Away Elective:Third-year residents have the opportunity to travel and learn the practice of family medicine in settings of their choosing. Residents are encouraged and enabled to pursue individual interests that are helpful to their professional growth.
Emergency Medicine: Interns are scheduled to work for six weeks in the emergency department, giving them the opportunity to learn the basics of both major and minor acute care of medical and surgical problems. Residents see everything from minor lacerations and chest pain to major trauma and ICU level admissions.
Family and Community Medicine Month (Intro Month): Family and Community Medicine Month is broken into two 2-week rotations during the first year of residency. Residents have the opportunity to explore San Francisco communities, get to know the Family Health Center, and learn more about the context and philosophy underlying family medicine for underserved communities. The month has many components, including: exposure to the family systems approach to care; exploration of health disparities and social determinants of health; site visits to neighborhoods served by our clinic and to community partners throughout San Francisco; seminar on resident wellbeing; modules on evidence-based medicine (EBM) and the opportunity to practice EBM skills; in-depth orientation to the Family Health Center and to the practice of outpatient medicine; seminars on musculoskeletal medicine, obstetrics, and other clinical topics; and increased continuity clinics to give residents the opportunity to practice their skills as outpatient continuity physicians.
Family Medicine Inpatient Service (FMIS): The Family Medicine Inpatient Service (FMIS) is an adult medical service providing acute inpatient care. FMIS is staffed by 4-5 R1s, 5-6 R2s/R3s, one chief resident, and two attending physicians, clinical pharmacists, pharmacy students, medical students, social workers, physical therapists, patient navigators, and discharge planners. The service is staffed using a night float model, with 4 R1s and 3 R2/R3s covering days and 0-1 R1s and 2-3 R2/R3s covering the nights. The average daily census is 18-23 patients, with about 1,500 patients discharged per year. Patients are almost exclusively uninsured or publicly insured, and many present with severe disease that is complicated by social determinants of health including unstable or unavailable housing, limited food access, language and cultural barriers, incarceration, and many other issues. Over 30% of our patients have substance use disorders complicating their other illnesses, and over 20% are living without housing. To manage this complexity, residents meet daily with a multidisciplinary team of social workers, physical therapists, and discharge planners to coordinate care and promote safe discharges. Family medicine residents maintain their continuity clinics in the Family Heath Center while rotating on FMIS. Residents manage patients with a variety of complex health concerns, ranging from HIV/AIDS to neurological disorders to heart issues to gynecologic problems. Medical and surgical specialties are available for consultation and patients are frequently co-managed.
Geriatrics: First-year residents learn to care for older patients during a two-week immersive rotation in geriatrics. Residents work across multiple settings, including ZSFG Acute Care for Elders (ACE) Inpatient Unit, outpatient palliative care, and home-based primary care, and with physicians and nurses specializing in elder care.
Intensive Care Unit (ICU): The overall goal of the SFGH ICU rotation is to help residents acquire essential knowledge, clinical skills, and professional attitudes in the management of critically ill patients. Residents rotate for 2 weeks in ZSFG’s closed ICU, where they are supervised by ICU attendings and senior medicine residents.
Labor and Delivery: Starting in the first year of residency, residents learn labor and delivery practices and develop skills in prenatal and postpartum care. R1s learn to manage labor, pre-eclampsia, prolonged rupture of membranes, and fetal distress, as well as how to repair lacerations. R1s also learn how to perform ultrasounds to assess for adequate fluid and fetal well-being. Interns with special interest are included in tubal ligations and caesarian sections. When on call, residents are responsible for covering all patients admitted to L&D and evaluating all pregnant women who present to ZSFG H22 triage for evaluation. Residents who have a strong interest in obstetrics can choose to participate in lengthier rotations in their second and third years, and rotate in delivery wards at Kaiser Permanente and Alta Bates.
Outpatient Block 1: In R2 year and R3 year, residents participate in 3-month long outpatient blocks twice per year. While they maintain their continuity clinic while on other schedule blocks, during these 12 week blocks, residents have no inpatient responsibility and have more frequent outpatient clinic while also participating in longitudinal didactic teaching. Resident continuity clinic is in the Family Health Center, a Federally Qualified Health Center (FQHC) that sees exclusively uninsured and publically insured patients. The FHC provides care for a diverse group of patients, 53% of whom are Latinx, 23% of whom are Asian/Pacific Islander, 11% of whom are African American, and 2% of whom are Native American. Over half of patients speak English as a second language, with Spanish being most common followed by Cantonese and Vietnamese.
R2 Outpatient Blocks: For 24 weeks of the year, during their outpatient blocks, R2s participate in weekly 4 hour clinical seminars that cover core topics ranging from pain management to adolescent medicine to geriatric medicine. In addition, they participate in ACQILA seminars (see below) fo 4 hours each week. They have continuity clinic at least twice per week and usually more, as well as drop-in clinic 2-4 times a month and administrative time designated for completing between-visit work on behalf of patients.
o Block 1: In one of the 12 week blocks, R2s participate in Family Oriented Outpatient Medicine (FOOM) seminars for 4 hours a week and in Family Care Unit (FCU) 4 hours a week. They also rotate through Substance Use Clinic, Teen Clinic, and Geriatrics Clinic. All of these clinics are part of the Family Health Center, the residency training clinic, and do not require residents to travel off site.
o Block 2: In the second 12 week block, residents continue to participate in weekly 4 hour clinical seminars. They rotate through the Women’s and Infants clinic, abortion training, gynecology clinic, minor procedure clinic, and orthopedics/ sports medicine clinic. All of these clinics are integrated into the family health center except for the sports medicine, which requires some travel, and orthopedics and gynecology, both of which are housed across the street in the specialty clinic building on campus.
R3 Outpatient Blocks: During their 24 months on outpatient blocks, R3s participate in weekly 4 hour sessions devoted to learning how to perform quality improvement work/practice transformation in a clinic and learning practice management/career development. R3s maintain continuity clinic while on other rotations, but during outpatient block have no inpatient responsibilities and have 3-4 clinics/week with drop-in clinic 2-4 times/month and administrative time to complete patient related tasks.
o Block 1: During Block 1, R3s participate in FOOM, FCU, urogynecology clinic, sports medicine clinic, and street outreach for people living without homes. Urogynecology clinic is on campus while sports medicine and street outreach require some travel.
o During block 2, R3s have 2 months of elective time. They also participate in minor procedure clinic, anesthesia pre-op clinic, and arthroplasty clinic. All of these clinics are on campus or integrated into the family health center.
At-Home Elective: During at-home electives, residents design their own rotation, practicing in local specialty clinics, visiting local community clinics or organizations, or conducting research, community engagement or advocacy projects. Residents continue to have continuity clinic and participate in longitudinal curriculum.
Outpatient Family Medicine: While on outpatient family medicine, residents see patients in their own continuity clinic and provide urgent care to drop-in patients at the Family Health Center.
Pediatric Emergency Room: The ZSFG emergency department serves patients of all ages and is staffed by pediatric emergency medicine board certified attendings. Residents rotate for 2 weeks in the pediatric ED, working directly with these attendings and learning the nuances of pediatric emergency care.
Pediatric Nursery: In the pediatric nursery, interns learn to care for newborns, including some born prematurely or with complications. The pediatric nursery houses both the well and NICU babies. Residents will be responsible for admitting and discharging babies in good health, as well as following the care of several of the NICU infants. Residents from the Family and Community Medicine program usually work alongside pediatric residents and attendings.
Pediatric Urgent Care: In the Pediatric Urgent Care, interns learn how to take care of common, acute problems of children and adolescents in the outpatient setting. Residents become skilled in managing problems such as otitis media, asthma, and fever in young children. Most of the patients seen in the pediatric clinic are drop-in visits from people who live in the neighborhoods surrounding the hospital. Residents may have the opportunity to spend some time working in pediatric subspecialty clinics during their clinic month and conducting well-child visits, especially for children in the foster care system. Residents rotate through the clinic alongside the pediatric residents.
Pediatric Ward: On the pediatric ward, residents learn to care for children with common illnesses requiring hospitalization. These range from pneumonia, pyelonephritis, and meningitis to appendicitis and other surgical cases. Occasionally, patients will require intensive care.
Specialty Training Clinical Experiences
FHC Minor Procedure Clinic: Residents learn to perform relevant history and physical exams on patients and then work with attending supervision to perform a variety of office-based minor procedures, including joint injections, paracentesis, skin biopsies, and lipoma removals.
Women and Infants Clinic: This clinic provides improved access to timely appointments to women and children who need urgent attention or are unable to get an appointment with a primary care provider, including pregnant women, postpartum women, and newborns after discharge from the hospital. Residents perform gynecologic procedures, including early pregnancy ultrasound, IUD placement, Nexplanon insertion/removal, and endometrial biopsies.
Acute Care for the Elderly Rounds: Residents spend each morning of their geriatrics rotation working with a geriatrician and geriatric medicine team in the hospital. This team assesses geriatric hospitalized patients and provides recommendations to the primary team about polypharmacy, delirium prevention, capacity assessment, and other issues relevant to the geriatric population. While rotating on the ACE team, residents have the opportunity to practice in-depth geriatric assessments and explore how care can be modified and improved in geriatric patients
Supervised Home Visits: Description needed: R1 year, residents will work with a home-visit geriatrician to see patients in their homes, practicing home-assessments and geriatric patient home-based assessments, as well as exploring interdisciplinary models of home-based primary care. In R2 year, residents will choose members of their own continuity panel to visit at home with the support of geriatrician faculty.
Anesthesia Pre-Op: The anesthesia pre-op clinic is on the ZSFG campus and is staffed by UCSF anesthesiologists. Residents attend clinic to learn how to perform pre-operative risk assessments and provide surgical clearance for primary care patients.
Arthroplasty Clinic: The arthroplasty clinic is on the ZSFG campus and is staffed by UCSF orthopedic surgeons and residents. In this clinic, residents have the opportunity to assess joint pathology and perform joint injections.
FHC Substance Use Clinic: The FHC has a substance use consultation clinic embedded in its primary care clinic. Patients can be referred for diagnosis or treatment of any substance use disorder, including illicit substances and legal substances like opioids, alcohol, and tobacco. Residents rotate through this clinic and have the opportunity to perform diagnostic assessments, buprenorphine treatment in pregnant and non-pregnant patients, medication management of alcohol use disorder, motivational interviewing, and other substance use disorder treatments with supervision of an addiction medicine board certified attending.
FHC Pain Group: Any patient with chronic pain at the FHC can be referred to the Chronic Pain Group, which provides CBT based care aimed at reducing pain, increasing resilience in the setting of pain, and addressing the isolation often associated with the pain experience. Residents will rotate through the group, having the opportunity to co-facilitate and learn about the patient perspective on chronic pain.
FHC Geriatrics Clinic: The FHC Geriatrics Clinic sees residents’ geriatrics patients. Residents on the geriatric rotation can schedule their own patients into this clinic and have the opportunity to see their patients with a geriatrician precepting the encounter. Residents practice comprehensive geriatric assessments, end of life discussions, and coordinated care planning.
Abortion and Early Pregnancy Loss Care: Second year residents will be scheduled at Planned Parenthood to learn uterine aspiration skills for first trimester abortion and miscarriage management. They will also rotate in our ultrasound/medication abortion clinic at the Family Health Center, where they will gain skills in first trimester dating ultrasounds, miscarriage management, and medication abortion. Residents can opt out of these sessions if they prefer. Throughout both of these experiences and in their continuity clinic, residents will learn about options counseling and contraceptive counseling. Third year residents have the opportunity to do additional training in first trimester abortion.
Gynecology Clinic: Residents work independently in the ZSFG Gynecology Clinic, assessing and treating a variety of complex gynecological issues. Residents work with OB attendings and OB chief residents.
Ortho Clinic: Residents will work with family medicine trained doctors to do minor procedures at Kaiser Permanente and/or ZSFG.
Urogynecology Clinic: The urogynecology clinic is on the ZSFG campus and is staffed by UCSF gynecologists. In this clinic, residents will practice assessment and management of incontinence and other urogynecologic issues.
Sports Medicine Clinics: Residents rotate in Sports Medicine Clinics during the program's third year. Sports Medicine Clinics give residents a unique opportunity to hone their physical examination skills and gain knowledge of a wide range of musculoskeletal problems, which comprise 10-20% of outpatient primary care. Residents will rotate offsite to local and regional Kaiser Permanente clinics to gain high volume exposure.
Street Outreach Homeless Medicine: In their third year, residents participate in a street outreach program and learn how to provide medical care to the homeless of San Francisco, one of the city's most vulnerable and underserved communities.
Family Care Unit (FCU): In the FCU, Residents learn to provide care from a systems approach to family practice. During their 12 week rotation on FCU, residents invite their most psychosocially complicated patients to attend 1 hour visits, where residents are supported in exploring family issues, psychosocial issues, or issues in the patient-doctor relationship. After obtaining patient consent, residents see their patients behind a one way mirror while being observed by a group of residents and a psychologist who specializes in family systems. The observers assist the provider in overcoming blocks in the conversation, testing new therapeutic approaches, and exploring their own reactions to the interaction. In FCU, residents have the opportunity to practice advanced therapeutic skills with support and feedback from colleagues and faculty.
FHC Teen Clinic: The FHC Teen Clinic is a drop-in clinic for teens and young adults ages 12-25 who are FHC primary care patients. Residents learn to take care of urgent needs and perform appropriate screening and preventive care in a teen-friendly environment.
Dermatology Clinics: Residents learn to examine patients and conduct dermatological procedures at ZSFG’s Adult and Pediatric Dermatology Clinics
Introduction Seminars: Introduction seminars provide an overview of the places, people, and philosophy that form Family and Community Medicine at SFGH and beyond. Seminars cover a variety of topics including evidence-based medicine, fundamental delivery procedures and practices, our clinic operations, and care for the homeless. Residents tour two hospitals in which they work -- Laguna Honda and ZSFG -- as well as the Mission neighborhood.
Behavioral Medicine Rounds: Training residents in the care of hospitalized patients offers a unique opportunity to integrate behavioral science education with medical care and to foster professional growth, given the severity of co-existing medical and psychosocial problems and the formation of intense transient relationships. Rarely do learners have the time or guidance to reflect on how these experiences and relationships affect them. Weekly Behavioral Science Rounds on our Family Medicine Inpatient Service provides dedicated time to reflect on and discuss challenging clinical and professional developmental issues arising during inpatient training.
R2 Seminar Series: Residents participate in weekly, 4 hour clinical medicine seminars while on outpatient blocks throughout the year. Topics range from pediatric development to musculoskeletal medicine, to adolescent medicine and strategies for leading group medical visits. Residents all receive buprenorphine waiver trainings as part of this curriculum.
R1 Core Conference Series: Every Thursday from 11-1, the R1 class gathers from every rotation for core family medicine teaching. The R1 conference series focuses on fundamental clinical topics like diabetes management, thyroid disorders, headache management, contraception, and substance use treatment. It is interwoven with the social medicine conference series and wellness support series, described below.
Social Medicine Conference Series: Once a month, an hour of the R1 core conference is replaced by a social medicine topic such as food insecurity, language discordance, incarceration, and the impact of neighborhood on health. These sessions serve as the foundation for the ACQILA curriculum, described below.
Wellness Support Series: Interspersed in the R1 core conference series is a wellness support series. Approximately once a month, an hour is set aside for wellness related activities. Because each class of residents has different wellness needs, we work with each class to develop a curriculum that is best for them. This may mean a year long meditation course, it may mean periodic free time to pursue self care, it may mean facilitated reflective writing or discussion sessions, or it may mean something completely different. Each group of residents has the opportunity to work together to meet their own needs as a group. This wellness support series is a small part of our overall wellness program, but does provide periodic opportunities throughout the year to reflect, reset, and re-orient to the work of caring for others.
ACQILA Curriculum: The Advocacy, Community Engagement, Quality Improvement, and Leadership Academy (ACQILA) aims to develop health leaders who have the knowledge, attitudes, and skills to promote equity and health for and with vulnerable populations, inside and outside clinic walls. The curriculum is designed to begin by building knowledge (R1 year), progress to building skills (R2) year, and culminate in skills application and practice (R3 year) In their first year, residents participate in seminars and site visits that focus on understanding the comprehensive needs of the ZSFG patient populations as well as monthly social medicine lectures. Resident progress to strengthening non-clinical skills in their second year, attending workshops and community meetings to learn how to take action to improve population and community health. Residents apply these skills in their third year, completing independent community-engaged leadership projects and quality improvement projects before graduation.
CQI and Practice Transformation Curriculum: The Continuous Quality Improvement (CQI) curriculum is designed to provide family medicine residents the knowledge and skills necessary to investigate and evaluate the care of patients in our system, and to improve and transform the quality of primary care and services delivered to our vulnerable patient population The curriculum begins in R1 year with an introduction to models of practice transformation designed to promote relationship-centered care. In the R2 year, themes from this model are explored, preparing residents to exakmin clinic structures and adjust models of care appropriately. During the second year, residents also learn the basic tools of project management and quality improvement and select a QI project that they would like to focus on. During R3 year, residents have dedicated project time that allows them to develop a team, gather data, and implement a quality improvement plan.
PM Curriculum: The practice management (PM) curriculum prepares R3s to begin careers after graduation. In the PM sessions, residents explore different models of clinical care, learn how to read and negotiate contracts, practice writing resumes, and receive training on interview techniques. Program graduates from diverse clinical settings attend the sessions and discuss their career paths, preparing residents to think about their own career trajectories.
Family Orientated Outpatient Medicine (FOOM): The Family Oriented Outpatient Medicine (FOOM) curriculum is an integrated longitudinal curriculum using a model of collaborative learning. The curriculum is designed to help residents and faculty develop skills to become life-long learners and to succeed in a rapidly changing health care environment. Collaborative teams of residents and faculty meet one morning each week for three months each year. Residents identify knowledge and skill gaps that they would like to fill and together build a curriculum, inviting guest speakers, teaching each other, and planning field trips. This curriculum allows residents to direct their own learning and to benefit from the expertise of classmates.
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