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Spring 2014

10 Questions .... Spiritual Care Services Page 6

Q & A with the Interim Chancellor & Dean

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Out & About... The Artisan Cheese Trail Page 14

The Residents in this issue Accountable Care 1 Lexicomp Mobile App 2 Incentive Update 4 GME Diversity 5 10 Questions 6 Question and Answer 8 Compassion Fatigue 10 Out & About: Brewery 12 Out & About: Cheese 14 Best of the Bay Area 16 SFGH Library 19 GME Cypher 20 Sustainability Box 20

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Report

Building a System of Accountable Care at UCSF Ami Parekh, MD, JD Medical Director, Health System Innovation Assistant Professor, Department of Medicine, Division of Hospital Medicine In the US we can be proud of many aspects of our health care system such as our ability to treat some of the most complex and life-threatening conditions in the world; however, our fragmented health care delivery system has, until now, lacked an ability to contain the high cost of health care and demonstrate improved health outcomes at a population level. Therefore, as we look to the future of American Health Care, the main question is: How do we maintain our technical and scientific expertise while tackling the high costs of

care and improving the outcomes of care for our population? There is a lot of hope that Accountable Care Organizations (ACOs) will be part of the solution. Accountable Care Organization is a term coined by the federal government for voluntary partnerships between health care providers to deliver tightly coordinated, high-quality care to their Medicare population. If the group of providers can also show that they have reduced the costs of care for this popuContinued on page 2


lation, they have the opportunity to share in the cost savings. The concept is based on the theory that if providers have a financial stake in improving quality and decreasing costs of care for a population, they will reduce unnecessary high cost, highvolume care and increase the provision of highquality but lower cost care; in other words, they will provide high value care. Although the term ACO technically applies to populations for whom Medicare is the payer, commercial payers have been encouraging similar partnerships amongst providers through innovative payer-provider contracting. Over the course of the last two years over 400 ACOs have been created across the country. Some of these are part of the Medicare program, but most are in partnership with private insurance companies. The basic structure of a commercial ACO is a partnership between a payer and a set of provider organizations to deliver coordinated care for a given population, such as an employer group or attributed set of patients. These partnerships are different from traditional payment contracts entered into between payers and providers -- in these new models of contracts, providers are at risk for the total cost of care of the population and may have additional financial incentives to meet specific quality metrics. Here at UCSF Medical Center, we are currently a part of two accountable care arrangements. One is for employees of the City and County of San Francisco (CCSF) and the other is for employees of the University of California (UC). In both cases, these employers were faced with high costs of health insurance for their employees and therefore worked with the health plans to develop ways to reduce the high cost of health insurance. For CCSF, the health plan partner is Blue Shield of California and for UC the partner is HealthNet. In both of these cases the health plans partnered with UCSF Medical Center, two Dignity Hospitals in San Francisco, and Hill Physicians Medical Group to be the provider network in an accountable care arrangement. 2

The goal for these groups is to work together to provide high-quality of care to the members across the continuum of care for an overall reduced cost. As we have worked in these partnerships over the past years, we have learned that each partner brings something unique and valuable to the table and together we can truly improve the quality of care patients receive and reduce unnecessary utilization. For example, health plans have highly accurate and reliable data on the actual costs of care across settings, while providers have more accurate understanding of the clinical demographics of a given population. By working together, we are able to gain a more complete view of our population’s health care patterns, allowing us to make focused improvements in our delivery system. Over the last two years we have focused on both outpatient and inpatient interventions and have seen a reduction in the costs of care across both populations. In the outpatient setting, we have focused on increasing access to primary care and urgent care so that patients can see an outpatient clinician when they need to, instead of having to go to the emergency room. The average ER visit costs between $900 and $1200, whereas the average PCP visit costs between $60 and $250. From the patient perspective, for one of our ACOs, a trip to a physician’s office has a $20 co-pay; whereas a trip to the emergency room has a $75 copay. Ensuring patients have access to the right level of care can have a large impact on overall costs. We have also worked on improving access to behavioral health services as patients with behavioral health co-morbidities often utilize medical care at a higher rate when their behavioral health needs are not adequately addressed. For patients who have complex medical needs, we have worked to ensure they are involved in outpatient complex case management because this has been shown to reduce the frequency of hospitalization for the chronically ill. Finally, for the generally healthy ACO patient we have developed interventions to improve health education and self-management abilities.


For ACO patients who do become hospitalized, they are followed by an inpatient care transitions manager, who helps coordinate their discharge and transition needs and continues to be a point of contact for the patient for 30 days after discharge. This high-touch care has helped avoid readmissions and ensures patients get the care they need both during and after hospitalization.

sions in both ACOs. Additionally, in one ACO we were able to increase the use of generic medications by approximately 10%.

Through these partnerships, we are learning to work with providers with whom we haven’t historically collaborated. While there is still much to learn about how to impact the costs of care for a large population, we have started to see that by workTo date, through our multiple interventions, we are ing together, we can, in fact, increase the value of starting to see cost savings while maintaining or care we deliver to a population. improving the quality of care we are delivering for our patients. For example, for one of our ACOs, we If you have any questions about or are interested reduced inpatient hospital days by 23% in 2013. In in getting involved in UCSF’s ACO efforts, please the other ACO, we have seen a 3 to 5% reduction contact Ami Parekh at aparekh@medicine.ucsf. in ED utilization over the last two years. We have edu. also seen a trend towards reduction in readmis-

Lexicomp Mobile App Access Our Lexicomp subscription allows you to download Lexi-Select and our formulary onto your mobile devices. The renewal code can be found online on the Lexi-comp page. On the right-hand side, there is an option “Mobile App Access,” click on that link and that will give you the new code. You will have to access your Lexi-comp account that was established when you first set-up the app on your device. http://www.crlonline.com/lco/action/home/switch

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Housestaff Incentive Update Glenn Rosenbluth, MD Director, Quality and Safety Programs, GME We are excited to share with you the news that we have achieved 20% of discharges before noon for 3 months! This was one of our all-program Resident and Fellow QI Incentive goals for the year. All eligible residents and fellows will receive $400 for achieving this goal. Metric

Patient Satisfaction: Press-Ganey mean score of 92.2 AND HCAHPS average of all survey domains at 60th percentile Discharges Before Noon: 20% of our discharges before noon for 3 of 12 months

Quarter 1

Quarter 2

Quarter 3

n k k

Unchanged, no improvement

Increased, but below target

Comments We’re making improvements in some areas, but not yet at our goal. On Press-Ganey, overall we are at 91.0 for the year, but for the most recent period we were at 92.1 which is close!

Increased, still below target On HCAHPS, we are at 55th percentile for the year.

k n k

Improving toward goal

On track to achieve goal

GOAL ACHIEVED!

Congratulations! We have achieved this goal! Prior to 2013, the Medical Center had never had a month with 20% of discharges before noon. We’ve now had 3, and achieved our goal. As of the end of January, we are 0.3% above our budgeted amount.

Cost per discharge: Achieve a 0.5% reduction in cost per discharge

m

Improving, ontarget

m k

Slightly down still on-target

Goal #1:

Patient Satisfaction - On the patient satisfaction survey likelihood of recommending question, maintain an annual average (July 2013 – June 2014) mean score of 92.2 (50%) AND the average of all HCAHPS survey domains for the last quarter improve from 46th percentile to 60th (50%).   .

Goal # 2: Patient Quality and Safety - Increase percent of patients discharged before noon from 17.6% to 20% for 3 of 12 months.  T

Goal #3: Resource Utilization - Achieve a 0.5% reduction in cost per discharge. 

For those who would like more detailed information

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Needs improvement!

Here are some things your team can do to reduce costs: • Use an oral equivalent for H2blocker or antibiotic • When doing a procedure, have extra supplies available, but don’t open them until you need them • Minimize the number of lab draws each day

about inpatient discharges, check out the Discharge Dashboard: http://dischdash.ucsfmedicalcenter.org (use your APeX login)


GME Diversity Rene Salazar, MD Associate Professor of Clinical Medicine GME Director of Diversity Our seventh annual Diversity Second Look program was held on January 31, 2014. 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 Caña Cuban Parlor in San Francisco’s Mission District. Special thanks to the following housestaff who participated in the panel discussion: Sarah Schaeffer MD, Willie Moses MD, Melissa Bent MD, and Kaija Romero MD. Over 40 applicants, faculty, fellows, and residents from several departments attended the evening reception. Thank you to everyone who participated and to Andrea Cunningham who helped organize this year’s activities.

UCSF GME Also Participated in: March Latino Medical Student Association Western Regional Conference UC March 21-22, 2014 Sacramento, CA GME Diversity Advisory Group Meeting March 24, 2014 6-7:30PM UCSF Multicultural Resource Center April Student National Medical Association Annual Medical Education Conference April 16-20, 2014 Washington, DC Latino Medical Student Association National Meeting Aprtil 25-26, 2014 Houston, TX 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.

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10 Questions from the Resident and Fellow Affairs Committee Inpatient Pediatric Palliative Program (IP3) at Parnassus. Staff chaplains are trained and certified in their discipline, and the students participate in a program called Clinical Pastoral Education, which is accredited and recognized by the U.S. Department of Education. A chaplain is available on-site 24/7 and can always be reached by paging 443CARE [2273].

Rev. Dr. Peter Yuichi Clark, PhD, Rev. Dr. Michele R. Shields, DMin, and Rev. Susan P. Conrad, MDiv, (left to right in the photo) answer resident and clinical fellow questions about working with Spiritual Care Services to care for patients and for the physicians at UCSF:

1. What is the mission of Spiritual Care Services? Our primary task is to offer spiritual and emotional support to inpatients and their families and loved ones, no matter what their religious faith (or even if they practice no faith at all). At the same time, caregivers – including physicians, nurses, and everyone else who has contact with our patients – need support too, and we gladly provide that care for you so that we all can better fulfill the Medical Center’s mission of “Caring, healing, teaching, and discovering.”

2. Who are the people working in this area? What is their availability, and how are they reached? We are a team of staff and student chaplains, representing a variety of faith traditions, serving clinical floors at both the Parnassus and Mount Zion campuses, including the adult Palliative Care Service and the 6

3. How can I identify situations and patient events that would benefit from this service? A PDF list of “Top ten reasons to call Spiritual Care Services” can be found at http:// ucsfspiritcare.org/materials-for-download/ and you can always consult with the on-call chaplain or the chaplain assigned to the clinical area where you’re working. If you do have a patient who would benefit from a chaplain’s visit, you can page us at 443CARE or order a consult in APeX.

4. Why would residents and fellows want to seek Spiritual Care Services for themselves? The responsibility you bear for patients’ medical care is daunting, and research indicates that depression, anxiety, and burnout occur at moderate to severe levels for over 50% of medical students, residents, and fellows. Chaplains can be a valuable resource to help you cope with the stress, exhaustion, and emotions that arise in your work, such as when you’re dealing with a patient’s death, a difficult family situation, an ethical dilemma, or other circumstance. We’re good listeners and we’re very willing to give you a few minutes to vent, debrief, or collect yourself so that you can resume your duties in a better frame of mind.


5. What type of educational programs can Spiritual Care Services provide?

past sixteen months, we’ve provided 51 debriefing sessions to 503 staff members.

We can provide workshops of any length from 20 minutes, as part of a staff meeting, to 60-minute in-services or longer, as needed and desired.

9. If I’m unable to attend a general debriefing, are there other options?

6. What are some of the workshops that you have led? Compassion fatigue, caring for yourself, caring for others, conflict resolution, addressing patients’ emotional needs, guided meditation, cultural and spiritual humility, fostering teamwork, case studies on spirituality and ethics, and spiritual care at the end of life: these are just some of the topics we have addressed, and can address, in workshops.

7. How would I go about arranging a workshop for myself and my fellow trainees? You can contact any of us (all three of us are in the UCSF global e-mail directory) or call our main office extension, which is 3531941. You also can mention your request to the chaplain serving your clinical area, and she/he will relay the message.

8. What is the program for debriefings after Codes and other stressful events? How does this work? Chaplains routinely respond whenever a Code is called at Parnassus or Mount Zion, and we provide support to family members and staff as appropriate. After the Code has ended, a chaplain will send an e-mail message to staff members, inviting you to a session (usually scheduled two days later) where you can talk about your emotional reactions and learn coping strategies to deal with the stress. A chaplain is present and serves as the discussion facilitator. In the

One-to-one sessions can be arranged if you are interested in talking with a chaplain after a Code, or other stressful event, and you cannot attend the general briefing. This can be arranged by paging the on-call chaplain at 443-CARE or calling the main office at 353-1941.

10. Are there any suggestions for selfcare or tips for being healthier at work? A PDF card called “Seven steps to self-care” has helpful tips and can be found at http:// ucsfspiritcare.org/materials-for-download/ you can ask any chaplain for a pocket-sized copy. In addition, please visit our Meditation Rooms, located near the main entrances at both the Moffitt/Long and Mount Zion hospital buildings. These are spaces where patients, family members, and you are welcome to pray, sit in silence, or meditate. They are open every day from 7 a.m. until 9 p.m. Finally, please remember that we stand ready to help you anytime, day or night. Feel free to call us!

Spiritual Care Services Main Office Phone: 353-1941 Pager: 443 -CARE [2273] Website: http://ucsfspiritcare.org/ A chaplain is available on-site 24/7 and can always be reached by pager.

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Photo by Elisabeth Fall

Q & A With The Interim Chancellor & Dean Rowland, and Amanda Sanders talked about how important it is to meet and work with different groups of people at UCSF. We are going to capitalize on the location of Mission Bay Hospital to design new programs for residents and fellows to collaborate with graduate students and postdocs on solving problems in human health.

Prior to the opening of the new hospitals, its clinical faculty and staff will move into the Mission Hall building across the street. The building contains a learning center with classrooms and indoor and outdoor breakout spaces, ample conference rooms of different sizes, and a cafeteria. Mission Hall will allow us for the first time to co-locate Sam Hawgood, MBBS certain departments and divisions in ways that Dean, School of Medicine, UCSF will help increase collaboration. It also joins Interim Chancellor, UCSF programs that are currently scattered across the city, including our global health programs, clinical How do you think the recent affiliation and translational science programs, and the with Children’s Hospital Oakland and Department of Epidemiology and Biostatistics.

the opening of the new hospitals at Mission Bay will affect resident and fellow Many residents have told me they came to UCSF to be part of an institution that integrates great education? The opening in early 2015 of the new hospitals at Mission Bay will be a transformational landmark in our history. When we admit our first patients to the new UCSF Benioff Children’s Hospital, the Betty Irene Moore Women’s Hospital, and the Bakar Cancer Hospital, our residents and fellows will form an integral part of our state-ofthe art care in each of the specialty areas these hospitals serve. At the recent School of Medicine Leadership Retreat, which was focused on learning and learning environments, we featured a panel of residents. Joe Ebinger, Lindsay Hampson, Nathan 8

research with a deep commitment to caring for the most vulnerable patients. The affiliation with Children’s Hospital Oakland is an opportunity for us to live this commitment while expanding both the variety and the quality of resident and fellow education on both sides of the Bay. We plan to share our respective expertise to provide a greater diversity of experiences and a critical mass of patients to enhance training, particularly in specialty areas. CHO has a worldclass children’s trauma service and an extremely busy emergency room with over 50,000 visits each year. They also have outstanding clinical and research programs, for example in blood disorders.


The rapidly rising cost of housing in San Francisco has received much nationwide publicity. Are there plans to increase the limited options for on-campus housing for residents and fellows? I am acutely aware of the impact of the high cost of living and especially housing in San Francisco. It is presenting a major challenge to all of our trainees and many of our employees. We are looking to expand our housing options on campus, but that is a multi-year project and unlikely to provide short-term relief. To expand availability for incoming trainees, we have changed our policy for housing by limiting UCSF housing tenancy to a two-year term. We are also working to develop more strategies for outgoing trainees to connect with incoming trainees to share housing resources, ideas and availability. We will continue to explore other options as well.

For the past six years, I have also served as a member of the Chancellor’s Executive Cabinet, which oversees all the major initiatives and addresses challenges the campus faces. Having thus gained a comprehensive understanding of the institution, I fell well prepared to take on the interim chancellor role during this transition.

As Chancellor, what challenge facing UCSF will be your first priority? The priority of any interim leader is to maintain the momentum and carry the institution towards a successful and seamless transition to a new chancellor.

UCSF has a lot of exciting momentum right now, and I want to make sure we don’t miss a beat in taking full advantage of all the opportunities offered to us. In the era of the Affordable Care Act, how can we position UCSF to be a leader in innovative high-value health care? In this time of remarkable scientific breakthroughs, how can we To what extent do you feel that your be at the forefront of innovation and discovery? experience as dean of the School of In this dynamic environment, how can we make Medicine will help you in your new role as sure that our students and residents not only learn to work effectively in today’s world, with today’s interim chancellor? knowledge, but are primed to lead the changes Its hard to believe now, but when I first came to needed for tomorrow? UCSF in 1982 as a research fellow, I intended to stay for no more than a couple of years. Like We are starting to implement our new strategic others before me, I then found that UCSF offered plan for the UCSF health system. The goal is not me unparalleled prospects for collaborations with just to remain a top academic health center but to play the leading role in a regional healthcare remarkable physicians and scientists. delivery system. Residents and fellows will play During my 32-year career at UCSF, I’ve a critical part, especially in building a culture of experienced the culture from many perspectives: continuous process improvement to optimize as a research fellow, a faculty member, division our delivery systems, enhance the patient chief, chair of Pediatrics, and since 2008, as dean experience, reduce waste and improve the safety of the school. Each position provided me with and quality of our care. Many of our trainees are new perspectives and insights on the institution already deeply engaged in this effort, and I really and its interlinked mission of education, research, appreciate their hard work and innumerable contributions. patient care and public service. 9


Compassion Fatigue: An Occupational Risk for Physicians Jamine Ergas, PsyD Faculty and Staff Assistance Program

over. Sometimes, it is not until something in our personal life starts to suffer that we realize workrelated interactions impact our psychological wellResidency and fellowship training is a very being. Although it makes sense to keep emotions stressful time in a physician’s life. The long as much “in check” as possible when caring for hours, multiple shifts, and difficult rotations can patients, it is also important to recognize that the be a significant source of stress. In addition to work you do can be emotionally draining, and to the demanding aspects of the work itself, many find the space to acknowledge and process these residents and fellows have the added stress of emotions and establish the skills to cope. a recent move, getting married, and/or starting a family. There are often not enough hours in the Emotionally Difficult Aspects of Patient Care day to take care of personal or relationship needs. Many residents and fellows feel exhausted in the • Patients who die alone free hours they do have and need that time to • Grief of family members recuperate before returning to work. All of these • Very sick patients factors are major contributors to the stress level • Patients who have a condition similar to of residents and fellows, and to some extent, that your own or someone close to you stress is obvious and expected. However, there is another contributing factor that also impacts the • Patients with whom you particularly connect wellbeing of resident physicians – the emotional • Suicidal patients stress of caring for sick, injured and/or dying • Sick and/or dying children patients. • Neglected/abused children Physicians, like many other helping professionals, come into regular contact with traumatized individuals. Studies conducted on the role of empathy in patient care have found that “… empathic doctors and nurses provide higher quality care and have patients who express higher satisfaction with service” (Regehr, Goldberg, and Hughes, 2002, p. 510). At the same time, the process of caring for and providing empathic treatment to traumatized patients puts physicians at risk for compassion fatigue, which Charles Figley (1995) defined as “the emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events.” The emotional impact of patient care may not always be obvious. In fact, individuals may unconsciously or consciously suppress difficult emotions until a shift or even an entire rotation is 10

The emotional impact of patient care can manifest in various ways. You may feel down, not quite yourself, anxious, hopeless, or unable to sleep or to concentrate. These feelings, along with those listed below, are all symptoms of what, in the research literature, has been interchangeably referred to as “burn-out”, secondary traumatic stress, and compassion fatigue.

Signs of Compassion Fatigue • • • • • •

Not wanting to go to work Changes in behavior – e.g., hypervigilance Recurring thoughts of the patient or situation Withdrawing from loved ones Apathy towards work and/or patients Increased substance use


Prevention/Self-Care Given the intensely stressful demands of your profession, coupled with consistent exposure to the suffering of patients, it is important to be on the lookout for the signs of compassion fatigue. Once identified, acknowledge and examine how your work impacts you emotionally. Seeking support from other residents, fellows, faculty mentors, friends, family, partners, spiritual counselors, and/or a therapist is an essential component to mitigating compassion fatigue. In addition to such social supports, your department’s Residency or Fellowship program can play a crucial role in preventing compassion fatigue, for example by offering trainings or group sessions for the purpose of processing feelings related to patient care. This not only normalizes the fact that residents, fellows, and attendings are emotionally impacted by their work, it also sends the message that addressing this impact is of vital importance to the well-being of physicians and patients alike.

Tips for Preventing Compassion Fatigue • Make time to do things unrelated to your work. This may be challenging for busy residents and fellows, but it needs to be a priority! • Take time off • Regular exercise and a healthy diet • Talk to someone about the emotional aspects of your work • Get supervision • Identify what is meaningful to you in life and connect with it • Focus on the meaning and joy you find in caring for your patients

developed by Beth Hudnall Stamm, online at www. isu.edu/~bhstamm or www.proqol.org.

Conclusion Many of you are under an extraordinary amount of stress and may have more demands on you now than ever before. It may feel like you do not have enough hours in the day to stop and ask yourself, “How am I doing?” Nevertheless, taking time for yourself to recoup from your busy shift or rotation will go a long way toward preventing compassion fatigue. Incorporating self-care into your routine will enable you to stay present and engaged with the important work you do. Not only will you benefit from taking care of yourself, your patients will too. If life starts to feel like it’s too much, reach out to someone. We at the Faculty and Staff Assistance Program can provide you with counseling services as well as referrals for therapists in the community. FSAP services are free and confidential and available for both personal and work-related issues. Please contact us at 415-476-8279 or visit our website at http://www.ucsfhr.ucsf.edu/assist for more information.

References B. Hudnall Stamm, 2009. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). /www.isu.edu/~bhstamm or www.proqol.org. Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder. New York: Brunner/Mazel. Regehr, C., Goldberg, G., & Hughes, J. (2002).

Assessing Compassion Satisfaction & Fatigue Exposure to human tragedy, empathy, and

trauma in ambulance paramedics. American If you are interested in assessing your risk of Journal of Orthopsychiatry, 72(4), 505-513. developing compassion fatigue, you can access the Professional Quality of Life: Compassion Huggard, P. (2003). Secondary traumatic stress: Satisfaction and Fatigue Scale (ProQOL) Doctor’s at risk. New Ethicals Journal. September 2003, pp 9-14. 11


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

Brewery Crawl Nilay Sethi, MD, PhD Internal Medicine Resident, PGY2 University of California, San Francisco

What is the most popular beverage after water and tea? What do you get when starch is saccharified and the resultant product undergoes fermentation? What do I need after a long clinic-day saturated with complex patients? The answer to all these and many other questions is beer. Once only a wide-eyed observer of its consumption as documented by numerous childhood photos, I have since adopted a different position on fermented saccharified sugar. Transcending the casual and often-time passive role of a consumer, I have now embraced the responsibility of an enthusiast. And what better way to celebrate my new function in society than to learn about the origin of these tasty brews by traveling to their respective birth sites. Here, you will find, and hopefully enjoy, the fruits of my elective investigation: a short description of my favorite breweries in northern California listed 12

in order from incredibly enjoyable to unpredictably pleasant.

1. Lagunitas Brewing Company Located less than an hour north of the city in Petaluma, Lagunitas stood out among the rest owing to its high marks in many domains not limited to great quality beer, a well-designed tour, and an exciting restaurant ambience occasionally augmented by live music. Patrons usually share benches in the communal outdoor seating, which offers a suitable setting for a collection of individuals united by an enthusiasm for beer and understandably inspires a sense of solidarity. The weekday tours are special. Self-identified participants are escorted to a spacious lounge resembling a hybrid between a bachelor pad and renovated frat house. Five free sample-size pours of Lagunitas’ seasonal beers are distributed. During my visit, the dialogue began abruptly when a husky red-bearded tour guide demanded our attention from behind the bar. He initiated a unique narrative less focused on specific brewing details and production stats. Rather, he engaged the audience by describing the genesis of the brewery, which is notably emboldened by misadventures and imbued with character. http://lagunitas.com

2. North Coast Brewery Company Born in 1988, North Coast is located along the Mendocino coast in Fort Bragg, home of the Glass Beach. Considering the ability to visit their museum, restaurant and/or gift shop, there are many ways to absorb the North Coast experience. I decided to visit their gift shop, which was adequately stocked with their brews. Among these beers, two Belgium-style


ales caught my attention and taste buds. The farmhouse ale Le Merle, which means Blackbird, is a saison derived from brewing traditions of the Flanders region of Belgium. This straw-colored, hoppy ale carries a subtle tropical fruit aroma. The Good Food award-winning PranQster is a Belgium-style golden ale. True to its name, it displays a healthy golden color in addition to providing a robust fruity flavor. http://www.northcoastbrewing.com

3. Redwood Curtain Brewing Company A little south of Redwood National Park in Humboldt County, Redwood Curtain is located in Arcata. It is a unique establishment akin to your favorite cafe except that it sells brews. Instead of ordering a venti coffee-to-go, one can fill a personalized growler with their favorite brew. Grab your favorite board game or word puzzle from their wide selection and challenge your friends to a game-filled afternoon. Come on the right night and you can test your knowledge in a trivia competition, take part in a cribbage tournament, or enjoy a musical performance. Among their large array of brews, my personal favorites include the Trippel and Imperial Gold Ale. They also served a collection of sour beers such as the Citra Pale Ale and Ipa Dry Hopped with Citra. http://www.redwoodcurtainbrewing.com

4. Russian River Brewing Company A restaurant brewery, Russian River is located in the heart of downtown Santa Rosa. We were able to take a leisurely stroll down 4th street, passing by murals, fountains, courtyards and live performances while waiting for our number to be called. After being seated, my friends and I enjoyed a pizza lunch complemented by a flight of sample-size beers served in a unique wooden tray. Two flights were offered - hoppy California style ales and Belgian inspired ales. In addition to the popular Pliny the Elder, I particularly enjoyed the golden ale

Sanctification and the darker red ale Salvation. Like Redwood Curtain, they also serve a large selection of sour brews as part of the Belgium cohort. http://russianriverbrewing.com

5. Lost Coast Brewing Company Another restaurant brewery, Lost Coast is located in Eureka along Highway 101 just before it bends around Arcata Bay. The restaurant generates a stimulating atmosphere. In addition to the great brews and American-style food selection, it stocks arcade games and a pool table in the posterior aspect of the establishment. As for the brews, my favorite is their pale ale, which took home the gold at the Humboldt county fair in 2004. Another popular choice is Downtown Brown, which, not surprisingly, is a nut-brown ale carrying a mild crystal malt flavor uniquely integrated with a strong porter taste. http://www.lostcoast.com

Honorable mentions: 21st Amendment Brewery Located in SOMA near downtown SF, this brewery is great for grabbing a quick one before heading to a Giants game as it is located walking distance from AT&T Park. Santa Cruz Brewery Nice cozy brewery with ample outdoor seating located a short distance away from the boardwalk/beach filled with miniature golf, bowling, and every arcade game a kid (or an adult in our case) could imagine. Bear Republic Brewery Conveniently located in downtown Healdsburg, this brewery has a large outdoor patio upon which one can enjoy a meal and their beer served in either 3.5oz or full pours. 13


OUT & ABOUT from the Resident and Fellow Affairs Committee

The Artisan Cheese Trail

located in rural west Marin, was founded in 1865 by Jefferson Thompson and produces cheeses under the Rouge et Noir brand name. It is the oldest cheese manufacturer still in operation in the United States. In 1979, Laura Chenel became America’s first commercial producer of goat cheese when she began producing chèvre in the west Sonoma town of Sebastopol. After several months of working to sell her product to local markets (with mixed success, due to American unfamiliarity with goat cheeses), she received her first major opportunity when Alice Waters of Chez Panisse placed a standing order for her cheese in 1980. This may have been the first American instance of goat cheese salad. www.marinfrenchcheese.com

David M. Jablons, MD, FACS Professor and Chief of Thoracic Surgery, Program Leader of Thoracic Oncology, and This brings us to pioneers Sue Conley and Peggy Smith who took a hippie trip to San Francisco Director of the UCSF Thoracic Oncology Lab after finishing their degrees at the University of I’m about to let you in on one of the best kept Tennessee in 1976. Each established careers in secrets of the Bay Area – the artisan cheese- San Francisco’s most famous kitchens: Peggy making movement. It was Spanish priests who spending 17 years at Chez Panisse, and Sue costarted making cheese from the milk of mission owning Bette’s Oceanview Diner in Berkeley. By livestock in the early 1800s. Later European the early 1990’s, Peggy and Sue were ready for immigrants, mostly Italian and Swiss families, a new challenge. They launched Tomales Bay established dairies in the lush pastures and Foods www.cowgirlcreamery.com/pt-reyes-shoprolling coastal hills of coastal west Marin. In creamery in Point Reyes, a marketing vehicle the mid-ninetieth century, there were over one- to help west Marin’s farms and dairies get hundred individual family farms in west Marin and their delicious products into the hands of the Sonoma with dairy operations flourishing during Bay Area’s finest chefs. Their first location, a the Gold Rush. Initially they supplied butter renovated hay barn in downtown Point Reyes, (milk would spoil absent refrigeration), but in the makes a great first stop on your tour and also early 20th century as the Bay Area developed houses their original creamery (where they and refrigeration became available, fresh milk currently make Red Hawk) at the entrance to could be supplied and the dairies thrived. With the building. Using milk from neighboring Straus the advent of milk price regulation, however, Family Creamery, they began making delicious and the emergence of industrial factory dairies fresh cheeses. The creamery is called Cowgirl in the Central Valley, local West Marin dairymen Creamery www.cowgirlcreamery.com and now faded from the scene as they could not compete. has cheeses in over 500 markets. The Tomales Sadly, today the total number of family run dairies Bay Food’s building has a nice view into the in west Marin is down to about fifteen! creamery and all of the ingredients (wine, salumi, olives, bread, etc.) you will need as well The  Marin French Cheese Company, as great cheese, for a wonderful picnic. 14


After touring the Creamery, walk around Point Reyes Station, a small hamlet at the southern base of Tomales Bay and the gateway to the Point Reyes Seashore National Park. Visit Toby’s Feed Barn www.tobysfeedbarn.com on the main drag –they have good espresso drinks in a small kiosk in the hay barn alley and tons of local fare, food, books and sweatshirts and the like inside. Two restaurants deserve special mention here: Osteria Stellina www.osteriastellina.com is an authentic Italian and California cuisine mélange with outstanding locally produced meats, shellfish, pastas and cheese dishes. The Sir and Star at the Olema Inn www.sirandstar.com has received rave reviews. And then there is Saltwater www. saltwateroysterdepot.com , a great new restaurant, oyster bar, and local hang-out just a few miles across the Bay in Inverness that’s worth a detour.

sample her amazing aged sheep’s milk cheeses and tour Barinaga Ranch, which runs along the top of the Marshall Ridge and has spectacular views of the Bay and Inverness on a clear day. www.barinagaranch.com If at this point you have not totally become bloated on remarkable cheeses, wine and/or beer and oysters, then take a break and rent a kayak for a surreal early morning paddle along the shore or a more strenuous ride in the afternoon against the winds and tide.

Continuing north after passing thru Walker Creek (my favorite part of the drive) you deadhead straight into the town of Tomales. At the outstanding Tomales Bakery on Hwy. 1, you can provision with great breads and scones, puff daddy’s, cinnamon raisin wheels, and the like, and But this is about the cheese. Head north then head west on Dillon Beach Road for a mile out of Pt. Reyes for three miles and just past and half and take your first right on Middle Road the Tomales Bay Oyster Company http:// and come visit us at Toluma Farms and Tomales tomalesbayoysters.com/ is the Giacomini Dairy Farmstead Creamery www.tolumafarms.com. and home of the Pt. Reyes Farmstead Cheese Our family purchased the farm over a decade ago. Company www.pointreyescheese.com. The We have worked steadfastly to restore it, certify Giacomini family has been a pioneer in the the land organic and repurpose the prior Jersey conversion of dairying from bulk milk production cow dairy into a goat and sheep dairy. Just this to farmstead artisan cheese production. They year we began making our very own farmstead produce California’s only classic-style blue cheese, goat and soon-to-be mixed milk (goat, sheep, and Original Blue, which has become a local classic eventually cow) soft ripened and aged cheeses. and recently won a prestigious SOFI (Specialty Sign up on-line for tours that are typically the first Outstanding Food Innovation) award. They are Sundays of the month. open to the public infrequently, but do rent out for events (at their beautiful facility called “The Fork”) Heading further north on Middle Road you and have cooking classes so check their website. come to the historic ranching town of Valley Ford where the local market sells many of the After winding along the inordinately beautiful regions local cheeses and McClelland butter. Route 1 headed north up through Marshall, you www.mcclellandsdairy.com You can also drop will pass many amazing places to stop and have in our friends Andrew and Curtis at di Bufala oysters: Hog Island Oyster Company Farm www. Dairy who make water buffalo milk cheese and hogislandoysters.com, Tony’s Seafood, or stop amazing gelato. Continue north out of the town for lunch and a to-die-for view at Nick’s Cove and and take your first right to head to Occidental and Cottages www.nickscove.com (great place to Freestone. Sample delicious local grown Phelps stay as well). If you have been smart enough to Winery http://josephphelps.com/ chardonnay and sign up in advance, go visit Marcia Barinaga and pinot noir and stop at the Wild Flour Bread Bakery 15


http://wildflourbread.com/ for surreal breads and scones. No more than a couple of hundred yards up from the bakery is the new Freestone Artisan Cheese shop. http://www.freestoneartisan.com/ Stop in and talk to owner/cheese monger Omar (tell him I sent you) and sample and buy any of the locally produced artisan cheeses as well as many of the phenomenal artisan cheeses he imports from around the country. At this point, you may be satiated, but just in case you have more cheese tasting left in you I highly recommend on your way back detouring thru Nicasio to visit the Nicasio Valley Cheese Company http://www.nicasiocheese.com/ (open for cheese tastings, no need for appointment) and tasting their many delicious organic cows’ milk fresh and aged cheeses.

Hopefully, this has given you a few ideas about a scenic and cheese-rich day out in the beauty of west Marin, probably the best-kept secret of the Bay Area. But if you still aren’t satisfied or your interests are truly piqued then go online and check out the other farms and cheese operations along the trail that are open to the public. Among the 29 producers listed on the Sonoma Marin Cheese Trail map, web site http://cheesetrail.org/ and mobile app, 21 are open for regular or periodic tours and tastings, or for visits by appointment. Guided cheese tours are also popping up, including a fivehour jaunt that includes four creameries, tastings of 30 cheeses, and a picnic ($152). http://www.foodandfarmtours.com/

BEST of the Bay Area: My TOP Restaurants - Part Two R. Hirose, MD (unofficial selfappointed Vice Chair of Food and Wine), Department of Surgery, UCSF This is the second part of a very personal, extremely biased, non-objective list of the absolute best eats in the San Francisco bay area. BEST Ramen: Tonkotsu Ramen at Izakaya Sozai – nice creamy broth, firm toothy noodles…although newcomer Waraku will give it a good run for its money. Close to Parnassus! BEST Karaage: Waraku as mentioned above – go for the tonkotsu ramen, but order the karaage– the karaage is outstanding crispy and not heavy as karaage can be. BEST Southeast Asian Noodle Dish: Mandalay Special Noodle at Mandalay. No, not a typical dish like pad thai from Marnee Thai, which isn’t bad but the mandalay special noodles (with chicken) is a unique winner. The Burmese favorite has been 16

cranking out excellent food for over 25 years. Just enjoy the Christmas ornaments hanging from the season and taste the best Burmese food around. The mango salad and the mandalay beef are all standby’s, but the mandalay special noodles will have you craving between visits. BEST Chinese Noodle Dish: Jajamen at King of Noodles – don’t miss the xiao long bao (Shaghai soup dumplings) as you stumble into this hole in the wall, with grandma handpulling the noodles in the back. BEST Scallops: Live Scallop nigiri (special) at Ebisu – the fresh live scallops at the local Sushi place close to UC is hard to beat. Best Uni: Uni is definitely an acquired taste, but once you get over the hump and can actually enjoy the briny finish that makes the consumer fully aware that they are enjoying the fresh bounty from the sea, the creamy sweetness of sea urchin roe is highly addictive. Uni from Hokkaido (when they have it) at Sushi Ran in Sausalito is beyond the fresh uni from Mendocino or Santa Barbara. Ask if


they have it in from Japan. Great sushi bar. Fresh fish flown in from Tsukiji Fish Market in Tokyo (where one has to visit to believe) – you can’t go wrong taking a date to Sushi Ran. BEST Crab: Roasted garlic crab at Thahn Long (add addictive garlic noodles) – Way out there in the Outer Sunset, the An family introduced the world of San Francisco to their fusion version of Vietnamese cuisine and to their family secret recipe for crab in 1971 at Thanh Long, and the rest is history. Then came Crustacean, and then other outposts in So Cal, etc. The real deal is still at Thahn Long where their famous garlic noodles (I think the secret is that they lace it with heroin) and roasted garlic crab (which is made from a closely guarded family recipe –he allegedly turned down a million dollars for the recipe).

the militant foie gras laws, this will suffice. Under Best Pizza category, I don’t really want to have to defend my choices as there now is decent pizza to be had in San Francisco, which I would argue didn’t really exist a decade ago. From local favorites like Pizzetta 211 to Delfina Pizzeria to the ever crowded Mozzeria to my neighborhood’s Gialina’s or even Zero Zero, there are actually a number of very good pizza in the city now. Here is my current list (always changing): BEST Neapolitan Pizza: Margherita Pizza at Una Pizza Napolitana – a true pizza Nazi, and one may have to wait, but one cannot deny the quality of the pizza.

BEST ‘New York Style’ Pizza: The New Yorker at Tony’s – my brother told me this has gone down BEST Izakaya and Sake List: Izakaya Yuzuki a notch recently, but I love this pizza. The multiple -The sake sommelier there is incredibly knowl- ovens etc makes for a great selection. The to go edgeable and is a great guide to the world of sake. window next door may be the way to-go if there is The food there is authentically Japanese, and I a huge wait. prefer it to the popular Nojo. BEST Street Pizza: Cheese slice at Arinelle’s – BEST Sushi: This is a tough one as my favorite street pizza reminiscent of walking around in Mansushi restaurants in the country are in NY, LA and hattan for a slice. even Boston, but worth visiting are Kiss and Kabuto in SF, Hana in Rohnert Park, and Sushi Ran BEST Chicago Style Pizza: The classic meat in Sausalito. I don’t think I want to give away ev- stuffed pizza at Patxi’s - No it isn’t Gino’s East, erything on this list, so if you really want the best or Giordano’s, but if you are hankerin’ for a slice sushi, I think I have to personally oversee the pro- of stuffed pizza, go for it at Patxi’s. I like the one ceedings and order very specific items. in the Marina, but the location on Irving is pretty convenient for UCSF staff (and they deliver!). If BEST Dim Sum: Yank Sing – Some could argue you’re down on the peninsula, stop in at Windy Ton Kiang or even better, Koi Palace in Daly City, City Pizza and BBQ in San Mateo. Not bad either. and I wouldn’t put up a huge fight in this category. Others would say it is overpriced here, and BEST Asian Type Salad: The Bangkok at Crepthe dim sum at City View is a better value, and evine (Irving) – A favorite among UCSF types, the again, I wouldn’t fight too hard. But no one would Bangkok makes even meat eaters like me order say the dim sum is not awesome here. When you salad. The Mango Salad from Mandalay is a winare bringing beginners or out of towners, this is ner as well. the place. BEST Seafood Salad: Lobster salad at Gary BEST Pasta Dish: Tube pasta with faux gras and Danko – what can I say? Fresh Maine lobster with black truffles at Acquerello – arguably the best avocado, shaved fennel and citrus with an acidic pasta dish on the planet was the original tube pas- and tart and herbaceous mustard- tarragon vinaita with a foie gras and black truffle sauce… with grette…but then again, I should not really single 17


out this dish. Just go to GD. Order anything on the plate of pork or smoked short rib followed by bourmenu – especially if someone else is treating! bon banana cream pie (dulce de leche, fleur de sel) – Take really good BBQ and crank it up to BEST Fried Chicken: Buttermilk Fried chicken the next level and you get Wexler’s – a small joint at Ad Hoc – herbaceous and delicious! Thomas downtown dishing out awesome food and best elKeller writes in his cookbook, Ad Hoc at Home: evated BBQ in the city. ‘If there is a better fried chicken, I have not had it.’ – at least TK is not lacking for confidence! – I BEST Seafood Pot Pie: Signature Lobster Pot have made his version at home several times and Pie at Michael Mina – another incredibly rich, I have to begrudgingly agree. Pretty spectacular stick to your ribs pot pie carried over for over 20 fried chicken. At my home, there is hot sauce and years since Michael was at Aqua (circling back to wildflower honey available to add on the side, but the same space years later partnering again with it doesn’t really need it. Just keep track of the on- Ron Siegel, aka Iron Chef beater). The best lobline menu and once a month, on a Monday, go up ster dish in the country is the warm lobster roll at to Yountville, and enjoy. P.S. During the summer Neptune’s Oyster in the North End of Boston, but months, they have it to go next door for a great MM’s lobster pot pie is a can’t miss SF item. picinic! BEST Lobster Bisque: Lobster Bisque at Park BEST Roast Chicken: Roasted Vinegar Chick- Tavern – if incredibly rich food is not your style, en at BarbersQ (Napa) – one of the better roast stay away from this luxurious, unctuous, over the chicken dishes around! Order it ahead of time so top rich bisque at Park Tavern. you don’t have to wait. BEST Steak: Japanese A5 at Alexander’s – BEST Chicken Wings: Dry fried dry chicken wings When they banned foie gras in California there at San Tung – I am not sure what dry fried dry ac- was real Japanese A5 to take over. You think $120 tually means, but believe me, the sweet sauce is is too much for three ounces of the most ridicunot dry. It is tasty and finger lickin’ good! Close to lously well marbeled beef in the world ? Then by UCSF Parnassus and so popular. Don’t miss the all means go for one of the more domestic cuts, dumplings! like the perfectly acceptable and nice dry or wet aged Niman-Ranch steaks, or Snake river domesBEST Chicken Pot Pie: Chicken Pot Pie at Chen- tic F1s or even Australian Wagyu and leave these ery Park – (special on some Thursdays) a flaky rich Japanese cuts to those of us in the know. crust, good filling, fresh chicken. Creamy sauce. What more can you want? BEST Tasting Menu: French Laundry – What can I say? Thomas Keller rules. Benu has a great BEST Pork Chop: Pork chop at Chenery Park – tasting menu, as does Meadowood, and Saison a seasonal item – when they have it, they brine it and even the inventive and quirky Coi. But no one and grill it. And not dry, but moist and succulent. in the SF Bay area bests TK. No ingredients repeated. Every dish leaves you wanting more. CelBEST BBQ: The Texas style Beef Rib at Baby ebrate the end of your residency with your parents Blues BBQ – a Fred Flinstone Brontosaurus ap- in Yountville at the best restaurant in the United pearing cut of meat. Perfect texture and great States. Make them pay. sauces. There are other candidates, but this one is unique. Come to the Mission (of course) and In conclusion, this is a highly subjective, nonhave great BBQ in SF! scientific and maybe even a little quirky list of my BEST EATS of San Francisco list. I am happy to BEST Upscale BBQ: At Wexler’s order - BBQ discuss and argue over decent wine or sake, and scotch eggs (do not omit this dish) with Wexler’s add to the list if I see fit. 18


SFGH Library - Can Clinical Questions be Crowdsourced? Stephen Kiyoi Library Director The Project - Invitation The Library at San Francisco General Hospital invites UCSF residents to participate in a small study to see whether Quora, an online, social Q&A platform, can help find answers to clinical questions.

The Problem Research has shown that although clinicians have multiple questions in the course of a typical patient encounter, many of these questions go unresearched and unanswered. If an answer is pursued, providers often turn to colleagues for quick answers, rather than the established research literature, which providers feel to be too time consuming. (1, 2)

Previous Attempts There have been several failed attempts to address this problem by crowdsourcing clinical questions and medical evidence. Medpedia, a “Wikipedia of medicine” that only physicians and biomedical researchers could edit, abruptly closed early in 2013, even though it had backing from prominent institutions, such as Harvard Medical School, Stanford School of Medicine, and The UC Berkeley School of Public Health. Smaller scale attempts in academic settings haven’t been more successful. In 2004, a team of researchers at the National Library of Medicine developed and piloted the “Virtual Evidence Cart”, an open, online platform to enable clinicians to submit and answer questions, to minimal fanfare and use. (3) A team of physicians and researchers at UNC Chapel Hill created the Critical Appraisal Resource (CAR) as a teaching tool for medical residents. Although this tool was widely used by the residents – there were 625 clinical questions entered, and 1035 searches in the 10 month study period – CAR relied on mandatory curriculum integration, and didn’t expand beyond the program for UNC medical residents. (4)

How We’re Different We hypothesize that previous attempts to crowdsource clinical questions have failed primarily because they have been limited to a specific group of people or a specific institution. By contrast, Quora is open to all, has a culture of expert based answers, and enables upvoting and downvoting of both questions and answers for easier discovery of relevant content. Posting questions on Quora could generate answers from a broad range of experts, and the most highly ranked answers can reach a large audience of clinicians as well as the general public. Our plan is to collect your questions, post them to Quora, and solicit participation from librarians, physicians and researchers across the country. We are planning to present our findings at the annual meeting of the Medical Library Association in May, 2014. Please consider contributing your clinical question via this survey link: https://ucsf.co1.qualtrics.com/SE/?SID=SV_dcaWXoy8xeH3h3f

1. Cook DA, Sorensen KJ, Wilkinson JM, Berger RA. Barriers and decisions when answering clinical questions at the point of care: a grounded theory study. JAMA internal medicine. 2013;173(21):1962-9. 2. Ely JW, Osheroff JA, Chambliss ML, Ebell MH, Rosenbaum ME. Answering physicians’ clinical questions: obstacles and potential solutions. Journal of the American Medical Informatics Association : JAMIA. 2005;12(2):217-24. 3. Liu F, Fontelo P, Muin M, Ackerman M. Virtual Evidence Cart - RP (VEC-RP). AMIA Annual Symposium proceedings / AMIA Symposium AMIA Symposium. 2005:1034. 4. Crowley SD, Owens TA, Schardt CM, Wardell SI, Peterson J, Garrison S, et al. A Web-based compendium of clinical questions and medical evidence to educate internal medicine residents. Academic medicine : journal of the Association of American Medical Colleges. 2003;78(3):270-4. 19


Spring 2014 The Residents Report

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Editorial Staff: Robert Baron Andrea Cunningham Amy Day Cover Photo: Jeffrey Lee, MD Gastroenterology Clinical Fellow Cover Photo by: Elisabeth Fall

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Congratulations to Pathology Resident Gabrielle Rizzuto, MD, PhD - our Fall/ Winter 2013 Winner!

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 card! The Fall/Winter 2013 Cypher Answer was: A wonderful fact to reflect upon, that every human creature is constituted to be that profound secret and mystery to every other. Charles Dickens

Many thanks to the following contributors: Peter Clark Susan Conrad Jamine Ergas Sam Hawgood Ryutaro Hirose David Jablons Stephen Kiyoi Mary McGrath Ami Parekh Sarah Paris Sara Plett Glenn Rosenbluth Rene Salazar Nilay Sethi Michele Shields Sandrijn van Schaik GME Contacts GME Confidential Help Line: (415) 502-9400 Amy Day, MBA Director of GME (415) 514-0146 daya@medsch.ucsf.edu Robert Baron, MD, MS Associate Dean, GME (415) 476-3414 baron@medicine.ucsf.edu

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

tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme

Spring 2014  

The Residents Report Spring 2014

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