Residents Report - Fall 2012 by GME UCSF

Fall 2012

The Residents Report Newsletter of the Office of Graduate Medical Education I University of California, San Francisco

The Essential Role of Residents and Fellows as Teachers Robert B. Baron MD MS Associate Dean for Graduate and Continuing Medical Education

in this issue Residents As Teachers 1-2 UCSF Library Update 3 Out and About 4-7 10 Questions 8-11 Pathways to Discovery 12-13 APeX Training Upate 12 UCSF Inclusion Survey 14 Milestones 15 Mental Health Care 16-17 Housestaff Incentive 18-19 GME Cypher 20

Teaching has always been a core part of being a physician. In fact, the Latin root of the word doctor, doctore, means to teach. And in reciting the Hippocratic Oath we pledge to future generations, “…to teach them this art, if they want to learn it, without fee or indenture.” Modern accreditation systems have further institutionalized this professional goal. The ACGME, for example, as part of it core competency in practice-based learning and improvement states that, “residents must be able to facilitate the learning of students and other health care professionals.” The Liason Committee on Medical Education (LCME), the body that accredits U.S. medical schools, similarly states that residents who teach medical students “must be prepared for their roles as teachers and evaluators of medical students.” Resident and fellow teaching of medical students is an essential part of medical education. Studies across specialties suggest that one-third to two-thirds of all teaching on inpatient core medical student clerkships is performed by residents. Teaching by residents and fellows is different from, and complements, teaching by faculty. Residents are more likely to teach bedside skills and procedural skills, have essential roles as near peer teachers allowing them to understand the best way for students to learn new material, and teach at different times than faculty (on call, etc.). Effective resident teachers increase student satisfaction with clinical clerkships and have been linked to student career choice.

UCSF School of Medicine Graduate Medical Education 500 Parnassus Avenue MU 250 East, 0474 San Francisco, CA 94143 tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme

Residents also benefit from their role as teachers. Better resident teachers have been shown to be better learners themselves, have better communication skills, and have higher satisfaction with their role as a resident. And of course, residents themselves receive nearly half of their teaching from fellow residents and fellows. Surveys suggest that residents and fellows value teaching and want more time to teach. Surveys also suggest, however, that residents describe insufficient time to teach, lack of confidence and insufficient training, and are typically unaware of the specific learning objectives of those that they teach. As expected, learning objectives of students are often not met. (continued on page 2)

The Essential Role of Residents and Fellows as Teachers

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Although some of us are “born teachers,” almost all of us benefit from explicit training on how to teach. Fortunately, a substantial body of work describes key features of an effective program to teach residents and fellows how to teach. One recent review of existing residents-as-teachers curricula recommends a minimum of three hours of training, emphasis on (among other things) the “One-Minute Preceptor,” opportunities for reinforcement, inclusion of residents during each year of training, and careful assessment. The best programs assess teachers with observed structured teaching exercises (OSTE), videotapes and/or direct observation, and learner assessments. The One Minute Preceptor teaches five microskills for clinical teaching. These include getting a commitment from the learner, probing for supporting evidence, teaching general rules, reinforcing what is right, and correcting mistakes. Other content in effective resident teaching programs include understanding learning theory and learning styles, creating a positive learning climate, building team leadership skills, understanding learning goals and objectives, learning techniques for questioning learners, and how to provide feedback and assess learners. Teaching for a variety of settings and for different content areas is also useful including teaching at the bedside and in the ambulatory setting, teaching procedures, conducting effective consultations, small group teaching and lecturing, and how to identify, assist and refer learners in trouble. At UCSF many similar efforts are underway. Several large departments offer excellent programs for residents and fellows as teachers and the Office of GME and the Academy of Medical (AME) educators offer multiple half-day workshops each year. UCSF medical student competencies and objectives are posted on the GME website and new residents and fellows receive orientation to the importance of the role of teacher. An on-line module is being developed for all trainees. Other efforts will include better distribution of student learning objectives to all supervising residents and fellows and the development of a cadre of faculty to assist departments with teaching this material. More ambitious, but extremely important goals, include the development of teaching “milestones” that will help learners (and their faculty) assess competence as a teacher and the development of OSTEs and other observation strategies. The GME Curriculum Committee, the AME, and the Office of Medical Education are all actively working to make UCSF a leader in this work. What can residents and fellows do immediately? A good first step is to identify all learners in one’s environment and make sure that you know their expectations, goals and objectives. Take a minute to make sure that everyone is on the same page. Secondly, create a collaborative, respectful learning climate, consistent with UCSF’s highest possible commitment to professionalism and the fair and respectful treatment of all learners. Third, be sure to give feedback frequently and request it for yourself. Feedback should be immediate, clear and concise, begin with positive comments, address specific behaviors, and include suggestions for improvement. Understand the learner assessment process and seek advice from faculty about any questions or concerns. Be sure to ask for help from faculty when you identify a learner who may be struggling. Learners in trouble have the very best chance of success when they can be identified and helped early. And finally be sure come to a GME/AME Teaching Skills Workshop workshop this winter! Acknowledgements: this discussion owes much to the work of Drs. Susan Promes, Patricia O’Sullivan, Lisa Caplit, Linda Snell and all the UCSF faculty and residents who have worked on making us all better teachers.

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UCSF LIBRARY Michelle Henley, MLS Education and Information Services UCSF Library

Point of Care Mobile Apps Many mobile apps are available to assist health professionals with clinical questions at the point of care. While some of the Library’s subscription based databases are available via mobile devices, there are also many free or inexpensive apps that can be downloaded to mobile devices without need of a subscription. These apps may be especially valuable for the rare times when a subscription may be suspended, or as adjuncts to the Library’s offerings. And you can keep the app even if you leave UCSF. Resources such as STAT!Ref, Procedures Consult, and AccessMedicine can all be used on a mobile device once you sign up for an account within the Library’s subscription. STAT!Ref is also available as an app. The mobile app includes all of the STAT!Ref textbooks, as well as evidence summaries from ACP Pier, APhA drug info, a medical calculator and medical dictionary. More information on STAT!Ref is available on the Library’s web site at www.library.ucsf.edu. For more information on mobile-optimized sites via the Library, see the “Mobile Apps and Resources” guide at: guides.library.ucsf.edu/mobile The guide also notes other free or inexpensive mobile apps available for download for iOS or Android devices. Below are some selected free apps for use at the point of care. All of these apps are compatible with the iPhone, iPad, iTouch and Android devices, with some available for other devices as well:  ACC Pocket Guidelines (http://www.skyscape.com/estore/productdetail.aspx?productid=2862) is a clinical practice support tool from the American College of Cardiology Foundation. It includes all of the ACC/AHA practice guidelines in a concise, easy to read format. The app is part of the free Skyscape app, which must be used to access Pocket Guidelines. Skyscape includes other tools such as a medical calculator and drug reference. It is also available for Blackberry devices.  AFP By Topic (www.aafp.org/online/en/home/publications/journals/afp/afpbytopicapp.html) is a collection of articles published in the American Family Physician (AFP) journal, organized by subject area. American Academy of Family Physicians (AAFP) members and AFP subscribers can get all current and archived articles. Non-members and non-subscribers get full text access to the online archives, but abstracts for articles from the last 12 months. The collection is updated regularly by AFP medical editors and includes practice guidelines, patient education handouts and articles from Family Practice Management.  Epocrates RX (www.epocrates.com/mobile) is a drug reference for U.S. physicians. Users can review prescribing information for thousands of prescription and OTC drugs and check drug interactions for up to 30 drugs at a time. There is also a pill ID tool for identifying drugs by color, shape or imprint code. The Mobile Resource Centers also provide up to date medical news selected by an Epocrates editor who is an expert in the field. Epocrates RX is also available for Blackberry devices.  mobilePDR (www.pdr.net/mobile/mobilepdr.aspx) is available to all US prescribers in full time practice, and is another offering via Skyscape. It is an authoritative source for FDA-approved drug labeling information on over 2,400 prescription drugs. It includes full prescribing information as well as color images of medications. mobilePDR is also available for BlackBerry and other devices.  Medscape Mobile (www.medscape.com/public/mobileapp) provides up to date medical news across 34 specialties. It also has a search tool for locating MEDLINE articles directly through the app. Other features include a disease and condition reference, procedures and protocols, and a drug reference and interaction checker. This app is also available for Blackberry and Kindle devices. 3

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

Bicycling in the San Francisco Bay Area

Edward H. Kim, MD Assistant Professor, Department of Surgery University of California, San Francisco

After finishing medical school and residency at UCSF, I left for a year to Minneapolis for my fellowship in colon and rectal surgery. Minneapolis is a great town, but I was pretty homesick for San Francisco. I really missed the mountains, the ocean and the fair weather â&#x20AC;&#x201C; all the elements that make the Bay Area an ideal place for cycling. In fact, when winter hit Minnesota, I actually had a custom built bicycle frame with special paint job with California costal scene highlighted by California Golden Poppies. As the snow fell outside, I would stare at this bike, daydreaming about all the wonderful riding I would get to do when my fellowship was done. Now that I am back, I relish my weekend rides which usually last three to four hours and cover 40 to 60 miles. Although they are more exhausting, I love rides with big climbs as they reward you with incredible views and of course the exhilarating descent. The best routes from the city cross the Golden Gate Bridge into Sausalito and to Mill Valley and up Marion Road where you meet up with Panoramic Hwy and from there you can head up all the way to the top of Mount Tam or go down to Stinson Beach. The ride along Hwy 1 from Stinson Beach back to the city is truly world class as are the views from the ridge on Panoramic. For the less ambitious or the saner folk, biking to Sausalito over the Golden Gate Bridge is a fun way to get out the city and enjoy some sun and get out of the fog, especially the case if you live in the Richmond or the Sunset. The Golden Gate Park is also an ideal place for relaxed riding and you can easily lengthen the trip by riding down the multiuse path along the great highway which gives you a nice view of Ocean Beach. 4

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OUT & ABOUT..... Bicycling in the San Francisco Bay Area (continued from previous page)

If you venture just thirty minutes south to the town of Woodside, you will find another hotbed of cycling with even more riding options for all levels with majority of roads that have nice wide shoulders or bicycle lanes. A great resource for routes in this area can be found on the website www.chainreaction.com. Scroll down to the bottom to the ride report selection and you will find detailed and entertaining descriptions of local routes. The ride up to Skyline on Old La Honda Road is a classic and a ride to the coast to San Gregorio or Pescadero takes you along idyllic meadows and farm, but donâ&#x20AC;&#x2122;t get too comfortable as the return trip requires you ride up over 2,000 feet on the unforgiving Tunitas Creek Road. For a less epic option you can consider La Canada Road south of Hwy 92 which is actually closed to traffic on Sundays. With its seven miles of the gentle rolling terrain, itâ&#x20AC;&#x2122;s a perfect route for a family outing or just a relaxing ride without worries about cars or crowds. If you are looking to get started, finding a good bike shop is the key. My favorite is Roaring Mouse Cycles located by the Presidio. They are true to their motto - Expert Service, No Attitude. Closer to campus is American Cyclery on Stanyan which is another quality shop with a neat collection of retro parts. A good shop will not only help you choose the right bike, but they will help with adjustments and repairs. In addition, they can also be a good source for free advice on how, where, and with whom to ride.

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OUT & ABOUT from the Resident and Fellow Affairs Committee Diversity Events in the Bay Area Rene Salazar, MD Associate Professor of Clinical Medicine, and GME Director of Diversity,

One of the greatest strengths of the Bay Area is the diversity of its population. San Francisco is truly a melting pot rich with cultural diversity. The city embraces people from all groups and is a place where people can be who they want to be. In addition to the stellar training provided at UCSF, the cultural diversity found in San Francisco played a significant part in my decision to move 1700 miles for my training in internal medicine. Thirteen years later, it remains a big part of why I’m still here. The Bay Area celebrates diversity throughout the year. From the largest LGBT gathering in the nation to the largest celebration of Asian culture outside of Asia, San Francisco is home to several year-round events. Here are a FEW of my favorite diversity events in the Bay Area: July Afrosolo Arts Festival- July 30-October 28, 2012 www.afrosolo.org The Afrosolo Theatre Company’s mission is to “nurture, promote and present African American and African Diaspora art and culture through solo performances and the visual arts”. This three month festival includes lectures, a community health fair, music performances and a visual arts exhibit. October Fiesta on the Hill- Sunday October 21, 2012 www.sresproductions.com/events.html This community based festival benefits the Bernal Heights Neighborhood Center whose mission it is to preserve and enhance the ethnic and cultural diversity of the Bernal Heights District of San Francisco. This is a great event for families (includes petting zoo, pony rides and a pumpkin patch!) November Dia de los Muertos [Day of the Dead]- November 2, 2012 www.dayofthedeadsf.org Dia de los Muertos is a traditional Meso-American holiday dedicated to the ancestors; it honors both death and the cycle of life. San Francisco has been celebrating this event since the early 70s with art, music performances and a walking procession. The San Francisco Symphony performs a community concert on Nov 3. Pre-concert festivities (at Davies Symphony Hall) include hot chocolate and pan de muertos, face painting and paper flower making, and a colorful art exhibition celebrating the unique tradition of Día de los Muertos. One of my most favorite events of the year! San Francisco Hip Hop DanceFest- November 16-18, 2012 www.sfhiphopdancefest.com The SF Hip Hop DanceFest is the premier event for presenting hip hop dance. It hosts some of the 6

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OUT & ABOUT..... Diversity Events in the Bay Area (continued from previous page)

best Hip Hop companies from all over the globe. This is a fun and funky event held at the Palace of Fine Arts. I highly recommend! January Dr. Martin Luther King Jr.’s Youth and Family Day and Freedom March Rally- January 2013 San Francisco honors the civil rights leader with a host of festivities including Youth and Family Day and an annual Freedom March Rally. February Chinese New Year Festival and Parade- February 23, 2013 www.chineseparade.com The Chinese New Year Festival and Parade is the largest celebration of Asian Culture outside of Asia. The parade includes beautiful floats and costumes, exploding firecrackers and the spectacular “Gum Lung” (Golden Dragon) a 268-foot long dragon that’s carried throughout the streets of San Francisco. You’ll definitely want to bring your camera for this one! April Northern California Cherry Blossom Festival- April 13-14 and 20-21, 2013 www.nccbf.org Over 200,000 people attend this annual event showcasing the color and grace of Japanese culture and the diversity of the Japanese American Community. Activities include cultural performances, music food and the Grand Parade on Sunday April 21, 2013. May San Francisco Carnaval- May 28-29, 2013 www.sfcarnaval.org This two-day street party celebrates life through dance, music, drumming and a dynamic array of food from Latin America and the Caribbean. Each year, hundreds of hours are spent preparing the costumes and perfecting the music in order to top the previous year’s carnaval. With its flashy dancers and amazing percussion performances, carnaval has it all! June San Francisco Juneteenth- June 2013 www.sfjuneteenth.org Every year, San Francisco celebrates Juneteenth, a holiday honoring African American Heritage by commemorating the announcement of the abolition of slavery. Events include a kick off at the African American Art and Cultural Complex, the Juneteenth Parade and Festival on Fillmore St. which includes music, food, a fashion show and health fair. San Francisco Pride- June 29-30, 2013 www.sfpride.org The San Francisco LGBT Pride Celebration and Parade is the largest LGBT gathering in the nation (estimated attendance for 2012 was more than 750,000!). SF Pride is home to 23 community-run stages and venues, which provides a great way to experience the amazing diversity of the LBGT Community in San Francisco.

Again, these are just a FEW of the many events celebrating diversity in San Francisco. I also encourage you to check out Diverse Destinations, a series of 10 self-guided itineraries that will immerse you in the best of San Francisco’s Culture, ethnic heritage and arts. www.destinationsf.com 7

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10 QUESTIONS FROM THE RESIDENT AND FELLOW AFFAIRS COMMITTEE

Leah Karliner, MD, MAS, Associate Professor of Medicine in the Division of General Internal Medicine, and Rita Ogden, MPP, Director of Ambulatory Services answer resident and fellow questions about UCSF Medical Center Interpreting Services.

1. When does a resident or fellow need an interpreter? A resident or clinical fellow should use a professional interpreter anytime he/she is not fluent in a patient’s language or is fluent, but not well-versed in medical terminology in that language. 2. Can I use fellow staff or a patient’s family to interpret? Can I use my own language skills? Family members may be used for interpretation when engaging in small talk with a patient that does not have any clinical content. However, there is a big difference between interpreting casual conversation and medical terminology. In conversations where interpretation of clinical content is required, a family member or friend, often unintentionally, can filter the information being passed between the physician and patient due to distress, a desire to advocate, or other emotions. In addition, interpretation is a skill and being able to speak the language does not mean one is able to interpret. This is important because errors in language can lead to errors in care. Residents and clinical fellows should use their own language skills for clinical communication with a patient only if they are fluent and comfortable with medical terminology in the necessary language. Casual language skills should only be used for casual conversation without clinical content. Physicians must know their own limitations and feel comfortable requesting an interpreter at any stage of communication. Residents and clinical fellows should never provide interpretation services for their colleagues or other staff and their patients. 3. What are the qualifications of a professional interpreter? A professional interpreter has a combination of experience, education, and skills that makes him/her highly qualified to work as an interpreter. Most professional interpreters have completed a minimum of 40 hours of training, possess national certification which requires at least some college coursework, and have had several years of experience interpreting in different types of clinical settings. National standards for interpretation are being expanded and created where they did not exist in the past. Master’s degree level coursework is also available. 8

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10 QUESTIONS FROM THE RESIDENT AND FELLOW AFFAIRS COMMITTEE Both UCSF employed interpreters and contract interpreters go through a rigorous screening process to ensure they are qualified to interpret medical terminology in their respective languages. UCSF staff interpreters are required to pass an internal exam, which has both written and verbal components. 4. What kinds of interpreters are available at UCSF? The two main types used at UCSF Medical Center are in-person and telephonic interpreters. UCSF has 18 staff interpreters for in-person interpreting. Telephonic interpreting services are available through our interpreter staff and through a contracted vendor. In-person interpreters can be unscheduled, but are usually arranged in advance. Telephonic interpreting services are used in several settings: outside of regular business hours, in an emergency or unplanned circumstance, if the required language is not among those of the UCSF staff interpreters, when the required language is uncommon or when it is not possible to schedule an interpreter. While telephonic interpretation is more readily available, there are times when an in-person interpreter is more appropriate. These might include: - end of life discussions - treatment plans with highly complex educational content - family conferences - difficult conversations such as a new diagnosis or bad news - for a patient with a hearing impairment - for a patient with a cognitive impairment 5. What languages are available at UCSF through Interpreting Services? Interpreting Services provides coverage for approximately 150 different languages. UCSF has Spanish, Russian, and Chinese (Mandarin and Cantonese) interpreters on staff and they are available in person during the following hours: Spanish - Weekdays from 8 am - midnight and weekends from 9am - 5pm. Chinese and Russian - Weekdays from 8am - 5pm. Interpreters in Vietnamese, Korean, and most other languages are available through a contracted vendor for in-person interpreting if scheduled in advance. Please call Interpreting Services at 353-2690 to schedule an in person interpreter. The service providing telephonic interpretation in all of the languages mentioned above as well as more than a hundred more is called Language Line, and the Medical Center is working with the vendor to obtain access to even more languages of lesser diffusion (for example, indigenous Mexican languages). 6. How do I reach an interpreter at UCSF? Call Interpreting Services at (415) 353-2690. There will be a selection menu with several options: for immediate telephonic interpreting services, the average wait time to get an interpreter on the line is about 90 seconds for common languages. For uncommon languages, for example, Cambodian, the wait time may take longer. Scheduling an in-person interpreter for the following services:  immediate service from a telephonic interpreter  paging an American Sign Language interpreter  emergency interpreting services during business hours. 7. How do the dual-handset telephones and videoconference devices work? Where are they located? (continued on page 10

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10 Questions.....from the RFA Committee (continued from page 9)

Dual handset telephones are more commonly found on the inpatient units at Moffitt and Long hospital. Each unit has at least a few dual handset telephones, and all units will be getting more over the next two months. Depending on the unit, phones may be located in each room, or centrally located and available as needed. The dual handset phone has two receivers, one for the clinician and the other for the patient. Instructions are located on each phone. Video Medical Interpreting (VMI) is not currently available at UCSF, but Interpreting Services is exploring a potential pilot for this in the future. Most residents and clinical fellows have experience with VMI at SFGH, where it is used almost exclusively instead of in-person interpreters in outpatient settings. The VMI has a screen and speaker which allows the interpreter to communicate visually and verbally with the patient and clinician from a remote location, in real time. 8. How do I access someone skilled in American Sign Language? American Sign Language (ASL) interpreters may be scheduled in advance by calling (415) 353-2690. For immediate assistance, a 24 hour on-call ASL interpreter can be paged at (415) 449-4114. An off-site, on-call ASL interpreter will be dispatched and will get to your site as soon as possible. For situations in which you need to communicate with a patient who does not use ASL, lip readers are also available. Interpreting Services will soon be piloting video ASL interpreting in the Emergency Department. 9. What techniques are recommended when using an interpreter? Rather than immediately starting the visit with the patient and interpreter, the clinician should briefly describe to the interpreter the circumstances and nature of the conversation/visit. For example, “I am here with my patient Ms. Smith for a follow-up visit. Before we got on the phone, she was telling me about her back pain.” With in-person interpretation the clinician should next consider the therapeutic triangle, which positions each person in the room so the provider has a direct line of sight with both the interpreter and the patient. For situations where ASL interpreters or lip readers are required, the interpreter should stand behind the physician, but in the direct line of sight of the patient. Other techniques for successful communication are: • The clinician should speak directly to the patient and look at him/her, not the interpreter; • Speak slowly and take natural pauses, so the interpreter does not miss valuable information • Do not stop in the middle of a sentence for the interpreter to interpret, as context may be lost. Interpreters interpret “meaning units,” not individual words. • Avoid using medical jargon (i.e., acronyms). 10. What should a resident or clinical fellow do if an interpreter is unavailable? What is my responsibility for interpretation in an emergency situation? In an emergency situation, the first responsibility of a clinician is to stabilize the patient. If the patient has not been stabilized clinically and a family member or staff member is present who can interpret basic questions, the person who is available should be used. However, UCSF does have 24/7 access to interpreters over the phone, so once the patient is in stable condition, the clinician should make every effort to follow policy and request a professional interpreter. By using a professional interpreter, the clinician takes a step towards ensuring an accurate diagnosis and treatment plan for the patient. 10

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SAN FRANCISCO GENERAL HOSPITAL INTERPRETER SERVICES Interpreter Services at SFGH are available 24 hours a day, seven days a week.  Staff Interpreters provide language services on site between the hours of 8:00 a.m. and 12 midnight.  Patient care areas are equipped with cordless Polycom phones that provide direct access to agency interpreter between the hours of midnight and 8 a.m.  Language services are provided through several modes: Videoconferencing, telephonic and in-person. The following is a list of services used to provide language assistance at SFGH. Please call 206-5133 for assistance in accessing these services.  On Site Interpreters and As-Needed Interpreters with language capabilities in Cantonese, Mandarin, Toishanese, Vietnamese, Thai, Laotian, Cambodian, Spanish, Russian, Polish.  Telephonic Language Agency supports over 180 languages (over the phone only). This is arranged through Interpreter Services when the above services are not available.  ASL Interpreters Services include oral interpreting, relay interpreting, and tactile interpreting for blind/deaf patients. Between 12 midnight and 8:00 a.m., please call the Telephone Operator at 206-8000 who will page the Sign Interpreter for an urgent or immediate need. When possible, please try to arrange for a Sign Interpreter at least 48 hours in advance. EVERYDAY 12 A.M. (midnight) to 8:00 A.M. Please use interpreter phones (Polycom/dual handset) if they are available at your location. If not, call the Hospital Operator (“0”) to arrange for language assistance. Sign Interpreters are also accessed through our telephone operators after midnight. To Access Interpreter Services at SFGH Between 8:00 a.m. to 5:00 p.m. Monday - Friday

Call extension 65133

Between 5:00 p.m. to 8:00 a.m. Monday - Friday and Between 8:00 a.m. to 12:00 a.m. (midnight) Weekends & Holidays

Use pre-programmed interpreter phones (Polycom/dualhandset) to be connected to interpreters

For in-person service only Between 5:00 p.m. to 12:00 midnight Monday – Friday and Between 8:00 a.m. to 12:00 midnight Weekends & Holidays

Call beeper # 1-877-4163 (Spanish), 1-877-4165 (Asian), for all other languages 1-877-4163 or 4165

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Pathways to Discovery GME Enrollment Deadline: 2/15/13 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 www.pathways.ucsf.edu 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.

APeX Training Update: Rotating Residents and Returning Faculty Kim Cloidt, APeX Communications Manager

Initial APeX training consisted of both web-based and in-class training. We received far more positive feedback from providers regarding the web-based training than the in-class training. Your feedback has been heard, and, as a result, we are transitioning to all web-based training as we move forward. Our goal is that training will be completely web-based (except for in-person competency assessment) in early 2013. Your feedback will be used by the training team to refine the course content to enrich the learning experience. There are currently many APeX e-Learnings available and plenty of space in the traditional instructor led classroom courses. The fastest way to see current course requirements, access e-Learnings and register for classroom sessions is on the Carelinks page: http://carelinks.ucsfmedicalcenter.org/ From CareLinks, go to the Knowledge Bank to find the Training Plan Finder tool. The Training Plan Finder tool provides step-by-step instructions to help you find your required e-Learnings and classroom courses. In the coming months, an advanced (300-level) Inpatient web-based course will be launched for current users to improve their knowledge and efficiency using APeX in the in-patient environment. Additionally, there will be drop-in sessions staffed with Super Users to provide â&#x20AC;&#x153;one-to-oneâ&#x20AC;? sessions in a live environment to provide you with hands-on experience to learn tips and tricks about how to better use the system. If you have questions about technical issues, call the IT UCSF Service Desk at 514-APEX (2739). If you have questions about training scheduling questions, contact the APeX Training Hotline at 514-8797. 12

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PATHWAYS TO DISCOVERY Courses for Residents and Fellows Pathway Contact

Requirements

Project Proposal Form

Designing Clinical Research course: MON and WED in August or October. The October course is the preferred course for GME learners. That course will be conducted on-line. Pre-application for course: http://www.epibiostat.ucsf. edu/courses/schedule/ course_descriptions.html

None but residents and fellows should discuss course enrollment with their program director in advance of applying for the program.

Deadline: rolling http://www.formstack. com/forms/?110066125zBTwKoww

http:// globalhealthsciences. ucsf.edu/educationtraining/pathways/ graduate-levelcurriculum

A three-week didactic course: 9/3/13-9/20/13

Deadline: Feb. 15 or by special arrangement with Pathway Director https://www.formstack. com/forms/?1305005YYRBGRRMhg

Deadline: June 1st or by special arrangement with Pathway Director

http://meded.ucsf.edu/ hs/residents-gradstudents-and-fellows-1

Intensive course: 10/7/1310/11/13

Deadline: Feb. 15 or by special arrangement with Pathway Director https://www.formstack. com/forms/?1305005YYRBGRRMhg

Deadline: June 1st or by special arrangement with Pathway Director

Deadline: Feb. 15 or by special arrangement with Pathway Director https://www.formstack. com/forms/?1305005YYRBGRRMhg

Deadline: June 1st or by special arrangement with Pathway Director

Deadline: Feb. 15 or by special arrangement with Pathway Director https://www.formstack. com/forms/?1305005YYRBGRRMhg

N/A, no proposal submission

Health & Society Jessaca Machado

http://meded.ucsf.edu/ hpe/residents-gradstudents-and-fellows-0

Core course: 8/26/139/20/13 OR 9/3/13-9/27/13

Health Professions Education Carrie Chen http://meded.ucsf.edu/ mmp/residents-gradstudents-and-fellows Molecular Medicine Robert Nussbaum

Residency Program Director Approval Form

http://meded.ucsf.edu/ ctr/residents-gradstudents-and-fellows-0 Clinical and Translational Research Christian Leiva

Global Health Chris Stewart

Curriculum Dates

Longitudinal curriculum: case conference on the second and fourth Fridays of each month

Form: Available at http://meded.ucsf.edu/ pathways/enroll one month prior to deadline

For Questions, contact the Pathways directors listed above. You may also contact Susan B. Promes MD, Associate Director of Pathways for Graduate Medical Education - susan.promes@ucsf.edu

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UCSF Inclusion Survey - November 15-19, 2012 We take it personally. You can too. The University of California is committed to creating a healthy and inclusive climate. Between October 2012 and February 2013, UC will survey all 235,000 students and 185,000 faculty and staff in the most comprehensive university survey focusing on institutional climate and inclusion. WHY IS UCSF PARTICIPATING IN THIS INITIATIVE? UCSF is committed to creating an inclusive and welcoming campus. The survey will gather data that will help assess the learning, living and working environments — or campus climate — for people who go to school or work at UCSF. Research shows that how students experience their campus environment influences both learning and developmental outcomes, and that discriminatory environments have a negative effect on student learning. Research also suggests that faculty members who consider their campus climate healthy and inclusive are more likely to feel personally and professionally supported. Quite simply, students, trainees, faculty and staff thrive in healthy environments, free of the negativity of discrimination, where inclusion and respect for diversity is the daily norm. UCSF is committed to creating these environments. The survey results will help UCSF develop or enhance policies and programs to foster a more welcoming, inclusive and healthy campus climate for its students, trainees, faculty and staff. WHAT IS CAMPUS CLIMATE? Campus climate encompasses the experience of people and groups and the quality and extent of the interaction between various groups and individuals. The quality and extent of these interactions determines a healthy campus climate, according to Susan Rankin, a Pennsylvania State University education professor whose consulting firm, Rankin & Associates, worked with UC to develop the survey. 

WHEN WILL THE SURVEY BEGIN? UCSF faculty, staff, students and trainees received an email invitation from Chancellor Susan Desmond-Hellmann on Nov. 5 with instructions on how to participate in the survey. All survey responses are strictly confidential. To access the Survey go to: https://myaccess2.ucsf.edu/climatesurvey/ Paper surveys are also available upon request from diversityoutreach@ucsf.edu

ADDITIONAL IMPORTANT INFORMATION  Survey responses are confidential. http://campusclimate.ucop.edu/faq/index.html#faq-07  The survey is independent. Dr. Sue Rankin of Rankin & Associates Consulting has been selected as consultant for this project. www.rankin-consulting.com  Findings and results will be posted online by March 2013.  Incentive prizes will be awarded, including five $2,000 staff development grants, twenty-four iPads for employees, $5,000 professional development award for faculty, and a $5,000 professional/graduate student award. FOR MORE INFORMATION: www.ucsf.edu/news/2012/11/13057/ucsf-survey-all-about-campus-culture-inclusion www.diversity.ucsf.edu www.campusclimate.ucop.edu 14

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Submitted by the Office of Diversity and Outreach

Where is Graduate Medical Education Heading? Competencies, Milestones and Entrustable Physician Activities Susan B. Promes, MD Director of Curricular Affairs Office of Graduate Medical Education

Competency based education is nothing new to graduate medical education. In 2002, the ACGME rolled out the Outcomes Project. The most important characteristic of competency-based education (CBE) is that CBE measures learning rather than time spent participating in an educational experience. Learners progress by demonstrating that they have mastered the knowledge and skills (called competencies) required for their training, regardless of how long it takes. There is an emphasis on the product (outcome) not the process of education. The impetus for the ACGME Outcomes Project was to emphasize educational outcomes in GME accreditation rather than the process of how a training program was put together on paper. Not surprising, the ACGME is accountable to public and must be able to demonstrate the quality and “outcomes” obtained from ACGME accreditation. The implementation of the six general competencies: Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills, System Based Practice and Practice Based Learning and Improvement were the backbone of the ACGME Outcomes Project. As a result, residency and fellowship programs over the past decade were expected to show evidence of achieving educational outcomes through data on resident and program performance. Unfortunately, the Outcomes Project was not as successful as the ACGME would have liked which brings us to ACGME’s New Accreditation System. One important aspect of the ACGME New Accreditation system involves the implementation of milestones. Milestones were developed with the goal of realizing the hopes of the Outcomes Project by identifying specific specialty specific outcomes. Milestones are meaningful and measurable markers of progression of competence of a trainee. Seven ACGME specialties will be rolling out milestones in July of 2013: Diagnostic Radiology, Emergency Medicine, Internal Medicine, Neurosurgery, Orthopedics, Pediatrics and Urology. The remainder of specialties will follow. Per ACGME program requirements, each specialty must use specialtyspecific milestones as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. The implementation of these milestones will likely follow a steep learning curve. GME programs are going to be expected to report on each trainee’s progress on attaining each of the specialty-specific milestones every six months. Of note, there was no limit on the number of milestones that a specialty could develop, so there is a wide range with respect to the number of milestones with Emergency Medicine having just over 20 milestones and Internal Medicine and Pediatrics, for example, having over 100 milestones. Olle ten Cate has further refined the idea of competency-based education by introducing the concept of entrustable physician activities (EPA) which builds on milestones. Professor ten Cate believes that by using the concept of EPA the potential gap between the theory of CBE and actual clinical practice can ultimately be closed. EPA are units of work that may be awarded a more or less formal qualification at the moment when supervisors (faculty) confirm that the trainee is ready to assume responsibility (i.e. competent) for such activities. In other words, the instructors and patients trust the trainee to perform a specific activity. EPA are designed with the goal to identify those professional responsibilities that a trainee will need to function independently. The major difference between milestones and EPA is the context—whereas milestones are specific knowledge, skills and abilities and EPA consistently take into account the clinical context. In summary, competency based education is the backbone of the US graduate medical education system. Milestones and entrustable physician activities are conceptual frameworks for realizing a system of education that provides measurable outcomes that can be shared publically to assure our patients that we are putting out qualified, competent physicians at the completion of their ACGME training. Frank JR, Snell LS, ten Cate O, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Medical Teacher. 2010:32;638-645. ten Cate O, Scheele F. Viewpoint: Competency Based Post Graduate Training: Can We Bridge the Gap between Theory and Clinical Practice. Academic Medicine. 2007;82(6):542-547. Special thanks to Karen Hauer, Carrie Chen, John Young, Patricia O’Sullivan for sharing their slides on Defining and Assessing Entrustable Professional Activities.

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Suffering in Silence: Fears and Stigmas that Keep Physicians from Receiving the Mental Health Care that They Need Johanna Workman, PsyD Faculty & Staff Assistance Program (FSAP) Reasons why physicians shy away from mental health treatment are vast and varied. There are many barriers and fears that prevent physicians suffering from depression and other mood and substance abuse disorders to get the help that they need. Physicians cite some of their biggest fears being: confidentiality issues, possible sanctions against their medical licenses, and stigma; however, for the physician’s own wellbeing, it is important to ensure any mental health issues are being therapeutically addressed. On the brighter side, depression is generally a very treatable disorder, and improvements can be made with psychotherapy, medication, behavioral changes such as exercise, or a combination. People with depression tend to have mistaken beliefs in how they see the world. Cognitive Behavioral Therapy (CBT) is an effective form of treating depression. Through CBT, you learn how you’ve come to have certain beliefs, called distorted thinking, and this distorted thinking stems from the lens in which you see the world, which in turn shapes one’s behavior. This distorted thinking gets challenged in therapy in order to have a successful outcome with learning how to manage one’s depression. Difficulties in Recognizing Symptoms of Depression Physicians may not readily recognize the symptoms of depression in themselves and may chalk it up to simply being tired and overworked. Symptoms of depression include:         

Difficulty concentrating, remembering details, and making decisions Fatigue and decreased energy Feelings of guilt, worthlessness, and/or helplessness Feelings of hopelessness and/or pessimism Insomnia, early-morning wakefulness, or excessive sleeping Irritability, restlessness Loss of interest in activities or hobbies once pleasurable, including sex Overeating or appetite loss Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment

 Persistent sad, anxious, or “empty” feelingsThoughts of suicide, suicide attempts

Reluctance to Use Insurance Benefits One barrier to treatment is physicians’ reluctance to use their insurance due to concerns about confidentiality. In order for treatment to be paid, most insurance companies require a mental health diagnosis, and possibly even a clinical assessment and treatment plans that the mental health clinician submits. Although insurance companies do not typically relay specific protected health information (PHI) to the employer, there are instances, such in the cases where there is an imminent danger to self or others, that confidentiality may be breached. Furthermore, physicians may be afraid have a mental health diagnosis on record at an insurance company that could be released with a court order, for example, in a criminal case against them. In order to avoid insurance companies having their diagnosis on record, some physicians opt to pay cash for the services, and many psychotherapists will work on a sliding-scale to keep the costs low. Physicians who opt to utilize their insurance benefits should find some comfort knowing that insurance companies usually ask only for the bare minimum when it comes to treatment plans submitted. If a physician has a concern about what information gets submitted to the insurance company, they are encouraged to have a discussion with the treating mental health clinician. 16

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Fears of Sanctions against Medical License One of the biggest barriers that prevent physicians from getting mental health care is the fear of sanctions against their medical license. The majority of state medical boards require physicians to indicate a mental health diagnosis on their application for licensure or renewal, and, understandably, physicians fear that the existence of a mental health diagnosis could put their medical license in jeopardy. In addition to sanctioning against one’s medical license, physicians fear that if they could lose hospital privileges, health insurance, life insurance, malpractice insurance, face practice restrictions, and increased supervision. This disclosure of mental health diagnoses on the licensure applications was intended to protect patients; however, patients may actually be at more risk if they are receiving treatment from a physician who is suffering from an untreated mental illness or substance abuse issue. Many states have physician health programs that allow physicians who are compliant with treatment to avoid disclosing depression or other mental illnesses to their licensing authorities, but the Diversion Program ended in California in 2008. The good news, however, is that most health care attorneys will say that many of these fears can be put to rest. Health care attorney, Brock Phillips of the Pacific West Law Group in Mill Valley, CA, stated, “I’ve been doing this work of representing physicians for 32 years and I’ve never seen a medical board take an interest in a mental health diagnosis unless it compromised the safety of the patient, and prevented the physician to competently practice medicine. There are two instances I can think of where a board would take an interest in a physician’s mental health diagnosis: (1) If there is a co-occurring substance abuse disorder that threatens the safety of patients and then the board takes appropriate action, and (2) If a physician is actually behaving inappropriately towards patients or coworkers and their diagnosis is a barrier to them behaving appropriately. But I’ve never seen the board take an adverse view of a physician who has a mental health diagnosis and sought treatment through psychotherapy or medication. In fact, I think the opposite is a more appropriate concern: Physicians should be willing to get help so a problem does not ripen further.” Stigma Physicians face pressure to appear healthy, and attitudes within the profession tend to discourage them from admitting any health vulnerabilities. Physicians often fear that their colleagues and patients would lose respect for them and question their competence to practice medicine, and this stigma prevents physicians from receiving the treatment that they need. Although the stigma of mental illness is real, there are many movements, such as National Depression Screening Day http://www.nmha.org/go/depressionscreening-day and Stop Stigma Sacramento http://www.stopstigmasacramento.org/ that are making inroads at lessening the shame, and the documentary, Struggling in Silence, which can be found at http:// www.doctorswithdepression.org/, helps to normalize the feelings physicians have in seeking treatment for their depression. Admitting to having depression and getting help for it is not a weakness; indeed, it shows strength of character. By taking care of one’s mental health, physicians are not only taking care of themselves, but they are also protecting their patients. Well-functioning physicians have more concentration, clarity, and energy to better serve their patients – and there’s no shame in that! We at the Faculty and Staff Assistance Program are sensitive to the concerns of physicians who seek treatment, so if you are experiencing symptoms of depression or other mental health issues, please know that we are available to provide you with counseling services as well as referrals to therapists in the community. FSAP services are free, confidential, and available for both personal and work-related issues. Please contact us at 476-8279 to make an appointment to meet with our staff, or visit our website at http://ucsfhr.ucsf.edu/index.php/assist/ for more information. Wieclaw, J., Agerbo, E., Mortensen, P. B., Bonde, J.P. (2006). Risk of affective and stress related disorders among employees in human service professions. Occupational and Environmental Medicine, 63 (5), 314-319. Wunsch, M.J., Knisely, J., Cropsey, K. L., Campbell, E. (2007). Women physicians and addiction. Journal of Addictive Diseases, 26 (2), 35-43. Hendin, H., Reynolds, C., Fox, D. (2007). Licensing and Physicians Mental Health: Problems and Possibilities. Journal of Medical Licensing and Mental Health, 93, 6-11. 17

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INCENTIVE UPDATE Glenn Rosenbluth, MD Director, Quality and Safety Programs, GME

We continue to make great progress in achieving the Housestaff Incentive Goals. We have three goals this year which affect all residents and fellows who rotate at the Parnassus or Mt. Zion campuses for at least 12 weeks: Goal #1: Patient Satisfaction On the patient satisfaction survey “likelihood of recommending question”, we want to maintain an annual average (July 2012 – June 2013) mean score of 91.6. This goal is the same as the target patient satisfaction goal that has been set for Medical Center Staff. Goal # 2: Patient Quality and Safety Our goal is to achieve 85% hand hygiene compliance by physicians for at least six of twelve months. This goal is the same as the hand hygiene goal that has been set for Medical Center Staff in prior years. The physician group baseline has ranged from 80-84% during 2012. Goal #3: Resource Utilization / Discharge Process We want to complete 20% of all inpatient discharges before 12pm, for at least six out of twelve months. This will include completion of all elements of the discharge process. The current baseline ranges from 14.5-19.4%. Here is the scorecard for the first 2 months of the academic year: CLINICAL HOUSESTAFF INCENTIVE GOALS SCORECARD: FY2012-2013 September Warning (≤5% below target)

Immediate Attention (>5% below target)

On Target (meets or exceeds target)

Likelihood of Recommending by Date of Discharge

100

PATIENT SATISFACTION:

91.4

91.3

91.391.4

For the period of July 2012-June 2013, on the patient satisfaction survey likelihood of recommending question, maintain an annual average mean score of 91.6. Percentile rankings shown are national benchmarks. Due to change from received date to date of discharge information will be lagging by 3 months.

60 40

FY12

July

Aug

Monthly percentile

Sept

Oct

Monthly mean score

Nov

Dec

Jan

Feb

Mar

Axis Title

Running average percentile

Apr

May

Jun

Running average mean score

Overall Hand Hygiene Summary Rolling 12 Month Period

PATIENT SAFETY AND QUALITY:

100% Compliance Rate

For the period of July 2012-June 2013, achieve 85% hand hygiene compliance by physicians for at least six of twelve months.

80% 60%

40% 20% 0%

Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 MD/NP/IPA (Provider)

Complete 20% of all inpatient discharges before 12 PM, for at least six out of twelve months. This will include completion of all elements of the discharge process.

Inpatient Discharges Completed before 12 PM Percent Completed

Resource Utilization/Discharge Process:

IAP-Goal

25.0% 20.0% 15.0%

10.0% 5.0% 0.0% Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Actual

Heather Leicester - Patient Safety and Quality Services

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Target Metrics Collected - 9/17/2012

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In addition, we have 19 Program-specific goals which have been championed by residents and fellows:                  

Anesthesia – improving delirium screening Dermatology – improving communication about diagnoses DOM Fellows – improving the quality of consultations Emergency Medicine – improving phone follow-up to patients General Surgery – improving timeliness of post-operative notes Heme-Onc Fellowship – improving the discharge template usage Internal Medicine – improving the admission time from the ED Lab Medicine – improving utilization of sendout tests Neurology – improving timeliness of therapeutic cooling Neurosurgery – improving timeliness of post-operative notes Obstetrics & Gynecology – improving prescribing of anticoagulants Orthopedic Surgery – improving screening and treatment of Vitamin D deficiency Otolaryngology – improving discharge instructions Pediatrics – improving use of the discharge checklist Radiation Oncology – improving coding accuracy Radiology – improving attestation of radiation dosing Transplant Hepatology – improving communication with primary care providers Urology – improving the post-procedure follow-up process

Kudos to everyone for your ongoing contributions to the safety and quality of the care we provide to our patients!

Faculty and Staff Assistance Program (FSAP) University of California San Francisco 3333 California St. Suite 293 San Francisco, CA 94143-0938(415) 476-8279 For additional information, please visit our website at: http://ucsfhr.ucsf.edu/index.php/assist/ For an appointment, please call (415) 476-8279

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GME GRAND ROUNDS The Office of Graduate Medical Education sponsors Grand Rounds for residents and clinical fellows on the third tuesday of each month (12noon - 1pm) UPCOMING Grand Rounds 2012-2013 “Electronic Medical Record and Medical Education” - Russ Cucina Tuesday, November 20, 2012 HSW 303

G M E

C Y P H E R Fall 2012

Solve the Fall 2012 Cypher FBI OBHX’D LQ BMEBXABIVB SAFNLZF XBQYBVFAIU AD TZDF LIB OBHX’D BMEBXABIVB XBEBHFBP IAIB FAKBD

No Grand Rounds in December 2012 Fatigue Management - Dorre Nicholau Tuesday, January 15, 2013 N 217 The Dean’s Office encourages all trainees to attend and makes every effort to coordinate Grand Rounds with the residency/fellowship noon teaching conferences. www.medschool.ucsf.edu/gme/grounds/index.html

The Residents

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

Congratulations to Kevin Yee, winner of the GME Summer Cypher.

You must be the change you wish to see in the world - Gandhi Xne cejh sf hyf tyrauf xne zgjy hr jff ga hyf znokb - Urabyg Kevin Yee, First Year Resident Internal Medicine Residency IMPORTANT GME CONTACT INFORMATION Office of GME GME Confidential Help Line Director, GME Associate Dean, GME UCSF Faculty & Staff Assistance Program (FSAP) GME Website

(415) 476-4562 (415) 502-9400 (415) 514-0146 daya@medsch.ucsf.edu (415) 476-3414 baron@medicine.ucsf.edu (415) 476-8279

Editorial Staff: Robert B. Baron Amy Day Gitanjali Kapur

Many Thanks The Office of Graduate Medical Education would like to thank the following contributors for submitting articles.

Contributors Robert B. Baron Amy Day Paul Day Kim Cloidt Michelle Henley Leah Karliner Edward H. Kim Rita Ogden Mary McGrath Susan Promes Glenn Rosenbluth Rene Salazar Johanna Workman Kevin Yee

UCSF School of Medicine Graduate Medical Education 500 Parnassus Avenue MU 250 East, 0474 San Francisco, CA 94143 tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme