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Newsletter of the Office of Graduate Medical Education I University of California, San Francisco
Doctors and Addiction: helping Good People with a Bad Disease
Elinore McCance-Katz, MD, PhD Adjunct Professor, Psychiatry Impairing illnesses can occur in anyone, including physicians. Impairing illnesses are defined as those disorders that cause a physician to be unable to perform their professional responsibilities adequately, including medical, mental or substance use. Substance use disorders occur frequently in Americans. The Substance Abuse and Mental Health Services in this issue Administration (SAMHSA) reports that approximately 10% of Americans currently meet 1 Doctors and Addiction 1 criteria for a drug or alcohol use disorder . Physicians are also vulnerable to substance News from SFGh 3 abuse problems and are thought to suffer these disorders at the same rate as other housestaff honors 4 Americans. Substance use disorders are the most common cause of impairing illness in APEX Update 5 physicians. Most of us know or have known a friend or relative with a substance abuse Award Recipients 5 problem and many of us have seen the devastation these disorders can bring. What do Procedures Consult 6 we do when we think a colleague may have a substance problem? And what happens to 10 Questions 8 physicians who have been identified as having an impairing illness? New ACGME Policies 10
New GME Curricular Affairs Director 11 Out & About 13 Quality/Safety Program Update 14 Resident/Fellow Council 16 GME Diversity 18 Cypher 20
Impairment in the workplace can be difficult to identify in our colleagues. Impairment in work function tends to be a late stage of illness rather than an early sign. However, there are some signs of impairment that can be clues to illness in our colleagues (Table 1). Possible Warning Signs of Impairment in Physicians • Alcohol on the breath • DUI charge • Tremors • Often late on Mondays • Calling in sick • Staying late or coming in early frequently • Mood swings • Drowsy at work • Slurred speech on phone • Inappropriate orders • Inconsistent work performance • Inappropriate orders • Missing medications • Unusual prescribing practices How does a physician get to the point of having a substance abuse problem without any of their co-workers knowing, with recognition often delayed until the impairment has reached the point of potential patient harm? Physicians often find it difficult to recognize these
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UCSF School of Medicine Graduate Medical Education 500 Parnassus Avenue MU 250 East, # 0474 San Francisco, CA 94143 tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme
Doctors And Addiction...
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problems in themselves. Many are unaware that safe levels of drinking are less than two drinks a day or less than five drinks in a sitting for men and less than one drink a day and less than four drinks in a sitting for women2 and that there are no safe levels established for street drug use or non-medical use of a prescription medication. Physicians often take care of themselves last. Physicians often adhere to the belief that a ‘good’ doctor does not have such problems and is self-sacrificing, preferring to ask a colleague about a medical problem or symptoms rather than go to their own doctor. Doctors may be exposed to high-risk situations in their lives such as stress at home or at work; may have ready access to mood-altering substances; or have a genetic vulnerability to addiction of which they may not be aware. how Is the Diagnosis of Substance Abuse or Addiction Made? The Diagnostic and Statistical Manual of Mental Disorders3 defines Substance Abuse and Substance Dependence (Addiction). Substance abuse requires one of the following four conditions in a 12 month period: recurrent use resulting in failure to fulfill major role obligations at work, home, or school; recurrent use in hazardous situations (e.g.: drinking and driving); legal problems related to substance use; or recurrent use despite social or interpersonal problems. The diagnosis of substance dependence requires three of seven diagnostic criteria be met. The diagnostic criteria include evidence of tolerance (greater amounts of drug needed over time-less effect if the same amount of drug is used); withdrawal (a constellation of physical and mental symptoms usually the opposite of what the drug produces); periods of more or longer consumption of the substance than intended; difficulty cutting down or controlling use; a great deal of time spent getting, using, and
recovering from the effects of the substance; giving up or reducing usual activities in favor of substance use; and continued use despite the knowledge of a related health problem. What happens if Impairment is Recognized in a Colleague? When impairment is observed an intervention must be made, often by the medical staff well-being committee or by the program director or other supervising physician depending on the level of the impaired physician (i.e., an attending level physician versus a resident physician). The physician is removed from practice and assisted with entering a facility that has skills in the assessment and treatment of impaired health professionals. Physicians generally enter treatment after a clinical assessment is made. Treatment for physicians with substance use disorders is usually undertaken in a residential setting for 30 to 90 days. While in this program there will be assistance with medical withdrawal from substances if needed and treatment for medical and/or mental illnesses will be given; individual, group family, and mutual help therapies will be started; and initiation of pharmacotherapy, if appropriate, will be undertaken. FDA approved medications for treatment of substance use disorders are available. Naltrexone can be used to treat either alcohol or opioid addiction while disulfiram (Antabuse) or acamprosate are also available for alcohol dependence4, 5. Once treatment is completed and the doctor has been discharged, he/she is generally referred to ongoing outpatient substance abuse treatment. Once abstinence has been initiated as evidenced by continuation in treatment and negative, random urine toxicology screens, the physician will be considered for a return to medical practice. This occurs under monitoring instituted through the state physician health program or through the residency training program. Monitoring includes ongoing random urine toxicology screening,
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NEWS FROM SFGh
Doug Eckman, MBA Operations Manager, SFGH Dean’s Offfice Rachael Kagan Director of Communications, SFGH
CONSTRUCTION PROGRESS Steady progress has occurred through the summer on digging the new hospital’s foundation. That, coupled with continuing success rerouting underground utility lines, spells real momentum on the project. The project has also installed new canopies at the hospital’s entrances to help guide pedestrians and drivers around the modified campus layout. There is a new turnaround and drop off point at the 23rd Street side of campus. The trenching work in the basement of the existing hospital will be concluding this fall. We look forward to the staged return of dislocated departments – including the sleep rooms – starting at the beginning of 2011. CONCESSION ChANGES With the current main hospital entrance set to close, the existing coffee cart at the main entrance is also closed. The SFGH Foundation and Webcor (the company building the new hospital) have purchased a new trailer three to four times the size of the current one to house the new concession. It will be located adjacent to the new turnaround on 23rd Street side of the campus. The Foundation conducted a competitive bidding process for the new service and the vendor has been selected. COMMUNITY MURAL Another upcoming improvement includes a community mural along the Potrero Avenue gate bordering the construction site. The hospital has engaged the Mission non-profit arts organization Precita Eyes. The mural was completed on October 2, 2010. The SFGH community extends a big Thank You to all that participated in the design and painting. SEISMIC SAFETY FAIR How earthquake safe is the new hospital? What makes it that way? Answers to these and other questions will be provided at the SFGH Rebuild Seismic Safety Fair. The October 23rd event (9am – noon) will feature architects, engineers, builders and other experts who can talk about the exciting safety features of the new building. While you are there, plan your own family disaster kit and talk to emergency preparedness experts. Please join us for an open house in the cafeteria (2nd floor of the main hospital) for this community event. MORE INFORMATION REGARDING ThE REBUILD Things around the SFGH campus have been changing rapidly and are a bit hectic and confusing at times. We greatly appreciate the can-do spirit of patients, staff, and neighbors as they negotiate the new routes and rules. Safety is the number one priority and we are working hard to provide appropriate signage, flaggers, and safety measures. A project this large and complex truly is a partnership. Please let us know how it is going and alert us to your needs. There are many ways to reach the rebuild team: • Information line at 206-5784 • Email at email@example.com • 24-hour safety hotline 206-4500 Also, check out the web site: www.sfdph.org/dph/RebuildSFGH/ Department-specific questions? Ask your supervisor or Chief of Service.
hONORS AND RECOGNITION FOR hOUSESTAFF IN CTST
Emily von Scheven, MD, MAS Co-Director, Clinical & Translational Science Institute
The Clinical & Translational Science Training (CTST) Program for residents provides opportunities to gain a foundation of understanding in clinical and translational research methods and evidence-based medicine skills, in addition to opportunities for career development. We aim to inspire residents to pursue careers as investigators. This year our ACTR resident scholar is Laurel Imhoff (Surgery). She received her undergraduate degree from the University of California, Berkeley in Molecular and Cellular Biology in 2000. She studied Infectious Diseases and Immunology at the School of Public Health at UCB, where she earned an MPH in 2002. Laurel then completed her medical training at University of California, San Diego in 2006 and entered the UCSF East Bay Surgery training program in 2007. Her goal is to utilize the training in clinical and translational research to improve surgical practice through the conduct of excellent outcomes based clinical research. The following 10 residents received research funding this spring: Michael Chen (Ophthalmology) Javier Rangel (Dermatology) Joshua Woolley (Psychiatry) Bret Ley (Medicine) Bory Kea (Emergency Medicine) hemal Kanzaria (Emergency Medicine) Lisa Bebell (Medicine) Darcy Wooten (Medicine) Michael Lu (Radiology) Jamison Feramisco (Dermatology) Resident travel grants were recently awarded to the following six residents: Barak Bar (Neurology) Joshua Wooley (Psychiatry) Kristen Adams (medicine) Javier Rangel (Dermatology) Patrick Unemori (Dermatology) Kea Bory (Emergency Medicine) Congratulations to all of these awardees! The next deadline for resident research grants is October 15, 2010. Please go to http://ctsi.ucsf.edu/funding/funding-for-residents for details. For further information or questions contact: Douglas Bauer, MD, Director firstname.lastname@example.org Emily von Scheven, MD, MAS, Co-Director email@example.com Miriam Kupperman, PhD, Co-Director firstname.lastname@example.org Jeffrey Kohlwes, MD, Co-Director email@example.com Olivia DeLeon, Administrative Assistant firstname.lastname@example.org
Advancing Patient-Centered Excellence (APEX) Update
Michael Blum, MD Chief Medical Information Officer
Validation sessions occurred from July to September at UCSF. A vast array of clinicians, nursing staff, and faculty were asked to participate in the three-day sessions. The validation sessions were a follow-up to Epic’s site visit earlier this year. The information collected will be used to configure the UCSF electronic health record’s build by Epic and will make the system unique to the campus community and will flesh out the optimal work flows specific to UCSF. The new UCSF system has been named APEX. A survey of the number and performance of workstations is also being conducted to make sure that there are enough points of access to provide safe and efficient care. Most of the positions for the project have been filled. Many staff were internally selected and some brought in from outside. All staff are now engaged in establishing relationships with their new teammates, and are completing their training and rigorous testing for their work on the APEX system. A clinical system inventory was conducted in August. The inventory will help make sure that departments will still have access to the information they need to continue with the individual work each department conducts outside the current electronic medical record.
Johns hopkins Award Recipients
Congratulations to Medicine Residents Palav Babaria and Dave Dowdy, recipients of Johns Hopkins awards for resident research in general internal medicine! Palev Babaria was awarded the Johns hopkins L. Randol Barker Award in Medical Education Project Name: “The Effect of Gender on the Clinical Clerkship Experiences of Female Medical Students: Results From a Qualitative Study.” Project Description: Palav’s research centers around how learning occurs in the medicine teaching environment; her results have been ground-breaking in documenting the different experiences that female medical students often have and shows the need for training programs in medicine to understand and address these differences. Faculty Advisor: Sharad Jain, MD
David Dowdy was awarded the Johns hopkins Diane Becker Award in Clinical Epidemiology and Prevention Project Name: “Mortality Trends Among Socially-Disadvantaged ART [Antiretroviral Therapy]-Eligible Patients” Project Description: This project evaluated rates and causes of death among patients who had received outpatient specialty HIV care at San Francisco General Hospital. We found that mortality rates had not improved over the last 10 years, and were increasing among those patients with the fewest social resources. AIDS complications remained the leading cause of death in this population. Faculty Advisor: Jeffrey Kohlwes, MD Drs. Babaria and Dowdy are the third and fourth UCSF residents to receive this honor in the past few years. Congratulations!
Procedures Consult: An Online Resource to Review Key Clinical Skills
Susan Promes, MD, Director, Curricular Affairs, GME Josephine Tan, MLIS, Education and Information Consultant
“See one. Do one. Teach One…Made Better and Safer.” That’s the tagline of Procedures Consult, an online resource that is now available to you thanks to the UCSF Medical Center, Library’, and the Office of GME’s combined efforts to obtain a subscription to this tool. This comprehensive and concise procedural reference tool details how to prepare for, perform, and follow up on the most common medical procedures.
Key features include: • Videos and illustrations for each procedure; • Self-directed procedures training and testing with trackable results; • Pre-, during, and post-procedure reference; • Procedural checklists and universal protocols; and • Billing codes for procedures. Additional educational benefits: • Highlights when patient “informed consent” is required; • Reinforces Joint Commission patient safety concepts; and • Conforms to ACGME and ABMS (American Board of Internal Medicine) standards. Searching or browsing this resource is simple. Helpful ways to browse the content from the Procedures Consult homepage are to: (a) look under Procedures by Specialty listed in the left menu bar; (b) type a specific procedure into the search box; or (c) select a particular region on the illustration of the human body. Below is an example of what a procedures listing contains. Go to http://tinyurl.com/pconsult to view a short narrated video tutorial on how to navigate Procedures Consult.
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Options of where to access Procedures Consult: • Listed under the Popular Resources section on the Library’s homepage or • Download the Clinician’s Toolbar to your browser for a one click link to Procedures Consult.
How to access this resource on your mobile device: • Go to m.proceduresconsult.com • Also check out the UCSF mobile page at m.ucsf.edu developed by the Library. Top 4 Reasons to use Procedures Consult: (1) Clear and concise information about how to perform major medical procedures (2) Excellent self-review of information you need to know for critical clinical skills training (3) Ideal teaching tool for residents, students, and other medical trainees which allows them to track their learning via self-paced tests. (4) You tell us. Test drive Procedures Consult and let us know what you think: • Where else should we make a link available to this resource? • Is it comprehensive enough to suit your needs? Contact either Susan Promes (email@example.com) or Josephine Tan (firstname.lastname@example.org) with your feedback.
UCSF Patient Care Fund Improves Patient Experiences
The Patient Care Fund, established by the UCSF Medical Center, is an opportunity for UCSF trainees to improve patient experiences at UCSF. Clinical trainees from all disciplines (medicine, nursing, pharmacy) have a unique perspective on patient care provided at UCSF Medical Center and are in a great position to recognize unmet patient needs and make important, innovative contributions! Recent projects included: * Condolence cards for families of deceased patients * Purchasing and coordinating additional computers for inpatient access to the internet and Skype We are always seeking new proposals. Get those creative juices flowing--no project is too small! Scrutinize your work environment and determine how patient experiences can be enhanced. For more information visit: http://medschool.ucsf.edu/gme/residents/pcfund.html
10 QUESTIONS FROM THE RESIDENT AND FELLOW AFFAIRS COMMITTEE
the two plans will be quite different. Because you pay a percentage of costs under the PPO for hospitalization, trainees who choose this option will pay a significantly higher out of pocket cost for having a baby than those who choose the HMO. For out-patient mental health visits under the PPO and HMO there is a $20 co-pay for in-network providers. There is no limit on the number of visits with both plans. More information regarding mental health coverage and the Faculty and Staff Assistance Program can be found at
David Buchholz, MD, Executive Medical Director, UCSF Primary Care and Amy Day, MBA, Director, Graduate Medicial Education answer resident and clinical fellow questions about health care benefits, including choosing a plan and finding a personal and family physician
The co-pay for generic and brand prescription drugs are the same for both plans. For non-formulary drugs, the co-pay is $40 under the PPO and $35 under the HMO. A detailed description and comparison of both plans can be found at
1) how are the health Net hMO plan and the Blue Cross PPO plan different with regard to access to physicians and specialists? There are several differences. Participants in the HMO plan can use only the doctors and specialists within the assigned HMO medical group. HMO’s typically are cheaper with fewer out of pocket expenses. There is no monthly payment for the Health Net HMO option. Additionally, with the HMO there is a flat co-pay for services while with the PPO you pay a percentage of your bill as well as a co-pay. 2) What are the cost differences between the health Net hMO and the Blue Cross PPO plans? (co-pays, maximum benefits, hospitalization coverage, mental health coverage, pharmacy) The HMO has no monthly cost for residents or clinical fellows even if dependents are added, such as a spouse or children. Like the trainee, the spouse and children must use the in-network providers. There is a $30 a month per individual cost for the PPO. This goes up to $60 a month for an individual and spouse and $90 a month for individual, spouse, and children. In addition to the monthly cost, the PPO requires the individual to pay a percentage of the cost for various services. For example, if hospitalized, there is no out-of-pocket cost for those with the HMO. The PPO covers only 80% of hospitalization. For those considering the birth of a baby, costs incurred under
3) how do each of the plans cover me if I need to go to an ER? Is it the same if I need emergency care while traveling? The HMO co-pay for emergency room visits is $100, while the PPO co-pay is $50. These co-pays are waived if you are admitted to the hospital. Both programs cover you if you must go to an ER that is outside of the plan. If visiting an ER away from home, be sure to obtain documentation about the visit, including physician notes, to ensure the visit is covered. 4) When and how can I change my health plan in the future? Selecting or changing a health plan can be done only during “open enrollment.” The open enrollment period for residents and clinical fellows is the two month period from June 1st to July 30th each year. This is different from the open enrollment period for other employees at UCSF who have only a one month open enrollment period in November. Another difference from other employees at UCSF is that, regardless of health plan selected, residents and clinical fellows are automatically enrolled in dental and vision benefits as well as disability and life insurance. This constitutes an excellent benefit package. While you can change your health plan only during this open enrollment period, dependents can be added
10 Questions.....from the RFA Committee Those enrolled in Health Net HMO are assigned to a medical group by virtue of having a designated primary care doctor. If your primary care physician is in the Hill For questions about which health plan you signed up Physicians medical group (San Francisco region), you for, adding dependents or enrollment, consult your can use the adult and child urgent care clinic at 400 program coordinator who can direct you to the correct Parnassus Ave: sources.http://ucsfhr.ucsf.edu/index.php/residents/ UCSF Screening & Acute Care 5) how do I find a primary care doctor who takes Ambulatory Care Center my insurance and has an office nearby? 400 Parnassus Avenue Start by accessing your health plan’s website (Health San Francisco, CA 94122 Net = https://www.healthnet.com/portal/home.do (415) 353-2602 Blue Cross= http://www.anthem.com/ca) and search Pediatrics on 2nd Floor the list of providers who are accepting new patients. (415) 353-2001 Since many residents and clinical fellows at UCSF express a preference for a UCSF physician, they Mon.- Fri: 8 a.m. - 8 p.m. and their families may wish to contact UCSF Primary Saturdays & Holidays: 8a.m. - 4 p.m. Care, whose offices are located on the Mt. Zion campus. The clinic provides primary care in internal Additionally, Health Net HMO has 24-hour coverage so medicine, family medicine, and pediatrics and offers patients with urgent needs can call and speak with an same day/next day access for clinical needs. Once on-call physician or nurse. This after-hours coverage established as a patient at the UCSF Primary Care can be reached by calling 1-800-893-5597. Clinic, you can “walk in” during business hours, but 7) My health plan assigned me a primary care it is better to call ahead for an appointment to avoid delays in being seen. The UCSF Primary Care Clinic doctor, but the location is inconvenient and I’d prefer another person. how do I change my primary is an option under both the PPO and HMO. The care doctor? UCSF Primary Care Clinic contact information is: You can change your designated primary care UCSF Primary Care Clinic physician at any time by contacting your insurance 1701 Divisadero St., Suite 280 company and providing the name of the person to San Francisco, CA 94115 whom you wish to be reassigned. Those enrolled in the 415-514-6200 Health Net HMO should call 1-800-638-3889 in order to http://www.ucsfhealth.org/adult/medical_services/primary/ change their physician. Under this HMO plan, medical groups or primary care physicians can be changed In addition to the Clinic, there are other primary once a month. Of note, in order for the change to take care doctors at UCSF with openings. To find these place on the first of the following month, you must physicians, go to the UCSF Medical Center website http://www.ucsfhealth.org/, click “Find a Doctor,” and make the change before the 15th of the current month. For example, for a change request on 11/14/10, the select “Primary Care.” change will be effective 12/1/10. 6) What should I do for health issues arising 8) What if I need to see a specialist? Do I have during weekends or evenings? Are there any access to the specialists at UCSF? What if my PCP drop-in locations? If there is a true emergency, trainees or their families is a part of Brown and Toland? should go to the emergency room. For urgent matters Trainees enrolled in the Blue Cross PPO can access that do not require an emergency room visit, trainees specialists at UCSF in most departments regardless of primary care provider and do not require a referral. may want to visit an urgent care facility. To find an However, before making an appointment with a urgent care facility covered under your insurance, you can contact your insurance company: Blue Cross specialist at UCSF or elsewhere, trainees should contact Blue Cross to make certain the physician is a PPO 1-800-759-3030; Health Net HMO 1-800-638part of the Blue Cross Preferred Provider Network. 3889. throughout the year within 31 days of birth, arrival in the United States, new marriage, etc.
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ACGME Approves New Duty hours and Supervision Standards
Heather Nichols Accreditation Manager, GME
After much public debate and internal discussion, the ACGME Board of Directors approved a new set of common program requirements on September 28, 2010. The new requirements, which go into effect July 2011, are a comprehensive approach to patient care, quality improvement, supervision, professionalism, transitions in care, resident well-being, and duty hours. They are intended to better match residents’ level of experience and emerging competencies, while advancing graduate medical education and patient care. Highlights of the new requirements include: Professionalism, Personal Responsibility, and Patient Safety Programs must create a culture of that supports professionalism, patient safety, and personal responsibility through education on fitness of duty; clinical quality improvement and patient safety programs; and balanced supervised patient care, clinical teaching, and didactics. Transitions of Care Programs must create schedules that minimize the number of transitions in patient care. Institutions and programs must monitor the hand-over process and ensure residents’ and clinical fellows’ competency in communicating with team members in the hand-over process. Alertness Management Programs must educate faculty, residents, and clinical fellows to recognize signs of fatigue and sleep deprivation, alertness management, and fatigue mitigation processes. Fatigue should be managed with naps or back-up call schedules. Processes must be established to ensure continuity of patient care if a resident/ clinical fellow is unable to perform patient care duties. Supervision of Residents Each patient should be assigned an attending physician who is ultimately responsible for their care. The patient should be informed of the roles of residents, clinical fellows, and faculty. Residents and clinical fellows caring for patients should have supervision appropriate to the activity. Levels of Supervision Three levels of supervision are defined: direct supervision, indirect supervision, and oversight. First-year residents must be supervised either directly or indirectly with direct supervision immediately available. Faculty must spend sufficient time supervising each resident and clinical fellow to assess their competence and to delegate the appropriate level of patient care authority and responsibility. Residents and clinical fellows must follow program guidelines on the circumstances in which they should communicate with supervising faculty members, such as a transfer of a patient to an intensive care unit, or end-of-life decisions. Residents and clinical fellows are responsible for knowing the limits of their scope of authority. Clinical Responsibilities Clinical responsibilities for each resident and clinical fellow must be based on PGY-level, patient safety, resident and clinical fellow education, severity and complexity of patient illness/condition, and available support services. Teamwork Residents and clinical fellows must have the opportunity to work as members of interprofessional teams. Resident Duty hours Moonlighting: Internal and external moonlighting must be counted towards the 80-hour workweek limit. Moonlighting is not allowed for PGY-1 residents.
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Mandatory Time Free of Duty: Residents/fellows must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). Maximum Duty Period Length: Duty periods of PGY-1 residents are limited to 16 hours. Duty periods of PGY-2 residents and clinical fellows and above are limited to 24 hours of continuous duty in the hospital. Residents and clinical fellows must not be assigned additional clinical responsibilities after 24 hours of continuous inhouse duty. In unusual circumstances, residents and clinical fellows, may remain beyond scheduled hours to continue to provide care for a single patient; justifications are limited to required continuity of care for a patient who is severely ill or whose condition is unstable, academic importance, or humanistic attention to the needs of a patient or family. Minimum Time Off between Scheduled Duty Periods: Residents and clinical fellows should have 10 hours free of duty, and must have eight hours free of duty between scheduled duty periods. Residents/fellows must have at least 14 hours free of duty after 24 hours of in-house duty. Maximum Frequency of In-House Night Float: Night float cannot exceed six consecutive nights. Maximum In-House On-Call Frequency: PGY-2 residents/clinical fellows and above must be scheduled for inhouse call no more frequently than every third-night (when averaged over a four-week period). At-Home Call: Time spent in the hospital by residents/clinical fellows on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks. The Office of GME will work with programs in the coming months to implement the new requirements by July 2011. Residents and fellows are encouraged to review the requirements at http://acgme-2010standards.org/
New Director, Curricular Affairs, GME: Susan Promes, MD, FACEP
Bobby Baron, MD, MS, Associate Dean, GME
I am most pleased to announce the appointment of Susan B. Promes MD, FACEP as the new Director of Curricular Affairs for GME. Dr. Promes replaces Dr. Michael Harper who provided outstanding leadership in this role. Dr. Promes is a Professor of Clinical Emergency Medicine, Vice Chair for Education in the Department of Emergency Medicine, and Program Director of the Emergency Medicine Residency Program. Susan has significant experience in curriculum design and learner assessment at the UME, GME, and CME levels. Susan came to UCSF in 2007 from Duke University, where she also served as Program Director of the Emergency Medicine Residency Program. She is a graduate of the UCSF Teaching Scholars Program and a member of the UCSF Academy of Medical Educators. She was honored with the Academy’s Teaching Excellence Award and the ACGME Courage to Teach Award. She serves as Course Director for the American College of Emergency Physicians Teaching Fellowship, is a member of the ACGME Emergency Medicine Residency Review Committee, and serves on the editorial board for the ACGME’s new journal, the Journal of Graduate Medical Education. As Director of Curricular Affairs Susan will provide leadership for curricular excellence and innovation in GME and for advanced learner assessment utilizing the framework of the common program requirements, the ACGME competencies, the UME/GME continuum, the UCSF portfolio project, the UCSF Pathways to Discovery Program, the Kanbar Simulation Center, and other opportunities to teach clinical procedures and teamwork. Susan will chair the GME Curriculum Committee and will serve as Associate Director of the UCSF Pathways to Discovery Program. 11
10 Questions.....from the RFA Committee
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For those enrolled in Health Net HMO, access to specialists at UCSF and elsewhere requires a referral and depends on the medical group with which your primary care provider is associated. Last year, UCSF Medical Center joined Hill Physicians medical group. Consequently, those with a primary care provider in the Hill Physicians medical group can be referred to UCSF’s specialists. Trainees who have a PCP in a medical group other than Hill Physicians may not be able to get a referral to a UCSF specialist unless that medical group does not have the type of specialist that is needed. 9) When should I go to UCSF Occupational health? What should I do about work related injuries? Occupational Health deals with work-related issues such as flu vaccinations, PPDs/chest x-rays, and injuries sustained while working. Occupational Health provides service at no charge to the employee, but they will not see employees for personal health problems. Unless it is emergent, a work-related injury should be reported to Occupational Health, who will arrange for an examination. They have their own staff physicians and will provide referrals as necessary. All work-related injuries are covered under workman’s compensation insurance. Because of this, employees should not visit their personal physicians for work-related injuries, but go first to Occupational Health. There are two Occupational Health locations. The main location is at 2330 Post St., Suite 460 on the Mt. Zion campus and a satellite location operates at 350 Parnassus Ave, Suite 206. You can access more information about Occupational Health at http://www.occupationalhealthprogram.ucsf.edu Needlestick and fluid exposures should be reported immediately to the Needlestick Hotline at 415-353-7842 (STIC). Information regarding the Needlestick Hotline can be found at http://www.medschool.ucsf.edu/gme/residents/RFA/RFA.html 10) What is a Travel Clinic and where can I find one? A travel clinic provides patients with the vaccinations/ immunizations that are needed before traveling abroad. UCSF does not have a travel clinic. However, the San Francisco Department of Public Health offers an excellent travel clinic near Civic Center. Details about the clinic can be found at http://www.sfcdcp.org/aitc
Water & sustainability
What does water have to do with sustainability? Everything! Clean, fresh water has become a scarce resource: less than 1% of the earth’s water is suitable for consumption yet in the US we use gallons of water everyday. Conserve water. Keep our water clean. Don’t let faucets run, Everything you flush down the shorten your showers, toilet or pour down the drain report or fix leaky faucets ends up in one of the waste and pipes. A leaky faucet water treatment facilities of that drops one drop per San Francisco, where solids are second can waste more separated out and the water is than 3,000 gallons of disinfected before it ends up in water, per year! the Pacific Ocean or the bay. Drink it…. but not from a bottle. San Francisco’s tap water comes from the Hetch Hetchy reservoir and is considered among the cleanest water available, cleaner than most bottled water! And did you know that bottled water produces up to 1.5 million tons of plastic waste per year? Even though these bottles can be recycled, over 80% are thrown away, and it costs an estimated 47 million gallons of oil per year to produce those bottles.
Comments or questions? Email Sandrijn van Schaik at email@example.com
Where members of the Resident and Fellow Affairs Committee recommend their favorite scenes outside UCSF.
OUT & ABOUT from the Resident and Fellow Affairs Committee
Mixologist’s Map of SF
Kevin Thornton, MD Assistant Clinical Professor, Anesthesia By now you’ve probably noticed that at every restaurant you go to there seems to be a cocktail list with ever-changing concoctions of never-heardof spirits and house-made infusions, bitters, and shrubs. Some are classics, the Negroni, the Aviation, some are new, the Dolores Park Swizzle, the Ginger Rogers. All are worth a sip - or two, or three. The truth is that we are terribly spoiled in this city. San Francisco is full of wonderful places to saddle up to a bar with a friend or two, order some great food, and experience the taste of a resurrected classic or a novel creation crafted by one of the many “mixologists” masquerading as bartenders around the city. My first taste of a true “cocktail” – in the form of the Old Fashioned - came at The Alembic when I was a resident and living in the Haight. Opened in 2006 by the guys behind Magnolia Pub down the street, it has achieved a reputation that has garnered a bartender exchange program with Death and Co. in NYC and more press coverage than any regular would ever desire. The food is great and the drinks are better. A must for anyone who is a whiskey fan – they are known for versatility and host a “you-name-it” night where patrons can choose any drink from The Savoy Cocktail Book – the bible of the cocktail world according to some. It fills up fast, but it’s a refreshing change from the average place in the Upper Haight. Any discussion of cocktails in San Francisco would be incomplete without a nod to the Tenderloin speakeasy that is Bourbon and Branch. Dark, hushed, and candlelit, this is not a place to swill beer and watch a game. Cocktails are served as haute cuisine – complete with an amuse bouche. The place is a legend for classics in addition to their own creations. The staff get very into the speakeasy concept – expect to see lots of period attire behind the bar. Get a reservation online to get the password
for the door (seriously), although you can drop in without a reservation and grab a drink in the Library. A little taste of what San Francisco might have been like in the 1920s… If you find yourself hungry and thirsty in the Mission, there’s no better place to quench both than at Beretta. Wood-fired pizza and Italian fare, including a nice variety of seafood, great wines, and, of course, cocktails! Known for citrus-driven drinks that pair well with their food, a host of mixological-celebrities can be seen making cameos behind the bar. The good news: they are open late. The bad news: the word is out. Don’t miss the squid ink risotto or the osso bucco. My all-time favorite place for a late-night meal with a well-made drink is the restaurant that named the neighborhood: NOPA. Known for some amazing organic/local/ sustainable food prepared over their woodburning grill, the somewhat modest cocktail list belies the talent behind the bar. Often serving drinks made with house-made bitters and other ingredients, they pair well with an amazing menu that’s served late seven nights a week. Their pork chop sets a new standard to which others should aspire. Finally, the longest-lived member of this short and, admittedly, incomplete list of cocktail destinations: Absinthe in Hayes Valley. With a large poster of the green fairy himself on the wall (and bottles of the real stuff behind the bar), this place has been serving great food and drinks since it was cool to work at a dot-com. A popular destination with the opera/symphony/ballet crowd before and after performances, the best time to visit is around 8pm on performance nights as the welldressed head down the street to find their seats. Scott Beattie (cocktail guru behind Cyrus in Healdsburg) credits Absinthe’s “Ginger Rogers” with launching his interest and career in cocktails – a must-sip. The snacks here are worth checking out as well. From salads to charcuterie, they also have what I consider to be a contender for the best burger in the city. Obviously, these aren’t your everyday destinations, but for a late-night treat after a hard week at work, San Francisco has a great selection of places to unwind. Don’t miss out!
GME Quality and Safety Program Update
Arpana Vidyarthi, MD, Director, Quality and Safety Programs, GME Paul Day, Communications and Events Analyst, GME
The GME quality and safety program is off to an exciting year. Make sure and let your Chief Residents know about relevant qualtiy and safety issues as we meet with them monthly for dinner. Also, check out the upcoming GME Grand Rounds on In Search of the Root Cause: Patient Safety at UCSF taking place on Tuesday, October 19, from noon to 1pm in HSW-301. Last month’s Grand Rounds topic on Lab Test Utilization administered by Tim Hamill, MD, Director of Clinical Laboratories at UCSF is now available for viewing on the GME website http://medschool.ucsf.edu/gme/grounds/index.html. Resident and Clinical Fellow Incentive Program A very exciting program here at the UCSF Medical Center is the HouIncentive Program. Residents and clinical fellows who spend 12 weeks caring for patients at UCSFMC are eligible for this incentive program and can earn up to $1200 for achieving these goals. There are two arms to this program, the overarching goals and program specific goals. Overarching Incentive Goals: Goal #1: Patient Satisfaction - On the patient satisfaction survey likelihood of recommending question, the goal is to maintain an annual average (July 10 – June 11) mean score of 90.5. We are doing pretty well on this goal—remember just that extra second you spend with patients and communicating with the care team can keep our satisfaction scores up. Goal # 2: Patient Quality and Safety - Achieve 85% hand hygiene compliance for at least six out of the of twelve months. We are VERY LOW here—much lower than the nurses! Hand washing seems so basic, but it is truly one of the key things that we can do to keep our patients safe from the crazy bugs that are acquired in the hospital. Hats off to Angela Walker who is the resident expert in this area—gel in and gel out!!! Goal #3: Laboratory Test Utilization - Decrease by 5% the aggregated utilization of common laboratory test including, CBC, CBC with differential, electrolytes (Na, K, Cl, CO2, HCO3, Mg, Ca, Phos), BUN, Cr, AST, ALT, total bilirubin, alkaline phosphatase and albumin. Ok, no daily labs and no panels—that should be enough to get us to this goal—but not quite. Remember to think twice before ordering tests on your patients—even those tests can result in unnecessary care and even harm. Program Specific Incentive Goals: Twelve programs/departments are also working toward quality goals: • Anatomic Pathology • Anesthesia • Dermatology • Department of Medicine Fellowships • Emergency Medicine • Internal Medicine • Neurology • Obstetrics and Gynecology • Otolaryngology • Pediatrics • Radiation Oncology • Urology
For a complete list of the program/department specific incentive goals please follow this link:
These programs came together on September 30, for the Program Specific Incentive Symposium. Arpana Vidyarthi, MD, Director Quality and Safety Programs for GME facilitated this first annual event. Trainee champions, QI champions, and program directors from all twelve programs/departments worked together to learn skills and progress their projects. It isn’t too early to start thinking about a program/ department specific incentive for your program—what would you and your peers like to improve?? Other Innovations Have you seen the QI bulletin board in the doctor’s dining room? Thanks to the efforts of Delphine Tuot, MD, a bulletin board dedicated to quality and safety issues has been established. The goal of the bulletin board is to highlight quality and safety issues within the UC Med Center and those specific to the twelve programs/departments participating in the program specific incentive program this year. New success stories, fun facts, and updates on the incentive program will be changed periodically. Stop by and take a look! If you have any questions regarding the incentive program, please don’t hesitate to contact Paul Day (firstname.lastname@example.org) or Arpana Vidyarthi, MD (email@example.com).
My Nguy, Senior Quality Analyst and Francis Wolf, MD, dicuss Anesthesia’s incentive goal
(l-r) Aparna Goel, MD, Michelle Mourad, MD and Kara Bischoff, MD discuss Internal Medicine’s incentive goal
(l - r) Dana Weiss, MD, Urology; Melissa Rosenstein, MD, OB/Gyn; Mari-Paule Thiet, MD OB/Gyn
UCSF Resident and Fellow’s Council
Angela Walker, MD and Barak Bar, MD Resident and Fellow’s Council Co-Chairs
Welcome to the start of another exciting year. For those of you new to San Francisco, welcome to UCSF! The Resident and Fellow’s Council (RFC) is always busy advocating for UCSF housestaff on issues ranging from quality of life to training and education. This year will be a particularly busy one and we would like to update you on the status of recent projects. In July, we transitioned to a single-payer system. Fortunately, there were very few problems reported. This was a landmark event which had been highly anticipated. Now, all residents rotating in the UCSF system will be paid once monthly on the same date. This marks great progress towards efforts to achieve resident pay parity, and we thank Bobby Baron, MD and Amy Day from OGME for their persistence, patience, and advocacy. At our monthly meeting in August, the RFC peerapproved approximately forty residents and clinical fellows to represent us at the ACGME institutional accreditation site visit that took place on September 14, 2010. We are eager to learn and share feedback following pivotal discussions during the visit. The 2010-2011 housestaff incentive goals were announced earlier this year. With the combined leadership of the Medical Center, the Office of GME, and the hard work of Arpana Vidyarthi, MD, Paul Day of OGME, and Kara Bischoff, MD, and many others we remain committed to improving patient satisfaction, achieving greater hand hygiene compliance, and decreasing unnecessary laboratory test utilization. Additionally, 12 departments have chosen programspecific incentive goals. Please look for quarterly reports to follow our progress in meeting these important quality improvement measures. Sharing a New York Times article titled, “Factory Efficiency Comes to the Hospital”, Gabe Aranovich, MD inspired us to brainstorm ways we can improve daily work routines within the UCSF system. While funding may be limited for some projects, we hope to identify some which our group can accomplish. Fortunately, resources continue to be available in the Patient Care Fund. Project proposals are always being reviewed and we encourage residents and clinical fellows to consider ways in which we can directly
improve the patient experience at UCSF. Delphine Tuot, MD can assist with any specific questions you may have. Housestaff well-being remains a priority of the RFC. In the upcoming months, we anticipate the re-opening of the Resident Housestaff Lounge which temporarily closed during Moffitt Cafeteria renovations. This should be a beautiful new space, dedicated to both relaxation and work. This year, we hope to work closely with the Resident & Fellow Affairs Committee to assist residents and clinical fellows with finding medical, dental and vision providers who can accommodate us for evening and weekend appointments. Additionally, the RFC remains open to other ideas to enrich our lives with wellness and prosperity. As fall arrives, we continue to recruit assistance for validation of the new UCSF electronic health record system developed by Epic Systems. APEX, an acronym for “Advancing Patient-Centered Excellence,” will provide multiple opportunities for residents and clinical fellows to help shape our new documentation interface. If you have ideas for projects or would like to get involved, please contact us, your department representative… or come to a meeting!!! New members are always welcome. Wishing you all the best, Angela and Barak
Confidential line for housestaff, faculty, and program administrators to voice their questions, comments, or concerns 24 hours a day. The Office of Graduate Medical Education will respond to all messages.
Doctors And Addiction...
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monitoring of practice by a peer monitor or supervisor who has direct contact with the physician, and continued treatment and regular reports of progress in treatment. If relapse occurs, the physician would again be removed from practice and a new treatment plan would be developed and undertaken. If there is an allegation of patient harm it would be reported to the state regulatory board which will conduct an investigation and will make decisions as to whether any action needs to be taken. Actions by medical boards depending on severity of the allegations and findings of fact include a range of actions: including dismissal of the case, placing the physician on probation, or possibly license revocation. Most regulatory boards will require ongoing monitoring and reporting back to the board periodically. Is Treatment and Monitoring Effective for Physicians with Substance Use Disorders? A study by McLellan and colleagues6 have looked at the question of whether physician health programs and the services offered by these programs are helpful. In a follow-up study of 804 physicians being monitored for substance use disorders they found that 81% of physicians completed the monitoring program while 19% relapsed early in the course of monitoring and left the program. At the end of five years, 19% of the physicians that completed monitoring successfully had at least one relapse and received additional treatment. 26% of those physicians had multiple relapses. At the end of the study period 78% were working as physicians, 11% had their licenses revoked, and the remaining individuals either retired, died, or their whereabouts were unknown. This study showed a high rate of successful treatment for physicians with substance use disorders with the ability of these physicians to continue in successful medical practice. Physicians, like others, may be vulnerable to substance use disorders. If this should occur, it is important to recognize the impairment and to assist the physician with getting needed help. Those that receive treatment and monitoring have high rates of successful return to practice. If you or someone you know has a substance problem, get some help. UCSF has a Faculty and Staff Assistance Program (415) 476-8279. The telephone line is covered 24-hours
a day and every effort will be made to make a rapid appointment (usually the same day). For more information: http://www.ucsfhr.ucsf.edu/index.php/assist/index.html References 1. SAMHSA, National Survey on Drug Use and Health, 2009 2. National Institute on Alcohol Abuse and Alcoholism: www.niaaa.nih.gov, accessed July 3, 2010. 3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC, 2000. 4. McCance-Katz EF, Kosten TR: Psychopharmacological treatments. In Clinical Textbook of Addictive Disorders (third edition), S. Miller and R. Frances (eds.) Guilford Press, New York, NY, pp. 588-614, 2005. 5. Garbutt JC. The state of pharmacotherapy for the treatment of alcohol dependence. J Subst Abuse Treat 36:S15-23, 2009 6. McLellan AT, Skipper GS: Campbell M, Dupont RL: Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008 337:a2038.
ThE OFFICE OF GRADUATE MEDICAL EDUCATION Welcomes New Program Directors, Program Coordinators, and Administrators PROGRAM DIRECTORS Carina Mari Aparici, MD, Nuclear Medicine Michael Conte, MD, Vascular Surgery John D. MacKenzie, MD, Pediatric Radiology Arie Perry, MD, Neuropathology PROGRAM COORDINATORS AND ADMINISTRATORS Rita Emelia-McLinn, Psychosomatic Medicine Jillian Maliszewski, Neurological Surgery Ben Ramos, Addiction Medicine Lorenzo Woo, Anesthesiology
Rene Salazar, MD GME Director of Diversity
The Office of Graduate Medical Education is committed to training physicians from all backgrounds and cultures and has an interest in developing a diverse community among residents and clinical fellows from all training programs. Several events are planned for this year including many social events, recruitment activities, volunteering at student-run clinics and opportunities to represent UCSF at various annual meetings of national medical organizations. There are also opportunities to serve on diversity committees within the School of Medicine and the UCSF campus. UCSF 4th Year Medical Student Workshops: On September 8, 2010 GME co-sponsored an event for 4th year UCSF underrepresented in medicine (UIM) medical students entitled, “Keys to Successfully Navigate the Residency Application Process: The Diverse Applicant Perspective.” Thanks to all the faculty and housestaff who participated in this year’s event which was co-sponsored by the UCSF Director of Academic Diversity (Renee Navarro, MD), the Pediatrics Diversity Committee, the Department of Medicine’s Residency Diversity Program (RDC), the UCSF PRIME-US Program, and the LGBT Resource Center. On September 21, 2010 GME and the LGBT Resource Center co-sponsored the event, “Applying for Residency as an LGBT Student: A Candid Discussion.” UCSF medical students attended this event with UCSF faculty, program directors, and housestaff for an open discussion on being an LGBT applicant. UIM Dinner Program: The UCSF School of Medicine Mentorship Program for Underrepresented in Medicine (UIM) Students held its first dinner on September 16, 2010. This year’s welcome dinner was one of its largest ever with post-bac students, medical students, residents, clinical fellows, and faculty in attendance. Now in its 12th year, this program aims to introduce and foster mentoring relationships between students, physicians, residents, and clinical fellows. The UIM dinners are themed
around topics of interest to students. Previous topics have included: “Community Service and Mentoring” and “Impact of Finances on Physician Careers.” The dinners are held monthly during the fall and winter quarters. The next dinner, co-sponsored by the UCSF Latino Medical Student Association, will be held on Wednesday, October 13th. GME will co-host a dinner in February. All residents and clinical fellows are encouraged to attend. For more information, please contact Irma Moreno at 514-1390. Save the Date-Dean’s Diversity Event: Residents and clinical fellows should save the date for this year’s Diversity Celebration Reception on November 4, 2010 hosted by Sam Hawgood, MBBS, Dean of the School of Medicine. All SOM residents, clinical fellows, and faculty interested in increasing and supporting diversity at UCSF are welcome. Bobby Baron, MD, MS, Associate Dean of Graduate Medical Education and Rene Salazar, MD, GME Director of Diversity will present an update on activities to promote diversity in GME. Renee Navarro, MD, UCSF Director of Academic Diversity, will also present a brief update on campus-wide diversity efforts. Recruitment Events: GME is planning a diversity holiday reception on December 15, 2010 for residency applicants, residents, clinical fellows, and faculty. This event is an opportunity for applicants to meet current residents and clinical fellows and learn more about diversity at UCSF. The fourth annual Second Look Diversity Event for residency program applicants will be on January 21, 2011. In addition to learning more about UCSF training programs, the program provides applicants with the opportunity to meet campus leaders committed to promoting diversity. A panel discussion with housestaff will be held in the afternoon followed by an evening reception. Volunteer Opportunities: UCSF sponsors several student-run clinics in the city. Volunteer preceptor opportunities for residents and clinical fellows are available year-round at the following clinics: Homeless Clinic (provides care to the homeless), Hepatitis B Clinic (focuses on hepatitis B screening in Asian communities), and Clinica Martin Baro (provides free primary care services for Latino day laborers in the Mission). In addition to providing free screening and health care to underserved populations, the clinics also provide a chance to work with first and second year UCSF medical students and
undergraduate students from UC-Berkeley and San Francisco State University. Contact Dr. Rene Salazar to learn more. National Meetings: Opportunities to represent UCSF at annual and regional meetings for various organizations are also available. Upcoming meetings include the SNMA annual meeting in Indianapolis (April 20-24, 2011) and the National Hispanic Medical Association annual meeting in Washington, DC (March 17-21, 2011). Residents or clinical fellows interested in attending or participating should contact Dr. René Salazar, GME Director of Diversity (firstname.lastname@example.org).
GME New Resident and Clinical Fellow Orientation June 18 & 30
GME EVENTS GALLERY
4th Year Medical Student Workshops September 8 & September 21
New interns enjoying lunch during GME Orientation.
(l - r) Rene Salazar, MD, Internal Medicine; Robert Daroff, Jr, MD, Psychiatry; Weston Fisher,MD, Psychiatry resident
New residents happy to receive their lab coats.
Fourth year medical students learning about the residency application process.
Tony Wagner, HR Benefits Coordinator, discussing HR enefits with a new intern.
GME GRAND ROUNDS Third Tuesday of each month from noon to 1 pm RESIDENT AND FELLOWS COUNCIL Third Monday of each month from 5:30pm to 7:30 pm TEAChING SKILLS WORKShOP November 2, 2010 3:00pm-6:00pm Faculty Alumni House DEAN hAWGOOD’S DIVERSITY RECEPTION November 4, 2010 6:30pm-8:30pm Dean Hawgood’s House GME DIVERSITY hOLIDAY RECEPTION December 15, 2010 6:00pm-8:00pm Bistro 9 NEW TEAChING AND LEARNING CENTER Parnassus Library Opening Week, January 18, 2011 http://tlc.library.ucsf.edu/
G M E
C Y P h E R
The Residents Report
Solve the Summer
2 0 1 0 C y p h e r
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Instructions: The above is an encoded quote from a famous person. Solve the cypher by substituting letters. Send your answers to Justin Akers, Resident & Fellow Affairs Manager, OGME: akersJT@medsch.ucsf.edu. Correct answers will be entered into a drawing to win a $50 gift certificate!
Robert Baron Amy Day Paul Day
The Dean’s Office of GME would like to thank the following contributors to articles in this issue.
The Summer 2010 Cypher answer was: “In dwelling, live close to the ground. In thinking, keep to the simple. In conﬂict, be fair and generous. In governing, don’t try to control. In work, do what you enjoy. In family life, be completely present. ” Lao Tzu Congratulations John Markley, MD, Anesthesia Intern, PGY1!!
Justin Akers Barak Bar Bobby Baron Michael Blum Paul Day Doug Eckman Rachael Kagan Elinore McCance-Katz Mary McGrath Heather Nichols Susan Promes Rene Salazar Josephine Tan Kevin Thornton Arpana Vidyarthi Emily von Scheven Angela Walker
Important GME Contact Information
Office of Graduate Medical Education GME Confidential help Line Director, GME Associate Dean, GME UCSF Faculty & Staff Assistance Program (FSAP) GME Website (415) 476-4562 (415) 502-9400 (415) 514-0146
UCSF School of Medicine Graduate Medical Education 500 Parnassus Avenue MU 250 East, # 0474 San Francisco, CA 94143 tel (415) 476-4562 fax (415) 502-4166 www.medschool.ucsf.edu/gme
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