Winter/ Spring 2013
The Residents Report Newsletter of the Office of Graduate Medical Education I University of California, San Francisco
Healthcare for Transgender People Madeline B. Deutsch, MD Clinical Lead, UCSF Center of Excellence for Transgender Health Assistant Clinical Professor, UCSF Department of Family & Community Medicine
in this issue Healthcare for Transgender 1 ODO Updates 4 Patient Safety Bulletin 5 Incentive Updates 6 10 Questions 8 Out and About 11 CTSI Update 17 OGME Diversity 18 GME Events Gallery 19 GME Cypher 20
UCSF School of Medicine Graduate Medical Education 500 Parnassus Avenue MU 250 East, Box 0474 San Francisco, CA 94143 tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme
1
Transgender is an umbrella term typically used to refer to people whose gender identity is incongruent with the sex that they were assigned at birth. While many stereotypes exist, transgender people represent a wide range of gender identities, gender expressions, and sexual orientations. Furthermore, not all transgender people seek the same transition path; some may seek cross-sex hormone therapy (csHT) only while others may seek any combination of genital, chest, facial and other surgical procedures with or without csHT. Transsexual is an older, more clinical term which had historically been used to refer to the subset of transgender persons seeking csHT and/ or surgery; this term is being used with decreasing frequency as the dividing lines become less clear and less relevant. Separate from gender identity is a spectrum of gender expression; just as with nontransgender people (often referred to as cisgender people) transgender people may have a range of gender expressions with few falling at a hyperfeminine or hypermasculine polar extreme. Lastly sexual orientation is completely uncoupled from gender identity with studies showing transgender people having a range of attractions to men, women or both. Table 1 contains a glossary of commonly encountered terminology; figure 1 illustrates the various spectrae of gender and sexuality. Demographic studies of transgender people are limited. Initial studies from Europe are not necessarily representative of US populations and have some methodologic limitations. A 2012 study published in the American Journal of Public Health by Conron, Scott, Stowell and Landers found that 0.5% of respondents to a land-line survey in Massachusetts identified as transgender. Increasing visibility in the media and in society will likely lead to increasing prevalence in the coming years as more people feel comfortable coming out of the closet and pursuing transition. The healthcare needs of transgender people range from basic primary and preventive care to a variety of transition-related treatments such as hormone therapy, surgery, and psychological counseling. A 2008 study of 646 transgender persons in California found that 30% reported postponing care due to prior discrimination. The 2011 National Transgender Discrimination Survey (NTDS) nationwide study of transgender patients found that 50% of 6450 respondents reported having to teach their providers about transgender healthcare. This (continued on page 2)
Healthcare for...
(continued from page 1)
same report found numerous disparities in income, education and housing access, all of which were magnified in transgender people of color. A 2006 survey by Clements-Noelle, Marx & Katz of 515 transgender people in San Francisco found that 32% had attempted suicide. HIV risk is significantly elevated among transgender populations, in particular among transgender women of color who have been found to have prevalences as high as 30% or more in some studies; a 2008 meta analysis by Operario, Soma & Underhill found a worldwide HIV prevalence of 14% in transgender women, with that figure climbing to 25% in transgender female sex workers – a trade often necessary for survival given the lack of other opportunities. A 2012 meta analysis by Baral, Poteat & Stromdahl et al found a nationwide prevalence of 21% with an odds ratio of 34 for transgender women being infected with HIV. A 2011 study published in JAMA by Obedin-Maliver, Goldsmith & Stewart et al found that only 30% of medical school curriculae included content on gender transition; in fact this subject area ranked last among 16 core LGBT subject areas measured for curricular inclusion in this study. Most transgender clinical research is conducted in Europe, where funding and academic centers exist. After a shift in the political climate in the US in the 1980’s, most academic transgender medicine programs shut down and care in this country moved into the private sector. As a result little currently exists in the US in the way of research funding or training on transgender medical and surgical care. Given these disparities the Institute of Medicine stated in their 2011 report on the health of LGBT people that “All aspects of the evidence base for transgender-specific health care need to be expanded”. Also of note is a position statement issued by the American College of Obstetricians and Gynecologists in 2011 which states that “Obstetrician–gynecologists should be prepared to assist or refer transgender individuals for routine treatment and screening as well as hormonal and surgical therapies”. The World Professional Association for Transgender Health is an international multidisciplinary professional organization which publishes transgender standards of care; the most recent update, “Standards for the Care of Transsexual, Transgender and Gender 2
Male -----------------------------------Female Biological sex Male------------------------------------Female Physical Sex Male------------------------------------Female Gender Identity Masculine-----------------------------------Feminine Gender Expression Homosexual------------------------------Heterosexual Sexual Orientation Figure 1. Spectrae of gender identity and sexuality. Transgender people, like non-transgendered (cisgender) people will each have their own unique array of point of these spectrae. Sexual orientation is independent of other spectrae; a transgender woman who is attracted to women would be considered a lesbian, and a transgender man who is attracted to men would be considered a gay man.
Nonconforming People, Seventh Version” (SOCv7)was released in 2011. These standards provide guidance on a range of topics including background information, diagnosis, and criteria and process for access to a range of services; details on care regimens such as hormone dosing are not included in this document. Deutsch & Feldman published a brief review of SOCv7 in the January 15, 2013 issue of American Family Physician. In addition to routine primary and preventive care, transgender patients often seek a range of medical and surgical treatments to help align their physical sex (i.e. body secondary sex characteristics) with their gender identity. Medical treatment typically involves some combination of cross-sex hormones and in some cases, hormone blocking medicine. Each regimen as well as individual surgeries sought are tailored to patient desires, with some patients requesting lower doses or only partial hormone therapy, some not desiring any surgical intervention, and some seeking a wide range of available services. Multiple studies have demonstrated that both hormone therapy individually as well as surgery improve social functioning and quality of life and reduce scores of depression and anxiety. Of note SOCv7 considers it unethical to deny transgender medical or surgical care on the basis of HIV status, and hormone-antiretroviral interactions are not clinically relevant. Medical care – MTF spectrum Transgender women and other transfeminine-spectrum people may seek (continued on page 3)
Healthcare for... (continued from page 2)
hormone therapy in the form of estrogens, typically combined with an anti-androgen. Hormone therapy brings on feminizing changes in physical secondary sex characteristics, such as breast development, distribution of body fat, reduction in muscle mass, facial and body hair, female perspiration odors and patterns, reduced erectile function and testicular atrophy. Mood changes also occur and patients may find shifting interests, sexual preferences, and a more female pattern of emotions. Supraphysiologic estrogen dosing is not necessary; more important is androgen blockade into the typical female ranges. Progestagens may be used in some cases and are believed by some to improve breast development, mood, and libido. Clinical progress is more useful for monitoring of therapy than are hormone levels; useful clinical indicators include loss of spontaneous erections and reductions in body hair to a female pattern. Transgender women may also access a range of surgical procedures, including facial feminization, breast augmentation, reduction thyrochondroplasty (removal of “adam’s apple), Trans(gender) woman
Person assigned male at birth who has a female gender identity
Trans(gender) man
Person assigned female at birth who has a male gender identity
MTF / FTM
“Male-to-Female” and “Female-to-Male”
Genderqueer
Range of identities which exist outside the gender binary; may include people who identify with both, neither or a uniquely defined gender
Transsexual
More clinical term falling less out of favor, typically refers to transgender people who seek medical or surgical treatments
Cisgender
Non-transgender person. Latin root “cis” means “same side”, as opposed to “trans”
Transition
Individualized process through which transgender people seek medical and surgical interventions as well as make important social disclosures and life adjustments in order to inhabit a more congruent gender space
GRS
Genital reassignment surgery [1]
SRS
Sexual reassignment surgery [1]
GCS
Genital confirmation surgery [1]
[1] All of these terms are used interchangeably to refer to a variety of genital procedures, typically vaginoplasty or phalloplasty but also may refer to mastectomy or metoidioplasty in transgender men. Table 1. Glossary of common transgender terminology
stand-alone orchiectomy and vaginoplasty. The primary vaginoplasty technique involves the penile-inversion method; an orchiectomy is performed followed by penile dissection and removal of erectile tissue. Penile skin is then inverted and secured into a created pelvic space which lies inferior to the retained prostate. Remaining penile skin, vulvar skin and perhaps from other graft sites are used to create vulva. The urethra is shortened and a meatus created within the vulva; a portion of glans penis tissue is taken as a flap and used to create a clitoris. Postoperative recovery is a slow and painful process, typically requiring dilation 3-4 times/ day for 1 hour over the course of several months; patients require a stable recovery environment and are typically out of work for 2-3 months. Because the neovagina is a skin lined cavity, pap screening is not indicated; discharge may represent a bacterial vagniosis-like picture however candidal infections have not been shown to occur. Often the discharge is related post-operative granulation tissue (which can be cauterized with silver nitrate) or due to retained sebum, cellular debris, semen or lubricant. Due to the retained prostate, transgender women should still be screened for prostate cancer as per current recommendations; this condition is limited to a few case reports which likely represent pre-existing undiagnosed disease, given that estrogen used in the treatment of prostate cancer. Breast cancer is also limited to a few case reports. While there is a likely under-reporting of such conditions in this highly marginalized population, incidences of these conditions are still likely quite low. Estrogen therapy may rarely cause growth of a pituitary microadenoma, presenting with an elevated prolactin or rarely visual symptoms; prolactin levels are usually profoundly elevated, mild elevations are not usually clinically relevant. It is generally wise to compare lab normal ranges to the affirmed (i.e. target) gender rather than that of the birth sex, though in all cases an analytical interpretation of lab values is important. Studies have demonstrated that transgender women on estrogen therapy retain bone density in the female normal ranges; if hormone therapy is stopped after orchiectomy patients may require screening and primary prevention for osteoporosis. While prior data from the 1980’s and 1990’s demonstrating increased risk of venous thromboembolic phenomenon with cross-sex estrogen therapy, (continued on page 14)
OFFICE OF DIVERSITY AND OUTREACH (ODO) UPDATES The Office of Diversity and Outreach (ODO) hopes the new year is treating you well. It’s barely March and ODO is already busy mapping out 2013 with some wonderful programmatic opportunities. The 6th Annual Chancellor’s Leadership Panel on Diversity is scheduled for March 26, 2013 from noon-1:30pm in Cole Hall. This year’s topic will focus solely on the influence of unconscious bias. The expectation is for all who attend to have taken the Implicit Bias Test (https://implicit.harvard.edu/ implicit/) to foster a thought provoking conversation on an issue that affects us all. We hope to see you there! Our Inside UCSF program is fast approaching again this year. The twoday program April 26-27, 2013 provides second and fourth year undergrad/postbac students the opportunity to get an inside look at a day in the life of a student at UCSF. Participants tour our state-of-the-art facilities, sit in on lectures, and meet with current UCSF students and key campus leadership. It’s a signature program for our office and focusses on our goal of diversifying the pipeline of our student population. If you’d like to be a part of the program at all, please contact Paul Day (paul.day@ucsf.edu). There are plenty of informal opportunities to mix and mingle with the participants. Here’s a link to the video produced from last year’s program (http://diversity.ucsf.edu/ InsideUCSF). Special congratulations to Mack Roach, MD and Alice Wong, MS! Dr. Roach has been nominated by President Obama to sit on the National Cancer Advisory Board and Alice Wong has been appointed to the National Council on Disability. President Obama has chosen two exemplary advocates in their respective fields. The office has begun the searches for its new Director of Affirmative Action and Diversity Program Manager/LGBT Specialist. In the next several weeks, search committees will begin the process of vetting and interviewing applicants. We expect a large pool of qualified people for both open positions. Please share this information with anyone you may know that can bring their experience to the ODO table. Lastly, ODO is extremely proud of the Insight to Diversity Award our office accepted on behalf of the University. This award is a testament to the tireless work our campus community performs daily to ensure we have a just and inclusive working environment. Congratulations to you! Please join in on the conversation on our Facebook (UcsfDiversity), Twitter (@UCSFODO), and Instagram (UCSFODO) accounts! Feel free to contact our office at diversityoutreach@ucsf.edu with any questions, concerns, or ideas you may have.
Confidential GME Helpline 415-502-9400 Confidential line for housestaff, faculty, and program administrators to voice their questions, comments, or concerns 24 hours a day. The Office of Graduate Medidcal Education will respond to all messages. 4
1 2 3
PATIENT safety bulletin Patient stories and quality of care improvement updates for residents and fellows at UCSF
MARCH, 2013
the threatening patient CASE:
A 24 year old male was admitted from the ED for management of an asthma flare. He was stabilized with breathing treatments. When resident staff approached him for further interview, he became very belligerent and threatened to hurt himself and others, noting he had a weapon.
RESIDENT RESPONSE:
The resident felt the threat was legitimate and asked the patient to not hurt anyone. She then left the room calmly, announcing she would return soon. She alerted the ED charge nurse and her attending, who noted he would come to help. Security was alerted and nursing called a “code grey” which identifies a threatening location, notifying non-security staff to stay away. An incident report was filed.
IMMEDIATE RESULTS:
The patient became more cooperative after some time to cool down and after noting the presence of security. The patient admitted he had no weapon.
RCA Process:
In response to several recent events involving threatening patients, a root cause analysis (RCA) was performed. The following improvement actions have been implemented: ¥ A “disruptive behavior” algorithm* was developed for early intervention. Please contact the unit charge nurse for assistance with all threatening patients and notify security ASAP. ¥ Multidisciplinary patient “Behavior Huddle” developed and can be activated by front line providers if needed. ¥ RNs on high risk units underwent formal behavior management training. ¥ Room search protocols were created for patients with violent behavior and 5150 patients. ¥ The Apex “FYI” Alert is used to communicate important information about patients with a history of disruptive behavior. *http://ucsfpolicies.ucsfmedicalcenter.org/Sha red%20Documents/DisruptiveBehavior_Manag ementof.pdf
Incident Reporting Website: https://ucsfincident.ucdmc.ucdavis.edu From the UCSF Patient Safety Committee and Office of GME Editors: Herman S. Bagga MD (Resident, Urology) and Mary H. McGrath, MD (Surgery and Office of GME) Questions? Susan L. Penney, JD, Director, Risk Management 353-1842
IMPORTANT POINTS Incident reports (IRs): ¥ Important, even if the situation is resolved! We want to learn from “near misses!” ¥ Allow review of adverse events and unsafe conditions to optimize processes – do not serve to punish individuals ¥ Safe, blame-free, confidential
Root cause analyses (RCAs): ¥ In-depth, multidisciplinary review of an event ¥ Focus on systems and process improvements to prevent future events ¥ Safe, blame-free, confidential
Residents/Fellows: ¥ Play a large role in quality of care improvement at UCSF ¥ Often the first to identify patient events ¥ Can improve quality of care by filing incident reports 5
INCENTIVE UPDATE Glenn Rosenbluth, MD Director, Quality and Safety Programs, GME
The Resident and Fellow Quality Improvement Incentive Program is now well into the third quarter of the academic year. As you know, we have three goals which apply to all residents and fellows who spend at least 12 weeks at UCSF Medical Center. Each of these goals is worth $400 per eligible resident. Goal 1: Patient Satisfaction: Maintain an annual average mean score of 91.6 on the likelihood of recommending question. For this goal, we are currently at 91.0, so there is room for improvement. This is score is based on the degree to which our patients would recommend UCSF Medical Center to others. It is a team effort, including physicians, nurses, environmental services, nutrition, etc. We are all doing our parts! What can you do to increase patient satisfaction? Try AIDET: A: Acknowledge and address the patient by name I: Introduce yourself by name and role D: Duration of the task at hand E: Explanation of the task at hand T: Thank you Sit down when talking to patients. Research has shown that patients rate visits more highly when the physician sits down, because they perceive the visit as lasting longer. Goal 2: Hand Hygiene: Achieve 85% compliance by physicians, for at least six of 12 months. This has been amazing! The physicians have met this goal for EVERY month this year! This is an incredible accomplishment and speaks highly of your commitment to patient safety. Our patients thank you! Goal 3: Discharge Process: Complete 20% of all inpatient discharges before 12 PM, for at least six out of 12 months. We’ve been close, but we haven’t had any months at 20% yet. There are a few services that have been high-achievers in this area, including Adult General Surgery, OMFS, Ophthalmology, Otolaryngology, Pediatrics, and most recently the Obstetrics service! What can you do to expedite the discharge process? About 20% of our patients are discharged between 12-2pm. Focus on those patients. They are the often the ones who you know are going home right after lunch. Is there a reason they can’t go home before lunch? We only need to make a slight improvement. If an additional 4 out of every 100 patients go home before lunch, we will achieve our goal! 6
(continued on page 7)
(continued from page 6)
• Start early. Long before discharge, start the discussion about needs for home tube feeds, PT/OT, other medical equipment, etc. • Think 24-hours in advance. If we identify patients who may be ready in the next 24 hours, there is time to ensure that all of the discharge planning is complete. Make this a part of daily rounds! • Alert nursing and pharmacy staff early in the morning. Even if the order is written at 11:00am, if no one was expecting the order it can be a challenge to get patients out the door by 12:00pm. • Tell the patient! Don’t forget that many patients need time to arrange transportation home.
Current Score Card: CLINICAL HOUSESTAFF INCENTIVE GOALS SCORECARD: FY2012-2013 March Immediate Attention (>5% below target)
PATIENT SATISFACTION: 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.
100
On Target (meets or exceeds target)
91.4
91.4
91.4
91.3
41
41
40
40
91.3
91.3
91.4
91.4
91.4
91.3
91.0 91.0
36
40
40
39
40
39
39
80 60 40 20
PATIENT SAFETY AND QUALITY:
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Monthly percentile
Axis Title Monthly mean score
Running average mean score
Linear (Running average percentile)
Aug-12
Sep-12
Oct-12
39 Nov-12
Running average percentile
Overall Hand Hygiene Summary Rolling 12 Month Period
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.
Warning (≤5% below target)
Likelihood of Recommending by Date of Discharge
80% 60% 40% 20% 0% Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 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
Target Metrics Collected - 3/5/2013
7
10 Questions from the Resident and Fellow Affairs Committee Molly Cooke MD, Director of Education, Global Health Sciences and Madhavi Dandu, MD MPH, Associate Director, Global Health Pathway, answer resident and clinical fellow questions about clinical rotations at international training sites.
1. What is required to set up a clinical rotation at an international site? There are five steps to set up an international elective rotation. First, interested residents and clinical fellows should check with their program director before making any plans or decisions. Not all specialties and/or programs allow an elective rotation while some programs at UCSF already have recommended or required international sites. Second, trainees should research what is available by reviewing websites and/or talking to colleagues who have gone abroad. http://medschool2.ucsf. edu/gme/Prog_Resources/taa.html Third, a successful and educational international elective requires an engaged supervisor in the international setting who will be responsible for the appropriate amount of supervision, and who is able to address health and safety concerns both during the planning phase and in case of emergency while abroad. Fourth, the resident or clinical fellow formalizes the agreement with the institution abroad by working with his/her program coordinator to complete the Teaching Affiliation Agreement (TAA) request form, Program Letter of Agreement (PLA), and goals and objectives for the rotation. Fifth, after final approval is obtained from the program director or his/her designee, the required paperwork is submitted for review to the Office of Graduate Medical Education (OGME). Ideally, if you are hoping to complete a clinical rotation, you should begin this process one year in advance of your desired travel date. 2. Does there have to be a UCSF faculty attending at the site? This varies by individual training program and 8
program director requirements. At the very least, the supervisor at the international institution has to be at the appropriate level to provide the necessary supervision and evaluation of the resident or clinical fellow. Each international supervisor must be approved by the traveling trainee’s program director. UCSF Global Health Sciences and several GME programs already have strong relationships with a number of sites that provide great experiences. Residents and clinical fellows are encouraged to research these opportunities and consider them before looking into a site where no established relationship exists. Traveling to a site for which agreements with UCSF are already in place will expedite arranging the rotation and decrease the length of time needed to create a new training relationship. A list of both domestic and international sites with established agreements with UCSF may be found on the GME website. http://medschool2.ucsf.edu/gme/ Prog_Resources/taa.html 3. Why does it take so long to get approval for a new foreign rotation as training elective? There are two reasons. Finding the right institution and faculty supervisor can and should take some time. It is common that once the appropriate site is selected, a program and the resident or clinical fellow will go back and forth for a while to identify the best supervising physician and to determine that person’s exact responsibilities. Secondly, the training affiliation agreement between institutions may take as long as six months to negotiate and execute. Again, when trainees decide to go to an established site these issues are significantly mitigated. (continued on page 9)
10 Questions.....from the RFA Committee (continued from page 8)
UC Office of the President requires TAAs (Teaching Affiliation Agreements) for all sites to which students, residents, and clinical fellows rotate. These agreements protect the trainee, the other institution, and the University. UCSF has an interest in making sure these relationships are mutually beneficial and working out the details involved in some of these arrangements may take time. For example, a TAA spells out which institution is responsible for testing and treatment if a trainee is exposed to a pathogen or sustains a needle stick injury while on the rotation.
continue. In addition, anyone on an officially approved rotation qualifies for registration for UC’s international Business Travel Insurance https://www.rmis.ucsf.edu/RMISDetails. aspx?Panel=9 which includes evacuation, emergency, and repatriation. Each trainee should call his/her health insurance carrier ahead of time to determine specifically what should be done in the case of emergency or if health care is needed. http://ucsfhr.ucsf.edu/index.php/ residents/ If you are on prescription medication, be certain to take an adequate supply with you.
5. Do I need a medical license for the country in which I will be doing the elective? In addition, there is a burden associated with It depends on the country. It is the trainee’s hosting a visitor. UCSF wants to be sure that the responsibility to make sure that he/she meets benefit to the trainee is appropriate in relation to the requirements as appropriate so this question the real costs of having a visitor who is unfamiliar should be asked and researched early in the with the environment and its demands. To be a process. For example, one country to which valuable educational experience, the relationship UCSF residents and clinical fellows rotate needs to be beneficial for both parties. In 2012, frequently is Uganda, and Uganda does require John A. Crump, et al introduced the WEIGHT an in-country license and it can take a few guidelines for the ethics and best practices for months to obtain this. In addition to licenses, training experiences in global health. Residents, other special visas or type of registration may be clinical fellows, and program directors are required. encouraged to read this article when making decisions regarding international rotations. http:// 6. What is the funding for an international medschool2.ucsf.edu/gme_committee/TAAPage/ rotation? Are there grants for this? WEIGHTGrouponInternationalRotations.pdf Beyond salary, which should be addressed with your program director in your initial conversation Occasionally, the process may take additional regarding the option of rotating internationally, time if the resident or clinical fellow is doing there is no funding available at UCSF for scholarly work for which CHR approval in the additional expenses, in most circumstances. United States and/or the equivalent in the other However, there may be extramural funding country is required. opportunities, but trainees would need to apply for these on their own. These grants may be 4. Do my UCSF salary, benefits, and available through foundations, private support, malpractice coverage continue while I am on and philanthropic organizations. Global Health an elective in a foreign country? Sciences is hopeful that our ability to provide For an officially approved rotation, yes. Officially some degree of assistance with travel and approved means the rotation has been approved project expenses will increase over time. by the trainee’s program director and all paperwork processed according to GME and 7. How do I find rotations at a site in another UCSF policy. Keep in mind that malpractice country? coverage only covers those activities within The GME website has a list of institutions the course and scope of a training program. that already have established relationships This means that a resident or clinical fellow with UCSF. http://medschool2.ucsf.edu/gme/ may only function at his/her level in his/her Prog_Resources/taa.html There are an training program, regardless of conditions at an increasing number of other UCSF websites to international site. Work under supervision may begin the search including, the Global Health be done at the same clinical level as at UCSF, Sciences website http://globalhealthsciences. but not beyond. ucsf.edu/, the global health section of the CTSI website http://ctsi.ucsf.edu/about-us/programs/ Regular health insurance coverage does global-health, and the Pathways to Discovery (continued on page 10)
9
(continued from page 9)
in Global Health website http://meded.ucsf.edu/ gh. Some of the UCSF student websites may also be helpful. Early in the process, residents and clinical fellows should talk to their program directors and other global health faculty in their departments for ideas as well. 8. What happens if I get sick or injured while on rotation in a foreign country? If you are travelling overseas on official university business, you are covered 24 hours a day worldwide by UC Business Travel Insurance provided you registered with them prior to departure. Once registered, you are issued a confirmation of coverage card with contact information to help travelers. If it is a non-emergent situation, call UC Business Travel Insurance first to find where to seek care. https://www.rmis.ucsf.edu/RMISDetails. aspx?Panel=9 In addition to out-of-country medical Referral and Expenses, the travel insurance will also provide Emergency Medical Evacuation if there is no local treatment facility. Next, the trainee should call his/her supervisor in the host country and his/her program director at UCSF immediately to help advocate for you as appropriate. Before residents and fellows travel, they should be sure to enter important numbers in their cell phones and also put key contact numbers on a card they should carry with them as well. 9. What happens if there is political upheaval in a country in which I am doing a rotation? Once you register for UC Travel Insurance, you are prompted to provide some additional information in order to register for iJet. https:// www.rmis.ucsf.edu/RMISDetails.aspx?Panel=9 This free service provides information about health issues, required immunizations, safety and security, culture, language, transportation, weather, and currency exchange rates. In addition, iJet registrants receive security and emergency alerts/instructions while traveling. If registered before departure, iJet and UCSF will contact you should an emergency situation unfold that may affect you or your fellow travelers. Political evacuation is covered by UCSF travel insurance if it is deemed necessary. It is important for international travelers to also register at the US embassy in the country to which you are travelling in the case of emergency or political upheaval. 10
10. Do I need to get travel insurance? Is there a Travel Clinic to which I can go prior to departure for shots or medications? Is this covered by my health insurance? As above, travel insurance is a UCSF benefit provided for work-related travel provided the traveler is registered before departure. However, it does not cover routine health care while travelling, so you should determine what health benefits are provided through your standard health insurance when you are travelling abroad. There are several travel clinics that UCSF residents and clinical fellows use. Most conventional health insurance does not cover travel immunizations, so be prepared to pay out of pocket, even if obtaining the services at UCSF. The UCSF Travel Medicine and Immunization Clinic, located at Parnassus, provides services, counseling, vaccinations, and prescriptions for prophylactic medications. http://www. occupationalhealthprogram.ucsf.edu/ohpTravel. asp CPMC also has a good travel clinic. http://www.sutterpacific.org/services/travelclinic. html The Department of Public Health Travel Clinic at 101 Grove Street in San Francisco is competent and well-informed and offers a number of vaccines not available at UCSF. http://www.sfcdcp.org/aitc.html Before deciding which provider to use, each trainee should call his/her health insurance to see if they cover any necessary services or a particular clinic. The CDC has a great website with information for travelers, including how to find a clinic, required/ recommended vaccinations, tips for how to stay healthy while abroad, and other resources. http:// wwwnc.cdc.gov/travel/ Some immunizations require a series of injections over a 3-4 weeks period and take weeks to reach full effectiveness. Therefore, be sure to make an appointment at least 6-8 weeks prior to departure to ensure full protection during travel. Health and safety concerns should be considered early in your planning process. Questions about this should be addressed to your physician as well as to your program director.
OUT & ABOUT from the Resident and Fellow Affairs Committee Where members of the Resident and Fellow Affairs Committee recommend their favorite scenes outside UCSF
Try a Triathlon
Jason Pomerantz, MD, Assistant Professor of Surgery, Division of Plastic Surgery
One of the lines in my offer letter for a faculty position at UCSF read “Additionally, you will have the Bay Area and San Francisco as an extensive playground at your leisure.” How true! For me, maintaining balance with a career dominated by time and energy spent at UCSF means being outdoors, using physical activity to connect with nature and to have fun, and sharing all of this with my family. One of my first memories of coming to the Bay Area is the smell, a mix of fresh, clean ocean air with the scent of redwoods. What better stuff could one wish to breathe? In the city, run up the stairs to Grand View Park on 14th Ave – great if you can escape for an hour during your work day. This place has an unbelievable view of the city and a direct breeze off the ocean. My mainstay is running. I love the simplicity. All you need is a little bit of time and, debatably, a pair of running shoes. There is no better way to connect with oneself and with our beautiful surroundings. My recommendation for those who are not already regulars is to try this not using gadgets, watches, or goals. These all have their place, but for starters just go out and see what happens. From Parnassus: 1) Golden Gate Park- Run down the hill and into the park; there is no wrong wayjust explore. Down to Ocean Beach and back is about seven miles. There is an endless number of shorter routes through the many gardens, mini parks, and sanctuaries. 2) Presidio to Golden Gate Bridge- Take Stanyan or go through the Park to Arguello and into the Presidio, then over the Bridgeabout 12 miles roundtrip. If you like trails and hills there are plenty. Dipsea is a great way to get to know the area. In Mill Valley park on Throckmorton near Old Mill Park. Go through the Park and ask someone where the Dipsea stairs are. I like to pound the stairs, but the Dipsea also makes for a great walk/hike. My wife and I love to do this with our kids- just be ready to carry them most of the way. The stairs lead to the trail- seven and a half miles of some of the most beautiful terrain in the area and perhaps the world. Have a beer and brunch in Stinson. Take the shuttle back to Mill Valley. Here is the link to the famous course (oldest trail race in the U.S.): www.dipsea.org/course.html. Get in the water. Although formidable here, if done correctly it is safe and a treasure at your fingertips. If you haven’t swam much since you were a kid, use the facilities and classes at UCSF to brush up. Then buy a wetsuit (Sports Basement or any surf shop). A 5mm suit will keep you warm. Practice swimming in the Bay at Aquatic Park. We like to drive to Santa Cruz for the dayCapitola has a great beach and protected cove. Once you feel the urge to venture out into the ocean, first be careful. But with a surfboard, boogie board, or paddle board enjoy the waves. Or, put it all together with biking (covered in a prior edition) dial up the intensity and train for a triathlon. There are many to choose from in the area. I like the vineman half. www.vineman.com 11
OUT & ABOUT from the Resident and Fellow Affairs Committee Harry Hollander, MD Professor of Medicine, and Director, Medicine Residency Program
Select Restaurants in San Francisco
Having grown up in New York and still having a chance to visit that city fairly often, I think that San Francisco does not really compare in terms of the high end, big splurge restaurants. On the other hand, New York can’t hold a candle to our city when it comes to great mid-range options that one can enjoy (at least occasionally) on a resident’s or fellow’s salary. In my opinion, this is our culinary sweet spot. I’ve picked out several restaurants that represent different neighborhoods and feature diverse styles of food. My suggestions have all been written up elsewhere and are no mystery to San Francisco diners or visitors to the city, yet it is still possible to have a deeply satisfying, interesting meal for less than $45-50 per person at any of these places. The medicine residents will laugh when they see my first choice, since I have joined many of them there for dinners and recommended it to most everyone else. Nopa (560 Divisadero) is the restaurant that spurred a renaissance in this part of the Western Addition when it opened six years ago. What’s not to like about it except the decibel level? Great buzz, unpretentious service, a friendly community table, wonderful wine and cocktail lists, and above all, well priced, locally sourced, simple food. You’ll always find staples on the menu such as little gem lettuce salad, oven roasted chicken, vegetable tagine, an award winning burger, and a killer pork chop. What keeps everything fresh and exciting is the 12
subtle seasonal tweaking that they do. The food is direct, honest, and copious. It took us a while to realize that it is a mistake for everyone to order a starter and a main dish here. Go with a group, share, order judiciously, and you will dine extremely well for a fraction of what you would pay at many other restaurants. Many people also know about the two Mexican restaurants run by Nopa’s owners. Both branches of Nopalito (Broderick between Oak and Fell, and 9th Avenue just south of the park) subscribe to the same philosophy as the mother restaurant of serving sparklingly fresh, mostly organic local products, but I’ve found that people who are used to traditional Mexican food have had mixed reactions to Nopalito. You’ll just have to try it and decide for yourself. Since it’s crab season, I can’t resist mentioning Thanh Long in the outer Sunset (Judah and 46th). Honestly, this is a rather ordinary Vietnamese restaurant except for two extraordinary dishes-the roast crab and the garlic noodles. Most nights of the week during the season (mid-November through April or so), you can book a table, don plastic bibs, and be part of the most diverse dining crowd in the city, happily devouring huge platters of these delicacies. The crabs are expensive, but they are huge; one for every 2 people will suffice and keep the bill down. The noodles are cheap (and serve as a vehicle for a boatload of butter and garlic, the so called “secret sauce”), so fill up on those. With so many Italian restaurants from which to choose, how can I select just one for these pages? I decided to eliminate a bunch of great pizza choices (such as Gialina, Una Pizza Napoletana, Delfina, for example) and pick a place that is both geographically and gastronomically off the beaten path. La Ciccia in outer Noe Valley (30th and Church) is run by a passionate couple dedicated to serving Sardinian food as you would find it on this Mediterranean island. I can’t think of another restaurant in the Bay Area that is as evocative of dining in Italy. This is seafood driven cuisine. While it may not be for everyone, the octopus in a fabulous spicy tomato sauce is a dish that (continued on page 11)
Out & About...
(continued from page 12)
I dream about between visits to this restaurant. Pastas are a model of simplicity and are perfectly cooked. The warmth and hospitality are remarkable. The only problem is getting a reservation! Book early through OpenTable to avoid disappointment. Finally, when she asked me to write this piece, Mary McGrath begged me to mention one of her favorites in the Castro, Contigo (at 24th and Castro). Great, I thought-here’s something upon which an internist and surgeon can agree. Mary is particularly fond of the Barcelona style hot chocolate, but there are many other treats on the menu before you get to this wicked cupful of dessert. Contigo specializes in tapas and other small(ish) plates. Anchovy montaditos and oxtail hamburguesas make great starting bites. The cana de cabra warm goat cheese salad is delicious, and the albondigas are a tasty version of a classic comfort food making its way onto all sorts of menus these days-meatballs. The only expensive thing on the menu is the otherworldly Iberico Spanish ham, which may actually be worth it if you’ve never tried it. Wash all of this down with a wonderful array of sherries and interesting Spanish wines by the glass, and even if it won’t replace your memories of Madrid tapas bars, you will be in for an enjoyable evening of grazing and sipping. I hope that you get a chance to try out some of these reasonable jewels in 2013. If you do, please let me know what you thought. Cheers!
13
Healthcare for... (continued from page 3)
more recent data using transdermal estradiol show no increased risk. Because the voice does not change in character with hormone therapy, transgender women who seek to feminize their voice may undergo self-directed re-training or may seek the assistance of a speech and language specialist for vocal feminization; the latter route is preferred due to the risk of self-induced vocal injury if the techniques used are not correct. Transgender women also typically seek facial hair removal via electrolysis or laser methods and may request prescriptions for analgesics or topical anasthetics. While body hair generally thins with hormone treatment, some may seek body hair removal as well. Transgender women who have not had vaginoplasty may “tuck” their genitals which involves displacing testicles (if present) into the inguinal canal and bringing the penis back over the perineum towards the anus to yield a more feminine contour; this procedure may place patients at increased risk of genitourinary conditions or infections. Medical Care – FTM Spectrum Transgender men and transmasculine spectrum people seeking hormonal reassignment are typically prescribed testosterone; estrogen blockade is not recommended nor is it necessary to affect the desired virilizing changes. Testosterone therapy brings about virilization of secondary sex characteristics, including deepening of voice, growth of body and facial hair, increased muscle mass, redistribution of facial and body fat, and a the development of male perspiration patterns and odors. Mood changes also occur and patients may find shifting interests, sexual preferences, and a more male pattern of emotions. Induction of amenorrhea will occur and is a useful clinical indicator for monitoring of therapy; hormone levels are less useful and reliable for such monitoring. Transgender men may seek a range of gender-affirming surgical procedures. Common procedures include double mastectomy, hysterectomy and bilateral salpingoopherectomy (HyBSO), metoidioplasty, and phalloplasty. Double mastectomy, commonly referred to as “top surgery” involves different techniques than those used in the setting of breast pathology since cosmesis is the primary goal and no wide dissection is required; in most cases the procedure used is a “double incision” technique 14
The UCSF Center of Excellence for Transgender Health and the World Professional Association for Transgender Health are co-sponsoring the upcoming 2013 National Transgender Health Summit, to be held in Oakland, CA on May 17-18. Learn more at Transhealth.UCSF.edu whereby parallel inframammary incisions are made, an island of skin and all breast tissue are removed, and the two remaining ends are sewn together with the nipple relocated as a free graft. HyBSO is generally performed using a laparoscopic approach and is a low-morbidity procedure since again no tissue pathology exists. Metoidioplasty involves removal of the clitoral hood and release of suspensory ligaments which allow the clitoris, which grows to 1-4cm with testosterone therapy to protrude in a phallic manner when aroused and engorged. Additional methods for this procedure may include a urethral hookup using cheek mucosa, and vaginal ablation or vaginectomy followed by labial closure and the placement of solid silicone scrotal implants. Phalloplasty involves a free graft taken from the arm, leg or abdomen and rolled into a tube which is then grafted to the genital area; urethral hookups, scrotoplasty with implants, vaginectomy, and the insertion of an erectile stent or device are common. Phalloplasty is a costly and lengthy process which may involve several stages over months. Studies have suggested that transgender men who have not had mastectomy are not at an increased risk of breast cancer in comparison to female controls; screening is still required for those men who have not had a mastectomy. Cervical screening is required for those who retain a cervix; maintaining an inventory of a transgender patient’s current organ status (eg. cervix, breasts in FTM; prostate, breasts in MTF) will help guide the need for preventive screening, which may not always be intuitive or contained within electronic medical record decision support systems depending on the gender with which the patient is registered in the system. Screening for dyslipidemias and polycythemia are important, utilizing male reference ranges. Dyslipidemia should be treated appropriately but should not involve withdrawal of testosterone therapy. (continued on page 15)
Healthcare for...
(continued from page 15)
Endometrial cancer in transgender men is limited to one case report and is unlikely; testosterone therapy and the related likely anovulatory state generally have an atrophic effect on the uterus. Studies of bone density show a mixed effect of testosterone therapy on osteoporotic risk, with men who have had an oopherectomy at potentially increased risk, likely due to the role estrogen plays in maintaining bone health; appropriate screening and primary prevention are important. Transgender men may bind their breasts using commercially available garments or ace-wrap style bandages. Fertility The administration of cross-sex hormones can have temporary or permanent effects on fertility; additional fertility issues must be considered in the context of gonadectomy. Transgender women must be considered permanently sterile within a short period of beginning hormone therapy. At the same time, sperm counts may remain elevated enough to lead to pregnancy in cases of sexual activity with cisgender women or transgender men. As such, estrogen hormone therapy in itself is not a reliable contraceptive method. Transgender women are advised to consider sperm cryopreservation prior to beginning hormone therapy. If sperm was not initially preserved, it is possible to cease hormone therapy for 3-6 months and observe for return of sperm count and motility; this process can be traumatic for the patient as there will be a concomitant return of virilization. Pregnancy in transgender men has experienced increasing visibility. In general this involves stopping testosterone therapy until ovulation resumes and a washout has occurred to avoid teratogenic effects; the length of time required for such a washout is unknown, with many experts recommending 3-6 months at minimum. Since changes such as beard growth and voice deepening are permanent, transgender men will remain virilized even when testosterone therapy has been withdrawn. As such , complex psychosocial factors may arise when accessing pregnancy related care such as in birthing classes, waiting rooms or labor and delivery units. Since testosterone does not reliably suppress ovulation, transgender men who are sexually active with someone capable of impregnating them (cisgender male, transgender
female) must use a contraception method to avoid becoming pregnant while on testosterone therapy. Cryopreservation of ova is also possible, though expensive. Care of Transgender Youth More and more transgender people are presenting in childhood and adolescence. As societal paradigms shift and become more accepting of gender diversity it is likely that the percentage of transgender people who do present before adulthood will continue to rise. Transgender youth present numerous ethical and social challenges; how can the fluid and multidimensional identity of a developing child be parsed in such a way as to determine if they are “really� transgender? Furthermore, how can decisions be made regarding the irreversible effects of hormone therapy, including sterility and unknown long-term effects in people who have not yet reached the age of majority and may lack capacity to provide appropriate informed consent? Given these concerns there are numerous potential benefits to allowing social and/or medical transition of pre-, peri-, and postpubertal youth; avoiding the emotional trauma and physical changes of the undesired natal puberty and allowing socialization in the target gender to progress at an age-appropriate pace have the potential for powerful positive impact on social functioning and emotional well being. This area is the subject of intense current research. Barring clearly defined predictors or universally accepted guidelines, most experts agree that prepubertal children should be allowed to socially transition based on local and familial factors. Examples include allowing cross-dressing only at home or with family, cross-dressing full time outside of school, or attending school in the targeted gender. The arrival of puberty brings additional concerns as physical changes commence. In general it is felt that children should experience their natal puberty until arrival at Tanner stage II; if gender dysphoria persists at this stage then it is appropriate to consider medical intervention. The child may be treated with GnRH analogs in order to delay puberty for up to 4 years and allow further exploration of identity and social and familial issues. In other cases it may be appropriate to initiate cross-sex hormone treatment. Surgery is generally deferred until age 18 though there are case reports of surgery (continued on page 16)
15
Healthcare for... (continued from page 15)
performed after age 16. Regardless of the route taken by transgender youth and adolescents, it is crucial that care occur in a supportive context and ideally with the support of a multidisciplinary team, such as the UCSF Child & Adolescent Gender Center . Diagnosing Gender The formal diagnosis of Gender Identity Disorder is listed in the Diagnostic and Statistical Manual, Fourth Version (DSM-IV) and has several subtypes. An updated diagnostic category of Gender Dysphoria is expected for the upcoming DSM-V revision. Diagnosis codes in the International Categorization of Disease (ICD) exist however all are within the mental health section; a process is currently underway to explore the addition of purely medical codes to upcoming ICD revisions. Great controversy surrounds the diagnosis of transgender persons and this area is in constant evolution. Practical Issues Historically transgender-related care has been excluded from coverage under health insurance plans, though the landscape is now changing and large organizations (such as the University of California) and certain corporations and municipalities are now adding such coverage to their contracted plans. Most analyses of the costs related to providing covered care demonstrate a negligible effect on premiums. The Veterans Administration has begun to implement transgender care policies, and coverage of hormone therapy is evolving under Medicare. MediCaid (i.e. Medi-Cal) coverage varies from state to state, with a minority of states (including California) providing some degree of coverage. Providers of transgender care may encounter claims denials on the basis of sex-incongruent coding
issues such as ordering a cervical pap smear on a man or a prostatic ultrasound on a woman. Such incidents typically require no more than a call or letter to the insurance carrier to clarify the situation. Transgender people often seek changes to their legal documentation. Court-ordered name and gender changes, updated passports and birth certificates and amended driver licenses all assist transgender people to integrate into society and lead normalized lives. While guidelines vary between juris dictions, medical providers are often asked to assist in the completion of forms or to write letters supporting such documentation amendments. Since transgender people may have preferred names and pronouns which differ from those listed on their current legal or insurance documents, it is important that clinical settings develop systems to remind staff and providers of the patient’s preferences. Failing to use the correct name or pronoun in a busy waiting area or intimate exam room can have devastating effects on patient morale and on the providerpatient relationship. Electronic medical record systems should include methods to address this need. Having materials, artwork, etc‌ in office waiting and exam areas can help diffuse anxiety among transgender patients and make them feel more welcome and accepted. Conclusion Transgender people represent a wide range of identities and have a similarly wide range of health needs. Significant disparities and barriers to healthcare access exist including a lack of trained and willing providers, lack of covered care and a lack of clear governmental policy support. The future of transgender wellness lies in the hands and hearts of the current crop of physicians-in-training.
Resources UCSF Center of Excellence for Transgender Health: Transhealth.ucsf.edu UCSF Primary Care Protocol for Transgender Care: Transhealth.ucsf.edu/protocols UCSF Child & Adolescent Gender Center: http://www.ucsfbenioffchildrens.org/clinics/child_and_ adolescent_gender_center/index.html World Professional Association for Transgender Health: wpath.org 16
CLINICAL AND TRANSLATIONAL RESIDENT RESEARCH TRAINING PROGRAM TRAINING AND FUNDING OPPORTUNITIES FOR SPRING 2013 Christian Leiva, CTSI Coordinator The Resident Research Training Program (RRTP) of UCSF’s Clinical and Translational Science Institute (CTSI) offers several programs and support to help promote residents’ career development: The Resident Clinical and Translational Research Symposium (RRSy) provides an opportunity for residents to present their work and to develop cross-departmental collaborations. For more information, please go to http://accelerate.ucsf.edu/training/resident#research. The Resident Research Travel (RRT) Program provides up to $600 of travel funding per academic year to full-time UCSF residents (or equivalent clinical trainees) to present their clinical or translational research abstract at a clinical or scientific conference. For more information, please go to http://accelerate.ucsf.edu/funding/funding-for-residents#travel. The Resident Research Funding (RRF) Program provides up to $2000 per academic year to residents for qualified clinical and translational research expenses not covered by their mentor or other sources. For more information, please go to http://accelerate.ucsf.edu/funding/funding-forresidents#funding. The Resident Research Scholars (RRSc) Program awards full tuition, a research stipend and provides co-mentoring for up to two highly qualified UCSF residents who enroll in the Advanced Training in Clinical Research (ATCR), a one-year training program sponsored by the Department of Epidemiology. For more information, please go to http://accelerate.ucsf.edu/funding/funding-forresidents#scholar. The Clinical & Translational Research (CTR) Pathway provides a more structured program that promotes and recognizes research scholarship. As each individual resident may complete the requirements for the Pathway over the course of their residency, participation is done via Open Enrollment. For more information, please go to http://accelerate.ucsf.edu/training/resident#clinical.
UPCOMING GME GRAND ROUNDS April 16, 2013 “Twitter to Tenure: Social Media and Medicine” Michelle Lin, MD; Jessica Schumer, MD; Alex Smith, MD; Eric Widera, MD Room: N 217 12 - 1 p.m. May 21, 2013 “Pain: The Fifth Vital Sign” Ramana K. Naidu, MD Room: N 217 12-1 p.m. 17
GME DIVERSITY UPDATE René Salazar, MD, Associate Professor of Clinical Medicine and GME Director of Diversity Our fifth annual Diversity Second Look program was held on January 25, 2013. Several departments participated in this opportunity for applicants to revisit UCSF and learn more about our training programs including our commitment to promoting diversity in our residency training programs. Activities included a discussion entitled “Diversity at UCSF-A Perspective from Campus Leaders” led by Dr. René Salazar, GME Director of Diversity. This was followed by a panel discussion with current housestaff led followed by a reception at Tacolicious in San Francisco’s Mission District. Special thanks to the following housestaff who participated in the panel discussion: Randi Smith MD, Willie Moses MD, Cynthia Maldonado MD, Kaija Romero MD, and Angela Echiverri MD. Over 40 applicants, faculty, fellows and residents from several departments attended the evening reception. Thank you to everyone who participated and to Sharon Freeman who helped organize this year’s activities.
GME Diversity Calendar Of Events 2013 March Latino Medical Student Association Annual Meeting 3/15-16, 2013 Miami, FL Student National Medical Association Annual Medical Education Conference 3/27-31, 2013 Louisville, KY Latino Medical Student Association West Region Meeting 3/29-30, 2013 UC San Diego April GME Diversity Advisory Group Meeting April 2, 2013 6-7:30PM UCSF Multicultural Resource Center
For more information or to learn how you can get involved, please contact Dr. René Salazar, GME Director of Diversity via email (salazarr@medicine.ucsf.edu) or phone (415) 514-8642. 18
GME EVENTS GALLERY Second Look Panel, UCSF January 25, 2013
Second Look Reception, Tacolicious January 25, 2013
19
Winter/ Spring 2013 THE OFFICE OF GRADUATE MEDICAL EDUCATION Welcomes New Program Directors and Program Coordinators
G M E
C Y P H E R Robert B. Baron, MD, MS
Solve the Winter 2 0 1 3
Program Directors
C y p h e r
The Residents Report
Marla Ferschl, Pediatric Anesthesia Katherine Rauen, Medical Genetics
Program Coordinators Kimberly Bissell, Neurological Surgery Caren Hale, Cytopathology Patricia Hiatt, Medical Toxicology Leslie Lind, Vascular & Interventional Radiology Jillian Maliszewski, Ophthalmology Joy Oson, Obstetrics and Gynecology
“PJKOLL LABOAJO KQNO IAP GWHOL W YFAKO WYZPK KAS, JASFQJV QL VAQJV SA VOS MOSSOH. QS’L JAS.” ― SFOARAH LOPLL VOQLOK, SFO KAHWU
Instructions: The above is an encoded quote from a famous person. Solve the cypher by substituting letters. Send your answers to CunninghamA@ medsch.ucsf.edu. Correct answers will be entered into a drawing to win a $50 gift certificate!
Congratulations to our Fall 2012 GME Cypher Winner: John Markley, MD
Nancy Robbins, Addiction Psychiatry and Psychosomatic Medicine
Anesthesia Resident
Faculty and Staff Assistance Program University of California San Francisco 3333 California St., Suite 293 San Francisco, CA 941430938
For additional information, please visit our website at: http://ucsfhr.ucsf.edu/index.php/assist/
(415) 476-8279
For an appointment, please call (415) 476-8279
Editorial Staff:
Robert Baron Andrea Cunningham Amy Day
Many Thanks The Office of Graduate Medical Education would like to thank the following contributors for submitting articles. Contributors Herman Bagga Paul Day Molly Cooke Madhavi Dandu Madeline Deutsch Harry Hollander Christian Leiva Mary McGrath Jason Pomerantz Glenn Rosenbluth Rene Salazar Sandrijn van Schaik
Important GME Contact Information
Office of GME
(415) 476-4562
GME Confidential Help Line
(415) 502-9400
Director, GME
(415) 514-0146 daya@medsch.ucsf.edu
Graduate Medical Education
Associate Dean, GME
(415) 476-3414 baron@medicine.ucsf.edu
San Francisco, CA 94143
UCSF Faculty & Staff Assistance Program (FSAP)
GME Website
(415) 476-8279 www.medschool.ucsf.edu/gme
UCSF School of Medicine 500 Parnassus Avenue MU 250 East, 0474 tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme
20