Trailblazing: The Family Medicine Inpatient Service at SFGH

Born in the tumult of nineteen sixties movements and the San Francisco counterculture flux of hippies in search of a better society, the UCSF Department of Family and Community Medicine (FCM) harkened to the times “They were a-changing”.

As emeritus chair, Dr. Kevin Grumbach boldly articulated, “It took blood, sweat, and tears to build a service where none existed, that was initially confronted with hostility and resistance to change.” 

Dr. Ron Goldschmidt, a pioneer physician who championed and propelled the FCM foundation, was honored at this assembly for his fifty years of service. With characteristic goodwill and good humor, he described the first years of residency, “We struggled, we learned, we suffered, we became doctors."

A focus of the event was to honor Dr. Goldschmidt, one of the first residents on the FCM service, who steadfastly built the department from seedling to force recognizing that a revolution in medicine was taking place as overdue changes were taking place all over the country.

Current Chair of FCM, Dr. Megan Mahoney, emphasized, “The accomplishments Family and Community Medicine Department has made since our founding, in delivering health in accessible ways, have expanded wellbeing for countless, strengthened institutions and public education. The respect the department has garnered is built on the vision and energies of our pioneering physicians, our trailblazers.”

Their vision stretched beyond the traditional norms of healthcare, challenging the status quo. A team of talented visionaries dedicated themselves to health care in the time when the war in Vietnam and the war on poverty had shaken and informed the social landscape. "Visionary' is often understood only in hindsight. By challenging traditional structures at medical institutions, the trailblazers at FCM were developing a better system to serve everyone but especially to serve the underserved.

The origin story of the department from meager support and old guard opposition, evolved from an experiment to transformer of systems. The burgeoning specialty of Family Medicine delivered improved outcomes, and harmonized healthcare practices with social justice.

All the panelists are all heroes of the early days, and mentors for the future. In real time reaction to medical, social, interpersonal, political and structural maelstrom, these pioneers were the prime movers of this movement to evolve medicine and its practice for patients and community. This meant envisioning and teaching a new generation to build a bridge from community to hospital. Colleagues called them crazy. 

An Underground Movement

The Department of Family and Community Medicine came to life in the context of imagining a new society. In San Francisco that was often underground, as in comics or revolution. The first clinic was also underground, in the basement of San Francisco General.

Family and Community Medicine is a movement like the civil rights or LGBTQ rights movement, centered in radically evolving thinking and results.  Black and brown liberation, farm workers’ rights, the women’s movement, support for refugees and the unhoused - were all potent forces that shaped the department’s mission, perception and practice.  Motivated by the same forces that drove a generation of idealists to grapple with war, inequality, racism, sexism, ableism and oppressions across society, physicians in training at UCSF were transforming the approach, structure and efficacy in healthcare. The trial by fire trailblazing of the early attendings and residents became a national model.  

FCM developed in response to need and crisis, incorporating an intersectionality of understandings, harnessing medical, social, cultural and political resources. Efforts to expand and engage access to care were initially hampered by the status quo. Improving medical access was a long, brave journey led by the FCM trailblazers. In the stalwart hierarchy of specialists who worked in the hospital there was no continuity for patients or community. Traditionalists deeply doubted the idea that 90% of outpatient needs could be addressed. FCM expanded thinking, tools, built teams of diverse expertise and broader access for individuals and community.

FCM physicians and staff delivered strong outcomes by advancing and providing innovation from early detection to social and emotional support to follow up and understand each patient in the context of their families and their community. FCM trailblazers were counterculture heroes, recognizing the gaps in access, new therapies and longevity relationships. Dr. Mahoney reinforced this accomplishment, “Our current department is the outgrowth of this vision demonstrating the power of health resources to address individuals and social realities simultaneously in mutual benefit, advocating social justice in coordination with the most sophisticated medical support.”

FCM's mission does not end at the clinic door. Any challenge from tainted water to toxic policy is addressed when medicine is tied to social justice. Teamwork augments expertise and service, observational skills and solutions. FCM implements system changes that extend the utility and power of strong healthcare services. 

AIDS history informed how FCM began. By the time the world was dealing with COVID, FCM was already a leader in HIV care, establishing protocols for best healthcare and crisis management. While each emergency has its own demands, what was learned during the early days of the AIDS epidemic, gave rigor to FCM's approach to the COVID-19 pandemic. 

Lessons the founding physicians learned were passed through their commitment to mentoring, and generous in attention to the highest standards of medicine with the mission of social justice at the forefront of service. This philosophy continues to attract idealistic medical students and hard-won approval and cooperation with the traditional medical establishment.  Idealism, comradery, extreme dedication, and a shared vision for the expansion of healthcare remain catalysts for the department's success.

FCM has shifted the outlook and training focus of medicine from fixing disease and broken parts to addressing the whole person in the context of family and community. Emphasis on preventative care, positions FCM in the role of public education, awareness, and engagement. FCM became and continues as a model for residency programs throughout the country. The revolution in understanding health care, gives agency to FCM contributions to patients, improving the world where they live and helping them thrive. This approach to integrated health care has adapted to new challenges and innovation from robust response to the pandemic to adaptation of telehealth. FCM doesn’t just treat the disease but engages the whole life in the interdependence of multiple systems. FCM thinks in the “we” not “I”, essential to clinical care. One of the most eloquent and moving testimonies during the gathering was from Dr. Saba who summarized the day, saying “Family Medicine is love in action”. 

 

FCM Historical Highlights ​

• In 1969 Dr. Don Fink launched the first outpatient clinic ambulatory and health services in Building 9 at San Francisco General Hospital. Before 1969 there were no clinics at the hospitals. The first FCM clinic was literally undergroundin the basement of SF General. The hierarchy of medicine had not provided for a channel between the hospital and follow-up care. What happened before and after procedures was haphazard. Surgeons would check patients' wounds in the hospital hallway. FCM for the first time provided continuity of care from diagnosis through ongoing whole person support. In the old model by the time most patients saw a specialist, the problem already existed. Family doctors who developed ongoing relationships could guide patients to avoid health risks, see them through the system, and recovery when serious illness occurs. 
• In 1972, the UCSF Family Medicine Residency Program at San Francisco General Hospital was established in response to the community’s need for family physicians and high levels of medical student interest in the new specialty of family medicine. Over the ensuing years the size of the residency training program steadily expanded, centered in the Family Health providing cradle to grave care.  
• An example of critical skills that strengthened during this period of FCM development, was better approaches to end-of-life care. Few in the department could anticipate those sensitivities would come into crisis service throughout the eighties. Dr. Ron Goldschmidt's words powerfully remind us, “We didn’t know we were preparing for a gigantic challenge.” 
• In 1980, the UCSF School of Medicine established Family and Community Medicine as an autonomous Division, which became a full-fledged Department by 1987. 

Learn more in this UCSF News article >>>

How the AIDs Epidemic Propelled the Department of Family & Community Medicine

The story of the department's formation is implicitly intertwined with the AIDS epidemic. In 1981, an unusually large number of young men presented with extreme symptoms, unusual infections and rapidly spreading cancers. Nascent ideas were put to the test in San Francisco as first showings of young otherwise healthy men were dying mysteriously, painfully, and in alarming numbers. The emerging epidemic forced the healthcare system to address unknowns and grow in understanding to envision long-term needs and the potential to transform community medicine. The pioneers of this department learned under fire that this new discipline required a full complement of skills that did not divide an individual into body parts, but integrated their lifestyle, family, community, and social landscape.

Many of FCM's strengths were forged by such urgent necessities. The synchronicity between the growth of the department and the AIDS epidemic can be traced to treating its first patient presenting with baffling symptoms. Dr. Goldschmidt noted that the medical record described "Jerry G as a 32-year-old ‘homosexual drifter’," pointing out how the pejorative language of the time reveals the ignorance that will fuel the epidemic with social stigma. “Jerry was one of the first in several diagnoses we did not realize was the beginning of AIDS sitting on our service. Sandy Ford of the Parasitic Disease Division at CDC responding to an uptick of requests for pentamidine (a drug for Pneumocystis carinii pneumonia), recognized that the spike signaled the pattern and virulence of an illness we didn’t know what to call or how to handle.” 

Nearly all departments at SFGH were on board with their forms of heroics. FCM learned under duress how to care for so many dying. As Dr. Goldschmidt said in honest reflection, “We were terrified. Treatment and understanding were years away. We had to become experts, we had to manage the disease. Lumbar punctures were daily events.”  Dr. George Saba raised questions that remain chilling decades later. “How do I emotionally deal with so many people of my age who are dying? How do I deal with my own fears of becoming infected? How do I deal with the discrepancy in the hospital of those who are protected and those who are not like the cleaners dealing with bed sheets stained with infected blood? How do I cope with so many moral and psychological disturbances with families in the community and do the medicine?” Excellent medicine was mandatory.

Dr. Goldschmidt passionately and compassionately articulated how the young residents first realized the scope and danger of this new illness. They coped with dramatic crisis management responses in the reality of so many medical mysteries, social stigma, and public hysteria. The staff themselves were vulnerable as it was not understood how the disease spread. Their courage, fortitude, and intellectual rigor that would remain a model for excellence under duress. Physical care and emotional support were first priority. The physical and mental suffering was extreme. Dr. Goldschmidt reports how care includes advocacy to face medical and social traumas and expand the model for compassionate end-of-life care.

Health workers were dealing with shame as much as ravage to the body. One story after another demonstrated the darkness of the situation and unexpected breakthroughs. One patient had not seen his family in years, was rejected for his homosexuality, and he was afraid to contact his mother. A resident found his mother. When she was told her son was dying, she made the trip the next day and told him she loved him and always knew he was gay. She sat at his bedside in his last days, holding him as he died.  A resident noted, “We learn any shame can be overcome.”

By 1989 the department labored at the center of this storm. Dr. Betty Dong, teamed up to provide the pharmaceutical council, with the development of essential protocols for managing AIDS. Dr. Dong recognized conventional antibiotics had limited utility. “I learned to use uncommon drugs on uncommon diseases. I knew what we were learning in San Francisco was important to share.”  It wasn’t until 1997 the decrease in the spread and mortality and increase in the management, diminished the crisis.