Musical Icon Graham Nash

Renowned experts in building professional and personal satisfaction will gather to provide you with tools to address and evaluate burnout, highlight programs that foster effective leadership, and identify organizational strategies to increase participation in collaborative solutions. Contact CPPPH via email at or call CPPPH Staff 800-381-2383.

“Teach your children” is the title of rock legend Graham Nash’s most-loved song, and also of the new SFMS video wherein he urges parents to fully vaccinate their children. Mr. Nash, of “America’s Beatles” Crosby, Stills, Nash and Young, graciously offers his words and classic music for this forty-five-second public message, “I vaccinated my kids and they’re all brilliant!” he says. Please enjoy and share this important message. See the



HEALTH POLICY PERSPECTIVE Evidence-Based Politics? Doing No Legislative Harm

Steve Heilig, MPH "Any person in the United States who requires medical attention and cannot provide it for himself should have it provided for him." —Ronald Reagan

As a health care ethicist, I am often called upon to help physicians and others make tough decisions for people who are very ill — regardless of their finances or insurance status. Beyond their sense of human

decency, these professionals have taken oaths that compel them to do all they can to keep their patients healthy and thriving. In California during the 1960s, especially in San Francisco, the concept spread of a “right” to health care. At UCSF in 1967, a so-called “summer of love” was brewing when a health policy forum was held. A young recent medical school graduate, David Smith, MD, who lived in the neighboring Haight-Ashbury district where “hippies” were congregating, saw a medical and moral crisis brewing. Other hospitals and even the local health department were refusing to see the legions of young arrivals. When somebody at the UCSF policy forum said something Dr. Smith found objectionable, he stood and said: “Health care is a right, not a privilege.” That slogan became the guiding principle of the pioneering Haight-Ashbury Free Clinic that Smith soon opened. That clinic has thrived and evolved to this day, with millions of patient encounters, and served as a model for many other such clinics. And when President Obama signed the Affordable Care Act (ACA) into law, he echoed Dr. Smith’s slogan. But what does that mean in practice? Of course granting “rights” is a tricky thing, and with respect to health care especially so. What are the limits? Surely we cannot enshrine a right to anything a patient or even their clinicians might want to provide. Perhaps we might call for “evidence-based” rights? In any event, the slogan in practice has often meant a right to primary care, including emergency care as mandated by law—otherwise, patients wind up in much more expensive emergency rooms or die outside hospital doors , which most people see as unacceptable. And many, if not most, civilized nations do better than us in providing healthcare, in terms of both outcomes and economics. There are multiple reasons that some form of the "single payor" concept has gradually but steadily gained support even among mainstream medical organizations, where that used to be anathema, and even derided as "socialism." Which brings us to current events. In the Republican efforts to repeal the ACA, one element seems enshrined — tax cuts for the highest earners. One striking detail in their original proposal is that the total amount of funding the Republicans want to cut from Medicaid was remarkably close to the total amount of those tax cuts. Correlation? Causation? Random, if statistically WWW.SFMMS.ORG

remarkable, chance? In any event, they have backed off a bit on the cuts, but only as it "looked bad." But once we get to actual policy proposals, hearing about many political plans for health care can be a jarring experience. It often seems as if politicians never thought of asking real experts what might be best. For clinicians, one analogous experience might be that of having an insurance company clerk deny a claim as being “not medically indicated.” Based upon what? Not training, evidence or expertise — somehow financial considerations seem to lurk behind it all. The “right” to health care is only one of the elements of progress rooted in the fabled 1960s, along with civil rights, women’s rights, the anti-war movement, environmentalism, and more — all of which are currently experiencing a huge political backlash, and not, it seems, with the majority of citizens' interests in mind. But most elected officials take oaths to serve the American people — not corporations, donors, some ideology or even the president. The disconnect between evidence and what might be called “fake science” is large and seems to be increasing. Couldn’t we have something like “evidence-based politics”? Virtually every relevant physician-based and medical organization opposes Trumpcare because it would hurt millions of Americans. Politicians considering voting for anything similar to such harmful proposals might well "gut check" their conscience to prevent violating their oath of office, and maybe even consider the medical dictum to "do no harm." As they consider their vote, I hope they will remember who they are elected to serve. Future historians — and voters — certainly will.

"I hope that all physicians, including those who are members of Congress, other health care professionals, and professional societies would speak with a single voice and say that health care is a basic right for every person, and not a privilege to be available and affordable only for a majority. The solution for how to achieve health care coverage for all may be uniquely American, but it is an exceedingly important and worthy goal, emblematic of a fair and just society." —Howard Bauchner, MD, Editor, JAMA, January 3, 2017 Steve Heilig, MPH, is director of public health and education for the San Francisco Marin Medical Society, co-editor of the Cambridge Quarterly of Healthcare Ethics, a former hospice director and caregiver, a clinical ethics consultant for numerous hospitals, and received the California Medical Association Foundation’s Sparks Leadership Award for contributions to community health. This piece originated as a letter published in the New York Times. JULY/AUGUST 2017 SAN FRANCISCO MARIN MEDICINE


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Edward Eisler, MD

Kaiser Permanente Maria Ansari, MD

California Pacific Medical Center (CPMC) offers unique and rewarding graduate medical education experiences through sixteen residency and fellowship training programs for 117 residents and fellows. A diverse group of Accreditation Council for Graduate Medical Education (ACGME) accredited programs are offered in Internal Medicine, Psychiatry, Cardiology, Radiation Oncology, Gastroenterology, Pulmonary & Critical Care, Hand Surgery, Endocrinology and Transplant Hepatology. There are also Fellowships in Shoulder/Elbow Surgery, Neuro-Critical Care, Retinal Surgery, Ophthalmic Plastic Surgery, Microsurgery, MRI and Melanoma. CPMC has a long-standing commitment to excellent patient care and graduate medical education, serving the diverse and vibrant population of San Francisco and the greater Bay Area. We are fortunate to consistently attract residents, fellows, and faculty of the highest caliber. CPMC’s training programs are known for their clinical excellence in training residents and fellows in evidence based quality care, research opportunities and mentorship opportunities. Residents and fellows have received recognition at national meetings for their research projects and faculty members have also received prestigious appointment in national organizations. The training programs collaborate with the CPMC Research Institute (CPMCRI) to mentor clinical and basic science research projects through guidance in research design, data analyses to presentation and publication of their findings. Residents and fellows have the opportunity to collaborate with a diverse array of principal investigators that lead innovative research at the CPMCRI. These research activities culminate in an annual Resident Research Day Open House to showcase each training programs’ talent and depth of research and quality improvement opportunities at CPMC. The top research projects are showcased at a reception that senior administration, faculty, and residents and fellows attend in May of each year. WWW.SFMMS.ORG

The physicians at Kaiser Permanente San Francisco Medical Center (KPSF) are dedicated to providing the highest quality care to their patients. As a California Medical Association (CMA) accredited provider of Continuing Medical Education (CME), KPSF seeks not only to increase the competence of its physicians, but also to affect and promote change in physician practice, patient care, and ultimately improve patient outcomes. Each year, KPSF offers five to six hundred CME hours, with approximately five thousand hours of CME credits claimed per year, allowing many KP physicians to meet their CME requirements without ever having to leave campus, which translates to better access and continuity for patients. Approximately twenty-five clinical departments, spanning primary care, surgical, and specialty care, participate in CME activities. The traditional didactic model (Grand Rounds by PowerPoint) has largely been replaced with more active learning formats such as case-based discussion, simulation, off-site experiential learning, skills workshops, flipped classrooms, role playing, inquiry learning, and hybrid learning models. Faculty development workshops have hugely improved the delivery of content and increased the enjoyment and retention of material among the learners. KPSF CME offerings are designed to be highly relevant to the practicing KP physician, targeting organizational priorities, inpatient and outpatient quality, and patient safety goals, diversity, communication skills, physician health, and wellness. Moreover, the abundance of data on performance metrics allows for easy identification of practice gaps and post-CME activity outcome assessments. The CME Department’s close collaboration with other departments and committees such as Diversity, Graduate Medical Education, Physician Health & Wellness, Pharmacy & Therapeutics, Service, Quality, Emergency Preparedness, and hospital leadership has resulted in demonstrated improvements in service and quality.


Sue Carlisle, MD, PhD

Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) serves as one of UCSF's primary teaching hospitals, and plays a central role in UCSF’s educational mission. On any given day, approximately one third of the School of Medicine’s students and residents are based at ZSFG. The UCSF Schools of Dentistry, Pharmacy, and Graduate Nursing also have strong linkages to ZSFG. Several unique School of Medicine programs are housed on this campus. Model ZSFG allows select third-year medical students to conduct six months of continuous core clinical rotations at ZSFG, while the Program in Medical Education for the Urban Underserved (PRIME-US) educates an annual diverse cohort of twelve medical students in both clinical and policy aspects of caring for the underserved. At the residency level, the Family and Community Medicine, ZSFG Primary Care Internal Medicine, and Pediatric Leadership for the Underserved (PLUS) programs are creating a cohort of physicians prepared to address the clinical and community health needs of urban underserved patients. In addition, our campus is home to the ZSFG Training and Education Programs for Underserved Populations (STEP UP), a crossdepartmental collaboration focused on training residents in the policy and advocacy skills needed to address the issues of vulnerable communities. Many of our other services–notably general surgery/trauma and psychiatry–provide specialized training opportunities for residents. Beyond ZSFG, many other services in the San Francisco Health Network—from community primary care and mental health clinics, to the homeless van and jail health resources—offer unique educational opportunities for UCSF students and trainees. In turn, these students and trainees become our future leaders in education, research, clinical care, and policy to help improve health and wellness for the underserved.




NEPO Building Healthy Communities Summit

September 6, 12:00 to 4:00 p.m. | San Francisco TBD September 7, 12:30 to 4:30 p.m. | Connection Center, 3240 Kerner Blvd., Room 110, San Rafael, CA SFMMS and MIEC, the doctor-owned professional liability insurance carrier endorsed by SFMMS, have teamed up with nationally recognized subject-matter experts to develop a free program to help you maximize reimbursement under MACRA. Join SFMMS and MIEC for a half-day in-person training for physicians, practice managers, and billers. We will take a deep-dive to begin developing a plan to earn incentives and maximize reimbursement. Included in this free program are an online library of online tutorials and recorded webinars, and also a free license for an online tool to help create and customize MIPS plans for your practice. Register at

October 19 to 20, 2017 | Disneyland Hotel, Anaheim, CA The 2017 Network of Ethnic Physician Organizations (NEPO) Building Healthy Communities Summit will be held on October 19-20 at the Disneyland Hotel in Anaheim. The theme this year is "Striving for Health Equity in the Era of Change." Register today at

September 11, 6:00 to 7:30 p.m. | Golden Gate Yacht Club Calling all SFMMS members: Join us at our General Meeting on September 11, 2017. Members are welcome to stay for the board meeting immediately following the General Meeting. This is a good opportunity to meet with SFMMS leadership and to learn firsthand the issues SFMMS and CMA are advocating for on behalf of physicians and their patients in San Francisco, Marin and California. Details will be available soon at RSVP to Posi Lyon, , (415) 561-0850 x260.


SFMMS 2017 General Membership Meeting

Essentials for Primary Care Pain Management

September 16 to 17, 2017 | 4610 X Street, Sacramento, CA The UC Davis Center for Advancing Pain Relief is hosting a twoday CME conference for primary care clinicians. The program integrates recent scientific data with current clinic practice regarding pain management. Topics include responsible opioid prescribing, pain and mental health, and pain management essentials. Participants will also learn about the management of co-morbid conditions and the integration and coordination of pain management within primary care. Buprenorphine training available. For more information, or to register, visit bit. ly/2qjXSb6.

DIGIMED17 – Transforming Healthcare through Evidence-Driven Digital Medicine

October 5 to 6, 2017 | La Jolla, CA Consumers are increasingly able to monitor their health using a vast array of wearable devices and digital technologies, at a small fraction of the cost imposed by our modern health care system. This change, powered by mobile internet, is giving patients unprecedented control over their health care. The Scripps Translational Science Institute is hosting a one-of-a-kind, interactive conference to jumpstart efforts to drive the widespread incorporation of evidence-based mobile health solutions for more personalized, individual-centric care to improve outcomes, advance satisfaction and decrease costs. Learn more at 30

CMA House of Delegates Meeting

October 21 to 22, 2017 | Disneyland Hotel, Anaheim, CA The House of Delegates convenes annually to debate and act on resolutions and reports dealing with myriad medical practice, public health and CMA governance issues. Policies adopted by the House are implemented by the Board of Trustees, which also deals with the many interim policy issues that arise between annual sessions. Learn more at

The Buzz on Zika: Should We Still Be Concerned? August 23, 2017, 12:15 to 1:15 p.m. While the Zika virus may have fallen from the headlines, it continues to have a significant impact in both clinical and public health spheres. This webinar will review current epidemiology and risks regarding the Zika virus, its impact on individuals and public health, the ongoing concern for pregnant women and their children, and the potential for both treatment and prevention. To register –

Medical Staff Self Governance and the Tulare Medical Staff Trial

September 13, 2017, 12:15 to 1:15 p.m. Medical staff self-governance is a vital part of a carefully crafted system designed to ensure the delivery of quality patient care in California hospitals. Join CMA for an overview of the rights and responsibilities of the self-governing medical staff under state and federal law, including credentialing, establishing clinical criteria and standards, organizing committees to monitor patient care, reviewing medical records, working with hospital administrators and governing bodies, and peer review, among other things. To register –


Leading the future of health care. ADULT & FAMILY MEDICINE AND PEDIATRICIAN PHYSICIAN OPPORTUNITIES Petaluma & San Rafael

Practice in your local community. The Permanente Medical Group, Inc. (TPMG) is one of the largest medical groups in the nation with over 9,000 physicians, 22 medical centers, numerous clinics throughout Northern and Central California and a 70-year tradition of providing quality medical care. We are currently seeking BC/BE Family Medicine, Internal Medicine and Pediatric Physicians to join us in Petaluma and San Rafael. Excellent opportunities are also available in other locations throughout the San Francisco Bay Area. We invite you to join your fellow members of the Medical Society who are already practicing at TPMG.




• Physician-led organization – career growth and leadership

• Shareholder track

• Professional development opportunities

Contact Aileen Ludlow at: (800) 777-4912

• State-of-the-art facilities


• Technology driven

Contact Bianca Davis at: (800) 777-4912

PEDIATRIC OPPORTUNITIES: Contact Judy Padilla at: (800) 777-4912

• Multi-specialty collaboration and integration

• Mission driven, patient care-centered and one of the largest progressive medical groups in the nation!

• Unparalleled stability – 70 years strong • Shared call • Moving allowance • No cost medical and dental • Home loan assistance (approval required) • Malpractice and tail insurance • Three retirement plans, including pension • Paid holidays, sick leave, education leave (with generous stipend) • Family-oriented communities with great schools We are an EOE/AA/M/F/D/V Employer. VEVRAA Federal Contractor.

San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133






California Medial Association (CMA) and its county

Through aggressive political and regulatory

medical societies have represented California’s

advocacy, CMA and its county medical societies

physicians for 160 years as the recognized voice

are positioned as one of the most influential

of the house of medicine. Together we stand taller

stakeholders in the development and implementation

and stronger as we fight to protect patients and

of health policy.

improve the health of our communities. We are a we do wouldn’t be possible without the support of


members like you.

CMA and its county medical societies bring together

dominant force in health care – but all the great work

SHAPE THE FUTURE OF MEDICINE Members receive direct access to our state and

physicians from all regions, specialties and modes of practice through leadership, collaboration, social and educational events, and community service.

national legislative leaders to influence how medical


care is provide today and in the future.

From tobacco use and obesity to prescription drug

PROTECT THE PROFESSION Your membership affirms your commitment to the medical profession and ensures physicians remain in control of the practice of medicine.


abuse and vaccinations, your membership dollars support forward-thinking public health advocacy to improve the health of Californians.

PROTECT MICRA CMA staunchly defends the landmark Medical Injury Compensation Reform Act (MICRA) year after

Members receive one-on-one assistance from CMA’s

year, saving each California physician an average of

reimbursement experts, who have recouped $13

$75,000 per year in professional liability insurance

million from payors on behalf of CMA physicians in


the past seven years.


STAY IN THE KNOW CMA and its county medical societies produce

CMA and its county medical societies provide many

publications to keep you up to date on the latest

opportunities to get involved, including opportunities

health care news and information affecting the

to volunteer, serve on a committee, council or board,

practice of medicine in California.

and shape the future of the medical profession.

Join or renew your membership today! Questions? Contact our Member Service Center at (800) 786-4262 or

July/August 2017  

San Francisco Marin Medicine, Vol. 90, No. 6, July/August 2017

July/August 2017  

San Francisco Marin Medicine, Vol. 90, No. 6, July/August 2017