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Fall/Winter 2013 10 Questions .... Healthcare Disparities and Workforce Diversity Page 6

Out & About .... Urban Adventure Racing

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Best of the Bay Area Restaurants Page 14

The Residents in this issue Managing Fatigue 1 Incentive Update 4 10 Questions 6 CTSI Update 8 Procedures Consult 9 Pocket Preceptor 10 Out & About 11 Bay Area Restaurants 14 Pathways to Discovery 16 SFGH Update 18 GME Diversity 18 Barnett Briggs Library 19 CME Cypher 20 GME Award Winners 20



Managing Fatigue in Residency Training Dorre Nicholau, MD, PhD Professor, Department of Anesthesia UCSF School of Medicine

considered legally drunk.

In fact, in New Jersey driving while fatigued is considered reckless under the vehicular Common sense tells us that fatigue homicide statute. Fatigue in this statute is can impair psychomotor and cognitive defined as having been without sleep for a performance. To what degree and with “period in excess of 24 hours.� what consequence is the question that the medical community has been asking for Specific to the practice of medicine, years. considerable data suggests that fatigue impairs both the cognitive and Here are some simple facts. On psychomotor performance of resident standardized cognitive psychomotor physicians post call. Here are just a computer testing, subjects kept awake for few examples: surgery residents require 24 hours performed equivalent to subjects more time to perform laparoscopic with blood alcohol concentrations of 0.08 procedures; medical residents are less to 0.1%. To put this into context, if driving accurate in EKG interpretation; pediatric an automobile, these subjects would be residents take more time to place arterial Continued on page 2

lines; emergency medicine residents are less comprehensive on their patient history and physical exams; and family medicine residents score lower on the ABFM in-training exam. A number of studies suggest that the deficits identified in these types of controlled studies translate into real practice medical errors. In 2004, The New England Journal of Medicine published a pair of landmark studies from the intensive care unit of the Brigham and Women’s hospital. These studies demonstrated that the attentional failures identified by continuous EEG monitoring in sleep-deprived residents working as part of a rigorous overnight call schedule correlated with documented medical errors. The best remedy for fatigue is to avoid it altogether with good sleeping and lifestyle habits. While it may seem that common sense should prevail, when it comes to fatigue management, “rocket science� is at the forefront.

Figure One: Performance in the sustained wakefulness condition expressed as mean relative performance [compared to the start of the study] and the % blood alcohol concentration equivalent. Fatigue, alcohol and performance impairment. Nature vol 388 pg 235. July 17, 1997

chewing gum; and using caffeine strategically one hour before times of expected decreased alertness The NASA Fatigue Countermeasures Program - 3 to 5 am and 3 to 5 pm. While these strategies operates out of the NASA Ames Research Center may be helpful in minimizing some of the risks in Mountain View, CA and serves military pilots associated with sleep deprivation, it is important and astronauts. This program distinguishes to understand that operational measures only sleepiness from fatigue; noting that sleepiness conceal underlying physiologic sleepiness. As a produces drowsiness and decreased alertness result the use of these strategies should be limited while fatigue produces a sense of weariness and to the middle of the night when you are providing depleted energy. Additionally, it distinguishes anesthesia, operating, or working-up a patient in preventative strategies that keep sleep loss the ER or on the wards. and circadian interruption to a minimum from operational countermeasures that provide relief NASA also encourages the strategic use of naps, from the symptoms of fatigue, by temporarily both prior to and during prolonged shifts. However, enhancing alertness and performance at times it warns of the risk of sleep inertia if one is to nap when one is physiologically sleepy during a shift. Sleep inertia is the disorientation, confusion, and cognitive dysfunction that may Preventative strategies include maximizing sleep accompany disruption from sleep during the prior to shift extension or change, taking preemptive slow wave cycle. It typically lasts minutes but naps, and developing good sleep habits in general. can be prolonged to hours in extremely fatigued Good sleep habits include, avoidance of alcohol and sleep-deprived subjects. In addition to sleep and caffeine, daily exercise, and establishment of stage upon awakening, the magnitude of sleep a routine sleep time in a dark, cool room with no inertia depends on sleep duration, time of day, TV. and prior sleep deprivation. Because of this, NASA recommends a nap duration of less than 45 Operational countermeasures include, remaining minutes or longer than two hours in order to avoid actively involved in conversation; keeping arousal during slow wave sleep. physically active by stretching, writing, or even 2

Currently the ACGME recommends a 16-hour limit for shifts without naps. This time limit corresponds to studies on sleep deprived anesthesia residents that show that at 16 hours of wakefulness performance on psychomotor vigilance tests begins to decline. Finally there are strategies to use when performing shift work. Each shift change results in disruption of our circadian clock. Our natural day-night circadian rhythm cycle produces a maximal drive to sleep in the early morning hours between 3 and 5 am and a lesser but significant drive from 3 to 5 pm. Disruption of this rhythm occurs when starting a series of 12-hour overnight shifts; however, once shifted, the circadian clock will reset over three to four days. To minimize rhythm disruption with each shift change (from day to night and back) the optimal management strategy would be to never rotate shifts. Since this is not feasible, working extended series of nights such as four to six weeks in a row is preferred over more frequent shift changes, because the longer time periods allow for fewer changes in circadian rhythm. Alternately, working short stretches of two to three nights in a row never resets the circadian rhythm. The worstcase scenario is the four to seven night stretch that disrupts your rhythm with each change. While12hour shifts offer the advantage of one-third more days off, the length of the shift lends to fatigue. Eight-hour shifts are the preference of most ER physicians. Rotating the shifts clockwise from days to evenings to nights takes advantage of the endogenous 25 hour circadian cycle (it is easier to travel east to west). In addition to allowing for recreational pursuits on workdays, this schedule may improve patient care by providing more rested alert physicians.

Burnout: Burnout is a separate entity from fatigue. Unlike fatigue, burnout develops over longer periods of time as overwhelming work demands continue to deplete energy. The Maslach Burnout Scale identifies burnout syndrome by the following three

characteristics. 1. Emotional exhaustion; 2. Depersonalization and cynicism; and 3. Feelings of inefficacy. The end result is a feeling of detachment from one’s job and an associated perceived lack of personal achievement. Unfortunately our natural coping mechanisms are counterproductive and successful intervention requires resisting our reflexes. For instance when emotionally stressed our natural tendency is to withdraw while the productive response should include outreach to colleagues, family, and friends. The following differentiation may be a useful guide to managing burnout: Reflex withdrawal vs comfort food vs couch potato vs alcohol vs

Productive communication healthy diet routine exercise healthy sleeping habits.

Although you may identify these reflex coping mechanisms as the response to depression (where they are equally ineffective and in fact serve to exacerbate it), it is important to distinguish burnout from depression. Burnout is “tuning out” and the inability to care, while depression is characterized by more active emotions such as depressed mood, inability to concentrate, fatigue, loss of energy, weight fluctuations, anhedonia, and thoughts of death or suicide.

A word about alcohol: The National Institute on Alcohol Abuse and Alcoholism provides a guideline as to what is considered hazardous use of alcohol. It is worth reviewing these guidelines here and to keep them in mind as a way to put our personal habits into perspective. Hazardous use identifies the pattern of drinking that may signal the development of dependence or abuse. In females this is more than seven drinks per week or more than three drinks Continued on page 9


Housestaff Incentive Update (July 2013 – June 2014) mean score of 92.2 (50%) Glenn Rosenbluth, MD Director, Quality and Safety Programs, GME AND the average of all HCAHPS survey domains

for the last quarter improve from 46th percentile to We are now in the eighth year of the highly suc- 60th (50%). cessful Resident and Fellow Quality Improvement Incentive Program. This program provides finan- Goal # 2: Patient Quality and Safety cial “bonuses” to residents and clinical fellows based on achieving quality and operational goals Increase percent of patients discharged before which are linked to achieving excellence in patient noon from 17.6% to 20% for 3 of 12 months. care at UCSF Medical Center and UCSF Benioff Children’s Hospital. We have three goals this year Goal #3: Resource Utilization / Discharge Process which affect all residents and fellows who rotate at the Parnassus, Mt. Zion, Mission Bay, and Langley Achieve a 0.5% reduction in case-mix adjusted cost per discharge. Porter campuses for at least 12 weeks: All of these goals have the same target for UCSF Medical Center employees. This reinforces the On the patient satisfaction survey likelihood of rec- fact that we’re all in this together, and teamwork is ommending question, maintain an annual average the best way to achieve results. Goal #1: Patient Satisfaction


Housestaff Incentive Update In addition, we have 20 program-specific goals which have been championed by residents and fellows: • Anesthesia: utilizing a standardized intra-opera-

• • • • • • • • • •

tive handoff checklist Dermatology: increased awareness and screening for glucocorticoid-induced osteoporosis Emergency Medicine: utilizing a real-time checklist for rapid sequence intubation Gastroenterology Fellows (Medicine): documenting pneumonia vaccination for IBD patients General Surgery: removing unnecessary foley catheters by day two of hospitalization Gynecology Oncology Fellows (Ob-Gyn & RS): increasing pre-operative nutrition counseling Internal Medicine: improving the quality of aftervisit summaries Lab Medicine: creating a relational database to guide test ordering Nephrology Fellows (Medicine): improving communication with outpatient providers Neurology: improving stroke teaching for inpatients Neurosurgery: utilizing a checklist for external ventricular drain placement

• Obstetrics & Gynecology: improving ordering

practices for intra-operative blood products • Orthopedic Surgery: improving screening and treatment of Vitamin D deficiency • Otolaryngology: providing surgery-specific instructions in after-visit summaries • Palliative Medicine Fellows (Medicine): improving pain scores after consultation • Pediatrics: improving the quality of after-visit summaries • Psychiatry: more complete documentation of BMI for patients on atypical antipsychotics • Pulmonary Critical Care Fellows (Medicine): limiting fluoroscopy time • Radiation Oncology: initiating treatments in a timely manner • Transplant Hepatology: decreasing the wait time for outpatient evaluations • Urology: obtaining smoking cessation consultations in inpatients Kudos to everyone for your ongoing contributions to the safety and quality of the care we provide to our patients!

The Annual Quality Celebration Event sponsored by the Clinical Quality Nursing Council and the Patient Safety & Quality Services Department was held on October 17, 2013. The posters from last year’s program-specifc goals were on display. In the physicians’ initiatives category, anesthesia champions Jed Wolpaw, MD, M.Ed; Catherine Chen, MD; Steven Long, MD; and Francis Wolf, MD won first place for their work on Pre-op Screen for Post-Op Delirium Risk. Neurology champion Laura Roscow, MD won second place for her work on Therapeutic Hypothermia Post-Arrest.

Jed Wolpaw, MD and Steven Long, MD with their winning poster.

Laura Roscow, MD presents her initiative at the award ceremony.


10 Questions from the Resident and Fellow Affairs Committee highlight research on health disparities during our annual Health Disparities Research Symposium. Now in its 7th year this symposium, lead by Drs. Eliseo Perez-Stable and Victor Fujimoto features presentations and posters on the research work by members of campus and local community.

J. Renee Navarro, PharmD, MD, Vice Chancellor of Diversity and Outreach, and Professor of Anesthesia and Perioperative Care answers resident and clinical fellow questions about health care disparities and medical workforce diversity 1. What are health disparities? Health disparities refer to gaps in the quality of health and health care across populations based on race, ethnicity, sex, sexual orientation, age disability, socioeconomic status, and geographic location. The definition of health disparities includes differences in the presence of disease, health outcomes, quality of health care, as well as access to health care. 2. Are there any clinical initiatives at UCSF that address health disparities? There are a number of initiatives at UCSF that address health disparities. They include the UCSF Hepatitis B Free Clinic, the Martin Baro Clinic for undocumented workers, and a health coaching program run by the Department of Family and Community Medicine. There are numerous UCSF affiliated clinics (including those at SFGH) that serve large numbers of individuals from groups with high health disparity. 3. What is UCSF doing to encourage and highlight research on health disparities? Sponsored by the Office of Diversity and Outreach and Division of General Internal Medicine we 6

Our faculty are leaders nationally and internationally for their research on disparities. A search of Faculty Profiles list over 200 UCSF faculty engaged in health disparities research. In addition, we have several established research programs and centers. The programs and organized research units include (partial list): • The Center for Aging in Diverse Communities (CADC) Established at the UCSF in 1997 under the leadership of Eliseo J. Pérez-Stable, MD., the CADC is one of six national Centers funded by the Resource Center for Minority Aging Research (RCMAR) program by the National Institute on Aging (NIA), th National Institutes of Health. The CADC is committed to increasing high quality research focused on the concerns of aging Latinos and African Americans by: •

• •

Increasing the number of researchers devoted to improving the health of Latino, Asian, and African American elder adults and reducing health disparities Developing and mentoring minority researchers by providing training and support for proposals, pilot studies, and dissemination of research findings Collecting and validating existing measures for research with Latinos, Asians, and African Americans, and developing new measures Recruiting and retaining Latinos and African Americans for clinical research Funding and implementing new pilot studies that advance knowledge on healthy aging, disease, and disability among older African Americans, Asians, and Latinos

Disseminating information about interventions to reduce disease and disability and improve the health of older Latino, Asian, and African American adults

• Center for Vulnerable Populations • Medical Effectiveness Research Center for Diverse Populations • Vietnamese Community Health Promotion Project • CTSI Community Engagement and Health Policy (SF HIP) community-engagement-health-policy

years) than their non-Hispanic white counterparts. • The prevalence of adult diabetes is higher among Hispanics, non-Hispanic blacks, and those of other or mixed races than among Asians and nonHispanic whites. Prevalence is also higher among adults without college degrees and those with lower household incomes. • The infant mortality rate for non-Hispanic blacks is more than double the rate for non-Hispanic whites. Rates also vary geographically, with higher rates in the South and Midwest than in other parts of the country. • Men are far more likely to commit suicide than women, regardless of age or race/ethnicity, with overall rates nearly four times those of women. For both men and women, suicide rates are highest among American Indians/Alaska Natives and nonHispanic whites.

5. Does UCSF have any models for identifying and addressing socioeconomic disparities in health care delivery in our geographic area? • Center on Social Disparities in Health UCSF is working with the city and county of San Francisco, the SF Hospital Consortium and community leaders to define a collaborative • Lesbian Health and Research Center effort to address local disparities. The SF Health Improvement Partnership was recently developed as a result of these collaborative • Cancer Disparities Research Helen Diller efforts In addition, Family Comprehensive Cancer Center University Community Partnerships works with community partners to build and support training-program-in-cancer-control-research/mtpccr partnerships that address the needs of the members of our local community and to facilitate • Asian American Research Center on Health service learning opportunities for our trainees • Community Network Programs on Cancer and students. Prevention and Control 6. Do we expect national health reform and 4. Are there any disease areas that are insurance expansion to affect the diversity particularly affected by health disparities? of our patients? The recent CDC Health Inequities Report The Affordable Care Act will substantially identified four key findings that exemplify the increase the availability of health care access for tremendous toll that disparities take: all populations. With over 45 million American currently uninsured we can expect an increase • Cardiovascular disease is the leading cause of across all segments of diversity. The increases death in the United States. Non-Hispanic black however will be mitigated by the fact that in San adults are at least 50% more likely to die of heart Francisco we have the Healthy San Francisco disease or stroke prematurely (i.e., before age 75 Program since 2007, which provides health care • SF Bay Area Collaborative Research Network


for all eligible residents. 7. Are there tools or skills I can learn to identify and address racial and ethnic disparities in my area of practice? Yes, the first step is to understand your own unconscious bias implicit/ and also partake in cultural humility/ competency training. These trainings will improve your understanding off effective modes of communication and provide insight into family and interpersonal dynamics. Another key is for you to identify the areas of disparity within your specialty and implement standard of care tools that assure the equitable utilization of diagnostic and therapeutic interventions for all patients. 8. Why is a diversified medical workforce desirable? Diversity is a critical element to innovation and performance improvement. Within the medical workforce it is one of the key ways in which we can reduce the inequities in health and health care. Individuals from minority groups are more likely to work in underserved communities (increasing access). Additionally the education and training for all is enhance by the diversity of your peers. The Institute of Medicine and the Sullivan Commission issued extensive reports on workforce diversity. 9. What is UCSF doing to insure racial/ ethnic diversity in the resident and faculty workforce? UCSF is committed to a diverse resident and

faculty workforce. The Office of Diversity and Outreach was created in 2010, to assure that campus-wide initiatives are implemented that address diversity, equity and inclusion. We have a Director of Diversity within GME, Dr. Rene Salazar, and he collaborates with my office on a number of outreach and inreach programs directed at assuring a diverse resident and faculty pipeline. I work with all the department chairs and the dean on efforts to recruit and retain diverse faculty members as well. The initiatives involve ongoing outreach (including our Visiting Students Program); developing equitable systems of recruitment and hiring; and assuring inclusion, support, and opportunities for all members of the campus community. 10. What should I do to recognize any unconscious attitudes or biases that might affect my clinical decision-making as a physician? The Office of Diversity and Outreach with support from the CTSI has launched an Unconscious Bias Initiative with the goal of educating trainees, faculty, students, and staff so that each gain insight and understanding of our individual biases, and also understand the strategies to minimize the impact of bias on interpersonal relationships, patient care and decision making. Departments are encouraged to schedule trainings for their trainees and faculty. Website: Contributions by: Drs. Perez–Stable, Napoles, Nguyen, and Salazar

UCSF Residents Research Training Program Provides Funding and Training Opportunities The Resident Research Training Program (RRTP) of the Clinical and Translational Science Institute (CTSI) at UCSF offers many funding and training opportunities for Residents interested in careers in clinical and translational research such as RRTP Ambassadors, a Designing Clinical Research for Residents course offered in August and October of each year, the Resident Research Funding Program, Resident Research Travel Program, the Resident Clinical and Translational Research Symposium, and the Clinical and Translational Research Pathway to Discovery. For information on all our opportunities please go to 8

Continued from page 3

per occasion. In males it is more than fourteen drinks per week or more than four drinks per occasion. What is most concerning is the evidence of alcohol use by physicians. Ten percent of US physicians report daily use of alcohol and recent data suggests that the prevalence of alcohol abuse or dependence among doctors is notably high.

prevalence was 25.6% compared to 5.1% among females in the general population. While this study does not prove that physicians use alcohol as a coping mechanism to deal with stress or fatigue, it should serve as a red flag for all of us.

In a 2012 study of over 25,000 surgeons who were members of the American College of Surgery, the prevalence of alcohol abuse or dependence was found to be 15.4%. This was compared to a 9.4% prevalence in the equivalent non-physician population. The data is even more concerning when singling out female surgeons where the

While I have presented a summary of the effect of fatigue and sleep deprivation on our psychomotor and cognitive function, I leave you with the question that many of you may be asking: Does more sleep make for a better doctor? Or conversely is a fatigued doctor who has a detailed knowledge of a patient’s history and condition better equipped to render appropriate care than a rested one who is less familiar with the patient? This is a topic of considerable debate and research. But I suggest to you that the trend toward shift work affects not only the continuity and quality of patient care, but our personal satisfaction as physicians. With the trend toward shift work, we must guard against giving up the special, intimate and singularly respected relationship we have with our patients. If we do not, we are robbing ourselves of the timehonored rewards of our profession. How do we do this? The answer is complicated and the topic for another essay.


Procedures Consult - Online Resource to Review Clinical Skills Procedures Consult is available for free to UCSF medical students, housestaff, and faculty through the UCSF library website. It is an on-line resource which helps practioners prepare for, perform, and follow-up on common medical procedures. Procedures Consult offers high quality illustrations and multi-media videos for each procedure. There are even on-line quizzes to test your knowledge of a given procedure. Procedures are listed by specialty: anesthesia, emergency medicine, family medicine, general surgery, internal medicine and orthopedics. Each procedure module describes the indications and contraindications. The relevant anatomy is reviewed as well as the equipment needed to perform the procedure. Clinical pearls are listed to highlight key tips for success. Post procedure care as well as complications are also described. When you have a chance take a few minutes to explore this valuable resource! 9

UCSF Pocket Preceptor - Now Available in Online App Mai-Khanh Bui-Duy, Jeffrey Hom, and Colin Scibetta UCSF Department of Medicine Residents It is no secret that housestaff have long relied on pocket guides as a quick reference for clinical medicine on the fly. With the ever-expanding body of medical knowledge,and the increasing amount of data being used to make medical decisions, it is no surprise that the size and sheer quantity of available pocket references has also grown. As illustrated in an October 2012 New York Times article featuring trainees at UCSF, these handbooks are increasingly being replaced by sophisticated medical websites and iPhone apps. Vast troves of information are now just a tap away, and these tools aid busy medical students and residents before, during, and after rounds. Despite the increasing emphasis on ambulatory training in residency, few books and even fever apps have been designed specifically for the outpatient setting. With the hope of filling this void, members of the Division of General Internal Medicine resolved to not only update the UCSF Pocket Preceptor, a home-grown handbook for primary care residents first published in 2009, but also make the contents available online. It was believed that trainees would be more likely to refer to an app than thumb through another small textbook, particularly during a brief 20-minute clinic visit. Under the leadership of a handful of residents in the Department of Medicine, the UCSF Pocket Preceptor was thoroughly updated and revamped between February 2012 to May 2013 to reflect updated clinical information in a more streamlined and usable interface. This project was made possible by contributions from many 10

clinicians including students, residents, and faculty from the departments of Internal Medicine, Dermatology, Psychiatry, Urology, Ophthalmology, Otolaryngology, Obstetrics/Gynecology, and the School of Pharmacy. With the incorporation of new guidelines, updated clinical information and the addition of multiple newly authored sections, the editorial team then partnered with AgileMD, a health-tech start-up company specializing in online clinical decision tools to bring the UCSF Pocket Preceptor into the digital age. Interested in advancing both medical education and patient care, AgileMD brought the UCSF Pocket Preceptor to life as an app. After much teamwork, many iterations and fine-tuning efforts, the resource, which was renamed the UCSF Outpatient Medicine Handbook, launched on July 30, 2013. Since then, the handbook has been downloaded and used by at least 300 individual students, housestaff, and faculty at over 26 institutions across the United States, who have collectively logged over 3,300 unique searches in the app in the last two months alone. To learn more and order, members of the UCSF community are invited to use the following link for an institutional discount: friendsofucsf

OUT & ABOUT from the Resident and Fellow Affairs Committee Where members of the UCSF Community recommend their favorite scenes outside UCSF

Urban Adventure Racing Jeff Kohlwes, MD, MPH Director, PRIME Residency Program So you don’t feel like you can spontaneously do something athletic anymore? Just wait until you top 50 years old- it only gets worse! Luckily there are ways of staying active, doing fun sports events that even allow you to get a team together and well. . . work as a team (and break a little sweat along the way). Adventure racing is a fun way to stay motivated to stay in shape without feeling like you need to train for an ultra-marathon. If you train for a marathon you know you have to run for 26.2 miles; for a triathlon you know you will swim, then bike ,then run. When you do an adventure race you may never know what is coming next! I started doing adventure racing with a couple of misguided friends about 15 years ago- and have never looked back as they are just so much fun. My favorite local race is in September and is called the San Francisco Oyster race - part of the Oyster racing series. Imagine starting your Saturday off in the parking lot of the Sports Basement in the Presidio. You have your bike, your running shoes, a couple of changes of shirts and plenty of snacks set up in your individual team parking space. The energy builds as the start time gets nearer and the other spaces start filling up with other teams, some of them dressed in ridiculous costumes, others just trying to figure out what the heck to do next. Then comes the start . . . but instead of a rush of bikes or running shoes, out come the cell phones.

You have been given several puzzles that require a QR reader to download. You solve the puzzles to get your first clue on where to go next and then . . . you are off! So you jump on your bike and take off down the Embarcadero towards Pac Bell park where you get off at the local Whole Foods and . . . line up with your team to throw fish to each other- don’t drop them or you have to start all over again! After smelling a little like stale fish you get your next clue and it seems to point you towards pier 40. Back on the bike to ride down the Embarcadero towards Pier 39 (must be close to 40, right?). This is the first big clue to adventure races - know where you are going next before speeding in that direction! Well known fact about the San Francisco piers- they run odd and even in opposite directions- a fact we discovered after getting all the way to pier 39 (we didn’t plan on winning anyway). OK, so we went back to pier 40 and discovered our next task was to do two laps around the pier 40 waterway on a standup paddle board. Only trick was that we had three team members and all of us had to make the trip and we could go around only twice and everyone could go only once. It was cold lying down on the SUP while my friend paddled. Then it was back on the bikes for a dash back to the Sports Basement where it was time to switch into running shoes to run through the Presidio to a bunker where we had to . . . solve SAT questions as a group, BUT we couldn’t talk. We noticed the younger crowd was going much faster than we were and only later did we realize that text messaging worked well to help solve the problems. Then it was further into the Presidio to do more stupid human tricks like shoot shoes to teammates using a funnel and surgical tubing to create a slingshot (much harder than it sounds), walking through an obstacle course blindfolded with your teammates giving you directions, and taking spontaneous team photos with tourists on the Golden Gate Bridge. The day ended with a quick game of beer pong which took me 25 years back to college and reminded me why even then I 11

was a geek. The day is a blast, you travel all over San Francisco doing fun stunts and you have a good workout by the end of the day. It also gives you a chance to raise money for several very good causes so you feel even better about your effort!

quite a trick). Then it is off with the ski gear for a 25 mile ride into town (this is almost all downhill and you get to feel like Lance Armstrong on steroids as you race down the Volcano). As you get back into Bend you change from bike to run and take a beautiful run along the Deschutes river that goes 2.5 miles up the river canyon, then back down I have to say that my favorite adventure race is not again. Finally, you get into your awaiting kayak for local, but in Bend, Oregon. It is a 12 hour drive a 2 mile flat water paddle on the Deschutes before or a 2 hour flight into the Redmond Oregon air- ending up at the finish line where there is a huge port. The race is called the Pole Peddle Paddle party that feels like the whole town has turned out and in my mind it is the pilgrimage that all dedi- to see the end of the race. Another perk is that the cated outdoors enthusiasts should make at least famous Deschutes brewery is just down the street once in their lives. The PPP as it is called, is at so if you need refreshment after the race it is easy the end of May and attracts teams and individuals to find. from all over the west coast to do exactly what the name implies. You start in downhill ski boots half Well I hope this gets you thinking about advenway up Mt. Bachelor and you do a short run up to ture racing, there is no shortage of opportunities your skis, click in and race down the hill. Then you to try one out either individually or with a group or your teammate cross-country ski a breathtak- of your friends - they are a blast! Have fun out ing 5 mile loop through the high alpine pine trees there. (the snow is usually pretty sloppy by then so this is

UCSF Clinician Bilingual Certification Residents and Fellows, keep your eyes peeled for a very brief (2-5 minute maximum) Qualtrics survey from the Office of Graduate Medical Education about your use of non-English languages to communicate with patients. The UCSF Medical Center is using responses to this survey to determine which clinicians qualify for the UCSF Clinician Bilingual Certification exam. UCSF policy requires the use of an approved interpreter for clinical encounters with nonEnglish speaking patients unless your oral proficiency in that language has been certified. Don’t miss your chance to get certified. Respond to the survey. Even if you don’t speak another language, please respond to the survey so the Medical Center has a record. Remember, you can access Interpreting Services by calling 353-2690 • Option 1 for on-demand telephone interpreting 24/7, 365 days a year, 200 languages. • Option 2 to page our after-hours Spanish interpreter at Moffitt/Long M-F 5pm – 12am, Saturday & Sunday 9am – 5pm. • Option 3 to request advance scheduling for an in-person interpreter, all languages, 8am – 5pm M-F. Coming soon: Video Medical Interpreting for ambulatory at UCSF Medical Center. Stay tuned! 12

OUT & ABOUT from the Resident and Fellow Affairs Committee

Art Around Town

If your finger is itching and is ready to get to work, here are a few of my favorites. The Institute of Wenia Lee Education Coordinator, Department of Surgery Mosaic Art (805 Allston Way, Berkeley) has everything you want to learn about contemporary While medicine mosaic. Classes are available in all skill levels. cures the body, Most classes are weekend long but the addiction creativity heals the can be lifelong (talking from experience). There soul. The Bay Area are also exhibitions all year round. If mosaic is is teeming with too much of a commitment, Workshop (1798 creative activities. If McAllister St, SF) has something for everybody – you are one of those screen printing, beer making, pickling, sewing etc. who have ever said The majority of their workshops are few hours long. “I am not creative”, Besides weekends, they have evening workshops check out some for those who are fortunate to have an 8-5 job. of the following SCRAP (801 Toland St, SF) is a place that sparks places and you may your imaginations! It is a nonprofit reuse center. All awaken the creative materials are donations of reusable. It is a resource self that is waiting center for many teachers and artists. They have very affordable workshops on Saturday. The first for its debut. part of the workshop often starts by students going Being an observer is a great way to start. Hot Glass out hunting for their own materials in the facility. Cold Beer is a monthly event at Public Glass Everything is possible at SCRAP! SCRAP’s Art (1750 Armstrong Ave, SF). For a $25 donation, Show during the holiday seasons is one of the you can select a hand-blown glass made by the most inspiring exhibitions. students, staffs and faculty there. Enjoy the glass blowing and flameworking demonstrations by A couple of the museums in San Francisco have feature artists while sipping beer or wine with your workshops that are free with museum admission. one-of-a-kind glass. Public Glass is a nonprofit Asian Art Museum (200 Larkin St, SF) has glass studio that offers blowing, casting, fusing workshops all year round including drawing, and flameworking classes. One-day introductory ikebana, Japanese tea. There are family activities workshops are scheduled on the weekends. and workshops for kids as well. Museum of Craft and Design (2569 Third St, SF) has an Etsy Meet Similar to Hot Glass Cold Beer, Bowlicious is an & Make Craft Lab about once a month. The lab is annual event at Ruby’s Clay Studio (552A Noe taught by local artists and the projects are quick St, SF). With a donation, you can select a clay and easy. It’s great for a night out with a small bowl made by Ruby’s artists and students to enjoy group of friends or with a date. free ice-cream, tour the studio and social with the artists during the event. Visitors are welcomes to Creativity can happen at any time in our daily life. observe potters at work during business hours. You Even if you have no desire to “create” something, may even get a chance to witness Maria Wamsley, you can support the local artists by visiting them at MD (Department of Medicine) getting her hands craft fairs and open studio. Learn about their works dirty! Across the bay, The Crucible (1260 7th St, and the stories behind them. They may inspire you Oakland) offers a variety of industrial art classes to make small creative changes in your life. There including blacksmithing, welding, woodworking are many shops and galleries in the Bay Area that and many more. During their Spring and Fall features local artists. Just to name a few, Foggy Open House, demonstrations are available in all Notion in Inner Richmond, Park and Pond in North classrooms. Don’t be alarmed if you see fire flying Beach, Studio Gallery in Nob Hill and City Art in around because fire dance performers wander Mission. Some of these are run by artists. around the facility during open houses! 13

BEST of the Bay Area: My TOP Restaurants - Part One R. Hirose, MD (unofficial selfappointed Vice Chair of Food and Wine), Department of Surgery, UCSF What follows is a very personal, extremely biased, non-objective list of the absolute best eats in the San Francisco bay area compiled by a very experienced eater, who has tasted a lot of food in the past 24 years since starting residency here at UCSF. I am sure this list may result in fascination, joy, disagreement, anger, frustration, may even provoke a boisterous fight, but I will happily defend every single one of my choices. I will even go out and re-taste others that I may have left off the list if someone can bring forward a plausible argument. If you can seek these following items out, however, I submit that you will have eaten much of the best that the Bay Area has to offer.

BEST Donut:

Bacon Maple Apple donut from Dynamo Donuts- Start out your hunt for best eats near SFGH. The Mission is the happenin’ neighborhood for good eats these days, from Mission Chinese Food and their Salt cod fried rice and Ma Po Tofu, to Commonwealth, to a myriad of cool restaurants. You will see that many of the first items on my list come from this neighborhood, and you can’t go wrong. Who doesn’t love maple with bacon on their donut? This is a no brainer. Have two. Chase it with a Passion Fruit Milk Chocolate or Caramel de Sel donut. You will not be sorry.

BEST Coffee: Phliharmonic from Philz CoffeeWith your donut, go for a cup from Phil’s. Choose one of the other countless variations like Soooo Good,or Philtered Soul and and keep trying till you’ve had them all. No one does it better than Phil’s. – way better than Ritual as far as I am concerned.

Cookies N’ Crème Dream as well as Boom Boom Banana all from the same Hayes Valley location are all worth trying. Cold varieties are surprisingly refreshing for bread pudding! Warm varieties are what you think they are. Sweet, decadent and comforting.

BEST Ice Cream: Secret Breakfast at Humphrey Slocum. Honorable mention to Salted Caramel at Bi-Rite Creamery and the tropical flavors at Mitchells, like Mango and Cantaloupe , but how can you out do Bourbon and Corn Flakes? You can’t.

BEST Chocolate Chip Cookie: This one is

a bit of a fake out, because you must bake them yourselves. Directions: 1) buy the cookbook Ad Hoc at home. 2) Follow Thomas Keller’s instructions and ingredients to a tee. DO NOT SUBSTITUTE – either the sugars or the chocolate. Include the mid bake spritz. 3) eat after requisite cooling period. These are the best choco chip cookies ever. Period.

BEST Savory Pastry: The Rebel Within from

Craftsman and Wolves – A pretty fancy, chi-chi, hipster bakery that looks too slick to be good. Not so. Try this baby on for size with an egg hidden in the middle of the pastry - a soft boiled egg baked into a muffin? How awesome is that?

BEST Sausage Sandwich: Aunt Malai’s Lao sausage sandwich from Pal’s Takeaway – one of the best overall sandwiches in the city. A few short blocks from SFGH tucked in the back of a nondescript local grocery store. The sweet sausage with a kick is a perfect foil to the cucumbers, pickled carrots, soy yuzu mayo and Acme Roll. Just about a perfect sandwich – maybe the best sandwich ever. Check the on line sandwich menu and if Mrs. Bihn’s sausage sandwich is on the list, run, don’t walk to get one of these before they run out!

BEST Bread Pudding: Dreamie Dulce de Leche Best Pork Sandwich: Roli Roti Porchetta from Schulzies – but the cold Charming Cheesecake, 14

sandwich at Ferry Building Farmer’s Market

(Thursdays and Saturdays): Is it worth standing in line for up to half an hour just for a sandwich? For this one, the answer is an emphatic yes. As your mouth will literally start to water as you watch in anticipation as they cut the moist juicy slices of rolled roast pork with crispy skin, as they sop up the juices with the custy ciabatta bread, and they heap fresh arugula and a sweet onion marmalade and julienne the crisp pieces of skin and hand over the masterpiece, you know that it in fact has been worth every minute in line. When you are halfway through, you are sad to know that then end of the sandwich is in sight, and when you are done, you wonder when you can next obtain another Porchetta sandwich and experience pork sandwich nirvana and enlightenment. Watch the video.

BEST Bahn Mi Sandwich: Roast Pork Bahn Mi from Saigon Sandwich – can’t beat the price, or the simplicity and no nonsense Bahn Mi from this takeout only place in the Vietnamese corner that is Larkin Street.

SFGH is Phat Philly which also is nothing to sneeze at. Don’t bother with the bacon or the mushrooms or the avocado. Simple is better here. Grilled onions and Whiz or white American.

BEST Burger: Umami Burger – One could have

gone for the Burger at Spruce from the Bar Menu, or the Marlowe Burger at the namesake restaurant or The Hubert Keller Burger at Burger Bar at the top of Macy’s, and some would even argue for the awesome and huge Challenger at the Bullshead, all great candidates for best burger in the City, but I chose the Manly Burger at Umami Burger on Union, because it is oozing with umami, that fifth taste, that is present in everything savory. No burger has the umami of umami burger. Except maybe the $60 Remixed Rossini Burger (no more foie gras since the recent ban, but they have put a lobster tail on top) at Burger Bar, but this is serious burger science.

BEST Korean Steak Sandwich: Korean Steak

BEST Pastrami Sandwich: The Toasted Slaw Sandwich from Rhea’s a line forms at 11:30 am so #19 at The Refuge – watch their video regarding the navel cut and their loving preparation of their pastrami. If you don’t have the time to drive to San Carlos, then go on over to Wise Sons Jewish Delicatessen (again in the Mission!), and go for the No. 19 or Reuben there. Either way, you will be a happy camper. Even if you are from New York.

BEST Philly Cheeseteak: The King of Philly from

the Cheesesteak Shop – with onions and sweet and hot peppers – this is their medium sized Philly Cheeseteak with extra meat and extra cheese. Maybe it is not quite Pat’s or Geno’s or even Jim’s steak or Tony Luke’s (btw, one must make a pilgrimage to all four when in the city of brotherly love) But it is greasy, messy, and music to the ears of the makers of statins and interventional cardiologists. It is also irresistible, and as the ads say, habit forming. Way too easy to walk here for a quick bite from Mt. Zion. Go for one. Maybe chow one down once a month at most if you want to survive your residency without a drug eluting stent. If you can’t make it to MZ, closer to

order a bit earlier and come back. Nothing like sweet Korean beef in a handheld form! Yes, back to the Mission.

BEST Fish Sandwich:

The Fried Rockfish Sandwich at the Alembic – located in the Haight, the selection of bourbon and other whiskeys is pretty hard to beat. The kitchen should not be ignored, though, and for lunch, the fried rockfish sandwich is not to be missed.

BEST Lobster Roll: This is a tough call, since the

only place to have lobster rolls is in New England, and the best one I have had in SF is the one I make myself from freshly flown in lobster at the New England Lobster Co. near the airport. I have won a few cook-offs with my lobster rolls. None come close to the warm lobster roll at Neptune’s Oyster in Boston, or the numerous ones I could rattle off to be had in Boothbay Harbor, Ogunquit, or Kennbunkport. The one at Woodhouse Fish Co. is pretty decent as is the one at Anchor & Hope. If you have the time, though, go to the Old Port Lobster Shack in a modest strip mall in Redwood City. Again, their fried clams are not 15

the Clam Box of Ipswich or JT Farham’s in Essex, MA (my personal favorite) or even Woodman’s of Essex (also pretty damn good, but I don’t think as good as JT Farnham’s), but out here on the left coast, if you miss a fresh lobster roll, come here and reminisce.

BEST Oversized Overstuffed Sub: Lex Luthor at Ike’s – actually any sub you order here will be huge and tasty – The Lex just seems to be so over the top, that even I (sometimes) struggle to finish it by myself. Share with a friend.

BEST Pupusa: Balompie Café – I like the one

BEST Fried Chicken Sandwich: When it is on further down on Mission near Bosworth. The ladies the specials board, the Fried Chicken Sandwich at the Broken Record This place is not for the faint of heart, but if you are into dive bars with a good beer selection, and surprisingly good food, this is the place to eat before heading over to a minor league hockey game cheering on the SF Bulls at the Cow Palace. Their chef just went to Rickybobby’s in the lower Haight to open up that burger joint, but they still have their Fried Shrimp Po’ Boy for weekend Brunch, and although I would still recommend Backsale Betty’s in Oakland for an honorable mention for their famed Fried Chicken Sandwich, try this one if it is available. You won’t be sorry! If it isn’t the special that day, go for one huge mac and cheese or other dishes. Wash it down with a local beer, and enjoy the ambiance.

handmaking your pupusas with love as you wait, salivating for the authentic pupusas…

BEST Burrito: Super Steak and Prawn Burrito

at La Corneta Taqueria – everyone has their own favorite Taqueria. Whether it’s La Cumbre or what seems to be the media’s darling, La Taqueria’s ricefree version in the Mission, I stand by the Super Steak and Prawn at Glen Park’s Corneta. I’d be happy to have a head to head with anyone else’s. Please see part two of this list in the next edition of The Residents Report.

Pathways to Discovery

GME Enrollment Deadline: 2/15/14

Do you want to make a difference in health and medicine beyond the care of individual patients? Are you interested in building skills as a researcher, advocate, educator, policymaker, local or global change agent while you complete your training? UCSF's Pathways to Discovery Program offers you a unique and effective way to accomplish these goals. The program offers coursework, mentored projects, networking, presentation opportunities, and communities in five areas: Clinical and Translational Research Global Health Health & Society Health Professions Education Molecular Medicine Visit to learn about opportunities, courses, schedules, application processes, contacts, and deadlines. The Pathways to Discovery Directors look forward to talking to you about these exciting programs.


PATHWAYS TO DISCOVERY Resident and Fellow Guide Application Deadline: February 15, 2014

Approved elective time by your residency Program Director is recommended in advance of application.

CTR: Clinical and Translational Research The Clinical and Translational Research (CTR) Pathway stimulates passion for discovery and provides training and mentoring to encourage and allow trainees to conduct innovative clinical and translational research to improve health outcomes.

GH: Global Health The vision of Global Health Pathway is to support and develop lifetime commitments to decreasing the health inequities and disparities in populations throughout the world.

H&S: Health and Society The Health & Society Pathway prepares trainees to be scholars and leaders in health policy, health systems, health disparities, community engagement, advocacy, social science, and/or behavioral science.

HPE: Health Professions Education The Health Professions Education Pathway trains innovators from all health professions fields who promote excellence in teaching, translate theory and novel strategies to the learning environment, and expand knowledge in the field of health professions education.

MM: Molecular Medicine

The Molecular Medicine Pathway assists trainees in envisioning and pursuing a career path combining clinical practice and disease-oriented laboratory research. This Pathway works to enrich the residency experience with opportunities to engage with clinician-scientists and peers, to continue to engage with current scientific literature, and to develop mentoring relationships to support career development.

Designing Clinical Research Four weeks Mondays and Wednesdays 9:00am – 12:00pm 8/4/14 - 8/28/14, or 9/29/14 – 10/26/14 (online)

Global Health Clinical Scholars Three weeks Monday – Friday 9:00am – 4:00pm 9/2/14 – 9/19/14

H&S Core Course One week Monday – Friday 8:00am – 12:00pm 10/13/14 – 10/17/14

Pathway Director: Peter Chin-Hong, MD Coordinator: Christian Leiva

Pathway Director: Christopher C. Stewart, MD Coordinator: Maggie Coffin, MA

Pathway Director: Naomi Wortis, MD Coordinator: Victoria Chen

Teaching Strategies and Curriculum Development:

Pathway Director: H. Carrie Chen, MD, MSEd

Four weeks Monday-Friday 8:00am – 12:00pm, and approx. 3 afternoons per week 9/2/14 – 9/26/14

Coordinator: Timothy Galbreath

Oral or Poster presentation at Resident Research Symposium – May 2014

Pathway Directors: Benjamin Cheyette, MD, PhD Anna Bakardjiev, MD Coordinator: Rosie Casella

For questions, contact the Pathways directors listed above. You may also contact Susan B. Promes, MD, MBA , Associate Director of Pathways for Graduate Medical Education -


SFGH Update SFGH Fire Stairwell Alarm Update

SFGH Rebuild Update

Security is a high priority at SFGH. To help maintain a secure environment, it is now the expectation that only appropriate doors will be used to enter or exit buildings on the SFGH campus.

Much of the Rebuild work is now focused on the interior of the new hospital, while final touches are being added to the exterior. The hospital construction continues to be on schedule and project leaders are working with hospital staff to plan and coordinate the hospital move-in for 2015.

Please note that all (clearly marked) emergency exits at SFGH are now alarmed and monitored by hospital security. It is unacceptable and illegal to use these exits in non-emergencies. Once door alarms are triggered, they must be manually deactivated by security and a full search of the area must be conducted. Upon activation of a fire stairwell alarm immediately call SFSD dispatch (206-8063)

The new hospital’s rounded glass exterior is being adorned with the last pieces of the white sunshades. Soon a ring at the very top called the halo will be installed. It will be delivered to the site in large sections False alarms are loud and disruptive to patients and starting in latestaff and necessitate unnecessary searches that November and distract from essential security activities. Effective lasting through immediately, the Sheriff’s Department will be December. issuing citations to those who use emergency exits inappropriately - with fines ranging from $250-500.

GME Diversity Congratulations to Tacara Soones, MD, MPH! Tacara is a clinical fellow in Geriatrics who received the 2013 Dr. Martin Luther King, Jr. Award in the postdoc/ student/trainee category. Tacara was recognized for her work with Department of Medicine’s Residency Diversity Committee (RDC) and UCSF Office of Graduate Medical Education Diversity Advisory Group (DAG). Since 2009, Tacara has worked hard to promote and support diversity in the department’s residency training programs. She’s the first resident/fellow to receive the award in this category. 18

GME Diversity Calendar of Events 2013-2014 January 31, 2014 1:30-2:30 PM 2:30-3:30 PM 6:00-8:00 PM

February 11, 2014 6-7:30PM

March 21-22, 2014 April 16-20, 2014 April 25-27, 2014

GME Second Look Program

“Diversity at UCSF” panel discussion C-130 (521 Parnassus Ave) “The UCSF Experience” panel discussion C-130 (521 Parnassus Ave) Applicant/Resident/Fellow/Faculty Reception Cana Cuban Parlor and Café 500 Florida Street SF CA 94110

Diversity Advisory Group Meeting

Multicultural Resource Center

Latino Medical Student Association Regional Meeting

UC Davis

Student National Association Annual Medical Education Conference

Washington, DC

Latino Medical Student Association National Conference

Houston, TX

May 13, 2014

Diversity Advisory Group Meeting


Multicultural Resource Center

Diversity Celebration Reception On October 23rd, Dean Sam Hawgood hosted his eighth annual Diversity Celebration Reception for residents, clinical fellows, and faculty. Trainees and faculty from all departments had an opportunity to learn more about efforts to promote and support a diverse workforce at UCSF. Dr. Rene Salazar, GME Director of Diversity, presented an update on activities to promote diversity in graduate medical education. Dr. Renee Navarro, Vice Chancellor, Diversity and Outreach, presented a brief update on campus-wide diversity efforts.

Lamercie Saint-Hilaire, MD, Sam Hawgood, MBBS; Renee Navarro, MD; Migdalia Ordonez, MD; Nazneen Uddin, MD

Rene Salazar, MD, Director of Diversity for GME, Speaks about upcoming events

50 Years at the General: The Barnett Briggs Medical Library Celebrates 50 Years of Service Griffin Burgess, MLIS SFGH Archivist, Barnett Briggs Medical Library This year, the BarnettBriggs Medical Library celebrates 50 years of service at San Francisco General Hospital. Created in 1963 and named for two former Chiefs of Medicine on the UC and Stanford service, the Library was formed for a simple but “A hospital or doctor without library facilities is like a master purpose: to craftsman with only part of the important tools necessary to do his job.” support and promote medical education.  The first - Norman J. Sweet, M.D., Chairman of the SFGH Chairman of the BarnettLibrary Committee. Briggs Library Committee, Norman J. Sweet, M.D., was essential in founding the library and in securing its first funding, materials, and supplies.  He once wrote, “I love this little library

Manual Diaz, MD; Alexandro Jimenez, MD; Josue Zapata, MD; Sarah Schaffer, MD

as I would love my own little child,” and it showed in the consistent support he provided to the library for over twenty years. It is fitting, then, that the library’s reading room bears his name. Support for the library came from the community of San Francisco, with funding and materials provided by the City and County of San Francisco, UCSF, Stanford Hospital Library, and private donors. The initial mission statement of the library was “to stimulate and assist the pursuit of medical education,” and while some of the specific duties of the library may have changed, the spirit of its original mission remains the same.  Now housed in the SFGH Dean’s Office, The library continues to provide relevant, up-to-date information and classes to the faculty, staff, and students of SFGH and UCSF in support of medical education and evidence-based practice. More recently, the library has also opened its doors to patients and the public, offering computer access, classes, and resources for members of the community to learn more about their own health and wellness. Please be sure to visit the library while at the General: 19

Summer 2013 The Residents Report


Editorial Staff: Robert Baron Andrea Cunningham Amy Day


Instructions: The above is an encoded quote from a famous person. Solve the cypher by substituting letters. Send your answers to Correct answers will be entered into a drawing to win a $50 gift card!

Cover Photo: Errol Bush, MD Surgery Cover Photo by: Elisabeth Fall

Many thanks to the following contributors: Mai-Khanh Bui-Duy Griffin Burgess Margaret DiLaura Ryutaro Hirose Jeffrey Hom Leah Karliner Jeff Kohlwes Wenia Lee Christian Leiva Mary McGrath Renee Navarro Dorre Nicholau Susan Promes Glenn Rosenbluth Rene Salazar Colin Scibetta Matt Trojnar GME Contacts

The Summer 2013 Cypher Answer was: Congratulations to Anesthesia Resident Paul Su, MD our Summer 2013 Winner!

Our goals can only be reached through a vehicle of a plan, in which we must fervently believe, and upon which we must vigorously act. There is no other route to success. Pablo Picasso

UCSF School of Medicine Graduate Medical Education 500 Parnassus Avenue, MU 250 East San Francisco CA, 94143

tel (415) 476-4562 fax (415) 502-4166

Congratulations to our first annual UCSF Excellence and Innovation in Graduate Medical Education Award winners. The five winners were honored at a reception on June 17, 2013.

Hali Hammer, MD Faculty Category

Sue Sheehan Staff Category

Herman Bagga, MD Housestaff Category

GME Confidential Help Line: (415) 502-9400 Amy Day, MBA Director of GME (415) 514-0146 Robert Baron, MD, MS Associate Dean, GME (415) 476-3414

Cathy Ratti Staff Category

Jeff Kohlwes, MD Faculty Category

Fall/ Winter 2013  
Fall/ Winter 2013